The diseases of infancy and childhood, for the use of students and practitioners of medicine

Front matter

Copyright Is

COPYRIGHT DEPOSIT.

k

Part I. Chapter Pagb

I. — Hygiene axd General Care of Infants and Young Children . . 1 Care of the newly-born child; bathing; clothing; care of the eyes; care of the mouth and teeth ; care of the skin ; care of the genital organs ; vaccination ; training to proper control of rectum and bladder ; general hygiene of the nervous system ; sleep ; exercise ; airing : the nursery ; the nurse ; the amount of air space required by infants ; the care of premature and delicate infants ; incubators ; the feeding of the premature infant.

II. — Growth and Development of the Body .15

Weight; height; growth of extremities as compared with the trunk; the head; the chest; the abdomen ; muscular development; development of special senses ; speech ; dentition.

III. — Peculiarities of Disease in Children .... . . 30

Etiology; symptomatology and diagnosis; pathology; prognosis and infant mortality ; prophylaxis ; therapeutics.

Section I. — Diseases of the Newly-Born. I. — Asphyxia . . 67

II. — Congenital Atelectasis 72

III.— Icterus 75

IV. — The Acute Infectious Diseases op the Newly-Born .... 78 The acute pyogenic diseases ; ophthalmia ; tetanus ; epidemic hsemoglobinuria ; fatty degeneration of the newly- born; pemphigus.

V. — HEMORRHAGES - . 93

Traumatic or accidental hasmorrhages ; spontaneous heemorrhages.

VI. — Birth Paralyses 105

Cerebral paralysis; facial paralysis; paralysis of the upper extremity.

VII. — Tumours of the Umbilicus, etc. Ill

Umbilical hernia; mastitis; intestinal obstruction; diaphragmatic hernia; sclerema; oedema; inanition fever.

Section II. — Nutrition. L — Introductory 122

The food constituents and the purposes they subserve in nutrition.

vii viii TABLE OF CONTENTS.

CHAPTER PAGE

II.— The Infant's Dietary 126

Woman's milk; cow's milk; coudeiised milk; kumyss: matzoon; junket, curds and whey; beef preparations; cereals; infant food.

III.— Infant Feeding 164

Choice of methods ; breast feeding ; maternal nursing ; wet-nursing ; weaning ; mixed feeding ; artificial feeding.

IV. — Feeding after the First Year . 216

Healthy infants during the second year; ditficult cases during the second year; feeding from the third to the sixth year: feeding during acute illness.

V. — The Derangements of Nutrition 224

Acute inanition; malnutrition; marasmus.

VI.— Diseases Due to Faulty Nutrition 242

Scorbutus ; rickets.

Section III.— Diseases of the Digestive System. I. — Diseases of the Lips, Tongue, and Mouth 272

Malformations ; diseases of the lips ; diseases of the tongue ; alveolar abscess ; difficult dentition ; catarrhal stomatitis ; herpetic stomatitis ; ulcerative stomatitis ; thrush ; gonorrhoeal stomatitis ; syphilitic stomatitis ; gangrenous stomatitis.

II. — Diseases of the Pharynx 291

Acute pharyngitis; nvulitis; elongated uvula; retro-pharyngeal abscess; adenoid vegetations of the vault of the pharynx.

III. — Diseases of the Tonsils 305

Croupous tonsillitis; ulcero-membranous tonsillitis; follicular tonsillitis; phlegmonous tonsillitis ; chronic hypertrophy of the tonsils.

IV. — Diseases of the CEsophagus 312

Malformations ; acute oesophagitis ; retro-oesophageal abscess, V. — Diseases of the Stomach 316

Digestion in infancy; malformations and malpositions of the stomach ; vomiting; cyclic vomiting; gastralgia ; acute gastric indigestion; acute gastritis; gastro-duodenitis ; chronic gastric indigestion ; dilatation of the stomach ; ulcer of the stomach ; tumours of the stomach ; haemorrhage from the stomach.

