M mm Class l\cT45 Book- F*"") Copyright^? C.ORfR!GttT BKPOS« Elements of Pediatrics for Medical Students THE MACMILLAN COMPANY NEW YORK • BOSTON • CHICAGO • DALLAS ATLANTA • SAN FRANCISCO MACMILLAN & CO., Limited LONDON • BOMBAY • CALCUTTA MELBOURNE THE MACMILLAN CO. OF CANADA, Ltd. TORONTO Elements of Pediatrics for Medical Students BY ROWLAND GODFREY FREEMAN, A.B., M.D. Adjunct Professor of Pediatrics New York University and Bellevue Hospital Medical School; Attending Pediatrist to The Roosevelt Hospital, New York, etc. Ex-President of The American Pediatric Society Sfom fork THE MACMILLAN COMPANY 1917 All rights reserved 1? <3"4S- ,4= .7 Copyright, 1917 By THE MA.CMILLAN COMPANY Set up and electrotyped. Published November, 1917. m -8 1917 0CU476982 PREFACE The study of Pediatrics has developed rapidly and has not yet assumed a reasonable or logical form. The fact that infants differ from adults in various points of anatomy, physiology, pathology, diagnosis and treatment is too little appreciated, so that works on pediatrics are still published which are devoted almost entirely to the diseases of infants and children with little or no information regarding the charac- teristics of children or of that part of pediatrics which occupies a large portion of the time of most pediatrists, the problem of keeping infants and chil- dren well by proper regime and feedings. It is the aim of this book to impart these facts in a simple and concise form, and in addition to sum- marise the important facts to be obtained by physical examination, by examination of the urine and feces and by Roentgen-ray examination and review briefly the essentials of diagnosis and treatment. The au- thor believes that the information it contains is of the sort that should be made familiar to medical stu- dents before they take up the study of the diseases of infancy and childhood. The author wishes to express his indebtedness to Professor William Perry Northrup, to Professor Ed- win Bradford Cragin, to Professor Francis Carter Wood, and to Doctor Oscar M. Schloss for valuable PEEFACE suggestions ; also to Doctor Anthony C. Freeman for aid in preparing the Chapters on "Urinary Anal- ysis/ ' and "Examination of the Feces"; and to Miss Nina A. Brown for the preparation of the illustra- tions, proofreading and the making of the index. TABLE OF CONTENTS CHAPTER PAGE I Anatomy of the New Born 1 II Physiology of the New Born 12 III Development 15 IV The Care of the Healthy Infant .... 57 V The Care of the Infant During the First Day 63 VI The Care of the Infant During the Second Day 73 VII Nursery Hygiene . 75 VIII Daily Regime 102 IX Vaccination 109 X Typhoid Immunisation 115 XI Feeding During the First Year 117 XII Weaning 134 XIII Wet Nursing 138 XIV Mixed Feeding 141 XV Artificial Feeding 144 XVI The Modification of Milk 154 XVII The Pasteurisation of Milk 168 XVIII Methods of Artificial Feeding 176 XIX Theory of Infant Feeding 197 XX Elimination of Bottle Feeding 204 XXI Care of Premature Children 210 XXII Mental Development of Children .... 215 TABLE OF CONTENTS CHAPTER PAGE XXIII The Moral Development and Control of Chil- dren 218 XXIV Physical Examination 221 XXV Urinary Analysis 229 XXVI Examination of the Feces 240 XXVII Examination by Roentgen-Ray 245 XXVIII Diagnosis .247 XXIX Treatment * . 252 LIST OF ILLUSTRATIONS FIGURE PAGE 1. Comparison of Infant at Birth with Adult .... 1 2. Foetal Circulation 3 3. Weight Chart of the First Week 17 4. Weight Chart of the First Year 18 5. Weight Chart of an Artificially Fed Child .... 20 6. Weight Chart of a Nursed and Artificially Fed Child . 21 7. Weight Chart During the First Year of Well-cared-for Children Compared with Institution Children ... 23 8. Weight Chart During the First Twelve Years of Well- cared-for Children Compared with Other Children . 25 9. Weight and Height of Boys and Girls from Birth to Sixteen Years 26 10. Chart Showing That Loss of Weight Is an Important Indication of Approaching Illness 28 11. Average Height of Children During the First Year . . 29 12. Length of Children of the Same Weight at Different Ages 31 13. Head and Chest Circumference at Different Ages . . 33 14. Comparison of Skull of an Infant at Birth with the Skull of an Adult 35 15. Spinal Curves 36 16. The Increase in Weight of Certain Organs During In- fancy and Childhood 38 17. First Dentition 40 18. Second Dentition 42 19. Stomach Capacity 48 20. Daily Secretion of Urine at Various Ages .... 55 21. Death Rate of Infants Under One Year in Various Countries 58 22. Deaths of Infants and Children by Months in New York 59 23. Clothing of Babies 69 24. Analysis of Human Milk and Colostrum 71 25. Breck Feeding Tube 72 LIST OF ILLUSTRATIONS FIGURE PAGE 26. Proper Scales for Weighing" Babies 80 27. Daily Regime of a Baby Under Three Months . . . 103 28. Daily Regime of a Child from Three to Six Months . . 103 29. Daily Regime of a Child from Six Months to One Year 104 30. Daily Regime of a Child in Its Second Year . . . 105 31. Daily Regime of a Child After the Second Year . . .107 32. Vaccination 112 33. Classification of Infant Feeding 118 34. Apparatus for Examination of Breast Milk .... 124 35. Plate Showing Origin of Milk Contamination . . . 148 36. Analysis of Cow's Milk .... 151 37. Mineral Matter in Milk 152 38. Chapin Dipper 162 39. Fat Content of the Different Layers of a Quart Bottle of Milk 162 40. Sugar of Milk Graduate 166 41. Sanitary Nursing Bottle 166 42. Thermal Death Point in a Moist Medium of Certain Pathogenic Bacteria 169 43. The Effect of Heat on Certain Biologic Characteris- tics of Milk 170 44. Pasteuriser 173 45. Temperatures during Pasteurisation of a Bottle of Milk 174 46. Examples of Feedings for the First Year . . . .178 47. Laboratory Feeding Prescription 183 48. Analysis of Barley Water 185 49. Feeding Chart 198 50. Feeding Chart 199 51. Feeding Chart 200 52. Feeding Chart 201 53. Feeding Chart 202 54. Analysis of Beef Juice and Beef Broth 205 55. Weight and Length of Foetus in Utero 211 56. Incubator 212 57. Apparatus for Schmidt's Fermentation Test . . . 243 58. Diagnosis Chart 248 ELEMENTS OF PEDIATRICS CHAPTER I ANATOMY OF THE NEW BOKN Characteristics of in- fant. — On examining a healthy infant, having in mind the adult type, one is immediately im- pressed with certain marked characteristics. (Figure No. 1.) The infant has a very large head and a small face, and apparently, al- though not really, a short neck, a rather small thorax in contrast with a large protruding abdomen, a very slightly developed pelvis and small legs. For an ex- planation of these pe- culiarities, which are most marked at birth, one has to consider the nourishment of the child in utero. l Infant at Birth Adult FIGURE 1. Comparison of Infant at Birth with Adult. 2 ELEMENTS OF PEDIATRICS Foetal circulation. — The foetus in utero is supplied with oxygen, as well as nourishment, from the pla- centa by means of the circulation of its blood through the placenta, where it obtains from the blood of the mother the nourishment it requires. (Figure 2.) The vessels that carry the blood of the f cetus to and from the placenta are three: the two umbilical ar- teries carry blood to the placenta ; while the umbilical vein passes from the placenta along the umbilical cord, carrying this fresh placental blood to the liver, where it divides into three branches, two of these supplying the liver, while the third, the ductus venosus, carries the blood to the inferior vena cava and thus to the right auricle of the heart. Here it does not pass into the right ventricle, as in the adult, but by means of the Eustachian valve this blood cur- rent is directed through the foramen ovale to the left auricle, from which it flows into the left ventricle, being forced from there into the aorta. This placen- tal blood, then, is supplied to the liver and to the head and upper extremities by means of the aorta, while before it reaches the descending aorta, it is mixed with blood from the right side of the heart. The portion of this blood which passes through the carotid and subclavian arteries to the head and upper extremities returns to the superior vena cava, passes into the right auricle and right ventricle, and is forced by the contractions of the ventricle into the pulmonary arteries, from which by means of the duc- tus arteriosus a considerable portion of it passes into the descending aorta, reaching, through the in- FIGURE 2. Diagram of the Circulation of the Foetus Indicating the Parts that Disappear After Birth. A. Umbilical Vein. D. Foramen Ovale. B. Ductus Venosus. C. Eustachian Valve. E. Ductus Arteriosus. F. Umbilical Arteries. 4 ELEMENTS OF PEDIATEICS ternal iliac and umbilical arteries, the umbilical cord and placenta. Respiration. — During the period of intra-uterine life, then, the lungs are solid organs ; and the heart has the Eustachian valve and the opening of the fora- men ovale between the auricles. It is thus evident that at birth very radical changes must take place in order that the infant may still obtain the necessities for life. The placental nourishment is cut off and the child gasps for breath. This air passes through the mouth, pharynx, larynx, and bronchi, and must be drawn into the lung, at this time practically a solid organ. With many infants breathing is at first difficult and insufficient, and only after considerable assistance through counter-irritation, the application of heat or cold, or the use of artificial respiration, is a sufficient function of the lungs established. Changes in the heart after birth. — With the estab- lishment of the function of the lungs the usefulness of the foetal appendages of the heart is passed, so that the Eustachian valve disappears, the foramen ovale gradually closes, the ductus venosus becomes a fibrous cord in from four to ten days, the umbilical vein becomes the round ligament of the liver in from two to five days, while the umbilical arteries form the anterior true ligaments of the bladder. A study of the foetal circulation, then, shows us one reason why the moment of birth is a critical moment for the infant ; why some parts of the body, such as the head and liver, receiving a better blood supply, should become more developed during intra-uterine life than ANATOMY OF THE NEW BORN 5 others, and it also shows us the direction that will be taken by navel infections in infancy; in such cases the umbilical vein is sometimes found rilled with pus. Proportions of infant body in comparison to adult. — As will be seen by reference to the chart (Figure 1) the large head of the infant occupies about one-fourth of its stature, while in the adult the line dividing off the upper fourth of the body passes through the axillary line, and the head occupies about one-eighth of the stature. Again the middle line of the body which in the child at birth passes just above the um- bilicus, in the adult is much lower, at about the level of the crest of the ilium. The trunk, Dr. Rotch has well said, resembles somewhat the shape of an egg; the large end of the egg represents the lower part of the body, the shoulders being attached to the smaller end. Appearance. — Healthy babies at birth should have a bright red color and should be plump with a fairly thick layer of adipose tissue below the skin. Sebaceous glands. — The sebaceous glands of the skin are well developed at birth and this is evident from the large amount of vernix caseosa, the excre- tion of these glands, which is often found on the body of the child at birth. Sweat glands. — The sweat glands are not well de- veloped. Weight. — These stocky little bodies should weigh about seven pounds at birth, but this weight may vary from six to nine pounds or more, depending on the 6 ELEMENTS fOF PEDIATEICS length of the body and the state of nourishment, these conditions again depending on the size and health of the parents and the duration of intra-uterine life. Length. — The length of the body should be about twenty inches; the circumference of the head thir- teen and one-half inches, that of the thorax thirteen, and that of the abdomen about fourteen inches. This latter measurement is very variable, depending to a considerable extent on the distention of the in- testines with gas at the time the measurement is taken. Navel wound. — One of the greatest dangers to the infant is its first wound, the severed cord, which if allowed to remain moist or if contaminated by an invasion of bacteria may lead to an infection which sometimes speedily ends life. The navel should be healed in about five days. Skeleton. — The skeleton of these babies is very in- completely developed. Skull. — The bones of the skull have not united so that during birth they are pressed together and often overlap. Four considerable openings exist, dimin- ishing in size in the order named : the anterior f on- tanelle (Figure 14), the largest, is at the junction of the frontal and parietal bone and is usually about an inch in lateral diameter and two inches in longitudi- nal diameter; the posterior fontanelle, at the junc- tion of the occipital bone with the two parietal bones in the median line at the back of the head is usually sufficiently open to be felt, as are also the two lateral fontanelles at the junction of the occipital, parietal ANATOMY OF THE NEW BOEN 7 and temporal bones, and so long as the sign known as cranio-tabes — the depression of the bones of the skull over the lateral f ontanelle on pressure by the fingers — is present it may be assumed that this closure is not complete. When one considers the very deficient ossification of the skull and the fact that the two frontal bones are never completely united, that the frontal and parietal, parietal and temporal, and the parietal and occipital, as well as the two parietal bones have no bony connection, being joined by mem- brane only, it is evident that the brain is but slightly protected, and that the skull may easily be unduly compressed by tight bandaging or its shape altered if the child is allowed to lie continuously on one side. Spinal column. — The spinal column is largely car- tilaginous and very flexible, so that when cut away from the ribs it may readily be bent in all directions. It, moreover, has but one curve with its convexity backward. Thus abnormal curvatures may result from fairly slight causes. Head. — We have noticed that the head of the child is very large, in fact, occupying one-fourth the length of the body instead of one-eighth as in the adult, and this is due to the large size of the brain, which often weighs three-fourths of a pound, that is one-ninth of the total weight of the child. It is thus five times as large in proportion to the body weight as in the adult. The dura mater is quite adherent to the bone. The face. — The face of the infant at birth is very 8 ELEMENTS OF PEDIATRICS small, being only one-eighth as large as the cranium and this small size is due to the fact that the nose and alveolar process of the maxillary bones are but little developed. The walls of the cheeks are thickened by large pads of fat, which render them more resistant and thus of service in sucking. Nasal cavity. — The nasal cavity is small, particu- larly the post-nares, so that this is easily occluded by inflammatory processes. Moreover, in this post- nasal pharynx there exists a mass of lymphoid tissue known as the third tonsil or adenoid, which is of con- siderable importance in children, because in certain climates it very commonly becomes enlarged, giving rise to symptoms, often very early in life, which if persistent necessitate its removal. The mouth. — The mouth is somewhat drier than in adults, due to the slight development of the salivary glands, and the tongue is proportionately smaller. While no teeth are to be seen, the twenty teeth of the first set are present in the sacs of the alveolar process of the superior and inferior maxillary bones. These are covered by mucous membrane and do not usually begin to pierce this membrane until after the sixth month. The eye. — The eye at birth is a perfect organ, the poor perception of these infants being due probably to insufficient brain development. The lachrymal glands are inactive, so that when these young babies cry they shed no tears. The orbital plate of the frontal bone is very thin, offering little resistance to foreign bodies brought in contact with it. ANATOMY OF THE NEW BOEN 9 The ears. — The ears at birth are in part well devel- oped, but the mastoid cells are not well developed until after puberty, although inflammation of the mastoid often occurs in early life. The neck. — The neck of the child is really propor- tionately longer than in adults, the apparent short- ness being due to adipose tissue under the chin and above the clavicle. Between the muscles of the neck there are a large number of lymph nodes which, though rarely noticeable at birth, are often the seat of enlargement in babies and young chil- dren. Thymus gland. — The thymus gland, which is sit- uated behind the upper part of the sternum, often com- ing down well over the pericardium, is a conspicuous organ at this period and important because children in whom it is enlarged seem particularly liable to sudden death, this enlargement being associated with the condition known as lymphatic constitution. The heart. — The heart of the baby at birth is pro- portionately somewhat larger than in the adult and occupies a considerable portion of the thoracic cavity, its weight being about six drachms. The lungs. — The lungs, even when well aerated, differ materially from the adult lungs. The bronchi are larger and more numerous; the air cells are much smaller; the interstitial tissue much more abundant. These facts are important in connection with the respiratory diseases of infants and young children, which differ in type from those found in adults. The pneumonia of infants is usually 10 ELEMENTS OF PEDIATEICS broncho-pneumonia instead of lobar pneumonia, which commonly occurs in adults. The diaphragm. — The diaphragm, which plays a comparatively more important part in respiration in babies than in adults, is well developed and occupies a higher position. The abdomen. — The abdomen is prominent in babies, owing to the large size of the liver, as well as to the small size of the pelvis. The liver. — The liver, as already stated, is very large, weighing about three ounces six drachms, or nearly one-fourth of a pound, that is one-twenty- eighth as much as the body weight instead of one- thirty-seventh as in the adult ; it contains much more fat than is contained in the liver of adults. The kidneys. — The kidneys also are of a relatively large size and frequently contain infarctions of uric acid, which cause red stains on the diapers. The bladder. — The bladder owing to the small size of the pelvis, is in the new born an abdominal organ, and when distended is readily palpable. Stomach and intestines. — The stomach and intes- tines vary in form and position from that of the adult, these variations being due to the type from which they are developed. In early fetal life the alimentary tract is a straight tube which, with growth in length, becomes doubled upon itself. Thus, the stomach, as would be expected, occupies a more ver- tical position than in the adult and is more tubular, the fundus of the stomach being but slightly devel- oped. The caecum is in infancy very movable, and ANATOMY OF THE NEW BORN 11 the appendix may be found in an infant at birth any- where between the liver and the region of the rectum, although usually it is found in the right iliac fossa. Weight of viscera. — In Figure 16 is shown the weight of the principal viscera at birth and to the fourteenth year. All the viscera are heavier at birth in proportion to the weight of the body than in adults. This is most marked in the brain which in infants is more than one-tenth of the body weight, while in adults it is about one-fiftieth. Next in order comes the liver, the kidneys, the heart, while the lungs and spleen are only slightly heavier in proportion to the body weight than in the adult. CHAPTER II PHYSIOLOGY OF THE NEW BORN" Vitality. — New born babies exhibit a degree of vi- tality which is somewhat proportionate to their weight. A well developed child of fair weight who is properly managed from birth usually gives little trouble. A baby of four or five pounds has very poor vi- tality and needs special treatment; a baby of seven pounds has normal vitality; while one of eight or nine pounds has a high degree of vitality. As soon as a new born child has established a good respiratory function, it should become quiet and sleepy. It should sleep practically all the time ex- cept when being fed; any deviation from this con- dition is an evidence of some abnormality. Al- though the eyes may open and close, the vision ap- parently makes little impression on the brain. When uncomfortable the infant will cry out. The rectal temperature is normally about ninety- nine degrees Fahrenheit; the pulse varies from one hundred and twenty to one hundred and forty, while the respirations are rather rapid, varying from forty to sixty or seventy per minute. The respirations are also very irregular, the child breath- ing quickly for a time and then again slowly. The 12 PHYSIOLOGY OF THE NEW BOEN 13 normal relation of respirations to pulse of one to four is not present in the new born but is established soon after birth. Salivary glands. — The salivary glands of the new- born, as has already been stated, produce but little secretion. This, however, has power to decompose starch. The secretion is increased after the second month and markedly so after teething. Digestion. — The stomach takes but little part in digestion of food in the infant, but provides a reservoir into which the milk is received and from which it passes quickly into the intestines. Pepsin is, however, found in the stomach at birth, as is free hydrochloric acid ; a fat splitting ferment is also said to be present. Protein is transformed into acid albumin, albuminose and peptone. Pancreas. — The pancreas is fairly developed, but its secretion probably has little amylolytic action. Bile — Meconium. — Bile and bile salts are secreted and pass into the intestines during intra-uterine life, and these, together with desquamated epithelium and other material, form the meconium which is con- tained in the intestines at birth and which is grad- ually expelled during the first day or two of life. The total amount of this meconium contained in the intestine at birth is two or three ounces. Urine. — The activity of the kidneys begins at birth. The amount of urine secreted during the first two days of life is small and the urine has a high specific gravity of about 1015 to 1020. Blood. — The blood of the new born shows varia- 14 ELEMENTS OF PEDIATRICS tions from the adult type. It contains about six million red blood corpuscles in each cubic millimeter while the white corpuscles are proportionately much more numerous during the first two days than in the adult, being about eighteen thousand to the cubic millimeter, but after the third day they are about the normal adult number. The haemoglobin is very high during the first week. It gradually drops from 23 grams per 100 c.c. of blood, so that by the latter part of the first year it reaches only 12-13 grams per 100 c.c. of blood, it then gradually increases until about the fifteenth year when it is about 16 grams per 100 c.c. of blood at which amount it continues during adult life. CHAPTER III DEVELOPMENT Weight as a standard of development. — The proper development of an infant dnring the first year may be measured by various standards, but there is no indi- cation more significant than the increase of weight. Charting weight. — The value of careful and fre- quent observation of the weight of a child and its record on a chart can hardly be overestimated. So important is this that at most institutions every in- fant at birth, or on admission, is carefully weighed and its weight recorded on a chart, on which subse- quent regular weighings are recorded, so that the physician in charge can always see at a glance the condition of nutrition of the child throughout its life in the institution. In private practice such records should never be neglected. Relation of weight to length. — It might be as- sumed that a growing child who does not gain in weight is actually losing, since its size is increasing without corresponding gain in weight, but this, as will be shown later, is to only a slight extent true, because a child who does not gain in weight grows little in length. Weight observations are of value in showing whether a child is getting the proper kind of food, a sufficient amount of food, or is thriving on 15 16 ELEMENTS OF PEDIATKICS its diet. A stationary weight for more than a week of an infant during the first year is always a cause of solicitude, while a loss of weight usually calls for some change in the daily regime. Sometimes this loss of weight is a danger signal of approaching ill- ness and is the earliest indication obtainable, as will be shown in charts. Gain in weight. — A child beginning life ivith a weight of about seven pounds should double this in five months, treble it in twelve months, and quad- ruple it in twenty-four months. A child should gain fourteen pounds by the end of the first year, and twenty-one pounds by the end of the second year, weighing at that time twenty-eight pounds. From that period the gain is slower, that of the third year averaging only about five pounds. Normal weight chart for first week. — A normal weight chart (Figure 3) of the first week of life shows a loss during the first two days of more than half a pound — about nine ounces — this being due to the loss of meconium, of urine and of evaporation from the surface of the body and the air passages, and to tissue waste, which is but little compensated for by food taken. The fourth day there is a loss of only about one ounce, due to the fact that by the third day some nourishment is usually obtained from the breasts; while on the fifth day, following the day on which the breasts are distended with milk, an actual gain is noted, which should persist during the remainder of the week. DEVELOPMENT 17 This chart, however, represents what one would expect in an infant the breasts of whose mother con- tained a normal milk supply. If there is no breast milk and a substitute food is supplied a very dif- ferent chart is often found, for it is during these Weight 8 Lbs. 14 OZ. 12 OZ. 10 OZ* 8 oz. 6 oz. 4 oz. 2 oz. 7 lbs t Days I 2 a 4 5 6 7 \ \ \ \ \ \ \ k \ / \ Y V > ''/? ''// S / / / y / / / / / ^^ / / r / y **- /// / /// #/ /// V/fe V FIGURE 7. Average Weight During the First Year of 120 Well Cared for Children A; Compared with that of 500 Institution Children B; That Given by Dr. Cammerer for 119 Breast Fed Children C; And 84 Artificially Fed Chil- dren in Private Practice — D. rapidly after obtaining* proper food but rarely weigh as much at the end of the first year as a child who does well from the start. It has been the custom to use weight charts with 24 ELEMENTS OF PEDIATRICS the so-called normal line made from the average of a number of charts which, it is readily seen, is a great mistake, as each individual child has its own normal line. A seven-pound baby has a different normal line from a nine-pound baby. An artificially fed baby has a different normal line from a breast fed baby and a baby of large parents a different normal line from a baby with small parents, and one's estimate as to how a baby is doing should be based on the gain or loss in weight and not on com- parison with a supposed normal line. Failure to gain. — Any failure to gain during one or more weeks of the first year must usually be at- tributed either to illness or to improper feeding, and the illness may be simply the result of improper feeding. This fact cannot be too strongly impressed on parents, for one frequently sees babies who have been allowed to go on for months with practically no increase in weight and without consulting a phy- sician. The relation of feeding to the weight of the child will be considered later in the chapter on feed- ing. Average gain in weight of older children. — The gain in weight during the second year has already been stated to be an average of about seven pounds ; during the third year it is about five pounds, while in the two succeeding years- a gain of less than five pounds is usually recorded, then the yearly gain gradually increases and after the tenth year it is from seven to ten pounds each year in well cared for children as shown by the heavy black line (A), o 03 < fQ s \ > \ T-" s, k *» \ \\ o \ \ v\ \ v \ \ V '. \ \ % \ \ CO \ v s V I- \ \ \ \ \ \ \ \o \ \ \ V \ CQ \ \ V s s< 2 ^88288? gas fi ,a J < w M o o o . 2o w : H . $ : B w p-i — I s .'' A * ^ // ' li li i A i B i FIGURE 13. A. Head. B. Chest. Head and Chest Circumference at Different Ages. same time the face has been growing even faster, so that by the second year the proportion of face to cranium has changed considerably. At birth the face is only one-eighth as large as the cranium; at 34 ELEMENTS OF PEDIATRICS the fifth year one-fourth ; at the tenth year one-third, while in the adult the proportion is as one to two and one-half. This increase in the size of the face is due to the development of the nose, the growth of the alveolar process, the teeth, and the development of the ramus of the inferior maxillary bone, and the change in the angle of the ramus with the body of this bone from an oblique angle to nearly a right angle. This is well shown in Figure 14. Ossification of bones of skull. — The ossification of the bones of the skull steadily increases and the pos- terior and lateral fontanelles disappear soon after birth; the anterior fontanelle in health persists, re- taining about the same dimensions until the tenth month, after which it gradually closes, so that by the eighteenth month or second year it should appear to be closed. Anterior fontanelle. — This anterior fontanelle is of great importance in diagnosis and one should remem- ber its normal dimensions and its time of closing. Moreover, while it is open, the skin covering it should preserve much the same level as the skin covering the surrounding portions of the skull, and a marked de- pression or bulging of this fontanelle always indicates some abnormality. A bulging of the anterior fon- tanelle usually indicates an increase of fluid in the ventricles, while a depression calls attention to a lack of body fluid. A delayed closing of the fon- tanelle, in like manner, gives evidence of some disor- der, usually rachitis. The spine. — The spine, which we have noted as A. Anterior Fontanelle. B. Posterior Fontanelle. C. Lateral Fontanelle. Skull of an Infant at Birth. Skull of an Adult. FIGURE 14. Comparison of Skull of an Infant at Birth with the Skull of an Adult. 35 36 ELEMENTS OF PEDIATRICS being largely cartilaginous at birth and very flexible, loses its flexibility and gradually becomes ossified. Moreover, with the growth of the child and its as- sumption of the erect posture, certain curves are developed in the spine which are entirely absent at birth. Thus, at birth there is a curve with the con- vexity backward from the neck to the sacrum ; while with the assumption of the sitting posture two curves Infant At Birth Infant Sitting InPant Standing FIGURE 15. Spinal Cueves. develop, a cervical curve with the convexity forward, and a dorsal and lumbar curve with the convexity backward. On standing, a third curve develops in the lumbar region, and we have then a curve with the convexity forward in the cervical region, a curve with the convexity backward in the dorsal, and a curve with the convexity forward in the lumbar DEVELOPMENT 37 region. The curve with the convexity backward in the sacral region persists during all these periods. (Figure 15.) Growth in length of the spine. — As the spine grows in length, the lumbar portion shows the greatest in- crease. Thus while at three months the cervical por- tion is 24 per cent., the dorsal 48 per cent., and the lumbar 28 per cent, of the total length, at sixteen years the cervical is but 21 per cent., the dorsal 47 per cent, and the lumbar 32 per cent. Growth of brain. — Although the brain is large pro- portionately to the other parts of the body at birth, it increases rapidly in weight during the first three years of life. (Figure 16.) During the first year it doubles its weight, increasing from thirteen ounces to one pound, ten ounces ; at two years it reaches one pound, fourteen ounces in weight ; and at three years, two pounds, two ounces. From the third to the tenth year it increases only about an ounce a year, weighing about two pounds, nine ounces, at the tenth year. Growth of post nares. — The opening from the nares into the pharynx, which is very small, almost doubles in size during the first year, increasing in measure- ment from % inch high by % inch wide to % inch high by % inch wide, reaching at this age about half the size it is in adults. At seven months it reaches the adult type in shape. Importance of nasopharynx. — The nasopharynx is a most important region in children, since it is the seat of the adenoid or third tonsil, which is fre- Weight 3 LBS. 150Z. 14 13 12 11 10 9 8 7 6 S 4 3 2 1 2LB3 150Z. 14 13 12 11 10 e e 6 5 4 3 2 1 ILB 15 OZ. 14 13 A 12 11 10 9 8 4 B 3 » D E F -Tea.r.3 1 2 3 4 5 S 7 6 9 lO 11 12 13 14 A S S ^ y / / zz / ~z_ / E 7Z / F / , <* zz D z: FIGURE 16. A. Brain. B. Liver. C. Lungs. D. Heart. E. Kidney. F. Spleen. The Increase in Weight of Certain Organs During Infancy and Childhood. DEVELOPMENT 39 quently hypertrophied during the first two years of life, giving rise to the so-called adenoid growth which often becomes a large mass that completely fills the nasopharynx. The pharyngeal tonsils do not usually cause trouble as early in life as this adenoid or third tonsil. Dentition. — There are two complete sets of teeth, the first or milk teeth numbering twenty, ten upper and ten lower, which are, after the sixth year, grad- ually replaced by the permanent teeth. Development of first dentition. — The development of the first set of teeth begins at about the seventh week of intra-uterine life, so that at birth these twenty embryo teeth are enclosed in the alveolar processes, covered by the mucous membrane of the gums. This fact is worth remembering, inasmuch as solicitation is frequently aroused by very late dentition, for in such cases the teeth are in place just as in children with early dentition, the difference being that in one case these teeth have pierced the gums, in the other they have not. Age at which first tooth appears. — It may be roughly stated that the first tooth usually appears at about the eighth month. Exceptions to this rule are not infrequent. Children have been born with teeth already erupted and not infrequently the lower mid- dle incisors appear at the fourth or fifth month. One may summarise teething in general in the fol- lowing manner, which renders it easy to remem- ber. 40 ELEMENTS OF PEDIATRICS No teeth at six months. Six teeth at twelve months. Twelve teeth at eighteen months. Second teeth beginning at six years. The first teeth to appear then may be looked for at about the eighth month, and are the two middle lower incisors (Figure 17). Both middle lower incisors Incisor Canine Molar 11 Mos. 27 Mos. * / V 1 \ J \ V \ \ N r ^\ \/ / \ w \*>" -'-& *\ s/ r V \ ■v —A FIGURE 22. A. Infants under one year. B. Children under five years Deaths of Infants and Children by Months in New York. the variations in infant mortality by months in New York, and is fairly typical although yearly varia- tions occur. It is interesting to note that while the mortality of infants under one year in winter is 60 ELEMENTS OF PEDIATBICS about one-half the mortality of all children under five years of age, during the hot months it amounts to about three-fourths that mortality. Infant mortality in summer. — The mortality, moreover, is apt to be higher in July than in August, although often the weather is quite as hot in August. This is thought to be due to the fact that in July very susceptible babies succumb and that those who are able to survive the heat of July have a better chance to withstand the heat of August. Humidity. — Humidity, as well as heat, is a con- siderable factor in the discomfort of babies in hot weather and may to some extent be an influence in this infant mortality. The heat is, however, by far the more important because it spoils the child's food as well as reducing its resistance to infection. Breast fed babies do not have a high mortality in summer. Poverty. — It is among the infants in tenements, those of the very poor, where the rules for care, which are here pointed out, are least heeded that the mortality is the highest. Under these conditions, many of the requirements mentioned are not easily carried out on account of the onerous duties of the ordinary tenement house mother with her household work and the care of a large family. Illegitimacy. — Illegitimate children, naturally, have less care, and show much higher mortality than legitimate children. Artificial food. — The mortality is less where most infants are nursed at the breast, as in Scandinavia, CAEE OF THE HEALTHY INFANT 61 and highest where artificial foods are largely used. It is thus evident from the study of the four prin- cipal causes of the high infant mortality, that un- hygienic surroundings and bad feeding are the main factors. Measures for reducing infant mortality. — The high infant mortality is being rapidly reduced in intelli- gent communities by milk depots and agencies that instruct the mothers of the poor to nurse their babies as far as possible and if artificial food is needed to give sterile food which will properly nourish the babies, as well as instruction in other precautions necessary for good health. Mortality of babies in private practice. — In contrast to the foregoing figures of infant mortality, the mortality of babies in private practice, where ample instruction is received and every care is taken, gives a good example of what may be accomplished and what will soon be accomplished among the intelli- gent people of the poorer classes. Of these children having every care not more than one in 100 or 150 die in the first year, although they are largely arti- ficially fed and if nursed it is often only partially or for a few months, and these figures include the babies with congenital defects. The writer has published recently a series of 120 consecutive cases with no death. It is very rare, under good conditions, to lose a child during the first year, for these children are well isolated and are thus protected from con- tagious diseases, while their feeding, exercise and 62 ELEMENTS OF PEDIATRICS exposure to fresh air can be absolutely controlled. In order to obtain these good results that have been mentioned it is necessary to take every precaution and there are no details so small that they should not be looked after by the physician. One of the most successful consultants in pedia- trics in a neighbouring city on taking charge of an artificially fed baby was in the habit of modifying the milk himself one day, so as to give the mother or nurse a practical lesson in the method used, in order that there might be no mistakes made in carrying out his directions. It is only by care in the smallest details that the greatest success in pediatrics is obtained. CHAPTEB V THE CAKE OF THE INFANT DUKING THE FIRST DAY Respiration. — At birth, our first care, with respect to the infant, should be to establish respiration. Infants at birth are often cyanosed, and their breath- ing is shallow and insufficient. At birth, the lung is a solid organ, and inflation must gradually take place. In autopsies on babies two or three days old, sometimes only one-half of the lung tissue is in- flated. At birth, then, the baby should be held by its feet to let the mucus run out of its mouth. Should the baby not cry vigorously of itself (the cry assists in the establishment of respiration) it should be slapped on the buttocks and if respiration is still insufficient, the baby should be dipped alternately in hot and cold water. Should this not be sufficient, artificial respiration may be used. Again, inflation of the lungs by means of a lung motor may be re- sorted to, while traction on the tongue applied eight or ten times a minute, is also of use in stimulating respiration. Babies that fail to react and remain persistently cyanotic are usually suffering from some congenital defect. Congenital heart defect. — The most common defect is in the heart and is usually associated with a loud, harsh systolic murmur and a thrill. In these cases, there is generally a stenosis of the pulmonary orifice 63 64 ELEMENTS OF PEDIATRICS as well as a defective intraventricular partition allowing a rush of blood from one ventricle to the other in systole. In other cases without murmur there may be a patent foramen ovale, while in other cases of cyanosis the defect is not in the heart at all, but in the formation of the diaphragm — a hernia of the diaphragm, the intestine occupying a part usually of the left half of the thorax crowding the heart over to the right side. Cutting the cord. — When respiration has been well established, the cord may be tied twice with sterile ligatures and cut between the ligatures with sterile scissors to prevent unnecessary loss of blood. It should be handled with sterile gloves. Especial care should be taken that a knot is tied that cannot slip. At the Sloane Maternity Hospital in New York four knots are tied. First one around the cord, then one over the end encircling one artery, then one over the second artery, and finally around the whole cord a second time. The navel. — The care of the navel is most im- portant, for here we have a surgical wound in the child at its least resistant age. We have constantly more reason to believe that many illnesses of the new born are due to navel infections. The navel should be kept dry and have a dressing of sterile gauze, and especial care should be taken that it is not moistened or soiled by wet diapers or fecal material. The eyes. — The eyes should be carefully cleansed with saturated boracic acid solution, and two or three drops of 1 per cent, nitrate of silver solution CAEE OF INFANT DURING FIRST DAY 65 or 20 per cent, argyrol solution should be instilled in each eye. This nitrate of silver, although irritating, does not cause inflammation and does prevent the subsequent appearance of ophthalmia. Ophthalmia. — Ophthalmia is usually due to a gono- coccus infection of the eyes during birth, and the pos- sibility of such an infection can rarely be absolutely excluded. Ophthalmia is the cause of a great deal of blindness among children, especially those deliv- ered by ignorant midwives, and should rarely occur in the practice of a properly instructed person. The use of the nitrate of silver or argyrol is a wise precaution, and should be used as a routine practice. Examination. — A careful examination should now be made of the child. The shape of the head is often distorted at birth, and the bones crowded together. The size of the f ontanelles may be noted ; the mouth should be examined for hare-lip or cleft palate, and any evidence of so-called branchiogenic clefts about the ears and neck should be recorded. Note the size and shape of the abdomen and thorax. Examine the genitals, and in the male retract some- what the foreskin to determine the presence of a sufficient opening for the discharge of urine, and if it is insufficient, one may stretch it by retraction. Examine the anus for a patent rectum. Note whether the palms of the hands and the soles of the feet have a normal colour. Listen to the heart ac- tion, and respiration, and, finally, weigh the baby and take the measurement of its length, circumfer- ence of head, thorax, and abdomen. Then make a 66 ELEMENTS OF PEDIATRICS record of what has been noted. All this need take but a few moments, and may furnish data of the greatest importance in the future care of the child. Serious results of the neglect of such an exam- ination are constantly appearing. An instance oc- curred in the grandchild of a prominent physician, the mother having been attended in confinement by another physician, where after some time the family were disturbed because the child was pale, was short of breath and failed to gain in weight. An examination was first made when the child was two and one-half months old. The child was cyan- otic, had respirations of seventy-two a minute and a loud, harsh murmur, accompanying a congenital heart defect, was heard all over the whole of the thorax in front and behind. This child's condition was much improved by a modification of its daily regime, made advisable by this discovery. After the establishment, if necessary, of res- piration, the cutting of the cord, and the physical examination and recording of the same, the baby should be allowed to rest for six hours. It should then be washed with warm water, care being taken to avoid contaminating the navel. Dressing. — The dressing of babies is, in all coun- tries absurd. In some countries they are simply wound round and round with a binder, which re- stricts all movements. With us, too many garments are used, and they are difficult to put on and off. The ideal clothing for a baby should be simple, warm and loose, allowing ample, free movement for res- CAEE OF INFANT DURING FIRST DAY 67 piration, and for the movement of the arms and legs. Navel dressing. — To the cut surface of the navel a sterile dressing for the cord is applied. A slit is cut in a piece of linen six inches square, and through this the cord is drawn, and the linen is folded over from above down, from below up and from each side inward. This dressing should be put on with sterile rubber gloves and the dressing should not be touched again for five days. Binder. — A binder of soft flannel is then applied around the abdomen. This is useful during the first days in keeping the dressing of the navel in place and protecting it from contamination. It is harmless, so long as it is not applied too tightly. The respiration of the new-born is diaphragmatic, and the diaphragm can with difficulty descend if the abdomen is tightly bound. The binder should be only so tight as may be necessary, in order that it may remain in place, and should be discarded when the navel has healed. When this is removed, it is often replaced by a gar- ment which is really a second undershirt. Diaper. — The diaper is next applied. It is an ar- ticle that should be superseded by something sim- pler, and less bulky, for, in its worst form, as when made of canton flannel, it presses the femora out- ward, and makes a large mass between the legs of the baby, which may have a tendency to bend the bones, while at the same time, it prevents free motion of the thighs. The best diapers are probably those made of stockinet, which is soft, not very bulky and quite absorbent. Absorbent gauze, or the so-called 68 ELEMENTS OF PEDIATEICS butter cloth of the dry goods stores, may also be used for this purpose, a roll being kept in the nursery and each piece being burned as soon as soiled. The use of a rubber covering over the diaper is very objec- tionable, as it shuts out air and when the diaper is wet really poultices the child with its urine. It should never be used except for emergencies, when dry diapers may not be available. Shirt. — A woollen shirt is then put on. It has long sleeves, and is buttoned or sewed around the neck behind. Petticoat. — Over this is worn a petticoat, which is made of flannel with long sleeves, low in the neck and very long. Dress. — While over all is a dress, also very long. It is evident that common sense indicates a simpli- fication of this costume to a navel dressing, until the navel is healed, a binder for a few days to hold the navel dressing in place, an improved diaper, and a long loose dress. (Figure 23.) This is the ordi- nary night costume. The enforcement of such a cos- tume during the day is, however, a difficult matter. Parents should be warned not to keep their babies too warmly clothed. Babies that give much trouble by throwing off the bed clothes, do so simply because they are kept too warm. This over-covering is the cause of considerable danger to babies, since they perspire when first put to bed, and then, after their skin and night clothes have become damp, free them- selves of all covering, and lie with nothing over them but their wet night clothes. Wet clothing conducts Binder i .. J or this IU1 Diaper Socks Shoes Undershirt Flannel skirt Dress Clothing all Babies Wear. Diaper Dress Clothing Babies Should Wear. FIGURE 23. 