HYGIENE OF THE STARR. GENERAL MANAGEMENT OF FEEDING* DIET -LISTS' CLOTHING' SLEEP' EMERGENCIES- MASSAGE* ILLUSTRATED* HYGIENE OF THE NURSERY STARR BY THE SAME AUTHOR THE DIGESTIVE ORGANS IN CHILDHOOD. The Diseases of the Digestive Organs in Infancy and Childhood. With Chapters on the Investigation of Disease, the Manage- ment of Children, Massage, etc. Third Revised Edition. With Lithograph Plates and Wood Engravings. Price, Cloth, $3.00 net. P. BLAKISTON'S SON & Co., Publishers 1012 Walnut Street, Philadelphia HYGIENE OF THE NURSERY INCLUDING THE GENERAL REGIMEN AND FEED- ING OF INFANTS AND CHILDREN; MASSAGE, AND THE DOMESTIC MANAGEMENT OF THE ORDINARY EMERGENCIES OF EARLY LIFE BY LOUIS STARR, M. D., L.L. D. EIGHTH EDITION WITH TWENTY-SIX ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1913 Twenty-second Thousand. COPYRIGHT, 1913, BY Louis STARR, M. D. THE MAPLE* PRESS* YORK. PA TO MY LITTLE PATIENTS SOME OF WHOM IN THE RAPID PASSING OF TIME, MAY SOON ASSUME PARENTAL DUTIES THIS VOLUME IS AFFECTIONATELY DEDICATED PREFACE TO THE EIGHTH EDITION. In the preparation of this edition of HYGIENE OF THE NURSERY the subject matter has been care- fully revised, and amended wherever necessary to keep abreast with the advances and improvements constantly being made in the methods of managing infants and children. Special attention has been given to the chapter on "Food," and numerous additions have been made to the "Dietary." These changes and additions the writer believes will materially enhance the working value of the book, and perhaps increase its claim to the favor which has been so flatteringly accorded to it in the past. LOUIS STARR. 1818 SOUTH RITTENHOUSE SQUARE, PHILADELPHIA. Vll PREFACE TO THE FIRST EDITION. Having a firm belief in the proverb that "an ounce of prevention is worth a pound of cure," the author has endeavored, in the succeeding pages, to point out a series of hygienic rules which, if applied to the nursling, can hardly fail to maintain good health, give vigor to the frame and so lessen suscep- tibility to disease. He feels, too, that intelligent parents are ever ready to be instructed and willing to cooperate in the great work of preventing disease the highest aim of scientific medicine. While every woman of ordinary brain-power can do much to keep her baby well, she should recog- nize that years of training and experience are necessary to acquire the ability to put the full value upon symptoms, and to handle the tools of medicine. Therefore, little or no reference has been made to drugs or methods of medical treatment. The first chapter is written with the object of hinting to the mother when, by deviations from the features of health, she may expect the onset of dis- ease and call in professional counsel. The last is ix X PREFACE TO THE FIRST EDITION offered, not as a complete guide to the practice of physic, but simply for the sake of giving informa- tion upon questions that often arise in the nursery. The child's doctor, in our day, regulates his patient's diet, clothing, bathing and exercise, and looks into the hygiene of the nursery before he orders medicines, and if the mother has sound ideas upon these subjects she is no mean assistant. The author's thanks are due to Dr. W. M. POWELL for efficient aid in the preparation of the manuscript and index, and to Dr. ALLEN J. SMITH for the illustrations. LOUIS STARR. PHILADELPHIA. CONTENTS. CHAPTER I. PAGE. THE FEATURES OF HEALTH i CHAPTER II. THE NURSERY 51 CHAPTER III. THE NURSE-MAID 69 CHAPTER IV. CLOTHING 75 CHAPTER V. EXERCISE AND AMUSEMENTS 98 CHAPTER VI. SLEEP in CHAPTER VII. BATHING 115 CHAPTER VIII. FOOD . 146 CHAPTER IX. DIETARY 230 CHAPTER X. MASSAGE 267 CHAPTER XI. EMERGENCIES 278 INDEX 323 xi HYGIENE OF THE NURSERY. CHAPTER I. THE FEATURES OF HEALTH. Every ill child presents certain well-defined alter- ations in the manner of performance of the various functions of the body. Thus, the pulse and respi- ration may be altered in character and frequency; the surface temperature may be elevated; the color and condition of the skin may be changed; the appetite may be diminished; weight may be lost, and so on. These alterations from the normal state are termed symptoms. Healthy children, on the other hand, as uniformly show evidences of their well-being, which, for want of a better name, may be called the features of health. Of these every mother should have a full knowledge, so that by appreciating variations she may anticipate the complete development of disease, and early summon skilled aid, at the time when it is of most service. Early life must be divided into two periods, namely, infancy and childhood. Infancy is the .'-* HYGIENE QF. THE NURSERY time elapsing between birth and the complete eruption of the milk teeth, an event that transpires about the end of the second year of life. Child- hood extends from this age to the development of puberty, or to the age of thirteen or fifteen years. It is important to remember these two divisions, as frequent reference will be made to them in the subsequent pages. With this brief preparation, the study of the features of health may be entered upon. i. The Face. The face of a healthy, sleeping child wears an expression of absolute repose. The eyelids are completely closed, the lips very slightly parted, and, though a faint sound of rhythmical breathing may be heard, there is no visible move- ment of the nostrils. When awake and undisturbed, the healthy infant's face has a look of wondering observation. As age advances, intelligence gradu- ally supplants the wondering gaze, and all are familiar with the bright, round, happy face of per- fect childhood, so indicative of careless content- ment, and so mobile in response to emotions. Examples of Variations in Disease. Incomplete closure of the eyelids, rendering the whites of the eyes visible during sleep, is a symptom in all acute and chronic diseases of a severe type; it is also to be observed when rest is rendered unsound by pain, wherever seated. Twitching of the eyelids, THE FEATURES OF HEALTH 3 associated with oscillation of the eyeballs or squinting, heralds the visit of convulsions. Widen- ing of the orifices of the nose, with movements of the nostrils to and fro, points to embarrassed breathing from diseases of the lungs or their pleural invest- ment. Contraction of the brows indicates pain in the head; sharpness of the nostrils, pain in the chest; and a drawn upper lip, pain in the abdomen. To make a general rule, it may be stated that the upper third of the face is altered in expression in affections of the brain; the middle third in diseases of the chest, and the lower third in diseases of the organs contained in the abdominal cavity. 2. The Skin and General Appearance. In the new-born infant the color of the skin varies from a deep to a light shade of red. After the first week this redness fades away, leaving the surface yellow- ish-white. At times this yellow color is so marked that it might be mistaken for jaundice were it not that the whites of the eyes remain perfectly pearly, which is never the case in the disease mentioned. After the second week all discoloration disappears and the skin assumes its typical appearance. With certain well-known natural variations in ^\ complexion the skin of a healthy child is beauti- fully white and transparent. The cheeks, palms of the hands and soles of the feet have a delicate pink color, while the general surface is rosy in a warm 4 HYGIENE OF THE NURSERY atmosphere and marbled with faint blue spots or lines in a cold one; this mottling is most marked on the extremities. As age advances the coloring becomes more pronounced, and until the comple- tion of childhood the complexion is much fresher than in adult life. Other characters of the healthy skin are a velvety smoothness and softness, a scarcely per- ceptible moisture, and a great degree of elasticity. If an infant be stripped the large size of the head and trunk, and the relatively short arms and even shorter legs, will strike the observer at once. This disproportion, especially noticeable in the head, is an actual one. For if in a child of one year, for example, the distance from the lower edge of the chin to the top of the head be measured, it will be found to be equal to one-fourth of the entire length of the body. The vertical length of the head, too, falls but little short of that of the trunk, and the latter in turn is nearly as long as the legs. Again, the abdomen is full and prominent, making the chest look, in comparison, rather contracted and narrow, and the navel is less deeply sunken than in adults. These features, which will be referred to more minutely in a later section, are most marked in young infants, and undergo gradual alterations as THE FEATURES OF HEALTH 5 growth progresses and the child develops into the lithe, active youth or maiden. The shape of the head varies greatly between the round, bullet form and the elongated oval one. When it has been subjected to much pressure, instrumental or otherwise, during delivery, it is often so distorted as to shock the expectant mother. Little fear of permanent disfigurement need be entertained, however, as in time the deformed head usually assumes a natural shape. The same is true of less noticeable depressions, prominences and irregularities. But it should be remembered that restoration to symmetry must be left entirely to nature, as any attempt to press or mould the bones of the skull into shape rarely fails to injure the deli- cate brain beneath. The anterior fontanelle, or, as it is called by nurses, "the opening of the head," is readily seen and felt in infants under a year old. In the nor- mal state it is level with, or very slightly depressed below, the surrounding bones of the skull, and may be observed to pulsate, or rise and fall, rhythmically. It is soft to the touch and yields readily to pressure. Examples of Variations in Disease. Lividity of the eyelids and lips is a sign of imperfect oxida- tion of the blood, and points to disease of the heart or lungs. A decided yellow color of the 6 HYGIENE OF THE NURSERY skin and whites of the eyes is seen in jaundice; an earthy tinge of the face, in long-standing disease of the bowels; a waxy pallor in kidney disease, and paleness in any acute or chronic affection attended by exhaustion. Marked squareness of the head with projection of the forehead, a widely-open fontanelle, and a FIG. i. DIAGRAM SHOWING SHAPE OF HEADS. a, Normal head; b, Hydrocephalic head; c, Rickety head. relatively small face indicate rickets. A very large, globular head is characteristic of hydrocephalus or "water on the brain;" bulging of the fontanelle is also a symptom of this disease. In this connection it must be observed, however, that certain children, in every respect healthy, are born with relatively THE FEATURES OF HEALTH 7 large globe-shaped heads. This peculiarity is especially apt to be observed when one of the parents notably the father has the same charac- teristic. In order to indicate disease, the deformity must be marked and combined with a widely open, bulging fontanelle, or with indications of impaired brain activity. Depression of the fontanelle shows general debility and the need of food or stimulants. The accompanying diagram (Fig. i) will aid in explaining this subject. Great distention of the abdomen is usually due to an accumulation of gas in the intestines, and indicates disease of this portion of the digestive tract; marked depression, on the other hand, is encountered in serious brain affections, in cholera infantum, inflammation of the intestines and dys- entery. 