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Hygiene of the Nursery.

Chapter I.

The Features of Health.

Every ill child presents certain well-defined alterations in the manner of performance of the various functions of his body. Thus, the pulse and respiration may be altered in character and frequency; the surface temperature may be elevated; the color and condition of the skin may be changed; the appetite may be diminished; weight may be lost; and so on. These alterations from the normal state are termed symptoms.

Healthy children, on the other hand, as uniformly show evidences of their well-being, which, for want of a better name, may be called the features of health. Of these, every mother should have a full knowledge, so that by appreciating variations she may anticipate the complete development of disease, and early summon skilled aid, at the time when it is of most service.

Early life must be divided into two periods, namely, infancy and childhood. Infancy is the time elapsing between birth and the complete eruption of the milk teeth, an event that transpires about the end of the second year of life. Childhood extends from this age to the development of puberty, or to the age of thirteen or fifteen years. It is important to remember these two divisions, as frequent reference will be made to them in the subsequent pages.

With this brief preparation, the study of the features of health may be entered upon.

1. The Face. -- The face of a healthy, sleeping child wears an expression of absolute repose. The eyelids are completely closed, the lips very slightly parted, and, though a faint sound of rhythmical breathing may be heard, there is no visible movement of the nostrils. When awake and undisturbed, the healthy infant's face has a look of wondering observation of whatever is going on around it. As age advances, intelligence gradually supplants the wondering gaze, and no one can be unfamiliar with the bright, round, happy face of perfect childhood, so indicative of careless contentment, and so mobile in response to emotions.

Examples of Variations in Disease. -- Incomplete closure of the eyelids, rendering the whites of the eyes visible during sleep, is a symptom in all acute and chronic diseases of a severe type; it is also to be observed when rest is rendered unsound by pain, wherever seated. Twitching of the eyelids, associated with oscillation of the eyeballs or squinting, herald the visit of convulsions. Widening of the orifices of the nose with movements of the nostrils to and fro, point to embarrassed breathing from disease of the lungs or their pleural investment. Contraction of the brows indicates pain in the head; sharpness of the nostrils, pain in the chest, and a drawn upper lip, pain in the abdomen. To make a general rule, it may be stated, that the upper third of the face is altered in expression in affections of the brain; the middle third in diseases of the chest, and the lower third in diseases of the organs contained in the abdominal cavity.

2. The Skin and General Appearance. -- In the new-born infant the color of the skin varies from a deep to a light shade of red. After the first week this redness fades away, leaving the surface yellowish-white. At times this yellow color is so marked that it might be mistaken for jaundice were it not that the whites of the eyes remain perfectly pearly, which is never the case in the disease mentioned. After the second week all discoloration disappears and the skin assumes its typical appearance.

With certain well-known natural variations in complexion the skin of a healthy child is beautifully white and transparent. The cheeks, palms of the hands and soles of the feet have a delicate pink color, while the general surface is rosy in a warm atmosphere and marbled with faint blue spots or lines in a cold one. As age advances the coloring becomes more pronounced, and until the completion of childhood the complexion is much fresher than in adult life.

Other characters of the healthy skin are, a velvety smoothness and softness, a scarcely perceptible moisture, and a great degree of elasticity.

If an infant be stripped the large size of the head and trunk, and the relatively short arms and even shorter legs, will strike the observer at once. This disproportion, especially noticeable in the head, is an actual one. For if in a child of one year, for example, the distance from the lower edge of the chin to the top of the head be measured, it will be found to be equal to one-fourth of the entire length of the body. The vertical length of the head, too, falls but little short of that of the trunk, and the latter in turn is nearly as long as the legs.

Again, the abdomen is full and prominent, making the chest look, in comparison, rather contracted and narrow, and the navel is less deeply sunken than in adults.

These features, which will be referred to more minutely in a later section, are most marked in young infants, and undergo gradual alterations as growth progresses and the child develops into the lithe, active youth or maiden.

The shape of the head varies greatly between the round, bullet form and the elongated oval one. When it has been subjected to much pressure, instrumental or otherwise, during delivery, it is often so distorted as to shock the expectant mother. Little fear of permanent disfigurement need be entertained, however, as the deformed head usually assumes a natural shape in time. The same is true of less noticeable depressions, prominences and irregularities. But it should be remembered that restoration to symmetry must be left entirely to nature, as any attempt to mould the skull by pressure rarely fails to injure the delicate brain beneath.

The anterior fontanelle, or, as it is called by nurses, the "opening of the head," is readily seen and felt in infants under a year old. In the normal state it is level with, or very slightly depressed below, the surrounding bones of the skull, and may be observed to pulsate, or rise and fall, rhythmically. It is soft to the touch and yields readily to pressure.

Examples of Variations in Disease. -- Lividity of the eyes and lips is a sign of imperfect oxidation of the blood, and points to disease of the heart or lungs. A decided yellow color of the skin and whites of the eyes is seen in jaundice; an earthy tinge of the face, in long-standing disease of the bowels; a waxy pallor in kidney disease, and paleness in any acute or chronic affection attended by exhaustion.

