■ > ' 1 1) 1 >!'! 11 Class. Book. _. Aj. GoKTightM?. COPYRIGHT DEPOSIT. H u o Q < INFANCY AND CHILDHOOD A Popular B c Care of Child? BY LTERREEV] Y M. D. Assistant Professor of Disc-. of Minnesota; Associate Visiting P University Hospital; Visiting Physician t Paul City and County Ho Director of St. Paul Baby We Association IPANY o INFANCY AND CHILDHOOD A Popular Book on the Care of Children BY WALTER REEVE RAMSEY M. D. Assistant Professor of Diseases of Children, University of Minnesota; Associate Visiting Physician to the University Hospital; Visiting Physician to St. Paul City and County Hospital; Medical Director of St. Paul Baby Welfare Association NEW YORK E. P. DUTTON & COMPANY 681 Fifth Avenue 1916 .1^2. Copyright, 1916 By E. P. DUTTON & COMPANY MAR 20 1916 S)C!.A428164 *H4> / . DEDICATED TO MY WIFE AND LITTLE BOY, FROM WHOM MUCH OF THE INSPIRATION IN THE WRITING OF THIS BOOK HAS COME PREFACE In the writing of this book I have had constantly in mind the now recognized fact that, in order to accomplish anything in the way of preventive medi- cine, there must be an intelligent cooperation of the public. Whatever progress is made in child-welfare will be largely along educational lines. The future well-being of the average child which is normal at birth depends to a great extent upon the physical and moral care it receives. For the first years, which in many respects are the most important in the life of the individual, this care devolves largely upon the mother and nurse. The old-time mysticism, which still to some ex- tent surrounds medicine, must disappear and the public be taught what it may rightfully expect of itself and the physician. It does not follow that the mother need have a technical knowledge of medicine. She should, how- ever, have an intelligent idea of foods and their values and at least a knowledge of the fundamen- tals of hygiene. vii viii PREFACE She should have a sufficient knowledge of disease, especially the contagious forms, to understand their significance, the manner in which they are carried, and the means of prevention. For example, she should know that a croup which persists for many hours, with progressive difficulty in breathing, may be a laryngeal diphtheria and that a physician should be summoned immediately, as the child's life may be in great danger. She should know that a high fever, severe vomit- ing and diarrhea, or any other severe symptom, is never due to teething but to some other cause. With the hope of aiding her to a better knowl- edge of such practical points as these, this book has been written. W. R. R. St. Paul, January 3, 191 5. INTRODUCTION The interest in child welfare during the past few- years has been especially marked. Men and women in all walks of life have joined hands in advancement of the cause. Societies have been formed in almost every city in America and Europe for the preven- tion of infant mortality and for the general improve- ment of conditions relative to child life. Why this world-wide interest, this great concern so lately awakened? While the advancement of science has greatly diminished the mortality among adults, the infant death rate has remained practically at a standstill. In the United States one infant out of every seven which come into the world dies before it has reached the end of the first year. When one considers that most of these infants are normal at birth the condi- tion is all the more shocking. The belief generally held that infant mortality is simply a matter of natural selection, that the fittest survive and that the race is thereby made stronger, is no longer tenable. The fact is that many children although they sur- vive the first year are much less " fit " as a result ix x INTRODUCTION of illness and defective feeding, and not a few of them succumb later or carry through life the effects of a bad early environment. What, then, is the cause of this appalling death rate in infants? Ignorance and bad social conditions are respon- sible for the greater part of the preventable death rate in infants. Ignorance on the part of society in general and of parents in particular concerning the fundamental conditions underlying child life and development. Many women are forced to do work which under- mines their health and makes them unfit to give birth to healthy children. The substitution of artificial for breast feeding is responsible for a large percentage of the deaths among infants. The breast-fed baby has six times as many chances of surviving the first year as the artificially fed infant. Crowding into cities where the cost of living is so high that neither the mother nor the infant has the proper housing or food, is also responsible for many deaths. Until recently the infant has been regarded as a miniature adult and was so treated even by the medi- cal profession. It is now known that the physiology of the in- fant is vastly different in many respects from that of the adult. In the infant we have to do with a sen- INTRODUCTION xi sitive, unstable and rapidly developing organism which must be supplied with the elements necessary to its growth, while in the adult it is only necessary to repair body waste. How can we prevent this un- necessary sacrifice of child life? By educating fathers and mothers concerning their own care and the care of their children. By improv- ing social conditions so that women employed will have proper sanitary conditions under which to live and work, a living wage and a proper knowledge of food and food values. How can this be done? Young women must be taught more at home and at school concerning the fundamentals which will fit them to be wives and mothers. Proper legislation if enforced would do much to remedy some of the evil conditions. Among the educated classes much may be taught through proper literature. For immediate results we must depend to a great extent upon properly educated physicians, nurses and social workers, who will devote much of their time to spreading useful knowledge and to uprooting false ideas, whenever and wherever they may be found. We are interested not only in saving the lives of infants but also in promoting their physical and moral welfare, so that they shall be the greatest pos- sible benefit to society and to themselves. CONTENTS INTRODUCTION PAGE History of the Progress in Child Welfare During the Past Few Years. Cause of Large Death Rate in Infants. Education, etc ix CHAPTER I STRUCTURE OF THE BODY The Skeleton i The Skull 2 The Teeth 3 The Spine 4 Development of Soft Parts of the Body 5 The Heart and Circulation of the Blood 6 Respiration — Lungs and Chest Wall 7 Brain and Nervous System 8 Digestive Tract 9 The Stomach 10 The Intestines 11 CHAPTER II GROWTH AND DEVELOPMENT Average Weight at Birth 13 Gain in Weight and Length 13 Development of Boys and Girls During Puberty . . 14 Table Showing the Average Weight, Height, and Cir- cumference of Head of Boys for the First Ten Years 17 Significance of Head Measurements, Movements, etc. . 20 Loss in Weight After Birth 20 The Normal Infant — Methods of Examination . . 21 Natural Movements of the Body 22 xiii xiv CONTENTS PAGE Rickets as Cause of Delayed Development .... 23 Development of the Special Senses — Seeing, Hearing, Talking, etc 24 The Mental and Moral Development of the Child. "Home Training" 26 CHAPTER III THE NURSE Qualifications, etc 37 CHAPTER IV CARE OF THE NEW BORN Care of the Cord 39 Hernia (Rupture) 40 Bathing 42 Care of the Skin 43 Care of the Genital Organs 44 Care of the Eyes 45 Care of the Mouth 46 Clothing of Young Infants 47 The Nursery 52 Airing Out of Doors 54 Sleep 55 Temperature 56 Premature Infants 57 CHAPTER V BREAST FEEDING Low Mortality of Breast Infants 60 Secretion of Milk 61 Discussion of Patent Foods in Comparison with Breast Milk 62 Technique of Breast Feeding 63 Quantity of Milk Secreted, etc 64 Menstruation and Pregnancy in the Mother . . 67, 68 Fissured Nipples 68 CONTENTS xv PAGE Mixed Feeding 69 Weaning 70 The Wet Nurse 70 CHAPTER VI ARTIFICIAL FEEDING General Discussion of Milk and Artificial Foods . 72 Care of Milk in the Home 75 Composition of Cow's Milk as Compared with Mother's Milk 78 Modification of Cow's Milk for Infants 79 Quantity of Food at a Meal 82 Different Milk Formulae 82 Fat, Sugar and Gruels 84 Substitutes for Fresh Milk 91 Proprietary Foods 91 Special Preparations of Milk 92 Peptonized Milk, etc 92 Bottles and Nipples 95 Sterilizers and Pasteurizers 97 Ice Box 98 CHAPTER VII TEETHING (DENTITION) Temporary and Permanent Teeth 100 Symptoms Due to Teething 100 Care of the Teeth 102 Results of Decayed Teeth 102 CHAPTER VIII THE STOOLS AND URINE Constipation 106 Urine 109 CHAPTER IX OVERFEEDING Vomiting 112 xvi CONTENTS PAGE Colic 114 CHAPTER X DIET Diet for Children from One to Two Years . . . .115 Diet for Children from Two to Five Years . . . .116 CHAPTER XI EXERCISE Exercise for Infants 122 Exercise for Older Children 123 CHAPTER XII DISEASES OF THE RESPIRATORY TRACT Cold in the Head 125 Croup 126 Bronchitis 127 Pneumonia 130 Grippe 131 CHAPTER XIII CONTAGIOUS DISEASES Tuberculosis 132 Diphtheria 134 Scarlet Fever 138 Measles 140 Smallpox 141 Chicken Pox 141 Mumps 142 Whooping Cough 142 Erysipelas 144 Gonorrhea 145 Syphilis k . . 146 Quarantine 147 Disinfection 148 CONTENTS xvii PAGE CHAPTER XIV MISCELLANEOUS Melena Neonatorum (Bleeding of the New Born) . . 150 Convulsions 151 Worms 152 Adenoids 155 Enlarged Tonsils 156 Enlarged Glands 157 Rheumatism and Chorea 158 Earache 159 Goiter 159 Cretinism 160 Rickets 161 Scurvy 162 Hives (Urticaria) 163 Milk Crusts (Eczema) 164 Thrush. Stomatitis 165 Summer Diarrhcea 166 Vaccination 168 Kissing 169 Habits 169 Thumb Sucking 169 Facial Movements 170 Bed Wetting 171 Masturbation 172 Proper Use of the Eyes 173 Errors of Refraction 174 Malnutrition 175 Delicate Children 176 Puberty 177 Clothing for Older Children 179 Toys 180 Foreign Bodies 181 Enlargement of Breasts in Infants 182 Care of Wounds 182 Milk for Traveling 183 Table of Caloric Values 185 Dietary 185 Index , m n . m 189 LIST OF ILLUSTRATIONS "Wrapped in Warm Blankets and Out of Harm's Way" Frontispiece PAGE Fairbanks Baby Scale 15 Fairbanks Scales 15 Weight Curve of the First Year 19 Outdoor Activities Which Keep Children Healthy ... 30 11 In the Country There Is Always Something to Interest and Instruct the Child " 34 The Correct Treatment of Abdominal Hernia .... 40 The Skull of an Infant 42 "At Eleven to Twelve Months the Child Will Stand by Taking Hold of Things " 42 Folding Bath-Tub 42 Handy Folding Table for Bathing and Dressing the Baby 50 A Knitted Hammock for the Baby 53 A Child Should Have Much Exercise in the Open Air, Both Summer and Winter 54 Nursery Pen 56 " In An Open Shady Grass Plot Under the Trees " . . .56 Simple Incubator for Premature Infants 57 Breck Feeder 58 Breast Feeding — The Proper Position for Nursing the the Baby 60 Breast Pump 65 Nipple Shield 69 LIST OF ILLUSTRATIONS PAGE A Modern Sanitary Cow Stable Contrasted With the Old Style Disease-Breeding Conditions 74 Chapin Cream Dipper 80 Cream Dipper in Use 80 Pint Graduate 84 Nursing Bottle With Correct Nipple 96 The Arnold Steam Sterilizer and Pasteurizer .... 96 A Simple Home-Made Ice Box 97 Temporary or Milk Teeth 99 Permanent Teeth 101 Soft Rubber Syringes 108 Simple Vaporizer 128 A Simple Arrangement for Steaming Which can Be Fitted to the Child's Bed 129 Simple Screened Bed for Outdoor Sleeping . . . .177 INFANCY AND CHILDHOOD INFANCY AND CHILDHOOD STRUCTURE OF THE BODY The body of the infant consists of : — i. The skeleton, or bony framework. 2. The soft parts, which are made up of liga- ments, muscles, blood-vessels, nerves, digestive and urinary organs, etc. 3. A liquid portion, consisting of blood and lymph. THE SKELETON Cartilage. The skeleton of the infant, unlike that of the adult, contains a large amount of cartilage. This is relatively soft compared with bone, but later, by the process of multiplication of the bone cells and the deposition of lime salts, it is transformed into bone proper. The skeleton, or bony framework, including the cartilage, serves a variety of purposes. It serves as a protection for the most vital and sensitive por- tions of the body — the brain, which is enclosed within a bony shell, the skull ; the spinal cord, which 2 INFANCY AND CHILDHOOD is enclosed within the spinal canal; and the lungs and heart, which are enclosed within the chest w T all. The Chest Wall. The chest wall serves not only as a protection to the organs mentioned, but also, in connection with certain muscles, as an aid to breathing. The bones also serve as an attachment for the muscles which by their contraction, produce the power of motion. Ligaments. The different bones in the infant are rather loosely held together by fibrous ligaments, so that there is a considerable amount of freedom of motion in all directions and there may be even some over-riding of the ends of the approximating bones. Change in Shape of Head at Birth. This is particularly true of the bones of the skull, which during a difficult birth so overlap, that for a short time the shape of the head may be changed. The bony framework of the head can be roughly divided into two parts: the cranium, which contains the brain, and the bones of the face. THE SKULL The Jaws. In the infant the upper portion of the skull is much greater in proportion to the lower, than in the adult. This is a result of the undevel- oped condition of the jaws. The cranium is composed of thin curved plates of bone rather loosely held together. STRUCTURE OF THE BODY 3 Sutures. The spaces between the opposing edges of the different bones in the skull are called sutures. Fontanels. The large, four-sided opening which exists at the upper, forward part of the skull, at the juncture of the two frontal and two parietal bones, is called the large fontanel, and the small triangular opening at the juncture of the two parietal bones with the occipital, is called the small fontanel. (See cut facing page 42.) The Brain. The brain lies within the skull and its growth and development have undoubtedly much to do with the size and shape of the head. Time of Closure of the Fontanels. The su- tures, as well as the small fontanel, close normally at the end of the first year, while the large fontanel does not normally close until the end of the fif- teenth to eighteenth month. Closing of the fonta- nels before the end of the first year may mean a limited brain development, a condition known as microcephalus. The nonclosure of the large fon- tanel after the eighteenth month, usually indicates the presence of rickets. THE TEETH At birth the teeth are well formed in the jaws and continue to grow so that, at the end of the sixth or eighth month after birth, the first teeth usually 4 INFANCY AND CHILDHOOD pierce the surface of the gums. The last ones ap- pear normally about the thirtieth month. The process of teething, therefore, contrary to what is generally believed by the laity, is practi- cally continuous, extending from the sixth to the thirtieth month. (For " Teething " see page 99.) THE SPINE The spine or vertebral column consists of thirty- three segments or vertebrae placed one on top of the other, separated by cushions of connective tissue, the whole column being held together by ligaments. The Vertebrae. These vertebrae consist largely of cartilage. The vertebrae form a bony canal which serves to protect the spinal cord from injury. Spinal Nerves. Through small openings, or foramina, come the nerves which carry the im- pulses to and from the brain. Curvature of the Spine. As the erect position of the spinal column can be maintained only by muscular contraction, and since in the young in- fant these muscles are undeveloped, the erect posi- tion of the body should never be enforced, as ab- normal curvatures may result. STRUCTURE OF THE BODY 5 DEVELOPMENT OF SOFT PARTS OF THE BODY The Skin. During the first few days after birth the skin of the new born infant is often intensely red. This redness gradually fades until, at the end of the second week, the skin assumes a pink color which from then on is characteristic of the normal breast infant. The Hair. The fine hair which covers the body of the new born usually disappears after a few weeks, as does the copious growth of hair which often occurs on the head. This hair may persist for a considerable time and then fall out, to be replaced by another crop less profuse and fre- quently of a different color. The skin of the new born baby is extremely tender and particularly susceptible to irritation either by undue friction or by irritating substances, such as impure soap or the discharges from the body, urine, stool and perspiration. Color of Mucous Membrane. The tissue of the healthy breast infant is relatively richer in fat than that of older children. The tissues of the healthy infant are characteris- tically firm and resilient. The first evidence of the disappearance of the fat from the body is shown by the flabby character which it assumes in com- parison to the firm feeling of normal flesh. 6 INFANCY AND CHILDHOOD The mucous membranes of the new born infant are also extremely red at birth but gradually be- come paler and assume after a couple of weeks the natural pink color. THE HEART AND CIRCULATION OF THE BLOOD Oxygenation of the Blood. The heart begins to beat and send blood through the vessels as early as the second month of foetal life. Since, how- ever, the blood of the unborn child is dependent for its oxygen upon the placenta of the mother, its circulation is somewhat different from that of the child after birth. At birth, when the cord is sev- ered, the child begins to breathe so that all blood must go through the lungs in order to get oxygen. Heart Valves. Valves and vessels which were necessary before birth now become unnecessary and must permanently close before proper circulation is possible. If for any reason the free circulation through the lungs is interfered with, the blood will not receive sufficient oxygen and will become blue in color. Such a condition exists in the so-called "blue baby." Frequency of Heart Beat. The frequency of the heartbeat during infancy is considerably greater than in older children and adults. At birth the heart beats 120 to 140 times per minute. At the end of the first year the frequency has been STRUCTURE OF THE BODY 7 reduced to 1 00-110. From this time on the heart- beat gradually diminishes in frequency, until at six years it averages 80-90 per minute. These are averages and are to be taken only when the child is quiet and undisturbed. RESPIRATION The lungs are situated within the chest wall and, together with the heart and large blood vessels, practically fill that cavity. It is by means of the lungs that the blood comes in contact with the air, taking up oxygen and giving up the waste gases such as carbondioxide. The act of breathing begins immediately after birth. The frequency and rhythm of the respiration in infants is considerably different from that of older children and adults. The breathing is more fre- quent and irregular in character than in later years. Chest and Abdominal Breathing. There is comparatively little movement of the chest wall in infants and most of the breathing is done by means of the diaphragm, that is, so-called abdominal breathing. Gradually as the infant grows older and as the chest muscles become more developed the chest breathing increases. Character of Breathing. The rhythm of the breathing in infants is irregular. This irregularity 8 INFANCY AND CHILDHOOD is not infrequently the source of much concern to mothers, as it is particularly noticeable during sleep. Frequency of Breathing. While the fre- quency of breathing in adults is 18-20 per minute, in infants during the first month it is as high as 30-40, and even in the second year it is 25-30 per minute. Nose and Mouth Breathing. Air should normally enter the body through the nose. When an infant does not breathe through its nose, and the mouth remains open during sleep, it means some obstruction in the nasal passage, either in the nose itself, or behind the nose, usually in the form of adenoids, which condition is not infrequent even in the new-born infant. THE BRAIN AND NERVOUS SYSTEM Growth of Brain. At birth the brain and cen- tral nervous system are, at least to all appearance, well developed. As early as the eighth month after birth the brain of the infant is so well de- veloped that, in comparison with the brain of the adult, no great difference can be detected. The growth of the brain during the first year is very rapid, in fact the growth during the first year equals, or exceeds, the growth during the entire remain- ing life of the individual. STRUCTURE OF THE BODY 9 Many of the bodily functions at birth are but poorly developed. Of all animals the young infant is by far the most helpless, and for the first few years or so is en- tirely dependent. Organs of Sense, The organs of sense during the first few weeks show very little development of function, although at an early age the infant is able to appreciate heat, cold and pain. Taste usually develops early; sweet things are taken bet- ter than sour or bitter. Eye Movements. The eyes of the baby dur- ing the first few days, or even weeks, make all sorts of incoordinate movements and at times a positive squint is present. This, however, is but temporary and is due to the lack of muscular con- trol. An infant acquires the ability to fix its eyes upon objects at about the third month. Winking and Shedding Tears. Winking is seldom seen in the new-born baby, as is also the shedding of tears. After the first few weeks the winking of the eyelids becomes more frequent and tears begin to appear. DIGESTIVE TRACT The digestive tract begins at the mouth and ends at the anus. io INFANCY AND CHILDHOOD Sucking. The act of sucking is a complicated procedure and one which demands for its consum- mation the following organs: The jaws, the tongue, the cheeks and the roof of the mouth. If any of these parts are deficient in development the act is liable to be impaired. Digestion of the milk begins in the mouth through the influence of the secretion from the salivary glands. The digestive action of these se- cretions is at first very feeble but increases consid- erably during the first three months. Gastric Secretion. After passing through the mouth the food enters the esophagus and by muscu- lar contraction is carried to the stomach, where it is acted upon by the secretions of that organ (gas- tric juice). The most active ferment in the in- fant stomach is the rennet, which results in the curdling of the proteid element of the milk. Pepsin and hydrochloric acid are present in the stomach of the new-born infant in small quantities. These secretions are undoubtedly rather inactive during the first weeks of life. THE STOMACH The form and position of the stomach of the infant is not unlike that of the adult, occupying rather an oblique position in the upper left side of the abdomen just below the heart under the diaphragm and extending from left to right. STRUCTURE OF THE BODY n The small end of the stomach is closed by a circular muscle known as the pylorus. This opens at intervals as a result of chemical and nervous in- fluence combined, and the contents are forced through by rhythmic muscular contraction into the small intestine. THE INTESTINES Small Intestine. The intestinal canal is di- vided anatomically into two parts, the small and large intestine. The length of the intestinal canal is relatively longer than in the adult. In the infant the intestinal canal is approximately six times the length of the body, while in the adult it is only four and a half times as long. Digestion in the Small Intestine. The milk is largely digested in the upper portion of the small intestine, through the influence of the secretions from the pancreas and the liver. The Large Intestine and Its Functions. Very little digestion occurs in the large intestine, al- though it has some ferments capable of digestion. A great deal of the absorption of the liquid por- tion of the food, however, takes place in the colon (large bower). Bacteria in the Intestinal Canal and Their Function. The whole intestinal tract at birth is free from any form of bacteria, but after twenty- 12 INFANCY AND CHILDHOOD four to thirty-six hours it contains millions of bac- teria of many varieties, some of which undoubtedly have much to do in assisting in the digestion and assimilation of the food. II GROWTH AND DEVELOPMENT Average Weight at Birth. Although there is considerable variation in the size of individual in- fants at birth, the average for boys is about seven and a half pounds and for girls about seven pounds. There is almost always some loss in weight di- rectly following birth, which will be explained in chapter on Breast Feeding, page 61. Gain in Weight. During the first three months the gain of a normal infant is from four to six ounces per week, or from one to one and one- half pounds per month. It is rather the exception that infants will maintain a gain of two pounds per month during the first three months. Gain in Weight During the First Year. At six months the weight should be about double that at birth, which for the entire time is an average of a little over one pound per month. During the second half of the first year the gain in weight is not quite so rapid as during the first half. At the end of the first year the weight should be approximately three times that at birth. 