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The Eugenic Marriage, Volume IV. (of IV.) - A Personal Guide to the New Science of Better Living and Better Babies
by Grant Hague
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Transcriber's notes: Obvious typographical errors have been corrected and a few punctuation usages have been normalized.



The Eugenic Marriage

A Personal Guide to the New Science of Better Living and Better Babies

By W. GRANT HAGUE, M.D.

College of Physicians and Surgeons (Columbia University), New York; Member of County Medical Society, and of the American Medical Association

In Four Volumes

VOLUME IV

New York THE REVIEW OF REVIEWS COMPANY 1914

Copyright, 1913, by W. GRANT HAGUE

Copyright, 1914, by W. GRANT HAGUE

* * * * *



TABLE OF CONTENTS

ACCIDENTS AND EMERGENCIES

CHAPTER XXXIV

COMMON DISEASES OF THE NOSE, MOUTH AND CHEST

PAGE

"Catching cold"—Sitting on the floor—Kicking the bedclothes off—Inadequate head covering—Subjecting baby to different temperatures suddenly—Wearing rubbers—Direct infection—Acute nasal catarrh—Acute coryza—Acute rhinitis—"Cold in the head"—"Snuffles"—Treatment of acute nasal catarrh, or rhinitis, or coryza, or "cold in the head," or "snuffles"—Chronic nasal catarrh—Chronic rhinitis—Chronic discharge from the nose—Nervous or persistent cough—Adenoids as a cause of persistent cough—Croup—Acute catarrhal laryngitis—Spasmodic croup—False croup—Tonsilitis—Angina—Sore throat—Symptoms of tonsilitis—Treatment of tonsilitis—Bronchitis in infants—Bronchitis in older children—"Don'ts" in bronchitis—Diet in bronchitis—Inhalations in bronchitis— External applications in bronchitis—Drugs in bronchitis— Chronic or recurrent bronchitis—Pneumonia—Acute broncho-pneumonia—Symptoms of broncho-pneumonia—How to tell when a child has broncho-pneumonia—Treatment of broncho-pneumonia—The after treatment of broncho-pneumonia—Adenoids—How to tell when a child has adenoids—Treatment of adenoids—Nasal hemorrhage— "Nose-bleeds"—Treatment of nose-bleeds—Quinsy—Hiccough— Sore-mouth—Stomatitis—Treatment of ulcers of the mouth— Sprue—Thrush 497

CHAPTER XXXV

DISEASES OF THE STOMACH AND GASTRO-INTESTINAL CANAL

Inflammation of the stomach—Acute gastritis—Persistent vomiting—Acute gastric indigestion—Iced champagne in persistent vomiting—Acute intestinal diseases of children— Conditions under which they exist and suggestions as to remedial measures—Acute intestinal indigestion—Symptoms of acute intestinal indigestion—Treatment of acute intestinal indigestion—Children with whom milk does not agree—Chronic, or persistent intestinal indigestion— Acute ileo-colitis—Dysentery—Enteritis—Enter-colitis— Inflammatory diarrhea—Chronic ileo-colitis—Chronic colitis—Summer diarrhea—Cholera infantum—Gastro-enteritis— Acute gastro-enteric infection—Gastro-enteric intoxication—Colic—Appendicitis—Jaundice in infants—Jaundice in older children—Catarrhal jaundice—Gastro-duodenitis—Intestinal worms—Worms, thread, pin and tape—Rupture 527

CHAPTER XXXVI

DISEASES OF CHILDREN (continued)

PAGE

Mastitis, or inflammation of the breasts in infancy—Mastitis in young girls—Let your ears alone—Never box a child's ears—Do not pick the ears—Earache—Inflammation of the ear—Acute otitis—Swollen glands—Acute adenitis— Swollen glands in the groin—Boils—Hives—Nettle rash— Prickly Heat—Ringworm in the scalp—Eczema—Poor blood—Simple anemia—Chlorosis—Severe anemia—Pernicious anemia 553

CHAPTER XXXVII

DISEASES OF CHILDREN (continued)

Rheumatism—Malaria—Rashes of childhood—Pimples—Acne— Blackheads—Convulsions—Fits—Spasms—Bed-wetting—Enuresis— Incontinence—Sleeplessness—Disturbed sleep—Nightmare— Night terrors—Headache—Thumb sucking—Biting the finger nails—Colon irrigation—How to wash out the bowels—A high enema—Enema—Methods of reducing fever—Ice cap—Cold sponging—Cold pack—The cold bath—Various baths—mustard baths—Hot pack—Hot bath—Hot air, or vapor bath—Bran bath—Tepid bath—Cold sponge—Shower bath—Poultices—Hot fomentations—How to make and how to apply a mustard paste—How to prepare and use the mustard pack—Turpentine stupes—Oiled silk, what it is and why it is used 569

DISEASES OF CHILDREN

CHAPTER XXXVIII

INFECTIOUS OR CONTAGIOUS DISEASES

Rules to be observed in the treatment of contagious diseases— What isolation means—The contagious sick room—Conduct and dress of the nurse—Feeding the patient and nurse—How to disinfect the clothing and linen—How to disinfect the urine and feces—How to disinfect the hands—Disinfection of the room necessary—How to disinfect the mouth and nose—How to disinfect the throat—Receptacle for the sputum—Care of the skin in contagious diseases—Convalescence after a contagious disease—Disinfecting the sick chamber—The after treatment of a disinfected room—How to disinfect the bed clothing and clothes—Mumps—Epidemic parotitis—Chicken pox— Varicella—La Grippe—Influenza—Diphtheria—Whooping Cough—Pertussis—Measles—Koplik's spots—Department of health rules in measles—Scarlet fever—Scarlatina— Typhoid fever—Various solutions—Boracic acid solution—Normal salt solution—Carron oil—Thiersch's solution—Solution of bichloride of mercury—How to make various solutions 599

ACCIDENTS AND EMERGENCIES

CHAPTER XXXIX

ACCIDENTS AND EMERGENCIES

Accidents and emergencies—Contents of the family medicine chest—Foreign bodies in the eye—Foreign bodies in the ear—Foreign bodies in the nose—Foreign bodies in the throat—A bruise or contusion—Wounds—Arrest of hemorrhage—Removal of foreign bodies from a wound—Cleansing a wound—Closing and dressing wounds—The condition of shock—Dog bites—Sprains—Dislocations—Wounds of the scalp—Run-around—Felon—Whitlow—Burns and scalds 629

MISCELLANEOUS

CHAPTER XL

MISCELLANEOUS

The dangerous housefly—Diseases transmitted by flies—Homes should be carefully screened and protected—The breeding places of flies—Special care should be given to stables, privy vaults, garbage, vacant lots, foodstuffs, water fronts, drains—Precautions to be observed—How to kill flies—Moths—What physicians are doing—Radium—X-Ray treatment and X-Ray diagnosis—Aseptic surgery—New anesthetics—Vaccine in typhoid fever—"606"—Transplanting the organs of dead men into the living—Bacteria that make soil barren or productive—Anti-meningitis serum—A serum for malaria in sight 645

* * * * *

ACCIDENTS AND EMERGENCIES



CHAPTER XXXIV

COMMON DISEASES OF THE NOSE, MOUTH, AND CHEST

"Catching Cold"—Sitting on the Floor—Kicking the Bed Clothes Off—Inadequate Head Covering—Subjecting Baby to Different Temperatures Suddenly—Wearing Rubbers—Direct Infection—Acute Nasal Catarrh—Acute Coryza—Acute Rhinitis—"Cold in the Head"—"Snuffles"—Treatment of Acute Nasal Catarrh, or Rhinitis, or Coryza, or "Cold in the Head," or "Snuffles"—Chronic Nasal Catarrh—Chronic Rhinitis—Chronic Discharge from the Nose—Nervous or Persistent Cough—Adenoids as a Cause of Persistent Cough—Croup—Acute Catarrhal Laryngitis—Spasmodic Croup—False Croup—Tonsilitis—Angina—Sore Throat—Symptoms of Tonsilitis—Treatment of Tonsilitis—Bronchitis in Infants—Bronchitis in Older Children—"Don'ts" in Bronchitis—Diet in Bronchitis—Inhalations in Bronchitis—External Applications in Bronchitis—Drugs in Bronchitis—Chronic or Recurrent Bronchitis—Pneumonia—Acute Broncho-pneumonia—Symptoms of Broncho-pneumonia—How to Tell When a Child has Broncho-pneumonia—Treatment of Broncho-pneumonia—The After-treatment of Broncho-pneumonia—Adenoids—How to Tell When a Child has Adenoids—Treatment of Adenoids—Nasal Hemorrhage—"Nose-bleeds"—Treatment of Nose-bleeds—Quinsy—Hiccough—Sore Mouth—Stomatitis—Treatment of Ulcers of the Mouth—Sprue—Thrush.

"CATCHING COLDS"

Mothers frequently wonder where their children get colds. Briefly we will point out some of the sources from which these apparently inexplicable colds may come.

A. Sitting on the Floor.—Children should not be allowed to sit or crawl upon the floor at any season of the year, but especially during the winter months. There is always a draught of cold air near the floor. It is a bad habit to begin allowing a child to play with its toys on the floor. Use the bed or a sofa or a platform raised a foot from the floor.

B. Kicking the Bed Clothes Off During the Night.—The bed clothes should be securely pinned to the mattress by large safety pins. When it is established as a habit a child who kicks off the bed clothes should wear a combination night suit with "feet," made of flannel during the winter and of cotton during the summer.

C. Inadequate Head Covering.—Professor Kerley states that this is one of the "most frequent causes of disease of the respiratory tract in the young." He calls attention to the fact that "mothers carefully clothe the baby with ample coats, blankets, leggings, etc., before they take him out for the daily walk. They dress him in a warm room taking plenty of time to put on the extra clothes, during which time the baby frets and perspires. When all is ready they place upon the hot, almost bald head of the baby a light artistically decorated airy creation which is sold in the shops as children's caps. The child is then taken out of doors and because of the inadequate covering of the hot perspiring head, catches cold and the mother never knows how it came." Every baby and child should wear under such caps a skull cap of thin flannel, especially in cold weather. In summer or windy day a light silk handkerchief folded under the cap is a very excellent protection.

