Class. Book. COPYRIGHT DEPOSIT MOTHER AND CHILD. PART I. MOTHER. MX EDWARD P. DAVIS, A.M., M.D. PART II. CHILD. / BY JOHN M. KEATING, M.D., LL.D. 92 ttUir) X ( PHILADELPHIA*. J. B. LIPPINCOTT COMPANY. London: io Henrietta Street, Covent Garden. I 893. \ ^ nf> Copyright, 1892, BY J. B. Lippincott Company. Printed by J. B. Lippincott Company, Philadelphia, U.S.A. ■j/16 -j/f PREFACE. We Lave endeavored to make this manual both instructive and readable. Our aim has been, not to supplant the physi-^ cian, but to supplement his advice and render intelligible those matters that mothers and nurses find difficult to under- stand. Although our own views are definite and positive, as the result of large experience, we recognize that the experi- ence of others causes them to differ in many points of detail and management, and in order to make our book cover as large a field as possible, we have added much material from the writings of other physicians whose opinions have great weight and whose advice is of incalculable value. Frequently a change of diet from a well-recognized formula to one possibly, in theory not so good, is most important for the child, and on that account we have endeavored to incorporate all the sugges- tions that experience has shown to be of value, at the risk of being prolix, that a choice may be made to suit each individual case. There are undoubtedly times when a competent physi- cian is not obtainable, also there are emergencies when some- thing has to be done at once, and consultation with books becomes a necessity ; under such circumstances we hope that our little work will prove useful. Then, again, frequently the physician has not the time to instruct his patient in all the 4 PREFACE. little details of treatment, nor can he answer in a few words the many questions put to him ; we have tried to anticipate this, and to place in his hands a manual that, instead of en- croaching upon his prescriptions, will, on the contrary, aid him by instructing the mother and care-taker, — not sufficiently to make them inferior doctors, but enough to make them intelli- gent patients and skilful nurses. In order to more thoroughly individualize each part, it was thought advisable to adopt the plan here presented; but each author carefully revised the proofs of the whole book, and the views and recommendations are endorsed by both. CONTENTS, PART I. MOTHER. CHAPTER PAGE I. — Girlhood 9 II. — The Period of Puberty . , 14 III. — The Hygiene of Womanhood 17 IV.— Conception 19 V. — Symptoms of Pregnancy ., 21 VI. — Duration of Pregnancy 22 VII. — Miscarriage 25 VIII. — Diseases affecting the "Woman during Preg- nancy . 26 IX. — Hygiene of Pregnancy— Diet 29 X. — Hygiene of Pregnancy — Exercise and Clothing 32 XI. — Hygiene of Pregnancy — Bathing — Care of Ner- vous System 33 XII. — Constipation 36 XIII. — Hygiene of Pregnancy — Breasts — Varicose Veins , 37 XIV. — General Hygiene of Pregnancy — Climate . . 40 XV. — Nurse and Koom 42 XVI. — Appliances for the Mother 45 XVII. — Appliances for the Child 50 XVIII. — Child's Cradle and Basket 53 XIX.— Labor 56 XX. — Puerperal Fever 60 XXI. — First Few Days after Confinement 63 XXII. — Mother's Becovery 70 XXIII. — Diet and Lactation 74 CONTENTS. PART II. G ZE3T I L ID. CHAPTER PAGE XXIV. — Care of New-Born Infant 79 «^XXV. — Child's Navel and Intestines 85 XXVI.— Care of the Brain and Nervous System ... 94 XXVII. — The Nursing of Infants 97 XXVII L— Bottle-Feeding 104 XXIX. — Sterilizing and Sterilizers 110 XXX. — How to Prepare the Bottle for a Healthy Babe from Birth to Two or Three Months of Age .... 119 XXXI. — How to Prepare the Bottle for a Delicate Babe from Birth to Three Months of Age . 128 XXXII.— Condensed Milk 132 XXXIII.— Prepared Bottle 138 XXXIV.— Weaning .;....... 154 XXXV.— Menstruation 162 XXXVI. — Education and School-Hygiene 179 XXXVII- — Surgical Emergencies 241 XXXVIII. — Fresh Air, Ventilation, Out-Door Exercise . 275 XXXIX.— Bathing 298 XL.— Teething 304 XLL— Diet after Early Dentition . . . 317 VXLIT.— The Bowels 336 XLIII.— Constipation . 337 XLTV.— Diarrhcea 348 XLV. — Nursing of Sick Children 357 XLVI.— Acute and Chronic Nasal Catarrh 380 XLVII. — Diseases of the Eye 388 XLVIIL— Diseases of the Ear 399 XLIX. — Diseases of the Throat and Air-Passages . . 411 L. — Whooping-Cough 424 LI— Fever 429 LII. — Scarlet Fever 434 LIII. — Measles — Mumps — Varicella, or Chicken-Pox . 440 LIV.— -Second Dentition 447 PART I. MOTHER. BY E. P. DAVIS, A.M., M.D. MOTHER AND CHILD. CHAPTEE I. GIRLHOOD. It has been truly said that " the boy is father of the man," and it is not less true that the girl is mother of the woman. The foundations then for sound and healthy womanhood must be laid in girlhood, and the system thus begun must be con- tinued faithfully, yet with wise moderation, if it is to be of permanent usefulness. No subject is of greater importance in this connection than the hygiene of the girl's life. For the first ten or twelve years, her capacity for physical exertion and endurance is practically that of a boy of the same age. Although naturally inferior in muscular development later in life, during these first years she should be fully his equal in strength, endurance, and dexterity. At this time tastes should be encouraged and habits formed which may eventually prove most important in the maintenance of health. G-irls should be allowed to become interested in out-door sports during the first ten or twelve years of life, and habits of out-door ex- ercise should be fostered in every way. This plan must of course often be modified to suit individual cases, and excess of exercise is to be deprecated. Parents and teachers should watch children carefully to see that lasting injury is not done to the latter by over exertion. Tennis is a game that lends itself admirably to the vigorous and healthful use of the mus- cles, but what benefit can possibly come to a girl of twelve who plays so many sets that she finally drops fainting on the grass ? Emulation and the desire not to spoil the game for 9 10 MOTHER AND CHILD. the companions who depended on her to complete the necessary number of players, was the motive for this fortitude, but her young friends could better bear to be disappointed once than she could to injure herself physically for life. A love for animals, which is not uncommon in childhood, may be advantageously encouraged, and often gives increased zest to open-air enjoyments. When possible, a girl should be taught at the earliest opportunity to ride and drive. Skating, running, jumping, and climbing are quite appropriate exercises for girls of this age, while there can be no better time to per- fect the art of swimming than in the years from eight to twelve. The girl then knows little fear of the water, and swims readily, whereas later in life timidity often prevents the acquirement of such knowledge. She can be taught even at this early period to save a life in danger from drowning, and such instruction has not infrequently borne fruit in suc- ceeding years. The writer recalls two women who learned to swim in early girlhood, each of whom has saved lives by ability in this accomplishment, and one of whom has been honored by a medal from a Humane Society. There has also been great harm done, however, to girls by immoderate exertion in gym- nasium and swimming-school, especially in jumping from a height of many feet into the water beneath, and it must there- fore be remembered that it is the " use, and not the abuse," of these aids to physical development that makes the healthy girl and woman. There can be no objection to teaching the girl the use of the rifle and shot-gun, and giving her a taste for hunting and fishing, and many a husband has been delighted to find his wife capable of sharing in his sports by reason of an educa- tion given in her girlhood. The idea that it is hoidenish for a girl to practise physical exercise and enjoy out-door sports is one of the prudish superstitions which has done much to re- tard the physical development of American women. A knowl- edge of the use of fire-arms is also of decided value to a girl in enabling her to be calm and courageous under various con- GIRLHOOD. 11 ditions of threatening danger. The tortures suffered by many- girls and women in the thought of a possible attack by burglars would probably disappear, certainly be much lessened, by the assurance of possessing the power of self-defence. America might not be now the land " of the free and the brave" if the "women of the first century" (unlike their sisters of a later date) had not cultivated the use of weapons, and nerved them- selves to feats of personal heroism in order to resist the onset of treacherous or desperate Indians. There is no fear that the pursuit of such qualifications will detract from the gentleness and delicacy of feeling which should characterize girlhood, for it is a well-known fact that the pioneer women just alluded to were as remarkable for feminine charms as for the undaunted bravery which was formerly thought the distinctive mark of the stronger sex. The domestic nature of the girl rarely needs stimulus ; she is usually willing to learn to sew, and to acquire familiarity with the household arts essential to a truly useful woman. Many children exhibit also a decided taste for music or draw- ing ; if an ability for the latter is manifest, the child will enjoy reproducing to the best of her power some favorite bit of scenery, or the head of a pet animal, and thus a knowledge of out-door life will directly foster an artistic instinct. Too much importance can scarcely be laid upon the out-door element in the girl's life, for there can be no more potent factor in laying the foundations for healthy womanhood than the vigor attained through out-door exercise. The dress of the girl should be adapted to permit the freest possible movement ; she should be supplied with thick-soled, low-heeled shoes, well fitting, but sufficiently large to encour- age walking and running. Fashion should be subservient en- tirely to health, comfort, and encouragement of exercise. The nutrition of a child so educated will require little attention be- yond the furnishing of an ample supply of thoroughly nutri- tious food, but this point of properly nourishing growing girls needs much more care and thought than the average American 12 MOTHER AND CHILD. mother seems inclined to bestow upon it. The nervous waste occasioned by constant exercise must be repaired by abundant and wholesome food, if the girl is to develop into a thoroughly healthy personality. . Ten hours of sleep should be the rule, and sponge-bathing in either warm or cold water should be practised daily. It is well known among athletes that exercise and cold sponging produce a marvellously clear complexion, and as the foundation of woman's beauty is laid in girlhood, a hint may be taken from athletes in this respect. Complete sponging, followed by energetic rubbing with the rough towel, produces a delightful feeling of exhilaration, and is succeeded by improved circulation. The girl should be carefully guarded from stimulants and narcotics in every form. Neither tea, coffee, nor alcohol should be given, nor should opium or other narcotics be administered for trivial ailments unless by the direct prescription of the physician. An excessive use of tea in this country is doing much to weaken the nerves of women, and is an evil tendency that may lead to serious consequences in producing permanent feebleness of constitution. A morbid appetite for candy, pickles, and other abnormal articles of food should be promptly suppressed in girls, and the helpful effects of really nutritious articles carefully explained, as these vagaries of appetite often arise from thoughtless ignorance of the laws of health and strength. The mental education of the girl should not be made a mat- ter of routine memorizing ; the child should learn to read, to write, and to count, but beyond this it is quite unnecessary to go until young womanhood is attained. An education, how- ever, of the best sort is to be gained during this period by ob- servation of the external world, and by the conversation and example of older persons with whom the child is thrown. How often a girl of twelve or thirteen accompanies her parents through Europe, and instead of using her eyes and brain, while travelling in the railway carriage, to note the interesting and novel objects around her, is buried deep in a romantic tale, use- GIRLHOOD. 13 fill and entertaining in its proper season, but not to be com- pared in its educational power, at such a time, with the devel- oping force of observation of nature and human character! While habits of regularity can be formed by certain definite times for study, yet application to books in-doors should never exceed a half-hour at any time. If the girl is to grow to womanhood with sound eyes and healthy nerves, she should not be obliged to apply herself assiduously to books in-doors. These statements may seem to the reader dogmatic and ex- treme, but they are founded upon the observation of women suffering from physical imperfections which began during the period of girlhood. It would probably be dim cult to find a school, college, or institution of instruction for girls anywhere, in this country, which is based upon this plan of study of books at school and dispensing of books at home ; but if such a system were to be adopted, there is little doubt that there would result a vast improvement in the health of the Ameri- can girl. When it is remembered that without individual vigor, a knowledge of all the sciences that exist will be of very slight value in rendering a woman happy and useful, it seems as if it might be worth while to sacrifice an acquaint- ance with Greek and trigonometry if the girl by such study is losing the opportunity of cultivating physical strength and endurance. The life of the healthy girl is an exceedingly happy one ; she finds no better friend or companion than kind parents or a congenial brother : prudery and tradition have not yet taught her that she is to be hedged about with many restrictions upon her taste and ambitions, and the happiest days of life in mind and body are often passed at this period. 14 MOTHER AND CHILD. CHAPTBE II. THE PERIOD OF PUBERTY. The development of the girl to womanhood exposes her to dangers which demand careful consideration. If it be remem- bered that the normal performance of the function of menstru- ation is almost directly dependent upon the general physical de- velopment of the woman, it will be seen that the hygiene of girlhood is the best preparation for healthy womanhood. The establishment of the functions of womanhood occurs at different ages, varying with the climate in which the girl lives and her individual peculiarities of temperament. If a warm climate and an out-door life have predisposed to early performance of physical functions, this may be established in the twelfth or thirteenth year ; on the contrary, if climatic influences are ad- verse, if the individual be naturally slow in maturing, and if those influences which stimulate unduly the nervous system be kept from the girl, the establishment of menstruation will occur as late as the fourteenth year or subsequently. As a preparation for this important function, all extra strain upon the nervous system should be assiduously avoided in this cli- mate after the years of twelve and thirteen. The girl need not be told the reason for this, except, in a general way, that she is growing older, and ought not to do as she has done three years previous. It is her mother's duty, however, to see to it that at this time she leads as tranquil and healthy a life as possible, in which the emotional nature is little disturbed, while abundant sleep, fresh air, and freedom from nervous strain are jealously secured for her. If the girl loses appetite and seems generally depressed, a physician should be consulted ; he may discover some poverty of blood, or deficiency in general vigor, which may be easily remedied by an appropriate tonic. It is most unwise, however, for mothers to select at random THE PERIOD OF PUBERTY. 15 one of the many patent medicines advertised in the market as specifics in this condition ; it should also be remembered that menstruation is rarely established with regularity for several months after its first appearance. A period of six months or a year is often observed before this function is performed at regular periods. Irregularity, then, at first need occasion no alarm provided the general health remains good. When the first symptoms of menstruation appear, especial caution should be exercised that the girl's clothing be warm, loose, and com- fortable. The administration of a simple laxative is often of value, while the use of the hot mustard foot-bath, absolute rest in a warm bed, the application of warm cloths to the abdomen, and the moderate use of hot but not stimulating drinks, have been often found of value. Although alcoholic liquors, either gin, rum, whiskey, or brandy, are often taken by adults to relieve distress at this time, yet the mother will do well to avoid these stimulants in caring for her daughters ; a taste for alcohol is too easily formed to render it safe to ad- minister these substances to secure the performance of a natu- ral function. There is no drug or medicine which a mother may safely give to her child at this time without the advice of a physician. Those nostrums in the market which are potent for good owe their value to some familiar drug which should be prescribed by a physician only : the vast majority of these medicines are inert, and of no value whatever. It is most important that absolute rest be enjoined during the first day or days of this period while it is about to be established, and the neglect of this simple precaution has often resulted in exposure, and in laying the foundations of lasting disease. The wetting of the feet, sitting in damp clothing, and the incurring of great fatigue at this season, are perils which, if thoroughly understood, would be shunned as serious dangers. Circum- stances point plainly to this period in the life of the woman as a time in which she is poorly fitted to assume active duties. The girl loses the freedom of motion and the careless good health of happy childhood : she becomes easily embarrassed, 16 MOTHER AND CHILD. awkward in action, and often shy in disposition. At the same time, new matters and ideas are developing in the mind, and need wise guidance into proper channels. At this period the girl should have the best and wisest nurses : one of those is her mother, the other is Nature, or the world about her. As the flowers mature best under the influence of the quiet forces of sunshine and moisture, so the physical and mental being is best unfolded to the stimulus of a simple life and the compan- ionship of maternal affection. No more injurious course of action can be taken than to urge a girl at this period to enter general society, to apply herself assiduously in any occupation or study which taxes the nervous system, or to indulge in those romances which often end in laying the foundations for future sorrow, if the girl be not protected by those wiser than she. It is a false and foolish parental ambition or indifference which refuses to listen to the growing girl's complaint of lassi- tude and disinclination to exertion at this time ; this is not the period when such desires are the result of hypochondriasis or indolence ; but the disposition to avoid great exertion and to husband the strength as much as possible is natural and right. Such tendencies should be met by careful scrutiny and a sym- pathetic, intelligent apprehension of the needs of the individual. While there are many boarding-schools which are presided over by wise teachers and guardians, it is far better for the girl at this time if she can be under the tranquillizing influences of a congenial home ; class rules which cannot be infringed upon for the sake of any one pupil (unless she be wholly in- capacitated) often oblige her to undergo more exertion than she is physically qualified to meet ; neither does she always receive the right kind of nourishment, nor has the teacher time to note and remedy a failure of appetite or vigor. THE HYGIENE OF WOMANHOOD. 17 CHAPTEE III. THE HYGIENE OF WOMANHOOD. In the climate of the United States, and under average cir- cumstances, womanhood may be said to begin at from eighteen to twenty years of age. If her previous years have been spent in surroundings calculated to secure good health, the girl will find herself possessed of strength sufficient not only for the ordinary domestic duties of life, but, should necessity de- mand it, to engage in some occupation for her livelihood. No matter whether she is obliged to maintain herself, or whether her ambition leads her into the arduous idleness of fashion, if the health and strength are to be preserved, the same precau- tions must continue which were enjoined during childhood. The clothing should remain well fitting, loose, and comfortable. Corsets should be left to those more ignorant and stupid than herself, and habits of exercise out of doors, the use of nutri- tious and easily-digested food, and the securing of a sufficient supply of sleep are still of vital importance. The most suc- cessful women understand perfectly the need for constant care in the preservation of health and beauty. The popularity of massage, the increased number of attractive health resorts, and the wide-spread interest in out-door athletics for women. as well as physical culture in-doors during the winter, give ample evidence of this fact. The additional suppleness, grace of movement, and elasticity of the whole body, attained by conscientious practise of the physical culture exercises, prove a more than sufficient reward for the time and energy bestowed upon them. An opportunity is given in the early spring, with the sanc- tion of the church, to avoid overtaxing in the loss of sleep and bad eating which the fashionable season imposes. The great desire to possess homes in the country, in addition to b 2* 18 MOTHER AND CHILD. city houses, has resulted in shortening the period of city life, so that, at the present time, many live in town but a third of the entire year. This is a distinct gain in the health and com- fort of those who are fortunately able to follow this custom. Among those who are obliged to work for a livelihood, suita- ble materials for proper clothing can be obtained at lower j)rices than formerly, and light woollen stuffs, which are so essential to health, are far more available than in former times. Food is better cooked in the average boarding-house and restaurant, to which women have access, than was the case ten or twenty years ago. A greater variety is afforded for a moderate price, and the maintenance of a fair condition of nutrition is thus within the reach of nearly all. Yery few workers in any pursuit are unable to obtain a summer holiday, however brief. Women are now offered lodgings, food, and care in various homes and hotels maintained for working- women, which give them the conditions necessary for health at the lowest possible prices. The heating and ven- tilation of shops and factories are better than formerly (although there is much still to be desired in this respect), and the use of machinery, of elevators, and other labor-saving devices, has reduced some injurious forms of muscular exertion very greatly. The increased opportunities for practising stenography and type-writing have given women an occupation which, under favorable circumstances, is not hurtful to those of average strength. Training-schools for nurses offer a safe, honorable, and lucra- tive employment, for which women are especially well fitted, to those of good constitution and sound nervous system. No others can become successful nurses, but such can derive good incomes, and if they possess sufficient education and executive ability, can secure, as superintendents of schools and hospitals, those medical positions for which women are best adapted. When American civilization advances sufficiently to furnish a class of properly- trained women for house service, one of CONCEPTION. 19 the most puzzling problems in securing healthy occupations for women will be solved. At present, the young woman coming to the city often prefers to stand behind a counter, adorned with cheap jewelry, as a ■" saleslady," when she could earn more money at less expense to herself and under condi- tions favorable to health as a trained waitress, child's nurse, seamstress, or maid. American democracy has placed these pursuits in an unfavorable light in the minds of women, and they are regarded as menial and undignified. A change in this can of course result but gradually, but when it shall come, the lives and health of many women will be preserved, which are now injured or lost by the disadvantageous surroundings found in many large shops and factories. CHAPTEE IT. CONCEPTION. The conditions influencing conception are so many and so different that a brief consideration of them can hardly fail to be of interest. It has been asserted by some authorities that conception occurs more frequently in the months of spring than in midsummer or midwinter. Next in frequency the autumnal months are given. It is well known that the gen- eral condition of a nation as regards plenty or famine, pros- perity or adversity, war or peace, freedom from excessive labor or necessity for toil, influences in a very marked degree the increase of population. In a general way climate also has something to do with the growth of the human family. The portions of the globe where man survives under the greatest difficulties by reason of the severity of heat or cold show, as a rule, less flourishing families than the more temperate regions. Eegarding the age at which conception is possible, we find that it varies from the period of puberty to several months 20 MOTHER AND CHILD. and, in some rare cases, several years after the cessation of menstruation. Conception often occurs about the " change of life." So far as age in years is concerned, this changes in different races and different climates, but the fact is familiar that in the tropics women bear children earlier and cease reproduction sooner than in temperate or cold climates. So far as the con- ditions favoring conception in individual cases are concerned, the many circumstances which make up the life of the wife have considerable influence. The years of greatest fecundity, when reproduction is least injurious to the woman and when children are born best developed, are between the years of twenty and thirty. Great unhappiness, severe nervous shock, prolonged ill health, and, in general, any excessively depressing and persistently acting influence may result in the suspension of the reproductive function. So far as the estimation of the time between the periods of menstruation when conception is most likely to occur, the former belief has been that immedi- ately after the cessation of the monthly period liability was greatest. More recent investigations have led us to believe that the four weeks or thirty days between the menstrual epochs may be divided into three periods of ten days each. During the first ten days after menstruation and during the ten days im- mediately preceding the next period, liability to conception is greatest. In the ten days between these periods, liability is less. Exceptions, however, to all rules and estimates, and to all methods of computation, are so frequent that no fixed rule can be given, and it must be understood that liability is always present, whatever may be the time, during the inter-menstrual period. SYMPTOMS OF PREGNANCY. 21 CHAPTEE V. SYMPTOMS OP PREGNANCY. The symptoms of pregnancy are naturally divided into the presumptive and the positive. The most frequent presumptive symptom is cessation of menstruation, and yet, when we con- sider the many causes which may disturb the regular course of this function, it can readily be seen that this is far from being a positive symptom, and is, in fact, only the most com- monly-observed presumptive symptom. Any unusual strain upon the vital powers, change of climate and residence, expo- sure to cold or to extreme heat, the disturbances incident to marriage, and, in general, any great depression of the woman's physical economy, or any sudden change in her environment, may result in the temporary suspension of menstruation. This may persist for several months without serious disease being present, and as the general balance of the economy is restored, so the function becomes re-established. Other pre- sumptive symptoms of pregnancy are a sensation of weight and fulness in the abdomen, enlargement of the breasts, with tenderness about the nipples, marked variation in the appetite, with desires for unusual sorts of food, all intensified by a strong desire for, and belief in, the occurrence of pregnancy. In rare cases, abdominal enlargement may even proceed to the size attained at the end of normal pregnancy, and still pregnancy may not exist. While too much stress should not be laid upon the presumptive symptoms of pregnancy, yet disturbance of menstruation and variation in the general health should arouse the woman's suspicions, and should lead her to consult her physician at once. He may be able to de- tect some temporary disorder which treatment may remedy, or his experienced scrutiny may determine the existence of pregnancy. So soon as presumptive evidence of pregnancy is 22 MOTHER AND CHILD. observed, the woman should avoid fatigue and extremes of every sort, and maintain the best possible general condition of health until her condition can be definitely ascertained. The positive symptoms of pregnancy are present when the child is sufficiently advanced so that its existence can be appre- ciated by the physician by the senses of hearing, of touch, or of sight. By these we mean that when the physician can hear the heart-beat of the child within the womb ; when by placing his hand upon the abdomen he can feel distinctly the movements of the child, and by watching closely the surface of the abdomen as the mother is resting quietly in a recum- bent position, can observe slight movements which are occa- sioned by the motions of the child's limbs within the womb, then the positive existence of pregnancy is established beyond doubt. Ordinarily, however, it is quite sufficient for the physi- cian to hear the beating of the child's heart, and this can usually be done soon after the fourth month of the child's ex- istence. In repeated pregnancies, the mother can often from experience assert positively regarding her condition ; but even the sensations of an experienced mother are occasionally at fault, and so a positive verdict must be deferred until the physician can demonstrate the existence of the child. CHAPTEE VI. DURATION OF PREGNANCY. It is well to define the terms used to express the premature birth of the child, and also the limits to the time in which a child may be born and survive. By the word viability we un- derstand the child's ability to survive when expelled from the womb. Modern methods of treatment have made it possible for children to live and thrive when born between six and seven months after conception. If a child is expelled from DURATION OF PREGNANCY. 23 the womb in the first four months of pregnancy, it is com- monly called an abortion. If the expulsion takes place after the fourth month, but before the time when the child is viable, it is known as a miscarriage, and if the child is born after the period of viability, and yet before the usual limit of pregnancy, it is known as premature labor. This brings us to consider the natural limit of pregnancy in the human species. It was formerly supposed that from two hundred and seventy to two hundred and eighty days was the usual period of gestation, but recent study has shown that while it is true in the majority of cases, yet occasionally gesta- tion may be prolonged to three hundred days, and even more, and still a perfectly healthy child be born after a safe and speedy labor. On the other hand, it is not infrequent for children to be born at any time between the two hundredth and two hun- dred and eightieth day after conception, and survive and flour- ish. Keeping these facts in mind, we can readily explain the miscalculations which occasionally arise, and the fact that children are sometimes born before their mothers are ready for them, before the arrival of the nurse, and when they are quite unexpected ; and again, a delay of several weeks may occur, giving rise to much annoyance and anxiety, and yet the whole be simply a delayed process. If we ask ourselves in what consists a perfectly healthy pregnancy, we may define it some- what as follows : It is the natural growth and development of the child in the womb, extending through a period, on the average, of nine months, and resulting in the birth of a child sufficiently strong to subsist with the aid of the mother's care. During this time, changes go on in the body of the mother as the child grows and develops. She frequently gains somewhat in weight, and increase in all of the tissues of her body takes place. As pregnancy progresses, the organs of respiration and digestion become encroached upon by the growing child, and hence modifications in every function result, which are adapted to the increased demand made upon her respiratory 24 MOTHER AND CHILD. and digestive functions. She is obliged to breathe and to digest for two, and hence in many instances a feeling of well- being and an increase of appetite take place. In other cases the burden of the new life seems excessive, and weakness and prostration may denote that her powers are unequal to the task ; but in the main, among healthy women, after the first months are past, the general health is in a condition of com- parative vigor. The wonderful changes which go on during these nine months are but imperfectly understood by even scientists. It is sufficient to say that if the mother remembers the dual life which she is leading, and that there is developing within her a being which not only breathes through the oxygen contained in her blood, but in addition is forming a nervous system, and receiving through her nervous system the trans- mission of some of the sensations which she experiences, the meaning and scope of what is meant by a natural pregnancy become more apparent. We introduce these apparently abstract scientific remarks to impress upon the minds of mothers the fact that their habits and environment during the period of pregnancy are forming not only the shape and size and health of the unborn child, but also its mental and physical peculiarities. It should be remembered that a normal pregnancy is a distinctly natural and physiological process ; that certain tissues and develop- mental forces resident in the woman's body have been given to her fbr this purpose, and that her forebodings and dread are to be tempered by the thought that she is thus fulfilling a design which results, in the healthy person, not in disease nor in death, but in the performance of a function which is part of her healthy life. MISCARRIAGE. 25 CHAPTER VII. MISCARRIAGE. It is necessary that we should also describe abortion and miscarriage, and draw attention to dangers which attend them. The two symptoms of abortion and miscarriage, which should at once arouse solicitude, are flooding and pain. They denote that the child is in danger of being separated from the womb, or that such separation has already occurred. This may be caused by disease on the part of the mother, and especially frequently by undue exertion or violence. Thus, as in a case which we recall, the use of a sewing-machine for half a day, in a woman who was not accustomed to active work, resulted in abortion. Thoughtless lifting or undue exertion in reaching up to high shelves, or hanging up clothing, has also caused abortion. A sudden shock, as falling down stairs, or being thrown from a carriage, or severely jolted upon a rough road, or in an elevator, or upon a railway train, has resulted in this accident. Occasionally, in persons who seem predisposed to abortion or miscarriage, a very slight jar will bring on this misfortune. Thus, a mis-step in the street has caused abortion. Sudden nervous or mental shock, grief and terror, have been repeatedly effectual ; in great disasters, where a city has been burned, or where a section of country has been suddenly attacked by a hostile army, or in time of sudden disaster of any sort, as during the Johnstown calamity, large numbers of women suf- fered from abortion or miscarriage. The occurrence of flooding and pain in a woman who is preg- nant should lead to her placing herself instantly at perfect rest, and sending for her physician. She should lie down, loosen her clothing, keep absolutely quiet, and summon medical aid as soon as possible. The dangers of such accidents are the b 3 26 MOTHER AND CHILD. bleeding which accompanies them, and the fact that, unless especial care is taken, women frequently do not recover health promptly, but suffer from various disorders afterwards. The physician's treatment and orders should be strictly carried out, and especially in the matter of remaining absolutely quiet until he gives permission to move about. Women not infre- quently think that rest in bed for a week or ten days after hemorrhage has ceased is quite sufficient for perfect recovery. This, however, is very rarely true, and frequently the avoid- ance of exertion from eight weeks to three or four months is needed to result in perfect restoration to health. If the physi- cian's limit as to remaining recumbent were more generally observed, women would suffer far less frequently from the con- sequences of these accidents. If women are so situated that they cannot obtain medical aid promptly, and flooding and pain continue, by keeping absolutely recumbent, the head low upon the bed, possibly without a pil- low, and by the exercise of the greatest cleanliness while the hemorrhage persists, they will do all that they can to favor a good recovery. It is especially important that, should a friend be present sufficiently experienced to understand what is going on, she should abstain in any way from touching the bag of fluid in which the child is contained until it has been expelled from the mother's body. Otherwise, she may precipitate a dangerous complication. CHAPTEE VIII. DISEASES AFFECTING THE WOMAN DURING PREGNANCY. Diseases occurring in pregnant women commonly occasion more than usual anxiety on the part of the patient and her friends. This anxiety is based upon good grounds, for if a pregnant woman becomes ill with some acute disease, her DISEASES DURING PREGNANCY. 27 pregnancy adds greatly to her danger. In fevers, occurring in such patients, the danger to mother and child becomes great in proportion as the patient's temperature is high and remains considerably elevated. Thus, in typhoid fever, in malarial fever, in rheumatic. fever, and in pneumonia, often known as lung fever, if the patient's temperature does not rise very high nor remain elevated for a considerable time, the patient's chances for recovery and those of her child are much better than if the fever is severe and prolonged. If abortion should occur during an illness, it is an injurious accident for the mother. She is apt to have severe flooding, and there is danger that some form of inflammation will attack the womb. It sometimes happens that the organs in the body which remove waste materials from the blood fail to property perform their functions during pregnancy. This results in the storing up of poisonous material in the patient's body, and when this poisonous matter becomes sufficiently abundant, it poisons the brain and spinal cord, and causes convulsions. This is known as eclampsia, or convulsions occurring in pregnancy. They are likely to come on sometimes without warning, and more often after the patient has suffered with headache, dimness of vision, a sense of heaviness and lassitude, accompanied by a gradual diminution of the product of the kidneys. Symptoms such as these, when observed by a nurse or by the patient her- self, should cause her to instantly consult her physician. Eclamptic convulsions occurring during pregnancy resemble epileptic fits ; they are more dangerous than epileptic fits, for many patients die in this condition. The convulsions usually bring on the labor, and the child sometimes survives and often perishes. If the patient suffers from headache, lack of vision, and diminished amount of kidney secretion, no time should be lost in communicating with her physician. It has long been a tradition that women who have incipient consumption become better in health if they marry and bear children; this is one of the many groundless beliefs extant. It is true that during the pregnancy the mother's health and 28 MOTHER AND CHILD. strength may improve under the influence of the increased nu- trition which pregnancy brings : so soon, however, as the preg- nancy ends, the disease which existed before pregnancy began goes on with increased severity. It is wrong for women who have incipient consumption, or for women who have a strong hereditary tendency to consumption and are themselves not robust, to marry and bear children. If this truth were ac- knowledged, much would be accomplished to check the spread of consumption. There is also a possibility that the child, when born, will be found affected by the same disease. A woman suffering from consumption should by no means nurse her child, as there is danger of conveying tuberculosis through her milk. Nervous diseases sometimes develop during pregnancy, and among these, St. Yitus's dance is not uncommon. Insanity is sometimes precipitated by pregnancy and the puerperal state. Where the mother has been healthy before she became preg- nant, she will probably recover her mental condition in a short time after the child is born. Where, however, the mother has a strong tendency to insanity, the chance for her permanent recovery is not so good. It has always been thought that pregnant women were especially liable to those diseases which are accompanied by eruptions : this opinion is well founded. The danger in these cases arises from the fever which accompanies them, from the liability to interruption of the pregnancy, and the danger of blood-poisoning which complicates such an accident. Cases of extraordinary resistance to such contagion are occasionally observed, and women have been known to nurse a child suffering from scarlatina without themselves contracting it. Such could scarcely be the case if the woman were pregnant and cared for another child ill with scarlatina. Where abortion or labor occurs in these cases, especial precautions regarding cleanliness should be observed, as the danger of blood-poison- ing is much greater than ordinarily. Women who have disease of the heart are often exceedingly HYGIENE OF PREGNANCY— DIET. 29 anxious lest pregnancy should terminate in a dangerous and severe labor. Fortunately, such fears have no great basis for their existence. It is remarkable how women who have suffered from heart-disease for many years will pass through a pregnancy and labor not only without growing worse, but oftentimes with apparent improvement. A patient's fears upon this point are happily generally without foundation, for when pregnancy terminates in labor, a remarkable degree of strength is often developed in the action of the heart. Women may receive severe injury during pregnancy from accidents, or from assault in occasional cases ; it is the rule, however, that if the mother be healthy, the pregnancy is often not inter- rupted, but the mother may recover, and the child continue to live until term. CHAPTEE IX. HYGIENE OF PREGNANCY — DIET. There can be no more important subject than the hygiene of pregnancy, and, as would be naturally inferred, the question of food is of the greatest interest. There are prevailing certain absurd ideas regarding the influence of the mother's diet upon the size and development of the child. It is alleged that by maintaining a continuous diet of fruit, and by carefully avoiding such articles of food as would contain matter nutritious for the child's skeleton, that children of small size and with easily- moulded and soft heads will be born as a consequence. While it may be possible by starving the mother to starve her child, yet no more injurious practice could be followed than one which diminishes the strength of the mother, and brings her to face the ordeal of labor with impoverished blood and de- pressed nervous system. The contrary is true, — that the patient needs a most abundant and easily-digested diet which shall be rich in nutrient material 3* 30 MOTHER AND CHILD. in proportion to the demands upon her for her own nourish- ment and that of her child. The question of drink during pregnancy is one which must be determined by reference to the usual habits of the patient. If she has been accustomed to drink wine and beer, there would bo no objection to her continuing the practice in moderation. But if not, she will do well not to commence the use of stimulants while pregnant. The question of diet, however, is greatly influenced by the irritability of the patient's stomach and her incapacity to digest large quantities of food, which are especially pronounced during the first four months. The phenomenon known as morning sickness may be de- scribed as follows : Soon after waking in the morning, and usually as soon as the head is raised from the pillow, the patient is suddenly seized with a desire to empty the stomach. When this desire is gratified, the sensation of nausea disap- pears, and soon after the patient is able to take a little food. In perfectly healthy women, where this derangement does not become severe, no treatment is necessary; if the patient drinks a glass of water and then ejects it at once, no harm is done, and in a few moments she will often be able to retain food. Yery frequently, this disagreeable symptom may be avoided by taking a small quantity of very easily digested food before the head is raised from the pillow. A little stimu- lant will prove effectual when food does not. Thus, a cup of well-made broth, rather highly seasoned and hot; a small cup of cocoa, tea, or coffee, especially black coffee ; a small glass of champagne, other wines, or bitter ale or beer; sometimes a little cordial, as Chartreuse ; brandy and soda, koumiss, and in hot weather a very little ice-cream,— all these are occasionally successful in giving relief, and in promoting an appetite for a subsequent breakfast. The patient must understand that the trouble is what is known as reflex ; that the growing of the child in the womb produces some irritation about the womb which is transmitted along its nerves to the nerves of the stomach. As a rule, EVGIENE OF PREGNANCY— DIET. 31 when four months of pregnancy have passed, this disorder ceases, and usually a good appetite is enjoyed for the remainder of the time. We desire to warn the patient against using drugs of any sort for morning sickness. When excessive acidity of the stomach is present, bicarbonate of sodium, or the soda-mint sold in the shops will be of use, but narcotics and remedies addressed to the nervous system should be taken upon a physician's prescription only. The appetite of the pregnant woman is likely to be peculiar, and, in fact, a number of cases are on record where the first intimation that the woman had of her condition was a sense of delight or of loathing at the existence of some especial article of diet, generally a reversal of the usual appetite. Pregnant women frequently seem to have excessively abnor- mal appetites, which are known as " longings." If these be analyzed, they will usually be found to be expressions of de- sire for the sort of food which will best nourish herself and her unborn child. A hint may often be taken from these long- ings, and the needed article of diet may thus be supplied to the patient. If food is important during pregnancy, it must be remem- bered that digestive power is commonly so lessened that a smaller amount than usual can be digested at any one time. Hence it is often necessary not to take three full meals in twenty-four hours, but to have five or six lunches or lighter meals instead. These may be taken at intervals of four or five hours, and are often admissible at such intervals as to come after the patient has lain down and slept for a short time. 32 MOTHER AND CHILD. CHAPTER X. HYGIENE OP PREGNANCY — EXERCISE AND CLOTHING. If proper nutrition is important for the pregnant woman, it must be remembered that there is no agent so efficient in producing this as sleep. Eest and sleep should be taken with regularity and abundance ; eight or nine hours at night, and from one to three during the daytime, are not too much for a person of average development. If sleep is interrupted, rest can often be taken at intervals most convenient. This should consist not only in the semi-recumbent position in a chair, but also in lying on a comfortable couch or bed. It quite often happens that if the child be vigorous, its movements within the womb may prevent sleep at night, and then rest in the day may be substituted. To keep up the condition of comfortable health, exercise is fully as important as food and sleep. Best of all is walking in moderation. Climbing stairs, lifting, running a sewing- machine, moving the arms rapidly, and excessively long walks are all extremely injurious, and likely to produce subsequent trouble; but a walk carefully graduated to the patient's strength and sensations in the earlier months of pregnancy, and driving in a comfortable vehicle in the latter months are especially indicated. The amount of housework incumbent upon a woman in comfortable circumstances usually suffices in ordinary cases. Exercise, however, will be uncomfortable and impossible without injury unless the patient is properly dressed. The very word enceinte denotes a person who is not wearing clothing closely belted about her. So soon as pregnancy is discovered, the ordinary corset should be laid aside. Some form of clothing should be adopted which supports the skirts upon the shoul- ders. There are a number of these devices in the market, BATHING— CARE OF NERVOUS SYSTEM. 33 Fig. 1. and the patient must choose that which fits her most com- fortably. Even in moderately warm weather, woollen underclothing should be worn. In winter, the Jaeger system of woollen underwear, and in warm weather, the finer and thinner goods similar are best, and should cover the body to the wrists and ankles. Garters should be made as loose as possible, or, better, discarded for some other device. ~No portion of the clothing should fit tightly, and should support fur the abdomen be de- manded, an abdominal bandage, or waist coming from the shoulders over the abdomen, may be em- ployed. In driving, great care should be taken that wraps are always within reach to avoid chill- ing the surface of the body. Easy shoes, loose-fitting wraps, and those forms of clothing which allow the freest movement of the chest should be worn. It is almost needless to say that, in the changeful climates of this country, thin woollen should be worn next to the skin for at least ten months of the year. Abdominal bandage for support in pregnancy. CHAPTEE XL HYGIENE OP PREGNANCY — BATHING — CARE OP NERVOUS SYSTEM. The care of the skin is a very important detail; the bath should be daily, avoiding extremes of hot or cold water, to be taken in the manner least likely to fatigue the patient, fol- lowed by gentle friction, and by repose in a recumbent posture for at least half an hour. A very disagreeable itching and burning in some parts of the body frequently occur during 34 MOTHER AND CHILD. pregnancy. The advice of the physician should bo at once sought, and occasionally the patient can do much to relieve herself by dissolving in the water of the bath sufficient sodium bicarbonate to give a smooth feeling to the fingers, or, occa- sionally, a warm bath into which bran has been mixed will be found an advantage. The nervous system of the patient undergoes modifications fully as great as those of other organs. In the beginning, a period of despondency may occasion great anxiety on the part of the patient and her friends. She will often urge her physi- cian to relieve her from the continuation of her condition, fearing its results for the child and herself. Other women feel much better than usually when in this condition, and are hopeful and courageous from the first. It should be remem- bered that forebodings and despondency have no basis of fact whatever, but are simply manifestations of the physical con- dition of the patient. They should be disregarded by her, her mind occupied as pleasantly and constantly as possible, and she should train herself to look forward to the termination of this trial with anticipations not of disaster, but of great hap- piness subsequently. Those about her should be careful to encourage her in this belief, and especially nurses, and women who have already had children, with whom she may come in contact, should forbear from relating accounts of dangers and complicated cases which they have seen or experienced. Such is the heartless idiocy of gossips, whether professional or other- wise, that they seem never happy unless relating some chapter of horrors in which they imagine that they have been heroines. When we pause to consider, however, that these stories are always exaggerated for the purpose of magnifying their own exploits, we readily see on what slight basis of truth most of them rest. The professional nurse who knows no better than to alarm pregnant women with tales of dreadful confinements should not receive a second engagement from any one. Occasional peculiarities in temper and temperament, not usually characteristic of the patient, should be kindly ascribed BATHING— CARE OF NERVOUS SYSTEM. 35 by her friends to her changed condition, and treated as purely physical and transient, with the greatest kindness. The patient herself and her friends should remember that the condition of her mind and her nervous system has an important bearing upon that of her unborn child. Intelligent women have fre- quently surrounded themselves during this period with all that was lofty, beautiful, and pleasing. It was the custom among the Greeks to take especial pains that nothing should be pre- sented to the view of such women except the most beautiful scenery and the most artistic forms. The aid of music and recitations from the poets were also invoked that the child's brain might be tuned, as it were, while still in process of con- struction, for that which was most beautiful. In modern times, we recall an instance of an intelligent woman leading a quiet life, who, during her pregnancy, chose such literature for her reading and such associations as she judged most likely to develop pure and good tastes in her child, and the result full}' justified her precautions. It is commonly supposed that the sight of a dreadful object, the receipt of sudden and dreadful news, great and horrible danger, the witnessing of a crime, or any great shock, often result in some permanent deformity or malformation in the child. There is certainly a basis of truth for this belief suffi- cient to cause a woman in this condition to carefully a^oid anything which is dangerous or terrifying. There can be no doubt that the mother's previous habits and also those during her pregnancy have a decided influence upon the formation of those of her child. The responsibility devolving upon parents can be readily appreciated on consideration of this fact. So far as the formation of a healthy brain and nervous system of the child go, regularity in habits upon the part of the mother, and the avoidance of exciting and endangering causes, with abstinence from stimulants, — in fact, a life as tranquil and happy as possible during these nine months, — can hardly fail to give the child the best possible chance for healthy develop- ment. 36 MOTHER AND CHILD. CHAPTEE XII. CONSTIPATION. The most common trouble from which patients suffer during this period is that of constipation. This is generally worse during the first few months, and during the last six or eight weeks. It is to be remedied so far as possible by a carefully- arranged diet in which whole wheat flour, fresh vegetables, fruits, and a free supply of water form a large part. Consti- pation is especially dangerous in pregnancy, and the greatest pains must be taken to avoid it. Drugs should be taken on the advice of a physician only. The simplest remedies should be employed as long as possible, and not abandoned hastily. Thus, a regular habit in this matter is of the greatest impor- tance. A glass of cold water, or of hot water, taken in the morning as soon as the patient rises, a small glass of one of the mineral waters, the gluten suppositories furnished by most druggists, or, if this fail, glycerin suppositories maybe em- ployed. Enemata will generally succeed in the failure of the other means which have been described, and should be com- posed of water only, or white castile soapsuds to which castor oil has been added, the whole beaten up together and administered while warm, and, occasionally, enemata in which the yolk of a raw egg and a few drops of spirits of turpentine have been beaten up in the soapsuds. The best time for the use of such an injection is usually before retiring, or soon after waking in the morning. Irritability of the bladder is also a source of great annoyance to pregnant women, and is frequently relieved by assuming the recumbent posture. It is caused by the pressure of the enlarged womb, which is removed by such change in the posi- tion. Salivation or excessive flow of saliva is occasionally a BREASTS— VARICOSE VEINS. 37 great annoyance, and can hardly be treated without the advice of a physician. The care of the teeth, however, is a matter which each woman should look after herself. After the fourth or fifth month of pregnancy she should visit her dentist, no matter whether she have suspicions that all is not right with her teeth or not. Her condition frequently gives rise to some change in the teeth, and this should be taken in hand promptly before it has gone sufficiently far to cause permanent trouble. Certain disorders of the skin not infrequently arise, and among them the curious formation known as the " mask of pregnancy." This is a peculiar pigmentation, often of a brownish-yellow, forming upon the forehead and face, and usually persisting during this time. It is caused by a deposit of coloring matter similar to that which is observed in other regions of the body during pregnancy. As a rule, it gradually fades away after the birth of the child, and it is not amenable to treatment. Although unpleasant, it is not in the least harmful, and should be let alone and disregarded as far as possible. The care of the skin, however, is a matter of very considerable impor- tance. The pregnant woman, in common with others, eliminates from the body, through the skin, poisonous material which is especially dangerous in her condition. CHAPTEE XIII. HYGIENE OF PREGNANCY — BREASTS — VARICOSE VEINS. One of the most important matters for consideration is the care of the breasts. As pregnancy advances they become more prominent, firmer in consistence, and a deposit of color- ing matter takes place about the nipple. Small projecting bodies are also seen in the colored ring which surrounds the nipple, and these are small and auxiliary glands. In some rare 4 38 MOTHER AND' CHILD. cases the breasts become so turgid early in pregnancy as to demand the use of a supporting bandage, or of some applica- tions of a soothing character. The care of the nipple itself is of extreme importance with regard to the subsequent nursing of the child. It not infrequently happens that from a lock of development the nipple is so flat and sunken that the child cannot grasp it. Fissures and cracks of the nipple, occasion- ing much distress when the child nurses, are also frequently met with. In cases of flat and retracted nipples, persistent efforts should be made to draw out and develop them during the months of pregnancy. This can be done by the thumb and finger, and should never be made a painful process. Occa- sionally a suction pump, called a breast-pump, and to be ob- tained at druggists, may be employed to advantage. A healthy nipple should stand upon the breast much as a raspberry stands upon its stem, and if this relative situation be not present, the child may have trouble subsequently in nursing. To avoid cracks and painful fissures in the nipple it is better not to ap- ply hardening agents which make its surface more brittle and more apt to crack, but to use some soothing ointment instead. The nipple should be washed at least once daily with warm water and castile soap. Afterwards it should be gently drawn out between the thumb and finger, and anointed with cold cream or cocoa butter. If fissures and cracks occur, the attention of the physician should be immediately called to them, If the breasts become uncomfortably heavy during pregnancy, they may be supported by a breast bandage, to be described later. Should great turgidity, sharp pain, and some fever be present, inflammation of the breasts is threatened, and the physician should be summoned at once. Yery fre- quently, the use of borax-water, one tablespoonful to the pint or half-pint, is of great service in bathing the nipple, in pre- venting soreness and fissures. The chronic const'pation of which we have spoken, together with the pressure of the womb upon the intestines, not infre- BREASTS— VARICOSE VEINS. 