13 14 INFANCY AND CHILDHOOD This tremendous gain in weight during the first year explains the large amount of food needed per pound of body weight during this period. After the first year the gain in weight is not so rapid. Gain in Weight During Second Year. Dur- ing the second year the child should gain three- fourths of a pound per month, or eight or nine pounds during the year. Gain in Weight to Fifth Year. During the third year it should gain about four or five pounds, during the fourth about four pounds, and during the fifth, four and a half pounds, so that at five years the child should weigh forty or forty-two pounds. The average weight of boys is one to one and a half pounds greater than girls at the same age. Development of Boys and Girls During Pu- berty. At the time of puberty, which comes earlier in girls than in boys, the girls forge ahead of the boys. Later, however, the boys regain their superiority in weight and maintain it until matur- ity. An approximately normal increase in weight of an infant is of vital importance. When an infant does not gain in weight for any length of time, there is always something wrong either with the feeding or with the child itself. GROWTH AND DEVELOPMENT 15 Fairbanks Baby Scale Weighing to 35 lbs. Fairbanks Scales Weighing to 200 lbs. 16 INFANCY AND CHILDHOOD Weighing. Infants should therefore be weighed regularly, at least weekly, during the first year, and at least once monthly during the second and third years. The gain in weight is not the only thing in the development of an infant to be considered; in fact a too rapid increase in weight may be a detriment and usually means over- feeding. Increase in Length During the First Year. The growth in length and a proper general develop- ment of the body are equally important with the in- crease in weight. The average length of the male infant at birth is twenty inches and of the female nineteen and a half inches. During the first month the infant increases in length from one and a half to one and three- fourths inches, and during the second month slightly less. This increase gradually becomes less after the third month, and at the end of the first year the increase is about one-half inch per month. There is a gain in length of about eight inches dur- ing the first year, three and one-half during the second year, and three inches during the third year. From the third to the eleventh year the gain is about two and a half inches per year. At the age of puberty there is a more rapid gain in height corresponding to the increased gain in weight. GROWTH AND DEVELOPMENT 17 Development During Puberty. During this period of rapid growth there is an unstable condi- tion of the nervous system, the significance of which will be discussed under the chapter on " Puberty." Table Showing the Average Weight, Height and Circumference of Head of Boys: The weight of girls at birth is on the average about one-half pound less than boys. Their height is only slightly less: at birth : Weight 7J/2 pounds Height 2oy 2 inches Chest 13^2 inches Head 14 inches one year: Weight 21 pounds Height 29 inches Chest 18 inches Head 18 inches two years: Weight 2J pounds Height 32 inches Chest 19 inches Head 19 inches three years: Weight 32 pounds Height 35 inches Chest 20 inches Head 19J4 inches 18 INFANCY AND CHILDHOOD four years: Weight 36 pounds Height 38 inches Chest 20^4 inches Head 19^ inches five years: Weight 41 pounds Height 41 y 2 inches Chest 21^4 inches Head 20J4 inches six years: Weight 45 pounds Height 44 inches Chest 23 inches seven years: Weight 49^ pounds Height 46 inches Chest 235/2 inches eight years: Weight 54^2 pounds Height 48 inches Chest 24J4 inches nine years: Weight 60 pounds Height 50 inches Chest 25 inches ten years: Weight 66 I /2 pounds Height 52 inches Chest 26 inches GROWTH AND DEVELOPMENT 19 The weights for the first four years are without clothes. After that the weights include ordinary- house clothes. (After Holt.) Some slight variation may occur from these WEIGHT CHART. Name - Date nf Birth. ' J ' s h MONTH OF AGE. 1 2 3 4 5 6 7 8 9 10 11 12 1 ! ! 1 1 | , |i | . ■ , 1 i 1 1 1 . : . . j 1 : : 1 . 1 . 1 ! 1 \CAV\- • • • ! ■ Ill 1 f 1 1 i 1 1 « ! ! 1 1 ! ,..,, — • 1C430 23 ' . i i : r , I ■ ' ! i 1 ' ' ■■ 1 ■ 1 i , -» v l _, : i | | VOJL Q. 1 1 1 1 1 i ' 1 NEW 20 ; | ■ ' ! 1 1 8620 19 j ■ • i ' i 1 i ' i ■ , , 1 ■ j . . 1 j I \ 1 ■ . 1 : 1 i i ' ■ . i ; 1 i^^*** "T nuivl _ -~~*^ 1 x ^*0~~~~^ 1 1 ' ml 16 ; ^— n^ 1 1 'iii 1 6800-15 . 1 , , ■ 1 I'M ■Mil 1 • 1 , . . 1 1 i 1 1 1 1 1 ' ' S - : ' ! ' 1 I I • • 5900 13 ■ ■ 1 • ^ ! ' 1 i ' \/ ■ ' • ' X< , ■ 1 1 1 1 1 1 , , i i 1 ~[~[ ■ S... . ! . I ! ! . 1 1 • , ■' ■ i i 1 / > i ! 1 1 | 1 . . . yr . ; , 1540 10 j' S\ > 1 1 ; . fi r •■ : ! ' III 1 j 3650 3180 127^0 '| '' : v 1 r 1 • ' \Ju ■ \ . : 1 i ;V: j , ■ >< Tl -f f r V^ ' 1 1 ! 1 i , r 1 1 ' l 1 i 1 "1 1 1 ■ U I 2270 ! . i 1 I , ' ! , ' 1 M j ; . , r 1 1 JJJL lit! | 1 III 1 1 1 1 1 1 XLL 1 II ■! 1 i 1 1 JLLL Weight Curve of the First Year measurements without having any special signifi- cance. For instance, a child born of small parents will usually be smaller than one born of large par- ents and the weight and measurements will be cor- 20 INFANCY AND CHILDHOOD respondingly less. Any wide divergence from these averages means something abnormal. For ex- ample, if a baby which weighed seven pounds at birth should at three months weigh only eight pounds, one would be certain that there was some- thing wrong; or if an infant at one year should have only the length of an infant of six months it would point strongly to " Cretinism " or some other abnormal condition. Significance of Head Measurements. If the head should measure only fourteen inches at the end of the first year we should be suspicious as to the brain development, or if at one year it measured twenty inches instead of eighteen we would feel the probability of a Hydrocephalus being present. Loss in Weight After Birth, During the first few days there is usually a loss in weight " which does not occur in other animals." The so-called physiological loss in body weight is proportionate to the size of the child ; the greater the weight the greater the loss. The loss continues from three to six days and then begins a gradual gain. It is generally taught that the loss is regained in from seven to ten days. This is frequently true where the mother has already nursed one or more infants, but in the case of a first born the period required to regain the loss is usually much longer, GROWTH AND DEVELOPMENT 21 extending from two to three weeks. During this time no anxiety need be felt unless the infant con- tinues to lose, in which case it must not be weaned but given additional food, after each breast feed- ing. The amount of food needed can only be de- termined by weighing the baby before and after each feeding. THE NORMAL INFANT It is usually not difficult to determine whether an infant is physically normal. There are definite measurements and other standards to which an in- fant must conform in order to be considered nor- mal. The determination of the nervous and mental condition of an infant is, however, much more diffi- cult. Even an experienced physician may make mistakes. It is particularly important in infants for adop- tion to ascertain whether there is any serious phys- ical or mental defect. In order to demonstrate the character of the special senses, examinations are made to determine the infant's sensibility to certain influences. For example, the sensibility of the skin is determined by tickling and by touching it with hot and cold objects: the hearing, by making a noise such as 22 INFANCY AND CHILDHOOD the ringing of a bell; the sight, by bringing bright objects before the eyes and watching to see if they follow them. It is difficult, or even impossible, to determine the mental development of infants before the fifth or sixth month. NATURAL MOVEMENTS OF THE BODY The natural movements of a normal infant are characteristic and by close observation much infor- mation may be secured. The impulsive movements of the hands, feet and legs, as well as those of crying and laughing, are characteristic. In contrast to the impulsive movements are the reflexive movements or those which arise from irri- tation; for example, the contraction of the pupils to light, swallowing, sneezing, or yawning. To re- flexive movements are added other instinctive ac- tions, such as sucking and sticking the fingers in the mouth. SUCKING THE FINGERS The sucking of the fingers is not necessarily indic- ative of hunger but is an instinctive impulse. The movements of the infant which are at first involuntary gradually become voluntary. The im- pulsive movements become less frequent and the GROWTH AND DEVELOPMENT 23 reflexive movements much more frequent. The movements of expression, as laughing and crying, will depend more upon how the child feels, whether it is happy or whether it approves or disapproves. Movements of the head after the third month are voluntary. From then on the child learns more complicated movements and combines these with the will, so that in time it walks, observes what is done by others, talks, etc. Mental Development. "At the third to fourth month an infant begins to follow objects with the eyes; at four to seven months it begins to take an interest in its surroundings, laughs, plays with its toys and begins to assume some of the character of an individual." At about eleven to twelve months the child will stand by taking hold of chairs and other objects, and by the thirteenth to the sixteenth month it will usually begin to walk alone. {See illustration facing page 42.) Rickets as Cause of Delayed Development. The normal time for the development of all the above mentioned functions is impeded in the case of premature infants, constitutional weakness, long illness and malnutrition from any cause. Rickets is one of the common causes for delayed physical development. The different appliances for teaching children to walk are rarely to be advised. 24 INFANCY AND CHILDHOOD DEVELOPMENT OF THE SPECIAL SENSES Instinct. Instinct in the new born is much less developed in the infant than in the young ani- mal. The young infant must therefore be much longer protected than any other animal. The senses of hunger, thirst, fatigue are early developed in the infant, as evidenced by crying and the per- fect contentment which follows when hunger and thirst are appeased. Taste and Smell. The sense of smell is but little developed in the new born, but is present to some extent even at birth. The sense of taste is already fairly well developed in the baby and by certain grimaces he makes his distaste known. The sense of like and dislike in many children however only appear by rather extreme irritation. Development of Hearing. Directly after birth all infants are deaf, as the organs of hearing only begin to functionate after the eustachian tubes, which lead from the throat to the middle ear, be- come free from secretion and are well inflated with air. This occurs within the first few days. In the first few weeks, although the infant can hear, it is not sensitive to sound and reacts but little. Sight. The same is true of the sense of sight, for although the pupils react to light the infant GROWTH AXD DEVELOPMENT 25 shows no evidence of being conscious of seeing the light. Movements of Eyes. In the new born the eyes do not coordinate, that is. act together. For example., one eye may be open while the other is closed, or one eye may be moved while the other remains still, there may be a distinct squint. The eyes move together when the child develops the power of fixation (about the fourth month). It is important that the mother understand the relative times for the development of the different ses: otherwise she is likely to worry, much : her own and the infant's detriment. Talking. There is a great difference even in normal children in their ability to talk. h.:s: children at twelve months are able to say, " Papa/' " Mamma," and to form short sentences at the end of the second year. Xot infrequently, however, chil- dren who understand perfectly do not form words or (fences until two and a half or three years. If they are not deaf, and if the understanding is good, no concern need be felt. The fact that a child is fluent at two years does not necessarily imply better brain power than one whose oratorical powers are less developed. The development of speech, with the exception of a few words learned mechanically, is preceded by an understanding of the speech. The speech 26 INFANCY AND CHILDHOOD center in the brain is very slow to develop in some children and very rapid in others. When a child at two years makes no effort at forming words, the advice of a competent physician should always be sought to determine the possibility of deaf-mutism. Deafness can usually be detected as early as the sixth or eighth month. Coordination of Muscles. If a child does not take things in its hands and stick them in its mouth when it is five or six months old, or if in attempting to grasp objects it does so with fingers extended and only closes its hands with difficulty and with in- coordinate movements approaches the mouth, it should be at once examined by a physician as it is probable that the child is suffering from an affection of the nervous system. Test to Determine the Mental Development. In determining the mental development of children after one year the Kuhlman modification of the Binet-Simon system * will be found useful in skilled hands. THE MENTAL AND MORAL DEVELOPMENT OF THE CHILD. "HOME TRAINING " The importance of " home training " in the minds of parents depends upon the extent of their 1 A Review of the Binet-Simon System for Measuring the Intelligence of Children, by F. Kuhlman, Director of Physi- ological Research, School for Feeble-minded, Faribault, Minn. GROWTH AND DEVELOPMENT 2*7 belief in heredity. The less importance they at- tach to heredity the greater is their responsibility. Parents are prone to attribute all the good traits in their children to their own efforts, and all the bad ones to heredity, coming of course from the other side of the house. It is the opinion of most authorities on children that in the great majority of cases, where a child is unruly, has an uncontrollable temper and other bad traits, the difficulty is more with the " training " than with heredity. " With the exception of chil- dren actually suffering from an abnormal condition, there are no defective children, only defective con- ditions." " The moral and mental makeup of the indi- vidual, his nature and character, is partly inherited and partly developed. Therefore the part which inheritance and development plays in the moral and mental influence is of widely different importance. Temperament, for example, is an inherited posses- sion, the over or under development of which may through the development of self-control be much restricted, the temperament, however, remaining the same through life." " The intelligence is also inherited, and through the influence of the home and the school may be brought to a much higher point of development, but it is from the beginning there and will scarcely 28 INFANCY AND CHILDHOOD be fundamentally changed by any influence. That knowledge and capability, during the whole life- time, may be developed and increased, and that the will to work, the pleasure taken in the work, may be influenced by training, has been positively demon- strated." On the other hand, the training has a much greater influence on the character than on the intelligence and temperament, especially during the first years of life. " The first five years are the most important for the development of the character of the indi- vidual. The later influences do no more than de- velop the already sprouting seed." The literature * of the past few years is rich in books concerning the rearing of children, their phys- ical, mental and moral development. The question arises, at what age we may begin to teach a child, or, in other words, begin its edu- cation ? Education and Memory. The education may begin as soon as the mind is sufficiently developed to hold impressions and long before the intelligence 1 Harrison, Elizabeth — The Study of Child Nature; Froe- bel — The Education of Man; Montessori — The Montessori Method; Hall, G. Stanley — Youth; Addams, J. — The Spirit of Youth and the City Streets; Adler, Felix — Moral Instruc- tion of Children; James — Talks on Psychology and Life's Ideals; Henderson, C. Hanford — What it is to be Educated; Conklin, Edward — Heredity and Environment; Galloway, Thos. Walton — Biology of Sex for Parents and Teachers; Ellis, Havelock — The Task of Social Hygiene. GROWTH AND DEVELOPMENT 29 is sufficiently developed to determine cause and effect. The memory is, however, very early devel- oped. This may be demonstrated by the way in which the very young infant may be taught regu- larity. For example, the regularity with which in- fants awake for their meals and the ease with which with some persistency these hours may be changed. We now know that each child is born with its limitations and possibilities. We do not know, however, what these possibilities and limitations are. Therefore, it is the duty of parents and the State to encourage the fullest development possible in each child. This development should be con- sidered as three-fold: physical, mental, and moral, and also in its relation to society as well as the in- dividual child. Many of the difficulties in the way of mental and moral growth are effects of improper diet, insuffi- cient sleep, and too little exercise in the open air. Many, on the other hand, are directly consequent upon improper direction and discipline. If par- ents, fathers as well as mothers, could be made to realize the importance of the first five years of the child's life in the formation of such habits as con- centration, observation, and self-control, and the importance of well thought out ideas toward which 30 INFANCY AND CHILDHOOD to aim, the question of discipline, with the direct- ing of work and play and the necessary correction, would not be simply one of moods on the part of those in authority, as is so often the case. Regard- ing the mental development, three important points should be emphasized: concentration, observation, and the training of the imagination. One of the best and simplest means of teaching children to ob- serve and concentrate is through the study of na- ture. This study should be encouraged early, so that these simple, healthful pleasures may develop into real resources for later life. Another of the simple ways to develop concentration and observa- tion is through the analysis of good pictures. Par- ents who encourage or allow their children to go from one thing to another aimlessly, without finish- ing anything begun, or to take over long to perform the simple duties required of them, are weakening their powers of concentration, which are so inval- uable in their school work and later occupations. Some children, through constant diverting on the part of the parents, lose what natural concentration they have. It is well to supervise and direct work and play to definite ends and to encourage children to carry out their ideas. But, on the other hand, when children are legitimately occupied and happy, they should not be interrupted more than is neces- sary. The aimless standing or walking around the Outdoor Activities Which Keep Children Healthy GROWTH AND DEVELOPMENT 31 streets that so many of the well-to-do children are allowed to indulge in, does not prepare them for definiteness of purpose later on. If a walk is to be taken, let a definite objective point be chosen. When a child goes out to play, let it be encouraged to plan what it is to do. Toys such as blocks for