D. Subjecting a Baby to Different Temperatures Suddenly, is liable to be followed by a cold—for example, taking the child from a warm room to a cold room, or through a cold hall, holding the child at an open window for a few moments.

E. The Practice of Wearing Rubbers Needs Some Consideration.—They should never be worn indoors for even five minutes. They should not therefore be kept on in school, nor should they be worn by women in stores when they go shopping. When it is actually raining, or snowing, or when there is slush or wet mud they are needful; but they should not be worn simply because the weather is threatening or damp. Children should not put them on to play—worn for any length of time when active they are harmful. If worn to and from school they should be taken off at once when in school or at home. Wearing rubbers prevents free evaporation of the natural secretion of the skin, keeps the feet moist and invites colds and catarrh. In damp weather, or when children play during winter months, they should be shod with stout shoes with cork insoles.

The same argument applies to storm coats of rubber, water-proof material. They should not be worn as overcoats all day, but only when going to and from school or business when it is actually storming.

Underclothing or hosiery should not be heavy enough to cause moisture of the skin. Health demands a dry skin at all times. The necessary degree of body heat should be attained by the quality of the outer clothing, not by the quantity of the underclothing. Many men and women wear heavy underclothing which causes moisture when indoors, with the result that they get surface chills when they go outside if the weather is cold and as a result catch cold. The underclothing should be just heavy enough to be comfortable indoors and the extra warmth necessary when outside should be supplied by a good overcoat or furs.

F. Direct Infection.—A baby may catch cold if kissed or "hugged" by an adult who has a cold.

Catching cold while bathing is possible, but scarcely probable, if ordinary precautions are taken. It is very bad practice to permit children to use one another's handkerchiefs or the handkerchief of an adult. Certain children are predisposed to attacks of "cold in the head" or acute coryza or nasal catarrh (these being the medical names for this condition). Sometimes this is an inherited characteristic. There is no doubt, however, that most of these children acquire the habit by bad sanitary and hygienic surroundings. These children do not as a rule get enough fresh air. They are kept indoors most of the time in stuffy, overheated, badly ventilated rooms, unless the weather is absolutely perfect. The windows in their bedrooms are always kept closed, because they are "liable to catch cold." They are overdressed and perspire easily and as a result "catch cold." These conditions all tend to create an unhealthy condition of the nasal mucous membrane and of the throat, and this is rendered worse if the child lives in a damp, changeable climate, such as that of New York City. In these susceptible children the exciting cause of an attack may be trivial; exposure, cold or wet feet, inadequate head covering (as already pointed out), a draught of cold air even may excite sneezing and a nasal discharge; hence we have:

Acute Nasal Catarrh (Acute Coryza, Acute Rhinitis, "Cold in the Head", "Snuffles").—Acute nasal catarrh may accompany measles, diphtheria, influenza, and whooping cough.

Symptoms.—The onset is sudden with sneezing, and difficulty in breathing through the nose. In a few hours, or it may be not for a day or two, a mucous, watery, nasal discharge appears. There are redness and slight swelling of the nose and upper lip, caused by the discharge. There is no fever as a general rule except in very young infants, in whom the fever may be very high. The discharge interferes with the nursing and the child suffers from lack of nourishment. The inflammation may extend to the eyes and ears, causing painful complications, or to the throat and bronchi, causing hoarseness and cough. Less frequently we have disturbances of the digestive tract with vomiting, or diarrhea.

The mild form of the disease lasts for two or three days, the severe form from one to two weeks.

Repeated attacks are said to contribute to the production of adenoid growths.

An acute attack of this disease is seldom a serious affliction in older children; it may be, however, very serious and even dangerous in very young infants. The tendency of the disease to extend downward, causing bronchitis or pneumonia, explains in part the possible danger to a baby. Another reason is because it may seriously interfere with suckling and with breathing in these little patients. It may even cause sudden attacks of strangulation. An infant, therefore, suffering with an acute attack of rhinitis requires constant attention. It may be necessary to feed it with a spoon, and if necessary mother's milk should be so fed. Plenty of fresh air should be provided. It may be essential to keep the mouth open in order that it may get enough fresh air. Every effort should be made to keep the nostrils open. The secretions must be removed from time to time. Causing the child to sneeze by tickling the nose with a camel's hair brush will clear the nose for the time being. The physician may be compelled to use a solution of cocaine for this purpose.

Treatment of Acute Rhinitis ("Taking Cold", Nasal Catarrh, Acute Coryza, "Snuffles").—A child suffering with an acute attack of "cold in the head" should be kept indoors in a room with a constant, uniform temperature; the particular reason for this is, that, if a child is exposed to cold at any time during an attack of "cold in the head," it may cause the disease to invade the chest,—a tendency which it has at all times. The bowels must be kept open; if they do not move every day of their own accord they must be made to move by means of an enema of sweet oil or of soap-suds. The amount of food should be reduced to suit the circumstances and the condition of the patient.

We treat the local condition in the nose with a menthol mixture. The following is a very good one: Menthol, 30 grains; Camphor, 30 grains; White Vaseline, 1 ounce. Put some of this on the end of the finger and push it gently into each nostril. When the nostrils become blocked and the child cannot breathe through the nose, tickle the nose with a feather until it sneezes; this will clear the passage. Immediately after the sneeze place the menthol mixture in each nostril. When the child is about to sneeze place a handkerchief before the nose, as this discharge is full of germs and will infect others when dry. Internal remedies should not be used unless the child is distinctly sick and is running a fever, in which case a physician should look the child over and prescribe whatever is called for.

The upper lip and the nostrils of the child should be protected, because the discharge very quickly irritates the parts and renders them raw and painful. Vaseline or cold cream is very suitable for this purpose.

Mothers should not wash out the nose of a child with any solution advised for this purpose where force is used, as, for example, with a syringe. Any forceful irrigation of the nose is dangerous, because it would carry the infection into the deeper parts and set up a more serious condition.

If the above treatment is carefully carried out and the child unexposed to a fresh cold, two or three days will be sufficient to cure the disease.

It is not, however, the treatment of an acute attack of "cold in the head" that is important; it is intelligently to follow out a plan which will prevent these attacks from repeating themselves that is of consequence. The tendency to take cold is a real condition in childhood and a very common one. When mothers appreciate that it is possible to prevent this condition and to cure it when it is seemingly an established habit, more interest will undoubtedly be taken in the subject. Too frequently it is looked upon as an unfortunate affliction, but it is never regarded as a condition that is caused by neglect and ignorance.

It is an exceedingly common occurence to find a mother worrying over her child's cold, dosing it with cod liver oil or some other unnecessary tonic, rubbing it with camphorated oil or plastering it over with certain useless patent plasters, dressing it with extra pieces of flannel on its chest and extra clothes pinned snugly around it, then shutting it up in a warm, stuffy, unsanitary, ill-smelling room, in order to keep it from "catching a fresh cold." Can you imagine anything else she could do to defeat her purpose?

No quantity of cod liver oil, no medicine, no coddling, will remove the tendency to "catch cold." The child's life must be lived amidst sanitary surroundings and hygienic conditions first; then other expedients may be utilized if necessary. These children must be kept out of doors most of the time, unless during the severest wet weather. They should sleep in a room the windows of which are open at the top and bottom every night in the year. They should not, however, be in a draught. The rooms in which they live should be of a uniform temperature, never too hot and never too cold, between 68 deg. and 70 deg. F. These delicate catarrhal children should be accustomed to light clothing on their beds. Chest protectors, mufflers, cotton pads, and heavy wraps of any description should be absolutely prohibited. It is advisable to use flannel underwear winter and summer, light in summer and a medium weight in winter. During the summer months the mother should begin cold sponging of the face, throat, chest, and spine every morning and carry it into the winter. The entire process need take only a moment or two. Always dry thoroughly with a fairly rough towel. If the cold sponging is begun in the warm summer time the child will become so accustomed to it that no objection will be made when the cold weather comes.

If the child continues to be "catarrhal," despite a course of this treatment, it would be well to investigate whether any adenoids or adenoid tissue exist in the naso-pharynx. If adenoids are found no treatment will be successful until they are removed.

It is a wise plan to place a flannel cap on an infant who has an acute attack of "cold in the head" (snuffles). This will prevent catching a fresh cold and it will aid in the speedy cure of the attack from which it is suffering when it is put on.

CHRONIC NASAL CATARRH—CHRONIC RHINITIS CHRONIC DISCHARGE FROM THE NOSE

Some children have a nasal discharge during all of their childhood. It is usually worse during the winter months. It may be a thin, watery discharge or a thick, nasty, yellow discharge.

It is a condition that is very frequently neglected even by the family physician. This is unfortunate because it may lead to serious disease, permanent damage sometimes being done to the hearing, the speech, the smell, and to the lungs of the child.

It may be caused by adenoids; disease of the bones or tissues in the nose; foreign bodies in the nose; or it may occur in children whose nutrition is bad. It may result from frequent acute attacks of "cold in the head." It also occurs in other less important conditions. The foreign bodies which usually cause a chronic nasal discharge are,—buttons, peas, beans, beads, paper balls, flies and bugs, cherry-stones, small pieces of coal, or stone, cork or other material. A child gets hold of a shoe-button for example and pushes it into its nostrils. In the effort to get it out the child pushes it further in. It may or may not cause pain at the time, and it may be overlooked, but shortly the mother will notice a discharge from one nostril. This discharge becomes thick and foul and when an investigation is made the button is found embedded firmly in the nose. It is sometimes quite difficult to get the button out and this should always be done by a physician.