30 quently results in the development of hemorrhoids, or in aggravating such as may be already present. Care should be taken to avoid constipation, and the physician's advice promptly summoned in such cases. Yaricose veins in the legs, and sometimes about the lower portion of the abdomen, may occasion great distress, and in the case of repeated pregnancy may become so greatly distended as to threaten rupture. They often cause great discomfort by reason of a sensation of weight and heaviness in the legs, and occasionally they are accompanied by intense itching. The most convenient and comfortable means of support for varicose veins is a bandage three inches wide, made of old, soft flannel. This should be applied in the morning before rising, while the patient is recumbent. It should begin at the toes and extend to the groin. Several of these band- ages should be pro- vided, and washed repeatedly, and thus a convenient and neat form of support is furnished. When once the knack of apply- ing them is acquired, they are more convenient than silk and rubber stockings, which are frequently used, as they can be varied in the tightness and looseness of application, and so 40 MOTHER AND CHILD. meet the individual needs of each case better than a less easily adjusted support. It is well to powder the skin over the vari- cose vein with finely -powdered borax, or with common rice- powder. Varicose veins occasionally become excessively distended, and rupture causes serious hemorrhage. Should this accident occur, the patient should lie flat at once upon the nearest con- venient support. The person aiding her may take a clean handkerchief, fold it into a square pad about two inches or so, and place the pad directly over the point of rupture. A bandage should be taken, and the limb bandaged from the toes up over the pad at the point of rupture. The leg should then be elevated upon a pillow, and a physician summoned (Fig. 2). It must be remembered that a bandage or string simply tied about the leg above or at the point of rupture may not only fail to check the hemorrhage, but may cause dangerous com- pression of the vein, increasing the bleeding ; so the whole leg must be included in a compression-bandage, to be effectual. If a bandage is not available, an old sheet may be torn up and one hastily improvised. Moderate pressure may be made with the hand upon the folded handkerchief, at the point of rupture, until assistance can arrive and the leg be bandaged. CHAPTEE XIV. GENERAL HYGIENE OF PREGNANCY — CLIMATE. So far as the general hygiene of pregnancy is concerned, whatever conduces to the tranquillity and general health of the patient is advisable. The claims of society should give way entirely to the patient's condition. Such social pleasures as are productive of rest and diversion may be enjoyed so long as the point of fatigue is not reached. But no restriction of dress and no positive engagements should be made which GENERAL HYGIENE OF PREGNANCY— CLIMATE. 41 might necessitate the patient's discomfort and cause a tax upon her strength. So far as society has claims they are ut- terly insignificant compared with the claims of the patient's own necessities and those of her unborn child. In persons who are able to vary their residence at will to secure the best possible climate at each season of the year, it may be advised that extremes of heat and cold and rigorous climates be carefully avoided. It would be best for the period of pregnancy to be passed in a temperate and equable climate where a large percentage of the days were fair, where extremes of temperature did not occur, and where severe storms were very infrequent. Such a climate would permit of the greatest amount of out-door exercise, and be the most favorable for the patient. This, however, is rarely obtainable in our latitude, and the fatigue and risk of a long journey to obtain such a climate might overbalance the advantages to be gained by it. How- ever, the modern luxuries of travel are making it more easily possible for frail and invalid persons to seek suitable climates, and hence the pregnant woman who has the necessary means may choose a suitable climate at will. As a general thing, long journeys are to be avoide 1, not only because of the danger of abortion caused by the jolting of railway cars and the mo- tion of a steamer, but on account also of the difficulty of carry- ing out that regular and systematic care which the patient's daily life demands. Amusements of various kinds often serve an important purpose in lessening the tedium of the patient's enforced retirement and in diverting her mind, and so long as fatigue and annoyance are avoided, they are a valuable adjunct in securing her well-being. It cannot be impressed upon the patient too strongly that she should consult her physician as soon as her condition is suspected or known. Modern obstetric science does not wait for complications to occur at labor, but endeavors by a careful scrutiny of the mother to anticipate and prevent them. It is possible for the physician to ascertain with comparative ease whether the mother is naturally shaped and developed, the 4* 42 MOTHER AND CHILD. position which her child occupies in the womb, its comparative vigor and development, and whether the general conditions favorable to a successful labor are present. Should the child be of excessive size in proportion to the mother ; should the mother be smaller than the average, or deformed, or the victim of a dangerous and chronic illness, it is possible to so treat her as to give the best possible chance for the life of her child and her own recovery. This must be done, however, some time before the termination of the ninth month of gestation, and hence the necessity for a careful examination of the patient as early as possible. Certain grave diseases which often threaten the pregnant woman can be detected and so treated as to give her child and herself the best chance for ultimate recovery. This preliminary examination by the physician can be conveniently made at the patient's house, the patient occu- pying a recumbent position, and does not necessarily call for anything painful or disagreeable. It is the physician's duty to make this examination, and it should be, and has been found to be, a source of comfort and encouragement to his patient. CHAPTER XY. NURSE AND ROOM. It is well to select a nurse early in this period, and to send the nurse as soon as possible to call upon the physician. No nurse should be taken in whom the physician has not confi- dence or who is not personally acceptable to him. The patient should remember that he is responsible for the nurse, and that, in the event of injury through her carelessness, criticism would fall not only upon the nurse, but also upon the physician. It is well to send the nurse to the physician early in the case to give him an opportunity to have any articles prepared for his patient which his methods of treatment may demand. No NURSE AND ROOM. 43 two physicians conduct a confinement in exactly the same manner, and physicians who are attentive to details, and who study their patient's comfort, are constantly devising methods and various appliances for her well-heing. It is important for these reasons that doctor and nurse have an early and distinct understanding as to the way in which the patient is to be treated. The nurse should take an inventory of what the patient has prepared for her confinement, and the patient should add such articles, if needed, as are deemed necessary by the physician. In case of accident and premature termi- nation of the pregnancy, the fact that the nurse is prepared will be found a great comfort indeed. In the selection of a nurse it is well to choose one who has been thoroughly educated. It does not make so much differ- ence how many confinements she has attended, or what doctors she has nursed for, or who have had her previously. It is of the greatest importance, however, that she understand the use of antiseptics, and that she has been so thoroughly trained that she will not meddle with the case, but will carry out the doctor's orders. Ambitious nurses who anticipate the doctor's questions by giving their own opinions, who always know that everything is right, who do not mention the minor complications until the doctor asks about them, but who treat them themselves, are not to be chosen, nor are nurses who are so far superior to their profession as to be ashamed to wear the uniform of the school from which they come. In choosing a room for the patient's use during confinement, one which is quiet, sunny, airy, and clean should be chosen. It is well that no plumbing should open into the room; in other words, that no waste-pipe, connecting with the sewer, should be in the room. This, of course, would include the modern wash-stand and closet ; but cases have been observed where these conveniences were sources of disease because of the germs conveyed through them from the sewer. It is better to have a room without carpets, in which rugs can be employed, with but few hangings, and with no article which 44 MOTHER AND CHILD. cannot be thoroughly cleaned and, if necessary, fumigated before the labor. An adjoining bedroom for the nurse and the infant is a great convenience, and will do much to favor the mother's repose. The furniture of the room should be com- fortable, but all superfluous articles should be removed. The bed should be a single bed, or three-quarters, not too low, and, preferably, not placed against the wall. It is very essential for the convenience of the nurse and the physician that the bed should be easily accessible in all directions. It should not have very elastic springs, although the ordinary woven wire mattress is not objectionable. The mattress should be of hair, and a liberal supply of linen and blankets should be provided. An experienced nurse will understand thoroughly the prepara- tion of a bed for confinement, and will tell her patient in ad- vance the articles required. It may be stated, however, that, in addition to the usual sheets, a half-dozen old sheets are an advantage; several old blankets, and two pieces of white rubber sheeting, one yard wide and covering the whole width of the bed, should be provided. The dress of the nurse is of importance not only as a matter of discipline, but also from the fact that carelessness in her dress may be a source of danger to her patient. The uniform of training schools consists of a " wash" dress, covered by a large apron and by linen over-sleeves, which can he frequently renewed. As it is essential that nothing come in contact with the patient, or come near her, which is not perfectly clean, it will readily be seen that untidy dress on the part of the nurse is a positive source of danger to the patient. If the nurse's washing is done in the house, the necessity for frequent changes of dresses and aprons should be kept in mind, and fulfilled as far as possible. The nurse's apron may contain but little starch to advantage, as it is thus less noisy about the patient. She should wear noiseless shoes; at night, felt slippers are useful, and during the day, slippers or pumps with over-gaiters, or a shoe made of some noiseless leather, as kangaroo-skin, are indicated. APPLIANCES FOR THE MOTHER. 45 CHAPTEE XVI. APPLIANCES FOR THE MOTHER. There are a number of appliances which can be employed to advantage in making the mother comfortable, and in pro- moting her recovery. She will need a certain number of nap- kins for the reception of what is known as the loehial discharge. It has been customary to use those which were washed and used repeatedly, but for many reasons it is better, if possible, to have them so made that they can be burned as soon as they are soiled. Any simple ataorbent material, which the nurse may dip into an antiseptic solution previously and then wring- out and dry, will be suitable for this purpose. The cheapest quality of cheese-cloth sold in the shops is an excellent material. The absorbent substance may be enclosed between two layers of cheese-cloth and loosely stitched at the edges. We have found that a napkin may be made by taking a piece of oakum about three inches wide and eight or nine inches long and an inch thick. On each side of this is placed the cheapest quality of cotton batting an inch thick. The whole is then enclosed between the two layers of a piece of cheese-cloth twelve or fifteen inches long and sufficiently wide to cover them. . The cut edge of the cheese-cloth is closed with cheap cotton thread, the whole napkin is dipped in a solution of bichloride of mer- cury (one to two thousand) and is wrung out and dried. The cost of these napkins, when all the material is purchased at wholesale, is a cent and a quarter each. When purchased at retail, between two and three cents. The ordinary patient will need six daily for the first three or four days, and four afterwards for a period of ten days or two weeks. It makes no difference whether they are made precisely after this de- scription, so long as the principle is carried out of an absorbent 46 MOTHER AND CHILD. substance which can be made antiseptic, and which is cheap and easily destroyed. It is customary among most women to wear after confine- ment an abdominal bandage or binder. In the case of strong and healthy women, this is not a necessity, but ft is a means of comfort to all, as a rule, and as such it may be employed. The Fig. 3. Buttoned binder. common belief, that it has much to do with restoring the woman's figure to its former proportions, has not much foun- dation in fact. If the patient be strong and well developed, the abdominal muscles will regain their former firmness, and thus the shape of the body will be restored. There are various sorts of binders, the simplest being a strip of hemmed muslin APPLIANCES FOR THE MOTHER. 47 about a foot wide and from twenty-four inches to a yard in length. Whatever form be employed, they must be so made that they can be frequently washed. The binder which we illustrate was devised originally in England, and has met with great acceptance in. that and other countries. This binder is nine and a half inches wide and a yard long. Twelve inches from either end is a gusset four and a half inches deep and four inches wide at the bottom, its widest part. The binder is made of two thicknesses of cloth, preferably, light canvas or muslin. At one end of the binder are two rows of button- holes, one row at the edge, seven in number, one and one-half inches apart, and a second row parallel to the first, one and a half inches distant from it. At the other end of the binder are three rows of linen buttons, one inch and three-quarters apart. At the lower edge of the binder, and midway between the two gussets, are two pairs of buttons to which a napkin may be fastened from below. The application of the binder is as follows : Immediately after confinement, when the abdomen is large, the row of buttons nearest the edge is buttoned into the row of button-holes also nearest the edge. As the abdomen becomes smaller, the rows of buttons are advanced successively to the rows of button-holes, and thus the length of the bandage may be varied to suit the needs of the case. A useful binder may also be prepared by putting gussets in an ordinary strip of hemmed muslin, and fastening the binder by pinning from above downward. The napkin worn by the patient should be pinned to the lower edge of the binder behind, and brought up and pinned to the lower edge of the binder in front. In addition to the binder, a skilful nurse may prepare pil- lows and cushions of various sizes, made of cotton and cheese- cloth, which are cheap and can be readily burned when soiled. They may be placed under the patient's hips, and will add to her comfort by aiding her to change her position in bed (Figs. 4 and 5). For use upon the breasts, a breast-binder or compression- bandage may be prepared as follows: 48 MOTHER AND CHILD. Fig. 4. y -? -if — * —a - APPLIANCES FOR THE MOTHER. 49 It is twenty-nine inches long by eight wide; three and a half inches from either extremity, and in the centre of the bandage, two holes have been cut the size of a quarter of a dollar, the edges of which are carefully overseamed to prevent the apertures from tearing out, the distance between them being the distance measured between the nipples. At the upper edge of the bandage, five inches from the end, two shoulder-straps are attached, two inches wide. The bandage is so applied that it pins over the centre of the chest between the breasts, the apertures giving room for the nipples, through which the child may nurse. The shoulder-straps come over the shoulders and may cross in front, or be pinned, without crossing, to the upper edge of the bandage after it has been Fig. 6. fastened about the body. The purpose of this bandage is to draw the breasts upward and inward, thus relieving the pain caused by engorgement. This bandage may be made of can- ton flannel or of firm muslin, as desired (Fig. 6). A plentiful supply of old, soft linen is also desirable. Besides the articles already described, the nurse should see that the patient has ready in her possession such antiseptics as the c d 5 50 MOTHER AND CHILD. doctor may select, two ounces of the fluid extract of ergot brandy or whiskey, a nipple-shielJ, and be sure that an abun- dance of hot water can be procured conveniently and imme- diately, if desired, in the room which the patient will occupy. There should be, if possible, no question regarding the burning of any bandage or inexpensive appliance which becomes soiled. Napkins can usually be rolled in a piece of newspaper and burned in the kitchen range or an open fire. Old night-dresses should be chosen for the patient's use while in bed, as it is sometimes convenient to tear them down the centre in front instead of slipping them off in the usual way. CHAPTEE XYIL APPLIANCES FOR THE CHILD. For the child, the elaborate and extensive wardrobes fre- quently purchased are worse than useless. Money is spent unnecessarily in what cun hardly be, from the nature of the case, in good taste, and for what is often improperly made. The child's clothing should be warm, soft, compressing the body in no direction, and its weight, like the weight of its mother's clothing, should be supported from the shoulders. It has been the custom among Indians to pack the new-born child in moss, and some soft and warm material like moss would certainly represent an excellent dress for a child. The finest quality of flannel, or garments knit of the finest worsted, are usually the best. The wardrobe of the new-born child should consist, first, of a dressing for the umbilical cord, then of an abdominal band or belly-band over that; a diaper; a woollen or knit shirt with long sleeves, a woollen skirt, and a white shirt and skirt combined, over the whole. For the feet, worsted socks can be readily knit, which are not only most comfortable and suitable, but also pretty. APPLIANCES FOR THE CHILD. 51 The best method of dressing the umbilical cord will be selected by the doctor, and will be outlined in the description of the conduct of labor. Not more than a half-dozen changes of clothing are needed for the child in the beginning, as its size cannot, of course, be known before birth. The making of its later wardrobe fur- nishes a most agreeable occupation for its mother and friends. If the baby's clothing be properly made, there need be but one pin employed in the whole dressing, and that a diaper-pin. Other garments should be fastened by strings or buttons. An abundance of diapers should be provided for the child, of cotton or limn, of such a size that when folded once they are less than a half-yard square ; and doubtless before many years some cheap, soft, and absorbent material, like Japanese paper, may be found which can be destroyed as soon as it has become soiled, thus obviating the necessity for washing. A description of the various babies' wardrobes devised by different nations would furnish an extensive catalogue of such articles : the pappoose of the Indian mother is familiar as a national relic, and her Scandinavian and German friends have embodied the same principle in what is known as the " child's mattress." This consists of a soft and thin mattress quilted and heavily wadded, but sufficiently large to contain the child, and permit of its being folded over its body. The child is thinly dressed, laid upon the mattress, and the mattress folded over it and held in place by an embroidered band about three inches in width, which is crossed and recrossed over the child diagonally. The child thus becomes virtually a little bundle, and can be transported with great ease (Fig. 7). Such a de- vice, however, is only of use during journeys, and, in the main, the mattress is too warm to be constant^ worn. It is some- times advantageous, however, either to employ something like the mattress if the child goes out in its carriage, or to take especial pains that the child's limbs and body are protected by a warm mattress in the bottom of the carriage, and by a thick, soft afghan or lap robe. 52 MOTHER AND CHILD. Former generations of American children were dressed upon the jorinciple of low neck and short sleeves, and those who re- member this usage will assert in support of it that children so dressed were certainly as robust and well developed as any at the present day. While that may be true, experience proves that to-day the best clothing for the infant child is woollen or silk of various grades of thicknesses, covering the entire body. Thus, an exceptionally fine and robust infant has been dressed in a silk undershirt and two petticoats sewed upon one waist or body, the whole so arranged that the child is dressed practi- cally simultaneously. Fig. 7. During the heated term it is .especially desirable that the infant live as much in the open air as possible, and that the surface of its body be protected from sudden changes of tem- perature, from moisture, and from draughts. This is best accomplished by removing all superfluous wraps and coverings, and dressing the child from neck to heels in the lightest and finest flannel. The difference in the customs of heating dwell- ings has also necessitated some difference in the clothing of children. The house clothing of the child must be propor- tionately much lighter than the clothing which it wears out of doors, because the average house is overheated, and the change is thereby greatly exaggerated from the air in-doors to the out-door atmosphere. The ordinary baby's cap, which covers the back of the head and the ears, is wisely planned, for the infant child has thus portions of the head carefully protected which are easily injured. It must be remembered also that the infant's eyes CHILD'S CRADLE AND BASKET. 53 are extremely sensitive, and hence its face should be shielded from the light by a veil or some suitable covering. The igno- rance and stupidity of the average child's maid who takes the baby upon the street in a carriage, its face upturned and frequently exposed to bright sunshine while she gossips with some other servant or with the traditional park policeman, cannot fail to result in some injury to the infant's sight. CHAPTER XVIII. child's cradle and basket. The cradle or sleeping-place of the child has been made the centre of most of the poetry of infancy. Whether the baby be rocked on the tree-top, carried on the back of its mother, or rolled up in a bundle with other baggage, it is still cradled in some fashion or other, even when lying upon her arm in bed. It is needless to say that from the day of birth the infant is entitled to its own separate, undisturbed sleeping- place. It should not sleep with the mother, it should not be rocked and jolted while asleep, and if it is expected to become a rational and thinking person, it should be accorded those opportunities for undisturbed repose which are necessary to the nourishment of any normal brain. Despite the desire of mothers to keep the child with them, of grandmothers and nurses to trot the baby and sing the baby to sleep, it is far better that the child, soon after its birth, should be taken to its place of sleep, placed comfortably upon a suitable bed, properly covered, and left entirely alone. Such is the un- thinking zeal of many nurses and friends of mothers that such an education for the child is possible only among the most intelligent people, in whom reason predominates over tradition and prejudice. The objections to placing the child in bed with the mother, among people of the better class, are 54 MOTHER AND CHILD. that the child inspires the air contaminated by the mother's secretions and excretions ; that the constant tendency is for the child to nurse too frequently, and that the repose of the mother and child is mutually disturbed. Among people of the poorer class and among the vicious, carelessness, excessive fatigue, and drunkenness on the part of the mother result in a considerable mortality among infants from what is known as overlaying. Owing to the mothers carelessness, or during the profound sleep of exhaustion or drunkenness, the child slips down beneath the mother's side, she rolls over upon it, and it dies from pressure and asphyxia. If the mother is without assistance, she may place the infant alongside of her bed in any suitable receptacle, but not in the bed with herself. We recently visited a happy mother, fertile in expedients, not rich in this world's goods, but rich in the possession of a fine baby, who took a clean, dry wash-tub, filled it full of blankets, and placed her baby in it upon a pillow. The baby slept peacefully beside the mother, and both were happy and contented. Ordi- narily, a solidly-built crib without rockers will be found most convenient and advantageous. This, of course, should be sur- rounded by sides sufficiently high to obviate any danger of the child's falling out. The mattress should be moderately firm, the child's pillow low, and when put to sleep, the child should be carefully guarded from the light. The contents of the bassinet (or baby-basket) should consist of the baby's toilet articles : simple rice powder, a little pot of white vaseline or cold cream, white Castile or spermaceti soap, and such other articles as an experienced nurse or mother may deem necessary. Appended is a list of an outfit which has been found of practical use : brush and comb, skein of white twisted embroidery silk, soft, fine sponge, bottle of white vase- line, sharp pair of pointed scissors, powder-box and puff, with talc powder; pin-cushion, small and large safety-pins, pure Castile soap, pair of socks, some old, fine linen, flannel or knitted band, flannel shirt, a petticoat and night-gown for in- fant ; an afghan or piece of extra flannel, in which to wrap the CHILD'S CRADLE AND BASKET. 55 child ; also piece of flannel, or old blanket, to receive it in ; in addition, the baby will require eight day-dresses, eight night- gowns, eight white skirts, four day-flannel skirts, four night- flannel skirts, four pairs of day-socks, four pairs of night-socks, six flannel shirts, six flannel bands, three dozen small, soft, linen diapers, three dozen larger, cotton ones, at least two little knitted sacks. The following description of a crocheted baby-band is taken from " Babyhood," vol. iii. page 33 : Single zephyr in ridge stitch, — that is, half stitch, in which, going back and forth, only the back half of the stitches in the lower row are picked up. Eegin on a chain of fifty and crochet forty-eight ridges, hence ninety-six rows, Join by a row of plain stitches, and at top by a picot edging (five chains and a tight stitch back into the first). To prevent chafing and excoriation of the infant skin, many mothers employ some favorite dusting-powder, and others who are very fond of the perfume of violet, have used powdered orris-root, and, as we have had occasion to remark, some of the finest babies we have ever seen were not powdered at all, but anointed with simple ointment. It is of the greatest importance that the mother Fig. 8. prepare not only the clothing for the child and articles intended for herself, but also that she prepare herself to nurse the child. We have described the care of the nipple, and this should be persistently kept up until the day of confinement. A nipple-shield (Fig. 8) should be included in her outfit, and if there has been trouble in drawing out the nipple, the simplest form of breast-pump should also be at Nipple- shield. hand. Unless she be the victim of some infection, she should have no other idea but that of nursing the child. She will remember that while a substance resem- bling milk may be present in the breast for some months prior 56 MOTHER AND CHILD. to the birth of the child, yet the formation of fully-formed milk will not take place until several days after confinement, and that fully-established lactation is a portion of the process of childbirth. CHAPTEE XIX. LABOR. A brief description of what is meant by normal labor may be of service to the patient in understanding the preparations to be made for it and the care to be given her during that time. Labor may be divided into three stages or divisions. The first of these is the period occupied in the gradual open- ing of the womb, and is a preparatory stage to the expulsion of the child. This stage lasts in first confinements a number of hours, varying greatly with the individual case. It is, as a rule, shorter in repeated confinements, and also attended with less pain. The pain which is present during this stage is gen- erally characterized as grinding, or bearing down, oftentimes commencing in the back and extending downward over the abdomen. It is most annoying and difficult to endure, as the patient cannot appreciate that progress is making, and realizes only what seems to be useless suffering. When, however, the womb is open, ready for the expulsion of the child, the membranes in which the child is contained rupture, there is an escape of fluid, and the birth of the child begins. This is a comparatively short interval in normal cases, compared with the first stage, and is usually completed under the care of a physician, and oftentimes w T ith the use of anaes- thetics. After the birth of the child, the after-birth or placenta still remains, and is expelled after a brief interval resembling the first period. It is of especial interest to know the symptoms which indi- cate that labor has actually begun. For some days before, the LABOR. 57 patient frequently suffers from pain in the back and in the thighs, from a feeling of weight or heaviness about the lower portion of the body, and is often extremely uncomfortable. These pains may be worse at night, and become so severe that the physician may be sent for, under the impression that birth has actually commenced. Subsequently, however, such pains die away, and there is a gradual return to a condition of com- parative comfort. There is this difference between so-called false and true labor pains, that the false or fugitive pains are irregular, coming and then going, and diminishing instead of increasing in intensity, while true pains at the beginning of labor grow steadily stronger, and are located more and more in the abdomen. This will enable the patient to distinguish between these two classes of pains. During the first stage of labor, all that can be done for the patient is to place her in the most comfortable position pos- sible, to sustain her strength, and to assist her to have patience until the more active progress of labor begins. It is best for her not to lie down at once in first labor, but to continue in the erect or semi-erect position, walking about the room, sit- ting, standing, or kneeling, as may be most comforting to her- self. If the nurse be present, she will look after certain mat- ters of importance at this stage. If the woman be without a nurse, she will do well to see that everything is in readiness, and also, if possible, to secure a movement of the bowels, and to see that water is passed freely. In women in repeated labors, who have borne many children, the first stage may be so short that the patient has to lie down at once, and if her labor come on suddenly when she is alone, it is not safe for her to continue upon her feet, as the danger is that the labor will be too rapid for the mother, and the child be injured (Fig. 9). She should lie down at once, preferably upon her left side, and remain as quietly as possible until assistance arrives. The second and third stages of labor are almost invariably conducted by some competent physician, but occasionally it happens, especially in strong and healthy women who have 58 MOTHER AND CHILD. borne children repeatedly, that labor may be' completed so quickly that assistance does not arrive until all is over. A neighbor or friend can always be summoned, and with such assistance — so perfect are the provisions of nature — it is quite possible for a woman to have a perfectly successful labor with- out skilled service. It is well for whoever is with her to see Fig. 9. Patient's Bed, prepared for Labor.— a, folded sheet; b, c, sheet and rubber sheet, which are removed with a, when soiled during labor; d, clean sheet, on which patient lies after labor. that during the birth of the child she lies upon the left side, with the thighs bent up towards the abdomen. The person who helps her should wash her hands carefully, and as the head of the child is born should endeavor to support it, press- ing it gently upward between the thighs towards the mother's abdomen. When the child is born, the cord should be grasped between the thumb and finger, when it will be felt to pul- sate, and when this beating ceases, it should be tied firmly with a bit of strong thread, three fingers'-breadth from the child's navel. It should be tied a second time, half an inch nearer the mother than the first tie, and cut between the two threads. The mother should then be kept perfectly quiet while her helper may place her hand over the abdomen and make gentle pressure. After a few moments, pains resembling LABOR. 59 those experienced during the birth of the child will return, and the after-birth will be expelled. The assistant should be very careful that she does not break the afier-birth, but as she lifts it away it should be received very carefully in both hands and removed. The. patient can then be bathed with warm water and soap and left quietly in bed, a clean towel and folded sheet (Fig. 10) having been placed beneath her. Should flooding come on after the birth of the child, the pa- tient's assistant should place the hand upon the abdomen and rub it gently but rapidly. She will then feel the enlarged womb Fig. 10. Bed after Labor,— soiled linen removed and patient's bandage and napkin ready for use.— a, 6, napkin ; c, binder. like a hard ball, the size of the baby's head, just beneath her hand. So long as thi3 ball remains hard, there is not much dan- ger of severe bleeding. When it becomes large and soft, then the rubbing should be repeated until contraction recurs. These simple directions may prove of value in case a physician or experienced nurse cannot be obtained, but it must be distinctly understood that the conduct of labor is a matter requiring the greatest skill and wisdom, and should never be undertaken without the supervision of an intelligent physician. Even if the labor have proceeded normally without assistance, a doctor 60 MOTHER AND CHILD. should be summoned as soon as possible, and should be asked to examine the patient thoroughly, as some injury may have happened, or some complication resulted which makes his ser- vices of the greatest importance, even although the child has been born. But returning to the care of the patient during her labor when she has the advantage of the assistance of a physician and nurse, it must be remembered that the process is one which taxes her strength severely, and that she needs all which can support and sustain. While a large quantity of food cannot be advantageously taken at any one time, yet nourishment in the form of broth, milk, egg beaten up with wine, cocoa, and any easily-digested article of food is much needed if the case be prolonged. Occasionally, stimulation is required, but that should be limited to tea or coffee, except by the doctor's orders. There. is danger of the patient taking cold if care be not exer- cised to keep her room warm enough, and to look carefully after her clothing. The directions which have been given already to the patient without assistance, will be carried out, of course, by the nurse. CHAPTER XX. PUERPERAL FEVER. The care of the patient during the latter part of labor, and afterwards, cannot be intelligently understood unless something be said regarding what is meant by blood-poisoning, puerperal fever, and antisepsis. It is within the present century that the two prominent teachers of obstetrics in the city of Phila- delphia declared that puerperal fever was in no way caused by the physician or nurse, but was entirely beyond their control. Puerperal fever, they taught, occurred as typhoid, malaria, rheumatism, and other diseases which were not contagious, PUERPERAL FEVER. 61 but depended upon some unknown condition of the atmos- phere or the influence of the soil for their existence. Mean- while, in Austria, the discovery had been made that puerperal fever generally resulted when the physician had been dissect- ing or making a post-mortem examination, and then immedi- ately attended an obstetric case. When disinfectants were used by such a physician, and especially when his hands were carefully scrubbed and then disinfected, his patients escaped puerperal fever. One of the brightest honors of the many which Oliver Wendell Holmes has won is the fact that at this time, and while he stood practically alone in the American profession in his opinions upon this point, he answered in a most trenchant article the teachings of the Philadelphia pro- fessors to whom allusion has been made, proving that they were wrong, and asserting positively that the Austrian discov- eries were correct, and that puerperal fever was contagious, or, according to a popular phrase, " catching." We think com- monty of Dr. Holmes as a poet, a wit, a literary man, but the services which he rendered in urging the truth regarding this matter upon the profession in his country, and the number of lives which have been saved by the knowledge of the true nature of puerperal fever, can never be appreciated. At the present day, we know positively, as far as any knowl- edge is obtainable by human beings, that puerperal fever is caused by a living ferment, and that in the vast majority of cases some one who touches the patient, usually the doctor or nurse, gives her puerperal fever. It is at once apparent that certain strenuous precautions are imperative upon those who attend such patients. Clean hands, clean instruments and ap- pliances, clean bedding about the patient, scrupulous cleanliness regarding herself, and, as an additional safeguard, the use of certain chemicals to cleanse the hands, instruments, and appli- ances which touch her, are what every woman has a right to demand in the present state of our knowledge. This recent knowledge should be of the greatest comfort and advantage to the woman who is about to become a mother. She has the 6 62 MOTHER AND CHILD. satisfaction of knowing that the most dreaded complication of maternity has been reduced to a minimum, and that where such intelligent care is given, her chances for safety and a good re- covery and the safety of her child are many times greater than in the last century. The fearful epidemics which at times de- stroyed large numbers of women are unknown in the practice of intelligent men. There still remain a number of physicians and nurses who have not informed themselves regarding the causes and prevention of puerperal fever, who do not know how to recognize some forms of this disease when they arise, and who cast doubts upon our knowledge regarding its origin and pre- vention. Such objections, however, are no more to be consid- ered in the discharge of duty towards patients or friends than are the theories of those who dispute the utility of vaccination or the fact that typhoid fever is caused by impure drinking- water. The living germs which cause puerperal fever have their most common production in the decomposition of the tissues or fluids of some animal. Hence it is extremely dangerous when the after-birth is not expelled, but remains in the womb, where it is liable to decompose. After it has been expelled it should be destroyed, if possible, by fire, or buried with lime. The lochial discharge is also liable to decompose, and hence the necessity for frequently changing the napkins used to re- ceive it, and for employing such napkins as have been pre- pared by antiseptics. Antiseptics are certain substances which have the property of destroying these living germs. Such are corrosive sublimate (bichloride of mercury) and carbolic acid. One of these is usually employed as an antiseptic or fer- ment-killer in caring for the patient during and after labor. The hands of the physician and nurse, as well as all instruments and appliances used, should be not only cleansed but also rendered free from ferments by the action of one of these substances, or heat. We know that equally powerful with chemical anti- septics is the action of a high degree of heat; hence a piece of cloth which has been thoroughly boiled cannot contain poison- FIRST FEW DAYS AFTER CONFINEMENT. 63 ous germs, and so it is comparatively easy to render clothing and bedding safe for use ; but the hands cannot be boiled, and there are certain appliances and instruments which are also damaged by heat, and so it is necessary not only to employ heat, but to make use of chemical antiseptics. The reason why we have urged that the napkins be burned and not used again is because they may not be thoroughly cleansed in washing, and when used a second time may retain decomposing material which is easily absorbed by the patient, causing puerperal fever, or blood-poisoning. We have taken the liberty of intro- ducing what may seem to be a purely scientific discussion as to the nature of puerperal fever, but we know from experience that the average woman of intelligence is not willing to accept a certain routine because her grandmother was cared for in that way, but that she is fully aware of the advance made by modern science in a general way, desires to profit by it, and is ready and anxious to co-operate with any sensible physician who will do her the justice which her intelligence deserves. CHAPTEE XXL FIRST FEW DAYS AFTER CONFINEMENT. The mother's first needs, after labor, will naturally be rest and quiet. It very often happens that the excessive exer- tion of labor and the perspiration which frequently accompa- nies it render the patient especially susceptible to cold, and hence the contact of the air after labor very often results in a slight chill. This is partly owing, also, to the nervous exhaus- tion and prostration from which the patient naturally suffers. It is of no importance, and should be treated by placing an extra blanket over the patient, or by giving a cup of hot tea, or some other acceptable hot drink. Jt cannot be too strongly insisted that the mother's greatest needs after confinement are 64 MOTHER AND CHILD. rest and quiet. The congratulations of friends, the idle curi- osity of those who are ready to intrude into a sick-room, should be warded off from the patient, and having been assured by the evidence of her own sight and touch that her child is living and safe, she should be given some slight nourishment or stim- ulant, as a cup of broth or of tea, or a glass of milk, and then allowed to go quietly to sleep. One of the great uses of the trained nurse in the sick-room is the somewhat disagreeable but necessary function of police, and in proportion as she is allowed to control the patient, in that proportion can the physi- cian's orders be intelligently carried out. In healthy women, a refreshing slumber of from two to four hours will follow delivery. This period gives the nurse ample opportunity to wash and dress the baby, and affords the child also an occasion for obtaining sleep. The mother's diet is not subject to the fear which formerly existed, that generous food produced puerperal fever or inflam- mations of some sort. It is the kind of food and the intervals at which it is given which occasion distress, and not the fact that the food is nutritious or abundant. For the first three or four days the most easily digested food is indicated; milk, broth, soups, milk-toast, soft-boiled eggs, koumiss, cocoa, and stewed fruits should be employed, the intervals of feeding being governed somewhat by the mother's desires. Nourish- ment, however, should be taken from four to six times in the twenty-four hours during the first three or four days. After this period, an abundant but easily -digested diet may be allowed, embracing any articles which agree with the patient. The old fear that acids and salads could not be taken is erroneous, as the acid is digested in the body, and the practical test of any article is not whether it is an acid or not, but whether it agrees or dis- agrees with the patient. Whatever agrees with her makes good milk for her child. The patient should be fed abundantly, and food may be taken in small quantities, if it be easily digested, as often as four or six times a day, although the mother may be up and about and able to resume her household duties. FIRST FEW DAYS AFTER CONFINEMENT. 65 After the third or fourth day, as we have already remarked, the patient's diet may be governed by her appetite. Certain sorts of food have been recommended as especially adapted to produce a now of healthy milk. Extract of malt tan be taken by many mothers with advantage. Young and tender sugar beets, it is said, may be eaten ; beer and porter seem, in some cases, to take a place which nothing else will fill. Milk as a beverage, foods made of milk, and cocoa are often suffi- cient; but the general principle that that which is best digested and the most thoroughly enjoyed is the best food \ery rarely leads us astray. So small a thing as the use of water as a beverage is sometimes overlooked in caring for such patients. At the third or fourth day the physician will usually prescribe a thorough laxative. After this time, the bowels should be moved by the simplest and mildest measures ; an injection of castor oil and soapsuds beaten up together and warmed, or of simple salt and water, the use of a gluten suppository, or a glycerin suppository, will generally be sufficient. Compound licorice powder, sold by druggists, will agree well with many patients, and some preparation of cascara sagrada is often effi- cient. It should be remembered that a dose of any laxative medicine which failed to produce an effect during pregnancy will often be sufficient to purge a patient violently after labor. Thus we recall a case where a woman who had taken very active cathartics during pregnancy urged her physician to give her a " strong pill," as she expressed it, the fourth day after labor. He could not yield to her request, but prescribed simple doses of licorice powder, which acted far too energetically for the patient's comfort. This difference is caused by the fact, already mentioned, that the enlarged womb, before confine- ment, presses upon the intestines, preventing their emptying. When the womb is emptied, after the delivery of the child, there is no obstruction then to movements of the bowels. The womb grows smaller after the expulsion of the child by process of contraction, which causes pain similar to that experi enced during labor. These are called afier-pains, and after the e 6* 6Q MOTHER AND CHILD. birth of the second or third child are frequently so severe as to keep the patient awake at night. A warm cloth or fomentation over the abdomen will often relieve them, and if not, a physician's prescription must be obtained. The diet of a mother after childbirth usually consists of ordinary sick-diet. The object of keeping a woman on diet of this kind is simply because she is in bed, her digestive system is rather weakened by the excessive strain, mental and other- wise, which she has gone through, with fatigue, and liquid nourishment can be given which is more readily digested and quickly absorbed than solid food. Doctors simply differ in their advice because patients differ in regard to their digestion. Sometimes a woman is ordered a mutton-chop, a bowl of thick gruel, or some milk-toast imme- diately after a confinement ; others, again, are allowed to get up before the ninth day. The family physician knows the peculiarities of his case, and is capable of judging what is best for his patient. Strong, healthy women can do many things that the frail and delicate cannot attempt. As the supply of milk contains so large a quantity of water (almost ninety parts in a hundred), a great deal of the food which the mother takes should be liquid to supply this demand. If a mother loses her baby in childbirth, and it is necessary to check the flow of milk, not only is it necessary to put bella- donna plasters on the breasts, but also to diminish the amount of fluid taken. If she wishes to increase the flow of milk, she should drink freely of milk, soups, water, and may also rub the breasts with some castor oil. it is probable that in this way the use of alcoholic stimulants, as beer and porter in large amounts, became fashionable for the purpose of increasing the milk- supply. Though excellent at times for delicate, worn-out women, we certainly would oppose their universal use. Alcohol rather lessens the milk-flow. FIRST FEW DAYS AFTER CONFINEMENT. 67 The preparations of malt are far more valuable, as they in- crease the appetite and aid digestion. There being a determination, of blood to the mammary glands during the secretion of milk, many substances may be carried along with it that should be thrown off in other ways ; thus, medicines are often secreted by the milk, and affect the child, that are intended to have a purgative action on the mother; a dose of castor oil will act sometimes in this way. Articles of diet also affect milk. We are all familiar with the garlic taste given to milk and retained in the butter, from cows turned out to grass in the spring-time. And, indeed, cases have occurred of acute poi- soning by milk from cows that have eaten largely of poisonous herbs in the pasture-field. Although a mixed diet, containing a free supply of vegetable food, also of animal food, of the cereals, together with a proper amount of fluid, is important for every nursing mother, there are certain times when additions should be made to one of these divisions of food to supply a demand ; thus, if a child is emaciating, does not seem to increase in weight, the free use of fats by the mother, as cod-liver oil, will soon be followed by an improvement in the health of her babe. If there is a ten- dency to rickets, the mother should eat more largely of prep- arations containing lime, such as oatmeal, cracked wheat, or even take lime itself. A woman who is fat and well nourished may have the poor- est kind of milk for her baby ; all the nourishment goes to herself, the milk probably being of a very thin, watery kind. Indeed, in the choice of a wet-nurse, it is often found that the lean but healthy woman gives the most and the best milk. Constipation resulting from torpidity of the liver, or over- feeding, will frequently affect the milk and cause it to disagree with the child. Not alone is milk altered in its nourishing qualities, or in its digestibility, by materials not belonging to it or entering into its composition, but we very frequently have 68 MOTHER AND CHILD. indigestion produced by milk«which has probably been changed in its characteristics by emotion, by strong nervous impressions due to worriment, fright, or the fatigues of society ; certainly, late dinner-parties, both from the character of the food and the late hour, would not be conducive to the production of nourishing milk. We have stated that regularity is the fundamental law to be observed by the nursing mother. DIET. The diet of the cursing woman should always be carefully regulated, for upon it greatly depends the amount and charac- ter of her milk. It is impossible to lay down any laws in regard to the kind of food she should have. Every sensible person knows what agrees with her and what does not ; little indiscretions may be pardoned when she alone has to suffer, but when indigestion means an infant with indi- gestion also, greater care should be observed. It is not the amount of food one takes, but the quantity one digests that should regulate the diet. Some people manage to live on much less than others be- cause the waste is less. A too generous meat diet, rich milk, cheese, and wines or beer will give the liver a heavy load to carry, and so-called biliousness will result. Therefore, a nursing woman should avoid this extreme. A too liberal diet of farinaceous food, potatoes, hot breads, oat- meal, etc., will produce flatulence and heart-burn. The diet, therefore, should be a mixed one, suited to the indi- vidual, to'the climate, to the amount of exercise she takes, and to her hereditary tendencies. A moderately rich milk, well- steamed rice, rare and juicy meats, tender fowls and game with fruits, light farinaceous and egg-puddings, well-made gruels, eggs, oysters, and fresh vegetables form the best dietary. But all fried dishes should be avoided. Her food should be most plentiful, palatable, of the most nourishing quality, and frequently taken. FIRST FEW DAYS AFTER CONFINEMENT. 69 Bread, butter, and milk should be used in large amounts. A cup of hot coffee or chocolate in the morning, hefore rising ; a substantial breakfast; the heaviest meal in the middle of the day; a light tea in the evening, with a bowl of gruel, such as oatmeal, the last thing upon retiring; a glass of milk just before or after each nursing, and possibly, if the patient feels much exhausted, malt extract will be of service. It is absolutely essential that the nursing woman should keep her bowels regular. The skin, kidneys, and bowels throw off poisonous matters, which, if not gotten rid of in the natural way, will find themselves in the milk. The organs of the body work as a co-operative association, and have a remarkable way of aiding one another. Should one organ become lazy or diseased, another will take its place. In this way the milk-glands, regardless of the welfare of the babe, will aid the kidneys, skin, or bowels. Much is written on the subject of water-drinking. Some are very decided in opposition to water at meals, others to water between meals, others to water at any time. Water is the great solvent for all those substances which are properly called the ashes of the economy. The main ingredient of all the secretions and excretions of the body is water. The water should be pure, fresh, and not iced, and a fair amount should be taken with each meal. Large amounts at meals will weaken the gastric juice and undoubtedly cause dyspepsia. But difficulty will just as readily attend the digestion of a meal which has not sufficient liquid with it to promote the secretion of the gastric juice. A glass of water the last thing at night, or upon rising a glass of warm milk or a cup of cafe au lait, a glass of water with a pinch of table salt before breakfast, will frequently overcome the most obstinate constipation if persevered with. It is neces- sary that the bowels should be daily moved; this may be accomplished by a free vegetable diet, the moderate use of fruits, exercise in the open air, and an occasional enema, if re- quired. 70 MOTHER AND CHILD. The use of purgatives should be confined to eascara cordial, compound licorice powder, a teaspoon ful at night, Husband's magnesia, or effervescing citrate. Great care should be taken by the mother that she does not take cold. It is well to have always a light shawl to throw over her while nursing her baby. tJHAPTEE XXII. MOTHER S RECOVERY. After lactation has become well established at the fourth or fifth day, the mother usually enters upon one of the most com- fortable periods of her physical existence. For the time being she is, in a large measure, free from the anxieties and cares of dail}' life ; the apprehension which she may have felt regarding the termination of her labor has given place to the joy and affection of maternity. If she is properly cared for, and is a healthy woman, she is generally extremely comfortable. The fatigue and soreness which follow labor have disappeared, her appetite rapidly returns, and is generally better than for weeks before her confinement. The companionship and care which she gives to her infant are a source of endless delight, and the affectionate solicitude of friends and relatives makes her the centre of all which is in the highest degree charming. It should be remembered, however, that while this period is one of repose, it is a time of the greatest activity in her physical organism. The balance between various functions of the body, which has been disturbed by the presence of the child in the womb, has been restored; the mother's blood, which was im- poverished by the nourishment given to the child, begins to make good its losses; disturbances of the nervous system and mental depression have passed away, and in many cases a new era of physical development begins. The womb, which has MOTHER'S RECOVERY. 71 been enlarged many times its usual size to contain the child, undergoes a process of becoming smaller, the successful com- pletion of which is of the greatest importance to the woman. The muscles of the abdomen, which have been stretched by the womb and its contents, must regain their former firmness and elasticity; this necessitates not only increased nutrition, but also increased absorption of portions of the enlarged womb. Hence it is that not only must the mother be fed, but those functions of the body which tend to remove material already used should be kept in full activity. The action of the skin should be maintained by daily bathing and massage ; the bowels, which generally have become distended through the pressure of the enlarged womb, should be thoroughly and regularly emptied. Sufficient fluid should be taken to assist the kidneys in their work, while fresh air in abundance should be given to the patient to replace the gases exhaled through the lungs. Sleep, the greatest promoter of nutrition, should be taken in abundance and with regularity, while the development and restoration of muscles over- distended or weak from lack of use may be encouraged by systematic massage. The patient must not exercise or assume the upright position for at least two weeks after the birth of her child, but passive exercise may be given by skilful massage after the first week of her lying-in period. This massage should begin with the arms and legs, the muscles being gently kneaded and the joints gently manipulated. The back may next be included, and gentle rubbing without severe kneading given to the chest and abdomen. This should be administered for fifteen minutes at first, increasing gradually until, at the third or fourth week after the birth of the child, the patient may enjoy three-quarters of an hour or even an hour of such treatment. Possibly no more important crisis occurs in the mother's life than her getting up after confinement. There are various well-settled traditions which govern the actions of the majority of women ; one is that the mothers nurse should remain in 72 MOTHER AND CHILD. all four weeks, hence the term " monthly nurse." Another belief is that at the tenth day, or after, the mother should sit up. Both traditions are the result of experience and observa- tion of a vast number of cases of confinement, but neither has the slightest value as a guide in any given single case. It would be just as rational to say that because one mother is fond of a certain article of diet, and does well on it while nursing her child, that therefore every mother should eat exactly that amount, and be expected to enjoy it, as it is to say that every mother needs the same repose after confinement. It is a ques- tion for the physician, and for him only, to decide. It makes no difference what the patient's mother or grandmother or ancestors have done, nor what her dearest friend, confined a few months before her, has done, nor what every woman re- garding whose confinement she has ever heard of has done. It is a question of careful study by the physician of the indi- vidual case. Women would be slow indeed, when reaching a certain age, to accept a costume exactly similar to that worn by every other woman at that age, and yet in a matter on which rests a mother's future health the endeavor is often made to enforce a uniform tradition. A woman who had borne a number of healthy children, and had retained her own beauty, health, and happiness, was asked the secret of her continued physical well-being. She replied. " For one thing, my mother never allows me to do anything for three months after the birth of a child. I get up when the doctor thinks best, and have no responsibility for at least three months." A woman after confinement was urged by her physician to remain recumbent two weeks ; being told by a friend, a woman of very different constitution and strength, that she had gotten up upon the tenth day, she hastily summoned her physician upon that day, with the remark that she could not remain recum- bent any longer. So great was her annoyance and restlessness that it was necessary to place her at once in a semi-recumbent posture upon a lounge, but the change in position marked a change in her progress towards recovery which, while it gave MOTHERS RECOVERY. 