COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00079316 i N Nursing ETERNITY, IN FAN AND Childhood. ByJoHNM.K; ID. RECAP Columbia Untoersrttp COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/maternityinfancyOOkeat PRACTICAL LESSONS IN NURSING. 12mo. Extra Cloth. $1.00 each. CHAS. K. MILLS, M.D. THE NURSING AND CARE OF THE NERVOUS AND THE INSANE. JOHN M. KEATING, M.D. MATERNITY; INFANCY; CHILDHOOD. The Hygiene of Pregnancy; the Nursing and Weaning of Infants ; the Care of Children in Health and Disease. E. T. BRUEN, M.D. OUTLINES FOR THE MANAGEMENT OF DIET; Or, the Regulation of Food to the Requirements of Health and the Treatment of Disease. J. C. WILSON, M.D. FEVER NURSING. including: i. On Fever Nursing in General. 2. Scarlet Fever. 3. Enteric or Typhoid Fever. 4. Pneumonia and Rheumatism. For sale by all Booksellers, or will be sent, free of postage, on receipt of the price by the Publishers, J. B. Lippincott Company, 715 and 717 Market St., Philadelphia. PRACTICAL LESSONS IN NURSING. Maternity, Infancy, Childhood. HYGIENE OF PREGNANCY; NURSING AND WEANING OF INFANTS; THE CARE OF CHILDREN IN HEALTH AND DISEASE. ADAPTED ESPECIALLY TO THE USE OF MOTHERS OR THOSE INTRUSTED WITH THE BRINGING UP OF INFANTS AND CHILDREN, AND TRAINING SCHOOLS FOR NURSES, AS AN AID TO THE TEACHING OF THE NURSING OF WOMEN AND CHILDREN. BY JOHN M. KEATING, M.D., VISITING OBSTETRICIAN AND LECTURER ON THE DISEASES OF WOMEN AND CHILDREN, PHILADELPHIA HOSPITAL (BLOCKLEY) ; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, ETC. is Huber SECOND EDITION. PHILADELPHIA: J. B. LIPPINCOTT COMPAl^Y. London: 10 Henrietta Street, Cotent Garden. 1888. Copyright, 1887, by J. B. Lippincott Company. TO J. M. DA COSTA, M.D., LL.D., PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, JEFFERSON MEDICAL COLLEGE, IN RECOGNITION OF MANY ACTS OF PERSONAL KINDNESS. PKEFAOE. This little work is intended for mothers, and for those who have undertaken the care of infants and children in health and sickness. The enormous mortal- ity of children under three years of age, the greater part of which is preventable, has attracted the notice not only of physicians, who have long ago insisted that the methods adopted in general for the weaning of children were unscientific, but of the public also, who are beginning to realize this fact, and now will- ingly accept the advice of those who are giving espe- cial attention to the subject. Much of the material appearing in this book has been taken from the manuscripts of my lectures to students of medicine and also pupils of training schools for nurses. I sincerely hope that the practical nature of many of the suggestions offered will find favor with the busy practitioner of medicine, and be looked upon as a sup- plement to the text-books on children's diseases that cannot give space to details of nursing. To Dr. Charles S. Turnbull I am indebted for the article on the care of the ear and eye, one of the most important chapters in the book. Dr. Alexander W. MacCoy kindly replied to some questions, and the matter is so practical and clear that I have placed it in a chapter as sent me. 1504 Walnut Street, Philadelphia. CONTENTS. PART I. MATERNITY. CHAPTER I. PREGNANCY. PAGE How to Calculate the Probable Date of Confinement — The Presumptive Evidences of Pregnancy — Morning Sickness ; the Cause, and how to Eemedy it — How to Avoid and Remedy the Constipation of Pregnancy — Exercise, and how it should be taken — Diet during Pregnancy — The Care which the Breasts should receive — The Baby-Basket — A List of Articles necessary in Confinement — The Binder — Miscarriage ; what is Meant by the Term — The most Frequent Causes — The Greatest Care and Caution should be Exercised after Miscarriage 13 IP ART II. INFANCY. CHAPTER H. CARE OF NEW-BORN INFANT. How to cleanse a New-born Babe — The Cord, and the Care which it should receive — The Binder and its Object — Im- portance of noting the Child's Secretions — A Babe should be given Water occasionally — All about the Mother's Milk first making its Appearance — The Diet of the Nursing Mother — How to check an excessive flow of Milk, and to increase an Insufficient Supply — The Child's Diet — How often a Child should receive Nourishment 38 CHAPTER III. BOTTLE-FEEDING. The Child's Bottle and how to prepare it — Great Care in pre- paring the Bottle must be Exercised — An Efficient Nurse indispensable to the Welfare of the Child— A Study of Milk — Condensed Milk and fresh Evaporated Milk .... 50 9 10 CONTENTS. CHAPTER TV. PREPARED BOTTLE. vkm Cow's Milk, its Advantages and Disadvantages — A Child's Digestion — Different Preparations of Bottle-Pood — "Why an Infant should have very Little Starchy Pood in its Diet — How to avoid either Constipation or Diarrhoea — A Bahy's Bottle Diet may be varied — Peptonized Milk — The Care which a Mother should exercise in the Selection of a Child's Diet 66 CHAPTER V. "WEANING. Weaning — "When to wean a Child — "Where to wean a Child ; and how to wean it 83 CHAPTER VI. FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. The Great Importance of Ventilation — The Selection and Care of the Nursery — How it should he Heated — The Danger of allowing Children to be left to the Care of Young and Inexperienced Girls — How Children frequently contract Diseases 87 CHAPTER VII. BATHING. The Importance of Bathing — A Child's Time for Bathing must be regulated by the Child's Condition, etc. — The Cruelty of forcing Young Children to have a Plunge in the Cold Sea — A Child should love its Bath, and how it can be taught to love it 94 CHAPTER VIII. TEETHING. The Milk-Teeth, and when they are usually Cut — Why a Slobbering Babe suffers less from its Teeth than another — Usual Symptoms — "Why Mothers dread a Child's Second Summer — Pickets and what is meant by the Term — Pick- ets a Prequent Cause of Spinal Affection — How a Pregnant "Woman may predispose her Child to Pickets — Fat Children are not always healthy ones — How to treat a Eickety Child — A Teething Child suffers frequently from other Causes than its Teeth — A Child should have Sufficient Sleep — "Why so many Little Ones are wakeful — How Sleeplessness can be remedied — The Diet of a Teething Child .... 100 CONTENTS. 11 CHAPTER IX. DIET AFTER EARLY DENTITION. pA(ffl The Necessity of a Careful Selection of Diet — The Advan- tages and the Disadvantages of taking a Child to the Table — The Necessity of discriminating between Children as to their Diet — Why what is Meat to one Child is Poison to Another — Exercise is Essential 112 CHAPTER X. ON THE BOWELS. What constitutes a Normal Condition of the Bowels in a Child — More Grease than Powder should he used for Young Children — What causes Disturbances of the Bow- els — Different Causes of Constipation — How Constipation can he overcome — Of what a Child's Diet should consist, and how it can be regulated when it is suffering from Bowel-Complaints — A few Useful Bernedies — Exercise a Specific for many Forms of Constipation 116 PART III. CHILDHOOD. CHAPTER XL ACUTE AND CHRONIC NASAL CATARRH. Affections of the Mucous Membrane of the Nose, Acute and Chronic, in Infants and Children — Their Prevention and Treatment 127 CHAPTER XII. DISEASES OF THE EAR AND EYE. Diseases of the Ear in Infancy and Childhood — The Care of the Ear in Childhood — Diseases of the Eye in the New- horn — Treatment of Simple Ophthalmia — Contagious Oph- thalmia ; how to prevent it ; its Treatment and Nursing . 135 CHAPTER XIH. DISEASES OF THE THROAT AND AIR-PASSAGES. Croup and Diphtheria — Simple Spasmodic Croup, what its Symptoms are and how to treat it — Membranous Croup, its Symptoms and Treatment — The Difference between Membranous Croup and Diphtheria — Diphtheria as a Cause of Membranous Croup — The Nursing, and the Use of Household Kemedies in their Treatment 161 12 CONTENTS. CHAPTER XIV. DIABEH03A. PAQ3 j The Causes of Diarrhoea; — Over-feeding; Tainted Milk; De- composition of Food ; Undigested Starches ; Teething ; Hot Weather — Inflammatory Diarrhoea — How it can be avoided — Change of Diet necessary, also Absolute Quiet, Pure Drinking- Water, and Presh Air — The Character of the Diet — Importance of Peptonized Milk and Nutritious Injections 164 CHAPTER XV. WHOOPING-COUGH. Its Character — Its Complications — The Nursing of it — Diet —Treatment 174 CHAPTER XVI. SCAELET FEVEE. Its Cause — The Eeasons why it does not appear to be as Con- tagious as other Similar Affections — The First Symptoms — Its Nursing — Complications — Sequela? 180 CHAPTER XVII. MEASLES. How it is contracted — How the Contagion is carried — Why it is the most contagious of the Eruptive Diseases — The Peculiarity of the Eruption — The Dangers of Pulmonary Troubles as Complications or following the Disease — The Nursing 186 CHAPTER XVIII. SECOND DENTITION. Forcing in Education to be Condemned — What is Meant by Second Dentition — Complications Due to Hereditary or Acquired Conditions — Rickets — How it is to be Avoided —Diet of Children at this Age — Clothing 191 CHAPTER XIX. PUBERTY. Puberty — The Four Second Molars — The tendency to Dis- turbance of Digestion at this Time — The Importance of Proper Food and Clothing, also Freedom from Excitement and the use of Iron — First Menstruation — Menstrual Irreg- ularities — Hysteria — Dysmenorrhcea — The Abase of Ano- dynes — The Mother the proper Confidant of her Daughter. 200 Maternity; Infancy; Childhood. PART I. MATERNITY. CHAPTER I. PKEGNANCY. How to Calculate the Provable Date of Confinement — The Pre- sumptive Evidences of Pregnancy — Morning Sickness ; the Cause, and how to Kemedy it — How to Avoid and Kemedy the Constipation of Pregnancy — Exercise, and how it should be taken — Diet during Pregnancy — The Care which the Breasts should receive — The Baby-Basket — A List of Articles necessaiy in Confinement — The Binder — -Miscarriage ; what is Meant by the Term — The most Frequent Causes — The Greatest Care and Caution should be Exercised after Miscarriage. Conception is more liable to take place either im- mediately before or immediately after the period, and, on that account, it is usual when calculating the date at which to expect labor to count from the day of disap- pearance of the last period. The easiest way to make a calculation is to count back three months from the date of the last period and add seven days ; thus we might say that the date was the 10th of June : counting back three months brings us to the 10th of March, and add- ing the seven days will bring us to the 17th. Very many medical authorities, distinguished in this line, have stated their belief that women never pass more than two or three days at the most beyond the 2 13 14 MATERNITY. forty weeks conceded to pregnancy, — that is, two hun- dred and eighty days or ten lunar months, or nine cal- endar months and a week. About two hundred and eighty days will represent the average duration of pregnancy, counting from the last day of the last period. Now, it must be borne in mind that there are many dis- turbing elements which might cause the young married woman to miss a time. Daring the first month of pregnancy there is no sign by which the condition may be positively known. The missing of a period, espe- cially in a person who has been regular for some time, may lead one to suspect it; but there are many at- tendant causes in married life, the little annoyances of household duties, embarrassments, and the enforced gayety which naturally surrounds the bride, and these should all be taken into consideration in the discussion as to whether or not she is pregnant. But then, again, there are some rare cases who have menstru- ated throughout their pregnancy, and also cases where menstruation was never established and pregnancy occurred. Nevertheless, the non-appearance of the period, with other signs, may be taken as presumptive evidence. The exact date at which to expect confinement is an important one to determine for many reasons; the en- gagement of a nurse is dependent upon it, the choice of a nurse being a matter of importance. Great diffi- culty attends the positive diagnosis of pregnancy until the fourth month, although there are many presumptive evidences of its existence. Among these may be noted the changes in the breasts, their increasing size and fulness ; they become larger and harder, the areola (the dark line which surrounds the nipple) becomes increased in size and darker in color, especially in brunettes; later the nipple itself becomes larger in size and darker in color, and here and there in the dark ring surrounding it will appear small tumors or indurations, that stand PREGNANCY. 15 out very prominently : these are glands. In the mean time the breasts themselves become very sensitive, there is a feeling of fulness, the clothing fits tightly, and there is a sense of congestion • these changes may take place without the existence of pregnancy, — such cases, however, being rare, — but these signs may be ranked as presumptive evidence, particularly if they follow the absence of a period and make their appearance about the sixth week. The time when undoubted signs of pregnancy appear is towards the end of the fourth month, and even then it would require the greatest cau- tion on the part of the physician as to a positive decla- ration of its existence, — until the sound of the infant's heart is heard distinctly and apart from the pulse of the mother ; soon after this follow the movements of the child, which is called quickening. At this period the timid and anxious wife develops feelings of a varied character ; doubts will arise as to what the future will bring forth : will she be a fruitful woman in reality, or will she be destined to go through life without the sacred name of mother? Strange emotions will be aroused, — that peculiar, mysterious dread, which is an admixture of fear and longing, possibly only appreciated by those who have gone through a like experience. With it all, she secretly welcomes, with all the fulness of her heart, the child who is slowly developing within her, receiving nourish- ment from her blood and dependent upon her for ex- istence; but she dreads the ordeal through which she must pass before pressing that infant to her bosom. Then, too, the uncertainty of her life and that of her offspring give her many hours of anxiety. Impres- sions from very slight causes are made more deeply than at any other time ; casual remarks, revolting sights, histories of horror, all leave an indelible stamp upon her sensitive nervous system, and in silence they come before her, steal upon her unawares, and require 16 MATERNITY. the strongest effort of the will to be overcome. It is right for us to discuss this matter freely with her, to give her a few words of sympathy and caution, — words of sympathy, to sustain in those lonely hours when doubt and fear are crowded upon the young wife who has no one in whom she can confide. Let her take courage ; she is not alone in her trouble ; hundreds of her sex, who one year ago were haunted by the same visions, troubled by the same uncertainties and doubts, are to-day as happy mothers as their fondest wishes could have enabled them to be. Pregnancy is not a disease, it is a normal function of woman, and this should be impressed upon the young wife that she may undertake its duties and responsi- bilities with a thorough knowledge of its requirements ; that she may submit wisely to the laws of hygiene, and make the proper preparation for the event which she naturally dreads. It is the natural function of woman to bear children, and nature endeavors to make all her functions normal ; and diseases or disorders of various kinds are usually brought about by something which is controllable or avoidable. We would not have it supposed for one moment that we propose to lay down certain cast-iron rules to be followed in every case. There being all kinds and conditions of women, differ- ences existing as to face, temperament, physical health, social position, as well as financial status, a rule which might govern one in her diet, occupation, and general hygiene, might not govern another. The object of this work is simply to state as clearly as possible, in language devoid of technical expressions, all that is of interest to a mother, and it must be, of course, limited to those suo-o-estions which will be of service in ordinary cases. All matters that differ from what is here written should be referred to the family physician for his advice. My own experience leads me to know that there are hundreds of things which a patient for- PREGNANCY. 