^^K% Columbia Win\\itriitv intf)E€itpofilcto»orb CoUcge of ^bpsiiciang anb ^urgcong Reference Hibrarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/practiceofpediatOOcarr LIST OF CONTRIBUTORS. ABT. ISAAC ARTHUR, M.D. BOVAIRD, DAVID, Jr., M.D. CRANDALL. FLOYD M., M.D. DADE. CHARLES TOWNSHEND. M.D. DAVIS. EDV/ARD P.. M.D. JENNINGS. CHARLES GODWIN. M.D. MCCARTHY. DANIEL J.. M.D. NICOLL. MATTHIAS, Jr., M.D. POYNTON, F. JOHN, M.D.. F. R. C. P. RIVIERE, CLIVE. M.D . M. R. C. P.. Etc. RUHRAH. JOHN, M.D. SOUTHWORTH. THOMAS S.. M.D. TUTTLE. GEORGE M., M.D. YALE. LEROY MILTON. M.D. Zbc practitioner's Xibrarie THE PRACTICE OF PEDIATRICS m ORIGINAL CONTRIBUTIONS AMEEICAN AND ENGLISH AUTHOES EDITED BY WALTER LESTER CARR, A.M., M.D. CONSULTING PHYSICIAN TO THE rREN9H HOSPITAL, NEW YOKK; TO THE NEW YORK EYE AND BAB INriRMARY; VISITING PHYSICIAN TO THE NEW YORK CITY CHILDREN'S HOSPITALS AND SCHOOLS ; MEMBER OF THE AMERICAN PEDIATRIC SOCIETY; FORMERLY EDITOR OF "ARCHIVES OF PEDIATRICS." ILLUSTRATED WITH 199 ENGRAVINGS AND 32 FULL-PAGE PLATES LEA BROTHERS & CO. PHILADELPHIA AND NEW YORK 1906 Entorcd accnnlinj: to tin' Aci f>l Conpnss. m the \'JHP:RS .t CO.. in the Office of the Libruriau of Congress. All rights reserved. DOR NAN, PRINTER P H I I. A n K I, P H I A PEEFACE. A COMPREHENSIVE and authoritative survey of each of the major divisions of medicine is necessary from time to time to record its latest development and to enable those who desire to master it as a whole, or to post themselves on special points, to do so with facility. With this object three companion volumes have been arranged covering respectively Gynecology, Obstetrics, and Pediatrics, and furnishing a compact presentation of the world's best knowledge upon these closely connected departments. The volume on Pediatrics, now in the reader's hands, is from the pens of well-known authorities in America and England, who have been selected as eminently fitted to write on the subjects assigned to them. These authors have kept in mind : first, the clinical picture of a disease, and second, the best methods for its treatment. This plan has allowed each author to give his own observations of a disease, and the thera- peutic measures which have resulted in the greatest success. Naturally this adds to each contribution a personal element which is entitled to consideration, as the authors are, without exception, clinicians and teachers of wide experience. In the arrangement of the volume more space than usual has been allotted to infant feeding, diseases of the alimentary tract, disorders of nutrition, respiration, and circulation, and to contagious diseases, the object being to describe the conditions most intimately associated with disease in children and not those which are more common in adult life and found but rarely in childhood. In a word, the line between Pediatrics and General Medicine has been carefully drawn, so that space has thereby been found for a full presentation of this specialty m a convenient volume. In some sections extra space has been given to methods of diagnosis which are now regarded as essential by physi- cians who wish to be exact in their work, but the details of which are not readily accessible elsewhere. On the other hand, mooted patho- logical questions have been omitted, and the pathology stated by each (V) vi PREFA CE author is limited to what is regarded as essential for a comprehensive knowletlge of the ihsease with which it is associated. The Editor's thanks are (hie to the authors for their contributions and for the care they have taken in revising their articles. Thanks are also due to Dr. Martha Wollstein, Pathologist to the Babies' Hos- pital, New York, and to Dr. David Bovaird, Jr., one of the contributors, for their valual)le aid. To the Publishers, who have co-operated in making the volume attractive in every way, the Editor wishes to express his appreciatic^n for the many courtesies they have extended. W. L. C. New York, 1906. LIST OF CONTRIBUTOES. ISAAC ARTHUR ABT, M.D., Assistant Professor of Pediatrics in the Rush Med- ical College (University of Chicago) ; Attending Ph\'sician, Diseases of Children, in the Michael Reese and Cook County Hospitals; Consulting Phj^sician to the Provident Hospital and Home for Crippled Children, Chicago, 111.; ^leniber