The diseases of infancy and childhood

Front matter

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Preface To The Sixth Edition

In the preparation of this edition the author has associated with him Dr. John Howland, his former assistant, who will hereafter be connected with the work as joint author.

Progress along many lines in paediatrics has been rapid during the last two )'ears. To make room for new knowledge without unduly enlarging the size of the volume has made it necessary to cut out about seventy-five pages of old material. It is believed that this has been accomplished without impairing the value of the chapters which have been abridged. The decision of the publishers to make entirely new plates has made this comparatively easy.

There is scarcely a page in the book which has not been subject to some revision. Many articles have been entirely rewritten and several new ones appear for the first time in this edition. The greater part of the new material will be found in the chapters upon Nutrition and Infant Feeding, Infant Mortality, Intestinal Intoxication, Pyloric Stenosis, Appendicitis, Acute Peritonitis, Endocarditis and Pericarditis, Cerebro-spinal and Other Forms of Acute Meningitis, Acute Poliomyelitis, Hereditary Syphilis and Tuberculosis.

A number of the old illustrations have been omitted as no longer necessary; others have been replaced by better ones. In all, thirty-six new illustrations have been introduced, including twelve radiographs. All illustrations are from original sources unless otherwise stated.

The authors desire to acknowledge their indebtedness to Dr. F. H. Bartlett for much assistance rendered in every way in the work of revision; to Dr. H. H. Mason for correction of the proof sheets, and to Dr. N". C. Holt for the preparation of the index.

14 West Fifty-fifth Street, New York.

Preface To The Seventh Edition

In this Seventh Edition the authors have endeavored to bring the book abreast of the science of the day. In the five years which have elapsed since the last revision there have been great advances in our knowledge of many of the subjects which are considered in a general textbook upon Pediatrics. The endeavor has been made to introduce this new knowledge without greatly changing the general arrangement of the book. To do this without increasing the size of the volume has made it necessary to cut out nearly one hundred pages of old material, and to condense other portions of the book. It is believed that this has been done without impairing the value of the chapters which have been abridged. The decision of the publishers to make entirely new plates has made this comparatively easy.

There is scarcely a page in the book but has been subjected to revision. Sixteen new articles appear for the first time in this edition. The more important ones are Acidosis, Xeuropathic and Exudative Diathesis, Cardiac Arrhythmia, Acute Lymphatic Leukemia, Banti's Disease, Osteogenesis Imperfecta, Still's Disease, Syphilis of the Xervous System, Pellagra, Epidemic Catarrh, Duodenal L T lcer, and Idiosyncrasies to Food Stuffs.

More than twenty chapters have been almost entirely rewritten, the most important being those upon Birth Paralyses. Milk and Infant Feeding, Digestion in Infancy, Chronic Intestinal Indigestion, Hirschsprung's Disease, Asthma, Accidental Heart Murmurs, Hydronephrosis, Gonococcus A^aginitis, Tetany, Convulsions, Epilepsy, Hydrocephalus, Poliomyelitis, Diseases of Ductless Glands, Diabetes, Hodgkin's Disease, and Tuberculous Adenitis.

Many old illustrations have been omitted and fifteen new ones introduced, all of them from original sources. Especial attention has been devoted by the authors to the newer methods of diagnosis and treatment.

The authors desire to acknowledge the assistance of Dr. X. Curtice Holt in the correction of the proof sheets and the preparation of the index.

L. Emmett Holt, John Howland.

Contents

PAET I

I. — Hygiene and 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

Section I. — Diseases of the Newly Born I. — Asphyxia 69

II. — Congenital Atelectasis 74

III. — Icterus 77

IV. — The Acute Infections of the Newly Born 82

The acute pyogenic diseases; ophthalmia; tetanus; epidemic hemoglobinuria; fatty degeneration of the newly born; pemphigus.

V. — Hemorrhages 96

Traumatic or accidental hemorrhages; spontaneous hemorrhages.

VI. — Birth Paralyses 106

Cerebral paralysis; facial paralysis; brachial paralysis.

ix x CONTENTS

VII. — Tumors of the Umbilicus, Mastitis, etc. 114

Umbilical hernia; mastitis; intestinal obstruction; diaphragmatic hernia; congenital stridor; sclerema; inanition fever.