building bridges and houses, modeling clay, draw- ing and sewing cards, are excellent for the in-door occupation of smaller children, with tools and books for older ones; for out-of-doors, sand-piles, wagons, barrows, balls, etc., and later, gardens. Children who are taught early to dress and undress, help in passing things, and run errands, are being trained in concentration and observation. In regard to the imagination, it is usually a ques- tion of stimulating it or holding it in check. Cer- tainly, a ready imagination means a quicker appreciation of another's point of view and greater sympathy with all conditions of society. It means that we are less dependent for our happiness on our material well-being. It means greater re- sourcefulness in work and play. It means that city children, by the happy art of " make-believe/ ' can have dogs and ponies, and even the wild animals of the forest, as their companions, with no expense and no trouble with the neighbors. They can be kings and queens, with palaces in their sand-piles and dolls as subjects, or dream of distant lands to 32 INFANCY AND CHILDHOOD conquer from the top of the old apple-tree. To play games with the wind or a shadow is often the first step toward a later faith in the unseen forces of the world. On the other hand, an over-devel- oped imagination may lead to an unstable nervous system. In the moral sphere there is no more important point than that of self-control. When we consider all that self-control may mean to the child, to the adult, and to society, too great emphasis cannot be laid upon its training to that end. Beginning with the first week in infancy, when the baby cries to be taken up when taking-up is not good for it, self- control may be taught in many simple ways, but to be a structure which will endure, it must be built upon a firm foundation of good inheritance and health and grow slowly from day to day through training in matters in themselves small, but on the whole, in the light of the future, of tremendous im- portance. One simple way of teaching self-control, from early childhood on, is not to remove objects about the room, or at the table, but train the child to let them alone. Grown people should not be deprived of things because children are present. Children should not think they have to have everything adults do. One small child of my acquaintance feels that his share in a box of candy, is passing it to others. GROWTH AND DEVELOPMENT 33 Children have learned a valuable lesson in self-con- trol when they have learned to eat what is put be- fore them without crying because they cannot have what is served to others. In close relation to the question of self-control comes that of cheerfulness, unselfishness, and courtesy towards other members of the family and playmates. Taking the family as a unit of society, how important it is that a child learn how to be fair to those with whom he comes in daily contact. Loyalty and devotion to the family is the corner- stone of loyalty and devotion to the nation. A parent's attitude towards servants of the household is very important. If a child can be made to realize the value of the work of the gardener or house serv- ant in the sum total of all labor, how much easier does the training in courtesy and consideration be- come. If a child is required to clean up the litter made from cutting paper, for instance, or put away his playthings, how much more does he appreciate the work of those who do that as a routine. A child should be given responsibility early. Let him have some duty to perform regularly, such as filling the bird-bath or weeding the garden. In regard to truth-telling, there is no better teacher than good example. How can a child value the truth when parents and nurses deceive him constantly and tell what may be called u white 34 INFANCY AND CHILDHOOD lies " with no apologies ! When children ask ques- tions, how many of them get an honest attempt at the truth! The question of sex teaching suggests itself in this connection. Children believing in their parents ask questions regarding the funda- mentals of life. Should their parents, cowardly or indifferently, shirk the great privilege of responding to this trust? Boast fulness in children should be discouraged, as it obscures the truth, and through it children grow in the practice of deceiving their companions and themselves, enjoying the commendation re- ceived even when undeserved. It is to be urged that those in authority over chil- dren have ideals, and after making a very early beginning persevere in the attempt to work them out, directing and correcting wisely, not as though the days had no relation to one another, and that a feeling of irritability w r ere sufficient to dictate the kind of treatment to be meted out. Let the ex- amples of the parents be worthy ones to follow, first of all, and then unite with the love and under- standing which a study of the individual child has given, a dignified firmness in enforcing obedience. Since much of life is necessarily a subordination of one's will to higher authority, the consequent re- lationship of child and parent is only the first lesson. Parents should realize that most normal, healthy * In the Country There Is Always Something to Interest and Instruct the Child" GROWTH AND DEVELOPMENT 35 children are active and energetic and need outlets for their energy. In the country where there are animals to feed and crops to be planted and gath- ered, there is always something to interest and in- struct the child, but in the city places for play and things to play with should be provided. The poorer children are being taken care of in the public play- grounds under trained supervisors, but are the chil- dren of the well-to-do? Children should have the companionship of their mothers and fathers on walks and picnics in the woods, which are the parks of rich and poor alike. If more fathers realized the right of their children to this companionship, they would not so often be mere fountains of ma- terial blessings, but there would be a real sympathy making necessary discipline easier for all. The first point to emphasize in the consideration of discipline is that the child should not be nagged all the time, but after a wish or command has been expressed it should be obeyed whenever and wher- ever made. A parent or person in authority must have absolute confidence in himself, confidence that the child will obey. The parent w T ho feels help- less in the hands of his child and doubts himself might as well not attempt to discipline. A child should not be allowed the center of the stage nor to interrupt conversation any more than should a grown person. If children are allowed to show off 36 INFANCY AND CHILDHOOD it develops in them not a love of accomplishment but of applause. In the matter of punishment and rewards there is a great difference of opinion. I believe many little things should be ignored as passing phases, since too frequent punishment loses in effectiveness. After a child is old enough to be reasoned with, such punishments as sending him to his room, stand- ing him in a corner, or depriving him of some play- thing, or prospective pleasure, are often more ef- fective than corporal punishment. Children should learn early not that good deeds are always rewarded materially, but that misbehavior means unhappi- ness either to themselves or some one else. Ill THE NURSE To be successful in the handling of children the nurse must first of all love children and besides this must have special qualifications fitting her for one of the most important duties which fall to any individual. She must be intelligent, and a keen observer. She must have an even temper and have endless patience. She must be firm and kind. She must be content with observing the results of her work without receiving much applause. Every action of a child is worth observing, es- pecially during sickness. Since an infant cannot talk, all information must be gotten from observa- tion. Frequently much more information may be derived when the child is alone with the nurse, or the mother, or when it is asleep, than when the physician is making his visit. The child in reality speaks a very definite lan- guage, the correct interpretation of which requires careful study. For example, the writer saw a beautiful child die, during the hot weather, as a 37 38 INFANCY AND CHILDHOOD result of an improper interpretation of its language. The baby cried much after feeding and the nurse, taking the cry to mean " hunger/' gave the infant food as often as it cried. For several weeks there had been frequent bowel movements which were at first normal in color, but gradually became green and watery. Had the nurse interpreted properly the child's language she would have known that the cry did not mean hunger but indigestion. She should have known this from the frequency and character of the movements and should have diminished the quantity of food and increased the intervals between feedings, or if there were any doubt as to the proper course to pursue, consulted the physician in charge. Besides having natural qualifications, a nurse should have special training. There are now in- stitutions in every city, directed to the special care of children, where such training may be secured. Courses for nursemaids in the care and feeding of children, extending over a period of six months, are now given in connection with many of the child welfare clinics. IV CARE OF THE NEW BORN The nurse assumes the care of the infant as soon as the cord has been tied, and from that time on its welfare is largely in her hands. Her first duty is to see that the baby is wrapped in warm blankets and placed out of " harm's way," in a well ventilated room, where the temperature is between 70 and 8o° F. [See Frontispiece.] Great care should be exercised in the use of the hot- water bottle, as frequently serious or even fatal burns occur in this way. Tying the Cord. The cord should be carefully watched for bleeding during the first twenty-four hours, and in case any hemorrhage occurs the physician should be notified at once. If he is not at hand, in case the bleeding is at all active, the cord should be retied with a good stout silk ligature which has first been boiled. Care of the Cord. The subsequent care of the cord is of the utmost importance. Whatever method is employed by the physician in charge, the ultimate object is to keep the cord 39 40 INFANCY AND CHILDHOOD free from infection and at the same time to have it dry up, (mumify) so that it will separate from the body as soon as possible. The cord normally " falls off " in a week or ten days. As a dressing for the cord some powder, such as bismuth subnitrate or starch which has been sterilized by baking, is to be recommended. This powder is dusted on sterilized gauze and the cord enveloped therein. Care of the Navel. // at any time the skin around the navel should become inflamed the phy- sician should be informed at once, as an infection of the navel may be a matter of the utmost gravity. After the cord has been separated the raw sur- face may be sponged once daily with a normal salt solution (teaspoon salt to pint boiled water), or a 50% alcohol solution, after which it is to be cov- ered with sterile gauze. HERNIA (RUPTURE) Rupture or nonclosure of the abdominal wall at the navel is a very common affection and may usually be prevented if the proper precautions are observed by the nurse. Binders. Even before the cord has separated a "snug" (not tight) binder should be applied; this should be worn until the navel is healed. It should then be discarded. The Correct Treatment of Abdominal Hernia CARE OF THE NEW BORN 41 Influence of Crying. Prolonged crying, be- fore the umbilical opening has healed, may result in rupture. Application of Adhesive Straps. A strip of surgeon's plaster (oxide of zinc) two inches wide and six inches long applied across the abdomen over the navel, so as to hold the edges of the opening firmly together, frequently results in a " cure." The objection to this form of support is that great care must be exercised so that the plaster does not become wet, otherwise it will not adhere. Another objection to the plaster is that the skin after a short time becomes irritated so that for a time its use may have to be discontinued. These " adhesive straps " should be removed by sponging with ben- zine, and after the skin is clean and dry a new strip of plaster should be at once applied. To apply this strip properly an assistant is necessary. It must be worn for several months at least and long after any evidence of the hernial opening has ceased to exist. The classical " button " as a cure for umbilical hernia is worse than nothing and should never be used. Yarn Trusses: for Hernia in the Groin. In the treatment for hernia in the groin in infants and young children trusses of soft yarn are often suffi- cient if properly and persistently applied. 42 INFANCY AND CHILDHOOD BATHING No bath need be given for the first few hours after birth. The infant should, however, be anointed with warm oil in order to soften the cheesy material (Vernix Caseosa) with which the skin is usually covered, and the first warm sponge bath given after 12-24 hours. Temperature of Bath. During the first month only sponge baths should be given, and these only in a room where the temperature is above 75° F. The baby should be covered with a warm blanket and only a portion of the body exposed at one time. The temperature of the water should be 95-100° F. for the first few weeks, after that slightly cooler. Tub baths may be given to rugged infants after the first month or two, provided the temperature of the room and water are properly maintained. Exposure to Cold. It must be remembered that young infants do not stand exposure to cold at all well, they lose heat rapidly, with resulting low- ered vitality and consequent bronchial and diges- tive disturbances. Cold baths should never be given to young children. Such a practice has no prece- dent in nature, neither among aboriginal races nor animals. We will do well not to try to improve too much upon nature. Influence of Soap on Skin. If any soap is The Skull of an Infant Showing Sutures and Fontanels [Page 3.] At Eleven to Twelve Months the Child Will Stand by Taking Hold of Things " [Page 23.J Folding Bath-Tub CARE OF THE NEW BORN 43 used it should be of the best quality, since many cheap soaps contain free alkali in such quantity as to be extremely irritating to the skin, not infre- quently producing an eruption. CARE OF THE SKIN The skin of the new baby should be dried with a soft towel by sponging, not by rubbing, as the latter is a frequent source of irritation. After six months, in vigorous infants, the temperature of the water may be reduced to 8o° F. or even less and some friction used so that the skin is made to glow. In older infants the face and neck should be sponged with cool water, since these parts are always more or less exposed to the atmos- phere. Skin Irritation. The skin soiled from the dis- charges from the bowel and bladder should be sponged off with warm water or oil every time the diaper is changed; otherwise it will become in- flamed. When some degree of irritation is present an ointment, such as zinc oxide, should be smeared over the cleaned surface in order to protect the skin from further contact with the discharges. Care of Skin Around the Genitals. Great care should be exercised in cleansing the skin around the genitals after a bowel movement, especially in fe- male infants, since it is not improbable that many 44 INFANCY AND CHILDHOOD cases of bladder infection result from contamina- tion about the vulva. A pledget of cotton dipped in clean water should be used to cleanse the vulva, wiping from before backward. Each cleansing will therefore require several pledgets. Wash Cloths. Wash cloths should never be used more than once without being washed and boiled. Soiled washcloths may readily be a source of infection to the eyes and genital organs. CARE OF THE GENITAL ORGANS The Female. The genital organs of the fe- male infant should be cleansed daily by sponging with warm water to which some borax may be added. All secretions should be removed from the folds and the surface dried by careful sponging with some soft material. No powder such as talcum should be used directly in or around the vulva. Such powder acts as a foreign body and serves only to produce irritation. If some irritation of the mucous membrane is present, absolute cleanliness is the best remedy, and if any application is made it should be in the form of a simple emolient, such as zinc oint- ment or vaseline., Not infrequently a concentrated urine, due to improper food or insufficient water, is the cause of the irritation. The Male. It is in the care of the genital or- gans of the male infant that the greatest diversity CARE OF THE NEW BORN 45 of opinion exists. Practically all male infants have an adherent foreskin at birth. Circumcision. The question is what should be done with this adherent foreskin? Should it be left alone, or shall stretching or circumcision be performed? The fact is that if left alone about one-third to one-half of the cases will correct them- selves after a few months. The remaining cases should be corrected either by stretching, or, where the foreskin is very long, by circumcision. These questions must be left to the decision of a phy- sician. Where there is a great amount of secre- tion around the glands, and where after one year it is found that it is difficult to keep the parts clean, then circumcision should be performed. I am con- vinced from long observation that altogether too much attention is directed to the genital organs in infants and young children. It is hard to conceive that nature should have made such a serious mis- take as many people would have us believe. It is usually sufficient to keep the genital organs of both sexes clean, and if any irritation or inflam- mation is found to be present, then the physician's attention should be called to the condition. CARE OF THE EYES OF THE NEW BORN Eye Infection Treatment. It is a well known fact that 80-90 per cent, of the cases of blindness 46 INFANCY AND CHILDHOOD are traceable to infections received from the secre- tions of the mother at the time of birth. Any puru- lent vaginal discharge from which the mother may be suffering at the time of the birth of the child is very liable to infect the eyes of the infant. There is one form of infection (gonorrhea) which is es- pecially liable to produce blindness. Since it is im- possible without a microscopic examination to rule out this infection, all suspicious cases should be treated at once by dropping a solution of nitrate of silver into the eyes. This should always be done under the direction of a physician. In some States this treatment is compulsory in all cases, and many physicians make it a routine. In my opinion, in all cases, the eyes of the new born should be washed with a solution of warm Boric Acid and a 15 per cent, solution of Argyrol dropped in. This treatment should be repeated at least three times daily for several days. If there is the least trace of pus present, or if the eyelids are stuck together in the morning, the condition should be at once reported to the physician. A cul- ture should be taken and the exact character of the infection determined. CARE OF THE MOUTH Swabbing. The mouth of the healthy infant rarely needs cleansing. Directly after birth if there CARE OF THE NEW BORN 47 is much mucus in the mouth or throat it should be wiped out. This, however, should be done with the greatest care; otherwise serious injury to the mucous membrane may result. The system gener- ally practiced of forcibly swabbing out the mouth daily one or more times with the index finger, over which a piece of gauze has been stretched, is respon- sible for many of the sore mouths in infants. Wherever the delicate epithelial covering of the mouth is brushed off, a white spot results. The secretions keep the mucous membrane of the mouth clean, and it is only when teeth appear that the mouth needs care, unless some infection has already occurred. The infected spots should be gently sponged with some mild alkaline and antiseptic solu- tion, such as boroglyceride. CLOTHING OF YOUNG INFANTS Exposure to Heat and Cold. The question of clothing must of course differ with the character of the climate and with the kind, and degree of heat in the home. The important thing is that the body of the infant be so protected by clothing, that it will be at no time exposed to degrees of cold or heat to which it cannot accommodate itself. Young infants do not stand exposure to cold well, they lose heat rapidly and are liable to suffer from some acute catarrhal condition as a result. Neither do 48 INFANCY AND CHILDHOOD they stand prolonged high temperature well. It is important therefore that the amount of clothing should vary with the temperature. The skin should be kept comfortable. During the winter in the northern climate, woolens should be worn, the amount to be determined by the temperature of the atmosphere. In extremely hot weather in summer much, and sometimes practically all, clothing should be re- moved. Prickly Heat. An extremely irritating rash, known as " prickly heat/' frequently results from too much clothing in hot weather. Care must be exercised, since, in this climate par- ticularly, sudden changes of the weather are apt to occur, and with a descending thermometer, cloth- ing should be gradually added. Not infrequently the most serious intestinal dis- turbances occur in infants not during the hottest weather, but directly after a sudden drop in the thermometer. LIST OF CLOTHING FOR NEW-BORN BABY Three flannel binders (one-half yard of twenty- seven inch flannel). Three shirts, wool and silk, or wool and cotton. Two flannel petticoats. Two flannel or knitted sacques. CARE OF THE NEW BORN 49 Two pairs of worsted socks. Two dozen diapers, twenty-two by forty- four inches. One dozen diapers, twenty-five by fifty inches. Four white muslin slips. One cloak. One warm cap. One pair of mittens. One veil. Two blankets. One box talcum powder. Two dozen safety-pins, large and small. Two bath towels. Two soft towels. Later — Three pairs of woolen stockings. Three knitted bands with shoulder straps. Additional diapers. (Supplement No. 10 U. S. Public Health Re- ports.) The flannel binder, four to six inches wide, should be worn snugly, not tightly, around the abdomen, until the navel is healed. This should be so applied as to approximate the edges of the umbilical open- ing. The woolen shirt in