Treatment.—Remove the cause first then treat the catarrh. If it is a product of a constitutional disease that causes general poor health, such as tuberculosis, syphilis, or scrofula, the child will need "building up" and a decided change of climate. Foreign bodies must be removed, adenoids taken out, large tonsils excised, and malformations of the nasal bones operated upon. The catarrh will in many cases be cured by removing its cause; if, however, it should persist it must be treated for some time with appropriate solutions. These solutions and the directions as to the method of giving them must be given by a physician, because there is great danger of carrying the disease to deeper structures if given wrongly.

SUMMARY:—

1st.—A chronic discharge from the nose is a sign that something is wrong and should be carefully and thoroughly investigated.

2nd.—The cause can usually be found out and the proper treatment will cure it.

3rd.—If the condition is neglected it may ruin the health of the child for the whole period of its life.

NERVOUS OR PERSISTENT COUGH

Cough in an infant or growing child is usually the result of a cold and the structure affected is some part of the nose, throat or bronchi. It is a comparatively simple matter to discover just where the trouble is and to prescribe the appropriate remedy and effect a cure.

There is another type of cough, however, that is of quite a different character. This cough will begin as an ordinary cough and it will only be discovered that it is not an ordinary cough because nothing will apparently cure it. We mean that the child is given cough remedies that usually cure a cold, is kept in the house and carefully watched for a sufficiently long period to justify a cure, and yet, despite this care and attention, the cough remains the same. The child is not sick, the appetite is good, there is no fever, it plays and seems to enjoy good health, yet for weeks and frequently for months the annoying cough hangs on. It is as a rule worse at night. It begins soon after the child falls asleep and spoils the entire night's rest or a great part of it. It may be a dry, hard, hacking cough, or a croupy, harsh bark. It may come in spells with a considerable interval between them, during which time the child falls asleep, or it may be almost constant, not quite severe enough to rouse the child, but bad enough to spoil the child's rest and the rest of the mother. If this condition lasts for a long time, as it occasionally does, the health of the little patient is apt to suffer from loss of sleep.

Treatment.—These children should be taken to a good physician and thoroughly examined. Special care should be devoted to investigating the condition of the nose, throat, ear, stomach, heart, and lungs.

A very large majority of these coughs are caused by adenoid growths in the back part of the nose. The child may not look like an adenoid child, nor may it breathe through its mouth when asleep, and it may have had its adenoids removed, yet in spite of these contra-indications it may have enough loose adenoid tissue in its nose to cause this kind of persistent cough. This has been proved many times.

It is not only useless but positively harmful to give these children cough remedies. The cause of the cough must be found and treated. The cough may be indirectly caused by anemia (poor blood) or heart or stomach trouble, or it may have a number of other causes. Whatever it is it must be found by a careful physical examination or a number of careful physical examinations, because these cases are as a rule obscure and difficult to diagnose, and even the most expert examiner cannot always tell where the trouble is without seeing the child a number of times. The parents must therefore have patience and confidence in the physician and must aid him all they can by watching and reporting all the symptoms, etc., to him. (See article on Adenoids).

SUMMARY:—

Coughs that resist careful treatment are not "ordinary coughs."

Coughs of this type require special medical care.

The usual cough medicines are not only useless in these coughs, but dangerous. Don't give them.

ACUTE CATARRHAL LARYNGITIS: SPASMODIC CROUP: FALSE CROUP

Croup is one of the common diseases of childhood. It usually follows a catarrhal "cold in the head" with a cough. Croup is most frequently associated with large tonsils and adenoids. It may come on gradually or it may occur suddenly. There is always fever with croup. One of the first symptoms is a hard, dry, croupy, barking cough, which gets worse toward night. If it occurs suddenly, the child will wake about midnight with the characteristic croupy cough. The disease may go no further than this and under the proper treatment is well in a few days. In other cases, however, there develops marked interference with breathing. Every inspiration is accompanied by a loud hissing or "crowing" sound. This feature of the disease is one that frightens the parents, though it seldom means anything serious. The child sits up in bed, frightened, and struggles for breath. It may clutch its throat with its hands as if something was tied round its neck. The lips may become slightly blue and the perspiration appears upon the child's brow. After some time,—it may be two or three hours,—the attack wears away and the child goes to sleep. Next morning it wakes up apparently well except for the croupy cough. The attack may repeat itself the next night and mildly on the third night.

Treatment.—The object of treatment during an acute attack, when the child is struggling for breath, is to relax quickly the spasm of the larynx which interferes with the breathing. The simplest way is to give the child a teaspoonful of the fresh syrup of ipecac. If the child does not vomit in fifteen minutes, give another teaspoonful and keep on giving it every fifteen minutes till the child vomits. One or two doses is usually enough, but it must be given till the child vomits.

If the attack comes suddenly during the night and there is no syrup of ipecac in the house, the physician should be sent for at once and informed that the child probably has croup, so he may know what to take with him. While waiting for the physician the mother should apply over the front of the neck (in the region of Adam's apple), hot applications. These are best made of flannel wrung out of quite hot water every two or three minutes: also a hot mustard foot bath. When the physician takes charge of the case he will also direct the treatment for the following day in order that the attack of the next night may be a very mild one, if it should came at all.

Children who have a tendency to frequent attacks of croup should receive the same attention as the children do who are subject to attacks of tonsilitis and acute catarrhal rhinitis.

SUMMARY:—

1st. Spasmodic Croup always requires prompt and efficient treatment.

2nd. It is called "false" croup, because "true" croup is always diphtheritic and is a very serious disease.

3rd. For that reason a physician should always be called because if it is "true" croup antitoxin must be given at once.

4th. Don't worry unnecessarily because, though "spasmodic croup" can make the child look exceedingly sick for a very short time, an uncomplicated case in a healthy child is seldom if ever dangerous.

TONSILITIS: ANGINA: "SORE THROAT"

This is one of the frequent diseases of childhood. We rarely see it in infants. It is caused by inhaling air which contains poisonous germs. These germs quickly develop when conditions are favorable. They lodge in the pores or follicles of the tonsils and set up an active inflammation. The tonsils swell up and the follicles exude a thick fluid which looks like curdled cream. This fluid sticks in the mouths of the follicles forming spots. If enough of this fluid is coming out, these spots join together forming patches, and the patches may join together forming membrane. This is why it is sometimes so difficult to tell whether the case is one of tonsilitis or diphtheria.

Conditions are favorable to the development of tonsilitis if the child is not in good health when he happens to inhale the infection, when the feet are wet or cold, or when the child is allowed out during inclement weather and it becomes chilled or numbed from cold, when the child has a cold in the head and a running nose, or when its stomach is out of order. Any condition in which the child should be carefully watched and tended to, rather than allowed further liberties, or risks, conduces to sore throat of some kind.

Some children have the disease a number of times; they seem to be predisposed toward a sore throat. These are children who have large tonsils or who are rheumatic. The tonsils should be removed in the one case, and the tendency to rheumatism should be the main treatment in the other case.

These children should be encouraged to cleanse the throat and nose morning and night with a warm salt solution (half a teaspoonful of ordinary table salt to three-quarters of a cup of warm water). This will help greatly to prevent these chronic sore throats.

Symptoms of Tonsilitis.—The disease begins suddenly. The child may have a chill or be seized with sudden vomiting or diarrhea. A very young infant may have a convulsion. The usual way is for the child to develop a fever quickly, to complain of being sick and tired. Muscular pains all over the body and a severe headache are constant symptoms. The fever is usually high from the beginning. The child will tell you its throat is sore, but there is as a rule very little pain in the throat. The little spots or patches can be seen on one or both tonsils. The general symptoms are more pronounced than the local throat symptoms. The amount of physical depression that is caused by a tonsilitis is out of all proportion to the seriousness of the disease.

Tonsilitis lasts three days usually. The throat symptoms may take a day or two longer to clear up, and the patients feel more or less weak for some time after all the symptoms have disappeared.

Tonsilitis is medically regarded as one of the mild diseases of childhood. It is, however, of very great importance because of its likeness to diphtheria, and inasmuch as a positive diagnosis must be promptly made, in the interest of the patient, it is given close attention and treated with considerable respect by the medical profession. The chief differences between the two diseases are as follows:

Tonsilitis begins abruptly with pronounced prostration and a high fever the first day. The patient feels distinctly sick all over. The second day the patient feels somewhat better, the fever is lower and the prostration and pain are not so marked. The third day he feels better still, and but for a little weakness would feel well. Diphtheria begins slowly and insidiously, with very little prostration and a very low fever the first day. The patient scarcely feels sick. The second day more prostration is present, the fever climbs upward a little more, and the patient begins to feel sick. On the third day the prostration is much more profound, the fever is higher, and all the evidences of a serious sickness are present. Two very different pictures: The one begins bad and ends easy, the other begins easy and may end bad.

The important fact, however, so far as the similarity of the two diseases is concerned, is, that we must make the diagnosis positive on the first or second day, because if we are dealing with a case of diphtheria we must give antitoxin at once. This is essential, because the efficacy of antitoxin is greatest when given early in the disease. By "early" we mean the first or second day of the disease. When antitoxin is given late (the third or fourth day of the disease) it is much less efficacious and must be given in relatively larger doses. The need, therefore, of a quick, positive diagnosis is a real one.

Another important element involved in a speedy diagnosis is, that we must not take any chances of infecting other children. So important are these conditions that it is the proper treatment to give antitoxin at once in every case of tonsilitis that in the slightest way resembles diphtheria. An examination of the throat contents,—a culture of which is taken during the first visit of the physician,—will, of course, reveal the true condition and dictate the future use of the antitoxin. Antitoxin is absolutely harmless when given to a patient who has no diphtheria. Every case of tonsilitis should be quarantined when there are other children in the house.