17 gets to ask her doctor, or thinks too trivial to consult him about, which she should know, or she may hesitate because she thinks it may show unparalleled ignorance on her part, and she dislikes to confess it. Having read all, then, that is contained in this little work on the subject which interests her for the moment, should she desire further information her family physician is the one to supply it. It would be difficult to place in order all the im- portant means to secure health during pregnancy, but we may sum them up in the statement that moderation in all things is a fundamental law of hygiene. There are many ways by which the physician can establish pretty conclusively the existence of pregnancy after the second or third month. After it has been fully determined that pregnancy exists, great care should be taken to give the child every opportunity to reach full term. A moment's thought will convince any one that the close relationship existing between mother and child, which continues up to the time of its birth, not only influences its growth and development, but also, through its close relationship, impresses upon it certain mental characteristics. In the earlier months of pregnancy the digestion becomes difficult ; in many cases the appetite is either lost altogether or perverted at times ; or there is a capriciousness which will give rise to an inordinate desire for food of a kind which may not be considered nutritious. There seems at times to be a demand for certain elements, owing possibly to the withdrawal of them in behalf of the child, which in the process of growth needs these various articles to form certain tissues. When on the subject of Rickets, I shall dwell at length upon this matter, because it is a disease of the child which proceeds from a deficient supply of lime in its constitution ; the child frequently needing 18 MATERNITY. the lime to form its bones, and if it does not get it from the food which is supplied to the mother, will withdraw it from her own tissues. It is scarcely necessary to call attention to the fact that the lower animals are in constant search of food that will supply these cravings of nature. The character of the egg laid by the hen will depend upon the kind of food she gets ; she will seek lime for the shell, and if she does not succeed in getting it the shell will be soft or thin. There are many curious records of the craving of women for articles of food, and if possible, when such cravings exist, they should be gratified within reason- able limits. Women have been known to eat earth for the lime. This craving for lime exists more especially toward the latter part of pregnancy, at which time food should be changed accordingly. In the ordinary mixed diet to which we are accus- tomed, a large amount of bone-forming material is always present ; elsewhere in this work I shall explain the whole subject of digestion, in order that the mother may have a clear understanding of the subject with reference to the feeding of the child. Indigestion should be avoided. This is, as we all know, easily caused by late suppers, eating when one is fatigued, a heavy breakfast in which hot cakes are one of the principal articles, the excessive use of tea or coffee, and similar indiscretions. The extent to which one may indulge depends upon an individual law for each individual case ; and we all know, without any deep study, exactly how much and what we can eat, but I fear we are fre- quently but too willing to run a little risk. In the earlier stages of pregnancy there is, as we have before stated, frequently a disturbance in the digestive functions, which gives rise to a great deal of annoyance, and at times may become quite a serious consideration ; particularly if it prevents the taking of PREGNANCY. 19 nourishing food, or produces strain from excessive vomiting. In many instances it does not need the actual pres- ence of food in the stomach to produce it ; it comes on at the earliest waking, and is often compared to the sensation of nausea which we have all experienced from want of food. At other times it seems to arise from the presence of food in the stomach, and the breakfast is no sooner taken than violent nausea and vomiting follow ; the matter expelled being extremely bitter, due possibly to a certain amount of bile collected in the stomach. The first food entering the stomach will likely be rejected; but after being relieved, a meal will then be retained with perfect ease and comfort. Though called morning sickness, this nausea differs with different individuals; some complaining of it in the evening and others in the earlier hours of the day. There is frequently in connection with this disturb- ance the regurgitation of intensely-acid, burning, watery material, which is very annoying, and is usually ac- companied by heartburn. This can be held in abeyance by some alkali, particularly one which has a lax- ative effect ; from one-half to one teaspoonful of light magnesia, taken in water at bedtime, the frequent use of bicarbonate of soda, or the preparation known as soda-mint, either in solution or the compressed pills, will give relief. When not contraindicated by persist- ent constipation, lime-water and milk, in the proportions of one tablespoonful of lime-water to an ordinary glass of milk, may be taken freely with very good results. Sometimes certain odors will induce nausea : they may be disagreeable ones, as those arising from cooking, and again the most fragrant flowers may produce the same effect. So apt is this to occur that the odors of various plants, which are at other times agreeable, will during the earlier months of pregnancy be decidedly nau- seating, and frequently be the first sign of the existence 20 MATERNITY. of this condition. Not only does the sense of smell show extreme delicacy as the result of this reflex stimu- lation, but all the other organs of special sense may be equally affected ; for instance, the taste, eyesight, or hearing may be subject to the same disturbances. The nausea in ordinary cases usually passes off by the third or fourth month; sometimes it lasts longer, frequently continuing until labor sets in. It is one of the most distressing symptoms of pregnancy, and this, with the heartburn which usually attends it, often resists all the means to which one would resort under ordinary circumstances. Should this be the case, consult your family physician as soon as possible. For morning sickness we may mention the value of some light nourishment in small quantities taken either before or immediately after first rising ; such as a cup of chocolate, coffee, cocoa, a cup of good broth well sea- soned, a glass of champagne, or brandy and cracked ice; a seidlitz powder or half of one even, or a claret glass of Congress water, taken before rising, will fre- quently control the nausea. Should there be excessive heartburn, from fifteen to twenty drops of aromatic spirits of ammonia in a wineglass of water, or a mix- ture of equal parts of lime-water and milk, will have a very beneficial effect. Frequently five drops of the wine of ipecac in a wineglass of water, given at intervals of from ten to fifteen minutes, will check the nausea. As this nausea is not dependent upon any disturbance in the stomach itself, but is reflex, it can frequently be avoided by attending to the precautionary measures of which we will make mention. The patient must endeavor, notwithstanding the un- settled state of her stomach, to take sufficient nourish- ment during the day, even at this early period. Very often a brisk walk, a little wine or cordial, or a glass of malt extract, which is both nourishing and stimu- PREGNANCY. 21 lating, or some preparation of pepsin, as lacto-peptine, for instance, if taken before a meal will cause it to be retained. Should there be craving after an unusual article of diet at any time, the matter should be referred to the physician, and possibly the substance which na- ture seems to demand may be supplied by medicinal means, or the diet be so arranged as to include those articles which would at first seem questionable, as pickles, etc. DIET AND HYGIENE. It is well that the patient should have regular habits from the very commencement of this condition, if pos- sible. I would not have it supposed, however, that she must be restricted to those subjects mentioned in the limits of this article. A few hints may be of advan- tage as suggesting the proper course to pursue. Upon awaking in the morning, a small cup of black coffee, cocoa, or chocolate should be taken before rising ; she should then take a bath or sponging, to invigorate the system and restore circulation ; if possible, she should then take a short walk before breakfast- One is frequently asked whether a bath is not contra- indicated at this time. By a bath we do not mean a plunge into ice-cold water. Cleanliness is never contra- indicated under any circumstances. It is as important to have a full action of the skin as of the kidneys or bowels. A bath of a temperature of 75°, taken in a warm room, followed by a gentle surface rubbing or a gentle massage to the limbs, would be of great service and should be insisted upon ; but if a bath cannot be taken, a rapid sponging of the body should not be omitted. There are some persons who find it suits them better to take a bath at night ; this is not a mere matter of fancy, and I think can be safely left to the patient's judgment. As for hot baths, except those used occasionally simply for the purpose of cleanliness, 22 MATERNITY. unless followed by a cold douche they are beyond a doubt debilitating, and the sudden action of cold water might be attended by serious results. We simply warn against extremes. At breakfast the patient should take either a broiled mutton-chop, one that is thick and juicy, or a piece of tender steak, bread and butter, with one of the cereals, either oatmeal or cracked wheat, in which the whole grain is crushed, or yellow corn ; these can be varied according to fancy. Eggs and oysters should be used freely ; if possible a pint of milk, or cream, should be taken at each meal ; this will supply bone, muscle, and nerve, and at the same time nourish the child, — not at the expense of the mother's own strength and depriv- ing her of the materials which are essential to her own well-being. The dinner, or heavy meal, should be taken in the middle of the day ; in the evening the patient should take only a light meal, so as to relieve the stomach of its digestive burden before bedtime. It is of great importance that there should be the utmost regularity in taking meals, and equally so that there be a diversity in the cooking. Nature requires a change ; condiments stimulate the digestive functions, which are apt to be- come sluggish owing to the fact that the stomach is frequently overloaded. The action of the liver being interfered with, the bowels become sluggish, attacks of biliousness supervene, and the patient loses her appetite and becomes emaciated. There are several things which we should take into consideration in discussing the dietary in the pregnant state : one is the free use of fruit and vegetables, and the other, the value of water to keep in solution those materials which are intended to be thrown off, — the ashes of the food, as it were, and the waste resulting from the destruction of tissue. For an average indi- vidual, taking a fair amount of exercise, five pints of PREGNANCY. 23 fluid should be takeu in twenty-four hours, to make up for the loss of that which passes away by the kidneys, bowels, skin, and breath ; this is in addition to about fifteen ounces of fluid contained in the solid food. It is for this reason that milk should form a large portion of the diet of a pregnant woman, and that she should eat freely of fruit, which, as is well known, contains a large amount of water. If such a diet were more generally adopted, the use of purgatives would not be required. Should the dinner-hour be late, it is advisable to re- lieve the fatigue incident to household duties, or the usual shopping and visiting, by taking a mid-day meal consisting principally of milk or some light farinaceous food, a milk-punch with an egg beaten up in it, a few biscuits with a glass of HofFs malt, — something light and easily digested, — after having taken a nap, in order to avoid the great fatigue's interfering with digestion. This should be done invariably. CONSTIPATION. One of the most important matters for our consider- ation is that referring to the regulation of the bowels. Habit, of course, is the best laxative upon which one can depend ; no duties, however pressing, should at any time interfere. It is usually the custom for persons to have a movement of the bowels after the first meal in the morning ; the presence of food or warm drinks in the stomach acts as a reflex stimulant. With many, the hour that is chosen is just before re- tiring ; the presence of a full rectum crowding the con- tents of the abdomen, and the gases which are formed during the day, making the patient restless and un comfortable. In the earlier stages of pregnancy, con- stipation is very apt to be obstinate and annoying, owing to the fact that the womb becoming heavier sinks at 24 MATERNITY. that time upon the rectum and causes accumulation to take place. After the fourth month constipation is not so preva- lent ; indeed, not until the eighth month, or towards full term, does it again become annoying in many cases. Constipation may be produced by two conditions, one the mechanical pressure, the other by what ordinarily is known as biliousness, which in reality is deficient action of the liver and impairment of its function, by which the bile is either not secreted or else it fails to be passed into the bowel. In individuals who take little exercise, no fresh air, and eat heavily, even should that eating consist only of extremely nutritious food, very readily digested, the liver has more than it can possibly manage, the bile is not properly made, and the symp- toms of biliousness occur, with constipation. The tongue becomes coated, the breath heavy, the urine is high-col- ored, the patient complains of loss of appetite, sleepless- ness, and irritability. The bile has various uses independent of its action in digestion ; it is a purgative of itself, and when flow- ing freely causes regularity in the bowel ; it is an anti- fermentative, and prevents flatulence. Constipation which is the result of so-called biliousness demands a variety of measures by way of treatment : less solid food, more fresh air, the free use of water, — pure water. It is a great mistake, and a very serious matter, for a person who is pregnant to use strong purgatives, un- less it be by the advice of a physician. The bowels should be moved by habituating herself to a certain hour, by a moderate amount of exercise, by a glass of water or a cup of chocolate or coffee taken the first thing in the morning, by eating fruit, raw or cooked, or by taking a glass of water at night before retiring. The simplest means should always be used first. Beef- tea or chicken broth, well salted, when taken before re- tiring, is quite often laxative. PREGNANCY. 