warm weather should be of the lightest weight. When extra clothing is needed at night, or when the child is out of doors, it may be added in the form of coats, blankets, robes, etc. 50 INFANCY AND CHILDHOOD The amount of clothing should only be sufficient to keep the skin comfortable. If the skin perspires, some clothing should be removed. If the baby per- spires when asleep, it is either too warm or suffering from rickets or malnutrition. Handy Folding Table for Bathing and Dressing the Baby All clothing should be so arranged as not to in- terfere with the free movements of the body. In older children all clothing should be suspended as far as possible from the shoulders. (See page 179.) Effects of Tight Clothing. Too tight clothing around the chest interferes with breathing. A tight band around the abdomen is a frequent cause of regurgitation of food, and in addition is a pos- sible factor in the production of ruptures in the groin. Freedom of Motion. The hands and feet should be allowed unrestricted movement, since it CARE OF THE NEW BORN 51 is only in this way that the baby gets the exercise it needs for proper development. DIAPERS Diapers should be of soft non-irritating material which will readily absorb moisture (cotton). They should be loosely applied so that the infant has freedom of movements and is comfortable. Soiled Diapers a Cause of Bladder Infection. Diapers should be changed as soon as soiled. Soiled diapers are always a source of discomfort and not infrequently the cause of severe irritations of the skin, as well as of infections of the genital and urinary tracts. This is especially true in the case of female infants. No diaper should be applied a second time with- out first being washed. All diapers which have been soiled by discharges from the bowel should be first washed and then boiled and thoroughly dried before being used. Danger of Safety Pins. The use of pins is frequently a source of great discomfort to infants. It is not uncommon that in fastening diapers safety- pins include the skin also, and the writer has on two occasions seen the scrotum pierced. When chil- dren shriek as if with pain it is always well to ex- plore the skin under the diaper. "Vanta Garments/' including diapers, are now '52 INFANCY AND CHILDHOOD procurable fastened with tape, no pins being neces- sary. They may be purchased at any general store. THE NURSERY The following requirements are essential for an ideal nursery : Sunshine. First, the room should be of good size, with plenty of light, the windows being so lo- cated that it has sunshine a part of the day at least, the year around. Fireplace. A fireplace is an excellent adjunct and serves not only to heat the room at special times, but also as a means of ventilation. The windows should be furnished with dark shades and no other hangings should be allowed in the room, as they simply serve to collect dust. Fresh Air. Open Windows. The air should be kept constantly fresh by means of some aperture communicating with the outside. It is sufficient if a window is left slightly open, preferably both at the top and bottom, for by this means there is a constant rotary motion of the air around the win- dow which serves to keep the air fresh. A screen placed before the window will prevent the air from blowing directly across the room. It is not suffi- cient to have the windows of a nursery opened once or twice daily for a few T minutes, as the air quickly becomes foul again. CARE OF THE NEW BORN 53 Number of Persons at One Time in Room. No more than one person should be in the nursery at one time with an infant, and during its sleeping hours it should be alone. Temperature of Nursery. The temperature of the nursery for an infant during the first few months should be 70° F. during the day and during the night slightly lower. After six months it may A Knitted Hammock for the Baby be allowed to go as low as 50 F. if the infant is rugged and has no catarrhal conditions of the respiratory tract. Zero temperatures are to be avoided in young children. The less the extremes of heat or cold to which the mucous membranes of "infants are ex- posed the less liable they are to suffer from catarrhal conditions of the respiratory tract. 54 INFANCY AND CHILDHOOD Fresh Air and Cold Air. It must be remem- bered that what is needed is fresh moist air and not cold air, and that it is not necessary that air be cold in order that it be fresh. Lighting of the Nursery. A nursery should never contain a gas jet; it is always liable to leak sufficiently to be a source of contamination to the air. A lamp or jet should never be permitted to burn for hours at a time in a nursery. Where electric lights are not available, a small wax candle will suffice and will use up a minimum of oxygen. AIRING OUT OF DOORS Where the conditions at home are at all ideal it is not necessary nor advisable that an infant be taken on the street for any airing. When a house has a number of windows through which the sun shines, or in addition a well situated porch, an in- fant can get just as much and as good air at home as it can anywhere. The Perambulator. Kissing. Wheeling the baby about the street has nothing to commend it and has the disadvantage of exposing the infant to being picked up and kissed by every admiring friend the mother happens to meet, with the added danger of contracting some form of contagion by the way. Shade. During the hot weather it is fre- A Child Should Have Much Exercise in the Open Air, Both Summer and Winter \Pages 56 and 123.] CARE OF THE NEW BORX 55 quently cooler on the shady side of the house with the windows open than it is out of doors. When the quarters are small and it is impossible to keep the room cool, the baby should be taken into the open air, on the shady side of some building, in an open shady grass plot under the trees, or in the pub- lic parks. SLEEP A new born baby should sleep practically all of the time except when it is nursing. From six months to a year an infant should sleep about two- thirds of the time. Up to the age of six years a child should sleep fully one-half of the time. An infant should never sleep with the mother or nurse. It should be given its food and put in its own bed, and preferably in its own room. After six months a baby may go all night, from 6 p.m. to 6 a.m., without a feeding. It is, how- ever, rather unusual that a baby will go so long without food. It is therefore usually better to give a feeding at ten o'clock. If a baby wakes up again in the night it should never be taken up unless to change its diaper, but should be given a little water (no food) and never carried about. The habit of taking up a crying baby at night, except for reasons given above, is fatal to the comfort of the household and bad for the baby itself. After two years many children sleep too much. 56 INFANCY AND CHILDHOOD A child who sleeps all night, from 6 p.m to 6 a.m., and takes a nap of one or two hours during the day, should spend the rest of the time out of doors, in reasonable weather. Effects of Exercise. In order that a child shall develop properly physically and mentally it must have much exercise in the open air. A child who has insufficient exercise will not sleep quietly; it takes its food without relish and does not assimilate well what it does take. The habit of taking a nap in the middle of the day should be insisted upon until the fifth or sixth year and as much longer as possible. Restlessness During Sleep. Restlessness dur- ing sleep is due to a number of causes : underfeed- ing, overfeeding, adenoids, soiled diapers, illness (fever), rickets, too much clothing, or to the child's having been spoiled by being carried about or rocked. TEMPERATURE The normal temperature of the baby is 98%° F. A slight variation of y 2 ° either above or be- low does not mean anything. An infant's tempera- ture should always be taken by rectum, as a tem- perature taken in the groin, or under the arm, is liable to be incorrect. It happens not infrequently, if the skin is moist, that even with a high fever the thermometer will not register. Nursery Pen [Pages 52 and 122.] : In an Open Shady Grass Plot Under the Trees n [Page 55.] CARE OF THE NEW BORN 57 Slight variations of temperature in children which are not persistent may be disregarded. A persistent temperature, however, of ioi° or 102° F. always means some systemic disturbance, never teeth. When a temperature persists after the simple remedies have been tried (cathartic and water diet) a physician should be consulted. PREMATURE INFANTS Infants born between the seventh and ninth months of intra uterine life are termed premature. The chance which these infants have for life and proper development depends upon many conditions. Simple Incubator for Premature Infants A premature infant born of syphilitic parents has little chance for life. A premature infant born of healthy parents, when the weight of the infant at birth exceeds four 58 INFANCY AND CHILDHOOD pounds, has a fairly good chance for life and nor- mal development, provided it can be placed in an incubator and have breast milk. Premature infants who cannot have breast milk have a relatively small chance; they sometimes de- velop for a few months, but are prone to be carried off by some infection. To maintain the body heat in premature infants they should be placed in an incubator or properly prepared basket and the temperature kept uniformly between 90 ° to 95 ° F. Fresh air must be con- stantly admitted from below. The infant is wrapped in cotton wool, not dressed, and only taken from the incubator to be fed and cleansed. Bathing except for simple clean- liness should be dispensed with. The baby should be rubbed daily with warm olive oil. Many premature infants have insufficient strength to take the breast. The milk should be removed regularly by expression, or by means of a breast pump, and given the in- fant with a medicine dropper or Breck Breck feeder. It is necessary often to dilute the Feeder milk at first with boiled water. When the mother has insufficient milk a wet nurse should be employed. Allowing the w r et nurse's baby to nurse the mother regularly for a while, will frequently result in a proper flow of milk, CARE OF THE NEW BORN '59 after which the services of the wet nurse may be dispensed with. The number of feedings and the amount at a feeding which a premature infant may have will depend upon the individual case. Weak seven- month babies will usually take very little at a feed- ing Cj/2 to 1 ounce). It may therefore be neces- sary to feed them rather often, say every two hours for eight to ten feedings in twenty- four hours. If the baby takes a good amount at a feed- ing it may be fed less often, every three hours, with six to seven feedings in the twenty-four hours. If the stools are curdy, or green, or if there is vomit- ing, the quantity should be diminished or the milk diluted. The diet of the nurse should be carefully supervised. (See chapter on the Wet Nurse.) As the baby approaches full term the surround- ing temperature may be gradually reduced, so that it may be removed from the incubator and placed in a basket, or box, which is properly padded and where the body temperature can be easily kept up. Where the regular hospital incubator is not ac- cessible one may be readily improvised by a good mechanic at little expense. The temperature can be maintained fairly uniform by means of a hot- water coil, or by several hot-water cans which are changed at regular intervals. A thermometer should always be kept near the baby. BREAST FEEDING There is but one ideal food for infants, and that is mother's milk. Reasons for Nursing. The death rate among infants who receive breast milk is only one-sixth of that of infants fed on the bottle. Ninety per cent, of mothers can nurse their babies in whole, or in part, for the first few months, and many can nurse them wholly, or in part, for the first year. About the only disease which should prohibit the mother from nursing her infant is tuberculosis, in which case the continued nursing would be danger- ous to both mother and child. When for some legitimate reason a mother can- not nurse her own baby a wet nurse whenever pos- sible should be procured. (Page 70.) Some of the common reasons given for not nurs- ing a baby are : " There was not enough milk " ; " the milk was bad," etc. These are not sufficient reasons. The baby should be kept at the breast, even if only a small amount of milk is secreted, and 60 Breast Feeding — The Proper Position for Nursing the Baby BREAST FEEDING 61 the deficiency made up with some other food. Gen- erally speaking, there is no such thing as " bad " breast milk. Loss in Weight During the First Weeks. It is a common occurrence, especially with first babies, that for the first few weeks there is insufficient milk in the breasts. If, however, nursing is per- sisted in regularly, the quantity will almost always increase. Secretion of Milk. In cases where during the first week or so there is insufficient milk secreted, the baby will lose in weight. This, however, is not serious and the weight will usually be rapidly re- gained when the secretion of milk is well estab- lished. It is during this time that great care must be taken not to produce serious digestive dis- turbances by over feeding with some artificial food. It is usually sufficient for the first few days to give in addition to the breast, some boiled water, and later, if the breast milk is insufficient, to begin with a little cow's milk (not cream) diluted in the propor- tion of one part of cow's milk to three parts of boiled water. Advantages. The advantages of breast feed- ing are : First : The low death rate. Second : The better nutrition of the infant. Third : The greater immunity to disease. 62 INFANCY AND CHILDHOOD Fourth: The greater chance of recovery from disease. Fifth: The greater sympathy which exists be- tween mother and child. Sixth : The greater economy of time and money in nursing an infant compared to feeding it arti- ficially. Cost of Patent Foods. The average daily cost of many of the patent fools is in excess of twenty- five cents. To successfully nurse her baby the prospective mother should consult a physician many months be- fore the birth of the infant with the idea of main- taining herself in the best possible physical and mental condition. The urine should be examined at least once monthly during the pregnancy. In case of undeveloped nipples much can be done by proper manipulation to develop them. Colostrum or First Milk. During the first twenty- four hours after birth the infant should be put to the breast only every six to eight hours, and in the interval given a little w r ater with a spoon. During the second twenty- four hours the baby may be put to the breast every five to six hours. If there is much milk in the breasts, which is not the rule, great care must be taken or the infant will get too much and as a result have an acute indiges- tion with vomiting and green watery stools, since BREAST FEEDING 63 the first milk (colostrum) is laxative in character. Technique of Nursing. After the third or fourth day the infant should be put to the breast regularly every three to four hours, but not to ex- ceed six times in twenty- four hours. It is important during the first week rather to underfeed an infant than to overfeed it. If it is found that the stools are good in charac- ter and the baby seems hungry, then the amount of milk allowed may gradually be increased. Number of Feedings. Where there is an abundant secretion of milk the intervals may be four hours with five feedings in the twenty- four hours. The important thing is that the baby get sufficient food for its needs and that it be given at long enough intervals, so that the stomach will have a period of rest before the next meal. Too frequent nursing is the most common cause of colic, vomiting and bad stools in breast-fed in- fants, and frequently results in the baby being weaned. When the breasts are small, as they often are in the case of first babies, and insufficient milk is secreted, both breasts may be given at each nursing. In the case of premature or very weak infants, where the capacity for food is very small, the num- ber of nursings may be increased to seven or eight in the twenty- four hours. 64 INFANCY AND CHILDHOOD Quantity of Milk at a Feeding. The quantity of milk taken at a nursing is extremely variable. It is not infrequent that at the age of two or three weeks the infant will get three to four ounces at the early morning nursings, while at the afternoon and evening meals it will not exceed one to one and a half ounces: Variation in Quantity and Quality of Breast Milk. Mental Condition of the Mother. There is a considerable variation both in the quantity and quality of the milk from day to day, depending upon the physical and mental condition of the mother, character of food, and quantity of fluid taken. It is important, therefore, that the mother should lead as even an existence as possible during the nursing period. She should have plenty of plain food at long intervals, plenty of water between meals, and uninterrupted sleep at night. In order to carry out these demands regular hours for nursings, with long periods between, especially at night, are absolutely essential. The Daily Quantity of Milk Needed by the Average Breast Infant During the First Year Is as Fol- lows (Camerer) : End of first week 291 grams, 9^ ounces End of first month 652 grams, 20 ounces End of second month 804 grams, 25 ounces End of third month 852 grams, 27 ounces End of sixth month 1000 grams, 32 ounces BREAST FEEDING 65 End of eighth month 1000 grams, 32 ounces Twelfth month 1000 grams, 32 ounces Green Stools. When a baby is gaining in weight and has large, curdy stools which are often tinged with green, it is usually getting too much milk, or sometimes, owing to the character of the diet of the mother, the milk is too rich in fat. In such cases the intervals between feed- ings should be lengthened to four hours, especially if there is vomit- ing, or the quantity of milk allowed the infant at each feeding should be reduced. If it is found by weighing before and after nursings that the baby does not get too much milk, then the diet of the mother should be reduced and she should be enjoined to drink large amounts of water between meals and take regular exercise in the open air. When for some reason the mother must tem- porarily stop nursing, milk should either be pumped or expressed from the breasts at regular intervals. Overfeeding and Underfeeding. Not infre- quently infants who are overfed stop gaining in weight after a time and do not gain again until the amount of food has been properly reduced. If a baby does not gain in weight, does not vomit, Breast Pump 66 INFANCY AND CHILDHOOD has normal but small stools, it is presumably not getting enough to eat. The stools in case of hun- ger, however, are frequently green in color, but rarely curdy. Hours for Nursing. The hours for nursing should be definite and the infant wakened if asleep. In a short time, if regular hours for feeding are adopted, the baby wakes at the proper time. Regular hours are better than the haphazard way, for several reasons : First, the intervals between feedings will be long enough for the stomach to empty itself and have a period of rest before the next feeding. Second, the mother can arrange her household duties and have some freedom and recreation with- out feeling that she may be neglecting the baby. It is important for both mother and infant that the mother should have some time each day to spend in the open air and for social intercourse. When the hours for nursings are irregular the mother never knows when she can leave the house or when she must be at home, and the result is that many babies are weaned who would otherwise be kept on the breast. Night Nursings. After the sixth month a baby who gets a proper amount of food during the day may go from 10 p.m. until 6 a.m. without any- thing but perhaps a drink of water. BREAST FEEDING 67 Diet of Mother. The diet of the nursing mother should consist of good, plain, properly cooked, nutritious food. Much of the talk about many articles of food, such as fruits, making the baby colicky, is rubbish. Pickles and highly seasoned foods, including candy and pastry, in any amount, should be excluded from the diet. The habit of eating many meals daily is a mistake. It is much better to eat three good meals daily and between to drink plenty of water. It fre- quently happens that where the mother " stuffs " herself between meals the digestion becomes de- ranged and the quantity and quality of the milk is seriously affected. Overfeeding of Mother. Many times where a mother takes great quantities of milk and gruels be- tween meals she gives a small amount of milk, usually too rich in quality, and gains rapidly in weight herself. Before early weaning a baby always consult a physician, as in ninety per cent, of the cases a solu- tion of the difficulty can be found and by some modi- fication of the diet the baby may be kept on the breast. Menstruation. In case the mother begins to menstruate during the nursing period the milk usually is reduced in quantity and quality for a few days, so that some extra food may have to be given 68 INFANCY AND CHILDHOOD the infant until the mother again has sufficient milk. This alone does not justify weaning the baby. Pregnancy. On the other hand, in case the mother becomes pregnant during the nursing period, the baby should be gradually weaned. First, be- cause the milk will rapidly deteriorate in quantity and quality, and, second, because the drain upon the mother is too great. Reasons for Infants Refusing to Nurse. When an infant refuses the breast but takes an artificial nipple, it is usually because it is easier to grasp, there is insufficient milk in the breast, or be- cause the food from the bottle is sweeter. If a baby takes the breast for a fraction of a minute and then lets it go and cries, and repeats this several times in succession, the usual reason is some obstruction, preventing nasal breathing, and conse- quent inability to nurse. The same symptoms will occur if a bottle is given in these cases. Weighing Before and After Nursings. Not infrequently when a baby refuses the breast it will be found that there is little milk there. The exact amount obtained at a feeding should be determined by accurate weighing before and after nursing. FISSURED NIPPLES Nipple Shield. When the nipples are sensi- tive it is frequently the result of fissures. Under BREAST FEEDING 69 these conditions a nipple shield should be used until