3. Development. To be robust the newly born infant must have a certain average length and weight. The length varies between sixteen and twenty-two inches, and the weight between six and eight pounds. From the first day, growth or increase in length and weight steadily progresses according to certain definitely fixed rules. Length increases most rapidly during the first week of life; afterward the progress is almost uni- form up to the fifth month, and then it becomes less 8 HYGIENE OF THE NURSERY rapid, though still uniform, until the end of the twelfth month. These facts may be seen in the following table: Age. Length. Birth 19.5 inches. i month 20.5 inches. 2 months 2 1 . inches. 3 months 22 . inches. 4 months 23 . inches. 5 months 23 . 5 inches. 6 months 24 . inches. 7 months 24.5 inches. 8 months 25. inches. 9 months 25.5 inches. 10 months 26 . inches. ii months 26.5 inches. 12 months 27. inches. During the second year the increase is from three to five inches; in the third from two to three and a half inches; in the fourth from two to three inches, and from this age up to the sixteenth year the average annual gain is from one and two-thirds to two inches. In the first three days of life there is always a loss of weight, but by the seventh day the baby should have regained weight and be as heavy as THE FEATURES OF HEALTH 9 at birth. The period of most rapid gain in this respect is during the first five months of life. The maximum is attained during the second month, when the increase is from four to seven ounces each week. Throughout the next three months the increase amounts to about five ounces per week, and in the remaining months of the first year, from two to five ounces. The subjoined table shows the average rate of gain: Age. Weight. Birth 7 pounds. i month 7f pounds. 2 months 9^ pounds. 3 months 1 1 pounds. 4 months 12 pounds. 5 months 14 pounds. 6 months 15 pounds. 7 months 1 6 pounds. 8 months 17 pounds. 9 months 18 pounds. 10 months 19 pounds. n months 20 pounds. 12 months 2 1 pounds. Increase in weight and stature are so closely re- lated to the quality and quantity of food supplied to 10 HYGIENE OF THE NURSERY 27 26* 26 25* 25 24 23 22 21 20| spunoj THE FEATURES OF HEALTH II ja;jcn5 ptiB spunoj en 12 HYGIENE OF THE NURSERY the infant, and to the processes of digestion, absorption and assimilation, in other words, are such perfect indices of proper nutrition or the re- verse, that it is important to keep a record, during the first year at least, of these two features of de- velopment. This can be graphically accomplished, and so more readily appreciated, by placing the data upon a chart, such as shown by Fig. 2. Here the average normal weight-gain and increase in length are indicated respectively by the blue and red lines. The figures at the top of the main chart denote the age by. weeks, the heavy vertical lines mark periods of four weeks, the lighter, periods of one week. The figures on the left are numerals of weight, the heavy horizontal lines mark pounds, the lighter, quarter-pounds. The intersection of these sets of lines form squares, one for every weight and age. In making the record mark a dot in the square corresponding to the weight and age. At the next observation make a second dot in the proper square, and so on. These dots are con- nected by a line, and a comparison of this line with the test blue line shows at once whether or not the special infant's weight-gain is normal. Gain in length is marked in the same way, near the red line, in the upper division of the chart; the figures, already mentioned as indicating the age in weeks, applying equally to this part of the record, while THE FEATURES OF HEALTH 13 the numbers at the extreme top of the chart indicate length in inches. From the first to the tenth year there should be a yearly gain of at least four or five pounds. After, to the sixteenth year, of about eight pounds in the same period. Parents frequently overestimate the weight of their children by placing them upon the scales when completely dressed. To be accurate, the weight of the clothing must be subtracted. This may be estimated at about three pounds for a child of three to five years, four pounds for one of eight years, and eight pounds at fifteen years. Another reliable evidence of the proper progress of development is the increase in the girth of the chest. In an infant weighing seven pounds and measuring nineteen and a half inches at birth, the girth should be a little over thirteen inches. By the fourth month it should be fifteen inches; by the sixth, sixteen; by the twelfth, about seven- teen; by the fifth year, twenty-one, and by the sixteenth year, thirty inches. As already mentioned, the proportions of the different members of the frame in infancy differ materially from those of adolescence. Primarily the head and secondarily the body are large when compared with the arms and legs, but in the progress of healthy development this dis- 14 HYGIENE OF THE NURSERY proportion is gradually lessened until the perfect human figure is attained. This developmental process, however, does not affect all parts of the body equally, as may be seen in the accompanying diagram.* (Fig. 3.) The description is so well put in the journal from which this figure is taken that I cannot do better than quote it word for word : FIG. 3. DIAGRAM SHOWING RELATIVE STATURE FROM i TO 22 YEARS OF AGE. "The six figures represent the average relative stature of males of the ages of one, five, nine, thir- teen, seventeen, and twenty-two years. It will be noticed that the figures all stand on a level plain. The tops of the heads are connected by a dotted line, and the height of each figure is divided into * "Babyhood," Vol. II. page 3 n. Paper by Leroy M. Yale, M. D. THE FEATURES OF HEALTH 15 four equal parts, the points of division being con- nected with the corresponding ones in each figure. If the rate of growth were uniform the dotted lines connecting the heads would, of course, be straight if a child for every year were included in the rank. But in the earlier years the growth is much more rapid than it is later, and hence the line is a curve, rising quite suddenly at the first, and becoming flatter toward the end of growth. It is to be under- stood that these are all averages, including, but not showing, the extremes of slowness and rapidity of growth as well as fitfulness of growth. The diagram also shows the different development of different parts of the person. The head, for in- stance, in the child of one year is nearly one-fourth of the whole height; that of the adult is about two-thirteenths, or, to use the phrase of artists, the little child is not much more than four heads high, while the adult of twenty-two is about six and one-half heads high; and even this is a much larger head than the average adult has. Notice that the third dotted line, marking one-half of the total height, crosses the navel in the infant, while in the adult the half height mark is but little above the juncture of the legs and the body, which shows how much larger, proportionately, the body of an infant is than an adult's. If this same line be fol- lowed it will be noticed that it keeps well up in 1 6 HYGIENE OF THE NURSERY the abdomen until after the age of nine. Between that age and puberty the growth of the lower ex- tremities is usually very rapid, and the well-known 'shooting up' of boys and girls takes place, the whole person growing, but the lower part in par- ticular. Similar changes of location will be noticed by following the quarter-lines, but the changes are not so abrupt." It may be well to mention here that children will often remain, for a considerable time, almost stationary in height, and then have periods of very rapid growth. The latter is often to be observed in the ninth or tenth year, and again at the approach of puberty. Variations in weight-gain are also often to be observed; these seem to hold a defi- nite relation to the fluctuations in the rapidity of height-increase. Besides these points, which are the most reliable evidences of the proper progress of development, there are certain features that appeal more directly to the notice of parents, and on this account deserve consideration. The age at which a child sits erect, at which it creeps, walks or talks, are instances of the class of features referred to. The head can usually be held erect by the end of the third month and the body maintained in the sitting posture a month later. By the sixth month the infant can sit up with ease, accomplish many THE FEATURES OF HEALTH 17 movements with the arms, hands and fingers, and enjoy playthings. At the eighth month he may be able to creep; by the ninth or tenth, to drag himself upon his feet with the assistance of his hands and arms and some artificial support; by the eleventh, to walk with assistance; by the fourteenth, to walk alone, and ty the eighteenth, to run. At eight months an infant will imitate sounds and articulate several syllables; at ten, can often speak one or two words, and after twelve months is able to join several words together. The anterior fontanelle should be completely closed at some period between the fifteenth and twentieth months. Tears begin to be secreted during the third or fourth month, and saliva, between the fifth and sixth. After birth both hair and eyes often change color as age advances. When an alteration takes place in the eyes which are quite commonly blue or blue-gray in the new-born it begins about the sixth or eighth week and may be to either a lighter or darker hue. Changes in the hair begin later, the tendency always being to darken, and the most marked alteration occurring between the seventh and fourteenth years. Examples of Variations in Disease. If on being measured and weighed, a child be found to fall 1 8 HYGIENE OF THE NURSERY short of the normal standard for its age, and if, at the same time, there be a want of plumpness of body, roundness of limb, and firmness of flesh, the existence of some fault in diet or in the digestion and absorption of food must be inferred. A delay in walking may be due to general feeble- ness or to paralysis of the muscles of one or both legs, and a limping gait with pain in the knee suggests hip-joint disease. Closure of the fontanelle is retarded by the disease called rickets, and also by hydrocephalus and constitutional syphilis. It is well to be cognizant of the fact that girls develop more rapidly than boys, and that the second or later children of the same family, by imitating their elders in the nursery, learn to talk and walk earlier than those who are born first. 