A constant tossing off of the covers at night occurs early in rickets, but, of course, is seen in many healthy infants, especially if they are too warmly covered. A baby shows a desire to be propped up with pillows or to sit erect or to be carried in the mother's arms with its head over her shoulder whenever breathing is much interfered with, as in diphtheria of the larynx and in affections of the heart and lungs. The constant assumption of one position or the keeping of one part of the body still, may indicate paralysis. When, however, a cry attends a forcible change of position, it shows that the child was still because movement caused pain.

Sleeping with the mouth open and the head thrown back often attends chronic enlargement of the tonsils and the presence of adenoid growths in young children, although it may be seen in other affections which make breathing difficult. In inflammation of the brain the head is often drawn far back and held stiffly so. Sometimes, too, in this disease the child lies upon one side with the back arched, the knees drawn up, and the arms crossed over the chest. A constant burying of the face in the pillow or in the mother's lap occurs in severe inflammation of the eyes.

GESTURES

The gestures are often indicative of disease. Babies frequently place the hands near the seat of pain; thus in slight inflammation of the mouth they tend to put the hand in the mouth; in earache to move it to the ear; and in headache to raise it to the head. In headache or in affections of the brain they sometimes pluck at the hair or the ears, although they may often do this when there is no such trouble. Picking at the nose or at the opening of the bowel is seen in irritation of the intestine from worms or oftener from other cause. A child with a painful disease of its chest may sometimes place its hand on its abdomen, or a hungry child try to put its fists into its mouth.

In approaching convulsions the thumbs are often drawn tightly into the palms of the hands and the toes are stiffly bent or straightened. Very young babies, however, tend to do this, although healthy. The alternate doubling up and straightening of the body, with squirming movements, making of fists, kicking, and crying, are indications of colic. This is especially true if the symptoms come on suddenly and disappear as suddenly, perhaps attended by the expulsion of gas from the bowel.

SKIN COLOR

The color of the skin is often altered in disease. It is yellow in jaundice, and is bluish, especially over the face, in congenital heart disease. There is a purplish tint around the eyes and mouth, with a prominence of the veins of the face, in weakly children or in those with disordered digestion. A pale circle around the mouth accompanies nausea. The skin frequently acquires an earthy hue in chronic diarrhea, and is pale in any condition in which the blood is impoverished, as in Bright's disease, rickets, consumption, or any exhausted state. Flushing of the face accompanies fever, but besides this there is often seen a flushing without fever in older children the subjects of chronic disorders of digestion. Sudden flushing or paling is sometimes seen in disease of the brain.

FACIAL EXPRESSION

The expression of the face varies with the disease. In whooping cough and measles the face is swollen and somewhat flushed, giving the child a heavy, stupid expression. There is also swelling of the face, especially about the eyes, in Bright's disease. Repeated momentary crossing of the eyes often indicates approaching convulsions. In very severe acute diarrhea it is astonishing with what rapidity the face will become sunken and shriveled, and so covered with deep lines that the baby is almost unrecognizable. The same thing occurs more slowly in the condition commonly known as marasmus. Often the face has an expression of distress in the beginning of any serious disease. If the edges of the nostrils move in and out with breathing, we may suspect some difficulty of respiration, such as attends pneumonia. The baby sleeps with its eyes half open in exhausted conditions or when suffering pain.

THE HEAD

The head exhibits certain noteworthy features. Excessive perspiration when sleeping is an early symptom of rickets. It must be remembered, however, that any debilitated child may perspire more or less when asleep. Both in rickets and in hydrocephalus (water on the brain) the face seems small and the head large, but in the former the head is square and flat on top, while in the latter it is of a somewhat globular shape. The fontanelle is prominent and throbs forcibly in inflammation of the brain, is too large in rickets and hydrocephalus, bulges in the latter affection, and sometimes sinks in conditions with only slight debility.

THE CHEST

The chest exhibits a heaving movement with a drawing in of the spaces between the ribs in any disease in which breathing is difficult. A chicken-breasted chest is seen in Pott's disease of the spine, and to some extent in bad cases of enlargement of the tonsillar tissue; a "violin-shaped" chest in rickets; a bulging of one side in pleurisy with fluid; and a long, narrow chest, with a general flattening of the upper part, in older children predisposed to consumption.

THE ABDOMEN

The abdomen is swollen and hard in colic. It is also much distended with gas in rickets, and is constantly so in chronic indigestion in later childhood. It is usually much sunken in inflammation of the brain or in severe exhausting diarrhea or marasmus. It may be distended with liquid in some cases of dropsy.

THE CRY

The study of the cry furnishes one of the most valuable means of learning what ails a baby. A persistent cry may be produced by the intense, constant itching of eczema.

The paroxysmal cry, very severe for a time and then ceasing absolutely, is probably due to colic, particularly if accompanied by the distention of the abdomen and the movements of the body already referred to. A frequent, peevish, whining cry is heard in children with general poor health or discomfort. A single shrill scream uttered now and then is often heard in inflammation of the brain. In any disease in which there is difficulty in getting enough air into the lungs, as in pneumonia, the cry is usually very short and the child cries but little, because it cannot hold its breath long enough for it. A nasal cry occurs with cold in the head.

A short cry immediately after coughing indicates that the cough hurts the chest. Crying when the bowels are moved shows that there is pain at that time. A child of from two to six years, waking at night with violent screaming, is probably suffering from night terrors. In conditions of very great weakness and exhaustion the baby moans feebly, or it may twist its face into the position for crying, but emit no sound at all. This latter is also true in some cases of inflammation of the larynx, while in other cases the cry is hoarse or croupy. Crying when anything goes into the mouth makes one suspect some trouble there. If it occurs with swallowing, it is probable that the throat is inflamed.

With the act of crying there ought always to be tears in children over three or four months of age. If there are none, serious disease is indicated, and their reappearance is then a good sign.

COUGHING

The character of the cough is also instructive. A frequent, loud, nearly painless cough, at first tight and later loose, is heard in bronchitis. A short, tight, suppressed cough, which is followed by a grimace, and, perhaps, by a cry, indicates some inflammation about the chest, often pneumonia. There is a brazen, barking, "croupy" cough in spasmodic croup. In inflammation of the larynx, including true croup, the cough may be hoarse, croupy, or sometimes almost noiseless.

The cough of whooping cough is so peculiar that it must be described separately when considering this disease. Then there are certain coughs which are purely nervous or dependent upon remote affections. Thus the so-called "stomach cough" is caused by some irritation of the stomach or bowels. It is not nearly so frequent as mothers suppose. Irritation about the nose or the canal of the ears sometimes induces a cough in a similar way. Enlarged tonsils or elongated palate or throat irritation may also produce a cough.

THE BREATHING

The breathing of a young child, particularly if under one year of age and awake, is always slightly irregular. If it becomes very decidedly so, we suspect disease, particularly of the brain. A combination of long pauses, lasting half a minute or a minute, with breathing which is at first very faint, gradually becomes more and more deep, and then slowly dies away entirely, goes by the name of "Cheyne-Stokes respiration," and is found in affections of the brain. It is one of the worst of symptoms except in infancy, and even then it is very serious.

The rate of respiration is increased in fever in proportion to the height of the temperature. It is increased also by pain in rickets, and especially in some affections of the lungs. Sixty respirations a minute are not at all excessive for a child of two years with pneumonia, and the speed is frequently decidedly greater than this.

Breathing is often very slow in disease of the brain, particularly tubercular meningitis. Poisoning by opiates produces the same effect. Frequent deep sighing or yawning occurs in affections of the brain, in faintness, or in great exhaustion, and may be a very unfavorable symptom. Breathing entirely through the mouth shows that the nose is completely blocked, while snuffling breathing is the result of a partial catarrhal obstruction. A gurgling in the throat not accompanied by cough may indicate that there is mucus in the back part of it, the result of an inflammation, sometimes slight, sometimes serious.

"Labored" breathing, in which the chest is pulled up with each breath while the muscles of the neck become tense, the pit of the stomach and the spaces between the ribs sink in, and the edges of the nostrils move in and out, is seen in conditions where the natural ease of respiration is greatly interfered with, as in pneumonia, diphtheria of the larynx, asthma, and the like. Long-drawn, noisy inspirations and expirations are heard in obstruction of the larynx, as from laryngeal diphtheria or spasmodic croup.

THE PULSE

The rate of the pulse is subject to such variations in infants that its examination is of less value than it would otherwise be. In early childhood its observation is of more service, although even then deceptive. Slight irregularity is not uncommon. Unusual irregularity is an important symptom in affections of the brain or heart. Fever produces an increase in the pulse rate, the degree of which depends, as a rule, upon the height of the temperature. Slowing of the pulse is a very significant symptom, seen particularly in affections of the brain, and sometimes in Bright's disease and jaundice.