they are healed and the nipples sponged frequently with a fifty per cent, solution of alcohol. In all cases after nursings the nipples should be sponged with an alcohol or boric acid solution in order to prevent infections of the breast. ADDITIONAL FOOD (MIXED FEEDING) At the age of seven to eight months a breast baby should begin to have some additional food. At first this may be a little soup or beef juice to which some toast or well cooked cereal has been added. When nine to twelve months of age the baby may have in addition to the soup two or three pieces of toast or zweibach daily. These pieces are about two inches wide and about three inches in length. Other food, such as rice, well- cooked oatmeal, or a little baked potato, may also be given. No food should be given between meals, but just before a feeding. It will be found that babies who are fed ex- clusively on breast milk during the entire first year are usually pale and the muscles flabby, while those given a little extra food will be plump and rosy. Nipple Shield 70 INFANCY AND CHILDHOOD Infants fed exclusively on the breast during the first year are difficult to wean and frequently lose much in weight before they can be prevailed upon to take a proper amount of other food. WEANING At one year a baby should be fully weaned and if the milk is scant and it is receiving only a few ounces in the twenty-four hours, artificial feeding may be started to advantage earlier. Weaning is often more readily accomplished by a competent nurse than by the mother. The best plan is to wean the baby gradually. At seven or eight months an occasional bottle of prop- erly modified milk may be given, then two may be substituted for two of the nursings. After a time a bottle may be substituted for the breast at every other feeding. By this means no inconvenience may be felt by either mother or child and the increase in weight may continue without interruption. After one year the number of feedings should be cut dow r n to four in the twenty- four hours and a mixed diet given. (See Diet for Infants Twelve to Eighteen Months, page 115.) THE WET NURSE The best wet nurse is one who has a healthy, thriving baby of her own. She should continue to BREAST FEEDING 71 nurse her own baby, and if she has not enough at first for both it is usually possible to supplement the breast milk with some other food. One must be sure that the wet nurse is not suf- fering from any communicable disease, such as tu- berculosis or syphilis. She and her baby should be carefully examined by a physician, and if there is any possibility of syphilis a blood test ( Wassermann reaction) should be "made. The diet and exercise of the wet nurse should be carefully regulated. Not infrequently an overin- dulgence in rich food is responsible for failures in wet nursing. A maximum of plain, nutritious food should be allowed at meal times, with plenty of water between. The habit of eating and drinking milk, etc., between meals usually results in a dis- ordered digestion, with an over rich milk supply. The nurse should have several hours' exercise in the open air daily and should have enough duties to per- form to keep her occupied and happy. VI ARTIFICIAL FEEDING The first thing to be remembered before putting a young infant upon an artificial food is that there is no real substitute for mother's milk. Even when a food is compounded of the same ingredients, in the same amounts as nearly as can be determined, still there is a wide difference in its effects and in the manner of its behavior in the digestive tract. Under certain circumstances infants must be fed artificially; therefore it is a matter of the most vital importance that a food be procured which will as far as possible meet the needs of the individual. In many instances serious conditions which affect the digestion and nutrition are produced at the very onset by giving a food which is not adapted to the infant's needs. Indigestion. Frequently an acute indigestion is produced from which it requires months to re- cover. The best available substitute for mother's milk is clean, fresh, properly diluted cow's milk. Any food which has not milk as a base is a dan- gerous food for any length of time. 72 ARTIFICIAL FEEDING 73 Patent Foods. Some of the patent foods which claim to have milk as a base are also dan- gerous for continuous use when diluted as directed, owing to the large percentage of sugar and the small percentage of proteid and fat they contain. Difficulty in Getting Clean Cow's Milk. In preparing an artificial food the first step is to pro- cure fresh, clean, cow's milk from healthy cows. This may be difficult even in the country and in small towns where the cows are untested for tu- berculosis, the stables unsanitary and filthy, and the milk improperly cooled and cared for. In the large cities it is a hard, and many times an impossible, task to secure clean milk. When the source of the milk supply is distant the chances of contamination are legion. Since it is almost impossible for the average family in a city to procure ideal milk, it is important that great care be taken to get the best available. Tuberculin Tested Cows. Whenever possi- ble, people living in a city should own their own cows, which have been tested for tuberculosis. The stable and the cows should be kept clean. Before each milking the cows' udders should be washed with warm water, as well as the hands of the milker. There is no comparison between milk from a cow kept under such sanitary conditions and that pro- cured from the average milk-wagon. The wa- 74 INFANCY AND CHILDHOOD ter-supply is a matter of the greatest import- ance. Wells are frequently infected by drain- age from the stables and outhouses, and the milk is frequently contaminated in this way. Other things being equal, the milk from a herd is more uniform and therefore better than that from a single cow. The great masses, however, are forced to procure milk from a dealer. Certified Milk. Certified milk x should be procured for infants whenever possible. The cost of this milk is somewhat more than the ordinary variety, but it is not usually prohibitive and the aver- age daily cost is much less than for any of the patent foods. When certified milk cannot be procured, the best milk possible, from a known source, should be purchased. The milk should be less than twelve hours old and should be kept on ice from the time of milking until it is used. Pasteurization and Sterilization of Milk. Since the sources of contamination of milk are many and the difficulty of determining the character of the milk so great, it is expedient that all milk {with perhaps the exception of certified milk) should be properly pasteurized, or boiled. We would not think of eating raw meat, and yet it is not nearly so fertile a source of contagion as milk. 1 Milk certified by the Department of Health as having a bacterial count of not over 10,000 per c. cm. A Modern Sanitary Cow Stable Contrasted with the Old Style Disease-Breeding Conditions ARTIFICIAL FEEDING 75 Contagious Diseases Carried by Milk. We now know that many :f the er:.:\" f ;:::s of infections disease, such as scarlet fever> diphtheria, tonsilitis, aftd typhoid fever, are frequently directly traceable to the milk supply. The pasteurization of milk changes its character very little. a::d boiling for a short time (two min- utes; does not change it sufficiently to outweigh its ntages on the side of safety. 1 Richness of Milk. For infants the milk rich- est in far should not be sought, but rather milk only moderately rich. Milk from a herd is usually to be preferred to milk from one cow. Breed of Cows. Holstein as a breed produce milk particularly adapted to infants. The fat per- centage is rather low and the fat globules small. THE CARE OF MILK IN THE HOME After having secured the best milk possible it is necessary that it be kept pure and cold. All milk for infants should be poured at once a::er milking into clean bottles which have been sterilized by live s:ea::: or boiled, and placed upon ice until delivered. Temperature for Pasteurization. As soon as the milk is received at the home it should be pre- 1 The City of New York now requires that all milk sold within the corporation, with the exception of A grade, be either pasteurized or boiled. 76 INFANCY AXD CHILDHOOD pared according to the formula prescribed. It should then be poured into nursing bottles, one for each feeding during the twenty- four hours, and each stopped with a plug of sterilized cotton wool. These bottles should first be thoroughly cleaned and boiled. The whole feeding may then be pas- teurized by placing the bottles in a water bath until the temperature of the milk reaches 170° F. and then allowed to stand at this temperature for twenty minutes, or the milk may be first brought to the boiling point for a couple of minutes and then poured into the bottles. The bottles should then be placed on the ice until needed. Just before using a bottle it should be placed in warm water until the milk reaches the proper temperature (blood heat). Milk left in a bottle after a feeding should never be used for a second feeding, but should be dis- carded and the bottle filled with water until it is cleaned and boiled. Improper Pasteurization. The safest and simplest method for the average family to pursue is to boil the milk. Pasteurization under any cir- cumstances does not kill all germs, and if improp- erly done it is worse than no pasteurization at all. Heating milk to an insufficient temperature merely stimulates the growth of organisms. Where ice cannot be procured, milk which has been boiled and rapidly cooled, if kept in a cool ARTIFICIAL FEEDING 77 place, sealed from the dust and flies, will be com- paratively safe for twenty- four hours. Ice Box. A simple ice box can be constructed at a cost of fifty cents which will keep a baby's milk cold at an expense of two or three cents per day. (See directions on pages 97-98.) It must be remembered that pasteurization, or boiling, will not transform filthy milk into clean milk. It will, however, remove the chances of such epidemics as some of our cities have suffered from during the past years. Nipples. Nipples should be thoroughly cleansed and kept free from moisture in a covered glass jar until needed. The habit which many mothers have of putting the nipple into their own mouths before giving it to the baby should be absolutely prohibited, as this is a frequent source of infection. Thermos Bottles. Thermos bottles may be used to keep milk cold, but never to keep milk warm, since germs develop rapidly in warm milk. The milk may be heated rather rapidly by putting the bottle under the hot-water faucet. Great care must be taken in the use of alcohol lamps, as fre- quent accidents happen in this way, and especially at night. 78 IXFAXCY AND CHILDHOOD Composition of Cow's Milk as Compared with Mother's Milk Mother's Milk: Con's Milk: Per cent. Per cent. Fat 4 Fat 3-4 Sugar 7 Sugar 4j4 Proteid iVi-iYa Proteid 3-3^ Mineral Salts . . % of 1 Mineral Salts ... % of 1 Water, about ... 88 Water, about . . 88 It will be noticed by a comparison of the two kinds of milk that the chief apparent difference is in the amounts of sugar, proteid and salts. Mothers milk contains about 3 per cent, more sugar than cow's milk, and cow's milk contains about twice as much proteid as mother's milk. Cow's milk also contains two to three times as much mineral salts as mother's milk. A study of these percentages has suggested to many in the past the possibility of substituting for mother's milk a chemically identical modification of cow's milk. This theory, however, was found to be false, as no amount of modification of the milk of one species can transform it into that of another. Percentage Feeding. It was, however, found necessary to modify cow's milk for young infants and the method generally known as Percentage Feeding was adopted. This is the system generally described in the books on children. ARTIFICIAL FEEDING 79 Food Elements. This method is somewhat difficult for the average mother and approximately the same results can be obtained by simple dilutions of milk. This method will be described here. Caloric Values. The different elements of the food : fat, sugar, and proteid, have definite food values. The food value is measured in units called calories, a calorie being the amount of heat required to raise one litre (approximately a quart) of water one degree centigrade. The food or caloric value of proteid and sugar are the same, 120 per ounce, while that of fat is more than twice as much as either of the other elements. (For caloric values of different foods, see chart on page 185.) WHOLE MILK AND CREAM By whole milk is meant the milk as it comes from the cow, without any modification. By cream is meant the part of the milk which rises to the top of the bottle after standing. It is usually known as gravity cream and has a fat content of about 16% in contrast to centrifuge cream, which has a fat content of about 32%. MODIFICATION OF COWS MILK FOR INFANTS Cow's milk is usually modified by diluting it with some fluid, such as water or gruel, and then adding 8o INFANCY AND CHILDHOOD sufficient of whatever elements are necessary to bring them up to the proper percentages. (For Sugar and Gruel, see pages 89-90. ) Since the caloric value of cow's milk is practically the same ounce for ounce as mother's milk, it is ap- parent that if we dilute cow's milk we must either Chapin Cream Dipper Cream Dipper in Use give a greater quantity or add something to bring up its food value. The usual procedure, therefore, is to dilute cow's milk and then add such a percentage of sugar and cream as the individual case will tolerate. Since individual infants differ so widely in their tolerance of fat and sugar, it is always advisable to begin with low percentages of these elements and gradually increase to the proper amount. ARTIFICIAL FEEDING 81 Tolerance of Fat. Young babies will not usually digest as much cream in cow's milk as is normally found in mother's milk. For the average normal infant the following rules for feeding may be observed. It will be found, however, that there are many exceptions in which the milk will need further modification. These changes will be found to be more often necessary with the fat than with the proteid. If the milk is not first boiled, or some alkali, such as lime-water or potassium citrate, added, large cheesy curds of cow's milk frequently give trouble in passing the small end of the stomach. (Pylorus.) It is always well in beginning with cow's milk to give much less in quantity than the infant needs and increase as rapidly as the tolerance will permit. By adhering to this rule many serious digestive dis- turbances will be avoided and in the long run greater progress will result than if the infant is put upon a full amount of food from the start. The rapid gain in weight for which so many young mothers strive is often obtained at a great sacrifice. Great increase in weight is of much less impor- tance than normal digestion, which if maintained will mean a steady gain in weight and nutrition and a happy, contented infant. 82 INFANCY AND CHILDHOOD QUANTITY OF FOOD AT A MEAL It is a safe rule to give at a feeding a quantity in ounces corresponding to the age of the baby in months, plus one. For example, at three months, four ounces; five months, six ounces, etc., up to eight months, when the quantity at a feeding should not be increased. When only five feedings are given in twenty-four hours, and when the milk is well diluted, this quan- tity will have to be exceeded in order that the infant shall get the proper amount of food. If, however, too large a quantity is given, the stomach walls will become permanently stretched and thereby lose the power of contraction. MILK FORMULA In normal infants the following formula will usually be tolerated : For the first few days — One- fourth whole milk, i.e., whole milk five ounces, three- fourths, boiled water — boiled water fifteen ounces. Give two ounces every three or four hours for six feedings. After a few days if the stools are good and there is no vomiting, some sugar (cane, milk or malt) may be added. This should be done gradually, add- ing at first one teaspoon and increasing up to one ARTIFICIAL FEEDING 83 ounce or eight level teaspoons in a twenty-ounce mixture. t:;r. tvh::h has a sh:try feelir.g :; the t:u:h. S::r. ea:h pazule he-: trr.es :^;:tl ~i:h a pustule. In severe cases these lusrules are so thickly crowded together that they form, when they dry, dense crusts. The disease is frequently fatal un- less the patient has been successful/ vaccinated. See chapter :r. Va:::r.i:::r..i CHICKEN POX An acute contagious disease characterized by fever and general indisposition and on die skin by an eruption which, unlike smallpox, has a vesicle full of serum instead of pus. In some cases it is 142 INFANCY AND CHILDHOOD difficult to tell whether the disease is chicken pox or a mild smallpox. A physician should always be called in order to make a diagnosis. MUMPS A contagious disease characterized by some gen- eral symptoms : fever and indisposition and swelling of the parotid gland. The swelling is in front and below the ear; not infrequently the ear stands out from the head. The chief danger is the possibility of involvement of the testes in boys and the ovaries in girls. An inflammation of these organs may re- sult in the destruction of their function. Patients suffering from this disease should be kept in bed and be under the supervision of a physician. WHOOPING COUGH A contagious disease occurring usually in epi- demics, and characterized by spasmodic attacks of coughing, accompanied by difficult inspiration (whooping). Many cases of whooping cough never " whoop," so that it is difficult often to make a diagnosis. It is always suggestive of whooping cough when a child wakens two or three times during the night out of a sound sleep and has a paroxysm of cough- ing and does not cough at all in the interval. Whooping cough must be regarded as a serious THE CONTAGIOUS DISEASES 143 disease. The death rate is high, especially in young and feeble children, in whom pneumonia is not an infrequent complication. Many children vomit with every paroxysm, and as a result become much depleted in health from lack of food. In these cases the food should be given in liquid form and rather frequently, every three or four hours. In many cases an adhesive strip, drawn rather tightly around the body at the level of the diaphragm, will prevent much of the regurgitation of food. In uncomplicated cases little is to be gained from medicine. Some of the simple cough mixtures will sometimes relieve the laryngeal and bronchial irrita- tion. There are hopes that in the near future some vaccine or serum may be found which will control the disease. The important things in the treatment are : fresh air and food. The more time the patients spend in the open air, the fewer paroxyms they will have. Many of the remedies common in use among the laity are harmful; such things as illuminating gas are dangerous to health. The characteristic cough persists for a variable period of from six weeks to several months. The disease, however, is probably not contagious after four or six weeks. If there is fever and any difficulty in breathing 144 INFANCY AND CHILDHOOD between the paroxysms a physician should always be consulted. All children with whooping cough should observe quarantine for several weeks. ERYSIPELAS Erysipelas is an acute contagious disease charac- terized by a localized inflammation of the skin with marked tendency to spread by continuity. The in- fection is due to a streptococcus. The infection takes place usually through some wound, many times only a slight abrasion. It be- gins usually with a small red spot, which rapidly spreads in all directions. The infected area is in- tensely red and raised noticeably above the normal skin. The face is the most common seat of infection, but any part of the body may be involved. The affected area is swollen and edematous and frequently there are small blisters filled with serum on the surface. During the course of the disease, which lasts for a variable time, there is fever and much general prostration. There is a marked tendency to an inflammation of the kidneys. The disease is especially serious in young and feeble infants. A physician should be called at the onset. THE CONTAGIOUS DISEASES 145 GONORRHEA A disease produced by the gonococcus. It is capable of producing an inflammation of almost any of the mucous membranes, but is particularly prone to involve the genito-urinary tract and the eyes. Perhaps as high as eighty per cent, of all cases of blindness are due to this disease. Many infants are infected at the time of birth from the mother's vaginal secretions. The disease is particularly contagious and is widely spread by means of soiled linen or utensils. Whenever a discharge appears, either from the eyes or the vagina or urethra, a physician should at once be consulted ; some of the discharge should be spread upon a glass slide, stained and examined un- der the microscope to determine the nature of the disease. When one or both eyes are infected with gon- orrhea the best medical aid possible should be sought. Irrigations and medication will be neces- sary every hour during the day and night. Even with the most thorough and heroic measures it is often impossible to save the sight. In case of gonorrheal infection of the genito- urinary tract in infants and children the utmost care will be required to prevent infection of the eyes by means of the hands. Irrigations and proper medi- 146 INFANCY AND CHILDHOOD cation will be required extending over a period of many weeks, and perhaps months, before a complete cure results. SYPHILIS A venereal disease communicated from one to another by contact or by inheritance. Infants frequently have the disease at birth, al- though marked symptoms may not appear until the infant is several weeks old. One of the most common early symptoms is " sniffles " and the appearance of an eruption on the skin. The eruption, which is variable in character, usually involves the soles of the feet, the palms of the hands, and the skin around the mouth and anus. A physician should always be consulted and the truth told to him. If proper treatment is begun early and maintained for a sufficient time, many of these infants recover, to all appearances, completely. Where there is any doubt about the diagnosis a blood examination of both parents, as well as of the infant, should be made (Wassermann). The disease is very contagious and