The local condition of the throat helps in the diagnosis: In tonsilitis (as the name implies) the disease is limited to the tonsils and on the tonsils (one or both) do we find the spots or patches. In diphtheria, on the other hand, the membrane is not limited to the tonsils, but may cover every part of the throat and extend into the nose and mouth. In tonsilitis it is spots or patches we see in the throat. In diphtheria it is membrane we see always. The difficulty here again is that if we wait till the diphtheritic membrane covers the whole throat, antitoxin will not be of much use.

In diphtheria we have a characteristic odor, in tonsilitis we have no characteristic odor.

The practical lesson to be learned from this uncertainty is, immediately to get a physician as soon as you find spots in the throat of your sick child, unless you are absolutely sure that the condition is not diphtheria and you are willing to take that chance.

Treatment of an Acute Attack of Tonsilitis.—Put the child in bed at once and keep him on a light diet during the fever. Give him all the cool boiled water he wants to drink. If the fever is very high it can be controlled by sponging the body with cool water. If the patient is an infant the food should be reduced to one-half strength. Tonsilitis is a disease that runs a certain course and gets better, or the patient develops some other more serious conditions as a result of neglect or carelessness. We therefore try to make the patient comfortable and let the disease take care of itself.

The throat can be gargled or sprayed with any mild antiseptic liquid, or it can be painted with tincture of iodine or 10 per cent. solution of silver nitrate. As a rule the gargles do not aid in the cure of the disease, though they contribute to the comfort of the patient.

A cold compress made of half a dozen thicknesses of cloth, such as a table napkin, and put under the jaw (not round the neck), and covered with oiled silk and held in place with a bandage that meets and is tied on the top of the head, is of distinct usefulness.

When it is known that the child is rheumatic, the heart must be carefully watched during the fever and anti-rheumatic remedies depended upon to effect a cure.

SUMMARY:—

Tonsilitis, because of its likeness to diphtheria, must be promptly and carefully diagnosed.

A physician only is capable of making a diagnosis.

Any sore throat in a child with spots or membrane is deserving of serious and immediate attention.

A mistake may mean death. Don't take a chance.

BRONCHITIS

Bronchitis is one of the commonest diseases of childhood. It is the cause of many deaths. Exposure during inclement weather is as a rule the cause of it. It occurs in all classes and conditions of children. Poorly nourished and badly clothed children are more liable to get it than are others. It is more dangerous in young children and infants than in older children. A young child or an infant will get bronchitis quicker than those older and stronger under the same conditions.

Bronchitis is often present while children are suffering from other diseases, measles, influenza, scarlet fever, typhoid fever, pneumonia, diphtheria, whooping-cough, for example. It may accompany any disease of childhood, however.

Symptoms.—In infants bronchitis usually follows a "cold in the head," with running nose and a cough. The child is indisposed and peevish because of the cold. In a few days the cough becomes worse, fever develops, the breathing is quicker, and the baby looks and acts sick. The cough may be constant and severe; sometimes the cough does not seem to bother the baby, although this is exceptional. The breathing is quite rapid and is accompanied with a moist, rattling sound in the chest. The baby is restless and if the cough is severe it becomes exhausted. Vomiting or diarrhea may be present.

Bronchitis in Older Children.—Bronchitis in older children comes on abruptly, with fever and cough. The child may complain of headache and pains in the chest or other parts of the body. It may begin with a chill or chilly feelings. These children "raise" with the cough. The expectoration may be quite profuse; at first it is a white, frothy mucus, then yellow, and later a yellowish green; it may be slightly tinged with blood.

There is a mild form of bronchitis in these older children where the serious symptoms are absent. The children are not sick enough to go to bed, but they appear to have a "heavy cold" with, at first, a tight, hard cough, which is usually worse at night. Later the cough turns loose and the same expectoration occurs as in the severe type. It is these cases of mild bronchitis which do not receive the proper care and treatment that develop into the so-called "winter cough," which lasts for months.

Treatment.—(See page 497 under heading, "Catching Colds.") Children who acquire bronchitis easily and frequently, should be built up. Cod liver oil should be given all winter. The sleeping apartment of these children should not be too cold, but it should be well aired through the day and well ventilated throughout the night. Flannel night clothes should be worn and the feet should be kept warm always. Mild attacks of "cold in the head" should be treated vigorously and not neglected.

The following "Don'ts" may be profitably studied when your child or baby has bronchitis:—

Don't keep the windows tightly closed; fresh air and good ventilation are absolutely necessary to the patient.

Don't use a cotton jacket or oil silk.

Don't wrap the child up in blankets and shawls.

Don't carry the child around; keep it in bed.

Don't dose the child with syrupy cough mixtures.

Don't overheat the room.

Don't let friends bother or annoy the baby.

Don't reduce the diet unnecessarily.

The child should be put to bed. The temperature of the room should be 70 degrees F. all the time. The windows should be opened top and bottom according to the weather, and the room should be well aired every day, the patient being taken to another room while it is being done. The child should have its usual night clothes on, nothing more. If the child is not very sick and insists on sitting up, a bath robe can be worn but it should be always removed when it sleeps. It is advisable to change the position of the baby from time to time. Have it rest on one side, then on the other, as well as on the back. Give a dose of castor oil at the beginning of the sickness and keep the bowels open during the disease.

Diet.—The diet will depend upon the severity of the disease. If the fever is high and the cough persistent, the strength of the food of nursing infants should be reduced. We can reduce the strength of the food by giving the child a drink of cool boiled water before each feeding and shortening the length of each feeding. Older children may be given toast, milk with lime water, cocoa with milk, broths, gruels, custards, cereals and fruit juices.

Inhalations.—The value of inhalations in bronchitis is very great. The ordinary croup kettle, which can be bought in any good drug store, is the best method of giving them. Full directions come with each kettle as to the best way to use it. The best drug to use in the kettle is creosote (beechwood). Ten drops are added to one quart of boiling water and the steaming continued for thirty minutes. The interval between steaming is two hours and a half in bad cases day and night. In mild cases the night treatments can be dispensed with. Sheets rigged up over the top and sides of the crib, in the form of a tent, is the most desirable way to give the inhalations.

External Applications.—Counter-irritation by means of mustard pastes are the best applications. They should be put back and front—one on back and one on the chest, overlapping at the sides beneath the arms. They should cover the entire body from the waist line to the neck. These pastes are made as follows:—Mix the mustard (English) and the flour in the following proportions, using a quantity according to the size of child and area to be covered; one tablespoonful mustard to three tablespoonfuls of flour. Mix with lukewarm water until a paste is formed, not too thick and not too thin. Spread on a cloth (put plenty on) and cover with one layer of cheesecloth and place the cheesecloth side next the skin. In order to guard against burning the skin it is advisable to rub the skin with vaseline, before and after putting on the paste. The paste should be left on until the skin is uniformly red. It may be applied from two to four times in the twenty-four hours according to the severity of the case. Mustard pastes are most effective during the first two or three days of the disease.

Drugs.—Drugs are of very little value in the treatment of bronchitis. In the first stage of the disease, when the cough is hard and dry, small doses of castor oil and syrup of ipecac may be given to good advantage. The following dosage should be followed closely: 1st year, 2 drops castor oil, 2 drops syrup of ipecac, every two hours; 3rd year, 3 drops castor oil, 3 drops syrup of ipecac, every two hours; over 3 years, 4 drops castor oil, 4 drops syrup of ipecac, every two hours.

The benefits from this treatment will be obtained in the first two or three days, when it should be discontinued. The cough under this treatment and the use of the mustard paste and inhalations of creosote will be soft and loose in two or three days and the fever will be distinctly on the mend. The disease lasts from five to ten days. It may, however, last much longer according to the condition of the child, etc.

There are other drugs that can be given, with good effect, but when other remedies are indicated a physician should be called to prescribe them according to indications.

SUMMARY:—

Bronchitis is one of the commonest diseases of childhood.

It is the cause of many deaths.

A large number of children have a tendency to bronchitis.

These children need careful attention and "building up."

Do not neglect a "little" cold. It means trouble.

Chronic or Recurrent Bronchitis.—Bronchitis becomes chronic when the treatment of an acute attack fails to cure the condition. The failure usually is dependent upon the condition of the child. It may be suffering with some disease resulting from poor nourishment or poor sanitary and hygienic surroundings or both. The bronchitis, in other words, is dependent upon some other condition, and will not get wholly better until the cause is cured. These children should lead an active outdoor life when the weather is favorable. Their sleeping-room should be well aired and ventilated. Red meats are allowed twice a week only. Sugar is cut down to the lowest limit. Skimmed milk only should be taken—the cream being too rich for them. They can eat freely of fruits in season, green vegetables and cereals. The bowels must move freely every day. Patients must be given a lukewarm bath, followed by a brief spray of cold water, daily. The cold spray should not be too cold; about 60 degrees F. is the suitable temperature of the water.

An absolute change of climate, to a warmer inland atmosphere, is imperative before some of these patients will begin to improve.

SUMMARY:—

A child with chronic bronchitis, or with frequent attacks of bronchitis (or chronic colds), is usually suffering from some other diseased condition.

The bronchitis, or the cold, will not get better until you find out what that "other diseased condition" is.

It takes a physician to find that out.

Having found the cause, cure it, and the bronchitis will disappear and the general health of the child will immediately improve.

PNEUMONIA

Pneumonia is a very common disease in childhood. It is the most frequent complication of the various acute infectious diseases. Pneumonia is an exceedingly important factor in the mortality of infancy.

There are two kinds of pneumonia:—

1. Broncho-pneumonia. 2. Lobar-pneumonia.

Acute Broncho-Pneumonia.—Up to the fourth year this is the form of pneumonia always present. It is the form that always complicates other diseases all through childhood.

It is most apt to occur during the spring and winter months.

It affects all classes, but especially those whose hygienic surroundings are poor. Catching cold is the exciting cause in a large percentage of primary pneumonias.

Symptoms.—Broncho-pneumonia has no regular course. It may or it may not follow a cold or an attack of bronchitis. As a rule it begins suddenly with a high fever, frequently accompanied by vomiting, rapid respiration, cough, and prostration.