of the American Pediatric Society. DAVID BOVAIRD, Jr., A.B., M.D., formerly Pathologist to the Foundling Hos- pital; Attending Phj'sician to the Seaside Hospital of St. John's Guild, Attend- ing Physician to the New York City Children's Hospitals and Schools; Associate Physician to the Presbj^terian Hospital, New York. FLOYD M. CRANDALL, M.D., Consulting Physician to the New York City Chil- dren's Hospitals and Schools: Late Visiting Physician to the Mintuna Hospital for Contagious Diseases, New York; Member of the .Ajnerican Pediatric Society. CHARLES TOWNSHEND DADE, M.D., Consulting Dermatologist to the Man- hattan State Hospital; Dermatologist to the New York City Children's Hos- pitals and Schools; Dennatologist to the Vanderbilt Clinic, College of Physi- cians and Surgeons; ^Member of the New York Dermatological Society, New York. EDWARD P. DAVIS, A.M., M.D., Professor of Obstetrics in the Jefferson Medical CoUege and the Philadelphia Polyclinic; Ob.stetrician to the Jefferson, Phila- delphia, and Polyclinic Hospitals; Consulting Obstetrician to the Preston Retreat, Philadelphia; Member of the American Pediatric Society. CHARLES GODWIN JENNINGS, M.D., Professor of the Practice" of ^Medicine and Diseases of Children in the Detroit CoUege of Medicine, Detroit, Mich. ; Member of the American Pediatric Society. DANIEL J. McCarthy, A.B., M.D., Professor of Medical Jurisprudence in the t'niversity of Pennsylvania; Associate in Medicine in William Pepper Clinical Laboratory of the LTniversity of Pennsylvania; Neurologist to the Henry Phipps Institute; Neurologist to Philadelphia General Hospital(Blockley), Philadelphia. MATTHIAS NICOLL, Jr., A.B., M.D., Visiting Physician to the^Willard Parker and Riverside Hospitals; Instructor in Pediatrics and Intubation at the LTni- versity and Bellevue Hospital ]\Iedical College; Phj'sician to Bellevue Hospital (Out-door Department) for Diseases of Children; Pathologist in the New York Foundling Hospital, New York. F. JOHN POYNTON, M.D., F.R.C.P. Lond., Subdean of the Medical Faculty of the University College, London ; Assistant Physician to University College Hospital, and to the Hospital for Sick Children, Great Ormond Street, London, England. CLR^E RIVIERE, M.D. Lond., M.R.C.P. Lond., :\I.R.C.S. Eng., Assistant Physi- cian in the East London Hospital for Children; Phvsician to the Out-patient Department City of London Hospital for Diseases of the Chest, London, England. JOHN RUHRAH, M.D., Clinical Professor of the Diseases of Children in the College of Physicians and Surgeons; Visiting Physician to the Baltimore City Hospital, to the Robert Garrett Free Hospital for Children, and to the Nursery and Child's Hospital, Baltimore, Md. ; ^lember of the American Pediatric Societv. THOMAS S. SOUTHWORTH, A.M., M.D., Attending Physician to the New York City Children's Hospitals and Schools, Nursery and Child's Hospital, and Min- turn Hospital for Contagious Diseases, New York; ^lember of the American Pediatric Society. GEORGE M. TUTTLE, A.B., M.D., Professor of Therapeutics in the Medical Department of Washington University; Attending Physician, St. Luke's Hos- pital, the Martha Parsons Children's Hospital, and tlae Bethesda Foundling Asylum, St. Louis, Mo. LEROY MILTON YALE, A.M., M.D., formerly Lecturer on Diseases of Children in the Belle^'ue Hospital Medical College, New York; Member of the American Pediatric Society. (vii) CONTENTS. SECTION I. DISEASES AND INJURIES OF THE NEWBORN. CHAPTER I. PAGE THE NORMAL INFANT— THE PREMATURE INFANT ... .17 By Edward P. Davis, M.D. CHAPTER II. ASPHYXIA NEONATORUM-ACCIDENTS TO THE UMBILICAL CORD 34 By Edward P. Davis, M.D. CHAPTER III. INJURY AT BIRTH— INFECTIONS . ...... 