69 70 ELEMENTS OF PEDIATRICS heat and cold. It is only when dry that clothing insulates and keeps one warm. Considerable care must be taken and each baby individually studied, to ascertain just how much clothing will keep the child comfortable, without causing perspiration. Temperature of room. — As soon as the new-born baby is dressed it should be well covered with a blan- ket, and kept in only a moderate light, and in a tem- perature of about eighty degrees Fahrenheit. It must be borne in mind that in intra-uterine life the baby has had quiet at a temperature of ninety-nine degrees Fahrenheit and a chance for fairly free movement of its arms and legs. Sleep. — The baby, during this first day, should sleep most of the time. Fondling or disturbing a new-born baby should be absolutely interdicted. Feeding. — Feeding during the first twenty-four hours is, with many babies, a matter which gives lit- tle trouble. If the baby sleeps almost continually, as it should, it may be put to the breast at the end of twelve hours, and at intervals of four hours during the day thereafter. Before it is pat to the breast, the nipple should be carefully and thoroughly cleansed with a saturated solution of boracic acid. The secretion of the mother's breast during the first days is not ordinary breast milk, but a modifica- tion of it, called colostrum. Breast milk contains fat, 3 to 4 per cent. ; sugar, 6 to 7 per cent. ; protein, 1 to 2 per cent. ; while colos- trum contains, according to an average of many analyses about 3 per cent, fat, 4 per cent* sugar and CAEE OF INFANT DUKING FIRST DAY 71 7 per cent, protein. (Figure 24.) The salts in colostrum are about three times more abundant than in ordinary breast milk, amounting to .7 per cent. FIGURE 24. ANALYSIS OF HUMAN MILK AND COLOSTRUM Low average High average Colostrum Fat 3. 4. 3. Sugar 6. 7. 4. Proteid 1. 2. 7. Salts 18 .25 .7 Water 89.82 86.75 85.3 100.00 100.00 100.00 Other analyses have shown as much as 4 per cent. fat and only 3 or 4 per cent, protein. While these analyses vary in the amounts, they agree as to the fact that colostrum contains less fat and sugar and more protein than ordinary breast milk. On microscopic examination, we find the so-called colostrum corpuscles, which are large cells, sup- posed to be epithelial cells that have undergone fatty degeneration. Colostrum, both human and of cows, coagulates on boiling. A purgative action has been attributed to this colostrum, which is thought to aid in expelling meconium from the intestines. The intestine of the infant at birth, as has been noted, is sterile, and the infant is very susceptible, so that we must guard, as far as possible, from dan- gerous infections. If the child is restless, and cries continually, and gets no comfort from the breast, or cannot be put to the breast, it may seem necessary to give it some 72 ELEMENTS OF PEDIATBICS food. If left to the mother and the nurse it is very likely to get some tea or sugar water, which may so f^. derange the digestive organs that it will require considerable time and patience to restore it to normal condition. If then, the baby needs some food beside what it can obtain at the breast, it should be given advisedly and with every precaution. Sterilised water may be given warm with a sterilised medicine dropper, or Breck feeding tube (Figure 25) and, if this is not taken well, a 4 per cent, solution of sugar of milk, sterilised, may be given in the same way. The 4 per cent, sugar so- lution contains some nourishment, is liked by the baby, and does not contain any in- gredient that colostrum does not contain. It should, however, be given cautiously, and not more than a teaspoonful every hour or two. The baby requires little figure 25. f°°d during the first twenty-four hours, Breck and usually nothing but what it can obtain Feeding f r0 m the mother's breast. Efforts to Tube avoid the loss of weight that normally oc- curs during the first two or three days before the breast milk comes in by giving artificial food have not demonstrated any advantage for that method. It should be carefully noted whether urine and feces are passed, and all diapers containing fecal matter should be saved for the inspection of the physician. CHAPTER VI CAKE OF THE INFANT DURING THE SECOND DAY The second day, also, of an infant's life presents certain problems which should be considered sepa- rately before going on to the discussion of the hygiene of infancy. Urination — Defecation. — It should especially be noted whether the infant has passed urine or feces. If there is a history of anuria, water should be freely administered by the mouth, and, if there is still no result, the meatus through the fore- skin being patent, a warm saline enema may be given, in the rectum, by means of a small sterile catheter, in order to stimulate the kidneys to ac- tion. It should, however, be remembered that the normal excretion of urine during the first twenty- four hours of life is only one ounce and all unnecessary interference with the child should be avoided. An infant size glycerine suppository may be used, if necessary, to stimulate the expulsion of meconium. The eyes. — The eyes should be carefully examined, as well as on each succeeding day during the first week, to ascertain whether there is any conjunc- tivitis, at the very beginning of which active treat- ment must always be used. The eyes should be 73 74 ELEMENTS OF PEDIATRICS washed with a saturated solution of boracic acid suf- ficiently frequently to keep them clean, while if there is any secretion a smear should be made and stained, to determine the infecting germ and a few drops of a 25 per cent, solution of argyrol or a 1 per cent, solu- tion of nitrate of silver should be applied. Feeding. — On the second day, it is usually possible for the baby to obtain some colostrum, although the breasts do not take on full activity before the third day. It is necessary at this time to decide whether the mother's breasts shall be used for nursing, or some other food resorted to. The indications for using or discarding the mother's milk we will take up later, so it will suffice to say, that, unless there is a positive danger to either the child or the mother from doing so, the child should be put to the breast every four hours during the second day, because there is no other food so well adapted to or so easily digested by the infant at this time. CHAPTER VII NURSEKY HYGIENE Before considering the daily care of an infant, the essential requirements for a satisfactory nursery will be briefly reviewed. The nursery. — In order to attain good results with young children it is desirable that the nursery should be a large, well ventilated room, with ample windows and light, and a southern exposure. Infants, if born in winter, are in the nursery most. of the day, and all night. The nursery should, if possible, have three thou- sand cubic feet of air space. That is, dimensions of not less than 15 feet by 20 feet by 10 feet. If one has to accept less space, care should be taken that the facilities for ventilation are particularly good. Good ventilation is, of course, essential, even with three thousand cubic feet of air space. The nursery should always contain moving, not stagnant air. Adjoining the nursery should be a second room with space for all the apparatus which pertains to a modern nursery outfit. The nursery should be free from heavy hangings. The walls should be painted, rather than papered, and the floor should be hardwood, covered with small rugs, rather than a carpet. In short, everything 75 76 ELEMENTS OF PEDIATRICS should be done to keep it clean, sunny and well ven- tilated. Ventilation. — Various means for allowing the en- trance of air from out of doors, without the produc- tion of a distinct draught, have been recommended and put into use. Of all means of ventilation the open fireplace probably furnishes one of the best, thus carrying a constant current of air from the room. Such open fireplace must, however, be pro- tected by a screen for the safety of the baby. Care should be taken that the air that enters the room comes from out of doors and not from another part of the house. Of the devices that may be used for securing out of door air without undue wind or dust, one or two may be mentioned. One method of ventilation in cold weather without draught and without apparatus is procured by lowering the upper sash of the win- dow one-half inch, and raising the lower sash an equal amount, thus allowing a slight inflow of air be- tween the two sashes, this air being driven in an up- ward direction. Or a piece of wood made in length equal to the width of the window and some three inches in height, may be placed on the window sill beneath the window after it has been raised, so that, when the window is placed against this contrivance but little air will enter the room from beneath the lower sash, while a considerable amount will pass in between the upper and lower sashes, thus being pro- jected in an upward direction, and preventing any draught in the lower part of the room. NURSERY HYGIENE 77 Another simple means of obtaining air without draught, and at the same time filtering the dust from the out of door air, is the use of a double pair of window sashes, the inner pair being the ordinary window sashes containing glass, the outer pair being covered with cheese cloth. With this arrangement, it is possible, even in winter, to have the glass win- dows wide open, the air passing through the cheese cloth so slowly that, while the air of the room is fresh, no draught is perceptible. The objections to this latter method are the disfigurement of the house as seen from the outside and the exclusion to some extent of sunlight. It is, however, by far the most satisfactory method of ventilating a room. Other patented devices for introduction into win- dow frames, some of which also filter the air through wire gauze, are available. In mentioning these methods of ventilation, the elimination of draughts has been noted although there is no evidence that draughts ever hurt young children ; excepting such draughts as produce intense chilling of the body, draughts probably hurt no one excepting the people who are afraid of them, and some people develop a coryza immediately upon be- ing subjected to a draught. Healthy children thrive in moving air, and children in a severe condition of marasmus may sometimes be saved by placing them in an open window in winter, well covered and with a hot water bottle at their feet. Light. — The nursery should be, for the most part, dark from sun-set to sun-rise, and the baby asleep. 78 ELEMENTS OF PEDIATEICS When artificial light is necessary, it should be, where possible, a well-shaded electric light. Candles, lamps and gas, are objectionable because they con- sume oxygen. Very young babies should be kept from staring in the light, as they often will do if not shaded, but should not during the day be kept in a dark corner of the room. The crib should be placed near a window. The shades of the nursery should be wide open during the day and no heavy hangings should be allowed in the nursery windows. Arrangement of room. — The nursery should have ample floor space, as has been stated, and as little furniture as is practicable. This furniture should be strong, simple, easy to keep clean, and should be kept clean. The crib should be four feet long, with sides that cannot easily let down, the giving away of the side of the crib being a not infrequent cause of a bad fall for children after they grow older and begin to stand. The infant should always sleep in a bed by itself, in order that it may have good air, and free- dom of movement, and to avoid the possibility of being over-lain and thus suffocated, the cause of oc- casional deaths in infants. In older children, a sep- arate bed should be equally insisted upon on moral grounds. Canopies hanging over the head of the crib are to be looked on with disfavour, as interfering with the free circulation of air for the child and also as a reservoir for dust. A still more objectionable protection to the crib, which is at present quite popu- lar, is a quilted hanging enclosing the four sides of the crib, placed there ostensibly to prevent the child NUESEEY HYGIENE 79 from hurting itself. It really puts the child at the bottom of a padded well and interferes with the free circulation of air about the child. Two chairs, a table and a bureau for the baby's clothes, should about complete the furniture of this room, which should be used entirely for the baby, the apparel for the nurse being kept in the adjoining room. The nursery table, for the modification of milk, should be in another room and not in a bath room, as one often sees it. It should have a glass or enamel top, and room for the bottles, a pitcher, a glass graduate, a funnel, the lime water, sugar and other articles used in preparing the feedings. The walls of the nursery should be of a light colour and preferably painted. Scales. — Certain articles of importance should be supplied in every nursery. Good scales for weigh- ing the baby should always be provided. Balance scales are the best. (Figure 26.) Spring scales are very unreliable. A healthy baby is an active, mov- ing creature, whose weight it is difficult to get on any scale. Spring scales easily move up and down, so that it is almost impossible to obtain an accurate weight. The scales should have a receptacle for the baby that is about eighteen by twelve inches in size and is made fast to the scales. The ordinary scoop is hazardous. Clock. — A good clock should also be provided, as everything in the nursery should be regulated, as far as possible, by the clock. 80 ELEMENTS OF PEDIATRICS Thermometer. — A thermometer hung on the wall to register the temperature of the room is a good precaution against over-heating. For a full term baby over a month old the room can be very cool if the baby's extremities are kept warm. A bath ther- mometer is desirable for testing the temperature of FIGURE 26. Propee Scales for Weighing Babies. the bath and the water in which the bottle is warmed. The temperature of the nursery during the first days of life should be between seventy and eighty degrees Fahrenheit. At the end of the first week a tempera- ture of seventy degrees is sufficient and at the end of the first month a temperature of sixty to seventy degrees may be maintained. There is no objection NUKSEBY HYGIENE 81 after the cliild is more than one month old to having the room temperature reduced considerably with ample ventilation, for additional bed covers will be sufficient to keep the baby comfortably warm. Quiet. — The nursery should also be kept as quiet as possible, and should be so situated that such quiet may be secured. The exceedingly nervous tempera- ment of all infants is not usually appreciated, and the disastrous effect of noise on babies is well illus- trated in all the larger hospitals for children. Thus, the nursery should be so situated that it will not only be free from disturbing street noises, but should also be sufficiently isolated from the other portions of the house, so that the child may not be disturbed by noises from that source. The nursery should never be a sitting-room or a place of social meeting for the family. Very young babies may go into a condition of acute neurasthenia, becoming nervous and sleepless from too much disturbance and too much company. A demonstration of the advantage of quiet in the care of sick babies was apparently made at a hospital where a large ward with forty- five beds and many crying babies had a mortality of 1.25 per cent, while a small ward of sixteen beds with equally sick babies, but with the exclusion of crying babies, had a mortality of only 0.6 per cent. The nurse. — Our babies probably suffer no greater evil than that of incompetent nurses, who, al- though often properly instructed, neglect their babies when not watched, who prepare the food care- lessly, give it at irregular intervals, and in many 82 ELEMENTS OF PEDIATRICS ways interfere with the proper regulation of their lives. A nurse must be obedient and loyal to both the mother of the child and the physician. She should be a healthy and amiable woman. It is not sufficient that she should be simply a good machine, she must take an active and sympathetic interest in the baby. Many old experienced nurses are very valuable if they have not from their really limited experience obtained preconceived ideas which may make them unwilling to carry out the orders of the physician, feeling that they know better. Their experience, of course, although extending over many years, is with comparatively few cases, and should not conflict with the experience of a physician in active practice. Younger women are often more easily controlled, and now there are available a large number of trained nursery maids who receive a training in an institution for less than one year and who demand little more in wages than the ordinary servant. Where people are well-to-do and especially where there are several children in the family there are many advantages in having a trained nurse in charge of the nursery. She is apt to be a woman of some culture and education, if a graduate of one of our better training schools, and her supervision should be more careful and intelligent than can be given by a mother who has had no training and who has many other important calls on her time. Amusing the baby. — Babies during the first months of life should never be amused. The only attention NURSERY HYGIENE 83 they require is to be fed regularly, have their diapers changed frequently, kept warm, in a quiet place, with good air; in case they are troubled with colic, to be turned on their stomachs or put over the shoulder and patted on the back. This should be the extent of attention given to a healthy child under four or five months of age. The ordinary methods of amus- ing such babies by dangling bright objects before their eyes, by sitting them up straight, and shaking them up and down, when they should be kept in a horizontal position — all these things tend to induce in the baby a condition corresponding to neuras- thenia in older persons. It makes them nervous, easily startled, and restless sleepers. Toys. — After six months, toys for the baby to play with may be appreciated, but, during the earlier months, too much care cannot be taken to avoid ex- citing the baby. The physician should exercise supervision over the toys that are used to divert the baby. As soon as the birth of the baby is announced, play- things of all sorts are showered on the poor little passive creatures who would much rather be left to their sucking and sleeping. Beside disturbing the baby, many of these articles are positively dan- gerous. Certain things to be avoided in the playthings of infants are : First — Small articles, such as grains, peas, beans, pieces of money, which may, when put into the mouth, lodge in the air passages. 84 ELEMENTS OF PEDIATBICS Second — Breakable articles, glass, porcelain. Third — Articles with sharp corners and points. Fourth — Articles made of lead or copper. Fifth— Articles which contain the oxide of lead. Sixth — Articles painted with dangerous colouring material, as well as boxes of paints. A toy that is frequently used in the nursery be- cause it is always available is a safety pin or a string of safety pins. These are often fastened together so that they make a noise when shaken and are found to answer the purpose of amusing babies. As a re- sult, not infrequently they are swallowed by babies and in some cases are swallowed open and with the point turned back. In one child of a distinguished physician six safety pins were swallowed and a long period of unexplained fever ensued until they were passed. In Austria a law has been passed regulating the employment of colours for candy and for toys. Con- cerning toys, it forbids the use of arsenic, antimony, lead, cadmium, copper, cobalt, nickel, mercury, cin- nabar, zinc or gutta percha ; and permits other metal- lic colours, but these colours must be covered by a varnish which resists moisture. As a matter of fact, it is well to forbid the use of painted toys for babies, since all their toys get into their mouths, and the varnish which may cover the paint is soon scratched or bitten off. The preceding enumeration of regulations favour- able to a young baby, as well as those that follow, may seem to some readers as only applicable to NURSERY HYGIENE 85 wealthy people. They are, however, applicable both to wealthy people and to intelligent people of little means. I have endeavoured to call attention to the ideal which should be approached as nearly as condi- tions will allow. Intelligent women who do their own housework may carry out most of these pro- visions, but can do it only by making the baby their first duty. The result of this attention to the baby during the first year of life amply repays for the sac- rifice it involves, for following the prescribed routine and keeping the baby well involves much less wear and tear than troublesome days and sleepless nights associated with the care of a baby that is badly man- aged, spoiled or sick. The bowels. — After the first feeding, at some con- venient hour early in the morning, before prepara- tion is made for the bath, an attempt should be made to obtain a movement of the bowels. Nothing about the baby is more important for the mother to watch than the character of the baby's stools. Quality of feces. — The normal stool of the healthy baby is yellow, smooth, shiny, and soft, and of normal odour. Colour. — The colour of the normal stool of the baby if breast fed is orange yellow, while when fed on modified milk it is usually canary yellow. A nor- mal stool after exposure to air often turns a green or grey colour. It is changed by slight indigestion to a brown, and as the condition becomes worse to a bright green. A white or clay coloured stool indi- 86 ELEMENTS OF PEDIATRICS cates sometimes too much fat in the food or an in- sufficient admixture of bile. This latter condition is rarely seen in infancy, but when present is usually accompanied by vomiting and jaundice. A stool may be dark in colour, from the administration of iron or bismuth or the presence of old blood, or be stained red from the presence of fresh blood. Smoothness. — By the smoothness of the normal stool we mean its homogeneous appearance, like that of butter. When digestion is imperfect, there ap- pear small or larger white masses called curds, vary- ing in size from a pin-head to that of a French pea. These masses have usually a lighter colour than the rest of the movement, and are composed of fats, fatty acids, and soaps held together by a skeleton curd of undigested milk, and indicate that part of the food taken by the child has not undergone digestion. I believe curds usually indicate protein indigestion. The smoothness of the stool may further be inter- fered with by the presence of mucus. This mucus is usually a secretion of the walls of the intes- tine, and due to irritation and inflammation of it. The presence of mucus is often evident on inspect- ing a stool. Sometimes its presence can only be demonstrated by pressing the stool between two layers of a diaper and then drawing them apart. The strings of mucus will stretch from one surface to the other. The possibility of respiratory mucus in the stool should be borne in mind. Shininess. — The shiny character of the baby's stool is due to the fat contained in it. Babies are fed much NURSERY HYGIENE 87 more fat than is needed for their nourishment or absorption, this excess of fat being desirable in favouring free movements from the bowels, and pro- tecting the child from constipation. A hard, dry stool may indicate a need of more or less fat or more water in the food, or more food. Softness. — Any deviation from the softness of the stool should call for some modification of the diet. If the stool is too hard, as has already been said, some modification of the child's food should be made by the physician, or a laxative given, in order to ameliorate this condition. Loose stools may be as- sociated with too much food or too little or a de- fective formula or an intestinal infection. Odour of stools. — While the normal odour of the stool may be variable it may be stated that a stool should not have a sour or a cheesy or a markedly putrefactive odour. Quantity of stool, — A stool of a properly fed baby should contain a certain amount of waste. Stools that are only stains on the diaper usually indicate too little food. This is an important indication in breast fed babies who are not gaining. Frequency of movements. — In infants during the first weeks of life two or three normal stools during the day are frequently seen, but, as the child becomes older, usually but one or two occur each day. Before the morning bath an attempt should be made each day to procure a movement of the bowels of the child, in a vessel used for that purpose. Usually this is easily accomplished by a little 88 ELEMENTS OF PEDIATRICS patience and the use of the following method, and this method may be begun when the baby is only a month old. Have a low round bowl with a simple curved edge, and a box of small glycerine suppositories. Each morning before the bath have the baby held over the bowl with its thighs well flexed on its body, and have inserted just through the sphincter of the rectum a small glycerine suppository, those of somewhat the size and shape of a cigarette, termed infant size, answer very well. If this procedure does not soon procure a movement from the bowels, the suppository may be pushed all the way in and left there, and the baby still held in the same position for a few mo- ments longer. Usually the simple irritation of the suppository in the rectum is sufficient to induce ac- tion. After some days the baby will make an effort to have its bowels act as soon as an attempt is made to introduce a suppository, later the mere position of the baby on the bowl with its thighs flexed is sufficient to induce an action of the bowels. By faithfully pur- suing this method regularly, day after day, it is pos- sible in most babies to establish a regular habit very early in life. Habit in micturition. — In a similar manner a child may be taught the control of the sphincter of the bladder by placing the child on a vessel previous to such time as it is usually found wet. No attempt should be made to control nocturnal incontinence until the child is kept dry all day. The bed wetting of older children is in some cases NURSERY HYGIENE 89 a difficult habit to control. In these resistent cases sources of reflex irritation, such as adenoids, phim- osis, or adherent prepuce shutting in masses of smega, should be eliminated and treatment under- taken by the systematic use of all the various in- fluences one can bring to bear to aid the child in keeping dry. Mechanical helps can be afforded by diminishing the amount of water taken after the mid- day meal, keeping the supper rather dry, and by elevating the foot of the bed three or four inches, which relieves the pressure of accumulated urine on the neck of the bladder. The co-operation of the child must be sought and suggestion used as the child is going to bed at night, by strict injunction and by emphasis on the uncleanliness of the habit, and as an aid to co-operation a prize may be offered for good behaviour. An effective aid is often obtained by having a large calendar hung in a conspicuous place on the wall of the nursery, each page having the days of one month, and pasting on the calendar a gold star as the result of a good record and a black star when the child has wet itself. Some article the child really wants may be given for a sufficient row of gold stars. These are the really effective measures. Belladonna given at bed-time still further aids in the cure. The bath. — The most convenient arrangement for bathing babies is a bath tub made of rubber cloth, hung in a frame which stands about three feet high from the floor. This is a convenient height for the nurse, and when not in use, the tub may be folded up 90 ELEMENTS OF PEDIATRICS and put out of the way. In preparation for the bath a chair should be arranged for the nurse, with the bath tub on one side and a table containing the neces- sary toilet articles on the other. A full bath should be given every morning, after the navel is healed, unless there is some contraindication, such as a gen- eral eczema, or a bad reaction after the bath, as shown by cold extremities or cyanosis. The bath should be given at first at a temperature of one hun- dred degrees Fahrenheit. The child should be put in the bath, taken out and soaped with castile or other clean, non-irritating soap, and again rinsed in the tub, and then dried thoroughly. Very young babies should be bathed quickly in a warm room. These baths should be continued daily, with a grad- ual reduction of the temperature of the water to seventy degrees Fahrenheit when the child is one year old, if the child shows a good reaction after the use of water at this temperature. A bath that leaves a child with cold extremities is too cold or too long continued for that particular child. Care of the teeth. — While mouth washing is un- necessary and often harmful, care of the teeth from the time the first teeth appear is very important. For this purpose a small, soft tooth brush and some cleansing tooth paste or powder should be used twice a day. As children grow older and brush the teeth them- selves, care must be taken that this is done thor- oughly, for not infrequently one finds the front teeth NUBSERY HYGIENE 91 fairly brushed, with the molars entirely neglected. The importance of this is appreciated after notic- ing the condition of the teeth generally found in cases of rheumatic heart disease, where extensive decay of the teeth usually precedes the attack. Teeth that are decayed, even if they are the tem- porary teeth, should be immediately filled or pulled, for decaying teeth react on the general health of the child. Weighing. — Either before or immediately after the bath, the baby should be weighed. This should be done every second or third day in babies under three months of age, and once a week thereafter during the first year. Rest. — After the bath and dressing, the child is allowed to rest, and this rest may be taken at home, but preferably out of doors in a baby carriage. Most babies sleep better in a baby carriage out of doors than anywhere else, during the day. Some babies, after crying incessantly in the house, will imme- diately go to sleep on being taken out in their car- riages. Babies who cannot be taken out should be placed before an open window. They should never be allowed to fall asleep in the nurse's arms or rocked in cradles, or on rocking chairs, as both these methods are no more efficient than other methods and are apt to become a nuisance, because the children will soon demand rocking before going to sleep. All children require a great deal of sleep. Babies should have all the sleep they will take and children, even as they grow older, and until they are ten years old, are 92 ELEMENTS OF PEDIATRICS benefited by at least one interval of sleep during the day. Fresh air. — Babies born in winter may be allowed out of doors on the first mild day after they are a month old, while those born in summer may be out when only a week old, if the weather is favourable, that is, with only a moderate wind and no dust. Damp days will not hurt them. On very windy days and dusty days they should never be allowed out. When it is not practicable to take a baby out of doors a modification of the same fresh air may be obtained by wrapping the baby up well, closing the doors of the room, and opening the windows. As soon as the baby is allowed out, it should be out twice on every favourable day for several hours each time. Even in fairly cold weather, babies may be kept out with- out injury, if well wrapped. It is often possible in cities to use the roof of an extension or the roof of the house for keeping babies and children in the fresh air. The roof of an exten- sion, if it happens to be on the same floor with the nursery is most convenient. It should have a suffi- ciently high railing around it and it must be fre- quently cleaned in order to remove dust that rapidly accumulates. Children may be conveniently put on such a roof to play while the nursery maid attends to the preparation of the food and to the other work that is necessary to be done before she is able to go out of doors herself. Where the roof of the house is used, it should be enclosed, if possible, on the north side. This protects the roof from the cold NURSERY HYGIENE 93 north winds and provides a room for play during rainy weather, as well as a protection for the toys that are nsed on the roof. For older children, in stead of a railing around the roof a complete cage is of advantage. This allows the children to play ball or foot-ball without having the ball drop into the street below. It is sometimes desirable as well that the openings of the chimney and vent pipe outlet from the sewer line be raised. Change of air from one part of the country to another has the same tonic effect on babies that it has on adults, and in summer, babies who will not do well in cities often improve remarkably on being taken to some healthful country resort. Exercise. — Exercise is as important an element in contributing to the health of the infant or young child as it is in the adult, and this should be remem- bered from the very beginning of an infant's life. Although during the first weeks of life the baby should sleep twenty hours out of the twenty-four, when awake it should have ample opportunity to move freely its legs and arms, and, therefore, all clothing and methods of carrying the baby which in- terfere with the freedom of the motion of the arms and legs or with the descent of the diaphragm inter- fere at the same time with the good health of the child. Baby jumper. — When the baby is able to sit alone, usually at the seventh month, a contrivance known as the baby jumper is useful for the further de- velopment of the legs without making it necessary 94 ELEMENTS OF PEDIATRICS to carry the weight of the body. In this baby jumper the baby sits in a saddle within a wooden circle, which is supported by a large hoop on castors. This saddle is adjusted so that the baby's feet may touch the ground. The baby soon learns to propel this from one part of the room to another, the lower and larger hoop being of too great circumference to allow the baby to get close to things near the wall or to get through an ordinary door. Nursery fence. — Another contrivance particularly valuable at this time is called the nursery fence, which makes an enclosure some two feet high around a square, — the enclosed space should be as large as the room will accommodate. A clean sheet is placed on the floor within the enclosure. The baby can then be put on the sheet, with soft dolls or other harm- less playthings and left to amuse itself. Here babies learn to crawl in getting things they cannot reach and later holding on to the fence will pull them- selves up on their legs. These enclosures are, there- fore, of value in obtaining exercise for the babies as well as in teaching them to amuse themselves and to help themselves. At the eighth month, most children begin to crawl, and at the twelfth month can stand holding on to some piece of furniture, while at the fifteenth month they are usually able to stand by themselves and take a few steps. Caution must be observed that at this period they are not allowed to over-exert themselves. Walking for them, while a possibility, is hard work, a very moderate amount being sufficient to tire them. NURSERY HYGIENE 95 It is not unusual to see little children in the streets, dragged along by their mothers, half crying, and evi- dently suffering severely from fatigue. Such exer- cise not only tires the child, but is apt to cause de- formities of the feet. The exercise children over two years old need is that obtained when playing with other children, exercise with recreation and spasmodic intermittent exercise. Young children can run hard for a moment or two and such running uses their muscles, inflates their lungs and does them much good. Roller skates, ice skates, and tricycles should be allowed young children, while for older healthy children tennis is to be insisted upon, or, as a compromise, golf. Boys should be allowed baseball, football, swimming and all healthy out of door sports for several hours every day. The feet. — The feet of babies should receive con- siderable care, the arch of the foot being easily broken down, so that by too much, too severe, or too prolonged exercise, a flat foot may be early produced. The shoes should be of proper size, so that they may fit snugly, especially around the instep and the sides of the heel, without causing undue pressure or crowding of the feet. The toes should lie flat and separate. The shoes should be made in rights and lefts, so that each shoe may be fitted to the shape of the foot and should be so shaped as to support the instep. Ordinary shoes which are cut off on the inner side, thus pressing the great toe in, cause an inflammation of the metatarso-phalangeal articula- tion, which ultimately results in what is ordinarily 96 ELEMENTS OF PEDIATEICS known as a bunion. Shoes which are too large or too loose, or too tight, on the other hand, may cause corns, even in little children. Care of genitals. — In the care of the genitals it is quite as important that cleanliness be used as in other parts of the body. Such cleanliness is impos- sible in a male baby with a phimosis. The simplest means of placing the male genital organs in a condi- tion of cleanliness is by circumcision. With the re- moval of the foreskin the openings of the glands which secrete the smegma are exposed so that this smegma is readily removed. At times, however, cir- cumcision is not done so completely but that adhe- sions may take place and in circumcised children we may still find irritation from enclosed smegma. Cir- cumcision is rarely necessary, as even -the tightest foreskin may be stretched and soon retracts readily, so that retraction of the foreskin is in a large ma- jority of cases the only interference needed. After retraction, however, adhesions will occur so that in babies a breaking down of these adhesions is neces- sary two or three times a year, in older children less often. Unless the smegma is removed as excreted it will be a cause of irritation which will annoy the child and may lead to masturbation, while the decom- position of the smegma may give rise to a balanitis. In female babies, although a similar condition of adhesions around the clitoris is usually present there is less secretion of smegma and this condition is ordinarily overlooked unless the irritation is suffi- cient to cause the habit of masturbation. Masturba- NUBSEBY HYGIENE 97 tion by means of thigh rubbing is not very uncommon in female babies under one year of age, and is a habit that should be controlled as promptly as pos- sible. The cause of this habit is apparently adhe- sion of the prepuce to the clitoris and irritation of the enclosed smegma, so that where symptoms of irri- tation occur these adhesions should be promptly broken down and the clitoris made free. Inasmuch, however, as the adhesions will quickly re-form, unless a circumcision is done, all masturbating female in- fants should, I believe, be put under an anesthetic and be well circumcised by some surgeon accus- tomed to perform this operation. Even after cir- cumcision, however, it may be necessary to break down any adhesions that have formed. Protection from infection. — The prevention of dis- ease in babies is, for the most part, a matter of proper diet, good air, scientific cleanliness, and avoidance of contagion. Most sickness is due to con- tagion from other people, receiving the sputum ex- pelled from the mouth of other persons, in talking or coughing or sneezing, or to eating or drinking or in- halation of dirt with the bacteria that accompany it. Many babies are made ill by dirty water ; still more by dirty milk • some by dusty air, and many by dirt from the floors, which gets into their mouths by means of their fingers. All babies are attracted by unusual objects and all babies put everything pos- sible into their mouths. Babies rarely get sick from too little clothing or from exposure to fresh air. It is possible, during the first years, to protect 98 ELEMENTS OF PEDIATEICS babies to a considerable extent from snch uncleanli- ness, thus, at the same time, protecting them from acute diseases, and particularly from intestinal dis- eases. During the first months of life, a baby should have its head kept continually on a clean pillow case, even when taken in the mother's arms the pillow should be transferred with it. Later, as it begins to crawl, a nursery fence (page 94) may be used to prevent a child from getting into dirt. After the first year, when it is able to run about, this contamination of dirt can only be avoided by warning the child, and punishing it if it puts its fingers into its mouth. Thumb sucking. — All babies suck their thumbs as soon as they have sufficient intelligence to put them into their mouths. This habit is objectionable be- cause it introduces into the mouth any dirt or bac- teria that may be on the thumb. It deforms the mouth, it presses forward the upper incisor teeth and makes the thumb sore. It is, therefore, desir- able to stop the habit as soon as possible. This may be accomplished by cheesecloth mits stuffed with ab- sorbent cotton, but as they are very warm in summer, ventilated aluminum spheres made for the purpose, which may be attached to the wristband of the dress, are usually preferable. Kissing. — A baby is subjected to a great deal of maltreatment by affectionate, but uninformed rela- tives and friends, and probably one of the worst of these is the habit of the mother and her friends of NUBSEBY HYGIENE 99 constantly kissing the baby. It has already been shown that a baby should be kept, as far as possible, isolated from bacteria that may be harmful, and the months of all persons are full of a large variety of bacteria, and the months of healthy people have been repeatedly found to contain virulent germs of diph- theria, and other diseases. It is thus evident that kissing is always a bad habit, and that it should never be imposed on babies. If a mother or father must kiss their child, they should kiss it on the cheek and give it a very dry kiss. School. — Physicians are often consulted by intelli- gent parents concerning the age when children may be sent to school ; the work they should do there ; and the number of hours they may remain ; all most im- portant matters bearing on the health and develop- ment of the child. A well developed child may be sent to a good kin- dergarten when three years old. A child at this age has no adaptation for prolonged application, so that the teaching should be done in the form of games and exercises, giving alternately short periods of active exercise and rest. The teacher in the kindergarten should be particu- larly well qualified, both by nature and by education, for her work, so that she may enter with enjoyment into the games. The kindergarten teaches children accurate observation, teaches them how to use their hands and feet, and teaches them also how to get on with other children. The exercise provided will occasionally cure an obstinate case of constipation. 