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THOMAS MORGAN ROTCH, M. D.

PEDIATRICS

The Hygienic and Medical Treatment

OF

CHILDREN

BY

CHARLES HUNTER DUNN, M. D.

INSTRUCTOR IN PEDIATRICS, HARVARD UNIVERSITY PHYSICIAN IN CHIEF AT THE INFANTS' HOSPITAL

FOUNDED UPON THE TEACHINGS OF THOMAS MORGAN ROTCH, M. D.

VOLUME I

Second Edition

THE SOUTHWORTH COMPANY, PUBLISHERS TROY, NEW YORK 1917

Copyright 19 17 By The Southworth Company

To

Clarence John Blake, M.D., O.M. (Vienna), F.A.C.S.

Professor of Otology (Emeritus), Harvard University

This Volume is Inscribed

As a tribute to his high professional attainments and to his unfailing

interest in the welfare of children, and in grateful

remembrance of many acts of kindness

By the Author

PREFACE

The "Pediatrics" of Dr. Thomas Morgan Rotch was for many years the official text-book used in the Harvard Medical School. Professor Rotch originated many new ideas, and his book contained many contributions of permanent value in the teaching of pediatrics. The last edition was published in 1906, and is now entirely out of date. At the time of Dr. Rotch's death, he was contemplating the bringing out of a new edition.

It seemed a pity that the permanent and distinctive features of Dr. Rotch's teaching, which constitute the foundation of the teaching of pediatrics at Harvard, should not be preserved in written form. As much therefore of this teaching as has seemed to the author of permanent value, has been incorporated in the present work, with such revision as modern progress demands.

The work is not, however, designed to be merely a revision of Dr. Rotch's book. It is designed to be an entirely new modern text-book of the diseases of infancy and childhood.

Recent progress in the diagnosis and treatment of disease is be- coming more and more centered upon the problems of etiology. For this reason, especial attention has been devoted to the discussion. of the causes of the various diseased conditions of early life. Modern diagnosis concerns itself less with names than in former times, and consists in a recognition of the nature of the lesions and functional disturbances which constitute disease, and of their causes. Modern treatment concerns itself mainly with the prevention or removal of etiological factors.

Progress in knowledge is so rapid, that before a book on any sub- ject in medicine is published, it is likely to be already out of date. One reason for this is that the writers of text-books hesitate to in- corporate many new advances in research for fear that they will not stand the test of final proof. This leads to the exclusion of much material which does prove of final value, and justifies the criticism that the latest advances, the things which are being most widely discussed, are not to be found in the most recent text-books. The author has in this book attempted to obviate this difficulty, by means of a special subdivision under each disease, which, under the heading of Problems and Research, deals with the most recent advances in scientific medicine, and summarizes the problems awaiting future solution. The reader can thus easily distinguish the proven facts from the interesting and suggestive theories.

VI

Preface

The author acknowledges his indebtedness to Dr. WilHam W. Howell, and Miss Margaret Farquhar, Head Social Worker at the Infants' Hospital, for many valuable suggestions, to Dr. Joseph I. Grover for revision of manuscript, to Dr. John W. Hammond for assistance in collecting material for the division on gastro-intestinal diseases, to Dr. William Weston for supplying material for the article on pellagra, and to Dr. Percy Brown for selecting and collecting the roentgenograms.