VI. — Diseases of the Intestines 347

Malformations and malpositions ; diarrhoea ; acute intestinal indigestion.

VII.— Diseases of the Intestines {contimied) . . . . . . . 357

Acute gastro-enteric intoxication ; cholera infantum.

VIII. — Diseases of the Intestines (continued) 381

Acute colitis and ileo-colitis ; chronic ileo-colitis ; amoebic colitis ; amyloid degeneration of the intestines ; tuberculosis of the intestines and mesenteric lymph nodes.

IX. — Diseases of the Intestines (continued) 409

Chronic intestinal indigestion ; intestinal colic ; chronic constipation ; intussusception.

X. — Diseases of the Intestines (continued) 434

Appendicitis ; intestinal worms.

XI. — Diseases of the Rectum 448

Prolapsus ani ; fissures of the anus ; proctitis ; ischio-rectal abscess ; haemorrhoids ; incontinence of fteces.

XII. — Diseases of the Liver 454

Icterus ; functional disorders ; acute yellow atrophy ; congestion of the liver ; abscess of the liver ; cin'hosis ; amyloid degeneration ; fatty liver ; hydatids ; biliary calculi.

TABLE OF CONTENTS. ix

CHAPTER PAGE

XIII. — Diseases of the Peritoneum 461

Acute peritonitis ; chronic (nou-tuberculous) peritonitis ; tuberculous peritonitis ; ascites ; subphrenic abscess.

Section IV.— Diseases of the Eespiratory System. I. — Nasal Cavities 474

Acute nasal catarrh; chronic nasal catarrh; chronic rhinitis; membranous rhinitis ; epistaxis.

II. — Diseases of the Larynx 485

Catarrhal spasm of the larynx ; acute catarrhal laryngitis ; pseudo-membranous laryngitis ; intubation ; submucous laryngitis ; chronic laryngitis ; new growths; foreign bodies in the larynx.

III. — Diseases of the Lungs 505

The peculiarities of the lungs in infancy and early childhood ; acute catarrhal bronchitis ; fibrinous bronchitis ; chronic bronchitis ; reflex cough ; asthma.

IV. — Diseases of the Lungs {continued) 523

Pneumonia ; acute broncho-pneumonia.

V. — Diseases of the Lungs {continued) 558

Lobar pneumonia ; pleuro-pneumonia ; hypostatic pneumonia ; chronic broncho-pneumonia ; gangrene of the lungs ; acquired atelectasis ; emphysema.

VL— Pleurisy 587

Dry pleurisy ; pleurisy with serous effusion ; empyema.

Section V. — Diseases of the Circulatory Sy^stem. I. — Peculiarities of the Heart and Circulation in Early Life . . 602 II. — Congenital Anomalies of the Heart 606

III. — Pericarditis 613

Acute pericarditis ; chronic pericarditis with adhesions. IV. — Endocarditis and Valvular Disease 618

Acute simple endocarditis ; malignant endocarditis : chronic valvular disease ; myocarditis ; anfemic murmurs ; functional disorders of the heart ; diseases of the blood-vessels.

Section VI.— Diseases of the Uro-G-enital System. I. — The Urine in Infancy and Childhood 638

Functional or cyclic albuminuria ; hcematuria ; ho?moglobinuria ; glycosuria ; pyuria; lithuria ; indicanuria ; acetonuria— diacetonuria ; anuria; diabetes insipidus.

11. — Diseases of the Kidneys 650

Malformations and malpositions ; uric-acid infarctions ; acute congestion of the kidneys ; chronic congestion of the kidneys ; acute degeneration of the kidneys; acute diffuse nephritis; chronic nephritis; tuberculosis of the kidney ; malignant tumours of the kidney ; pyelitis — pyelo-cystitis ; renal calculi ; traumatic hydro-nephrosis : perinephritis ; general cedema not dependent on renal disease.

III. — Diseases of the Genital Organs 679

Malformations ; diseases of the male genitals ; diseases of the female genitals.