73 rise to no serious complications, yet made an evident difference in her subsequent strength. It occasionally happens that a physician has the courage of his convictions, and positively refuses to be responsible for a patient who sits up before his best judgment permits, but the subject is one upon which both physicians and patients can profit by education and mutual stud}'. It is quite true that the Indian squaw may drop out of the line of march of her tribe and, attended by one or two friends, crawl into a thicket and there be confined, and in two or three days rejoin her tribe at their next camp. It is also true that the healthy peasant woman of Europe, on the average, is able to leave the maternity hospital in which she has been con- fined on the tenth day thereafter, with a healthy baby in her arms. It is frequently observed that farmers' wives in America are often up upon the tenth day after confinement, but it is equally true that the more delicate inhabitants of towns and cities, especially women who have taken little exercise to de- velop their muscles, in whom the absurdities of fashion have dislocated the abdominal organs by tight lacing and weakened the patient's powers of recovery, are no more fit to get up the tenth day after confinement than they are fit to do the physical work of the squaw, the peasant woman, or the farmers wife. They are the women who make the practice for physi- cians whose specialty is the treatment of the diseases of women, and they are the mothers who fail not only to recover their own health, but to nourish their offspring. In this con- nection it must be understood that, if the mother be healthy, it is of the greatest importance that 3he nurse the child. One of the best ways of reducing the womb to its usual size is nursing the infant, and it is a happy sign for the American people that at the present day it is considered not only not a disgrace but also a source of gratification and pride if a mother is able to nurse her child. The subject has been thought of such importance as to be legislated upon by several European countries, and the better physical development of American women, resulting from the fact that exercise has become d 7 74 MOTHER AND CHILD. fashionable among the well-to-do, has resulted in furnishing mothers whose offspring not only profit by their better de- velopment, but can also be nursed by them up to a vigorous childhood. CHAPTEK XXIII. DIET AND LACTATION. It is often a matter of interest to know how healthy mother's milk may be recognized. Of course, the surest proof of the pudding is in the appearance and appetite of the one who eats, and a well-nourished baby cannot be such without good mother's milk. However, in appearance, poor mother's milk is very thin, bluish, or occasionally streaked with yellow or with red. A sore or cracked nipple may bleed when the child nurses, or a sore upon the nipple may form matter which dis- colors the milk. If the infant does not thrive, the physician can determine by suitable examination whether the mother's milk is normal or not, and his attention should always be called to any indigestion or lack of thriving on the part of the child. The marks of a well-fed baby are its plumpness, rosy color, good nature, easj T and lively movements, good appetite, and sound sleep. When any one of these characteristics is notably absent, there is something wrong which demands a careful investigation. The decision on the part of the mother that she cannot nurse her child should never be made without the physician's approval. In general it may be said that when the mother is affected by any serious disease, such as consump- tion, puerperal fever, typhoid fever, and other serious troubles, that then she should not nurse her infant, but the decision not to nurse the child should not be made because she may have a sore nipple, or the child may give her pain at first upon nursing, and least of all because she dislikes the trouble and exertion which the care of her infant causes. Sore nipples can DIET AND LACTATION. 75 almost always be cured by simple means which the doctor will direct. A child frequently gives the mother some pain upon beginning to nurse, seeming to bite the nipple, but this will grow less with time, and finally disappear; and when the mother realizes that a refusal to nurse her child means de- priving it of eight out of ten of its chances for life, she may well hesitate before taking, or desiring to take, this step. When a child gives evidence of hunger, as if the mother's nour- ishment was insufficient, other food may be added at the physi- cian's direction. The mother and nurse, however, must be sure first that the child is not thirsty, and the administration of water will easily settle this point. In the absence of a physi- cian, boiled milk and water, half and half, may be prepared, warmed to a blood heat, and fed to the child by a teaspoon or from a carefully-cleansed bottle to which is attached a simple rubber nipple. If the mother be travelling, and good milk cannot be obtained, condensed milk will often bridge over the difficulty until she can arrive where proper milk can be had, but the administration of anything but mother's milk to an infant is a matter so serious as to demand a physician's atten- tion. The selection of a wet-nurse is also a matter for the physi- cian only. It requires an experienced eye to detect in her marks of disease which might prove most injurious to the infant. The healthy wet-nurse is of course next best to the mother, but no task is more difficult than the selection of such a woman. Not only should she be of about the same age as the mother, her child of relatively the same age and devel- opment, her history give no evidence of disease or vice, but the physician himself must make a thorough examination to de- termine her physical fitness for this important trust. It occasionally happens that an excessive flow of milk threatens the mother with inflammation of the breast through engorgement. This can usually be relieved by withdrawing, with a simple breast-pump, sufficient milk to relieve the dis- tention. The free administration of saline laxatives, giving 76 MOTHER AND CHILD. the mother a diet which contains but little fluid, and limiting her diet somewhat, will often aid in checking the excessive flow. The breast-bandage already described is of the greatest utility in such cases. A scanty supply of milk may be rein- forced by the careful selection of milk-producing articles of diet, as already described, by gentle rubbing, manipulation of the breast, and by perseverance in urging the child to nurse. Occasionally the infant will refuse the nipple ; if then it be ascertained that the nipple is naturally formed, is not sore, and that the child's mouth is not deformed, a little milk may be drawn by a breast-pump and the nipple wet with the milk. The child, when then applied, will often grasp the nipple and nurse eagerly. The most easy and rational way of determining whether the child can nurse or not consists in putting the finger in its mouth. It is very rare for a child to be so de- formed that the lips cannot grasp the nipple and make suction. Prematurely born and excessively weak children may fail from lack of muscular strength, but malformation is not common. Mothers frequently consult physicians for alleged tongue-tie in their infants. This, like deformity preventing nursing, is rare, and a little observation will generally convince the mother that the tongue can move freely. If the child can grasp the finger with the mouth, and the tongue can be felt applied upon the under surface of the finger, no serious tongue-tie exists. There are deformities in the upper jaw of the child, producing what is known as " cleft palate," which might cause difficulty in the child's nursing, but such de- formities could not be recognized without the assistance of the physician. PART II. CHILD BY J. M. KEATING, M.D., LL.D. 7* CHAPTEE XXIY. CARE OF NEW-BORN INFANT. It is not necessary to dwell very long on the care of the infant immediately after its birth ; that matter devolves entirely upon the doctor and the nurse. But there are a great many things that a mother should know about her infant, and these we will endeavor to explain as simply as pos- sible. The child is commonly received from the hands of the physi- cian in a soft, thick woollen blanket or cloth, which should be warmed before use. The child, when well wrapped, may be laid aside in a warm place until the mother's needs have been attended to. If the nurse have an opportunity, it is w T ell for her to anoint the child's body thoroughly with some simple ointment which will assist greatly in removing what is known as the vernix caseosa, a cheese-like substance which covers the skin. A misapprehension commonly exists that the new-born infant needs a plentiful supply of fresh air at once. Eespira- tion begins a very few moments after birth, but the child will obtain sufficient air if it be entirely but loosely wrapped in a coarsely-woven woollen blanket. The head may be covered without fear that the child will suffocate, for its lungs are but partially expanded, and its respiratory power is often not fully developed until some time after birth. It is important that the child be protected from draughts of cold air, and that its eyes be spared the irritation of strong light; hence the folly of keeping the child's head exposed so that it may breathe, and of carrying it to a door or window to look at it immediately after birth. Before giving the bath, its clothing should be selected and placed in front of the fire to become thoroughly warmed. In 79 80 MOTHER AND CHILD. large bedrooms a folding screen is of great service, and may be placed about the nurse and the basin or tub in which the child is bathed. It will thus protect the child from draughts and allow free ventilation for the mother. The temperature of the water should not be less than 100° F., and the soap used white Castile or spermaceti (Fig. 11). It should be remembered that two separate toilets of the child's body are to be made : that of the head and that of the trunk and extremities. Many toilet sets contain two washbowls and pitchers, large and small, and the smaller set is especially convenient to use in cleansing the child's face and head. It is important to do this separately, because poisonous material may be conveyed from the child's navel to the eyes or mouth. Accordingly, the head and face Fig. 11. iSsiiii^^i^ A convenient folding bath. The tub of heavy rubber cloth. should first be bathed, the head being well lathered with soap and' the eyes flushed out with a solution of boracic acid (ten grains to the ounce) ; this is easily done by using a medicine- dropper ; a bit of old handkerchief which has been carefully boiled may be dipped in the boracic solution, placed upon the tip of the little finger, and the child's mouth be thoroughly cleansed. The child may then be grasped with the palm of the left hand resting upon its back between the shoulders, the CARE OF NEW-BORN INFANT. 81 fingers grasping the trunk, while the thighs are taken in the right hand. It should be lowered gently into the water up to the neck, and thoroughly but quickly bathed with a soft, new sponge or wash-cloth. Many nurses prefer a bathing-apron, consisting of a large, full apron of white flannel. The apron is so large that, as the nurse sits beside the baby's tub, a portion of the apron lays over her left arm, and may be used as a towel when the child is received upon her lap. After the bath the child should be powdered or anointed with simple ointment, dressed, and laid in its bed to sleep. It is well to give to the child, after the first bath, a teaspoon ful of water which has been boiled and cooled, as it is not infrequently thirsty. An inquiry by anxious mothers and friends is often made as to how long the child can survive without nursing: it is even thought that within an hour after birth the child must obtain nourishment from the mother. It is well to put the child to the breast first when the mother wakes from her first nap. There is no danger in waiting for several hours until this rest has been obtained. The teas so frequently given new-born children by nurses are worse than useless, and should be posi- tively forbidden. If the child cries and frets, and no other cause can be found for its restlessness, it should be laid upon its stomach across the nurse's knee, and water as hot as can be taken may be given to the child in teaspoonfuls, and, in addition, a little peppermint and hot water. Cases are occa- sionally met with where nothing but a hot alcoholic stimulant seems efficient in controlling the spasmodic contractions of the intestines which cause what is known as "colic." Should the nipples be sore, nipple-shields should be employed. Of these the simplest are the best, as is true of all appliances and all articles to aid in the care of the child. The nipple should be bathed, after nursing, in a solution of boracic acid (ten grains to the ounce), to which has been added a little glycerin. The child's mouth should also be cleansed, after each nursing, with a bit of soft, old linen dipped in the boracic solution / 82 MOTHER AND CHILD. employed for the nipple, carried thoroughly but gently over the mouth, gums, and tongue by the little finger. The first meal which the child obtains is a partially-formed milk, which acts as a laxative. Soon after birth the child commonly has a bowel movement which is of a peculiar dark, tarry color, and is called meconium. It sometimes resembles burnt molasses. The child should have several evacuations of this substance during the first day of its life, and colostrum, or material first obtained from the breast, is especially adapted to secure this result. Should this fail, a simple laxative may be necessary, such as a teaspoonful of syrup, or a little castor oil ; but none should be given without the doctor's order. The child, at birth, is covered with a waxy material, differing more or less in amount in different cases. It is said that in children who have very delicate skins the amount of this ma- terial is often greater than otherwise. As it occupies every portion of the body, and can be removed by greasing the surface, the new-born child should be thor- oughly anointed with either washed lard or vaseline, and then, with a soft sponge, tepid water, and a little Castile soap, given a superficial cleansing to remove as much as possible of the material. Unfortunately, many nurses believe that it is neces- sary that the babe should be made thoroughly clean at its first washing, and the poor little thing is rubbed and scrubbed in a most merciless manner. If the birth has been a hard one, or the little one is feeble, it would be far better to postpone the thorough washing till the next day. The eyes, mouth, ears, and nostrils — in fact, all of the mucous surfaces — should be carefully washed with clean warm water applied by means of a clean sponge or piece of old linen. This should be done after the cord has been severed. In- deed, it is now customary among many obstetricians to wash carefully the child's eyes the moment its head is born. Usually the child's mouth, at birth, is full of a thick, viscid mucus, and its first cry will cause it to inspire this. As soon CARE OF NEW-BORN INFANT. 83 as possible it should be turned over on its stomach, the head somewhat lowered, and the mouth thoroughly cleansed with a soft, wet rag. The cord, which is the attachment between the child and the after-birth, contains the blood-vessels embedded in a gelat- inous material more or less thick. As soon as the child is born and takes its first breath, the circulation in the blood- vessels of the cord gradually ceases. It is not at all necessary that the cord of the child should oe cut immediately after birth, nor should it be done until breathing has been fully established. The cord is usually grasped by the hands, and the jelly-like material within it squeezed with the fingers towards the mother ; in this way com- pression of the blood-vessels takes place. A ligature is placed tightly around it, about three inches from the child's surface, and another one about three inches from that towards the maternal parts ; it is then cut with scissors between the two. After the child has received its first wash- ing, the navel-string should be enveloped in a mass of sub- limated absorbent cotton, folded up in a piece of linen, laid to one side, and then the child's binder placed about it. The object of this binder is simply to give warmth and sup- port the cord. Undoubtedly, if the navel-string were allowed to hang, be caught in the clothing, or be pulled about as the child receives its daily washing, a rupture might take place. Undue stress has been laid upon the value of a binder to prevent rupture, and not half sufficient importance given to the binder as a protector in our changeable, treacherous climate. But it should be remembered that a misapplied binder is worse than none at all. It will, if applied tightly, produce rupture, undoubtedly, and will interfere with the intestines. We recall a case we once had : the babe screamed for hours, and the mother and nurse were almost distracted, but failed to find the cause. Upon being called, we found a tight belly-band which was acting like a vice around a flatulent belly. 84 MOTHER AND CHILD. Many physicians do not approve of a binder for either mother or child, and we must confess that if they are to be misapplied, we, also, would like to see them discarded altogether. There should always be ample room for the hand to be run between the binder and the skin, and the material used should always be soft and very elastic (Fig. 12). ■ While the child is being washed and dressed it is well to secure deep and full respira- tions. It is said by old nurses that a crying child at birth has stronger lungs afterwards. If, also, it is turned over on its stomach, with head lower than the rest of its body dur- ing the process of washing, the mucus will not be drawn in during inspiration, and a healthy inflation of the lungs will take place. As soon as possible the mother and child should get some sleep. After several hours' sleep the child can be again washed, if necessary, or sponged off; and this time it should be much more thoroughly done. The circulation wall be more thoroughly established, and the skin will assume the delicate, soft, red appearance of health. Extended experience has convinced us that for the first few days a little vaseline or cocoa-butter is better to use on the child after its bath than the dry powders heretofore in vogue. It needs but very slight greasing of the surface to make the skin soft and pliable and to prevent eruptions ; and when it becomes necessary to use a powder for dusting to prevent chafing, the non-scented talcum is decidedly the best ; indeed, the only kind to use. Child wearing knit binder. CHILD'S NAVEL. 85 The child's clothing should have two important qualifica- tions : it should be warm and absolutely loose over all parts of the body. After the child has had its first nap, attention should be paid to its secretions. If the bowels have been moved, use vaseline instead of water for its washing ; if it has not passed its water, call the doctor's attention to it at his next visit : this is an im- portant matter. CHAPTEE XXY. CHILD'S NAVEL — APPLICATION TO THE BREAST — WET-NURSES. In the care of the child, and closely associated with what we have described under the head of antiseptic precautions for the mother, is the care of the child's umbilicus. As a rule, when the umbilical cord is cut, a stump or remnant from two to three inches long is left, requiring attention for from five to ten days. The dropping off of this cord usually occurs, by process of drying, between the fourth and sixth day. The umbilicus is left oftentimes in a state of soreness which requires atten- tion. This sore may be contaminated by septic poison just as any wound upon the mother maybe found infected, and hence it should be dressed with some antiseptic dressing. The better way is to buy at the druggist's some antiseptic gauze, satu- rated with bichloride of mercury or boracic acid. Cotton im- pregnated with these substances is often preferable. At each dressing of the child, the stump of the umbilical cord should be carefully enveloped in such gauze or cotton, laid upon the child's left side, and over it should be placed a knit abdominal band or flannel binder. This has already been described, and need not be repeated here. At the time of bathing, the cotton should be cautiously removed and replaced. Care should be taken not to make traction upon the cord, and in a few days it will have loosened and come away. 86 MOTHER AND CHILD. After the expulsion of the meconium, — the burnt-molasses- like substance, to which reference has been made, — the healthy child has usually two to four stools in the twenty-four hours. They should be bright yellow in color, in consistence varying from thinly-boiled to semi-solid corn-meal mush. The functions of the kidneys are also early established in the child, and the diaper will require changing a number of times during the first and second days. The urine is often almost free from color, and hence the delusion which exists in the minds of many mothers and nurses, that this urine does not contain the usual substances in solution, and that the diaper wet with it does not require washing, but simply drying before being used again. Nothing can excuse the uncleanliness and filth of such a practice, and the child's diaper from its first hours of life should not be worn a second time unless it has been thoroughly washed and dried. It is possible that some cheap absorbent paper may be found which can be used for this purpose, and can be burned when soiled. If the child does not pass urine freely, simple means may be taken to secure its expulsion : placing the child in a warm bath ; laying upon the abdomen a flannel wrung out in hot water and sprinkled with a few drops of spirits of turpentine ; holding the child with its naked back exposed to the heat of an open fire or stove, so that decided warmth shall be felt. All of these expedients are harmless and in mild cases often efficient. A half- teas poonful of sweet spirits of nitre in a little warm water will often bring about the desired result. It will be noted that the navel-string will come away in four or five days without any offensive odor whatever. The above method of dressing the cord is a convenient one, as it does not require to be touched after its first arrangement. The navel should be kept absolutely dry, not the least grease being used near it; in this way there will be no odor and the remains of the cord will dry up and fall off. Should any odor be perceptible, the part can be dusted with boric acid or with a powder containing one-half boric acid and one-half talc. CHILD'S NAVEL. 87 As a rule, there is very little trouble from the navel, though possibly at times, if the child should become constipated, or have a severe cough, great straining may take place, when bulging or rupture ensues. This can be readily obviated by placing a small pad beneath the binder, not exerting great pressure ; indeed, a binder which is too tight is more apt to cause a rupture than none at all. Should there be any discharge from the navel, the nurse should make a careful examination of it when the child is being washed, and if a small ulceration is found, as is sometimes the ease, it can be dusted with boric acid, and if the little red pro- jection still remains, and there should be no doctor to call upon, it can be touched with bluest one and then dressed with ben- zoated oxide of zinc ointment. It makes very little difference on which side the child lies after its birth. It is scarcely necessary to dwell to any great length upon the appearance of a healthy child at its birth. The soft, peach-like character of its skin, the constant ten- dency to sleep, which is uninterrupted and quiet, associated with an air of repose, are well-known evidences of health. It is not necessary to dwell at length on the fact that the child at this age is a noted creature of habit ; indeed, as we come to consider infants as they grow, and to study the many causes for that most distressing state of affairs, sleeplessness of infants, we can trace it back, I can almost say in one-half of the cases, to the unfortunate indiscretion in humoring the child when it is not more than a few weeks old. The young mother feels that the cry of her child must naturally come from hunger; but as nature has failed to supply constant material for the fountain, she is often indiscreetly advised to substitute milk and water or a little catnip tea. Our own experience teaches us that this is wrong, and that the following procedure is the one to be recommended. After the mother has rested thoroughly the child should be placed to her breast. Some children will immediately go 88 MOTHER AND CHILD. to work, knowing exactly what they have to do ; others again may refuse absolutely to nurse. Those that seem to know all about it will find it hard at first to obtain any nourishment. After many attempts, and suc- ceeding only in extracting what is known as colostrum, a lax- ative secretion which precedes the milk-flow, they will from sheer exhaustion give up the attempt and fall asleep. Infants that refuse the breast cry and fret. To these it may be well to give a linen rag moistened in water to suck, or a little water with a spoon, and then at a regular definite in- terval, say an hour, place them once more to the breast until they become used to it. There is no danger, under any circumstances, of a child starving to death ; for several hours, at least, it can exist without food, and needs only a little water; and then, if it is placed during the next twenty-four hours, in daytime, every hour to the breast, and after that regularly every two hours, by the time the flow of milk is thoroughly established the child will have its little programme laid down for it, from which it must not deviate under any circumstances. If it becomes absolutely necessary to feed the child, condensed milk, one tea- spoonful to twelve or fifteen of boiled water, is to be preferred. Mothers and nurses should recognize the fact that the habits which a child acquires in its first few days of existence are very hard to break. If it be spoon-fed, it will be difficult to make it take the nipple ; if it be bottle-fed with rubber nipple, it will be difficult to get it to nurse its mother. Then, again, the taste of cow's milk, however carefully it be prepared so as to resemble breast milk, will often cause it to refuse to. nurse. Often the nipples are so tender or the suction will so affect the nursing woman as to restrain the milk-flow, and the child will nurse in vain, while the mother will suffer such torture that nursing will be abandoned and the child be hand-fed. A glass nipple-shield will frequently obviate the difficulties, or, by gentle pressure and coaxing, sufficient milk can be WET-NURSES. 89 taken from the mother to spoon-feed the babe until nursing can be gradually accomplished. We have been so much im pressed with the importance of a healthy mother nursing her child that we believe in temporizing as much as possible to secure this end. For about two or three weeks the child should be nursed every two hours day and night, and during the periods of intermission both the mother and child should sleep as much as possible. It is understood that the child should nurse at each breast alternately. This is an important matter, because a child would soon get accustomed to one breast and refuse the other, and this leads to incalculable suffering. After the child is nursed the nipple should be washe'd with a little plain water or soda, or borax and water, and greased with some vaseline. The flow of milk generally begins on the third day. This flow may come on suddenly. There seems to be a rush of milk to the breasts. Indeed, this is usually the way the milk comes at each nursing. Frequently the woman will have no evidence of milk what- ever, when, at the hour at which her child usually nurses, or even at emotion or thought of her child alone, the flow of milk will take place. This is especially the case with those who have had children before. These women sometimes make the very best wet-nurses. WET-NURSES. It sometimes, as we all know, becomes necessary to decide on very short notice the question of having a wet-nurse. We will not go deeply into this matter, because the circumstances of each case so group themselves as to bring the answer with- out consulting a book. The age of the child, the financial condition of the family, the residence, are all to b.e taken into consideration. The wet-nurse should, preferably, have had other children ; her child should be about the age of the one she is to nurse ; she should be a perfectly healthy woman ; her child should 8* 90 MOTHER AND CHILD. also be seen, be thoroughly examined, and should give all the evidences of perfect health. First of all, the family record should be investigated. Did her father, mother, sisters, or brothers die of consump- tion, cancer, scrofula? If she has had other children, were they strong and healthy ? Did they thrive upon her milk ? If they died, of what did they die ? The physical condition of a wet-nurse is as important, of course, as her family record. She should have no constitutional disease of any kind ; her lungs should be healthy; her skin should be clean, free from any eruption, or the remains of one ; her teeth should be good, which is an evidence of good digestion ; her eyes bright, her muscles firm and well formed ; she should have no loss of hair, sore throat, or chronic nasal catarrh, and her breasts should be well formed. Then comes the question of temper, and indeed, as regards this, it is as hard to get satisfactory testimony as it is for the physical condition. She should be pleasant in disposition, not stupid; energetic, willing, devoid of high temper, and possessed of those traits which will soon endear the child to her. Such a nurse would probably give about two quarts of milk in twenty-four hours. Of course, much of this examination is made by the family physician, who is the one to decide whether the nurse is suit- able or not ; but there are times in cases of emergency, when the mother, or monthly nurse, has to decide. On that account we have dwelt at length on this subject. The nurse's child should be plump, well formed, free from any eruption. Its odor should be sweet and fresh, not sour; should it vomit, the material should be simply the overloading of the stomach and not sour milk. A healthy baby will often take more than its stomach will hold, especially if the mother's milk is plentiful and flows freely. Having, then, decided upon the health of the wet-nurse and on the chances that her milk will be plentiful, she should be questioned carefully about her supply of milk. The question * WET-NURSES. 91 as to the employment of a wet-nurse is one with so many- phases that in a work of this sort it cannot be answered by "yes" or "no." Dr. A. Jacobi, writing of the diet of wet-nurses, expresses himself as follows : " Powerful salts are to be avoided under all circumstances, as well the salines as the more powerful drastics, likewise an injudicious use of table salt, ethereal oils, and strong condi- ments. Furthermore, everything is to be avoided, whether of substances taken into the stomach or improper habits, which have a tendency to derange or to weaken digestion and assimila- tion. Generally the wet-nurse looks upon her position as one would regard ' a land which flows with milk and honey,' and where 'roasted pigeons fly into the mouth,' — Canaan and America at once, — and where there is no end of things to eat until the appetite is satisfied or spoiled. Somewhat more of albuminous food is indicated than under ordinary circum- stances. Too much of this, or a diet composed exclusively of it, would destroy health and the milk-secreting power as well. Much fluid food and an abundance of water will increase the volume of the milk. Water and barley gruel act upon the milk as well by virtue of the water which they contain as by their nutritious qualities, and the same is true of tea in mod- erate quantities. Potatoes, in large quantity, and other carbo- hydrates are to be avoided as a principal means of nourish- ment. Fat in moderate amount is desirable. In general it may be laid down as a fundamental principle that a wet-nurse will have the largest quantity and the best kind of milk when using the same nutriment to which she was accustomed before pregnancy, provided it kept her in good physical condition, with the addition of a certain quantity of albuminoids and plenty of fluid food. What the nursing woman spends in the shape of milk must be returned to her. Where we are dealing with small, atrophied breasts, and it is necessary to stimulate the secreting function, considerable time is required before a free and satisfactory flow of milk can be obtained. If 92 MOTHER' AND CHILD. we are looking simply to keeping up an abundant supply, carbo- hydrates may prove satisfactory. The most common question, however, is in regard to the improvement of the substance of the mammary glands themselves. It must not be forgotten that tissue-changes and good health do not depend alone upon what is eaten. A wet-nurse must not be thrown too suddenly upon conditions which are quite strange to her. She must live, as nearly as possible, in the manner to which she has been accustomed. A nurse who is removed from the hay-field or the kitchen-table to the boudoir of a lady, and who is held in re- straint from fear lest she might eat a raw apple, or drink a glass of beer, or meet her lover, or who is deprived of her cus- tomary physical exercise, will not remain healthy nor give a proper quality of milk. In accordance with these fundamental directions, the various articles must be criticised which have been recommended as proper means of nourishment and diet during the period of lactation. The list of such articles contains beer (?), buttermilk, milk, chocolate, thick soups, husked grains, oysters, crabs, sea-eel soup, etc. If all these dietetic means do not accomplish their end, one has to look around for therapeu- tic measures for the stimulation of the milk-secreting function, with more or less of reason and more or less of confidence." If the question be asked, Can a babe be brought up without the wet-nurse, depending upon the bottle alone ? we will say "yes;" but so careful must be this bringing up, so vigilant the nurse or care-taker, so conscientious, so scrupulous in attention to details, that one almost feels like saying that if a wet-nurse can be obtained who fulfils all the above require- ments, — who is healthy, docile, and of an affectionate dispo- sition, intelligent, and one especially who has lost her babe and takes the new one to her heart in its place, — secure her by all means. In times of illness, there are occasions when a wet- nurse seems to be, for a time at least, a necessity. One objection which is frequently raised by mothers is that they do not like to see their babe nursed by other women. This may be valid when the balance is equally divided between WET-NURSES. 93 the wet-nurse and the bottle, but where the babe is deli- cate, where a strong hereditary taint is present, and the chances for the child's future health would be made greater by the nourishment it would receive from a strong, healthy woman, this objection should have no weight whatever. The mother who really cares for the future of her offspring will cast aside such feelings and gladly see her child get a start in life that will enable it to compete with others in the struggle for existence. Indeed, the condition of her own baby will be evidence in itself. There are other matters to be taken into consideration. The nurse's child will have to be taken by some one who will give it care, so that her mind may be entirely relieved on that score, as anxiety and fretting may cause her to lose all her milk in a short time. It must be remembered that she comes from a class who, as a rule, are accustomed to much out-door life, very plain diet, and regular habits, and that a sudden change to a life of luxury, variety in cooking, and over-stimulating food is apt to bring about a condition of biliousness, laziness, and irritability of temper which is difficult indeed to regulate. We have frequently known the very best of wet-nurses, who have given satisfaction for a month or so, suddenly, without any apparent cause, lose all their milk, and in such cases the whole trouble of selection, together with the risk of getting a milk which disagrees with the child, has to be gone over. Indeed, if under such circumstances the woman proves herself to be reliable and affectionate, it is often far better to put the child upon the bottle and keep her as ordinary nurse. When the question comes up for decision between a wet- nurse and bottle-feeding, we should bear in mind that the child who is to be subject to city influences should be wet-nursed, especially during the hot summer months. We believe that bottle-feeding, which, as we shall see further on, requires the greatest amount of care and watchfulness, is successful in many cases, but the more we see of it the more we are satis- fied that every child, if possible, should receive breast-milk 94 MOTHER AND CHILD. until it is four months old; at least this is imperative for a city child. Of course, when a child is delicate, or where there is an in- herited taint in the family, such as consumption, or the family is known as a delicate one, wet-nursing becomes all the more important. The choice of the wet-nurse, when possible, should always be left to the family physician ; indeed, a doctor's examination of her milk and her baby should always be obtained. The system recently established at the nurses' directories in our large cities, of having certified wet-nurses, is a very valu- able step forward, and should be encouraged by the public. CHAPTEE XXYI. CARE OF THE BRAIN AND NERVOUS SYSTEM. So far as the child's mind is concerned, the fond delusion which mothers commonly cherish, that children perceive and recognize as soon as born, or soon after birth, must be disre- garded. It is probably not before the third or fourth month of infancy that the human being perceives. By this we mean that while rays of light may fall upon the child's eyes, and waves of sound may strike its ears, and sensations of cold or warmth or roughness or smoothness be excited in its skin, and while sound may be heard as a confused noise, yet the child has no idea as to the meaning, source, or character of these sen- sations. It seeks its mother as any other young animal seeks its natural source of food ; but perception, will, like or dislike, other than the animal desires for food, warmth, quiet, and muscular movements are undoubtedly absent. The child, then, should be treated as a precious but very prosaic little animal, and while imagination and affection may detect elo- CARE OF THE BRAIN AND NERVOUS SYSTEM. 95 quence in its cries for food, and rejoice in caresses which are largely involuntary, and sympathize with lamentations which contain no prophecy except a warning that the stomach is empty, all of these manifestations should be taken in the most matter-of-fact way. If a vase is to be made by a potter, the mass of clay is first prepared, and then the rude shape is turned upon the wheel. It is only by repeated applications of the hand and the potter's tools that a design becomes apparent and the shape takes meaning. The infant resembles at birth an organism whose general form is complete, whose design may easily be inferred, but which utterly lacks details and connected manifestations. It requires the many little touches given by the different sights, sounds, and impressions which the child receives to mould it into an intelligent being, and this process cannot be accomplished to any extent before the period which we have mentioned. This disquisition on mental philosophy is not introduced to rob the mother of delight in her offspring, but to allay her anxieties and enable her to lay aside worries which otherwise would injure herself and her child. If babies were exhibited more as kittens are,— as objects to be looked at, admired, but let alone except by the mother and nurse, — the babies would be more comfortable and their mothers likewise. If it be true that the child does not perceive until three or four months old, it is also true, however, that habits can be formed from the day of birth. It is therefore of the greatest impor- tance that quiet, regularity, and strict discipline should be the atmosphere of the child's first months of life; the object being to form a solid physical background for the development of its nervous system, this process should not be interrupted, and the greatest regularity, the kindest but most efficient care should be given not only that it be regularly fed, but that it be fully protected from useless disturbance. Any one who has watched in a public conveyance a fretting, restless baby trying to sleep, while an ignorant mother or the confusion about it prevented its slumber, will recognize a species of physical unhappiness which is very near frenzy. If the child must be taken in 96 MOTHER AND CHILD. public conveyances, it should be done in the most careful and judicious way. The introduction of sterilized milk has made it possible to take an infant upon a journey, maintaining the regularity of its hours of feeding with the utmost nicety. Possibly the time will come when the luxurious trains, which now offer the conveniences of a good hotel, will contain cars adapted for the transportation of women and infants, where sterilized milk can be easily warmed, where' a mother and her infant and nurse can occupy their own apartment, and the miseries of infant travel be almost removed. It is a familiar fact that a child no older than six months can travel with very little annoyance to itself and its attendants, if the prerequisites — warmth, quiet, food, and sleep — be scrupulously maintained. The very fact that the infant ordinarily notices its surround- ings very little, makes its transportation comparatively easy. There is no reason why these simple prerequisites should not be placed within the reach of the poor. In several countries of Europe nobility has interested itself in establishing depots where sterilized milk can be obtained at the lowest possible cost by peasant families. Similar movements are on foot in this country, and we trust that the time will soon arrive when sterilized milk, and any other food which science can prove to be essential for infants, may be obtainable at or near our great railway stations. Of course, a nursing child needs only its mother's food, but the mother should receive the same consid- eration as is shown the child, and thus her nourishment will remain uninjured by fatigue or deprivation. THE NURSING OF INFANTS. 97 CHAPTEE XXVII. THE NURSING OF INFANTS. We have elsewhere written 1 as follows, when on the subject of nursing : How much food does a babe require in twenty -four hours ? Much depends on the infant : if the bowels be normal and there is no evidence of indigestion, the breath sweet, and the child seems desirous for more after it has finished its bottle, there is no reason why it should not be satisfied. From birth until it is a month old a babe should be nursed every two hours ; it will take one ounce or a little less at each feeding. There is one matter of great importance, and that is, the child should be made to nurse from both breasts from its birth, alternating at each nursing. It is strange that an infant nearly always shows a prefer- ence for one breast, and there may be a struggle to conquer this ; nevertheless, the battle must be fought, or the neglected breast will give much trouble. Dr. Jacobi says, " The child ought to drink from the breast or the bottle until it has had enough. It takes twenty to twenty-five minutes to empty one or both breasts. After having nursed, the infant should be quiet, should play with its arms, should breathe somewhat more regularly than usual, or go to sleep. If it be not allowed to have absolute rest, if it be rocked, allowed to lie on its belly, or be carried around, lying face downward upon the hand of the person carrying it, vom- iting will be provoked. The facts which have been introduced show that nature requires play-room; even the most careful measurements may be incorrect." A child a month old should be nursed about ten times in 1 Annals of Hygiene, July 1, 1886. Kg 9 98 MOTHER AND CHILD. twenty-four hours, — every two hours during the day and three hours during the night; at each nursing it should take from two to three ounces of milk. At the age of three months it will probably nurse only about eight times, taking some six ounces at each feeding; at the end of six months it will take about eight ounces. We believe that the above represents about the amount of breast-milk that a very robust child would receive, though Dr. Rotch makes the estimate a little less. The child gets the same food as does an adult, — that is to say, the milk which forms its diet is composed of all the arti- cles of food that enter into the diet required by a human being. These may be divided into five classes : water, caseine (curds) or albuminoids, salts, which go to the formation of bones and secretions, fats and sugar, which are burned up to make ani- mal heat, and are also valuable in nutrition. Eighty-seven parts of a child's food is water, but then we know that seventy per cent, of the human body- weight is water. Mother's milk is a bland, watery substance, sweetish to the taste, and has the property of forming curds in flakes ; whereas the milk of the cow precipitates in heavy masses, as a rule, and is on that account difficult of digestion. A healthy infant, if properly instructed in the earlier hours of its life, will awaken with the regularity of clock-work and seek its meal every second hour. It should be placed at the breasts alternately, and after it has received its nourishment it will probably fall asleep, showing no evidence of indigestion or flatulence, so frequent in bottle-fed children. Babies are very apt to get into the bad habit of falling asleep after taking two or three mouthfuls. Should this habit be en- couraged, it will be very difficult to break. The child should be promptly awakened and made to continue the meal until it has taken a sufficient amount. At the third month a child should nurse about every three hours, or possibly, if it is a large child, craves food, and takes a great deal at once, every two hours during the day and at THE NURSING OF INFANTS. 99 longer intervals at night. If the mother has a very free flow of milk, — more, indeed, than she can possibly retain, — it is well for her to wear the ordinary disk or cracker-shaped nip- ple-glass during the daytime, with a towel pinned over it, which will absorb the surplus milk, and will prevent her being constantly wet and catching cold. As can be readily understood, the breasts of a nursing woman demand con- stant attention. The nipples being of various shapes, there is often a singular want of compatibility between them and the infant. Often a nipple will be so small that the child cannot grasp it readily, and in its great impatience it will fail to effect any suction whatever; then, again, the nipple will be too large a mouthful, and a free flow of milk will almost choke the child. These conditions can be regulated by the mother grasping the nipple between two fingers (index and second) of the unoccupied hand, and either making gentle pressure to increase the flow or restraining the current by slightly squeezing the nipple at its base. Some nipples are sunken in, and it is impossible to keep them sufficiently raised to allow the babe to grasp them or to prevent chafing and crack- ing at their base. It is wrong to attempt to harden them by astringents ; they should be kept clean, free from any acidity, dry, soft, and pliable. They should be sponged off with a weak solution of boric acid in water after each nursing, and then thoroughly dried and the base anointed with a non-irri- tating salve, — something that will not be disagreeable in taste or odor to the child. White vaseline or cocoa butter is as useful as anything ; the latter can be rubbed up with a little glycerin to make it softer, if necessary. There is an excel- lent old fashioned salve, known as "Pomade Divine," de- scribed in many old English books. It is made of wax, suet, herbs, etc., and no better ointment of a soothing, heal- ing character can be found. Many people keep it to put on bruises. Some mothers suffer the most intense agony, at first, when their babes nurse ; they become nervous, and the very thought 100 MOTHER AND CHILD. of it puts them into such a nervous state as either to entirely stop the milk-flow or certainly to make the milk disagree. When this is the case a glass shield with rubber nipple will be of service, for a few days at least, until they become accus- tomed to the suction. Breast-pumps should never be employed unless ordered by the doctor, and then only under the super- vision or direction of a trained nurse. What should be done if the breasts cake or become tense? If the flow comes very quickly this is apt to occur when the demand of the child is not equal to the supply. To prevent this, and to relieve it when it takes place, there is nothing better than gentle but firm stroking of the breasts from their margins towards the nipple. Hot lard is the best thing to use for this. Some nurses have a special knack of relieving engorged breasts in this way. The breasts should be sup- ported by a suspensory bandage : a soft towel, folded bias, passed beneath the breast and arm and tied behind the neck, or a silk handkerchief, is the best thing to use for this. Nursing women should be most careful not to get chilled; although possibly breast abscesses are more apt to follow sore nipples and bruises, they may result from cold, and are indeed most serious things. Sleep and exercise, ease of mind,— a contented disposition, — are of great importance to a nursing mother; fresh air and good food stimulate the appetite and make good milk. A daily sponging of the body, or a bath, makes the skin do its share of work and keeps the other organs in good working order also ; in a sleeping room, fresh air with- out draught is essential. If these things are necessary for the mother, they are equally, if not more, so for the wet-nurse, and the mother must see that they are attended to. Colic is so frequent in nursing as well as bottle-fed babes that it is not out of place to consider it here, though when writing on bottle-feeding we will dwell more at length upon it. What a mother wants to know is how to distinguish the various causes of colic, so that she may properly apply those domestic remedies that will relieve it. Frequently THE NURSING OF INFANTS. 101 a babe will be seized with severe pain at the first attempt to nurse; it will suddenly scream, draw its legs up, and re- fuse the breast. If this were due to flatulency, the belly would be round and tense. It is the result of what is called reflex action or stimulation transmitted from one set of nerves to another; the intestinal canal is set in motion and its nervous centres are stimulated by the act of sucking, just as the sight of food makes an animal's mouth water. There ought to be a rule that, whenever a babe screams suddenly, with evidence of acute pain, all its clothing should be re- moved to search for erring pins or too great pressure. Ear- ache is a frequent cause of acute pain in babes, and is often overlooked, but it is most common in infants of over three months, and it would be well for the mother to send for her doctor should the child not be relieved by the measures in- tended to check intestinal colic ; he may be able to locate the pain elsewhere and suggest appropriate measures. The presence of food in the stomach and intestines will often induce colic, until the digestive processes are fairly established. That is one reason why it is desirable to allow the child to nurse at regular intervals only, and to apply it early to the breast, while the mother's milk is scanty. The early secretion from the mother's breast has a somewhat laxative effect, and probably is intended to act as such in order to purge the babe's intestinal canal of the accumulations that have taken place during its foetal life. If the babe has colic following the first attempt at nursing, it is often advisa- ble to give it a teaspoonful of olive oil in a teaspoonful of warm liquid "soda mint" before nursing, and to draw from the mother the first secretions. Another cause of colic is overloading of the stomach and intestines. Some babes evince a greediness which is remarkable, or the flow of milk may be totally beyond their storage capacity, and from bulk alone promote pain. Again, fermentation may take place very rapidly. Some babes regurgitate the milk Yerv readily, and thus the bowels do not suffer from distention by the gases 9* 102 MOTHER AND CHILD. of decomposition. Mothers often complain of this and fail to see that it is nature's safety-valve ; indeed, it is only the excess of food that is got rid of in this way. A babe can digest only a certain amount and no more; the amount that can be digested differs with every infant. It is not the amount of food a babe takes into the stomachy but the amount it digests, that does it good: this must never be forgotten. One often sees a babe crying from colic, and the nurse or mother at- tempting in vain to soothe it by dancing it up and down or by singing a lullaby ! Imagine the torture to the poor little one from such a proceeding ! Unless a vent for the wind be found the crying will continue, and the wonder is that convulsions do not oftener occur. "When a child, then, has colic, do not nurse it ; unclothe it, give it a warm drink by the spoonful, — catnip tea, liquid soda mint (some advise gin and water, but, as a rule, we are opposed to any stimulants in such cases unless ordered by the doctor). Rub the abdomen very gently from right to left with some warm olive oil, or, what is still better, let the child lie face downward on the lap and gently rub its back with some warm liniment, or even the bare hand. If it still continues to cry, give an enema of a teaspoonful of tincture of assafoetida in two ounces of water, introduced very gently; and if the pain still continues after the enema has acted, put the feet in hot water, tested first by the mother's arm that it may not burn. Should this fail, send for the doctor. The strictest attention should be paid to the clothing of a babe ; not infrequently colic may be caused by cold, especially cold feet. Sometimes a babe will seize the breast with avidity, give a few attempts at sucking, apparently choke on the milk, and cry. This may be caused by cold in its head, the mucus stopping the nose so that it is impossible for it to breathe and suck at the same time. The doctor's attention should always be called to the babe's nose if it has sniffles, or if it breathes noisily or with difficulty, that he may use appropriate meas- uaes to clear out the nasal passages. The nurse should take care, when washing the child, and especially in cold weather, THE NURSING OF INFANTS. 103 that it be not in a draught. I have often seen a faithful nurse bathing a babe in a stifling hot nursery, near the fire probably, and the constant opening and shutting of an adjacent door supplying a direct draught to the child. In my experience, nasal catarrhs are. very common with infants. In choosing a wet-nurse it is, perhaps, better to select one who does not menstruate. Not that ordinarily normal men- struation will affect a nursing babe after it is three or four months old ; but excessive menstruation will act as a drain upon a woman and certainly affect her milk. Matrimonial in- tercourse need not, either, interfere with nursing, provided it is indulged in with caution and in moderation ; but great watchful- ness must be exercised over wet-nurses in this matter, coming as they frequently do from a class not over-particular in morals, unless one is fortunate enough to secure a married woman. Wet-nurses are liable to excesses, and these will have a very baneful effect upon a delicate child ; indeed, this and intem- perance is a risk always run. The child being healthy, it may be well to gradually enlarge its bill of fare as it grows older, in order to accustom it to a change in diet, or to prepare for any change that may become necessary. It has been said that a child digests bottle-food when it also takes breast-milk, and therefore that weaning should be a gradual process, — so gradual, indeed, as to take several months for its accomplish- ment. When it is deemed desirable to substitute it for breast- milk, the bottle should be given in the daytime, after the morning bath; or better still, if the nurse has the child, to give it the breast in daytime, so that the mother may get her night's rest. By this time the child takes, as we have noted, more food at each nursing and nurses less frequently, and now it may have the bottle at about ten or eleven o'clock at night, when the mother retires ; in this way she can nurse the child at the early morning hour, and thus avoid the exposure of getting up and preparing a bottle of food at that hour, if she takes charge of the child herself. 104 MOTHER AND CHILD. CHAPTEK XXYIII. BOTTLE-FEEDING. If we have impressed sufficiently upon the reader the impor- tance of care in the selection of a wet-nurse, we did not do so with the object of undervaluing the subject of bottle-feeding by contrast, although there is no question but that the valu- able suggestions, the outgrowth of careful study, that have been published by such writers as Leeds, Smith, Meigs, Jacobi, Eotch, and others in this country have impressed upon the community the fact that the raising of children by means of the bottle is by no means as difficult a matter as it was thought even ten years ago. They have all premised their teachings by impressing the fact that care is the primary step to suc- cess. If it is a difficult matter to keep a wet-nurse in order, it is no less difficult to give the requisite attention to each bottle. One bottle of tainted milk may be fatal to an infant, and though a mother or nurse may day after day watch with the most zealous care the preparation of the baby's food, the souring of the milk, its admixture with contaminated water, the change of pasture of the cow, may bring on an attack of diarrhoea or vomiting which would be uncontrollable. We wish, therefore, to impress upon all those who have anything to do with the bottle-feeding of children that a child, not exposed to the dangers of a large city in the summer-time, can be brought up on the bottle from the day of its birth and be free from disease, become strong and healthy, provided the same attention is given to it as would be given by a mother to her new- born nursing babe. At the same time, we believe that every mother should be impressed with the fact that no form of bottle-feeding, however perfect it may be, and however closely it may resemble breast-milk, can take the place of breast-milk for a child under three months of age. Breast- BOTTLE-FEEDING. 