Marked squareness of the head with projection of the forehead, a widely-open fontanelle, and a relatively small face indicate rickets. A very large, globular head is characteristic of hydrocephalus or "water on the brain;" bulging of the fontanelle is also a symptom of this disease. In this connection it must be observed, however, that certain children are born with relatively large, globe-shaped heads, though in every respect healthy. The peculiarity is especially apt to be observed when one of the parents -- notably the father -- has the same characteristic. In order to indicate disease, the deformity must be marked and combined with a widely-open, bulging fontanelle, or with indications of impaired brain activity. Depression of the fontanelle shows general debility and the need of food or stimulants.

The accompanying diagram, Figure 1, will aid in explaining this subject.

Great distension of the abdomen is usually due to an accumulation of gas in the intestines, and indicates disease of this portion of the digestive tract; marked depression, on the other hand, is encountered in serious brain affections, in cholera infantum, inflammation of the intestines and dysentery.

3. Development. -- To be robust the newly-born infant must have a certain average length and weight. The length varies between sixteen and twenty-two inches, and the weight between six and eight pounds.

From the first day, growth or increase in height and weight, steadily progresses, according to certain definitely fixed rates.

Length increases most rapidly during the first week of life; afterward the process is almost uniform up to the fifth month, and then it becomes less rapid, although still uniform, until the end of the twelfth month.

These facts may be seen in the following table: --

Age

Length

Birth

19.5 inches

1 month

20.5 "

2 "

21. "

3 "

22. "

4 "

23. "

5 "

23.5 "

6 "

24. "

7 "

24.5 "

8 "

25. "

9 "

25.5 "

10 "

26. "

11 "

26.5 "

12 "

27. "

During the second year the increase is from three to five inches; in the third from two to three and a half inches; in the fourth from two to three inches, and from this age up to the sixteenth year the average annual gain is from one and two-thirds to two inches.

In the first three days of life there is always a loss of weight, but by the seventh day the babe should have regained weight and be as heavy as at birth. The period of most rapid weight gain in this respect is during the first five months of life. The maximum is attained during the second month, when the increase is from four to seven ounces each week. Throughout the next three months the increase amounts to about five ounces per week, and in the remaining months of the year, from two to five ounces.

The subjoined table shows the average rate of gain: --

Age

Weight

Birth

7 pounds.

1 month

7 3/4 "

2 "

9 1/2 "

3 "

11 "

4 "

12 1/2 "

5 "

14 "

6 "

15 "

7 "

16 "

8 "

17 "

9 "

18 "

10 "

19 "

11 "

20 "

12 "

21 "

From the first to the tenth year there should be a yearly gain of at least four or five pounds, and after, to the sixteenth year, of about eight pounds in the same period.

Parents frequently over-estimate the weight of their children by placing them upon the scales when completely dressed. To be accurate, the weight of the clothing must be subtracted. This may be estimated at about three pounds for a child of three to five years, four pounds for one of eight years, and eight pounds at fifteen years.

Another reliable evidence of the proper progress of development is the increase in the girth of the chest. Taking an infant weighing seven pounds and measuring nineteen and a half inches at birth, this should be a little over thirteen inches. By the fourth month it should be increased to fifteen inches; by the sixth, to sixteen; by the twelfth, to about seventeen; by the fifth year to twenty-one, and by the sixteenth year to thirty.

As already mentioned, the proportions of the different members of the frame in infancy differ materially from those of adolescence.

Primarily the head and secondarily the body are large when compared with the arms and legs, but in the progress of healthy development this disproportion is gradually lessened until the perfect human figure is attained. This process, however, does not affect all parts of the body equally, as may be seen in the accompanying diagram.* (Fig. 2.)

The description is so well put in the journal from which this figure is taken that I cannot do better than quote it word for word.

"The six figures represent the average relative stature of males of the ages of one, five, nine, thirteen, seventeen, and twenty-two years. It will be noticed that the figures all stand on a level plain. The tops of the heads are connected by a dotted line, and the height of each figure is divided into four equal parts, the points of division being connected with the corresponding ones in each figure. If the rate of growth were uniform the dotted lines connecting the heads would, of course, be straight if a child for every year were included in the rank. But in the earlier years the growth is much more rapid than it is later, and hence the line is a curve, rising quite suddenly at the first, and becoming flatter toward the end of growth. It is to be understood that these are all averages -- including, but not showing, the extremes of slowness and rapidity of growth as well as fitfulness of growth. The diagram also shows the different development of different parts of the person. The head, for instance, in the child of one year is nearly one-fourth of the whole height; that of the adult is about two-thirteenths, or, to use the phrase of artists, the little child is not much more than four heads high, while the adult of twenty-two is about six and one-half heads high; and even this is a much larger head than the average adult has. Notice that the third dotted line, marking one-half of the total height, crosses the navel in the infant, while in the adult the half height mark is but little above the juncture of the legs and body, which shows how much larger, proportionately, the body of an infant is than an adult's. If this same line be followed it will be noticed that it keeps well up in the abdomen until after the age of nine. Between that age and puberty the growth of the lower extremities is usually very rapid, and the well-known "shooting up" of boys and girls takes place, the whole person growing, but the lower part in particular. Similar changes of location will be noticed by following the quarter lines, but the changes are not so abrupt."

It may be well to mention here that children will often remain, for a considerable time, almost stationary in height, and then have periods of very rapid growth. The latter is often to be observed in the ninth and tenth year, and again at the approach of puberty. Variations in weight-gain are also often to be observed; these seem to hold a definite relation to the fluctuations in the rapidity of height increase.