100 ELEMENTS OF PEDIATRICS Dull children. — Children who appear dull at school should receive special individual attention, and a laboratory for complete physical examination should be established in connection with all schools. Dull children, then, should be carefully examined to deter- mine the cause of their backwardness. Some of these children are found to be eye-minded, that is, they can understand and remember only what they see, and when taught by reading are equal to their school-mates. Other dull children are found on examination to be ear-minded, that is they cannot learn well by seeing but only by hearing, and these again, when taught with reference to this peculiarity, are equal to their fellows. Others appear dull because they are deaf, and their deafness may be due to the presence of wax in the ears or adenoid growths in the pharynx, on the removal of which their hear- ing is restored, and 'they are found to be as bright as their schoolmates. The early correction and proper treatment of any of these troubles is most im- portant for the proper development of the child. All children have a tendency to be what they are considered to be, so that a constant position at the foot of a class due to one of these troubles, will soon injure the child permanently. Mentally deficient children should have special classes. Defective children. — Mentally deficient children may belong to one of several types, the most com- mon being that due to cerebral hemorrhage at birth, while the Mongolian type of idiocy and the micro- cephalic and hydrocephalic types are frequently NUESEBY HYGIENE 101 seen. All of these obtain little benefit from treat- ment. On the other hand, the cretin, whose condition is due to lack of thyroid extract, may, if diagnosti- cated early, be much benefited by proper treatment. CHAPTEE VIII DAILY REGIME Regime for a baby under three months. — The daily regime of a baby depends upon its age, as well as somewhat on the individual baby itself. A baby under three months (Figure 27) will usually wake promptly at six a. m. for a bottle. If it sleeps later it may be allowed to do so, but after its bottle it should go to sleep again. It should, however, be wakened at eight-thirty a. m. and an effort made to secure a movement of the bowels by the method in- dicated on page 87 if they have not already moved. The baby should then be allowed to lie naked in a warm place for ten minutes and swing its arms and legs. It is then bathed and dressed in time to be ready for the bottle at nine o'clock. The baby should sleep from nine-thirty until twelve, at which time another bottle is given and after which it should sleep again until three o'clock. From five-thirty to six p. m. the child should be exposed without clothing in a warm room as it was in the morning. It should then be prepared for bed and after the six o'clock feeding should sleep until the last bottle is given at ten o'clock. At each time the baby is awake the diaper should be changed if it is wet. From ten- thirty p. m. to six a. m. the baby should sleep. The 102 DAILY EEGIME 103 only disturbance that the child should have at other times should be to change a wet diaper. FIGURE 27. DAILY REGIME BABY UNDER THREE MONTHS 6 :00 a. m. Bottle. 6 :00-8 :30 a. m. Sleep. 8 :30 a. m. Effort to secure movement of bowels. 8 :40 a. m. Allow to lie on back naked and exercise arms and legs. 8 :50 a. m. Bathe and dress. 9 :00 a. m. Bottle. 9:30-12 m. Sleep. 12:00 m. Bottle. 12 :30-3 p. m. Sleep. 3 :00 p. m. Bottle. 5 :30-6 p. m. Exercise. 6 :00 p. m. Bottle. 6 :30-10 :00 p. m. Sleep. 10 :00 p. m. Bottle. 10 :30-6 :00 a. m. Sleep. Regime from three to six months. — The regime from three to six months (Figure 28) is similar to that of the first three months, excepting that orange juice is administered at eight-twenty a. m. FIGURE 28. DAILY REGIME CHILD THREE TO SIX MONTHS 6 -.00 a. m. Bottle. 8 :20 a. m. Teaspoonful to a tablespoonful of orange juice. 104 ELEMENTS OF PEDIATRICS 8 :20 a. m. Movement of bowels. 8 :30 a. m. Exercise naked. 8 :50 a. m. Bathe and dress. 9:00 a.m. Bottle. 9:30-12:00 M. Sleep. 12:00 m. Bottle. 12:30-3:00 p.m. Sleep. 3 :00 p. m. Bottle. 5 :30-6 :00 p. m. Exercise naked. 6 :00 p. m. Bottle. 6 :30-10 :00 p. M. Sleep. 10 :00 p. m. Bottle. 10 :30 p. M.-6 :00 a. m. Sleep. Regime for sixth month to first year. — At the sixth month, however. (Figure 29), a considerable change is usually advisable. The baby is then put on f our- FIGURE 29. DAILY REGIME CHILD SIX MONTHS TO ONE YEAR 6 :00 A. M. Bottle. 9 :00 A. M. Orange juice, tablespoonful to juice of one orange. 9 :10 a. M. Move bowels. 9 :15-9 :45 A. M. Allow to exercise naked. 9 :45 a. m. Bathe and dress. 10 :00 a. m. Feeding. 10 :30-2 :00 p. m. Sleep. 2:00 p.m. Feeding. 5 :00-6 :00 p. m. Exercise. 6:00 p.m. Feeding. 6 :00-10 :00 p. M. Sleep. 10 :00 p. M. Bottle. 10:30 p.m. to 6 a.m. Sleep. DAILY EEGIME 105 hour feedings, the feedings thus coming at six and ten a. m. and two, six and ten p. m., and the orange juice is given at nine a. m., after which the bowels are moved. After that a period of one-half hour may be given to exercise without clothing. At this period the child will take rather less sleep and during the latter part of the afternoon it is well for it to remain awake, so that it may be ready for sleep after the six o'clock bottle. During this period the character of the food also changes somewhat and by the eighth or ninth month, rusk, soup, and cereal fed by a spoon may be added, perhaps with some vegetable which may first be added to the soup. Regime during second year. — During the second year the evening feeding may be omitted, and the FIGURE 30. DAILY REGIME SECOND YEAR 6 :30 to 7 a. m. Rise. Drink glassful of water. Bathe. Dress. 7 to 7 :30 a. M. Breakfast. 8 :00 a. m. Movement of the bowels. 8 :15 to 10 a. m. Out of door play. 10 :00 A. m. Bottle. 10 :30 to 1 :30 p. m. Sleep. 1 :30 p. m. Glassful of water. 2 :00 P. m. • Dinner. 3 to 5 :30 p. m. Out of door play. 5 :30 p. m. Glassful of water. 6 :00 p. m. Supper. 7 p. m. to 7 a. m. Sleep. 106 ELEMENTS OF PEDIATRICS orange juice transferred to the two o'clock feeding. It is also customary to give a mixed feeding when the child arises and only a bottle later in the morning. The amount of sleep the child will take during the day is less. (Figure 30.) The first meal at seven or half past in the morning would correspond to the meal previously given at ten o'clock in the morning, the baby having been bathed and dressed before breakfast. Immediately after breakfast the child should be placed on a chair for the movement of the bowels, and after this taken out of doors, or placed in a nursery fence, where it may have facilities for walking and standing. A return to the house must be made for the ten o 'clock bottle, after which the baby should sleep out of doors in its carriage, or before an open window, until the two o'clock feeding. A child of this age rarely sleeps after this feeding. It should then be taken out and when brought in the house it may be un- dressed and allowed to exercise without clothes for a half hour before supper. After supper it should immediately be put in a dark room and left to sleep. Regime after the second year. — After the second year (Figure 31) but three meals a day should be given; a breakfast in the morning after dressing; a substantial meal at twelve o'clock and a supper at five or five-thirty. The child now needs more exercise and should be allowed to run and play games that require running. The exercise should be active and intermittent, and not persisted in long enough to cause marked fatigue. DAILY EEGIME 107 These children will rarely sleep during the morning, but are usually ready for a nap after the midday meal, and this nap should, if possible, last from one to two hours. The bed-time should be immediately after a six o'clock supper. This regime is applicable to all children up to ten years of age, excepting that with each increased year FIGURE 31. DAILY REGIME AFTER THE SECOND YEAR 7:00 a.m. Rise. Drink glassful of water Cool bath and rub. Dress. 7 :30 A. M. Breakfast. 8 :00 A. m. Move bowels. 8:30 to 11:30 A. M. Out of door play. 11:30 A.M. Drink glassful of water. 12:00 Noon. Dinner. 1 to 3 P. M. Sleep. 3 to 5 :30 p. m. Out of door play. 5 :30 p. m. Glassful of water. 6 :00 P. m. Supper. 7 P. m. to 7 A. M. Sleep. of age somewhat more exercise is required and some- what less sleep. The after dinner nap should be per- sisted in up to the tenth year in all frail children, but must be dispensed with in some robust children. The exercise may be varied by the use of roller skates, ice skates, tricycles, bicycles, and tennis. An interference with this regime occurs when the child goes to school, but for little children there is only a morning session and this allows them a full 108 ELEMENTS OF PEDIATRICS afternoon in which to be out of doors. If the school is an out of door school or a proper kindergarten, giving the children plenty of exercise, it may leave a very good regime. As soon as the child returns to school for an after- noon session the after-dinner nap must be abandoned. CHAPTEK IX VACCINATION Definition. — Vaccination is the inoculation of the germs of smallpox (as yet unknown), modified by their passage through a less susceptible animal. Time for first vaccination. — Children should, as a rule, be vaccinated before the end of the first year. It has been a routine practice with many physicians to vaccinate the baby within a month after birth, and indeed, if the baby is doing absolutely well, there is no objection to this practice. Often, however, dur- ing the first three months, there is some difficulty in feeding babies, and keeping them well, so that it has seemed to me better, as a usual practice, to vaccinate babies when they are about three months old, if at that time the weather is not hot and the baby is in good health. All girl babies in good health should be vaccinated before the eighth month for reasons given below (page 111). Virus. — The virus to be used in vaccination is the bovine virus, which is the only sort that is now com- monly used, and should be one of the glycerine preparations put up in capillary tubes, the old- fashioned points of virus being often dirty and sub- ject to contamination from handling. The glycerine preparation, on the other hand, increases in activity 109 110 ELEMENTS OF PEDIATEICS during the first three months that it is stored in a cold place, while the contaminating bacteria which were present in the virus as taken from the calf, are very much lessened by the prolonged cold and the presence of considerable proportion of glycerine. This virus being sealed in capillary tubes is not con- taminated by handling, but is subject to deterioration on keeping, owing to a loss of virulence in the small- pox organism, so that a virus which when three or four months old is very active, may when seven months old be of little value for inoculation. Of the different preparations of virus, that of the New York Board of Health is usually preferred in New York, since we are familiar with the precautions that are used in preparing it, and have confidence in the experts who have control of its preparation. Site for vaccination. — The point of election for vaccination in babies and young children differs from that in adults. In adults we vaccinate on the upper part of the arm, below the insertion of the deltoid, because vaccination on the lower extremities in adults is apt to do badly unless the person is kept in a horizontal position. In babies, the circulation being more active, and the leg not being a dependent part, vaccinations on the legs do perfectly well, as a rule. We thus avoid the disfigurement of the arm and, at the same time, find the position easier to get at and to care for afterwards. In children leg vaccinations should be watched and the child put to bed if much inflammation ensues or if the inflammation travels up and the inguinal glands VACCINATION 111 become involved. The point of election for vaccin- ation in infants is over the upper end of the tibia, on its outer surface. In this position the dressing is easily retained, and the vaccination may be examined by simply lowering the stocking and perhaps pulling up the drawers. All girls should be vaccinated before the eighth month, at which age they usually begin to crawl and would break a scab over the upper end of the tibia. Girl babies over eight months of age, who are vaccinated, should be vaccinated on the lower outer portion of the thigh, and care must be taken that the vaccination is not contaminated by soiled diapers. Boys may be vaccinated on the arm below the inser- tion of the deltoid muscle. Method. — In vaccinating we are careful to cleanse the skin, usually with alcohol, which quickly evapor- ates, since the presence of other antiseptic solutions may injure the small-pox germs which we in- oculate. For scarification a needle may be used, but it is objectionable, as it too readily makes a bleeding wound and the blood may wash away the virus, thus causing a negative result. A von Pirquet scarifica- tor or a jeweller's screw-driver makes the best in- strument, for it provides an oozing surface without bleeding. (Figure 32.) The two ends of the capillary tube, containing the virus, are broken off and after sterilisation in a flame a little rubber bulb is passed over one end and by means of pressure over the hole at the end of it the 112 ELEMENTS OF PEDIATRICS virus may be driven out and dropped on the area for scarification. The jeweller's screw-driver, which has been sterilised in .the flame, is now rotated in the virus until an oozing surface is obtained. Making Scarification. Ejecting Virus from Tube. FIGUKE 32. Vaccination. Protection. — It has formerly been the practice to let the virus dry on the skin, and then pull the clothing over it and allow the case to pass from ob- servation. It has been found that many of these vaccinations, in very susceptible infants, have become contaminated through the rubbing into the wound of septic bacteria from the clothing or finger nails, thus causing considerable irritation, and in some cases VACCINATION 113 septicemia and death. It has, therefore, seemed ad- visable to treat vaccinations in the same cleanly man- ner as other surgical wounds, and also to protect them from contamination. The common surgical dressing of cotton or gauze and a bandage has proved impracticable, since it softens the scab and allows exudation of serum from the vaccination, which irri- tates the surrounding skin and quickly soils the dress- ing. On this account, ventilated protectors have been adopted, and the best, I believe, at the present time, is the little celluloid cap held down by zinc oxide plaster. This cap has the advantage of being trans- parent, so that the vaccination may be watched, and the zinc plaster that retains it is not very irritating. Before the site of vaccination becomes inflamed the celluloid cap should be removed because it interferes with the peripheral circulation and makes a taking- vaccination very much more severe than it should be. It ought, therefore, to be replaced by three or four thicknesses of gauze about two inches square, held in place by two narrow strips of zinc oxide plaster. Period at which they begin to take. — Primary vac- cinations very regularly show some evidence of tak- ing in five days, and by the sixth day there is usually a vesicle surrounded by a red areola. The inflammation continues to increase until about the twelfth day, when there is usually an elevated vesicle one-half to three-fourths of an inch in diameter surrounded by an area about two inches in diameter of redness and induration. Often small vesicles appear in the inflamed area. The thirteenth 114 ELEMENTS OF PEDIATRICS day there is usually some subsidence of the inflamma- tory reaction and by the fourteenth day the vesicle should be drying and the inflammation materially lessened. It is usually four weeks before the scab is off and t during this period no full bath should be given. If a vaccination on the leg takes severely or if there is an enlargement of the lymph nodes of the groin on that side or red streaks running up the leg on that side it is necessary to keep the child in a horizontal position and sometimes wet dressings must be applied to the groin but not to the vac- cination. In vaccinating babies the operation is rendered painless if provision is made for some unusual noise at the time the scarification is made. A tin can and an iron spoon make a good combination for this pur- pose. Revaccination. — All children who have not pre- viously been vaccinated should, if a negative result is obtained be promptly revaccinated by a more viru- lent virus, that is, a fresh virus. This can be ob- tained from the maker of the virus who will supply one that has had a shorter period of storage. After the first vaccination has taken, subsequent vaccina- tions are liable to be followed by negative results, and when they do take are much more irregular in their course. Revaccination should take place every five or seven years, or whenever there may be an epidemic of small-pox. CHAPTER X TYPHOID IMMUNISATION Protective treatment against typhoid fever is com- ing into general use. This consists in injecting into the subject a large number of dead typhoid bacilli. The efficiency of this treatment has been well demon- strated in armies. In epidemics of typhoid fever spread by milk, children are the most frequent vic- tims, while in other epidemics of the disease young adults predominate. It is, therefore, important that the protection be given in childhood if typhoid fever is prevalent. The immunity lasts only two years, so that reinoculation must take place at intervals of two years unless the subject is found to have a posi- tive Widal reaction. Intervals between injections. — The treatment con- sists of three injections at intervals of five to ten days. The first consists of five hundred million dead typhoid bacilli and the second and third of a thou- sand million. Each injection is followed by a consti- tutional and local reaction. Reaction. — The constitutional reaction is most pro- nounced during the first twelve hours after the injec- tion and consists in malaise, headache, nausea, et- cetera, while the local reaction consists in redness, tenderness and swelling for an area two or three 115 116 ELEMENTS OF PEDIATRICS inches in diameter arcund the injection and this lasts for two days. The injections are best given at about four- thirty p. m., so that the constitutional symptoms are most severe at night while the subject is asleep. Method. — For giving the treatment a set of three small flasks is obtained, each containing a sufficient number of bacilli for one injection. In the New York Board of Health set the five hundred million dose for the first injection is in a brown flask, the other two in white flasks. The stem of the flask is best broken by means of the fingers protected by a towel, to avoid being cut by the glass, and the con- tents are drawn into a sterilised hypodermic syringe. The skin of the arm near the insertion of the deltoid is painted with tincture of iodine and through this painted skin the needle is thrust. As the needle is withdrawn, firm pressure may be made for a moment over the skin under which the needle passed and then after wiping the point of entrance of the needle with sterile absorbent cotton, a small piece of cotton may be held in place by a strip of plaster. While the reaction to this treatment may be rather unpleasant, it gives one for a time a fairly complete immunity from a prolonged and severe disease. It is very desirable that this treatment become general and obligatory, so that typhoid fever may no longer be endemic. We have in this treatment a weapon which, if thoroughly used, would entirely eliminate this severe disease. CHAPTEE XI FEEDING DURING THE FIRST YEAR Importance of intelligent infant feeding. — An ac- curate knowledge of the science of infant feeding is a most important requisite in pediatric practice. In the general care of infants the provision for fresh air to breathe, for quiet and for exercise, while most valuable for their well-being, are, after all, of far less importance than the administration of an appro- priate food in proper quantity, at correct intervals, for only by proper feeding, combined with good care, can one keep children healthy. Choice of food. — The food must be carefully chosen and in any particular child changes may be necessary before a food is found that is both a good food for the child's development and at the same time sufficiently nourishing to secure for him a gain in weight. Having found such a food ; the amount to be given must be carefully determined, so that while not sufficient to cause vomiting or intestinal disturb- ance it may be ample to provide for a proper gain in weight. The food chosen will, of course, depend upon the age of the child, its weight, and its general condition of nutrition. During the first three to six months a good breast 117 118 ELEMENTS OF PEDIATRICS milk is usually far superior to any other food. After the sixth month, babies will often do better on modi- fied cow's milk. When babies are under good conditions for obser- vation and control, they may usually be weaned and successfully fed artificially between the third and sixth month, although if a baby is doing well at the breast and the mother is in good health, a longer period of nursing should be urged. When babies are born in poverty it is well to have them nursed as long as they do well on breast milk, for here it is much more difficult to feed artificially with success. These mothers should be instructed to have their babies weighed at intervals and if they are not gaining, to seek medical advice. The different methods of feeding may be tabu- lated as follows, and they will be discussed in the order in which they are placed in the table. (Figure 33.) FIGURE 33. CLASSIFICATION OF INFANT FEEDING fa. Mother's milk. 1. Natural. | b _ mt Nurge _ 2. Mixed. Breast milk with artificial food. 3. Artificial. Superiority of breast milk. — Breast milk for some infants under three months is the only satisfactory food. No other milk is, for such infants, so digest- able and nourishing, and the mother ? s milk is usually preferable to that of a wet nurse, so that, in feeding a FEEDING DURING THE FIRST YEAR 119 young infant, the milk of its mother is by far our first choice. And it should be impressed upon every mother that in giving birth to her baby she has done only half her duty and that she must nurse the baby that she has brought into the world until it is able to thrive equally well on artificial food. Reasons for the superiority of breast milk. — Breast milk is a much better food for young infants than cow's milk because it is more easily digested, more nourishing, is always obtained fresh from the breast, and is thus at a proper temperature and is little con- taminated with bacteria. Its protein is for the most part lactalbumin ; it is in solution and forms in small friable curds ; and it contains ferments that are not present in cow's milk. Almost all mothers have breasts distended with milk on the third day after labour, although the milk does not flow as freely then as it does later, but if we are to nurse the baby at the breast it is neces- sary from the third day to have care to keep the breasts active. Contra-indications to use of breast milk. — Certain objections to or difficulties in the use of breast milk may arise at this time or soon after. In very rare cases the child may be unable to suck because the presence of hair lip or a cleft palate interferes with the closure of the lips around the nipple or the shutting off of the mouth from the nasal cavity dur- ing an attempt at sucking. In such cases the only way in which the breast milk can be used is by taking it with a breast pump and feeding it with a spoon. 120 ELEMENTS OF PEDIATEICS This is a tedious task, and is not likely to stimulate good lactation, so that these children must fre- quently be fed with a substitute food. On the other hand, an abnormality of the nipple of the mother may interfere with nursing. The so- called depressed nipple, which fails to protrude suffi- ciently for the child to grasp it firmly, interferes se- riously in some cases with nursing. Fortunately this usually occurs on one side only, and in some cases the condition may be helped by the use of a breast pump to draw the nipple out, or a nipple shield, although it is rarely possible to improve con- ditions so that the baby can be satisfactorily nursed from such a nipple. Illness on the part of the mother may interfere with nursing, especially if the illness is of such a character as to render the child liable to acquire the same disease. Tuberculosis, or the acute exan- themata, or any serious communicable disease should contra-indicate breast feeding, both on account of the baby and the mother. It should, however, be well understood that lactation is a normal process after pregnancy and nursing is not contra-indicated simply because the mother is delicate and frail. Most women can nurse their babies if properly in- structed and controlled. — Having made these reser- vations we still have left a large majority of the women who give birth to babies and do not nurse them. These babies are not nursed, on account of lack of secretion in the breast, or in some cases be- cause with previous children the mother has been FEEDING DURING THE FIRST YEAR 121 unable to nurse them satisfactorily. It seems prob- able from the experience of the writer that nine- tenths of these women could nurse their babies if properly encouraged and aided by such effective measures as we have at hand. This can be done, however, only by the persistent use of appropriate measures, by careful observation, and by daily rec- ords of weight. The first two days after birth there is a normal loss of weight, amounting usually to about three-fourths of a pound, while on the third day the child should begin to hold its own and then gradually gain. If at the end of a week or ten days the child is not gain- ing, accurate information must be obtained as to the quality and quantity of breast milk secreted. Determination of quantity of breast milk. — The quantity of breast milk obtained by the child is read- ily determined by weighing the baby immediately be- fore and after nursing, no change in the clothing of the child being made in the meantime. For this pur- pose, a balance scale (Figure 26, page 80), not a spring scale, should be used, the latter being inaccur- ate, because every movement on the part of the child makes a long movement of the indicator. The dif- ference between the weight before and after nursing will be the weight of the milk taken. If the child is weighed before and after every nursing for a day or two a fairly accurate estimate may be made of the amount of milk the child takes at the breast. Quantity of milk necessary. — The quantity of breast milk necessary for the support of the child 122 ELEMENTS OF PEDIATBICS depends not only upon the age of the child but upon its size and weight; upon the frequency of feeding and the quality of the food. Considering, however, that the feedings are at such intervals as are here- after indicated, that the food is of fair quality and that the child is of the average size, it may be said that the amount of food taken at each feeding at first should be that indicated in the table on stomach ca- pacity (Figure 19, page 48). Test for quality of breast milk. — The determination of the quality of breast milk is somewhat more diffi- cult and in order that the result may be at all accu- rate the specimens for examination must be very carefully taken, so as to represent good mixed breast milk and not the first milk or the last milk from the breast, for it is true in breast milk as in cow's milk that the first milk is very poor in fat, while the last milk is comparatively rich. It has been suggested that all the milk from the breasts should be taken, but this is practically impossible with a breast pump or massage and it is quite sufficient to obtain a mix- ture of the first and last milk. But it is important that the samples should be taken from each breast, as the breasts may differ both in the amount and the quality of milk secreted. Method of obtaining specimens for examination. — The mother should be provided with four one-ounce bottles with labels. She first procures a little more than one-half ounce of milk from the left breast be- fore nursing and puts it into a bottle labeled L. 1. FEEDING DURING THE FIRST YEAR 123 This sample taken before nursing is fairly easily obtained. The child is then nursed at the left breast for not more than three or five minutes, when the breast pump or massage is again applied and an at- tempt made to procure another sample in excess of a half ounce, which is labeled L. 2. In the same way a specimen of the first milk from the right breast is obtained and marked R. 1, and another obtained after three or five minutes nursing is marked R. 2. If at the first attempt the full amount is not obtained, the remainder may be procured in the same way at the next regular time for the use of that breast. In this way the samples before and after nursing each breast can usually be obtained during one day, so that they may be sent in the afternoon to the physician for examination. Normal breast milk analyses. — An anlysis of nor- mal breast milk will show from 3 to 4 per cent, fat ; about 6 or 7 per cent, sugar, and 1 or 2 per cent, protein. (Figure 24, page 71.) The fat is in emul- sion and seen under the microscope consists of small globules suspended in a watery solution. The sugar is lactose or sugar of milk which is in solu- tion, while the protein consists mostly of lactal- bumin, which is in solution and forms a fine curd and comprises two-thirds of the protein of breast milk, one-third being caseinogen, which forms in much tougher curds and corresponds to the protein which predominates in cow's milk. In addition, breast milk contains from .18 per cent, to .25 per cent, of 124 ELEMENTS OF PEDIATRICS salts of various sort, but with these we do not usually concern ourselves in our endeavours to ascertain the quality of breast milk. The components of breast milk vary somewhat in the amount present, the sugars being fairly constant, the protein somewhat variable, while the fats vary in amount still more. There are three methods of obtaining information as to the chemical constituents of milk, varying in accuracy in the order in which they are taken up. Holt's test. — Of the methods of analysing breast milk the least reliable, but the one gen- erally used for ordinary clin- ical purposes because it is readily made, is the method devised by Dr. Holt. This method is based on the fact that since fats make milk light, while the sugar and pro- tein make it heavy, if one can learn the amount of fat pres- ent in any specimen and also learn its specific gravity he can then estimate the total solids, and variation in the other solids usually means variation in protein. Dr. Holt's apparatus (Fig- ure 34) consists of a very small lactometer and glass, H-IO s— $o Lactometer. Cream Gauge. FIGURE 34. Apparatus for Examina- tion of Breast Milk. Dr. Holt. FEEDING DURING THE FIRST YEAR 125 which will take the specific gravity of one-half ounce of milk ; and a creamometer, which can be used with the same or smaller amounts. To make the test, the milk is first put into the lactometer glass, the spe- cific gravity taken and recorded and then poured into the creamometer, where it is allowed to stand at room temperature for from eighteen to twenty-four hours, when the amount of cream present may be read off. Such a test should be made of all four spe- cimens, then by adding together the results of the examination of the first and last milk of each breast and dividing by two a mixed milk result is obtained as well as some information as to what the child re- ceives at both ends of nursing. An interpretation of the results thus obtained is aided by a table which is prepared by Dr. Holt and which is supplied with this apparatus, and from this we learn that a sample containing 7 per cent, cream and having a specific gravity of 1030 may be con- sidered normal. If the specific gravity is low and the fat high, we assume that the milk is a rich milk with a normal amount of protein. If the specific gravity is high and the fat is high we know that both protein and fats are in excess. If the specific gravity is high and the fat is low we have a milk that is poor in fat and perhaps normal in protein, whereas if we have a specific gravit}^ that is low and the fat is low, it is evident that the milk is poor in both protein and fat. Difficulty in using this apparatus sometimes exists 126 ELEMENTS OF PEDIATRICS where there is an excess of fats, as fats may not under these circumstances readily rise. Babcock test. — A method of obtaining a more ac- curate fat test is by the use of a Babcock centrifuge, and this is the method the writer uses. For this purpose an electric or hand centrifuge can be pur- chased with the necessary glassware from dairy sup- ply houses. To make the test, about 17.6 C.C. (a little more than half an ounce) of milk are drawn into a pipette graduated for this purpose and then allowed to pass into a long-necked flask made for use with this ap- paratus. Then 17.5 C.C. of sulphuric acid, having a specific gravity of 182 is poured into a glass graduate and this in turn is emptied into the flask, care being taken that the flask is held in an oblique position, so that when the acid passes into the flask the air passes out above the stream. The flask is now agitated, so that the acid and milk may become thoroughly mixed and the flask for the test is then placed in the cen- trifuge and turned at a speed indicated on it, for five minutes. This speed being intended to produce nine hundred revolutions a minute. The flask is then taken out and filled to the bottom of the neck with hot water, replaced and turned for two minutes, after which hot water is again added, so as to bring the level of the fluid well up into the graduated neck, and replaced for a final two minutes' centrifugation, after which the fat can be readily read off as a trans- parent layer in the neck of the flask. This test should be made in a warm place and the water added FEEDING DURING THE FIRST YEAR 127 should be fairly hot, in order that an accurate deter- mination can be made. Chemical analysis. — This determination of fat together with the specific gravity allows a moder- ately accurate estimation of the solids, but in cases where the greatest accuracy is desired a thorough chemical analysis may be preferred. This, however, is a matter of considerably more expense and delay than the simpler methods that have here been de- scribed. Value of analysis. — Although by such analyses we may obtain data as to the condition of the milk at the time the specimen was secured, it cannot be assumed that a similar result of analysis could be obtained a day or a week later. Nervous shock, worry or even attacks of indigestion or physical fatigue, may cause rapid changes in the chemical composition of breast milk. Inadequate nursing. — The symptoms which are produced by inadequate feeding should be clearly in the mind of every practitioner, for babies are fre- quently seen who, while breast fed, have been allowed to go from three to nine months with no appreciation on the part of the parent and physician that the feed- ings were inadequate. The most important evidence of inadequate feeding is not necessarily a loss in weight, but a failure to gain in weight. Any healthy child who, during the first year, fails to gain for several successive weeks, is not being satisfactorily fed, for a normal child will show an almost constant weekly gain throughout the first year. Restlessness 128 ELEMENTS OF PEDIATRICS is present in some of the underfed children, although many of them neither cry on being taken from the breast nor show any eagerness for more food. The intestines often show disturbances, the most common of which is constipation, while other children, in whom the starvation is more severe, have loose, green, undigested stools each day. A noticeable fea- ture of these stools is that they contain very little fecal matter. A symptom of starvation which is not uncommon during the first week of life is a rise of temperature, sometimes to 102 or 104 degrees Fahrenheit. This temperature rapidly becomes normal on the adminis- tration of sufficient food. Bacteriology of mother's milk. — Considerable mis- apprehension has arisen concerning the bacteriology of mother's milk, it having been assumed that in- fants in nursing obtain a sterile food, and this has been used as an argument for the sterilisation of milk for infant feeding. This, however, is far from true, careful investigation of breast milk by different observers having shown that not more than one- eighth or one-ninth of the women's breasts examined contained sterile milk ; that usually some one of the pyogenic bacteria were present; the staphylococcus pyogenes albus having been the most frequent, while the staphylococcus pyogenes aureus and the strepto- coccus were frequently present. Moreover, if the milk in the breasts were sterile it is evident that babies in many households where cleanliness is not emphasised, must obtain many bac- FEEDING DURING THE FIRST YEAR 129 teria from a nipple that is depressed between folds of skin, except when nsed by the baby for feeding; that in snch cases the baby really cleanses the nipple with its lips and tongue at the time of nursing. Care of nursing mother. — Before considering the treatment of any abnormality of the milk, it may be well to lay down the rules that should be followed in order that nursing may be successfully carried on. The nursing mother should have a full nutritious diet, taking three regular meals, with sometimes an extra feeding at night, but the method of over-feed- ing a nursing woman and thus giving rise often to a disordered digestion should be avoided. She should take no indigestible food, but may take an ordinary mixed diet, being careful only that it contains suffi- cient food value and plenty of fluid. She should be protected as far as possible from sources of worry, as nervous shock to the mother may materially diminish and injure the quality of the breast milk, while prolonged nervous irritation may put an end to lactation. What is true of nervous fatigue is also true of phy- sical fatigue, and it is not uncommon to see a woman, who, while confined to bed, has sufficient milk to nurse her baby, but is unable to nurse the child after getting up. Thus a nursing woman should be free from nervous worry, and physical exertion should be increased only so long as there is no deterioration in the milk. After lactation is well established, it is perfectly feasible for many women to take very con- siderable exercise, and I have known women to play 130 ELEMENTS OF PEDIATRICS tennis all summer while successfully nursing a baby. It is during the first month or two of lactation that these precautions must be particularly observed. In the beginning of lactation a diminution in the amount of milk can often be overcome by increased rest and increased fluids, particularly by drinking more milk, and by nursing both breasts at each feed- ing; while the administration of two drachms of a thick malt extract after each meal, with massage of the breasts for five or ten minutes night and morn- ing will, in most cases, give satisfactory results. It must, however, be remembered that in some cases these results are obtained very slowly and so long as some increase in the milk is being obtained all these measures should be persisted in. If it is found, on chemical analysis, that the quality of the milk is disturbed, there may be other special indications for its treatment. Although the methods already advocated for increasing the quantity are also effective in increasing the quality of the milk, and while certain methods are advocated for chang- ing the chemical composition as hereinafter indicated, success with these special methods is not to be de- pended upon. It may also be said that when breast milk shows marked deviation from normal, particu- larly when having both very low protein and fats, the chances of obtaining normal milk from the breasts are not good. It should, however, be remembered that no matter what abnormality of the milk may exist, if such as the mother is able to supply seems to agree with the FEEDING DURING THE FIRST YEAR 131 baby, every effort should be made to keep it, and in addition accessory feedings of artificial food may be given to supply the baby with sufficient nourishment to cause an increase in weight. Some modification of the character of breast milk may be occasionally accomplished by treatment of the mother. Too abundant breast milk soon adapts itself to the requirements of the baby while a deficient amount or a milk of moderately poor character may be im- proved often by the administration of a thick malt extract and massage of the breast, as well as by a strict regime for the mother. The quiet environ- ment of a country home will often aid. Milk of a low specific gravity, 1025, and with only 1 or 1% per cent, fat can rarely be raised to a satisfactory standard. A very frequent abnormality in breast milk among the better classes in New York is a condition of high protein and low fat; this is usually found in rather active, nervous women and is frequently accom- panied by severe colic on the part of the baby. This condition may often be modified as the lactation goes on, if the mother can be kept free from excitement, worry and fatigue. While it is difficult to make poor breast milk good, it is perfectly feasible on ascertaining the deficien- cies of the breast milk, to add supplementary feed- ings, and thus provide the child with both a normal formula and with breast milk. (See Mixed Feeding, p. 141.) 