nurses should exercise great care not to become infected. Syphilitic children should always nurse their own mothers (never a wet nurse). If put on an arti- ficial food their chance of recovery is relatively small THE CONTAGIOUS DISEASES 147 QUARANTINE When any member of a family is suffering from a contagious disease the parents are under moral obligation to themselves and to the community, even if not required by law, to maintain as thorough a quarantine as possible. It is surprising how zealous parents frequently are that strict quarantine shall be observed by every one but themselves. A child suffering from such a serious disease as diphtheria or scarlet fever should at once be isolated from other members of the family. If possible a nurse should be employed. It is always dangerous for the mother to undertake the care of the sick child and at the same time administer to the needs of other members of the family. A room should be selected as far removed from the others as possible, with a bath room in connec- tion. An open fireplace or wood stove is an im- portant adjunct to any sick room. All hangings and rugs should be removed. Toys and books should be limited to those which may be burned. All dishes and soiled clothing should be kept sep- arate and disinfected by boiling. A clean gown should be worn by the nurse or attendant and removed before leaving the room, 148 INFANCY AND CHILDHOOD and the hands should always be washed thor- oughly. Milk bottles should always be boiled before re- turning them to the dairy. It is a mistake to expose children to any con- tagious disease with the idea that they are sure to get it sometime anyway. Such a disease as whooping cough, which is not usually quarantined by the departments of health, is attended by a large death rate, especially in young infants, and one is morally culpable if he exposes his own or other people's children to the disease. Time of Quarantine. There is no way of telling when many diseases cease to be contagious. It is therefore important to keep the child isolated long enough so that there is no longer any possibility of its carrying infection. DISINFECTION AND FUMIGATION Before a child who has had a contagious disease is allowed to mix with other members of the family, or community, it should have a thorough bath and shampoo and then be rubbed with alcohol or a 1-2000 solution of bichloride of mercury. All toys and books should be burned. All clothing should be immersed for several hours in a carbolic acid solution, one ounce to two quarts of water. It may then be removed to the laundry THE CONTAGIOUS DISEASES 149 and boiled. Such things as mattresses should be so arranged that they can be thoroughly fumigated. The windows and doors should be sealed and the room, charged with formaldehyde gas and al- lowed to remain closed for twenty-four hours. Formalin candles may be purchased at any drug store, with accompanying directions for their use. Where the department of health does the fumigat- ing it should be seen to that it is properly done. After the room has been opened the woodwork and walls should all be gone over with a solution of bichloride of mercury 1-1000, and if the walls are papered, repapering should be done, if possible. These last precautions are to be observed especially in scarlet fever. XIV MISCELLANEOUS MELENA NEONATORUM (BLEEDING OF THE NEW BORN) Bleeding in the new-born infant may occur from the cord or from any wound made by instruments or otherwise at birth. This is more apt to occur in bleeders or those in whom jaundice is present. The most common form of bleeding, however, is that which occurs from the stomach, in which the infant vomits blood, or from the bowel or urinary tract, in which blood is found in the urine and stools. The bleeding is apt to occur during the first few days after birth. The condition is serious, but not necessarily fatal. The administration of solutions of gelatin by mouth and hypodermically is often followed by cessation of the bleeding. It is frequently neces- sary to resort to the injection of blood serum, or even the transfusion of blood from some other per- son to the veins of the infant. No time should be lost in summoning a physician at the first appearance of bleeding in an infant, so 150 MISCELLANEOUS 151 that proper treatment may be started at once ; other- wise many infants will succumb who might be saved. JAUNDICE OF THE NEW BORN Jaundice is a common affection of the new-born infant. In mild cases it has no special significance and after a week or two generally disappears. Extreme cases sometimes occur attended with fever and great prostration. This condition may result from infection of the navel. Where the jaundice is progressive and no fever is present there may be congenital absence of the bile ducts. CONVULSIONS Some infants are particularly prone to convul- sions. In these children every attack of indiges- tion, or the onset of any infection, is liable to be followed by a convulsion. Such children should be fed most carefully and always under a physician's directions, as much can be done by diet and other means to prevent their recurrence. When such at- tacks recur at intervals the possibility of epilepsy must always be considered. In all cases where a convulsion occurs, the bowels should be emptied as quickly as possible by a high enema, and as soon as practicable after the attack is over a dose of castor oil given. A physician 152 INFANCY AND CHILDHOOD should always be sent for. All food should be withheld for twelve or twenty-four hours and only water given. A warm bath at 105 F. to which some mustard has been added will bring the blood to the surface and relieve the internal congestion. At the same time the head should be kept cool with cold cloths or an ice bag. If the temperature is high the child may be wrapped in a cool pack, made by wringing a large bath towel out of cool water, one-third alcohol. It should then be rolled in a blanket and the pack renewed when necessary. When hot baths are given, great care should be exercised that in the excitement the infant is not burned. Worms, teething, and adherent foreskin are overestimated as causes of convulsions. WORMS Intestinal worms occur rather frequently in chil- dren. They are not, however, nearly as frequent as generally supposed. They rarely occur until the infant has been put on a mixed diet. The varieties of worms which are common to children are the following: Round worm, two to three inches in length and the size of a small angle worm. MISCELLANEOUS 153 Pin, or thread, worm, one-third to two-thirds of an inch in length and about the thickness of a No. 36 thread. Tape worm, varying from three to ten feet in length and divided into small segments. These parasites enter the intestinal canal usually by means of the food. Eating uncooked meat is the common cause of tape worm. There are no definite symptoms which can be said to be characteristic. Such symptoms as grinding the teeth, picking the nose, restlessness in sleep, do occur in children who have worms, but they also occur from many other causes. When children are suspected of having worms they should be given a large dose of castor oil and the stools watched. If worms are present usually some will appear. If none appear and there is still doubt a specimen of the stool should be taken to a physician for examination. If worms are present in the intestinal canal eggs will be found under the microscope. Worm powders should never be given to children except when a definite diagnosis of worms has been made, and then only under a physician's direction. Not infrequently serious poisoning occurs by giv- ing worm-remedies and usually without any worms being present. 154 INFANCY AND CHILDHOOD Round worms infest the small intestine prin- cipally. Pin, or thread, worms inhabit the lower part of the colon and rectum and occur in the stools in the form of tiny threads. They produce intense irrita- tion around the rectum. In girls they may gain access to the vagina and even the bladder. They are readily gotten rid of by emptying the lower bowel once daily for a week with an infusion of Quassia (i pint) and by keeping the child's hands tied so that it cannot scratch itself around the anus. If there is any possibility of contamination, the finger nails should be kept scrupulously clean, since by this means children may reinfect them- selves through the food over and over again. The presence of a tape worm may usually be de- termined by watching the stools for segments, par- ticularly after a brisk cathartic These sections should always be preserved in water and taken to the physician for examination. When a remedy has been given to expel the worm, care should be taken to preserve every part which comes away, for the physician's examination. If the head of the worm has not been expelled the worm will usually grow again. MISCELLANEOUS l DD ADENOIDS Every child has a certain amount of lymphoid or adenoid tissue in the throat behind the nose. When there is any marked increase in the amount of this tissue the child is said to have adenoids. As a result there is obstruction to breathing through the nose (the proper channel) and the child is compelled to breathe through the mouth (the improper chan- nel). In climates of extreme changes, probably one- third of all children have adenoids to some extent. It is not uncommon to see children with adenoids at birth. They cannot breathe through the nose and cannot as a consequence nurse properly until the obstruction has been removed. Children who have adenoids of any size, sleep with their mouths open, snore, and are restless in their sleep. The glands at the side of the neck are usually somewhat enlarged. Progressive deafness due to adenoids is common. Infection of the adenoid tissue frequently leads to inflammation of the middle ear, with the formation of an abscess. If mouth-breathing persists for any length of time the face and mouth become deformed and as- sume a typical appearance. There is usually some deformity of the chest-wall, due to improper breathing. In marked cases the mentality is slug- 156 INFANCY AND CHILDHOOD gish, and as a result the children fall behind in their school work. Whenever there is persistent obstruction to the breathing through the nose that obstruction should be removed. The operation for the removal of adenoids is a simple one, involving little, if any, danger to life. In many cases it may be done without giving an anaesthetic. ENLARGED TONSILS Adenoids and enlarged tonsils frequently go to- gether. Many children, however, who have en- larged tonsils have no symptoms as a result. Moderately large tonsils causing no symptoms: sore throat, fever, or large glands at the angle of the jaw, do not require removal. It were well, however, if such children could be taught to gargle the throat daily, at bedtime, and at the same time brush their teeth with some simple alkaline solution, such as Seiler's Solution. 1 By this means particles of food would be prevented from collecting in the crypts of the tonsils, thereby producing more or less inflammation. Tonsils, however, which are enlarged and often inflamed, frequently contain pockets of pus which poisons the system and may, and often does, pro- 1 Seiler's Tablets, under the name of Alkaline and Anti- septic Tablets, can be purchased at any drug store. MISCELLANEOUS 157 duce serious complications, such as rheumatism and heart affections. Such tonsils should be removed as soon as possible after an attack. ENLARGED GLANDS Some children suffer at an early age from en- larged glands in the neck. These glands, varying in size from that of a pea to a hazel nut, may form a chain extending from the mastoid process to the clavicle (collar bone) ; or the glands at the angle of the jaw, on one or both sides, only may be en- larged. Formerly children with enlarged glands were said to be " strumous," and it was thought that prac- tically all enlarged glands were of tubercular origin. It is true that children of certain families are particularly prone to enlargement of the glands, but most of them are not tubercular. Many enlarged glands in the neck come as a direct result of infections from the throat. Children with enlarged tonsils and adenoids are very liable to have enlarged glands of the neck as a result of direct infection from these organs. After possible sources of infection from the throat have been re- moved the general nutrition of the child should be in every way improved. Sudden enlargement of the glands in the neck should always be followed by a careful examination 158 INFANCY AND CHILDHOOD of the throat, in order that some serious infection, such as diphtheria, may not be overlooked. RHEUMATISM Inflammatory rheumatism is now believed to re- sult from an infection. The source of the infection may be unknown, but in many cases it is undoubt- edly from the throat and nose. Abscess of the ton- sils is a more frequent source of rheumatism than was formerly supposed. It does not, however, fol- low that every tonsil which is larger than normal should be removed. Children with inflammatory rheumatism are prone to suffer from some involvement of the heart, particularly of the valves and the serous covering (pericardium). Children who have any inflamma- tory involvement of the joints should remain in bed longer than may seem necessary, because of the possible heart involvement. Children with inflam- matory rheumatism should always be under the care of a physician and long after they are apparently well they should be taken occasionally for examina- tion. CHOREA (ST. VITUS' DANCE) This affection is not uncommon in children as they approach the age of puberty (maturity). The symptoms consist in involuntary movements of the voluntary muscles. In some cases these movements MISCELLANEOUS 159 are so exaggerated as to absolutely incapacitate the child from walking or even from feeding itself. The bladder and bowel are rarely involved. This condition is sometimes attended by slight fever and not infrequently by pains in or about the joints. The frequency with which there is an involvement of the heart similar to that in rheumatism, has led many to believe that the diseases have a common origin. Children with chorea should always be un- der the care of a physician. Absolute rest and nutritious food are the two important factors in the treatment of this affection. EARACHE Earache usually occurs as a result of an infection of the middle ear, extending up the eustachian tube from the throat. When the inflammation is mild and there is no accumulation of fluid behind the drum, much relief may be gotten from dropping into the ear a solution of 2 per cent, carbolic acid in glycerine. If pain and temperature are persistent a physician should be consulted. Abscess of the middle ear in infants is of common occurrence. GOITER (THICK NECK) Goiter is an enlargement of the thyroid gland. The condition is common in girls at about the time of puberty. 160 INFANCY AND CHILDHOOD Unless the enlargement is progressive and accom- panied by symptoms, such as shortness of breath, rapid heart, or some prominence of the eyes, it may be disregarded. In many cases the enlargement does not progress and even diminishes after adoles- cence is well established. In case there, are any symptoms which might be attributed to the goiter a physician should be consulted. CRETINISM Cretinism is an abnormal condition in infants, produced by a congenital deficiency of the thyroid secretion. The infant may seem perfectly normal at birth, but after a few months it is observed that it does not develop properly, although the food is adequate. The mental condition remains as undeveloped as the physical. The skin is dry and not infrequently covered by an abnormal amount of hair. The point of the tongue in many cases remains almost constantly between the lips. The long bones are all shorter than normal and the fingers present a stubby appearance. The treatment of this disease consists in supply- ing the necessary amount of thyroid extract, which is obtained from the thyroid gland of the sheep. If given in proper amounts, early and persistently, MISCELLANEOUS 161 these children frequently develop almost normally. The treatment should always be given under the supervision of a physician, as it is quite possible to get marked and even dangerous symptoms from overdosing with Thyroid Extract. The administration of Thyroid Extract should be continued indefinitely, sometimes for life. RICKETS Rickets is a disease of nutrition produced usually by improper food. Artificially fed infants are par- ticularly prone to the disease, and especially those fed upon the patent foods, which are low in fat and proteid. Frequently the first symptom is sweating about the head. It will be noticed that after the baby awakens from sleep the pillow is wet with perspira- tion. It is restless, sleeps badly, and cries when lifted, as if from* pain. Not infrequently after a child has begun to walk it suddenly stops and makes no further effort in that direction, but sits, moving its legs, if at all, reluctantly. The most marked changes are in the bones, which are markedly lack- ing in lime salts. The bones, during rickets are particularly prone to deformity. The most obvious changes occur at the ends of the long bones, where growth is most active. This is most apparent at the wrists and at the junction of the ribs with the 162 INFANCY AND CHILDHOOD sternum. Bowlegs are common in children who have rickets, and particularly if allowed to walk while the bones are soft. The square shape of the head is another charac- teristic symptom of rickets and delayed closure of the large fontanel is the rule. Children who have proper food and are well nourished will rarely develop rickets. Infants should receive breast milk, and after eight to nine months should have some additional food, such as beef juice, orange juice, and a little toast or other starchy food well cooked. Children who are forced to have artificial food should have properly modified cow's milk, with the addition, after five or six months, of beef juice, orange juice, and if they do not tolerate cream well, some cod liver oil or olive oil (one-half to one teaspoon three times daily). With the first evidence of rickets a physician should be consulted. Deformities are much more easily prevented than corrected. SCURVY Scurvy is a disease of nutrition due usually to the long continued use of some patent food or to milk which has been sterilized too long (boiled from twenty to thirty minutes). It practically never oc- curs in breast-fed infants. MISCELLANEOUS 163 The symptoms are at first indefinite. The infant is pale, easily tired, sleeps badly, and frequently cries if the legs and arms are handled. Later there is bleeding into the gums around the teeth and there is often free bleeding if the gums are touched. There are frequently hemorrhages along the bones of the legs and arms, which often manifest themselves on the skin in the form of black and blue spots. Prevention. Breast-fed children practically never have scurvy. Children on sterilized foods should always have in addition, some uncooked fruit juice (orange juice). No other medication is necessary. HIVES. URTICARIA. NETTLE RASH Urticaria is characterized by an eruption on the skin consisting of circular or spiral elevations (wheels) scattered over various portions of the body. The color of the spots is usually a reddish pink, frequently with a white center. The size varies from one-eighth to several inches in diam- eter. Urticaria is frequently accompanied by gastro- intestinal disturbance and some rise in tempera- ture. Certain articles of diet, such as strawberries, eggs, shell fish, etc., frequently produce the eruption in i"64 INFANCY AND CHILDHOOD susceptible individuals. Such individuals are said to have an idiosyncrasy to these particular foods. The skin is usually intensely itchy and whenever scratched becomes red and slightly raised above the surface. Treatment. The intestinal canal should be emptied by a dose of castor oil and the suspected food eliminated from the diet. In relieving the intense itching sponging with a solution of soda is sometimes effective. It will, however, frequently be necessary to resort to some simple sedative, such as asafetida, until the toxic substance has been eliminated from the system. EXUDATIVE DIATHESIS. MILK CRUSTS. ECZEMA A considerable number of infants within the first few months after birth have a scaly condition of the scalp which to the ordinary observer resembles dirt. It is, however, an exudate, and when it is removed the skin underneath is inflamed. The more the sur- face is irritated by rubbing or scratching, the more serum is exuded and soon crusts are formed. Fre- quently pus forms under the crusts and the whole scalp rapidly becomes involved, and not infre- quently the face, hands, and in fact any part of the body. It is a mistaken idea that the breast milk is re- sponsible for the condition. The disease is inher- MISCELLANEOUS 165 ited, but is much exaggerated by overfeeding, especially with fat. These cases should be kept on the breast, but not overfed. If they do badly on the breast they usually do worse on any other food. In bathing these children soap should be used as little as possible. The hands should be restrained so that the infant cannot scratch the skin, which is always intensely itchy; otherwise no treatment will have any effect. 1 If the condition does not respond to simple reme- dies a physician should be consulted. The treat- ment must combine proper feeding with local ap- plications to the skin. A simple eczema may result from irritants, such as soap, without any constitutional cause. SPRU. THRUSH. STOMATITIS Spru, or Thrush, is an infection of the mucous membrane of the mouth, characterized by the ap- pearance of small white flecks which may be limited to the inside of the lips and cheeks, but not infre- quently also involves the tongue and roof of the mouth. Forcibly swabbing the mouth, or the continuous 1 See article by the author, " Exudative Diathesis in its Relation to Infants." St. Paul Medical Journal, October, 191 0. 