The child does not maintain a high fever continuously; it varies considerably throughout each twenty-four hours. It lasts from one to three weeks, and subsides gradually.

The respirations vary between 60 and 80 per minute, though they may be much more frequent than this. The child breathes with apparent difficulty, the soft parts of the cheeks and nose rising and falling as it breathes.

The prostration becomes, as the disease progresses, more and more marked, until the child looks profoundly sick.

Cough is a constant and incessant symptom. It disturbs rest and sleep and may cause frequent vomiting. There is no expectoration. A strong cough is a good symptom; if it stops it is a bad symptom.

Pain is seldom present.

Blueness of the skin is a bad sign and indicates failure of respiration and suggests constant and careful watching.

Delirium may be present during the disease. It is not necessarily a bad sign. Accompanying stomach troubles are frequent if the patient is very young, and are very important. The bowels may be loose; they may be green in color and contain much mucus. Large quantities of gas may accumulate in the intestines and may cause much distress and convulsions. Death may occur at any time or the process may be arrested and recovery take place at any stage of the disease. Broncho-pneumonia is not necessarily a fatal disease in a fairly healthy child. It is, however, always a serious disease.

Various complications may occur in the course of the disease. The most frequent are: pleurisy, emphysema, abscess of the lung, meningitis, heart disease, stomach troubles, thrush, intestinal disease.

How to Tell When a Child Has Broncho-Pneumonia.—If a child develops a high fever, breathes rapidly, coughs, and is content to lie in bed because of the degree of prostration, broncho-pneumonia is almost certain to be the disease present. If in addition to these symptoms there is any blueness of the fingers or around the mouth it is more strongly suggestive of pneumonia.

If the child has been suffering with bronchitis it is sometimes difficult to tell just when the pneumonia begins. The child will appear more profoundly sick, the fever will go higher, and the respiration will be more frequent when pneumonia sets in on top of bronchitis.

Treatment.—The nursing of a little patient with pneumonia is the most important part. He must get plenty of fresh air; consequently he should be kept in a well-ventilated room. It is an excellent plan to change the patient twice daily from the sick room into another which has previously been thoroughly aired. While he is in this room the sick room should be as thoroughly aired as is possible. Keep this plan up all through the disease; change the position of the patient in bed every two hours. He should never be allowed to lie on his back for hours at a time. In this way the different parts of the lungs get a chance to air themselves,—the air cells expand and the oxygen in the air and the fresh blood tend to heal the parts more quickly.

It would be distinctly wrong to go into the detailed symptomatic treatment of broncho-pneumonia in a book of this character. Inasmuch as this is one of the most serious diseases of infancy, no mother should attempt to treat it alone. A physician is absolutely necessary and the most the mother can hope to do is to follow out his directions to the letter.

He may direct the use of mustard pastes but it is essential to know where to apply them. If he should request the use of the cotton jacket, the height and character of the fever must regulate its use. Stimulants are always necessary, whisky and strychnine being given in every case, but if given at the wrong time they may do more harm than good. Cough mixtures may be necessary, but frequently they are contra-indicated. Drugs and cold sponging may be used to reduce the fever, but they are dangerous if used when conditions do not justify their use. Complications must be diagnosed when they occur, and the correct methods of treatment promptly instituted. A competent physician alone can assume the responsibility of these various phases of the disease.

Every mother should appreciate, however, that pneumonia is frequently the result of carelessness. It is a well-known fact that pneumonia is an infrequent disease among children of the well-to-do, because the hygienic surroundings of these children are better and because they receive competent attention if suffering with colds and bronchitis. Bronchitis is quite common in all classes of children, but in the lower walks of life it is the custom to allow children to run around while they give every sign of having a heavy cold, and a beginning bronchitis. These children should receive treatment and should be kept indoors and in bed if they have even a slight fever, as pneumonia is frequently the inevitable outcome. They should be carefully fed, and all signs of stomach or intestinal troubles attended to at once.

"of a feeble-minded woman with a husband who is alcoholic and the offspring either feeble-minded or miscarriages."

"Isaac is exceedingly dangerous. He is a potential criminal or bad man, or under the best conditions would at least marry and probably become the father of defectives like himself."

This and the succeeding pictures in this volume contrast vividly with the frontispiece. Terrible are the results when we disregard the inevitable laws of nature, and so mate ourselves that our children will be parasites on society.]

[A] "Feeble-mindedness; Its Causes and Consequences", Goddard, The Macmillan Company.

The After-Treatment of Pneumonia is important, and every detail has a distinct bearing on the ultimate recovery and establishment of good health. Careful feeding, a good tonic, and the proper attention to exercise, fresh air and bathing are requisite. A change of air after the fever is gone is more important than all other measures put together. A dry, warm climate where patients can be kept in the open air is preferable. The danger of allowing a slow, long drawn-out convalescence after pneumonia is the development of tuberculosis.

ADENOIDS

Adenoids are very common, almost popular, in childhood. The condition is one that causes more real trouble and discomfort than any other childhood affliction. Adenoids are associated with, and are responsible for, many of the ailments of childhood. They may be associated with enlarged tonsils or they may be independent of them. They may be present at birth or develop any time thereafter, though they are more frequent between the ages of two and six years. Children who have adenoids invariably suffer from chronic "head-colds" with a discharge from the nose. These chronic colds are caused by the adenoids. Nearly every disease, and every diseased, or abnormal, condition of the nose, throat, larynx, and lungs can be directly caused by the presence of adenoids. They are also responsible for numerous other conditions of very grave importance in the growing child. The accompanying "head-colds" may develop into a bronchitis which may keep the child indoors for a long period. Adenoids always interfere with respiration, thereby depriving the child of a normal quantity of oxygen, thus rendering the blood less pure, and, as a consequence, seriously interfering with the nourishment and general health. The impaired nourishment and poor health thus produced, as a direct result of adenoids, renders the child more liable to disease; he may thus acquire ailments that may affect his whole subsequent life. The mental side of a child's development is also affected by the presence of adenoids, so much so that actual statistics prove that these children cannot keep up with their classes in the public school.

We must therefore regard the presence of adenoids as a serious menace to the health and comfort of the patient. It has already been pointed out in discussing other diseases that before a cure of these diseases could be permanently accomplished it would be absolutely necessary to remove the adenoids, which were, no doubt, the actual cause, or an important contributing cause, of the disease. Such conditions as catarrhal laryngitis, croup, chronic recurring winter coughs, acute catarrhal rhinitis, "snuffles", "cold in the head", chronic catarrh, bronchial asthma, incontinence of urine, "bed-wetting", "nose-bleeding", headaches in growing children, anemia, deafness, night terrors, defective speech, diphtheria, consumption, are frequently caused by the presence of adenoids.

These patients contract certain diseases easier than other children, and when they do, they have them more severely; such diseases are diphtheria, tuberculosis, scarlet fever, measles, and whooping cough.

Adenoid children are, as a rule, in better health during the warm, equable, summer weather than during the changeable, uncertain weather we have in the winter months. If the case is neglected, and if the adenoids have existed for a long time, the growth of the child is impaired. He remains small and stunted, and the expression of the face is dull and stupid. The temperament and disposition are affected also; such children are languid, listless and depressed.

How to Tell When a Child Has Adenoids.—Children with well-developed adenoids are "mouth-breathers." Instead of breathing through the nose they breathe with the mouth open, especially when sound asleep. If a child has a discharge from its nose and a chronic cough, both of which resist treatment, and if in addition it is a mouth-breather, it is safe to investigate the naso-pharynx for adenoids. If a child with these symptoms is not in good health, is listless and depressed, looks stupid, snores at night, has difficulty in breathing and cannot blow its nose satisfactorily, is troubled occasionally with "nose bleeds" and headaches, we may be satisfied that the child has adenoids, as no other condition could produce such a picture.

Adenoids, like enlarged tonsils, are dangerous, apart from the physical distress and disease which they cause, owing to the fact that they harbor deadly bacteria, and from these bacteria, which find a lodgment in the adenoids and tonsils, a fatal attack of diphtheria or consumption may have its beginning.

Treatment of Adenoids.—Absolute removal is the only justifiable treatment. This is rendered imperative for so many reasons that it is unnecessary to go into details in justification of the procedure.

The physical well-being, the mental development, the life of the child depend upon it. Any parent who would wittingly interpose an objection to the removal of his or her child's adenoids, after they have been demonstrated to exist, would be guilty of a grave crime.

The operation itself is not at all dangerous. It is over in a few moments and the child is well in an hour or two, so far as any pain or suffering is concerned.

Physicians are frequently asked if adenoids "grow" again after removal. The answer is, "Yes," they sometimes do. In a very small percentage of the cases they do return. The older the child is when they are removed the less chance there is of a recurrence. A child operated on before it is two years of age is more liable to a recurrence than a child operated on at six years of age. This must not, however, be construed as an excuse for putting an operation off, because if a child needs an operation at two years and it is postponed till later, its health will be permanently injured before it is four years of age.

SUMMARY:—

1. Adenoids cause more trouble and more actual disease than any other condition during childhood.

2. It is a crime for a parent to refuse operation if the presence of adenoids has been proved.

3. Removal is the only treatment and it should be done in every case as soon as possible.

4. The operation is a trivial one and is free from danger.

NASAL HEMORRHAGE—"NOSE BLEEDS"

A hemorrhage from the nose may occur at any time from birth on. It depends upon the rupture of one or more blood vessels. The great majority of "nose-bleeds" are caused by adenoids, or by a small ulcer in the nose, or by an injury, such as a blow or fall. A nasal hemorrhage, however, may be caused by other, more serious conditions, and for that reason may justify a careful inquiry into the cause, especially if bleeding should occur a number of times, or be of a serious character the first time.

Of the more common causes as given above, the adenoids should be removed, and the chronic catarrh which is invariably the cause of the ulcer should be cured.