CONTENTS

DIVISION I

THE NORMAL CHILD PAGE

I. Introduction i

II. ^The Infant at Term 3

Physical Examination 3

Internal Structure 5

III. Normal Development 8

Physical Examination 8

Internal Structure 27

IV. Hygiene and Care of Normal Infants 34

Care of the Newborn 34

Weighing '. 35

Bathing 35

Care of the Mouth and Teeth 36

Care of the Skin 37

Care of the Genitals 37

Care of the Hair 37

Clothing 37

Sleep 42

F esh Air and Going Outdoors 42

Exercise 45

Hygiene of the Nervous System 46

Training and Discipline Habits 48

The Nursery 51

Nursery Maids 52

Prevention of Exposure to Contagion 53

Summer Resorts 53

The Daily Routine of the Normal Child 53

DIVISION II

disease in early life

I. Etiology and Classification 55

The Causes of Disease 56

How the Various Causes Act in Producing Disease 57

The Classification of Disease 59

II. Pathological Anatomy 60

III. Symptomatology and Diagnosis 63

The History 63

a. Significance of Symptoms in Early Life 64

b. The Family History 64

c. The Previous History 65

d. The Present Illness 66

e. General Questions as to Symptoms 67

The Physical Examination 67

a. Method of Examining a Sick Child 67

viii Contents

III. Symptomatology and Diagnosis Continued.

The Physical Examination Continued. page

b. General Examination of the Body 72

(i) Nutrition, size, weight 73

(2) Skin 73

(3) Position of the body 73

(4) Mental condition 73

(s) Lymphnodes 74

(6) Bones and joints 74

(7) Muscles 74

(8) Temperature 75

(9) Pulse 75

(10) Respiration 76

c. The Head 77

(i) The cranium 77

(2) The facies 78

(3) The eyes 79

(4) The nose 79

(5) The mouth 80

(6) The throat 81

(7) The nasopharynx 82

(8) The larynx 83

(9) The ear 83

(10) The neck 83

d. The Chest 84

(i) Inspection 84

(2) Palpation 85

(3) The thymus ' 85

e. The Heart 85

(i) Inspection 85

(2) Palpation 85

(3) Percussion 86

(4) Auscultation 86

f . The Lungs 87

(i) Inspection 87

(2) Palpation 87

(3) Percussion 87

(4) Auscultation 90

g. The Abdomen 93

(i) Inspection 93

(2) Palpation 94

(3) The stomach 95

(4) The liver 95

(5) The spleen 95

(6) The kidneys 96

(7) The bladder 96

(8) The external genitals 97

(9) The anus 97

(10) The rectum 97

h. The Extremities 97

(i) The limbs 97

(2) The spine 99

Contents ix

III. Symptomatology and Diagnosis Continued.

The Physical Examination Continued. page

i. The Nervous System 99

(i) Testing the mental condition 99

(2) Paralysis and spasm 99

(3) The reflexes 100

(4) Special signs loi

(s) Sensation 104

(6) The special senses 104

Special Methods of Examination 105

a. Lumbar Puncture 105

b. Thoracentesis 108

c. Exploratory Puncture of the Peritoneal Cavity 108

d. Exploratory Puncture of the Pericardial Cavity 109

e. Examination of Gastric Capacity 109

1. Examination by Duodenal Catheter 109

g. The Electrical Reactions 109

h. Laryngoscopy no

i. Ophthalmoscopy no

j Rectal Examination no

k. Roentgen Ray Examination no

Laboratory Methods of Diagnosis no

a. The Urine 112

b. The Blood n8

c. The Stools 125

d. The Cerebrospinal Fluid 13°

e. Exudates and Transudates 134

f . The Vaginal Discharge 136

g. The Sputum 136

h. The Gastric Contents 138

i. The Widal Reaction for Typhoid 138

j. The von Pirquet Test for Tuberculosis 139

k. The Wassermann Reaction for Syphilis 140

1. The Schick Test for Immunity in Diphtheria 141

m. Throat Cultures 142

n. Blood Cultures 142

o. The Phenolsulphonephthalein Test of Renal Function 143

Differential Diagnosis i43

IV. Prognosis in Early Life i45

V. Treatment i47

General Principles i47

Special Indications in Early Life 148

Specific Treatment 148

a. Serum Therapy i49

b. Vaccine Therapy 151

c. Drugs 153

Hygienic Treatment T-S3

Dietetic Treatment i54

Symptomatic Treatment i54

Therapeutic Measures Other than Drugs i55

a. Heat and Cold i5S

(i) The ice bag i5S

(2) The hot pack i55

(3) The hot air bath i5S

X Contents

V. Treatment Continued. page

b. Hydrotherapy ' 155

(i) The hot bath 155

(2) The tepid bath 156

(3) The cold sponge 156

c. Counterirritation 157

(i) Mustard paste 157

(2) The mustard pack 157

(3) The turpentine stupe 157

(4) Dry cupping 157

(5) Bleeding 157

d. Irrigations and Sprays 157

(i) Irrigation of the colon 157

(2) Gastric lavage 159

(3) Irrigation of the nose 161

(4) Spraying the nose and throat i6r

(5) Gargles 161

(6) Syringing the mouth and pharynx 161

(7) Irrigation of the ears 160

e. Inhalations 162

f . Enemata 162

(i) Cleansing enemata 162