IV.— Enuresis ■ 688

Vesical spasm ; vesical calculi.

Section VII.— Diseases of the Nervous System. CHAPTER PAGE

I. — Introductory 695

II. — General and Functional Nervous Diseases . . . . , . 697 Convulsions ; epilepsy ; tetany ; laryngismus stridulus ; chorea ; other spasmodic affections; hysteria; headaches; disorders of speech; disorders of sleep ; injurious habits of infancy and childhood.

III. — Diseases of the Brain and Meninges 743

Malformations ; pachymeningitis ; acute meningitis ; tuberculous meningitis ; chronic basilar meningitis in infants ; thrombosis of the sinuses of the dura mater; cerebral abscess ; cerebral tumour; hydrocephalus; infantile cerebral paralysis ; feeble-mindedness, idiocy, imbecility ; sporadic cretinism ; insanity ; the stigmata of degeneration ; deaf-mutism.

IV. — Diseases of the Spinal Cord 805

Malformations ; spinal meningitis ; myelitis ; compression-myelitis ; acute poliomyelitis ; tumours of the spinal cord ; syringo-myelia ; Fricdreich''s ataxia ; Landry's paralysis ; the muscular atrophies.

V. — Diseases of the Peripheral Nerves 831

Multiple neuritis ; diphtheritic paralysis ; facial paralysis.

Section VIII. — Diseases op the Blood, Lymph Nodes, Bones, etc. I. — Diseases of the Blood 841

Leucocytosis ; simple anaemia ; chlorosis ; pseudo-leuksemic anaemia of infancy; pernicious anaemia; leukaemia; haemophilia; purpura.

II. — Diseases of the Lymph Nodes 86S

Lymphatism ; simple acute adenitis ; simple chronic adenitis ; syphilitic adenitis ; tuberculous adenitis ; Hodgkin's disease.

III. — Diseases of the Spleen 878

IV. — Diseases of the Bones and Joints 881

Acute arthritis of infants ; tuberculous diseases of the bones and joints ; syphilitic diseases of bone.

V. — Diseases of the Skin 904

Congenital ichthyosis; miliaria; seborrhoea; eczema; furunculosis ; gangrenoi^s dermatitis ; impetigo contagiosa ; urticaria ; scabies ; tinea tonsurans. VI.— Acute Otitis 925

Section IX.— The Specific Infectious Diseases. I. — Scarlet Fever 935

II.— Measles 958

III.— Rubella . . . .974

V. — Vaccinia — Vaccination 979

VI.— Pertussis 990

VII.— Mumps 997

VIII.— Diphtheria . . . . . . 1000

IX.— Typhoid Fever 1050

X.— Tuberculosis 1058

TABLE OF CONTENTS. xi

CHAPTER PAGE

XL— Syphilis 1094

XIL — Influenza 1111

XIIL— Malaria 1119

Section X. — Other General Diseases. L — Rheumatism 1129

II. — Diabetes Mellitus . .1135

LIST OF ILLUSTKATIOXS.

PLATES. FACING

PAGE

I. Chart showing by months the mortality of Xew York city for the different ages for three years 41 ,

II. Meningeal hgeraorrhage in the newly born 106

III. Chart showing composition of various infant foods compared with

IV. Bone in rickets 253

V. Typical rickets 256 '

VI. Deformity of the chest in severe rickets 259 "^

VII. The stomach at the different periods of infancy 317

VIII. Intestinal bacteria, and lesions 364

IX. Extensive superficial ulceration of the colon 385

X. Deep follicular ulcers of the colon 386 t-'

XI. ^Membranous inflammation of the ileum 388

XII. Chronic hyperplasia of the lymph nodules (solitary follicles) of the

colon 410

XIII. Acute broncho-pneumonia 530

XIV. Acute pleuro-pneumonia 576

XV. Chronic broncho-pneumonia 579

XVI. Acute meningitis, complicating pleuro-pneumonia 752 '

XVII. The blood in leukaemia and pernicious anaemia 842 ^y

X\^III. The pathognomonic sign of measles (Koplik's spots) .... 970 ^

XIX. The diphtheritic membrane 1015

XX. Diphtheria bacilli and their associates 1024

XXI. Tuberculosis of the tracheo-bronchial lymph nodes .... 1070

ILLUSTRATIONS IN THE TEXT.