Besides these points, which are the most reliable evidences of the proper progress of development, there are certain features that appeal more directly to the notice of parents, and on this account deserve consideration. The age at which a child sits erect, at which it creeps, walks or talks, are instances of the class of features referred to.

The head can usually be held erect by the end of the third month and the body maintained in the sitting posture a month later. By the sixth month the infant can sit up with ease, accomplish many movements with the arms, hands, and fingers, and enjoy playthings. At the eighth month he may be able to creep; by the ninth or tenth, to drag himself upon his feet with the assistance of his hands and arms and some artificial support; by the eleventh, to walk with assistance; by the fourteenth, to walk alone, and by the eighteenth, to run.

At eight months an infant will imitate sounds and articulate several syllables; at ten, can often speak one or two words, and after twelve months is able to join several words together.

The anterior fontanelle should be completely closed at some period between the fifteenth and twentieth months.

Tears being to be secreted during the third or fourth month, and saliva, between the fifth and sixth.

After birth both hair and eyes often change color as age advances. When an alteration takes place in the eyes, it begins about the sixth or eighth week and may be to either a lighter or darker hue. Changes in the hair begin later, the tendency always being to darken, and the most marked alteration occurring between the seventh and fourteenth years.

Examples of Variations in Disease. -- If on being measured and weighed, a child be found to fall short of the normal standard for its age, and if, at the same time, there is a want of plumpness of body, roundness of limb, and firmness of flesh, the existence of some fault in diet or in the digestion and absorption of food must be inferred.

A delay in walking may be due to general feebleness or to paralysis of the muscles of one or both legs, and a limping gait with pain in the knee suggests hip-joint disease.

Closure of the fontanelle is retarded by the disease called rickets, and also by hydrocephalus and constitutional syphilis.

It is well to be cognizant of the fact that girls develop more rapidly than boys, and that the second or later children of the same family, by imitating their elders in the nursery, learn to talk and walk earlier than those who are born first.

4. Position and Gestures. -- The complete repose depicted on the countenance of a sleeping child when free from illness is shown also by the posture of the body. The head lies easy on the pillow, the trunk rests on the side, slightly inclined backward, the limbs assume various but always most graceful attitudes, and no movement is observable but the gentle rise and fall of the abdomen in respiration. In the waking state, the child, after early infancy, is rarely still. The movements of the arms, at first awkward, soon become full of purpose as he reaches to handle and examine various objects around him. The legs are idle longer, though these, too, soon begin to move about with method, feeling the ground, in preparation, as it were, for creeping and walking.

Examples of Variations in Disease. -- Restless sleep with a desired to be rocked, fondled or "walked" in the nurse's arms, are common symptoms of acute attacks of illness, especially when attended by pain. Children beyond the age of infancy toss about uneasily in bed or demand a change from the bed to the lap, under similar circumstances. Extreme and long-continued drowsiness and quietness, on the other hand, often precede the onset of such specific fevers as scarlatina or measles.

Sleeping with the head thrown back and the mouth open indicates enlarged tonsils; a tendency to "sleep high," or with the head and shoulders elevated by the pillow accompanies disease of the heart and lungs, and "sleeping cool," that is, resting only after the bed clothing has been kicked off, is an early symptom of rickets.

Frequent carrying of the hand to the head, ear or mouth shows headache, earache, or the pain of a coming tooth, as the case may be, while constant rubbing of the nose is a feature of irritation of the bowels or stomach.

Should the thumbs be drawn into the palms of the hands, and the fingers tightly clasped over them, or if the toes be strongly flexed or extended, a convulsion may be expected.

5. The Voice. -- Crying is the chief if not the only method that the young infant possess of making known his displeasure, discomfort or suffering, and affords almost the sole means of determining the characters of the voice at this early age. Again, even long after the powers of speech have been developed, the cry continues to be the main channel of complaint.

One rarely hears a healthy child cry, unless a harsh word, a fall or a blow cause a passing storm of grief, anger or pain. Hence, frequent, peevish crying points to some disturbance of the healthy balance.

The sound of the voice, whether in crying or speaking, should have a clear ring, without either muffling, hoarseness or nasal tone. Weeping should accompany crying, after the establishment of tear secretion. Cough, although not a normal vocal sound, is also worthy of attention.

Examples of Variations in Disease. -- Incessant, unappeasable crying is usually due to earache or hunger; it frequently, too, is caused by the constant pricking of a badly adjusted safety pin or other mechanical irritant.

If crying occur during an attack of coughing it is an indication of some painful affection of the chest; if just before or after an evacuation of the bowels, of intestinal pain.

When the cry has a nasal tone it should suggest swelling of the lining membrane of the nose, or other obstructing condition. Thickening and indistinctness occur with throat affections. A loud, brazen cry is a precursor of spasmodic croup, and a faint whispering cry of true or membranous croup. Hoarseness points to disease of the lining membrane of the larynx, either catarrhal or syphilitic in nature.

Finally, a manifest unwillingness to cry can be seen in pneumonia and pleurisy, when the disease is severe enough to interfere materially with breathing.

Tear-secretion having been established, it is a bad omen if the secretion be arrested during the progress of an illness, but an equally good one if there be no suppression, or if there be a reëstablishment after suppression.