THE TEMPERATURE

The temperature is of all things important to remember in infancy and childhood because fever is easily produced and runs high from slight causes.

Even slight cold or the presence of constipation or slight disturbances of digestion may in babies sometimes produce a temperature of 103 F. or more. We do not speak of fever unless the elevation reaches 100 F. A temperature of 102 or 103 F. constitutes moderate fever, while that of 104 or 105 F. is high fever, and above 105 F. very high. A temperature of 107 F. is very dangerous, and is usually not recovered from. The danger from fever depends not only upon its height, but upon its duration also. An elevation of 105 F. may be easily borne for a short time, but it becomes alarming if much prolonged.

THE MOUTH

The tongue of newborn infants is generally whitish and continues to be so until the saliva becomes plentiful. After this we usually find it coated in disturbances of the stomach and bowels and in nearly any disorder accompanied by fever. In scarlet fever the tongue becomes bright red after a few days, and in measles and whooping cough it is often faintly bluish. In the latter affection an ulcer may sometimes be found directly under the tongue, where the thin membrane binds it to the floor of the mouth. In thrush the tongue is covered with white patches like curdled milk. A pale, flabby tongue, marked by the teeth at its edges, indicates debility or impaired digestion. In prolonged or very high fever the tongue grows dry, and in some diseases of the stomach or bowels it may look like raw beef.

Grinding of the teeth is a frequent symptom in infants in whom dentition has commenced. It generally indicates an irritated nervous system. Most often this depends upon some disturbance of digestion; less often upon the presence of worms. The symptom is present during or preceding a convulsion, and may occur, too, in disease of the brain. In some babies it appears to be only a nervous habit.

NURSING

The manner of nursing or swallowing frequently affords important information. A baby whose nose is much obstructed or who has pneumonia can nurse but for a moment, and then has to let the nipple go in order to breathe more satisfactorily. If it gives a few sucks and then drops the nipple with a cry, we must suspect that the mouth is sore and that nursing is painful. If it swallows with a gurgling noise, often stops to cough, and does as little nursing as possible, we suspect that the throat may be sore. The ceasing to nurse at all, in the case of a very sick baby, is an evidence of great weakness or increasing stupor, and is a most unfavorable symptom.

THE URINE

Urine that is high-colored and stains the diaper, or that shows a thick, reddish cloud after standing, may accompany fever or indigestion. Sometimes the urine under these conditions is milky when first passed. In some babies a diet containing beef juice or other highly nitrogenous food will produce the reddish cloud, or even actual, red, sandlike particles. A decidedly yellow stain on the diaper occurs when there is jaundice. A faint reddish stain seldom indicates blood. The amount of urine passed is scanty in fever, in diarrhea, and especially in acute Bright's disease. In the latter disease the urine is often of a smoky or even a muddy appearance. The possibility of the occurrence of this symptom after scarlet fever must always be kept in mind, in order that a physician may be summoned very quickly, since it is a serious matter.

THE STOOLS

We find that the passages are often putty-colored in disorders of the liver, frequently bloody or tarry in appearance in bleeding within the bowel, and liable to be black after taking bismuth, charcoal, or iron, and red after krameria, kino, or haematoxylon. Infants who are receiving more milk than they can digest constantly have whitish lumps in their stools, or even entirely formed but almost white passages. The presence of a certain amount of greenish coloration of the passages is not infrequent. This is usually an evidence of indigestion, but passages which are yellow when passed and turn to a faint pea green some time later are not an indication of disease.

WHEN BABY GETS SICK

When baby shows that he is sick, take his temperature as directed elsewhere, cut down the feeding to at least one half, or, if his temperature is around 102 F. give him nothing but rice water or barley water. If he is constipated give him a cleansing enema, and if hot and feverish a sponge bath may be administered. He should then be put into a bed with light covers and wait further orders which the doctor will give on his arrival. Give the baby no medicine unless ordered to do so by the physician.

Known to every physician who undertakes the care of children, is the failure of many well-meaning mothers to call him early. The mother attempts the care of the baby herself, and not until the condition gets beyond her knowledge and wisdom does she seek medical advice. In the early hours of an approaching cold, the beginning of intestinal indigestion, or at the beginning of bronchitis, if the physician can see the child early, prolonged illness may be avoided as well as unnecessary expense and many heart-breaking experiences.

FEEDING THE SICK BABY

Feeding the sick baby differs somewhat with the character of the individual disease, but in the outset of any and all diseases the intestinal tract should not be overburdened with food. At the approach of any illness, the food should at least be cut down one half; for instance, in the case of a serious acute illness accompanied by fever, not only should the strength of the food be reduced one half, but water should be given plentifully between feedings. It is better never to urge the baby to eat at such times—for the ability to digest food is very much reduced.

In cases of acute attacks with much vomiting and fever, all milk should be immediately stopped and rice water or barley water substituted. When vomiting ceases and the fever approaches normal and food is desired, begin with boiled skim milk in small amounts, well diluted with cereal water, and do not approach the normal amount of milk for twenty-four to forty-eight hours. In this way the weak digestive organs are not overtaxed and they gradually resume their usual work of good digestion. When a baby seems to have no appetite for food, lengthen the intervals from three to four or five hours, for feeding when food is not desired usually aggravates disease disturbances.

EXAMINING SICK CHILDREN

And now, above all times, the early seed sowing of teaching the child self-control, teaching him to gargle if he is sufficiently old enough, to open his mouth and allow observation without resistance, brings sure results. The great harm of making the doctor and his medicine a threat to obtain obedience also brings its harvest at this time; for the doctor, of all people, ought to be regarded as the child's best friend. When baby is sick, the doctor is needed, his daily visits must not be resisted, his medicines must not be feared—these and such other matters should be made a part of every child's early education.

Under no circumstances or conditions should we directly falsify to a child. Nothing is accomplished by telling a child it will not hurt when you know that it will hurt, or that the medicine tastes good when you know it is bad-tasting. Every physician can recall unnecessary disturbances in the office because a mother has allowed a child to acquire a wrong mental attitude toward the family physician.

One mother told her little girl in my office when I wished to make an examination for adenoids which necessitated my putting my finger back of the child's uvula, "Now Mary, the doctor won't hurt you at all, it will feel nice." I turned to the little girl and said: "Mary, it will not feel nice, it really won't hurt you, but it will feel uncomfortable." It was a grave mistake to tell her that it would feel nice. The child resisted, and, while the examination was successfully made, the greatest of tact had to be used in securing the friendship of the child after the examination.

It is far better when the throat is to be examined to wrap the child in a shawl or a sheet with his arms placed at his side, and for a member of the family to take him in her lap and hold him securely while the physician quickly makes the observation. And while we appreciate that sickness is not the time to introduce new methods of training, in instances where children have been spoiled, it is far better quietly and firmly to go about the task in a manner that you know can be carried through to a successful finish.

TREATMENT OF SICK CHILDREN

A sick child should be encouraged to lie in his bed much of the time, and the bed should be kept clean and cool. He should never be set up suddenly or laid back quickly. In the case of a broken leg, all rapid movements should be avoided. A simple story or a soothing lullaby, or the giving of a toy, will often divert attention when some painful movement must be made or some disagreeable task performed.

Both cleanliness of the body and cleanliness of the mouth are exceedingly necessary in sickness. In all instances of disease or indisposition, the mouth must receive daily care, for stomatitis or gangrene of the mouth often follows neglect. A listerine wash in proportion of one to four, or a magnesia wash, or the addition of a few drops of essence of cinnamon to the mouth wash will do much to prevent such conditions, as well as to relieve them.

Applications of medicine to the throat may be made without resistance if the tactful nurse watches her time. She should slowly introduce the tongue depressor which may be a flat stick or a spoon, when the application of medicine with a camel's-hair brush is quickly made to the rolled-out throat as the child gags, and if the nurse then quickly diverts his attention to some beautiful story or a picture or a new toy, the treatment is soon forgotten. Under no circumstances argue with or scold a sick child. Get everything ready, if possible behind his back or in another room, and then with plenty of help make the application or the observation without words, always with gentleness and firmness.

NURSING RECORDS

Whether the nurse be the mother, caretaker, practical or professional nurse, a record should always be kept of the condition of the patient. The temperature should be reported at different periods designated by the physician. The pulse should be recorded, the amount of urine passed and the time it was passed, the number of bowel movements, all feedings and the general well being of the child—whether it is restless or comfortable, sleeping or awake, together with the water that he drinks.