41 By Edward P. Davis, M.D. SECTION II. DEVELOPMENT, GROWTH, AND HYGIENE. CHAPTER IV. CHANGES AFTER BIRTH— HYGIENE OF THE INFANT AND NURSERY 61 By Leroy Milton Yale, M.D. CHAPTER V. GROWTH AND HYGIENE 70 By Leroy Milton Yale, M.D. (ix) X CONTENTS SECTION TIT. INFANT FF:EDING. CHAlTHi; VI. PAGE MATERNAL FEEDING— WEANING 89 JiY Thomas S. Sof^TiiwoRTii, M.D. CIIAITKK Vri. COWS' MILK 107 Ev Thomas 8. Soitthwouth, M.I). CHAPTER VIII. SUBSTITUTE INFANT FEEDING -FEEDING AFTERTHE FIRST YEAR 123 By Thomas S. Southworth, M.I). SECTION IV. DISEASF^S OF THE ALIMENTARY TRACT. CHAPTER IX. DISEASF.S OF THE MOUTH AND PHARYNX 175 By David JiovAiiiD, Jr., M.D. CHAPTER X. DISEASES OF THE STOMACH 196 By David Bovaird, Jr., M.D. CHAPTER XI. ACUTE GASTROENTERIC INFECTIONS 225 By David Bovaird, Jit., M.D. CHAPTER XII. THE DIARRHEAS OF INFANCY AND CHILDHOOD— DISEASES OF THE INTESTINES 242 By David Bovaird, Jr., M.D. CONTENTS xi CHAPTER XIII. JAUNDICE, DISEASES OF THE LIVER, INTUSSUSCEPTION, APPEN- DICITIS, DISEASES OF THE PERITONEUM, INTESTINAL PARA- SITES 282 By David Bovaird, Jr., M.D. SECTION V. DISEASES OF NUTRITION. CHAPTER XIV. RACHITIS-SCORBUTUS— MARASMUS 321 By George M. Tuttle, M.D. SECTION VI. INFECTIOUS DISEASES. CHAPTER XV. TUBERCULOSIS 343 By Isaac A. Abt, M.D., David Bovaird, Jr., M.D., and D. J. McCarthy, M.D. CHAPTER XVI. DIPHTHERIA 385 By Matthias Nicoll, Jr., M.D. CHAPTER XVII. TYPHOID FEVER— MALARIA— EPIDEMIC CEREBROSPINAL MENIN- GITIS— INFLUENZA 427 By Isaac A. Abt, M.D., John Ruhrah, M.D., D. J. McCarthy, M.D., AND Matthias Nicoll, Jr., M.D. CHAPTER XVIII. WHOOPING-COUGH-MUMPS— GLANDULAR FEVER . . . -472 By Matthias Nicoll, Jr., M.D., and Floyd M. Crandall, M.D. xii CONTENTS CHAITKK XTX. PACK SCARLET FEVER -JSG By ri>OVl) M. CUANDALL, M.I). CHAPTER XX. ME.\SLES— RUBELLA— FOURTH DISEASE— ERYTHEMA INFECTI- OSUM '"ilQ By Floyd M. Cuandall, M.I>., am> .I«»hn Ruhrah, M.D. (IIAPTKK XXI. VARICELLA— VACCINL\— SMALLPOX 641 By Floyd M, Crandall, M.J). CHAPTER XXII. CONGENITAL SYPHILIS— RHEUMATISM 563 By George M. Tuttle, M.D., and John Ruhrah, M.D. SECTION VII. DISEASES OF THE RESPIRATORY TRACT. CHAPTER XXIII. DISEASES OF THE NOSE— NASOPHAIiYNX— LARYNX . . . 585 By Clive Riviere, M.D. CHAPTER XXIV. THE LUNGS IN EARLY CHILDHOOD— BRONCHITIS— PULMONARY COLLAPSE— BRONCHIAL ASTHMA 601 By Clive Riviere, M.D. CHAPTER XXV. BRONCHOPNEUMONIA— LOBAR PNEUMONIA 617 By Clive Riviere, M.D. CHAPTER XXVI. PLEURISY— EMPYEMA— PNEUMOTHORAX 646 By Clive Riviere, M.D. CONTENTS xiii CHAPTER XXVII. ABSCESS OF THE LUNG— GANGKENE OF THE LUNG— BRONCHI- ECTASIS AND PULMONAEY FIBROSIS-FOREIGN BODIES IN THE AIK TUBES By Clive Riviere, M.D. 666 SECTION YIII. DISEASES OF THE HEART AND BLOODVESSELS. CHAPTER XXVIII. METHOD OF EXAMINATION— CONGENITAL HEART DISEASE- RHEUMATIC HEART DISEASE 683 By F. J. PoYNTON, M.D. CHAPTER XXIX. CHRONIC RHEUMATIC HEART DISEASE-TREATMENT OF RHEU- MATIC HEART DISEASE "^^2 By F. J. PoYNTON, M.D. CHAPTER XXX. HEART DISEASE FROM DIPHTHERIA AND OTHER INFECTIONS- DISEASES OF THE ARTERIES 740 By F. J. Poynton, M.D. SECTION IX. DISEASES OF THE GENITOURINARY SYSTEM. CHAPTER XXXI. URETHRITIS- VULVOVAGINITIS-DISEASES OF THE BLADDER- DISEASES OF THE KIDNEYS '^^^ By Charles G. Jennings, M.D. ^Iy contents SECTION X. DISEASED OF THE FU.OOD. LYMPHATIC SYSTEM AND GLANDS. CJIAlTKi; XXXIT. i'a«;e THE BLCKin — ANEML\ — CHLOROSIS — LEUKEMIA — PrKPUKA — HEMOPHILIA ^'^''' JJv .loiiN KrnuAii, M.I). CllAlTKllXWIlI. THE THYMUS— STATUS LYMPHATICUS-ADENITIS-HODGKIN'S DISEASE— THE SPLEEN 836 ]5v .loiiN liiHi:.\n, M.l). CHAlTEIi XXXIV. THE ADRENALS- ADDISON'S DISEASE-CRETINISM-DIABETES MELLITUS ^"^^ By John Uuiiuah, M.D. sp:ction XI. DISEASES OF THE NERVOUS SYSTEM. CHAPTER XXXV. FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM— CONVULSIVE DISORDERS ««51 By I). J. McCakthy, M.I). chaptp:rxxxvi. ORGANIC NERVOUS DISEASES— DISEASES OF THE NERVES AND SPINAL CORD— ABIOTROPHIC DISEASES 885 ByD. J. McCarthy, M.D. chapter XXXVII. DISEASES OF THE BRAIN AND MENINGES 929 By D.J. McCarthy, M.D. CONTENTS XV SECTION XII. DISEASES OF THE SKIN. CHAPTER XXXVIII. -UETICAEIA— IMPETIGO- By Charles Townshend Dade, M.D. PAGE ECZEMA— ERYTHEMA— UETICAEIA— IMPETIGO— SCABIES . . 969 SECTION I. DISEASES AND INJURIES OF THE NEWBORN. By EDWARD P. DAVIS, M.D. CHAPTER I. THE NORMAL INFANT— THE PREAIATURE INFANT. THE NORMAL INFANT. In order to understand the normal infant so as to appreciate patho- logical conditions it may be well briefly to consider the characteristics of the viable infant at full term. Size and Weight. — Various criteria of viability have been consid- ered important. The length of the finger-nails, growth of hair on the head, brightness and clearness of the eyes, weight, and the ability of the infant to nurse and to cry have been regarded as affording an accurate basis for the recognition of viability. Infants, however, differ so much in development that some more accurate data than these