The cough, like the voice, may be brazen in spasmodic croup, hoarse in laryngeal catarrh, and suppressed in true croup. The qualities "tightness" and "looseness" are readily appreciated and give a good idea of the progress of lung affections, especially bronchitis, the former being an evidence of the beginning, the latter of the favorable termination of an attack.

Cough is always unproductive, that is, unattended by expectoration, in children under seven years of age.

6. Mode of Drinking and Swallowing. -- By watching an infant taking the breast or bottle, some information can be obtained of the condition of the mouth and throat, and of the respiratory organs.

A healthy child drinks continuously without stopping to breath, and swallows easily.

Examples of Variations in Disease. -- If there be any soreness of the mouth the nipple will be held only for a moment and then dropped with a cry of pain. When the throat is affected in infants, swallowing is performed with a gulp and an expression of pain passes over the face, and no more efforts are made than to satisfy the first cravings of hunger. Older children, under similar circumstances, drink little and refuse solid food.

An infant suffering from the oppressed breathing of pneumonia or severe bronchitis, seizes the nipple with avidity, swallows quickly several times and then pauses for breath. In older children the act of drinking, which should be continuous, is interrupted in the same way.

If the finger be put into the mouth of a healthy baby it will be vigorously sucked for some little time. Diminution of this act of suction during a severe illness is a sign of danger; its reéstablishment a good omen. In conditions of stupor it is noticeably absent.

7. Appetite. -- Hunger and appetite must not be regarded as synonymous terms. The former is the craving of all the tissues of the body for nutritive material, or food, and is expressed by a sinking or craving sensation in the stomach. The latter, on the other hand, although it is certainly an attendant of hunger, is simply a sensation of the desire for something with a food-taste, having its seat in the mouth and surrounding parts. Appetite having its post, as it were, at the entrance of the stomach, may be regarded as a gate-keeper to supervise everything presented for entrance and to reject all that may be injurious either to the stomach of the general economy.

Like its analogue the gate-keeper, the trustworthiness of the appetite may be destroyed by over-indulgence and bad habits. Under the last head come the constant administration of too much or too little food, the use of over-rich food and irregularity in meal hours.

A healthy appetite -- that is one that leads a child to consume with enjoyment the food set before him -- may be encouraged by muscular and mental exercise; by contentment; by regular habits as to the hours of eating; by the use of plain food only; and by varying the food, in a greater or less degree, according to the age. If the quantity of food consumed at the regular meals does not come up to the parent's standard of sufficiency, it does nothing but harm to resort to too dainty feeding and to an encouragement to eat between meals.

There can be no question that a good appetite is a useful as well as a pleasant faculty for a child to possess, for there is no doubt that food eaten with relish is much better digested and therefore more serviceable in nutrition than that which is simply crowded into the stomach.

Examples of Variations in Disease. -- Loss of appetite is encountered in febrile attacks and in acute disorders of the stomach. Inordinate appetite, on the contrary, is usually met with when too strong food has been administered. Here the increased hunger is due to the fact that the food administered, while it may be very rich in nutritive properties, is ill-adapted to the delicate digestive power of early life, and thus, by not being properly prepared for absorption, places the child in the anomalous position of starving in the midst of plenty. In more advanced children gluttony may depend upon gastric irritation, a condition which often leads older and presumably wiser heads to over-indulgence at table.

8. Eructation. -- Eructation or regurgitation is readily produced and of frequent occurrence in infancy, on account of the vertical position and more cylindrical outline of the stomach at this period of line.

Babies suckled at a freely-secreting breast often eructate, though they may be in the best possible health. In these cases, the supply of food being large, the infant, as it lies at the breast, is apt to draw more than it needs and more than it can digest, and the stomach, through a wise provision of nature, rids itself of the superabundance by the simple act of regurgitation. In this process, which in reality is an evidence of health, there is no violent muscular effort, as in retching or vomiting, nor any evidence of nausea, and the material ejected is the breast milk alone, either entirely unaltered or slightly curdled.

In older children, expulsion of the contents of the stomach, or vomiting, may also occur after the stomach has been overladen. If the act be followed by relief from a feeling of general distress, headache and pain in the upper abdomen, it is not to be regarded as a symptom of disease.

Examples of Variations in Disease. -- Vomiting, with its violent muscular effort and the attendance of the train of symptoms embraced under the term nausea -- namely, paleness, languor, faintness, and an increased secretion of saliva -- occurs in many different conditions. It may indicate disease of the stomach, of the intestines, of the lungs or their pleural investment, and of the brain; or it may be an initial symptom of one of the eruptive fevers, scarlet fever or measles, for example, which condition, when existent, can only be determined by closely observing the special case.

The character of the material ejected from the stomach is more definite. Thus, the expulsion of mucus is a symptom of gastric catarrh. The regurgitation of mouthfuls of curdled milk, partly digested food and liquid, so sour that it causes a grimace to pass over the face, is an indication of dyspepsia with fermentation and the formation of an irritant acid. The appearance of lumbricoid worms in the vomit, a not very infrequent occurrence, shows, without dispute, the existence of these parasites in the digestive canal.