132 ELEMENTS OF PEDIATEICS An ounce or two of breast milk at each feeding is of advantage during the first five months, although this may seem an insignificant part of the total feed- ing. It is not uncommon to see babies who during nurs- ing continue to gain although having stools that always contain curds and mucus, and when put on artificial food their stools become normal, but they may not gain in weight. Therefore, poor stools in themselves in nursing babies are not an indication for weaning. Finally, do not abandon the breasts, as long as they give any material assistance. Methods of feeding. — Previous to feeding, the nip- ple should be well washed with a solution of boracic acid, but the mouth of the baby should not be washed. The washing of the baby's mouth often results in a contamination and in the removal of epithelium and the production of superficial ulcers. Nothing should be put in the baby's mouth that is not absolutely clean. The washing of the mouth is unnecessary and dan- gerous. The baby should be held at the breast in an ap- proximately horizontal position with the head sup- ported. If it takes the milk very fast and chokes, it should be taken occasionally from the breast for an instant and then put back. The child may remain at the breast until it is satisfied, if it is not vomiting and is gaining well. If, however, it vomits after feeding, the amount taken ought to be determined and the duration of nursing cut down until such vomiting ceases. FEEDING DURING THE FIRST YEAR 133 No normal baby should be kept at the breast after it becomes sleepy, this condition being an indication that the baby has had sufficient food. The child should then be taken from the breast and not fed again until the next regular interval. After each feeding the baby should be held in an upright position and patted on the back until the air it has swallowed during nursing has been expelled and when put to bed, if subject to colic, should be laid on the stomach or right side, for in such position the opening of the oesophagus into the stomach is above the level of the stomach contents. CHAPTER XII WEANING Weaning, the process of taking a child from breast milk and putting it entirely on an artificial food, should not be undertaken, if avoidable, before the third month and should not often be delayed after the eighth or ninth month. Within these limits, the longer it is delayed the better, even if the amount of breast milk is but a small proportion of the total amount of food taken. In the case of very poor per- sons a longer period of nursing may be deemed ad- visable on account of the difficulty in providing clean, fresh, cow's milk, and in securing its proper modifi- cation. Indications. — The indications for weaning may exist in the child or in the mother. The child. — First — A child who has nursed eight months and ceased to gain at a satisfactory rate, that is, three or four ounces a week, should usually be weaned. Second — A child who in the early months has con- tinual colic, with bad stools and failure to gain, and who is found on trial to do much better on artificial food, should be put on mixed feeding, or if the symptoms persist even with a small amount of breast milk, should be weaned. 134 WEANING 135 Third — Occasionally a child apparently doing well on breast milk will suddenly refuse the breast, but will take what is offered from the bottle. Such a demand for weaning may be imperative. The mother.— Indications on the part of the mother are more numerous. First — Occasionally the mother is rendered most uncomfortable by cracked nipples and dreads nurs- ing on account of pain accompanying it. In this case proper applications to the nipples and the use of a nipple shield should relieve the condition, which is rarely an indication for weaning. Second — Menstruation of the mother is never an indication for weaning. The baby may not do quite as well while the mother is menstruating, but will do well again during the interval between menstrua- tion. Third — Pregnancy is always an indication for prompt weaning. No mother should be required to feed a baby at the breast while nourishing a foetus. Fourth — Acute disease on the part of the mother, if of short duration, is rarely an indication for wean- ing, although a lessened activity of the breasts may require accessory feeding. The child should, how- ever, be protected as far as possible from acquiring the disease from which the mother is suffering. If it involves the upper air passages of the mother a towel should be thrown over the head of the child during nursing. Fifth — Septic complications after childbirth, if 136 ELEMENTS OF PEDIATEICS long continued, usually compel weaning by loss of activity of the breasts. Sixth — Syphilis on the part of the mother need not contra-indicate nursing, unless the baby has a nega- tive Wassermann reaction. Seventh — While a robust mother with an inactive tuberculous lesion might be allowed to nurse her baby, no mother with an active tuberculous process should nurse, both on account of the danger to the baby, for babies have very slight resistance to tuber- culous infection, and in them tuberculosis is usually an acute, rapidly spreading, general disease, and also on account of the fact that tuberculous mothers are very liable to a rapid spread of the disease in the period of relaxation following pregnancy. The method. — In beginning to wean a child first introduce one bottle of a normal feeding (p. 178) suitable usually for a somewhat younger and smaller child and watch the effect, whether it satisfies the child and whether its administration is followed by any evidence of disturbance of the stomach or intes- tines of the child. This will aid in forming a judg- ment as to whether more or less food, or a weaker or stronger formula should be used. When the bottle is suited to the needs and digestive capacity of the child, a second should be introduced and every two or three days another, until the mother is nursing the baby at both breasts every twelve hours, the remain- ing feedings being from bottles. These two nurs- ings a day should be continued until there is little filling of the breasts and the baby does not get more WEANING 137 than two or three ounces from the breasts. Then the mother may be given a very dry diet and have a tight breast binder put on for two or three days, during which period the bowels should be kept loose by saline laxatives. One nursing a day should never be used. CHAPTEB XIII WET NUESING Although the milk of a wet nurse is in some re- spects the best substitute for mother's milk, for many reasons wet nurses are being less and less used as our resources for artificial feeding increase, and the wet nurse now is ordinarily used only for those babies so seriously handicapped by prematurity, con- genital defect, or early neglect, as to be extraor- dinarily difficult to feed artificially. In private prac- tice, where the babies are carefully controlled from birth, wet nurses are rarely seen. On the contrary, in our institutions, where the babies have suffered from early neglect, bad heredity and frequently from specific infection, wet nurses are most necessary, in order to reduce the high mortality. The objections to wet nurses may be briefly sum- marised when we state that they are difficult to find, they are usually unmarried, and unmarried mothers are women of a low grade of intelligence, and are undesirable in a household; that it is impossible to demonstrate absolutely that they have no dan- gerous disease; that they usually have to be taken from their own infant, of whom they are fond, and their unsatisfied desire to see their infant after being isolated in a household will often react badly on their 138 WET NURSING 139 milk supply. Accustomed to poor food and hard work, the richer food and comparative freedom from labour is likely to result in digestive derangement which interferes with lactation. Often they cannot be trusted to care for the baby on account of igno- rance or unreliability. In selecting a wet nurse it is best always to obtain her from an obstetrical institution, where the woman has been under observation for several days, or from a milk depot registry, but, failing in this, an agent must be employed to look one up in the tenements. The wet nurse should preferably be young and one whose baby is from two to three months old, as her lactation is then well established and the prospect of her own baby doing well on artificial food is better the older it is. There is no advantage in obtaining a woman whose baby is the same age as the baby to be nursed. The wet nurse should be thoroughly examined for evidence of tuberculosis, syphilis, gonorrhea or other diseases that may be transmitted, and her milk should be examined as to both its quantity and quality. Abnormalities in the quantity and quality of the milk in an otherwise promising woman should not bear too much weight, as the nervous strain of this examination may cause temporary irregularities in the milk. If the woman's baby appears to be healthy and doing well, such irregularities need not result in the immediate rejection of the woman. It is most important that the wet nurse's baby should also be placed under proper control, for 140 ELEMENTS OF PEDIATEICS unless this is done the mother sends the baby to some baby farm, where the child is likely to obtain a gonorrheal infection and to be badly fed. These wet nurses' babies should be placed in proper insti- tutions for their care. The wet nurse's diet should be regulated so as to be simple and nourishing and in the larger establish- ments one has to take care that sufficient milk is sup- plied to the wet nurse and not too much rich food, while some work that she can do must be found for her. It is also desirable that the woman should take a bath as soon as she enters the house and that an entire set of clean clothes be furnished, her. CHAPTER XIV MIXED FEEDING So-called mixed feeding, the use of some breast milk and as much artificial food as is necessary to meet the needs of the child, is one of the most satis- factory methods of feeding. The first mixed feeding resorted to is usually an emergency bottle to allow the mother more freedom or to gradually accustom the baby to digest cow's milk. This should only be used when the supply of breast milk is well estab- lished, for frequent nursing stimulates the secretion of the breasts. Emergency bottles. — An occasional emergency bottle is most easily prepared from a dried or malted milk, and should contain an amount appropriate to the age and general condition of the child, but when the emergency bottle becomes a daily feeding, in order to give the mother more freedom, and espe- cially if weaning is contemplated, it should be pre- pared from a modification of cow's milk suitable to the child, always beginning with a low formula, which can be increased gradually. Accessory feedings. — The second kind of mixed feeding is that in which a bottle is fed with each nursing. This is used most often when the mother is nursing, but when her milk is either inadequate in 141 142 ELEMENTS OF PEDIATEICS quantity or quality, so that the child does not gain on her milk alone. Accessory feedings may be given before or after nursing. If used to replace a deficiency in the quality of breast milk or to dilute a too rich breast milk it is better to feed before nursing. Also, if the breast is well taken and the bottle often rejected, the bottle should be given before the breast milk. When, however, one is correcting a deficiency in the amount of breast milk and the bottle is taken well, it should be given last, so that there may be an oppor- tunity to weigh the baby before and after nursing, and thus ascertain just how much of the bottle may be fed. The amount of breast milk secreted usually varies at different times of day, so that ordinarily weighing, for two or three days, before and after the early morning, noon and evening feeding will indicate the amount of accessory artificial food needed at each feeding. In inadequate lactation, much more milk is usually secreted at the morning feeding than either at noon or at night. If the breast milk is too rich, thus causing diges- tive derangements in the child, one-half to one ounce of barley water may be given to the child before each nursing, sometimes with great benefit. If the quantity of the mother's milk is too much, it may be reduced by shortening the duration of nurs- ing until the amount taken by the child corresponds to the child's gastric capacity. When the breast milk contains too little fat, the MIXED FEEDING 143 feeding of a pasteurised cream before nursing will often determine a gain in a child who is keeping a stationary weight. For this purpose one-half drachm or a drachm of the top ounce of a bottle of milk may be given to the child before nursing, or enough to supply a normal fat content. On the other hand, if the protein is low, a dry milk or a malted milk dissolved in one-half ounce of barley water may be given to the child before each feeding. If the analysis shows the milk low, both in fat and protein but sufficient in amount, then the cream and dry milk dissolved in one-half ounce of barley water, while supplying the solids of the milk, will not dis- place the watery elements and the ferments they con- tain. If the breast milk is deficient in amount, a modified milk feeding after nursing is best, used with the per- centage of fat, sugar and protein in it, adjusted in accordance with the richness of the breast milk the child receives. Mixed feeding of this sort has received much less attention than it deserves and when properly carried out is infinitely better than weaning, and is often much more satisfactory than breast feeding alone, for we can, while still using breast milk, arrange the formula of the food to best suit the need of the child. In case of illness, worry or extreme fatigue on the part of the mother, a temporary diminution in the amount of breast milk will have to be corrected by similar accessory feedings until a normal activity of the breasts is restored. CHAPTER XV ARTIFICIAL FEEDING The successful artificial feeding of any large group of babies requires special skill, many re- sources, and large experience, and it is probably on account of the poor success of general practitioners in the feeding of babies, that the specialty of pedia- trics has been as fully developed as it is, and the wet nurse has become a rare resource. Many babies digest easily almost any kind of arti- ficial food on which they are fed, if they have had a fair start on breast milk, and some even at first do well on artificial food, others are difficult to make gain on artificial food, but by the use of good judg- ment in changing from one formula to another almost all babies can, in a reasonable time, be fitted to an artificial food on which they will thrive. The subject of infant feeding is, therefore, perhaps the most important of all subjects in pediatrics. Cow's milk. — In seeking a substitute for breast milk, one naturally turns to cow's milk as the avail- able commercial product, and the milk of other ani- mals has not been shown to have sufficient advantage over cow's milk to replace it. The author has re- cently had an opportunity of comparing the results of feeding goat's milk and cow's milk, and is inclined 144 AETIFICIAL FEEDING 145 to think that in some cases there is an advantage in feeding goat's milk. To use cow's milk successfully, we should first ob- tain clean cow's milk, and should then modify it to suit the digestive capacity of the baby. We should render it as free from bacteria as possible, and should feed it in proper amount and at regular in- tervals. The obtaining of clean cow's milk is not difficult in large communities where a supply of good certified milk is at hand, but where this is not the case an effort must be made to create such a supply. Certified milk. — Certified milk is milk produced under a plan devised by the late Dr. Henry L. Coit, of Newark, New Jersey, who felt the need in his pediatric practice of a milk supply subject to bac- teriological and chemical tests, and produced on a farm where he could control the conditions. This plan involved a contract between a commission of physicians, who served without compensation, and a dairyman, who was under bond to satisfy the reason- able desires of the commission for the production of a clean, safe milk, he to receive the support of the members of the commission and to have the privilege of using the word certified which carried with it an opportunity for an increased price for his milk. Dr. Coit's original commission employed, at the expense of the dairyman, a chemist, who analysed the milk at regular intervals; a bacteriologist, who also acted as a hygienist, who examined the milk for bacteria and then devised methods for improving 146 ELEMENTS OF PEDIATEICS the handling of the milk at the farm in order to reduce the contamination ; a veterinary who was re- sponsible for the good health of the cows and for the elimination of cows that were sick or a danger to the milk supply ; and a physician who was respon- sible for the health of the employes and the isolation of the sick. This scheme has been very successful and has really put the production of clean milk in the hands of the physicians who are using it in their practice, and it has also taught these physicians, as well as Boards of Health and the public, the essential details in the production of clean milk. It has also resulted in the application of scientific methods to dairy hy- giene. This plan of Dr. Coit's has been adopted all over this country, so that many of the large cities now have supplies of certified milk. The essentials for the production of clean, health- ful milk may be briefly summarised as follows : The cows should be tuberculin tested. The sta- bles must be well lighted, well ventilated, and kept absolutely clean. Cement floors are essential. The udders of the cows should be clipped as well as the left side above the udder, in order to remove the long hairs which retain dirt. The hair on the cow's tail should be kept closely cut. The cows should be groomed before milking and before they are groomed a chain should be fastened across the yoke under the neck, to prevent them from lying down after grooming and before milking. The udder, flank and tail of the cow should be washed, rinsed ARTIFICIAL FEEDING 147 and dried before milking. The milking should be done by a man in a clean white suit, and cap, with hands that have been washed clean and dried, and kept dry during milking. The milk should be re- ceived into a pail with a hood to protect it from the perpendicular droppings of dust and bacteria from the belly and udder of the cow, and should be cooled as soon after milking as possible and kept below fifty degrees F. until it is delivered to the con- sumer. All the receptacles into which the milk is drawn or placed should be sterilised and the bottles in which the milk is sold should be carefully cooled after sterilisation, so that they will have a temper- ature of fifty degrees when the milk is put into them. While ordinary milk often contains a million bacteria to a drop, milk produced in the above man- ner usually contains less than 100 bacteria per drop, sometimes none. Contamination of milk with bacteria. — The writer has demonstrated by bacteriological experiments that the great contamination of milk with bacteria is ordinarily from the perpendicular droppings of dirt loaded with bacteria from the hair covered udder and belly of the cow, which is agitated dur- ing milking. Thus by exposing three sterile petrie plates containing sterile neutral agar, two minutes each, out of doors, in the barn, and under the udder of the cow during milking, he found on the plate ex- posed outdoors only six colonies of bacteria, in the barn, something over one hundred, and under the 148 ELEMENTS OF PEDIATRICS cow over two thousand. (Figure 35.) This experi- ment he has repeated several times, with similar re- sults. To avoid this contamination, the clipping of the cow, the washing of the belly and udder, the hooded pail and quiet milking are necessary. A less extensive but more dangerous source of contamination is from the hands of the milkmen, FIGURE 35. Plates Showing Contamination to Which Milk is Exposed feom the Dust of the Barn and the Droppings from the Belly and Udder of the Cow. A. Petrie plate exposed two minutes out of doors. Contains 6 colonies. B. Petrie plate exposed two minutes in barn. Contains 111 colonies. C. Petrie plate exposed two minutes under cow being milked. Contains 1800 colonies. particularly if their hands or fingers have come in contact with bacteria which carry disease in man, such as typhoid, diphtheria, etc. It is, therefore, necessary that the milkers should wash their hands before and after each milking, so as to keep them clean, that the barns should be equipped with wash- AKTIFICIAL FEEDING 149 ing facilities, soap, water, nail brushes and towels, and that the milkers should be instructed to keep their hands dry during milking. Moreover, it is necessary that the milkers should milk quietly with- out jerking the teats, for experiments by the author have shown that milkers who jerk the teats cause about ten times as much contamination of the milk with bacteria as those that simply squeeze the teats. A third source of contamination is dirty water, which may be used for washing the utensils or for diluting the milk. A dirty towel used for drying milk utensils which had previously been used in the care of a typhoid fever patient caused one milk epi- demic of typhoid fever. Another source of con- tamination of milk is the presence of bacteria in the udcler of the cow, but this is one easily avoided by intelligent supervision, for unless the cow has evi- dent disease of the udder or leaky teats there is rarely any extensive growth of bacteria in the udder. When there is much udder contamination it is usually most marked in the lower segment, so that the greatest contamination is in the first milk, but some contamination persists even to the last of the milking. A number of milk epidemics have been caused by married employes contaminating the milk with germs of disease present in their families. On some farms, therefore, the employes are all single men, who live on the farm and are under medical supervision and who are not allowed to handle the milk unless they are well. In order to eliminate the danger of typhoid ba- 150 ELEMENTS OF PEDIATRICS cilli being conveyed to the milk from the milkers or handlers of the milk, all the employes of the farms certified by the Milk Commission of the Connty of New York are tested by means of the Widal reaction. Those men having a negative test receive a certificate to that effect. 'No man who has had typhoid fever or who has a positive Widal test is allowed to work on their certified farms ; and no man who has worked on one of their certified farms and has not a certifi- cate of a negative Widal may be employed on an- other of their certified farms. The elimination of all tuberculosis in the herds on certified farms has been a difficult matter and usually on re-testing one of these herds a certain number of reactors are found. At the present time, therefore, it is being urged on the farmers that they keep their herds free from tuberculosis by frequent tuberculin tests, and by raising their own calves, thus eliminating the danger from newly purchased cows. Cows bought for certified farms are all sub- jected to the tuberculin test, but if they have re- cently been injected, the test will be negative and only a subsequent test will reveal the tuberculous in- fection of the animal. The frequency of the re- testing of these herds should depend on the number of reactors found, the interval should not be longer than one year and usually not more frequent than once in six months. Now, having resorted to milk that has been pro- tected by all these precautions, it is still advisable to pasteurise it, for while these precautions protect ARTIFICIAL FEEDING 151 the milk to a certain extent, they cannot absolutely secure it against the conveyance of disease. Composition of cow's milk. — Cow's milk contains, as seen by the table (Figure 36), about 4 per cent. FIGURE 36. ANALYSIS OF COWS' MILK Fat 4. Sugar 4.30 Protein 4. Salts 70 Water 87. 100.00 each of fat, sugar, and protein, and .7 of 1 per cent, of salts, as against 3 to 4 per cent, fat, 6 per cent, sugar, and 1 to 2 per cent, protein, and one-fourth of 1 per cent, of salts in woman's milk. It is thus evident that we have a very much larger amount of protein in cow's milk, which will need diluting in order to allow this milk to compare at all with mother's milk. The fat of cow's milk, which is about equal to the protein in amount, is the same sort of fat as that in mother's milk, and is in emulsion. The salts in cow's milk exist in about three times the amount they do in breast milk and differ some- what in the proportion of each, as seen by Figure 37, which is made up from averages of a number of the more recent chemical analyses of the salts in human and cow's milk. It is evident that potas- 152 ELEMENTS OF PEDIATRICS sium, sodium and chlorine are present in large pro- portion in human milk, while in cow's milk the pro- portion of lime and phosphorus is greater. Iron is present in about seven times as great a quantity in human milk as in cow 's milk. The richer appearance of cow's milk, as compared with mother's milk, is due to an increase in the opacity caused by the combination of calcium phos- F1GURE 37. MINERAL MATTER IN MILK Human milk Cow's milk Potassium oxide 24. 21. Sodium oxide 16. 11. Calcium oxide 17. 21. Magnesium oxide 3.25 2.9 Ferric oxide 75 .1 Phosphorus Pentoxide 19. 28. Chlorine 20. 16. 100.00 100.00 phate with casein, calcium phosphate being much more abundant in cow's milk than in mother's milk. The sugar of cow's milk is lactose, as in human milk, but is present in about one-third less amount. The protein of cow's milk, as we have already seen, is present in larger proportion than in human milk, and is also of a character more difficult of digestion, for while in breast milk we have both lact- albumin and caseinogen, the proportion of each in cow's milk is entirely different. Lactalbumin which is in solution and forms fine curds, comprises two- ARTIFICIAL FEEDING 153 thirds of the protein of breast milk and only one- sixth the protein of cow's milk, so that the remaining five-sixths of caseinogen makes the curds of cow's milk much larger and tougher and more difficult of digestion. Fortunately, however, we are able to split the protein of cow's milk and feed whey, which is a lactalbumin milk. The composition of cow's milk, as shown in the table, represents approximately the composition of a mixed certified cow's milk. Ordinary cow's milk in New York contains little more than 3 per cent, fat, which is required by the regulations of the Health Department. Certified milk contains 4 per cent. fat. The milk of special cows or special herds will vary materially, thus Jersey cows may give 5% or 6 per cent, fat, while Holsteins may give less than 3 per cent. The sugar and protein in these milks remain much the same. It is, therefore, necessary before modifying milk for infant feeding to know not only the conditions at the dairy where the milk is produced, but the fat content of the milk as well. CHAPTER XVI THE MODIFICATION OF MILK The modification of milk for infant feeding has for years been used in different countries, because undiluted cow's milk has not been successful clini- cally in feeding infants during the first months of life. The dilutions of milk with water or barley water to one-fourth, one-third, or one-half have for many years been used. In this country a much more accurate dilution, with an attempt to simu- late mother's milk, has been in vogue for the past twenty-five years, as urged by Dr. Eotch. The same reasonable method had been urged fifty years before by Dr. Cummings, of Williamstown, Massachusetts, who wrote a book on his method, which was entirely forgotten before Dr. Botch's work. Dr. Eotch urged that, as breast milk contained two or three times as much fat as protein and cow's milk equal parts fat and protein, an infant should not be fed on diluted cow's milk, but on a diluted cream mixture, in which the proportion of fat to protein would be the same as mother's milk, and that as there was no cereal diluent in the breast milk, plain water should be used for diluting cow's milk, and sugar of milk should be added to cow's milk 154 THE MODIFICATION OF MILK 155 to raise the percentage of sugar of the milk to that which exists in mother's milk. He also stated that fractional differences in composition should be used in making changes from one formula to another, and he was instrumental in establishing laboratories for the accurate modification of milk. A great deal that Dr. Rotch taught has been so modified as to have little application at present. The most valu- able of all the essentials of his teaching was that we should, in feeding babies, think in percentages of milk and know always just what percentages we were feeding, and should bear in mind the compo- sition of breast milk. It is generally accepted, however, that the fats of mother 's milk are too high to use in the modification of cow's milk for many babies; that cereals are help- ful for digestion, and that the proportion of fat and protein in cow's milk is better adapted to some babies fed on cow's milk formulae than the propor- tion existing in mother's milk. In feeding babies artificially it is necessary to fit them with a food, and it is customary to start them on a formula rather lower than the one we think they can take. When they are doing well, we make changes about every three days until we reach a feeding on which the child will gain satisfactorily — the optimum of von Pirquet. If this is a normal feeding the baby is left on it as long as it continues to thrive. A normal feeding is a feeding of modi- fied milk with a proper relationship in the propor- tion of fat, sugar and protein. Sometimes it is 156 ELEMENTS OF PEDIATEICS necessary to put a child on feedings containing con- siderable malt or other sugar, and low fat, these* one tries to reduce gradually, so as to feed what might be termed a well-balanced ration. Failing to find a food on which a young infant will gain a wet nurse should be held in mind as a final resort. The modification of milk, as usually presented, is very complex and often requires algebraic formu- lae or tables to be carried or memorised. It is desir- able that physicians should be able to modify milk without such aid. The following method of milk modification requires only such facts as are easily memorised, and while not absolutely accurate, is suf- ficiently accurate for all practical purposes, and can be applied to the preparation of any formula. Modification is a dilution of milk or cream, to which sugar of milk is usually added. Method of modification. — Decide on the formula you need and the number of ounces in each feeding. Note the relationship of fat to protein in the for- mula, and use for dilution a milk or cream with the same proportion. Then dilute and add sugar of milk. The formula chosen may contain : 1. Equal amount of fat and protein. 2. Less fat than protein. 3. More fat than protein. In the formula we use the fat is placed first, then the sugar and finally the protein. This rotation is always adhered to. Suppose we wish to feed daily five bottles of THE MODIFICATION OF MILK 157 eight ounces or forty ounces of a modification con- taining 2 per cent, fat, 7 per cent, sugar, and 2 per cent, protein. Cow's milk may be considered to con- tain 4 per cent, fat, 4 per cent, sugar, and 4 per cent, protein, so the relationship between fats and protein is the same in cow's milk as in the formula selected. The dilution necessary to reduce these materials one-half must be an equal part, which may be shown mathematically as follows : Su- Pro- Fat gar tein 4 — 4 — 4 milk — — water 2) 4 — 4 — 4 2 — 2 — 2 Thus of our forty ounces we would use milk one- half, twenty ounces, and water twenty ounces, but if 5 per cent, of lime water is added, as is customary (page 167), that amount must be deducted from the amount of plain water used, leaving eighteen ounces of water and two ounces of lime water. The sugar in the milk after dilution has been reduced to 2 per cent., while our formula calls for 7 per cent, or an addition of 5 per cent, to the whole forty ounces, and 5 per cent, of forty ounces is two ounces. Thus our complete formula would read : Whole milk 20 ounces Water 18 ounces Lime water 2 ounces Sugar of milk 2 ounces 158 ELEMENTS OF PEDIATEICS Another example of a formula for a young baby requiring low fats might be, eight bottles of three ounces, or twenty-four ounces of a 1-6-1. Here again the fat and protein are equal and a dilution of whole milk is called for, but it is evi- dent that to get 1 per cent, only of fat and protein three parts water must be used, thus : 4 — 4 — 4 milk — — 0] — — O^water — — 0J 4) 4 — 4 — 4 1 — 1 — 1 For twenty-four ounces of this formula we would use one-fourth milk or six ounces, and three-fourths water or eighteen ounces, less one ounce of lime water, thus seventeen ounces of water and one ounce of lime water. The sugar must be raised from 1 per cent, in the dilution to the 6 per cent, called for in the formula, requiring the addition of 5 per cent, of the twenty-four ounces or 1.2 ounces or one ounce, one and one-half drachms. Thus the direc- tions would be : Milk 6 ounces "Water 17 ounces Lime water 1 ounce Sugar of milk 1 ounce, iy 2 drachms To obtain a formula with less fat than protein, a skimmed milk must be used. Milk from which grav- ity cream has been skimmed usually contains about THE MODIFICATION OF MILK 159 1 per cent, fat or a 1-4-4, while centrifuged milk contains so little fat that it may be called a 0-4^4. In a difficult case we may want to eliminate the fat and use for modification skimmed milk. If we wish to make five bottles of six ounces or thirty ounces of 0-7-2 formula we would use as in the first example one-half milk, but use skimmed instead of whole milk, that is to say, of our thirty ounces, fif- teen ounces are skim milk and fifteen ounces are water, except that one and one-half ounces of the water are replaced with lime water, leaving thirteen and one-half ounces of water, and 5 per cent, of sugar is added, or one and one-half ounces, for we find that 5 per cent, of thirty ounces is one and one- half ounces, which will give us our formula of 0-7-2, that we desired. 5 bottles of 6 ounces = 30 ounces of — 7 — 2. Skim milk — 4 — 4 = 15oz. milk 15 oz. milk fLS 1 /^ oz. water Water — — = 15 oz. water =■{ IV2 oz - h me [ water 2 )0 — 4 — 4 — 2 — 2 5 = iy 2 oz. sugar 1% oz. sugar — 7 — 2 Skim milk 15 oz. Water 13V 2 oz. Lime water IV2 oz. Sugar of milk 1% oz. If 1 per cent, protein and no fat is desired, the skim milk is diluted with three parts of water or : 160 ELEMENTS OF PEDIATEICS Skim milk — 4 — 4 CO _ — Water^ — — 1 _ Q _ Q 4)0 _ 4 _ 4 — 1 — 1 Sugar of milk 5 — 6 — 1 Therefore if we wish to make up five bottles of six ounces, or thirty ounces of a mixture containing no fat, 6 per cent, sugar and 1 per cent, protein, we would take seven and one-half ounces skim milk, and twenty-two and one-half ounces of water, except that we will replace one and one-half ounces of the water with lime water, giving us twenty-one ounces of water and one and one-half ounces of lime water. We also add 5 per cent, sugar, which gives us one and one-half ounces of sugar. Our formula then will read as follows: Skim milk 7% ounces Water 21 ounces Lime water 1% ounces Sugar of milk 1% ounces By combining these skim milks with different pro- portions of whole milk, any formula containing less fat than protein may be obtained. Thus to make up six bottles of six ounces, or thirty-six ounces of a 1-6-2 we would use one part skim milk, one part whole milk and two parts water, and would need 4 per cent, of sugar of milk to raise the amount from 2 to 6 per cent. THE MODIFICATION OF MILK 161 Whole milk 4 - - 4 - - 4 Skim milk - - 4 - - 4 Water - - - - Lime water - - - - 4)4 - - 8 - - 8 1 - - 2 - - 2 Sugar of milk, 4 % 4 9 ounces 9 ounces 17 ounces 1 ounce 36 X .04 = loz.,4dr. 1 6 — 2 Again, to obtain five bottles of eight ounces, or forty ounces of 1.50 per cent, fat, 7 per cent, sugar and 3 per cent, protein, we would use three-fourths or thirty ounces of 2 per cent, milk, made from equal parts whole milk and centrifugated skim milk, adding sugar of milk, 4 per cent, of forty ounces or 1.6 or one ounce, five drachms. Thus : Whole milk 4 — 4 — 4 Skim milk — 4 — 4 2)4 — 8 — 8 2 — 4 — 4 Whole milk, 15 ounces Skim milk, 15 ounces j2 — 4 — 4 — 4 30 ounces Water, 8 ounces Lime water, 2 ounces 1 — — 10 ounces 4) 6 —12 -12 1.5 — 3 — 3 Sugar of milk 4 1 oz., 5 dr. 1.5 An endless number of combinations may be thus arranged for whole and skim milk combinations. 162 ELEMENTS OF PEDIATEICS When more fat than protein is needed, in order to get the required proportion between the fat and pro- tein, cream or rich milk mnst be diluted. Cream. — Cream may be obtained in three different ways: •Top 2oz. 24% Fat 41" 20" " 6k" 9 " 16" " 12" " . •• 10 - 10" " 14 " S" - 20 " 6" " 24 5* " FIGURE 38. Chapin Dipper. FIGURE 39. Fat Content of the Different Layers of a Quart Bottle of Milk. 1. If a milk laboratory is available a percentage cream of the required amount may be ordered de- livered each day. 2. In cities where milk is delivered in quart bot- tles, a sufficiently accurate percentage cream may be obtained by removing with a Chapin dipper (Figure 38), a certain number of ounces from the top of a THE MODIFICATION OF MILK 163 bottle of milk which has been left standing nntil a clearly defined cream line has formed. The top two ounces will give a 24 per cent, fat; the top fonr and one-half ounces, 20 per cent, fat ; the top nine ounces, 12 per cent, fat ; top ten ounces, 10 per cent, fat ; top fourteen ounces, 8 per cent, fat; top twenty ounces, 6 per cent, fat; top twenty-four ounces 5 per cent, fat. (Figure 39.) 3. If a quart milk bottle is not available, gravity cream skimmed from a pan of milk that has stood twelve or twenty-four hours may be used. Such skimmed cream usually has about 16 per cent, fat and is thus a 16-4-4. By combining this with whole milk, 4-4-4, in different proportions, a cream of any desired percentage may be obtained. Two parts cream and one part milk will give a 12 per cent, cream : 16—4—4 16—4—4 4—4—4 3 )36 — 12 — 12 12—4—4 Equal parts milk and cream will give a 10 per cent, cream : 16 — 4 — 4 4—4 — 4 2)20 — 8 — 8 10 — 4 — 4 One part cream and two parts milk an eight per cent, cream, and one part cream and five parts milk a 6 per cent, cream. 164 ELEMENTS OF PEDIATEICS The problem of the preparation of modifications containing more fat than protein is the same as in those with equal fat and protein or less fat than protein. If we wish five bottles of seven ounces, or thirty- five ounces of 3-6-1.50 we note that it calls for twice the amount of fat as protein. Thus we would use an 8 per cent, cream, 8-4-4, which must be diluted in the proportion of two-fifths cream to three-fifths diluent to obtain approximately the formula desired. Thus: 8 — 4 — 4 8 — 4 — 4 _0 — _ — — Q _ Q 5) 16 — 8 — 8 3% - 1% - 1% We must raise the sugar from about V/2 to 6 per cent., or add 4% per cent, of thirty-five ounces, or 1.57 ounces, or about one ounce and four drachms. The formula would then read : 8 per cent, cream 14 ounces "Water 19 ounces Lime water 2 ounces Sugar of milk l 1 /^ ounces To make six bottles of four ounces, or twenty-four ounces, of a l%-6-I, we must have a cream for dilution having one and one-half times as much fat as protein, or a 6 per cent, cream, 6-4-4. It is THE MODIFICATION OF MILK 165 evident from the previous examples that this must be diluted with three parts water and the sugar raised from 1 to 6 per cent., or 5 per cent, must be added or 1.2 ounces or one ounce, one and one-half drachms. Thus the directions would be: 6 per cent, cream 6 ounces Water 17 ounces Lime water 1 ounce Sugar of milk 1 ounce, V/ 2 drachms Formulae for different ages. — A baby a few days old can usually be fed on a formula calling for a one- fourth dilution of milk or cream or top milk, with 5 per cent, sugar added. That is a 1.6.1, or a 2.6.1, or a 3.6.1. By a month or six weeks usually one- third milk or cream may be used, with 5 per cent. sugar added, that is 1%.6%.1%, or of a cream modi- fication 2%.6%.1%, etc. By three to five months equal parts milk and diluent can usually be fed. The proportion of milk is gradually increased so that by the ninth or twelfth month whole milk is fed. These directions, however, do not apply to delicate or sick babies. APPAEATUS NECESSARY FOR MODIFICATION Before preparing modifications of milk in the home the following articles should be obtained: 1. A two quart porcelain pitcher. 2. A one quart glass graduate. 3. A sugar of milk graduate which will measure weighed quantities of sugar of milk. (Figure 40.) A spoon is very inaccurate. 166 ELEMENTS OF PEDIATEICS 4. One or two dozen bottles so designed as to be readily kept clean. Those designed by the writer (Fignre 41) answers the purpose well, being con- structed with a large opening, no neck and a trun- cated cone leading to the body of the bottle, instead of a truncated sphere. FIGURE 40. Sugar of Milk Graduate. FIGURE 41. Sanitary Nurs- ing Bottle. 5. One or two dozen nipples of simple design, which can readily be turned inside out, so that they may be kept perfectly clean. 