FIGURE PAGE

1. Incubator 12

2. Incubator, sectional view 13

3. 4. Scales 15

5. Weight curve for the first twenty days . . . . v . . .16

6. Weight curve for the first year 18

7. Skull, showing premature ossification 23

8. Apparatus for albolene spray . . 55

9. Nasal syringe 56

10. Position for nasal syringing . . . 57

xiii xiv LIST OF ILLUSTRATIONS.

FIGURE PAGE

IL Croup kettle 58

12. Vapoiirizer 59

13. Steam atomizer 59

14. Oiled-silk jacket 59

15. Apparatus for stomach-washing GO

16. Position for stomach-washing 61

17. Colon of a child six months old ,64

18. Ribemont's tube 71

19. Double eephalhferaatoma, infant seven days old 96

20. Erb's paralysis 110

21. Umbilical tumours . . .112

22. Temperature chart in inanition fever 120

23. Human milk, colostrum period 127

24. Human milk, later period 127

25. xVpparatus for examination of human milk 132

26. Fesers lactoscope 145

27. Cooley creamer, cans 149

28. Arnold sterilizer 152

29. Freeman Pasteurizer 153

30. Weight curve of nursing and artificial feeding compared .... 166

31. Weight curve showing effect of bad nursing and good feeding . . .171

32. Chart showing effect of pregnancy on weight of nursing infant . . . 175

33. Weight curve of infant proj^erly weaned 176

34. Percentage of fat in different layers of milk 188

35. Chapin's dipper for removing upper layers of milk 188

36. Weight curve of bottle-fed infant for first six months 193

37. Weight curve of artificially fed infant, showing effect of beginning with too

high percentages 195

38. The " Materna " measuring glass 201

39. Weight chart showing the effect of intelligent care 204

40. Weight curve showing the advantage of temporarily stopping milk . . 212

41. Case of marasmus 238

42. Normal bone 254

43. Rachitic bone 255

44. Rachitic skull, inside view , 258

45. Rachitic head 259

46. Rachitic skull, external xlew . . 260

47. Rachitic thorax in outline . 260

48. Rachitic bow-legs . , „ , 261

49. Rachitic knock-knees 262

50. Rachitic deformity of legs . , . 263

51. Rachitic bow-legs in outline 270

52. Epithelial desquamation of the tongue . . . . . . . . 275

53. Thrush 285

54. Cancrum oris 290

55. Adenoid vegetations, natural size 298

56. Chest deformity from adenoid vegetations of the pharynx .... 300

57. 58. Child with adenoid vegetations, before and after operation . . . 304

59. Dilatation of the stomach . . . 343

60. Malformations of the rectum 347

61. Chart showing mortality from diarrha-al diseases in New York . . . 349

LIST OF ILLUSTRATIONS. XV

FIGURE PAGE

63. Chart showing frequency of cliarrhoeal diseases 350

63. Weight curve s-howing effect of acute gastro-enteric intoxication during

first year 3G3

6-4. Temperature chart of acute intestinal intoxication with fatal re-infection . 366