The record may be kept, if necessary, on a piece of common letter paper, and should read something like this:

March 26, 1916

7 A. M. Temperature 102; pulse 132; respiration 40; morning toilet; took 4 ounces of milk; 2 ounces of barley water; 1 ounce of lime water.

9 A. M. Enema given; good bowel movement; mustard paste applied to chest, front and back, and oil-silk jacket applied; drank boiled water, 4 ounces.

11 A. M. Took the juice of one orange; temperature 103; pulse 135.

12 Noon. Very listless and nervous; temperature 104. Has coughed a great deal. Gave mustard paste to chest, front and back, and wet-sheet pack.

1:30 P. M. Temperature 101.8; 4 ounces of water to drink; looks better.

3 P. M. Has slept 11/2 hours; temperature 102.5; pulse 134; respiration 40; 6 ounces of food given (3 ounces of milk, 2 ounces of barley water and 1 ounce of lime water).

A record like this is a great help to the physician, and such a record may be kept by anyone who can read and write. There are printed record blanks which may be procured from any medical supply house and most drug stores.

BAD-TASTING MEDICINES

Castor oil has neither a pleasant smell nor taste, and nothing is accomplished by telling the child that it does smell good or taste good. If the patient is old enough to drink from a cup, put in a layer of orange juice and then the castor oil and then another layer of orange juice, and in this way it often can be easily taken. Someone has suggested that a piece of ice held in the mouth just before the medicine is taken will often make a bad dose go down without so much forcing. A taste of currant jelly, or a bit of sweet chocolate, or the chewing of a stick of cinnamon is a great adjunct to the administration of bad-tasting medicines. All oily medicines must be kept in a cool place and should always be given in spoons or from medicine glasses that have first been dipped in very cold water. Very often the addition of sugar to bad-tasting medicines will in no wise interfere with their action, while it often facilitates the administration of the disagreeable dose. The majority of bad-tasting medicines are now put up in the form of chocolate-flavored candy tablets.

TEMPERATURES AND PULSE

The normal temperature of a baby is 98.5 to 99 F. in the rectum. After shaking the mercury of the thermometer down below the 97 mark it is well lubricated with vaseline and then carefully, gently, pushed into the rectum for about an inch and a half or two inches, and left there for three minutes before removing.

Mothers should exercise self-control in taking the temperature, for nothing is gained by allowing a panicky fear to seize you should the mercury register higher than you anticipated. Notify your physician when the temperature registers above 100 F.

The respirations of a child are fairly regular and rhythmic and occur about forty times per minute during the first month of life and about thirty times per minute during the remainder of the year. From one to two years, twenty-six to twenty-eight is the average. Breathing is somewhat irregular when the child is awake and may be a bit slower when asleep. Before the baby is born the fetal pulse is about 150. At birth it ranges from 130 to 140. During the first month the pulse is found to be from 120 to 140. By the sixth month it gets down to 120 or 130, and from that on to a year the normal pulse beat of the baby is about 120. The pulse is influenced very much by exercise and is often increased by crying or nursing or any other excitement.

FEVER

Children get fever very easily—the digestive disturbance of overeating, constipation, a slight bilious attack—all produce fever which disappears quite as suddenly as it came. The first thing to do under such circumstances is to withhold food, give plenty of water to drink, produce a brisk movement of the bowel by giving a dose of castor oil, give a cleansing enema, and treat the fever as follows:

After removing all of the clothes from the child, place him in a warm blanket and then prepare a sponge bath which may be equal parts of alcohol and water; expose one portion of the body at a time and apply the water and alcohol first to one arm and then to the other arm, the chest, one leg, the other leg, the back and then the buttocks. Do not dry the part but allow evaporation to take place, and this, accompanied by the cooling of the blood which is brought to the skin by the friction, readily reduces the fever. Another procedure which may be employed if the fever registers high is the wet-sheet pack which is administered as follows:

Three thicknesses of wool blankets are placed on the bed and a sheet as long as the baby and just enough to wrap around him once, is wrung out of cool water and spread over these blankets. With a hot-water bottle to the feet, the child is then laid down in the wet sheet which is now brought in contact with every portion of his body, then the blankets are quickly brought around, and he is allowed to warm up the sheet—which lowers his temperature.

Another valuable procedure is the cooling enema. Water the same temperature as that of the body, is allowed to enter the bowel and is then quickly cooled down to 90 or 85 F.; in this manner much heat is taken out of the body and the fever quickly reduced. (For further treatment of fevers see Appendix.)



CHAPTER XXVI

BABY'S SICK ROOM

Visitors should never be allowed in the sick room during the height of a disease, and during convalescence not more than one visitor should be allowed at one time, and the visit then should be only two or three minutes in length. The order and the quietness and the system of the sick room should be perfect. Visitors and loitering members of the family do no good and they may do much harm to the recuperating nervous system of the child.

LOCATION OF THE SICK ROOM

In these days of high rents, we realize that the greater per cent of our readers are living in apartments and homes just big enough conveniently to care for the family during health, and while it would be pleasant and convenient to have a spare room or an attic chamber that could be used in case of illness, it is the exception rather than the rule that the families to whom sickness comes have these extra apartments. When a contagious or an infectious disease comes to the family, it is of great importance that the sick child be isolated, preferably on another floor, from that used by the immediate family.

Those living in homes, more than likely can fix up a room on the attic floor for the isolation, and those living in apartments may put the sick child in one end of the apartment, while they inhabit the other end. One family under my observation not long ago had a child stricken with the measles. In the same apartment there lived a puny baby not quite two years old. Coming as it did in February, the mother of the child was apprehensive, fearing that measles would leave a severe bronchitis which might mean the death of the already too-delicate baby. She was instructed to move the baby's bed to the sun parlor in the front of the flat, while the boy with the measles was put in the parents' room in the rear end of the flat. A sheet was suspended in the middle of the hall leading from the living-room to the bedrooms. Door knobs were disinfected daily, a caretaker was put in charge of the measles patient, the mother very frequently was compelled to go back and administer a treatment, but each time she donned a large apron and completely covered her hair with a towel, she administered the treatment, took off her wrappings, thoroughly washed her face and hands—disinfected them—and returned to her baby in the front part of the house.

At night this mother slept on the floor on springs and mattress in the living-room, and to that home the measles came and departed, and the baby did not get them at all, so perfect was the isolation, so vigilant the disinfection, and so scrupulous the care to prevent contamination. So you see from this one instance that it is altogether possible to make isolation complete even on the same floor. But, mind you, the dishes that the lad ate from were all kept in his room. Food was brought to the sheet and there the caretaker held her dishes while the cook poured or lifted the food from her clean dishes to the dishes the caretaker brought from the sick room.

Whether the sick room is in the attic or whether it be the rear end of an apartment, if the principles of contagion and disinfection are understood I believe it is perfectly possible to isolate even scarlet fever without danger to the other members of the family.

NECESSARY FURNISHINGS

For slight indispositions and trifling disorders, it is not necessary to strip the room of its adornment, but it is well to clear off the dresser tops, protect them well with many thicknesses of newspapers covered over by a folded sheet so that alcohol, witch-hazel and other necessaries will not injure the mahogany or oak-top dresser. Whenever the children are sick, rob the room of anything that is going to be in your way. In instances of infectious or contagious diseases, take down all silk or wool hangings, replace them by washable curtains or inexpensive ones that can be burned if necessary, and remove valuable paintings and other bric-a-brac that later fumigation will harm or that may gather the dust during the days of illness.

Just as it is necessary for the man who mines the coal to wear suitable garments, and for the woman who does the scrubbing to dress accordingly, and for the nurse who cares for the case to wear washable clothes—so it is necessary to dress the sick room in garments that are suitable, convenient, and capable of being thoroughly disinfected, fumigated, or even burned if the occasion demands. Hence, expensive rugs should be replaced by rag carpets or no rug at all, while unnecessary articles and garments should be removed from closets, etc.

Remembering that the little fellow is to remain in this room for possibly two weeks or maybe six weeks, let us put up some bright-colored pictures that he will enjoy, bring in some books and magazines by which he may be entertained, secure a few simple toys that will not tax the brain, but serve as a help to pass away the long hours. There are many paper games that may be had, such as transfer pictures, picture puzzles, kindergarten papers, drawing pictures, as well as toys that may be put together to fashion new articles. A whole lot of fun can be gotten out of a bunch of burrs that can be stuck together to make men, animals, houses, etc. Scissors and pictures are entertaining as well as paper dolls with their wardrobes. Rubber balloons, or a target gun for the boy of six will be a great source of delight to him; as will a doll with a trunk full of clothes for the little girl during her convalescent days. A tactful nurse and a resourceful mother will think of all the rest that we have not mentioned—which will amuse, entertain and keep happy our convalescent children, help them to forget that they are "shut ins."