6. A small glass funnel for pouring the milk from the pitcher or graduate into the bottles. Preparation of modified milk. — The required THE MODIFICATION OF MILK 167 weight of sugar of milk should first be measured in the sugar of milk graduate, and this should be mixed with the specified amount of lime water, 1 and to this the water or other diluent should be added. No milk should be added until the sugar of milk is en- tirely dissolved, for the milk renders the mixture opaque, and it is essential that all the sugar should be in solution. On addition of the milk it should be thoroughly mixed in the pitcher, and the prescribed amount poured accurately into each bottle. A small funnel inserted in the neck of the bottle will prevent the spilling of milk in filling the bottle. The bottles should be stoppered with non-absorbent cotton. i Lime water is added to milk modifications because it is alkaline and it neutralizes the increased acidity of cow's milk. CHAPTER XVII \ THE PASTEURISATION OF MILK The question now arises whether this milk should be fed raw or should be sujected to heat, in order to pasteurise it and make it safer. About 1890 almost all milk used for infant feeding was sterilised at a boiling temperature and such sterilisation is still used in Europe. With the obtaining of a clean milk in this country and the spread of an unfounded idea that heated milk is less nutritious, much raw milk has been fed. It has, however, been demon- strated recently that a very slight amount of heat applied to milk, if continued for a long time, kills the bacteria causing typhoid fever, diphtheria, tubercu- losis and other diseases, without impairing in any way the quality of the milk. (Figure 42.) It also has the advantage of securing the sterilisation of the sugar of milk, which is not a clean product, and of the lime water and the bottle. It neither alters the ferments (Figure 43) nor the taste of the milk, nor make's any material chemical change in the milk that has been discovered, and neither does the writer be- lieve that children fed on this milk are in any way more liable to rachitis, scurvy or any other nutri- tional disease. 168 THE PASTEURISATION OF MILK 169 Those who feed raw milk assume that what we call clean, raw milk, especially certified milk, is a safe FIGURE 42. TABLE OF THE THERMAL DEATH-POINT, IN A MOIST MEDIUM, OF CERTAIN PATHOGENIC BACTERIA Species Exposures Observer Spirillum cholerse 60° C. for ten minutes Kitasato Asiaticse. 59° C. for one minute Van Geuns 54° C. for five minutes Van Geuns 52° C. for four minutes Sternberg Streptococcus pyo- 52° C. for ten minutes Sternberg genes. Bacillus typhosis. 60° C. for five minutes Buchner 60° C. for one minute Van Geuns 57° C. for five minutes Janowski 56° C. for ten minutes Sternberg 56° c. for five minutes Van Geuns Bacillus diphtheria?. 58° c. for ten minutes Welch and Abbott Staphylococcus pyo- 56° c. -58° C. for ten min- Sternberg genes aureus. utes Bacillus coli commu- 60° c. for ten minutes Weisser nis. Pneumococcus 56° c. Sternberg 60° c. for one minute Van Geuns Bacillus tuberculosis. 70° c. for one minute Grancher and Lidoux-Libard 70° c. for ten minutes Yersin 68° c. -68% C. for twenty minutes Bitter 65° c. for fifteen minutes Forster 60° c. for twenty minutes Bonhoff 60° c. for fifteen minutes Schroeder 55° c. for four to six hours Kolle and Wassermann food for babies : that pasteurisation of milk induces scurvy in babies and interferes with their nutrition by changes that it produces in the milk. 170 ELEMENTS OF PEDIATRICS Temperature of pasteurisation. — The temperature at which pasteurisation is accomplished has been FIGURE 43. THE EFFECT OF HEAT ON CERTAIN BIOLOGIC CHARACTERISTICS OF MILK AS DETERMINED BY HIPPIUS Unchanged by 1. In Woman's Milk. Salol-splitting ferment fl hr. at 140° F Amylolytic ferment "i v h t [ 149° F. Weakened bv Destroyed by 140°-149° F. 151° -fF. 158° F. short time 167° F. 2. In Woman's Milk Less Active in Cow's Milk. Fat-splitting ferment 143° F. 145° F. 147° F. 3. Active in Woman's and Cow's Milk. 'I hr. at Proteolytic ferment 1 % 140° F. hr. at 149° F. Boiling Oxidizing ferment ^1 hr. 140° 149° F. f% hr. at 1 minute at 169° F. Bactericidal action I 149° F. min. at 185° F. Boiling Alexins according to hr. at Von Behring 149° F. Boiling min. at I 185° F. Lactoserum 1 hr. at 248° F. gradually reduced with increasing knowledge of the thermal death point of the bacteria that we feared in milk. So that now we know that a temperature of THE PASTEURISATION OF MILK 171 140° Fahrenheit continued for forty minutes, is suf- ficient to destroy these bacteria, including the tuber- cle bacillus, without producing any chemical change in the milk, or altering its taste. The thermal death point of these bacteria is shown in the table. (Fig- ure 42.) Both human and cow's milk contain many fer- ments which have been studied and which may be of value in the assimilation of milk by the child. These are tabulated (Figure 43), with information as to the influence of different temperatures on their activities, and it is seen that a pasteurising temper- ature would not destroy and would scarcely weaken any of them. When the milk is pasteurised in the nursing bottle it gives one a security that can be obtained in no other way. Moreover, any danger of scurvy is readily obviated by the administration of orange juice daily after the fifth month. Pasteurisation can be accomplished without the use of an apparatus or thermometer at about 160° Fahrenheit, by watching undiluted milk being heated until a film forms. It may then be so placed as to retain its temperature for fifteen minutes and then rapidly cooled. By this method a temperature of some fifty degrees below the boiling point is used, and some of the damage done to the milk by a high temperature avoided. It is, however, unnecessary to use so high a tem- perature, but if a lower temperature is used, a longer duration must be sustained. Any desired temper- ature may be produced by heat in milk controlled by 172 ELEMENTS OF PEDIATRICS a thermometer, and, so far as possible, this may be sustained by a modification of exposure to heat. If the lowest possible efficient temperature is desired, that is, 140°, it should be sustained, if possible, for forty minutes, and facilities for rapid cooling should be furnished. The simplest method of accomplish- ing such pasteurisation is by means of an apparatus devised by the author, which requires neither watch- ing nor the use of a thermometer. The pasteuriser. — This pasteuriser consists of a pail (Figure 44), in which a measured amount of water is boiled, and a receptacle for the bottles, in which the bottles, when filled, are placed, surrounded by cold water. When the water in the pail boils vigorously, the pail is taken from the stove and placed on any non-conducting surface, such as the floor or rug, and out of a draft. The cover is re- moved and the receptacle containing the bottles quickly inserted ; the cover is replaced and the pail is allowed to stand undisturbed for an hour. An equalisation of temperature between the measured amount of boiling water and the cold milk takes place so that at the end of fifteen minutes the pas- teurising temperature is reached and persists until the end of an hour. The pail is then uncovered and set into a sink where cold water is allowed to replace the hot water and in twenty minutes the bottles are at about the temperature of the water used, and are ready to be placed in the refrigerator. The two lines on the chart (Figure 45) show the temperatures of bottles of milk in the pasteuriser. THE PASTEUEISATION OF MILK 173 The upper line indicates a bottle inserted in the pas- teuriser at a temperature of 17° C, which reaches in twenty minutes a temperature of 62° C. (147° F.), in thirty-five minutes a temperature of 64° C, which it nearly retains for sixty minutes, when the pail is uncovered and the cold water added, so that in five minutes the temperature is reduced to 28° C. 1. 2. 1. Apparatus arranged for heating the milk before the pail is covered. 2. Apparatus arranged for cooling the milk. FIGURE 44. Pasteuriser. The second line indicates the result when the milk is much colder, so that beginning with a temperature of only 10° C. we have in twenty minutes a temper- ature of 60° and a maximum temperature at thirty- five minutes of 62°, which is nearly held until sixty minutes, when a rapid decline during cooling takes place to 28° C. It is thus evident that a variation in temperature 174 ELEMENTS OF PEDIATEICS of ten degrees, when the milk is put in the pasteur- iser, is reduced to a difference of only two degrees in the resultant temperature during pasteurisation. TEMP. C. 65 60 55 50 45 40 35 30 25 20 15 10 Time in Minutes 5 10 15 20 25 30 35 40 45 50 55 60 65 70 ^ ^^ \ / / J / \ \ 1 ^\ v~ FIGURE 45. Temperatures During Pasteurisation of a Bottle of Milk at 10° C. and a Bottle of Milk at 17° C. Showing the Elimination During Pasteur- isation of an Initial Variation in Temperature of 7° to a Resultant Variation in Temperature of 2°. This is due to the fact that a measured amount of boiling water will elevate the temperature, increas- ing proportionately to the degree of cold in the milk. THE PASTEUBISATION OF MILK 175 Commercial pasteurisation. — It is possible now in many cities to buy so-called pasteurised milk, but this milk is not to be recommended for infant feed- ing, because it is not produced under as good condi- tions as certified milk, and also has a much higher bacterial count. This pasteurisation has often been done at a much higher temperature than is necessary and kept at this temperature only momentarily. In New York now milk is pasteurised at 140 to 145 de- grees Fahrenheit for twenty minutes in large vats. This milk is re-contaminated either in bottling or by the bottles into which it is put after pasteurisation. At the present time it contains on the average some thirty-five thousand bacteria per cubic centimeter, while certified milk averages less than five thousand, and that from one herd supplying New York only four hundred. CHAPTER XVIII METHODS OF ABTIFICIAL FEEDING In the artificial feeding of babies the same inter- vals of feeding (page 102) and regulations should be observed as in breast feeding. The child should take a feeding in not less than ten minutes and not more than twenty minutes. The length of time taken over the bottle is regulated by the size of the hole in the nipple and the elevation of the bottle during feeding. The nipple should be a simple one without valves and so constructed that it can be turned inside out, otherwise desirable cleanliness in the care of the nipple is impossible. The bottle should be held by the nurse during the entire time of feeding, it should never be propped up or put on a stand. As the baby empties it, the bot- tom should be raised so that no air can enter the neck of the bottle from which the baby sucks. Estimation of caloric requirements. — The applica- tion of modifications of milk to the requirements of any special infant during the first year of life must be based on the age, weight, activity, stomach ca- pacity, caloric needs, and the ability for digestion and assimilation of that particular infant. Each one of these factors must receive attention. It may be said, however, that the caloric needs of an emaciated 176 METHODS OF AETIFICIAL FEEDING 177 baby of several months of age is much more accur- ately judged by an estimate based on age than one based on weight. A rough estimate of the stomach capacity has been given in a previous section (page 49), but the adap- tation of this to any particular infant must be deter- mined after trial. The caloric needs of babies have been carefully worked out, and sufficient knowledge to determine whether any baby who is not doing well is obtaining its caloric needs, is essential to any one who under- takes to feed babies intelligently. The caloric needs of an infant at birth are consid- ered to be about fifty calories for each pound of weight, and at one year thirty-five or forty, so that an average baby at birth requires about 350 calories of food a day and at a year old about 840. One ounce of fat yields 300 calories and one ounce of carbohydrates or protein about 130 calories each. Any one knowing these facts and the formula he is feeding can in a moment ascertain the caloric value of the food. In an appended table there is worked out (Figure 46) a scheme for the average feeding of a baby dur- ing the first year. In the first column is the age; next the average weight for that age ; the caloric requirements for the weight; a formula adapted to that age and weight; the number of feedings; the amount in each feeding; the way the formula is prepared from milk ; and the caloric value of the formula. o TtH t> s - : : ^ ^# P3 \a la 16 1ft tH CO 02 xn OB t3 'd 2 Pi .2 i CD P3 l-H _cd o O Id o ft CD Ph CD P-. u P-4 CO GO CO CO ^ o M En o o CO o o CO CO rH rH o CO 3! r^^^^ II II 11 II II N ~ PS o - O CD O CO rH IXMOlO CO ■H CD o £ CM rH II II cm II II II II l-H ft *CD ■+-3 CO CD a O -4-3 1 o - tM cm CO rfl l> Q0 CO CO LO lO o ; t-j CO CO* HH & rH T— 1 T— 1 1 s O rH CO CO* co' CO* HH* <1 tff* LO lO o o o o o k3 t— t- LQ lO O LO o M Of cS CO CO ^H ID t> t> oo H SI Ci (MCOC5H rH tH tH cq c3 T5 M .... per cent, protein would be a fair feeding, while seven bottles of three ounces or twenty-one ounces would represent a moderate amount. It is evident since the fat is twice as much as the pro- tein, that an 8 per cent, cream should be used, and it is found that if three parts of this are taken and five parts of diluent that the required formula is ob- tained. The caloric value of this food is ascertained in the following manner : Our food contains twenty-one ounces of which 3 per cent, or .63 of an ounce is fat. If one ounce of fat has a caloric value of 300, .63 will have a value of 189 calories. The protein and carbohydrate hav- ing the same caloric value may be estimated together, and by adding 7 and 1% we have 8% per cent., or 1.78 of an ounce of carbohydrate and protein in our for- mula. Since the value of these is 130 calories an ounce, we have a caloric value of our sugar and pro- tein of 231, or a total caloric value of 420. It is seen by the table (Figure 46) that starting a 180 ELEMENTS OF PEDIATRICS baby during the first three days on two ounces of a simple 4 per cent, sugar solution every two hours for ten feedings, at the end of the week we may run the formula up to 1 per cent, fat, 6 per cent, sugar and 1 per cent, protein, giving only 8 feedings of 2 ounces. At a month we may give 3 per cent, fat, 7 per cent, sugar and 1% per cent, protein, with 7 feedings of 3 ounces; at three months, we may feed 3% per cent, fat, 6 per cent, sugar and 3 per cent, protein, with six feedings of four ounces. This formula then is gradually advanced and at the end of the year all diluents are abandoned and the child gets &ve bottles of nine ounces of whole milk. This table simply indicates what certain healthy children might take, but it is only a rough indication, each child being given what it needs and what it can digest. The fat in many of these formulae is too high for some children, so that if a child shows any indication of fat indigestion through gastro-intesti- nal disturbance, with white stools, the fat should be reduced. In some children high sugar causes vomit- ing and acid stools, and in these cases the sugar should be reduced. Other children with poor pro- tein digestion and putrid stools should have a reduc- tion in the amount of protein in the food, while any child who vomits must usually have the total amount of food in each bottle reduced or a change made in the food. Persistent vomiting in babies may be due to too much food or to an element in the food which is unsuitable to that baby, or to a pyloric spasm or METHODS OF ARTIFICIAL FEEDING 181 stenosis, or to some acute disease. The first indica- tion in persistent vomiting is to reduce the amount of food and often to lengthen the interval between feedings. If this is not successful and especially if the movements are sour, all sugar may be taken from the feedings for a day, or if this does not rectify the trouble a day without fats may be tried. Should these changes give no relief, stomach retention should be investigated by means of a stomach tube. The first feeding ordered for any baby is, as has been stated, usually rather lower than it is thought the baby can take, and then it is gradually raised in accordance with the demands of the baby's appetite and the indications of the weight chart. In labo- ratory feedings the changes are usually made by advances of a quarter of 1 per cent, in those ele- ments in which it is thought advisable. The usual maximum of fat for babies under six months is 3 per cent., in sugar 7 per cent., and in protein 2 per cent. In home modification, the changes are made in a different way. Take, for instance, the last feeding which was made with six ounces of 6 per cent, cream, or the top twenty ounces of a quart bottle of milk, one could increase the fat by taking the top eighteen or sixteen ounces, thus using the same amount of a richer cream, or raise both fat and protein by using more of the top twenty ounces, six and one-half or seven or more ounces, or one could raise the pro- tein without raising the fat by taking six and one- 182 ELEMENTS OF PEDIATRICS half or seven ounces of the top twenty-two or twenty- four ounces. Orange juice. — In the foregoing we have summar- ised what we may term normal feeding of the baby, with the exception that all babies who are artificially fed should, after the first three months have, in addi- tion to their feedings, a certain amount of orange juice, for no baby who is given this in sufficient quan- tity has scurvy, while all other artificially fed babies are liable to it. In the administration of orange juice, if given early, iive to ten drops each day are sufficient, a few days afterward a coff eespoonful and later a teaspoonful or a tablespoonful or more. It is customary to give this one hour before one of the morning feedings, and this is all that should be given between feedings except water, which may be given at the same interval before any other feed- ing. Milk laboratories. — In cities that afford the facili- ties of milk laboratories for the feeding of infants they should be used, where people can afford this luxury, on account of the greater accuracy in the preparation and handling of the milk, and the fact that it takes from the nurse a certain amount of detail work which usually limits the amount of time that the baby can be kept out of doors. These laboratories will undertake to supply daily in sterilised nursing bottles any modification and amount ordered, according to the prescription writ- ten by the physician. A sample (Figure 47) of a prescription is as follows : METHODS OF ARTIFICIAL FEEDING 183 FIGURE 47. LABORATORY FEEDING PRESCRIPTION Take of Fat 3 % Lactose 7 % Protein iy 2 % Lime water 5 % Make 6 bottles of 6 ounces. Pasteurise at 140° F. for 40 minutes. For Baby Smith. John Jones, M.D. There is almost as much reason why milk labo- ratories should be used, when available, as there is why drug stores should be used for medicines. The same accuracy is desirable in milk modification. Changes are more readily made in the formula and, therefore, are more often made if indicated. The milk laboratories, while prepared to use gravity creams in these modifications, ordinarily use milk separated by a centrifuge, obtaining thus a cream with a higher percentage of fat and a skim milk with a lower percentage of fat, which is desir- able for some modifications. FEEDING OF DIFFICULT CASES We have taken up the methods for the normal feed- ing of children with a fair or good digestion, and will pass now to a consideration of our resources for feeding babies who will not thrive on the sort of feedings we have already described. Failures, how- ever, with the preceding feedings are often due to lack of facility on the part of the physician to so ad- just the amount and ingredients as to fit the require- 184 ELEMENTS OF PEDIATEICS ments of the baby. An excellent illustration of this was related concerning a young physician in one of the hospitals, who after feeding a baby on many different f ormulse, at last, in despair, resorted to con- densed milk on which the baby thrived. During a visit from his superior he showed this baby to him remarking that he had been unable to make it thrive on modified milk. He was told to work out the for- mula he was giving in condensed milk, and make it up from fresh milk, and that the baby would do as well as on condensed milk. On doing this, he had no further trouble with feeding modified milk, and was using a much better food for the baby and one from which he could more readily pass to a modification of milk that did not contain an excess of cane sugar. Cereal diluents. — The use of cereal decoctions in place of water for diluting the milk has proved a great aid to the digestion of milk in many infants. The objection has been raised against the use of these cereal decoctions in early life, that infants have no digestive capacity for starch, and although there is conflicting evidence on this point, we now believe that they have some digestive capacity for starch, and whether they have or not, we know from clinical experience that even in the first days of life, if the breast milk is not well digested, an improvement is often obtained if a little barle}^ water is given before the nursings. These cereal decoctions supply a mucilaginous material which stimulates the secre- tion of the gastric juice, and modifies materially the size of the curds which the milk forms in the infant's METHODS OF AETIFICIAL FEEDING 185 stomach. Their food value is very slight. Thus barley water of the usual strength contains only 1% per cent, starch and an insignificant amount of fat and protein. (Figure 48.) FIGURE 48. ANALYSIS OF BARLEY WATER Starch 1.63 Fat 05 Protein .' 09 Inorganic salts .03 Water 98.20 100.00 Inasmuch as many children digest the modified milk with cereal diluents better than without, the use of such diluents instead of simple water may be recommended. In preparing the cereal diluents the cereal ground into flour is to be preferred on account of the greater ease in preparing it. Whether the cereal be barley, oatmeal, cornmeal or a legume, we use ordinarily a rounded tablespoonful of the flour to a quart of water, boil in a double boiler for one hour and strain through cheesecloth, or a fine strainer. These cereal decoctions also have an important place in feeding sick children, particularly where milk is temporarily abandoned, and in that case they may be made much stronger and dextrinised by the addition of malt, which will make quite thin a very thick cereal decoction that would not otherwise pass through the nipple. So if it is necessary to keep the 186 ELEMENTS OP PEDIATRICS child many days on cereal decoctions without milk, one may dextrinise and increase the strength. The strength can be increased to such an extent that these cereal decoctions have almost the nutritive value of milk, but my experience has been that while babies often gain well on such dextrinised cereal decoctions, this gain generally does not continue for more than ten days or two weeks, and if persistently fed on this alone they are liable to lose as fast as they have gained, or faster. Legume or bean cereal has been recently recom- mended, especially because it contains more protein than other cereals. On the other hand, children do not, as a rule, like it and are often upset by it. Peptonising. — The peptonising of milk is an aid to digestion and is particularly useful when curds are seen in the stools. There has been a good deal of controversy in pediatric literature recently concern- ing the character of curds and the evidence seems to favour the fact that the curds seen during the first months contain little protein, but fat, fatty acids and soap. They seem, however, to be an evidence of poor protein digestion and efficient protein digestion often results in the disappearance of curds. Of the methods for improving protein digestion and elim- inating curds peptonising is one of the most im- portant. The effect of the trypsin and soda powders contained in the peptonising tube, if they are allowed to act in warm milk for fifteen or twenty minutes, is to predigest the protein of milk. A much more marked peptonising effect may be obtained by a METHODS OF AETIFICIAL FEEDING 187 longer duration, but the milk then becomes bitter and distasteful and can ordinarily only be used by forced feeding with the stomach tube. There is possibly another reason why children often gain better when the milk is peptonised, besides the predigestion of the milk, for the administration of pancreatic extract in some children, and for that matter in some adults, will increase the weight by providing for a more thorough absorption of food. In such cases there is probably a lack of activity in the pancreatic gland of the individual. Whey. — A still more effective means of improving protein digestion is by the use of whey instead of whole milk protein. As already stated, the protein of breast milk consist of two-thirds la ct albumin, which forms in fine curds and only one-third casein- ogen, which forms in tough curds. In cow's milk, on the contrary, the caseinogen is five-sixths of the protein and the lactalbumin only one-sixth, thus Ave have large hard curds of cow's milk, which do not occur in mother's milk. Fortunately we can separ- ate the caseinogen, which is in suspension, from the lactalbumin, which is in solution, by the use of rennet, which added to warm milk causes the curdling in a large mass of the caseinogen, leaving the lactalbumin a thin fluid that is easily strained off. The best whey is made from skim milk and to be at all pure the whey should be extracted from the milk without pressure. Slight pressure will add to the whey a considerable amount of caseinogen. Whey, when properly made from skim milk, will contain no Pat, 188 ELEMENTS OF. PEDIATRICS about 4 per cent, sugar and about .8 per cent, protein, and while we may with success feed this to sick children its caloric value is not sufficient for a constant diet. When this is added to cream, we can obtain a food nearly .8 per cent, of the protein of which is of this digestible whey and the fat and balance of the protein whatever we desire to have them. If we wish to keep the protein low we add the fat in the form of a very rich cream, but if we wish to add whole milk protein we use a cream containing less fat. The feeding of whey milk is particularly applicable to very young babies and the change from a simple modification of milk to a whey milk will often immediately cure a severe colic of a young baby or will effect a gain in weight in a child who has failed to gain or who has been losing. When, as in older children, we wish to feed two or more per cent, of protein, the proportion of whey protein in the mixture is so small that' little ad- vantage is gained by feeding a whey-cream mixture. Sometimes a child who has been on a barley water diluent will have more colic when put on a whey- cream mixture, in which case one may introduce one or two ounces of a thick barley jelly into the mixture. Unfortunately the preparation of such milk is rather complicated and not readily made at home unless there is an intelligent and expert nurse in the house- hold. Two examples follow of the way that modifications of whey milk may be worked out. In a young baby, where one wishes to feed eight METHODS OF ABTIFICIAL FEEDING 189 bottles of two ounces or sixteen ounces of a modifica- tion containing 2 per cent, fat, 6 per cent, sugar and 1 per cent, protein, if we use one part 32 per cent, cream and fifteen parts whey our required for- mula will be obtained, except that we must add 2 per cent, sugar, 2 per cent, of sixteen ounces be- ing one-third of an ounce or two drachms. Exam- ple: 8 bottles of 2 ounces =16 ounces of formula containing 2 per cent, fat, 6 per cent, sugar, and 1 per cent, protein 1 part 32 per cent, cream or 32 — 4 — 4 = 32 — 4 — 4= 1 ounce 15 parts whey or — 4 — .8= — 60 — 12 = 15 ounces 16) 32 — 64—16 2— 4— 1 2 per cent, sugar = 2 drachms. 2 2— 6— 1 If later a stronger modification is required a cream with a lower fat content would be used. If seven feedings of four ounces each or twenty- eight ounces were needed a mixture containing 2% per cent, fat, 6 per cent, sugar, and 1 V± per cent, pro- tein might be obtained in the following manner : 4 oz. 24 oz. 1 part gravity cream or the top 6 oz. of a bottle of milk 6 parts Avhey or 16—4 — 4 = 16— 4 — 4 — 4— .8= — 24 — 4.8 Sugar 2 per cent, of 28 oz.= 7) 16 — 28 — 8.8 2%— 6 — 1H = about y-2 oz. 2 2% _ 8-11/4 190 ELEMENTS OF PEDIATRICS Buttermilk. — For many years buttermilk, that is, soured skim milk, has been used with success in cer- tain institutions for babies in Europe. This buttermilk was used, in all probability, be- cause it was a refuse product from the manufacture of butter, which could be bought for little and had a good nutritive value. It was reported that children fed upon it did well. Since the recent popularity of buttermilk, associated with the enthusiastic commen- dation of Metchnikoff, it has been tried to some extent in infant feeding. In many children when the stools are very offen- sive or there is much gas expelled with the move- ment, and especially when this condition is asso- ciated with the presence of indican and phenol in the urine, buttermilk may be of great value. It is well to secure a brand of buttermilk that is not allowed to become very sour and this may be mixed at first with sweet milk, beginning with a small addition of but- termilk and increasing the proportion gradually as the child becomes accustomed to it. If the butter- milk is not well taken, a lacto-bacillary culture may be used. Better than ordinary buttermilk is prop- erly prepared lacto-bacillary milk. This is made from skim or partly skimmed milk, which is first pas- teurised and then planted with the bacillus Bulgari- cus. This may be obtained from the milk labora- tories. Finklestein milk. Eiweiss milk. Protein milk. — A modification of milk containing buttermilk which was recommended by Finklestein has recently been METHODS OF AETIFICIAL FEEDING 191 used extensively. This milk is prepared as follows : A quart of whole milk is made lukewarm and pepsin or rennet is added to coagulate it. After filtering off the whey, the curd, ordinarily known as junket, is passed several times through a fine sieve, to this a pint of water is added and then a pint of butter- milk. This Finklestein milk has the characteristic of con- taining a small amount of milk sugar, a moderate amount of fat, a considerable amount of protein, and the living lactic acid bacilli. It is, moreover, very palatable. Its formula is fat, 2% per cent.; sugar, 1% per cent.; protein, 3 per cent.; and it has a fair caloric value. It is useful in some babies who are vomiting, or having diarrhoea with offensive stools, but babies do not gain in weight while on this food, unless sugar is added, for in children who can take it, milk sugar is a most important element of the food, containing the same caloric value as protein and being more thoroughly digested, with much less labour on the part of the infant. Thus it is possible to feed many times more sugar than protein, and have apparently no sugar in the stools, while of protein a consider- able percentage is always present in the stools. The indication for Finklestein milk may be ful- filled by feeding an appropriate formula and giving in addition, several times a day, a good lacto-bacil- lary culture, or by the addition of a moderate amount of buttermilk to the formula. Maltose. — For children who are not gaining on a 192 ELEMENTS OF PEDIATRICS normal formula with a sufficient amount of sugar of milk, or children who vomit when sugar of milk is fed, or who are constipated, the use of maltose in- stead of lactose often gives most satisfactory results. This is readily accomplished by substituting for the 4 or 5 per cent, of added sugar of milk an equal amount of dextri-maltose or malted milk, which latter gives, in addition to the maltose, some protein food and an insignificant amount of fat. In many cases children who have failed to gain on other food will immediately show a marked gain as soon as this change is made. Either a dry or moist form of maltose may be used. Mead's dextri-maltose is a convenient form of the dry dextri-maltose and con- tains 51 per cent, maltose and 47 per cent, diatase. Certain children, who do not gain well or are, con- stipated on a dry dextri-maltose preparation ap- parently do better when one of the moist prepara- tions are used. Malt soup. — A food that depends for its popularity on the comparatively large amount of malt sugar it contains is the malt soup advocated by Keller. As the liquid malt extract in the food is cooked with the milk and as ordinary malt extract has an acid re- action, which would curdle the milk, a neutralised malt extract is used. To an ordinary malt extract about five grains of carbonate of potash are added to each ounce. A common proportion for feeding, if using five bottles of eight ounces, or forty ounces, is as follows : METHODS OF ARTIFICIAL FEEDING 193 Mixed milk 20 ounces Water 18 ounces Neutralised malt extract 2 ounces Wheat flour 2 ounces The proportion of these ingredients may be varied. For very young babies only one-third milk may be used, while for those of nine months two-thirds milk may be used. Also for infants with poor sugar tol- erance less than two ounces of malt extract may be well taken, while others may take more. The objec- tion to this food is that a. large amount of sugar is often fed. It is, however, a very useful resource in some babies who are difficult to make gain in weight. There is one class of babies in which malt makes the bowels too loose and the waste from the bowel in this way is sufficient to cause a loss in weight instead of a gain. But in most cases the movements are simply soft, of normal frequency, of a brown colour, and often with a malt odour. A convenient way to prepare malt soup is to use Loeffland's malt soup or maltine, or neutralised maltzyme, in which the carbonate of potash is com- bined with the malt extract. Cane sugar. — In some infants a better result may be obtained by the use of cane sugar in place of sugar of milk. The tolerance of cane sugar in some infants is shown by the good results obtained in putting babies on condensed milk, when on a dilution of one to six- teen they obtain only % per cent, protein, but little 194 ELEMENTS OF PEDIATEICS more fat and 3 per cent, sugar, mostly cane sugar, while on the one to eight dilution the amount of fat is but little more than 1 per cent., protein 1 per cent., and sugar 6 per cent., 5 per cent of which is cane sugar. The feeding of condensed milk, therefore, is a feed- ing of cane sugar with an insufficient amount of fat and protein. While some children will do better on cane sugar and many children quite as well, a certain number will do very much worse. Cane sugar has, however, a place in the feedings of babies of the poor, for it is materially cheaper than sugar of milk or dextri-maltose and some babies do perfectly well when it is added to the food in place of other forms of sugar. Dry milk. — In those babies whose bowels become loose from the administration of malt soup and who evidently need a very readily digested form of pro- tein and high sugar, and low fat, we have another resource in dry milk preparations without the addi- tion of malt. Attempts to produce milk in a dry form were never successful until recently, the dry milk being dry skim milk, for the presence of fat in the milk made an im- possible preparation. In recent years, however, it has been found that by passing milk over a hot cylin- der on which it would form a crust, a dry milk could be obtained, which contained fat in an unobjection- able form. The first dry milk, so far as I know, to obtain much reputation was a preparation contain- ing 12 per cent, fat, 56 per cent, lactose and 24 per METHODS OF ARTIFICIAL FEEDING 195 cent, protein, and which soon obtained some little sale in this country under the name of Mammala. There is a similar preparation made in this country for infant feeding, but which is less known. Most dry milk made in this country is sold to bakers as a cheap form of milk. In preparing these dried milks which contain fat one must mix the dry milk with the required proportion of warm water just before each feeding. To make a four ounce bottle, 1% or 2 ounces of the dry milk preparation may be measured in a liquid graduate and the water, somewhat too warm for feeding, added to four ounces, or it may be made up in the same way in a graduated bottle. If an eight-ounce bottle is needed, about four ounces of the dry milk preparation, measured in a liquid grad- uate, may generally be used. This food is often very assimilable in babies who are difficult to feed. In changing from such a food to a modification of milk, it is best to substitute milk and gruel and sugar of milk gradually, increasing, little by little, these ingredients as the dry milk preparation is dimin- ished in amount. When one has intelligently run through the dietary resources that have been outlined without being able to find a "feeding that fits," he should resort to a wet nurse rather than to the proprietary foods to which the parents of the child have no doubt re- peatedly called his attention during the changes. The advertised proprietary foods, while differing somewhat in their analyses have certain character- istics in common. They all contain very little fat, a 196 ELEMENTS OF PEDIATRICS great deal of sugar or starch, and low protein. Some contain sugar of milk and others malt sugar. None of them have any advantage over the methods of feeding that have been reviewed. CHAPTER XIX THEORY OF INFANT FEEDING The best graphic representation of the principles of infant feeding is portrayed in the charts modified from those of von Pirquet, particularly with refer- ence to the amount of food administered. Thus in Figure 49, the upper line represents the weight of a child and the perpendicular lines the amount of food administered. We notice that a child fed on what is designated as the minimum amount of food holds about an even weight (Section 1), neither gaining nor losing, and that if the food is withdrawn for a certain period a rapid loss in weight ensues. (Section 2.) Administration of food up to one-half the minimum required for the support of life causes a less rapid loss in weight (Section 3), while with the restoration of the minimum amount of food a prac- tically stationary weight is obtained. (Section 4.) If then another increase in food is made, a slight gain in weight occurs (Section 5), and with a fur- ther increase a rapid gain occurs. (Section 6.) In the feeding of babies, the smallest amount of food which will cause this rapid gain in weight is usually the best amount for that child for the time, and should be adhered to with slight variations, as 197 198 ELEMENTS OF PEDIATRICS changes in tolerance occur, in which way a per- sistent gain in weight should be obtained. Very often the amount of food is increased after this optimum has been given . and with each increase a less rapid gain in weight takes place (Sections 7 and 8), until finally, with a considerable increase, a station- ary weight results, while this over-feed- i n g , if continued, produces symptoms in abnormal move- ments, often too fre- q u e n t movements, sometimes fever, and with this a rapid diminution i n t h e tolerance of the child to food. Thus, as seen in (Figure 50) Section 9, the tolerance becomes less than the former optimum, descending in Section 11 to less than the former minimum, while at the same time the weight is grad- ually diminished, and finally, if no change in the FIGURE 49. The Effect on Weight of the With- drawal of Food and of the Ad- ministration of the Minimum, Op- timum and Maximum Amount of Food, and an Amount Exceeding the Maximum or Tolerance of the Child. THEOEY OF INFANT FEEDING 199 food is made, the child loses all tolerance and dies. The reaction of the child to a modification of the amount of food will depend upon how early this modification takes place and what the tolerance of FIGURE 50. The Effect of the Persistent Feeding of Food in Excess of the Maxi- mum Amount or Tolerance of the Child, Resulting in A Diminu- tion of the Tolerance. the child is at the time the food is reduced. Thus if the food is reduced to the child's minimum require- ment, as in Figure 51, when the tolerance is only slightly reduced, the tolerance will immediately in- 200 ELEMENTS OF PEDIATEICS crease, so that the amount of food can be gradually brought up to the optimum with a gain in weight and a normal tolerance line. FIGURE 51. The Effect of Reducing the Food to a Minimum When the Tolerance is but Slightly Reduced. If, on the other hand, this large amount of food is persisted in until a marked reduction in weight has THEORY OF INFANT FEEDING 201 taken place (Figure 52) and the tolerance is still above the line of the minimum amount of food neces- FIGURE 52. The Effect of the Temporary Withdrawal of the Food When the Tolerance is Considerably Reduced. sary to support life, and the food is cut off entirely and then gradually increased, the tolerance will in- crease and the child will begin to gain in weight after = o § w a H O 02 W O o p 202 THEORY OF INFANT FEEDING 203 the amount of food is built up above the minimum. In case, however, the reduction in the amount of food (Figure 53) is delayed until Section 11 of Fig- ure 50, where the tolerance line is far below the minimum of food necessary to support the body, there may be some reaction from starvation and a gradual building up of the food, but this is likely to be only transitory and to end fatally. Other charts of von Pirquet which are not given here, show equally well the diminished tolerance to food caused by febrile disease or excessive heat, with the rapid increase in tolerance on a subsidence of the fever, as well as the advantage often to be gained by giving foods of a higher tolerance limit, such as breast milk, in place of cow's milk. CHAPTER XX ELIMINATION OF BOTTLE FEEDING Between the eighth and twelfth months there may be added to the ten a. m. feeding two onnces of cereal, fed with a spoon. This cereal should at first be strained, preferably the cereal that has been used for diluting the milk, only made thicker. In addition, whether the teeth have appeared or not, a piece of rusk or hard bread may be added for the child to chew. It is desirable that rusk should be given at this time, because it teaches the child to chew, and it is the only food that can be given for this purpose, because if it is swallowed without chewing it will do no harm. It is useful not only in encouraging chew- ing, but in stimulating the gastric juice, and in de- veloping the jaws, and it undoubtedly assists the eruption of the teeth through the mucous membrane. The rusks are better than other forms of bread be- cause they are hard and not sweetened. In some cases pulled bread, toast or zweibach may be sub- stituted. This should be given only at the feeding time and not between feedings. At two f. m., in addition to the bottle and rusk, the baby may be given two ounces of clear soup. This may be a consomme, mutton broth, or chicken broth, which after cooking has been allowed to cool and has 204 ELIMINATION OF BOTTLE FEEDING 205 had all the fat removed. These soups should contain a little salt, but no pepper. Later a vegetable soup may be given, care being taken that the vegetables are thoroughly cooked until soft, and that it contains no tomato. At six p. m. the same feeding may be used as at ten A. M. Beef juice. — Beef juice, which is very popular with the laity, is