must be obtained for scientific judgment. Diihrssen's table, giving the length of the fetus at different periods of gestation, has been commonly accepted as practically accurate. By this we find that at six months the fetus is 30 cm. (llf in.) long, at seven months 35 cm. (13f in.), at eight months 40 cm. (15f in.), at nine months 45 cm. (17f in.), and at ten months 50 cm. (19f in.) long. The earliest recorded period of viability is twenty -six weeks, and at this time the fetus of average development should be 32 cm. (12^ in.) in length. The difference between the length of the viable fetus and the length of the fetus at full term is sufficiently great to show that many infants may be born viable and yet sometime removed from full development. In estimating the degree of development of the newborn infant we may have reference to the proportionate length, chest circimiference, and cranial circumference. Thus, if the length be 50 cm. (19f in.) the circumference of the chest is half this plus 10 cm., or 35 cm, (13f in.), and the circumference of the cranium is 2 or 3 cm. greater, or 37 or 38 cm. (14^ to M^^Q in.). Essential variations from these proportions indicate lack of development and in some cases disease. 2 (17) 18 DISEASES A \i> /\./r/,7/-;N OF Till-: \i-:\yiu)U'\ 'V\\v iivfi-a^'c \vt'iti;lit of full-tt-rm iiiiilr iiifaiils .")() cm. (I!);-| in.) lonj; is ;i274.1() <,'rains; of ft-inale infants 11) cm. (19,! in.) loIl<,^ '.i\ 12.S()^rram.s. As a fj;cncral criterion of (leveloj)ment Jung' observed that in well- developed or full-term infants the circumference of the shoulders equalled or exceeded the oc(ij)itofr()ntal diameter of the head. In considerini^ the char.icteristics of an infant at full term, Herz^ found, in fully developed infants, lanu<^o widely develoj)e(l over the entire i)0(ly. He also oh.served tliat comedones were present upon the face in hut 5.7 per cent, of full-term infants outside the region of the nose and h'j)s, while in premature infants they extended over the entire face in S'SM percent, 'riie skin of a normal infant is reddened and covered in many parts by vernix ca.seosa. After removal of the vernix caseo.sa the skin gradually becomes more pinkish in color. In premature infants the mammary glands are much less developed than in full-term infants, secretion forming much later or not at all. Umbilicus. — The portion of umbilical cord remaining attached to the newljorn infant is its only visii)le remnant of intrauterine existence, and this undergo:^s necrosis and separates from the infant between the sixth and eighth days of life. While the umbilical cord is free from bacteria at birth, mimerous micro-organisms make their appearance in the stumj) within five or six hours. Among the j)athogenic bacteria present are the staphylococcus pyogenes albus, citreus, and aureus. The number of bacteria is less in infants who are not bathed daily than in tho.se who are. In view of such observations it becomes evident that the closure of the umi)ilical ves.sels must play an important part in the prevention of infection with these bacteria. The Blood. — The blood of the newborn infant presents .several char- acteristic features: the number of red cells is (5,000 ,()()() to 7,000,000 per cubic millimetre, of leukocytes about 18,030; the hemoglobin i)er cent, is always ai)ove 100 and may reach 120; the specific gravity is lOOO; nucleated red corj)uscles are present in the proportion of ^-q to ^ of the total number of leukocytes, and, finally, the hemolytic, bactericidal, anil agglutinating jxnver of the infant's blood serum is far less marked than in later life. Within two weeks the red cells diminish from r),()()(),0()() to 4,r)0(),()(:0 per cubic millimetre, the leukocytes to 10,000, and the nucleated red cells also fliminish in numbers. The lymphocytes number three-fourths to two-thirds of the total leukocytes. Scipiade.s'^ found that both red and wliite cells diminish during the first ten days and this is e(|ually true whether infants are bathed or not l)athed. There is, however, after the initial lo.ss of w'cight a greater gain in blood cells in bathed infants than in those who are not bathed. Late ligation of the cord does not prevent the early loss of cells, but in the long run it increases the volume of the fetal