Treatment of an Acute Attack.—Have the patient sit erect; loosen all tight clothing around neck; fold the hands over the head; apply cold to the back of the neck and the nose. Pieces of ice can be put into the nostril and the ice bag to the nape of the neck, or a piece of ice can be put into a folded napkin and held on the back of the neck. Taking a long breath and holding it as long as possible and repeating it while the ice is being applied is an aid. Placing the feet in hot mustard water is of decided use. Another excellent expedient is to wrap absorbent cotton round a smooth probe (piece of whalebone, for example), dip the cotton in an alum-water mixture (half teaspoonful powdered alum in a half cupful of water), and then push it into the bleeding nostril as far as you can with gentle force. A valuable remedy is Peroxide of Hydrogen used full strength and freely dropped into the nostril. If these measures fail, send for a physician at once.

SUMMARY:—

1st. Nose bleeds may be caused by some serious condition.

2nd. If they occur a number of times have the child examined.

3rd. If the treatment outlined above does not stop the bleeding in a few moments send immediately for a physician.

QUINSY

Quinsy is not common in childhood. It usually follows tonsilitis when it is seen. The child complains of pain in the neck, extreme pain and difficulty upon swallowing, and inability to open the mouth as much as usual. There is a tendency to hold the head to one side. The treatment is to open the abscess at the earliest moment after pus is present.

HICCOUGH

Hiccough is, in most cases, in infancy and childhood caused by some irritation of the stomach, may be over-filled with food or gas. In these cases it is an unimportant incident and may be quickly relieved by giving the child an enema of soap-water and a laxative of rhubarb and soda.

Infrequently hiccough may be the result of cold feet, or a surface chill. Simple methods of relief are, to hold the breath, to expire, or blow the breath out as long as possible before taking the next breath; to sip water from a cup held by another person while the tips of the two fore-fingers are in the ears.

Hiccough is quite frequent in hysteria in girls, but it is of no consequence. When hiccoughs set in during the course of any serious disease it is a very unfavorable sign.

SORE MOUTH: STOMATITIS

Stomatitis is an inflammation of the mucous membrane (inner lining) of the mouth. The gums and the inner surface of the lips and cheeks may be red and angry-looking. There may be small grayish spots on any part of the mouth. If the case is very bad or if it has lasted some time and has been neglected, these spots grow larger and join together forming irregular grayish plaques. A large percentage of the cases never go further than this because the proper care and attention is given them. It is possible, however, for any case to progress further and become ulcerative. This will be observed first as a faint yellow line at the margin of the teeth and gum. Ulceration never takes place unless the child has teeth. The quantity of saliva is very greatly increased, so much so that it flows out of the mouth soiling the clothes. The saliva is intensely acid and it consequently irritates the skin, causing more or less eczema. The mouth is painful and hot. There is slight fever, but seldom any marked prostration. If, however, the ulceration should be severe, the fever may be quite high.

There is one feature of these cases that sometimes proves vexatious and annoying. Because of the soreness of the mouth, the child cannot draw strongly enough on the nipple to get a normal feeding, and as a result the nutrition of the child is poor. These children are hungry and when offered the nipple grasp it greedily, draw a few mouthfuls then stop because of the pain and begin to cry.

If the ulceration is extensive, there is usually an odor and the gums bleed easily. Sometimes the teeth fall out or have to be drawn out.

Strong, well-fed children are as likely to develop stomatitis as are those who are weakly and ill fed.

The disease is caused by infection and is contagious. Just what the infection is we do not know; we do, however, know that children whose mouths are carefully cleaned after each feeding do not have sore mouths of this character. When cleaning the mouth care must be observed not to injure the tender mucous membrane.

Treatment.—As soon as the condition is observed mouth-washing should be systematically and thoroughly carried out. After each feeding the mouth should be washed with a saturated solution of boric acid in boiled water. (See page 626.)

It is not necessary to use any further treatment, as a rule. Patients recover in four to eight days. Strict attention to cleanliness, however, is imperative. The feeding bottle and nipple, or the mother's nipple, if breast fed, must be kept scrupulously clean.

The feeding of these children is sometimes a problem for a day or two, because, as stated above, of the soreness of the mouth. This is best overcome by feeding the baby with a spoon. If breast fed, it is necessary to pump the milk and then feed with the spoon. Children will take the milk better if it is fed cold. Cold boiled water is largely taken and is good for them at this time.

Treatment for Ulcers in Mouth.—The ulcers should be touched with a camel's-hair brush which has been dipped into finely powdered burnt alum. If a stronger caustic is necessary, the solid stick of nitrate of silver may be used.

A mouth wash may also be used in the ulcerative cases, composed of the peroxide of hydrogen diluted with two parts of water. If this is used wash the mouth out afterward with plain, cool, boiled water. The peroxide mouth wash can be used four or five times daily.

In addition to the mouth washing in the ulcerative cases it is advisable to use internally chlorate of potash. The druggist should be requested to make a two-ounce saturated solution, and of this you can give one-half teaspoonful, largely diluted with cool water, every hour during the day for the first twenty-four hours, then every two hours until marked improvement is shown, when it can be further reduced by lengthening the interval between doses.

SPRUE—THRUSH

Sprue is a form of sore mouth. It is seen only during the first six months of life, as a rule. It affects the mucous membrane of the mouth; it appears in the form of small white spots that look like drops of curdled milk. They are on the inner surface of the cheek and may be all over the mouth, and on the tongue. The spots are firmly attached, and if forcibly removed the mucous membrane will bleed.

The disease is caused by infection through lack of cleanliness and it invariably affects poorly nourished children, especially those who are bottle-fed.

There are no symptoms other than those of the mouth; the child frequently refuses to nurse because of evident pain and distress while nursing. The condition is not contagious. It may be cured in from six to eight days without difficulty.

Treatment.—Mouth irrigations of boracic acid are all that are necessary. They are given in the following way: Place the child on its side, roll around the index finger a piece of absorbent cotton, dip this in a saturated solution of boracic acid, and put into the mouth of the child. Let the cotton take up as much of the solution as it will hold, so that when it is lightly pressed on the tongue and cheeks it will flow out of the mouth, thus "irrigating the mouth." Repeat this a number of times, pressing the cotton to a different part each time. This should be gone through from four to six times daily.

If the child is a bottle-fed baby, care should be taken in cleaning the nipples and bottles as directed on page 264. If the patient is breast-fed, care must be taken to note that the mother's nipples are clean. They should be washed with the same solution of boracic acid and not handled. If the child cannot nurse it is necessary to feed it with a spoon.

In obstinate cases the parts may be touched with a one per cent. solution of formalin. Mothers should particularly note not to use honey and borax, as is often recommended by women who know no better, in any disease of the mouth in children.

* * * * *

CHAPTER XXXV

DISEASES OF THE STOMACH AND GASTRO-INTESTINAL CANAL

Inflammation of the Stomach—Acute Gastritis—Persistent Vomiting—Acute Gastric Indigestion—Iced Champagne in Persistent Vomiting—Acute Intestinal Diseases of Children—Conditions Under Which They Exist and Suggestions as to Remedial Measures—Acute Intestinal Indigestion—Symptoms of Acute Intestinal Indigestion—Treatment of Acute Intestinal Indigestion—Children with Whom Milk Does Not Agree—Chronic or Persistent Intestinal Indigestion—Acute Ileo-colitis—Dysentery—Enteritis—Entero-colitis—Inflammatory Diarrhea—Chronic Ileo-colitis—Chronic Colitis—Summer Diarrhea—Cholera Infantum—Gastro-enteritis—Acute Gastro-enteric Infection—Gastro-enteric Intoxication—Colic Appendicitis—Jaundice in Infants—Jaundice in Older Children—Catarrhal Jaundice—Gastro-duodenitis—Intestinal Worms—Worms, Thread, Pin and Tape—Rupture

ACUTE GASTRIC INDIGESTION

Acute Inflammation of the Stomach—Acute Gastritis—Persistent Vomiting

An infant seldom has real inflammation of the stomach. Gastric, or stomach, indigestion is the better name, because it actually signifies the true condition. It is indigestion that causes a child to vomit, though it is possible to have a true inflammation caused by the taking of irritant or corrosive drugs.

Gastric indigestion causes sudden, repeated vomiting, with prostration and occasional fever. It is caused by unsuitable food, the wrong quantity of food, irregular feeding, and food the quality of which is not good.

Treatment.—The stomach should be immediately washed out. Until the physician arrives the mother can encourage the child to drink a large quantity of cool boiled water. This will be vomited and it will wash out the stomach at the same time. No further treatment may be necessary, as the vomiting may stop. All food should be withheld for at least twenty-four hours. A high rectal irrigation should now be given. It is essential to know that the bowel is absolutely clean in all vomiting cases. The normal salt solution is the best agent to use for a high enema in infants. (See page 586.)

After twelve or twenty-four hours' abstinence from food, the child can be given teaspoonful doses every twenty minutes of cooled boiled water, or barley or albumen water, weak tea, or chicken broth. Cold liquids are better retained and more readily taken than those that are heated. If the liquid feedings are vomited, another twelve hours must elapse before trying stomach feedings. In these cases we must try to satisfy the thirst by giving cold colon flushings. If the case becomes protracted and we find it impossible to nourish the child by the mouth, we must wash the stomach out once every day with a five per cent. solution of bicarbonate of soda, and feed the child by the rectum. Sometimes we can feed through the stomach tube. Liquids will frequently be retained when put into the stomach through a tube when they will be vomited if swallowed.

The best food by the rectum is plain peptonized milk.

Drugs are absolutely useless. If the vomiting persists, despite the above efforts to stop it, there is nothing to be gained by experimenting. You will not only render the condition worse but you will weaken the child. Morphine given hypodermatically is the only remedy. Given in appropriate doses, according to age, it is absolutely harmless. It will not only stop the vomiting, but it will give the child a much-needed rest, by allowing it to go to sleep. When it wakes up it will be stronger and its stomach will most likely retain small doses of nourishment.