4. Position and Gestures. The complete re- pose depicted on the countenance of a sleeping child when free from illness is shown also by the posture of the body. The head lies easy on the pillow, the trunk rests on the side, slightly inclined backward, the limbs assume various but always most graceful attitudes, and no movement is observable but the gentle rise and fall of the abdomen in respiration. In the waking state, the child, after early infancy, is rarely still. The move- ments of the arms, at first awkward, soon become THE FEATURES OF HEALTH 1 9 full of purpose as he reaches to handle and examine various objects about him. The legs are idle longer, although these, too, soon begin to move about with method, feeling the ground in prepara- tion, as it were, for creeping and walking. Examples of Variations in Disease. Restless sleep, with a desire to be rocked, fondled or "walked" in the nurse's arms, are common symptoms of acute attacks of illness, especially when attended by pain. Children beyond the age of infancy toss about uneasily in bed or want a change from the bed to the lap, under similar circumstances. Extreme and long-continued drowsiness and quietness, on the other hand, often precede the onset of such specific fevers as scarlatina or measles. Sleeping with the head thrown back and the mouth open indicates enlarged tonsils or adenoid growths; a tendency to "sleep high," or with the head and shoulders elevated by the pillow, accom- panies disease of the heart and lungs, and "sleeping cool," that is, resting only after the bedclothes have been kicked off, is an early symptom of rickets. Frequent carrying of the hand to the head, ear, or mouth shows headache, earache, or pain of a coming tooth. Constant rubbing of the nose is a feature of irritation of the bowels or stomach. Should the thumbs be drawn into the palms of the hands, and the fingers tightly clasped over 20 HYGIENE OF THE NURSERY them, or if the toes be strongly flexed or extended, a convulsion may be expected. 5. The Voice. -Crying is the chief if not the only method that the young infant possesses of making known his displeasure, discomfort or suffer- ing and affords almost the sole means of determin- ing the characters of the voice at this early age. Again, even long after the powers of speech have been developed, the cry continues to be the main channel of complaint. One rarely hears a healthy child cry, unless a harsh word, a fall or a blow cause a passing storm of grief, anger or pain. Hence, frequent, peevish crying points to some disturbance of the healthy balance. The sound of the voice, whether in crying or speaking, should have a clear ring, without either muffling, hoarseness or nasal tone. Weeping should accompany crying, after the establishment of tear secretion. Cough, although not a normal vocal sound, is also worthy of attention. Examples of Variations in Disease. Incessant, unappeasable crying is usually due to earache or hunger; it frequently, too, is caused by the constant pricking of a badly-adjusted safety-pin or other mechanical irritant. If crying occur during an attack of coughing it is an indication of some painful affection of the THE FEATURES OF HEALTH 21 chest; if just before or after an evacuation of the bowels, of intestinal pain. When the cry has a nasal tone it should suggest swelling of the lining membrane of the nose, or other obstructing condition. Thickening and indis- tinctness occur with throat affections. A loud, brazen cry is a precursor of spasmodic croup, and a faint, whispering cry, of true or membranous croup. Hoarseness points to disease of the lining membrane of the larynx, either catarrhal or syphi- litic in nature. Finally, a manifest unwillingness to cry can be seen in pneumonia and pleurisy, when the dis- ease is severe enough to interfere materially with breathing. Tear-secretion having been established, it is a bad omen if the secretion be arrested during the progress of an illness, but an equally good one if there be no suppression, or if there be a reestab- lishment after suppression. The cough, like the voice, may be brazen in spasmodic croup, hoarse in laryngeal catarrh, and suppressed in true croup. The qualities " tight- ness" and "looseness" are readily appreciated and give a good idea of the progress of lung affections, especially bronchitis, the former being an evidence of the beginning, the latter of the favorable termina- tion of an attack. 22 HYGIENE OF THE NURSERY Cough is always unproductive, that is, unattended by expectoration, in children under seven years of age. 6. Mode of Drinking and Swallowing. By watching an infant taking the breast or bottle, some information can be obtained of the condition of the mouth and throat, and of the respiratory organs. A healthy child drinks continuously with- out stopping to breathe, and swallows easily. Examples of Variations in Disease. If there be any soreness of the mouth the nipple will be held only for a moment and then dropped with a cry of pain. When the throat is affected in infants, swal- lowing is performed with a gulp, an expression of pain passes over the face, and no more efforts are made than required to satisfy the cravings of hunger. Older children, under similar circum- stances, drink little and refuse solid food. An infant suffering from the oppressed breathing of pneumonia or severe bronchitis, seizes the nipple with avidity, swallows quickly several times and then pauses for breath. In older children the act of drinking, which should be continuous, is inter- rupted in the same way. If the finger be put into the mouth of a healthy baby it will be vigorously sucked for some little time. Diminution of this act of suction during a severe illness is a sign of danger; its reestablish- THE FEATURES OF HEALTH 23 ment a good omen. In conditions of stupor it is noticeably absent. 7. Appetite. Hunger and appetite must not be regarded as synonymous terms. The former is the craving of all the tissues of the body for nutritive material, or food, and is expressed by a sinking or craving sensation in the stomach. The latter, on the other hand, though it is certainly an attendant of hunger, is simply a sensation of the desire for something with a food-taste, having its seat in the mouth and surrounding parts. Appetite having its post, as it were, at the entrance of the stomach, may be regarded as a gate-keeper to supervise everything presented for entrance and to reject all that may be injurious either to the stomach or the general economy. Like its analogue the gate-keper, the trust- worthiness of the appetite may be destroyed by overindulgence and bad 'habits. Under the last head come the constant administration of too much or too little food, the use of overrich food and irregularity in meal hours. A healthy appetite that is, one that leads a child to consume with enjoyment the food set before him may be encouraged by muscular and mental exercise; by contentment; by regular habits as to the hours of eating; by the use of plain food only, and by varying the food, in a greater or less degree, 24 HYGIENE OF THE NURSERY according to the age. If the quantity of food con- sumed at the regular meals does not come up to the parent's standard of sufficiency, it does nothing but harm to resort to too dainty feeding and to an encouragement to eat between meals. There can be no question that a good appetite is a useful as well as a pleasant faculty for a child to possess, for there is no doubt that food eaten with relish is much better digested and therefore more serviceable in nutrition than that which is simply crowded into the stomach. Examples of Variations in Disease. Loss of appe- tite is encountered in febrile attacks and in acute disorders of the stomach. Inordinate appetite, on the contrary, is usually met with when too strong food has been administered. Here the increased hunger is due to the fact that the food administered, while it may be very rich in nutritive properties, is ill-adapted to the delicate digestive power of early life, and thus, by not being properly prepared for absorption, places the child in the anomalous position of starving in the midst of plenty. In more advanced children gluttony may depend upon gas- tric irritation, a condition which often leads older and presumably wiser heads to over-indulgence at table. . 8. Eructation. Eructation or regurgitation is readily produced and of frequent occurrence in THE FEATURES OF HEALTH 25 infancy, on account of the vertical position and more cylindrical outline of the stomach at this period of life. Babies suckled at a freely- secreting breast often eructate, though they may be in the best possible health. In these cases, the supply of food being large, the infant, as it lies at the breast, is apt to draw more than it needs and more than it can digest, and the stomach, through a wise provision of nature, rids itself of the superabundance by the simple act of regurgitation. In this process, which in reality is an evidence of health, there is no vio- lent muscular effort, as in retching or vomiting, nor any evidence of nausea, and the material ejected is the breast milk alone, either entirely unaltered or slightly curdled. In older children, expulsion of the contents of the stomach, or vomiting, may also occur after the stomach has been overladen. If the act be followed by relief from a feeling of general distress, head- ache and pain in the upper abdomen, it is not to be regarded as a symptom of disease. Examples of Variations in Disease. Vomiting, with its violent muscular effort and the attendance of the train of symptoms embraced under the term nausea namely, paleness, languor, faintness and an increased secretion of saliva occurs in many different conditions. It may indicate disease of the 26 HYGIENE OF THE NURSERY stomach, of the intestines, of the lungs or their pleural investment, and of the brain; or it may be an initial symptom of one of the eruptive fevers, scarlet fever or measles, for example, which con- dition, when existent, can only be determined by closely observing the special case. The character of the material ejected from the stomach is more definite. Thus, the expulsion of mucus is a symptom of gastric catarrh. The regurgitation of mouthfuls of curdled milk, partly digested food and liquid, so sour that it causes a grimace to pass over the face, is an indication of dyspepsia with fermentation and the formation of an irritant acid. The appearance of lumbricoid worms in the vomit, a not very infrequent occur- rence, shows, without dispute, the existence of these parasites in the digestive canal. 