9. The Faecal Evacuations. -- The daily number of evacuations of the bowels natural for a child varies greatly with its age. For the first six weeks there should be three or four movements every twenty-four hours. After this time up to the end of the second year, two movements a day is the normal average. Subsequently, the frequency is the same as in adults -- once per diem -- though two or three movements in the same interval may occur, especially after over-feeding or after eating food difficult of digestion, and must be looked upon as conservative rather than as the evidence of ill-health.

During the first period the passages have the consistence of thick soup, are yellowish-white or orange-yellow in color, with sometimes a tinge of green; have a faint faecal, slightly sour odor, and are acid in reaction. In the second, they are mushy or imperfectly formed, of uniform consistence throughout, brownish-yellow in color, and have a more faecal odor. The last two characters become more marked as additions are made to the diet. After the completion of the first dentition the motions have the same appearance as in adult life; they are formed, are brownish in color, and have a decided faecal odor.

Examples of Variations in Disease. -- Many alterations occur in disease. The frequency of the movements may be increased, constituting diarrhea, or lessened, constituting constipation. In the former condition the consistency is diminished; in the latter, increased. Instead of being uniform throughout, the movement may be mixed, partly liquid, partly solid, indicating imperfect digestion, and curds of milk or pieces of undigested solid food may be mingled with the mass. Flaky, yellowish or yellowish-green evacuations, containing whitish, cheesy lumps, are also met with in cases of indigestion. Scanty, lumpy evacuations, dark brown or even black in color, and mixed with mucus, are characteristic of intestinal catarrh. Doughy, grayish, or clay-colored motions show an inactive liver. An intermixture of blood, altered blood clots, and shreds of mucous membrane, indicate ulceration of the intestinal lining, such as occurs in intestinal inflammation, typhoid fever, dysentery and tubercular disease. Watery, almost odorless passages occur in the latter stages of summer complaint; most offensive, carrion-like motions, in both catarrhal and tuberculous ulceration of the intestines, and sour-smelling evacuations in the diarrhoea of sucklings. The discovery of worms in the movements is the only certain evidence of the existence of intestinal parasites.

This mere outline of the changes that may take place will serve to show how much may be learned from the evacuations, and the importance of preserving them for the physician's inspection.

10. The Urine. -- It is impossible to make a definite statement as to the number of times the urine is voided by a healthy infant in each twenty-four hours. In any given case the frequency will differ very much from day to day, depending upon the temperature of the surrounding air and the amount of moisture that it contains. Sometimes it will be necessary to change the napkin every hour during the day and three or four times at night. Again, it may remain dry for six, eight, or even ten hours. Neither condition indicates disease. If, however, the urine is not passed for twelve hours, a careful examination should be made.

Between these two extremes there is a wide range of variation.

As the child grows older the frequency diminishes, and at the age of three years the number of voidings will be reduced to six or eight during the waking hours, and perhaps one at night. When the desire does arise during sleep, the child, if in a normal state, wakes up and demands the chamber, and never passes urine unconsciously. Wetting the bed, therefore, or the involuntary passage of the urine during sleep, is indicative of an abnormal condition and requires investigation. From a few observations, I am led to believe that the quantity of urine voided by healthy children from the fourth to the seventh years is not nearly so large as supposed; eighteen to twenty ounces being the average in several cases in which I have lately made measurements.

The urine of an infant, while it wets, should not stain the napkin.

Examples of Variations in Disease. -- In certain cases of bad digestion the urine becomes very concentrated and high-colored, and gives a light yellow tinge to the napkin. When the stain is decidedly yellow, jaundice is indicated, and other symptoms of this condition should be looked for.

In older children a high-colored urine, and one which deposits a whitish or purplish sediment on standing, is symptomatic of acute digestive disorder, either catarrhal in its nature, or secondary to some acute febrile affection. A smoky, blackish hue, looking as if there had been an admixture of soot, is characteristic of the acute kidney disease that often follows in the wake of scarlet fever; in this state, too, there is a great diminution in the amount passed.

Painful urination points to inflammation of the urethra, a narrow orifice, a highly acid condition of the excretion, or stone in the bladder.

11. The Respiration. -- In adults there are two well-marked types of respiration, viz., the abdominal and the superior costal. The abdominal -- met with in perfection in adult males -- is the type in which the movements of inspiration and expiration are performed by the muscles of the abdomen and lower third of the chest. In superior costal respiration, on the other hand, the movements are most marked in the upper third of the chest; this form is best developed in healthy adult females.

In children the respiration is chiefly abdominal in type, irrespective of sex, and it is not until just before the age of puberty that the movements in the female change, becoming superior costal. Consequently, in estimating the number of movements per minute it is best to place the fingers lightly on the upper abdomen. The count should always be made by the watch, the most convenient time for the observation being while the child sleeps.

Soon after birth the number of movements per minute is 44, between the ages of two months and two years, 35, and between two and twelve years, 23. During sleep the frequency is reduced about twenty per cent.

Children under two yeas, while awake, breath unevenly and irregularly; there are frequent pauses followed by hurry and precipitation, and some of the movements are shallow, others deep. In sleep there is greater regularity. After the second year the movements become steady and even, like those of adults. All children, however, but particularly the very young, are subject to a great increase in the rapidity of respiration under the excitement of muscular movement and mental emotion.

Perfectly healthy children breath through the nose, and so softly that it is necessary to place the ear close to the face to hear the breezy sound of the ingoing and outgoing air.