(2) Nutrient enemata 162

(3) Stimulant enemata 163

g. Gavage and Nasal Feeding , 163

h. Massage 163

i. Hypodermoclysis 164

j. Intravenous Injections 165

Useful Drugs in Infancy and Childhood 167

a. List and Description 167

b. Table of Dosage 167

c. Methods of Administration 167

The Routine Treatment of an Acute Self-limited Disease 180

The Routine Treatment of Chronic Diseases 183

DIVISION III

DISEASES OF THE NEWBORN

I. Malformations 184

II. Traumatic Conditions 184

Caput Succedaneum 184

Cephalhematoma 185

Hematoma of the Sterno-Cleido-Mastoid Muscle 186

Intracranial Hemorrhage 186

Obstetrical Paralysis '. 189

III. Non-Traumatic Mechanical Disturbances 194

Umbilical Hernia i94

Prolapse of Meckel's Diverticulum 196

IV. New Growths 107

Umbilical Granuloma i97

Naevus i97

V. Functional Disturbances i99

Congenital Pulmonary Atelectasis i99

Hemorrhagic Disease of the Newborn 202

Contents xi

V Functional Disturbances Continued page

Icterus Neonatorum 212

Congenital Cirrhosis of the Liver; Congenital Obliteration of the Bile

Ducts 214

Sclerema 218

Edema 219

VI. Infections 221

Infectious Disease of the Newborn 221

Ophthalmia Neonatorum 225

Tetanus Neonatorum 227

Dermatitis Exfoliativa 228

Infectious Haemoglobinuria (Winckel's Disease) 229

VII. Premature Infants 231

DIVISION IV

FEEDING

I. General Principles 239

The Mammary Gland 240

II. Maternal Feeding 243

Human Milk 243

a. Physical Characteristics 243

b. Chemical Composition 244

c. Variations in Milk 245

d. Colostrum 246

e. Daily Quantity of Milk 248

f . Bacteriology 249

g. Conditions Affecting Lactation 249

Maternal Nursing 250

a. Normal Maternal Conditions 250

b. Contraindications for Breast Feeding 250

c. Sucking 250

d. Care of the Breasts 251

e. Nursing the Newborn ^ 252

f. Management of Normal Nursing 253

g. Hygiene of the Nursing Mother 255

Disturbances of Breast Feeding 257

a. Causes 257

b. Symptoms and Diagnosis 258

c. Management of Disturbed Breast Feeding 259

Wet-Nursing 262

Weaning 264

III. Artificial Feeding 266

Preliminary Considerations 266

Source of Food 267

a. Requirements 267

b. Cow's Milk 267

(i) The cow 267

(2) Composition of cow's milk 267

(3) Bacteriology 269

(4) Certified milk 270

c. Sterilization and Pasteurization 271

(i) Effect of heat on bacteriology 271

(2) Effect of heat on composition 272

xii Contents

III Artificial Feeding Continued

Sterilization and Pasteurization Continued page

(3) Effect of lieat on digestibility 272

(4) Sterilization or pasteurization 273

(5) Indications for pasteurization 274

(6) Technique of pasteurization 274

d. The Examination of Milk 275

(i) The fat 275

(2) The protein 276

(3) The carbohydrate and salts 277

(4) Microscopic examination 277

The Modification of Cow's Milk 277

a. Sources of Difficulty in Artificial Feeding 277

b. Caloric Requirements and Digestive Requirements '. 279

(i) Minimum caloric requirements 280

(2) Protein requirements 280

(3) Caloric requirements as a basis for feeding 280

(4) Digestive requirements . 281

(5) Value of caloric estimation 281

c. Percentage Feeding 282

d. The Modification of Cow's Milk Theory 283

(i) Milk and cream dilution 284

(2) Starch; cereal diluents 286

(3) The alkaUes; lime water, sodium bicarbonate, and

sodium citrate 286

(4) Peptonization 288

(5) Whey mixtures; the split protein 289

(6) Maltose, dextri-maltose, and cane sugar 291

(7) Lactic acid milk 292

(8) Precipitated casein .' 293

(9) Cooking ; 294

(10) Homogenized fat 295

(11) Albumin milk 295

(12) Malt soup 297

How the Resources of Cow's Milk Modifications are Realized in Practice 298

a. Prerequisites 298

b. The Patent Foods 299

c. Milk Laboratories 299

d. Home Modification 3°''-

(i) Technique 302

(2) Calculation 3°3

e. Laboratory Feeding and Home Modification Relative Advan-

tages and Disadvantages 3^^^

f. Calculation of the Calories 3^7

g. Calculation of Percentage Composition in a Food of Known

Ingredients 3^^

The Practical Management of Artificial Feeding 321

a. General Principles 321

(i) Ends to be attained 321

(2) Conditions of the problem 322

(3) General conduct of artificial feeding 322

b. The Feeding of Normal Infants 323

(i) Quantity of food 324

(2) Intervals between feedings 32S

Contents xiii

III Artificial Feeding Continued

The Feeding of Normal Infants Continued page

(3) Percentage formulae for starting average well babies. 326