9. The Faecal Evacuations. The daily num- ber of evacuations of the bowels natural for a child varies greatly with its age. For the first six weeks there should be three or four movements every twenty-four hours. After this time, up to the end of the second year, two movements a day is the normal average. Subsequently, the frequency is the same as in adults once per diem though two or three movements in the same interval may occur, especially after overfeeding or after eating food difficult of digestion, and must be looked upon as THE FEATURES OF HEALTH 2J conservative rather than as the evidence of ill health. During the first period the passages have the consistence of thick soup, are yellowish-white or orange-yellow in color, with sometimes a tinge of green; have a faint faecal, slightly sour odor, and are acid in reaction. In the second, they are mushy or imperfectly formed, of uniform consistence throughout, brownish-yellow in color, and have a more faecal odor. The last two characters become more marked as additions are made to the diet. After the completion of the first dentition the motions have the same appearance as in adult life; they are formed, are brownish in color, and have a decidedly faecal odor. Examples of Variations in Disease. Many altera- tions occur in disease. The frequency of the movements may be increased, constituting diar- rhoea, or lessened, constituting constipation. In the former condition the consistency is diminished, in the latter, increased. Instead of being uniform throughout, the movement may be mixed, partly liquid, partly solid, indicating imperfect digestion, and curds of milk or pieces of undigested solid food may be mingled with the mass. Flaky, yellowish or yellowish-green evacuations containing whitish, cheesy lumps, are also met with in cases of indiges- tion. Scanty, lumpy evacuations, dark brown or 28 HYGIENE OF THE NURSERY even black in color, and mixed with mucus, are characteristic of intestinal catarrh. Doughy, gray- ish, or clay-colored motions show an inactive liver. An intermixture of blood, altered blood clots, and shreds of mucous membrane, indicate ulceration of the intestinal lining, such as occurs in intestinal inflammation, typhoid fever, dysentery and tuber- culous disease. Watery, almost odorless passages occur in the later stages of summer complaint; most offensive, carrion-like motions, in both ca- tarrhal and tuberculous ulceration of the intestines, and sour-smelling evacuations in the diarrhoea of sucklings. The discovery of worms in the move- ments is the only certain evidence of the existence of intestinal parasites. This mere outline of the changes that may take place will serve to show how much may be learned from the evacuations, and the importance of pre- serving them for the physician's inspection. 10. The Urine. It is impossible to make a definite statement as to the number of times the urine is voided by a healthy infant in each twenty- four hours. In any given case the frequency will differ very much from day to day, depending upon the temperature of the surrounding air and the amount of moisture that it contains. Sometimes it will be necessary to change the napkin every hour during the day and three or four times at THE FEATURES OF HEALTH 2 9 night. Again, it may remain dry for six, eight, or even ten hours. Neither condition indicates dis- ease. If, however, the urine is not passed for twelve hours, a careful examination should be made. Between these two extremes there is a wide range of variation. As the child grows older the frequency dimin- ishes, and at the age of three years the number of voidings will be reduced to six or eight during the waking hours, and perhaps one at night. When the desire does arise during sleep, the child, if in a normal state, wakes up and demands the chamber, and never passes urine unconsciously. Wetting the bed, therefore, or the involuntary passage of the urine during sleep, is indicative of an abnormal condition and requires investigation. The quantity of urine voided at different ages may be stated as follows, the figures being approximate only: From birth to 2d year 8-12 fluid ounces. From 2d to 5th year 15-25 fluid ounces. From 5th to roth year 2 5~35 fluid ounces. From loth to i5th year 35~4O fluid ounces. From a few observations, I am led to believe that the quantity of urine voided by healthy children from the fourth to the seventh years is often not as large as supposed, eighteen to twenty ounces being the average in several cases in which I have made measurements. 30 HYGIENE OF THE NURSERY The urine of an infant, while it wets, should not stain the napkin. Examples of Variations in Disease. In certain cases of bad digestion the urine becomes very con- centrated and high-colored, and gives a light yellow tinge to the napkin. When the stain is decidedly yellow, jaundice is indicated, and other symptoms of this condition should be looked for. In older children a high-colored urine, and one which deposits a whitish or pinkish sediment on standing, is symptomatic of acute digestive dis- order, either catarrhal in its nature, or secondary to some acute febrile affection. A smoky, blackish hue, looking as if there had been an admixture of soot, is characteristic of the acute kidney disease that often follows in the wake of scarlet fever. In this state, too, there is a great diminution in the amount passed. The deposition of a "brick-dust" sediment in the napkin, or upon the bottom of the chamber after the urine has been standing for a time, indicates an excessive formation of uric acid. Painful urination points to inflammation of the bladder or urethra, a narrow orifice, a highly acid condition of the excretion, or stone in the bladder. ii. The Respiration. In adults there are two well-marked types of respiration, viz., the abdominal and the superior costal. The abdominal met with THE FEATURES OF HEALTH 31 in perfection in adult males is the type in which the movements of inspiration and expiration are performed by the muscles of the abdomen and lower third of the chest. In superior costal respi- ration, on the other hand, the movements are most marked in the upper third of the chest. This form is best developed injiealthy adult females. In children the respiration is chiefly abdominal in type, irrespective of sex, and it is not until just before the age of puberty that the movements in the female change, becoming superior costal. Con- sequently, in estimating the number of movements per minute it is best to place the fingers lightly on the upper abdomen. The count should always be made by the watch, the most convenient time for the observation being while the child sleeps. Soon after birth the number of movements per minute is 44, between the ages of two months and two years, 35, and between two and twelve years, 23. During sleep the frequency is reduced about twenty per cent. Children under two years, while awake, breathe unevenly and irregularly; there are frequent pauses followed by hurry and precipitancy, and some of the movements are shallow, others deep. In sleep there is greater regularity. After the second year the movements become steady and even, like those of adults. All children, however, but particularly 32 HYGIENE OF THE NURSERY the very young, are subject to a great increase in the rapidity of respiration under the excitement of muscular movement and mental emotion. Perfectly healthy children breathe through the nose, and so softly that it is necessary to place the ear close to the face to hear the breezy sound of the ingoing and outgoing air. Examples of Variations in Disease. Accelerated breathing occurs during the course of diseases at- tended by severe fever. Acute affections of the lungs are especially characterized by this alteration, and the more the breathing area is lessened the greater is the increase. Thus, in pneumonia, 60, 80 or loo movements a minute are not at all un- usual. To speak broadly, rapid breathing may be caused by an elevation in the body temperature, by an interference with the blood aeration, and by thoracic or abdominal pain. Diminished frequency the movements being reduced to 16, 12, or even 8 in the minute is en- countered in certain brain affections namely, in chronic hydrocephalus, and the later stages of tuberculous meningitis. In such cases the rhythm may be greatly altered a tidal form being assumed, in which the breathing ebbs and flows, beginning with an act which is scarcely perceptible or audible, gradually growing deeper until a full, noisy respi- ration is made, and then slowly subsiding into a THE FEATURES OF HEALTH 33 period of absolute quiet, variable in its duration. This is termed Cheyne-Stokes respiration. A dry, hissing sound, or a moist sound of snuf- fling, indicates partial obstruction of the nasal passages; oral respiration shows their complete occlusion. Yawning, one of the modifications of the re- spiratory act, if it recur frequently, denotes great failure of the vital powers and is an unfavorable prognostic element. 12. The Pulse. To obtain any reliable data from the pulse it must be felt during perfect quiet. During sleep is the best time, but if the child can- not be caught in this condition, advantage may be taken of its placidity while feeding or amused by a toy. With very young infants it is sometimes impossible to feel the beat of the artery at the wrist, and it is necessary to ascertain the frequency of the pulse by listening to the heart. After the second month feeling the pulse at the wrist in the ordinary way is not difficult. The child's pulse differs from the adult's in being much more frequent, more irregular, and more irritable. The frequency, or the number of beats per minute, varies with the age. The following is the average rate : 34 HYGIENE OF THE NURSERY From birth to 2d month 160 to 130 From 2d to 6th month 130 to 120 From 6th to i2th month 120 to no From ist to 3d year no to 100 From 3d to 5th year 100 to 90 From 5th to loth year 90 to 80 From loth to I2th year 80 to 70 These figures represent the pulse in a waking, but passive state. During sleep the frequency is less. Thus, between the second and ninth years there are about sixteen beats less per minute while asleep than when awake; between the ninth and twelfth years, eight less; and between the twelfth and fifteenth years, only two less. Below the age of two years the disparity is even greater. The irregularity of the pulse in childhood is confined to an alteration of the rhythm, in other words, of the intervals at which the beats succeed each other and the relative strength and volume of each beat. It is most marked in infants and is greatest during sleep, when the pulse is lowest. The feature of irritability, that is, the facility with which the frequency is increased by muscular activity and mental excitement, is greater in pro- portion to the youth of the child. A rise of 20, 30, or even 40 beats a minute is not uncommon in early infancy, under the excitement of the slightest effort or disturbance. Examples of Variations in Disease. On account THE FEATURES OF HEALTH 35 of the wide variations in health, little meaning need be attached to alterations of the rhythm and frequency while unassociated with other abnormal features. When so associated they become impor- tant in determining the existence of disease. Increased frequency is a constant attendant of the febrile state. The extent of the increase corre- sponds with the degree of elevation of temperature, though the pulse curve always runs higher than the temperature curve. As a rule, the more frequent the pulse the higher the fever. In estimating the risk of the increase, however, the law of the fever in question must be taken into consideration. For example, in scarlet fever a pulse of 160 is usual and not indicative of special gravity. In measles, the same degree of acceleration would be abnormal and show great danger. Jaundice and inflammation of the kidneys are accompanied by a diminution of the pulse rate. Irregularity is met with in diseases of the brain and heart, and sometimes in nervous and blood- impoverished children. 