Examples of Variations in Disease. -- Accelerated breathing occurs during the course of diseases accompanied by severe fever. Acute affections of the lungs are especially characterized by this alteration, and the more the breathing area is lessened, the greater is the increase. Thus, in pneumonia, 60, 80 or 100 movements a minute are not at all unusual. To speak broadly, rapid breathing may be caused by an elevation in body temperature, by an interference with the blood aeration and by thoracic or abdominal pain.

Diminished frequency -- the movements being reduced to 16, 12, or even 8 in the minute -- is encountered in certain brain affections; namely, in chronic hydrocephalus, and in the later stages of tuberculous meningitis. In such cases the rhythm may be greatly altered -- a tidal form being assumed, in which the breathing ebbs and flows, beginning with an act which is scarcely perceptible or audible, gradually growing deeper until a full, noisy respiration is made, and then slowly subsiding into a period of absolute quiet, variable in its duration. This is termed Cheyne-Stokes' respiration.

A dry, hissing sound, or a moist sound of snuffling indicates partial obstruction of the nasal passages; oral respiration shows their complete occlusion.

Yawning, one of the modifications of the respiratory act, if it recur frequently, denotes great failure of the vital powers and is an unfavorable prognostic element.

12. The Pulse. -- To obtain any reliable data from the pulse it must be felt during perfect quiet. During sleep is the best time, but if the child cannot be caught in this condition, advantage may be taken of its placidity while feeding or amused by a toy. With very young infants it is sometimes impossible to feel the beat of the artery at the wrist, and it is necessary to ascertain the frequency of the pulse by listening to the heart. After the second month feeling the pulse at the wrist in the ordinary way is not difficult.

The child's pulse differs from the adult's by being much more frequent, more irregular, and more irritable.

The frequency, or the number of beats per minute, varies with the age. The following is the average rate:

From the birth, to the 2d month

160 to 130

From the 2d to the 6th month

130 to 120

" " 6th " 12th "

120 to 110

" " 1st " 3d year

110 to 100

" " 3d " 5th "

100 to 90

" " 5th " 10th "

90 to 80

" " 10th " 12th "

80 to 70

These figures represent the pulse in a waking, but passive state. During sleep the frequency is less. Thus, between the second and ninth years, there are about sixteen beats less per minute while asleep than when awake; between the ninth and twelfth years, eight less; and between the twelfth and fifteenth years, only two less. Below the age of two years the disparity is even greater.

The irregularity of the pulse in childhood is confined to an alteration of the rhythm, in other words, of the intervals at which the beats succeed each other and the relative strength and volume of each beat. It is most marked in infants and is greatest during sleep, when the pulse is slowest.

The feature of irritability, that is, the facility with which the frequency is increased by muscular activity and mental excitement, is greater in proportion to the youth of the child. A rise of 20, 30, or even 40 beats a minute is not uncommon in early infancy, under the excitement of the slightest effort or disturbance.

Examples of Variations in Disease. -- On account of the wide variations in health, little meaning need to be attached to alterations of the rhythm and frequency while unassociated with other abnormal features. When so associated they become important in determining the existence of disease.

Increased frequency is a constant attendant of the febrile state. The extent of the increase corresponds with the degree of elevation of temperature, though the pulse curve always runs higher than the temperature curve. As a rule, the more frequent the pulse the higher the fever. In estimating the risk of the increase, however, the law of the fever in question must be taken into consideration. For example, in scarlet fever a pulse of 160 is usual and not indicative of especial gravity. In measles, the same degree of acceleration would be abnormal and show great danger.

Jaundice and inflammation of the kidneys are accompanied by a diminution of the pulse rate.

Irregularity is met with in diseases of the brain and heart, and sometimes in nervous and blood-impoverished children.

13. The Temperature. -- By placing the hand upon the surface of the body we can readily detect market variations in the temperature; thus the nose and extremities feel cold in diseases associated with depression of the vital forces, and the palms of the hands and back of the head feel hot in those attended by fever. But the only possible means of detecting slight variations or of obtaining reliable information concerning normal or abnormal body-heat is by the employment of an accurate thermometer. Clinical thermometers, as these instruments are called, are made entirely of glass, and are usually furnished in the shapes shown in Figs. 3 and 4.

Both of these instruments are graduated according to the Fahrenheit scale and provided with a self-registering index, which is simply a column of mercury separated from that in the bulb of the thermometer.

Figure 3.

Figure 4.

Temperature is usually taken in the rectum of the infant or young child, in the arm-pit of one old enough to understand the importance of keeping the arm in the proper position, and in the mouth of a child still older. In the first locality a straight thermometer is the best to use, in the last two a curved instrument will be found more convenient.

Supposing the rectum be chosen as the place of observation, it is first necessary to be sure that this portion of the gut is free from faeces. The upper end o the stem of the thermometer is then held between the thumb and finger, and the index, by a few vigorous shaking movements, is forced down so far that its upper extremity will be well below the normal mark, to 95° for instance; next, the bulb is covered with sweet oil or vaseline and gently inserted through the anus into the rectum for a sufficient distance to completely conceal the mercury. Here it is allowed to remain for five minutes by the watch, and on being removed the degree of temperature is read from the top of the index. The position of the patient in the meanwhile is upon the back, on the nurse's lap, with the legs elevated and controlled by her left hand, the right hand being used in steadying the thermometer.