166 INFANCY AND CHILDHOOD sucking on a rubber nipple or pacifier, may predis- pose to this condition. A more severe form of infection, known as stomatitis, in which ulcers of the mucous membrane occur, is also common. Treatment. Remove all mechanical irrita- tion. It may be necessary to feed the infant from a spoon until the spots disappear. The mouth should be washed with a boric acid or boroglyceride solution after each feeding. If ulcers are present it may be necessary to have them cauterized. If the food is at fault it should be properly modified. SUMMER DIARRHOEA During the hot summer months many infants suffer from digestive disturbances of varying de- grees of severity. These attacks may be nothing more than a slight diarrhoea accompanied perhaps by vomiting and fever, or they may be so severe as to endanger the child's life. The death rate in infants during the hot weather is greatly increased, particularly in large cities. The most common causes of disturbances of the digestive tract during hot weather are : 1. Artificial feeding. 2. Overfeeding. 3. Impure milk. 4. Too much clothing. MISCELLANEOUS 167 The death rate in artificially fed children is 8-10 times as great as in children fed at the breast. The amount of food required for the body needs during the hot weather is much less than during cool weather. Dliring hot weather the chance for milk to un- dergo putrefactive changes is much greater than during cool weather. During hot weather infants should be dressed so that they are comfortable. The heavy woolen clothes should be removed, as infants do not stand extreme heat any better than they do extreme cold. When an infant begins to have any digestive dis- turbance, stop all food at once, and for twelve or twenty-four hours give only boiled water or a little barley, rice or oatmeal water. The bowels should be emptied by one or two teaspoonfuls of castor oil or other effective laxative, and the dose not re- peated. For several days following the food should be greatly restricted. The cream should be re- moved from the milk and only boiled skimmed milk given. If the stools are sour and green, all sugar should be left out and the food sweetened if neces- sary with saccharine (one tablet to pint of food). If the symptoms do not promptly subside a phy- sician should be consulted. Serious digestive disturbances attended by fever, 168 INFANCY AND CHILDHOOD vomiting and diarrhoea and great prostration are never due to teething. VACCINATION The only means of modifying or preventing smallpox is by means of vaccination. When vaccination is carefully done, the vaccine pure, and the wound kept clean and covered until healed, serious results almost never occur. The area to be vaccinated should first be washed with alcohol or soap and water and then dried. After the skin has been scratched and the vaccine applied, the wound should be covered with a shield or sterile gauze. When the vaccination begins to " take " the dressing should be removed daily and the whole area, including the vesicle, washed with alcohol and the dressing reapplied. When serious infections occur it is always due to carelessness. When vaccination has " taken " it is usually not necessary to repeat the process within seven years. Usually the second vaccination will " take lightly " if the first "took well." If infants with eczema are vaccinated the greatest care must be taken to prevent them from scratching " the vaccination " ; otherwise it may be spread over the entire body, with fatal results. No child is too young to acquire smallpox, but MISCELLANEOUS 169 since exposure may occur at any time infants should be vaccinated during the first year. KISSING Such diseases as diphtheria, syphilis, tuberculosis, etc., may be readily transmitted by kissing. Indiscriminate kissing should never be permitted, and when practiced the child should be kissed upon the cheek or forehead — never on the mouth. HABITS Infants as well as adults are creatures of habit. After habits have become fixed they are difficult to break. Since it is universally agreed that " an ounce of prevention is worth a pound of cure," in- fants should be allowed to form only good habits. There are certain bad habits to which infants and children are addicted, the most important of which are thumb-sucking, bed-wetting, dirt-eating, facial movements, masturbation. These symptoms may have for their cause some diseased condition, and if not promptly righted by simple means, a physician should be consulted. THUMB SUCKING The habit of thumb or finger sucking is of course a natural one, but it becomes a vice when persisted 170 INFANCY AND CHILDHOOD in. As a result, the mouth is frequently the seat of irritation or other catarrhal inflammations, the fingers or thumbs are deformed, and the front upper teeth are not infrequently displaced. If the habit has not been allowed to persist for long it is not difficult of correction. To prevent the infant from sucking its thumbs or fingers the arms may be pinned to the sides, or cardboard splints applied at the elbow, allowing free movement but not permitting the hand to reach the mouth. The Pacifier. The pacifier habit is a vicious one and should never be permitted. The mucous membrane is constantly irritated by contact with the rubber. It is a frequent source of infection, as it is usually dirty. The glands of the mouth are stimu- lated so that there is a constant flow of saliva, with more or less digestive disturbance. The best way to correct the habit is not to begin it, and if al- ready formed, it should be stopped, even at the ex- pense of considerable loss of sleep on the part of the infant and the household generally. FACIAL MOVEMENTS The different facial movements, such as blinking, drawing up the upper lip, sniffling, jerking the head, etc., have frequently some local irritation which is responsible for their beginning. Blinking is usually MISCELLANEOUS 171 caused by some irritation in the eyes or spas- mophilia ; drawing up of the lip, to some irritation in the nose. These habits should never be allowed to become fixed. The cause should be at once sought and re- moved. BED WETTING Bed wetting in older children is sometimes a habit, but more often a weakness for which the child cannot in any way be held responsible. When one can be sure that the cause is simply indifference, punishment may be efficacious ; other- wise it does more harm than good. When the trouble occurs only during sleep the child should have plenty of fluid during the earlier part of the day and the fluids restricted greatly from four o'clock on. The child should be taken up (actually awakened) at ten o'clock and again in the early morning, if necessary. The hours at which it is awakened should always be the same. An im- proper diet (too many sweets) is a frequent cause of bed wetting, by producing irritation in the blad- der and urethra from a concentrated urine. In- fection of the bladder due to the colon bacillus is a common cause of incontinence, especially in girls. In such cases a careful microscopic examination of the urine should always be made. Suspected ab- 172 INFANCY AND CHILDHOOD normalities of the genital and urinary tract, as possible causes, should always be referred to the physician for diagnosis and treatment. MASTURBATION This is a habit which is rather common to both sexes. It consists of irritating the genital organs with the hands, the clothing, or not infrequently by rubbing the thighs together. Infants less than a year old acquire the habit, so that " peculiar move- ments," which are often passed by the nurse as " smart," should be carefully scrutinized. Any abnormal irritation about the genitals, lack of cleanliness, tight foreskin in boys, may be ex- citing causes. In older children the habit is frequently acquired from others who practice it. Young children should never be allowed to play together, or alone, without being observed. As soon as old enough to understand, children should be taught not to handle the genital organs, and given the reason why. In intelligent older children the habit is usually not difficult to break. Older children are not feeble-minded because they masturbate, but they may persistently mastur- bate because they are feeble-minded. In young infants it is necessary often to restrain MISCELLANEOUS 173 the hands by 1r>' i r % them to the sides of the crib. or. if the irritation is produced by rubbing the thighs together, this may be overcome by any device v/hich will keep the legs apart Children should be ob- ved until they go to sleep and after they awaken. ve plaything should always be at hand. Chil- dren will play with something, and if there is noth- ing else at hand they are apt to play with their own organs. THE PROPER USE OF THE EYES That the eyes shall perform their proper function life, their care during infancy and ch: hood is of the greatest importance In yv children the long continued use of the e any one time should be avoided. So much depe upon the muscular control that over-taxing of the eye muscles should be avoided. The holding of picture books at improper angles an important cause of muscular strain. The reading of books while the child is lying down al- tys results in their being held at an improper angle, and should therefore be forbidden. The proper lighting of the play-room is of the greatest importance. Artificial light should be avoided whenever f It is. howev e r, much better to have artificial light, properly placed., than insufficient sunlight. 174 INFANCY AND CHILDHOOD The windows in the play or schoolroom should be so arranged that the light comes in from behind or from above. Blackboards and charts should al- ways be arranged so as to be properly lighted, with- out having the light shine directly in the child's eyes. Any inflammation of the eyes should be reported to the physician if it does not promptly clear up, by the application of a simple wash, such as boric acid solution. ERRORS OF REFRACTION (DEFECTIVE VISION) Many children have defective vision from birth. These errors may be of various kinds and may to the ordinary observer be difficult or impossible of de- tection. The most common defects are the fol- lowing : Improper muscle control. Near sightedness. Far sightedness. Astigmatism. These errors are frequently not manifested by marked symptoms until a child reaches the school age, when inflammation of the eye-lids, headache, or other nervous symptoms should lead the parent to have the child's eyes examined by a competent ocu- list. The author has seen children so near sighted that MISCELLANEOUS 175 they were thought to be defective mentally. A pair of properly adjusted glasses was all that was needed to restore them to the normal. MALNUTRITION. MARASMUS. SIMPLE ATROPHY Not infrequently infants who have been badly fed, particularly upon artificial food, develop a con- dition known to the laity as " marasmus." It often happens that the child is normal at birth and for a time, while on the breast, gains in weight. Owing to the advice of some well meaning but illy informed person, the baby is weaned and put on an artificial food. From this time on, the baby begins to go down hill. All kinds of foods are tried, with the same result. These infants, after a time, look like little old men and women. The face is pinched and wrinkled and the skin, which is pale and dry, hangs in folds on the extremities. The abdomen is usually distended. The stools are large and ill smelling. If there is no disease such as tuberculosis or syphilis in the background, these cases may entirely recover. The recovery will usually be slow, as a consider- able time must elapse before the normal power of digestion and assimilation of food can be reestab- lished. 176 INFANCY AND CHILDHOOD Breast milk in these cases is of the greatest im- portance. If a wet nurse cannot be secured some breast milk should be procured and given the infant, combined with a properly modified diet adapted to its needs. These infants are particularly prone to infections of the skin, which appear in the form of boils. These should be opened at the proper time; other- wise they are liable to produce serious general in- fection. In addition to the food, fresh air and massage are valuable adjuncts in the treatment of these cases. DELICATE CHILDREN Not infrequently we meet children who have no particular disease but who are not well, and may be described as " delicate." Such a condition may be the result of bad inheritance or of a serious illness. More often, however, the condition is a direct result of bad feeding. A searching examination should be made in order to eliminate a possible tuberculosis in these cases. These children are prone to sit about and mope, take little exercise, and eat little at meals, with the exception of highly seasoned things and sweets. They should be kept in the open air much of the time and should have regular exercises, including deep breathing. The food should be of the plain- MISCELLANEOUS 177 est character. Eating between meals should be for- bidden and sweets should be practically eliminated. They should not be crowded at school, but should have regular duties to perform at home. A rest of an hour or so during the middle of the day should be insisted upon. This should come Simple Screened Bed for Out-Door Sleeping preferably after the noon day meal, which should be the hearty meal of the day. Change of climate, particularly sea or mountain air, will sometimes do much to start these children on the road to recovery. PUBERTY Puberty is the transition period between childhood iand adult life. i;8 INFANCY AND CHILDHOOD In girls there is usually a greatly increased growth both in weight and height, while in boys the gain both in weight and height is somewhat slower. After this period is passed the boys again forge ahead of the girls in both height and weight. The following evidences of the approach of pu- berty will be observed : In boys, a change of voice, beginning development of the beard, and a growth of hair under the arms and around the genitals. In girls, a rapid gain in weight and height, de- velopment of the breasts, growth of hair under the arms and around the genitals, and the beginning of menstruation (12 to 14 years). In warm climates and among southern races the age of puberty is rather earlier than in cold ones. During this period the nervous system in both sexes is prone to be unstable, so that the general health of children should be maintained at the high- est point. Many children are prone to sit around and read sentimental stories when they should be exercising in the open air. Irregularity of menstruation in young girls is fre- quently due to faulty conditions of living ( food, air, and exercise) . The old idea that girls are " sick" because they do not menstruate is putting the cart before the MISCELLANEOUS 179 horse. They do not menstruate usually because they are already sick. A physician should always be consulted when any irregularities, either physical :: mental, develop. There is no time during the chiii's life when w an ounce of prevention " is so applicable as during the age of puberty. CLOTHING FOR OLDER CHILDREN The clothing for :i:er children should be sus- pended from the shoulders, bat not from the points of the shoulders. Properly made waists, with broad shoulder straps which come we'd up :: the base :: the neck, should be worn; upon these the stockings, drawers and tit users are suspended. A light woolen undershirt should be worn, even in the summer. Children are particularly prone to be- come overheated during play, and in the coolirr- off process they rarely use better judgment than do their older brothers and sisters. A woolen shirt D pi event many a cold and rob the doctor of many a fee. Since practically all houses are warm throughout the year, heavy ;i: thirty should never be worn in- doors. 1 : v temperatures out of doors should be met by an adequate amount of outer clothing. 180 INFANCY AND CHILDHOOD TOYS In selecting toys for babies one should always have in mind the fact that everything not too large goes promptly into the mouth. Toys which can be kept clean easily, without de- tachable points or sharp edges, should be chosen. Painted toys should never be purchased. Toys for older children should be selected not only as a means of amusement but also for their educational and disciplinary value. Plenty of wooden blocks of all sizes, from which the simplest to the most complex structures may be erected, are among the best. In addition, figures of people and domestic animals make a combination which gives endless play to the imagination and call forth real constructive ability. The complicated mechanical toys have little real value ; children quickly tire of them and nothing re- mains but the desire to take them apart in order to see what makes them go. For girls, miniature houses with proper furnish- ings and cooking utensils, inhabited by dolls of various sizes, offer a wide and important field. Children should never have many toys at a time, but should be allowed to exhaust the possibilities of one before another is given. Habits acquired during the first five years are the MISCELLANEOUS 181 ones that abide. Children should therefore be re- quired to put their toys away in some convenient but stated place when they are through with them. Their garden tools, as well as wagons, carts, etc., should be put in a shed when the day's work is done. There is no better way of acquiring the habit of orderliness and concentration than by the proper use and care of well chosen toys. The effects of this training will influence the whole char- acter. FOREIGN BODIES When foreign bodies, such as buttons, pennies, etc., have been swallowed there is nothing to be done but watch the stools to see when they come through. This usually requires from three to seven days. Cathartics should never be given. Solid food, such as bread and potato, will often surround the object and lessen the irritation which sharp edges might otherwise produce. When foreign bodies are stuck into the nose or ears an effort may be made to remove them, but un- less great care is taken serious injury to the tissues may result. It is usually better to take the child at once to a physician, and if the object cannot be otherwise located an X-ray picture should be made. 1 82 INFANCY AND CHILDHOOD ENLARGEMENT OF THE BREASTS IN INFANTS (WITCHES MILK) Occasionally new-born infants of both sexes have an enlargement of the breasts, with the secretion of a fluid resembling milk. The condition is a harmless one and soon becomes normal if left alone. Massage and manipulation only do harm and may, if persisted in, produce a rather severe local inflammation. CARE OF WOUNDS Any wound, no matter how simple, may be fol- lowed by infection. That this does not usually occur is because most germs are not disease-produc- ing and also because nature makes a strong re- sistance to all forms of infection. It is important that every abrasion or cut be thoroughly cleansed. This can best be done with normal salt solution (one level teaspoon common salt to pint of boiled water). After the wound is clean it should be covered with sterilized gauze until healed. Freshly ironed clean linen is practically sterile. The most dangerous simple wounds are what are known as punctured wounds. Such wounds are frequently received by children stepping on a nail. These wounds are not infrequently followed by tetanus (lock-jaw). The reason for this is that the MISCELLANEOUS 183 tetanus bacillus is frequently found in garden earth and horse manure. A wound received from step- ping on a nail introduces the tetanus bacillus and when the nail is withdrawn the wound immediately closes, producing ideal conditions for the growth of the bacillus. A child receiving such a wound should be taken at once to a physician and the wound should be thor- oughly washed out and cauterized. Wounds received from toy pistols are also fol- lowed frequently by tetanus because the " wads " in the cartridge are made from waste paper picked from the streets and frequently contain tetanus bacilli. If there is any probability that these wounds have not been thoroughly cleansed an in- jection of " tetanus anti-toxin " should be given at once. This serum is useless if given after the dis- ease has developed. Hemorrhage from wounds may usually be con- trolled temporarily by the application of pressure, or if on the extremities by a tight bandage or tourniquet above the wound. MILK, FOR TRAVELING For artificially fed infants the preparation of the milk for a railway journey of several days is not nearly so difficult as is generally supposed. For the first twenty- four hours of the journey the milk may 184 INFANCY AND CHILDHOOD be prepared as usual, the bottles being kept in the icebox in the dining car and warmed when needed. Milk for the remainder of the journey should be thoroughly sterilized by boiling for twenty minutes. The same principle may be applied as in canning fruits. The jars are thoroughly sterilized, includ- ing the covers, and then sealed while the milk is still at boiling heat. These should be kept on ice and opened only as required. It is better to use small bottles, each holding only enough for a couple of feedings. When people can afford the luxury of trained at- tendants a small ice box containing the food may be taken along. The necessary ice may readily be procured on the train. At certain cities it is pos- sible to arrange for a fresh supply of milk from the so-called milk laboratories. When for some reason it is impractical to carry the necessary quantity of milk for a long journey, it is usually quite safe to give condensed milk. It is always safe, however, to give an occasional feeding of the food, beginning several days before starting, in order to determine whether the infant has an intolerance of that particular food. As soon as practicable the proper feedings should be resumed. All water given the infant on the journey should be boiled. MISCELLANEOUS 185 Table Showing the Percentage of Albumen, Fat, and Carbohydrate, with the Food Value in Calories in One Ounce of the Following Articles of Diet (Seifert & Muller). Albumen Fat Carbohy- Value drate in Per cent. Per cent. Per cent. Calories Mother's milk 1-1^2 Cow's milk 2-3 White flour 11.0 Butter or other fat 1.0 Raw lean beefsteak 22 Raw fat beef 17 Raw veal steak 15 Fried veal steak 28 Roast pork 28 Boiled ham 24 Fried bacon 9 Baked chicken with stuffing 32 Shell-fish 24 One egg (iy 2 oz.) 6.5 Cream (thick) .. . 3.5 Cheese (Swiss) 27.2 White bread 8.1 Baked or boiled potato .. 1.8 Dried peas 22.5 Rice (dried) 7.5 Meat soup o Vegetable puree 3 DIETARY Albumen Water. Stir whites of two eggs into one pint of cold water. (Do not beat.) Add pinch of salt. This food may be used in certain digestive disturbances for a short time instead of milk. 3-4 6-7 23 3-4 4 23 i.3 74.2 120 S3 260 5.2 — 28 28 — 108 1-3 — - 24 1.3 — 43 10 — 69 36 — 146 76 — 249 4.5 2.1 60 0.5 — 34 4.9 — 76 25.5 3.5 87 30.4 2.5 135 — 62.5 97 0.2 20.5 31 1.8 52.5 108 — 78.1 117 0.8 — 7.5 6.5 20.5 53 1 86 INFANCY AND CHILDHOOD Barley Water. 