65. Acute catarrhal ileo-colitis, superficial type 383

66. Acute catarrhal ileo-colitis, severe form 384

•67. Follicular ulceration of the colon, early stage 386

68. Follicular ulceration of the colon, later stage 387

69. Membranous colitis 389

70. Weight curve showing loss from ileo-colitis 391

7L Temperature chart in ileo-colitis . . -. 393

72. Temperature chart in membranous colitis 395

•73. Temperature chart in membranous colitis, long case 396

74. Chronic catarrhal inflammation of the ileum 401

75. Ileo-caecal intussusception 425

76. 77. Mechanism of intussusception 426

78. Taenia saginata 442

79. Taenia solium 442

50. Taenia cucumerina . • 443

51. Bothriocephalus latus 443

52. Ascaris lumbricoides 444

^3. Oxyuris vermicularis 446

84. Prolapsus ani 449

85. O'Dwyer's intubation set 495

86. An air vesicle in broncho-pneumonia . . 524

87. An air vesicle in lobar pneumonia 525

88. Broncho-pneumonia with thickened bronchus 530

89. Broncho-pneumonia, hasmorrhagic form 532

00. Broncho-pneumonia with emphysema 533

91. Broncho-pneumonia, diffuse purulent infiltration 534

•92. Persistent broncho-pneumonia 536

93. Temperature chart in mild uncomplicated broncho-pneumonia . . • 541

94. Temperature chart, prolonged course, broncho-pneumonia .... 542

95. Temperature chart, relapsing broncho-pneumonia 542

96. Temperature chart, rapidly fatal broncho-pneumonia 542

97-100. Physical signs in broncho-pneumonia 544

101. Temperature chart, persistent broncho-pneumonia 547

102. Temperature chart, broncho-pneumonia following pertussis .... 548

103. Temperature chart, typical lobar pneumonia 564

104. Temperature chart, remittent type, lobar pneumonia 564

105. Temperature chart, lobar pneumonia, subnormal temperature after crisis . 565

106. Temperature chart, abortive pneumonia 565

107-109. Physical signs, lobar pneumonia 569

110. Section of lung, showing distribution of fluid in chest ..... 594

111, 112. Empyema following pneumonia 595

113. Deformity after old empyema . . . 600

114. Apparatus for inducing lung expansion after empyema . "*>. . . 601

115. Showing normal areas of cardiac dulness 605

116. Congenital cardiac disease 607

117. Clubbing of fingers in congenital cardiac disease 610

118. Congenital malformations of the kidney and ureters 653 xvi LIST OF ILLUSTRATIONS.

FIGl-RE PAGE

119, 130. Sarcoma of the kidney before and after operation 669

123. Spasmodic torticollis 727

123. Meningocele 743

134. Encephalocele 743

125. Ilydrencephalocele 743

126. Meningocele 743

127. Xaso-frontul meningocele 744

128. Tracing of respiration in tuberculous meningitis 763

129. Temperature chart in tuberculous meningitis 763

130. Chronic basilar meningitis 766

131. Section of the brain in hydrocephalus 780

132. Head in chronic hydrocephalus, globular form 781

133. Head in chronic hydrocephalus, pyramidal form 783

134. Brain, showing results of old meningeal ha?morrhage, lateral view . . 786

135. Brain, showing results of old meningeal Jiaemorrhage, superior view . . 787

136. Convulsions in infantile cerebral paralysis 788

137. Spastic paraplegia 789

138. Contractures following infantile cerebral paralysis 793

139. Brain in idiocy 795

140. A typical cretin 798

141-144. Cretins, showing effect of thyroid treatment . . . . . . 799

145. Spina bifida, meningocele (partially diagrammatic) 806

146. Spina bifida, meningocele, case of 806

147. Spina bifida, meningo-myelocele (partially diagrammatic) .... 807

148. Spina bifida, syringo-myelocele 808

149. Spina bifida, sacral 808

150. Spina bifida, section of cord in 809

151. Infantile spinal paralysis of lower extremity 820

153. Infantile spinal paralysis of shoulder 831

153. Muscular pseudo-hypertrophy 830

154. Alcoholic neuritis 833

155. Diphtheritic paralysis 834

156. Facial paralysis 839

157. Acute suppurative adenitis, cervical 867

158. Acute suppurative adenitis, inguinal . . 867

159. Chain of tuberculous lymph nodes (posterior cervical) 873

160. Cicatrices following tuberculous adenitis " 874