13. The Temperature. By placing the hand, upon the surface of the body we can readily detect marked variations in the temperature; thus the nose and extremities feel cold in diseases associ- ated with depression of the vital forces, and the palms of the hands and back of the head feel hot HYGIENE OF THE NURSERY in those attended by fever. But the only possible means of detecting slight variations or of obtain- 98.5 normal mark. Index, read from top, stands now at 98.5. FIG. 4. CLINICAL THERMOMETER. ing reliable information concerning normal or ab- normal body-heat is by the employment of an THE FEATURES OF HEALTH 37 accurate thermometer. Clinical thermometers, as these instruments are called, are made entirely of glass, and are usually furnished in the shape seen in Fig. 4. This instrument is graduated according to the Fahrenheit scale and provided with a self -register- ing index, which is simply a short column of mercury separated from that in the bulb of the thermometer. Temperature is usually taken in the rectum of the infant or young child, and in the mouth of a child old enough to understand the purpose of the procedure, and to obey directions to keep the lips closed, the tongue over the bulb of the instrument, and to avoid breaking the glass by the forcible closing of the teeth. Supposing the rectum be chosen as the place of observation, it is first necessary to be sure that this portion of the gut is free from faeces. The upper end of the stem of the thermometer is then held between the thumb and finger, and the index, by a few vigorous shaking movements, is forced down so far that its upper extremity will be well below the normal mark, to 95 for instance; next, the bulb is covered with sweet oil or vaseline and gently inserted through the anus into the rectum for a sufficient distance to conceal completely the mer- cury. Here it is allowed to remain, according to the sensitiveness of the instrument, from one-half to two 38 HYGIENE OF THE NURSERY or even five minutes by the watch, and on being removed the degree of temperature is read from the top of the index. The position of the patient in the meanwhile is upon the back, on the nurse's lap, with the legs elevated and controlled by her left hand, the right hand being used in steadying the thermometer. When taking the temperature in the mouth direct the child to lie down on his back and instruct him not to bite upon the delicate glass. Then, having seen that the instrument is thoroughly clean and that the top of the index is below the normal point, insert the bulb, crosswise, beneath the tongue. The teeth must be lightly closed so as to hold it in position, and the lips closely shut about its stem. For the time necessary to complete the observation breathing must be performed entirely through the nose. Temperature is also taken in the arm-pit and groin, but the observation in these positions is inac- curate and unreliable. One more fact is important, namely, that a simul- taneous observation in the different positions men- tioned will not furnish identical results; the rectal and oral temperature being, normally, at least i higher than that of the arm-pit, and 1.5 higher than that of the groin in the same individual. When properly used the thermometer is of great THE FEATURES OF HEALTH 39 value in the nursery. At the same time, under oppo- site conditions, it may be the source of much unnec- essary alarm to overanxious parents. To prevent the latter misfortune, all who intend to use the instrument should be familiar with the healthy range of temperature and some of the characteristic variations in disease. During the first week of healthy life the temper- ature fluctuates considerably. After this the pu- erile norm 98.5 to 99 F. is established, but until the fourth or fifth month it is greatly influenced by physiological causes of variation, the fluctuations ranging between .9 and 3.6. By the fifth month regular morning and evening oscillations begin to be noticeable, and certain definite laws are followed. Thus there is a fall in the evening of i or 2. The greatest fall occurs between 7 and 9 p. M., and the minimum is reached at, or before, 2 A. M. After 2 A. M. there is a gradual rise, the maximum being reached between 8 and TO A. M. Throughout the day the oscillation is trifling. These variations are independent of eating and sleeping. It may be taken for granted, therefore, that a temperature between 98 and 99 in the morning and 97.5 and 98.5 in the evening is the range to be expected in a healthy child beyond the age of five months. Examples of Variations in Disease. In disease 4O HYGIENE OF THE NURSERY there may be either a rise above or a fall below the normal standard. Fever is always associated with an elevation. Rapid and transient rises attend slight catarrhs and passing indigestions. Prolonged rises indicate inflammatory and essential fevers, for example, typhoid, scarlet fever and measles. The degree of elevation marks the type of the fever. This is moderate when the mercury stands at 102, severe at 104 or 105, and very grave above 107. It is known, however, that infants are extremely sensitive to conditions productive of fever, and that, in them, the temperature, like the pulse, is easily influenced by slight and transient causes: therefore, a high degree of temperature, I04-io5, in young children is less alarming than in adults, and of less import than a continuance of the elevation, in estimating the gravity of a fever. The duration of the elevation and the peculiar range of the oscillations (for there are oscillations in disease as well as in health) determine the nature of the fever. The febrile oscillations differ from the healthy, in that the lowest marking is noticed in the morning, the highest in the evening. Variations in the typical range of any given fever are important prognostic omens: a sudden fall of the temperature, together with improvement in the general symptoms, indicates the beginning of THE FEATURES OF HEALTH 41 convalescence; a similar fall, with an increase of the general symptoms, is a precursor of death. When the morning temperature is equal to that of the preceding evening, there is great danger; if higher, greater danger still. Marked remission in continued fevers is generally a forerunner of con- valescence. Abnormal depression of temperature is occasioned by hemorrhage and by the loss of fluids in cholera infantum or entero-colitis. It is also met with in anaemia, in wasting from insufficient nourishment, in diseases of the heart and lungs attended by im- perfect oxidation of the blood, and it constantly attends collapse and the death agony. A main- tained temperature of 97 is dangerous in children, and for every degree of reduction below this the risk for life is more than proportionately increased. 14. The Mouth and Throat. In infants, gentle pressure of the fingers upon the chin is sufficient to cause wide opening of the mouth. An older child will frequently open the mouth when requested, but if he refuses, the ringer, or, far better, the handle of a spoon, or some other smooth, flat instru- ment, may be inserted in the mouth, and downward pressure made upon the tongue, when the jaws will be widely separated. In some cases, when the child is old enough to do as he is bid, the fauces can be seen by directing the mouth to be opened wide and 42 HYGIENE OF THE NURSERY the tongue to be alternately protruded and retracted, or a prolonged sound of "Ah" to be made. With the refractory, and always with infants, the tongue has to be held down by a spoon-handle or tongue- depressor. If there be resistance, the patient must be taken on the lap of the nurse, who holds his back against her breast, directs his face toward a bright light, and controls the movements of his hands and feet. The healthy oral mucous membrane has a deep pink color, and is smooth, moist and warm to the touch. The color is deeper on the lips and cheeks, lighter on the gums. The latter, up to the sixth month, as a rule, have a moderately sharp edge. Subsequently, the edge begins to broaden and soften, and the color of the investing mucous mem- brane deepens to a vivid red, and becomes hot, as the teeth begin to force their way through. The tongue should be freely movable. It is pink in color, and the dorsum or upper surface, marked in the centre by a slight longitudinal depres- sion, has a velvety appearance, and is soft, moist and warm to the finger. The velvety nap is due to the numberless hair-like processes of the filiform papil- lae. There are also scattered over the surface, but most closely at the tip, a number of eminences, the size of a small pin's head, circular in outline, and deeper pink than the general surface the fungi- THE FEATURES OF HEALTH 43 form papillae. While far back, defining the papil- lary layer, are the circumvallate papillae, numbering about twelve, and arranged in a V-shaped row. These have the form of an inverted cone, sur- rounded by an annular elevation. The hard palate, or roof of the mouth, is rough- ened anteriorly by transverse ridges. The soft palate its continuation is smooth, and its mucous membrane is paler than that of the rest of the mouth. The fauces, or walls of the throat, on the contrary, are redder. In the triangular recess between the half arches of the palate the tonsils can always be seen. They should be about the size and shape of almond kernels, and they present a number of cir- cular openings, the orifices 6f pouches, into which the follicles open. The uvula or, in popular lan- guage, the palate is short and tongue-shaped. The posterior wall of the throat should be red, smooth and moist. Examples of Variations in Disease. Fever makes the mouth hot and dry, and causes the tongue to be frosted or coated. Affections of the stomach and bowels are usually attended by coating of the tongue. Inflammation of the mouth itself reddens the lining membrane, makes it hot and tender to the touch, increases its moisture, alters the surface of the tongue and leads to the formation of aphthae and to ulceration. 44 HYGIENE OF THE NURSERY 15. Dentition. Normally, the first or "milk teeth," twenty in number, are cut in groups, each effort being succeeded by a pause or period of rest. The diagram and table following show the group- ing, the date of eruption, and the duration of the FIG. 5. DIAGRAM SHOWING ERUPTION OF MILK TEETH. i i, Between the 4th and ?th months. Pause of 3 to 9 weeks. 2222, Between the 8th and loth months. Pause of 6 to 12 weeks. 33333 3, Between the i2th and isth months. Pause until the i8th month. 4444, Between the i8th and 24th months. Pause of 2 to 3 months. 