apt to be suggested by the parents, under the supposition that it is a valuable food. In Figure FIGURE 54. ANALYSES OF BEEF JUICE OBTAINED BY PROCESS 1, AND PROCESS 2, AND OF BEEF BROTH Beef juice Beef juice Beef broth Process 1 Process 2 Protein 2.90 3.00 1.02 Fat 60 0.00 Extractives 3.40 1.90 1.82 Salts 20 .20 .88 Water 92.90 94.90 96.28 100.00 100.00 100.00 BEEF JUICE Process 1. — Lean beef, boil slightly, squeeze in a meat press or lemon squeezer. Two ounces of beef juice are ob- tained from one pound of beef. Process 2. — One pound of chopped meat; 8 ounces of water. Put meat with the water in a refrigerator and allow it to remain 6 to 12 hours. Then squeeze through coarse muslin. Six ounces of beef juice are obtained from one pound of beef. 206 ELEMENTS OF PEDIATRICS 54 a comparison between the analyses of beef juice and beef broth is presented. The beef juice may be prepared, as it usually is, in a meat press, when about two ounces of juice may be extracted from one pound of meat. The analysis shows that such meat juice contains much less nour- ishment than an equal amount of skim milk, contain- ing less than three per cent, protein, and little more than % of 1 per cent. fat. It, however, contains nearly 3% per cent, extractives, which are not con- sidered a food but a tonic. If the beef juice is pre- pared as it is in the bacteriological laboratory, by allowing chopped meat to stand in a refrigerator with water for a number of hours, the resultant juice is somewhat less palatable but more juice (about six ounces to a pound of meat) may be obtained. Such meat juice contains quite as much protein as the other but less than 2 per cent, extractives. Beef broth. — A beef broth, on the other hand, made from soup stock, contains more than 1 per cent, pro- tein and nearly the same amount of extractives as the juice obtained under the last mentioned pro- cess. Moreover, if one uses beef juice it should be steril- ised by heat before it is fed to a child. Cattle that are condemned on account of tuberculosis, if the le- sion is not widespread, are used for meat, and babies are very susceptible to tuberculosis. On this ac- count no raw meat juice should be fed to any baby. For all practical purposes then soup replaces beef juice. It is more economical, much safer than raw ELIMINATION OF BOTTLE FEEDING 207 meat juice and does not usually have to be espe- cially prepared for the baby. Vegetables. — At the beginning of the second year vegetables may be given in addition to the soup — potato, mashed or baked; stewed squash, lettuce, or celery, or puree of peas or beans. A rounded table- spoonful of one vegetable may be given at first and later the same amount of a second vegetable. Eggs. — An egg may then be added, preferably soft boiled. As eggs occasionally cause a severe anaphy- laxis, a minute portion — the size of a French pea — of the white of an egg, may be given, and if this causes no reaction, the following day half an egg, and the third day a whole egg may be given. The reaction of children to eggs is peculiar. Some children exhibit a severe anaphylaxis, vomiting with convulsions, rash and oedema ; others simply vomit N eggs, while still other children refuse to take them. In any event it is well to accustom the child to the use of egg, and this can be done by feeding small quantities at first, and even in cases of severe anaphylaxis, minute quantities insufficient to produce a reaction should be fed daily, increasing gradually, but keeping as far as possible within the amount that causes reaction. If any reaction occurs, a smaller amount may be given. The egg should at first be given at the two o'clock feeding, but may later be transferred to the breakfast, meat taking its place at the midday meal. Meat. — The first meat given a child may be beef or lamb, preferably a steak or chop, cooked sufficiently to destroy the raw meat colour. The outside is cut 208 ELEMENTS OF PEDIATRICS away and the inside scraped to a pulp with a knife blade held at right angles. Of this meat a rounded after-dinner coffeespoonful may be fed each day at the two o'clock feeding. This amount may be in- creased gradually to a teaspoonful or a rounded tablespoonful, the latter amount fed once a day being sufficient for any child under two years of age. Number of feedings. — In the second year it is well to eliminate the evening bottle, leaving three meals and one feeding of a bottle of milk. After the second year, but three meals a day should be given. The diet should be mainly farinaceous, with a moderate nitrogenous element and moderate sugars and fats. Nothing should be given between meals excepting water. Such a diet for children of three to five years may be as follows : Breakfast: Cereal, milk, egg y rusk, toast or crust, and one pat of butter. Dinner: Soup, four ounces; meat, rounded table- spoonful ; two vegetables, one rounded tablespoon- ful of each ; and for older children a milk dessert with fruit juice over it. Supper: Cereal, milk, toast or rusk, small pat of butter. A glassful of water should be given a half to one hour before each meal. From the fifth to the tenth year : Breakfast: Cereal, milk, one egg y roll and butter. Dinner: Soup; meat, equivalent to amount con- ELIMINATION OF BOTTLE FEEDING 209 tained in a French chop ; two heaping tablespoon- fuls of vegetables ; milk dessert with fruit juice or stewed fruit. Supper: Cereal and milk, or milk toast ; toast, hard bread or rusk ; one pat of butter. A glassful of water should be given a half to one hour before each meal. CHAPTER XXI CAKE OF PREMATURE CHILDREN Children born prematurely, especially those of less than eight and one-half months of intra-uterine life, need special care and the success attained with them depends on the methods used. With the best care in institutions in France it has been found that the fol- lowing results may be obtained. An eight month baby weighs about four pounds and measures seventeen inches in length, and of these about 90 per cent, may be saved. A seven month baby weighs about three pounds and measures fifteen inches in length, and of these 50 per cent, may be saved. The class of six month babies shows a much greater mortality. They weigh only one and one-half pounds, are twelve inches long and only 16 per cent, of them are saved under the best conditions. We may say, then, that there is practically no chance of saving a baby of less than six months intra- uterine life, or one weighing less than one and one- half pounds. After six months of intra-uterine life they have some chance, this increasing with the longer duration of intra-uterine life. It will be noticed by reference to the chart that the gain in length is fairly steady from the sixth month, while 210 CAEE OF PEEMATURE CHILDREN 211 the gain in weight increases much more rapidly the last month of intra-nterine life. (Figure 55.) Premature babies are very inactive, they are apt to have a subnormal temperature under ordinary room conditions, their lungs are not well adapted to support life by res- piration and their digestive activity is small. The proper care of these babies in- volves, therefore, a quiet environment, little handling, the securing of a nor- m a 1 temperature by preventing too great loss of heat from the surface of the body, a supply of air of good quality, and correct food. Incubator. — A proper incubator (Figure 56) is the first essential. An incubator is a receptacle supplied with moving air, warm enough to keep the baby's temperature normal; this is usually somewhere be- tween eighty and ninety degrees Fahrenheit. It consists of a box with glass windows, and a door with an air inlet, preferably from out of doors. It con- tains a thermometer for determining the temper- Weight and Length of Foetus in Utero Length A Weight B Months 6 7 8 9 Lbs. 9 8 7 6 6 4 3 3 1 r Ins. 19 16 17 16 15 14 IS 12 11 j / J / /* / / / / S-* A ,s* / FIGURE 55. FIGURE 56. Incubator. 212 CAEE OF PREMATUEE CHILDREN 213 ature of the air. The air is heated by passing over a receptacle containing water kept at the desired tem- perature by a Bunsen burner or kerosene lamp or by electric lights. The air is moistened by passing over a wet sponge or basin of water. Sometimes oxygen may be added at intervals with advantage. A little wind-mill at the exit for the air is a good indicator of the amount of movement of the air. If the wind-mill is whirling rapidly, we know that there is sufficient movement in the air. Such an incubator shuts out the noises of the room and in winter supplies good moving air sufficiently heated to preserve normal temperature. The degree of heat must be adjusted to the needs of each individual child. The child should not be clothed, but wrapped in a slight covering of gauze or absorbent cotton in such a manner as not to interfere with the movement of its legs and arms. The indication for the use of an incubator is a sub- normal temperature of the child and the child should be kept in the incubator until no increase of heat over room temperature is necessary to keep the child's temperature normal. Boxes or tents are poor sub- stitutes for a properly constructed incubator. Espe- cial rooms with a temperature of 80° to 85° Fahren- heit are used in babies' hospitals where many pre- mature babies receive care. Feeding of a premature baby. — Premature babies are always entitled to breast milk and every effort should be made to supply them with it. If they are six or seven month babies the breast milk may have 214 ELEMENTS OE PEDIATEICS to be pumped or expressed and modified before feed- ing, often a one-half dilution with 3 or 4 per cent, sugar of milk added does well. Sometimes pepton- ising is an additional help. It is usually of advantage to allow the wet nurse to nurse her own baby after sufficient milk has been ex- pressed to feed the premature baby, for a premature baby will not use enough milk to keep the wet nurse's breasts active. These babies should not be bathed, but may be kept sufficiently clean by being washed with soap and water when the diaper is soiled. This should be done with the least handling possible. Although these babies often do remarkably well, it should be borne in mind that they are liable to be somewhat handicapped in their future development. CHAPTER XXII MENTAL. DEVELOPMENT OF CHILDREN Babies at birth can see and hear, but sight evi- dently registers nothing in the brain. They have no mental activity. They should be fed and left to sleep between feedings. Constant attention and handling can put these young babies in a condition of acute neurasthenia. One baby of six weeks jumped in the crib as I leaned over it. It had been awake all night for several nights. By abolishing the devoted attention of four grandparents, two parents and two trained nurses, leaving the baby alone with one at- tendant all day, and giving a warm bath at bed- time, all trouble was removed. No attempt should be made to amuse young babies. At three months they usually begin to recognise some person, especially a mother who nurses the baby. The cry at this age is characteristic and dif- fers entirely from the cry of a six months baby. It is not until the ninth to twelfth month that they use any words, and then it is usually only mamma or papa or no. During the latter part of the second year babies should begin to put w T ords together and from that time on their vocabulary increases rapidly. Instruction. — Systematic attempts to teach these 215 216 ELEMENTS OF PEDIATEICS young children should be avoided, all means being focused on building up a good physique. At three years of age, many active children may be sent to a proper kindergarten. By proper, I mean one that provides a sunny, well ventilated room, and is presided over by a woman who has natural ability and love for the work, as well as a good education. Kindergartens are useful for giving children sys- tematic exercise under supervision, for teaching them ethics, teaching them to play peaceably with other children, and to give and take, and this is the first experience many children have in doing any- thing but take. Children are also taught observa- tion, to differentiate one colour from another, or one tree from another, and for this latter purpose classes in parks are especially useful. Little children have no ability for prolonged con- centration, in fact, this is true until early adult life, and is one of the reasons why schools, with their long sessions, make very slow progress. A child at three years should not have more than an hour a day at school. A child of six, no more than two hours a day, and a child of ten, no more than three hours a day, and after each half hour there should be a period of five or ten minutes of active exercise. No school day should exceed five hours and should include half hourly recesses, during which all children are com- pelled to exercise. All schools ought primarily to be under the care of physicians, who should know the children intimately and regulate their study and ex- MENTAL DEVELOPMENT 217 ercise. Schools should be institutions for physical as well as mental development of the child, and the physical development should be considered of more importance than the mental development. CHAPTEB XXIII THE MOEAL DEVELOPMENT AND CONTEOL OP CHILDEEN It is a safe assumption that all healthy children are born good, and if they are really bad children it is the fault of the parents, just as a balky horse is the result of bad management. As an exception to this rule there are some children born of alcoholic or syphilitic parents who have nervous derangements, as may children who have suffered from a cerebral hemorrhage at birth or a meningitis. A normal child needs only kind, firm control with plenty of good suggestion to become a model child. Under these conditions an active child will remain an active child and an indolent child will be less active but both should be tractable and happy. When suggestion is wisely used other means are seldom necessary in controlling children. Suggestion. — Suggestion is less applicable to chil- dren under a year of age but often the suggestion of a bowl under the buttocks and the flexing of the thighs on the body will cause them to strain so as to avoid the suppository which they have learned will be used if necessary to procure a movement of the bowels. Control. — Children should never be threatened; 218 MOEAL DEVELOPMENT 219 they should never be deceived or told a falsehood. They are easily frightened. Ghost stories and stories of horrors should never be told them. They should, so long as possible, be considered good children and encouraged to live up to that reputa- tion. If they are called bad children the reflection is usually on the parent not on the child. When suggestion fails, the best means of control are re- wards and deprivations. Nothing is more appre- ciated by healthy young children than food and the withdrawing of desserts, if emphasised, is apt to be remembered. Rewards also of toys that are much desired are apt to secure co-operation but this pre- cludes the giving to children of many toys whether they behave well or not. Corporal punishment is rarely needed; most chil- dren if wisely managed never need it. If adminis- tered it should never be done in anger but only after mature deliberation. The telling of falsehoods by young children should not be considered the offence it might be in older children. Young children do not differentiate well between fact and fancy. They are highly imagina- tive. One distracted mother said of her boy of six years : i ' and the worst of it is he lies when there is no object in lying, when there is nothing to be gained by it," the best evidence that it was not really a serious offence in a boy of that age or an indication of a really bad character. Many young children show a great deal of grit and determination and do what they believe they should 220 ELEMENTS OF PEDIATRICS do with great mental distress without a word of complaint. A sturdy little boy on being sent to school for the first time made no complaint but every week-day morning for the first two weeks vomited his breakfast on the way to school. He never vomited any other meal nor did he vomit at all on Saturday or Sunday. He showed no evidence of any ordinary digestive disturbance. CHAPTER XXIV PHYSICAL EXAMINATION In no other department of medicine is a complete physical examination, frequently repeated, of such importance as in pediatrics. The history obtained from parents or attendants should be carefully con- sidered as should any information that may be ob- tained from the child, but this can never render unnecessary a complete examination. Such a com- plete examination should be made not only at the first visit but at every visit. Method of examination. — The following is a gen- eral outline of the method of examining infants and young children. Space does not allow of a detailed description. In order that such an examination may be under- taken without resistance it is most desirable that the child be made friendly to the physician and for this purpose the co-operation of the parents and nurse is necessary. The child should be taught to look on the physician as its best friend and the phy- sician while making his examination thorough should undertake it in such a manner as to avoid frightening the child. The most unpleasant examinations, such as the adenoid examination for example, may be made without resistance if done sufficiently quickly. 221 222 ELEMENTS OF PEDIATRICS The physician should obtain the child's confidence by kind, sympathetic behaviour and by truthfulness. If you once deceive a child you cannot expect any further confidence. The desire of the parent to awaken a sleeping child on the advent of the physi- cian should be forestalled for many valuable obser- vations may be made on a sleeping child that are impossible when it is awake, especially if frightened. Examination while sleeping. — An indication of the diagnosis may often be reached by watching a sleep- ing child. Character of sleep. — Notice the character of the sleep whether quiet or disturbed and restless, and count the respirations for a full minute because they are irregular in infancy and early childhood. Respirations; expiratory grunt. — Eapid respira- tions if associated with an expiratory grunt and a pause at the end of inspiration suggest pneumonia. Sunken eyes. — Sunken eyes suggest a lack of fluid in the body usually due to diarrhoea or vomiting, or both. Retraction of head. — If the head is drawn back and the legs drawn up one thinks of meningitis. Pulse. — The pulse can often be counted if the child is sound asleep and it furnishes a diagnostic sign in the pulse rapidity and pulse respiration ratio, nor- mally one to four but in pneumonia one to three, or in the irregular pulse of meningitis. Before crying — Abdomen. — Palpation of the abdo- men, which should never be omitted, is not satisfac- tory if the child is frightened or crying. PHYSICAL EXAMINATION 223 Appendix. — Palpation over the right and left iliac region may make or exclude a diagnosis of appen- dicitis ; rigidity over the right iliac region being one of the best signs. The additional sign of tenderness may also be elicited. Intussusception. — Any sausage shaped tumour found in the abdomen on palpation should suggest the diagnosis of intussusception. Fecal impactions occur but not commonly in babies. Liver. — Enlargement of the liver is common in children, a fatty infiltration with enlargement being the regular accompaniment of infections in babies. Palpation on the left side for enlargement of the spleen should be regularly made. A spleen that does not come to the free border of the ribs may be felt by pressing the hand under the rib during a forced inspiration. Kidneys. — Deep palpation in the back may disclose tenderness over one or both kidneys. Abdomen. — Percussion of the abdomen enables one to form a judgment of the pressure and location of gas in the stomach or intestine. Heart. — The heart is another organ that should be examined while the child is quiet. Soft blowing murmurs cannot be heard under other conditions. One should first palpate to locate the apex beat ; per- cuss or use auscultatory percussion to form a judg- ment of the size of the heart and the location of its outline, and then listen to the character of the heart sounds and rhythm, bearing in mind that children under five years of age are not ordinarily subject to 224 ELEMENTS OF PEDIATRICS rheumatic heart disease, while murmurs due to con- genital defect in the heart are not very rare, and that murmurs may be hsemic, congenital, inflammatory, or due to violent action of the heart from fright. After crying. — This part of the examination being completed the remainder can be done more easily if the child is quiet, but can be carried out even if the child fights against it. Rachitis. — The chest should be examined for evi- dence of rachitis, the rosary, Harrison's groove and the contracted thorax with large abdomen, and then the examination of the lungs should be undertaken. Lungs. — Palpation may first be applied and then one should proceed to auscultation as being usually much more valuable in locating a lesion than per- cussion. Results obtained on examining a sleeping child should be confirmed by examination when awake. A frail, feeble child may breathe when asleep without inflating one lobe of the lungs. Cry- ing is a distinct advantage in this examination for it provides forced inspiration and voice sounds dur- ing expiration and sometimes the only way to get voice sounds in babies is to make them cry. Auscul- tation should be followed by careful percussion and mensuration if indicated. Ears. — The ears should next be examined with some instrument that the physician is accustomed to use, and this examination should never be neglected. An instrument with a magnifying lens and a little electric lamp in the speculum probably furnishes the easiest method of definite diagnosis of ear con- PHYSICAL EXAMINATION 225 ditions by the pediatrist. In little babies with a narrow, crooked passage the examination is often difficult. The physician should determine whether the drum is shiny or dull, white or red, and whether the ossicles project in a normal manner or the pos- terior segment bulges. In case of doubt or in the presence of bulging an ear specialist should be called. This examination need not frighten or hurt the child. The mastoid region behind the ear should be care- fully examined in every case of ear trouble for in- flammation, tenderness, oedema or fluctuation. Fontanelles. — In children under two years of age the four fontanelles should be felt and if the anterior fontanelle is open its edges should be mapped out and the fingers should be passed over it to determine whether there is any bulging due to pressure in the cranial cavity. Cranio-tabes. — The neighbourhood of the lateral fontanelle should be pressed to determine whether it denotes the sign called cranio-tabes which is pres- ent in many cases of rachitis during the first year and sometimes later. Stiffness of the back of the neck. — The head may be pressed forward to ascertain whether there is any resistance in the muscles of the back such as is found in certain nervous diseases. Nits indicating pediculi may be looked for in the hair. Glands. — Enlargement of the parotid or submaxil- lary glands should be noticed if present, as well as of the anterior and posterior cervical lymph nodes. 226 ELEMENTS 'OF PEDIATRICS Eyes. — The eyes should be examined for inflamma- tion, discharge or ulceration, and the equality or in- equality of the pupils noted as well as their reaction to light. Nose. — Evidence of inflammation of the nasal mucous membrane should be looked for and a one- sided inflammation or discharge especially noted, as denoting a possible foreign body or sinus trouble. Tongue. — The tongue should be carefully examined as to the amount of coating, irregular coating, geo- graphical tongue, ulceration and moisture. Mouth.— In children under eighteen months of age the handle of a spoon, or a tongue depressor, that has been washed in alcohol may be used for examin- ing the mouth just previous to the throat examina- tion. Have the child held with the head firm in a good light or use a pocket flash light. Examine first the gums for irritation of erupting teeth. Look for Koplik spots, ulcerations and sprue, and then press the back of the tongue down to get a good view of the pharynx. In older children the spoon may usually be dispensed with except in looking for Koplik spots. Pharynx. — If children are instructed to open their mouths wide, put out their tongues as far as possible and then cough hard, a better view of the pharynx can usually be obtained than by the use of the spoon or tongue depressor. In doing this the examiner should be careful to keep his own mouth closed in order to avoid infections himself. Adenoid. — The adenoid examination can be made PHYSICAL EXAMINATION 227 with little trouble if the examiner is quick. Have the child open its month wide, then press the thumb of the left hand into the child's cheek so as to force a fold of the child's cheek between its molar teeth, allowing the fingers of the examiner's left hand to make pressure over the left side of the inferior maxillary bone. Then the index finger of the right hand is quickly passed through the mouth into the naso-pharynx where the characteristic soft feel of the adenoid is quickly recognised, and in older chil- dren a fair estimate of the size of the remaining post- nasal space may be made. This method is not safe if the child has cut its front teeth but not its back teeth. In this case a gag should be used. Genitals. — Examination of genitals should be made for the presence of discharge and in boys any ad- hesions between the glans and the foreskin should be separated. This is best done without an instru- ment. The examiner, with his hands dry, should place one thumb on the glans, the other on the foreskin, and then press them apart. This read- ily separates adhesions and exposes shut in smegma. Feet. — In cases of doubtful diagnosis every portion of the body should be examined, including the feet where a small abscess has sometimes explained an obscure fever. Kernig — Brudzinski. — In addition to the test for stiffness of the back of the neck and the equality re- action of the pupils, Kernig's sign and the Brud- zinski sign should be looked for. In case of their 228 ELEMENTS OF PEDIATRICS presence a tache cerebral reaction may be looked for. Measurement. — Measurement of the length of the body, the head, chest and abdominal circumferences should never be omitted. Blood pressure. — Blood pressure determination has not been proved to be of sufficient value in chil- dren to be included in ordinary examinations. Should it be determined a narrow arm band must be used. This completes the examinations that should or- dinarily be made at the bedside. Other examina- tions while equally important need special labora- tory equipment. CHAPTER XXV URINARY ANALYSIS Of the laboratory examinations the most import- ant is the examination of the urine and this to be of real value must be much more complete than the ordinary routine examinations made in physicians' offices or in medical laboratories. Obtaining specimen. — A delayed diagnosis is often due to difficulty in obtaining a specimen of urine for as already stated (page 56) babies make water very frequently and a very little at a time. An intelli- gent attendant will usually obtain all the specimens desired, for infants usually pass water when awake and before or during feeding. If a cup is ready and placed under a child when it wakes with a dry diaper and held there while gentle pressure is made above the pubes a specimen of urine can be obtained. In male babies all delay may be avoided by inserting the penis in a bottle with a large mouth and strap- ping the bottle in place with zinc oxide plaster at- tached to the abdominal wall. Older children should be placed on a chamber and in case they are having frequent loose movements from the bowels a sepa- rate receptacle must be used for the urine. Of the conditions to be looked for in the urine we may note in order : 229 230 ELEMENTS OF PEDIATKICS 1. Dilution 2. Evidences of nephritis 3. Evidences of diabetes 4. Evidences of acidity 5. Evidences of acidosis 6. Evidences of intestinal intoxication 7. Evidences of pyelitis 1. Specific gravity. — The specific gravity of the urine gives one information as to the dilution, and the solids it contains. A high specific gravity of the urine is not uncommon in older children who are not naturally thirsty and who thus take little water. Such children should be advised to drink water sys- tematically between meals. 2. Nephritis. — Evidences of a real nephritis are rarely found in infancy and early childhood. When a nephritis is present it is apt to be a sharp attack with acute symptoms although a chronic nephritis may occur. The presence of a small amount of albumin in urine during an acute illness is a frequent finding. It is occasionally found without acute illness. A slight disturbance with the presence of nucleo- albumin need not be considered as important as the presence of serum albumin. Albumin without casts need not lead to serious concern. 3. Diabetes. — The presence of sugar in the urine is very rare, but is found occasionally in cases of diar- rhoea. If it is present in considerable quantity and is accompanied by other symptoms of diabetes it means a very serious disease which until very re- cently has been universally fatal. UEINARY ANALYSIS 231 4. Acidity. — Acidity of the urine is a cause of con- siderable irritation of the skin in some cases, and as an accompaniment is an index of the extent of the de- rangement in other conditions, so that a quantitative test of the acidity or alkalinity of the urine is very valuable in treating these disorders and may easily be carried out in accordance with, the methods con- sidered later. Acidity is usually readily controlled by treatment, while alkalinity of the urine is less amenable to drug treatment. 5. Acidosis. — Several acid bodies appear in the urine associated with the condition known as acido- sis. Some of these are more readily tested for than others, and two that may be detected by simple tests and that form a good general index of the condition are acetone and diacetic acid. Any one making such routine examinations every day can soon readily judge of the extent of the pres- ence of these bodies by the sharpness of the reaction, so that it becomes easy to index the intensity of the reaction by using the numbers from 1 to 10 ; number 1 or 2 indicating a trace ; 4 or 5 a fair amount ; 6 or 7 a great deal ; and 10 a maximum amount. 6. Intestinal intoxication. — Another very common derangement of young children known as intestinal intoxication or intestinal putrefaction gives rise to certain products two of which are readily deter- mined by simple tests and like the two bodies in aci- dosis give a fair indication of certain conditions in the bowel; these are indican and phenol, and with these as with the acid bodies an index of 1 to 10 is 232 ELEMENTS OF PEDIATEICS fairly accurate. Therefore, in the treatment of this condition one can judge of its effects by an increase or a diminution in the amount of indican and phenol present. 7. Pyelitis. — Probably the most important finding in the urine is the presence of leucocytes, an evidence of an inflammatory process in the urinary tract of the child. The presence of one leucocyte in a high power or Zeiss D field in a girl is a normal finding, but the presence of this amount in a boy or the presence of more than this amount in either a boy or a girl is usually an evidence of pyelitis. For the benefit of the physician who is treating the case the number of leucocytes present should be known. When there are only a few, the number in a D field should be recorded, but where there is a great deal of pus the amount of such precipitate in a test tube is a good index. In cases of pyelitis the urine is usually pale, colourless, smoky, and of low specific gravity, with more or less perceptible precipitate. The bac- teria present are for the most part motile bacilli easily detected by a Zeiss D lens. 8. Blood. — The presence of blood in the urine is most important in diagnosis. If in an infant it ap- pears with no other abnormality scurvy should im- mediately be suspected. If it is an accompaniment of nephritis other evidences of this disease may be present, or it may be found in an active pyelitis. The methods of making the tests that have been alluded to are as follows : UEINARY ANALYSIS 233 General appearance. — This includes examination of the sediment and supernatent fluid. The fluid is generally amber or straw col- oured. It may be entirely colourless or of a deep yellow bile colour, or red from blood or amorphous urates. It is generally clear. A turbid urine usually indi- cates amorphous urates or phosphates; a smoky urine bacteria. The sediment may be brick red from amorphous urates, red from blood cells, white from pus or phosphates, crystalline from uric acid or other crystals. Reaction. — Acid — turns blue litmus paper red. Alkaline — turns red litmus paper blue. Quantitative acidity. — For this determination one needs : 10 c.c. of urine. 1 drop of 0.5 per cent, phenolphthalein in 50 per cent, alcohol. 1 burette filled with decinormal sodium hydrate solution. Shake up the urine with about 10 grams of potas- sium oxalate crystals. Add one drop of phenolphthalein solution, and place in evaporating dish. Eead level of solution in burette. Allow sodium hydrate solution to flow, drop by drop, into the evaporating dish until the urine is pink. 234 ELEMENTS OF PEDIATKICS Eead burette. The difference between this read- ing and the first one indicates the acidity of 10 c.c. of urine expressed in centimeters of deci- normal sodium hydrate solution. Thus, if the first reading is 18.7 and the second 21.5, the dif- ference is 2.8 for 10 c.c. of urine, which would be .28 for 1 c.c. A normal acidity is about 6 c.c. for 10 c.c. of urine. Specific gravity. — May be obtained with an urinome- ter. As specimens from children are apt to be scanty in amount a small urinometer and a one-inch urine glass will be of advantage. Albumin. — Heat and acetic acid test: Fill a narrow test tube three-quarters full of urine. If turbid, filter. Add a few drops of 2 per cent, acetic acid. Boil top of urine. A cloud seen against a black background indicates albumin. The density of the cloud is an indica- tion of the amount of albumin. When albumin is present in large amounts, a rough estimate of the amount in terms of per- centage may be made as follows: Boil 10 c.c. of urine that has been acidified by acetic acid. Place this in a graduated centrifuge tube and rotate rapidly for two minutes. A reading of the percentage of albumin at the bot- tom of the tube may then be made. UEINAEY ANALYSIS 235 Cold nitric acid test: Over 3-5 c.c. of concentrated nitric acid in a test tube place, by means of a pipette, about 10 c.c. of urine. A white line at the junction of these two fluids in- dicates serum albumin. A white cloud above the line of junction indicates nucleo albumin. Glucose. — Fehling's test: Mix 2 c.c. each of Fehling's alka- line 1 and copper 2 solutions in a test tube. Dilute this with 10 c.c. of water, and boil. Add 1 to 2 c.c. of urine. Heat to a boiling point and allow to stand at least ten minutes. A gradually forming red colour or a precipitate generally indicates sugar. Benedict's solution. To 5 c.c. of Benedict's solution 3 in a test tube Acid 8 to 10 drops of urine. Boil three minutes. Allow to cool spontaneously. A precipitate of greenish, yellow or red tinge fill- ing the entire solution indicates sugar. If the i Fehling's Alkaline solution : 346 grams of sodium and potassium tartrate. 100 grams of sodium hydrate. Water up to 1000 c.c. 2 Fehling's Copper solution : 69% grams of crystalline copper sulphate. Water up to 1000 c.c. 3 Benedict's solution : Copper sulphate crystals, 17%0 g rams ; Sodium citrate, 173 grams; Sodium carbonate crystals, 200 grams; Water up to 1000 c.c. 236 ELEMENTS OF PEDIATEICS solution is clear on cooling or shows only a slight blue turbidity sugar is absent. Fermentation. If reduction takes place in the above tests the fer- mentation test should be used, in order to ex- clude reducing substances other than glucose. Shake up in urine a piece of baker's yeast the size of a pea until it is in suspension. With this mixture fill a fermentation glass and place in a thermostat, where it should be allowed to remain for at least twelve hours. An accumulation of gas in the closed arm indicates the presence of sugar. The amount of gas varies with the amount of sugar in the specimen. Acetone. — To 5 c.c. of urine in a test tube of small calibre Add two to four drops of a freshly prepared aqueous solution of sodium nitro prusside (strength about 1 per cent.). Add one drop of glacial acetic acid. Place over this mixture by means of a pipette 5 c.c. of 10 per cent, ammonium hydrate solution. Allow this to stand for 1rve minutes. A red ring at the line of the junction indicates acetone. The more acetone there is present the denser will be the ring. 1 Diacetic acid. — To 10 c.c. of urine in a test tube i For purposes of recording the result of this and the three follow- ing tests, the author uses a scale of 1 to 10. A faint reaction being designated as 1, and the most marked reaction possible as 10. UEINAEY ANALYSIS 237 Add 10 per cent, aqueous ferric chloride solution, drop by drop. If a precipitate forms, filter and add a few more drops of ferric chloride solution. A Burgundy red colour indicates the presence of diacetic acid. This test is also positive in the presence of salicy- lates, but if the urine is boiled in an open dish for five minutes the diacetic acid will be de- stroyed, while the salicylates will still give the test. Indican. — Pour into a test tube 5 c.c. of urine. 5 c.c. of Obermayer's reagent. 1 2 c.c. of chloroform. Place a cork in the open end of the test tube and invert tube fifteen times. Allow to stand ten minutes. A blue colour in the chloroform, which falls to the bottom of the tube denotes indican. A purple colour indicates potassium iodide. Phenol. — Boil 5 c.c. of Millon's reagent 2 in a test tube. Add a distillate of urine, drop by drop, shaking i Obermayer's reagent : Ferric chloride 2 grams; Concentrated hydrochloric acid 1 litre. Dissolve ferric chloride in the hydrochloric acid. 2 Millon's reagent : Warm one part of mercury with two parts nitric acid until the mercury is fully dissolved. To each volume of this solution of mercuric nitrate add two volumes of distilled water. 238 ELEMENTS OF PEDIATEICS between each until the colour ceases to deepen, or a precipitate begins to form. A red colour in the fluid indicates phenol. Microscopic. — This examination should be made on a glass slide, employing high and low powers of the microscope. The urine is examined for the following : Casts. — Not often found in children and usually of the hyaline variety. Granular casts or other varieties may be found. Blood cells. — Eed blood cells are recognised by the uniformity of their size, absence of nucleus, and crenation when the latter is present. Eed blood cells are not a frequent finding. White blood cells are found fairly frequently. It is of the greatest importance to recognise the number of these and whether they are clumped so as to form pus. If few are present, the average number in a high power field may be recorded. If much pus is present, the percentage may be determined by agitating the specimen so that the pus is uniformly distributed. A portion is placed in a graduated centrifuge tube and ro- tated rapidly for about two minutes. The per- centage may then be read. Bacteria. — These are easily seen with a high power lens, — usually motile bacilli. Epithelial cells. — These are of two types, squamous and round celled. URINARY ANALYSIS 239 Urates. — Found in acid urine, — amorphous brick red urates and uric acid crystals. Calcium oxalate crystals. — These are rare in very young babies — occasionally found in older chil- dren after they have eaten certain fruits and vegetables containing oxalates. Ammonium urates. — Rarely found in children. Triple phosphate crystals and amorphous phosphates are found in alkaline and neutral urines. Mucus. — Strings of mucus are found in almost all specimens. Recording the test. — The record of the test should appear as follows: Date : Name : Appearance : Reaction : Sp. Gr. Albumin : Glucose : Acetone : Diacetic acid: Indican : Phenol : Microscopic : CHAPTER XXVI EXAMINATION OF THE FECES Of all the clinical pathology of the diseases of children, the subject of feces is probably the most neglected and unexplored. It is, however, full of interest and promise. There are two ways of ap- proaching this study, the chemical and the clinical. By chemical, I mean the exact pains and time taking work that is done by a chemist in a complete chemi- cal laboratory. By clinical, I mean the more rapid and relative and less exact means that can be per- formed by any physician in his laboratory. These latter methods give valuable information to the phy- sician and with them this chapter will deal. Obtaining specimens. — Feces for examination should be obtained without the aid of cathartic or enema, and free from urine, if possible, as varying amounts of water make the findings less accurate. The amount should be at least equivalent to one heaping tablespoonful. To obviate the unpleasant and adherent odour, it is well' for the observer to wear a gown over the clothing and work under a hood or in the draught of an electric fan. Colour. — The colour, consistency, odour and re- action should first be determined. The normal stool 240 EXAMINATION OF THE FECES 241 varies in colour from yellow to brown, depending somewhat upon the age and diet of the child. Grey stools generally suggest undigested food material or mucus; green stools undigested protein; clay-col- oured stools stoppage or absence of bile and the presence of undigested fat ; and black or tarry stools the presence of bismuth, iron or old blood. Consistency. — The consistency is usually either solid, semi-solid, liquid, or liquid with hard masses. Bits of undigested food of varying sort, curds of un- digested protein or soaps of undigested fat may be present. Odour. — The odour of a normal stool is often only mildly offensive. A putrid odour suggests protein indigestion and autointoxication. A sour stool points to carbohydrate fermentation. This may be very irritating to the skin of a diaper baby. Reaction. — The reaction of normal feces is gen- erally faintly acid. Strong acidity points to carbo- hydrate fermentation, and strong alkalinity to pro- tein indigestion. Microscopic examination. — Under the microscope the feces should be examined for meat fibres, vege- table spirals, seeds, hard fruit particles, ova and parasites. The relative number of bacteria and their type present in stools is of interest. A thin smear prep- aration may be fixed on a glass slide by passing it nine times rather rapidly through a flame in a horizontal direction. The preparation is stained by the Gram method and counter-stained. Large num- 242 ELEMENTS OF PEDIATRICS bers of Gram negative bacilli are generally found. Gram negative cocci may also be present. Large numbers of Gram positive organisms are found in the feces of children suffering from the Intestinal Infantilism of Herter. These may be bifurcated bacilli, square ended or pointed bacilli or micro- cocci. Undigested food. — For the pediatrist a knowledge of the undigested food present in the feces is of con- siderable importance. In the case of fat in the feces we look with the naked eye for fatty curds and we examine micros- copically for fat droplets. The microscopical exam- ination for fat is unsatisfactory, as only a very small portion of the stool is examined. A smear of the stool is made and stained under a cover glass with Sudan III. 1 This stains all the neutral fats. The droplets can be counted under a high power lens. There should be in a normal stool not more than twelve droplets of fat to a slide. A drop of glacial acetic acid is then run under the cover glass and gentle heat applied until the prep- aration begins to bubble. This changes the soap to fatty acids, which then take the stain. There should be not more than six droplets in a high power field in a normal specimen. For protein determination, three methods are open to the observer. Macro scopically the specimen is examined for casein curds; microscopically it is i Sudan III. Sudan III, 0.3 gram ; 70 per cent. Ethyl alcohol 100 c.c. EXAMINATION OF THE FECES 243 examined for meat fibres; and lastly the Schmidt test, described below, may be applied. To find undigested starch, we may examine a smear stained with Lugol's solution. 