THE NURSERY REFRIGERATOR

It is wise in instances of the more severe childhood troubles, such as infectious and contagious diseases, to keep as many things in the sick room as possible, and so we remind our reader of the home-made ice box, described elsewhere in this book, in which may be kept the fruit juices and the fruits, as well as the milk and the buttermilk. Many medicines, particularly the oily medicines, should be kept in this home-made ice box and five cents worth of ice a day will not only make things taste better, especially during the warm months, but will protect the other members of the family, for the family ice box is a big central station which must be protected against infections and carriers of disease.

In connection with the ice box, we are reminded that it would be a great convenience to have a simple contrivance for heating bouillon, milk, or making a piece of toast, which can be readily done with an electric heater, an alcohol stove, or a small apparatus fitting over the gas jet.

SICK ROOM DISINFECTANTS

The most important thing which we are going to mention in this division of the chapter is the disinfection of the door knobs. According to the directions on the poison bottle, place an antiseptic tablet into a small amount of water which will make a solution of 1 to 1000 of bichlorid of mercury, and several times a day disinfect the door knobs, particularly in the sick end of the house—thoroughly washing and adequately rubbing with a towel moistened in this solution.

All stools and urine from the sick one will receive attention as directed by the physician. The stools from a typhoid patient should stand for one-half hour in a chamber covered with a layer of lime.

It is not at all necessary to have vessels containing disinfectant substances standing about the room and in the closet. In a room adjoining should be kept all of the dishes used by the sick patient, his tray, half a dozen napkins, knife, fork, spoon, serving dishes, drinking glass, pitcher, etc. All bedding and all linen used by the sick member should be allowed to stand in a solution of disinfectant for several hours when they may be wrung out of the solution, dropped into a bucket and carried to the laundry without any danger to other members of the family.

The nurse is not allowed to leave this room in the garments that are worn while caring for the sick. She should have her meals in an adjoining room which is also under strict isolation.

THE MEDICINE CHEST

The sick room medicine chest should be so placed on the wall that it is outside the reach of the smaller members of the family, for in it should be placed poisons for external use that are capable of producing death if taken internally. Bottles that hold these poisons—such as bichlorid of mercury, lysol, carbolic acid, laudanum, paregoric, belladonna, etc.—should be so different from the other bottles in the medicine chest that if one should reach for them with his eyes shut or in the dark he would at once recognize that he had hold of a poison bottle. This is absolutely necessary. It usually means a bit of extra expense, but when we realize what tragedies may be avoided by such slight expense, it must not be considered.

Bottles may be procured that have been molded with points of glass projecting from the outside which make them rough to the touch, or they may be covered with a wire mesh or with a wicker covering which may easily be told from the other bottles in the case.

One woman lost her life because the nurse placed two ounces of carbolic acid in the enema instead of two ounces of saline solution. Saline solution is nothing but salt and water, while carbolic acid cost the woman her life, simply because the carbolic acid was not placed in a specialized poison bottle and the attendant could not read the label in the dark.

Under no circumstances keep from one year to another the remnants of unused medicine of a former sickness, for medicines do not keep well and often lose their strength if kept longer than the physician intended.

In this medicine chest should be found the following articles:

A glass graduate marked with fluid drachms (1 teaspoon), and fluid ounces (8 teaspoons). A medicine dropper. Absorbent cotton. Boric acid. Camphorated oil. Castor oil. Aromatic spirits of ammonia. Alcohol. Olive oil. Epsom salts. Soda-mint tablets. Vaseline. Zinc ointment, together with other medicines the physician orders. Ice bag, hot-water bottle and oiled silk.

Besides these articles, in the nursery—in readiness for emergencies and accidents—should be found the following:

Gauze bandages of various sizes. Sterile gauze. Boric acid crystals and powder. Mustard. A pocket case of instruments containing scissors, knife, dressing forceps, etc. Syrup of ipecac. Glycerin. Tincture of iodine. Package of ordinary baking soda. Peroxid of hydrogen. Absorbent cotton. Needle and thread. Lime water.

PATENT MEDICINES

Aside from the giving of castor oil and the application of vaseline to the nose, or of applying boracic acid to the eyes, no medicine should be administered to the baby without competent medical advice. There are numerous widely advertised nostrums frequently sold as soothing syrups to be used during the teething or during attacks of diarrhea, or cough spasms, croup, or worms, that contain dangerous drugs and should not be given to children. Many well-meaning but ignorant mothers are slowly but surely laying the foundations for serious nervous disorders and are often making veritable dope fiends out of their children. Patent medicines are dangerous things in the hands of the people; if we are going to give medicines to our little babies let us at least know what we are giving. Let some conscientious, scientific physician examine the baby and prescribe for its needs.

If urged to use a patent medicine, examine the label carefully, for the Federal Food and Drug Act requires the manufacturer of patent medicines to print plainly on the label of the bottle the name and amount of certain dangerous drugs which it may contain.

The drugs mentioned in this drug act and which are often used in patent medicine nostrums are, chloral hydrate, cocaine, heroin, chloroform, alpha or beta eucaine, opium, morphin, alcohol, cannabis indica, or any derivative or preparation of any such substance contained therein.

There are many other drugs sold on the market containing syrups or flavoring materials which may do harm—which may upset the baby's digestion.

Mothers avoid patent medicines. Consult your physician. Never give a baby any sort of medicine to induce sleep. Unless babies are sick or spoiled or hungry, they will go to sleep of themselves, and even in the days of a high fever a wet-sheet pack seldom ever fails to put the baby to sleep and can do no harm if properly given.

This may be as good a place as any to mention the dosage of castor oil which is as follows:

Up to three months, 1/2 teaspoon. From three to six months, 1 teaspoon. From six to nine months, 11/2 teaspoons. From nine to twelve months, 1 dessert spoon (2 teaspoons). From twelve months on, 1 to 2 tablespoons.

AFTER THE SICKNESS IS OVER

The physician will direct when the disinfectant bath is to be given to the patient previous to his liberation from isolation. The different diseases demand different treatment, but, on the whole, it is about as follows:

The day before the boy is to be allowed to go out among the family once more he receives a soap wash, clean sheet and bedding on the bed, and puts on clean garments. The following morning, his head thoroughly shampooed, his nails manicured, a second soap wash is given followed by a weak bichlorid bath (1 to 10,000 solution) which is followed by an alcohol rub. He is then allowed to go out of the sick room which is now to be thoroughly disinfected and fumigated.

After the illness is over, the sick room and the adjoining closets and ante rooms must be thoroughly disinfected or fumigated. If you are located in a city, the health authorities will do this after an infectious or contagious disease. Away from such conveniences, use the following method:

Place two ounces of crystals of permanganate of potash in a pan and have a pint bottle of formalin near by. Everything in the room is now exposed, dresser drawers are opened, all bedding, all garments—in fact everything that is in the room—is put in such a position as to be readily exposed to the fumes which are to follow. A line should be stretched across the room over which are thrown the bedding, garments, etc. The cracks of the windows and doors, except the one door of exit, are now sealed up with paper which has been dipped in green soap, and having the paper strips and pan of green soap ready just outside the exit door, the formalin is now poured over the permanganate crystals. Fumes will immediately arise and permeate every corner, crack and crevice of the sick room. Now quickly make your exit, close the door and seal up key hole and cracks and space under the door with paper dipped in green soap. Leave the room for six hours. After this with a well-moistened cloth to the nose, rush in and throw the windows open, hurry out and allow the room to air from twelve to twenty-four hours, after which wash woodwork and painted walls or take paper off and repaper walls; recalcimine ceilings and closets; scrub closet shelves and dresser drawers, bedsteads, and other furniture thoroughly. If the mattress is old throw it away, but if not, sun it for several days following the fumigation.



CHAPTER XXVII

DIGESTIVE DISORDERS

In this chapter we will consider the diseases which commonly occur during infancy and early childhood relative to digestion and the alimentary tract. Irregularity of feeding, feeding between meals, feeding too much at any given time, as well as feeding the wrong kind of food may cause stomach disturbances and intestinal troubles.

VOMITING

In a previous chapter, "The Feeding Problem," a common stomach disturbance, vomiting, was gone into quite thoroughly, and in passing to other disorders, we wish to remind the mother that vomiting should always be taken seriously. The interval between meals should usually be lengthened, the time spent in feeding shortened, and it is often necessary to withhold all milk and food of any kind for twelve or eighteen hours, giving only boiled, unsweetened water. Vomiting frequently ushers in some acute disease, and in remote cases, when it is very persistent, it may indicate inflammation of the brain. Complete rest is essential, trotting on the knee, suddenly changing the baby's position, or other quick movements must all be avoided. A physician should see the sick one and determine the cause of the trouble.