2 Tablespoons pearl barley, i Quart cold water, Bring to a boil, simmer one hour. Add sufficient water to make one quart. Strain through a cheese- cloth. To make barley, oatmeal, rice, or arrowroot gruel, the same rule may be followed as for barley water, substituting the flour for the grain. Lime Water. i teaspoon slack lime, i quart boiled or distilled water. Stir thoroughly several times. Then allow lime to settle. The upper clear fluid is then ready for use. Beef Juice. Broil a piece of lean beef slightly ; press out the juice by means of a lemon squeezer or meat press. One pound of steak will yield from 2 to 3 ounces of juice. To make Beef Juice by the cold process, take one pound of round steak, chopped fine, six ounces of water, pinch of salt. Place in a covered jar and put in a cool place for five or six hours. Then squeeze out the juice. Mutton Broth. I pound chopped lean mutton with bone, i pint cold water, Pinch of salt. Simmer for three hours, until half a pint remains, MISCELLANEOUS 187 adding water if necessary. Strain through a mus- lin and when cool remove the fat. Peptonized Milk. In a clean quart bottle put the powder contained in one Fairchild's peptonizing tubes, and ad t d one-half pint cold water and a pint fresh milk. Shake the mixture thoroughly. Place the bottle in water at 1 15 F. and keep there for ten to fifteen minutes, then place on ice to prevent fur- ther digestion of milk. Milk which has been well peptonized will have a bitter taste. When it is desired to absolutely stop the action of the peptonizing powder the milk should be brought quickly to the boiling point for a minute or two, after the temperature has remained at blood heat for ten to fifteen minutes. Cocoa. Make a paste of one teaspoon each of cocoa and sugar and a little milk or water. Add to one cup of milk or water and boil three to five minutes. Orangeade with White of Egg. Juice of one orange, White of one egg f 8 oz. cold water, y 2 teaspoon sugar. Mix thoroughly without heating. If desired the whole egg may be used. Scraped Beef and Mutton. Take a tender piece of beef or mutton, broil slightly and scrape 188 INFANCY AND CHILDHOOD with a sharp knife. Add a pinch of salt. From one-half to one tablespoon with other food may be given to a child of from eighteen months to two years. Coddled Egg (Soft boiled without boiling). Place one fresh egg in boiling water, cover, let stand at the back of the stove 8-10 minutes. The white of the egg should be of a jelly-like consist- ency. Milk Toast. To one cup of milk add one-half teaspoon cornstarch, one-half teaspoon butter, rubbed together ; let come to boil. Pour over toast, and serve after it has stood long enough for toast to become soft. Junket or Curds and Whey. Take one pint of fresh cow's milk, a pinch of salt, one tablespoon of sugar. Add one ounce Fairchild's Essence of Pep- sin, Liquid Rennet or one Junket Tablet dissolved in water. Stir well. Raise to body temperature for twenty minutes, or until firmly coagulated. Place on ice until cold. This may be flavored ac- cording to taste. Custard Pudding. Break one egg into custard cup, add a little sugar and mix well. Fill the cup with milk. Place in a shallow sauce-pan half pint of water and bake and boil ten minutes. Other recipes required may be found in any good cook-book. INDEX Additional food, 69. Adenoids, in new-born, 8, 155. Adhesive straps, for hernia, 41; removal of, 41. Adrenalin ointment, 126. Air, cold and fresh, 54. Air passages, taking cold in, 125. Airing out of doors, 54. Albumen water, 185. Antitoxin for diphtheria, 134, 135, 136. Anus, fissures of, 109. Apple sauce, 119. Appliances for teaching walk- ing, 23. Argyrol, in eyes, 46. Artificial feeding, 72. Astigmatism, 174. Atrophy, simple, 175. Automobiles for children, 122, 123. B Bacteria in intestines, 12. Barley gruel, 90, 186. Barley water, 186. Basket, 39; illustration of, frontispiece. Bathing, 42; temperature of bath, 42 ; tub bath and cold baths, 42; warm bath, for convulsions, 151 ; bath tub, folding, 42. Bed-wetting, 171. Beef juice, 86, 186. Beef scraped, 187. 189 Benzoin, tincture, in croup and bronchitis, 128, 129. Bichloride of mercury, 148. Bile in urine, no. Binders, flannel abdominal, 49- Bladder infections, 51. See also Urine, no. Blankets, list of clothing, 48, 49. Bleeding from the cord, 39. Bleeding, from stomach, bow- els and urinary tract, 150. Bleeding of the new-born, 150. Blindness, gonorrhea as cause of, 45, 46. Blood, 1, 6; circulation of, 6; Wassermann test, 146; in- jection of blood serum, 150. Blood vessels, 6. Blue baby, 6. Bone, 1, 2; bone cells, 1. Boric acid in eyes, 46. Bottles, cleansing of, 75, 76; kind of, 103; bottles and nipples, 77y 95, 96. Bowel, large and small, 1, n, 12. Brain, 1, 3 ; growth of, 8. Bran and whole wheat flour, laxative properties, 90. Breasts, enlargement of in in- fants, 182. Breast feeding, advantages of, 60, 61 ; position in, 61 ; mor- tality in, 60; diseases dis- qualifying the mother from nursing, 60; table of quan- tity, 64; quantity at a feed- ing determined by weighing 190 INDEX before and after nursing, 64, 65, 68. Breast pump, 65. Breathing, muscles in, 2, 7; chest breathing, 7; abdomi- nal, 7; character of, 7; rhythm of, 7 ; frequency of, 8; nose and mouth breath- ing, 8; due to adenoids, 127, 155. Breck feeder, 58. Bronchitis, 127. Brown flour in buttermilk formula, 94. Bulb syringe, 108. Buttermilk, in fat intolerance, 88, 93; preparation and use of, 94; in diarrhoea, 93. Button for hernia, 40, 41. Caloric values of foods, 79, 80, 185; of cow's milk, 83; of simple articles of food, 120. Calories, definition of, 78, 79. Carbon dioxide, 7. Carrots, 115, 119, 121. Cartilage, 1. Catheter, soft and bulb syringe, 108. Character, development of, 28, 36. Chest, 2; chest wall, 2; de- formed chest and hollow chest, 123, 124. Chest wall, 2. Chicken pox, 141. Chorea, or St. Vitus' dance, 158. Clothing, in hot weather, 4.8; for young infants, 47; list of , 48 ; tight clothing effects of, 50; for older children, 179. Circulation of blood, 6. Circumcision, 45 ; stretching of foreskin, 45. Cocoa, 187. Coddled tgg f 188. Coffee, 119. Cold air and fresh air, 54; in pneumonia, 131. Cold in head, coryza or snif- fles, 125. Colic, 114; soothing syrups in, 114. Concentration of mind, 28 to 34. Colostrum, 62. Condensed milk, 91. Constipation, causes and treatment of, 106; graham bread for, 107. Contagious diseases, list of, 132. Convulsions, 151. Cord, umbilical, tying of, 39; bleeding from, 39; care of, 39- Cough syrups, 129. Cow's milk, percentage com- position of, 78; clean, 73; certified milk, 74. Cows, tuberculin tested, 73; sanitary conditions of, ^z\ breeds of, 75. Crackers, graham, 119. Cranium, 2. Cream, gravity and centri- fuge, 79; cream dipper, 80; tolerance and intolerance of, 81. Cream of wheat, 118. Crisis in pneumonia, 130. Croup, spasmodic, 126; mem- branous, 126, 134; catar- rhal, inflammation of re- spiratory tract, 125. Crying, influence of on rup- ture, 41. Curds and whey, 188. Curvature of the spine, 4, 161 ; posture as cause of, 124. Custard, 116, 119; pudding, 88. INDEX 191 Curds, large cheesy, 81 ; small white, 87; condensed milk, cane sugar content, 91 ; casein milk, 95. D Dairies, sanitary and unsan- itary, 73. Deafness, directly after birth, due to adenoids, 155. Deformities, due to posture, 4, 124; to rickets, 161, 162. Delicate children, 176. Dentition, time for and symptoms from, 99. Dessert, 119. Development and growth, 13 ; mental, 23 ; moral, 26 ; de- layed rickets as cause of, 23. Diapers, 49; soiled, 51; char- acter of, 51. Diaphragm, in breathing, 7. Diarrhoea, buttermilk in, 93 ; summer diarrhoea, causes and treatment of, 166. Diet, for children from 1 to 2 years, 115; second to fifth year, 116, 121. Diet, for mothers, 67; for wet nurse, 71 ; in vomiting, 113. Dietary, 185. Digestive tract and digestion, 9, 10; disturbances of, dur- ing hot weather, 48. Diphtheria, chapter on, 134; intubation in, 138; heart condition in, 137; antitoxin in, 135 ; laryngeal croup, 137. Discipline, 28 to 36; in eating, 117; drinking between meals, 118. Disinfection and fumigation, 148. Ear, middle ear infection, 131 ; deafness in new-born, 24; earache, 159; abscess of middle ear, 159. Eczema, due to over-feeding, in; chapter on, 164. Education, beginning of, 28; list of books on education, 28. Eggs in diet, 115 to 119; cod- dled egg, 188. Enlarged glands, 157. Enlarged tonsils, 156. Eruption, smallpox, 141 ; chicken pox, 141 ; syphilis, 146 ; exudative diathesis (eczema), 164. Erysipelas, 144. Eyes, movements of, 9, 24; tears, 9; winking of, 9; eyelids, 9; proper use of, J3 ; care of in new-born, 45 ; gonorrheal infection of, 45, 46, 145 ; defective vision, 174 ; squint, 25 ; de- velopment of sight, 24; pu- pils, 24; in measles, 140. Exercise, for babies, 50; ef- fects of, 56; effects on sleep, 56; chapter on, for infants, 121 ; exercises for older children, 53, 56, 123. Facial movements, 170. Far-sightedness, 174. Fat, tolerance of, 81. Feeder, Breck, 58. Feeding, Artificial, 72-98 ; cow's milk best substitute for mother's milk, J2 ; sub- stitutes for fresh milk, 91 ; arguments against proprie- tary foods, 91, 92; compari- son of cow's milk with mother's milk, 78; percent- 192 INDEX age feeding, 78; quantity at meal, 82 ; milk formulae, 82 ; chart comparing mother's, cow's, malted, condensed milk, 83 ; at the end of the first week, 83 ; after two or three weeks, 84; third to sixth month, 85 ; sixth to ninth month, 86; from ninth month on, 86; sched- ule for first year, 87 ; sugar, 89; use of gruels in dilu- tion of milk, 90; special preparations of milk, 92-95 ; bottles and nipples, 95. Feeding, Breast, 60-71 ; ad- vantages of, 61, 62; proper position for, 61 ; first few days of, 61 ; first few weeks of, 61 ; number of feedings 63 ; hours for feeding, 66 frequent feedings, 63 quantity at a feeding, 64 chart of quantity of milk needed for average breast- fed infant during first year, 64; mixed feeding, 69; over-feeding and under- feeding, 65 ; wet nurse, 58, 70. Fever, see Temperature, Fireplace in nursery, 52. Fissures in nipples, 68; in anus, 108. Flour, browned, 89; by weight and measure, 84. Fontanels, large and small, 3 ; time of closure, 3. Illustra- tion, 43. Food, how to tell when agree- ing, 89; for older children from one to two years, 115 ; after two years, 116-119; caloric value, 120. Foreign bodies, swallowed or in nose, 181. Formaldehyde, 148. Formalin candles, 149. Fresh air in nursery, 52, 54; bronchitis, 127. Fruit juice in scurvy, 92. Fumigation and disinfection, 148. Gas in stomach and bowels, 112. Gastric secretion, 10; gastric juice, 10. Gelatine, treatment of bleed- ing of new-born, 150. Genital organs, care of skin around the, 43 ; care of male and female, 44; cir- cumcision, 45 ; infection with gonorrhea, 145. German measles, 141. Glands, in scarlet fever, 139; enlarged, 157; parotid, en- largement of, 142. Glasses, adjustment of, 175. Glycerine suppositories, 108. Goitre (thick neck), 159. Gonorrhea, chapter on, 145 ; involving eyes and urinary tract, 45, 46. Graduate, pint, 83. Green stools, 65. Grippe, or influenza, 131. Growth and development, 13. Gruels, in dilution of milk, 90; preparation of, 186; graham flour gruel, 90; graham flour for constipa- tion, 108; graham crackers, 119. Gymnasium for older chil- dren, 124. H Habits, 169. Hair, of new-born, 5. Hammock, for the baby, 53. Head, change in shape at birth, 2 ; shape later, 3 ; cir- cumference of, 20. INDEX 193 Hearing, development of, 24. Heart, 2; valves of, 6; heart beat, frequency of, 6. Height, 18. Hemorrhage of the new-born, 150. Heredity, 27, 28. Hernia, 40; crying as cause of, 41 ; treatment of, 41 ; illustration, 41; hernia in the groin, 41. Hip joint disease (see Tuber- culosis), 133, 134- Hives, following antitoxin, 136; chapter on, 163. Hooping cough (whooping cough), 142. Hot water bottles, danger of, 39; in incubator, 59. Hours for nursing, 66. Hunger, 24. Hydrocephalus, 20. Hydrochloric acid, 10. Ice box, yy 9 97; description of, 98. Ice water, 116. Incubator, 57; improvised or home-made, 59. Immunity to disease of breast-fed babies, 61. Indigestion, at beginning of artificial feeding and from over-feeding, y2. Influenza, grippe, 131. Inhaler, for croup and bron- chitis, 128. Inheritance, 27. Injections, for constipation, 109. Instinct, 24. Insufficient milk, 58, 61. Intelligence, 28. Intestines, small and large, 11, 12; digestion in, 11; length of, 11; bacteria in, 11, 12; disturbances of di- gestion due to too much clothing, 48. Involuntary movements, 23. Ipecac, in treatment of spas- modic croup, 127. Jaundice of the new born, 150. Jaws, undeveloped condition of, 2. Junket, curds and whey, 188. K Kidneys, inflammation of, with erysipelas, 144. Kissing, 54, 169. Lactone milk, 93. Lancing the gums, 102. Legislation, Introduction, Length, increase in, 16; table of, 17. Ligaments, 2, 5. Lighting the nursery, 54. Lime salts, 1. Lime water, 186. Loss in weight after birth, 20, 61; from overfeeding, in. Lungs, 2, 7. Lymph, 7. Lysis in broncho-pneumonia, 131. M Malnutrition, due to improp- er food, 91-92, 175. Malt soup, preparation of, 94. Marasmus, 175. Massage, abdominal for con- stipation, 108. Masturbation, 172. Measles, 140 ; German measles, 141. i94 INDEX Measurements of head, chest and height, 17. Meat, carrier of contagion, 74- Mechanical devices for exer- cise and walking, 123. Meconium, 105. Melena neonatorum (bleed- ing of the new-born), 150. Membranous croup.. 135. Membrane in throat, 134. Memory. 29. Mental condition of nursing mother, 64. Mental development, 23, 26- 30; tests, 26. Menstruation of nursing mother, 67. Microcephalia, 3. Milk crust, 164. Milk, mother's milk and cow's milk, composition of, 78; percentages of fat, sugar and proteid, 78; breast feeding, importance of. 60; mental condition of mother as influencing. 64; menstru- ation of mother as influenc- ing, 67 ; secretion of, 61 ; quantity secreted, 64 : mixed feeding, 69 ; clean milk. 73 ; certified, 74; care of, in home, 75 : richness of, 75 ; whole milk, 79; modifica- tion of, 79; formulas, 82-87; quantity at meal or in 24 hours, 86: as carrier of dis- ease, 75 ; milk wagon, 73, 75 ; pasteurization and ster- ilization of, 74-76 : boiling of, 76; advantages over im- proper pasteurization, 76 ; special preparations of, 92 ; peptonized, 92, 187: sour milk, buttermilk. 93, 94; casein, 95 ; whey, 95 ; skimmed. 93 : for traveling, substitutes for, 91 ; con- densed, 91; malted, 94; charts showing contents of mother's milk, cow's milk, condensed milk, malted milk, 83 ; for older children, 117, 118. Milk toast, 188. Mittens, list of clothing, 49. Moral development, home training, 26. Mortality of infants, Intro- duction. Motion, freedom of, 50. Mother, nursing, mental con- dition of, 64; overfeeding of, 67, Mouth breathing, 127, 155 ; adenoids as cause of cough, 128. Mouth, care of, 46, 47; swab- bing, 46. Movements, 22 ; impulsive and reflexive of head, 22. Mucous membrane, color of, 5,6. Mumps, 142. Muscles, 2; coordination of, 26. Mustard plasters in bron- chitis, 129. Mutton, broth, 186; scraped, 187. N Nasal passage, blockade of, 125. Navel, care of, 40. Nerves, 4; spinal, 4. Nervous mental condition, 26: tests of, 26. Nettle rash, hives, urticaria, 163. New born, care of, 39. Nipples, artificial, care of, 77 ; kinds of, 95-96; picture of, 96. Nipples, fissures of, 68, 69. Nipple shields, 69. Normal infant, 21. INDEX 195 Normal salt solution, 40. Nurse, 37 \ training for, 37. Nursery pen, 55, 122. Nursery, temperature of, 53; general consideration of, 52; lighting of, 54. Nursing Bottles good and bad, 96-97; correct shape, 97. Nursing, technique of, 61, 63; night nursing, 66; hours for, 66; intervals between, 66 ; refusal to nurse, 68. O Oatmeal, 90, 118, 186. Opium in cough syrups, 129; in soothing syrups, 114. Orangeade, 187. Orange juice, with sterilized foods, 92; to prevent and cure scurvy, 92; at meal, 118. Orthopedic surgeon, 124. Overfeeding, 65; of mother, 67; chapter on, in; as cause of colic, 114. Overheated houses, as cause of bronchitis, 127. Oxygenation of blood, 6. Pacifier, 170. Packs in bronchitis, 128. Pancreas, 11. Paralysis, in diphtheria, 137; of the heart, 137. Pasteurization and steriliza- tion of, 74, 96, 97. Pasteurization, improper, 76. 'Pasteurizers and sterilizers, picture and description of, 97- Patent foods, 62, 83, 91 ; cost of, 62. Pepsin and hydrochloric acid, 10. Peptonized milk, 92, 187. Peptonizing tubes, 92. Perambulator, 54. Percentage feeding, 79. Physiology of infant, 1. Pineapple, 119. Pin or thread worms, 153. Pins, 49; safety pins, danger of, 51. Pneumonia, lobar, 130; bron- chial, 130; in measles, 140; in grippe, 131 ; complication in whooping cough, 143. Posture, proper for feeding, 112; as cause for regurgi- tation and vomiting, 112; correct and incorrect in sit- ting, 124. Pregnancy in nursing moth- ers, 68. Premature infants, 57 to 59. Prickly heat, 48. Proprietary foods, 91 ; argu- ments against their use, 92 ; as cause of malnutrition, rickets, and scurvy, 91-92. Prunes, 119. Puberty development, during, 14, 16, 17, 177. Puddings, 119. Pulse in diphtheria, 137. Punishment, 36. Pupils, reaction to light, 24. Pylorospasms, or Stenosis, 112. Pylorus, 10. Q Quantity of food at a meal, 64, 82. Quarantine, 147, 148. Rash, accompanied by sniffles, 125; blotchy, 140; nettle- rash, 163. Recurrent vomiting, 113. 196 INDEX Reflexive movements, 23. Refraction, errors of, 174. Refusing the breasts, 68. Regurgitation, tight clothing as the cause of, 50; over- feeding, in; posture, 112; other causes, 112. Rennet, 10. Respiration, 7. Respiratory tract, diseases of, 125-130. Restlessness during sleep, 56. Rheumatism, 158 ; complica- tion of tonsilitis, 158. Rice, 90, 115, 120. Rickets, shown by slow clo- sure of fontanels, 3; as cause of delayed develop- ment in walking, 23 ; due to proprietary foods, 91-92 ; chapter on, 161. Round worms, 152. Rupture, 40; tight clothing as cause of, 50. (See Hernia.) S Safety pins, 51. Sago, 119. Salivary glands, 10. Salt solution, normal, 40. Salts in milk, 78 ; whey, 95. Scales, 15. Scarlet fever, 138; streptococ- cus, as cause of, 138; en- largement of glands, mid- dle ear, 139; kidneys, 139; scaling, 140. Scraped beef, 187. Scurvy, due to sterilized food, 92; use of fruit juice in, 92. Secretion of milk, 61. Self control, 33. Sense, organs of, 9; special, 24. Shade, 54, 55- Shirts, list of clothing, 48, 49. Sight, development of, 24. Silver nitrate in treatment of eyes, 46. Simon-Binet, test, 26. Simplex vaporizer for croup and bronchitis, 128. Skeleton, 1. Skin, color and character of, 5; care of, around genitals, 43 ; irritation of, 21, 43. Skull, 2; sutures and fonta- nels, 41. Sleep, 55 ; restlessness during, 56. Smallpox, 141. Smell, 24. Soap, influence on skin, 42, 43; kinds of, 43. Soothing syrups, 114. Soup, vegetable, 118. Sour milk, 93. Spasmodic croup, 126. Special senses, instinct, hun- ger, thirst, fatigue, 24. Speech, 25. Spinach, 118, 120. Spinal canal, 4. Spinal column, 4. Spinal cord, 4. Spine, curvature of, 4. Spru, Stomatitis, 165. Squint, 9. Standing and walking, 23, 41. Starch, 90. Steam kettle, 128. Steam tent in laryngeal diph- theria, 129, 138. Sterilization and pasteuriza- tion of milk, 74, 97; illus- tration, 96, 97. Stomach, gastric juice in, 10; position of, 10. Stools, green, 65, S3, 106 ; pale and dry, 108; large curds in, 87 ; small curds in, 87 ; acid and loose, 88; chapter on, 105 ; character in arti- ficially fed, 106; color of due to malt food, 106; con- stipation, 107, 108; foul, in; sources of infection, 134. INDEX 197 Structure of the body, i, St. Vitus' dance, 158. Sucking of ringers, 22. Sucking, organs involved in, 9, 10. Sugar, varieties in feeding, malt, cane and milk, 89; by- weight and measure, 84. Sunshine in the nursery, 52. Suppositories, 108. Sutures, 2. Swabbing of the mouth as cause of spru, 46, 165. Sweets in diet, 117. Syphilis, in premature in- fants, 57; in wet nurse, 71 ; sniffles, as symptoms of, 125; other symptoms, 146; chapter on, 146. Syringe, bulb, 109. Table, folding, for use in nursery, 50. Talcum powder, 49. Talking, 25. Tape worm, 152, 153. Tapioca, 119. Taste, development of, 9, 24. Teeth, development of, 3; temporary, 99; permanent, 100; care of, 102. Teething, time for, 99, 101 ; symptoms from, 101. Temperament, 33. Temperature, of room, 39; of nursery, 53; of body, 56; in pasteurization, 75; of incu- bator, 58. Tests for special senses, 26; mental, 26 ; Simon-Binet system, 26. Thermometer, clinical, 56; in incubator, 59; dairy in pas- teurization of milk, 97. Thermos bottles, yy. Thick neck goitre, 159. Thirst, 29. Thumb-sucking, 169. Thread worms, 154. Thrush, 165. Tight clothing, effects of, 50. Toast, milk, 188. Tongue-tie, 104. Tonsils, enlarged, 156. Toys, 180. Training, home, 26. Transfusion of blood for hemorrhage, 150. Trusses, yarn, 41. Truthfulness, 34. Tub baths, 42. Tuberculin tested cows, y^. Tuberculosis, bacillus, 132; of lungs, 133; glands, 133; bones, 133; hip joint and knee, 134; milk, 133; cows, 133 ; of the mother, 60 ; as reason for not nursing, 60; wet nurse, 71. U Umbilical cord, tying of, 39. Umbilical hernia, 40. Umbilical opening, 41, 49. Under-feeding, 65. Urethra, infections of, 145. Urine, odor of ammonia in, 88; chapter on, no. Urticaria, 163. V Vaccination, for smallpox, 168. Valves, of heart, 6. Vaginal discharges, 44, 145. "Vanta" garments, 51. Vaporizer, simplex, 128. Vegetables, for constipation, 108, 116. Ventilation, 39, 52. Vertebrae, number and shape of, 4. Vision, defective, 174. Vomiting, due to posture, 198 INDEX 112; overfeeding, 85, 112, 113; general causes, 112; before the next meal, 113; recurrent, 113. W Walking, time for, 23; de- layed, as result of rickets, 23 ; appliances in aid of, 23. Wash cloths, 44; as sources of infection, 44. Wassermann reaction, for syphilis, 16; in wet nurse, 7i. Weaning, 70. Wet nurse, for premature ba- bies, 57, 70; diet and exer- cise of, 71. Wetting the bed, 171. Weighing, 16; scales, 15; be- fore and after nursing, 21, 68. Weight, at birth, 13 ; gain in, for first year, 13 ; second to fifth years, 14; loss in, after birth, 20 and 61 ; table of, 17; chart, 19; rapid gain, 81 ; normal gain, 13, 04 ; loss of, due to overfeeding, in. Wheat flour, 90. Whey, 95 ; curds and whey, 188. Whole wheat flour, 90. Whooping cough, 142. Windows in nursery, open, 52. V\ inking, 9. Witches milk, 182. Woolens, 48. Worm powder, 153. Worms, intestinal, 152; tape worm, 152 ; thread or pin worm, 154; round worm, 154. Wounds, care of, 182. X-Ray, in location of foreign bodies, 181. Yarn trusses, 41. u I !,m^ ARY 0F CONGRESS A " ' " " i! mil II mi • I 022 169 364 4