25 If these fail, the compound liquorice powder, a tea- spoon or dessertspoonful, can be taken in a little water or milk. A wineglass of Hunyadi water taken in the morning, two or three times a week, a seidlitz powder, or the patient may prefer a glass of Congress water ; when cold and sparkling it is ndt unpleasant to take, arrests nausea, and acts gently upon the bowel. The elixir of cascara sagrada, a teaspoonful taken at night, should other things fail or become monotonous, or a tea- spoonful of maltine, with cascara, taken in the same way, is often efficacious. I consider it unwise to sug- gest any form of pills for the patient in this state to take without consulting the physician. Constipation sometimes causes swelling of the left leg or enlargement of the veins, which disappears when the bowels are regulated. The family physician should al- ways have his attention called to any swelling of the body, be it the hands, feet, or face, as it may be a very important matter. Very frequently it will be necessary for the patient to take an enema. After the fourth month, this should be done at least once a week ; before that time it is well to consult the physician, for should there be any evidence of threatened miscarriage it might be productive of harm. It is not at all essential that a large quantity of water be injected into the bowel in these cases in order to get a movement : one or two teacupfuls of warm Castile soapsuds, or simply warm water with a pinch of salt, will be all that is required. The gluten suppository made by the Health Food Company acts admirably in many cases, the object being simply to avoid all strain- ing. Under no circumstances should a strong effort at bearing down be made. The Davidson syringe is prob- ably the most convenient to use, though a fountain syringe often serves better. Mr. Snowden, an instrument-maker of Philadelphia, has made for me what we call a traveller's syringe. It B 3 26 MATERNITY. is made on the principle of an ordinary rubber flower- sprinkler. It can be fully charged with whatever ma- terials are to be used, and put aside until the most con- venient time to use it. The patient can readily use it herself, which is a great advantage. The best time for an enema is probably upon retiring. The weight in the abdomen, and the displacement of its contents, owing to the increasing size of the child, causes pressure on the bladder, and frequently gives rise to distressing symptoms, with a desire to pass water ; of course these cannot be relieved entirely, they must be recognized as physiological. Standing much upon the feet or walking is apt to increase this, therefore the recumbent position, for a few moments at a time, is the most desirable, in addition to relieving the bladder frequently. Indeed, during the earlier months of pregnancy this should be attended to with great regularity, for often thoughtlessness, or possibly em- barrassment, will permit an over-distended bladder to press the womb out of its position, and possibly give rise to a miscarriage. The pressure of the womb and its contents upon the blood-vessels in the abdomen produces at times not only disturbances in the action of the liver, but also interferes with the circulation through the kidneys, and if allowed to continue without proper medical treatment might produce serious disturbance ; for this purpose it is usual for an examination of the urine to be made frequently during the course of pregnancy. There is also a variety of distressing symptoms produced by pressure on the larger nerves, especially the sciatic nerve, as pregnancy advances ; this is particularly no- ticeable a few weeks before the full term, although it may occur at any period. Those who swim know the disagreeable sensation caused by sudden cramp in one of the limbs. This same cramp, to a greater or less degree, may come on while the patient is sitting or walking, PREGNANCY. 27 and be productive of great pain ; it is usually felt down the back of the thigh, in the foot, or down the leg, especially on the left side ; this is greatly relieved by rubbing with chloroform liniment, but the most rapid means is for the patient to assume what is known as the knee chest position, — getting on her knees in bed, with her head on the pillow, thus throwing the weight of the child forward. The greatest relief follows this position, if taken upon retiring at night, in many cases also where there has been distressing flatulence. A FEW WORDS IJST REGARD TO EXERCISE. It is scarcely necessary for me to dwell long upon the importance of exercise in- the open air for giving an appetite, in fact, for the maintenance of health ; but just how much exercise to take is often a difficult matter for one to determine. The muscles should be made strong and healthy, the body erect, the circulation free in all parts of the body, and at the same time the exercise should cease before the sense of fatigue is so great as to cause prostration. Then, again, the exercise should be of a pleasant nature ; if possible, the patient should be entertained ; she should have a purpose in view. The habit of strolling listlessly from place to place simply for the sake of fresh air falls far short of giving the benefit which a brisk walk or a healthy, pleasant occupation would bring about. We all recog- nize this fact, and we all know the healthy individual is the one who is occupied, whether the occupation be household duties, which are in themselves by no means devoid of active exertion, or whether it be the obligatory hard work of the laboring woman whose robust health will enable her to bear her child with ease compared with the labor of the delicate, weak- backed girl who is brought up in the lap of luxury with every wish gratified, with every muscle unde- veloped, and who will suffer in her confinement from 28 MATERNITY. the want of physical force. There is a theory at the present day, which is a most interesting one and prob- ably correct, advocated by Darwin and his disciples, that excessive development of the intellect from the universal higher education has produced and is still producing a relative increase in the size of the heads of the children of intellectual classes. If associated with this we have feeble muscular development on the part of the girl, what else can we expect but difficult con- finements? And undoubtedly the many cases of serious womb-troubles following childbirth are due to these causes. It is not necessary, then, that exercise should mean gymnastics or a stated walk of a mile each day ; but when we say that a woman while she is carrying her infant should use her muscles, we are satisfied that the ordinary exercise which falls to the lot of the house- keeper, especially if she take pride in the appearance of her own home, will be sufficient, together with the attention to those duties which call her out of doors, and give her all the fresh air and muscular development that she needs. In the earlier stages of pregnancy, — and by early stages we mean before the seventh month, — there is very little need for a woman to change her habits as regards going about; if she keeps perfectly well, walking in moderation, driving, bathing daily, provided it is not in hot water or water that is too cold. As regards dancing, the use of the sewing-machine, swimming, horse-back-riding, these questions are constantly asked of the family physician. There are some people who will immediately take the ell if the inch is granted, and lay all the blame on their doctor ; but, as it is his duty to understand all the little peculiarities of his pa- tients, and, indeed, this study is as important and diffi- cult as the study of medicine itself, he is the proper one to give the answers in each individual case. My own opinion is that they should be avoided ; and yet PREGNANCY. 29 a good strong healthy woman may work over a wash- tub doing the hardest kind of laboring work until her term is up. The answer to this is that if the young mother who reads this book is as strong as this woman who has been brought up to hardships, she probably could do the same thing. Should our patient at any time have a sense of fatigue after exercise, it would be well to rest before meals, to loosen her clothing thoroughly, to lie first on one side, then on the other, to relieve the pressure which the strain of walking has made her child exert upon the large blood-vessels and nerve-trunks. Indeed, towards the latter end of pregnancy, after her walk she will find a recumbent position much more comfortable and resting than a sitting one, especially if she attempt to sit in a comfortable easy-chair with soft cushions. It is very rare that a woman cannot take a brisk walk, especially in the evening before retiring ; it will enable her to get a good night's rest, and at the same time she will feel a certain amount of freedom in going out at this hour without the restraint of wearing close-fitting clothes ; and this leads me to speak of the way in which pregnant women should dress. If we consider the subject of dress we shall find the object to be gained twofold, — first warmth, the other fulfilling the dictates of fashion, or, in other words, personal adornment. The matter of clothing is a very important one at this time. Shortly after conception takes place there is a feeling of weight, which is usually experienced in the lower part of the abdomen, — a sense of fulness, which fre- quently gives rise to discomfort owing to the sinking in of the abdomen from enlargement of the womb. There may be, possibly, a dragging weight in the knees, back- ache, constant desire to urinate, and the fulness in the bowel which accompanies constipation. By the third month the abdomen will increase in size, and will grad- 30 MATERNITY. ually show enlargement ; as we have before noted, the breasts will become enlarged, fuller. Then the matter of dress becomes one for further consideration. It should be definitely borne in mind that at no one part of the body should the clothing be so tight as to interfere with the breathing or circulation ; indeed, there should not be the least uncomfortable pressure. We may set this down as a rule to be observed in all cases. Physiologists tell us that women breathe more with the upper part of their chests than men, and that this is intended by nature to obviate the disadvantages which would otherwise occur during pregnancy. Should, then, a tight band be placed around the waist, or heavy skirts hang from the abdomen, or corsets be used to make the wearer look small and not show her condition, in- terference with breathing, many disorders incidental to pregnancy, would occur. The word enceinte itself is derived from the Latin, which signifies that the Roman women when they became pregnant divested themselves of the girdle which was always worn by married women. We have already said that the question of dress was one of warmth and adornment. As far as warmth is con- cerned, there is no doubt that the accumulation of fat, which is greater in women than in men, permits them to wear clothes of lighter texture than the opposite sex. The beauty and rotundity of form, the absence of angles, is due to a deposit of fat, and especially is this the case over the chest, — a delicate portion of the body, where exposure carries with it most danger. In this latitude of 40° it is absolute folly for women, especially young girls and those about reaching the meno- pause, or change of life, to pass our winter and spring months without wearing woollen garments, should it only be the lightest gauze-flannel, in a complete set, with high neck and long sleeves ; in fact, the argument against it is that an evening-dress necessitates the taking off of this dress, and consequently the greater exposure to PREGNANCY. 31 cold in consequence. At the same time there is in reality less risk to be run in a heated ball-room, or when the individual is flushed with the excitement of pleasure, than when exposed to the dampness of the street, with nervous depression, in a cold wind or bleak storm, or the draughts of a house when the system i? below par and the circulation feeble. All pregnant women should most certainly wear flannel in winter, or they can use the more expensive materials of wool and silk. There is a fact which we all take for granted, though the fashion fails so far to make it a custom in this pari of the world, certainly not so with our English cousins, — that all articles of clothing for women should hang from the shoulder ; that is, the shoulders should bear the weight. In England the fashion is rapidly gaining ground of supporting heavy skirts by means of sus- penders ; at any rate, at no time should the pregnant woman have any article of clothing which will constrict the waist or drag from the loins or hips. This should be an imperative rule ; and, indeed, when we come to consider the question of dress in young, growing girls, we will see why it is that heavy skirts, when fastened around the waist, are productive of harm. We may say that there are actually two waists in all women, — one just above the hip-bone and at a point where tight lacing will cause pressure on all organs contained in the pelvis (the space between the hip-bones) : this is the smallest part of the body, below the last rib ; the other one is made use of in high-waisted, old-fashioned dresses. The former bears the weight of heavy skirts that are belted and worn without corsets. The high- (short-) waisted dresses are certainly less harmful than low- (long-) waisted dresses. This leads to the ques- tion of corsets. Our own opinion is that a light, short corset which does not press anywhere unduly is of great comfort to a pregnant woman ; it permits the skirts and 32 MATERNITY. undergarments to be fastened readily without compres- sion of the waist, and in so doing distributes the weight very much as if the garments hung from the shoulder. Moreover, it gives support to the back, which is fre- quently restful, especially when the weight of the child becomes excessive, and when the small of the back suffers great strain from fatigue. It will also give warmth to the body, — that is to say, an even temperature, espec- ially around the abdomen. THE CARE OF THE BREASTS DEMANDS ATTENTION. From the very first month we have seen that the breasts take upon themselves certain changes ; they be- come larger, become tender, and are apt to contain, as time goes on, a small quantity of milk. The stretching of the skin from this enlargement, as also the stretching of the skin of the abdomen, causes a great deal of dis- comfort. The clothes should be made to fit closely with- out undue pressure. When the tension and feeling of fulness in the breasts and abdomen becomes intense, it can be relieved by anointing the skin thoroughly at night before retiring with vaseline, sweet oil, cocoa-butter, or almond oil. Great attention from the first should be paid to the nipple, owing to the fact that in most cases abscesses of the breast are frequently caused by an abra- sion or crack in a tender nipple ; and indeed at many times a depression or sinking in of the nipple will pre- vent the mother from nursing her child, which could be obviated by attention during pregnancy. It is well known that the nipple should stand out prominently in the centre of the breast without any indentation or gutter around it whatever. By gradually accustoming herself to it she will be enabled to manipulate it with- out the least feeling of tenderness. It should be sponged every morning and gently dried with a mod- erate amount of friction. If the nipple sinks to the level of the breast or below it, it should be pulled out, which PREGNANCY. 