Section II. — Nutrition I. — Introductory 127

The food constituents and the purposes they subserve in nutrition.

II. — The Infant's Dietary .' 134

Woman's milk; cow's milk; top milk — skimmed milk; milk sterilization; commercial pasteurization of milk; pasteurization vs. sterilization; methods of heating milk; frozen milk; peptonized milk; condensed milk; dried milk; buttermilk and other forms of fermented milk; protein milk; junket, curds and whey; beef preparations; cereals; infant foods.

III. — Infant Feeding 165

Choice of methods; breast feeding; maternal nursing; wet-nursing; weaning; mixed feeding; artificial feeding; formulas for whole milk ; schedule for healthy infants during the first year ; feeding in difficult cases.

IV. — Feeding after the First Year 209

Healthy infants during the second year; feeding from the third to the sixth year; feeding during acute illness; idiosyncrasies to foodstuffs; acidosis.

V. — The Derangements of Nutrition 218

Inanition; marasmus; malnutrition.

VI. — Diseases Due to Faulty Nutrition . 231

Scorbutus ; rickets.

VII.— Diatheses 260

The exudative diathesis; the neuropathic diathesis.

Section III. — Diseases of the Digestive System I. — Diseases of the Lips, Tongue, and Mouth 267

Malformations; diseases of the lips; diseases of the tongue; dental caries; alveolar abscess; difficult dentition; catarrhal stomatitis; herpetic stomatitis; ulcerative stomatitis; thrush; gonorrheal stomatitis; syphilitic stomatitis; diphtheritic stomatitis; gangrenous stomatitis.

II. — Diseases op the Pharynx . 288

Aeulr pharyngitis; uvulitis; elongated uvulva; retropharyngeal abscess; adenoid vegetations of the vault of the pharynx.

CONTENTS xi

III. — Diseases of the Tonsils 300

Membranous tonsillitis; ulceromembranous tonsillitis; follicular

tonsillitis; phlegmonous tonsillitis; chronic hypertrophy of the tonsils.

IV. — Diseases of the Esophagus 311

Malformations; acute esophagitis; retro-esophageal abscess.

V. — Diseases of the Stomach . - . . . . ' . . . . 315 Digestion in infancy ; malformations and malpositions of the stomach; hypertrophic stenosis of the pylorus; vomiting; cyclic vomiting; acute gastritis; chronic gastric indigestion; dilatation of the stomach ; ulcer of the stomach ; duodenal ulcers ; tumors of the stomach; hemorrhage from the stomach; the swallowing of foreign bodies.

VI. — Diseases of the Intestines 348

Malformations and malpositions; diarrhea; acute intestinal indigestion and diarrhea.

VII. — Diseases of the Intestines (continued) 373

Acute ileocolitis — dysentery; amebic colitis; amyloid degeneration of the intestines; tuberculosis of the intestines and mesenteric lymph nodes.

VIII. — Diseases of the Intestines (continued) 395

Chronic intestinal indigestion; intestinal colic; chronic constipation; hypertrophy and dilatation of the colon; intussusception.

IX. — Diseases of the Intestines (continued) 418

Appendicitis; intestinal worms.

X. — Diseases of the Rectum 430

Prolapsus ani; fissure of the anus; proctitis; ischiorectal abscess; rectal polypus; hemorrhoids; incontinence of feces.

XI. — Diseases of the Liver 436

Catarrhal jaundice; new growths; acute yellow atrophy; congestion of the liver; abscess of the liver — suppurative hepatitis; cirrhosis; amyloid degeneration; fatty liver; hydatids; biliary calculi.

XII. — Diseases of the Peritoneum . . 444

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

Section IV. — Diseases on the Respiratory System I.— Nasal Cavities 457

Acute rhinopharyngitis; chronic nasal catarrh; chronic rhinitis; cpistaxis.

xii CONTENTS

II. — Diseases of the Larynx . 465

Catarrhal spasm of the larynx; acute catarrhal laryngitis; submucous laryngitis — edema of the glottis; chronic laryngitis; new growths; foreign bodies in the larynx and bronchi.