105 milk is the ideal infant's food, and if we dwell at length upon bottle-feeding, we do not for a moment wish it understood that we undervalue the milk of the mother or, next to it, that of a reliable wet-nurse. The first requisite for carrying out bottle-feeding with thor- oughness is that somebody should take charge of the child who has a special interest in it. If we are talking to a young mother whose milk has given out, or whom the family physician has advised to bottle-feed her child, then she is the one to undertake the work, and either to prepare each bottle or to superintend its preparation for a time at least. Possibly she has had a wet- nurse whose milk has gone, and it has been decided to use a bottle instead of procuring another. Then let that nurse undertake the duties. She has a special interest in the child who has drawn its nourishment from her breast. If not, then get some middle-aged woman, not too old or cranky, or over- burdened by previous experience, but never a small chit of a girl who would require a nurse to look after her. Strange to say, these latter are often engaged as child-nurses, and no won- der the doctors are kept busy. Choose a middle-aged woman, or a strong, healthy young woman of intelligence, — one who is bright, cheerful, satisfied. Make your pecuniary arrangements with her perfectly satisfactory, so that she has nothing what- ever on her mind. After you have tested her ability, give her your entire confidence ; let her see that she is trusted. It is well that the child and nurse should have a room to themselves near to the mother's bedroom, and this room should have in it two things of great importance : one, a small sick-room refrig- erator ; the other, a gas-lamp or something by which the milk or water can be readily heated. It is necessary to have a half- dozen nursing-bottles holding about eight ounces each. A child a month old will take not quite one-quarter of this at each nursing. At the age of six months it should take at one feed- ing about six ounces. As there is more danger of decomposi- tion from cow's milk, it is wiser to give an infant less bottle- than it would get breast-milk at the same age ; but as the 106 MOTHER AND CHILD. capacity of a babe's stomach is in proportion to the weight of the child, a feeble babe needs less food, but the intervals of its nursing may be made somewhat shorter ; an extra bottle may be given at night. Overfeeding is a great cause of diarrhoea. Most mothers overfeed their bottle-fed babies : it is a temptation hard to resist ; but the lesson is frequently a bitter one. It is far better to underfeed for a time, and let the doctor regulate the increasing diet, which he can gauge by the child's weight. A gain in weight and a healthy condition of the passages is the test of the amount of food a babe should receive. The average healthy babe may gain by proper food from a half to one ounce a day in weight for the first four or five months, and half that amount daily for the rest of the year. The question as to whether a woman becoming pregnant should continue to nurse her child is one to be left to the family physician to answer. The fresher the milk the more readily it will be digested ; indeed, we feel satisfied that the warm milk, just from the cow, is far more digestible than that which has been kept with every precaution for a few hours. There must be some change which milk undergoes, as it is noted by all observers that the milk when warm from the cow is but slightly acid, or neutral, by litmus paper, but after it has stood for a while it always shows a very decided acid change. Mother's milk is always slightly alkaline. The greater part of the secret of success in bottle-feeding is to have pure, fresh milk ; and we would say beforehand that if there is the least doubt of the character of the milk served, there should be no hesitation about putting the child at once upon condensed milk until this matter is thoroughly investi- gated ; though it must be remembered that the condensed milk must be either sterilized or treated with boiling water, as will be de- scribed later, just the same as would be cow's milk. Although one may be most careful in the selection of a milkman, in the city, yet the jolting that the milk gets in transit, the risk that is run from diseased cows, dirty cans, contaminated water in BOTTLE-FEEDING. 107 milk-houses, is by no means small, and especially during the heated season, when the child's intestinal tract is weakened. These causes of bad milk are followed by disease ; possibly this accounts for the fact that milk from the same dairy that has agreed perfectly during the spring months will sometimes disagree with the child in summer. So much attention has been paid to this matter recently that the public has become interested in the establishment of dairies where every precaution is taken to secure the very best of milk by legislative interference. The pasture and winter- feed- ing should be regulated ; the health of the cattle, the methods of preserving the milk, and its transportation looked after; the milk-inspectors should be on the alert to prevent the intro- duction of such substances as boracic acid or salicylic acid to preserve the milk. Great care should be taken in the selection of milk, and in its preservation, even after it has reached the house, until used. The milk should always be tested with litmus ; if it is alkaline, it has been made so by the addition of some preserva- tive. Cow's milk always presents to litmus paper more or less acid reaction, turning the litmus red. If there is the slightest suspicion that the milk has been watered, is not very fresh, or that it has been subjected to much jolting, our opinion is that it should be boiled at once and then put in a refrigerator, and warmed for each bottle. The boiling will destroy its fer- ments, and in that way diminish the chances for intestinal dis- turbances ; but boiling will not make milk sweet that has been turned or make fresh that which is stale. The propriety of obtaining milk from a single cow is one that has been frequently insisted upon, and if one is satisfied that such milk is obtained and is found to have agreed with the child, it may have many advantages ; but we think that the ordi- nary mixed milk from a dairy of common cattle will be less liable to daily changes ; it will maintain, as it were, an average. Not only should the milk be pure and sweet, but it should be free from all matters that carry disease with them. Our medical 108 MOTHER AND CHILD. literature contains very many authentic cases of scarlet fever, typhoid fever, and diphtheria which were undoubtedly carried from the dairy by means of the milk, the farmer's family suffering at the time from the disease in question. If, for instance, the water of the milk-house should be contaminated by an out- house well, and the washing of the pans convey these materials to the milk, the result, of course, would be apparent ; indeed, milk is undoubtedly frequently diluted, and the water will carry the germs with it. Milk also has the propensity of ab- sorbing odors and gases that probably contain the germs of disease. Milk also may contain the germs of disease affecting the cow herself: so we see that there is a great risk to be run, and be we ever so careful and watchful we can only avoid the most apparent evils, and will have to trust to Providence to save us from the others. If each householder was more particular about his milk, gave it the strictest watching, and if the laws in regard to that outrageous and most criminal proceeding, the adulteration or di- lution of milk, were rigidly enforced, dairymen would soon feel the importance of obtaining and sustaining a reputation for honesty. It is a very difficult matter to reach the legisla- tors of the land, those who make its laws ; but possibly, by placing these matters in a clear light before their wives, they will be made to see the criminality of adulteration of food when it becomes a matter of their own individual interest. We lay great stress upon this subject, because absolutely pure, fresh milk — that used immediately after milking — does not have to be sterilized or boiled, as it is free from germs of disease or fer- mentation. Sterilizing and boiling the milk implies that a doubt is cast upon its purity. A babe will not thrive as well upon boiled or overheated sterilized milk as it will upon the fresh article ; but unless a person has access to a cow and can milk it for each bottle (which is the thing to do, when possible), no danger of diarrhoea and indigestion should be incurred : the milk must be rendered sterile. Or if this be not convenient, the cow can be milked twice a dav, with the following precau- BOTTLE-FEEDING. 109 tions : The bag and teats must be thoroughly washed, and the cow then milked directly into a well-scoured jug or large bottle ; this should be corked at once and placed on ice, and a sufficient portion poured from it to make up each bottle. I dwell at some length upon the importance of considering step by step the preparation of a child's bottle, and this is done because it becomes a monotonous work, and unless the mother sees to it personally, the nurse, however devoted, may some time or other become a little careless, and the result may be the souring of the milk, formation of curd, and inflammation of the bowels, and its consequences. Dr. Parker recommends a pure gum nipple, with two holes as far apart as possible, as the best for the nursing-bottle, and in this connection makes the following remarks : " When there is only one hole, the infant, in nursing, compresses the nipple and sends the milk in a stream in such a manner as often to nearly strangle itself. Milk coming through one hole is not as comfortable as when it comes through two, and the effort of nursing becomes disagreeable and wearisome to the little feeder. The best way to nurse an infant is by holding it in the arms, and give it the bottle in the same position and at the same height as if it were really being nursed by its mother. When it has finished nursing, the bottle should be removed, emptied, and cleansed. Never should the bottle be left in the infant's care to use at will." We all acknowledge 1 that cow's milk has the following ad- vantages : it serves as the basis for the preparation of a milk resembling that of the mother; it contains all the ingredi- ents that are necessary for nutrition ; it is easy to obtain. Its disadvantages are : that the relative proportion existing be- tween its different constituents is not that found in mother's milk ; it contains a form of casein which forms hard curds ; this casein exists in larger amounts (at least twice as much) than in human milk. It is acid. 1 Dr. Keating 's paper, read before the Convention of State Boards of Health in May, 1886. 10 110 MOTHER AND CHILD. A certain time must elapse during which the milk undergoes, possibly, some alteration from exposure to the air, and is liable to be tainted with the germs which produce decomposition ; this, indeed, is the greatest objection to its use in our large cities. It is scarcely necessary to impress upon mothers the im- portance of always using clean nursing- bottles. Unless the following rules are strictly adhered to, there is no use of reading this book further. 1. Have a number of nursing -bottles, so that a perfectly clean one is always in use. 2. Keep the extra ones, after thorough washing in boiling suds and water, in your sterilizer or in a pan of boiled water, with a teaspoonful of borax and soda in each. 3. Use only plain black rubber nipples, have a number on hand, and treat the unused as you treat the bottles. 4. Never use nipples with tubes. CHAPTER XXIX. STERILIZING AND STERILIZERS. By sterilizing milk, water, or, in fact, any material, we mean destroying within it those germs which render it more or less noxious, and making it for a time thereafter an infertile soil for the growth of germs. This may be done (1) by boiling, (2) by more or less prolonged steaming, (3) by keeping the milk at about 155° F. for six minutes, (4) by the use of chemical agents. The latter would be as harmful to the babe as they would be to the germs. Every bottle given to a babe should go through one of these sterilizing processes. Moreover, all the ingredients of the bottle should be sterilized, and the food must be either prepared as needed or made up in bulk, and that drawn from as needed, provided that bulk is most jeal- ously guarded. The whole matter, indeed, would be simplified, STERILIZING AND STERILIZERS. Ill provided we could be certain that milk raised to a temperature of 212° F., was as nourishing as that which is raw, and pro- vided also that those ingredients which we are obliged to add to cow's milk were not altered by so high a temperature. We will deal with these methods in detail. 1. What are the advantages of boiling the milk ? As a sterilizer, boiling is certain ; there can be no question about it. The germs of typhoid fever die at a temperature of 132.8° F., but it takes a temperature of 212° F., a short time sustained, to completely destroy those of tubercular disease. Boiled milk will keep sweet, when exposed to the air, at least twenty-four hours. Boiling is most readily accomplished ; it needs only such kitchen apparatus as every household, however poor, has already. Boiled milk, in summer, will control diar- rhoea; in fact, one of the objections is that it is constipating ; but on the whole, taking everything into consideration, in emer- gencies, or when there is the least doubt about the character of the milk or the dairy it comes from, the advantages of boiling a child's milk in the preparation of its food are greater than the disadvantages. What are the disadvantages? The principal disadvantage, we are told, is that boiled milk is not as nutritious as raw milk ; but as the most eminent authori- ties have taken opposite sides in this matter, we can take whichever side is most convenient and most judicious at the time, and watch carefully those indications which point to gain or not in the child's weight and nutrition, and act accordingly. Dr. Eotch tells us that the investigations concerning the relative digestibility of raw milk and boiled milk are so con- trary in their results that he will not dwell upon them in his article. The principal disadvantages, in our opinion, are the tendency to constipation and the fact that the usefulness of lime-water and milk-sugar is in a measure destroyed by the high temperature. 2. What are the advantages of steam sterilizing? The gradual increase of temperature to the boiling-point by means of steam does not have the effect upon the milk of changing 112 MOTHER AND CHILD. its taste, or of rendering it so constipating. The milk thus prepared is claimed to be as thoroughly sterilized as when boiled in the ordinary way. It is claimed for this process that it has no outward effect upon the milk, leaving it appar- ently the same as if it had not been sterilized, but that the process is a most thorough one, and when the proper apparatus is used, is the simplest possible way of preparing child's milk. "We have strongly advocated this method ever since its suggestion by Dr. Soxhlet and the strong argu- ments used in its behalf by Dr. Caille, of New York, and we believe that the number of lives that have been saved by this measure is incalculable ; moreover, we felt certain that the purchase of a sterilizer, and the enthusiasm attached to a new thing, would stimulate mothers and others interested in infants to more care in the details of feeding and in the preparation of the milk. Many who would scorn the proposition of using boiled milk would jump for joy at the thought of a sterilizer instead of a farina boiler. This process applied to dispensary practice, as is the case already in some of the large cities, will save hundreds of babes who would otherwise succumb to tainted milk. Undoubtedly the best form of steam sterilizer is the Arnold, manufactured by Wilmot, Castle & Co., Eochester, New York (Figs. 13 and 14). In order to make this matter thoroughly understood we will quote at length from Dr. Walter Mendelson's article in "Baby- hood " upon the subject of the Arnold sterilizer. "Precautions. — The milk (or mixture of milk, water, cream, and sugar suitable to age of the child) should be prepared as early in the morning as possible, before the heat of the day has caused the bacteria to multiply. Enough should be made up for the whole twenty-four hours, by multiplying the amount to be used in each bottle by the number of bottles needed. In making the mixture use a pitcher previously cleaned with hot water and soda and by plenty of rubbing. Simple rinsing is Dot enough; so let the pitcher be sufficiently large to easily STERILIZING AND STERILIZERS. 113 admit the whole hand. Scrupulous cleanliness must be insisted on at every step. It is the indispensable element of success, for bacteria nourish in dirt. Fig. 13. " Bottles. — The bottles should be the plain, old-fashioned kind, without shoulders, and with a flat bottom, so that they may be stood upright. There is much complaint of the bottles cracking. h 10* 114 MOTHER AND CHILD. To avoid this, heat the sterilizer rather slowly at first, and when the bottles are taken out do not put them upon a cold marble wash-stand, or in the draught of a window-sill, but place them, rather, upon a wooden table to cool gradually. Bottles will last longer if annealed, which may be done by placing them in a large pan of cold water and gradually heating this to the boiling-point, and as gradually allowing it to cool again. They should be of such a size that when filled with the quantity needed, there will be at least two inches of space between the Fig. 14. surface of the milk and the lower end of the stopper, so as to prevent the latter being wet with milk. " Too much attention cannot be bestowed upon the care and cleaning of the bottles and nipples. New bottles should be thoroughly scoured with a hot solution of washing soda and a bottle-brush. If, by chance, milk has soured in a bottle, it should be well boiled in soda, then thoroughly rinsed, and set aside for several hours, filled with hot water to which a tea- spoonful of borax has been added. When the child has finished STERILIZING AND STERILIZERS. 115 nursing, the bottle should not be allowed to stand about with the remaining milk in it, but should at once be emptied, rinsed with hot water, and left filled with borax water till the time for final cleaning. " It is often quite difficult to thoroughly clean a bottle, es- pecially of the greasy rim that forms at the level of the milk. After trying many things, I have found that ' pearl ine' gives the best results. Use it with hot water and a bottle-brush. Fine specks, consisting probably of some crystalline compound of the milk sugar, are often found adhering with great tenacity to the inside of the bottle. Those that still remain after using the brush may safely be left. After cleaning and thoroughly rinsing in fresh water, the empty bottles should be put on some shelf, out of the way of. being splashed or soiled in any way. It is not necessary to keep them filled with water. In filling the bottles, always use a funnel — by preference a glass one — with a stem an inch and a half or two inches long. In this way you prevent the inside of the neck, the top, and the out- side of the bottle from being wet with milk, which might, later, prove a path along which germs from without might, travel downward into the milk. Should the bottle, after all, have become wet with milk, let a few drops of water run down the inside of the neck and over the top, to wash away that which may have lodged there. Never use the same bottle for more than one feeding. This is a cardinal rule, and I have known all the good effects of sterilizing to be done away with, and a child become very ill, from its having been disobeyed. " Stoppers. — The best stopper consists of a plug made of ordi- nary cotton batting (not necessarily absorbent cotton), folded into a pretty firm wad, and pushed down for half an inch or more into the neck of the bottle. Make sure that there is no milk about the mouth of the bottle when the plug is put in, and that the stopper is not wet with milk from shaking the bottle before being put into the sterilizer. The advantages of cotton stoppers are : that they are clean, — being always used new ; that they are cheap j and that they save labor by re- 116 MOTHER AND CHILD. quiring no washing, as rubber ones do. When the bottle is in the sterilizer they allow the heated vapors to escape, and when it is cooled again the outside air re-enters filtered of all germs by the cotton it has had to pass through. Eubber stoppers, with a hole for a glass plug, are not readily cleaned. Those with a notch in the side, as in Seibert's apparatus, are better. Only when bottles have to be kept a long time, as for sea- voyages, are rubber stoppers to be preferred to cotton ones. The cotton stopper must not be removed until the bottle is wanted for nursing, and it should then be withdrawn with a twisting motion that will carry all the fibres with it. " Nipples. — The plain conical, pure gum nipple, that has no constrictions in it, and can be easily turned inside out for cleaning, is the best. Nipples should be scrubbed clean like the bottles, and when not in use, kept in a glass of water, to which a teaspoonful of borax has been added." What are the disadvantages of the steam sterilizer? They are precisely the same as attend boiling. Lately, Professor Albert E. Leeds, of the Stevens Institute, Hoboken, in a paper in the American Journal of the Medical Sciences for June, 1891, has demonstrated the fact that, for all practical purposes in the feeding of infants, a temperature higher than 155° F. so changes the milk as to render some of its ingredients innutri- tious ; that the sugar is changed to a certain degree, and that the casein and fats are largely altered; that, in fact, milk raised to a temperature of 212° F. is not a nutritious form of food. Dr. E. P. Davis, of Philadelphia, as a joint writer of the same paper, taking his experience from hospitals and dispensary practice, confirms these statements, and claims that the steam sterilizing of milk forms a non-nutritious substance, which, though an admirable substitute for the tainted milk of the alleys in hot summer weather, is not to be recommended as a regular article of diet. Steam sterilizing also has the disadvantage that the lime- water cannot be put into the milk till it is cool ; nevertheless, as this whole matter is still under consideration, and as the weight STERILIZING AND STERILIZERS. 117 of experience seems still to be in favor of the sterilizer, our great test of its value is the condition of the child. If the infant thrives upon its bottles of steam-sterilized milk, that is all that is needed. 3. The marvels of modern surgery grew out of the germi- cidal action of antiseptics ; but when the excitement calmed down, cooler minds discovered that it was asepsis — cleanliness — that did the work. Just so I believe that in the majority of cases the milk can be rendered aseptic by care and good sense without prolonged steam sterilization. Fig. 15. i f8 Sterilizer Professor Leeds has recently demonstrated that a tempera- ture of 155° F., prolonged for six minutes, is amply sufficient, and that the whole mixture can be made without the danger of destroying the lime-water and other ingredients by over- heating. You can use for this purpose a sterilizer such as represented in Fig. 15, made by Blair Sons, Philadelphia. All the small bottles can be filled with the prepared mix- ture, — that is, milk, cream, lime-water, sugar of milk, — or a large stock bottle may be used, from which a bottle can be filled at 118 MOTHER AND CHILD. each nursing; for a cork, either a plug of cotton batting or a gum cover can be used ; the bottles should be surrounded entirely 'by water, — a thermometer hanging in the water somewhere, where it can be readily seen ; there is no necessity for a cover in this case. You now place the sterilizer on your nursery lamp, the oil stove, or the kitchen range, if necessary; but an oil stove or lamp is much better, as the flame can be regulated so that the temperature of 155° F. can be maintained for about six minutes. Immediately after the heating is over each bottle should be placed in a nursery refrigerator and warmed up as needed, the nipple taking the place of the cotton plug or rubber cover. What are the advantages of this process ? As will be readily seen, the principal advantages of this method are, that we have a sterilized milk about whose nutritive qualities there can be no question, and that the entire ingredients of a child's bottle can be sterilized. What are the disadvantages ? The disadvantages are, that if the milk should happen to be tuberculous, — and some lay great stress on the necessity for precaution in that regard, — the tem- perature is not high enough to kill its bacilli or spores, as it needs a somewhat prolonged temperature of 212° F. for that purpose. Again, it is by no means as simple as boiling or steam sterilizing, and requires more care and intelligence. It is prob- able also that the milk will not remain sterile for any length of time. It is a method which should only be used when the milk is intended to be given to the child within twenty-four hours. HOW TO PREPARE THE BOTTLE. 119 CHAPTEE XXX. HOW TO PREPARE THE BOTTLE FOR A HEALTHY BABE PROM BIRTH TO TWO OR THREE MONTHS OF AGE. One would imagine that nothing could be easier than to prepare a formula by which an exact imitation of mother's milk could be attained. We know the ingredients, and the question seems to be one of chemistry alone, — simply the pro- portions in which to mix them. And yet the matter is by no means settled to the satisfaction of the profession gen- erally. A few years ago it was practically guessed at, and the baby's bottle was never the same. To-day we are working it out on a scientific basis in the laboratory, and are now wait- ing for our chemists to settle amicably upon one formula, — not that we would always strictly adhere to it; change is a good thing for the digestion ; a little less cream to-day and a little more water if the child be fretful or constipated ; the omission of the lime-water if the child is very constipated, and the addition of cane-sugar instead of milk sugar, may now .and then be of advantage. We will endeavor to make the matter as clear as possible, and to give the formula for, and an account of, each method of preparation, so that a mother may so thoroughly understand the subject that she can change from one preparation to another if she finds it necessary, should there be no physician to consult. We now enter upon one of the most difficult subjects of our book; the reason of this being that it is a subject to which much attention is being paid at the present day, and the brightest talent of the profession is at work by careful study, in the nursery and in the laboratory, to get a perfect substitute for mother's milk. This has not yet been arrived at, though we can now produce a milk mixture which will 120 MOTHER AND CHILD. agree with the average healthy babe under the ordinary cir- cumstances of life. But when it comes to an unfortunate little one who has not been born with the traditional "silver spoon in its mouth," and who has to withstand the vitiated, devitalized air of a crowded, filthy city in summer-time, there can -be but one opinion, and that is, it should have a wet-nurse, we will give a variety of directions in regard to the prepara- tion of the bottle, because the digestion of infants is a complex matter and every babe is a law unto itself, and what agrees with one may not agree with another. Indeed, what agrees with a babe one week may not the next, and the doctor may find it necessary to frequently change the kind of food to suit the child's conditions. "We have known splendidly- formed, healthy children result from a prolonged use of con- densed milk, though we would never advise its use alone for any length of time ; again, we have known babes whose own mother's milk acted upon them like poison, and who never could nurse. Some most excellent ways of preparing a bottle have been recommended, but the methods are tedious and require great skill and patience and often certain apparatus that mothers cannot get, and therefore a simpler method, which may not be quite as good but almost so, has to be adopted. For instance, the word sterilize has a very formidable sound and seems wonderfully scientific, smacks of the laboratory, etc. It really means a destruction of the germs of fermentation and disease, and a temperature of 155° F. will do this, and if the air is excluded the milk will remain pure. But if the milk must be sterile, so must the water that is put into it, the cream, the sugar, the lime-water; the bottle must be clean also, and the nipple, and they must be kept so. Now, it is a difficult and very tedious matter to keep each of these articles sterile separately, and on that account the bottle of milk, when prepared for the babe, is sterilized in bulk, as we shall see later. It must be remembered that cold will not sterilize : it checks germ-growth and development; but once warm up the HOW TO PREPARE THE BOTTLE. 121 material and the germs return to life. Freezing will not kill the typhoid -fever germ : it will be preserved in ice, and when that ice melts it will regain its activity. So if you put milk on the ice you only put such germs as are in it to sleep, and when the bottle- is warmed or the heat of the child's stomach and intestines warms the milk, the germs of diarrhoea become very active. Cold milk keeps sweet because the germs of fermentation and putrefaction are made torpid ; that is why milk is put on the ice when fresh. Milk can be made sterile in the morning, and corked air-tight, and the great Pasteur has taught us that a plug of cotton batting as a cork is im- pervious to germs; indeed, it is the exclusion of germs, not air, that we want, and this milk (or prepared food) need not, if so kept, be sterilized again as each bottle for feeding is drawn off. But the cotton batting must have been previously laid for a few moments in the hot oven to sterilize it. There is very little trouble about rendering a babe's bottle of milk sterile ; every house has a stove or range, every kitchen has a wash-boiler, ordinary bottles are easily obtained, and a thermometer is not an expensive article ; these, with a few rubber thumb-stalls that will fit over the bottles, or some cot- ton batting, will complete all the requirements for the most perfect sterilization. Of this we will speak later; suffice it to say that no babe should be allowed to take a bottle of milk that is not sterilized. The following method of preparation of the bottle has been suggested by Dr. A. Y. Meigs, and though it is somewhat more complicated, makes a food much like mother's milk, according to Dr. Meigs's analyses: Order from a druggist a number of packages of sugar of milk, each containing seventeen and three-fourths drachms ; dissolve one of these packages in a pint of water each day. Take three tablespoonfuls of this sugar-water, two tablespoonfuls of ordinary cream, one tablespoonful of milk, two tablespoon- fuls of lime-water. Put in nursing-bottle, to be taken warm. , Dr. T. M. Eotch has modified this according to the careful F 11 122 MOTHER AND CHILD. studies of himself and Dr. Harrington, and gives us the follow- ing method. He concludes that there is too much lime-water in the above mixture ; that one-quarter of the amount would give sufficient alkaline reaction and make it more closely re- semble mother's milk, the proportions necessary being one- half ounce (a tablespoonful) to the half-pint of the mixture, or, in other words, one-sixteenth part of the whole. He has a measure made of tin or wood that will exactly hold three and three-eighths drachms of sugar of milk, and he advises the mother to buy the sugar of milk by the pound. It is well to prepare each morning, or morning and evening if fresh milk comes twice a day, sufficient food to last. Cream (twenty per cent, fat), one ounce and a half; Milk, one ounce ; Water, five ounces ; Milk-sugar, one measure. Mix. A glass graduate should be used for this purpose. This mixture should be introduced into a clean bottle by means of a funnel, so that the neck of the bottle be kept dry. The bottle is stoppered tightly with a cotton plug. After steaming for twenty minutes, remove the bottle and allow it to cool slightly, and then add half an ounce of lime-water. Place on ice. As lime-water figures so largely in the bottle-feeding of babes, we will here quote the method of its preparation from the United States Pharmacopoeia (sixth edition). LIQUOR CALCIS. It contains about .15 per cent, of hydrate of calcium. " Slake the lime by the gradual additions of six parts of water, then add thirty parts of water, and stir occasionally during half an hour. Allow the mixture to settle, decant the liquid, and throw it away. Then add to the residue three hun- dred parts of distilled water, stir well, wait a short time for HOW TO PREPARE THE BOTTLE. 123 the coarser particles to subside, and pour the liquid holding the undissolved lime in suspension into a glass-stoppered bottle. Pour off the clear liquid when wanted for use. When heated to boiling it becomes cloudy, and is then probably valueless" Remarks. — To make this matter clear and more practical we will suggest the following, based upon the above: Take a piece of clean unslaked lime about the size of a hen's egg, put it into a clean preserving jar, and add six tablespoonfuls or, if you have a graduated glass (this and a funnel you should by all means have), three ounces of water. This will effervesce slightly, and generally heat in so doing. In a few moments add thirty tablespoonfuls or fifteen ounces of water, and stir with a glass rod occasionally for half an hour. Now lei this mixture settle ; in the course of an hour or two decant the liquid and add to the lime in the bottom about one gallon of water that has been previously boiled and cooled. When this has settled so far as the larger particles of lime are con- cerned, pour it into a clean, glass-stoppered, gallon bottle, and keep in a moderately cool place while using. Mothers often want to know the apothecary's measurements : One drachm equals about sixty grains, — about sixty minims, about one hundred and twenty drops of alcohol (a little less of water), — and is represented by a teaspoon. One-half ounce equals four drachms, — two hundred and forty grains, two hundred and forty minims, four hundred and eighty drops, — and is represented by the tablespoon. Thirty-two tablespoonfuls liquid measure make about a pint, and though a pint is equivalent to a pound, a level tablespoon- ful of a light powder will be equal to only the half of a level tablespoonful of a liquid. This shows the great uncertainty attached to the use of spoons in measuring, and we hope the readers of this book will only use glass graduates in future. The milk from an ordinary dairy should be obtained as fresh as possible : mix together half a pint of this milk and half a 124 MOTHER AND CHILD. pint of pure water, and to this should be added about two hundred grains or two heaping teaspoonfuls of milk-sugar with four grains of bicarbonate of soda, after which two table- spoonfuls of cream should be stirred in, and it is ready for use, to be given by bottle or drinking-cup, at about the body tem- perature. We have here a mixture which, according to Leeds, closely resembles mother's milk. This should, of course, be rendered sterile. We have always, in practice, adhered to the rule that the nearer we could approach to nature's standard the more fortu- nate we would be in our results in baby-feeding. Thus, the fresher the milk the better; that directly from the cow the best of all; the less we altered it by cooking and extras the more easily assimilated it would be. The feeding of a healthy babe and that of a delicate one are matters totally different, and we are now considering the feeding of the healthy one. Moreover, we have always attempted the simplest measure first, and then gradually felt our way by changing the prepa- ration of the food until we succeeded in finding that which suited the individual case. On this account we have given a variety of suggestions, so that a doctor or a mother may never be at a loss what to "try next," for it is a question of trial, and he who has the most resources at his command makes the greatest success of it. Our first attempt at bottle-feeding, when we have to aban- don mother and wet-nurse, is to use fresh milk and scald it; order, for instance, a half-pint of medium (unskimmed) milk, and this is better obtained direct from the cow or dairy ; to this add two teaspoonfuls, heaping, of milk-sugar and two tablesjpoonfuls of lime-water, and then pour upon it a half-pint of boiling water. This is then tightly corked and kept on the ice, and a portion withdrawn for each bottle and the bottle immersed in hot water until the milk reaches about blood-heat (98° to 100° R). If it be possible to obtain the cow's milk oftener than twice a day, so much the better: it will make fresher food ; but it should be HOW TO PREPARE THE BOTTLE. 125 obtained twice, morning and evening, at least. A slight pinch of salt is a useful addition to this mixture. Dr. A. Jacobi dwells at length on the great importance of salt in the diet of the nursing mother, or in the bottle of a hand-fed infant. " The quantity of salt in woman's milk is influenced greatly by the direct addition of the same to the food. These facts are of great importance in the preparation of an artificial diet, whether of vegetables or of animal milk, designed for the human infant. The addition of salt is not only of great physiological importance, in the interest of tissue changes in general, but without such addition artificial diet is deprived, from the beginning, of the chemical mixture which renders it quite similar in this respect to the natural. An extremely im- portant fact is also this, that the addition of chloride of sodium [salt] delays and renders difficult the firm curdling of the milk by rennet. Thus, it ought to be added to cow's milk as a general rule, and to woman's milk when the large curds brought up by vomiting, or excavated by rectum, exhibit an undue amount of coagulation." Watch the passages; if they are curdled, and the child has colic, the food does not agree, and must be changed, as, if persisted in, it will set up a ca- tarrh and cause trouble. In this case we would try the fol- lowing : For new-born children, or those a month or two old, we may diminish the amount of casein and increase the amount of sugar by the following means: Take one ounce of ordinary milk and three ounces of water; add one ounce of ordinary cream and about a level teaspoonful and a half (eighty grains) of milk-sugar. Indeed, it is better to run the risk of making a mixture with too little casein than with too much, gradu- ally increasing the strength of the milk by diminishing the water. Or we may dilute the milk as follows : If to a mixture composed of one ounce of ordinary milk and three ounces of water we add one ounce of ordinary cream (about fourteen and a half per cent, of butter) and about eighty 11* 126 MOTHER AND CHILD. grains of sugar of milk (a level teaspoonful and a half), 1 we will get a result which closely resembles woman's milk, though containing less casein and more sugar than most authorities give as the result of their investigation. Still, for very young infants this is an advantage. As the babe grows older the amount of casein can be increased as follows : Take two ounces of ordinary fresh milk, add two ounces of water. Now add two tablespoonfuls of ordinary cream of good quality and a heaping teaspoonful (about one hundred grains) of milk-sugar. Cream itself contains about three per cent, of casein. But we have insisted that there must be a certain amount of lime added to the mixture, and for this purpose lime-water can be used, a tablespoonful to the bottle replacing one of water. As we bave before suggested, if there is the least doubt about the keeping of milk it should be im- mediately brought to a boil and then placed in the refrigerator, a certain amount being withdrawn and heated over for each bottle. Under no circumstances should a bottle of made food be heated again. — that is to say, what remains over after the child is nursed should be thrown away. It can readily be understood why this is the case when we consider that as the child draws milk from the bottle the air which replaces the milk is that exhaled by the child, and acts most quickly as a putrefacient. The milk should be given to the child at about the tempera- ture of the body or a little warmer, — that is to say, about as hot as can be borne in the mouth, — a temperature of 100° F. Each bottle should be tasted, to see that there is nothing wrong with it and also to see that it draws well through the nipple. A black rubber nipple is certainly the best to use, and there should be a number of them, so that a clean one which has 1 A silver teaspoon, such as is in ordinary use, when filled with sugar of milk and " levelled," will contain about fifty-seven grains ; a plated teaspoon con- tains about five grains less, — practically one drachm. A "heaping" silver teaspoon holds about one hundred and seventeen grains of sugar of milk, — practically two drachms. HO W TO PREPARE THE BOTTLE. 127 been well washed may be used each time. After a child has taken its bottle, if it is drowsy, it should be laid gently on its right side and allowed to sleep. The clothes should be thor- oughly loosened, and under no circumstances should it be allowed immediately after taking its food to be tossed or romped with, which, unfortunately, is a very common practice and always ends in indigestion. To some children lime-water seems to be objectionable, and on that account it may be necessary to neutralize the milk with another alkali ; and then, again, it would seem more con- venient and accurate to have the lime or soda, or whatever is used, and the sugar of milk, in a form that could be kept by mothers and readily introduced into the milk. For this pur- pose we suggested {Medical News, June 5, 1886) the following powder made into tablets, each one containing — Sugar of milk, 26 grains ; Calcis lactophos., £ grain ; Calcis carb., T ^ grain ; Sodii bicarb. , J grain ; Potass, bicarb., T \ grain ; Sodii chloridi, £ grain. These can be made up in large quantities, put in wide- mouthed bottles, and used as follows : To prepare the bottle for a child about a month old or younger, take one ounce of ordinary fresh milk, one ounce of ordinary fresh cream, three ounces of boiling water, and add three tablets and thoroughly dissolve. If curds appear in the passages, diminish the milk and add water in its place. It is not intended that this whole quantity should be fed to a babe ; a child at this age should not take more than two ounces at the most at each feeding. For a child two or three months old, prepare the bottle as follows : Take two ounces of good, fresh, ordinary milk, one ounce of fresh, ordinary cream, add to this two ounces of boiling water, and dissolve into the mixture four tablets. 128 MOTHER AND CHILD. The material can be put up in cans in powder form with a measure holding the quantity that would equal a tablet, and this used in the preparation of the bottle. It needs no addi- tional lime-water. CHAPTEK XXXI. HOW TO PREPARE THE BOTTLE FOR A DELICATE BABE FROM BIRTH TO THREE MONTHS OF AGE. In the last chapter we considered the various methods that might be adopted to prepare the food of a healthy new-born babe ; but enfeeblement of the digestive apparatus, otherwise dyspepsia, is so common in infants that we are often taxed to our wit's end when we are obliged to bottle-feed them. So far we have spoken entirely of cow's milk as a substitute for that of the breast; but, as has been heretofore noted, the tendency in cow's milk is to the formation of curds that are compact and indigestible, and, though this can be to a certain extent obviated by diluting the milk as recommended, there are times when, owing to the difficulty in obtaining the pure cow's milk, which is primarily essential, or owing to the deli- cate digestion of the child, cow's milk seems to be indigestible. We are then obliged to have recourse to some process that will render the milk more digestible, and for this purpose various means have been adopted to make up a child's bottle. The simplest means of all would probably be to use whey only for the first few weeks of life, and, indeed, in many cases this would suffice, as Professor Leeds tells us that the nutritious albuminoids remain in the whey after the curd has been re- moved by rennet. The milk is warmed and a tablespoonful of liquid rennet is used to the pint of milk. The milk will turn if undisturbed, and when the separation has entirely taken place the whey can be strained off. We have frequently found a mixture of two tablespoonfuls of whey, one table- HOW TO PREPARE THE BOTTLE. 129 spoonful of cream, and two tablespoonfuls of boiling water an excellent thing for a new-born babe, especially if curds have been noticed in the passages after a more complete milk diet. Eustace Smith, for years the pre-eminent authority in Eng- land on these subjects, has used the following as bottle-food for babes deprived of breast-milk : One tablespoonful of fresh cream ; Two tablespoonfuls of whey ; Two tablespoonfuls of hot water. The whey can easily be prepared in the morning and placed in a clean, well-stoppered bottle on the ice and used during the day. We have frequently advised the mother, if she is obliged to care for her babe at night, to place the child in a crib be- side her, and to take to bed with her sufficient bottles filled with whatever preparation is used, well corked and wrapped in flannel. If the food has been sterilized at a temperature of 155° F., and the bottles well corked, they will keep perfectly well, and all she has to do is to slip a clean nipple over the bottle in place of the stopper, and the warmth given by the flannel will be sufficient to heat the food. She will thus avoid the danger of catching cold and the annoyance of preparing food so often. As will be seen hereafter, the curd or casein of cow's milk is the great obstacle to its use generally, and especially with delicate babes. On this account we have always found it advisable not to persist in the administration of milk if curds are found in the passages, or in case of diarrhoea with greenish and watery evacuations. We would advise that the babe be at once placed on the following until a physician is consulted : Whey, two tablespoonfuls ; Albumen water or acacia water, two tablespoonfuls ; Sugar of milk, level teaspoonful. The albumen water — a preparation we have the greatest con- fidence in as a substitute for milk with sick children — is made by dissolving the white of a fresh egg in a tumbler of water. 130 MOTHER AND CHILD. The acacia water, which is slightly astringent, is made by dissolving a teaspoonful of powdered gum acacia in a tumbler of boiling water. If the babe is weak, and it becomes neces- sary to feed often and in small quantities, ten drops of wine of pepsin can be added to each bottle. After the child's digestion has become more tolerant, — in- deed, in many cases of infants deprived of the breast without having recourse to anything else, — peptogenic milk powder (Fairchild) may be used and the curd predigested. There are cases that seem to resist all forms of bottle-feeding, and whose lives are saved alone by the wet-nurse ; again, there are hundreds of babes with good digestion who will thrive on plain cow's milk even undiluted with water. If a babe will digest fresh cow's milk, it is the best food of all. The following are the directions for using the peptogenic milk powder : DIRECTIONS FOR " HUMANIZED MILK." No. 1. For the Daily Food of a Healthy Nursing Infant.— Put into a clean agate-ware or porcelain-lined saucepan four small measures, 1 or one large measure, of the peptogenic powder, a half-pint of cold water, a half-pint of cold, fresh milk, and four tablespoonfuls of cream. Place the saucepan on a hot range or gas stove and heat, with constant stirring, until the mixture boils. The heat should be so applied as to make the milk boil in ten minutes. Keep in a clean, well-corked bottle in a cold place. "When needed, shake the bottle and pour out the desired portion and heat to the proper degree for feeding, — lukewarm. No. 2. Specially-prepared Food for Infants with Feeble Diges- tion or xohen suffering from Disordered Stomach and Bowels. — Put into a clean bottle four small measures, or one large measure, 1 Each can of peptogenic milk powder contains a large and a small measure. Put the powder into the measure with the blade of a knife, shaking it down firmly so as to well and evenly fill the measure. HOW TO PREPARE THE BOTTLE. 131 of the peptogenic powder, a half-pint of cold water, a half-pint of cold, fresh milk, and four tablespoon fuls of cream. Shake well, place the bottle in a pail or tin kettle of water (at least a gallon) as hot as can be borne by the whole hand (115° F.), and keep the- bottle there for exactly thirty minutes. Then pour all into a saucepan and quickly heat to the boiling-point, with constant stirring. Keep and feed in the same way as directed in No. 1. If it is absolutely necessary to use condensed milk, one part of pure, unsweetened milk should be first mixed with from two and a half to three parts of water, and it may then be presumed to be equivalent to cow's milk. Then to eight ounces of this mixture add eight ounces of water and the cream and peptogenic milk powder in the usual manner. In other words, we first require to dilute pure, unsweetened con- densed milk with about seven parts of water, and to each pint of this diluted milk should be added four tablespoonfuls of cream and one large measure of the peptogenic powder, and treated in the usual manner. In this connection Dr. Leeds writes to us as follows : " I know of no process that secures these advantages, except that I have so constantly recommended and now am using without seeing any difference, chemically, physiologically, or practically, from mother's milk: four tablespoonfuls of milk, four tablespoonfuls of water, one tablespoon fill of cream, and one measure of peptogenic powder, heated for five minutes as directed. This (temperature is 155°) Pasteurizes; converts the cow's milk to a point at which it gives the reactions char- acteristic of the albuminoids of cow's milk, gives the same flocculi and has the same susceptibility to digestion, and insures and secures the essential mineral constituents. In short, this process secures the advantages of Pasteurization and of a proper degree of contact with the ferment at one and the same time, and renders cow's milk both innocent and whole- some for infants." 132 MOTHER AND CHILD. CHAPTEE XXXII. CONDENSED MILK. This brings us to the subject of condensed milk. A reliable brand, such as Borden's or Canfield's, has the following advan tages : When diluted with about ten parts of water, it repre- sents mother's milk pretty closely, with the exception that there is less cream, but to a pint of this mixture four table- spoonfuls can readily be added. It is absolutely necessary that cream should be added to a mixture of condensed milk, and when made the whole mixture sterilized at 155° F. The evap- oration of the milk in its preparation has destroyed its tendency to fermentation to a great extent. This most certainly is a great advantage. It will coagulate in flakes, and does not require the addition of any sugar, as by analysis it is shown that when the mixture is thus prepared the amount of sugar it contains is about equal to that in mothers milk. It can be universally obtained, and is useful on that score ; its disadvan- tage in many instances is due to the cane-sugar, and some object to it on the ground that it is supposed in many cases to lead to rickets. Our own experience does not bear this out, though certainly if we were to find that a child fed on condensed milk showed undue acidity, either in its stools or ill its breath, due to the presence of lactic acid, we would at once change its diet. In summer weather the presence of cane-sugar, which is a decided laxative, is objectionable, and herein exists the great difficulty in the proper selection of a food for that season. Dr. A. Jacobi does not believe that sugar of milk is better than ordinary cane-sugar, and he writes as follows : " The conversion of milk-sugar into lactic acid takes place very rapidly. When this change occurs in cow's milk, it be- comes sour at once. Cane-sugar is not so easily transformed. CONDENSED MILK. 133 Indeed, cane-sugar is utilized for the purpose of counteracting the rapid conversion of milk-sugar, and the preservation of articles of food in general. " Condensed milk remains intact a long time, on account of the addition of cane-sugar, in spite of the presence of milk- sugar. Therefore, it is not at all an indifferent matter, whether milk-sugar or cane-sugar is added to the artificial diet. Still, the use of the milk-sugar has been urged upon other grounds. It has been stated that milk-sugar is to be preferred because it contains phosphatic salts, but verily these may be introduced into the body in other and less dangerous ways. Besides, it will be proven in another part of this book, that phosphates are so plentiful in all kinds of foods that they are eliminated as fast as they are introduced. It has also been said that milk-sugar is contained in milk by virtue of a natural arrange- ment, and if nature had intended to have cane-sugar in milk, the same nature would have supplied cane-sugar. After all, it is a fact, and often a disagreeable one, that milk-sugar is quickly converted into lactic acid, so that an excess of acid accumulates in the stomach and causes the protein substances to coagulate and become indigestible; it dissolves the alkalies and the calcium out of the phosphate combinations to no pur- pose except to produce dyspepsia and diarrhoea ; it eliminates phosphoric acid before the proj)er time, and gives rise again to diarrhoea, and, according to Heitzmann and others, to rhachitis. These facts furnish reason enough for carefully avoiding the use of milk-sugar, and for preferring cane-sugar as an addition to cow's milk and artificial foods. '• In accordance with what has been said, I assert that arti- ficial nutriments for children ought to be mixed with cane- sugar, not with milk-sugar, in view of the active production of acids in the young, their tendency to diarrhoea, and the danger incurred by the premature discharge of salts." Let us study for a moment the question of the " fresh evapo- rated milk," which offers for the future the best field for infant- feeding in those cities where it is daily supplied, especially in 12 134 MOTHER AND CHILD. summer-time, and where the dairy milk, as served, is of doubt- ful character. We may add to one part of it seven parts of water previously boiled or filtered. We find that it will be necessary to add to the half-pint of the above mixture of evaporated milk two tablespoon fuls of cream and two heaping teaspoonfuls of sugar of milk. This will be equal to cows' milk, with about the same percentage of casein as mother's milk. The absence of cane-sugar in this preparation renders it valuable in summer in our large cities, when diarrhoea is prevalent. Indeed, in such cases half an ounce of this milk in a graduated glass with four ounces of water, previously boiled and filtered, given at the temperature of the body, about 99° F., without adding cream or sugar, would in many cases be a most suitable diet. If the bowels are loose, lime-water could be used. Unquestionably, disorders of the intestinal tract are produced by fermentation and also by mechanical irritation of undigested cards, and this is often due, not alone to the method of preparing the food, but also to the deficient supply of the gastric juices. If a large supply of gastric juice could be encouraged, both of these causes would cease to exist, as the acid mixture is antiputrefactive as well as digestive. We are often obliged to use some means to pre- pare the milk and destroy its ferments, and to diminish its casein, or so affect it as to allow precipitation in fine masses. The former is readily accomplished by boiling, or by subjecting the milk to heated steam ; the latter by several means now in vogue. The first, by rendering the milk alkaline, which retards in a measure the coagulating property of the gastric juice. The second^ by diluting the milk with water, which diminishes the percentage of casein. The third, by thoroughly incorporating with it some material, , such as gelatin, or a small amount of starchy matter, such as oatmeal-water, barley-water, rice-water, or arrow-root, that will intimately incorporate itself in the casein as it falls, and thus allow the gastric juice to completely attack it. CONDENSED MILK. 135 The fourth^ by partially predigesting the casein — peptonizing it, as it is called — before it enters the stomach. We have, in addition to these, various other preparations, which are sometimes added to the milk to render it more nutritious ; for example, soluble carbo-hydrates, the so-called "Liebig foods," as dextrin, glucose, or substances rich in albu- minous matters. This, in fact, covers the whole ground of the various preparations used in the bottle-feeding of infants, and 3-011 will thus see that they all have some scientific basis to work upon, and their choice depends on questions of expediency and reliability, which should be studied in connection with each particular case. Cow's milk can readily be rendered alkaline by the addition of lime-water, soda, or potash, and the curd affected thereby. We think the importance of alkalinity is somewhat overesti- mated, — that is, the tendency seems to be to put too much soda in the milk ; all that is required is to make it neutral, even for peptonizing purposes. When lime-water is added to the bottle, one tablespoonful to a half-pint mixture will be in most cases sufficient. It is always well to consult a physician before lime or soda is added to the bottle of milk ; there may be reasons why a choice should be made between the two. Indeed, too much alkali may weaken the digestive organs and make the child flatulent and dyspeptic. Yichy or Manitou water is a very good addition to milk instead of lime-water; if the child should continue to pass curds, it should be used in the same strength as lime-water. Dilution with water is a very important matter, because by weakening the milk with the object of diluting the curd we also diminish the fat or cream, the sugar and salts. Now, as all of these are essential to nutrition, it is obvious that by diluting them we are obliged to give the child greater bulk than it would otherwise take, and to overcome this difficulty it is necessary to add cream, sugar, and salts to the bottle in its preparation. The question of the digestion of fat is a very im- portant one. The fats and sugars serve pretty much the same 136 MOTHER AND CHILD. purpose in the system : they are the so-called carbo-hydrates, and go to the formation of animal heat. But the fats serve even a greater purpose : they are found essential to nutrition ; they give strength, and act in that way the same as the curd or nitrogenous principle. Fat is in greatest demand at the time when animal heat is the most required, — that is, during the winter months ; the fats and soluble carbo-hydrates, when sup- plied in excess, are stored for future use ; their excess in hot seasons is productive of intestinal disorders. In such cases a change to soups, or albuminous water, made by dissolving the white of egg in water, makes a nutritious diet and is a valuable change. The oils, when stored, give a condition of body which is firm and elastic to the touch, and when this reserve is called upon the emaciation is gradual. On the contrary, when the storage takes place from excess of sugar fat, the fat is not staying and its disappearance is sudden. This is well seen in children fattened on condensed milk to which no cream has been added. Lessen, then, the amount of cream and sugar for the summer season and increase the nitrogenous elements. The question so often arises as to the exact value of condensed milk and the cases in which it may be used, that we may well be pardoned if we again dwell upon it for a few moments. The heat which is used in making it has destroyed the germs of putrefaction and thereby helped to preserve it. This is a very great gain. Then, also, the statement that only fresh, sweet milk can be condensed is undoubtedly true, as the odor which arises from stale milk would at once expose its character. But in all probability the heat which has driven off the water has acted in the same manner as the heat in the steam sterili- zation : it has deprived the milk of some of its nutritious quali- ties, and as a regular article of diet, to be depended upon alone for nutrition, it is not to be recommended. The soft, floccu- lent masses into which it is coagulated are of immense advan- tage, especially in young infants ; it is the nearest approach to mother's milk. The only question which is at all worthy of CONDENSED MILK. 137 consideration is that of the sugar which it contains and the deficiency of cream, when the mixture is diluted, compared with that of mother's milk. For instance, a bottle made up of an ounce of condensed milk (mothers and nurses should use a large graduated measure in preparing babies' bottles) with ten ounces of water is almost identical in its composition to mother's milk, with the exception that it contains cane-sugar instead of sugar of milk, and has less cream. For a very young infant, one who has been suddenly deprived of breast- milk, a mixture of this kind probably possesses greater ad- vantages than any other milk food, and we feel satisfied that it will agree better and can be more easily prepared than any other bottle. The water should be previously boiled and filtered, the can kept in a cold place, well covered, and each bottle made up fresh. We would even prefer this form of condensed milk to the evaporated fresh milk, which has no sugar, for a very young infant, unless it is previously under- stood that to the freshly-evaporated milk sugar of milk should be added to each bottle. In order to be on the safe side, even this mixture should be sterilized at 155° F., as the milk is liable to contamination after the can is opened. Let us, then, be distinctly understood as recommending condensed milk, not as a regular article of diet, but simply to be used to bridge over that most delicate period in a child's existence when it is deprived, at an early age, of breast-milk, and when there are doubts as regards the character of the cow's milk from which its food is to be made. It will carry the child safely over a change in the character of its food, which is all- important ; it also has the advantages of being always at hand, and when obtained fresh and from reliable sources is usually of about the same quality. We have seen children a year or more old brought up entirely on condensed milk, with every appearance of health and strength, and they are unusually fat children, as a rule, but at the same time we would not advise it. There is no necessity for this, as most certainly by the time a child is five or six months old it can 12* 138 MOTHER AND CHILD. easily digest one of the preparations hereafter recommended, containing cow's milk boiled with oatmeal or barley. Of course, as a child grows older its digestion becomes stronger: it becomes, in fact, accustomed to its food. A change can be made by adding cream to each bottle in the proportion before recommended, — that is, to a half-pint of the condensed milk, as prepared above, an ounce of ordinary cream may be added. If one lives in the country and milk can be obtained warm, fresh from the cow, it should be used instead of condensed milk ; but we would not recommend a city child to be given, shortly after its birth, ordinary cow's milk and water, such as is supplied by the ordinary milkman. CHAPTEE XXXIII. PREPARED BOTTLE. The question of the curd commands the most serious atten- tion. This curd is always in the way, although it is an im- portant article of diet, being a muscle-forming element ; and yet it is not the most important by any means to the young infant, as nature has shown by supplying so little to the human milk compared with that of the cow. We must either get rid of this curd entirely for children who are suffering from disease or indigestion, or we have to so act upon it as to make it either coagulate in nocculi, or to digest it in the bottle, as has been done in the process called peptonizing. The whey food, or a mixture of cream and hot water, gives us a preparation without the curd at all, or, as in the latter, very little of it, so that children with the weakest digestion can probably live comfortably and thrive on such food; but of course when it comes to growth and development, requiring active muscular exercise, a stronger food is needed, and casein, or curd, becomes a necessity. We will quote here, for the in- PREPARED BOTTLE. 