33 can be readily done either by suction or wearing glasses made for that purpose, which can be procured at any drug-store ; they are simply glass disks with a hole in the middle. In our opinion it is a great mistake to use brandy or any drying subject to harden the skin, unless ordered by the physician. The small glands which sur- round the nipple and are prominent in the dark areola or ring are lubricating glands, and these prevent soften- ing or excoriation, cracks or fissures, which will event- ually produce abscesses. Drying substances check the action of the glands and produce chapped, hardened tissues, which easily crack. As regards the effect of emotions and the result of maternal impressions, from time immemorial it has been known that the closest relationship through nervous in- fluence exists between the mother and her unborn child. To quote from Parvin, the following directions were laid down by one of the medical writers of India four- teen hundred years B.C. : " The pregnant woman shall avoid becoming weary, . . . sleeping in the daytime, watching at night, sorrow, climbing into a wagon, sitting upright, violent move- ments, . . . and long-continued exertion. From the first day she must be cheerful, pious, and clean in cloth- ing and person. . . . She must avoid getting angry, carrying loads, or talking too loud." The ancients, especially among the Greeks, sur- rounded their women during this period with all that was beautiful in art, that their sons might become strong and muscular and their daughters graceful. Undoubtedly there have been noted cases wherein ma- ternal impressions affected the offspring, but far more frequently have been the cases where the fear of some such result has made the mother brood over sights which she has witnessed until a passing impression has indelibly fixed itself upon her nervous system and af- fected the nutrition of her child. A woman should 34 MATERNITY. avoid all emotions, should lead a life as placid as the most devout follower of Buddha, should use moderation in all things, and if perchance in the ordinary course of her daily avocations, or in the bustle and turmoil of a large city, unpleasant sights, narrations, or thoughts make impressions upon her, she should cast them aside as unworthy of consideration, and believe with the ma- jority of the medical profession of the present day that her child will be uninfluenced by them. I cannot do better than quote a recent extract from The Fortnightly : " The ideal mother is undoubtedly a woman more placid than nervous in temperament, more energetic than restless in habits, and with more strength of char- acter and general good sense than specialized intellec- tual acquirements. Strong emotions, strained nerves, excitement, anxiety, absorption, are all hurtful to the unborn child. They tend to bring on premature birth; and if not this, then they create sickly offspring, whom the mother cannot nourish when they are born." I will complete this chapter by giving a list of the things which should be provided for an ordinary case of confinement. Of course as much more can be added as the social position or wealth of the family may re- quire. What I give here are merely the necessities : BASKET. Brush and comb. Skein of white twisted embroidery-silk. Soft fine sponge. Bottle of white vaseline. Sharp pair of pointed scissors. Powder-box and puff, with talc-powder. Pincushion. Small and large safety-pins. Pure Castile soap. Pair of socks. Some old fine linen. PREGNANCY. 35 Flannel or knitted band. Flannel shirt, a petticoat and night-gown for infant. An afghan, or piece of extra flannel, in which to wrap 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 sacques. The mother will require for herself — One gum blanket two yards square. One comfortable, and in addition to this an old one had better be at hand. Some old cotton sheets. A Davidson syringe. A bed-pan. A couple of binders made of well-washed unbleached muslin, not too coarse, wide enough to extend from the ribs to below the hips. In winter these can be made out of baby-flannel. A supply of old towels or old sheets, to be thoroughly washed and packed away until required. A glass tube for taking medicine. Also some prepared absorbent cotton ; the sublimated or borated is the best. The use of the binder at the present day is not in- sisted upon by most accoucheurs, but its object is to give warmth and gentle support; that used for the child is for the same purpose, therefore if it is too tight it does far more harm than good, and had better be abandoned altogether. It certainly does help the overstretched muscles to regain their tonicity, and undoubtedly in this way allows the figure to resume its normal propor- tions. A few words to the monthly nurse. 36 MATERNITY. Your position is one of great responsibility, as fre- quently emergencies will arise that will tax your in- genuity and knowledge to the utmost. You do not degrade yourself by attending thoroughly to every de- tail that will add to the comfort of your patient and the maintenance of the equilibrium of the household during this trying period. You should be neat, in- terested in your case, guarded in your conversation, ready and willing to wait upon yourself, affable to all, have tact and dignity in your dealings with those with whom you are obliged to come in contact. Do not under any circumstances narrate the histories of other cases you have nursed, or enter into the discussion of private family affairs and scandals. Take your patient thoroughly under your charge, and do everything for her comfort both of mind and body. When the patient is in bed, after confinement, under no circumstances allow her to be in a draught. If you open the window for a moment to ventilate or dust, always cover your patient and close the doors. When you sponge her, surround the parts with a dry towel, so as not to wet the sheets, and only sponge one part at a time, then dry thoroughly, and do not use damp towels. In a work of this kind it is well to give some advice upon miscarriage. By this we mean a prema- ture birth, though in strictly medical language this name is applied only to that which occurs after quick- ening. There are many things which prevent the full time of pregnancy. Some of these are due to disease of the unborn child, which causes its early death ; others to disease of the mother, which prevents the womb from enlarging beyond a certain point, or fevers, or severe illnesses; and others, again, are due to ac- cidents. Frequently carelessness on the part of the mother, over-fatigue in her household duties or social requirements, ill-fitting clothing, obstinate constipation, PREGNANCY. 37 unduly long walks, heavy lifting, or any strain or ex- citement. At times there seems to be a certain fatality wliich prevents mothers from carrying their children to full term. A woman will conceive, everything will go on well till the third or fourth month, and then mis- carry ; a sort of habit will be established, and she will do this for several times in succession. Her womb needs a rest, it has become irritable ; and if this physio- logical rest is given it and she again conceives, she will go on to full term. The earliest symptom of miscarriage is usually the appearance of a flow. If, then, immediate rest in bed be enforced, — and this rest in bed is absolutely necessary, — and proper medical treatment is instituted, it may be checked. The patient should at once go to bed, remain absolutely quiet, and send for her physician. Even after the flow has been established the child's life may be saved. Miscarriages are by no means as simple and harmless things as some women try to impress upon themselves that they are. Many of the diseases of the womb, which entail a long course of medical treatment and give rise to permanent ill health, date from this cause, which a little care would have avoided. Many cases of miscarriage in early married life are undoubtedly due to the fact that these young mar- ried women endeavor to conceal their condition from their friends; and, instead of adapting their life as they should to their changed state, they thoughtlessly join in the amusements and fatigues of society, dress as is most becoming to them, and conceal the annoyance and suffering which this often entails. PART II. INFANCY. CHAPTER II. CAEE OF NEW-BOKN INFANT. How to cleanse a New-born Babe — -The Cord, and the Care which it should receive — The Binder and its Object — Importance of noting the Child's Secretions — A Babe should be given "Water occasionally — All about the Mother's Milk first making its Ap- pearance — The Diet of the Nursing Mother — How to check an excessive flow of Milk, and to increase an Insufficient Supply — The Child's Diet — How often a Child should receive Nourish- ment. It is scarcely necessary for me 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 I will endeavor to explain as simply as possible. 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 thoroughly anointed with either washed lard or vase- line, and then, with a soft sponge, tepid water, and a little Castile soap, given a superficial cleansing to re- move as much as possible of the material. The eyes, mouth, ears, and nostrils, in fact, all of the mucous 38 CARE OF NEW-BORN INFANT. 39 surfaces, should be carefully washed with warm water and a clean sponge or piece of old linen. This should be done after the cord has been severed. The cord, which is the attachment between the child and the after-birth, contains the blood-vessels embedded in a gelatinous material more or less thick. As soon as the child is born and takes its first breath, the circu- lation in the blood-vessels of the cord gradually ceases. It is not at all necessary that the cord of the child should be 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 compression of the blood-vessels takes place. A ligature is placed tightly about 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 washing the navel-string should be enveloped in a mass of the sublimated absorb- ent 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 support the cord. Undoubtedly, if the navel-string were al- lowed to hang, be caught in the clothing, be pulled about as the child receives its daily washing, a rupture might take place. I think 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. While the child is being washed and dressed it is well to secure deep and full respirations. It is said that a crying child at birth has stronger lungs afterwards. If it is turned over on its stomach with head lower than the rest of its body during process of washing, the mucus will not be drawn in during its inspiration, and a healthy infla- tion of the lungs will take place. As soon as possible 40 INFANCY 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 will be more thoroughly established, and the skin will assume the delicate, soft red appearance of health. Extended experience has convinced me 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 erup- tions. The child's clothing should have two important qualifications : it should be warm, and absolutely loose in 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 important matter. It will be noted that the navel-string will come away in four or five days without any offensive odor whatsoever. This method of dressing the cord is a convenient one, as it does not require to be touched after its first arrangement. The use of the ligature is simply a matter of precaution, it is not a matter of necessity. 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 ulcer- ation is found, as is sometimes the case, it can be CARE OF NEW-BORN INFANT. 41 touched with Milestone and then dressed with benzoated 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 appear- ance of a healthy child at its birth. The soft, peach- like character of its skin, the constant tendency 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 we study the many causes for that most distressing state of affairs, sleeplessness, 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 material for the fountain, she is often indiscreetly advised to substitute milk and water, a little catnip tea, or Mellin's food. My own experience teaches me 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 i proceed 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 laxative secretion which precedes the milk-flow, they will from sheer exhaustion give up the attempt and fall asleep. The 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 interval, 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 4* 42 INFANCY. 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 teaspoonful to twelve or fifteen of water, is to be preferred. 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 washed 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. The 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. The woman frequently will have no evidence of milk whatever, the breasts hanging flabby and long, 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. The diet of a mother after childbirth usually con- sists 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 otherwise, which she has CARE OF NEW-BORN INFANT. 43 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 immediately after a confinement; others, again, are allowed to get up before the ninth day. The family physician knows the pecu- liarities 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 customary to put belladonna-plasters on the breasts, but also to diminish the amount of fluid taken. If she wishes to increase the flow of milk, she can drink freely of milk, soups, water, also rub the breasts on the outside with some castor oil. It is probable in this way the use of alco- holic 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, I certainly would oppose their uni- versal use. I think the alcohol rather lessens the milk- flow. The preparations of malt are far more valuable, as they increase the appetite and aid digestion. There being what is known as 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 44 INFANCY. 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 poison- ing by milk from cows that have eaten largely of poi- sonous 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 in- crease in weight, the free use of fats by the mother, as cod-liver oil, will soon show an improvement. If there is a tendency to rickets, the mother should eat more largely of preparations containing lime, such as oat- meal, cracked wheat, or even take lime itself. A woman who is fat and well nourished may have the poorest 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, 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 com- position, but we very frequently have indigestion pro- duced by milk which has probably been changed in its characteristics by emotion, by strong nervous impressions due to worriment, fright, or the engagements 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. Her food should be most plentiful, palatable, of the most nourishing quality, and fre- CARE OF NEW-BORN INFANT. 