(4) Percentage formulae for feeding average well babies. . 328

(5) Increasing the strength of the food 328

c. The Feeding of Infants Having Difficulties of Digestion 329

(i) Causes of digestive disturbance 329

(2) Symptoms of digestive disturbance 329

(3) Clinical types of disturbance seen in artificial feeding. 330

(4) Vomiting cases 330

(5) Undigested movements 331

(6) Green or discolored movements 332

(7) No symptoms 332

d. The Feeding of Difficult Cases 333

e. Clinical Indications for the Various Methods of Modif^-ing

Cow's Milk 334

f. Inability or Refusal to Take Food From the Bottle 337

IV. Feeding in the Second Ye.ar 339

Feeding of Healthy Infants 339

a. Weaning From the Bottle 341

b. Preparation of Foods 341

c. Diet From the Twelfth to the Fifteenth Month 342

d. Diet From the Fifteenth to the Eighteenth Month 343

e. Diet From the Eighteenth to the Twenty-fourth Month 344

Feeding in Difficult Cases 345

V. Feeding After the Secont) Year 347

DIVISION V

diseases of the g.astro-enteric tract

Class fication 349

I. ^Malformations 351

II. Traumatic Mechanical Injuries 353

Foreign Bodies 353

"Hair Ball" in the Stomach 354

Corrosive Gastritis 354

III. Mechanical Conditions of Internal Origin 356

Hypertrophic Stenosis of the Pylorus 356

Spasm o the Pylorus 367

D latat'on of the Stomach 370

Contraction of the Stomach 373

Dilatation and Hypertrophy of the Colon 374

Intussusception 377

Volvulus f 380

Hernia 380

Fissure of the .\nus 381

Hemorrhoids 381

Prolapse of the Rectum 381

IV. New Growths 383

V. Nervous Disturbances 384

Nervous Diarrhea 384

Nervous Vomiting 386

xiv Contents

PAGE

VI. DiSTUKBANCES OF DIGESTION 388

General Considerations 388

a. Etiology 388

b. Pathology 392

c. Classification 394

d. Symptomatolog}'' 398

e. Diagnostic Methods 399

f . General Treatment 399

Indigestion from an Excess of Food 402

Indigestion from an Excess of Fat 407

Indigestion from an Excess of Carbohydrate 422

Indigestion from an Excess of Protein 433

Indigestion from an Excess of Mineral Salts 440

Indigestion with Fermentation 442

VII. Infections 457

Infectious Diarrhea 457

Summary of the Diarrheas and Disturbances of Digestion 481

Problems and Research in Diseases of the Digestive Tract 484

Cholera Infantum 485

Gastritis 488

Proctitis 490

Appendicitis 49

VITI. Unclassified Diseases 496

Constipation 496

Incontinence of Feces 505

Intestinal Worms 505

LIST OF ILLUSTRATIONS

PLATE COLORED PLATES page

XV. The blood in infancy and childhood 120

II. Icterus neonatorum 213

FIG. FULL PAGE ILLUSTRATIONS page

19. Position for examination of the ears 83

21.— Normal areas of dulness to percussion of the front of the chest 86

23. Boundaries of the lobes of the lungs from in front 89

27. Proper method of palpating the spleen 96

28. Examination of the flexibility of the spine 99

SS- Lumbar puncture 107

35. Obtaining urine from the male infant 113

40- Scarifying for the von Pirquet tuberculin test 139

44- Gastric lavage, first step .^ . 159

45. Gastric lavage, second step 161

46. Gastric lavage, third step '. 163

49- Tube feeding, first step 167

SO. Tube feeding, second step 169

68. Incubator bed for premature infant 232

69. Articles for premature infant 234

70. Premature infant in incubator bed 236

81. Congenital atresia of the intestine 351

82. Pyloric stenosis with complete occlusion, roentgenogram , 359

83. Pyloric stenosis with partial occlusion, roentgenogram 360

Contents xv

FIG. PAGE

84. Pyloric stenosis with partial occlusion, roentgenogram 361

85. Pyloric stenosis with partial occlusion, roentgenogram 362

86. Pyloric stenosis with partial occlusion, roentgenogram 363

94. Hirschprung's disease, roentgenogram 376

95. Hirschprung's disease, roentgenogram 377

99. Follicular inflammation of the intestine 461

100. Follicular ulceration of the colon 462

loi.— Colitis 463

102. Follicular ulceration of the colon 464

103. Follicular colitis 465

104. Pseudomembranous colitis 466

105. Ulcerative colitis 467

106. Ulcerative ileo-colitis 468

FIG. ILLUSTRATIONS IN THE TEXT page

I. Stomach, natural size 7

2. Five periods of development in the first dentition 10

3. Eight periods of development in the second dentition 12

4. Normal infant seven months old 14

5. Normal development at six years 15

6. Normal development at twelve years 16

7. Respiration at birth 21

8. Section of fetal lung at five months, section of infant's lung at ten months . 30

9. Clothing for an infant 39