139 formation of those who are interested in the subject of di- gestion, a portion of a paper read by one of us. 1 " Digestion is not merely a process of disintegration ; certain secretions are requisite to bring about the chemical changes required. What are these secretions? First, we have that from the salivary glands which changes starch into sugar. The saliva secreted by a child under six months is at a mini- mum ; very little' is required, simply enough to lubricate ; but I may say that in a series of experiments I have recorded a child of seven days who secreted saliva which possessed suffi- cient diastase to convert the boiled starch used into grape- sugar. This readily accounts for those infants who fatten on corn-starch, much to the surprise of the family medical attendant. "As the child grows and teething begins, quite a large amount of saliva is secreted, and undoubtedly the activity of this secretion forms a prominent part in its digestive process ; in other words, a child that slobbers, as a rule, has little diges- tive disturbance. " The curd is precipitated and turned into peptones, or albu- minose. All albuminous matter is so converted, and a burden by no means light is placed upon the liver, — an organ more prominent in infancy than in adult life. " The precipitation of the casein presents some curious features; indeed, this matter is of fundamental importance in our studies. Woman's milk is alkaline, it is watery, its curd is precipitated in soft flakes. Cow's milk is slightly acid, its curd forms in firm, hard masses of cheesy consist- ence. The curd in all cud-chewing animals, of which the cow represents the class, is thrown down in masses so as to be readily regurgitated by the calf for the purpose of tritu- ration. In the non-cud-chewers the reverse is the rule. There may be other peculiarities of the curd, — chemical differ- ences, — but these have not as yet been determined." 1 Keating, Annals of Hygiene. 140 MOTHER AND CHILD. Dr. E. P. Davis writes, " These results of investigation, com- bined with the clinical study of infantile digestion and its disorders, warrant the inference that in the digestion of the infant hydrochloric and lactic acids do not normally exist; that milk is clotted by a rennet ferment active in alkaline or neutral media ; that the stomach serves the purpose of a co- agulating bottle which is empty in less than an hour after feeding; that digestion and absorption proceed according to the activity of the pancreatic and intestinal secretions, the pancreas being especially concerned in normal digestion, and the lack of its functional activity being most apparent in gastro-intestinal disease." The secretion from the pancreas is the next and last of im- portance. It is composed principally of two materials; in fact, a third may be added, the curdling principle ; these will act in an alkaline or faintly-acid solution : the first a material analogous to the pepsin of gastric juice, which converts casein, or other albuminous matters, into peptones, and substances that have escaped the action of the gastric juice ; and a diastase like that of the saliva, which converts starchy matters and cane-sugar into dextrin or grape-sugar. To the infant the gastric juice is the most important of its secretions ; only such food as contains albuminous matter with soluble carbo-hydrates, as glucose and oil in emulsion, should be given ; such, indeed, is milk. We have, then, two matters to consider in the artificial feeding of infants, and we shall limit ourselves to those within the first year : one, the preparation of a food containing the elements of mother's milk, in a combination as much like it as possible ; and the other, no less important, the elaboration of those secretions which digest it. An equal balance must be maintained between the two. The coagulation of the casein of cow's milk into hard masses can be prevented by certain means ; one of the most impor- tant of them is diluting with water. It is for this purpose that water is added to cow's milk ; but it has also been noted that PREPARED BOTTLE. 141 if certain materials which are not digested in the stomach are allowed to become thoroughly mixed with the milk, they will, acting in that way, so honey-comb the curd, as it were, as to prevent its forming a solid lump of cheese. Lime-water may do this, — if the -bottle is shaken there will be seen a great deal of lime which is not dissolved in it, — but farinaceous foods, such as the cereals, the starches, if they enter the stomach as such, are not digested there, but probably act in a measure towards the curd as sand does in the stomach of a bird. The cereals, when examined under the microscope, are found to be cov- ered with a material that is destroyed by heat or digested by the gastric juice; the starch in either case becomes free, and the saliva, if it comes in thorough contact with it, will turn it into dextrin or grape-sugar ; in that state it is carried to the liver. The same takes place when the pancreatic secretion attacks it, — that is, after the food has left ,the stomach; but as a child has both the saliva and the pan- creas secretion in but small amount, to feed it entirely on starchy food is simply to give it starvation diet. It cannot live on such material. Very fortunately fur the baby, its corn- starch has to be boiled, and this boiling process converts it into grape-sugar, or at least so nearly so as to allow the con- tact of the feeblest secretions to finish the work ; and* fortu- nately, also, nature often supplies the child with very active salivary glands during its teething period : it slobbers con- stantly, and the corn-starch food comes in contact with this secretion, which renders it digestible ; but the poor infant who is given half-boiled arrow-root, or flour, or corn-starch too 'thick to flow readily through the bottle, and who cuts its teeth hard, — that is to say, has dry gums, little secretion, — will not be long before it shows an inflammation of the bowels that will be the cause of its death. The reader can now see why it is that some children get along well on corn-starch food and thrive from a very early age upon boiled bread and milk, cracker-dust food, or sub- stances of that sort; but, unfortunately, it is these very chil- 112 MOTHER AND CHILD. dren who form exceptions to the rule that cause the invariable evil result by tempting mothers to give starchy food to two- thirds of the children when too young. A cereal may be added to the child's bottle after it is three or four months old, if it be deemed advisable, beginning with a very small quantity. The simplest and one of the best ways of preparing the bottle is the mixture suggested by Dr. J. F. Meigs and used by him for so many years with success. A two-ineh-square gelatin cake is soaked for a short time in half a pint of cold water, the water is then boiled for fifteen minutes until the gelatin is thoroughly dissolved, a teaspoonful of arrow-root, rubbed into a paste, is stirred into the boiling water, and then the milk added in the proportion of one-third milk and two-thirds water for the new-born, two-thirds milk and one- third water at six months, varying in proportion at the ages between. These are allowed to boil together for a few min- utes, and then for the young infant two tablespoonfuls of cream are added to the pint of food, and to this about six and a half drachms (or teaspoonfuls) of sugar of milk, or three tea- spoonfuls of white sugar. Dr. J. Lewis Smith recommends for the preparation of in- fants' food the following plan : Take from five to ten pounds of well-selected wheat flour, put this into a bag, tie firmly, and keep covered w r ith water for several days, possibly a week; this should occasionally be made to boil. In the prep- aration of the bottle for a child under three months, the water used for diluting the milk should have boiled with it some of this flour, grated in the proportion of two heaping tea- poonfuls to a pint; after the sixth month four teaspoonfuls. Another excellent preparation is made as follows: The milk is diluted with its bulk of water, which should be pre- viously thoroughly boiled with either ground barley, oatmeal, or baked flour, in the proportion of a dessertspoonful to the pint, the milk poured in while the water is boiling, the whole boiled together for from twenty minutes to a half-hour at least, and then strained. This may be sweetened, an ounce of cream PREPARED BOTTLE. 143 added, and the whole forms an excellent food for a child after its fourth month. It being understood that a cereal such as barley, oatmeal, or Graham flour is not to be given to a child as the basis of its food, but only to slightly thicken the milk and give it substance, and to prevent heavy curding, the choice of the article is a matter for consideration in each individual case. Mothers ought to know that the outer portion of a grain of wheat, corn, or oats — in other words, the bran— acts as a laxative, and it is on that account the crushed grain is more valuable where there is a tendency to constipation. Next to the outer surface we have that portion of the grain in which resides most of the nitrogenous principle, the so- called gluten: so that in the debranned flour we have a prep- aration which is nourishing and fattening, but not laxative. The internal portion of the kernel of all these cereals con- tains the starch -granule, and this part we know gives the tendency towards constipation, and is least nutritious of all, but is the heat-forming element; thus, in the whole crushed grain we have all the elements necessary for health and nutrition. When it is desirable to use any of these cereals it is far better to use the whole grain, crushed, unless there should be looseness of the bowels or irritation of some sort, in which case the flour alone should be used. But mothers should bear in mind what we have laid stress on before, that whenever a starchy food is used the starch-granule should be thoroughly broken up by heat, either by baking or by boiling. This is an essential matter, and we cannot repeat it too often. When a mother wishes to put her child on the bottle (sup- posing it to be about the age of four months), and wishes to add something to the bottle, it is a difficult matter to know with what to begin. Dr. J. F. Meigs advises gelatin and arrow-root ; Dr. J. Lewis Smith, of New York, advocates the flour-ball, — that is to sa}~, flour tied in a linen rag and boiled for hours, then taken out, grated, and used with the milk. Our own preference is for barley: it is the hast constipating 144 MOTHER AND CHILD. and usually agrees well, and after the child has become accustomed to it and the digestion is in good condition, a small amount of oatmeal may be added with each or every alternate bottle, and a variety of diet in that way insti- tuted. Now, in preparing the barley for the bottle we may either take the whole-grain pearl barley, and have it crushed in a coffee-mill, or use Eobinson's barley, which comes in packages, finely powdered. Of course the latter is easier manipulated and requires less time to prepare. Of the powdered barley, take ' a dessertspoonful, mix it into a smooth paste with a little water, and gradually stir this into a pint of boiling milk. If the child is under six months of age you can then add from one-half to one-third of water, and, stirring constantly, allow the mixture to boil fully twenty minutes. To this can be added a heaping teaspoonful of white granulated sugar and a pinch of salt. It should then be strained. Now, if this mixt- ure is put in the refrigerator at once when it is made, in the morning, it can be used for each bottle by warming over and straining. If there is much constipation, oatmeal or Graham flour (cracked wheat) can be used in the same way. A variety of oatmeal known as the Bethlehem oatmeal comes powdered for this purpose. It is simply a carefully-selected meal well ground ; any good oatmeal will do as well. Of course, if the coarser grain is used, the boiling process will have to be very much prolonged ; and in such cases, if simply the crushed barley, the cracked wheat, or the ordinary oatmeal is made use of, it will be necessary to boil it in water beforehand, say a heaping dessertspoonful to a quart, and the whole allowed to simmer until it is boiled down one-half. Then this can be added to the milk, stirring well, and either both boiled together for a few minutes, or, if the child is constipated, simply scald the milk by pouring the boiling water and meal into it, stir- ring it meanwhile, and then strain. The sugar and salt can be added. In city practice we always recommend the boiling of the PREPARED BOTTLE. H5 milk for precaution's sake, and think the tendency to con- stipation can be overcome by giving the child occasionally a bottle of water, which it will readily take. It is important to bear in mind that the food should never be made so thick that it will not run through the nipple. The food should be made in a farina-boiler, that the milk may not become scorched. As we have said, the selection of food is to a certain extent an experiment, and therefore the child should be watched to see whether it exhibits any symptoms of indigestion. Begur- gitation of food, the souring of it in the stomach, flatulence, hiccough, nausea, and, finally, either constipation with great pain, passage of curd, undigested milk which has a disagreea- ble odor, white passages, or diarrhoea, are of course all evi- dences of indigestion, but these must not be confounded with the symptoms that are brought about by tight bandaging, jolting, dancing the child up and down after a meal, forcing it to take more food than it can conveniently carry or digest. We have often seen cases in which the mother blamed the indigestion on the diet when the food had agreed perfectly well, but the indigestion had been brought about by the way in which the child had been treated. If the child uses the bottle, it should not lie flat on its back, but should assume the same position that it occupies when nursing from its mother. It is well always to avoid the use of purgatives or laxatives, in bottle-fed children, as far as possible. Use in their stead the more laxative cereals. Eemember that water is nature's most efficient laxative, that when salt is added to the food it has the same excellent effect, and that regularity and the establishment of habit, both in its feeding and in the timely movement of its bowels, is of the greatest value to the child, Do not think the amount of material you put into a child's stomach is alone necessary for its sustenance. Do not think that because a child is given a quart or more of milk a day it is all that is necessary, and that it must thrive whether or not. This is a mistake which o k 13 146 MOTHER AND CHILD. mothers are constantly making. It is the amount that is digested and absorbed that nourishes, the rest decomposes or irritates. This brings us to the subject of predigesting the curd. Professor Albert K. Leeds, of Hoboken, gives us the follow- ing way of preparing milk for infants : One gill of cow's milk, fresh, unskimmed ; One gill of water ; Two tablespoon fuls of rich cream. To these can be added one powder which contains two hundred grains of sugar of milk and four grains of bicarbonate of soda with a grain and a half of extract of pancreas. These powders, each one containing the above formula, can be made up in any drug store. The milk, with this powder added to it, should be put into a nursing-bottle, which should be placed in hot water — so hot that the hand cannot be held in it for more than a minute at a time (115° F.) — and kept there for about twenty minutes, and then allowed to cool sufficiently for the child to take. This powder is called peptogenic milk powder. In a lecture before the Philadelphia Hospital Nurses' Train- ing School, Mr. Fairchild spoke as follows : 1 " When we speak of peptonizing food, we do not mean that pepsin is employed in the digestion of the food. We simply mean that the albuminous portion, the casein of milk, for in- stance, is converted into peptone. The materials used for the purpose are the ferments of the pancreatic juice in the form of a powder, — the extract of pancreas. 2 This contains several ferments, each of which acts on a different form of food. The conditions under which these ferments act are very simple. If, in attempting to digest milk, you add the ferment to the milk when it is very cold, no action will be obtained. Again, if it is added to very hot milk, no action will be obtained. The conditions under which these ferments act are similar to those found in the body. A good test for determining the 1 Keported by I)r. William H. Morrison, Holmesburg, Pennsylvania. 2 Or the " essence of pancreas," or the " liquor pancreaticus." PREPARED BOTTLE. 147 temperature of the food is to taste it. If it is hotter than can be sipped with ease, it is too hot. If it is desired, a little ther- mometer may be employed to obtain the proper temperature, which is 100° F. " I shall now show you how to make peptonized milk. I take one of these ' peptonizing tubes,' which contains five grains of pancreatic extract and fifteen grains of bicarbonate of soda, and empty its contents into a quart bottle. To this I add a gill — that is, four ounces or eight tablespoon fuls — of cold water, and if it is for infant feeding, the water had better be previously boiled. Enough may be boiled in the morning to last all day. I next pour into the bottle a pint of milk, and shake the bottle well. By adding the water and milk cold, we run no risks. Having done this, the bottle is set into a bowl of warm water, which should be of such a heat that you can hold your hand in it for a minute ; the temperature of the milk is thus raised to about 100°. The milk is allowed to remain in the water for half an hour; it is then put upon the ice, and the digestion will still continue for some time, — until the milk is thoroughly chilled, after which no further digestive change can take place. " I have here a bottle of milk which has been digested in this way. I have allowed the digestion to be carried a little further than is usually necessary, in order that I might show you the properties of peptonized milk. I first take ordinary milk and add an acid to it. At once a mass of coagulated casein falls to the bottom of the glass. I treat a sample of peptonized milk in the same way, and there is no trace of casein. As I have said, it is not usually necessary to digest all the casein, and the directions which I have given are for average cases. You have to observe the effect of the milk on the patient's digestion. If it is assimilated readily, the proper pre- digestion has been secured ; but if it is necessary to digest it still further, the milk may be allowed to remain longer in the hot water. If the milk has been digested too much, and is a little bitter, it may be made agreeable by the addition of a little 148 MOTHER AND CHILD. sugar. You will soon learn by experience how to adapt the process to the requirements of each case. "Instead of using plain water, we may take a quantity of starch paste, add a little pancreatic extract to it, and stir it up. When starch is boiled it simply swells up, but within a few min- utes after the addition of the pancreatic extract it becomes a thin liquid from the digestion of the starch, — by the pancreatic diastase ; this starch is now in the way of being converted into glucose or grape-sugar. This may be put into a bottle with the soda and milk, and digested in the manner just shown, and we shall have peptonized milk gruel. Here the nutritious elements of the starch are added to the milk. In using the peptonizing powder a little water is always used to dissolve it, otherwise it would be slightly curdled by the extract of pancreas. " This peptonized milk can readily be made into lemonade. It may strike you as rather odd to add lemon-juice to milk, but as the milk has been completely peptonized, it will not curdle, and the lemon is often desirable to make the milk pleasant. Eum and suuar may be added if stimulants are required, making a delicious punch. It may also be taken with carbonic-acid water, and, if thought necessary, lime-water may be added, although we have already added an alkali. " You may make a peptonized milk jelly. If you wish to make a jelly, it is necessary to allow the digestion to progress for a longer time. A pint of peptonized milk is heated to the boiling-point, — that is, you scald the milk. This is necessary to destroy the ferment. Then take three-fourths of an ounce of Coxe's gelatin, a tablespoonful of lemon-juice, and a couple of tablespoonfitls of orange-juice. When the milk is scalded some of the lemon- and orange-peel may be scalded with it, which gives a fresh flavor of the peel. The gelatin is then added, and wine, brandy, or St. Croix rum may also be added. If you do not remember to scald the milk, you will not get a jelly, for the extract of pancreas will not only digest the casein, but it will also digest the gelatin. PREPARED BOTTLE. 119 " In digesting meat, take two tablespoonfuls of chicken or beef finely minced and boil it with a gill of water. This makes the meat soft and facilitates its digestion. The meat is then rnbbed into a fine pulp and put back into the water. You may now add a gill of the starch mucilage and one of the pepto- nizing powders. It is then set aside for two or three hours, and at the end of that time scalded. The peptonized soup may be seasoned to suit taste. The scalding is necessary to stop the digestion, which otherwise would go on and lead to but refractive changes. " This plan may be used with ordinary soup. Take two or three tablespoonfuls of the meat, barley, etc., strained from soup, rub it to a pulp, and add fifteen or twenty grains of pan- creatic extract and half a drachm of bicarbonate of soda ; add to a pint of the soup, and proceed as just shown. There is no doubt that you get artificial digestion of all the substances, and at the same time you have no more trouble than in making ordinary food. If this is strained, and gelatin added, you ob- tain a nice clear jelly. The peptonized milk jelly is more agreeable than those made with ordinary milk. <; In preparing peptonized milk for babies, we follow a little different plan. In using cow's milk we have to dilute it with an equal quantity of water in order to obtain the proper amount of casein. We have to add a small quantity of milk- sugar to make up for that lost by the dilution with water, because mother's milk contains a little more sugar than cow's milk. Then we have to add the alkaline salts which are found in human milk. Dr. Keating spoke of the acidity of cow's milk, and this is a point which few people properly appreciate. Testing this sample of milk with litmus-paper, it is found to be distinctly acid, and, in fact, I have never tested cow's milk without finding this acid reaction. Here we have a powder (peptogenic milk powder) which presents the proper proportion of milk-salts, milk-sugar, and the digestive ferment to change the casein into the soluble form in which the albuminoids exist in mother's milk. I take four ounces of milk, add the proper 150 , MOTHER AND CHILD. amount of the peptogenic milk powder ; next we add four ounces of water and two tablespoonfuls of cream. This latter is an im- portant element, for mother's milk contains more fat than cow's milk. In this way we obtain the same proportions of the dif- ferent elements as are found in human milk. All that is now required is to heat it to the proper temperature for five or six minutes in order to properly modify the casein. The temper- ature is to be determined as in the former case by sipping or by the use of the thermometer. In this process, having first made a milk mixture which contains the right quantity of all the elements of mother's milk, and with its peculiar alkaline character, then we seek to effect just such a change of the casein — the \ curd' — as will present it to the infant's stomach in the condition fit for digestion, in such a condition that it will behave in the stomach just as mother's milk does, and make the same demand upon the natural digestive functions. If, however, the baby is very ill, and not even capable of digesting its natural food, this method allows you to digest it still further, " There are two other ways in which the ' humanized' milk may be prepared. Instead of taking the quantity of milk which I have done, we may take a larger quantity and a pro- portionately larger quantity of the other ingredients, mix them and keep them on ice. There will be no action as long as the low temperature is continued. The proper amount may be poured out and heated whenever it is required. " The other way is to make the mixture as just described, and stand it in warm water for fifteen minutes. This will give the proper amount of digestion. Then scald it ; this kills the ferment, and the milk can be kept with no more care than or- dinary milk. You can then take the proper amount and warm when it is needed, and you have no further trouble with it. For asylums, where there are many children, this is probably the best way. This gives us milk which is as exact an imita- tion of the natural milk of the mother as we can expect to obtain it in practice." The extract of pancreas can be obtained at any drug store, PREPARED BOTTLE. 151 and peptonized milk is at present highly recommended by all physicians in this country and Europe, when prepared according to the directions just given, for infants who are suddenly de- prived of mother's milk or for those that are sick. A certain amount of care is required in the preparation of this food, because if the peptonizing process goes on too long the milk will become bitter and the child will refuse it ; if it does not go on long enough, the curd, of course, will not be affected. There is another quality which the extract of pancreas pos- sesses that is as important as that of the digestion of casein, which is, that a small quantity of it, when added to the broken starch-granule, will aid in converting it into grape-sugar and thereby render it digestible ; for instance, if a child's bottle be made up of barley-water and milk or oatmeal, a few drops of the extract of pancreas in solution will render certain its digestibility. And for children who have a tendency to diar- rhoea, or with whom starchy food fails to agree, this can be made use of. This brings us to another subject. Anything which will con- vert the cereals into grape-sugar before the food is taken to the child, will aid in nutrition. Why ? Because these cereals not only contain starch, which goes to supply fat and heat, but they also contain albuminoids, as gluten and other nitrogenous materials, which go to the formation of muscular tissue, and salts, which are bone-forming. If the whole grain can be so prepared as to be perfectly digested, a great deal will have been gained in the nutrition of the child, and for this object various foods have been suggested. A substance which converts starch into sugar is diastase, or malt. Each granule of the cereals possesses a certain ferment which, if allowed to develop by heat and moisture, will turn the starch into sugar. This is made use of in the preparation of food for children, such as Liebig's foods, where the starch has been turned into grape- sugar by malting. As will be readily appreciated, there is no necessity for the addition to the milk for very young babes, or for those that are very delicate. Mellin's food is prepared on 152 MOTHER AND CHILD. the same principle. It is a fat-making and nourishing food, which when taken into the stomach will increase the nutrition of the body and store up a certain amount of fat. and is valuable because it requires very little digestion. The child at birth, however, requires simply milk of the character which nature presents. It needs no more albumen and no more sugar. What we want is to supply a milk as nearly as possible of the quality furnished by nature. All that we need is a milk which will be digested and readily absorbed. But we insist upon the importance of feeding a babe from birth to at least three months on some preparation of milk alone. Any preparation of malt that will aid the digestion of starchy food is useful, not only for adults who suffer from flatulence and debility of the digestive organs, but it is also good for infants, when given in moderation ; but we advise mothers to avoid these preparations for their very young babies. This leads us to the consideration of those foods, in addition to the child's bottle, which either aid in the digestibility or are themselves of value in supplying nourishment. According to Professor Leeds, these classes of foods may be divided into the milk foods, the farinaceous foods, and the Liebig foods. We give many of the different preparations under these headings, in order that the mother can intelligently make her choice, should one not agree with her child. We have said before, and may repeat it here, as it is a very important matter, that the choice of a food for a child is a matter of experiment, for what agrees with one may not agree with another, even in the same family ; that the test of whether or not a food agrees with a child is if the child thrives upon it,- — if it sleeps well, if its flesh becomes firm, if its digestion is good, if its temper is amiable, and if it gains in weight, — because a cross child, in nine cases out of ten, is either a dyspeptic or a sickly one. These tests are the only ones that are of value, not- withstanding the advertisement that such and such foods are the only ones that agree with the baby. As the child grows older, a farinaceous food may be given in the way described PREPARED BOTTLE. 153 before. Should the passages become constipated and there be much flatulence, should the child suffer from colic, become rest- less at night, lose its appetite, then the change should be made to one of the Liebig foods, and in this way its digestion encour- aged and nutrition established. An intelligent mother watch- ing carefully her child can thus be guided in the choice of its food; but it should be always borne in mind that as milk con- tains all of the elements for nutrition in such proportion as is required, those foods which are not milk foods should always be made up with milk in the preparation of the bottle; and if fresh cow's milk cannot be obtained for this purpose, a milk food well diluted should be used, such as ordinary condensed milk, fresh evaporated milk, or one of the milk foods given in the table : MILK FOODS. Carnrick's Soluble Food, Anglo-Swiss, Grerber's, American Swiss, and others. FARINACEOUS FOODS. Blair's Wheat, Hubbell's Wheat, Imperial Granum, Hard's Food, Kidge's Food, Eobinson's Patent Barley, Bethlehem Oatmeal, and others. LIEBIG FOODS. Mellin's, Malted Milk, Lactated Food, Hawley's, Keasby & Mattison's, Savory & Moore, and others. 154 MOTHER AND CHILD. Frequently a child may be so weak or exhausted from disease or from inanition that food of the mildest character will not remain on its stomach. It would be useless to keep on diluting condensed milk, as it would render it valueless. In cases of this sort, the white of an vgg shaken up in a bottle of warm water to which a couple of grains of lactopeptine or Fairchild's liquor pancreaticus is added, sweetened and given by the bottle if the child will nurse, and by spoon in small amounts if the child will not, is very nourishing. Wine-whey can be given in the same manner. Gum-arabic water will nourish for a sur- prisingly long time, and allay irritability of the stomach and bowels, and finally, the child can be gradually encouraged to take small and repeated quantities of peptonized milk. No babe, of whatever age, should be fed exclusively for any length of time on bottle-food that has not fresh milk as one of its ingredients. We insist upon this, as cases of scurvy have un- doubtedly come from the prolonged use of stale preparations. It should be remembered that all infants need water. For the nursing babe a tablespoonful of boiled water should occa- sionally be given ; for the bottle-fed babe an occasional bottle of .vatcr is a necessity and must not be forgotten. CHAPTEE XXXIV. WEANING. The question is often asked, At what age should weaning begin, provided that there is no immediate necessity, and how should the process be managed ? It greatly depends on the family arrangements for spending that season of the year which in this part of the world is most to be dreaded, the summer. Of course, if a child is to be taken to the sea-shore, or some cool summer resort, where milk can be supplied fresh and in abundance, the question of weaning in the summer-time WEANING. 155 has not half the importance attached to it that it has to those who are obliged to spend the summer in, or near, one of our large cities. Our own opinion is that if a child has been nursed for four months, certainly for six months, the gradual addition of a bottle to its dietary will be of advantage. A child partly nursed and partly bottle-fed, after its fourth month, thrives better than one bottle-fed alone ; in fact, breast-milk helps to make the bottle-food more digestible. Not only is this the case, but it is a great relief to the mother, gives her more time to rest, occasions less drain upon her nutrition, and is also of importance should the child be obliged to take the bottle, either because the mother's milk gives out, she becomes pregnant, or her health gives way; but four months is young enough, provided the mother's milk is found to be of good quality, nourishing, and the child thrive upon it. An occa- sional bottle, in addition to nursing, will have a tendency to concentrate the breast-milk, making it more nourishing, and thus avoid the necessity of weaning altogether for a few months more. The addition of a bottle or two during the night will give the mother a good night's rest, — a most important matter. Apart from the great importance to the child, the nursing by its mother will have usually a most desirable effect upon her own health, unless she be consumptive. It is a law of nature and therefore is beneficial. It will aid much in reducing the womb to its normal size ; indeed, a mother who does not nurse her babe is apt to have some womb trouble following her labor. For a child that is born as late as January or February we would not recommend the addition of any bottle-food until the following October, provided the mother is able to nurse it. For a child born in October or November, and especially when the following summer can be spent out of town or at the sea- shore, the w^eaning process could possibly be all over by May. If a mother is strong and hearty, has no consumption in the family, has plenty of milk, is not in the least pulled down by nourishing her baby, and can nurse it a year, it is so much 156 MOTHER AND CHILD. the better. For the last six months her child can take some bottle-food in addition. A mother should not nurse her child for more than a year ; there is no necessity for it. The milk is not sufficiently nourishing, and unless it is supplemented by the bottle the chances are that the child will become sickly. Indeed, a good, strong, healthy child that becomes accustomed to the bottle-food will wean itself before that time is up, and this is exactly what we wish a child to do, — to wean itself. Now, in the gradual process of weaning or the addition of a bottle to its regular nursing, the babe of five or six months may take its food according to the following programme : It should nurse from its mother in the morning at six or seven, and then after its bath take a bottle about half- past ten or eleven o'clock ; possibly nurse from its mother about one or two o'clock; again a bottle at five or six; and then the mother should nurse it on retiring at ten or eleven. In this way it becomes gradually accustomed to the bottle at the time of day when it is most apt to agree. This also gives the mother an opportunity to take exercise and rest. Possibly it may need a bottle about four o'clock in the morning. The question is asked, What should be the first choice when* selecting the bottle-food of a child at this age, — four months? Certainly the first choice should be the simplest preparation and one which will tax the digestive organs least. The chapter on bottle-feeding should be consulted in regard to this matter, and that preparation of milk, cream, milk-sugar, and lime-water rec- ommended by Dr. Eotch or the proportions advised by Professor Leeds should be tried first, remembering that the mixture must be sterilized, and that the sterilization at 155° F. is the one we particularly advise. The next bottle-food that can be tried is the formula of Dr. J. F. Meigs, of milk, cream, gelatin, arrow- root, and lime-water, and finally, barley, oatmeal, rice, or flour can be added as is advised in the chapter under consideration. As the child grows older, the mid-day bottle can be varied. We believe that by using a mixture of the cereals we often get a more palatable and more nutritious preparation than by using WEANING. 157 them singly ; thus, oatmeal and barley, or Graham flour, can be used together, or oatmeal and rice. The child will show a decided preference for some kind of bottle-food, but bear in mind that it is a great mistake to stuff a child. The mother will often be tempted "to add a little more oatmeal, or Mellin's food, etc., thinking that a little increase will make her baby stronger and rosier. This may be true if the child lives in the country or at the sea-shore, where it is out of doors all day long, in a cool, bracing climate, especially if it is able to run about ; but if mothers could see, as doctors do, the numbers of sluggish, heavy children that our cities afford, with coated tongues and foul breaths, and constipation, who are fairly packed with " baby foods" and all the most concentrated articles of diet that modern chemistry presents us with, they would under- stand why it is that the ill-fed, ill-clothed children of the poor, who live on a crust and digest it, are so much more able to resist disease than their own. It is on this account we believe that, although outmeal is a most valuable addition to the diet, it should only be used in small amounts, should be thoroughly boiled, the children when taking it kept out of doors as much as possible, and should not be used in hot weather, nor with children who have what is called a " bilious tendency." If fresh cow's milk is not obtainable, condensed milk can be used in this gradual weaning of children : one part to ten parts of water, and fresh cream as before recommended. Some studies we made a few years ago convinced us that woman's milk contains a diastase or ferment capable to a slight degree of turning starch into grape-sugar, and that cow's milk does not possess this. Possibly this accounts for the excellent results that are frequently found in the association of breast- and bottle-feeding. Let us here say again that when we use any substance besides milk in its bottle, such as the cereals, we should not forget that the child needs water, — pure, clean water to drink. Yery often a child that is partly bottle-fed and partly nursed is restless at night, — will not sleep. Instead of the mother's trying to put it to sleep by nursing it, if she 14 158 MOTHER AND CHILD. would simply give it some water in its bottle, or possibly a little Mellin's food in the water, it would go to sleep and not run the risk of indigestion from over-feeding. Dr. A. Jacobi, 1 writing of the necessity at times for supple- mental feeding, says, — "Such practitioners and authors who convinced themselves of the ill success often attending the use of milk, or watered milk, commenced at an early period to mix it with meat-soups, meat-tea, or egg. The administration of some beef-soup, well made, a cupful every day (mutton-broth when there is a ten- dency to diarrhoea), is advisable towards the end of the first year. Long before this period, indeed, at any time during infancy, is it indicated in cases of early rhachitis, rhachitical constipation, undue adiposity, and retarded teething. "Beef-tea, well made, in the bottle swimming in the water- bath, is still believed by some to be the model food. That it is not so rich in soluble albuminoids as was believed, ought to be generally understood by this time. What, however, it does contain in large quantities is salts. Thus, it is a dangerous article in summer diarrhoea, and must never be administered by itself. "When given at all, it ought to be in combination with farinacea, raw albumin (which, in this mixture, requires very little salt, if any). " Egg has been utilized as an admixture to milk, or as its substitute in a great many ways. The yolk and the albumin have been so employed. The white of an egg, with a little salt and six ounces of water, well beaten and shaken, is a good mixture, which can take the place of infant food but temporarily, but is an invaluable makeshift in severe intestinal catarrh, or a permanent nutriment in the same when added to other food. " In the course of the second half-year some changes may be made in infants' diet. In the relation of the barley prepara- tion to the milk a change should be made ; the milk may exceed — • 1 Intestinal Diseases of Infancy and Childhood, p. 89. WEANING. 159 its former quantity, and in the same proportion in which the children are permitted and accustomed to drink pure water, the food may become more condensed. Towards the end of the first year the quantity of barley or oatmeal to be used in the decoction may be increased. It is soon enough to begin the use of pure milk in the third half-year, if at all. About the eighth or the tenth month the chewing of a crust of bread or of a piece of " zwieback" may be allowed. About this time, too, the daily allowance of meat-soup may be increased to two hundred and fifty grammes, and in addition one or two tea- spoonfuls of broiled beef may be given. These articles, dis- tributed through four or perhaps five meals, will be sufficient for the greater part of the second year. The quantity may be gradually increased, but a more radical change is useless. If a child, which is healthy and is not spoiled, awakens at night, it needs and desires nothing but a drink of water, or of thin barley-water without milk. . " About the middle of the second year, when the child begins to use a spoon, the breakfast may be made up of more solid elements than heretofore, barley broth or oatmeal mush, thor- oughly cooked, an egg, a glass of milk, a piece of stale bread with or without butter. The child must be taught never to drink milk in haste. It will be digested better when time is taken. The daily quantity of meat, preferably beef, to which gradually may be added lamb or chicken, may now be increased to one hundred grammes, and this is to be at two or three meals. The evening meal must be similar to that of the morn- ing, and lighter than the mid-day meal. Neither at this age, nor later, should nervines, stimulants, condiments, coarse vege- tables or salads, coffee, tea, wine, beer, play any part in chil- dren's diet. A piece of sugar, after a meal which is frugal but rich in albuminoids, will prove an agreeable and useful addition. Children from two to three years of age will get along well on four meals daily. Those who are a little older may do with three, provided they get once a day between meals a piece of bread and a drink of milk, made agreeable and more digestible 160 MOTHER AND CHILD. by the addition of a little salt. Before children are two years of age no vegetables in any quantity should be given to them. Small quantities may be given later on ; they will be accept- able and be readily digested. As age advances, the diet should approximate, more and more, that of grown people. Alto- gether, there is no easier and no more grateful task than that which consists in accustoming children to a simple diet, and to shape their habits and their demands into harmony with those of nature from the first year of life." Bear in mind, that if in the summer-time, a child takes more food than it can digest, this food is apt to decompose, act as an irritant, and possibly give rise to an inflammation that will end in summer complaint. Suppose, then, that a child has been weaned from the breast, and the object now is to gradually take it off the bottle or give it some additional food besides that which it takes in its bottle. We may presume that its bottle has been agreeing with it, but that for the last few weeks it has turned against it, as it were: it seems to crave more solid food. Certainly by the time it is twelve months old it could very well be given a small cupful of chicken-broth or beef-soup. Possibly before this time it has been given, instead of the usual bottle after waking from its mid-day nap, some boiled bread and milk ; and now, instead of bread and milk, some chicken-broth, with a little dry toast soaked in it, can take the place of this meal, and the bread and milk be given for supper about six o'clock. In this way the " bill of fare" for three meals can be gradually mapped out, and the child permitted to masticate part of its food ; this will aid the cut- ting of the teeth as well as increase its digestion. When a child takes bread and milk in this way it is always well to let it have an occasional drink of plain milk, and we must never forget that it also needs from time to time some fresh water. We repeat this constantly, as we want to impress upon mothers that much of the complaint about the constipation of bottle-fed babes comes from the want of drinking-water. Yery often during the course of weaning it is advisable to WEANING. 161 give a child soups or, preferably, broths and beef-juice. The latter is frequently given in preference to soups, as it is readily , digested and is most nutritious and blood- ' making. To make good beef- juice a piece of lean beef from the round, preferably of fresh meat and not that which has been frozen, should be used. Chop this fine and remove every shred of fat, heat slightly, and use a meat-press. A tablespoonful of juice thus expressed is enough for any infant at a time. Of the read}' -made ex- tracts we have found Yalentine's most reliable and also Eudisch's sareo- pep tones. Dr. Jacobi, writing of delicate children who suffer from dys- pepsia caused by intestinal catarrh, says, — " Most cases, in older children, bear boiled milk, strained oat- meal, barley gruel, stale wheat bread, and a few also raw beef. Some take nothing but boiled milk, or buttermilk, or koumiss. Many, particularly convalescents or adults, will tell you that they do not digest milk. That may be true, but then they gulped it down and it formed a large caseous cake in the stomach that was not afterwards dissolved and digested. They must boil their milk in the morning and heat it several times during the day almost to the boiling-point. They must add a small quantity of table salt to it ; also, in case the stomach is Meat -juice press. very acid, some bicarbonate of sodium, I 14* or calcium, or magne- 162 MOTHER AKD CHILD. sium. They must not drink their milk, but pour it upon a plate and sip it with a spoon. Thus prepared, they will digest it, particularly when it is not quite cold. In fact, many require their meals warm or hot. " For the purpose of easier digestion, milk may be peptonized according to Fairchild's directions, or it may be rendered more digestible by the process recommended by Dr. Eudisch. This consists in mixing one part of dilute muriatic acid with two hundred and fifty parts of water and five hundred parts of raw milk, and then boiling it. CHAPTEE XXXY. MENSTRUATION. We will devote a few moments to the consideration of the changes which take place in girls at puberty, partly from the fact that at this time we are still within the period of the second or permanent dentition. Indeed, it will be noticed that at the very age when menstruation first shows itself, the girl is susceptible to all those functional disturbances that may be brought about by the cutting of the four second molars, a set of teeth that are developed anew, not replacing any of the milk-teeth. Sufficient attention has not been called to the dis- turbances caused by the pressure of the twelfth-year molars. These may show themselves in either dental neuralgia or, in fact, any form of trifacial neuralgia, gastric disorders, or men- tal peculiarities amounting to melancholia, or symptoms of acute meningeal irritation. No wonder, then, that it is most important that the young girl should be under the care of a mother properly instructed to guide her and guard her during this time. The natural impulse of her sex is towards sedentary occupation, seclusion, long dresses, and possibly her first real novel, — all of these in themselves pernicious : they weaken MENSTRUATION. 163 her muscles, lessen her appetite, tend to constipation, and ex- cite her brain. It is scarcely necessary to mention the boys at this age. The out-door life that tbey lead, especially at the present time, when there is so much for a boy to do, tends to keep them in good physical condition, and renders them insusceptible to the many reflex disturbances which might otherwise exist. We quote from a paper upon this subject as follows : x We all recognize the very great importance of all that tends towards muscular development in growing girls. They should be symmetrically developed, should have full chests, straight backs, and strong limbs. We should also urge the importance of clothing of light weight and loose fitting, the principal strain being on the shoulders, not on the waist and hips, and also the evil results of cramped, stooped positions in the school- room, eye-strain, and bad ventilation. We all urge these mat- ters daily, and we know how little attention is paid to them. But there are certain forms of various disorders which occur about the time of the second dentition that deserve more than a passing notice. These are manifested either as chorea, (St. Yitus's dance), nervous excitement, such as night ter- rors, and various mental disturbances (misnamed hysteria), gastro-intestinal disorders, and evidences of malnutrition. The child will probably become languid, suffer with frontal headache, become peculiar in her disposition and show fits of temper, shun society of other children, lose her appetite, be- come despondent, and possibly develop a local twitching of some of the facial muscles. It is customary to say that this is all reflex, is possibly a warning that the system is undergoing some change preparatory to the menstrual functions, — that it is, in fact, a true hysteria. This may or may not be the case. Our own impression is that it is often due to the anae- mia (impoverished blood) brought about by rapid growth and 1 Published in the Medical and Surgical Keporter by Dr. J. M. Keating October 23, 1886. 164 MOTHER AND CHILD. development, with faulty assimilation and deficient oxygena- tion. The nervous system seems to run riot, but this very excite- ment in itself is an evidence of the demand on the part of nature for a blood-supply which is nutritious and well oxygen- ated. All the exercise in the world, all the most nutritious and sustaining of foods, will have no effect until the digestive organs are made to perform their normal functions. If you examine the tongue you will find it coated; the breath is foul, the bowels are sluggish, the appetite is perverted, the child craves extraordinary articles of food, especially acids and sweets. She has a disgust for her regular meals. There is flatulence, cardiac palpitation, often asthma after exertion. The urine is either scanty and high-colored or very copious and light. If the menses have been established, they are scanty, colorless, and irregular, or there is a leucorrhcea. In these cases the recommendations of popular writers for gymnastics, friction, milk diet, etc., are admirable after the digestive organs have been cleared of their accumulation and the normal func- tions whipped into activity. As far as the general treatment is concerned, the patient should be sponged every morning with tepid water; she should stand in a tub, and have a pitcher of it poured down her spine from the nape of her neck, and then be thoroughly rubbed into a glow with a soft Turkish towel. The breakfast should consist of warm milk or cocoa, a soft-boiled egg, a rare steak or chop, either oatmeal, cracked wheat, grits, or Indian meal alternating; bread and butter, not hot cakes. For dinner, soup, rare meat, fresh vegetables, ripe or stewed fruits. For supper, stewed fruits, bread and butter, warm milk or cocoa, neither tea nor coffee. She should retire early, and not be permitted to read at night. The supply of oxygen should come from out-door exercise, not an over-indulgence in walks or games that fatigue ; let the school-hours be limited to the early part of the day, and avoid that abomination of preparing long lessons in the afternoon or evening for next day's recitations. MENSTR UA TION. 165 Moderate calisthenics, or massage, should be daily given. In about a week's time the girl will be able to bear iron alone, and the tincture of the chloride can be given in ten- or fifteen- drop doses for some time, or a chalybeate water can be given with arsenic. The digestive organs will now also tolerate milk in large quantities, provided it is of medium richness, is fresh, and given warm. But this is not all. There are very many cases of a highly- nervous type which, despite the most careful treatment, will not improve at home. The constant association with parents of like temperament, however solicitous they may be in carrying out instructions, is of itself a cause of nervous irri- tation. It may be necessary to send such children from home, either to some relative, living possibly in the country or some distant city, or perhaps to some suburban or country boarding- school, where a thorough change of air and scene and the association with girls of a different temperament will work wonders. The age at which menstruation appears cannot, of course, be definitely stated, so much depends upon climate, race, social position, and family peculiarities. Ordinarily, about the age of fourteen may be taken as the average in the temperate climate. Of course, whatever tends to early development, such as warm climate, in-door occupation, and especially among those whose occupation is sedentary or where it is attended with much mental excitement pertaining to literary pursuits or the excitement from the whirl of society life at too early an age. may bring about an early appearance ; whereas the contrary may have a retarding effect. The period at which this change to pubert}" takes place is marked by a series of phenomena which show the revolution undergone by the system. For some time previous the nervous system has felt the change ; the temper becomes variable, at times uncertain. A girl who before was probably gay and boisterous in her deportment becomes timid and shy, easily em- barrassed, the slightest cause making her blush, the knowledge 166 MOTHER AND CHILD. of which may add to her embarrassment. She may notice a gradually increasing development of her figure, which annoys her and makes her shun company. Her younger companions no longer have the same charm; involuntarily she prefers the society and dress of those older than herself. The watchful mother at once recognizes the cause which is bringing about these changes, and it is her duty to gain the confidence of her child and, without exciting her suspicions or disturbing her already uncertain nervous system, lead her to understand that she is no longer a child. In this way should the matter be ex- plained to her by her mother. She is a woman, and it falls to the lot of all women who are in good health to have a certain monthly drain upon their system which is calculated to relieve the other organs of the body ; and should it appear at any time, which it is now likely to do, she should avoid all things that might check it, and take certain precautions, as rest, etc., to secure its regular return, which should be painless. As this often in many cases comes unawares, certain precautions in clothing have to be taken ; especially is this the case if the child should happen to be away from home at this time. Then, again, it is well for her to learn that the menstrual flow may at times, especially in delicate girls, be attended by severe pain, by nervous prostration, in fact, by a constitutional thunder- storm. There may be severe headache (frequent in such cases), colic, — this latter may be extremely severe ; there may be giddiness, nausea, extreme nervousness, chills or creeps, exces- sive backache, all of which may come on suddenly, following some slight indiscretion in diet which tends to mislead the person as to its true cause. "When a young girl once distinctly understands that the object of her monthly flow is to keep her in good health, — and this surely is the light in which it should be presented to her, — she will readily understand that to secure the health which is heaven's greatest blessing she must be strictly guarded as to the care of herself. She should understand that after one ap- pearance the periodicity of this function is not at once estab- MENSTRUATION. 