COLIC

Cases of ordinary colic are usually relieved by heat to the abdomen and feet, drinking hot water in which there has been dissolved a pinch of ordinary baking soda, or a portion of a soda mint tablet, or by the use of the photophore, as previously described. The treatment of such ordinary colic need not be given further consideration here because it has been described at length in a former chapter; but we do call the attention of the mother to a more serious form of recurring colic which so often accompanies chronic intestinal indigestion, marasmus, and malnutrition.

In most instances the food is radically at fault and should be reduced to a mixture which can more readily be digested and assimilated by the child. Often whey mixtures, peptonized foods, or buttermilk may be indicated. The weight of the baby, the age of the baby, and the color of the stools, must all be taken into account in the preparation of this easily digested food. Weak mixtures should be given at first and then gradually and carefully the quality may be strengthened until the normal formula is again used for the baby.

Injections into the bowel of water, to which has been added one level teaspoon of soda to the pint, will often give relief in this form of colic.

CHRONIC INDIGESTION

While this condition may occur at any time during babyhood days, it often makes its appearance during the last half of the first year and up to the fifth year. It is accompanied by mucus in the stools, chronic flatulence, constipation or diarrhea, or the alternating of the two, restlessness at night, distention of the abdomen ("pot bellied") accompanied by pain, a coated tongue with a fetid breath, and loss of appetite. It is a pitiable picture—the weight is usually reduced and the child gives the appearance of being decidedly undernourished. This condition is usually occasioned by errors in diet, whether it be over-feeding or feeding of the wrong element of food, and, since the diet is usually responsible for the condition, in the line of treatment diet is a prime factor.

All fats must be taken from the food, sugars should be avoided, and the amount of starchy foods, such as flour, potatoes and bread, should be greatly reduced. Buttermilk, skimmed milk, eggs, green vegetables, and fruit juices should be given. In the older child, if grains are used, they should be well toasted or baked.

JAUNDICE

It is altogether common and physiological for the newborn baby to pass through a few days of yellow skin which usually clears up in the second or third week, but it should not recur. Occasionally this yellow tint deepens, the whites of the eyes are yellow, the urine passed leaves a yellow stain on the diaper, while passages from the bowels are white or clay colored. If the child shows symptoms of ill health other than the yellow tint, it should receive medical attention. Older children troubled with jaundice should receive the following treatment: The photophore as described elsewhere should be applied to the liver and abdomen (the liver is on the right side), and this should be followed by the application of what is known as a heating compress, consisting of three layers—a cloth wrung from cold water, a mackintosh, and then two thicknesses of blanket flannel—which are all applied when the skin has been made red by the application of heat. (If the photophore is unavailable, a hot-water bottle may be applied.) The flannel is pinned snugly on the outside as the wet cloth goes next to the skin with the mackintosh between. This should remain on the abdomen for three or four hours, after which the hot application is again made to the liver and abdomen. The administration of broken doses of calomel is sometimes indicated in obstinate cases in connection with these applications of heat to the liver. Hot milk or mineral water may be taken with dry toast. In a day or two the color should clear up, the stools should be normal again, and the treatment may be discontinued.

WORMS

Irritation about the rectum which cannot be otherwise explained is usually suggestive of pinworms. These seatworms or pinworms are very much like little pieces of cotton thread—one-fourth of an inch in length. They grow and thrive in the lower part of the large bowel. Simple and effective treatment is as follows:

It is well to bathe the parts about the rectum after each bowel movement and often two or three times a day with a weak antiseptic solution. Itching may be controlled by the application of a disinfectant ointment, or the local applications of ice may serve the same purpose. After a thorough cleansing of the colon by an injection of lukewarm water containing a teaspoon of borax to the pint in order to remove the mucus, Doctor Holt suggests that after the discharge of this borated enema, infusions of quassia are very helpful (See Appendix).

Children suffering from roundworms experience a loss of appetite, varying temperature from above normal to subnormal, with colicky pains in the abdomen on coming to the table and beginning to eat. They are pale and listless, or nervous and irritable.

Roundworms very much resemble earthworms in shape and color. While their home is in the small intestines they often travel to other parts of the body. They have sometimes crawled into the stomach and have been vomited. The only definite symptom of worms is to find the eggs or the worms themselves in the stool. No worm medicine should ever be given by the mouth without being prescribed by a physician. Cases are on record where well-meaning mothers have killed their children by giving an over dose of worm medicine.

Tapeworms sometimes trouble children; their segments are found in the stool, and look like small pieces of tape line. The segments are flat and thin, one-fourth inch to one-half inch in width and three-fourths to one inch in length. They are joined together and often their number is so great the worm is many feet in length. The segments grow smaller and smaller as they approach the neck, the head of the worm being a mere point. As the worm is passing from the child it should never be pulled, as the head is easily broken off, and, on remaining in the bowel, it will grow to a full-sized worm.

Worms come from the eating of half-cooked meats; they enter the stomach as eggs or tiny worms, and pass out into the small intestines, where they begin to grow. They are a common parasite in the human family and should be suspected in all instances where digestive symptoms are masked or do not yield to treatment.

HOOKWORM DISEASE

This disease, once seen only in the southern part of the United States, is leaving its former domains as the migrating population is distributing it more or less widely everywhere. Sandy soil and country districts are infected by a tiny worm which thrives in polluted soil and enters the body through the skin of the feet. It also gets into the body through the drinking water or from the eating of uncooked vegetables, such as are used in salads.

The disease is manifested by "sallow skin, paleness, headache, swollen abdomen and sores on the legs." Little swollen places where the worm enters the skin may be seen on the flesh. The condition yields readily to treatment. If a child is discovered scratching his feet (especially in the southern part of this country), he should be taken at once to a physician.

DISORDERED STOMACH

At the first symptom of a disordered stomach take all food from the baby and give him rice water prepared by throwing a cupful of well-washed rice into a kettle of boiling water and allowing it to continue to boil for a couple of hours. The water which is strained off is rice water, ready for use after it is cooled. This may be given to the child at the meal hour in the place of his regular food. It should be kept in a glass-covered jar in the ice box. A dose of castor oil, according to the age, should be administered before the feed. The bowels should be washed out and boiled water given freely between the meals of rice water. For a day or two (twenty-four to forty-eight hours), the child should be fed only this rice water, or until the temperature returns to normal and he appears very hungry, at which time milk, which has been boiled for five minutes, may be added to the rice water, first in one-half ounce quantities and gradually increased. Each day a little more milk is added until baby is taking his regular food again.

Many a death and many acute attacks of summer complaint are avoided by the quick use of castor oil, and by withholding food and stopping the use of milk as soon as the child becomes ill.

STOMATITIS OR THRUSH

Thrush is evidenced by fretfulness or crying on attempting to nurse. On examination of the mouth it is found to be hot and very tender and covered with little white specks which, if looked at under the microscope, appear to be a fungus growth. If scratched off, the mucous membrane bleeds easily. Thrush often occurs during a fever or in connection with other diseases, and is often due to neglect and lack of cleanliness about the bottles, nipples, etc. Taken in time it is quickly cured. An immediate dose of castor oil or milk of magnesia is indicated, and the use of a mouth wash which will be prescribed by the physician. If neglected, it may become ulcerous or gangrenous, which is a very serious condition. Everything pertaining to the feeding, as well as the child's toys, hands, etc., must be kept scrupulously clean.

CONSTIPATION

In the chapter, "The Feeding Problem," constipation in bottle-fed babies was discussed. The bowels should move at least once in twenty-four hours. The passages are frequently very hard and leave the body only after a very great effort of straining. This constipation, often continuing until late childhood, should be corrected in the following manner:

In early infancy—as early as the fourth month—prune juice may be given as directed elsewhere, while in later months prune pulp or fig pulp, which has been carefully rubbed through a fine-mesh colander, may be given at meal time. By the time the baby is eleven or twelve months old, strained apple sauce may be given.

We deplore the use of the water enema as a regular daily procedure; in its place we suggest the use of the enema of oil or the introduction into the rectum of a gluten suppository or in obstinate cases a glycerine suppository. Abdominal massage should be daily administered. With a well-oiled hand, begin on the right abdomen and proceed upward to the lower border of the right ribs and across to the left side and down. This should be repeated many times at a regular hour each day. The mother should select an hour for the bowels to move, preferably after the forenoon feeding, and if the child is too small to sit upon the toilet chair, a gluten suppository may be placed into the rectum before the forenoon feed and some time during the middle of the day the bowel movement will be found in the napkin.