III. — Diseases of the Lungs 476

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

IV. — Diseases of the Lungs (continued) 492

Pneumonia; acute bronchopneumonia.

V. — Diseases of the Lungs (continued) . 526

Lobar pneumonia; pleuropneumonia; hypostatic pneumonia; chronic bronchopneumonia — chronic interstitial pneumonia — bronchiectasis; abscess of the lung; gangrene of the lung; acquired atelectasis — pulmonary collapse; emphysema.

VI. — Pleurisy 557

Dry pleurisy; pleurisy with serous effusion; empyema.

Section V. — Diseases of the Circulatory System

I. — Peculiarities of the Heart and Circulation in Early Life . . 575

II. — Congenital Anomalies of the Heart 579

III. — Pericarditis 588

Acute pericarditis; chrOnic pericarditis with adhesions.

IV. — Endocarditis and Valvular Disease of the Heart .... 594 Malignant endocarditis; myocarditis; accidental murmurs; functional disturbances of the heart; diseases of the blood vessels.

Section VI. — Diseases of the Urogenital System

I. — The Urine in Infancy and Childhood ..;.... 615 Lordotic, orthostatic or cyclic albuminuria; hematuria; hemoglobinuria; pyuria; anuria; diabetes insipidus.

II. — Diseases of the Kidneys 623

Malformations and malpositions; uric-acid infarctions; chronic congestion of the kidney ; acute degeneration of the kidneys ; acute diffuse nephritis; chronic nephritis; tuberculosis of the kidney; tumors of the kidney; pyelitis — pyelocystitis ; renal calculi; perinephritis.

CONTENTS xiii

III. — Diseases of the Genital Organs . . . . . . . . 650

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

IV.— Enuresis 662

Vesical calculus.

Section VII. — Diseases of the Nervous System I. — Introductory 669 II. — General and Functional Nervous Diseases ...... 671

Convulsions ; tetany ; epilepsy ; 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 719

Malformations; pachymeningitis; acute meningitis; cerebrospinal meningitis ; acute meningitis due to other causes ; tuberculous meningitis; chronic basilar meningitis in infants; thrombosis of the sinuses of the dura mater; cerebral abscess; cerebral tumor; hydrocephalus; chronic internal hydrocephalus; infantile cerebral paralysis; amaurotic family idiocy; mental deficiency; Mongolian idiocy; deaf-mutism.

IV. — Diseases of the Spinal Cord • . . . 796

Malformations; spinal meningitis; myelitis; compression-myelitis; acute poliomyelitis; tumors of the spinal cord; hereditary ataxia, diseases associated with progressive wasting; congenital myatonia.

V. — Diseases of the Peripheral Nerves 828

Multiple neuritis; diphtheritic paralysis; facial paralysis.

Section VIII. — Diseases of the Blood, Lymph Nodes, Ductless Glands, Bones and Joints

I. — Diseases of the Blood 839

Secondary anemia; chlorosis; pseudoleukemic anemia; pernicious anemia; leukemia; hemophilia; purpura.

II. — Diseases of the Lymph Nodes . . 860

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

III. — Diseases of the Ductless Glands • . . . 876

The spleen; enlargement of the spleen; diseases of the thyroid; sporatic cretinism; hypothyroidism; Graves' disease; hyperthyroidism; diseases of other ductless glands; diseases of the thymus; status lvmDhaticus.

xiv CONTENTS

IV. — Diseases of the Bones and Joints 896

Osteogenesis imperfecta; chondrodystrophy; acute arthritis of infants; chronic arthritis; tuberculous diseases of the bones and joints.

V. — Diseases of the Skin . . . 920

Congenital ichthyosis; miliaria; seborrhea; eczema; f urunculosis ; gangrenous dermatitis; impetigo contagiosa; urticaria; scabies; tinea tonsurans — ringworm of the scalp.

VI. — Diseases of the Ear . . . 938

Acute otitis.