161. Section of the spine in Pott's disease . , . . ' . . . . 885

162. Hip-joint disease 891

163. Tuberculous dactylitis 896

164. Syphilitic disease of the radius and ulna 898

165. Syphilitic disease of the tibia . . . . 900

166. Syphilitic disease of both tibiae 901

167. Syphilitic necrosis of the tibia 903

168. Syphilitic dactylitis 903

169. Congenital ichthyosis 905

170. Temperature chart, acute otitis following influenza 926

171. Temperature chart, acute otitis, early paracentesis 937

173. Mastoid abscess 930

173. Temperature chart in scarlet fever, typical curve 941

LIST OF ILLUSTRATIONS.

xvu

FIGURE

174. Temperature chart in scarlet fever, prolonged course .

175. Temperature chart in complicated scarlet fever

176. Temperature chart in fatal septic scarlet fever

177. 178. Temperature charts in measles, typical curve.

179. Temperature chart in measles, occasional course .

180. Temperature chart in measles, prolonged course .

181. 182. Temperate charts in measles complicated by pneumonia

183. Table showing protective power of vaccination

184. Vaccination vesicles, normal

185. Vaccination vesicles, severe course

186. Temperature chart in pseudo-diphtheria

187. Temperature chart in typhoid fever, short course .

188. Temperature chart in typhoid fever, with relapse .

189. Tuberculous broncho-pneumonia, diffuse consolidation ,

190. Cavity from tuberculous broncho-pneumonia , . .

191. A tuberculous nodule

192. Tuberculous broncho-pneumonia, early stage .

193. Tuberculous bronchial lymph nodes ....

194. Temperature chart of tuberculosis following measles

195. Temperature chart of tuberculous broncho-pneumonia, general tuberculo;

196. Temperature chart of tuberculous broncho-pneumonia with softening.

197. Syphilitic scaling in an infant

198. Syphilitic notched teeth

199. Syphilitic teeth, variously deformed

200. Temperature chart of severe influenza in an infant ....

201. Temperature chart of acute broncho-pneumonia complicating influenza

202. Temperature chart, quotidian intermittent fever

203. Temperature chart, tertian intermittent fever

204. Temperature chart in malaria, irregular type

PAGE

THE DISEASES OF INFANCY AND CHILDHOOD,

PART L

Chapter I. Hygiene And General Care Of Infants And Young

CHILDREN.

The physical development of the child is essentially the product of the three factors — inheritance, surroundings, and food. The first of these it is beyond the physician's power to alter ; the second is largely and the third almost entirely within his control, at least in the more intelligent classes of society. These two subjects, infant hygiene and infant feeding, are the most important departments of pediatrics.

The Care of the Newly-Born Child. — After the ligature of the cord the child should be wrapped in a thick blanket and placed in a warm room. In hospital practice the eyes should be cleansed with absorbent cotton and water which has been boiled, and then two or three drops of a two-per-cent solution of nitrate of silver, after Crede's method, instilled into each eye by means of a glass rod or eye- dropper. In private practice a saturated solution of boric acid may be substituted, unless the mother has had a purulent vaginal discharge, in which case the silver solution should always be used. The bath should now be given in a warm room ; the body being first oiled thoroughly in order to remove the vernix caseosa and then washed in water at a temperature of 100° F. The mouth should be cleansed with plain tepid water and a soft cloth, and no violence employed. The cord may be covered with salicylic acid one part and starch nineteen parts, or simply with subnitrate of bismuth, and wrapped in sterile gauze or surgeon's lint. The abdomen should now be enveloped in a flannel band, eight or ten inches wide, and pinned rather snugly. Before dressing is completed, the child should be submitted to a thorough examination for injuries received during delivery, congenital deformities^ also as to the condition of the respiration, circulation, etc.