blood, and hence is indicated. ' Inaugural Dis.sertation, Bern, 1902. * Klin. UntersuchuiiKen an 100 Neugeboren, Inaug Diss., Freiburg. » Archiv f. Gynak., 1903, Band Ixx. THE NORMAL INFANT 19 Circulation. — Immediately after birth the heart beat does not differ materially from that which was heard within the womb. The impulse of the heart may be plainly felt by placing the finger-tips over the precordium. The reddish color of the baby's skin shows that oxy- genation is going on and that asphyxia is absent. The pulse of a newly born infant varies from the first minute of birth. It may fall 20 or 30 beats and then be accelerated beyond the fetal rate. Usually it falls 10 to 30 beats, but the rate is easily increased. As Ballantyne remarks, the physiological transition from the fetal to the postnatal form of circulation is no doubt very rapid, but the ana- tomical transition, evidenced by the obliteration of the lumina of the ductus arteriosus, foramen ovale, umbilical vessels, and ductus venosus may not be complete for some days or even weeks. Respiration. — Respiratory movements of the newborn are at first abdominal and become thoracic only as the lungs expand. It is a question whether the use of the abdominal binder, by impeding the movements of the abdominal muscles, stimulates or retards the full development of respiration. The healthy full-term infant, so soon as its nostrils are freed from mucus, can breathe with the mouth shut and frequently does so. Persistent failure on the part of the infant to close the mouth during respiration indicates some abnormality in the nose or throat. The respiratory rate of the newborn is relatively high — from 30 to 45 per minute — but as the lungs expand it gradually falls. The condition known as atelectasis may, in premature and weak infants, be the cause of delayed aeration. The first cry of the infant plays an important part in expanding the lungs. The full-term infant is able to suck vigorously. The fact that the infant can close its mouth on the nipple and keep the mouth closed for some moments shows that no pathological condition of moment exists in the nose or throat. When the baby drops the nipple to cough or becomes restless and disturbed during the effort to nurse, abnormality or disease in the respiratory tract should be suspected, and a proper examination made. The Temperature. — The temperature of the fetus within the uterus has been ascertained by measurement to be above 100° F. The average temperature of the newborn is 99.5° to 100.2° F. There is a daily fluc- tuation from one-tenth to three-tenths of a degree. The temperature of the newborn falls after the first bath, and it must vary greatly in accordance with the precautions taken or the lack of care in preventing exposure to cold. It is hot definitely known how low the temperature of the newborn can fall and not occasion death, but in my observation a newborn child was exposed on a winter's night for several hours, and survived. Kidney Action. — Ferroni^ examined the urine of ninety-two newborn infants during the first week of life, and believes that the character of this urine, the anatomical arrangement of the kidneys and the mechanical 1 Annali di Ost. e Gin., 1902, p. 75. 20 DISEASES A\D l.XJili'lES OF THE \EWBORN conditions in the circulation of the newborn show that a true ki(hiey function could not have been present in intrauterine life. A /A./rA'/Z-N ,>F THE SEWBORN Fig. 5 Chart of premature infant. THE PREMATURE INFANT Fig. 6 31 i S § WEIGHT MEDICINE TREATMENT 3 s m 1 18 Tr is ..^ f'N Dfl ?r m 1 ill "Jr Vi ..SE ^ I|m !'l! ill H 1 VI IV 05 8 19 Vr iiS . *[ ill 01 'JlL' -fl'"' fi 11 II . XH X 3 '■'ifi jj i'l 1 1 ■ -^ LBS. Dip y G t - H: ] IV IV i ■jiS y G 'Jlf! IS ■ ■■ 1 L VI IV 5 52 1^ 1 uiS ■■i G r ^ . VII V U 53 9 if .'i G l_ 01^ jJ^G 1 ■■ X vu 7 "'n jiO j J 'n f' 'M tl- 1 oi's _g.o It! ix ill Itl 1 XII VI 8 55 yi>' a G tt! It ill ■J ip -ii° nil nil ;tii ■i;-. oz.' . L ■ U\ XII VII 9 ■jif.' 3 . A . 9 12 3 IV IV 10 57 'J it -2 '' " 1 iliI7 -:; ip 3 1 J \\ L mi ' XI V 11 -0 9 12 3 G "1 1^ 1 LP5. y 12 3 G 1 til ■ ■ V II 12 9 1^ 3 G 1 il ; - 1 9 it 3 G n ill i IV II 13 60 9 12 3 \\\ 1 u[i^ ITg 11 t' 1 ' XI II 9tl'2 3 Ml 1 Oil ■'■■irjfi li Ul 9' ^2 :; '■> 1 "■ il., .1. II L 1 I 10 02 'J 1 -J : ; ' 1 H .li LBS. XI X ',1 1-J ■; '■. -il lGiG3 9 !