10. Clothing for an infant 39

1 1 . Clothing for an infant

12. Clothing for an infant

13. Infant's bed. Infants' Hospital 51

14. Proper position for the child when examined in a sitting position 69

15. Method of holding an infant for examination of the back of the chest 70

16. ^^Position for examination of the throat 71

17. Method of holding an infant for examination of the mouth and throat 72

18. Obtaining pulse rate in infants 75

20. Examination for rigidity of the neck 88

22. Percussion of the front of the chest 84

24. Boundaries of the lobes of the lungs from behind : 89

25. Percussion of the back of the chest 90

26. Percussion of the apex of the lungs 91

29. Testing the knee-Jerks loi

30. Examination for Kernig's sign 102

31. Examination for Brudzinski's neck sign 103

32.- Position for lumbar puncture 106

34. Normal roentgenogram, infant six months old m

36. Apparatus for obtaining urine from a female infant ii'3

37. Method of collecting urine from a female infant 113

38. Catheterization of a female infant 114

41. Obtaining blood for the Wassermann reaction from the longitudinal sinus of

an infant 140

42. Injecting diphtheria toxin for the Schick reaction 141

43. Irrigation of the colon 158

47. Irrigation of the ear 160

48. Irrigation of the no?e 161

51. Nasal feeding 164

xvi Contents

riG. PAGE

52. Intravenous injections in infancy tapping the cerebral ventricles 165

53. Intravenous injection in infancy 166

54. Caput succedaneum 184

55. Double cephalematoma 185

56. Characteristic position of the arm in obstetrical paralysis 190

57. Obstetrical parah'sis 192

58. Large umbilical hernia i94

59. Adhesive strap for umbilical hernia 195

60. Naevus of the face and neck 198

61. Complete congenital atelectasis of the left lung. H3'pertrophy of the heart. . 200

62. Dr. Beth Vincent's apparatus for transfusion 207

63. Obtaining blood in parraffin treated tube from the donor in transfusion 208

64. Transfusion in the newborn 208

65. Congenital cirrhosis of the liver 214

66. Congenital cirrhosis of the liver 215

67. Infant premature at the seventh month 231

71. Feeder for premature infants 234

72. Colostrom milk 47

73. Breast pump 251

74. Sterilizer and thermometer 275

75 Babcock fat tester 276

76. Apparatus for homogenizing fat for infant feeding 294

77. Walker-Gordon laboratory prescription blank 301

78. Home modification of cow's milk apparatus 302

79. Home modification of cow's milk obtaining the cream 303

80. Home modification of cow's milk mixing the ingredients 304

87. Apparatus for estimating gastric retenfon time 360

88 Aspiration of the gastric contents 361

89. Dilated stomach 37i

90. Dilatation of the stomach 372

91. Hirschprung's disease section through colon 374

92. Congenital dilatation of the colon 375

93. Dilatation of the colon 37^

96. Worsted truss for nguinal hernia 380

97. Infantile atrophy 4i4

98 Infantile atrophy 4iS

107 Oxyuris vermicular s. Ascaris lumbricoides 5^7

108. Taenia SOQ

DIVISION I

THE NORMAL CHILD

I. INTRODUCTION

Pediatrics is a branch of medicine the importance of which as a special study has gradually come to be more and more generally recognized. It has become a specialty, partly from the same causes which have led to the great increase in specialization in all branches of medicine, but more particularly because of the great number of peculiarities inherent in the manifestations of disease in early life. From the very beginning, the diagnosis and treatment of disease in infants and young children is attended by difficulties not encoun- tered with adult patients. These young patients can give no ade- quate description of their subjective symptoms, and the physician must rely on intimate and profound knowledge of the ways of young children, which can only be gained by long observation, if he will read aright the manifestations before him. Moreover, the most thorough knowledge of normal and abnormal conditions, if gained wholly from observation of adult patients, is of little value in chil- dren, because of the difference in the normal standard. Not only are all the standards by which deviations from the normal are recog- nized different from those of adults, but there is a different standard for each age. Manifestations which are normal at one age, are abnormal at another, and even the anatomic lesions of disease are seen to be modified in the various stages of the child's development. Young human beings must be regarded, throughout their early life, as incomplete. Growth is not merely increase in size, but it is a continuous process of anatomical and functional development, which is not completed until some time after the age of puberty. In early life, arrest, or retardation of the process of normal development may in itself constitute a disease picture; developmental conditions form an important division in the etiology of disease in childhood, but play no part after adult life is reached.