After dressing, the child should be placed in its crib and covered with blankets, and if the feet are cold, or the fingers and lips a little blue, it

2 HYGIEXE AXD GENERAL CARE OF IXFAXTS.

should be surrounded by hot-water bottles covered with flannels, and placed near, but not in contact with, the body. The crib should be placed in a quiet, darkened room. The young infant should not occupy the same bed as the mother, unless it greatly needs the warmth of her body, other means of artificial heat not being at hand.

The cord should be kept dry and disturbed as little as possible until it falls off. Under ordinary circumstances the cord separates from the fourth to the seventh day, the average being the fifth day. The stump should then be covered with the salicylic acid and starch powder, and a pad of sterile gauze about one fourth of an inch thick and two inches square applied and secured in position by means of the abdominal band. The purpose of this is to prevent umbilical hernia. The pad should be continued for the first month. The use of stronger antiseptic dressings than that recommended is somewhat objectionable, since it preserves the cord too long and delays separation. The full bath should not be given until the cord has separated.

The physician should always see to it that the infant cries enough to keep the lungs properly expanded.

The question of food for the newly-born infant is considered in the chapter upon infant feeding.

Bathing. — For the first few months the bath should be given at 98° r. The room should be warm, preferably there should be an open fire. The bath should be short and the body dried quickly, without too vigorous rubbing. The addition of salt to the bath is an advantage where the skin is unusually delicate or excoriations are present. One large handful should be used to a gallon of water. By the sixth month the temperature of the bath for healthy infants may be lowered to 95° F., and by the end of the first year to 90° F. Older children who are healthy should be sponged or douched for a moment at the close of the tepid bath with water at 65° or 70° F. During childhood the warm bath is preferably given at night. In the morning a cold sponge bath is desirable. This should be given in a warm room and while the child standi in a tub partly filled with warm water. This cold sponge should last but half a minute, and be followed by a brisk rubbing of the entire body.

In some young infants and even older children there is no proper reaction after the bath, even when given at the temperatures mentioned ; children being pale, slightly blue about the lips and under the eyes. All tub bathing, and especially all cold bathing, should then be stopped, since a continuance can only be a drain upon the child's vitality.

Clothing. — The' clothing of infants should be light, warm, non-irritating to the skin, and loose enough to allow free motion of the extremities ; nor should bands be pinned so tightly about the trunk as to emharrass the movements either of the chest or of the abdomen. The chest should be covered with a woollen shirt, high in the neck and with long

BATHING— CLOTHING. 3

sleeves. All petticoats should be supported from the shoulders and not from waistbands. Canton flannel and stockinet are both superior as absorbents to the more commonly used linen diapers. Stockinet has the advantage of being very soft and pliable. Care should be given that in infants the feet be kept warm. If the circulation is very poor, a bag of hot water should always be in the crib. Cold feet are responsible for many attacks of colic and indigestion.

The abdominal band is usually worn during infancy. It cannot be considered in any sense a necessity after the first few months, excepting in cases of very thin infants whose supply of fat in the abdominal walls is an insufficient protection to the viscera. For the first few weeks a band of plain flannel is to be preferred ; later, a knitted band with shoulder-straps. The fashion of low neck and short sleeves for infants and very young children has fortunately passed away — let us ho23e, never to return.

During the summer the outer clothing should be light and the under clothing of the thinnest flannel or gauze. The changes in the temperature of morning and evening may be met by extra wraps. The custom of allowing j^oung children to go with legs bare has many enthusiastic advocates ; while it may not be objectionable during the heat of summer, its advantages at any season are very questionable in a changeable climate like that of Xew York or the Atlantic coast. Many delicate children are certainly injured by such ill-advised attempts at hardening.

The night clothing of infants should be similar to that worn during the day, but should be loose, the material being of the lightest flannel. The night clothing for older children should consist of a thin woollen shirt and a union suit with waist and trousers, and in some cases with feet, if there is a tendency to get outside the coverings. The common mistake is to overload all children, but especially infants, with covering at night. This is an explanation of much of the restless sleep which is seen particularly in delicate children.