Great care must be exercised, in getting the child back on a normal diet, not to try to go too fast.

In cases of persistent vomiting in children I have found it advisable to use teaspoonful doses of ice-cold champagne. These children will sometimes keep this down when all other liquids will be vomited. It is absolutely necessary to keep the child lying down. If he is restless or sits up, the vomiting may begin all over again. The champagne not only is excellent nourishment for the child, but it quiets the stomach, allays irritability, and frequently favors sleep, during which time a cure very often results. The champagne must be drawn through a champagne siphon (procured in the drug store), and the bottle must be kept on ice with the mouth downward; otherwise it will get stale very quickly and be of no use. If kept as advised it will remain good to the end.

SUMMARY:—

1st. Persistent vomiting in a child means acute gastritis. Stop all food for twenty-four hours.

2nd. Encourage the child to drink large quantities of slightly warm water; this will wash the stomach out and frequently stops the vomiting.

3rd. When the child is quiet wash out the bowels.

4th. If vomiting persists, use iced champagne as directed.

ACUTE INTESTINAL DISEASES OF CHILDREN

The large infant mortality that results from intestinal diseases during the summer months is deserving of the most careful consideration, both of the physician and the parent.

Apart from the excessive heat of the summer, there is no doubt that an unfavorable environment, which means bad hygienic surroundings, bad sanitary conditions, bad food and home influences, contributes largely to the enormous number of these serious cases. Education, while it may be expected to influence favorably the sanitary and other conditions in the home, cannot change the home location. The child must continue to live in the same environment. It is in this class of cases that these summer diseases are so very fatal. Children in better circumstances can take advantage of conditions which are denied to the tenement child. The diseases must therefore be faced and treated under these existing conditions.

In addition to the climate and the environment, there are certain factors that occur in all classes which result in intestinal derangement. If the stomach or bowels are not performing their function properly, or if the food or method of feeding is wrong, these, plus very hot, humid weather, invariably result in serious intestinal disease. The mother must be taught to interpret properly the meaning of a green, loose stool in the summertime; she must appreciate that it is the danger signal and must be regarded seriously.

The very best preventive against summer diseases of the intestine is to guard particularly against any trouble with the child's stomach at all seasons of the year. A healthy stomach and bowel will resist disease, even in very hot weather.

The most important food product which has a direct relationship to this class of diseases is milk. In a large city like New York it will remain impossible to solve the milk problem, despite the splendid efforts of the Health Department and the members of the medical profession, until the city itself shall establish milk depots and ice stations where safe milk, and ice to keep it safe, may be obtained at a nominal cost, or free, if the parents cannot afford to buy it. We, therefore, must recognize that the vast majority of children to-day are taking milk that is not suited to them, that is really not fit as a food for children. The mothers do not know this and no steps are taken to render the milk more safe for them to feed to their children. These mothers are willing to do what is essential in the interest of their children, but they do not know what should be done. These people cannot afford a physician or a nurse to teach them, nor do they even know that their methods are wrong or that they need any instruction. We must carry the information and the explanation to them. We must show them the need for a change of methods. This is the work for those charitably disposed women who desire some worthy purpose in life, who really wish to do some real good. All the equipment they need is good common sense. They will tell these mothers why it is necessary to pasteurize the milk before feeding it to the baby. They will show how to keep the nursing bottles clean, and the nipples sweet and fresh. They will instruct them how to dress the baby in the hot weather and impress them with the need of giving it all the cool, fresh air possible. In short, they will gain the confidence and the good will of these mothers in a tactful and diplomatic way, and they will tell them all they know in language which they will understand regarding the care of the baby. In every city in the country this work is needed and is waiting for the missionaries who will volunteer. To teach mothers the need for boiled water as a necessary drink for baby and older children is alone a worthy avocation. To impress upon one of these willing but ignorant mothers the absolute necessity for washing her hands before she prepares her baby's food, that she must keep a covered vessel in which the soiled napkins are placed until washed, that she should frequently sponge her baby in the hot weather, and explain thoroughly why these are important details, is a work of true religious charity. They should be specially taught to immediately discontinue milk at the first sign of intestinal trouble, to give a suitable dose of castor oil and to put the child on barley water as a food until the danger is passed. They should be taught to know the significance of a green, watery stool, they should know that is the one danger signal in the summer time that no mother can ignore without wilfully risking the life of her baby. They should be taught to prepare special articles of diet when they are needed. If every mother were educated to the extent as indicated in the above outline the appalling infant mortality would fall into insignificance. It is not a difficult task nor would it take a long time to carry it out; it is the work for willing women who have time and who perhaps spend that time in less desirable but more dramatic ways.

It is the knowledge that aids in catching disease in its inception that counts. The worst infections begin as a mild condition and prompt treatment robs them of their sting. When treatment is delayed and the child is fed for twenty-four hours too long on milk, the condition which in the beginning could have been stopped promptly has developed and it becomes a fight for life.

It will be seen from the above that all we need is education. Education of the mother primarily, but education of the missionary, the nurse, the physician, the municipality, and the State, each co-operating, each willing to work in the interest of a great cause, for the benefit of the human race and for the brotherhood of man.

ACUTE INTESTINAL INDIGESTION

Causes.—Overfeeding, unsuitable and improper food, irregular and indiscriminate feeding, sudden change from one food to another, as at weaning time, a change from a poor quality to a rich food, or vice versa. Conditions affecting the health of the child, especially the nervous system, such as hot weather, extreme cold, fatigue, or at the beginning of any of the acute diseases. Children sometimes are predisposed to attacks of intestinal indigestion; these children are delicate in health and have weak digestive ability. The slightest irregularity or error in diet will cause an attack in these children.

Symptoms.—The attack may come on suddenly or it may develop slowly. The important constitutional symptoms are fever, prostration, and a general nervous irritability. The child is seized with pain in the abdomen. The pain is referred to the region around the navel. It is sharp, colicky, and severe, causing the child to cry out and draw up its legs in an effort to lessen its severity. The child is exceedingly restless and acts as if it were on the verge of a dangerous illness. Gas in the bowel is not present as a rule as frequently as it is in infants under the same circumstances. In a few hours diarrhea sets in, the stools may number from four to twelve or more in twenty-four hours. The stools are acid, sour, and the odor may be very foul. They are thinner than usual and frothy from the presence of gas.

In very young infants suffering from a sudden attack of intestinal indigestion, the stomach, as well as the bowels, is invariably upset. If the indigestion is the result of a slower process, the stomach does not participate in the process. The color of the stools in infancy is yellow, then yellowish-green, and later grass-green. Undigested food is always present and in infants the curdled casein of the milk appears as white specks or lumps in the movements.

The fever is high in the sudden cases and lower in the cases of gradual onset. The prostration is more severe when the onset is sudden and in infants may be very marked.

The termination of the disease depends upon the cause, the treatment, and the previous health of the child. In healthy children promptly and properly treated it may be all over in a week. In delicate, poorly nourished children, and especially in the summer time, it may be the beginning of trouble that may eventuate in death.

Treatment.—There is no condition in the whole realm of diseases of childhood where the knowledge of the mother may have such important results as this condition. The most effective time to treat these cases of intestinal indigestion is before the physician is called. There are few diseases in which time is so valuable, so far as final results are concerned, as it is here. Every mother should know the significance of a loose, green stool. She should be taught that it means danger and consequently demands prompt treatment. The first indication is to empty, thoroughly, the bowel. The best means for this purpose, if it is immediately procurable, is calomel. If calomel is not procurable at once give castor oil, two teaspoonfuls to an infant, one tablespoonful to an older child. Calomel should be given in one-eighth-grain doses, repeated every three-quarters of an hour for eight or twelve doses, until the bowel is thoroughly cleaned out. Don't be afraid of a few extra movements at the beginning. Better clean out thoroughly at the start than to be compelled to do it all over again after the child is weak and suffering from the poison of the disease. The next important thing to do is to stop milk at once. The thirst is usually intense and if vomiting is not present it can be moderately relieved by giving small quantities frequently of cool boiled water or mineral water or strained albumen or barley water. We quite often have to stop all food and liquids by the mouth for twenty-four hours.

If the prostration is very great and the child looks as though it might collapse, it can be given brandy in cracked ice from time to time.

After the bowels have been thoroughly cleaned out, never before, some medicinal agent may be given to stop the unnecessary diarrhea. In a very large number of promptly and properly treated cases this is not needed. If it is thought best to use it the physician will select the agent according to the conditions present and prescribe it.

Breast-fed infants rarely have intestinal diseases of a severe type. If they should develop diarrhea they must be taken off the mother's milk for twenty-four hours. They should be given a dose of castor oil or calomel and fed on barley water in the interval. The feedings should be reduced in quantity and the interval doubled. The two-hour interval will become a four-hour feeding: the three or four ounces at each feeding can be reduced to two ounces. The intention is to simply give as little as possible while the diarrhea is under way.

The mother's breasts must be pumped at the regular feeding time in order to preserve the flow, release the pressure, and keep the milk fresh.

It is sometimes a problem to renew feedings of milk without exciting a relapse of the diarrhea. It should not be tried until the stools are normal in color and consistency. This may not be for three or four days. In resuming the milk it should be given in smaller amounts and diluted with lime water or barley water for the first day. Gruels may be given to which skimmed milk may be added: later add the ordinary milk. If it is well digested and does not cause any return of the diarrhea, the quantity of milk can be slowly increased until the former feedings are resumed. It is often of very great advantage to boil the milk for some time. Peptonized milk is safe and can be used in bottle-fed infants after diarrhea. In older children, meat, broths, eggs, boiled milk, and dry toast bread may be used sparingly for some time. Cereals, vegetables, fruits, should be withheld for a considerable time and watched carefully when resumed. Kumyss, buttermilk, matzoon, bacillac, and other fermented milks are better borne than plain milk. All of these children need rest, fresh air, change of air, frequent bathing, and tonics, as an attack of this kind leaves them depressed, weak, languid, and anemic.