The incompleteness of the child's development plays a still greater role in those actual diseases which are produced by conditions out- side the body. It may be true that the same diseased conditions are seen in childhood and in adult Hfe. But their manifestations are greatly modified by the incompleteness of the child's development, and often vary even with the different ages of childhood. Even the

2 The Normal Child

reaction to treatment dilTers in the different stages of development. The rules laid down for the diagnosis and treatment of these diseases common both to childhood and to adult Hfe, if gained by a study of adults, cannot hold for children.

There is further need for special study and training in pediatrics. Children, in addition to being liable to most of the diseases seen in adults, have also a group of diseases which are entirely their own. Here again, the fundamental cause lies in their uncompleted develop- ment, through which conditions acting upon their bodies from the outside w^orld, which can have no injurious effect upon the com- pleted adult, have a very injurious effect upon the young, unde- veloped child. These young human beings, at each stage of devel- opment, have their own peculiarities of resistance or lack of resist- ance to these conditions. Their treatment must be modified at all times, to correspond to their age, and stage of development. The high rate of infant mortality is still one of the greatest problems of medicine. It is due primarily to no other cause than the lack of resistance to the conditions of its surroundings which exists in the undeveloped infant. Its existence is alone sufficient to point to the need for a special study of the pathology of early life.

The fundamental requisite in recognizing the abnormal, is a thorough knowledge of the normal. In pediatrics, a thorough un- derstanding of normal conditions at every stage of development is essential. The distinction between infancy and childhood is neither so artificial nor so arbitrary as it seems at first.. At about the age of two years, certain very important processes of anatomical and functional development become completed. The incompleteness of these functions in the first two years has been an important source of difliculty, and a cause of abnormahty, which later are no longer seen. Hence we refer to the first two years as infancy, and to the later years as childhood. The distinctive fine between childhood and adult life is much harder to draw. It is difficult to say at just what age normal development is finally completed, but the period is arbi- trarily placed at the age of puberty. From birth to the age of puberty, then, is the period through which the development of the normal child must be studied.

II. THE INFANT AT TERM

A normal infant at birth has a reddened skin, and is covered thickly in many parts by the vernix caseosa, which is removed by the first bath. The description of the newborn infant will be given in two divisions. The first will be a description of a complete physical examination of a normal infant at birth, in the form in which physical examinations are usually recorded in case histories. The second division will be a description of certain features of the infant's internal structure, in the form in which they are recorded in records of post-mortem examinations. This form of description will afford the student a standard of comparison by which he may recognize at once the abnormal, both in physical examination, and in pathological anatomy.

THE PHYSICAL EXAMINATION

The baby appears well nourished, the body and limbs are well rounded, the cry is vigorous, the extremities are warm, and the grasp of the hands is strong and vigorous. The skin is usually clear, but may be somewhat mottled, and is some shade of delicate pink. The eyes are half open when the baby is awake, and are expres- sionless, of a dull grayish-blue color. The spine is very flexible, and can be twisted and bent at will in any direction. The neck appears short.