167 iished ; there is frequently great irregularity in its return. It may last but a few hours and then return in fifteen days; it- may be copious at first and then not return for two months or more. Instead of appearing, as it should, at the time of its ex- pectation, it may appear as a bleeding from the nose, or it may be replaced by a diarrhoea or by a leucorrhcea. There are certain signs which note the advance of a period, and it is well for the mother to impress upon her daughter to watch them carefullv. Although the normal return of the period is calculated by the lunar month, really the idea that the moon exerts an influence upon this condition has no basis; this is shown by the fact that the day of return differs in women. Again, some have the normal return every thirty, others every twenty-five or twenty-eight days. The duration of the period also differs in most women ; in some it lasts three or four days, in others eight or more. The quantity also differs ; the range comprised within the area of health is widely spread. These facts are important to bear in mind ; though should any devia- tion exist from that which the mother believes to be the normal condition, she should mention the fact to the family physician, and let him be the judge of its importance. During this period of life there is a tendency in certain types of young girls to develop what is known as hysterical phenomena. !N"ow, it is well to know that what is understood as hysteria by physicians is not merely those attacks which people call hysterics. Physicians frequently hear this reply, "But, doctor, my daughter is not hysterical; she is of the most amiable disposi- tion . I know her to be extremely brave and fearless." At the same time she may be a marked subject of hysterical vomiting, or some of the paralyses. It is a difficult matter to decide whether these troubles — which are usually termed reflex by doctors, because they are sympathetic or reflected from other organs through the chain they have in common, the delicate nervous system — are due to disturbance in the generative sys- tem or are simply the result of an associated weakness, of 168 MOTHER AND CHILD. which the disturbed menstruation, the pain, or the diminished quantity of the flow is another evidence. In many cases the "womb-troubles," which may simply be irregularity of the function of menstruation, may be the cause, and rest, hot foot-baths, laxatives, etc., bring about a cure ; or it may be due to weakness on the part of the individual, poor blood, deficient out-door employment, too much standing, as is so common with store-girls, and only yield to tonics, fresh air, ample diet, and exercise. What is generally understood as hysteria by the non pro- fessional is an outburst from the nervous system upon the slightest irritation, whether pleasurable or painful. To a certain extent this is independent of any disease or even disorder of the generative system, and is solely, we regret to have to say, due to bad " bringing up." Gentle, over-indulgent, tactless parents are themselves the cause of such a state of affairs. It is not for us to study the cause of these changes in indi- viduals that produce this function, nor to describe the anatomy and physiology of the organs that are engaged in it. It is merely necessary to insist upon the fact that normal menstrua- tion should be painless, and that disturbances occurring at this time, whether in the form of local pain, headache, or lassitude, bear the same relation to normal menstruation that discomfort, nausea, and pain bear to healthy digestion. Just as dyspepsia is dependent upon indiscretion in diet, or weakened digestion from debility, so difficult or painful menstruation is the result of indiscretion at the time when care and watchfulness should be the rule, or it is the penalty paid for neglect at some earlier period. Debility in early girlhood is one of the principal causes of pain when the function is established. It is usually found in rapidly-growing girls whoso tastes have led them enthusias- tically into literary pursuits, partly from a feeling on their part that their muscular weakness will prevent their taking pleasure in the rough out-door pleasures of their more robust companions, and partly from the extreme excitability of their nervous MENSTR UA TION. 169 system, which makes them at an early age noted for their brilliancy, and which will also exaggerate their liability to pain. Such children are easily recognized, and to them the watchful mother should give her careful attention in anticipation of what their development will bring forth. Their studies should be gently directed towards those pursuits that lead them out of doors ; the muscular exercise involved in household duty should be gradually given them ; habits of early rising and early to bed should be insisted upon. There should be a judicious division of their school-hours, the selection of well- ventilated and bright school-rooms, daily gymnastic exercise, swimming, riding, and walks, — not the aimless promenading the streets, but walks that are calculated to give both pleasure and profit. There is no better way of making healthy girls than to make the various branches of science, according to their taste, a part of their education ; there is not a girl, or in fact any individual, who has not a latent taste which, with a little care, can be developed. If fond of drawing or painting, encourage it from the earliest moment: teach her to draw from nature, and she will spend hours in the open air. Botany, mineralogy, photography, will embrace the repertoire of an educated woman as well as Latin and Greek, and a woman's mind is capable of accommodating them all, if necessary. Unfortunately, the present fashion is totally at variance, strange to say, with that of the ancient days of Greece and Rome. Nowadays it seems that a person can learn nothing except in an ill ventilated school-room, in a barrel-hoop posi- tion. The philosophers of ancient days studied as hard as those of modern times, but they sought the solitude of the woods, and made their studies a pleasure instead of a task. It is not intense study that breaks so many down ; it is the confined air, the sitting in a bent posture, the loss of appetite, the muscular weakness, and the poor blood that does the harm. We wish we could impress firmly upon mothers the importance of an erect carriage in young, growing girls. It is h 15 170 MOTHER AND CHILD. not merely the case tbat stooping shoulders and curved spines make their daughters unattractive in appearance, hut such conditions are absolutely a predisposing cause of disease; and we are satisfied from personal observation that such girls are fit subjects for tuberculosis and are always more or less affected with painful periods. To correct this before the age of puberty should be the aim of every mother. Make your girls straight from habit with shoulders well thrown back, and they will avoid many womb-troubles in the future. If out-door exercise does not seem to correct this habit, there are certain movements of the muscles, — light gymnastics, — which your family physician can tell you of, that are beneficial. One of the straightest and best-formed girls we ever saw — a picture of health — owed it all to her mother, who, noticing a gradual habit of stooping, required her to lie flat on her back on the floor without a pillow for one hour each day, while she read some entertaining book to her. Another matter, which is im- portant in this connection, is the question of young girls wearing corsets. Fortunately, so much attention has been paid lately to the subject of dress in England that those whose opinion is most valuable have freely expressed themselves. We fully en- dorse the view of the London Lancet in an editorial, that cor- sets should not be worn by young women ; their dress should always be made so as to give free and independent movement to every part of the body; their garments should be light in weight, and the burden should fall as much as possible on the shoulders ; there should be no restriction of any part of the body, and if a girl's figure needs a corset to make it shapely, let her endeavor to accomplish the same end by the more natural means of muscular development, which will at the same time give health as well as beauty. A strong back is far better than a corset. Young girls should know that when the time comes for their period they should avoid everything that would either postpone it or make it painful. If a horseback excursion has been fixed for that time, some excuse must be made ; if a boat- MENSTRUATION. 171 ing-party involve exposure to the chilling air, by all means avoid it. Swimming, climbing, tennis, should be interdicted at such times. In avoiding extremes, one does not merely mean the extreme of doing too much, but also that of doing too little. The lounging about one's bedroom, or spending the whole day sitting reading a novel, will be as apt to give trouble as the opposite extreme ; it will make the circulation sluggish, tend to headache, make the liver torpid, give rise to indigestion, and weaken the system. If one is accustomed to moderate exercise, the daily avocations of life should not be interfered with ; but heavy lifting, or over-fatigue in walking, or too long standing, riding, dancing, or tennis, should be carefully avoided. We cannot lay too much stress on the importance of a careful regulation of the bowels, especially in its bearing upon the dis orders of women. Every one knows the necessity of estab lishing a daily habit, from the fact that the wastes of the body which are discharged through the intestine, if allowed to remain, decompose, are reabsorbed, and produce a certain poisoned condition of the system, made evident by furred tongue, nausea, distaste for food, disagreeable taste in the mouth, headaches, bad complexion, pimples and other disorders of the skin, rendering the individual miserable to herself and others. Constipation also allows an accumulation to take place in the bowel, which by distending it will press upon the organs that lie in contact, and cause the extreme pain so common at times, especially in the left side. Xothing should interfere with this daily duty ; but no one should use powerful purgatives icithout consulting a physician. Of course, fresh, pure water is the best laxative we know of, and a proper amount should be taken each day, usually at meals. Then fruits, ripe, raw, or cooked, should not be for- gotten, also fresh vegetables. The compound liquorice powder — a teaspoonful or more at night in milk or water — is a mild and excellent laxative. Occasionally upon rising in the morning a wineglassful of Eubinat-Condal water, Friedrich shall, Tarrant's aperient (teaspoonful), are excellent. The elixir cascara sagrada, 172 MOTHER AND CHILD. compound rhubarb pills, and Lady Webster pills are efficacious, but the latter should not be taken for any length of time nor im- mediately before menstruation. Whatever medicinal laxative is used, it should not be made a matter of daily routine ; once or twice a week is sufficient, and alternating with an enema. Gluten (Health Food Co.) suppositories or glycerin supposi- tories are often useful. But whatever means is used, the child should be impressed with the importance of regularity as to the hour, and should never vary, never let anything else call her away; and parents should see that she has a comfortable closet to go to. Many a case of obstinate constipation has come from the dread of a cold out-house in an exposed yard. The varieties of disordered menstruation are known as amenorrhea, dysmenorrhea, and menorrhagia ; the former mean- ing absence of menstruation, the second difficult or painful menstruation, and the third an unusual flow at that time. Delayed menstruation — that is, where a young girl has reached, say, the age of nineteen without the appearance of the flow — is apt to give rise to much anxiety. If this is associated with evidences of tardy sexual development, it is not of itself alarming, and cases are on record where women have married and given birth to children without ever having menstruated. But it is always well, and especially if occasional signs are present of an attempt at the establishment of menstrual flow, not to allow this state of affairs to run on long. The family physician should be consulted, as the obstacle may be a me- chanical one, or certain causes may exist which could be readily removed, but which otherwise might lead to serious disease. It is a recognized fact that the general mortality of women is increased at this period of life, and as soon as the establish- ment of the menstrual flow takes place the mortality shows a reduction. In the cases just mentioned it will be readily un- derstood that to attempt to bring on the period by hot baths, or especially by the severe and forcible means of powerful drugs obtained without the doctor's consent, would be harmful, even fatal, and we regret to say that many such accidents happen. MENSTRUATION. 173 Dr. Mathews Duncan thus writes of delayed menstruation : " Like other processes of development, that of the generative system admits of considerable variation in point of time, with- out of necessity passing the limits of health. Indeed, just as one child cuts its first tooth at seven months and another not till a year old, so one girl will menstruate at fourteen to fifteen, and another not till seventeen." Weakness or feebleness of constitution, more or less the result of city life, may be in itself another cause for this condition. We quote again from the above author : " A girl previously in good health approaches the time of puberty; some of the changes characteristic of it take place: the form assumes the contour of womanhood, and nothing but the occurrence of menstruation is wanting to announce the completion of the change. The menses, however, do not show themselves, but the girl begins to suffer from frequent head- aches ; and the flushed face, frequent backache, pains in the lower portion of the abdomen, constipation, a furred tongue, and a full pulse, and all these signs of constitutional disorder undergo a marked increase at stated periods of about a month. At length menstruation occurs, though in all probability scantily, and attended with much pain, and then for several months together there is no sign of its return. The general health was at first probably not seriously disturbed, but by degrees the patient becomes habitually ailing, the appetite falls off, the powers of digestion are weakened, the strength becomes unequal to ordinary exertion, the pulse grows feeble and frequent, and the face itself assumes a pallid, sallow tinge, whence the term ' chlorosis,' ' green sickness,' has been selected ;" and it might be added that such patients are not by any means necessarily thinner than usual. The great mistake most people make is to attribute this to disorder of the liver ; they call it biliousness, and are apt to do harm by overdosing for this supposed condition. Again, they will imagine languor represents weakness, and immediately have recourse to some strong preparation of iron or the inevitable dose of quinine, 15* 174 MOTHER AND CHILD. and then seem surprised that no improvement follows. It is the tonic influence of fresh air, healthful pursuits, exercise short of fatigue, and a nourishing, wholesome diet, of which milk should form the essential feature, that does most good, aided by those drugs which the investigation of the careful physician has warranted his suggesting to aid nature. In the treatment of this form of difficult menstruation, which is applicable as well to those cases where, from one cause or another, the period has been missed by an ordinarily healthy girl, either from exposure to cold or the result of some shock to the system, or perhaps from the debility consequent upon convalescence from fever, or some such cause, Dr. Dun- can saj-s, " The patient should be kept quiet, and if there is any considerable suffering or much disturbance of the circula- tion, it is desirable that she remain in bed, while the hot hip- bath night and morning should be rendered still more -stimu- lating, in cases where the local pain is not considerable, by the addition of some mustard." A gentle laxative should be admin- istered, such as a dessertspoonful of the compound liquorice powder, or a teaspoonful of magnesia or phosphate of soda, or, better than all, probably, a dose of castor oil. Should there be much pain, hot applications to the abdomen, either in the form of a light meal poultice or a flannel bag of hops wrung out fre- quently in hot water, in addition to a hot foot-bath. Under no circumstances whatever should the powerful irritants sold in the drug-shops for such purposes be used ; all drugs should be left for the physician to order. The use of hot teas is recom- mended, — ginger tea, tansy tea, etc., — and by such means en- deavor to encourage and not force the habit of menstruation. An excellent tea can be made from powdered ginger, senna, and dulcamara ; it is laxative, and can be used every night with no bad effects. The subject of pain during this time next claims our atten- tion. At times it is so intense as to demand immediate relief; and frequently persons, especially those who have not the mother's care or her experience to guide them, will put off MENSTRUATION. 175 » month after month the consultation with their physician, hoping that time will bring relief, and endeavor by various means to struggle through the periods which to them bring re- newed horrors, and which finally wear them out by the constant effort to withstand the pain. And what means do they adopt to obtain relief? We regret to say it, little reflection is given as to the cause of the disturbance. The period once over, they assume the same habits which have resulted in making a func- tion normally painless fraught with pain ; the same giddy life of society or the same over-indulgence in mental excitement and all that tends to enervate both body and mind. The cause of their trouble never for a moment attracts their serious atten- tion ; the treatment that they apply for their relief consists only in that which dulls their sensibility and deadens their nervous system. Alcohol in some form, whether gin or brandy, and opium, bromides, or chloral are used in large amounts, and made to play the part of the greatest curse of a house- hold. We do not mean to say that all those who suffer do so on account of indiscretion, nor do we believe that the most rigorous and careful living would at once relieve the tendencies to peri- odical pain ; but we cannot dwell forcibly enough upon the fact that those whose temperament is such that the slightest cause will result in hours of torture, can be in time relieved by rest, nutritious diet, and careful living. If there be one cause more frequent than others to which the agony of the period is due, it is constipation. When the question is asked, they will positively assert that their bowels are moved daily with regularity ; but probably a very small portion of the matter contained is passed, and a large amount remains accumulated, which presses against the tender, con- gested -ovary as a morsel of food or a filling presses on the sensitive nerve of an inflamed tooth and causes the severest form of neuralgia. We have not gone deeply into this subject, but have been sufficiently explicit to enable any one to under- stand this matter so as to prevent it. It is on this account that 178 MOTHER AND CHILD. freely by compound liquorice powder or some such simple laxative. Exposure to cold is very apt to bring this on, and it is especially liable to occur in girls who sit out of doors after dark in their thin summer clothing, and thus allow the damp, cool air after nightfall to chill the surface before the expected period. This is frequently noticed at the sea-shore or mountain resorts. How many of the gayly-dressed beauties, in their lightest clothing, will dance a waltz through and then rush frantically for a walk on the porch, and will next day suffer tortures in their rooms for their imprudence, while their friends marvel at the number of sick headaches they seem to have! Sleep, rest, — absolute rest in bed, — hot foot-baths prolonged and frequently repeated, a strong, hot, well-seasoned cup of beef-tea, are the best means of procuring relief. If the pain still continue, a hot lemonade with a dessertspoonful of sweet spirits of nitre to the tumblerful. The applications to the surface of the abdomen are usually valuable on account of their warmth ; a mush poultice well sprinkled with laudanum is useful, or a bag of hops, quilted, wrung out frequently in hot water and wet with the spirits of chloroform. Frequently a hot salt bag to the back will give relief, or the rubber bag filled with hot water. " In some of the cases, the discharge, having continued for a few hours, ceases and then comes on again, while, though scanty, it is intermixed with small ' clots.' " 'In these cases anodynes no longer furnish the ready relief which follows their administration in the neuralgic form. There are so many causes for this form of dysmenorrhea that the physician should at once be consulted, in order that the proper treatment may be instituted before the next period. Laxatives, such as the various purgative waters, give relief in these cases; the granular effervescent Carlsbad salt, a table- spoonful in water, may be taken, or a claret glass of Hunyadi water, or Friedrichshall water with an equal part of hot water. A free purgative action of the bowels should be the first thing to accomplish. If the patient is away from a physician, she should take a tablespoonful of liquor ammonice acetatis during EDUCATION AND SCHOOL-HYGIENE. 179 the painful time, when the flow is scanty, in some weak, hot lemonade every two hours, until three or four doses have been taken. Should the pain still remain severe, notwithstanding these domestic remedies, the physician should be sent for and the matter fully explained to him. It is so obviously the mother's duty to be the confidante of her child while nature is establishing these physiological processes, that we have felt the necessity of adding this chapter to our book. Most of the disorders of the nervous system which attend this time of life are directly traceable to indiscretions which are the result of ignorance. The intellectual girl of sedentary habit offends nature by retarding her physical de- velopment. The thoughtless enthusiast lays the seed of future disorders by an ignorance which the timely admonition of a watchful mother would avoid. • CHAPTEE XXXY1. EDUCATION AND SCHOOL-HYGIENE. The question of education is a most important one, and it will not be long after the child ceases to need the ever-careful watchfulness of its nurse before that problem will present itself. The Kindergarten system serves as an admirable initia- tion to more elaborate methods, and serves to interest the little one while it gradually educates its mind in the proper methods of thought, and teaches it to observe, reason, and express its thoughts. Education does not mean mere book- learning; it enters, or should do so (alas! in how many house- holds this part is totally disregarded!), into the training of a child from the date of its dawning reason. The mental disci- pline from obedience, from example, from proper surroundings, constitutes the first great educational step. Unfortunately, in this country the ambition of parents or the political manage- 178 MOTHER AND CHILD. freely by compound liquorice powder or some such simple laxative. Exposure to cold is very apt to bring this on, and it is especially liable to occur in girls who sit out of doors after dark in their thin summer clothing, and thus allow the damp, cool air after nightfall to chill the surface before the expected period. This is frequently noticed at the sea-shore or mountain resorts. How many of the gayly-dressed beauties, in their lightest clothing, will dance a waltz through and then rush frantically for a walk on the porch, and will next day suffer tortures in their rooms for their imprudence, while their friends marvel at the number of sick headaches they seem to have! Sleep, rest, — absolute rest in bed, — hot foot-baths prolonged and frequently repeated, a strong, hot, well-seasoned cup of beef-tea, are the best means of procuring relief. If the pain still continue, a hot lemonade with a dessertspoonful of sweet spirits of nitre to the tumblerful. The applications to the surface of the abdomen are usually valuable on account of their warmth ; a mush poultice well sprinkled with laudanum is useful, or a bag of hops, quilted, wrung out frequently in hot water and wet with the spirits of chloroform. Frequently a hot salt bag to the back will give relief, or the rubber bag filled with hot water. " In some of the cases, the discharge, having continued for a few hours, ceases and then comes on again, while, though scanty, it is intermixed with small ' clots.' " 'In these cases anodynes no longer furnish the ready relief which follows their administration in the neuralgic form. There are so many causes for this form of dysmenorrhea that the physician should at once be consulted, in order that the proper treatment may be instituted before the next period. Laxatives, such as the various purgative waters, give relief in these cases; the granular effervescent Carlsbad salt, a table- spoonful in water, may be taken, or a claret glass of Hunyadi water, or Friedrichshall water with an equal part of hot water. A free purgative action of the bowels should be the first thing to accomplish. If the patient is away from a physician, she should take a tablespoonful of liquor ammonice acetatis during EDUCATION AND SCHOOL-HYGIENE. 179 the painful time, when the flow is scanty, in some weak, hot lemonade every two hours, until three or four doses have been taken. Should the pain still remain severe, notwithstanding these domestic remedies, the physician should be sent for and the matter fully explained to him. It is so obviously the mother's duty to be the confidante of her child while nature is establishing these physiological processes, that we have felt the necessity of adding this chapter to our book. Most of the disorders of the nervous system which attend this time of life are directly traceable to indiscretions which are the result of ignorance. The intellectual girl of sedentary habit offends nature by retarding her physical de- velopment. The thoughtless enthusiast lays the seed of future disorders by an ignorance which the timely admonition of a watchful mother would avoid. - CHAPTEE XXXY1. EDUCATION AND SCHOOL-HYGIENE. The question of education is a most important one, and it will not be long after the child ceases to need the ever-careful watchfulness of its nurse before that problem will present itself. The Kindergarten system serves as an admirable initia- tion to more elaborate methods, and serves to interest the little one while it gradually educates its mind in the proper methods of thought, and teaches it to observe, reason, and express its thoughts. Education does not mean mere book- learning; it enters, or should do so (alas! in how many house- holds this part is totally disregarded !), into the training of a child from the date of its dawning reason. The mental disci- pline from obedience, from example, from proper surroundings, constitutes the first great educational step. Unfortunately, in this country the ambition of parents or the political manage- 180 MOTHER AND CHILD. ment of public schools educates children of the working classes above their sphere in life. Not for a moment do we mean that persons can know too much, but they can obtain a veneering of dangerous knowledge by reason of its superficiality, which only renders them unfit to assume positions attainable by knowledge, and makes them too proud to labor in meritorious work beneath their dignity. "Knowledge is power," but <; a little knowledge is a dangerous thing." Mental and physical development should go hand in hand ; overbalance in favor of the first will lead to disease ; of the latter, to brutality. A mother should remember that " the boy is father of the man ;" the child's early training and discipline will be the key-note of its after-life. The lessons of the nursery, by its mother's knee, are the beacon light of its conscience in after- years ; the seed then sown bears fruit in manhood. " A sound mind in a sound body." Dr. D. F. Lincoln thus writes 1 in regard to school-hygiene : ' ; Measured by the standard of the German schools, our chil- dren do not have much overwork to complain of. Ten hours a day, study and recitation, is a common requirement in gym- nasia (classical schools) for boys of ten to fourteen years of age; with us the work done in 'high schools' from the age of twelve to eighteen varies from six to about seven and a half hours for average pupils ; in colleges it is about eight hours, and at West Point and Annapolis nine or ten at most. These requirements for American schools are not excessive. But it is beyond a doubt that we compel younger children to attend too long. If a child enters a primary school at five, he is kept three hours in the morning and two in the afternoon, — or fully two hours too long for his good. He is kept in, nominally at work, far beyond the period for which he has the power to use his mind at the work. The researches of Edwin Chadwick have furnished us with data governing this point, 1 Keating's Cyclopaedia of the Diseases of Children, vol. iv. We take pleasure in quoting freely from this valuable article. EDUCATION AND SCHOOL-HYGIENE. 181 which have never been set aside. He states that a child from five to seven years old is able to attend to one subject for about fifteen minutes, which should be the length of a lesson ; from seven to ten years, about twenty minutes ; from ten to twelve years, about twenty-five minutes; from twelve to six- teen or eighteen years, about thirty minutes. The total power of attention for one day is somewhat in proportion to this. It is a disgrace to our communities that they insist on having the little ones sent, more to be taken care of than taught, for the same number of hours that make a banker's day. Every minute in school, after their power of attention is exhausted, is given to forming the habit of inattention, which is clear loss to education. That health must suffer, is certain. " The city of St. Louis fixes the age for admission at seven ; but there are numerous kindergartens which take younger children. The kindergarten is one of the best charities of modern times ; it teaches neglected children habits of neatness, order, punctuality, civility; feeds, washes, and clothes them when necessary; keeps them half a day in an atmosphere of physical purity and health, and must be classed as the best evidence of what schools may do for hygiene. On the other hand, the kindergartens for children of wealthy parents are not wholly free from the charge of over-stimulating their pupils. There is a constant tendency among the new teachers to urge and arouse children who are doing well enough already : I quote the words of a very experienced senior teacher. Some children, in fact, are too much aroused, and have to be re- moved ; but the danger is understood ; and, on the whole, these children also receive moral lessons that are of inestima- ble value. " The fault of the old-fashioned school was in neglecting the pupil's understanding of the subject and his interest in it. These points have now been so thoroughly studied that it seems as if lesions had become far too interesting for some children. A bright boy, making no progress in a common school, is transferred to a ' Quincy' school and becomes devoted 16 182 MOTHER AND CHILD. to study, but he has to be taken out every few months to rest his brain. The teacher ought of right to be taken out for the same purpose, but she holds out — by the aid of coffee. " A very exaggerated notion is entertained by some parents regarding the value of primary work : as if children at the age of five could be said to be students in the proper sense of the word. Schooling at that age means something radically different from what comes later. In the words of W". T. Harris, ' We do not look so much to the gain in intellectual possessions as to the training of the will into correct habits, during the years previous to the seventh.' l In protest against the popular delusion about losing no time, there is an occasional expression of individual will, like this : ' I kept my little girl out of school till she was eight (or ten) years old, and now she is up with the rest.' There is a certain number of bright excitable children who are- benefited by this postponement of school-life. . . . But the effects of anxiety are worse than those of carrying heavy loads. " It is a universal complaint among teachers that girls ruin their health by social dissipation. The complaint is justified by the facts, and it applies to almost all ages in school. The fault is in the age we live in, which exacts too much and too early display, and expresses the height of its contempt by the word ' slow.' " The parents of school-boys and school-girls ought to con- sider that ' society' has not yet begun for them, — that school is entitled to their entire strength ; in return for which, the school ought to see that the children grow into the possession of firm health. Many boarding-schools deserve praise for their success in this matter, and it often happens that children of rich and indulgent parents are never quite well except when at boarding-school, where regular hours are kept and sweetmeats are not allowed to be received from home. A return to old-fashioned, English notions about the value of 1 St. Louis School Eeport, 1872-73, p. 18. EDUCATION AND SCHOOL-HYGIENE. 183 play seems to be making, also, in boys' schools. But it is the girls that give most anxiety, because of their readiness to undertake double tasks. . . . " DYSPEPSIA. " This is an established national trait of Americans, and a familiar symptom of overwork at school. The first point to be noticed here is the fact that it is not (as seems to be popu- larly supposed) a local trouble, to be cured by some doses of medicine, but a symptom of general want of force in the system, to be cured by fresh air, exercise, food, sleep, and good regimen in general. " The school is responsible for dyspepsia, in some cases, by interfering with the pupils' opportuuities for regular meals. The old plan gave two hours of free time at noon, during which children had a good dinner ; the new plan, already in- troduced into high schools and beginning to creep into those of lower grade, keeps the child from nine to two o'clock, with no food except the wretched ' lunch' of cake and sweets, dis- missing him in an exhausted state from the day's work, to seek for more cake or pie in the cupboard, or else to await the family supper or dinner with what patience he may command. " The privilege of having a whole afternoon to one's self is so highly esteemed that we shall not probably see a return to the old plan. A modification, however, by which an hour's recess is given midway in the session affords ample time for the con- sumption of a proper lunch, as is the custom in one of the Chicago fitting-schools. " Children often lose appetite during the course of a school year, nor is this always evidence of overpressure, but some- times of mere confinement to the house and want of exercise. Some, particularly girls, have no appetite for breakfast : they must not be allowed to indulge this want of appetite. Yery many think it worse to be tardy than to lose a breakfast: they perhaps are lazy at times in the morning, or have been up late at an entertainment; or they may live a great way 184 MOTHER AND CHILD. from school, and may leave home before the family are quite ready for breakfast. Many teachers notice children occasion- ally coming to school in a famished state from such causes; it is a duty to send them home at once, with advice. " Other children there are in whom this failure of appetite is a warning to investigate the day's doings. It is fully as bad when children acquire a habit of depending on a cup of tea or coffee at breakfast. " HEADACHE. " The causes of headache are as various as those of dyspepsia. " If there is distinct excess of mental work, this will often produce increased irritability of the brain, and disturbances in the circulation of that organ. There is not a very great amount of this overwork in our own schools, perhaps. In Germany, and in the countries that have formed their educa- tional systems upon her models, excessive study is the rule, and the result is coming to light in some of the more recent statistical reports, as well as in a general popular protest against the cruel exactions that are made. . . . " The headaches suffered by hypermetropic [far sighted] chil- dren are cured at once by suitable (convex) glasses, and by no other treatment. The public ought to become aware of this rather common class of cases. The patients are literally unable to accommodate their eyes for reading without hurtful efforts. "NERVOUS DERANGEMENT. " The term nervous derangement covers a wide field. One of the common forms among school-children is sleeplessness, or restless sleep disturbed by dreams. Chorea [St. Yitus's dance] is brought on in some predisposed children by school-work. Either of these conditions should give instant warning. "A fair statement of the general condition of city public- school children has been given by I)r. C. F. Folsom: 1 'Pale 1 Six Lectures on School-Hygiene, Ginn & Co., 1885. EDUCATION AND SCHOOL-HYGIENE. 185 faces, languid work, poor appetite, disturbed sleep, headache, and what is vaguely called nervousness, are more common among them than they should be among children of their ages. I doubt whether there is an exaggerated prevalence of manifest or well-marked diseases of the nervous system among them. If due to the school-drill, my impression is that they come for the most part later in life, after the children have left school, and because of constitutions weakened during the school-years, instead of strengthened, as they should be.' " The impression which the appearance of city school-children made on the writer, when a visitor, precisely corresponded with the above statement. " Some children are extremely sensitive to the influence of their comrades. They are unfit to mingle in a crowd; they lose the power of expressing themselves in reciting; their manner betrays mental pain and constraint. The rigid air of discipline in large schools keeps many in an unnatural state. Young girls entering college sometimes suffer greatly from being obliged to live in the midst of crowds, with so much less of personal freedom than young men enjoy under like circum- stances. " CHOREA. " St. Yitus's dance is mainly a disease of the time of bodily development : the greater part of the cases occur from the sixth to the fifteenth year, which includes the second dentition and puberty. It belongs to the class of diseases which may spread by psychical contagion among children. Among the first symptoms is a change of temper from cheerfulness to fret ful- ness or apathy, and along with this the powers of attention and memory fail in a way which the teacher may be the first to notice. A child suffering from chorea, therefore, is unfitted for associating with school-children or performing school-work ; and the first step in the treatment must be to remove it from school and stop all head-work at home. There is a certain number of children who possess a predisposition to complaints 16* 186 MOTHER AND CHILD. of this sort, and are not fit members of ordinary schools, with the strain on the faculties which seems a necessary attendant upon our system of large classes and fixed tasks. Such chil- dren may develop well, if educated quietly and with much open-air freedom. f EPILEPSY. " Children liable to attacks of epileptic fits are not proper in- mates of school-houses. They are often backward, or even feeble-minded. They are usually peculiar in temper, — easily excited and falling into ungovernable rages, given to lying, and licentious. It is impossible to manage them by the ordinary course of discipline ; they are not understood by the average teacher, and do not belong in the common school, but in those special establishments where their nature is understood. Be- sides the moral danger to which their presence exposes the scholars, the occurrence of an attack in the presence of young people is a thing to be greatly dreaded. Fright is a recognized cause of epilepsy in well persons ; and a person in a fit is a spectacle quite ugly enough to frighten others into fits. Add to this the facts that childhood is eminently susceptible to nervous impressions, whether of fright or otherwise, and that most cases of epilepsy originate in childhood. " Of epilepsy as a possible consequence of overwork in school, little may be said. The connection 'is not proved, but we cannot wholly reject the possibility of it.' l " NEURASTHENIA, OR BREAK-DOWN. " A complete failure of strength, bodily and mental, is some- times the reward of excessive zeal in study. A partial break- down, implying a year's semi-illness, with a recovery to one- half the former working-powers, is rather common. High schools, normal schools, and colleges furnish the cases. . . . "Break-down is notoriously common in young women, and 1 Nothnagel, in Ziemssen's Cyclopaedia. EDUCATION AND SCHOOL-HYGIENE. 187 excess of work or some other distinct cause is usually traceable. It may occur shortly after the graduation, rather unexpectedly. " BACKACHE. " This is not the name of a disease, but is used here as desig- nating a class of cases described with admirable vigor by Haward, 1 — cases, not of spinal disease, nor of uterine disorder, but of over-fatigue. " *' It is very common,' says Haward, ' to see cases in which such symptoms (backache and weakness of the spinal muscles) are the more obvious evidences of over-fatigue, and in which a careful examination will reveal other signs of the same evil. This is especially the case with young girls of feeble circula- tion (evidenced by their cold hands and feet), whose enthusiasm for work is in excess of their physical powers. They rise early, study before breakfast, sit long hours before the piano or easel, or attend long and frequent religious services, retire to rest late, take insufficient or innutritious food, and still further ex- haust themselves by irregular and fatiguing exercise under- taken with the idea of " working off the effect of over-study." At last comes the break-down ; the poor girl who has been cramming into one day the work of six, and who has been held up by the fond and foolish mother as an example of industry, piety, and intellectual excellence, finds herself exhausted and ill. She cannot sit upright, her back aches terribly, her brain feels weak, and in her depression and anxiety she thinks she has some serious spinal disease.' " DISORDERED MENSES. " Painful or irregular menstruation is to be classed with neu- ralgia, anaemia, headache, and the like, as a symptom of over- pressure. " In 1873 a work was published which attracted universal at- tention in America, attacking, as it seemed to do, some cherished 1 Treatise on Orthopaedic Surgery, p. 148. 188 MOTHER AND CHILD. features in American education. The book, Dr. Clarke's ' Sex in Education,' was certainly written with the intention of stir- ring up discussion; and it succeeded. The author affirmed that he had seen vast numbers of women whose health had broken down, as he thought, owing to neglect of the menstrual function at the formative period, and especially owing to over- study, or, rather, uninterrupted study, during this period. The purpose was to show that girls needed special care while the menses were developing; that the healthy performance of the function is so important that no sacrifices are too great which further its proper establishment ; that for many girls hard study was one of the worst things that could be done during the monthly periods ; that a rest was imperatively called for by nature, and must be granted ' for a single day, for two or three days, or half work for two or three days.' The inference drawn from these important truisms was that girls cannot stand the strain of working side by side with boys in high schools and colleges, where it seems necessary to treat all alike on every day of the year. If Dr. Clarke had refrained from certain galling expressions, the tone of the rejoinders would have been milder ; but his end was attained, and the public was the- gainer from the prominence given to the question. " The replies made to Dr. Clarke showed that many women are, apparently, complete exceptions to his rule in regard to an abso- lute need of rest every month. One such exceptional lady, in her book, incidentally states that she has stood ten hours a day in a store for five years, without the least trouble ; a remark which may be improved by us as the occasion of proposing a new rule for mixed high schools, — namely, that in the upper classes girls ought never to rise in recitation. Opinions may certainly differ on the point of rules for school-government, but at this day there are many masters who are accustomed to make allowance for girls, even to the extent of never giving penalties for absence. If this does not meet the case, the remedy ought to work through the feminine tact of assistants. A little want of tact .may spoil the arrangement ; a word of EDUCATION AND SCHOOL-HYGIENE. 189 complaint about frequent absences may appeal to the pride of the girls in such a way that they will accept no more favors. It was Clarke's opinion that girls could get through as much work as boys, on the whole, ' working in their own way.' " The principal of the St. Louis Normal School states 1 that ' excuses relieving the students temporarily from work are granted, whenever asked for on account of sickness, without further explanation ; and I may say that it is my belief that this privilege has been of great advantage.' The school in question is exclusively for young women. " CONSUMPTION. " There is reason for believing that this disease is rather fre- quently caused by school-influences, though it would be hard to say how frequently. The story of the cases brings to mind those of 'general break-down,' — the familiar 'nervous pros- tration ;' the general list of causes is the same, — bad air, con- tinued overwork without rest for repair of waste, — and the difference in the effect is doubtless largely due to hereditary predisposition. "Bad air is notoriously influential in causing consumption. ' The impure condition of the air of our houses, be they fac- tories, public buildings, or dwelling-houses, has much to do with the great prevalence of such diseases as phthisis pulmonalis, bronchitis, and pneumonia, which together make up nearly one- quarter of the total mortality. . . . Unventilated and crowded workshops and schools are, moreover, the nurseries of strumous diseases in general, which sap the strength of the community.' " The following observations by Parkes bear upon this point : ' Usually a person who is compelled to breathe such an atmos- phere [vitiated by respiration] is at the same time sedentary, and perhaps remains in a constrained position for several hours, or possibly is also under-fed or intemperate. But, allowing the fullest effect to all other agencies, there is no 1 Report of Public Schools for 1878-79. 190 MOTHER AND CHILD. doubt that the breathing the vitiated atmosphere of respiration has a most injurious effect on the health. Persons soon be- come pale, and partially lose their appetite, and after a time decline in muscular strength and spirits. The aeration and nutrition of the blood seem to be interfered with, and the general tone of the system falls below par. Of special dis- eases it appears pretty clearly that pulmonary affections are more common. Such persons do certainly appear to furnish a most undue percentage of phthisical cases, — that is, of destruc- tive lung-disease of some kind.' " Carmiehael (1810) and Neil Arnott (1832) describe cases where the diet of schools was excellent, and the only causes for the excessive phthisis were the foul air and the want of exercise. In fact, medical testimony lies all in the same direc- tion. The presence of dust in the air is a very frequent cause of bronchitis, asthma, or pneumonia in various trades, and ought to be mentioned here. Consumption has been a terrible scourge to the British and other foreign armies, chiefly owing to the impure air of the barracks. The same is true of the navy; of prisons in general; of monkeys in menageries, and other unhappy confined creatures. " In America the experience of Prof. H. I. Bowditeh as a specialist has led him to utter repeated warnings to the mis- guided parents who urge their weakly children beyond their powers. The following quotation outlines the history of this class of cases : " ' A young person, male or female, walks into my study for the purpose of consultation in regard to health. I observe great paleness of face, extreme emaciation, and trembling steps, combined with a slight cough, and evidently more or less diffi- culty of breath. These, if combined with a certain intellectual expression of the face, almost immediately enable me to fore- shadow a history somewhat as follows : " ' Stimulated by ambition to be in the front rank of scholar- ship, and desiring, owing to poverty or the known wishes of parents, to obtain rapidly an education, the poor, scarcely de- EDUCATION AND SCHOOL-HYGIENE, 191 veloped child has beeu laboring for months, always overwork- ing intellectually, and at times also physically. Perhaps the victim has been carried many miles daily to and from school. Study at school, in the cars, and after return at night, some- times twelve to fourteen hours, has been the daily rule. [In one case the girl went forty miles daily to and from school, in all weather, winter and summer.] " ' Of course, utter prostration is the result. The appetite fails or becomes capricious under severe fatigue and irregularity of meals. Gradually a cough is noticed, and it is thought " a cold has been taken." . . . " 'The cough and the educational race continue on together. Finally a failure of strength manifests itself, and then, for the first time, the parents begin to look with concern at the ap- pearance of their child. But neither child nor parent thinks of giving up school. Perhaps it is towards the end of the term. " Only a few weeks more," and the coveted prize will be gained, and then rest and cure can be attempted. ... At last the long-wished-for goal is reached. The first honors are gained, but they are now of little comfort, for all strength, which has been artificially kept up by the excitement of the race, suddenly leave the patient, and the pupil does nothing afterwards. . . . All ideas of cure, or even of partial relief, have disappeared.' . . . " It is important to note that the blame for such abuse of life is placed upon the parents, rather than upon any stimulus supplied by the teachers. " If a child has hereditary tendencies to consumption, it is imperatively necessary to select 'a proper, reasonable, well- ventilated school (especially one in which the frequent opening of windows is avoided). No overwork of mind or body should be permitted. If the health fail at all, absolute removal from school is required ; travel or anything else should be under- taken that will interest and keep the pupil from books and out of doors, and let the education, so called, take care of itself " In another place the same eminent authority remarks that 192 MOTHER AND CHILD. 'in a consumptive family the steadfast rule should be, that the mind be wholly subservient to the body's welfare.' " In a report on the causes or antecedents of consumption, the opinions of two hundred and ten correspondents were summed up as follows. The question having been put, ' Is consumption ever caused by over-study at school or college ?' the answer ' yes' was given by one hundred and forty-six ; ' yes, indirectly,' by seven ; ' no,' by twenty-one ; ' doubtful,' by ten; and twenty-six gave no answer. " The circumstance that residence on a damp soil is one of the most powerful predisposing agents to consumption ought to have its influence when the site of the school-house is selected. " Here we may end the description of the ailments commonly grouped together when the effects of overwork are described. Spinal deformity and near-sight are susceptible of being classi- fied with these, for weakness is an element in both. It is more suitable, on the whole, to describe them separately, on account both of their special importance and of their mechanical rela- tions to desks and seats. "SPINAL DEFORMITIES. " Under this heading belong two distinct affections, — lateral curvature and round shoulders. With the latter is associated the ' hollow back' or excessive curve at the loins. Lateral curvature is the object of our present study. " Lateral curvature, in the popular eye, is an inelegance of person, surmountable by the aid of the dress-maker. The physician sees in it a consequence and a cause of low vitality. ' ; The great majority of cases of this curvature originate in children from the age of five or six upward, and in young persons who have lately been in school. This might be thought a mere coincidence ; for the school-period is necessarily the period of development, and the curvature is a disease of development. But there is evidence that school work and EDUCATIOy AND SCHOOL-HYGIENE. 193 customs are genuine causes, — not by any means the sole causes, but rather prominent ones. •• The origin of lateral curvature depends chiefly on two things, — weakness of the muscles which support the spine, and bad positions of the body. Weakness, however, is not a necessary circumstance, though an extremely common and often important one. A bad posi- tion constantly maintained will Fig. 17. ' Fig. 18. twist the most athletic frame. A very muscular person may be forced to stand in a one-sided position by the circumstance of having one leg shorter than the other. Pig. 17 gives a rough but sufficient idea of the way in which the body is sup- ported on the legs. If the right leg is shortened (Fig. 18), the pelvis (^~^0 or hip-bone will be tilted to the \_j^yC right, and the lower part of the spinal column, being firmly attached to the pelvis, will tilt with it. If the whole spine remained straight, the person would be thrown off his balance ; the spine must therefore curve to the left at a higher part; and further- more, to make up for the overweight thrown to the right below, there occurs a ' compensating' curve to the left at the height of the shoulders. In addition to this, the spine is in parts twisted, with a gimlet-motion ; but this is not represented here. ; - A similar thing happens when children stand on one leg, — a position which practically shortens the other leg. • A most pernicious habit, and one which is very often to be noticed in school-girls (I think I have observed it in girls more frequently than in boys), is that while we are talking to them, or during recitations, especially if they are much interested in what is going on, they are standing on one leg. The position is assumed in 17 194 MOTHER AND CHILD. involuntarily, and it is always, or almost always, one and the same leg on which the weight is thrown. The effect of this is easily understood : one side of the pelvis is lifted up, curv- ing the spine in the loins ; the opposite leg is advanced in front of the other, twisting the pelvis and rotating the verte- brae. Of course the curve of compensation takes place be- tween the shoulders. One is depressed, the shoulder-blade gradually projecting, and with the change, and in fact assist- ing to produce it, occurs the spiral twist. 71 " Many curvatures begin in the region of the shoulders ; of these, beyond doubt, the cause is largely to be found in false positions in writing or drawing. ' I have visited rooms in which drawing was taught,' writes Brown, ' where all, — male and female, — with scarcely an exception, were sitting in a position not only to curve but to twist or rotate the spine, and in most the position was such as to produce a triple curve.' The deformed attitudes (so to speak) assumed in writing are powerfully described by Lie- breich. Such occupations can hardly be conducted in entirely normal postures, but a great deal can be done to correct tbe grosser faults. One cause of the defect is the raising of the right shoulder by a high desk Fig. 19. or table, as is seen in the sketch (Fig. 19) borrowed from Guillaume. " Another frequent cause ex- ists when the desk is too far from the seat, and the pupil is forced to bend over his work in an unbalanced posture, which cannot be maintained ; in a short time, if not at once, he leans one side forward, puts elbow 1 Lecture before the American Social Science Association, 1879. EDUCATION AND SCHOOL-HYGIENE 195 on desk or knee, and head on hand, and gets his spine into the shape of a corkscrew. "It is desirable that every person directing or teaching a school should have a notion of the proportions suitable for desks and seats. Farther on, this matter is illustrated with a few representative figures. Eut it is of the greatest conse- quence to remember that no seats or desks can be devised which will remove the original iceakness of muscle, which ranks as one of the two chief causes, and would by many be named as the one important cause. Children cannot be made strong by supports. . . . " That muscular weakness is a chief cause is further shown by the treatment which is successful, consisting essentially of prolonged and perfect rest to the weak muscles, by reclining, combined with occasional moderate yet active exertion of the muscles by appropriate exercises. Cases that are not far ad- vanced may do well by using scientifically directed gymnastics. Some need never be told that they have ' anything the matter with the spine,' provided they can be got to change their habits of living. " These principles need to be applied to the prevention of spinal curvature in schools. The preventive treatment should consist, when possible, of very varied muscular activity of an active sort, taken at proper times. The best kinds are out-door games of an athletic tendency, — leaping, running, coasting, skating, climbing, and all sorts of ' hard play.' For boys, wrestling, foot-ball, and boxing, and many more, may be added, ^o doubt, children must be kept from excesses, such as trying to make a high score with the skipping-rope. Some sports have a tendency to develop curvature, — croquet, decid- edly; tennis, — when played with one hand; base-ball; horse- back-riding on a one-sided saddle. Ladies should use two saddles, one for each side alternately. Sports liberally indulged in are, with this class of exceptions, the usual and natural pre- ventive of spinal curvature among boys; if girls played out of doors as boys do, they would have little trouble of that sort. 196 MOTHER AND CHILD. " The physical indolence of girls, however we may deplore it, is Dot to be overcome at once. It arises in part from their unwillingness to assert themselves as boys do ; their readiness to submit to custom; and their power of sacrificing comfort (i.e., health) for the sake of propriety. The misguided sense of decorum, which prevents even walking in many cases, is the same feeling that, neglecting certain of the lower func- tions of the body, leads to the prevalent habit of constipation, and occasionally to disease of the bladder. Every argument, therefore, in favor of bodily training, or of the teaching of gymnastics in schools, should apply with double force to the female sex. " The programme of a girl's life consumes the greater part of the day in sedentary occupations. Sewing, piano-practice, drawing-lessons, embroidery, are among the added burdens of the life of girls at home. If parents cannot be induced to take active steps for their children's physical training (and 1 fear they cannot), the school must undertake the task, on be- half, at least, of the girls. " The existence of spinal deformity has not yet received due attention from our public. It is hard to get at the facts. There are very few collected observations of masses of chil- dren. Parents would dread the exposure of their children ; but perhaps the popular mind would not object to a lady sur- geon for girls. ~No figures are procurable from female colleges, though the very great prevalence of curvature is admitted. The late Dr. J. C. Warren in 1830 stated that of the well- educated females within his sphere, about one-half were affected with some degree of distortion of the spine. It is not a wild guess to suppose that this is nearly true at present. " Spinal curvature is not only a product of low vitality, but it does harm by permanently fixing vitality at a low standard. The spiromctric observations of Schildbach (Amsterdam, 1862) showed that the respiratory capacity of this class of children at the ages of from thirteen to seventeen was lessened by one- EDUCATION AND SCHOOL-HYGIENE. 