-J :; 1. jl XI 11 9 !■_' :; '. ■•i 1" a OIL Hut 17 I'l 9 12 :; '.> j 1 IV 11 91)2 :;o| 1 .. •f 18 65 3 '! ;;t! H IV V 9jl2 3 G ii II [ •f 19 66 9 lb 3 i 1 IJ il -^ 63 V X 9 I" 3 G tt 4 1 jj M. OZ ' 20 67 9 I^' 3 G T II IX 91;! J-'' ^1 ' 1 1 21 68 9 1^ 3 '• il 1 11 ■■■ .■;i. X X •■1^ 'sl ii I III' llli 1 22 69 9lS Jl G 1 ii [ li ■* l!b&: i_ nil 1 V 111 9 12 4i -u L " 14 6z;| ,J T 23 70 u 1;.' 3 J " 1 li i'! lili " V 11 9l'' 3 • 11 ■'''■' V 24 71 9 i;2 3 r f* n. L " \ IV -^ 9 12 iiS '' 11 1 i( 1 — - 'IC 25 72 9 1^' iiO w It . 1 V 9 12 3 G 11 1 26 -0 9 12 G 11 il"'F" M - (J 9 12 iJli n n l^i r 27 71 9l5 30 2 CM. I 1 9 12 [3 1* il ' It II |l 1 28 75 9 1,5 3 G tM 'i "TT '1 1' ; j 9 12'" C [' .<■' 'Hi ':iL ■' ^c 29 76 9 \1 :; i' 1 T f| ] J .; I-, 1 30 77 9 12 ':, h\ j " 'SIT2 l3 C ! H-L 31 3 G I ft'' 9l5 3G 1 r " 1 M" 15'!^ il 9^2 30 ; •' Li?i. ■ ,i| llll 2 80 9;ii> 3 G ' Il F 9 IS 3 ; ■■ 1 1 OIL ':/iNC. 3 81 9,12 12 X • f M ;• n 9:i'2 3 u if 4 82 oli^ 3 9' lb 3 G Ij 6 83 9 1" 3 I It LBS '•>!'§ 3 il 2 \A 6 81 9; 12 3 G 1 if 1 ¥? "so iL L ' 1 "n" 7 85 9 1? 3 G If it ! Ii 1 ' ' i ;i IV V 3 If ■■1! 8 86 9ll5 3 i) :•: IX X 9] 12 3 •■ 9 87 9 12 3 G 1 ■■ |> > 1" L L V II ■m- 3 " .^ 1-- ir '■■: 10 3i!t._^|'M_..:^ ,■■.::■■_ V 1 III 11 S9 9 lb :;■.■,! •• ■' ! 1" IV X 9 12 i;!';; * •■ ■• 1 !'■ :':. 12 90 9 12 ; 3 '' 1 i " .. ;i |.. XI l\' 9|12 3 G " 1 i" 13 91 9 12 3 ■■ 1 1" VI 11 M 11 T il 11 M.iil- ■ : Chart showing gain of premature infants treated by incubation, artificial feeding, massage, and oil inunction at the JefTerson Maternity Hospital. 32 DISEASES AND I \. JURIES OF THE SEWBOItS twenty-four hours and have the additional advantaj^e that the massage which accompanies the inunctions stimulates the infant's circulation, and its assimilation. Such massage should he done beneath a flannel sack and without exposing the infant to the external air. The care of the intestine in the prejnature infant is of great importance. Meconium is fretjuently retained and the development of digestion retarded through sluggish action of the intestine. 1 have found ilaily irrigation of the bowels with equal parts of normal salt solution and boiled water of especial value. This must be not less than ]()()° F.,and should be given with a funnel and not with a piston or valve syringe. It should be done at a regular time when it is desirable to have the bowels move. Occasionally, it is necessary to do this twice in twenty- four hours, but care must be taken not to irritate the intestinal mucous membrane. In cases where the bowel beconu-s irritable salt solution may be replaced by two ounces of warm olive oil. This will encourage a movement of the bowels, and a little of the oil may be retained to advantage. In the general care of premature infants, patience and good sense are of the greatest importance'. The premature infant should not be removed from the incubator until it has attained the age of normal development and continues to gain in weight and vigor. With some mothers it is difficult to maintain a good secretion of milk without the stimulus of the infant's nursing. Besides tlie physical there is to some extent a psychical element in the presence of the infant, and when this is lacking the supply of milk may diminish or cease. Care should be taken to explain to the mother that the enforced a])sence of the infant will terminate as soon as possible, and she should be encouraged to hope that she will be enabled to nourish the infant until it can be applied directly to the breast. As the infant begins to gain in weight its oil inunction may be accom- panied by general massage combined with massage of the intestine, gently given for twenty minutes or half an hour. This develops the muscles, stimulates the circulation, and improves the infant's nutrition. Absolute regularity should be observed in the care of premature infants. As they are not yet sufficiently developed to notice objects about them, this care is more easy than in the case of infants born at term. Premature infants in incubators properly cared for usually cry less than full-term infants, partly because they are disturbed so little and partly because they are weaker. To care for such an infant two nurses are necessary. For several weeks the infant must be constantly watched, and this is almost impossible