5555, Between the 2oth and 3oth months. pauses, the numbers, i to 5, indicating the groups to which the individual teeth belong and their order of appearance, and the letters a and b the prece- dence of eruption in the different groups (Fig. 5). The pauses are, to say the least, most helpful, giving the infant's system an opportunity to rest THE FEATURES OF HEALTH 45 after each effort, to recover from any coincident ill- ness, and to prepare for the next strain. The dates here given show the time within which the different teeth naturally may be expected. In regard to the period given for the eruption of the lower central incisors, 1 would state that the fourth month, although an early is not a very rare time for their appearance. For example, I have seen during one winter five cases in which these teeth pierced the gum at this age. Often the teeth appear without the production of any symptoms. Sometimes the edges of the gums lose their sharpness and become swollen, rounded, and reddened as the teeth approach the surface. At the same time the saliva is increased in quantity, and the mouth is unnaturally warm and the seat of abnormal sensations, evidenced by the tendency to bite upon any object that comes to hand in other words, there is a condition of mild catarrhal stomatitis. The consequent discomfort is not suf- ficient to interfere with the child's appetite, good humor, or sleep, and when, after a few days, the margin of the tooth is free, all the local symptoms vanish. Examples of Variations. Abnormal dentition is manifested by departures from the laws if develop- ment already stated. The standard rules may be departed from in three ways: 46 HYGIENE OF THE NURSERY 1 . The appearance of the teeth may be premature. Children may be born with one or more of their teeth already cut; these are usually imperfect, and soon fall out, to be replaced, at the proper age, by well-formed milk teeth. Sometimes, however, they remain permanently, as in a case that came under my own observation. Natal teeth are always incisors. Instances of the lower central incisors being cut in the third month are not uncommon. Girls are more apt than boys to cut their teeth early, and, as an early dentition is likely to be an easy one, the occurrence is to be looked upon as fortunate. 2. Dentition may be delayed. This deviation is more frequently seen and of more consequence than the first. Bottle-fed babies, as a class, are more tardy in cutting their teeth than those reared at the breast. With such, though healthy in every re- spect, a delay of one or two months is a common and not at all serious event. On the contrary, whatever the method of feeding, if no teeth have appeared by the end of a year, it may be assumed that the child's general nutrition is faulty, or that rachitis is present. Delay does not necessarily imply difficulty in cutting the teeth, although the two conditions are often associated. 3. The teeth may appear out of their regular order. Bottle-fed infants are most likely to show THE FEATURES OF HEALTH 47 this irregularity, which is of some importance as an indication of general feebleness. In other instances, however, it is merely a family peculiarity, and, as such, bears no special significance. The order of eruption of the permanent teeth is as follows: The two central incisors of lower jaw, from 6th to 8th year. The two central incisors of upper jaw, from yth to 8th year. The four lateral incisors, from 8th to gth year. The four first bicuspids, from gth to roth year. The four canines, from loth to nth year. The four second bicuspids, from 1 2th to 13 th year. These replace the temporary teeth; those which are developed de novo appear thus: The four first molars, from 5th to yth year. The four second molars, from iath to 13 th year. The four third molars, from i7th to 2ist year. There are, therefore, twelve more permanent teeth, making thirty- two in all, sixteen in each jaw. The diagram, Fig. 6, will aid in explaining the process. As these teeth approach the surface, absorption begins in the alveoli and at the roots of the deciduous teeth, and this continues until the latter are loosened and readily extracted, or if this be not done, until little is left but their crowns. When the first and second molars approach the surface, the gums, just as in primary dentition, 4 8 HYGIENE OF THE NURSERY may become red, swollen, rounded, and tender. The salivary secretion is increased, the mouth is hot, the patient complains of aching in the gum, and, on account of tenderness, refuses food requir- ing mastication. With the other sets there is a gradual loosening of the superimposed temporary FIG. 6. DIAGRAM SHOWING RELATION BETWEEN PERMANENT AND TEMPORARY TEETH. The figures i, 2, 3, etc., indicate the groups of teeth and the order of their appearance. teeth, pain on mastication, redness and tumefaction of the gum, and augmented flow of saliva. As there is no impairment of the general health, these trifling symptoms must be regarded merely as manifestations of the progress of a physiological process. THE FEATURES OF HEALTH 4Q In concluding this subject it is important to em- phasize the fact that many diseases occurring in infancy were formerly attributed to dentition, but as the affections of early life have been more care- fully studied and better understood, one disorder after another has been relegated to its proper etio- logical class, and teething is now regarded as a purely physiological process, unproductive of symp- toms. All that can be said is that the interval be- tween the fourth and thirtieth months of an in- fant's life the period of primary dentition is an era of great and widely extended physical progress. The teeth are advancing; the follicular apparatus of the stomach and intestinal canal is undergoing development in preparation for the digestion and absorption of mixed food; the cerebrospinal system is rapidly growing and functionally very active, and the organs and tissues of the whole body are in a state of active change. This period of normal transition must also be one in which there is great susceptibility to abnormal change, or disease, pro- vided there be a causal influence at work. Such an influence usually originates outside of the body, as when there is exposure to cold or to contagion. Second dentition, has perhaps a greater but still a merely indirect effect upon the health. During this process the loss of teeth and the local irritation of the gums interfere materially with mastication of 4 50 HYGIENE OF THE NURSERY the older child's solid food, and digestion and nutrition being consequently impaired, the general health suffers and there is less resistance to the various external causes of disease. The approach of puberty at this time also puts an additional strain on the system. CHAPTER II. THE NURSERY. Every well-regulated house in which there are children should be provided with two nurseries, one for occupation by day, the other by night. Before entering further into the subject, how- ever, attention must be directed to the fact that the American city-bred child, belonging to the class in which it is possible to provide separate rooms for nurseries, is to a greater or less degree a migratory creature. For when the first warm days of May or early June make the parents bask at open windows, the child is hurried off to a suburban hotel or f arm- House or to the sea-coast. Again, as soon as the cold evenings of late September suggest the com- fort of an open fire, equal energy is exhibited to get him back to cozy winter quarters. In summer, most of the waking hours are spent in the open air, in winter, the greater proportion indoors; hence the day nursey must be regarded as a winter resort, and as such must possess qualities that would render it uninhabitable by the child in hot weather. The night nursery should have, though to a much less degree, the same qualities. In other words, to put 52 HYGIENE OF THE NURSERY the whole subject concisely, the nurseries for winter use should be warm and freely exposed to the sun; for summer use, cool and rather shaded, though always perfectly dry. Since the child spends so much time in the open air during warm weather, the nurseries will be dis- cussed in this chapter purely from their winter standpoint, and will be described under the follow- ing heads: Situation. Any room in the house will not do for a day nursery. Rather, on the contrary, must the best room be selected. It should have a south- west exposure, and be, if possible, so situated in the building as to allow of at least two broad win- dows, one in the southern end and one in the western side, and these windows must always be strongly barred. Into such a room the sun plays with full force from a few hours after rising until nearly the time of setting. The third floor of a house is a better elevation for the nursery, especially if there be an attic above, than either of the lower floors, partly because such rooms are remote from the ordinary domestic disturbances, but chiefly because they are drier and more readily heated, and being elevated are less cut off from sunlight by surround- ing buildings. The night nursery should, if possible, adjoin and communicate with the day nursery, although this THE NURSERY 53 feature is less important than proximity to the parents' sleeping-room. It should have a good- sized window so placed that it will freely admit sunlight during the day. When the nurseries connect, the opening of communication must be capable of being com- pletely closed by a well-fitting door or folding doors, so that one room may be thoroughly aired with- out chilling the other. Neither apartment ought to communicate with a bath-room having sewer connections; in fact, although it may be an object of complaint from the nurse, the further off such a bath-room is the better for the health of the child. While it is a matter of difficulty to accomplish in an ordinary city house, it is, nevertheless, a necessary thing to have the nurseries in close prox- imity to, or even in communication with, the apart- ment in which the parents sleep; for then the nurse is forced to be morally purer and physically more attentive than if she have a section of the house to herself. Many mothers prefer to keep their children at night. Under this condition, the bedroom becomes the night nursery, and its situation must be as care- fully selected, and its hygiene as particularly guard- ed, as the regular night nursery. When, too, there are several children in the family, the risk of over- 54 HYGIENE OF THE NURSERY crowding in such apartments must be recognized and carefully guarded against. The factor of dis- turbed rest, by the different hours of retirement of children and parents, is also one of importance. On all of these accounts a night nursery, under the control of a competent nurse, is, in my opinion, to be preferred. Size. The amount of atmospheric air required by a healthy child to accomplish thorough oxida- tion of the blood in respiration is about the same as that demanded by adults. Therefore the small- est admissible room for either a day or night nur- sery for a single child must have a