I- II.-

III.-

IV.-

VI.-

VII.-

VIIL-

IX,

X,

XI,

XII,

XIII,

Section IX.- — The Specific Infectious -Scarlet Fever . -Mi

-Rubella

-Varicella

-Vaccinia — Vaccination

-Typhoid Fever .

-Syphilis

-Influenza .

Diseases

Section X. — Other General Diseases I. — Rheumatism 1149

II. — Diabetes Mellitus . 1155

III.— Pellagra 1158

Index 1163

LIST OF ILLUSTRATIONS

PLATES

PLATE FACING

PAGE

I. Chart showing by months the mortality of New York City for the

different ages for three consecutive years ..... 44 II. A, Costochondral junction in early rickets; B, Normal costochondral

junction 244

III. Typical rickets 248

IV. Deformity of the chest in severe rickets 252

V. Extensive superficial ulceration of the colon 376

VI. Deep follicular ulcers of the colon . 378

VII. Membranous inflammation of the ileum ....... 386

VIII. Acute bronchopneumonia 498

IX. Acute pleuropneumonia 546

X. Chronic bronchopneumonia 548

XI. Acute pneumococcus meningitis, complicating pleuropneumonia . . 744

XII. A, Blood of an eight-months' fetus; B, Simple anemia; C, von

Jaksch's anemia ; D, Acute lymphatic leukemia .... 840

XIII. Tuberculosis of the tracheobronchial lymph nodes .... 1078

ILLUSTRATIONS IN THE TEXT

FIGURE

1. Weight curve for the first twenty days

2. Weight curve for the first year .

3. Skull, showing premature ossification .

4. Deaths, New York City, per 1,000 of population

5. Deaths by months, New York City .

6. Chief causes of death first year .

7. Colon of a child six months old .

8. Pemphigus neonatorum

9. Triple cephalhematoma

10. Meningeal hemorrhage of the newly born

11. Erb's paralysis

12. Umbilical fistula and tumors .

13. Diaphragmatic hernia ....

14. Temperature chart in inanition fever .

15. Apparatus for examination of human milk

xv

PAGE

A\ xvi LIST OF ILLUSTRATIONS

FIGURE PAC E

16. A, Babcock tubes; B, Lewi's modification for human milk . . . 140

17. Chart showing effect of pregnancy on weight of nursing infant . . . 178

18. Case of marasmus 223

19. Case of scurvy 235

20. Costochondral junction in marked rickets 247

21. Rachitic skull, inside view . . 249

22. Rachitic head 250

23. Rachitic skull, external view 250

24. Rachitic thorax in outline . 251

25. Rachitic spine . 252

26. Multiple fractures in rickets 253

27. Epithelial desquamation of the tongue . . . . . . . 270

29. Adenoid vegetations 295

30. Temperature chart, streptococcus angina following measles . . . 303

31. Gastric peristalsis in pyloric stenosis 323

32. Malformations of the rectum 349

33. Chart showing mortality from diarrheal diseases in New York . . 352

34. Chart showing deaths under one year per 1,000 of population under

one year, New York City, summer months 353

35. Temperature chart of acute intestinal intoxication with fatal relapse . 362

36. Acute catarrhal ileocolitis, severe form 376

37. Follicular ulceration of the colon, early stage 378

38. Follicular ulceration of the colon, later stage 379

39. Membranous colitis 380

40. Temperature chart in ileocolitis 383

41. Temperature chart in membranous colitis . . . ... . 385

42. Temperature chart in membranous colitis 386

44. Ileocecal intussusception 411

45. Mechanism of intussusception 413

46. An air vesicle in bronchopneumonia 493

47. An air vesicle in lobar pneumonia 494

48. Bronchopneumonia with thickened bronchus 499

49. Bronchopneumonia with emphysema ........ 501

50. Bronchopneumonia, diffuse purulent infiltration 502

51. Persistent bronchopneumonia . 504

52. Temperature chart in mild uncomplicated bronchopneumonia . . . 509

53. Temperature chart, prolonged bronchopneumonia 510

54. Temperature chart, relapsing bronchopneumonia 510

55. Temperature chart, rapidly fatal bronchopneumonia . . . . .511

56-59. Physical signs in bronchopneumonia 513

60. Temperature chart, persistent bronchopneumonia 515

LIST OF ILLUSTRATIONS xvii

FIGURE PAGE

61. Temperature chart, bronchopneumonia following pertussis . . . 516

62. Temperature chart, bronchopneumonia complicating influenza . . 518

63. Bronchopneumonia — X-ray 520

64. Temperature chart, typical lobar pneumonia . . . . . . 531

65. Temperature chart, remittent type, lobar pneumonia 532

66. Temperature chart, lobar pneumonia, subnormal temperature after crisis 532

67. Temperature chart, abortive pneumonia , 533