1 After stain- FIGURE 57. Apparatus foe Schmidt's Fermentation Test. ing, the smear is washed for an instant in tap water and examined with the microscope for blue starch particles. In a normal stool there should be no starch present. i Lugol's Solution. Iodine, 1 part ; Iodide of Potassium, 2 parts ; Water, 17 parts. 244 ELEMENTS OF PEDIATKICS Schmidt fermentation test: A standard amount of feces, such as 10-15 grams or a teaspoonful, taken from the more solid part of the specimen is shaken up with warm water until the material is evenly liquified. An apparatus designed for this purpose (Figure 57) is completely filled with the fluid and left in a thermostat at a temperature of 35 to 37° C. for three days, a reading being recorded each day. Carbohydrate ferments the first and second days, and the gas evolved by this fermentation rises to the top of the cylinder. The amount of gas gives an indication of the relative amount of undigested carbohydrate. At this time, if there is carbohy- drate fermentation the specimen should have an acid reaction. 1 The protein decomposes on the third day and if this takes place more gas rises in the tube and the reaction of the specimen becomes alkaline. i The reaction may be tested by pressing down the glass rod and so forcing out through the tube on to a piece of litmus paper a drop of the contents of the cylinder. CHAPTEE XXVII EXAMINATION BY ROENTGEN-RAY In many cases valuable evidence for diagnosis may be obtained by Boentgen-Ray examination, and this is more readily accomplished in the case of children than adults, for children are easily moved, and this may be done without injury even when they are fairly sick. The use of the Roentgen-Bay in determining in- jury to bones has long been evident but its value in ascertaining changes in the cavities of the body is only now becoming appreciated. In intra-thoracic diseases it is particularly valuable. In cases of acute miliary tuberculosis it gives one a typical pic- ture when physical signs may be wanting, and the same is true of pneumonia. Pneumonia that pre- sents no physical signs may be discovered by Roent- gen-Ray and even when the location of the consolida- tion is thus made evident it may be impossible to elicit any physical signs. The Roentgen-Ray is valuable in differentiating consolidated lung from fluid, while in pneumo-thorax it gives a definite picture of the condition. Again in endocarditis we obtain not only evidence of the condition but definite information, better than can be obtained by percussion, of the enlargement of 245 246 ELEMENTS OF PEDIATEICS the heart and the damage to it ; while in pericarditis the Roentgen-Ray will differentiate between plastic exudate and fluid. In abdominal disease it is of less value, for in some evident conditions, such as certain tumours, it gives little shadow; it, however, shows well the distribu- tion of gas in the intestines, the presence and location of obstruction and the existence of ulcers in the stomach and duodenum. Cases of ptosis or abnor- malities of the colon or sigmoid flexure are well por- trayed by this method. In hospital work, examination by Roentgen-Ray has become almost a routine procedure for diagnosis, prognosis and a control of treatment, but in private practice it has still not attained the use to which it is entitled. CHAPTER XXVIII DIAGNOSIS Only a brief sketch can be made here of the gen- eral method of reaching a diagnosis of the common illnesses of infancy and early childhood. Diagnosis in infancy and early childhood must be based primarily on physical examination and rarely does an experienced pediatrist have difficulty in reaching a definite diagnosis. Figure 58 illustrates a method of judging in diag- nosis The history and temperature record show whether the disease is probably in the afebrile or febrile class, while if in the latter class the rapidity ot the respirations gives one a clue to further sub- division. Rapid respirations, that is, respirations over torty, suggest an involvement of the lungs No matter how much confidence a physician has in his nurse he should take the pulse and respirations him- selt. It the respirations are not persistently accel- erated, the diagnosis is more apt to fall in the last class, m which the diseases are arranged in order of tJieir frequency. «. Th !A X P J 6SSi0n ° f the Cbild ' flusLed or P^e cheeks, the attitude, retraction of the head, flexion of the legs the active motion of the alae nasi, the type of breathing, whether the pause is at the end of expira- 248 ELEMENTS OF PEDIATRICS tion, as in normal breathing, or at the end of in- spiration, as in pneumonic breathing, should all be noted as these factors aid in arriving at a diagnosis. One should always bear in mind the two condi- tions most apt to be over-looked on account of too superficial an examination: a pyelitis, the diagnosis Figure 58. DIAGNOSIS CHART Afebbile Febeile Rapid Respirations modebate nobmal Respirations ("Tuberculous Meningitis ■1 Certain Blood Diseases [Chronic Diseases Bronchitis Pneumonia Acute Pulmonary Tuberculosis Empyema Pneumo-thorax Cardiac Disease Gastrointestinal Disorder Pharyngitis Tonsillitis Otitis Media Dentition Acute Contagious Diseases, Measles, Scarlet Fever, Diph- theria, Mumps, Chicken-pox Meningitis Pyelitis Rheumatic Disease Typhoid Fever Malaria Intestinal Worms of which can only be made after a urinalysis, and an otitis, which often in infants gives no indication of its presence and is only discovered by careful exam- ination of the ear drum. DIAGNOSIS 249 Under afebrile conditions there is noticed tuber- culous meningitis. Although some rise of temper- ature may exist, this temperature is rarely much above normal. Also in diseases of the blood, some of these, such as a simple anaemia, may have no rise of temperature, while with Hodgkin's Disease, leuke- mia, or von Jaksch's Disease, a rise of temperature may exist. In most chronic diseases fever plays lit- tle part. Of febrile diseases with rapid respirations we note different conditions of the lungs and heart, but it should also be remembered that conditions in the abdomen that force the diaphragm up or cause great pain may produce some dyspnoea. Also in pneu- monia there may be only slight acceleration of res- pirations if the pneumonia is not accompanied by bronchitis, and the same is true of pulmonary tuber- culosis. In empyema the rapidity of respirations is somewhat proportionate to the amount of fluid present, just as in pneumothorax the respira- tions are proportionate to the amount of air pres- ent. Of those febrile disturbances, with moderate or normal respirations, we may note that an acute ill- ness with fever is most apt to be a stomach disturb- ance associated with a coated tongue or nausea or vomiting or constipation or diarrhoea. With such disturbances, chills and a very high temperature may occur. Influenza often causes a fairly high remitting tem- perature for a number of days and while generally 250 ELEMENTS OF PEDIATBICS associated with local signs these may be entirely lacking. Otitis media, usually a complication of a cold or influenza, should always be kept in mind and looked for in every child who is sick, even if it has rapid respirations or is afebrile, for this is a most uncer- tain, deceptive and often very dangerous compli- cation. Ears that are bulging and filled with pus and require immediate puncture of the drum, will at times give no evidence of pain or tenderness in babies. A diagnosis of dentition is allowable if the child has swollen red gums and little else to find, after a careful, thorough physical examination. The acute contagious diseases which most children must have in order to gain an immunity should be borne in mind, especially in children over a year old. These diseases begin mostly with symptoms in the upper air passages : measles, scarlet fever, German measles, mumps, chicken-pox, meningococcus menin- gitis, acute poliomyelitis. The Pons asinorum of pediatrics is pyelitis. Eunning an irregular temperature with marked re- missions lasting a day or two, it produces an irreg- ular temperature chart on which in many cases a presumption of the diagnosis can be made. This can only be confirmed by a microscopic examination of the urine, which shows many pus cells and bacteria. In children over five years of age, rheumatic dis- ease should be borne in mind, the only evidence often at the beginning of the disease in children being a DIAGNOSIS 251 soft, blowing murmur over the heart. Any child in whom a physical examination reveals nothing but an increasing temperature and a developing soft blow- ing murmur over the apex of the heart should be given the benefit of anti-rheumatic treatment. Typhoid fever and malaria are both very rare now in young children in well regulated communities, and the diagnosis should only be positively made when confirmed by blood examinations or other scientific tests. Intestinal worms should be borne in mind as occa- sionally causing severe prostration with fever in sus- ceptible children. CHAPTER XXIX TKEATMENT The treatment of children should consist much more in the general management of the case than in the administration of drugs, for, as a general rule, babies tolerate drugs poorly. Fever. — All children with fever should imme- diately be put to bed in a well ventilated, sunny and quiet room. The bowels should be moved by an effi- cient purgative and, if indicated, the bowels should be washed. If the fever is high, baths at 100° Fah- renheit for ten minutes, followed by hve minutes at 85° or 90° F. should be used. The diet should con- sist of plenty of water, clear soups and gruels. On the prompt institution of these precautions the rapid recovery of many cases depends. The drug treat- ment that is adopted in addition to this will depend on the result of the physical examination and urin- ary analysis. Method of administering drugs. — In giving drugs to babies, they must be administered in solution, sus- pension, or as powders moistened, for babies cannot swallow tablets or pills. In babies under one year of age, drugs with flavours most repulsive to adults will be taken with apparent relish. Thus asafoetida, which has a flavour most objectionable to adults, is 252 TBEATMENT 253 taken well by babies and is often most valuable in the control of colic. Castor oil also is usually taken well by babies and is, perhaps, the most valuable of all drugs in the treatment of babies under one year of age. In children more than a year old, care must be taken to administer drugs in as acceptable a form as possible, but one should not hesitate to give quinine or salicylate of soda if indicated, for if given with sufficient syrup, most children will take them with little objection. These drugs are best given in an undiluted com- pound syrup of sarsaparilla or syrup of Yerba Santa. Quinine is best given as the bisulphate, a soluble salt, in the proportion of two grains to the drachm. Dose. — The proportion of the adult dose to be given children of different ages may be estimated by either Young's or Cowling's formulae, remembering that some drugs are much more poorly tolerated by children than others, and that these formulae are only a rough estimate. Young's formula states that the dose equals the age divided by the age plus twelve : Age Dose = Age + 12. This gives the dose at different ages as the follow- ing proportions of the adult dose, 1 year i/ 13 2 years y 7 4 years % 12 years y 2 254 ELEMENTS OF PEDIATKICS Cowling's formula states that the dose should be the age at the next birthday divided by twenty-four. This gives the dose as follows : _^ Age at next birthday Dose = — — 24 1 year y 12 2 years % 5 years % 11 years % Of strychnine, babies over a year old can take a comparatively large dose, while to belladonna and opium and coal tar derivatives they are very suscep- tible. Tablets or pills may be administered dissolved in water or syrup in a teaspoon. If the medicine is ordered in fluid form in syrup it is well often to give it in a smaller dose than a teaspoonful. For these fractions of a teaspoon two measures are con- venient : one squeeze of a medicine dropper bulb will usually give about fifteen drops, or a quarter tea- spoonful, while an after-dinner coffeespoon holds thirty drops or half teaspoonful. In using spoons as measures it must be remem- bered that it is possible to pile liquid in a spoon and thus measure much more than a drachm in a tea- spoon. Thus one may say that One medicine dropperful = y S2 oz. Two medicine dropperfuls = 1 coffeespoonful = y 16 oz. Two coffeespoonfuls = 1 teaspoonful — y 8 oz. Two teaspoonfuls — 1 dessertspoonful = % oz. Two dessertspoonfuls — 1 tablespoonful = y 2 oz. These are convenient but rough inaccurate measurements. TREATMENT 255 The vehicle used is usually water with one-eighth part glycerine or one quarter part syrup. This may be a simple syrup or orange syrup, or if it is desired to cover a strong or bitter flavour the compound syrup of sarsaparilla or the syrup of Yerba Santa. In older children of four to six years cachets are well taken, while in children over six years of age pills may usually be administered. Therapeutic measures. — A very brief summary of some of the most useful measures for fulfilling clinical indications for treatment are indicated be- low. To empty the alimentary tract and move the bowels quickly, especially where the contents are suspected of causing trouble, no other drug is as useful as castor oil. It should be given alone during the first year, but later may be given with orange juice, a second glass of orange juice without oil being given immediately after, or syrup or some other agent to cover the taste of it. If the parents state that the child cannot take it, the doctor should ad- minister it himself, giving the child no notice of what is coming until he is ready to administer it, then pour it rapidly into the mouth from a spoon, press the lips together and have the face toward the ceiling. It will then flow into the throat and be swallowed. Should the first dose be vomited, a sec- ond dose will usually be retained, if given half an hour later. A dose of ten drops of castor oil is usually suffi- cient during the first month, while by the end of the 256 ELEMENTS OF PEDIATRICS first year two drachms are usually required and at two years a tablespoonful. Possibly the most useful internal treatment in diarrhoea in infancy is the administration of castor oil in doses of one or two drops with each feeding. In older children these small doses may be given in mucilage and sarsaparilla, which completely disguise the taste. Proprietary substitutes for castor oil have seemed to me to have no advantages. Calomel stands next to castor oil in the treatment of intestinal infections and may often have some ad- vantage over castor oil where a severe lung compli- cation exists or is feared. This is best given in tablet triturate dissolved in warm water in a tea- spoon. The dose in babies under one year is usually one-tenth grain repeated every hour or half hour, until the bowels act or one grain is given. When severe symptoms exist in children over six months old, the whole dose may be given at once. In chronic constipation, which is most apt to be troublesome at the end of the first year in children who are inactive and have not been put on a mixed diet, milk of magnesia is perhaps most useful, or rhubarb or cascara. Exercise and coarse foods are the most important curative agents. In the latter class, oatmeal, graham bread and bran biscuits are efficient. Alkalis are most important in the treat- ment of the digestive disturbances of children, espe- cially if associated with the odour of acetone in the breath and a marked acidity of the urine with the presence of acetone and diacetic acid in the urine. TKEATMENT 257 Bicarbonate of soda may be given in solution in one-fourth orange syrup and water in doses of two to ten grains every hour until the urine is rendered alkaline. Milk of magnesia being strongly alkaline is a good laxative to give in association with this treatment. Intestinal putrefaction characterised by foul breath, abdominal distention and offensive move- ments with indican and phenol in the urine is best treated by laxatives, especially rhubarb, as well as lacto-bacillary culture and bowel washings. Tonics are little indicated in early childhood. Nux vomica is perhaps the best appetizer given in doses of one-half to two minims three times a day, while in cases of anaemia the syrup of the iodide of iron in doses of three to ten minims three times a day after meals is most useful. Sedatives, on the other hand, are much more fre- quently indicated. Quiet is the most important sedative for babies. Warm baths at 100 degrees Fahrenheit continued for twenty minutes are most efficient. Very small amounts (% 6 grain) of gum asafcetida in solution is most efficient in babies under three months. Next in order are bromide and chloral, sometimes of use in convulsions, and last, opium, rarely indicated, which may be given in the form of paregoric in three or five minim doses in babies under a year, or morphine sulphate by hypo- dermic in Vwo or % grain doses in a child under a year. Cough syrups should rarely be given babies, as 258 ELEMENTS OF P^DIATEICS they are apt to upset them. A safe and efficient application for pharyngeal coughs is a solution of tincture of the chloride of iron. This may be given as early as the third month in a solution containing one scruple to one-half ounce of glycerine and water to four ounces; Of this, a coffeespoonful may be given every hour when the child is awake. Older children will take a stronger solution up to one drachm to the same amount of glycerine and water. For persistent and disturbing cough at night, a mix- ture of tincture of belladonna one-half drachm, wine of ipecac, one-half drachm, and paregoric, three to five minims in syrup and water, may be given every three hours p.r.n. Mustard plasters or capsicum vaseline over throat or chest relieve cough and in chronic catarrhal in- flammation cod liver oil is a valuable remedy. Antipyretics do young children much harm when administered as they are in adults. The legitimate, harmless, valuable antipyretics are cool air circu- lating about the body and warm baths at 100 degrees Fahrenheit, followed by five minutes at 85 degrees or 90 degrees Fahrenheit. Cold baths and ice packs are resented by babies and are rarely needed. Coal tar antipyretics should never be given to young children. Heart stimulants are rarely required by young children except in extreme conditions. Strychnine in doses of Koo grain may be used in babies a year old. Digitalis is often useful but must usually be given in large doses to obtain a definite effect. I TEEATMENT 259 have given repeatedly an adult dose of the tincture (ten drops) to a child of six years, with no effect on the pulse. One should always begin with a small dose of two or three drops and increase gradually. Digitalin is sometimes of more use and digipuratum sometimes gives excellent results. Antirheumatics are the same for children as for adults and when needed are often well taken. Chil- dren of six or eight years often require ten grains of sodium salicylate every two hours to control rheu- matic symptoms, or aspirin in the same dose. Atophan, grains 7/->, night and morning, is often more efficient and less disturbing. Methods of medication. Stomach. — Drugs are ad- ministered to children usually by the stomach and if apt to upset the stomach they are given after feed- ing, so that they become part of a very considerable volume of food and are thus well dissolved and ab- sorbed more slowly. Tonics to stimulate appetite and laxatives are more efficient often if taken on an empty stomach. Rectal medication. — Rectal medication may be used for nauseating drugs in infancy. Thus in per- sistent convulsions, bromide and chloral are usually given in solution by rectum. In acidosis with per- sistent vomiting alkalis are often introduced by means of an alkaline enema. In dysentery, starch is often valuable if injected in solution after a bowel washing. Suppositories of glycerine or gluten are often valuable in constipation. Skin. — a. The skin may be used for absorbing 260 ELEMENTS OF PEDIATEICS drugs. Thus in syphilis in babies a blue ointment diluted one-half is an excellent method of medication. In emaciated children with dry skin, cod liver oil inunctions are believed to be valuable. b. Counter-irritation of the skin is often valuable. Hot water or ice bags produce a useful local hyper- emia. Mustard pastes are most valuable, made with ground flaxseed one part in six to one part in two. A mixture of equal parts turpentine and olive oil is an excellent liniment for babies. c. Scarification, as in vaccination or von Pirquet test. d. Hypodermic medication as in the introduction of antitoxin or typhoid or other vaccine inoculation. e. Intravenous medication is sometimes used when very prompt action is needed. Inhalation. — The most valuable inhalation for all children is good, fresh, cool out of door air for twenty-four hours each day. Oxygen is an excellent stimulant in babies too young for the usual stimu- lation by stomach. Steam or creosote inhalations are useful occa- sionally, but they involve usually a hot, close room, which deprives the child of the cold, fresh air, which gives it resistance. In conclusion : Babies should have little medicine and unless there is some specific medication avail- able it is well to resort to those simple methods which enable the body to resist infections and are harmless. Coal tar derivatives should be given with caution. INDEX Abdomen, 10 protruding, 1 at birth, variability in meas- urement of, 6 circumference of, 6 prominence of, in infants, 10 at birth, 65 examination of, 222 palpation of, 223 percussion of, 223 tumor of, 223 Abdominal binder, 07 conditions, Roentgen ray in diagnosis of, 246 distention, 257 Abnormalities of breast milk, 130-131 Accessory feedings, 131, 141 Acetic acid test for albumin in urine, 234 Acetone, 231 in urine, test for, 236 in breath, 256 Acidity of urine, 231, 256 quantitative, 233 milk of magnesia in, 256 Acidosis, 231 Adenoid, 8 enlargement of, 8 necessity for removal of, 8 seat of, 37 hypertrophy of, 39 a cause of enuresis, 89 examination may be made without resistance, 221 examination, method of mak- ing, 226 Adhesions of foreskin, 96, 227 Adipose tissue, 5 Adult skull compared to that of infant at birth, 35 Afebrile conditions, 248 261 Age at which girls are heavier than boys, 27 at which boys are heavier than girls, 27 at which boys are taller than girls, 30 at which girls are taller than boys, 30 feeding of child in regard to, 165 a factor in caloric needs, 177 Air in nursery, fresh, 76 fresh, 92 fresh air in house, 92 roof extensions for securing fresh, 92 benefit derived from change of, 93 change of, 93 swallowed during feeding, 133 out of door, a stimulant, 260 Alae nasi in diagnosis, 247 Albumin, acid, 13 Albumin in urine, 230 in urine, tests for, 234 Albuminose, 13 Alexins according to Von Beh- ring, 170 Alimentary tract, contamination of by bacteria, 51 emptying of, 255 Alkaline laxative, milk of mag- nesia, 257 Alkalis in digestive disturbances, 256 Alveolar process, development of, at birth, 8 Amino acids, splitting up of pep- tones into, 50 Ammonium urates in urine, 239 Amorphous phosphates in urine, 233 262 INDEX Amorphous urates in urine, 233 Amusing the baby, 82 toys for, 83 Amylolytic action of secretion of pancreas, 13 Amylolytic ferment, 170 Analysis of breast milk, 123 of milk, value of, 127 of barley water, 185 Anaphylaxis, eggs a cause of, 207 Anatomy of the new born, 1. Anemia, simple, 249 treatment of, 257 Anorexia during dentition, 43 Antipyretics, 258 Antirheumatics, 259 Antitoxin, 260 Anuria, 73 method of overcoming, 73 Anus at birth, 65 Aorta, 2 descending, 2 Apparatus for modification of milk, 165 for Schmidt fermentation test, 243 Appearance of infant at birth, 5 of urine, 233 Appendages of foetal heart, 4 Appendix, position of, at birth, 11 vermiform, 50 vermiform, situation of, 50 examination, 223 Arch of foot, broken, 95 Argyrol, use of in eyes, 65, 74 Arrangement of nursery, 78 Arteries, carotid, 2 pulmonary, 2 subclavian, 2 umbilical, 2 Arteriosus, ductus, 2 Artificial feeding, 144 methods of, 176 Asafoetida, 252 as a sedative, 257 Aspirin, 259 Atophan, 259 Auricle of heart, left, 2 Auricle of heart — Continued. right, 2 opening between, 4 Auscultation of lungs, 224 Auscultatory percussion of heart, 223 Austria-Hungary, infant mortal- ity in, 58 Austrian laws regarding toys, 84 Babcock test, 126 Babies, new born, 12 feeding of those who do not thrive, 183 susceptibility of to tubercu- losis, 206 care of premature, 211 inactivity of premature, 211 incubator for premature, 211 feeding of premature, 213 cleansing of premature, 214 wet nurse for premature, 214 time when they begin to rec- ognise people, 215 amusing of, 215 at birth, sight and hearing of, 215 (See also Infants) Baby jumper, 93 Bacillus typhosis. Thermal death point of, 169 Bulgaricus, 190 Bacteria. Usefulness of, 51 present in breast milk, 128 in milk, 148 thermal death-point of, in a moist medium, 169 of feces, 241 Bacteria, Intestinal, 51 experiments on, 51 bacillus acidophilous, 52 bacillus bifidus, 52 bacillus coli communis, 52 bacillus lactis aerogenes, 52 bacillus perfringans, 52 Bacteria in milk, 147 contamination with, 147 method of avoiding, 148 killed by pasteurisation, 168 INDEX 263 Bacteria in urine, 238 in pyelitis, 232 Bactericidal action. Effect of heat on, 170 Bad children fault of parents, 218 Balanitis, 96 Barley water, 185 analysis of, 185 Barns, for cows, 146 certified milk. Washing facil- ities in, 148 Bath, the, 89 arrangements for, 90 contraindications to, 90 method of bathing, 90 temperature of, 90 for fever, 252 as a sedative. Warm, 257 as an antipyretic. Warm, 258 Bath tub. Convenient, 89 Bathing of baby at birth, 66 Bean cereal, 186 Bed-wetting, 88 cause of, 89 control of, 89 Beef, 207 from tuberculous cattle, 206 Beef broth. Analysis of, 205 preparation of, 206 Beef juice, 205 analyses of, 205 methods of preparing, 205 amount of nourishment in, 206 Belladonna, the use of in enure- sis, 89 dose of, 254 tincture of, 258 Benedict's test for glucose in urine, 235 Bicarbonate of soda, 257 Bile, excretion of in intrauter- ine life, 13 action in digestion, 50 when secreted, 50 clay coloured stools an indi- cation of insufficient, 86 Bile salts, secretion of in in- tra-uterine life, 13 Binder, abdominal, 67 Birth, peculiarities of child at, 1 a critical moment, 4 changes in infant at, 4 colour of child at, 5 sebaceous glands at, 5 cerebral hemorrhage at, 100 Bismuth a cause of dark stools, 86 Bladder, ligaments of, 4 at birth, 10 an abdominal organ at birth, 10 control of, 88 Blindness due to ophthalmia, 65 Blood, placental, 2 supply of foetus, 2 vessels supplying foetus, 2 at birth, 13 corpuscles, number at birth, 14 hemoglobin in, 14 hemoglobin at birth. 14 fresh, a cause of red stain in feces, 86 old, a cause of dark stools, 86 in urine, significance of, 232 cells in urine, 238 Blood pressure, 228 Bones, of skull, ossification of, 34 Roentgen ray in diagnosis of injury to, 245 Boracic acid solution, 64 Bottle, emergency, 141 sanitary nursing, 166 position of during feeding, 176 feeding, elimination of, 204 elimination of evening, 208 Bovaird, Doctor, 46 Bowels, securing movement of, 218 cleansing of in case of fever, 252 measures for moving, 255 (See also intestines) Boys, age at which they are heavier than girls, 27 age at which they are taller than girls, 30 Brain, size of at birth, 7 264 INDEX Brain — Continued. slight protection of at birth, 7 development of, at birth, 8 growth of, 37 weight of, 37 weight chart of, 38 Branchiogenic clefts, 65 Bread, pulled, 204 Breast feeding, weight results of, 22 mortality in, 60 possible for most mothers, 120 inadequate, 127 position for baby in, 132 air swallowed during, 133 position after, 133 sleepy infant at, 133 Breast milk, percentage of fat, sugar, and protein in, 70 analyses of, 71, 123 percentage of water in, 71 salts in, 71 table of percentage of ingredi- ents in, 71 in poverty, 118 superiority of, 118 contra-indications to use of, 119 curds of, 119 protein of, 119 reasons for superiority of, 119 determination of quantity of, 121 necessary quantity of, 121 method of obtaining speci- mens of, 122 quality of, 122 caseinogen in, 123 fat in, 123 protein in, 123 sugar in, 123 Holt's test for, 124 Dr. Holt's apparatus for ex- amination of, 124 salts in, 124 specific gravity of, 124 Babcock test for fat in, 126 chemical analysis of, 127 inadequate, 127 Breast milk — Continued. value of analysis of, 127 bacteria of, 128 not a sterile food, 128 effect of exercise on, 129 effect of worry, shock and fa- tigue on, 129 abnormalities of, 130-131 treatment of abnormalities of, 130-131 accessory feedings, 131 correction of deficiency in, 142 variation in secretion at dif- ferent times of day, 142 cow's milk a substitute for, 144 higher tolerance limit of, 203 Breast, secretion of in first days, 70 stimulation of secretion by nursing, 141 Breathing of infants, difficult, 4 insufficient, 4 type of, 247 Breck feeding tube, 72 Bromides, 257 Bronchi, 9 Broth, beef, 205 Brudzinski's sign, 227 Bulgaricus bacillus, 190 Bulging of ear drums, 250 Bunion, cause of, 96 Buttermilk in infant feeding, 190 Cachets, 255 Caecum at birth, 10 Caecum, 50 inflammation of, 50 situation of, 50 Calcium oxalate crystals in urine, 239 Calcium phosphate in cow's milk. 152 Calendar, use of in enuresis, 89 Calomel, 256 dose of, 256 Caloric requirements, estimation of, 176 needs at different ages, 177 values of different elements of food, 177 INDEX 265 Cane sugar, 193 Canopies over crib, 78 Capsicum vaseline, 258 Carbohydrates, caloric value of, 177 Carbonate of potash, used to neutralise malt extract, 192 Care of infant during first day, 63 during second day, 73 Carotid arteries, 2 Caseinogen in breast milk, 123 in cow's milk, 153 separation of, 187 Castor oil, 253-255 dose of, 255 substitutes for, 256 Casts in urine, 238 Catarrhal inflammation, 258 Cattle, tuberculosis of, 206 Cereal, 204 bean, 186 flour, 185 Cereal diluents, 154-184 food value of, 185 method of preparing, 185 Cerebral hemorrhage at birth, ef- fect of, 100 Certified milk, 144 commission, Dr. Coit's orig- inal, 145 barns, equipment of, 148 Cervical lymph nodes, 225 Changes in the heart after birth, 4 in infant at birth, 4 Chapin dipper, 162 Characteristics of infant, 1 Charts, weight, 15 normal weight of first week of life, 17 normal weight of first year, 18 individual weight, 20-21 weight, variation in average, 22 average weight of first year, 23 with normal weight line, 24 average weight from birth to twelfth year, 25 Charts — Continued. average weight and height of boys and girls from birth to sixteen years, 26 showing that loss of weight is an important indication of approaching illness, 28 average height during first year of 120 well cared for children, 29 length of children of the same weight at different ages, 31 head and chest circumference at different ages, 33 showing increase in weight of certain organs during in- fancy and childhood, 38 showing deaths by months in New York, 59 temperature during pasteur- isation of a bottle of milk at 10°C. and one at 17°C, 174 Von Pirquet, 198, 199, 200, 201, 202 weight and length of foetus in utero, 211 Cheese-cloth screens, 77 Chemical analysis of breast milk, 127 Chest circumference, 32 at different ages, chart of, 33 Chewing, encouragement of, 204 Chicken-pox, 250 Child in utero, nourishment of, 1 Children, older, average gain in weight of, 24 school, average weight of 69,- 000, 26 orphan asylum, average weight of, 26 proper exercise for, 95 eye-minded, 100 defective, 100 dull, 100 feeding of at different ages, 165 reaction of to modification of amount of food, 199 266 INDEX Children — Continued. premature, 210 age at which, they first use words, 215 at birth, mental activity of, 215 mental development of, 215 instruction of, 215 age at which children may at- tend kindergarten, 216 bad, 218 born good, 218 moral development and con- trol of, 218 suggestion in control of, 218 frightening of, 219 imagination of, 219 rewards and deprivations in control of, 219 should be made friendly to physician, 221 physical examination of, 221 confidence of, 222 deceiving of, 222 emaciated, 260 Chloral, 257 Circulation, foetal, 2 Circumcision, 96 of female children, 97 Circumference of abdomen, 6 Clean milk, 145 essentials for production of 146 Cleft palate, 65 interference of in nursing, 119 Clitoris, adhesions around, 96 Clock for nursery, 79 Clothing, danger of too tight, 66 binder, 67 time for discarding binder, 67 diaper, 67 danger of too much bed, 68 dress, 68 for night, 68 petticoat, 68 proper, 68 shirt, 68 too warm, 68 wet, 68 all babies wear, 69 Clothing — Continued. babies should wear, 69 of individual child, 70 insulation by, 70 Coal tar, derivatives, 254, 260 antipyretics, 258 Coit, Dr. Henry L., 145 Coli communis bacillus. Ther- mal death point of, 169 Colic, 133 effect of feeding whey milk on, 188 asafcetida in, 253 Colostrum, 70 percentage of fat, sugar and protein in, 70 analysis of, 71 coagulation of, 71 . microscopic examination of, 71 percentage of water in, 71 purgative action of, 71 salts in, 71 table snowing amount of in- gredients in, 71 on second day, 74 Colour of infant at birth, 5 of urine, 233 of feces, 240 Column, spinal, 7 Commission, certified milk, 145 Concentration, lack of ability for in children, 216 Condensed milk, proportion of elements in, 193-194 in infant feeding, 193 Confidence of child toward phy- sician, 222 Congenital defect, 63 of heart, 63 Conjunctivitis, 73 Consistency of feces, 241 Constipation, fat in food a pre- ventative, 87 control of by kindergarten ex- ercises, 99 in underfed children, 128 chronic, 256 exercise in, 256 milk of magnesia in, 256 INDEX 267 Constitution, lymphatic, 9 Contagion, 97 Contagious diseases, 250 Contamination of vaccination, 112 Control of children, 218 Convalescence, weight a guide in, 27 Convulsions due to eggs, 207 treatment of, 257 Cool air as an antipyretic, 258 Cord, umbilical, 2, 4 fibrous, 4 cutting of the, 64 Cornmeal, 185 Corns, cause of, 96 Corporal punishment, 219 Corpuscles, red blood, number at birth, 14 white blood, number at birth, 14 Cough, syrups, 257 treatment for, 258 Coughing at night, treatment for, 258 Counter-irritation of skin, 260 Cows, proper barns for, 146 clipping of udders and sides, 146 grooming of, 146 tail, clipping of, 146 washing of, 146 contamination of udder of, 149 tuberculosis of, 150 Cow's milk, a substitute for breast milk, 144 composition of, 151, 153 mineral matter in, 152 protein of, 152 dilution of, 154 modification of, 154 Cowling's formula of dose of drugs for children, 253, 254 Cramps, treatment for, 83 Cranial cavity pressure in, 225 Cranio-tabes, 7, 225 Crawling, period at which chil- dren begin, 94 Cream, in milk modifications, 162 Cream — Continued. gravity, 163 Creosote inhalations, 260 Cretinism, 101 delayed dentition in, 43 Crib, canopies over, 78 construction of, 78 position of in nursery, 78 quilted hangings for, 78 Cry of baby, character of, 215 Crying, examination before, 222 Crystals in urine, 239 Cummings, method for modifica- tion of milk used by Doctor, 154 Curds, in feces, composition of, 86 in feces, due to indigestion, 86 in feces, 242 an evidence of protein indiges- tion, 86 of breast milk, 118 of cow's milk, 152 effect of cereal diluents on, 184 composition of, 186 in stools, effect of peptonising on, 186 size of, in cow's and mother's milk, 187 Curves of spine, normal, 36 Cyanosis, 64 Damp days, 92 Dangers to milk, 148 Dangerous articles used for toys, 83-84 Day, regime for, 102 Deafness, 100 Deceiving children, 219 result of, 222 Defecation on second day, 73 Defective children, 100 Dentition, 39 age at which first tooth ap- pears, 39 development of first, 39 late, 39 age of eruption of teeth, 40 figure showing first, 40 268 INDEX Dentition — Continued. summary of, 40 second, 41 age of appearance of second teeth, 41 summary of second, 41 figure indicating age of erup- tion of second, 42 anorexia during, 43 delayed in cretinism, 43 delayed in rachitis, 43 disturbances of, 43 early in syphilis, 43 fever during, 43 Hutchinson's teeth, 43, indications of early, 43 a cause of pharyngitis^ 43 sore gums in, 43 symptoms of, 43 examination of teething child, 44 rubbing teeth through gum, 44 diagnosis of, 250 (See also teeth and teething.) Determination of children, 219 Development, 15 reason why certain parts of infant are more developed than other parts, 4 of alveolar process at birth, 8 of nose at birth, 8 weight as a standard of, 15 of first dentition, 39 of children, mental, 215 moral, of children, 218 Dextri-maltose, 192 Mead's, 192 Dextrinised cereal, 185 Diabetes, 230 Diacetic acid, 231 test for, in urine, 236 Diagnosis, 247 pulse in, 247 respirations in, 247 chart, 248 Diagnostic sign of pulse, 222 Diaper, 67 cause of red stains of, 10 best form of, 67 Diaper — Con tinned. objection to rubber covering over, 68 changing of, 104 Diaphragm, 10 development of at birth, 10 position of at birth, 10 importance in respiration, 10 hernia of, 64 Diaphragmatic respiration, 67 Diarrhoea, 59 castor oil in, 256 Diet, after second year, 208 fifth to tenth year, 208 of wet nurse, 140 in fever, 252 (See also Feeding.) Digestion, 13-46 part taken by stomach in, 13 of starch, saliva in, 47 action of bile in, 50 Digestive fluid, saliva, 47 Digestive disturbances, alkalis in treatment of, 256 Digipuratum, 259 Digitalin, 259 Digitalis as a heart stimulant, 258 Dilution, of cow's milk, 154 of urine, 230 Diphtheria, bacilli in milk, 148 bacillus, thermal death point of, 169 Dipper, Chapin, 162 Dirt, inhalation of, a cause of infection, 97 Disease of mother not always an indication for weaning, 135 Dose of drugs for children, 253 Draughts, effect of on children, 77 Dress, 68 Dressing of babies, 66 Drugs, flavours of, *252 method of administering, 252 in solution, 252 treatment in fever, 252 Dry milk, 194 composition of, 194 method of producing, 194 INDEX 269 Dry milk — Continued. method of preparing formulae containing, 195 Ductus, arteriosus, 2 venosus, 2 venosus, changes of, 4 venosus, time of change, 4 Dull children, 100 treatment of, 100 Dura mater, 7 Dyspnoea, cause of, 249 Ear-minded children, 100 Ear-drums, bulging of, 250 Ears, 9 development of, at birth, 9 mastoid cells, 9 deafness, 100 examination of, 224 instrument for examining, 224 difficulty of examining babies, 225 pain in, 250 pus in, 250 Eggs, 207 convulsions due to, 207 method of first giving, 207 reaction of children to, 207 Eiweiss milk, 190 Elasticity of gastric wall, 48 Elimination of bottle feeding, 204 Emergency feedings, 141 Encouraging children, 219 Endocarditis, Roentgen-ray in diagnosis of, 245 England, infant mortality in, 58 Engle, experiments on micturi- tion, 56 Enuresis, nocturnal, 88 causes of, 89 methods for control of, 89 Epithelial cells in urine, 238 Establishment of function of lungs, 4 Eustachian valve, 2 disappearance of, 4 Examination, of child at birth, 65 Examination — Continued. at birth, serious results of neglect to make, 66 laboratories for physical, 100 of school children, 100 adenoid, 221 physical, 221 before crying, 222 after crying, 224 of feces, 240 of feces. Microscopic, 241 by Roentgen-ray, 245 Exanthemata, acute, in nursing mother, 120 Exercise, 106 for children, 93 baby jumper a means of ob- taining, 93 walking, 94 proper kind for children, 95 for constipation, 256 Experiment for determining number of bacteria in milk, 147 Expiratory grunt in connection with respirations, 222 Expression of child in diagnosis, 247 Extremities, blood supply of foetal, 2 nourishment of, 2 Eye, at birth, 8, 64 a perfect organ at birth, 8 cause of poor perception at birth, 8 lachrymal glands at birth, 8 care of at birth, 64 ophthalmia, 65 conjunctivitis of, 73 examination of on second day, 73 use of argyrol in, 74 use of silver nitrate in, 74 washing of with boracic acid solution, 74 minded children, 100 sunken, cause of, 222 examination of, 226 Face, small, 1 270 INDEX Face — Continued. Feces — Continued at birth, 7, 33 dark colour due to old blood, at birth, size of, 8 86 increase in size of, 33 dark colour due to iron, 86 reason for increase in size of, fresh blood a cause of red stain 34 in, 86 Failure to gain, 24 mucus in, 86 Falsehoods, telling of by chil- respiratory mucus in, 86 dren, 219 shininess of, 86 Fatigue, 95 smoothness of, 86 effect of, on breast milk, 129 frequency of movement of, 87 a cause of inadequate breast softness of, 87 milk, 143 odour of, 87, 241 Fats, absorption of in intestines, quantity of normal, 87 50 method of obtaining movement action of pancreatic secretion of, 88 on, 50 loose, 128 in breast milk, 70 offensive, effect of buttermilk in colostrum, 70 on, 190 in food, clay coloured stools effect of malt on, 193 an indication of too much, impactions of, 223 86 colour of, 240 in feces a cause of shiny char- examination of, 240 acter, 86 obtaining specimens of, 240 excess of in food, 87 bacteria of, 241 in breast milk, 123 consistency of, 241 in breast milk, Babcock's test microscopic examination of, for, 126 241 too much in breast milk, 142 reaction of, 241 deficiency of in breast milk, protein in, 242 142 test for undigested food in, in cow's milk, 151 242 content of a quart bottle of undigested food in, 242 milk, 162 Schmidt fermentation test, percentage of in quart bottle 243 of milk, 163 (See also Stools) splitting ferment, 170 Feeding, improper, a cause of caloric value of, 177 failure to gain, 24 indigestion, evidences of, 180 during first twenty-four hours, Febrile conditions, 248 70 Feces, passed in first days, 72 tube, Breck, 72 on second day, 73 breast, interval of on second normal appearance of, 85 day, 74 colour of normal, 85 on second day, 74 quality of, 85 time at which change is made colour of abnormal, 85-86 to four hour interval, 104 curds in, 86, 242 during first year, 117 dark colour due to bismuth, 86 different methods of, 118 clay coloured, an indication of breast, inadequate. 