If the arm-pit be selected, place the child on his back, and dry this region of all moisture; next shake down the index and insert the bulb well into the cavity; lay the arm across the chest, place the hand on the opposite shoulder and hold in this position for five minutes.

When taking the temperature in the mouth direct the child to lie down on his back and instruct him not to bite upon the delicate glass. Then, having seen that the instrument is thoroughly clean and that the top of the index is below the normal point, insert the bulb, crosswise, beneath the tongue. The teeth must be lightly closed so as to hold it in position, and the lips closely shut about its stem. For the three minutes necessary to complete the observation, breathing must be performed entirely through the nose.

One more fact is important, namely, that a simultaneous observation in the three positions mentioned will not furnish identical results; the rectal temperature being, normally, from 1° to 2° higher, and the oral at least 1° higher, than that of the arm-pit in the same individual.

When properly used the thermometer is of great value in the nursery; at the same time, under opposite conditions, it may be the source of much unnecessary alarm to over-anxious parents. To prevent the latter misfortune, all who intend to use the instrument should be familiar with the healthy range of temperature and some of the characteristic fluctuations in disease.

During the first week of healthy life the temperature fluctuates considerably. After this the puerile norme -- 98.5° to 99° F. -- is established, but until the fourth or fifth month it is greatly influenced by physiological causes of variation, the fluctuations being between .9° and 3.6°. By the fifth month regular morning and evening oscillations begin to be noticeable and certain definite laws are followed. Thus there is a fall in the evening of 1° or 2°. The greatest fall occurs between 7 and 9 P.M., and the minimum is reached at, or before, 2 A.M. After 2 A.M. there is a gradual rise, the maximum being reached between 8 and 10 A.M. Throughout the day the oscillation is trifling. These variations are independent of eating and sleeping.

It may be taken for granted, therefore, that a temperature between 98° and 99° in the morning and 97.5° and 98.5° in the evening is the range to be expected in a healthy child beyond the age of five months.

Examples of Variations in Disease. -- In disease there may be either a rise above, or a fall below the normal standard.

Fever is always associated with an elevation. Rapid and transient rises attend slight catarrhs and passing indigestions. Prolonged rises indicate inflammatory and essential fevers, for example, typhoid, scarlet fever and measles.

The degree of elevation marks the type of the fever. This is moderate when the mercury stands at 102°, severe at 104° or 105°, and very grave above 107°. The duration of the elevation and the peculiar range of the oscillations (for there are oscillations in disease as well as in health) determine the nature of the fever. The febrile oscillations differ from the healthy, in that the lowest marking is noticed in the morning, the highest in the evening.

Variations in the typical range of any given fever are important prognostic omens -- a sudden fall of the temperature, together with improvement in the general symptoms, indicates the beginning of convalescence -- a similar fall, with an increase of the general symptoms, is a precursor of death. When the morning temperature is equal to that of the preceding evening, there is great danger; if higher, greater danger still. Marked remission in continued fevers is generally a fore-runner of convalescence.

Abnormal depression of temperature is occasioned by hemorrhage and by the loss of fluids in cholera infantum or entero-colitis. It is also met with in anaemia, in wasting from insufficient nourishment, in diseases of the heat and lungs attended by imperfect oxidation of the blood, and it constantly attends collapse and the death agony. A temperature of 97° is dangerous in children, and for every degree of reduction below this point the risk for life is more than proportionately increased.

14. The Mouth and Throat. -- In infants, gentle pressure of the fingers upon the chin is sufficient to cause wide opening of the mouth. An older child will frequently open the mouth when requested, but if he refuse, the finger, or far better, the handle of a spoon, or some other smooth, flat instrument, may be inserted in the mouth, and downward pressure made upon the tongue, when the jaws will be widely separated. In some cases, when the child is old enough to do as he is bid, the fauces can be seen by directing the mouth to be opened wide and the tongue to be alternately protruded and retracted, or a prolonged sound of "Ah" to be made. With the refractory, and always with infants, the tongue has to be held down by a spoon-handle or tongue-depressor. If there be resistance, the patient must be taken on the lap of the nurse, who holds his back against her breast, directs his face toward a bright light, and controls the movements of the hands and feet.

The healthy oral mucous membrane has a deep pink color, and is smooth, moist and warm to the touch. The color is deeper on the lips and cheeks, lighter on the gums. The latter, up to the sixth month, as a rule, have a moderately sharp edge. Subsequently, the edge begins to broaden and soften, and the color of the investing mucous membrane deepens to a vivid red, and becomes hot, as the teeth begin to force their way through.

The tongue should be freely movable. It is pink in color, and the dorsum or upper surface, marked in the centre by a slight longitudinal depression, has a velvety appearance, and is soft, moist and warm to the finger. The velvety nap is due to the numberless hair-like processes of the filiform papillae. There are also scattered over the surface, but most closely at the tip, a number of eminences, the size of a small pin's head, circular in outline, and deeper pink than the surrounding surface -- the fungiform papillae. While far back, defining the papillary layer, are the circumvallate papillae, numbering about twelve, and arranged in a V-shaped row. These have the form of an inverted cone, surrounded by an angular elevation.