HEAD The head appears large in proportion to the body, while the face is quite small in proportion to the cranium. The length and thickness of the hair is very variable. The cranium may be somewhat distorted by the pressure of birth, but these abnormal appearances pass away in a few months. An average circumference of the cranium at birth is t^t, cm. (13 in.). The anterior fontanelle may be somewhat depressed immediately after birth, but is soon on a level with the bones. Its size is variable, but the measurements are usually 2 to 3 cm. in length, by about 2 cm. in width. The frontal suture is usually open in its upper part, and the posterior fontanelle, while open, is often obliterated by overlapping of the bones.

MOUTH AND THROAT.— The mucus membrane of the mouth is of a clear pink. The tongue is slightly coated, and comparatively dry. The gums do not completely meet. The soft palate runs backward almost horizontally, descending much less than in the adult. The uvula is rudimentary.

4 The Normal Child

THE EAR. The meatus passing inward, inclines downward, and the membranum tympani is almost horizontal, so that its inspection is difficult.

THORAX.^ The thorax presents a very different appearance from that of the adult. It is much smaller in proportion to the head and abdomen, forming the upper and smaller portion of the egg- shaped trunk. Its whole shape presents a peculiar appearance, which is accentuated by the small shoulders. The sternum is rela- tively much smaller than that of the adult male, and its top is placed relatively higher, while the sides of the thorax are relatively shorter than in the adult. The ribs are more nearly horizontal, and their borders diverge relatively rapidly. The transverse diameter is shorter in proportion to the antero-posterior.

THYMUS. The thymus is present and well developed at birth, but its outline cannot be clearly distinguished by percussion.

HEART. The impulse is visible and palpable rather higher and nearer to the mammary line in the infant than in the adult. The entire position of the cardiac dulness is higher in proportion to the chest walls. The infant's heart is less covered by the lungs than is the adult's. The superficial dulness lies between the left border of the sternum and the mammary line, and the entire area can easily be covered by the tip of the finger used in percussing. The upper border, and the relative dulness are difficult to determine. The heart sounds are still largely of the fetal type, the diastolic pause being absent, and the first sound being much like the second. The rhythm is regular. Murmurs are frequently present at birth, with- out any abnormal significance; only their persistence should attract attention.

LUNGS. The lungs are resonant to percussion, but at birth the resonance is less than in later life. The respiratory murmur is loud and harsh.

ABDOMEN. The abdomen is large in proportion to the thorax. Its physical examination differs from that of the normal adult only in one important particular, namely, in the relatively large size of the liver. Its border is felt fully 2 cm. below the edge of the ribs in the right epigastric and hypochondriac regions, and its upper border of dulness encroaches on the resonance of the right lung to the extent of fully one rib and interspace. The dull area of the spleen is rarely perceptible, but when found corresponds to that of the adult. The border is not normally palpable. The bladder is an abdominal rather than a pelvic organ, but normally gives no dulness in a newborn infant.

The Infant at Term 5

TESTICLES. The testicles are normally found in the scrotum.

LIMBS. The limbs are well formed, and present no features of particular note in newborn infants. The grasp of the hands is re- markably strong. The feet appear flat, but this apparent flatness is due to a pad of fat tissue, and not to any flattening of the arch.

HEIGHT AND WEIGHT.— The height and weight are variable. The average height of a newborn male infant is 49.5 cm. (igf in.); in the female it is 48.5 cm. (19^ in.). The weight is still more variable than the height. The average weight for males is about 3,520 grammes (7! pounds), and for females is about 3,290 grammes (7 J pounds).

THE SPECIAL SENSES.— Although at birth the eye is anatom- ically perfect, visual perception is not developed. Hearing appears dull during the first few days of life. The sense of touch is well developed. No satisfactory conclusions can be drawn as to taste and smell.

The newborn infant passes very little urine. He does not usually perspire. He cannot cry tears. He can have a movement of the bowels, which consists of meconium. Meconium is inodorous, viscid, slightly acid, and of a brownish-black color. It consists of bile constituents and intestinal secretions, and contains mucus, epithelium, and fat drops from the vernix caseosa. At birth, it is sterile.

INTERNAL STRUCTURE

Among the features in the anatomy of the newborn infant which cannot be perceived by ordinary physical examination, only those will be described which present essential differences from those of adults.

BRAIN. The brain of the newborn infant is proportionately very much larger than in the adult.