capacity of eight feet cube. For more than one child the rule ordinarily given is, to multiple this figure eight feet cube by the number of individuals. This rule works well enough for a family of two or three children, but if the number be greater, the size of apartments required would much exceed any that could be found in ordinary houses. Lack of space, then, must be made up by more perfect methods of ventilation. To put the question in a more practical form, a room nine or ten feet high, twenty feet long and fifteen feet broad will readily accom- modate, either for playing or sleeping purposes, two or three children, with one attendant, pro- vided foul air be constantly removed and fresh air supplied by ventilation. THE NURSERY 55 In every room the undermost stratum of air, and the one in which the child must pass the greater part of his time, whether awake or asleep, has a much lower temperature than the middle, and this, again, than the highest, the tendency of the heated air being always to rise to the top. Now, the greater the height of the apartment, the cooler will be the floor and its neighborhood; consequently, a lofty ceiling namely, one over ten, or, at most, twelve feet while it makes an imposing show, is far from being desirable for a nursery, where ease of heating and the comfort and health of the occu- pants are the ends to be attained. On the other hand, a ceiling less than eight feet high will tend to make the room close, stuffy and overwarm, and correspondingly unhealthy. Lighting. As already indicated, the only per- missible light for a day nursery is that derived from the sun, and the more plentiful this is, and the more directly it enters, the better. The night nursery may be illuminated by electricity, by gas, by an oil lamp, by a candle, or by a night light. Older writers recommend the last three, upon the supposition that gas, while burning, not only consumes a con- siderable proportion of the oxygen of the air, but gives off certain injurious products of combustion. This may be true to a certain extent, but the dis- advantages are greatly discounted by the increase 56 HYGIENE OF THE NURSERY in convenience and the greater safety, so far as causing fire is concerned. Gas, or much better, electricity, certainly may be used in the late afternoon and evening. During the night hours, should a light be constantly required, the best means of obtaining it is from one of the regular night lights. A very admirable form of such a light is shown in Fig. 7. This light, called the "Pyramid Night FIG. 7. NIGHT LIGHT. Light," consists of a low brass stand having a movable pyramidal glass chimney, and provided with a porcelain cup upon which the candle rests. The candle itself is about one inch and a half in height and breadth, and is so constructed that the combustible material is completely incased in a fireproof plaster-of-Paris cup. Each candle will burn eight or ten hours. These lights are perfectly THE NURSERY 57 safe and may be utilized for the further purpose of keeping water warm. For occasional use at night, nothing can be better or of more ready service than electricity or gas. The safest way to make a light is to use a safety- match. The taking of a flame from an open fire or the use of ordinary friction matches are danger- ous and to be strongly discouraged. Furnishing. This heading may be made to include the finish of the floor, walls and ceiling, as well as the necessary articles of furniture and their arrangement. The floor, which ought to be laid with good yellow pine boards, should have a hard finish. To accomplish this, the crevices between the boards and all the nail holes must first be filled with putty, then, after this has dried, coated with a rapidly- drying, hard shellac varnish, next sandpapered, when the varnish has had time to harden thor- oughly, and, finally, finished by a second coat of shellac. This gives a light-colored floor that bright- ens the room and at the same time is readily cleaned. A dark staining, besides being sombre, always looks soiled. A painted floor is not easily cleaned. Should either of the latter be already in a nursery, their defects may be overcome by a well-laid parquet floor. A carpet tacked to the floor is not to be recom- 58 HYGIENE OF THE NURSERY mended; far better is it to have rugs, which can be frequently taken up and well shaken, the house- maid having in the meanwhile free access to the floor itself. Paint is the best finish for the walls. Individual taste will of course weigh in the selection of the color and amount of decoration, though a light tint, but still one not trying to the eyes, is most desirable. Next to paint, varnished paper is to be preferred. Within the past few years light and soft-tinted fabrics, covered with the representations in figure of familiar nursery legends, have been for sale by paper dealers. Such papers render the nursery attractive to older children, and, to a "great extent, take the place of pictures. Paint, however, has the advantage, in that it may be washed and thoroughly disinfected in case of the occurrence of contagious disease. To return to the subject of pictures, it is best to interdict any that are valuable or expensively framed. A few well-colored, striking, prints taken from one of the good weekly illustrated papers, and fixed to the painted wall by glue, will give as much pleasure to the childish eyes as the works of the best artists. They can, too, be changed from time to time, and after exposure to contagious germs may, without regret, be removed and burned in the process of cleaning. THE NURSERY 59 The ceiling of the rooms should always be painted with some light color, and be perfectly free from ornamentation. In the matter of furniture, the windows of the day nursery should be fitted with dark shades, but never with curtains or hangings. In summer when the windows are often open, they must be carefully screened to keep out insects, especially mosquitoes and flies. These not only annoy the child', but the mosquito may introduce the germ of malaria or poison with its sting, and the feet of the fly may carry the germs of such diseases as typhoid fever, diphtheria or tuberculosis. Other furnishings are : a table, at which the older children may take their meals or use in play and study; one or more large chairs and several small ones; a plentiful supply of toys and picture books, and, if there be room enough, a chest of drawers or wardrobe for clothing, and so on. All the furniture must be plain, that it may be more easily kept clean. The center of the room must be kept clear, to give an opportunity for play. The table, therefore, should be a folding one, that it may be placed out of the way against the wall and take up the least space possible when not in use. Any other heavy article of furniture must also occupy a position against the wall and be fitted with casters, so that 60 HYGIENE OF THE NURSERY it can be readily moved to facilitate cleaning the floor beneath. The toys may vary in character with the age of the child soft, white India-rubber ones for infants, more complicated mechanisms for older children; but inexpensive toys are the best, because they can be more frequently changed. The same is true of books. For both, by the way, there should be a special drawer or closet provided, where they can be put out of the way when not required. A few plants, a bird, or a globe of fish add bright- ness to the child's room and greatly assist in culti- vating good taste and in affording amusement. The night nursery must contain the beds, the bathing and toilet utensils, several chairs one being a rocker a small table, a medicine closet and a chest of drawers or other convenient recep- tacle for clothing and extra bed covering. It is essential to have a separate bed for the nurse and one for each child. They should be placed so as to be protected from any chance draught of air, be far enough apart to allow of a free passage be- tween; and the bed of the youngest, or of an ill child, ought to be nearest the one belonging to the nurse. About these beds nothing that may not be washed can be allowed. Old-fashioned pitchers and basins are to be pre- ferred to stationary washstands. The latter, though, THE NURSERY 6 1 are so convenient especially when supplied with hot- and cold-water faucets that they may be per- mitted when the waste pipe is short and runs directly through the wall into a rain spout, instead of com- municating with the sewer, and when the nurse can be trusted not to use them as a convenient means of disposing of the ordinary chamber waste. Each child should have his or her own brushes, combs, sponges, soap and towels, and all of them must be kept clean and sweet and have a place of their own. The medicine closet must contain only such articles as may be often required, and can be used with safety by a person of average intelligence; for example, olive oil, vaseline, oxide of zinc ointment, talcum powder, soda-mint, sweet spirits of nitre, syrup of ipecacuanha, chalk mixture, etc. Any preparation containing opium even paregoric is especially out of place in the nursery medicine chest. Feeding bottles, implements for the heating and preparation of food and for bathing, also belong to the furniture of the nurseries, but their consideration may be conveniently postponed to later sections. Heating. Each room requires an accurate ther- mometer, so hung that it may record the mean tem- perature not too close to the fireplace or the win- 62 HYGIENE OF THE NURSERY dows, where it runs the chance of being unduly heated or chilled. The temperature of the day nursery should range between 68 and 70 F. ; that of the night nursery from 64 to 68 for infants under three months old; after the third month a temperature of 55 is allow- able, and when the child is a year old it may be as low as 50 or 45. The proper method of heating is by an open fire- place in which either wood or coal is burnt. Either of these fires is superior to a furnace, simply because they serve a double purpose, namely, heating and ventilating. My personal preference is for an old- fashioned hearth, where oak or other quietly burn- ing logs can be used, since a wood fire is more readily lighted and regulated, and is a better venti- lator than one of coals. Still, in our climate, with its manifold and sudden changes, it is so jessential to have a source of heat constantly at hand that it is difficult to banish the furnace register from any living room. Therefore, while recognizing the dis- advantage of furnace heat, in that it makes the air too dry, it is well to supply the nurseries with both means of heating, using the open fire in moderate weather and the furnace only in the presence of severe cold. For general heating the modern hot- water radiating system is to be much preferred to the old hot-air furnace and to steam heating; with THE NURSERY 63 it, an even temperature is easily secured without over-drying the air of the house, or loading it with dust and coal-gas. In my experience, where the nurseries are so situated as to receive direct sunlight through ample windows, there is