with but one nurse, even though some friend or relative assists. It is not infrequent for premature infants to lose slightly or remain stationary in development for a short time after birth. So long as the infant's strength is well maintained, its movements well digested, and it is not fretful this need occasion no alarm. After a slight pause it will usually commence to gain. If, however, the infant loses considerably or fails within a reasonable time to gain, then some essential change in THE PREMATURE IX FAX T 33 its hygiene must be made. In order to estimate the progress of such an infant it must be weighed at regular and frequent intervals. It is safest to weigh the incubator with its contents, and, knowing the weight of the incubator and appendages without the infant, the weight of the child is readily obtained. If this is impossible, then the infant must be placed upon the scales, every precaution being taken to avoid chill. A further means of estimating the development of a premature infant consists in ascertaining and recording its length. Bv reference to the chart (Fig. 6) it wall be observed that a considerable increase in length accompanied the gradual growth of the infant. It is not infrequent for an infant while growing in length to remain stationary in weight. If this be known the failure of the infant to gain in weight is explained. If the infant does well it may leave the incubator perma- nently when it has come to full term, it being possible to secure for it adequate protection against cold. The chance for a premature infant born in the spring or early autumn is somewhat better than that of a child bom in winter or in the heat of midsummer. Premature infants are so sensitive that they feel extremes in temperature even though protected by an artificial environment. In early summer the lid of the incubator may be removed and the infant may be given sun baths at a temperature as nearly as possible that maintained by artificial heat. Prognosis. — A physician will do wisely to withhold a prognosis regarding a premature infant. While many survive, others do not, and some fail without appreciable cause. The influence of infection must not be forgotten, as it may be the cause of death. Sudden death is not uncommon in these cases and nurses should be warned of this fact in undertaking their care. Death sometimes occurs in con^'ulsions, but most often quietly and with so little disturbance that the death of the infant may not be recognized for some time. The state of the heart, the power of digestion, the action of the lungs, and the influence of infection all affect the prognosis. CHAPTER IT. ASPHYXIA NEOxNATORUM— ACCIDENTS TO THE UMBILICAL CORD. ASPHYXIA NEONATORUM. By the term asphyxia we understand laek of oxy(|;enati()n of the hlood with consecjuent accuinuhition of earbon dioxide and its poisonous effects upon the nerve centres. Asphyxia may be intrauterine, the infant perishin*]^ before birth, or it may become apparent after the infant has been expelled from the uterus. Intrauterine Asphyxia. — Disease or premature separation of the placenta, prolongation of the second stage of labor from any cause, or death of the mother may cause intrauterine asphyxia. Extrauterine Asphyxia. — This form of asphyxia of the newborn commonly arises from occlusion of the umbilical cord through coiling or prolapse of the cord with pressure. Congenital atelectasis may be associated with asphyxia. It sometimes arises from the inspiration of mucus, amniotic liquid, or blood. It may also follow birth pressure, which may produce cerebral or pulmonary hemorrhage. Its effect on the future health of the infant may thus be most important. Symptomatology. — Asphyxia has been divided into livid or blue asphyxia and pallid or pale asphyxia. In the livid or l)lue asphyxia the infant's color is dusky reddish-blue, the heart beat is evident, the muscles are not completely relaxed, the pupils are not widely dilated, and the reflexes are, to some extent, present. In pallid or pale asphyxia the infant's color is cadaveric white, its heart beat is imperceptible or very feeble, its pupils are widely dilated, and its reflexes cannot be excited. Treatment. — The prevention of asphyxia is entirely obstetrical. Prolonged labor with excessive birth pressure and injury