The hard palate, or roof of the mouth, is roughened anteriorly by transverse ridges. The soft palate -- its continuation -- is smooth, and its mucous membrane is paler than that of the rest of the mouth. The fauces, or walls of the throat, on the contrary, are redder. In the triangular recess between the half arches of the palate the tonsils can always be seen. They should be about the size and shape of almond kernels, and they present a number of circular openings, the orifices of pouches, into which the follicles open. The uvula -- or, in popular language, the palate -- is short and tongue-shaped. The posterior wall of the throat should be red, smooth and moist.

Examples of Variations in Disease. -- Fever makes the mouth hot and dry, and causes the tongue to be frosted or coated. Affections of the stomach and bowels are usually attended by coating of the tongue. Inflammation of the mouth itself reddens the lining membrane, makes it hot and tender to the touch, increases its moisture, alters the surface of the tongue and leads to the formation of aphthae and to ulceration.

15. Dentition. -- The eruption of the twenty milk teeth may, like other physiological processes, be unattended by noticeable symptoms, but in many instances it is accomplished with difficulty, giving rise to disturbances which, on the one hand, may be so trifling as simply to annoy the infant, or, on the other, so serious as to endanger life.

Normally, the teeth are cut in groups, each effort being succeeded by a pause or period of rest. The diagram and table below (Figure 5) show the grouping, the date of eruption and the duration of the pauses. The numbers, 1 to 5, indicating the groups to which the individual teeth belong and their order of appearance, and the letters a and b the precedence of eruption in the different groups.

The pauses are, to say the least, most helpful, giving the infant's system an opportunity to rest after each effort, to recover from any coincident illnesses, and to prepare for the next strain.

Even under normal conditions the edges of the gums lose their sharpness and become swollen, rounded, and reddened as the teeth approach the surface. At the same time the saliva is increased in quantity, and the mouth is unnaturally warm and the seat of abnormal sensations, as evidenced by the tendency to bite upon any object that comes to hand; in other words, there is a mild catarrh of the mucous membrane. The consequent discomfort, though, is not sufficient to interfere with the child's appetite, good humor or sleep, and when, after a few days, the margin of the tooth is free, all of the local symptoms vanish.

Examples of Variations. -- Abnormal dentition is manifested either by departures from the laws of development already stated, or by actual difficulty in the process of cutting.

The standard rules for the eruption of the teeth may be departed from in three ways:--

1. The appearance of the teeth may be premature. Children may be born with one or more of their teeth already cut; these are usually imperfect, and soon fall out, to be replaced, at the proper age, by well-formed milk teeth. Sometimes, however, they remain permanently, as in a case that came under my own observation. Natal teeth are always incisors. Instances of the lower central incisors being cut in the third month are not uncommon. Girls are more apt than boys to cut their teeth early, and, as an early dentition is likely to be an easy one, the occurrence is to be looked upon as fortunate.

2. Dentition may be delayed. This deviation is more frequently seen and of more consequence than the first. Bottle-fed babies, as a class, are more tardy in cutting their teeth than those reared at the breast. With such, though healthy in every respect, a delay of one or two months is a common and not at all serious event. On the contrary, whatever the method of feeding, if no teeth have appeared by the end of a year, it may be assumed that the child's general nutrition is faulty, or that rachitis is present. Delay does not necessarily imply difficulty in cutting the teeth, though the two conditions are often associated.

3. The teeth may appear out of their regular order. Bottle-fed infants are most likely to show this irregularity, which is of some importance as an indication of general feebleness. In other instances, however, it is merely a family peculiarity, and, as such, bears no special significance.

Difficult dentition gives rise to two classes of affections, viz., local, and sympathetic or reflex. Difficulty, like delay, is more apt to occur in hand-fed babies than in those nourished entirely from the healthy breast, but beyond this it is is impossible to prognosticate the ease or difficulty of dentition. The author has frequently seen the most robust infants suffer at the time of eruption of each group of teeth, and has also observed puny and feeble subjects pass through the process with little or no trouble.

The third and fourth groups of teeth are most prone to make trouble, and when the child is born at such a time of year as to bring the eruption of these during the hot months, illness of some sort may be anticipated. This is often dangerous and sometimes fatal; hence the popular dread of the "second summer."

The order of eruption of the permanent teeth is as follows:--

The two central incisors of lower jaw, from the 6th to 8th year.

The two central incisors of upper jaw, from the 7th to 8th year.

The four lateral incisors, from the 8th to 9th year.

The four first bicuspids, from the 9th to 10th year.

The four canines, from the 10th to 11th year.

The four second bicuspids, from the 11th to 13th year.

These replace the temporary teeth; those which are developed de novo appear thus: --

The four first molars, from the 5th to 7th year.

The four second molars, from the 12th to 13th year.

The four third molars, from the 17th to 21st year.

There are, therefore, twelve more permanent teeth, making thirty-two in all -- sixteen in each jaw.

The diagram, Fig. 6, will aid in explaining the process:--

Second dentition is a common cause of ill health in late childhood. The disorders produced by this process, however, are not so well defined nor so dangerous as those of primary dentition, and, in consequence, the relation of cause and effect is often overlooked.

It is probable that the first and seventh sets are the most apt to give rise to both local and constitutional disturbances.

 

 


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