197 third, and in some cases by one-half, — a matter of the gravest importance in the maintenance of life. " Brown calls attention to the fact that too much mental stimulus has an undoubted effect as one of the predisposing causes of spinal curvature. Mental rest combined with other appropriate conditions will sometimes cure the trouble in its incipient stage. " The disease may exist in a fully-developed form without any apparent change in the direction of the spine as seen from be- hind, even when the body is stripped : this is because the twisting may be confined to the bodies of the vertebrae, which are out of sight. The first thing usually noticed is that "the shoulder grows out," or else is higher than the other one. The ribs partake, and the chest is twisted out of shape. "Patients may sometimes be kept in school who need special seats. This is a matter for the surgeon to decide. "DESKS AND SEATS. " The improvement which has been made in American school- desks and seats within half a century is very great. Few city schools are now unprovided with ' modern' furniture, which in most cases is decidedly better than the old. It is to be hoped that the excellence already attained will not stand in the way of further progress. We have been quite successful in reaching our ideal of comfort ; but we ought not to forget that the subject has been much studied, from various other points of view, by German and other investigators, and with- results which certainly differ from ours. "Bad desks are chargeable with aiding the formation of two of the most important < school-diseases,' — near-sight and spinal curvature. They cause the first by compelling pupils to hold the eyes too near the object, and by favoring a stoop- ing position at work. Spinal curvature is very much assisted by the twisted postures which children take, especially in writing. " Let it be understood that it is not our object to make desks 17* 198 MOTHER AND CHILD. and seats which a scholar can occupy with comfort, assuming and maintaining one 'normal' position, for hours at a time; no, nor for one hour. It is not possible to do this ; and, if it were, it must needs injure the child. The discipline of a school is a precious thing, but it should not interfere with the child's need for change of attitude; nor must the teacher fancy that in prescribing fixed attitudes he is following the dictates of 'medical science.' Attitudes assumed for a few moments, for purposes of respect and attention, may properly be formal ; attitudes in study should be decent, but may be as varied as possible, subject to correction when they become in- jurious. The teacher should be a judge of the latter fact. Especially should liberty be given to the younger classes. There is indeed a great difference between the mobility of a kindergarten and the studious self-possession of a high-school class at the age of sixteen or eighteen. " Strength cannot be gained by maintaining any one posture, unless in the sense that a comfortable posture gives strength by resting the muscles. If a comfortable position is given, let the child not be kept in it till rest itself is fatigue. "As standing is undesirable exercise, so is sitting in a chair without a back. It will not make the child's back strong, but only causes fatigue, and drives the child to take all kinds of unsuitable positions for relief. " The young pupil should have a scat and desk so well adapted to its form that it will be tempted to take the most correct position, as being the most comfortable. It will not keep this position long, however comfortable it may be, but it will return to it after making its little excursions and changes, and will by degrees become accustomed to a normal position without much being said about the matter. " Little children may properly be taught to sit still, facing squarely to the front, for five minutes at a time, when circum- stances favor it. They may be taught, by degrees, to sit ten minutes, but not through a school-session ; every rest must be made up by a corresponding activity, — a change or a move- EDUCATION AND SCHOOL-HYGIENE. 199 merit, a song or a bit of gymnastic drill. Movement is a child's way of resting : rest is a kind of work, to be taught by degrees. "As regards faulty positions, stooping contracts the chest and compresses the abdominal organs. The child, sitting erect, and wishing to bow the head towards the book, may be shown that a very slight movement will accomplish that object, — a hinge-movement at the upper part of the neck, and not at the shoulders. The trunk does not need the support of the elbows on the desk. One-sided positions easily become habitual, and are then exceedingly objectionable : they are chiefly caused by propping the arm or elbow on the desk. " A comfortable back for the chair is best secured, not by giving a series of marked curves intended to follow the natural Fia. 20. curves of the body, but by giving, first of all, an emphatic support to the lower part of the spine. The writer was re- cently shown a rather stiff-looking seat, of which the dealer remarked that all those who sat down in it at first said ' no,' but if he could induce them to remain sitting fifteen minutes 200 MOTHER AND CHILD. he was sure to sell it. The seat in question has a flat bottom, sloping a little down and back ; the back is tilted, and is com- posed of two flat surfaces set together at an angle so small as hardly to be noticeable, — the projection being one-quarter of an inch from a straight line. (See Fig. 20.) This chair, sup- porting the pelvis solidly, gives great comfort. A somewhat greater projection of the lower middle part of the back might be useful. " This principle, which the writer is convinced is of the greatest value, may be carried out in other ways. The matter Fig. 21. Fig. 22. Liebreich's desk and seat. Varrentrapp's desk and adjustable seat. is not wholly settled, as may be seen by comparing Figs. 21, 22, and 23, given by different authorities. Liebreich's chair (Fig. 21) is intended to support the pelvis by following its outline by a curve up into the small of the back : the projection of the curve may be too great. Fig. 22 (Varrentrapp's), and the unshaded spaces in Figs. 23 and 24, give the impression of stiff- ness; they come to the height of the elbow, and give support solely by a horizontal cross-bar at the top, allowing a little open space below the bar. It is noticeable that many of the later German plans proposed by scientific men give support in EDUCATION AND SCHOOL-HYGIENE. 201 Fig. 23. J mm////mi/i \ — r s n Varrentrapp's seat and desk compared with a Boston school-chair aud desk (see Fig 25) for corresponding ages. Fig. 24. American curved-back seat and desk (shaded), and Buchner's pattern, for corresponding ages. 202 MOTHER AND CHILD. this way. Their object is to enable the child to sit erect while writing, with the aid of a partial support, not necessarily used at all moments : it is thought that such a support gives the habit of a correct attitude. Buehner was an inspector of schools : he says, ' The children very soon feel that the per- pendicular piece supporting the small of the back corresponds with the structure of the body much better than the slanting back which supports the shoulders. I often used to ask the children whether they would not like to have a rest for the shoulders, as well as for the back, but the girls always an- swered in the negative.' Cohn and Fahrner are also in favor of the low support. It is of wood, two and a half to three inches broad, and long enough to be reached by both elbows, which may rest upon it when the child is not writing. It must not be placed too high, or it fails to give due support. " It may be doubted whether a low back-rest of this kind or a slightly-inclined rest for leaning back, supporting shoul- ders as well as pelvis, is, on the whole, the better. The present writer is not in a position to decide ; yet a choice must be made, since it seems impossible to secure a resting-chair which shall also give support in writing. " The popular American school-seat, with its back curved like a long italic /, is not an ideal model. It is comfortable, — at least some are, for there are varieties. Some of them let the body slide down so that upright sitting is impossible; others are too low, which tends to increase the constriction of the abdomen ; as a rule, they give the body a round-shouldered position, being essentially lounging-chairs with the head-rest cut off. Fig. 24 gives a good pattern. " Our common wooden chair, with the back-sticks set in a curved line, quite fails to support the pelvis; in fact, its defi- ciency in this respect is a positive annoyance. Fig. 23 shows a chair with this fault. It is built thus to give strength ; this is better secured in an old pattern which prolongs the middle piece down to the pedestal, following the dotted line, and so is able to bring the side-pieces in line with the middle piece. EDUCATION AND SCHOOL-HYGIENE. 203 "Fig. 21 gives Liebreich's desk and seat, as designed for the London School Board. The desk remains the same; the ac- commodation for different ages is made by changing the chair and moving the foot-rest. The shape of the seat is slightly different for the two sexes. The lid is hinged so that it can be thrown into a convenient book-holder for reading. In writing, the chair is placed so near that the edge of the desk just touches the body. The height of the seat is correct when the sloping line of the desk, prolonged, just touches the elbows. " Fig. 22 gives the design for the desk and seat published by the late Dr. George Yarrentrapp, of Frankfort-on-the-Main, in the Vierteljahrsschrift fur Gesundheitspflege for 1869. It is the one from which the unshaded spaces in Fig. 23 are taken. The desk remains the same for different ages ; the seats are of different sizes, the dotted outlines corresponding to larger pupils. " Fig. 23 gives a side-view, drawn to scale, of a highly-ap- proved American school-seat, of a size intended for pupils from ten to twelve years old. The position of the lid of the desk is also given. The unshaded spaces show the position of correspond- ing parts of the model designed by Yarrentrapp, of dimensions suited for children of the average height of one hundred and forty-three centimetres, which for American children repre- sents a little over twelve years. The lower edge of the desk, measured from the seat, is 4 J centimetres =1.8 inches higher in the American than in the German seat. The German back- rest is on a level with the desk, and the pupil while reading can easily prop his elbows upon it, maintaining an erect posture. " The dimensions, in centimetres, are as follows : £< &, O o iZ?2 o^ gg £~ H H H « K M "t" H 5 2§hm B £52 w z a ft < m PL, American . . . 36.9 64.8 27.9 (35) 30 5.2 Varrentrupp . . 40.2 63.6 23.4 23.4 23 2.6 204 MOTHER AND CHILD. " Fig. 24 gives the side-elevation of two full-sized desk-seats, drawn to scale. The American desk is the largest size of one of the most popular kinds. To correspond with this, Buchner's tables were taken, and the dimensions calculated for a person five feet six inches in height ; the lines of desk and seat are given with shading for the latter case. The difference between the heights of the desks is nearly 4 centimetres = 1.6 inches. The difference is increased, practically, by the downward and backward curve of the American seat. " The dimensions, in centimetres, are as follows : o S < o IS Seat projects UNDER Desk. H w «« w a ! S^nrP.Wr Stimulate, if necessary. Give an alkali 0xahc ' I Stimulate, if necessary. Carbolic, J L ' J SURGICAL EMERGENCIES. 273 "Poison. Alkalies : Hartshorn, i Soda, j- . . Potash, Lye, J Arsenic : Paris green, Scheele's green, Acetate of Lead : •> Sugar of Lead, j Corrosive Sublimate, -» Tartar Emetic, j Phosphorus Nitrate of Silver r Treatment. Give an acid (vinegar) ; Provoke vomiting ; Give hland liquids ; Secure rest ; Stimulate, if necessary. Provoke vomiting ; -\ repeat sev- Give dialyzed iron and salt ; J era! times ; Give dose of castor oil ; Secure rest; Stimulate, if necessary. Give Epsom salt ; | repeat seyeral timeg Provoke vomiting ; i Give bland liquids ; Give dose of castor oil. } repeat several times : Iodine Opium : Morphine, Laudanum, Paregoric, etc. Chloral, Strychnine Aconite, -\ Veratrum Viride, j Provoke vomiting ; Give strong tea, without milk ; Give raw eggs and milk ; Give dose of castor oil ; Stimulate, if necessary. Provoke vomiting ; Give five-grain doses of sulphate of copper, or teaspoonful doses of turpentine ; Give dose of magnesia, but no oil. Give strong salt-and- water ; \ repeat many Provoke vomiting ; J times. Provoke vomiting ; Give starch-and- water ; Give bland fluids. Provoke vomiting repeatedly ; Give strong coffee, without milk ; Keep up the breathing. Provoke vomiting once or twice ; Give a purgative ; Secure absolute quiet. Provoke vomiting ; Stimulate well ; Keep head low. f Provoke vomiting ; I Stimulate well. 274 MOTHER AND CHILD. " Poison. Treatment. Jamestown Weed, Hemlock , Nightshade (belladonna) , Toadstools, Tobacco, Alcohol j Provoke vomiting ; I G-ive hartshorn-and-water. {Provoke vomiting ; Give a purgative ; Give powdered charcoal. u t jp rovo ] ie vomiting, warm water may be used, with or without ground mustard (a teaspoonful to half a pint of water), or ipecacuanha (a teaspoonful of the powder or a tablespoonful or so of the syrup), and titillating the fauces. It is best to give large quantities (half a pint at a time) of warm water whenever vomiting is to be excited. " Bland liquids are milk, raw eggs, some sort of oil, gruel, etc. " Stimulants are tea, coffee, whiskey, wine, etc., or hartshorn- and-water. A teaspoonful of hartshorn in a teacupful of water will be enough for a dose. In making tea or coffee one must not wait to do it as if for the table, but mix hot water and the leaves or grounds, squeeze them well, stir together, and give the whole, — leaves, grounds, everything. At the same time, some may be made regularly, if there are con- veniences for it. " Alkaline antidotes are hartshorn-and-water (a tablespoonful in two teacupfuls of water), soap-and-water, lime, whiting soda, chalk, tooth-powder, plaster, magnesia, whitewash, and even wood-ashes. " Acid antidotes are vinegar and lemon-juice. " In giving an antidote, never wait for it to dissolve. Just stir it up in any fluid at hand, except oil, and have it swallowed immediately." FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 275 CH-APTEE XXXYIII. FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. There is no more important subject for us to study than that of ventilation, by which we mean the getting rid of foul air and the entrance of pure air in as easy a manner as pos- sible, free from draughts. We all know that cold air passing through a chink, and then striking against some sensitive nerve-point on the surface of the body, has a peculiar faculty of abstracting heat, or giving what is known as ' ; a cold," affecting the mucous membranes. Of course, the more deli- cate or the younger the individual the more susceptible he will be to such an impression. There are certain parts of the body very susceptible to these currents of cold air ; these are the face, neck, and feet; neuralgia, sore throats, and colds in the head being the consequence. But it is to be observed that these draughts are more apt to make themselves felt when the parts on which they strike are in a state of relaxa- tion ; naturally, should there be perspiration, its evaporation would intensify the cold impression. "When children, then, after active play, and perspiring freely, sit in a room in a draught, they will take cold, while, on the other hand, they might continue their play in a colder room and not feel it; the action of their muscles, the excitement, giving them an immunity which they would not have in a state of quiescence. It should be our object, then, in the choice of a nursery, to have a room, or two rooms communicating (when speaking of these matters we specially refer to city houses), as far removed as possible from the contaminations and filth of the streets. The play-room should be large, should be situ- ated in the second or third story, and should have the sun- shine in it at least part of the day. A child's room should 276 MOTHER AND CHILD. have no communication whatever with a bath-room, water- closet, or stationary wash-stands. Children are peculiarly sus- ceptible to the effects of sewer-gas, or sewer-air contaminated with germs, and many a case of diphtheria, or so-called mem- branous croup, has succumbed to the subtle influence of the poison of the disease which has most insidiously been con- veyed to the air of the room through traps that the plumber has pronounced absolutely safe. We have witnessed such distressing scenes in the houses — one might say palaces — of the wealthy, have seen such frightful cases of malignant diph- theria where money was no object in making the house perfect in all respects, but where, unfortunately, ignorance or avarice on the plumber's part allowed a deadly leakage of non-odorless sewer-air to go directly to a babe's room, that we feel we cannot say too much by way of caution. Of course, for a few weeks the new-born babe will sleep with its mother; if it is a strong and vigorous child it may be put in a crib or bassinet by her side. The great objection to placing the child away from the mother is that, after the nurse leaves, she will have to reach for it, and if her room is cooler at night, as it should always be, there will be great danger of her taking cold when she nurses the baby. On this account, the child's crib should be placed as near as possible to the mother's bed, or she should allow it to sleep in the bed with her, but so placed that it will have a portion of the bed entirely to itself. The child is, certainly, after a couple of months, healthier when sleeping alone. For the first month, at least, after birth, while the nurse is still with the mother, she should take charge of the infant and bring it in to nurse at the proper hour. The choice of a nur- sery and sleeping-apartment is a matter of great importance. The essentials are purity of atmosphere, uniformity of tem- perature, and freedom from dust and gases which may arise from methods of heating ; especially is this the case with faulty hot-air furnaces. There should be plenty of sunshine when possible. At the present day. with our extended knowl- FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 277 edge of the causes of disease, impurity in the atmosphere has assumed great importance ; we are now able to recognize the fact that certain diseases which were hitherto attributed to cold, are in reality due to filth ; that certain other intestinal disturbances which were attributed to heat, are in reality due to decomposed or fermented food and to bad milk, These facts are most important to bear in mind, not only to enable us to cure disease, but also because, by a thorough recognition of them, diseases or disorders which have been attributed to climacteric disturbances, may, by the timely institution of hygienic measures, be avoided. There is no reason why a child that has a well-ventilated, clean, bright nursery, whose milk is watched with zealous care and never allowed to become tainted, one who is daily bathed, not overfed, neither debili- tated by too heavy clothing nor subjected to daily fluctuations in bodily temperature, should not pass through the summer season in a city unharmed by the so much dreaded summer weather. We mention this because, probably, many mothers who read this book cannot afford to spend the summers out of town. A nursery should always have an open fireplace for ventila- tion, and a counter-opening should be made over the window, so as to allow the air to be changed with the least draught possible ; this can be done by pulling down the top sash and inserting a four-inch strip of board to keep it down ; by this means an indirect current will be made between the sashes. Of all the methods of heating, probably the most used, but, unfortunately, the one that can be most abused, is the hot-air furnace. Parents should see that their nurseries are supplied with air that is, first of all, pure : it must be taken at as great a distance as possible from the ground, and not immediately off gutters and damp yards, as is very frequently the case. The air most charged with atmospheric impurities, whether they be germs or gases, is that which is usually heated and sent to the nursery ; the heating simply making it more poi- sonous than before. The heated air should be passed over a 24 278 MOTHER AND CHILD. surface of pure water, by which means it will receive a cer- tain amount of moisture, and should then be carried, as free from dust as possible, directly to the nursery. Air which is not passed over water, but simply dried, will undoubtedly pro- duce various forms of irritation of the mucous membranes, dryness of the throat and nose, languor, — symptoms which we all recognize at once. Certainly nothing can be better than an open grate, with a wood fire, even if it be only oc- casionally used, to supplement the furnace, especially at night ; but we much prefer a system of hot water and indi- rect radiation for the heating of houses in our changeable climate. We have always insisted that either an earthen water-vessel which comes for the purpose be filled with water and placed in front of the "register" in the nursery, or else a basin of water with a towel dipped into it, the upper corner of the towel being pinned above the register. In a sick-room the water can be medicated, if necessary. The sleeping-room should be heated through the nursery, if possible, and should be occupied only at night. Of course, these matters are difficult to control, but at the same time, if parents know what ought to be done and take an interest in the matter, — think for themselves, — many arrangements can be made to overcome temporary difficulties which at first seem insurmountable, and thus render a dreary, unhealthy nursery healthful and habitable. The nursery should always have a thermometer, and the temperature should be kept at about 68° or 70° F. The heat should be always shut off at night, and the bedclothing so arranged as to prevent its being thrown off while the child is perspiring during the early morning hours, when the system is most depressed, and at which time the danger of catching cold is most imminent. For an infant, the sleejnng-room should be kept as much as possible at the same temperature day and night. Avoid all sewerage arrangements — pipes of every kind — in a nursery. The science of ventila- tion and house-drainage gives us probably as perfect a system FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 279 as we shall ever have, but, unfortunately, the slightest fault of construction will turn the otherwise harmless contrivance for our comfort into one of the most deadly ; and there is no means by which we can detect the presence of the sewer-air that serves as a carrier of the poison of diphtheria or typhoid fever, any more than there is evidence of the existence of their germs in drinking-water. The most costly habitations of the wealthy have these dreaded diseases carried into their midst to a greater extent even than is found among the poor. The classes of persons who suffer most from diphtheria are the very wealthy and the very poor. Those of moderate wealth guard their children carefully against cold, in the first place, and their limited means prevent them from having those lux- uries by means of which the deadly sewer-air is carried into their bedrooms. Physicians believe that diphtheria most fre- quently requires a cold, a catarrh in the throat, before the poison is thoroughly absorbed, and probably this accounts for the resistance which is observed in so many cases to an attack in the summer. Just as soon as the child takes cold, becomes a little run down, that dreaded disease will show itself. The drinking-water should be pure ; when there is the least doubt about its purity it should be boiled. We think every household would be safer in having a Pasteur filter. " A stitch in time saves nine;" a little expense and trouble may save a loved one from death by typhoid or diphtheria. It should also be remembered that ice is a great carrier of dis- eased germs ; in fact, that the freezing process merely benumbs them to render them as virulent as ever when thawed. If possible, only artificially-made ice should be used, and if it cam not be obtained, the strictest care should be taken that natural ice, from however pure a source, should not come in contact with the infant's food. With the Pasteur filter comes a " cooler" by which the water can be cooled. Iced water is not healthy for children ; water should be cool, not cold. We have laid great stress on the importance of thorough ventilation and fresh air, but we wish it distinctly under- 280 MOTHER AND CHILD. stood that constancy in the purity of air, both day and night, is not only requisite in the nursery, but also in the sick-room. Cold air is not necessarily pure air, nor is air which is warmed made impure by warming ; at the same time it should be remembered that air filled with germs of disease, warmed by a "heater," may become most deadly when carried to the sleeping-chamber. A child's vitality is lowered at. night, its circulation is slower, its resistance to disease is less. A person sleeping and chilled is much more liable to take cold than one who is awake ; especially is this so in childhood and old age ; but the temperature of the sleeping-room may be reduced at night (the heat being turned off), with benefit, if the child is covered — not enough to induce perspiration — and the cloth- ing so arranged as not to be thrown off. Of course, a child, up to at least six months, should be kept in a room which has as nearly as possible the same temperature day and night, as it sleeps most of the time, and when taken out of doors is so warmly clad that the change of air cannot affect it. To sum up, then, a nursery, or child's living-room and bed- room, should be kept scrupulously clean, thoroughly aired, and should be free from dust ; dust, independently of its irri- tating character upon the mucous membrane, is the means of conveying disease. The room should be swept with a patent sweeper, and the dust which has accumulated should be care- fully wiped off the places of its lodgement by means of a damp cloth. The ideal nursery floor is one of hard wood, well laid and polished, with rounded corners, and covered with a rug, which should be shaken frequently. There are many days in our treacherous climate when a child cannot be taken out of doors ; indeed, there are many days when it had better remain in its well-aired nursery, — days during which, if it went out of doors in its perambulator, it would inhale the exhalations from the foul masses that accumulate in our city streets. A child in arms is far safer when carried out of doors for fresh air than is one in a perambulator upon its first going out. The day nursery should be supplied with plants. They are FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 281 undoubtedly beneficial to health when properly cared for, and make the living-room bright and cheerful, and this reacts on the disposition of the child. A bright, happy home makes a bright, happy child, and what is freqently taken for temper, perverseness, in many children is often sickness and unhappi- ness. Happiness tends to health, and health is greatly depend- ent on happiness. A child, from its infancy, that can take a "no" from its parents as an ultimatum is far happier than one who constantly frets for the purpose of having its whims gratified. The parent who forbids the child five times and then relents establishes a precedent that will invariably give rise to trouble in the future. A command should always be observed, a "no" should always be a "no," and such a bring- ing up will help the doctor in case of illness— save life, perhaps — and make the child a blessing in the house and a delight to all who come in contact with it. An unhappy time indeed has the doctor who is called to attend a child in illness who has been accustomed to say, "I won't" or "I will." Those who are much thrown among children recognize this fact ; in- deed, it is one which every grown person feels when he or she looks back to childhood days. The energy and buoyancy which comes with good health is in marked contrast to the depression and irritability that is associated with illness, or, if not ex- actly illness, with those sedentary pursuits that are in them- selves unhealthful. In an excellent article on "Xursery Hygiene," 1 Dr. L. M. Yale says, — " In selecting a room for a nursery, that should be chosen which is the sunniest, best aired, and driest; and in deciding between two or more houses in other respects equally eligible, distinct preference should be given to that one admitting of the best arrangements for nursery purposes. In houses where no room is to be specifically set apart as a nursery, and chil- dren are to occupy the general living-room by day and the 1 Keating's Cyclopaedia of the Diseases of Children, vol. i. 24* 282 MOTHER AND CHILD. parents' bedroom by night, the same rules should govern the selection of these rooms, the sanitary benefit in such case accruing to adults and children alike. When the nursery is separate it is preferably to be placed above the ground-floor, unless the latter be unusually well raised from the ground, but it should not be immediately under a roof, on account of the difficulty of regulating the temperature in such a situa- tion. " The beneficial influence of sunlight needs no insisting upon ; nevertheless it is constantly overlooked. The nursery should, if possible, look to the south, or as nearly so as the situation of the house permits, with a morning exposure in preference to an afternoon sun, if but one can be had. The windows should be ample in size, and more than one if possible, as they not only serve for the admission of light, but in the ordinary dwelling are the only avenues of ventilation. The sensibility to the loss of sunlight seems to vary somewhat with adult in- dividuals, but we believe that all children suffer from its ab- sence ; and the physician should insist upon the daily complete sunning of the apartment. In summer, even, it is usually better to have the sun and to mitigate its power at proper times by means of awnings and blinds than to have a room upon which it does not shine. There may be circumstances of climate or of prevailing winds which will modify this rule, but it holds in general. The room should be of ample size, particularly if it serve, as is the rule in ordinary houses, the double purpose of night and day nursery. The precise amount of space required for each child will vary with the arrange- ments for ventilation, but not less than fifteen hundred cubic feet of air per hour should be allowed, and preferably double that amount. " As only in the houses of the wealthy can a room be specially set apart as a sick-bay or hospital, the nursery must ordinarily serve that purpose whenever illness occurs. For this reason, as well as for others, the furnishing of a nursery should be as simple and as easy of cleansing as is consistent with comfort. FRESH AIR. VENTILATION, OUT-DOOR EXERCISE. 283 The floor should be of smooth, closely -joined boards, preferably of hard, close-grained wood. The seams, if they open by shrinkage, should be closed either by relaying or by calking well done. Poor calking is worse than useless, and any calk- ing is inconvenient in rooms the floors of which must be raised to reach gas- or water-pipes, as is unfortunately often the case. Carpets are necessary to comfort, but movable carpets or rugs are far preferable, as permitting more frequent cleansing both of the carpet and floor. At the present time even cheap grades of carpets are made in rug form, or the desired pattern can be made up with tasty borders without much expense. In case of actual illness of a contagious nature the rugs may be taken away at once, and their contamination be prevented, which in view of the difficulty of subsequent disinfection is very desira- ble. The same precaution against dangerous dirt leads to the preferring of painted and varnished to papered walls for the nursery, even at the loss of some beauty in the apartment. If paper is strongly insisted on, it should be of a kind that can be thoroughly varnished and will admit of being washed, and ail old paper must be first removed before new is laid. The furniture of the room should be as lio*ht as consistent with serviceability, in order that the pieces may be easily moved from place to place to admit of frequent cleansing ; and for the same reason, every bulky or heavy article should have large and strong casters. It is further desirable that all furni- ture should be as plain and simple as possible, carved wood and thick upholstery stuffs being objectionable as receptacles for dust. Taste may be gratified without violating this require- ment. Further, all cupboards, closets, and similar places of deposit should be as open to inspection as possible, in order that offensive or untidy things may easily be detected and re- moved. On account of this facility of examination and cleans- ing, the writer usually prefers shelves with a removable curtain in front to closed cupboards and deep drawers. The latter are suitable enough for clean linen, but are temptations to careless attendants to indulge in ' tuck-away neatness.' 284 MOTHER AND CHILD. " Warming and ventilation can only be touched upon in this article. If the nursery is in a house with a good system of heating and ventilating, nothing in particular will be needed except a grate or a stove for use in emergencies. Ordinarily, however, even houses which have a fairly good furnace or other heating-apparatus have no specific arrangements for ventilation beyond what are afforded by the windows, chim- neys, and imperfections of structure. The ordinary methods of warming in use in this country are open fires, stoves, and hot-air furnaces. The hot-air furnace, if properly constructed, is quite satisfactory. Its commonest faults are the delivery of too small a quantity of air at too high a temperature (a larger quantity at a lower temperature being preferable), and such an arrangement of its cold-air flue that the supply is from an impure source. The former difficulty is overcome by having the furnace considerably larger than necessary and by kteeping the fire moderate ; the latter, by using a tight metal flue the outer end of which is free from unwholesome surround- ing and preferably raised some feet from the ground, by which means some of the foul air of dark city back-yards or of the gutters is avoided. The same precaution is of use in many country houses. The outer end must be protected by a wire screen, to prevent mischief being done by children or small animals. It the screen be fine-textured it will diminish the amount of dust drawn into the house. For a nursery it is of advantage to have the registers for warm air rather high, as this arrangement makes a better general circulation of air, diminishes the intensity of floor-draughts, and renders med- dling with the register by small children more difficult. " The open fireplace has for advantages cheerfulness of aspect and a fair amount of ventilating -power, for disadvantages great wastefulness of fuel in proportion to its heating-power, so that ordinarily, when this is the only source of heat, great differences of temperature exist in different parts of the room ; if the neighborhood of the fire is comfortable, the remoter parts are cold. Further, it ventilates by the production of FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 285 draughts, particularly of floor-draughts, which are especially dangerous in the nursery, where little children spend so much of their time upon the floor. The wood fire is very beautiful and useful when a short, quick heat is needed, but, aside from its costliness, it is not so good for steady heating as a coal fire. In the nursery any open fire must be carefully guarded by a strong wire screen, to prevent accidents from sparks or from the clothing of children taking fire. Stoves of the ordinary close varieties, the ' air-tights,' are very economical of fuel, but nearly useless as ventilators, and if used make especial watchfulness as to ventilation necessary. The ventilating stoves which are the offspring of the old ' Franklin' make a compromise by which all the ventilating value of the open grate is preserved with far less waste of fuel, about three times as much of the heat-value of a given amount of fuel being utilized by these stoves as by the open fire. The prin- ciple of construction in its simplicity is to surround the stove and its smoke-flue for some distance with an air-chamber ; to this chamber air is admitted, preferably from out of doors, and as it is warmed it is poured into the room at a higher point, — for instance, near the mantel. As regards all stoves, it is perhaps safer to have no damper in the smoke-flue, or else to fasten it so that it cannot be closed without difficulty, since by so doing the danger of the gases of combustion being forced into the room is removed. " Ventilation, in a house which has been constructed with no reference to it, usually must be accomplished by simple devices or not at all; any radical improvements would be practical reconstruction. The most natural thing to do to let in . fresh air and let out foul is to open a window ; but this of course in cold weather involves dangerous draughts. We cannot, with our fickle and often severe climate, even do as some English writers suggest should be done, — fasten the upper sash so that it cannot be quite closed. Window-ventilation, therefore, must in winter be carried on by means of some contrivance which will break the force of the current of air and direct it upward 286 MOTHER AND CHILD. so that it may be diffused about the room. The 'elbow-tube' ventilator placed under the lower sash is well known ; so are various wire screens, either vertical or ro- Fig. 34 fating like at ransom. A very useful one, and the simplest and cheapest, is the common window-board, which, fitting against the in- side of the lower sash, allows the latter to be raised and the current of air inward is sent directly upward at the overlapping of the two sashes. The board should be at least eight inches high. The plan of a stout cloth nailed across the lower part of the window allows, when the sash is raised, two currents, one above and one below. The writer thinks he gets the same advantages by modifying the window-board as in the figure. The strip B runs the whole length of the board. If it is desired to shut off the lower current, the sash is left in contact with the strip ; if the lower current is desired, it is left below the strip, as at A. "The stove with jacket used in barracks seems to be well adapted for nursery use. The stove is surrounded by a jacket of sheet zinc or iron, with necessary doors, leaving space between the stove and the jacket. This should come to the floor, and the cold air be brought from out of doors to within the "svC^ jacket by means of a small pipe ; the air es- capes warmed at the top of the jacket. For the nursery the jacket has the advantage of being a safeguard against burns, at least against severe ones. " The getting of foul air out is a rather more difficult problem, especially with stove heat. An open window with the double current described will do fairly well under favorable circum- stances, but is rarely sufficient when an air-tight stove is used. FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 287 If in the construction of chimneys a ventilating-flue is in- cluded, or if the smoke-flue is enclosed in a space which may serve as a ventilation-flue (as, for instance, a stove-pipe run- ning up within a chimney which has a fireplace at the bottom), it is easy to ventilate a room. If the chimneys are already closed in, the cheapest and at the same time an efficient method is to have an air-flue leading from near the floor into the chimney higher up. The upward current of air in the latter draws the air through the ventilating-shaft. It is more efficient if placed near the stove, so that the air within it is heated and its upward movement hastened. Its mouth is placed low, to save unnecessary waste of warm air. " It should be remembered that the artificial light of lamps or gas in a room rapidly spoils air for breathing. Lighting- capacity is usually measured in candles, and an average adult produces rather less than twice as much carbonic acid as one candle: as a consequence, a large kerosene lamp or gas-burner often equals the production of five or six adults. It is very desirable, therefore, if a night-light is necessary in the nursery, that its carbonic acid be got rid of; and by the device, often used for ventilating purposes, of putting the burner or lamp within or beneath a tube or flue going to the roof or chimney, the results of combustion are carried away and an outward current of small power is also established. By having at the bottom of the flue a box, with a door, to contain the light, the latter may be shut off partly or wholly except when needed. " As to the temperature of the nursery authorities are not quite agreed ; but it is certain that in American cities it is usu- ally too high, in common with that of the rest of the house. Children and adults are often forced to endure in winter apparel a temperature (70° F. and upward) which in summer is con- sidered to demand much lighter dress. There are good reasons why the standard of house-temperature is usually set high in America, but it is carried too far, The discrepancy between in-door and out-door temperature is made too great, the skin and mucous membranes are made sensitive, and the multitudi- 288 MOTHER AND CHILD. nous forms of ' colds' favored. We believe that if a room can be uniformly heated, 65° F. will be found, on the whole, more comfortable and healthful than the usual 70° F., which latter should not be exceeded. "Where intelligent supervision of the temperature can be relied upon, we believe that a still lower degree than 65° F. will be healthful to children old enough to play about. At night the temperature should not be allowed to fall too far below the day standard ; and especial pains should be taken to guard against the uncovering of children in bed. " A word should be added concerning windows. As is well known, the loss of heat from the cold glass is very great : Mr. Hood puts it that by each square foot of glass more than ono and one-quarter cubic feet of air (1.279 cu. ft.) will be lowered each minute as many degrees as the difference between the internal and external temperatures. If, for instance, the ther- mometer outside showed no colder than freezing temperature, 32° F., and within no higher than 67° F., the discrepancy would be still 35° F. A window three feet by six feet would expose eighteen feet of glass surface, and according to this rule it would cool each minute (18 X 35 X 1-279 ±=) 805 + cubic feet one degree, or about two hundred cubic feet four degrees. This makes a constant current of descending cold air near a window very sensibly felt by any one obliged to work in such a place in cold weather. It is important, then, that children should not play immediately near a window in cold weather, and a low article of furniture may be often so placed as to keep them away without the trouble of constant oversight. The ingenuity of the attendant will similarly devise means of keeping them from sitting on the floor if it be draughty. "Besides the admission of pure air and the discharge of foul air, purity of atmosphere demands that no nursery nuisances be allowed to exist. It is better that no plumbing of any sort should be in the room itself. Bath and closet conveniences are very necessary, but should be a little removed and well venti- FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 289 lated. In houses that are not plumbed, a place to which all offensive or soiled articles can be directly removed should be provided, which place should have free ventilation. In especial all soiled napkins and vessels containing evacuations or urine should be promptly removed, and in case of sickness a vessel should be provided in which the napkins or stools can be disinfected. "Under ordinary circumstances, however, disinfectants, in the usual sense of the word, have no place in the nursery nor in hygiene generally. A place that cannot be made wholesome by sunlight, air, and cleanliness should not be occupied. When- ever emergencies demand their use, they should be of the safest kinds consistent with efficiency, and after a contagious illness only the more costly contents of the nursery should be disinfected ; the cheaper ones can be burnt with greater ulti- mate economy. For this reason we always urge that toys be of the cheapest description, particularly if of such a kind as readily to conceal supposed sources of contagion. The paint- ing of walls and ceilings and the closely-laid floor already urged are of great assistance in promoting efficiency of disin- fection. . . . "The care of the hair consists in infancy chiefly in the care of the scalp, which must be kept strictly clean. If the vernix caseosa is as completely removed from the scalp at birth as from other parts of the person, there is usually little difficulty in preventing future accumulations. A soft brush should be frequently used upon the hair, a comb only as a separator for parting the locks and in emergency for disentangling. " The teeth require the same care as in adult life, but brush- ing should be of the gentlest sort, for fear of irritation of the gums, which may cause their subsequent retraction. In in- fancy after each feeding or nursing the gums should be washed, to prevent the formation of aphthous growths, and the teeth treated likewise as they appear. When the child is old enough to be quiet while the cleansing is done, a soft badger- hair tooth-brush should be used. n t 25 290 MOTHER AND CHILD. "Dress. — The hygienic essentials of dress are — sufficient warmth without burdensomeness, uniformity of protection as far as consistent with activity, freedom, and, for children at least, softness. The problem of warmth without undue weight is best solved by the use of woollen garments. By reason of the poor conducting power of wool, such garments retain the bodily heat longer than those made of other materials. This slowness of conduction is greater in loose-textured fabrics. That is to say, a given weight of wool is warmer if loosely than if tightly woven. Hence the warmth of knitted gar- ments. The difference is due to the retention in the interstices of a certain amount of air, which is a poor conductor. For the same reason, two garments, two shirts for instance, are warmer than one shirt of weight equal to the two, and loose- fitting garments are warmer than tight ones. In hot weather, however, tight garments are distressing for other reasons. Linen stands at the other extreme of ordinary dress-materials, being the best conductor of heat. It follows that woollen garments give the best protection against change of temper ature and chilling, and in proper weight they make the safest dress in all places where temperature may vary or for all children who may become heated in play. Fashion or taste usually calls for outer garments of linen, but the protective garments should be beneath. The absorption of heat from the sun varies very much according to the color of the gar- ment, the material and texture being unchanged, white taking the least heat, or being the coolest, while black will absorb about twice as much. Singularly enough, the ' cool-looking' light blue is found by some experiments to be very nearly as hot as black. For very young children who are little exposed to the sun's heat this question of color is of minor importance. " Softness of material is essential for children on account of the sensitiveness of their skins. To most infants fine soft woollen shirts, either knitted or of ' baby flannel,' are seem- ingly entirely comfortable. Some, however, manifest unusual irritability of skin, and for such a shirt of fine linen should be FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 291 placed within the flannel. This precaution is more often necessary in hot weather, when the flow of perspiration is increased. "The ordinary dress of very young children is objectionable in several ways. It is ordinarily unnecessarily confining about the body and limbs, although it has never in this country reached the degree in this respect that seems- to be usual in some Continental countries. There is also an unnecessary number of layers of fabric involved, as they are not required for the child's warmth under ordinary circumstances. The process of dressing or undressing is really an ordeal to the infant, as it is alternately rolled upon its back and belly in the nurse's lap, in order that one band after another shall be fastened by pins or stitches. Yery much of this dressing is unnecessary, if not harmful. First of all is the ' band,' a girdle enveloping the trunk from about the nipples to the iliac crest. Such an appliance may possibly be useful during the healing of the navel ; afterwards it is not of use if tight. The abdomen needs no support in health, the compression of the ribs is not advantageous, and so far as such a girdle affects the question of hernia (which it is popularly supposed to prevent) at all. it rather favors the production of the in- guinal or femoral variety. A loose girdle worn to prevent chilling is, however, often advisable in hot weather; and in cold weather a flannel girdle, or binder, ' cut bias' to secure elasticity, makes a useful envelope for the entire trunk of very young children as a preventive of bronchitis. " As a means of getting rid of the objectionable features of the ordinary dress, the writer has for some years recommended the following plan 1 or some modification of it. There are three garments (besides the napkins), all covering the neck and shoulders and reaching ten or twelve inches below the feet. The outer garment, as well as the middle one, is a little 1 •' This plan was originally devised by Dr. Grosvenor, of Chicago, for use in his own family, and subsequently published by him. ^92 MOTHER AND CHILD. larger in every dimension than that beneath it, so that no binding shall take place. They are all cut in the girdle-less pattern called 'Princess.' The inner one has sleeves, and may be made of cotton flannel or very soft wool flannel ; if wool is used, care must be taken against shrinkage in washing. The next garment has no sleeves, and no seams at the arm- holes, to insure against pressure there ; the material is wool flannel. The outer one is the usual dress, with high neck and sleeves, the details of which may be modified to suit taste. Thus, except the sleeves, the thickness is the same throughout. At night a garment like the inner one above described and a napkin only are worn. These three garments are placed one within the other before the dressing commences, pains being taken to avoid wrinkles and folds, and they are put upon the child as one garment with very little trouble. They are removed with equal ease. "The napkins may be of any suitable kind, — i.e., soft and absorbent material, easily washed. Linen has no real advan- tage ordinarily over cotton, except aesthetically. Old linen is soft, but likely to be thin. It is desirable to diminish the bulk of the napkins as far as possible, to prevent uncomfortable pressure: this is accomplished by having a small napkin simply to cover the seat and genitals thick enough to retain the urine or faeces, covered by another one not thick, but large enough to envelop the hips. The age at which napkins may be discontinued depends upon circumstances. Among English families of the better classes, apparently, children are taught to make their needs known earlier than is usual with us. Much can be done by an attentive and intelligent nurse who holds the child over a vessel with suitable frequency. But children vary greatly in this particular, and under no cir- cumstances is any severity justified, or even scolding, as nervousness or anxiety on the part of the child simply aggra- vates the trouble. As soon as the child can regularly give notice of its wants in this respect it is better to discontinue the diaper, as its absence gives greater freedom to the limbs. FRESH AIR, VEATILATION, OUT-DOOR EXERCISE. 293 Of course at all times napkins should be changed as soon as discovered to be damp or soiled. Eubber or other impervious covers for diapers should not be used. Even the exigencies of a railway-journey, with the conveniences usual in this country, do not require their employment. They simply convert a wet napkin into an unclean fomentation. * : When a child begins to use its limbs freely, the clothing should be shortened. In fact, there is no real need of long clothes at any time, except to save labor in keeping the in- fant's feet covered. When it begins to creep, its manoeuvres are facilitated by slipping over its skirts a loose baggy pair of breeches of woollen which is tied around its waist and buttoned about its knees. This keeps the skirts from im- peding its progress, and protects it against floor-draughts in a measure. "The dress of older children should conform to the same hygienic requirements as given above. The two most fre- quently disregarded are freedom from constriction and uni- formity of protection. The former is violated by the use of tight girdles, or even by corsets, tight sleeves, garters, and misshapen stockings and shoes. Their harmfulness is well understood : the neglect is usually a wilful preference of fash- ion to healthfulness. The same might perhaps be said of the fashion of unevenly distributing the clothing over the person ; but the injurious effects of this are less understood. Chilling is resisted far better if the whole person is exposed to the same temperature than if one part is exposed to a lower temperature than another. It is a matter of universal experi- ence that many persons who rejoice in out-door life even in severe weather are directly injured by a draught and by sitting near a window. Yet formerly more than now low- necked dresses were used for children, the entire shoulders being exposed, while the remainder of the trunk was burdened with dress. At the present time fashion exposes the legs more. Shoes and stockings are often too thin, but in par- ticular children are too often dressed with the lower limbs 25* 294 MOTHER AND CHILD. bare from above the knee to a little way above the ankle, the foot being covered by a slipper. The difference is often aggra- vated by too much clothing on the body and a sash over all. The lower limbs should be thoroughly clad, — not cumbrously, but warmly. The stocking of a child old enough to run about should be long enough to meet or be overlapped by the next article, napkin or drawers, as the case may be. Stockings of wool, for the reasons already given, are to be preferred. They should be soft. They should not be pointed, at the toes, but be wide enough to admit of ample play in every direction of the anterior part of the foot. Color is not indif- ferent, as some dyes have been found to produce eruptions on the skin. Public attention has, however, been so thor- oughly drawn to this subject as to have led in some instances to legislative enactments, and such dyes are probably less frequently used than formerly. Aniline reds have been thought to be especially irritating. " Shoes of proper shape are not easy to get for children ; not nearly so easy as for adults. This comes probably partly from the supposed necessity of making them for a low price and partly from a belief, often openly expressed, that 'a baby's foot has no shape.' The real shape of the human foot is followed in the true ' waukenphast' shoe, but this we have never seen of proper sizes for infants or young children. It is not enough that a shoe should be as wide or wider than the foot, but it should have its width rightly disposed: space where the foot does not demand it in no wise compensates for pressure elsewhere. The result must inevitably be a distortion. In choosing shoe3 for infants it is better that they should be unduly long, if that be necessary to obtain the requisite width in front, than that they should be narrow." The following, taken from Miss A. M. Bacon's fascinating book on "Japanese Girls and Women," will be of interest. Writing of the Japanese baby, she says, " It is not jolted, rocked, or tossed to sleep ; it is allowed to cry, if it chooses, without anybody supposing that the world will come to an end because FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 295 of the crying ; and its dress is loose and easily put on, so that very little time is spent in the tiresome process of dressing and undressing, . . . and it is not subject to fits of hysterical or passionate crying, brought on by much jolting or tossing, or by the wearisome process of pinning, buttoning, tying of strings, and thrusting of arms into tight sleeves. " The Japanese baby's dress, though not as pretty as that of our babies, is in many ways much more sensible. It con- sists of as many wide-sleeved, straight, silk, cotton, or flannel garments as the season of the year may require, — all cut after exactly the same pattern, and that pattern the same in shape as the grown-up kimono. These garments are fitted one inside of the other before they are put on, then they are laid down on the floor and the baby is laid into them ; a soft belt, attached to the outer garment or dress, is tied around the waist, and the baby is dressed without a shriek or a wail, as simply and easily as possible. The baby's dresses, like those of our babies, are made long enough to cover the little bare feet, and the sleeves cover the hands as well, so preventing the unmerciful scratching that most babies give the face, as well as keeping the hands warm and dry." Would that some bold and brave mothers would make fashionable such baby-dressing in this country ! By way of contrast we will quote the following : Dr. W. Thornton Parker, writing of American Indian women, says, "As soon as the Indian baby is born it is placed in a coffin-shaped receptacle, where it passes nearly the whole of the first year of its existence, being taken out only once or twice a day for washing or change of clothing. This clothing is of the most primitive character, the baby being simply swaddled in a dressed deerskin or piece of thick cotton cloth, which envelops the whole body below the neck. The outside of the cradle varies with the wealth or taste of the mother, scarcely two being exactly alike. Some are elaborately ornamented with furs, feathers, and bead-work, others are perfectly plain. Whatever the outside, the cases 296 MOTHER AND CHILD. themselves are nearly the same. A piece of dried buffalo hide is cut into proper shape, then turned on itself, and the front fastened to a board or, in the most approved cradles, to two narrow pieces of board joined in the form of an X. " It forms a real ' nest of comfort,' and, as the Indians are not sticklers on the score of cleanliness, it is the very best cradle that they could adopt. To the board or boards is attached a strap, which, forced over the head, rests on the mother's chest and shoulders, leaving the arms free. " When about the lodge the mother stands the cradle in some out-of-the-way corner, or in fine weather against a tree ; or if the wind is blowing fresh it is hung to a branch, where it fulfils all the promise of the nursery rhyme. When the baby is ten months old it is released from its confinement and for a year or two more of its life takes its short journeys on its mother's back in a simple way." The question is often asked, at what age a child should go out of doors, and whether it should go out every day, not- withstanding the weather. It makes a very great difference whether the parents live in the country or the city. Country children, of course, are out most of the time, as they grow older especially; whereas, in the city, the impossibility of thus turning them loose and the necessity of a nurse to accom- pany them are matters that have to be taken into consider- ation. After a babe is about six weeks or two months old, if the weather be at all moderate, the nurse can wrap the child well and take it in her arms out for a walk. There is less risk of young children taking coid than older ones, from the fact that they are much easier wrapped- and kept warm, and the nurse is able to carry them. At the same time, if the house is well ventilated and warm and the weather cold and changeable, — dirty streets, snow, and dampness rising from the ground, — it is far better for the child to remain in the house. As soon as a child arrives at the age when it is a drag upon the nurse, is difficult to carry, and at the same time cannot walk, and a perambulator is required, the time to exer- FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 297 cise the most judgment has come. Any mother can see this for herself by going to one of our city parks and watching the congregation of nurse-girls there assembled, noting the position of the baby carriages and the condition of their occu- pants. A child will be left facing the bleakest March wind, or the midsummer sun fiercely attacking its unprotected head, while the nurse is engaged in conversation with a number of her friends. We have often been at a loss to under- stand how mothers could select these young, inexperienced creatures to take care of their children, knowing full well what would be the consequences, and then be surprised if the child should be taken with a severe sore throat, earache, pneu- monia, or inflammation of the brain. It would be far better if all children, until they are old enough to sit up by themselves, were carried by their nurses On their every-day outing, and that after a child is too big to carry, and too young to walk, it should sit up in its carriage, well wrapped, then the nurse take a long walk, with the distinct understanding that under no circumstances is the carriage to be stopped ; when she is tired she is to come home. We are very particular in laying stress upon this matter, because, notwithstanding all that has been written on the subject and the full knowledge that mothers obtain from their family physicians, who are one and all opposed ta the present system and acknowledge that a larger part of the diseases of children is due, undoubtedly, to the carelessness, in oneway or another, of their nurses, — these girls, without any experience whatever, with no judgment, certainly no affection for their charges, are hired and intrusted with the care of an infant, and are allowed to take it out, going where they will, to carry it into heated rooms, to leave its out- door wraps on, to carry it out of doors while it is perspiring, and to expose it to contagion of every kind, taking it into all sorts of atmospheres ; and yet, after the child has been returned, its fond mother will fondle and caress it, guard it against the least exposure, treat it as the tenderest flower, and be struck with wonder and surprise when it is taken ill. So important 298 MOTHER AND CHILD. do we deem it that a child's nurse should be selected with the greatest possible care, that she should be a woman chosen on account of her experience, conscientiousness, and truthfulness, that we believe the mortality from contagious diseases, and from those disorders due to direct exposure, would be dimin- ished if mothers could be made to appreciate this matter. CHAPTER XXXIX. BATHING. The child should be gently washed in warm water with a soft sponge, or soft linen, with Pears' non-scented or with Castile soap, and care should be taken that every part of the body be carefully washed, so as to free it from any impurities that cause irritation to the tender skin ; the nostrils, the eyes, the mouth, the various crevices of the groin, the armpits, and the genitals should be thoroughly cleansed. There should be a thermometer in the nursery, and the child's bath should be always regulated by it. The tempera- ture of the water should be such as to give a sense of gentle warmth to the hand, and as the child grows older and becomes strong, the circulation well established, the temperature should be gradually reduced until it is about 75° F., or cooler. It is not at all necessary that a child should receive a full bath twice a day; once a day is amply sufficient, — in the morning. A child should always delight in its bath ; when it is old enough to have its tub, the bathing should be made a pleasure to it. Give it something to play with in the water ; make a frolic of it. Should it at first dread the bath, be careful not to frighten it ; place a blanket over the water and let the child gradually become surrounded by water by immersing it with the blanket. Always wet the head first, even with babes. At bedtime a BA THING. 