68-70. Physical signs, lobar pneumonia 536

71. Lobar pneumonia — X-ray 537

72. General subcutaneous emphysema . . . . . . . 557

73. Section of lung, showing distribution of fluid in chest .... 564

74. Empyema — X-ray . 565

75. Empyema — X-ray . . 565

76. Temperature chart, empyema following pneumonia 566

77. Temperature chart, empyema following pneumonia 566

78. Deformity after old empyema 572

79. Apparatus for inducing pulmonary expansion after empyema . . . 573

80. Congenital cardiac disease 581

81. Clubbing of fingers in congenital cardiac disease 584

82-83. Pericarditis with effusion — X-ray . . 591

84. Congenital malformations of the kidneys and ureters . . . 626

85. Sarcoma of the kidney ........... 641

87. Meningocele 720

88. Encephalocele . . 720

89. Hydrencephalocele 720

90. Meningocele 720

91. Frontal meningocele 721

92. Nasofrontal meningocele 721

93. Incidence of cerebrospinal meningitis 727

94. Posture in cerebrospinal meningitis 731

95. Temperature chart, cerebrospinal meningitis, recovery .... 735

96. Temperature chart, cerebrospinal meningitis, treated by serum . . 739

97. Temperature chart, cerebrospinal meningitis, with late injection of

serum 740

98. Seasonal occurrence of tuberculous meningitis 749

99. Tracing of respiration in tuberculous meningitis 751

100. Temperature chart in tuberculous meningitis 752

101. Chronic basilar meningitis 755

102. Chronic basilar meningitis 756

103. Brain in external hydrocephalus 770

104. Brain in internal hydrocephalus 771

105. Section of a normal brain 772 xviii LIST OF ILLUSTRATIONS

FIGURE PAGE

106. Vertical transverse section of a brain in congenital hydrocephalus . . 774

107. Oxycephaly with exophthalmus 777

108. Scaphocephaly 778

109. Brain showing atrophy 779

110. Convulsions in spastic paraplegia 781

111. Spastic paraplegia 782

112. Recent meningeal hemorrhage 784

113. Infantile hemiplegia showing contractures 786

114. Brain in idiocy 791

115-117. Various types of mental defect 792

118-120. Mongolian idiocy 794

121. Spina bifida, meningocele (partially diagrammatic) 797

122. Spina bifida, meningocele 798

123. Spina bifida, meningomyelocele (partially diagrammatic) . . . 798

124. Spina bifida, sacral 800

125. Infantile spinal paralysis of lower extremity 815

126. Infantile spinal paralysis of shoulder 816

127. Muscular pseudohypertrophy 825

128. Alcoholic neuritis 830

129. Diphtheritic paralysis 831

130. Facial paralysis 836

131. Acute suppurative adenitis, cervical 863

132. Acute suppurative adenitis, inguinal . . ... . . . 864

133. Cicatrices following tuberculous adenitis ....... 871

134-135. Cretins, showing effect of thyroid treatment 883

136-137. Cretins, showing effect of thyroid treatment 885

138. Infantile myxedema 887

139. Enlarged thymus 892

140. Osteogenesis imperfecta — X-ray . . . 896

141. Chondrodystrophy, radiograph of skull 898

142. Chondrodystrophy, long bones 898

143. Chondrodystrophy, infantile figure 899

144. Chondrodystrophy, trident hand 899

145. Chondrodystrophy, adult figure 899

146. Section of the spine in Pott's disease 908

147. Hip-joint disease 913

148. Tuberculous dactylitis 919

149. Congenital ichthyosis . . . 921

150. Temperature chart, acute otitis, following influenza 940

151. Temperature chart, acute otitis, early paracentesis 941

152. Temperature charts in scarlet fever, mild cases 958

153. Temperature chart in scarlet fever, typical curve 959

154. Temperature chart in severe uncomplicated scarlet fever .... 960

LIST OF ILLUSTRATIONS x i x

FIGURE PAGE

155. Temperature chart in fatal -septic scarlet fever 961

156. Temperature chart in scarlet fever with late otitis 965

157. Temperature chart in scarlet fever with late nephritis .... 966 158-159. Temperature charts in measles, typical curve 981

160. Temperature chart in measles, occasional course ...... 982

161. Temperature chart in measles, prolonged course 982

162-163. Temperature charts in measles complicated by pneumonia . . 983 164. Table showing protective power of vaccination ...... 998

165-169. Vaccination vesicles 1000

170. Generalized vaccinia . 1001

171. Temperature chart in typhoid fever, short course 1062

172. Temperature chart in typhoid fever, with relapse 1062