For the older child, before a certain meal each day, a well-vaselined piece of cotton may be inserted in the rectum; this often produces a bowel movement immediately after the meal. Laxative foods, such as bran, stewed figs, stewed prunes, or a raw apple, should be used faithfully—as repeated medication never corrects the difficulty, but usually prolongs it.

To immediately flush out the bowel, a soapsuds enema or a plain water enema may be allowed to flow into the lower colon, or a glycerine suppository inserted into the rectum will quickly bring a bowel movement. These methods are only of temporary value; a regular habit should be formed, if possible, to bring about a natural, normal bowel movement. When necessary to resort to drugs—such remedies as cascara sagrada, milk of magnesia, or syrup of rhubarb, are satisfactory, as well as our old stand-by—castor oil. Regular habits must be insisted upon, and if the mother pays attention to regularity at stool in early childhood very little trouble will be met later on in adolescence and adult life.

Chronic constipation often produces abnormal conditions about the rectum such as fissures, hemorrhoids, or prolapse, which may be of serious import.

DIARRHEA

Diarrhea is a symptom of an acute illness, or it may be associated with a chronic condition such as chronic intestinal indigestion, tuberculosis of the bowel, or may occur alternately with constipation in colitis. It is the most dangerous of all symptoms that babies develop, and in spite of all the instruction given to mothers at the present time, in spite of all the welfare stations in large cities, and in spite of all the efforts put forth by the commissioner of health, with his corps of visiting nurses—even yet, more babies die of diarrhea each summer than from any other single cause.

There are usually just two reasons for diarrhea—uncleanliness and bad milk. During the hot summer days flies multiply greatly and all manner of bacteria and germs grow in warm, moist, shadowy places, so that usually before the milk leaves the dairy farm it is seriously contaminated with disease-producing germs. If the milk is not kept at a temperature of 35 or 40 F. (which is just above the freezing point), these bacteria, particularly the manure germ, grow at such a rate that by the time the milk gets to the infant it is teeming with bacteria, and diarrhea is the sure result.

Another form of diarrhea is cholera infantum, where the stools soon become watery and colorless. The vomiting is almost incessant and there is high fever. Fortunately it is a rare disease, but when once seen it is never forgotten. One beautiful baby weighing nearly thirty pounds was reduced to sixteen within forty-eight hours, and when death came he could hardly be recognized because of the wasting from this most dreaded of infant diseases.

Another form of diarrhea is seen in an acute inflammatory condition of the intestine itself. The stools contain more or less mucus and blood. The bowel movements, which are very frequent, are accompanied by a great deal of pain and straining. This form is often seen in the more severe types of summer dysentery. We wish to impress upon the reader's mind that these diarrheas may all be avoided if the baby's food is clean and free from germs, if the apple or pear is not only washed, but thoroughly scrubbed before paring during the summer months. If all the bottles, nipples, water, toys, etc., are adequately clean, no summer diarrhea, no dysentery, no other infection due to dirt, will attack the baby. Of paramount importance is the pasteurization of milk during the summer months, as mentioned elsewhere.

TREATMENT OF DIARRHEA

Simple diarrhea in the older child of two or three years is treated as follows: Take away all solid foods. Give a big dose of castor oil, thoroughly wash out the bowel by warm water containing a level teaspoon of salt and a level teaspoon of baking soda to the pint, and put the child to bed in a quiet room. Boil all milk for ten minutes and thicken it with flour that has been browned in the oven; feed this to the child at five-hour intervals. After each bowel movement, no matter how often they come, the colon should be washed out with the salt and soda enema as before mentioned.

Bear in mind that the child is losing liquids, and so, after the bowels have moved, boiled water should be given by mouth, or a cupful of water can often be retained if it is introduced into the rectum slowly under very low pressure. Twenty-four or forty hours should clear up a case of simple diarrhea, and on returning to food it should be dry toast and boiled milk. For the younger baby, withhold all milk and give barley water or rice water for the first twenty-four hours, returning to milk very gradually and slowly.

For the more severe types, such as the dysentery containing mucus and blood, everything that has been done for the simple diarrhea should be done; the baby should be kept very quiet, while castor oil should be promptly administered. Food is withheld and the bowels are carefully irrigated after each movement with the salt and soda solutions. After the bowels have moved from the castor oil, then bismuth subnitrate, which has been dissolved in two ounces of water, should be given—one or two teaspoons every three hours. This will naturally turn the bowel movements dark.

Under no circumstances should any other medicines be given without the physician's knowledge, as it is at such times as this that many "would-be friends" advise laudanum, paregoric, and other opiates. The skin must be kept warm, and fluids must replace those that have been carried off in the many stools. Water may be given by an enema, by water drinking, and in such rare cases as cholera infantum, when water cannot be retained on the stomach, it often becomes necessary to inject it under the skin (hypodermoclysis) so that it may go at once to the wasted tissues and perhaps save the baby's life.

Give the baby ten days or two weeks to return to normal condition, and under no circumstances hurry the feeding of milk, as a second attack may occur much more readily than the first; may more profoundly overcome the baby and result in death.

RUPTURE

A protrusion of a loop or portion of intestine through a weakened abdominal muscle—which grows larger when baby cries and smaller when he is lying down in a relaxed condition—is known as rupture or hernia, and is of common occurrence in infancy. It is often seen at the navel and sometimes in the groin as early as the second week.

Hernia is always dangerous and should never be neglected. The physician will protect the navel by a special support with adhesive plaster which is carefully renewed twice a week, and if worn for several months usually entirely corrects the condition. A comfortable truss made from skeins of white yarn will amply protect a groin hernia. The condition should always be taken seriously and receive immediate treatment.

PROLAPSE OF THE BOWEL

Occasionally, as the result of severe straining in constipation, the rectum protrudes sometimes one-half inch, and in rare instances two or three inches. The placing of a young child upon a toilet chair and insisting upon severe straining sometimes results in such a protrusion of the rectum. This may be avoided by the application of vaseline to the rectum or by the use of the gluten or glycerine suppositories which cause the hardened masses to make their way out easily. Someone has suggested that if the buttocks are supported by a board placed over the toilet seat with a two-inch opening so that severe straining of the rectal muscles is impossible, the prolapse of the rectum will not recur.

The moment the mother observes the slightest protrusion of the rectum she should quickly put it back and have the child lie down and move the bowel in the diaper. Very severe cases require a physician's attention, but if prompt and quick measures are taken on the first appearance it may be quickly corrected and serious consequences be avoided.

In this connection we might mention a condition which sometimes babies are born with—the absence of the rectal opening. If the baby's bowels do not move for the first two days, surgical interference is more than likely necessary. Often the external opening alone is missing. Sometimes there is a complete closure or atresia of the lower part of the colon.

BLEEDING FROM THE NAVEL

There should be no hemorrhage from the umbilical stump after it has been properly tied, but occasionally a bit of blood is found upon the dressing and a second tying of the cord stump is necessary. The cord drops off in eight or ten days, and the umbilicus that is left may be moist or it may bleed slightly; if such is the case, great care should be exercised in bathing this ulcer that has been left behind. It simply should be touched with alcohol, a bit of boric acid powder applied, and a small piece of sterile gauze be placed over it. In the course of two or three days it will entirely heal. Care should always be exercised in washing the umbilicus. Extensive hemorrhage from this portion of the body is rare, but it does happen occasionally and is a severe condition which demands surgical attention.

If the umbilicus remains moist and foul smelling, general blood poisoning of the infant may easily follow. Thorough dusting with boric acid powder, with possibly a little oxide of zinc, will usually effect a cure promptly, but should the condition continue, which it does only in rare instances, the doctor may have to cauterize it.



CHAPTER XXVIII

CONTAGIOUS DISEASES

Never under any circumstances knowingly expose a child to any of the so-called "childhood diseases." The old method of "have the child get them as quickly as possible and get over them," has laid the foundation for many chronic disorders later in life. For instance, eye troubles and running ears are often the sequelae of measles; chronic coughs, tuberculosis and bronchitis frequently follow in the wake of whooping cough; heart disorders follow diphtheria, while kidney disease often follows in the course of scarlet fever.

CATCHING DISEASE

Under all circumstances keep the children away from these dangerous childhood diseases. When a contagious disease breaks out in a school and the little fellow has, along with the other pupils, been exposed to it, begin at once systematically to keep the nose and throat very clean with such well-known sprays as the champhor-menthol-albolene spray, which should be used in the nose morning, noon, and night. Throat gargles, such as listerine, or equal parts of alcohol and water, help to keep the throat in condition to resist the microbic invasion.

During this anxious time of patient waiting the bowels should move every day and the food should be cut down at least a third. In other words, moderate eating and a clean bowel tract go a long way toward keeping a child well and preparing him for an attack of disease. The skin at this time should be kept well bathed and free from the accumulated skin secretions which clog up the sweat glands and otherwise lower the vitality.