Care of the Eyes. — During the first few days at the daily bath, the eyes should be cleansed with a saturated solution of boric acid. They should be carefully protected from too strong light during early infancy. It is desirable that a child should alwaj's sleep in a darkened room.

Care of the Mouth and Teeth. — The mouth of the newly-born infant should be gently cleansed at each morning bath with boiled water and a soft cloth. On the first appearance of thrush the mouth should be washed after every feeding with a solution of bicarbonate of soda or borax (twenty grains to the ounce). Harm is often done by the use of too much force in cleansing the mouth of a young infant.

The jDrimary teeth as well as those of the permanent set should receive daily attention. Too often they are neglected altogether. Dirty teeth are likely sooner or later to become carious ; and carious teeth, besides being a cause of bad breath and neuralgia, are a constant menace to the

4 HYGIENE AND GENERAL CARE OP INFANTS.

health of the child, since they may harbour infections germs of all varieties. Such teeth shonlcl either be filled or removed.

Care of the Skin. — The skin of a yonng infant is exceedingly delicate, and excoriations, intertrigo, and eczema are of very common occurrence. These conditions are much easier of prevention than of cure. The first essential in the care of the skin is cleanliness, and this must be secured without the nse of strong soaps or too much rubbing. Napkins^ must be removed as soon as soiled or wet. Some bland absorbent powder^ like starch, talcum, or the stearate of zinc, should be used in all the foldsof the skin, in the neck, in the axillae, groins, and about the genitals, and in the folds of the thighs, particularly in very fat infants. If plain water produces an nndue amount of irritation, the salt or bran bath should be^ employed.

Care of the Genital Organs. — The female genitals need but little attention in young children, excepting as to cleanliness. This is more often neglected in older children than in infants. Vulvo-vaginitis is very common among the children of the poorer classes where cleanliness isneglected.

In males the prepuce should receive attention during the first few weeks of life. If the foreskin is long and the preputial orifice small,, circumcision should invariably be done. If it is not long, but is only adherent, these adhesions should be broken up, the parts thoroughly cleansed and the foreskin retracted daily until there is no disposition to a recurrence of the adhesions. These operations will be discussed more at length in a subsequent chapter. The only thing to be emphasised in the present connection is that the prepuce should receive proper attention in early infancy, since this can now be done with less pain and discomfort to the child, and at the same time better results are obtained. If this matter is neglected during infancy, it is apt to be overlooked until harm has been produced by local or reflex irritation which phimosis or adherent prepuce may have excited.

Vaccination. — This, although considered elsewhere, should be mentioned in this connection as among the things requiring the physician's attention during the first months of life.

Training to Proper Control of Rectum and Bladder. — It is surprising to see what can be accomplished by intelligent efforts at training in these particulars. An infant can often be trained at three months tohave its movements from the bowels when placed upon a small chamber. This not only saves a great amount of washing of napkins, but there is soon formed a habit of having the bowels move at a regular time or times each day. The infant must be put upon the chamber soon after its feeding. The importance of training young children to regular habits regarding evacuations from the bowels can hardly be overestimated. It should be impressed upon every mother and nurse by the physician, and

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especially the necessity of beginning training during infancy. Much of course will depend upon the food and the digestion ; but habit is a very large factor in the case.

The training of the bladder is not quite so important, but the proper education of this organ adds much to the comfort of the child and the ease with which it is cared for. Before the end of the first year most intelligent children can be trained to indicate a desire to empty the bladder. Many mothers and nurses succeed in training children so well that by the tenth or eleventh month napkins are dispensed with during the day. On the other hand, it is very common to see children of two and even two and a half years still wearing napkins because of the lack of proper training. Before it has reached the latter age a healthy child should go from 10 p. M. until morning without emptying the bladder. The annoyance and discomfort from the neglect of early training in this particular are very great. Xight feeding is responsible for much of the difficulty experienced in training children to hold the water during the night.