45 quently taken. Bread, butter, and milk should be used in large amounts. A cup of hot coffee, or chocolate, in the morning before 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. We will repeat the same directions in regard to the bowels as are found in a previous chapter. It is neces- sary that they 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 required. The use of purgatives should, be confined to cascara cordial, compound liquorice powder, a teaspoonful at night, Husband's magnesia, or effer- vescing 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. Let me say a few words in regard to wet- nurses. WET-NURSES. It sometimes, as we all know, becomes necessary to decide on very short notice on the question of having a wet-nurse. I will not go deeply into this matter, be- cause the circumstances of each case so group them- selves as to bring the answer without consulting a book. The age of the child, the financial condition of the family, residence, are all to be taken into consideration. The wet-nurse should, if it is possible, 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 also be seen, thoroughly examined, and 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 consumption, cancer, 46 INFANCY. 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 con- dition of the wet-nurse is as important, of course, as her family record. She should have no constitutional dis- ease of any kind ; her lungs should be healthy ; her skin should be clean, free from any eruption, or the re- mains of one; her teeth should be good, which is an evidence of good digestion ; her eyes bright, her mus- cles firm and well formed ; she should have no loss of hair, sore throat, or chronic nasal catarrh ; her breasts should be well formed and such as I have described on page 32. She should not menstruate. C Then comes the question of temper, and indeed it is as hard here to get a satisfactory testimony as it was for the physical condi- tion. 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 suitable or not, but there are times when the mother, or monthly nurse, has to decide in cases of emergency. On that account I have dwelt at some 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. Indeed, the condition of her own baby will be evidence in itself. There are other matters CARE OF NEW-BORN INFANT. 47 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 which is luxury, variety in cooking, over-stimulating food, is apt to bring about a condition of biliousness, laziness, irrita- bility of temper, which is difficult indeed to regulate. I have frequently known of the very best of wet-nurses, who have given satisfaction for a month or so, sud- denly without any apparent cause lose all their milk, and the whole trouble of selection and the risk of get- ting a milk which does not agree 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 a 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. I believe that bottle-feeding, which, as we shall see farther on, requires the greatest amount of care and watchful- ness, is successful in many cases, but the more I see of it the more satisfied I am that every child should receive breast-milk 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 inherited 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 48 INFANCY. always be obtained. The system recently established at the nurses' directories in our large cities of having certified wet-nurses is a very valuable step forward, and should be encouraged by the public. THE NURSING OF INFANTS. I have elsewhere written 1 as follows, when on the subject of bottle-feeding : How much food does a child require in twenty-four hours ? So 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 i not be satisfied. A child of a month should be nursed about _ten times in 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 about three months it will probably nurse only about eight times, taking about six ounces at each feeding; at the end of about six months it will take about eight ounces. I believe that this would represent about the amount of breast-milk that such a child would receive. 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 articles of food that enter into the diet required by a human being. These may be divided into five classes : water, casein (curds) or albuminoids, salts which go to the formation of bones and secretions, fats, and sugar, which are burned up to make animal heat, and also are 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 1 Annals of Hygiene, July 1, 1886. CARE OF NEW-BORN INFANT. 49 flakes. This is readily noticed in children who have eaten too much, when the milk has been regurgitated ; 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 fre- quent in bottle-fed children. Babies are very apt to get into bad habits of falling asleep after taking two or three mouthfuls. If this habit should be encour- aged, it is one very difficult to break. It should be promptly awakened and made to continue the meal until it has taken the sufficient amount. About 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 a longer interval 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 nipple-glass during the daytime, with a towel pinned over it, which will take off the surplus milk, and will prevent her from being constantly wet and catching cold. The question is often asked, How long should a child be nursed? The universal opinion seems to be that for at least six months the child should take nothing but its mother's milk; but of course if it is feeble and weak from difficult labor, or disease, it should be kept at the breast very much longer, and should a summer intervene, as it would for a child born in Octo- ber or November, no attempt should be made at wean- ing, unless advised by the family physician, until the fol- lowing autumn. After the age of six months, all things c d 5 50 INFANCY. being equal and the child being healthy, it may be well to gradually enlarge its bill of fare, 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 accomplishment. When it is deemed desirable to sub- stitute breast-milk, the bottle should be given in the daytime, after the morning bath ; or better still, if the nurse has the child, give it the breast in daytime 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 could have a 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. CHAPTER III. BOTTLE-FEEDING. The Child's Bottle and how to prepare it — Great Care in preparing the Bottle must he exercised — An Efficient Nurse indispensable to the Welfare of the Child — A study of Milk — Condensed Milk and fresh Evaporated Milk. If I have impressed sufficiently upon the reader the importance of care in the selection of a wet-nurse, I did not do so with the object of undervaluing the sub- ject of bottle-feeding by contrast, although there is no question but what the valuable suggestions, the out- growth of careful study, that have been published by BOTTLE-FEEDING. 51 such writers as Leeds, Smith, Meigs, Jacoby, and others in this country have impressed upon the com- munity 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 that care is the primary step to success. 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 oh an attack of diarrhoea or vomiting which would be uncontrollable. I wish, therefore, to impress upon all those who have anything to do with the bottle-feeding of children, that when I state that a child that is not exposed to the dangers of a large city in the summer- time — and I make this exception — can be brought up on the bottle from the day of its birth and be free from dis- ease, become strong and healthy, it is provided the same attention is given to it as would be given by a mother to her new-born nursing babe. The first requisite for carrying out bottle-feeding with thoroughness is that somebody should take charge of the child who has a special interest in it. If I am 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 the nurse undertake the duties. She has a special in- terest in the child that has drawn its nourishment from her breast. If not, then get some middle-aged woman, 52 INFANCY. not too old, or cranky, or over-burdened by previous experience, or on the contrary, a small chit of a girl who would require a nurse to look after her. Strange to say, these are often engaged as child-nurses, and no wonder 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 on her mind whatever. After you have tested her ability, give her your entire con- fidence ; 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 refrigerator, the other a gas-lamp or some- thing by which the milk or water can be readily heated. It is necessary to have a nursing-bottle holding about eight ounces. A child a month old will take not quite one-half of this at each nursing. At the age of six months it should take at one feeding this bottle full. The fresher the milk, the more readily it will be digested ; indeed, I 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 under- goes, as it is noted by all observers that the milk when warm from the cow is but slightly acid, or neutral, in its action to litmus-paper, but after it has stood for a while always shows a very decided acid change. Mothers' milk is always alkaline. The greater part of the secret of success in bottle- feeding is to have pure, fresh milk ; and I would say beforehand that if there is the least doubt of the char- acter of the milk served, there should be no hesitation about putting the child at once upon condensed milk until this matter is thoroughly arranged. Although one may be most careful in the selection of a milkman, BOTTLE-FEEDING. 53 in the city, the jolting that the milk gets in transit, the risk that is run from diseased cows, dirty cans, con- taminated water in 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 very apt to be followed by disease ; pos- sibly this accounts for the fact that the milk from the same dairy will disagree with the child in summer that has agreed perfectly during the spring months. So much attention has been paid to this matter re- cently 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-feeding 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 be always, for a very young child, be tested with litmus ; if it is alkaline, it has been made so by the addition of some preservative. Cows' milk always presents to litmus-paper more or less acid reaction, turning the litmus red. If there is the slightest suspi- cion that the milk is not very fresh, or that it has been subjected to much jolting, my opinion is that it should be boiled at once, and then put in a refrigerator to be warmed for each bottle. The boiling will destroy its ferments, and in that way diminish the chances for intestinal disturbances. The question 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 advan- tages, but I think that the ordinary mixed milk from 5* 54 INFANCY. 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 with them disease. Our medical 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; or, indeed, milk undoubtedly is frequently diluted, and the water will carry the germs with it. Milk also has the propensity of absorbing odors, and gases that probably have with them the germs of dis- ease may be absorbed by the milk and carried that way. 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 were we ever so careful and watch- ful we could only avoid the most apparent evils, and we 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 diluting of milk, should be 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 legislators of the land, those who make its laws, but possibly by placing these matters in a clear way 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. I dwell at great length upon the importance of step by step considering the preparation of a child's bottle, BOTTLE-FEEDING. 55 and this is done because it becomes a monotonous work, and unless the mother sees to it personally, no nurse, however devoted, may not some time or another become a little careless, and the result may be the souring of the milk, formation of the curd, and inflammation of the bowels and its consequences. Dr. W. Thornton Parker, of Newport, Rhode Island, recommends a pure gum nipple, witli two holes as far apart as possible, as the best for the nursing-bottle, and also says regarding the matter as follows : " 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 height as if it were really being nursed by its mother. When it has fin- ished 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 follow- ing advantages : it serves as the basis for the prepara- tion of a milk resembling that of the human mother, it possesses all the ingredients that are necessary for nutri- tion, it is easy to obtain. Its disadvantages are, that the relative proportion existing between its different constituents is not that found in mother's milk, it pos- sesses a form of casein which forms hard curds, this casein exists in larger amounts, at least twice or more than in human milk. A certain time must elapse during which the milk undergoes possibly some alteration from exposure to *I quote here from my paper read before the convention of State Boards of Health in May, 1886. 56 INFANCY. the air, is liable to be tainted with the germs which produce decomposition, and this indeed is the greatest objection to its use in our large cities. It is acid, though precisely what effect this has, or what it is due to, is not exactly clear to my mind. But these objections can be readily obviated by the following means : The milk from an ordinary dairy should be obtained as fresh as possible, mix together half a pint of this milk and half a pint of pure water, and to this should be added about two hundred grains or two heaping tea- spoonfuls of milk sugar, with four grains of bicarbonate of soda ; it should then be brought to a boil, after which two tablespoonfuls of cream should be stirred in, and it is ready for use, to be given by bottle or drinking-cup, at about the body temperature. We have here a mixture which, according to Leeds, closely resembles mother's milk ; we have also a prep- aration which has been freed by boiling from the ob- jection stated above to cow's milk, that due to a ten- dency to fermentation, and indeed the milk is rendered more digestible by it. 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, three ounces of water; add one ounce of ordinary cream and about a level tea- spoonful and a half (eighty grains) of milk sugar. In- deed, it is better to run the risk of making a mixture with too little casein than with too much, gradually in- creasing strength of the milk by diminishing the water, as the child grows older ; but it should also be borne in mind that as we increase the water we should also increase the carbo-hydrates, by adding either sugar of milk or some of the malted foods. Sugar of milk rapidly sours and turns to lactic acid when dissolved in water ; and, indeed, I believe that on this account there BOTTLE-FEEDING. 57 is little choice between it and cane sugar. In a case of diarrhoea, I would leave out sugar altogether. My own experience teaches me that ; with care, cane sugar has not the disadvantages in most cases, in winter, that some fear. Or we may dilute the milk as follows : If to a four-ounce 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 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. 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 tea- spoonful (about one hundred grains) of milk sugar. Cream itself contains about three per cent, of casein. But I 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 I have before suggested, if there is the least doubt about the keeping of milk it should be immediately brought to a boil and then placed in the refrigerator, a certain amount being with- drawn 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 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 contains 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. 