THE NASO-PHARYNX.— The nasal cavity is relatively long and shallow, and its respiratory portion is very narrow. The opening of the posterior nares is relatively very small. The naso-pharynx is simply a narrow passage running obliquely backward and down- ward from the constricted opening of the posterior nares. The lym- phoid tissue on the posterior wall of the pharynx is well developed, and much richer in absorbents than are the faucial tonsils. The openings of the eustachian tubes are opposite a higher part of the nose than in the adult, although their direction is more horizontal. The ends of their cartilages, which make such prominent folds in the adult, are not developed, so that these prominences do not exist.

6 The Normal Child

TEETH. There are at birth twenty embryo teeth, ten in each jaw, enveloped in their tooth sacs.

EAR. The development of the ear in its several parts is very unequal at birth. The structures of the internal ear and of the tympanic cavity are fully formed at birth, while the external audi- tory meatus is very different in its development from that of later life. The mastoid antrum exists at birth, but the cells are wholly undeveloped.

THYMUS GLAND.— The thymus gland exists at birth, is well developed, and lies partly above, and partly in front of the heart.

HEART. The anatomy of the heart at birth, and the changes in the circulation which take place shortly after birth, are so inti- mately connected with the subject of congenital cardiac disease, that their description will be postponed till that subject is discussed. In a baby dying immediately after birth, it would not be abnormal to find an open foramen ovale, or an open ductus arteriosus.

LUNGS. ^The lungs at birth present a very notable difference from the lungs of older individuals. Their chief characteristic is their embryonic type. The alveoH are relatively small in size, and their number is small in proportion to the bronchioles. Their walls are relatively thick, and the connective-tissue stroma is in greater proportion. Blood vessels are relatively abundant, and play a more important role than the lymphatic absorbents. These conditions, while gradually diminishing, persist to a great extent throughout childhood.

KIDNEYS. The kidneys and adrenals are of relatively large size in the newborn infant. The kidneys are markedly lobulated. A prenatal condition called the uric acid infarction exists normally in the kidneys at birth. This shows itself as an orange or light red deposit in the straight tubules, which cause these tubules to appear prominent on section of the organ. This deposit consists of urate of ammonia, amorphous urates, uric acid crystals, and epitheHal cells. The adrenals quite cover the tops of the kidneys at birth.

STOMACH. The stomach at birth is remarkably small, and more tubular than in the adult, the fundus being but slightly devel- oped. It is consequently even more vertically placed, for it is the enlargement of the greater curvature which causes the later obliquity of the stomach'^s axis. Its capacity is about 25 to 30 c.c.

The Infant at Term

Fig. I

^"■"

Stomach, natural size. Infant three hours old. Warren Museum, Harvard University.

THE INTESTINE. The chief pecuharity of the intestine in new- born infants, is that it is much less fixed than in adult life. This difference is most striking in the large intestine, particularly in the cecum, ascending colon, and sigmoid flexure, which show a con- siderable mesentery. The average length of the small intestine is 287 cm. (9 ft. 5 in.); of the large intestine it is 56 cm. (i ft. 10 in,). The total variation may amount to 61 cm. (2 ft.).

LYMPHATIC SYSTEM.- oped and active at birth.

-The lymphatic system is well devel-

BONE MARROW.— At birth, and indeed, throughout the early- months of life, the bone marrow is red. The red color is caused by the numerous injected blood vessels, and is more intense toward the central portion of the bones.

III. NORMAL DEVELOPMENT

In following the normal development of the baby through the periods of infancy and childhood, those changes will be considered first which appear on physical examination. In a second division will be considered the development of internal structure.

NORMAL DEVELOPMENT AS SEEN ON PHYSICAL EXAMINATION

THE CORD. By a process of disintegration the cord separates from the living tissues at the umbilicus, and falls off. This occurs at about the seventh or eighth day. The umbilical scar normally is always depressed.

THE SPINE. The flexibility of the spine gradually becomes less as the infant grows older, although it always remains greater than that of the adult spine. There are at birth no natural curves in the spine except the sacral curve. As the dorsal curve is 'a permanent condition, part of the general curve of the body, it is the develop- ment of the cervical and lumbar curves which are of interest from the point of view of development. The cervical curve is produced by the pull of the muscles of the back of the neck, when the child begins to raise its head. * The child usually begins to hold up its head, only the trunk being supported, during the fourth month. The cervical curve begins to appear at about this period, but is never more than a habitual position, as the convexity of the front of the neck can always be obliterated by changing the position of the head. The lumbar