299 sponging off will be enough, unless the child possesses one of those excitable dispositions to which we have already alluded, — is the child of intellectual parents, those who depend upon their brains for a livelihood : these children always exhibit a more or less nervous, irritable disposition, which renders them at times restless and sleepless. For such, the sedative effect of a bath at night is most marked ; indeed, for these it is well to usually sponge off with cool water in the morning, and leave the bath for the night, making the water about blood- heat in order to get its full sedative influence. It is a very great mistake to accustom a child to bromide, valerianate of ammonia, brandy, or gin, to make it sleep ; these should never be used without the consent of a physician; but the sedative influence of a warm bath, or warm foot- bath, can never be harmful. The usual time for giving the morning bath is about nine or ten o'clock ; at this time diges- tion is not going on, as a rule, and the child can be thoroughly washed, the surface being brought to a glow either with the hand or with a soft towel ; the child may then take its bottle or breast, get its hour's sleep, and there will be still time for it to spend the best part of the day out of doors. Of course in summer, when the child should be out as much as possible, the bath may be given at an earlier or later hour, to suit the cir- cumstances. For a very young infant it is not absolutely necessary to give a bath in the tub ; the room should be warmed to a temperature of about 75° F., and guarded against draughts. The temperature of the bath, if the child is immersed, should be about 90° F., but if it is delicate and young a thor- ough sponging of the surface will be sufficient, and it should be gradually accustomed to the water until it will of its own accord show a liking for the bath. When travelling, a port- able bath, such as is figured in the plate preceding Part II., is a useful companion, and in these days of electric lighting a spirit lamp is a necessity, and should never be forgotten when leaving home. 300 MOTHER AND CHILD. The question often arises, How long a time should elapse after feeding before the child has its bath ? Certainly not less than an hour, better if two hours should elapse after a heavy meal. Of course this refers entirely to a bath by immersion, but for a young infant that is simply sponged and nursed with breast-milk, an hour will be sufficient. It is often necessary to bring about a glow on the surface of the bodies of children who are delicate, when, for some reason or other, the bath cannot be given ; the. body should be gently rubbed with either spirits of wine or washing whiskey, to which a little salt may be added to make it more stimulating ; or, if the child is very delicate, cod-liver oil may be used, to- gether with rubbing. About a tablespoonful of a solution of Castile soap (scraped) dissolved in alcohol, to a basin of water, is frequently an excellent addition to the sponge-bath. This can be made up by the pint and kept for that purpose. The child should not be permitted to go out immediately after its bath, nor indeed for an hour or so, if the weather be cold; but as the day's sleep is taken immediately after the bath, scarcely any mother would be tempted to take her child out. Mothers ought to make it a rule never to take a child out of doors on an empty stomach ; not only will a child that has been given food before going out be better able to resist cold, but there will also be less chance of it becoming infected by contagious diseases. In most places children and delicate people should be in-doors at sundown ; the sudden chilling of the air renders it harmful, and at this time germs of malaria that have been carried upward by the warm day air are precipitated. If a child objects very seriously to its bath, it is far better to gradually accustom it to being immersed, and this can be readily accomplished as it grows older by teaching it to play in its tub, which should be gradually filled with water; or over the tub can be thrown a light blanket, and the child slowly immersed, gently lowered into the water. The question as to when a salt bath should be used is often BATHING. 301 asked. This, of course, is a matter which, as a rule, should be left to the family physician to decide. Salt water is more stimulating than plain water ; it also has the advantage of being especially valuable in cases of chronic enlargements of the glands and tonsils, — a tendency to scrofula. Children who lack muscular strength, are troubled with loss of appetite, or who sleep badly, are especially benefited by salt baths. It is not necessary to obtain what is known as sea-salt, though this is usually sold for that purpose. A tablespoonful of ordinary salt to the gallon is about the strength of sea water. As children grow older the question arises as to the sea- shore and its advantages, especially sea-bathing. All children who are delicate, those that are scrofulous, those that are threatened with spinal curvature, or who have a tendency to become bandy-legged or pigeon-breasted, improve wonderfully at the sea-shore. As far as the bathing is concerned, surf- bathing or cold sea-water should not be used for children under three years of age ; until that time the sea-water can be given in the ordinary tub, to which has been added sufficient hot water to give it a temperature of at least 80° F. Any one who has spent summers at the sea-shore has certainly seen a great deal of the cruel practice of carrying a screaming, struggling infant in the arms and plunging it into the sea-water. We can- not imagine a more barbarous proceeding. The sudden shock from the use of cold water, the fright, is enough to bring on convulsions. A child at the age of two years may have its bathing-suit put on in the middle of the day, run in its bare feet in the sands, bask in the sunshine, get its feet wet in the cool sea-water, and receive very much more benefit than it would from a plunge into the ocean, even if that could be done without the struggle which usually accompanies this proced ure. Even for infants of a year old, sponging the neck with cold water and dipping the feet in the same, followed by brisk rubbing, will prevent in many cases the taking of cold. We call the attention of mothers to this point. It will be a very valu- able procedure, especially in our changeable winter climate, if 26 302 MOTHER AND CHILD. adopted every night before retiring, to prevent the many at- tacks of cold that are so annoying and prevalent. Sea-bathing is to be interdicted for rheumatic children, for those with asthma; skin-diseases, and fevers. Kidney-disease, irritable lungs, a tendency to bronchitis, and some chronic eruptions come under the same category. In the case of heart- disease, the stimulating atmosphere excites this organ to too rapid action and aggravates the disorder. Weak eyes are to be kept from the shore, where the air, impregnated with salt and fine sand, and the glare keep up a constant irritation. The same applies to ear affections, but with exceptions, which, how- ever, should be made only under the advice of a competent physician. Little consumptives do better in the interior, as the coast air is too damp for their weak lungs. Children with tubercular tendencies and those with chronic joint diseases should be sent for residence to such places as Colorado, New Mexico, or parts of Texas. The establishment of children's sanitaria and boarding-schools in these localities should receive attention. The action of the skin is so essential to good health, that w T hen a child is really ill, a simple sponging of the surface of its skin may not do any harm ; of course the water should be tepid, the room carefully guarded against draughts, and the child, after being thoroughly dried, should not be allowed to run out in the cold entries until the skin has entirely re- acted. The mother will often say, "Doctor, my child has a cold; shall I wash it?" We may answer that when these precautions are taken, the sponging of the chest and throat, with subsequent friction, is the best thing she can do for the cold. In regard to the use of cold water in nursery bathing, it is a great mistake to believe that a child should be sponged with cold water, notwithstanding its dread of it and the shock which it gives to its nervous system. A child should be made to love its bath, to look forward to it with delight ; it should have a big sponge to play with, and in a very short time, as it grows BATHING. 303 older, it will gladly sit in the tub of water, splash around to its heart's content, and get sufficient exercise to avoid any chances of taking cold. In using soap, great care should be taken that it be pure, with no free alkali,, such as the ordinary common cheap soaps. That which is non-scented is to be preferred. After the child has been dried, in summer-time, its body shoul i be powdered with a little starch or talc powder, which has a soothing effect upon the skin ; or in winter-time its chest and back, and the folds of the skin in the groin and axilla, can be greased with a little vaseline, just enough to make the skin soft and pliable, and also to protect it from cold, There is one caution which we think is in place here : a bath in tepid or cool water for a short time is invigorating; a pro- longed soaking in warm water has precisely the opposite effect. If the child is debilitated during hot weather by the pro- longed heat, and a more stimulating bath than the ordinary cool one is required, a teacupful or two of cider vinegar may be added to the bath, with or without the addition of salt. In children who have delicate skins, the red spots or blotchy eruption which appears shortly after birth is usually due to too active use of soap and water immediately following their birth. This can be obviated by following the directions given when speaking of the washing of the new-born babe ; but very frequently a child's skin becomes dry, rough to the touch, and needs constant attention to prevent eruptions, especially the much-dreaded eczema of children. Such children should not have salt baths, except when advised by the physi- cian ; they need fresh air, plain food, and probably cod-liver oil. 304 MOTHER AND CHILD. CHAPTER XL. TEETHING. The first lower incisors — that is, the two lower front teeth —are usually cut when the child is from six to seven months old. For some time previous it has probably been noticed that the child has been restless and uneasy, that its sleep has either been disturbed or it has been wakeful. Before this time the child's secretions have been pretty well established. The tears, the saliva, will probably flow readily ; indeed, such children usually cut their teeth with but little trouble. It is doubtful whether all the troubles that are associated with teething are really due to that condition. There is no question but that the pressure upon the delicate nerve-pulp beneath a tooth that is bound down by a thick capsule, and probably on top of that a congested gum, may give rise to serious trouble, amounting to convulsions or intestinal disturbance at times ; or the irritation which is produced may inflame the gum, and thus starting as a sore mouth, the dryness of the mucous mem- brane extends to the stomach, and is the starting-point of a severe catarrh or earache. As a rule, children suffer comparatively little with their early teeth; possibly because, while these are being cut, ihey are still nursing in many cases, or they have not yet had a large amount of farinaceous food added to their diet. Then, also, the large back teeth and the eye teeth cause far more pressure on the delicate nerve-pulp, more disturbance in the jaw, and therefore are followed by a greater degree of sympa- thetic derangement. This sympathetic derangement may show itself in excitement of the nervous system, especially at night, and be one of the most active causes of sleeplessness ; also in its action upon the glands that secrete the fluids used in digestion ; and it is on this account that the second summer is to TEETHING. Fig. 35. " c -w- :> Appearance of mouth at about seventh month. ,0OOo. x Appearance of mouth at about tenth month. 305 Appearance of mouth at about fifteenth month. r 4 r h Appearance of mouth at about twenty fourth month. Appearance of mouth at about thirtieth month. 26* 306 MO THER A ND CHILD. most mothers a dreaded time, as then a baby is usually weaned, and the slightest neglect in the preparation of its bottle will permit of the fermentation of the starchy material that faulty secretion prevents from turning into grape sugar. Nature's plan is to keep the gum softened by being soaked in saliva ; it also uses the bowels as a sort of safety-valve to relieve the congested nervous system. A large watery movement of the bowels will cause a shrinkage in the gums, by depriving them of water, and will often take the place of the lancet. Congestion may be present in the delicate nerve-pulp beneath the teeth, and give rise to annoyance, irritation, pain, and at the same time the gum above give no evidence whatever, by its appearance, of what is going on beneath. A child suffering in this way from its teeth will crave something to bite upon, but as soon as it takes the nipple of its bottle, its fingers, or even its thumb in its mouth, and bites upon it, it will suddenly throw it aside, and show evidences of pain. The relief that comes from the soaking of the gums is very great; it is said that children who suck their thumbs seldom have trouble, and yet thumb-sucking should be discouraged, as it certainly de- forms the mouth and renders the upper teeth prominent. By the time a child reaches two and a half years, it should have cut its entire twenty teeth. They are usually cut in pairs : first the lower two incisors, then the upper two, then the outside two above, then below, next to those first cut ; then skipping a space for the eye- and stomach-teeth, the others will come in turn. From the sixteenth to the twentieth month the eye- and stomach-teeth will be cut. By referring to the diagram (Fig. 35) this will appear plain. The cutting of the teeth by no means always follows in this order, nor indeed do we always find the first appearance of the lower incisors as early as the sixth or seventh month. Sir William Jenner has stated that if a child does not cut its first tooth within a year, it is an undoubted sign of rickets. We think it well here to make a few remarks on the sub- ject of rickets, that the mother may fully understand what is TEETHING. 307 meant by the term. To some people no greater insult can be offered than to suggest that their children are rickety ; to their mind, the word seems to imply some constitutional taint to be ashamed of. This is a great mistake. So large a proportion of children have rickets to a more or less marked extent that physicians feel the necessity of impressing upon the community the great importance of attention to the very subjects to which this book is devoted. Eickets is a condition, the result of faulty nutrition; it is found among the rich as well as the poor. It is the result, in the latter, of exposure, starvation, neglect; in the former, the direct consequence of high pressure, nervous exhaustion, improper feeding, — in other words, negli- gence or ignorance. The mother who fails to nurse her babe, and turns it over to the tender mercies of an ignorant nurse and a bottle, should not be surprised if her child suffers in consequence. ISTo more, indeed, should one ignorant of the fact that starchy food w r ill ferment and be productive of harm, be surprised to see her child develop spine-disease or become bow-legged. By rickets we mean a disease of the nutrition of the body, whereby its natural growth and development are arrested, the formation of bone is retarded, and the pressure exerted by the muscles and the weight of the body causes deformities which later in the disease become permanent. This want of bone- deposit delays the formation of teeth ; the interference with nutrition causes wasting of the muscles, produces disorders of digestion, and also shows itself in affections of the lymphatic glands, the liver, the spleen, and the brain. Its causes are bad feeding, want of sunshine, dampness, want of cleanliness ; and yet so gradual and slow is the process by which this faulty nutrition shows itself, that many children who are seemingly strong and hearty will manifest signs of rickets towards the end of their early dentition. Rickets is in nearly all cases developed after birth, usually about the fifth or sixth month. As regards the normal growth of the child during the first 308 MOTHER AND CHILD. year of its life, the average growth is about eight inches; during the second year about four inches, and at this time it is supposed to have attained half of its full adult height. As regards weight, at the end of the first year it has gained about three times its weight at birth, but during the second year it has only increased this by about one-third. We have endeavored to impress upon mothers the great importance during pregnancy of leading the sort of life that will give them good digestion, — plenty of fresh air and exer- cise, — and of a diet that will supply all the demands of nature. Otherwise, at this time they are the ones who will suffer ; nature will draw from them the material to supply bone to their infant. The nursing mother should also be most careful in her mode of life, knowing that the nutrition of two indi- viduals depends upon herself. Should the supply fail, one or the other will suffer. Infants deprived of the materials that go to the formation of bone (lime-salts) will develop rickets though they may be fat ; because excessive storage of fat is no evidence of health, but, on the contrary, is often evidence of faulty nutrition. The failure of the diamond-shaped open- ing on the top of a child's head to close before the end of the first year; the delay in cutting its first tooth until the expira- tion of this period ; the tendency to enlargements of the glands, especially the tonsils; disturbances of the bowels, especially that form where bile does not seem to be properly secreted ; the tendency to perspire at night about the head or neck, notwithstanding the fact that the child seems fat and well nourished, are all, particularly when found associated in the same case, evidences of rickets, and a child presenting these symptoms should at once have a change of air and diet, and be placed under medical treatment. These symptoms may occur in a child that is nursed by a seemingly healthy mother ; in fact, we often find that the healthiest looking woman may be the one whose milk is least nutritious. They are apt to occur in a child that has followed rapid successive pregnancies, are almost certain to take place TEETHING. 309 should the mother while pregnant attempt to nurse a child, and will very frequently be noticed exclusively in children who have been nursed too long. Too early weaning, especially if the bottle be made up of starchy food improperlj- cooked or given in too large quantities, will be a cause of rickets. Such children will develop, besides the other evidences above noted, large bellies distended with wind, vomiting occasionally sour matter, alternating diarrhoea and constipation, and the stools will most frequently be found either chalky or putty- like, and containing quantities of mucus. If a child is late in cutting its first teeth, though rickets may not be present, there is something faulty in. its condition. By late, we mean if it has not cut its front tooth by the tenth month. Such a child should be carefully watched, and its diet freely supplied with bone-forming material ; it should be given Mellin's food with its bottle, or (Trommer's) extract of malt, without hops (a teaspoonful to the bottle). It should have a salt bath daily, its muscles should be exercised by daily gentle rubbing or massage, and under no circumstances should such a child be allowed to stand on its feet until it has demonstrated its ability to do so after the gradual strengthening of its bones and muscles by creeping. A great mistake is often made by permitting a child to creep in one position. These children also should be watched with care, that they receive no sudden shock, or blow, or fall. Spinal curvature may be the result ; distortion of their hip- bone or pelvis, — a serious matter if they are girls. Diseases of the lungs should be guarded against, as bronchitis, pneu- monia, etc., as the difficulty in breathing will press the weak ribs out of position and keep them so, making the child pigeon-breasted. We have dwelt at length upon this matter in order to show that what is usually attributed to difficult dentition — the head- sweating, digestive disturbances, sleeplessness — in many cases may have nothing whatever to do with dentition, the difficult dentition being simply a symptom in the course of the disease. 310 MOTHER AND CHILD. Malnutrition is the true cause. There are certain disturbances (mechanical ones), that are caused by the pressure of the teeth upon the nerve-pulps beneath, that are especially noticeable in children of highly-nervous organization, those whose parents are brain-workers, and in these cases we are apt to have dis- orders of digestion, malnutrition, brain-excitement, resulting in sleeplessness and possibly convulsions. Especially do these conditions manifest themselves during; the cutting of the back teeth, as the molars ; also the eye-teeth and stomach-teeth ; the eye-teeth, so called because their cutting is usually accom- panied by more or less disturbance in the circulation of the brain and the upper parts of the face, giving rise to excite- ment, to sleeplessness, or to catarrh in the nose or in the eyes ; and the stomach-teeth because their cutting is usually accompanied by disorders of digestion. Sleeplessness and irritability seem a constant accompani- ment of the teething process. A new-born infant sleeps from fifteen to eighteen hours out of the twenty-four ; a child of two years should sleep with little interruption at least ten or eleven hours at night, and from one to two hours in the middle of the day. But sleeplessness is not always an evidence that the child is suffering ; habit has much to do with this condi- tion. A child should be prepared for sleep ; its hours should be as regular as clock-work, and under no circumstances should it be allowed to pass its sleep-time. Especially is this rule important during the time of teething. The reasons for the sleeplessness of many children are, first of all, our city children are of an excitable temperament; they do not get sufficient fresh air or exercise, and in consequence the fatigue which should naturally invite profound and peaceful sleep is accom- panied by a degree of excitement that prevents this. Sleeplessness from this cause can be remedied by attention to these matters. It is produced by exciting a child just before its sleep-time, especially after it has taken its bottle ; its bottle or bowl of food should be given the very last thing. The drowsiness which follows this meal, if once disturbed, will TEETHING. 311 cause a wakeful night. Among the poor, the father comes home tired from overwork, and the family retire together at an early hour; with the well-to-do, the lights are all lighted, the older children have their romp, or the baby, if it be the first, has to have its half-hour of play with the father, and possibly the excitement of its brain may cause a restless first sleep and wakefulness for the greater part of the night. This is altogether wrong, and is undoubtedly the cause of many brain disorders. For cases of wakefulness from no apparent cause, a hot foot-bath will have a most soothing effect, or, if they still resist, the morning bath can be postponed until evening, giving a warm bath at this time, and a sponging in the morning instead. In these cases, a bottle of food as warm as the child can take it, consisting of Mellin's food and water, the proportions being a tablespoonful of the fuod and water to fill the bottle, which will put the child to sleep. If the wake- fulness is due simply to excitement, the child seeming perfectly well otherwise during the daytime, medicine should be avoided unless specially ordered by a physician. The habit of giving bromide, for no other reason than simply wakefulness, is a mistake. Another cause of sleeplessness is insufficient nourishment ; we sometimes see such cases, where the mother is gradually losing her milk ; its bulk remains probably the same, but it is losing its richness or quality. Children fed on condensed milk alone are sometimes underfed, from the fact that the milk is given too highly diluted. One part to twelve of water should be the strength up to the second or third month ; after that, about one part to ten or eight, as the child grows older, or, better still, increasing the quantity of cream, and from a pint and a half to a quart of the mixture in the twenty-four hours ; but if the child seems hungry after each bottle, give it more until it is satisfied. But we fear that among those who will be readers of this book the greater cause will come from over- feeding. A restless infant, and especially a child about a year old. who tosses in its sleep, cries out, mutters, dreams, is one 312 MOTHER AND CHILD. who in all probability is receiving food in excess, or is certainly not getting rid of the surplus in a proper way. If the mother notices that a sleepless, restless child, at whatever age it be, has a furred tongue, that its breath is foul, that its urine is scanty, high-colored, or that it passes water very frequently, probably wets its bed at night, is constipated, and the move- ments are light and pasty, she will know that the child needs a laxative, to be followed by a change in its diet, — a dose of Husband's magnesia, about a quarter of a teaspoonful, or, probably better than all, a dose of castor oil, followed next day by a limited amount of milk, substituting chicken-broth and avoiding oatmeal or beef-juice until the bowels become more normal. Castor oil can be given in warm water in which has been dissolved a peppermint drop, or a tablespoonful of liquid soda mint, a preparation now so well known that it can be obtained at any drug-store. The " soda mint" compressed tablets should be kept in every house, as they are frequently useful for "hiccups" or slight indigestion, though for infants the liquid is better. This form of sleeplessness is most apt to be noted at about the end of the first year. With some chil- dren the constant diet of oatmeal without any variation, the daily use of the expressed juice of beef, and at the same time large quantities of milk, which at this period is not often much diluted, will bring about the form of digestive disturbance just mentioned, and a degree of nervous excitability that is often referred to the teething process alone. On that account barley is preferable to oatmeal. We often hear of children who are said to be suffering when cutting their back teeth, and upon investigation find that tliey are taking about a quart of milk a day, with a tablespoonful of Mellin's food in each bottle, an ounce or two of the expressed beef, possibly a bowl of oatmeal food, and in addi- tion are constipated, get no fresh air, — in fact, are city chil- dren, surrounded by all the disadvantages that our changeable and treacherous climate affords ; viz., overheated houses and impure air. A child of this sort, if given chicken-broth instead TEETHING. 313 of beef-juice, less Mellin's food, thin bread and milk instead of oatmeal, allowed to drink freely of water, and given an occa- sional laxative, will soon cease to suffer with its teeth. Over- feeding — stuffing, even with good, wholesome food — is the cause of much of the. disorder and febrile attacks of children, to say nothing of the " sweets" that are permitted between meals. Sleeplessness may arise from pain ; especially is this the case in bottle-fed children, who suffer from neuralgia, muscular soreness, possibly vague rheumatic pains, supposed by many to be caused by the fermentation of the sugar or starches which they are unable to digest. A child that is fed upon too much sugar will develop acidity ; the same with starch ; this leads possibly to rheumatism, or rheumatic neuralgia, called growing pain, and eventually to rickets, restlessness, sleepless- ness, or sudden starting, soreness to the touch, no desire for exercise, peevishness, or possibly extreme pain upon move- ment. When the child is lifted suddenly, or is handled while dressing, it will cry, — all important symptoms of this con- dition. An extra-sensitive nervous system will probably cause neuralgia through the jaw and head, earache, in some chil- dren, from tooth-pressure ; this cause is recognized from the fact that these children will avoid anything placed in the mouth, even the nipple of their nursing-bottle. The gums may be slightly swollen, but not inflamed or in themselves tender, but the least pressure upon them with the finger will cause intense suffering. In a case of this kind, if severe, — the child restless, starts in its sleep, refuses food, — the gum should be lanced. A cross-cut that will open the capsule of the tooth will in a moment relieve the pressure. If this is impossible, a hot bath or hot foot-bath should be given, also an enema of warm water, and if the child still suffer, and the mother is away from the doctor, she may give two grains of bromide of potassium, or five drops of the elixir of the valerianate of ammonia, the latter to be repeated in the course of an hour, if o 27 314 MOTHER AND CHILD. necessary. These are the cases in which the bromide of potas- sium, if given judiciously, is of the greatest value ; they present the purely nervous type, and the nervous system should be soothed by precisely the same mode of treatment that one would adopt for a severe neuralgic headache. The bromide may be given with a teaspoonful of syrup of lactu- carium, or a teaspoonful of orange-flower water. If the excitement is great, the child of a year old should take about four grains of bromide ; should a convulsion threaten or occur, the proper treatment i3 warmth and counter-irritation to the legs, and an enema of two ounces of water, at about the tem- perature of 100° F., containing one teaspoonful of the tincture of assafcetida. After the foot-bath the child's legs should be thoroughly wrapped in a blanket, and the only food given h for a time should consist of the blandest kind, such as barley- water, wine-whey, or chicken-tea. Dr. A. Jacobi, on the treatment of convulsions, writes as fol- lows : "Remove the injurious substances from the stomach. If vomiting have not occurred or not sufficiently, it should be provoked by tickling the fauces, and friction of the precordial [heart] region. These, as a rule, will suffice, but if they do not, quantities of warm water or mustard water will answer a good purpose. The syrup of ipecac is a doubtful and unreliable preparation. Purgatives should not be given in the begin- ning ; large enemata will act more favorably, as warm water, or warm water with antispasmodics, such as assafcetida, or local stimulants, such as turpentine. " Fever, unless it be high, requires no special treatment. As a rule, cold applications to the head will act well when there is a tendency to convulsions. Cold applications to the heart will reduce the temperature of the whole body. A warm bath will frequently do good. I do not adoise bathing or handling the child much while the convulsion is on. When thirst is very great, small quantities of ice-water should be given often, or Seltzer water, or Yichy or Apollinaris. TEETHING. 315 " Solid food must not be given." A teaspoonful of the tincture of assafoetida in a teacup of water is the proper strength for an injection. Mothers should not give their children ipecac in this condi- tion, it being very irritating, and the strain produced by vomiting may be productive of harm. Ten drops of the aromatic spirits of ammonia, or ten drops of brandy, whiskey, or gin, in two tablespoonfuls of warm water, are Jar better, when given to the child as soon as it can swallow ; if there is any offending matter in the stomach, it will act sometimes as an emetic. There is another cause of restlessness and sleeplessness from teething, that due to the congestion of the gum and inflamma- tion of the mucous membrane of the mouth. We more fre- quently find this condition when the back teeth are being cut, and in children who secrete but little saliva. The gum is found swollen, red ; the mouth is dry ; the child will turn away from more solid food, and will eagerly drink water to allay the irritation in its mouth. Frequently, during the second summer, it will be accompanied by diarrhoea, from the fact that the mucous membrane extends to the stomach and bowel Yery often small ulcers (aphthae) form in the fold of the cheek or the surface of the gum, become coated with secretion, and are exceedingly painful. If there is disturbance in diges- tion, little round vesicles, which burst and form ulcers with a grayish coating, will form On the inside of the cheek or the lips, and on, or beneath, the tongue. These aphthae will annoy the child extremely, and produce sleeplessness ; they are the result of indigestion, not of teething, though fre- quently associated with it. The physician will probably give a little calomel and soda to correct the digestive disturbance, or the mother can give some magnesia, or from ten to twenty drops of spitted syrup of rhubarb with a teaspoonful or two of soda mint, given once a day until the bowels become reg- ulated ; at the same time the child can have its mouth washed gently with a soft piece of linen, with a solution composed of 316 MOTHER AND CHILD. a pinch of borax, a teaspoonful of glycerin, and a tablespoon- ful of rose-water. The congestion of the gum of which we have been speaking causes the child to crave salty food ; indeed, this is an effort of nature to relieve this condition by inducing a flow of saliva. Lancing the gums will often be of great service, by the relief it gives to congestion ; the incision should be deep enough to cut through the capsule of the tooth ; instead of this the child should be given something to bite upon, and it will probably obtain relief in that way. The small bone of a well-boiled ham is salt, and the child will eagerly suck it and frequentry bite it. A chicken-bone, slightly salted, is also useful, or the child may be allowed to bite on a piece of rare roast beef, and possibly the eagerness with which it will seize upon it may cut the gum from below with the sharp points of its tooth. Children who suffer thus from their gums often get relief from Mellin's food, tied in a rag to suck or bite upon. To sum up, the object to be secured is the free flow of saliva ; it will relieve congestion and soften the gum. It is a mistake to rub a gum under such circumstances by hard, dry friction, but if the little one suffers so as to disturb its sleep, the mother's finger, dipped in the syrup of lactucarium, or even in paregoric and glycerin, ten drops to the teaspoonful, can be gently carried over the tender and inflamed gum, and, by gentle pressure, soothe instead of irritate ; and now and then a little firmer pressure may allow the point of a tooth to force its way through. Some children will eagerly suck a piece of ice wrapped in linen, and it will relieve the congestion of the gum. In these cases a hot foot-bath again has its advantages, by relieving the congestion of the head and mouth ; or, if the child is constipated, the operation of a laxative will be followed by relief to its congested gum. The latter will shrink, and a point of the tooth emerge from its captivity. DIET AFTER EARLY DENTITION. 317 CHAPTEE XLI. DIET AFTER EARLY DENTITION. After a child has cut its twelve teeth, it is well to give it more solid food than that which it has been accustomed to take. The milk diet has been continued, or the bread and milk, up to this period, in addition to the mutton-broth, chicken-broth, or beef-soup, and our endeavor now should be to encourage the digestion of more solid food by gradually adding it to the diet to which the child has been accustomed. In almost every house is kept on hand what is known as stock ; this forms a very valuable addition to a child's dietary, as it is nutritious, palatable, and can be flavored so as to make a change. A child about two years old may have a more solid mid-day meal, composed of a piece of rare tenderloin or juicy mutton- chop, with some well-boiled rice or a thoroughly-roasted, dry, mealy potato, well minced, in addition to its soup, or the white meat of a tender fowl, or sweetbread finely chopped, first heated, though not fried. For its breakfast, instead of the bottle, a child of this age may take about a tablespoonful of cracked wheat (which must be thoroughly boiled or steamed), or oatmeal, or yellow corn-meal, or white grits of moderate consistency (thoroughly boiled), and milk. A little salt should be added to these while boiling ; this is preferable to flavoring with sugar. We think, indeed, it is better than using salt and butter ; butter used in that way will certainly upset a child's digestion. The sanitary foods (cereals) prepared at Battle Creek, Michigan, are useful in this connection. A soft-boiled egg, with bread and butter and a tumbler of milk (" cambric tea"), is about the best breakfast a child can have at this age. If it sits at the table and is taught to eat slowly, it will not become dyspetic. Between times, if the child is thirsty, a drink of milk is admirable. With its dinner, 27* 318 MOTHER AND CHILD. water is probably better; we have certainly found it so in children who are of a bilious habit. It is a great mistake to give a child sweet things before its meal; after dinner it may be allowed to have some mild dessert, light custard or pudding, sponge-cake, a baked apple, or, indeed (after it has cut its twelve teeth), a piece of ripe, raw apple or peach will have a good effect on its bowels. The great advantage of bring- ing a child to the table to eat with its parents is that it is taught to eat properly, to masticate its food thoroughly, which is the only way of avoiding dyspepsia ; and also, that the child can thus be trained to see but not ask for things that it knows it should not have. It is a great mistake to so spoil a child that it will refuse when at the table the proper sort of food, and cry constantly for that which is forbidden. A taste of this or that at the table may not result, for the time being, in an attack of indigestion, but the parents are sure to suffer for it in the future. We so often make the mistake of believing that children are rendered strong and healthy by inattention to these matters of diet and clothing, that care- lessness makes the child hardy, that the child who is strictly brought up is usually a sickly one. We acknowledge that at times great mistakes have been made by over-carefulness, that the scientifically-brought-up child is not always the most healthy. This carefulness may be carried to extremes, as may everything else. It is always well to make your list for the child's bill of fare as large as possible, and give it its choice ; but always adhere to the lines of digestibility, and avoid those articles that every one knows are absolutely indigestible or at least harmful and irritating, such as veal, pastry, unripe fruit, sweets in quantity ; and do not imagine that, because children sometimes escape the dangers which indulgent parents bring upon them, the words of advice only come from those who are too highly scientific in their ideas. The highly-educated classes and those who live by their brains alone are notoriously dyspeptic, and the children of these undoubtedly inherit the weak digestions of their parents DIET AFTER EARLY DENTITION. 319 us they do their more highly organized brains and possibly larger heads. They are more subject to acute brain-troubles from this cause, and the}' are certainly more subject to all the influences which produce intestinal disorders, and cannot possibly digest the same food that will agree with a child of the same age, the offspring of the less intellectual and the laboring classes. This is a matter which every mother should thoroughly understand; it explains to her why one child will thrive on food that would be poison to another; it will prove to her beforehand, without the necessity of an experiment, that her child would not be made more hearty by feeding on the boiled potatoes, soggy bread, corn-starch, or apple-dumpling that has failed to kill her washerwoman's child. Nature has so constituted food that it is not all concentrated nourishment; in grain, in fruit, in meat, the easily digested portions are associated with certain materials that are harder to digest; in a mixed diet the various substances have dif- ferent degrees of digestibility, and in this way the digestive juices come more closely in contact with the food, owing to its bulk, and the muscular contraction of the stomach and intestines is promoted by the mass of material which passes through them. It would be, then, a mistake to feed a healthy person entirely on concentrated nourishment; the intestinal digestive juices would fail to be secreted, the liver would become congested and diseased, the bowels would be coated with mucus and would fail to act, and the refuse from the destruction of tissue, which is normally carried off by them, would remain behind and poison the system. But during illness, when digestion is checked, and when it is neces- sary to supply in small amounts the most concentrated nourishment to sustain the system of the patient, then the well-known preparations of peptonized foods, of concentrated meat-extracts, are not only most valuable but often absolutely indispensable. After it has cut its twelve teeth, the child will naturally desire a greater variety of food, and within bounds this de- 320 MOTHER AND CHILD. sire may be satisfied. Its bill of fare should include articles that are easy of digestion, — mutton, beef, sweetbread, fowl of various kinds, soft-boiled eggs, scrambled eggs, or light omelet ; vege- tables, as carrots, spinach, young beans, young beets, asparagus, old potatoes, — the latter well boiled and mashed, or roasted ; by all means avoid parsnips, cabbage, turnips, etc. For fruits, baked apples, raw apples scraped, oranges (of course only the juice), grapes (avoiding the skins and seeds), peaches (pro- vided they are not picked green and then ripened) ; and avoid berries of every kind, also pineapples, green apples, etc. Figs, dates, and raisins are all bad for children at this tender age. The seeds of raw berries, also cherry-stones and chestnuts, are apt to lodge in a certain portion of the intestine and become impacted, thus giving rise to a serious disease that will require surgical interference. Dr. S. S. Adams, of Washington, has given us an interesting resume of the subject, and we will quote at length from his valuable paper : * " For convenience it is necessary to assume that the child has been deprived of the breast-milk at the twelfth month, and to formulate a dietary accordingly. The eruption of the lower central incisors, during the seventh or eighth month, seems to be the indication to mothers to begin supplemental feeding. Yery few infants pass far beyond this physiological epoch without it. . . . " The object being to prescribe a suitable dietary for the child, in health and disease, from weaning to puberty, it will be best attained by making divisions to conform to the recog- nized anatomical and physiological changes in the organism. The following divisions seem, therefore, to meet all the require- ments: 1, twelfth to eighteenth month; 2, eighteenth to thirty- sixth month ; 3, third to fifth year ; 4, fifth to eighth year ; 5, eighth year to puberty. " While most mothers will appreciate the value of milk as the chief food for infants during the first year, very few will 1 Keating's Cyclopaedia of the Diseases of Children, vol. i. p. 337. DIET AFTER EARLY DENTITION. 321 be convinced of its value as such after weaning. Several months before the child is weaned, in many instances, it has had some of the farinaceae, and also, probably, meat-broths. If weaning takes place before the eruption of the molars, the diet should be milk. If it is weaned during the summer months, milk should be its only food, although the molars and, perhaps, the canines have appeared. If, however, the child does not seem to derive sufficient nourishment from the milk, it may be given some additional food, provided the weather be cool, but always remembering that its chief constituent must be milk. If it seems to thrive on milk alone, it will be advisa- ble to limit it to it until the eighteenth month. It is the ex- ception, however, when a child will be satisfied with milk until this late period. It is generally necessary to supplement its food by adding some farinaceous aliment. If there is a ten- dency to loose bowels, barley-water is preferable. It is made by grinding a tablespoonful of the grain barley and adding to it six ounces of water : this should be boiled for fifteen or twenty minutes, salt added to suit the taste, and the mixture strained. This decoction should be made fresh twice a day and kept cool. It should be added to the milk in the propor- tion of one to three or one to two. The prepared barley may be used in the same manner, but it is not so reliable. If con- stipation is the rule, oatmeal may be used by preparing a de- coction similar to that of the barky. Arrow-root should not be used, on account of the large proportion of starch it contains. " Bread jelly has been highly recommended by Churchill and others as an excellent food for children just after weaning. It is made by taking a quantity of the soft part of stale bread, breaking it into small pieces, covering it with boiling water, and allowing it to soak for some time. The water is then strained off, and fresh water added. This should now be boiled until it becomes soft ; the water is then pressed out, and the bread on cooling will form a jelly. A portion of this should be mixed with sweetened milk. " In some cases beef-tea will be well borne. That made in a 322 MOTHER AND CHILD. bottle swimming in a water-bath does not contain soluble albu- minoids. It contains large quantities of salts, and should not be given when there is a tendency to diarrhoea. Excellent beef-tea is made by mincing one pound of lean beef and add- ing a pint of cold water and ten drops of dilute hydrochloric acid. This should stand for two or three hours, with occasional stirring. It should then be left to simmer for fifteen or twenty minutes, when it will be ready for use. " Beef-broth is not very nutritious, and is not recommended. Mutton-, veal-, and chicken -broths are nutritious, and are appli- cable in many cases. It must be borne in mind, however, that mutton causes constipation, and veal diarrhoea. . . . " With the sixteen teeth the child should be allowed a more liberal diet. Its digestive apparatus is now capable of digest- ing food which has been masticated. It may be allowable to give it* stale, well cooked bread, and butter, or crackers. It may also be given a little mashed white potato, with gravy. A sandwich of scraped lean beef and bread, seasoned with salt or sugar, will be relished, and is very nutritious. It may have a piece of rare beef or a chicken-bone to suck, care being taken that it does not swallow the pulp or bone. " Peptonized beef preparations have been recommended by the recognized authorities. "In regulating the regimen of a healthy infant during this period, very little change is required in its food. It should be fed five or six times, at the same hours, every day, but should not be awakened for the purpose. If it desire its food before its accustomed time, it should have it. " First meal, 6 a.m. — A cup of milk, with cream biscuit or a slice of buttered bread. "Second meal, 8 a.m. — Stale bread, broken and soaked in a tumblerful of rich milk. "Third meal, 12 m. — A slice of buttered bread, with about half a pint of weak beef tea or mutton- or chicken-broth. " Fourth meal, 4 p.m. — A tumblerful of milk, with crackers or a slice of buttered bread. DIET AFTER EARLY DENTITION. 323 "Fifth meal, 8 p.m. — A tumblerful of milk, with bread or crackers. " Towards the latter part of this period, when the child has sixteen teeth, it may be desirable to substitute the following : " First meal, 6 a.m.— Bread or crackers, with a half-pint of milk. " Second meal, 8 a.m. — A tablespoonful of oatmeal, cracked wheat, or corn-meal mush, with milk, and a couple of slices of buttered bread. " Third meal, 12 m. — Bread-and-butter, milk, and a soft-boiled " Fourth meal, 4 p.m.— A piece of rare roast beef to suck ; mashed boiled potatoes, moistened with dish-gravy ; bread and milk ; and a small portion of rice, bread jelly, or farina. " Fifth meal, 8 p.m. — Milk and bread or crackers. 1 " This is a modification of the diet laid down by L. Starr ; but the writer usually insists that the infant should be con- fined to milk, milk and barley-water, or milk and oatmeal- water, during this entire period. When his advice has been fol- lowed, the perils of the ' second summer' have been avoided. " Fruits and berries of all kinds should be interdicted. " Every case of infant-feeding must be regulated by its own indicated requirements. There is no uniform rule applicable to all. Each must be studied carefully, and that mode of feeding must be adopted which proves best suited to it. " The child should not be permitted to sit at the family table. It may have a separate table, where it can have its frugal meal without being tempted by unwholesome dishes. " The diet in sickness during the first period must be regu- lated by the nature of the case. It is impossible to prescribe a regimen suitable to all sick children. "Yomiting is unquestionably the most frequent symptom to be controlled. It may be due to overfeeding, or to some 1 Often it would be preferable to give the fourth meal at three p.m., and the fifth meal at six p.m., especially in winter, so that the child can be put to bed by seven o'clock. — K. 324 MOTHER AND CHILD. fault in the quality of the food. "When it is caused by over- feeding, a diminution in the quantity of food, as well as a longer interval between meals, will usually correct it. If it should be caused by a defect in the quality, this should be discovered and remedied. If the ejected matter is sour- smelling, the alkali must be increased. Frequently, forced abstinence will correct it ; and in many cases small quantities of food given every fifteen, twenty, or thirty minutes will have a salutary effect. " Diarrhoea is often the result of improper feeding. The food may be too concentrated, or its quality may be poor. "When it is due to too much solid food, the indicated treatment is to confine the patient to a liquid diet. If the quality of the food is not good, it should be improved. In many cases the addi- tion of barley-water to the milk will prove effectual in check- ing the diarrhoea. " Constipation may often be corrected by adding oatmeal to the second meal, or oatmeal-water to the milk. " It should be the invariable rule to confine children to a liquid diet as soon as any impairment of digestion or assimi- lation is noticeable or they become ill. Milk should always have the preference. It may be given pure, diluted, boiled, or, perhaps, predigested. In rare instances milk will not be retained by the stomach, or will be passed from the bowels only partially digested. In such cases a mixture of equal parts of milk and lime-water, given in teaspoooful doses every ten or fifteen minutes, will not infrequently be retained and digested. In some cases where milk cannot be retained, barley- or rice-water may be temporarily substituted. In other cases beef-tea, beef-essence, or beef-juice may be admin- istered in small quantities, frequently repeated, with marked benefit. Tea and coffee should not be allowed. " In weakly children the following may be given : l 1 The following are very good recipes, recommended on high authority: For "beef-essence take one pound of beef free from skin and fat, chop as DIET AFTER EARLY DENTITION. 325 " Chicken Jelly. — Clean a fowl that is about a year old, and remove the skin and fat. Chop it, bones and flesh, and put it in a pan with two quarts of water. Heat slowly, and skim often and carefully. Let it simmer for five or six hours ; then add salt and mace or parsley to taste, and strain. Set away to cool. When cold, skim off the fat. The jelly is usually relished cold, but may be heated. Give this in small quan- tities, very often. " Wine- Whey. — Boil three wineglasses of milk, and add a wineglass of sherry or port wine. Strain, and add a wineglass of warm water. A wineglassful of this may be given once or twice a day. " White Wine- Whey. — To half a pint of boiling milk add a wineglassful of sherry ; strain through a fine muslin cloth, and sweeten. A tablespoonful of this may be given every two or three hours. " Eighteenth to Thirty-sixth Month. — It is quite as important to regulate the diet of the second period as that of the first, but much more difficult. At this period the child is walking, and often helps itself to indigestible substances. It now has all its milk-teeth, and is capable of mastication. Its mind is fine as mince-meat and pound in a mortar with two tablespoonfuls of water. Put into an earthen jar with a little salt, cementing the edges of the cover with pudding paste ; then put the jar in an oven or tie tightly in a cloth and keep in a pot of boiling water for three hours. Strain through a coarse sieve. Give two or more teaspoonfuls. For chicken-broth take half a chicken, one quart of water, a small bunch of sweet herbs, one blade of mace, and salt to taste. Put into a saucepan and allow to simmer gently for one and a half hours, carefully skimming in the mean time. Then strain and cool. "When cool remove all fat from the surface. This may be warmed as needed. Mutton-broth is made by taking one pound of the scrag end of the neck of mutton, a small bunch of sweet herbs, half a turnip, and a little salt. Put into a stewpan and pour over it three pints of cold water. When it boils, skim carefully, cover closely, and allow it to simmer gently for an hour ; then strain, cool, and take off all fat. This may be warmed as re- quired. Pearl barley or rice may be added, but must be boiled thoroughly. 28 326 MOTHER AND CHILD. generally sufficiently active to be taught what edible articles it should have. Its power of masticating, its flow of saliva, its good digestion and assimilation, and its increasing bodily growth demand a greater variety of food. If it reach its second period during the summer, and have the appearance of health, and seem satisfied with its milk and simple food, it will be prudent to wait until cool weather to change its diet to a more substantial kind. " It is now admissible to allow it to eat at the family table, because the opportunity to begin its training early should not be overlooked. It can be taught to eat slowly, that certain articles are not suitable for it, and that it can have enough of the proper kind of food. When a child frets for different articles of food on the table it is generally because some impru- dent person has allowed it to taste them. If it is not tempted by tasting other, it will be contented with its simple food. It should be fed at least four times daily, and occasionally will require a few crackers or a slice of bread-and-butter between meals. "First meal, 8 a.m. — A portion of well-cooked oatmeal, wheaten grits, or corn-meal mush, with a liberal supply of milk ; cold bread-and-butter ; and a piece of finely-cut, tender beefsteak, or a soft-boiled egg. " Second meal, 12 m. — A bowl of chicken or oyster soup, or weak beef-tea ; milk, with bread or crackers, and butter. " Third meal, 4 p.m. — Eoast beef, mutton, chicken, or turkey ; fresh white fish ; mashed white potato, moistened with gravy ; bread-and-butter ; and rice and milk. " Fourth meal, 8 p.m. — Milk, with bread or crackers. " It may be necessary to give a glass of milk and a piece of bread-and-butter between the first and second meals ; and if the child is particularly hearty the same may be occasionally required in the early morning. Towards the latter part of this period fresh ripe fruits are admissible, provided due care is taken to prevent the ingestion of seeds and rinds. A pop- ular fruit is the banana; but the writer's experience has been DIET AFTER EARLY DENTITION. 327 such that he considers it more productive of eclampsia than any other fruit, and consequently he cannot recommend it. 1 " The meal-hours vary in different communities, so that those for children will be governed by the local customs. It may be necessary to givethe principal meal earlier than four p.m. It must be remembered, however, that most children sleep the greater part of the afternoon, so that if they eat dinner at two o'clock they will be asleep during the digestion of the bulk of the day's solid food; on the other hand, if the meal be at four o'clock there will be active exercise after it to aid di- gestion and assimilation. " It will need constant watching to prevent it from obtaining unsuitable food. " Frequently the neuroses, as eclampsia, ' night-terrors,' petit mal, and the numerous symptoms attributable to 'worms,' may be directly traceable to the presence of indigestible food in the alimentary tract. A brisk purgative seldom finds the ' worms,' but generally allays the excessive exaltation of the nervous system by removing the offending material. " When the child is suffering from an acute disease, its diet should be limited to milk and beef-tea. In chronic ailments, or in protracted convalescence from acute disease, each case must be treated by its individual requirements, while good judgment will render valuable assistance in the selection of those foods which are easily digested and which possess the maximum quantity of nutritious matter to the quantity in- gested. In sickness, tea and toast are favorite articles, but only load the alimentary tract with in nutritious matter. " During the third period — from the third to the fifth year — the difficulty of regulating the child's diet will be great. It has now reached the a^e when its friends will humor it with 1 The plantain, or banana, is brought to this country green, and on that account is indigestible. When picked ripe in its native land it is most digestible. It is said that a pound of ripe bananas is equal in nourishment to a pound of bread or a pound of steak. — E. 328 MOTHER AND CHILD. knick-knacks and table-food of difficult digestion. It has twenty teeth, and its friends cannot understand why it should not have such food as a healthy adult can digest. A devoted mother, or usually grandmother, will argue that all her chil- dren, at this age, were fed from the table and were not injured. Such children lived in spite of mismanagement. Granting that its diet must be more liberal at this age, it must still be restricted, for even now the presence of indigestible or undigested food in the alimentary tract may be productive of reflex nervous disturbances. " Its activity and waste and repair demand an increase in the quantity of nutritious food. Three substantial meals a day will usually suffice, but occasionally a snack between meals will be required. While it is well to apply the rule of regu- larity, it is not always prudent to enforce it, especially if the child is hungry. The practice of children running to the pantry and helping themselves should be discouraged. In such cases children do not eat enough at the regular meals. "It is impossible to lay down