58 INFANCY. replaces the milk is that exhaled by the child, and acts most quickly as a putrefacient. The milk should be given to the child about the temperature 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°. Dr. Thornton Parker, of New- port, Rhode Island, says that the best method of pre- paring the milk for the bottle is as follows : For a child of three months old take of pure Alclerney milk one cupful (one gill), boiling water two cupfuls (one-half pint), lime-water one tablespoonful, sugar of milk one teaspoonful. Mix carefully. 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 that has 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 thoroughly 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. 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 delicate digestion of the child, cow's milk seems to be indigestible. We are 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. BOTTLE-FEEDING. 59 This brings us to the subject of condensed milk. A reliable brand of Borden or Canfield's has the following advantages : When diluted with from ten to five parts of water, it represents mother's milk pretty closely, depending on the age of the child, with the exception that there is less cream, but to a pint of this mixture four tablespoonfuls can readily be added. The evapo- ration 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 mother's milk. It can be universally obtained, and is useful on that score ; its disadvantage 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. My own experience does not bear this out, though certainly if I were to find that a child fed on condensed milk should show undue acidity, either in its stools or its breath, due to the presence of lactic acid, I would at once change its diet. This, care- ful watching should avoid. In summer weather the presence of cane sugar, which is a decided laxative, is objectionable, and herein exists the great difficulty of the proper selection of a food for that season. In order to counteract any tendency to rickets, I usually incorporate in the milk some lime, — either lime- water, or still better, I think, the lactophosphate and carbonate of lime ; indeed, I would establish this as a rule in the preparation of all milk foods that require the addition of sugar. Let us study for a moment the question of the " fresh evaporated milk," served daily in some cities by the Canfield Company, and which, I think, offers for the future the best field for infant feeding in those cities 60 INFANCY. where it is daily supplied, especially in summer-time. 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 tablespoonfuls of cream and two heaping teaspoonfuls of sugar of milk. This will be equal to cow's milk, with about the same percentage of casein as mother's milk. The absence of cane sugar in this preparation renders it most 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°, 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 pro- duced by fermentation and also by mechanical irritation of undigested curds, and this is often due, not alone to the method of preparing the food, but also to the de- ficient 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 anti- putrefactive as well as digestive. We are often obliged to use some means so as to prepare 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 re- tards in a measure the coagulating property of the gas- tric 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 BOTTLE-FEEDING. 61 matter, such as oatmeal-water, that will intimately in- corporate itself in the casein as it falls, and thus allow the gastric juice to completely attack it. The fourth, by partially predigesting the casein, pep- tonize it as it is called, before it enters the stomach. We have, in addition to these, various other prepara- tions, which are sometimes added to the milk to render it more nutritious ; for example, soluble carbo-hydrates, as dextrine, glucose, or substances rich in albuminous matters. This, in fact, covers the whole ground of the various preparations used in the bottle-feeding of in- fants, and you 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 in large amounts, soda or potash, and the curd affected thereby. I think the im- portance of alkalinity is somewhat over-estimated, — 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, two table- spoonfuls to a four-ounce mixture will be in most cases sufficient. It is always well to consult the phy- sician 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 flatu- lent and dyspeptic. Vichy water is a very good addi- tion 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 6 62 INFANCY. we are obliged to give the child greater bulk than it would otherwise take, aud to overcome this difficulty it is necessary to add cream, sugar, and salts to the bottle in its preparation. A question of the digestion of fat is a very important one. The fats and sugars serve pretty much the same 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 princi- ple. Fat is in greatest demand at the time when animal heat is the most required, that is, during the winter mouths; the fats aud 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 stor- age 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. It is admirably described by Dr. S. Weir Mitchell in his book. 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, I can well be pardoned if I again dwell upon it for a few moments. The intense 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 ex- BOTTLE-FEEDING. 63 pose its character. The soft flocculent masses into which it is coagulated are of immense advantage, especially in young infants ; it is the nearest approach to mother's milk. The only question which is at all worthy of 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, it is so much more reliable than the ordinary tablespoon), with ten ounces of water, is almost identical in its composition to mother's milk, possessing very much the same quality, with the exception that it has 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 advantages than any other milk food, and I feel satis- fied that it will agree best and 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. I 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 understood that to the freshly- evaporated milk, sugar of milk should be added to each bottle. Let me, then, be distinctly understood as recommend- ing 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, or when there are doubts as regards the character of the cow's milk from which its food is to be made. It serves as a bridge to carry the child safely over a change in the character of its food which is all-important ; it also has advantages of being always at hand, and when obtained fresh and from 64 INFANCY. reliable sources is usually of about the same quality. I 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 I would not advise it. Of course, as a child grows older its digestion be- comes 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 pre- pared above an ounce of ordinary cream can be added. If one lives in the country and milk can be obtained warm, fresh from the cow, it can be used instead of condensed milk, but I must confess that I would not recommend a city child to be given, shortly after its birth, ordinary cow's milk and water. In addition to those recommended already, includ- ing the mixture of cream and water, which I have known to be an excellent substitute for the bottle on many occasions, we have the mixture suggested by Dr. J. F. Meigs and used by him for so many years with success. 1 A two-inches 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 small 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, two-thirds water for the new-born, two-thirds milk and one-third water at six months, varying at the ages between in proportion. These are 1 Dr. A. V. Meigs recommends the following way of preparing the hottle : Order from druggist a number of packages of sugar of milk, each containing seventeen and three-fourths drachms ; dis- solve 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 tablespoonfuls of lime-water. Put in nursing-bottle, to be taken warm. BOTTLE-FEEDING. 65 allowed to boil together for a few minutes, 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 teaspoonfuls of white sugar. Lime-water is used almost universally in the prepa- ration of bottle-food, both with the object of making the milk slightly alkaline, and for the purpose of lessening the consistency of the curd. There are some children with whom it does not agree, undoubtedly, but as a rule it is safer to use this form of alkali than either soda or potash, because lime-water is a very weak preparation, and there is no danger of giving too much in the bottle, which certainly would be the case if soda or potash were used at the discretion of nurse or mother. The value of whey as a substitute for milk has been advocated by many writers in cases where the child's digestion is weak and the milk curdles in large masses and very readily, or in cases of illness. Whey is certainly an admirable substitute for the ordinary bottle. It can be made by curdling the milk with rennet and strain- ing, and according to Dr. Eustace Smith, the promi- nent English authority, it can be given to a child in this way : Two tablespoonfuls of whey, Two tablespoonfuls of hot water, One tablespoonful of fresh cream, given in the nursing-bottle. 6* 66 INFANCY. CHAPTER IY. PKEPAEED BOTTLE. Cow's Milk, its Advantages and Disadvantages — A Child's Di- gestion — Different Preparations of Bottle-Food — Why an Infant should have very little Starchy Food in its Diet — How to avoid either Constipation or Diarrhoea — A Baby's Bottle Diet may be varied — Peptonized Milk— The Care which a Mother should exercise in the Selection of a Child's Diet. The question of the curd commands the most serious attention. It is this curd that is always in the way, although it is an important article of diet, as it is 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 suffer- ing from disease or indigestion, or we have to so act upon it as to make it either coagulate in flocculi, 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 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 digestions 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. I will quote here, for the informa- tion of those who care about the subject of digestion, a portion of a paper recently read by me. 1 Digestion is not merely a process of disintegration ; certain secretions are requisite to bring about the chemical 1 Annals of Hygiene. PREPARED BOTTLE. 67 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 minimum ; 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 sufficient 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 digestive disturbance. From birth the gastric juice takes a prominent part. By it the curd is precipitated and turned into peptones, or albuminose. All albuminous matter is so converted, and a burden by no means light is placed upon the liver, an organ more prominent in infancv than in adult life. The precipitation by gastric juice of the casein pre- sents some curious features ; indeed, this matter is of fundamental importance in our studies. AYoman'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 consistence. Brush, in 1879, told us that the curd in all cud-chewing animals, of which the cow represents the class, was thrown down in masses so as to be readily regurgitated by the calf for the purpose of trituration. In the non-cud-chewers the reverse is the rule. There may be other peculiar- ities of the curd, chemical differences, but these have not as yet been determined. The secretion from the pancreas is the next and last of importance. It is composed principally of two 6g INFANCY. 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 es- caped the action of the gastric juice; and a diastase like that of the saliva, which converts starchy matters and cane sugar into dextrine 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 arti- ficial feeding of infants, and I shall limit myself 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 important of them is diluting with water. It is for this purpose water is added to cow's milk; but also it has been noted that if certain materials which are not digested in the stomach are allowed to become thor- oughly mixed with the milk, they will, acting in that way, so honeycomb 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 is a good deal of lime which is not dissolved in it, — but farinaceous food 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 the sand does in the stomach of a bird. The cereals are composed of grains, when examined under the microscope, that are covered with a material that is destroyed by heat or PREPARED BOTTLE. 69 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 dextrine 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 pancreas secretion in a small amount, to feed it entirely on starchy food is simply to give it starvation diet. It cannot live on such material. Very fortunately for the baby, its corn-starch has to be boiled, and this boiling process partly converts it into grape sugar, or at least so nearly so as to allow the contact of the feeblest secretions to finish the work, and for- tunately, also, nature often supplies the child with very active salivary glands during its teething period ; it slob- bers constantly, and the corn-starch food comes in contact with this secretion, that 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 bot- tle, 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 do get along well on corn -starch food and thrive from a very early age upon boiled bread and milk, cracker-dust food, or substances of that sort; but unfortunately it is these very children who form exceptions to the rule that prove the invariable evil result of attempting to give starchy food to two-thirds of the children too young. An amount of a cereal can be added to the child's bottle after it is three or four months old, if it is deemed advisable, beginning with a very small quantity. Dr. J. Lewis Smith recommends for preparation of infants' food the following plan : Take from five to ten pounds of well-selected wheat flour, put this in a bag, tied firmly, and allow it to keep covered with water for 70 INFANCY. several days, possibly a week, and this should occasion- ally be made to boil. In the preparation of the bottle for a child under three months, the water used for diluting the milk can have boiled with it some of this flour, grated in the proportion of two heaping teaspoon- fuls to a pint ; after the sixth month four teaspoonfuls. The milk can be diluted with its bulk of water, which can be previously thoroughly boiled with either ground barley, oatmeal, or baked flour, in the propor- tion 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 can be sweetened, an ounce of cream added, and it forms an excellent food for a child after its fourth month. If it is then understood that the addition of 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 the grain of wheat, corn, or oats acts as the laxative, — in other words, the bran, — and it is on that account the crushed grain is more valuable where there is a ten- dency to constipation. Next in order 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 preparation which is nourishing and fattening, but is not laxative. The internal portion of the kernel of all these cereals contains the starch-grannie, and this part we know gives the tendency towards constipation. 