173. Tuberculous bronchopneumonia, diffuse consolidation .... 1076

174. Cavity from tuberculous bronchopneumonia 1076

175. Pulmonary tuberculosis, extensive caseation 1077

176. Miliary tuberculosis of the lungs . 1085

177. Temperature chart of tuberculosis following measles .... 1088

178. Temperature chart of tuberculous bronchopneumonia, general tuber-

culosis ... 1089

179. Temperature chart of tuberculous bronchopneumonia with softening . 1090

180. Tuberculous bronchial glands . . . . 1098

181. Early eruption of hereditary syphilis, legs 1111

182. Early eruption of hereditary syphilis, face 1112

183. Syphilitic scaling of the sole 1112

184. A later form of eruption in hereditary syphilis 1113

186. Syphilitic periostitis of the fibula, radiograph 1115

187-188. Syphilitic dactylitis 1116

189-190. Syphilitic dactylitis, radiograph . . 1117

191. Syphilitic notched teeth 1117

192. Syphilitic teeth, deformed 1118

193. Syphilitic osteoperiostitis of the tibia 1119

194. Syphilitic osteoperiostitis of the tibia, radiograph 1120

195. Temperature chart of severe influenza in an infant 1132

196. Temperature chart of acute bronchopneumonia complicating influenza . 1133

197. Temperature chart, influenza, bronchitis, otitis 1134

198. Temperature chart, double tertian intermittent fever . . . .1141

199. Temperature chart, tertian intermittent fever 1142

200. Temperature chart in malaria, irregular type 1143

201. Pellagra 1160

THE DISEASES OF INFANCY AND CHILDHOOD

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 ten per cent solution of argvrol 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 sterile water and a soft cloth, and no violence employed. The cord may be covered with sterilized talcum or bismuth powder, 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.

l

After dressing, the child should be placed in his crib and covered with blankets, and if the feet are cold, or the fingers and lips a little blue, he should be surrounded by hot-water bottles covered with flannel, 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 he 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 sterilized talcum or bismuth 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 those 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° F. 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 stands 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 extrem-

THE CARE OF THE XEW LY-BORX CHILD 3

ities ; nor should bands be pinned so tightly about the trunk as to embarrass 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 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 taken 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. Chilling of the surface is sometimes responsible for attacks of colic.

The abdominal band is usually worn during infancy. It cannot be considered in any sense a necessity after the first few months, except 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 shoulderstraps. The fashion of low neck and short sleeves for infants and very young children has fortunately passed away — let us hope, not 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 young 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 always 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 boric acid (ten grains to the ounce). It should be applied with a swab made by twisting a bit of cotton upon a wooden toothpick, and not by the nurse's finger. Harm is often done by the use of too much zeal in cleansing the mouth of a young infant.

The primary 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 pain, are a constant menace to the health of the child, since they are frequently the cause of severe infections. Such teeth should either be filled or removed.

Care of the Skin. — The skin of a young 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 use 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 folds of 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 undue 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, except as to cleanliness. This is more often neglected in older children than in infants.

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 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 dally 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 emphasized 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.