Stuffy, close rooms, where the ventilation is poor, not only harbor disease germs, but also lower the vitality of the child. Never take your child into a household where there is any form of sickness, for it may turn out to be a contagious disease—no matter how it began, it must be remembered that many contagious diseases, in their earlier stages, much resemble a simple cold.

Measles come on rather gradually, and one might suspect that the child was simply suffering from a severe cold in the head.

Scarlet fever usually begins with a sore throat, while chickenpox has very few initial symptoms; usually the first thing noted is the rash itself. Diphtheria begins with a sore throat, while whooping cough begins very insidiously.

The most important thing is to keep children away from people who are sick, and if a contagious or infectious disease is prevalent in the neighborhood discourage the mingling of the children in hot, illy ventilated rooms. Put a stop to "parties" and all similar gatherings. Let the little folks have good books, plenty of toys, in a well-ventilated room, and the more they keep to themselves at this particular time the better they are off.

THE SPREAD OF CONTAGION

It is possible to "stamp out" any known disease if only proper cooperation takes place and certain sanitary regulations are maintained. It is within the memory of most of our readers when yellow fever was put to flight and the cause of malaria discovered. We learned to screen our camps and no longer did our soldiers contract the fever; while the simple covering of stagnant pools with oil, together with proper screenage, stopped the ravages of malaria.

Likewise, many of the woeful tragedies of infant summer diarrhea and dysenteries have been tracked to the so-called "innocent house fly." We have all learned—only recently—that if we move the manure pile once in seven days the hatching of the maggots may be prevented, and so millions, yes trillions, of these carriers of disease may never be born.

If there is one sweet morsel above another for this fly pest it is tubercular sputum or feces, and from these feasts they go directly to walk over baby's hands, crawl over his cheek, and wash their feet in his milk. Proper screenage will prevent such contamination of food, such opportunities for carrying disease.

Sunshine, hot water, soap, and fresh air, are the best ordinary every-day disinfectants. It is possible so to conduct the treatment of a contagious or infectious disease that no other member of the family may contract it. A few simple but very important hints are:

1. Door knobs are one of the very greatest avenues of contagion—disinfect them.

2. Cleanse the hands both before and after attending to the sick; first, scrub with stiff brush, soap and water, then dip in alcohol.

3. An epidemic of sore eyes may be stopped by absolute "hand disinfection" and using separate towels.

4. Do not go visiting when you have a "common cold."

5. Kissing is one of the best ways of spreading many diseases.

6. In cases of contagious and infectious diseases completely cover all excretions from the body with lime.

7. Country homes would be as healthy as city homes if the privies and stables were screened.

8. In the country, the well water should be boiled; one infected well may be the cause of the death of a score of beautiful children.

INCUBATION PERIODS

The incubation period of scarlet fever is from one to seven days.

Measles, ten to twenty days. Whooping cough, from one to two weeks. Chicken-pox, fourteen to sixteen days. German measles, seven to twenty-one days. Diphtheria, any time from one to twelve days. Mumps, from one week to three weeks.

Of all the diseases, measles and chicken-pox are probably the most contagious. In scarlet fever and diphtheria, close contact is necessary for exposure, while whooping cough can actually be contracted in the open air, young babies being particularly susceptible.

TYPHOID FEVER

Typhoid fever is a disease of the small intestine. Typhoid germs accumulate in the little lymph nodes of the small intestines and that is the reason why we often have so many hemorrhages from the bowel—actual ulcerations take place—and if an ulcer is situated in the neighborhood of a blood vessel hemorrhage may result.

Typhoid fever begins rather insidiously with a slight debility and loss of appetite, but if a temperature record is kept the fever will be found to rise from one-half to a degree higher each day. A steady climb in the temperature curve is noted until the end of the first week, when it remains for a week, possibly 103 or 104 F. After one week it begins slowly to decrease and, if all goes well, the early part of the fourth week usually finds the temperature about normal. It is exceedingly important that the child be kept in bed during the entire course of the disease. The bed pan must be used at each bowel movement or urination.

First Week Treatment. During this week the child may feel quite well, but he should be kept in bed and sustaining treatments begun—such as wet-sheet packs and cold frictions to the skin (during which time there should always be external heat to the feet). The diet must be full and nourishing, but all pastries and "knicknacks" should be avoided. Abundance of fresh fruit that has been well washed before paring, eggs, pasteurized milk, baked potatoes, and toasted bread may be taken at regular periods—with an interval of not less than five hours between meals.

The bowels should be opened in the beginning of the disease with a liberal dose of castor oil, after which daily colonic irrigations should be employed. These enemas should be given at least once a day, the temperature being about that of the body, with a smaller terminal enema about five degrees cooler at the close of each bowel cleansing.

Second Week Treatment. The normal temperature at this time is no longer 98.6, it is 101.5 F. This fever is essential to the curative and defensive processes of the body; and while we do not care to have the fever fall below 101.5, at the same time nothing is to be gained by allowing the fever to go up much above 102.5 or 103 degrees F. And so, during the second week, while the disease is at its height, we make frequent use of the wet-sheet pack, always remembering that the extremities must be kept warm and never permitting the skin to become blue or mottled while the cold treatment is being administered. Since the real disease is localized in the small intestine, we will now describe a very important treatment for the diseased bowel—and one which is also very useful in combating high temperature.

The Cooling Enema. The temperature of this enema begins one degree higher than that of the body (supposing the body temperature to be 103, the temperature of the enema would start at 104 F.). This is allowed to flow into the colon and out again, under low pressure, without disturbing the patient, by means of a glass tube connection (See Fig. 15). The temperature is quickly brought down to 100, then to 98, then to 90, usually finishing up at 80 or 85 F. The water is allowed to enter the rectum slowly through a soft rubber catheter (not a hard rectal point), and as it comes out it will be noted that the water is very warm, sometimes registering 105, and it is needless to add that if the water goes in at 80 and comes out at 105 F., much heat has been taken from the body; and so, of all the treatments we have to suggest for typhoid fever, the one just mentioned is possibly the most important. When it is necessary to keep up this enema for an hour or two, the cool water may cramp the bowels, but this may be entirely obviated by applying hot compresses to the abdomen.

Another treatment of great importance in this second week is the cold abdominal compress. Much fever is occasioned in the abdomen because it is the seat of disease, and the much dreaded hemorrhages which often cause the death of the patient are usually avoided by the use of abdominal compresses—wrung out of water at 55 F.—the temperature of ordinary well water—and changed every twenty minutes.



I recall one mother in my dispensary practice who was so poor she could not afford a nurse, her only helper being a son twelve years old. A nurse went to the house twice each day and taught this lad of twelve years to give his mother the cooling colonic irrigation; he was also taught to warm up the abdomen by a hot application and afterwards to apply the cold compresses. The mother made a good recovery.

During this second week the diet should be sustaining. It should consist of boiled milk, eggs, fresh fruit and fresh fruit juices, dextrinized grains (hard toast, toasted corn flakes, shredded wheat biscuits, etc.). The mouth should be kept scrupulously clean, for in all the infectious and contagious diseases there is always the possibility of gangrene in the mouth if it is neglected.

Third Week Treatment. This is the week we look for hemorrhage from the bowel unless the abdomen has been well treated during the second week; and even so, the cool compresses to the abdomen will be continued well into the third week—also the daily or semi-daily enema. The skin is kept in good condition with soap washing and friction baths, and a fairly liberal diet is maintained. During the whole course of the disease the skin is never allowed to get blue or mottled, being quickly restored to the normal red color by the mustard sheet bath, the short hot-blanket pack, or the dry-blanket pack with hot-water bottles. Under no circumstances let the child leave the room or his bed for at least another week.

MUMPS

Infants are rarely affected with mumps. It is a disease of the salivary glands and (as a rule) is usually preceded by pain between the ear and the angle of the jaw, accompanied in a short time by swelling and temperature. It is distinctly contagious even during the incubation period. There is much tenderness on pressure, and chewing is difficult and may be impossible. It usually occurs on the face and only one side may be affected. The bowels should be kept open, the mouth should be kept clean, and the side of the face should be protected by a layer of cotton held in place by bandages.

Hot fomentations may be applied if the pain is severe. The electric light bulb on an extension cord, that was mentioned in connection with earache, is very comforting in this condition.

Isolation should be maintained for ten days or two weeks after all symptoms have disappeared.

SCARLET FEVER

Scarlet fever is one of childhood's most dreaded diseases because of, first, its long quarantine; second, its terrible possibilities of contagion; and, third, its sequelae.