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 PREPARED BOTTLE. 71 should bear in mind what I 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 I cannot repeat it too often. When a mother wishes to put her child on the bottle, supposing it to be about the age of four months, and we wish to add something to the bottle, it is a difficult matter to know with what to begin. Dr. J. F. Meigs advised gelatin and arrow-root ; Dr. J. Lewis Smith, of New York, advocates the flour ball, — that is to say, the flour tied in a linen rag and boiled for hours, opened, and the interior taken out and grated and used with the milk. My own preference is for barley ; it is the least constipating, 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 can be added with each, or every alternate, bottle, and a variety of diet in that way instituted. 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 Robinson's barley, which comes in packages, finely powdered. Of course the latter is easier manipulated and requires less time to prepare it. Of the powdered barley, take a dessert- spoonful, 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 con- stantly, 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 mixture is put in the re- frigerator 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 72 INFANCY. way. A variety of oatmeal known as the Bethlehem oatmeal comes powdered for this purpose. 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 put them to boil in water beforehand, say a heaping dessert- spoonful to a quart, and 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 scalding the milk by pouring the boiling water and meal into it, stirring it meanwhile, and then strain. The sugar and salt can be added. In city practice I always recommend the boiling of the milk for precaution sake, and I think the tendency to constipation can be overcome by adding cream to the bottle and 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 I 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. Regurgitation 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 disagreeable odor, white passages, or diarrhoea, are of course all evidences of in- digestion, 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. I have often seen cases in which the mother had PREPARED BOTTLE. 73 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. Remember 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 the timely movement of its bowels, is of the greatest value to the child. Do not think that it is the amount of material you put into a child's stomach that 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, it seems to me, 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 pre-digesting the curd. Professor Albert R. Leeds, of Hoboken, gives us the following way of preparing milk for infants : One gill of cow's milk, fresh, unskimmed, One gill of water, Two tablespoonfuls of rich cream. To these can be added one powder which contains two hundred grains of sugar of milk and four grains bicar- bonate 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 in a nursing- bottle and placed in hot water, — water so hot that it can- not bear the hand more than a minute at a time, — and d 7 74 INFANCY. kept there for about twenty minutes, and allowed to cool sufficiently for the child to take. This powder is called Peptogenie Milk Powder. In a lecture before the Philadelphia Hospital Nurses Training School, Mr. Fairchild spoke as follows : l " 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 instance, is converted into pep- tone. The materials used for the purpose are the fer- ments of the pancreatic juice in the form of a powder, — the extract of pancreas. 2 This contains several fer- ments, 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 proper 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 tem- perature, which is 100° F. " I shall now show you how to make peptonized milk. I take one of these l 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 tablespoonfuls — 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 1 Keported by Dr. "William H. Morrison, Holmesburg, Pa. 2 Or the " essence of pancreas," or the " liquor pancreaticus. " PREPARED BOTTLE. 75 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 di- gested 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 pepton- ized 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 eifect 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 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 quan- tity 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 minutes 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 76 INFANCY. 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 dilute the milk, 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 com- pletely peptonized, it will not curdle, and the lemon is often desirable to make the milk pleasant. Rum and sugar 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 Ave 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 tablespoonfuls 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 re- member 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. " 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 rubbed into a fine pulp and put back into the water. You may now add a gill of the starch mucilage and one of the peptonizing powders. It is then set aside for two or three hours, and at the end of that time scalded. The peptonized soup may be PREPARED BOTTLE. 77 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 tablespoon fuls of the meat, barley, etc., strained from soup, rub it to a pulp, and add fifteen or twenty grains of pancreatic 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 ob- tain 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 amount of the peptogenic milk powder; next we add four ounces of water and two tablespoonfuls of cream. This latter is an important element, for mother's milk contains more fat than cow's milk. In this way we obtain the same proportions of the different elements as are 7* 78 INFANCY. 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 temperature 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, how- ever, the baby is very ill, and not even capable of di- gesting 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 quan- tity and a proportionately 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 con- tinued. The proper amount may be poured out and heated whenever it is required. " The other way is to make the mixture as just de- scribed, 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 ordinary 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 imitation 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, and is at present highly recommended by all PREPARED BOTTLE. 79 physicians in this country and Europe when prepared according to the directions just given, for infants who are suddenly deprived 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. I think on this account it is considered troublesome, and, in institutions especially, condensed milk appears to have the greater number of advantages. There is another quality which the extract of pancreas possesses which 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 diarrhoea, or with whom starchy food fails to agree, this can be made use of. This brings us to another subject. Anything which will convert 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 sug- gested. 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, 80 INFANCY. such as Liebig's foods, where the starch has been turned into grape sugar by malting. Mellin's food and Horlick's food are prepared on the same principle. These foods are nothing more than malted grain. 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 valuable be- cause 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. It is therefore, in my opinion, not necessary to add Mellin's or Horlick's food to the milk of children at birth. All that we need is a milk which will be digested and readily absorbed. 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 ; and when I advise, as a rule, mothers to avoid these prep- arations for their very young babies, I am only speak- ing of healthy children. This leads me to the question 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, of Hoboken, these classes of foods may be divided into the milk foods, the farinaceous foods, and the IAebig foods. I give many of the different prepara- tions under these headings, in order that the mother can intelligently make her choice, should one not agree with her child. I have said before, and I 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 fam- ily ; that the test of whether or not a food agrees with PREPARED BOTTLE. 81 a child is if the child thrives upon it, — if it sleeps well, its flesh becomes firm, its digestion is good, its temper is amiable, — 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, notwithstanding the advertisement that such and such foods are the only ones that agree with the baby. Should a child be lan- guid, drooping, appear weak, and not thrive, one of the milk foods — such as Nestle' s, pre-eminently — would be a useful addition to its food, or it can be used simply with water, as it contains condensed milk, also Carn- rick's Soluble Food can be advised in this way. As the child grows older, a farinaceous food may be given in the way described on page 71. Should the passages become constipated and there be much flatulence, the child suffer from colic, become restless at night, lose its appetite, then the change should be made to one of the Liebig foods, and in this way its digestion encouraged 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 contains 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, Borden's or Canfield's fresh evaporated milk, or one of the milk foods given in the table : MILK FOODS. Nestle's, Carnrick's Soluble Food, Anglo-Swiss, Gerber's, American Swiss, and others. 82 INFANCY. FARINACEOUS FOODS. Blair's Wheat, Hubbell's Wheat, Imperial Granum, Hard's Food, Ridge's Food, Robinson's Patent Barley, Bethlehem Oatmeal, and others. LIEBIG FOODS. Mellin's, Horlick's, Lactated Food, Hawley's, Keasby & Mattison's, Savory & Moore, and others. Frequently a child may be so weak or exhausted from disease or from inanition that food of the mildest char- acter will not remain on its stomach. It would be use- less to keep on diluting condensed milk, as it would render it valueless. In cases of this sort, the white of an egg shaken np in a bottle of warm water to which a couple of grains of lactopeptine 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 surpris- ingly long time, and allay irritability of the stomach and bowel, and finally the child can be gradually encouraged to take small and repeated quantities of peptonized milk or one of the milk foods. WEANING. 83 CHAPTER V. WEANING. "Weaning — When to wean a Child — Where to wean a Child ; and how to wean it. 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 abundant, the question of weaning in the summer-time has not half the importance attached to it as it has to those who are obliged to spend the summer in, or near, one of our large cities. My own opinion is that if a child has been nursed for four months, certainly for six months, the gradual addition to its dietary of a bottle will be of advantage. I have studied this matter con- siderably of later years, and somewhat modified my former views on the subject, and my own investigation and those of others have recently confirmed them, that a child, partly nursed and partly bottle-fed, after its fourth month, thrives better than one bottle-fed alone, — that, in fact, breast-milk helps to make the bottle more digestible. Not only is this the case, but I believe that it is a great relief to the mother, gives her more time to rest, is less drain upon her nutrition, and it also is 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 I certainly think that four months is young enough, provided the mother's milk is found to be of good 84 INFANCY. quality, nourishing, and the child thrive upon it. Should this not be the case, the addition to nursing by an occasional bottle will have a tendency to concentrate the breast-milk, making it more nourishing, and thus avoid the necessity of weaning altogether. For a child that is born as late as January or Feb- ruary I should 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 sum- mer can be spent out of town or at the sea-shore, the weaning 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, and is not in the least pulled down by nourishing her baby, if she can nurse it a year I think it so much the better, and for the last four months her child can take some bottle food in addition. I do not think any mother should nurse her child for more than a year ; there is no necessity for it as a rule. 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, 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 at 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. It gives the mother an opportunity to take exercise and WEANING. 85 rest. Possibly it may need a bottle about four o'clock in the morning. The question would be asked, What should be the first choice when selecting the bottle food of a child at this age ? I would recommend that the bottle be pre- pared with barley, or Imperial Granum, cracker-dust, or grated flour ball, and add in increasing quantities, beginning probably with a small teaspoonful, Mellin's or Horlick's food. As the child grows older, the mid- day bottle can be varied. I believe that by using a mixture of the cereals we often get a more palatable and more nutritious preparation than by using them singly ; thus, oatmeal and barley, or Graham flour, can be used together, or oatmeal and Hubbell's food. The child will show a decided preference for some kind of bottle food, but bear in mind that it is a great mistake to stutf a child. A 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 is 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 heavy 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 understand 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 I be- lieve that although oatmeal is a most valuable addi- tion 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 it should not be used in hot weather, nor with children who have what is called a " bilious tendency." 