127 too little bile, 86 accessory, 131, 141 INDEX 271 Feeding — Continued. method of breast, 132 emergency, 141 mixed, 141 artificial, 144 infant, 144 modification of milk for in- fant, 154 normal, 155 malt in infant, 156 cream modifications in infant, 163 for babies of different ages, 165 methods of artificial, 176 amount of time that should be taken over, 176 average of a baby during the first year, 177 for the first year, 178 changes in amount of labora- tory, 181 amount of first, 181 of difficult cases, 183 buttermilk in infant, 190 maltose in infant, 192 malt soup in infant, 192 theory of infant, 197 over-, 198 after second year. 208 of premature baby, 213 modification of breast milk for premature babies, 214 Feedings, number of, 208 "Feedings that fit," 195 Feet at birth, 65 Feet, 95 the care of the, 95 examination of, 227 Fehling's test for glucose in urine, 235 Femora, effect on, by diaper, 67 Fence, nursery, 94 Fermentation test, for glucose in urine, 236 of feces, 243 Schmidt's, 243 Ferments of milk, 168 effect of heat on, 170 Fever, inanition, 18 Fever — Continued. during dentition, 43 treatment of, 252 Finklestein milk, 190 preparation of, 191 substitute for, 191 uses of, 191 Fireplace as a means of ventila- tion, 76 First year feeding, 117 examples of, 178 Flat foot, cause of, 95 Fleischner, Doctor, 30 Flour, cereal, 185 Foetal, circulation, 2 appendages of heart, useful- ness of, 4 Foetus, blood vessels supplying, 2 heart of, 2 in utero, 211 in utero, weight and length of, 211 Fontanelles, 6 anterior, 6, 34 lateral, 6, 7 posterior, 6 size of at birth, 6 anterior, bulging of, 34 anterior, importance in diag- nosis, 34 closing of, 34 figure showing, 35 at birth, 65 examination of, 225 Food, passage of into intestines, 13 spoiling of by heat, 60 mortality in infants fed on artificial, 60 first artificial, 72 clay coloured stools an indi- cation of too much fat in, 86 excess of fat in, 87 time at which character of food is changed, 105 choice of in first year, 117 conditions that govern choice of, 117 value of cereal diluents, 185 272 INDEX Food — Continued. proprietary, 195 administration of, 197 maximum amount of, 197 minimum amount of, 197 optimum amount of, 198 tolerance of, 198 reaction of child to modifica- tion of amount of, 199 effect of reducing to a mini- mum when the tolerance is only slightly reduced, 200 effect of temporary with- drawal of when tolerance is considerably reduced, 201 effect of withdrawal of when tolerance is of or below the minimum, 202 first food to be added after bottle, 204 undigested as shown in feces, 242 coarse food in treatment of constipation, 256 Foot, flat, cause of, 95 Foramen ovale, 2, 4 closing of, 4 patent, 64 Foreskin, adhesions of, 96, 227 retraction of, 96 Formula, defective, a cause of loose stools, 87 preparation of, 156-161 for malt soup, 193 containing dry milk, 195 France, infant mortality in, 58 Frequency of movements^ 87 Fresh air, 92 in nursery, 76 rest in, 91 not a cause of illness, 97 Frightening of children, 219 Frontal bone, orbital plate of, 8 Function of lungs, establishment of, 4 Furniture for nursery, 78, 79 Gain in weight, failure to, 24 in spite of bad stools, 132 Games, 95 Gas in intestines, effect of but- termilk on, 190 Gastric, wall, elasticity of, 48 capacity, measurement of, 49 juice, stimulation of, 204 Genitals, at birth, 65 retraction of foreskin, 65 care of, 96 examination of, 227 Geographical tongue, 226 German measles, 250 Germany, infant mortality in, 58 Ghost stories, 219 Girls, age at which they surpass boys in weight, 27 age at which they are taller than boys, 30 Gland, Thymus, 9 enlargement of, 9 size of, 9 weight of, 44 position of, 44 Glands, 225 sebaceous, 5 sweat, development of at birth, 5 salivary, secretion of, 13 salivary, time of increase of se- cretion of, 13 Glucose, tests for, 235 in urine, fermentation test for, 236 Goat's milk, 144 Gonococcus infection of eyes, 65 Gravity cream, 163 Graduate, sugar of milk, 165 Grooming of cows, 146 Growth, in height, 29 of special parts of body, 30 of brain, 37 in length of spine, 37 of post-nares, 37 Gums, sore, due to teething, 43 Habit, in micturition, 88 in moving bowels, 88 masturbation, 96, 97 thumb sucking, 98 kissing, 99 Hands at birth, 65 INDEX 273 Hare lip, 65 an interference with sucking, 46 interference of in nursing, 119 Head, 7 of infant, 1 blood supply to, 2 proportion of, 5 circumference of at birth, 6 size of at birth, 7 and chest circumference, 32 circumference, 32 circumference at different ages, chart of, 33 distortion of at birth, 65 retraction of, 222, 247 Heart, foetal, 2 changes in after birth, 4 changes in at birth, 4 opening between auricles of, 4 structure of in intra-uterine life, 4 at birth, size of, 9 weight chart of, 38 increase in weight of, 44 position of, 45 congenital defect of, 63 action at birth, 65 disease, decayed teeth a cause of, 91 examination of, 223 sounds, 223 disease, rheumatic, 224 murmurs, 224 stimulants, 258 Heat, effect of on certain biologic characteristics of milk, 170 Height, 27 of boys and girls, comparison of, 27 during first year of 120 well cared for children, 29 first year, 29 growth in, 29 second year, 29 importance of record of, 29 variation between that of boys and girls, 30 of premature babies of differ- ent ages, 210 Hemoglobin, amount of, 14 Hemorrhage, cerebral at birth, 100 Hernia, diaphragmatic, 64 Herter, intestinal infantilism of, 242 Hippius, effect of heat on cer- tain biologic characteristics of milk as determined by, 170 Hodgkins' disease, 249 Holt, Doctor, 47 test for breast milk, 129 Home modification of milk, 181 Hospital rooms, especially for premature babies, 213 Hot water bag, 260 Human milk, percentage of in- gredients of, 71 (See also breast milk.) Humidity, a cause of infant mor- tality, 60 Hutchinson's teeth, 43 Hydrocephalic type of idiocy, 100 Hydrochloric acid, free, 13 Hygiene of nurse^, 75 Hyperaemia, 260 Hypodermic medication, 260 Ice bags, 260 ldiocv, hydrocephalic type of, ioo microcephalic type of, 100 Mongolian type of, 100 benefit of treatment of, 101 cretinism, 101 Iliac, internal, 4 Illegitimacy, a cause of infant mortality, 60 Illness, a cause of failure to gain, 24 a cause of inadequate breast milk, 143 on part of mother a contra- indication to nursing, 120 Imagination of children, 219 Immunisation for typhoid fever, 115 Inactivity of premature babies, 211 274 INDEX Inanition fever, 18 Incubator for premature babies, 211 illustration of, 212 air supply of, 213 heating of, 213 substitutes for, 213 Indexing, reaction of urine to acetone and diacetic acid, 231 pus in urine, 232 Indican in urine, 231 in urine, test for, 237 in intestinal putrefaction, 257 Indigestion, evidences of, 180 Infant, characteristics of, 1 comparison of with adult, 1 examination of, 1 head of at birth, 1 reason for development of cer- tain parts of, 4 at birth, appearance of, 5 at birth, colour of, 5 at birth, length of, 6 at birth, examination of, 65 body, proportions of compared to adult, 5 absence of intestinal bacteria in newly born, 51 care of the healthy, 57 the care during the first day of the, 63 dressing of, 66 first washing of, 66 newly born, light for, 70 care of during the second day, 73 treatment of during first months, 82 result of attention paid to during first year, 85 exercise for, 93 indications in, for weaning, 134 loss of weight in first few days, 121 of wet nurse, control of, 139 Infant feeding, 144 importance of intelligent, 117 modification of milk for, 154 Infant Feeding — Continued. malt in, 156 cream modifications in, 163 cereal diluents in, 184 buttermilk in, 190 malt soup in, 192 maltose in, 192 graphic representation of, 197 theory of, 197 Infant mortality, 57 in various countries, 57 causes of, 58 hot weather in cities a cause of, 58 reduction of, 58 by months in New York, va- riation in, 59 in artificially fed children, 60 humidity a cause of, 60 illegitimacy a cause of, 60 in summer, 60 poverty a cause of, 60 measures for reducing, 61 in private practice, 61 Infantilism of Herter, intestinal, 242 Infections, navel, direction taken by, 5 navel, 64 of eyes, 65 of eyes by gonococcus, 65 of intestine, 71 protection from, 97 methods for prevention of, 98 Inferior vena cava, 2 Inflammation of urinary tract, 232 Influenza, 249 Inhalation medication, 260 Instruction of children, 215 Instrument for examination of ears, 224 Internal iliac, 4 Intestinal bacteria, 51 absence of in new born, 51 time at which invasion takes place, 51 u^pfnlness of, 51 bacillus acidophilous, 52 bacillus bifidus, 52 INDEX 275 Intestinal bacteria — Continued, bacillus coli communis, 52 bacillus lactis aerogenes, 52 bacillus perfringans, 52 Intestinal infantilism of Her- ter, 242 Intestinal infection, 71 a cause of loose stools, 87 Intestinal, intoxication, 231 worms, 251 putrefaction, 257 Intestines, 49 at birth, 10 elastic nature of, 49 length of, 49 length of large, 49 length of small, 49 absorption from, 50 growth of, 50 at birth, sterile, 71 time for obtaining movement from, 85 Intoxication, intestinal, 231 Intra-thoracic diseases, Roent- gen-ray in, 245 Intra-uterine life, organs in, 4 viability of babies with differ- ent periods of, 210 Intravenous medication, 260 Intraventricular partition, defec- tive, 64 Intussusception, 223 Inunctions, 260 Iron, a cause of dark stools, 86 syrup of the iodide of, 257 tincture of chloride of, 258 Italy, infant mortality in, 58 Jaws, development of, 204 Juice, beef, 205 Jumper, baby, 93 Keller's malt soup, 192 Kernig's sign, 227 Kidneys, size of at birth, 10 weight chart of, 38 growth of, 46 increase in weight of, 46 examination of, 223 Kindergarten, 99 proper teacher for, 99 age at which children may at- tend, 216 benefits of, 216 proper, 216 Kissing, 98 dangers of, 99 Koplik spots, 226 Laboratory milk, 162 Laboratories for modification of milk, 155, 182 Lachrymal glands at birth, 8 Lactalbumin in cow's milk, 152 Lactation, inadequate, 142 Lacto-bacillary, culture, 190 milk, 190 Lactose, in breast milk, 123 in cow's milk, 152 Lactoserum, 170 Lamb, 207 Laws regarding toys, 84 Laxatives, 257 milk of magnesia, 257 Legs, 1 growth of, 30 flexion of, 247 Legume flour, 185 Length, relation of weight to, 15 growth of children who do not gain in weight, 30 of children of the same weight at different ages. 31 of foetus in utero. 211 Leucocytes in urine. 232 normal number in urine, 232 Leukemia, 249 Ligaments of bladder, 4 Light in nursery, 77 Lighting of nursery, artificial, 78 Lime water in milk modifica- tions, 157 Liniment, 260 Liver, 50 Liver, blood supply of, 2 nourishment of, 4 at birth, 10 276 INDEX Liver — Continued. fat of, 10 size of at birth, 10 weight chart of, 38 fatty, 45 increase in size of, 45 position of, 45 enlargement of, 223 examination of, 223 Loeffland's malt soup, 193 Loss of weight in first days, ef- forts to avoid, 72 Lungs, changes in at birth, 4 establishment of function of, 4 in intra-uterine life, 4 solid organs, 4 structure of, at birth, 9 of infant, variation in struc- ture from adult type, 9 weight chart of, 38 changes in structure of, 45 growth of, 45 weight of, 45 unequal expansion of, 54 at birth, 63 palpation of, 224 physical examination of, 224 Lymphatic constitution, 9 Lymph nodes cervical, enlarge- ment of, 9, 225 Macroscopic examination of .feces, 242 Magnesia, milk of, 256 Malaria, 251 Malt, 185 in infant feeding, 156 extract, use of neutralised, 192 soup, 192 soup formula, 192-193 effect of on feces, 193 Maltine, 193 Maltose, 191 Maltzyme, neutralised, in the preparation of malt soup, 193 Mammala, 195 Marasmus, fresh air an aid in, 77 Mastoid, cells, development of at birth, 9 inflammation of, 9 region, examination of, 225 Masturbation, 96 in female babies, 96 Maximum amount of food, 197 Mead's dextri-maltose, 192 Measles, 250 German, 250 Measurements, at birth, 6 chest, 32 head, 32 of body, 228 for doses of medicine, 254 Meat, from tuberculous cattle, 206 first meat to be given a child, 207 method of preparing for chil- dren, 207 Meconium, 13, 71 amount of, 13 method for expulsion of, 73 Medication, methods of, 259 by rectum, 259 through the skin, 259 by stomach, 259 by counter-irritation, 260 by hypodermic, 260 by inhalation, 260 intravenous, 260 by inunctions, 260 Meningitis, pulse in, 222 retraction of head in, 222 tuberculous, 249 Meningococcus meningitis, 250 Menstruation of mother no indi- cation for weaning, 135 Mental development of children, 215 Metchnikoff, commendation of buttermilk by, 190 Methods, of supplementing de- ficiencies in breast milk, 142 of modification of milk, 156 of artificial feeding, 176 INDEX 277 Methods — Continued. of preparing formulae contain- ing dry milk, 195 for care of premature children, 210 of making physical examina- tion, 221 of medication, 259 Microcephalic type of idiocy, 100 Microscopic examination, of urine, 238 of feces, 241 Micturition, frequency of, 56 Milk (see breast milk also), 71 superiority of breast, 118 superiority of over other food for infants, 118 reasons for superiority of breast, 119 contra-indications to use of breast, 119 certified, 144 cow's, a substitute for breast, 144 goat's, 144 clean, 145 commissions, Dr. Coit's plan for, 145 essentials for production of clean, 146 bacteria in, 147, 148 contamination of with bac- teria, 147 cooling of, 147 receptacles, sterilisation of, 147 dangers to, 148 contamination of from bac- teria in udder of cow, 149 typhoid bacilli in, 149 commission of county of New York, 150 composition of cow's, 151 dirty water as a source of con- tamination of, 149 fat content of cow's, 153 dilution of, 157 fat content of a quart bottle of, 162 preparation of modified, 166 Milk — Continued. sterilisation of, 168 ferments of, 170 prescription, 183 peptonising of, 186-187 action of rennet on, 187 Eiweiss, 190 Finklestein, 190 lacto-bacillary, 190 protein, 190 maltose in, 192 condensed, in infant feeding, 193 dry, 194 composition of dry, 194 method of producing dry, 194 method of preparing formulae containing dry, 195 Milk depots, 61 Milk laboratories, 155, 162, 182 Milk modification, 154, 156- 161 apparatus for, 165 home, 181 cereal diluents in, 184 conditions that control, 176 cream in, 162 Dr. Cumming's method for, 154 equipment for, 79 lime water in, 157 Dr. Rotch's method for, 154 skimmed milk in, 159 Milk, pasteurisation of, 150, 168 in pasteuriser, temperature of, 172 recontamination of after com- mercial pasteurisation, 175 taste of unaltered by pasteur- isation, 168 commercial pasteurisation of, 175 Milk sugar graduate, 166 Milk of magnesia, 256 Milkmen, danger from, 148 Milking, proper method of, 147 Millon's reagent, 237 Mineral matter in cow's milk, 152 Minimum amount of food, 197 278 INDEX Mixed feeding, 141 Modification of amount of food, reaction of child to, 199 Modification of cream, 163 Modification of milk, equipment for, 79 laboratories for, 155 method of, 156 necessary apparatus for, 165 preparation of, 165 conditions that control, 176 home, 181 of whey milk, 188-189 Mongolian type of idiocy, 100 Moral development and control of children, 218 Morphine sulphate, 257 Mortality, infant, 57 infant, in various countries, 57 infant, causes of, 58 infant, hot weather in cities a cause of, 58 infant, reduction of, 58 infant, variation in by months in New York, 59 in breast fed babies, 60 in infants fed on artificial food, 60 infant, humidity a cause of, 60 infant, illegitimacy a cause of, 60 infant, poverty a cause of, 60 infant, in summer, 60 infant, in private practice, 61 of premature babies of differ- ent ages, 210 Mother, duties of, 119 illness of, a contra-indication to nursing, 120 if properly instructed and con- trolled can nurse babies, 120 care of nursing, 129 diet for nursing, 129 indications for weaning in, 135 menstruation of, no indication for weaning, 135 treatment of during weaning, 137 Mouth, 8 moisture of, 8 at birth, 65 cause of deformity of, 98 method of examining, 226 Mouth washing, 90 danger of, 132 Movements, method of obtaining, 88 offensive, 257 Mucus, in feces, 86 method of determining pres- ence of, in stool, 86 respiratory in stools, 86 in stool, cause of, 86 in urine, 239 Mumps, 250 Murmurs, heart, 224 Mustard, plasters, 258 paste, 260 Nap, 91, 107 Nares, growth of post-, 37 Nasal cavity, 8 size of at birth, 8 obstruction, an interference with sucking, 46 Nasopharynx, importance of, 37 Navel, infections, direction of, 5 infection, 6, 64 time of healing of, 6 wound, 6 care of, 64, 67 dressing, 67 Neck, 1 lymph nodes of, 9 size of at birth, 9 stiffness of back of, 225 Nephritis, 230 blood in urine in, 232 Nervous irritation, effect of, on breast milk, 129 Nervousness of infants, 81 Neurasthenia in infants, 81, 215 Neutral fats in feces, staining for, 242 Neutralisation of malt .extract by carbonate of potash, 192 New born, anatomy of, 1 baby, 12 INDEX 279 New York State, infant mortal- ity in, 57 Nicoll, Doctor, 46 Nipple, cleansing of, 70 abnormality of, 120 cleansing of by infant, 129 cracked, 135 Nipples for bottles, 166, 176 Nitrate of silver, 64 Nitric acid test for albumin in urine, 234 Nits, 225 Nocturnal enuresis, 88 Noise, disastrous effect of, on children, 81 effect of on sick children, 81 Normal child, control of, 218 Nose, development of at birth, 8 examination of, 226 Nourishment, of child in utero, 1 placental, 4 Nurses, 81 incompetent, 81 necessary attributes of, 82 trained nursery maids, 82 wet, 138 wet, as a final resort, 156 Nursery, exposure of, 75 hygiene, 75 size of, 75 ventilation of, 75 fresh air in, 76 ventilation, methods of, 76 lighting of, 77 arrangement of, 78 artificial lighting of, 78 furniture, 78, 79 scales, 79 table, 79 walls, 79 temperature, correct, 80 isolation of from other parts of house, 81 quiet in, 81 should not be a sitting room, 81 situation of, 81 fence, 94 Nursery maids, trained, 82 Nursing bottle, sanitary, 166 Nursing, contra-indications to, 119 interference with by abnor- mality of nipple, 120 inadequate, 127 mother, care of, 129 cracked nipple, 135 pain in, 135 stimulation of secretion of breasts by, 141 Nutritional diseases not due to pasteurised milk, 168 Nuttall, experiments on intes- tinal bacteria by, 51 Nux vomica, 257 Oatmeal, 185 Obermayer's reagent, 237 Odour, of feces, 87, 241 (Edema due to eggs, 207 Ophthalmia, 65 cause of, 65 Opium, 257 dose of, 254 Optimum of Von Pirquet, 198 Orange juice, 104, 182 amount fed, 182 for artificially fed babies, 182 as a preventative of scurvy, 182 Organs, lungs, solid, 4 proportional weight of, 46 Orphan asylum children, average weight of, 26 Ossification of bones of skull, 34 Otitis media, 248, 250 Out of doors, time when baby should first go, 92 Ovale, foramen, 2 closing of, 4 Oxidising ferment, 170 Oxygen as a stimulant, 260 Pail, proper milking, 147 Pain in ears, 250 Palate, cleft, an interference in sucking, 46 Palpation of heart, 223 of lungs, 224 280 INDEX Pancreas, 50 amylolytic action of secretion of, 13 at birth, development of, 13 at birth, secretion of, 13 secretion of, 50 Pancreatic, secretion, action of, 50 extract, effect of on children, 187 Paregoric, 257 Parotid glands, 225 Pasteurisation of milk, 150, 168 not a cause of nutritional dis- ease, 168 not a cause of rachitis, 168 not a cause of scurvy, 168 temperature of, 170 in nursing bottle, 171 length of time that heat should be sustained, 172 without use of apparatus, 171 temperature of bottle of milk at 10°C. and one at 17°C, 174 commercial, 175 Pasteuriser, 172 directions for using, 172 illustration of, 173 Peculiarities of child at birth, 1 Pediculi, 225 Pelvis of infant, 1 size of at birth, 10 Pepsin, 13 Peptone, 13 Peptones, splitting up into amino acids, 50 absorption of in intestines, 51 Peptonising, 186 effect on milk of long contin- ued, 187 for premature babies, 214 Percentage cream, 162 Perception, cause of poor, at birth, 8 Percussion, of abdomen, 223 of lungs, 224 Pericarditis, Roentgen-ray in diagnosis of, 246 Petticoat, 68 Pfaundler, Doctor, 48 Pharyngitis during dentition, 43 Pharyngeal cough, application for, 258 Pharynx, examination of, 226 Phenol, in urine, 231 in urine, test for, 237 in intestinal putrefaction, 257 Phimosis, 96 a cause of enuresis, 89 Phosphates, amorphous, in urine, 233, 239 triple, 239 in urine, 239 Physical development, of chil- dren, 217 Physical examination of chil- dren, 221 method of making, 221 of child while asleep, 222 in diagnosis, 247 Physician, friendliness of child to, 221 Physiology of the new born, 12 Physique, importance of good, 216 Pills, 252 administration of, 254 Placenta, 2 Placental, blood, 2 nourishment, 4 Playgrounds, roof, 92 Pneumonia, type common in in- fants, 9 broncho-, 10 lobar, 10 pulse in, 222 respiration in, 222 Roentgen-ray in diagnosis of, 245 Pneumonia, 249 Pneumococcus, thermal death point of, 169 Pneumonic breathing, 248 Poliomyelitis, 250 Post-nares, growth of, 37 size of, 37 Poverty, a cause of infant mor- tality, 60 INDEX 281 Poverty — Continued. use of breast milk for children born in, 118 Powders, 252 Pregnancy an indication for weaning, 135 Premature babies, 210 inactivity of, 211 feeding of, 213 cleansing of, 214 Preparation of modified milk* 165 Prepuce, adherent, a cause of enuresis, 89 Prescription for milk modifica- tion, 183 Private practice, infant mortal- ity in, 61 Proportions of infant body in comparison to adult, 5 Proprietary foods, 195 analyses of, 195 Protein, transformation of in di- gestion, 13 action of pancreatic secretion on, 50 in breast milk, 70, 119, 123 in colostrum, 71 indigestion, curds an indica- tion of, 86 deficiency of in breast milk, 143 in cow's milk, 151, 152 caloric value of, 177 indigestion, evidences of, 180 milk, 190 in feces, 242 Proteolytic ferment, 170 Pulmonary, arteries, 2 orifice, stenosis of, 63 Pulse, at birth, 12 normal ratio of respiration at birth to, 13 rate, 53 rate, table of, 53 in physical examination, 222 in pneumonia, 222 in diagnosis, 247 Punishment, corporal, 219 Pupils, equality of, 226 reaction of, 226, 227 Pus, in umbilical vein, 5 in urine, 232, 238 in ears, 250 Putrefaction, intestinal, 231 Pyelitis, 232 bacteria present in urine in cases of, 232 blood in, 232 diagnosis of, 248, 250 Pyloric spasm, 180 stenosis, 181 stenosis, vomiting in, 181 Quantity of stool, 87 Quiet, effect of on sick children, 81 in nursery, 81 as a sedative, 257 Quinine, 253 Rachitis, evidence of, 34 delayed dentition in, 43 not caused by pasteurised milk, 168 physical examination for, 224 cranio tabes in, 225 Rash due to eggs, 207 Raw meat juice should not be fed to babies, reason why, 206 Reaction, of child to modification of amount of food, 199 to eggs by children, 207 of urine, 233 of feces, 241 Reagent, Millon's, 237 Obermayer's, 237 Recording, results of certain tests of urine, 236 the test for urine, 239 Records, weight, importance of, 27 importance of height, 29 of findings at birth, 65 Rectal medication, 259 Rectum, patent at birth, 65 Red corpuscles, number at birth, 14 282 INDEX Regime, daily, 102 for baby under three months, 102, 103 from three to six months, 103, 104 for sixth month to first year, 104, 105 for second year, 105 after second year, 106, 107 Rennet, action of on milk, 187 Respirations, 53 at birth, 4 number of at birth, 12 regularity of at birth, 12 normal relation at birth of pulse to, 13 slower in sleep, 54 table of, 54 establishment of at birth, 63 method of establishing, 63 of new born, 67 expiratory grunt, 222 in diagnosis, 247 conditions with normal res- pirations, 248 conditions with rapid, 248 Respiratory diseases in infants, 9 Rest, 91 method of taking, 91 Restlessness, 71 Retraction, of foreskin, 65 of head, 222 Rewards and deprivations, 219 Rheumatic, heart disease, 224 decayed teeth a cause of, 91 disease, 250 symptoms, treatment of, 259 Rhubarb, 257 Rhythm of heart, 223 Rickets (see rachitis), 168 Rocking, 91 Roentgen-ray, examination by, 245 in diagnosis, 245 in diagnosis of tuberculosis, 245 in diagnosis of endocarditis, 245 Roentgen-ray — Continued. in diagnosis of pneumonia, 245 in diagnosis of abdominal con- ditions, 246 Roof, enclosures, 92 extensions, 92 protection of, 93 Room, temperature of, 70 especial for premature babies in hospital, 213 Rotch, Doctor, 47, 155 method for modification of milk advocated by, 154 Roumania, infant mortality in, 58 Rusk, 204 Russia, infant mortality in, 57, 58 Safety-pins as toys, danger of, 84 Salicylate of soda, 253, 259 Saliva, 47 first digestive fluid, 47 in starch digestion, 47 Salivary glands, development of at birth, 8 power of secretion, to decom- pose starch, 13 secretion of, 13 time of increase of secretion of, 13 Salol-splitting ferment, 170 Salt, absorption of in intestines, 51 Salts, percentage in breast milk, 71 percentage in colostrum, 71 in breast milk, 124 in cow's milk, 151 Sanitary nursing bottle, 166 Sarsaparilla, syrup of, 253, 255 Scales, 79, 121 balance, 79 receptacle for, 79 spring, 79 proper scales for weighing babies, 80 Scarification, for vaccination, 111 in treatment, 260 L INDEX 283 Scarlet fever, 250 Schmidt, fermentation test appa- ratus, 243 test for undigested food in feces, 243 School, 99 age at which children should attend, 99 interference of with nap, 107 examination of children in, 100 periods for children of differ- ent ages, 216 reason for slow progress in, 216 supervision of physicians over, 216 School children, average weight of 69,000, 26 Schottilius, experiments on intes- tinal bacteria, 52 Screens, cheese-cloth, as ventilat- ors, 77 Scurvy, not caused by pasteur- ised milk, 168 orange juice as a preventative of, 182 blood in urine an indication of, 232 Sebaceous glands at birth, 5 Second day, care of infant dur- ing, 73 Second year, diet for, 208 Sedatives, 257 Sediment of urine, 233 Septic complications, weaning in, 135 Sex, sign of, 53 Shininess of feces, 86 Shirt, 68 Shock, effect of, on breast milk, 129 Shoes, 95 Sight of babies, 215 Sigmoid flexure, length of, 49 Silver nitrate, use of in eyes, 74 Sinus trouble, examination for, 226 Skeleton at birth, 6 Skin, sebaceous glands of, 5 irritation due to acidity of urine, 231 medication, 259 cod liver oil inunctions for dry, 260 Skull, at birth, 6 bones of, 6-7 overlapping of bones of, 6 compression of by tight ban- daging, 7 deficient ossification of at birth, 7 depression of bones of, 7 membrane joining bones of, 7 shape altered of, 7 of infant at birth compared with that of adult, 35 Sleep, voiding of urine during, 56 during first day, 70 place for taking, 91 necessary number of hours of, 93 character of, 222 breathing during, 224 Sleeping alone, 78 Small-pox, vaccination for, 109 Smegma, 96, 227 Soda, bicarbonate of, 257 Sodium salicylate, 253, 259 Softness of stools, 87 Solution, Benedict's, 235 Fehling's, 235 Soup, 204 method of preparing, 204 a substitute for meat juice, 206 Specific gravity of urine, 230 measurement of, 234 Specimens, of breast milk, method of obtaining, 122 of urine, method of obtaining, 229 of feces, obtaining, 240 Speech, age of beginning, 215 Spinal column, 7 curve of at birth, 7 flexibility of, 7 284 INDEX Spinal Column — Continued. curvature, 7 Spine, 34 changes in, 36 normal curves of, 36 growth in length of, 37 Spirillum cholerse Asiaticse, ther- mal death point of, 169 Spleen, 45 weight chart of, 38 increase in weight of, 46 enlargement of, 223 Sprue, 226 Sputum a conveyer of infection, 97 Standing, period at which chil- dren begin, 94 Staphylococcus pyogenes aureus, 128 thermal death point of, 169 Starch, power of secretion of salivary glands to decom- pose, 13 digestion, saliva in, 47 action of bile on, 50 action of intestinal secretion on, 50 Starvation, 128 Sterilisation, of milk,. 168 of beef juice, 206 Stiffness of back of neck, 225 Stools, colour of normal, 85 quality of, 85 colour of abnormal, 85-86 importance of character of, 85 clay-coloured, an indication of too much fat in food, 86 dark colour due to bismuth, 86 dark colour due to old blood, 86 dark colour due to iron, 86 fresh blood a cause of red stain in, 86 mucus in, 86 shininess of, cause of, 86 smoothness of, 86 frequency of, 87 hard an indication for more fat in food, 87 loose, cause of, 87 Stools — Continued. odour of, 87 quantity of, 87 softness of, 87 time for procuring, 87 method of obtaining, 88 bad, in breast fed children, 132 (See also feces) Stomach, at birth, 10 Form of, at birth, 10 position of, at birth, 10 at birth, fat-splitting ferment in, 13 at birth, hydrochloric acid in, 13 at birth, pepsin in, 13 a reservoir, 13 tube, 44 capacity of, 47 capacity, importance of, 47 capacity, methods of determin- ing, 47 position of, 47 shape of, 47 capacity, table of, 48 capacity, variations found by different investigators, 48 wall, elasticity of, 48 capacity, rule for, 49 disturbance, 249 Streptococcus, 128 pyogenes, thermal death-point of, 169 Strychnine, dose of, 254 as a stimulant, 258 Stimulants, heart, 258 Steam inhalations, 260 Submaxillary glands, 225 Sucking, 46 method of, 46 a process of digestion, 46 thumb, 98 interference with, 119 Sudan III, 242 Sugar, absorption of in intes- tines, 51 in breast milk, 70, 123 in colostrum, 70 in cow's milk, 151 INDEX 285 Sugar — Continued. indigestion, evidences of, 180 cane, as a substitute for milk sugar, 193 Sugar of milk, graduate, 165, 166 not a clean product, 168 Sugar in urine, 230 tests for, 235 Suggestion in control of chil- dren, 218 Summer mortality of infants, 60 Suppositories, glycerine, 88 Sweat glands, development of at birth, 5 Sweden, infant mortality in, 58 Syphilis, early dentition in, 43 Hutchinson's teeth in, 43 weaning in, 136 blue ointment in, 260 Syrup, as a medium in admin- istration of drugs, 253, 255 of sarsaparilla, 253 of Yerba Santa, 253 Systolic murmur, 63 Table of measurements, 254 Tablets, 252 administration of, 254 Tache cerebral reaction, 228 Tail, clipping of cow's, 146 Teacher, proper for kindergar- ten, 99 Tears, lack of, at birth, 8 Teeth, 39 (See also Dentition) development of at birth, 8 period at which membrane is pierced, 8 age at which first tooth ap- pears, 39 eruption of at birth, 39 age of eruption of first, 40 age of appearance of second, 41 age of eruption of second, 42 chart showing age of eruption of second, 42 Hutchinson's, 43 Teeth — Continued. rubbing through gum, 44 care of, 90 decayed, danger of, 91 heart trouble due to, 91 importance of care of, 91 rheumatism due to decayed, 91 eruption of, 204 Teething, disturbances of, 43 (See also Dentition) Relief of symptoms by rubbing teeth through gum, 44 Temperature, at birth, 12 during dentition, 43 of children, 53 subnormal, 53 of room for newly born in- fant, 70 of nursery, 80 of milk in pasteuriser, 172 during pasteurisation of bot- tles of milk, 174 record in diagnosis, 247 Test, Holt's, 124 Babcock, 126 for quantitative acidity of urine, 233 Schmidt fermentation, 243 for acetone in urine, 236 for diacetic acid in urine, 236 Theory of infant feeding, 197 Therapeutic measures, 255 Thermal death point of bacteria in a moist medium, table of, 169 Thermometer, 80 Thierfelder, experiments on in- testinal bacteria by, 51 Thorax, small, 1 circumference at birth, 6 at birth, 65 Threatening children, 218 Thrill over heart, 63 Thumb sucking, 98 method for control of, 98 Thymus gland, 9, 44 (See also Gland) position of, 44 weight of, 44 286 INDEX Thyroid extract in Cretinism, 101 Toast, 204 Tongue, size of at birth, 8 coating of, 226 examination of, 226 Tonics, 257 Tonsil, third, 8 third, seat of, 37 Tonsils pharyngeal, 39 Toys, 83 articles to be avoided, 83-84 dangers of, 83 law regarding, 84 as rewards, 219 Training in order to procure movement of bowels, 88 Treatment, 252 Triple phosphate crystals, 239 Trunk of infant, shape of, 5 growth of, 30 Trypsin, 186 Tuberculin test for cows, 146, 150 Tuberculosis, in nursing mother, 120 weaning in, 136 in cattle, 150 bacillus, thermal death point of, 169 susceptibility of babies to, 206 Roentgen-ray in diagnosis of, 245 pulmonary, 249 Tuberculous meningitis, 249 Tumor of abdomen, 223 Typhoid, immunisation, 115 immunisation, reaction to, 115 immunisation, number of ba- cilli injected, 115 immunisation, interval be- tween injections, 115 immunisation, time of im- munity, 115 immunisation, method of, 116 immunisation, time at which injections should be given, 116 bacilli in milk, 148, 149 fever, 251 Typhoid — Continued. inoculation, 260 Typhosis, bacillus, thermal death -point of, 169 Udders of cows, clipping of, 146 Ulcerations in mouth, 226 Umbilical, arteries, 2, 4 cord, 2 veins, 2 vein, changes in, 4 vein, pus in, 5 United States, infant mortality in, 57, 58 Uric acid infarctions at birth, 10 Urinary, analysis, 229 tract, inflammation of, 232 Urine, 54 at birth, 13 amount of, 13 amount passed, 54 specific gravity of, 13, 54, 56, 230, 234 daily secretion of, 55 frequency with which it is passed, 55 summary of amount secreted, 55 frequency of micturition, 56 voided during sleep, 56 voided when awake, 56 poulticing of child with, 68 passed in first days, 72 normal excretion of in first twenty-four hours, 73 in second day, 73 habit in passing, 88 obtaining specimen of, 229 sugar in, 230 phenol in, 231 albumin in, 230 dilution of, 230 evidences of diabetes in, 230 evidences of nephritis in, 230 acidity of, 231 acidosis, 231 index of reaction to acetone and diacetic acid, 231 indican in, 231 INDEX 287 Urine — Continued. blood in, 232 blood in, an indication of nephritis, 232 evidences of pyelitis in, 232 leucocytes in, 232 pus in, 232, 238 amorphous phosphates in, 233 amorphous urates, 233 colour of, 233 colour of sediment, 233 general appearance of, 233 quantitative acidity of, 233 reaction of, 233 smoky, 233 tests for albumin in, 234 tests for glucose in, 235 tests for sugar in, 235 diacetic acid in, 236 fermentation test for sugar, 236 test for acetone in, 236 test for indican in, 237 test for phenol in, 237 bacteria in, 238 blood cells in, 238 casts in, 238 ephithelial cells in, 238 microscopic examination of, 238 ammonium urates in, 239 calcium oxalate crystals in, 239 mucus in, 239 phosphates in, 239 recording the test for, 239 urates in, 239 bicarbonate of soda to alkalin- ise, 257 urates in. 239 Utero, nourishment of child in, 1 Vaccination, 109 definition of, 109 time for first. 109 virus for, 109 site for, 110 method of. Ill scarification for, 111 time at which girls should have, 111 Vaccination — Continued. contamination of, 112 illustration of, 112 protection of, 112 evidence of taking, 113 period at which it begins to take, 113 revaccination, 114 Vaccine inoculation, 260 Valve, Eustachian, 2 Vegetables, 207 amount and kind that may be given in second year, 207 Vehicles for medicine, 255 Veins, umbilical, 2 umbilical, in navel infections, 5 Vena cava, inferior, 2 superior, 2 Ventilation, 76 Ventricle, contraction of, 2 left, 2 right, 2 Vernix caseosa, 5 Virus for small-pox vaccination, 109 Viscera, weight of, at birth, 11 Vitality of infant at birth, 12 Vocabulary of children, increase of, 215 Vomiting, persistent, cause of, 180 in pyloric stenosis, 180 due to eggs, 207 Von Jaksch's disease, 249 Von Pirquet, optimum of, 155 charts of infant feeding, 197 Walking for children, 94 Warm baths as a sedative, 257 Warm rooms no substitute for incubator, 213 Washing of cows, 146 Water, percentage in breast milk, 71 percentage in colostrum, 71 dirty, a cause of illness, 97 dirtv, a source of contamina- tion, 149 in cow's milk, 151 288 INDEX Weaning, 134 time for, 118, 134 indications for, 134 indications in child for, 134 loss in weight, an indication for, 134 disease in mother not always an indication for, 135 indications in mother for, 135 menstruation no indication for, 135 pregnancy an indication for, 135 in septic complications, 135 method of, 136 in syphilis, 136 in tuberculosis, 136 treatment of mother during, 137 Weighing, baby, proper scales for, 79 the baby, time for, 91 before and after nursing, 121, 142 Weight of infant at birth, 5, 16 proportion of vitality to, 12 relation of length to, 15 as a standard of development, 15 charting of, 15 gain in, 16 loss of, 16 loss of in first few days' of life, 16 at one year, 16 at second year, 16 stationary, 16 rate of gain of, 19 failure to gain in, 24 of older children, average gain in, 24 variation in normal, 24 of boys and girls, comparison of, 27 # a guide in convalescence, 27 an indication of illness, 27 record, importance of, 27 growth in length of children who do not gain in, 30 Weight — Continued. of organs in infancy and child- hood, 38 of heart, increase in, 44 of lungs, 45 proportional, of organs, 46 loss of in first few days, 121 failure to gain, 127 loss of, an evidence of inade- quate feeding, 127 gain in, even with bad stools, 132 gain in, on dextrinised cereal decoctions, 186 effect on, of withdrawal of food, 198 of eight month baby, 210 of premature babies of differ- ent ages, 210 of foetus in utero, 211 Weight chart for first week, nor- mal, 16 of first year, normal, 18 individual, 19, 21 variation in average, 22 average weight chart of first year of children under vari- ous conditions, 23 with normal lines, 24 showing that loss of weight is an important indication of approaching illness, 28 Wet nurses, 138 necessity for, 138 objections to, 138 control of baby of, 139 examination of, 139 selection of, 139 diet of, 140 as a final resort, 156 reason for employing, 195 for premature baby, 214 Whey, 153, 187 elements of, 187-188 milk, difficulty of preparing, 188 milk, modification of, 188- 189 use of in cases of colic, 188 Widal reaction, 115 INDEX 289 Words, age at which babies first Yerba Santa, 255 use, 215 syrup of, 253 Worms, intestinal, 251 Young's formula of dose of drugs Worry, effect on breast milk, 129 for children, 253 a cause of inadequate breast milk, 143 Zweibach, 204 X-Ray, 245 ( See also Roentgen-Ray. ) Printed in the United States of America. "HE following pages contain advertisements of a few of the Macmillan books on kindred subjects. NEW MEDICAL BOOKS Diseases of Nutrition and Infant Feeding By JOHN LOVETT MORSE, M.D. Professor of Pediatrics, Harvard Medical School, AND FRITZ B. TALBOT, M.D. Instructor in Pediatrics, Harvard Medical School. Cloth, 8vo, $3.00 This important work is based on the unique meth- ods of the Pediatric Department of the Harvard Med- ical School. By these methods the food is fitted to the baby and not the baby to the food, while all pro- cedures are presented for a definite reason and on a scientific basis. There has, up to the present, been no book in English presenting in detail the physiology of digestion and metabolism in infancy — which must form the basis of all scientific and rational infant feeding — and none describing in detail how to feed babies accord- ing to the indications in the individual case. The authors first present the scientific facts on which each condition is based, and then apply them practically and in detail. Publishers 64^-66 Fifth Avenue New York THE MACMILLAN COMPANY The Healthy Baby THE CARE AND FEEDING OF INFANTS By ROGER H. DENNETT, M.D. Instructor in Diseases of Children in the New York Post-Graduate Medical School; Assistant Attending Physician to the Babies' Wards in the New York Post-Graduate Hospital; Chief of Clinic in the Post-Graduate Dispensary for Children; Fellow of the New York Academy of Medicine Cloth, i2mo, $1.2$ This work makes clear to the mother Just how to do best the ordinary, everyday things that every mother has to do for her child. The author believes that there is a definite need for a book which will describe in the minutest detail the daily care of the baby. The description or treatment of any but the simplest ailments has purposely been left out, because a book of this sort which attempts in any way to describe disease does more harm than it does good. A well-trained physician or a specialist in children's diseases finds it difficult enough at times to diagnose the different affections, and it only confuses the mother or nurse to describe the different diseases to her. The chapter on feeding has purposely been cut down, and all complicated formulas omitted. Probably more harm has been done than can possibly be estimated, by giving to mothers sets of complicated formulas which she tries to use herself. In this way the baby's digestion is often ruined. The author here describes the simplest kinds of milk, water, and sugar mixtures, and if these do not agree with the baby, he recommends seeking the physician's help. There is no one but can be interested in the numerous and valuable suggestions which the book offers; parents and teachers alike will find in it a wealth of suggestive matter. Dr. Dennett is a well-known physician in New York City and is also a writer of reputation, his page in the Woman's Home Companion called The Healthy Baby having made him the friend of mothers throughout the land. What he has to say, therefore, on such subjects as appetite, clothing, the bath, teeth, milk, the mixing and care of the food, and food for traveling is certain to secure wide attention. His book is divided into six parts, consid- ering, respectively, Development and the Bodily Functions, Hygiene and Treatment, Common Ailments, Care of the Special Organs, Feeding and Diet, and Lists. "A useful book to young mothers, young fathers, and older people of all ages."— St. Louis Globe-Democrat. THE MACMILLAN COMPANY Publishers 64=66 Fifth Avenue New YorK ]V4y Rirtlv ^^ e Autobiography of an ^ * Unborn Infant By ARMENOUHIE T. LAMSON ///., i2mo, $1.25 The motive of this remarkable little book and the reasons for its publication are perhaps best expressed in the words of the author and mother, who wrote it: "Surely it will not be amiss to tell you just how this strange autobiography came to be. Unlike other personal diaries, this one begins and ends before the birth of the autobiographer, who tells in simple form just how, when and where his body came to be. It was in the fourth month of approaching motherhood that I was seized with intense desire and determination to tear down all barriers of convention, of ignorant superstition and preju- dice and, henceforth, to seek openly true knowledge concerning the birth of my child. "It seemed appalling that I was allowed to become a mother without knowing the method and significance of approaching motherhood. . . . The medical books, which my doctor kindly brought me, contained many a lengthy discourse, but their lan- guage was utterly foreign to me. Finally, I learned the great truths I sought, and, one day, I determined to write them down as though told by my unborn baby who inspired me to learn them through and for him. I have done so for the sake of all those mothers and fathers, maturing girls and boys, who are anxious to know the real truth about the birth of a child. This humble but daring narrative is based on the most up-to-date, scientific facts presented in the language of Everyman and Everywoman, while for their pleasure and thorough understanding, I have inserted a number of illustrations taken from the most authoritative sources." "It is no medical treatise, this strange autobiography which ends where all other biography begins, but a clear, simple narrative that robs birth of its mystery and illuminates life in its origin for the lay searcher after truth in an impressive manner contributory to the betterment of the human kind. In these days of idle socio- logical discussions having no better purpose than to catch the at- tention of the prurient-minded, current birth-control controversies sensationalized by a thoughtless press, and the never-ending prob- lems of sex exploited in trashy fiction and decadent play, it is reassuring and vivifying to discover, as in Armenouhie Lamson's extraordinary little volume, something worth while — of real and enduring value. To the teacher and to the young mother, to Everywoman and Everyman, in whom God-given trusts are reposed, the narrative, 'My Birth,' based upon fact, will give strength to teach and live aright.'' — Post Intelligence, Seattle, Wash. THE MACMILLAN COMPANY Publishers 64^66 Fifth Avenue New York Tuberculosis of the Bones and Joints in Children By JOHN FRASER, M.D., F.R.C.S.E., Ch.M., Assistant Surgeon, Royal Hospital for Sick Children, Edinburgh With 51 full page plates {2 in color) and 164 figures in the text. Royal 8vo,. 352 pp., index, $4.50 Tuberculous disease of the bones and joints is in large measure a disease of children, and as a result of the disastrous consequences which so often follow its course, it is one of the most important of the various forms of Tuberculosis. This work deals fully with the condition. The more recent investigations on the Eti- ology are fully discussed, the Pathology is a special fea- ture, and much of the material in this relation is original. Diagnosis, Prognosis and Treatment are fully discussed. Special attention has been paid to the making and fitting of the various splints. Dr. Fraser is well known to American physicians through his various magazine contributions and lectures. His book is without doubt one of the most important publications that has yet appeared on this subject. THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New York