Absolute quarantine is necessary until ten days after the last signs of desquamation have disappeared.

This disease is always alarming because of the possibilities of its sequelae—the danger of pneumonia, inflammation of the ears, abscesses of the glands of the neck, and nephritis (inflammation of the kidneys).

Scarlet fever is highly contagious at any time during its onset and course. Among the first symptoms of the disease are sore throat, swollen glands, fever, etc. Vomiting on a street car or at the movie may spread the disease to more than one child who might otherwise have escaped. One child who may have only a very light form of the disease may give it to another child in the most severe form. Any such group of classic symptoms—vomiting, fever, rapid pulse, and sore throat—should cause any parent immediately to isolate the little sufferer for several days—awaiting the "rash"—which usually puts in its appearance after three or four days of increasing temperature.

This rash has an appearance "all of its own," unlike any other. Because the fine "meal-like" red points are in such close proximity, the skin assumes a smooth "lobster red" color that is never to be forgotten. After three days of increasing redness, the color begins slowly to fade, and after four or five days of this fading a peculiar peeling takes place, whose scales vary in size from a small fleck to casts of the whole of the soles of the feet and the palms of the hands.

During the height of the disease, the throat is very red, the tonsils are not only inflamed, but covered over with white patches, the head aches and the tongue possesses a peculiar coating through which peep the red points of the swollen papillae, presenting the classic "strawberry tongue" of scarlet fever.

After ten days the fever disappears and the "real sick" stage of the disease is in the past.

Each morning of the ten previous days a small dose of Epsom salts is usually administered and the itching, which so often accompanies the rash, is relieved by carbolized-water sponge baths.

The nose, throat, and ears receive daily care—sprays to the nose and gargles to the throat, as well as special swabbing to the tonsils.

The physician in charge of the case will note the urinary findings, guard the heart and kidneys, prevent the spreading of the scales of desquamation by frequent rubbing of the skin with oil, and otherwise work for the future well-being of the patient.

MEASLES

Measles, one of the most common diseases of childhood, is not to be regarded lightly, for very often its sequelae—running ears, weak eyes, and bronchial coughs—may prove very serious and troublesome. Tuberculosis of the lungs not infrequently follows in the wake of measles. The early symptoms of measles are so mild that often the child is out of doors, at school, or about his usual play, until the second or third day of the fever. He was supposed merely to be suffering from a simple "cold in the head."

On the third or fourth day the patient begins heavy sneezing and wears a stupid expression; and it is then that the mother ascertains that his temperature is perhaps 101 to 102 F. He is put to bed and the next day the rash usually appears. The rash is peculiar to itself, not usually mistaken for anything else, being a purplish red, slightly elevated, flattened papule, about the size of a split pea. The coughing, which is very annoying, usually remains until about the seventh or eighth day—at which time the fever also disappears.

The bowels must be kept open; a daily bath be given—in which has been dissolved a small amount of bicarbonate of soda (simple baking soda)—after which an oil rub should be administered. The nose should be frequently sprayed with three per cent camphor-menthol-alboline spray, while the throat is gargled with equal parts of alcohol and water. The feet should be kept warm by external heat, while the physician in charge may order additional attention to the chest, such as a pneumonia jacket, etc.

Care should be taken to guard against "catching cold," for bronchitis or pneumonia is quite likely to develop in many cases of measles. The eyes should be protected by goggles and the room should be darkened; under no circumstances should the little patient be allowed to read. Carelessness in this respect may mean weakened eyesight all the rest of his life. Until two weeks after the rash has disappeared, the little fellow should be kept by himself, for the desquamation keeps up almost continuously during this time.

The food during the course of the disease is a liquid and soft diet. Children should never be allowed to go to a party or gathering with a cold in the head; the mothers of a group of small children will never forget the time that one certain mother allowed her little fellow to attend a party with "simply a cold in the head." He laughed, talked, and sneezed during the afternoon and when he went home the rash appeared that night, while eight of the ten exposed children came down with measles during the next two weeks.

CHICKENPOX

The incubation period of chickenpox is from ten to seventeen days. It is a mild disease, with a troublesome rash consisting of widely scattered pimples appearing over the scalp, face, and body. These pimples soon became vesicles (small blisters), which in turn quickly become pustular, afterwards drying up with heavy crust formation. Severe itching which attends these pustules may be greatly allayed by either the daily carbolic-acid-water bath or a baking-soda bath. The itching must be relieved by proper measures, for if the crust is removed from the top of the blebs by scratching, a scar usually results. The bowels should be kept open, the diet should be soft. Rigidly isolate, for chickenpox is highly contagious.

SMALLPOX

This disease occurs oftenest during the cold season. It spares no one unless vaccinated, attacking children and adults alike. The early symptoms are: headache, pain in the back, high fever, vomiting, and general lassitude. In many respects these resemble the symptoms of the grippe, while on the third day the eruption appears. The pimples are hard and feel like shot under the skin. Within a day or two these shotlike pimples have grown and pushed themselves beyond the skin into little conical vesicles which soon turn to pus. By the eighth or ninth day crusts are formed over the vesicle, beginning to fall off about the fifteenth day.

Patients are quarantined usually eight weeks and when a case of smallpox in the home breaks out everyone in the family should be revaccinated. The strictest isolation is important from the first of the disease.

We will not enter into the treatment of smallpox, for medical aid is sought at once and usually the patient is removed to a special isolation hospital.

VACCINATION

The history of the change brought about in the Philippines since vaccination has been introduced is an argument of itself which ought to convince the most skeptical of the value of vaccination. By all means, every child in a fair degree of health should be vaccinated. It is wise to vaccinate babies before the teething period—from the third to the sixth month. Babies with any skin trouble or suffering from malnutrition, but not living in a smallpox district, should be vaccinated during the second year. In young babies, under six months, the leg is the proper place to receive the vaccination.

If proper surgical cleanliness is practiced and ample protection is afforded in after dressing, vaccination need not be a taxing process. The child suffers from general lassitude—a little drowsiness with loss of appetite and a small amount of fever—but this passes off in a reasonable length of time, especially if he is not overfed and his bowels are looked after. On the second or third day after vaccination a red papule appears which soon grows larger, and, after five or six days, it becomes filled with a watery fluid. By the tenth day it has the appearance of a pustule about the size of a ten-cent piece, surrounded by a red areola about three inches in diameter. At the end of two weeks the pustule has dried down to a good crust or scab, in another week it falls off, leaving a pitted white scar.

If the vaccination does not take, it should be repeated after an interval of two months.

DIPHTHERIA

Diphtheria is a disease much dreaded during childhood and adolescence. It may attack any age—even little babies are susceptible. It begins with a general feeling of heavy, drowsy lassitude with a sore throat. White spots appear on the tonsils which may resemble a simple follicular tonsillitis, while in a short time white patches spread over the throat and tonsils.

It is not at all uncommon for this membrane to attack the nose, producing a bloody, pustular discharge; and when it does attack the nose, it is none the less contagious and must be regarded just as seriously. A physician is called at once, and, not only to the child, but to the other members of the family, antitoxin is immediately administered. The disease runs a regular course and its most dangerous complication is the membrane which forms in the larynx and threatens to suffocate the child unless prompt intubation is performed—the slipping of a silver tube in the larynx to prevent suffocation and death. The early use of antitoxin greatly lessens all these serious complications.

Care must be exercised to prevent sudden heart failure; and this is done by raising the child to an upright position with the utmost care; while you insist upon him lying quietly upon his back or his side, long after the disease has left his throat. While the throat or nose is the seat of disease, the toxins from these most dreaded diphtheritic microbes spread through the lymph channels and the blood vessels to the heart itself—so weakening that organ that it sometimes suddenly fails, or becomes more or less crippled for life. These serious results are to be prevented by the science of good nursing and the prompt use of antitoxin. In these days the "Schick test" may be administered for the purpose of ascertaining whether one is susceptible to contracting diphtheria.

A physician is always in charge of diphtheria, and he will supply directions for the bowels, the diet, and the sprays for the nose and throat, and the general well-being of the suffering child. Isolation and quarantine should continue for two weeks, and in bad cases three weeks, after the membrane has disappeared from the throat.

WHOOPING COUGH

A child suffering from a continuous cough, particularly if it is accompanied by a whoop or a condition which is so often seen in children who cough—not able to stop—should not be taken to church, nor to the movies, nor allowed to go to school; neither should he be allowed to leave his own yard. The average duration of the disease is usually six weeks. The child should have an abundance of fresh air, should spend much of his time out of doors, and while in the house should avoid dust of every kind; at night he should not be exposed to drafts. Call the physician early in the case and he may attempt to thwart the progress of the disease by certain administrations of vaccine medication.