SUMMARY:—

1st. When a child complains of sharp, colicky, severe pains in the abdomen, around navel, which are shortly followed by foul, sour, frothy diarrhea,—greenish in color, it has acute intestinal indigestion.

2nd. Every mother should know that a green stool means danger. She should know to give at once a cathartic,—castor oil is good, but give a good large dose—then stop all food for twenty-four hours. If she learns this lesson she will have time to wait for the doctor; meantime, she may have saved her child's life.

CHILDREN WITH WHOM MILK DOES NOT AGREE

Contrary to the general belief, there are quite a large number of children in whom milk seems to act as a poison. These children are not necessarily constipated. They suffer, however, from a slow, continuous intestinal toxemia or poison. The symptoms of this condition are headache, disorders of speech, habitual sleep-talking, sleep-walking, and general nervous irritability without cause: they are listless, languid, and constantly tired. They may be bright in the morning and sleepy in the afternoon. They are irritable and cross and touchy.

Treatment.—Milk must be wholly discontinued. Eggs must be restricted to one every second day, and meat but once daily. The use of green vegetables is particularly suitable and should be given daily. Cereals and fruit also are good. Malted milk, kumyss, or matzoon may be given in place of milk. If constipation is present, rhubarb and soda mixture is an excellent laxative in these cases. A tonic should be prescribed for all these children.

DYSENTERY—ENTERITIS—ENTERO-COLITIS—INFLAMMATORY DIARRHEA

Cause.—Any cause which has been mentioned as a cause of ordinary diarrhea may result in this disease. It may occur at any time of the year and at any age. It may follow the infectious diseases. It may follow any other disease of the intestines.

Symptoms.—It may begin like an ordinary attack of acute intestinal indigestion. There is usually vomiting, fever, pain, and frequent yellow or green stools. The passages may be blood-stained and there may be little or much mucus. The stools at the beginning have no odor as a rule. The bowels move very frequently, often with little or nothing to pass. There may be pain with each movement. The blood may disappear in a few days, but the mucus remains, often in large quantity in each stool.

At the beginning the fever is high, but it soon falls and remains low during the attack. The child loses weight, is irritable, has no appetite, and looks and acts sick. When the attack is over these children do not gain their strength as readily as we would like; recovery is slow.

The acute symptoms usually last about one week, after this time the child begins to recover, but the process is a tedious one and one in which much care has to be exercised. It is an encouraging sign to note the disappearance of the blood in the stools and the return of the movements to the normal brown color. When these favorable signs are wanting the bowel is probably ulcerated and it will take a much longer time to return to normal and to be free from blood and mucus.

The above is the ordinary form of this disease and it ends in recovery as a rule. There is a more severe form, however, which differs from the above in the following way:

The fever is high and remains high; the stools are more frequent and there is more blood and more mucus in them; the child is much more irritable and is more profoundly sick. Death may occur at any time from the second day. If the little patient survives, the return to health is a very slow process; it often takes months and frequently years before a reasonable degree of strength is regained. Relapses are common, and they are very difficult to treat and care for. In some cases the child never wholly regains its former strength.

There are children who have been the victims of other intestinal diseases or conditions who develop colitis. The colitis in these cases may come on suddenly with vomiting and high fever, or it begins slowly, with no vomiting and with little fever. Their appetite is poor, their digestion is feeble, their prostration is pronounced. They lose flesh rapidly and may be emaciated to a remarkable degree. Very few of these cases recover completely. Serious and sometimes fatal relapses may take place. The feeding of these children is a difficult task and the greatest care must be constantly taken; a very little mistake may cost the life of the child.

Treatment.—All diseases of the intestine in childhood should be promptly and efficiently treated. If any form of diarrhea is neglected, it may result in the development of ileo-colitis with all its risks and uncertainty. When a child is seized with sudden bowel trouble, no matter what variety it is, it should be treated with the greatest care because "sudden" bowel trouble usually means plenty of trouble if it is neglected.

Fresh air is essential in all these cases. A change of air is of decided value as soon as the immediate symptoms have abated. The diet is the same as for children who have gastro-enteric intoxication. Later, much difficulty will be met because these patients have absolutely no appetite,—peptonized skimmed milk is always good, beef broths are often well borne, liquid beef peptonoids may be tried. The food should be given every three hours. Boiled water and stimulants may be given between the feedings. Later in older children, raw beef, eggs, boiled milk, kumyss, or matzoon and gruels may be given. Great care has to be taken for months after an attack; relapses may be caused by changes of temperature, by fatigue, and, of course, by improper feeding. These children should avoid potatoes, tomatoes, fruits, corn, oatmeal, and a great many other things which an intelligent mother would not give any sick child, as candy, cakes, pastries, etc.

Cases which begin with free vomiting, thin stools; and fever should be treated at once. The bowels must be thoroughly cleaned out, the colon should be thoroughly irrigated, and all food should be stopped. When there are bloody stools with mucus and pain we must depend upon castor oil, irrigations of the colon, and opium and bismuth by the mouth. A good big dose of oil at the beginning is always necessary. If, however, the stomach is irritable and will not tolerate castor oil, we may substitute calomel in one-fourth-grain doses every hour for six doses, to be followed by citrate of magnesium. Irrigation of the colon in these cases is one of the essential means of successful treatment; it should be done twice a day during the first few days of the disease.

Stimulants are needed in all the cases. They help the heart, act as a food, and tend to quiet the general nervousness by favoring sleep. Good brandy given in boiled cool water is the best stimulant.

After the child is over the worst of the acute symptoms all medicine should be withdrawn and the proper kind of food given. Tonics will aid in restoring the strength. Cod Liver Oil during the following winter is a very good plan to aid in building up the vitality of the weakened bowel, but it must not be given too soon.

CHRONIC ILEO-COLITIS—CHRONIC COLITIS

Chronic Ileo-colitis fellows the acute variety. Cases which are unusually severe or which have been badly managed are likely to become chronic. A child suffering from this disease presents the following picture: The patient is emaciated, the abdomen is usually enlarged with gas, the feet are cold, the circulation of the blood is poor, the fever is low or absent altogether except when the child is having a relapse, when it jumps up suddenly. The bowels are loose and contain mucus, frequently in large quantities. The mucus may stop for a few days; then it appears again with a rise of temperature accompanied with loose stools with foul odor. These children are exceedingly nervous and irritable and are very poor sleepers.

Parents should be told it will be impossible to effect a rapid cure of these cases. It often takes months to get them started on the safe road. The slightest mistake or change in the weather will upset the progress of the cure and it will be necessary to begin all over again. The entire hope of cure rests with the mother. She must be faithful, patient, and must carry out the physician's instructions implicitly. The management consists in diet, change of climate, and such other treatment as the physician finds necessary in each individual case.

Treatment.—In children under one year of age the only hope is breast milk, which must be given in small quantities. They do not do well on any starch food for a considerable period.

Where breast milk is not available the whites of two or three eggs may be given daily. They may be beaten up and given in skimmed milk, or in plain water with a little salt added. Zwieback or bread crumbs may be given in small quantities. They should be fed at four-hour intervals.

Older children may take skimmed milk, raw scraped beef, junket, and coddled white of egg or raw egg, bread crumbs, toasted, or zwieback.

A rectal enema must be given every twenty-four hours if the bowels have not moved. If constipation is the habit a laxative should be given; the aromatic fluid extract of cascara sagrada or magnesia are suitable. At least one free movement every day is essential to success.

Colon irrigations are only to be used when there is a rise of temperature, irrespective of whether the bowels have moved or not.

When convalescence is established these children should be given a maximum of fresh air and should be treated as recommended in cases of malnutrition.

SUMMER DIARRHEA

As the name implies, this is the form of diarrhea that is so common, especially in cities, in summer. It is always preceded by some milder condition which paves the way for the more serious diarrhea. Acute indigestion is, as a general rule, the forerunner of cholera infantum. The influence of hot weather must always be kept in mind as the underlying factor which no doubt conduces to gastro-intestinal disease of infancy and childhood. The depression incident to a spell of hot and possibly humid weather tends to interfere with the digestive process of babies and children. When this function is carried on imperfectly, the strength and vitality of the child fails, and if immediate steps are not taken to check the process, diarrhea makes its appearance. If these children are improperly fed, or if their surroundings are not sanitary; if they are not getting fresh air enough, or if they suffer because of lack of attention, and have at the same time a little indigestion, it is only a step further to develop a full-fledged cholera infantum.

The outcome of any case of summer diarrhea is questionable. It is not safe to make any promise. An apparently mild attack may prove quickly fatal. Much depends upon the previous history of the child. If it has been a strong, healthy child it has a very good chance if treated energetically and correctly. If it has previously suffered from bad nutrition, is not robust, has had trouble with its stomach, etc., the chances are against it.

The one lesson to be learned by all mothers is, as stated above, to act quickly; to be on the watch all through the summer months for any trouble with the baby's stomach or bowels. It is much easier to treat and cure a little trouble than to battle against an established gastro-enteric intoxication. Overfeeding and indiscriminate feeding must be religiously avoided,—they are the two most prolific causes of stomach and intestinal troubles in childhood.

Symptoms.—The onset is sudden and pronounced. The child begins to vomit and continues vomiting and retching persistently. The bowels are loose, and large, watery, greenish stools are frequent. The prostration is very marked, the child looks seriously sick, respiration is quick and shallow, the eyes sunken, the skin becomes ashen gray in color, and the pulse is soft and very rapid. The fever may be very high or it may remain low. The low febrile cases are the worst.

If taken in hand quickly and if the treatment is energetic and if the child reacts, the case may go rapidly on to recovery and the child be wholly well in a few days; or it may not react, but be overwhelmed by the poison and sink and die in twenty-four hours.

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