86 INFANCY. If fresh cow's milk is not obtainable, condensed milk can be used in this gradual weaning of children. Let me here say again that when we use any substance be- sides milk in its bottle, such as the cereals, we should not forget that the child needs water — pure, clean water to drink. Very 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 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. Bear in mind that in the summer-time if 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 cutting 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. FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 87 CHAPTER VI. FEESH AIE, VENTILATION, OUT-DOOE EXEECISE. The Great Importance of Ventilation — The Selection and Care of the Nursery — How it should be Heated — The Danger of allow- ing Children to be left to the Care of Young and Inexperienced Girls — How Children frequently contract Diseases. There are a great many facts that have been given us by scientific men that should be applied to every-day custom ; among these none more important than those relating to the subject of ventilation, by which we mean the getting rid of foul air and the entrance of pure air in as easy a manner as possible, free from draughts. We all kuow that the passage of cold air through a chink, when striking against some sensitive nerve-point on the surface of the body, which is exposed, will have a peculiar way of abstracting heat, or give what is known as " a cold," affecting the mucous membranes. Of course, the more delicate or the younger the indi- vidual the more susceptible it would be to such an im- pression. There are certain parts of the body more 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 ob- served that these draughts are more apt to make them- selves felt when the parts on which they strike are in a state of relaxation ; naturally, should there be perspira- tion, its evaporation would intensify the cold impres- sion. When children, then, after active play, perspiring freely, sit in a room in a draught, they will take cold, and at the same time they might continue their play in a colder room, and not feel it ; the action of their mus- cles, the excitement, will give them resistance which 88 INFANCY. they would not have in a state of quiet. 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 I specially refer to our city nouses), as far removed as possible from the contaminations and the filth of the streets. The play-room should be large, certainly, situated in the second or third story, and should have the sun in it at least part of the day. Of course, for a few weeks the new-born babe will sleep with its mother ; if it is a strong and vigorous child it can be placed 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 would 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 manage to allow it to sleep in the bed with her, but so arranged that it will have a portion of the bed entirely to itself. The child is, certainly, after a couple of months, health- ier 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 nursery and sleeping-apartment is a matter of great importance. The essentials are, purity of atmosphere and uniformity of temperature, 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 knowledge of the cause of disease, impurity in the atmosphere has assumed great importance ; we are now able to recognize the fact that certain diseases which we hitherto attributed to cold are in reality due to filth ; that certain other intestinal disturbances, which FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 89 were attributed to heat, are in reality due to decomposed or fermented food ; these facts are most important for us to bear in mind, not only to enable us to cure dis- ease, but also because by a thorough recognition of them, these diseases or disorders which have been attributed to climacteric disturbances may, by the timely institu- tion 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 be tainted, one who is daily bathed, not overfed, neither debilitated by too heavy clothing nor subjected to daily fluctuations in bodily temperature, should not pass through the dreaded sum- mer season in a city unharmed by the so much dreaded summer weather. I mention this because, probably, many mothers who read this book cannot afford to spend the summers out of town. I think a nursery should always have an open fire- place for ventilation, 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, putting about a four-inch strip of board to keep it down, and an in- direct current will be made between the sashes. Of all the methods of heating, probably the most scientific, but unfortunately the one that can be most abused, is the hot-air furnace. Parents should see that their nur- series are supplied with air that is, first of all, pure, — it must be taken at as great a distance as possible from the ground, not immediately off of gutters and damp yards, as is usually 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 poisonous than before. The air should be taken as far from the ground as possible, heated, and then passed over a sur- face of pure water ; it will receive a certain amount of 8* 90 INFANCY. moisture, and then be carried, as free from dust as pos- sible, directly to the nursery. Air which is not passed over water but simply dried will, undoubtedly, produce various forms of irritation of the mucous membranes, dryness of the throat and nose, languor, — symptoms which we all recognize at once. Certainly nothing could be better than an open grate, with a wood-fire, even if it be only occasionally used, to supplement the furnace, especially at night. . The sleeping-room should be heated through the nursery, if possible, and should be only occupied at night. Of course, I recognize that 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 unsurmountable, and render a dreary, un- healthy nursery, healthful and habitable. The nursery should always have a thermometer, and the temperature be kept about 70°. The heat should be always shut off at night, and the child's clothing so arranged as to prevent its being thrown off while the child is perspir- ing during the early morning hours, when the system is most depressed, at which time the danger of catching cold is most imminent. Avoid all sewerage arrange- ments, — -pipes of every kind, — in a nursery. The sci- ence of ventilation and house-drainage gives us prob- ably as perfect a system 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 its existence in drinking-water, which equally will serve to dissemi- nate this poison. The most costly habitation of the wealthy will find these dreaded diseases carried into its FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 91 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 care- fully against cold, in the first place, and their means prevent them from having the luxuries which carry the deadly sewer air into their bedrooms. Physicians be- lieve that diphtheria most frequently 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 against an attack in the summer. Just as soon as the child takes cold, becomes a little run down, that dreaded disease, diph- theritic croup, will show itself. I have laid great stress on the importance of thor- ough ventilation and fresh air, but I wish to be distinctly understood 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 warm- ing ; at the same time it should be remembered that frosty air, filled with germs of disease, may be harmless to breathe, but the same air warmed by a " heater" may become most deadly. A child's vitality is lowered at night, its circulation less, its resistance to disease 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 become reduced at night, when the heat is turned off, with benefit, if the child is covered — not enough to induce perspiration, and the clothing 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. 92 INFANCY. To sum up, then, a nursery, or child's living-room and bedroom, should be kept scrupulously clean, thor- oughly aired, freed from dust ; dust, independent of its irritating character upon the mucous membrane, is the means of conveying disease. There are many days in our treacherous climate when a child cannot be taken out of doors ; indeed, there are many days when a child had better remain in its well-aired nursery, days during which, if it went out of doors in its peram- bulator, 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 one in its perambulator, or one who walks. The day nursery should be supplied with plants. They are 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 taken for temper, perverseness, in many children is often sickness and unhappiness. Those who are much thrown with children recognize this fact; indeed, it is one which every grown person feels when he or she looks back to childhood days. The energy, buoyancy, which comes with good health, is in marked contrast to the depres- sion and irritability that is associated with illness, or, if not exactly illness, with those sedentary pursuits that are in themselves unhealthful. The question is often asked at what age a child should go out of doors, and whether it should go out every day, notwithstanding 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 accompany them are matters, of course, that have to be taken into consideration. After a babe is about six weeks or two FRESH AIR, VENTILATION, OUT-DOOR EXERCISE. 93 months old, if the weather is 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 cold 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 change- able, — 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 that age when it is a drag upon the nurse, difficult to carry, and at the same time cannot walk, and a perambulator is required, the time to exercise 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 assembled, noting the position of the baby carriages and the condition of their occupants. A child will be left facing the bleakest March wind, or the midsummer sun fiercely attacking its unprotected head, while the nurse will be engaged in conversation with a number of her friends. I have often been at a loss to know 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, pneumonia, or inflammation of the brain, as a consequence. It would be far better if all children; until they were old enough to sit up by them- selves, were carried by their nurses in their every-day outing, and that after a child was 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 dis- tinct understanding that under no circumstances is the carriage to be stopped ; when she is tired she is to come home. I am very particular in laying stress upon this matter, because, notwithstanding all that has been written on the subject and the full knowledge that 94 INFANCY. mothers obtain from their family physicians, who are one and all opposed to the present system and acknowl- edge that a larger part of the diseases of children is due, undoubtedly, to the carelessness, in one way or another, of their nurses, — these girls, without any experience whatever, with no judgment, certainly no affection for their charges, hired and intrusted with the care of an infant, and allowed to take it out, going where they will, carry it into heated rooms, leave its out-door wraps on, carry it out of doors while it is perspiring, expose it to contagion of every kind, taking it into all sorts of atmos- pheres ; 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, be struck with wonder and surprise when it is taken ill. So important do I 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 experi- ence, conscientiousness, and truthfulness, that I believe the mortality from contagious diseases, and from those disorders due to direct exposure, would be diminished if mothers could be made to appreciate this matter. CHAPTER VII. BATHING. The Importance of Bathing — A Child's Time for Bathing must he regulated by the Child's Condition, etc. — The Cruelty of forcing Young Children to have a Plunge in the Cold Sea — A Child should love its Bath, and how it can be taught to love it. In speaking of the new-born babe, it was noted that immediately after birth, instead of being washed, it should thoroughly be greased with some material. The BATHING. 95 best substance to be used for this would probably be washed lard, or the non-scented white vaseline. The child can then be gently washed in warm water with a soft sponge, or soft linen, with Pears' non-scented, or 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 may have secreted and caused irri- tation to the tender skin. It is not necessary that at first the child should receive a thorough washing, but certainly by the end of twenty-four hours its skin should be soft and pink, and every particle of secretion be re- moved from it ; the nostrils, the eyes, the mouth, the various crevices of the groin and the arm-pits thoroughly cleansed. There should be a thermometer always in the nursery, and the child's bath should be always regulated by it. The temperature of the water should be 95°, and as the child grows older and becomes strong, the circula- tion well established, the temperature should be gradually reduced until it is about 75° 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. At bedtime a sponging off will be enough, unless the child is one of those excitable dispositions to whom we have already alluded, the child of intellectual parents, or those who depend upon their brains for a livelihood : these children always exhibit more or less of a nervous, irritable disposition, which renders them at times rest- less 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 morn- ing, and leave the bath for the night, making the water about 95° in order to get its full sedative influence. It is a very great mistake for a child to get accus- tomed to bromide, valerianate of ammonia, brandy, or gin, to make it sleep ; these should never be used with- out the consent of the physician ; but the sedative influ- 96 INFANCY. ence 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 digestion is not going on, as a rule, the child can be thoroughly washed, the surface brought into a glow either with the hand or a soft towel ; the child can 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 can be given at an earlier or later hour to suit the circumstances. For a very young infant it is not absolutely necessary to give the child a bath in the tub ; the room should be warmed to a temperature of about 75°, guarded against draughts. The temperature of the bath, if the child is immersed, should be about 90°, but if the child is delicate and young a thorough sponging of the surface will be suffi- cient, and gradually it should be accustomed to the water until it will of its own accord show a liking for the bath. The question often arises, How long after feeding should the child have a 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 im- mersion, but for a young infant that is simply sponged and nursed with breast-milk, an hour will be sufficient. Often it is necessary to bring about a glow on the surface of the body for children who are delicate, when for some reason or another the bath cannot be given ; the body can be gently rubbed with either spirits of wine or washing whiskey, to which a little salt can be added to make it more stimulating ; or, if the child is very delicate, cod-liver oil can be used with rubbing. The child should not be permitted to go out imme- diately after its bath, nor indeed for an hour or so, if the weather be cold; but as the day's sleep is given immediately after the bath, scarcely any mother would BATHING. 97 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 taken food before going out be better able to resist cold, but also there will be less chance of it becoming infected by contagious diseases. " To dare the vile contagion of the night And ternpt the rheumy and unpurged air, To add unto his sickness." 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 a child grows older by teaching it to play in its tub, and gradually fill it with water; or over the tub can be thrown a light blanket, and the child gradually immersed, gently low- ered into the water. The question of when a salt bath should be used is often 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 ten- dency to scrofula. Children who lack muscular strength, have loss of appetite, sleep badly, are especially bene- fited by salt-baths. It is not necessary to obtain what is known as sea-salt, though this is usually sold for that purpose. 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, 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 ; until that time the sea-water can be given in the ordinary e c *.s ■<;