to the cord must be avoided. Late ligation of the umbilical cord indirectly helps to prevent asphyxia, as it gives to the infant a greater quantity of oxygenated blood, thus supporting its circulation. In the treatment of livid or blue asphyxia it must be remembered that the infant resembles a clock which has been wound, but whose pendulum must be moved to put the works in motion. What is needed in these cases is to excite respiration by arousing the nervous reflexes. If the cord is beating and the piiysician allows pulsation to cease spontaneously before tying and cutting the cord, he should then determine the presence of fetal heart beats by auscultation or by pressing with the finger-tips against the apex of the heart. Where asphyxia is slight, slapping the infant lightly, dashing a few drops of cold water on (34) ASPHYXIA NEONATORUM 35 the chest, placing the infant in a warm bath, and spraying a Httle cold water upon the chest will arouse the muscles of respiration. If the infant seems plethoric and oppressed with blood it may be allowed to lose a few drachms of blood from the cord. If the finger be dipped in whiskey and carried downward into the fauces the infant will make a sucking motion and may then respire. Laborde's^ method of making rhythmical traction upon the tongue is endorsed by Rivemont-Desaignes," and also by Fronczak,^ who believes that it is safer than those methods which expose the child to rapid cool- ing of its body and to the danger of injury to the clavicles. Laborde, in investigations made to determine the length of time after apparent death in which the reflexes could be excited, found this period to be three hours, and would continue rhythmical tractions upon the tongue for that length of time. Cases of livid asphyxia require especial attention to the cutaneous reflexes. Gentle friction while the infant's body is immersed in a bath of warm water containing mustard acts as a powerful stimulant to respiratory reflexes. The external application of warmth is less necessary in these than in cases of pale asphyxia. I believe that in cases of livid asphyxia the right heart of the infant and the large veins of the body are overdistended with blood. The simple maneuvre of folding and unfolding the body of the infant, proposed and described by various observers, I have found of great value. After the mouth has been thoroughly cleansed of mucus and the cord tied and cut, the infant is grasped with one hand across the back, the fingers resting upon the clavicles; the other hand grasps the thighs. Holding the infant with the head down, the trunk is then folded and unfolded. From ten to sixteen may be counted during each movement of the child's body. During folding the abdominal viscera are carried up against the diaphragm, the diaphragm is pushed upward, whatever air may be in the lungs is forced out, while the pressure brought to bear upon the abdominal viscera forces the blood upward from the abdominal veins and the pressure of the diaphragm against the heart and lungs tends to promote the emptying of the chambers of the heart. When the infant is unfolded air may enter the lungs, the pressure on the veins is removed, and the conditions are more favorable for the circulation of arterial blood. So successful in my experience has this sim.ple maneuvre been in the treatment of asphyxia that it has largely superseded other methods of treatment. The fact that it enables us to directly stimulate the circulation by simple means while furthering the establishment of respiration makes the method especially valuable, even in the treatment of pale asphyxia where the problem is more difficult, for oxygen must be introduced into the blood and as rapidly as possible to remove the paralyzing effects of the carbon dioxide already accumulated. The physician must not only introduce air into 1 Gaz. des hSpitaux, 1901, tome Ixxiv. p. 1319. 2 Annal. de GynSc, 1900, tome liv. p. 101. » Buffalo Medical Journal, vol. Iv. 1899, 190O. 36 DISI'JASES AM) I.\./l'l{Jh'S OF THE SlCWIiORS the child's chest, l)ut \\v must stimulate the action of the heart, maintain the warmth of the body, while avoiding injury to the child hy any method of treatment. To secure the entrance of air into the lungs artificial respiration may be practised. Marshall Hall's metho