rarely any need of furnace heat except in the early morning, before the servants have time to make up the wood or coal fire. Care must be taken to guard every open fireplace with a high fender, one that can neither be knocked down nor climbed over by an active child. Ventilation. In addition to furnishing ample space in the nurseries, it is necessary to provide a constant supply of fresh air by ventilation. By all odds the best ventilator is an open fireplace in which wood is burnt. Such a fire, by creating a draught up the chimney, carries off the impure air, and there are few doors and windows so closely fitting that they prevent the entrance of fresh air to supply the place of that so removed. Should this not prove sufficient, one of the windows may be utilized, the upper sash being slightly lowered and the lower sash slightly raised, the open- ings being sufficient to allow of the entrance and exit of air, but not enough to cause a current or draught in the room. When the rooms are heated by a furnace or stove, some permanent ventilator must be used. For the HYGIENE OF THE NURSERY egress of foul air an opening may be made in the chimney at a convenient distance from the floor; this may be guarded by an ordinary adjustable register, such as is used to regulate the entrance of heated air from a furnace flue. The same purpose may also be accomplished by making an opening in the upper part of the door. This should be guarded by a movable sash, or by one of the ventilating appliances to be mentioned later. FIG. 8. WINDOW VENTILATOR. To allow of the free entrance of pure air, one of the glass lights may be replaced by a plate of tin having a multitude of minute perforations, or a ventilator made to fit the window may be used. The best of these are shown in the four following figures. One apparatus (Fig. 8) consists of two pieces of board, one of which slides upon the other, so that it may be readily adapted to any breadth of win- THE NURSERY 65 dow frame. Each portion has a circular opening to which is fitted a tin or sheet-iron pipe, eight inches long by four inches in diameter, and having a slight upward bend. These pipes are provided with a solid diaphragm (Fig. 9) readily moved by a handle, and intended to regulate the quantity of air admitted. When in position the pipes, of course, project inward. FIG. 9. WINDOW VENTILATOR IN PROFILE SHOWING DAMPER. The wheel window ventilator (Fig. 10) consists of a movable diaphragm and a revolving wheel, the whole varying from six to eight inches in diameter. When placed in position, which is readily done by cutting a circular hole in a window pane or in the door, the difference in temperature between the interior and exterior of the room will create a current, and cause the wheel to revolve noiselessly. 5 66 HYGIENE OF THE NURSERY The revolving wheel, while it prevents a draught, allows of the passage of two currents, that of fresh air inward and foul air outward, and the diaphragm enables one to control the supply of air. FIG. 10. WHEEL VENTILATOR. FIG. ii. BOARD VENTILATOR IN PLACE. An admirable domestic arrangement for ventila- tion consists of a board eight or ten inches in height placed across, and close to, the window sill, as in Fig. ii. THE NURSERY 67 This, when the lower sash is raised, as indicated by the dotted lines, allows of a free entrance of air without a draught, the current being directed up- ward (as shown by the arrows). Together with the above careful provision for constant purification of the atmosphere, it is essen- tial to " air" thoroughly both of the nurseries through widely opened windows. With the day nursery this must be done whenever the child leaves it for any length of time, care being taken to close the windows and get the temperature to the proper degree before his return. The night nursery should be aired after the children leave it in the morning, and after the midday nap. The air of the nurseries should, of course, never be unnecessarily contaminated. Cooking or smok- ing in the rooms is to be specially avoided. In regard to the latter, there is no doubt that children are often made sick by the fumes of tobacco, and that, of all forms, cigarette smoke is the most in- jurious. Cleaning. It is hardly necessary to say that the nurseries must be kept perfectly clean. Napkins and bed clothing that have been soiled by the dis- charges from the bladder or bowels must be re- moved at once from the room, and the practice of hanging diapers wet with urine before the nursery fire to dry should be emphatically discouraged. 68 HYGIENE OF THE NURSERY Equal care must be taken to promptly empty and clean chamber vessels after use. The furniture, woodwork and window glass, as well as the floors, must be kept clean and free from dust by wiping with a damp cloth at least once or twice a week. Should there be a stationary washstand in either room, it is most important to thoroughly clean the basin every day, and to disinfect the waste pipe, how- ever short it may be, twice every week. The latter may be done with ammonia, copperas or Platt's chlo- rides. The process is very simple, and consists in pouring down the pipe a gallon or more of a diluted solution of either of the above articles. Copperas is the cheapest and in my opinion the best; a double handful of it in an ordinary bucketful of water forms an efficient disinfectant and deodorizer. The substance known as household ammonia may be employed in the strength of two table- spoonfuls to a gallon of water, and is especially useful where there is a suspicion that the interior of the waste pipe has become coated with a layer of soap. Platt's chlorides is used in the proportion of one part to four of water, and is very efficient, though more expensive than either of the other materials. The nurseries must never be cleaned while the children are occupying them. CHAPTER III. THE NURSE-MAID. While the mother is the natural guardian of the physical and moral welfare of her children, the nurse-maid has a considerable influence over both; for the former, however anxious and watchful, has so many other duties, both domestic and social, that she must absent herself at times from the nursery; the latter, on the contrary, lives there. By day, and often, too, at night, she has the care of the children, attending to their apartments, to their persons, food and clothing, participating in their amusements and exercise, and watching over their sleep. The selection of a nurse-maid, there- fore, is a matter of much importance. The celebrated Dr. West, in discussing the nurs- ing of sick children, makes the following statement in regard to a nurse's qualifications: "Indeed, if any of you have entered on your office (hospital nursing) without a feeling of very earnest love to little children a feeling which makes you long to be with them, to take care of them, to help them you have made a great mistake in under- 70 HYGIENE OF THE NURSERY taking such duties as you are now engaged in." Now, though this was addressed to those who were occupied in caring for ill children, it is alike appli- cable to the nurse whose chief duties are with the healthy. Love of children, therefore, is essential in a good nurse, but it must be combined with several other traits of character, since love alone will not com- pensate for such faults as stupidity, inexperience, forgetfulness and lack of judgment. What, then, are the qualifications to be sought for? First. The woman should be in the prime of life, between twenty-five and sixty, for example. For if she be under the former age, she is apt to be frivo- lous and think more of her " afternoon out" and of her male friends than of her charge, while if over the latter, besides being set in her ways and opin- ionated, she is usually too worn out for efficient day service and too prone to heavy steeping to be trusted for night duty. Second. Strength, activity and freedom from dis- ease are necessary. Consumption of the lungs, indi- cated by a cough, and syphilis, indicated, usually, by an eruption upon the skin, are two diseases to be specially avoided. Besides these two, which are to be shunned because they positively endanger the child's health, there are others that, without doing THE NURSE-MAID 71 appreciable harm, render the sufferer's presence un- bearable in the nursery. These chiefly offend through the sense of smell, as in the case of old leg ulcers; too freely perspiring feet; overactive axillary glands; certain forms of chronic catarrh of the nose, throat or tonsils; and of decayed or badly kept teeth. Third. While beauty is not to be specially sought after, the maid's face should, at least, have a cheer- ful expression. A markedly homely or sinister face is a disadvantage, and still more so is any decided deformity. This reference to personal appearance at first sight, perhaps, seems trivial, but any one who has seen much of children can- not fail to have noticed how a young child will crow and hold out its arms to one who has a placid, comely and smiling face, and turn away from one who wears a sombre and unsympathetic expression. Much is said about the magic of touch in managing young children, but I have observed that their eyes always seek the face and eyes of those about them, and that it is what they see there that guides their instinct for like or dislike. Fourth. Children resemble dogs and horses as far as the instinct of knowing those who love them is concerned, and the element of love toward babies is, as already hinted, the most important feature in the disposition of a nurse. A woman having this 72 HYGIENE OF THE NURSERY quality will never be cross or impatient, and, by the very contagion of her good nature, prevents her charges from being fretful and makes her nursery happy. Besides love, with the patience and con- sideration it implies, truthfulness is a most impor- tant trait of character, not only for the physical welfare of the child, but also that, since children are such imitative creatures, the bad habit of lying may not be formed. A truthful, loving woman is generally a cheerful one; if not, her place is out of the nursery, for children must be happy to be healthy, and the constant contact with sadness will bring unhappi- ness to any child. Gentle speech is also a desideratum. Children will never learn politeness if every sentence they hear in the nursery is spoken in the fewest, shortest words; and "please" and "thank you" are good elements of a nurse's conversation. Fifth. The nurse-maid should have a sufficiently developed mind to follow out and remember gen- eral directions, whether given by the physician or mother, and to do routine work without constant supervision. A certain amount of experience is a good thing, and on this account it is recommend- ation for a woman to have had a partial hospital training, to have nursed children before, or to have been a mother. On the other hand, one must THE NURSE-MAID 73 beware of the self-opinionated maid, who, having cared for several children, thinks she knows every- thing, and will be controlled by neither professional nor maternal directions. Such women are as igno- rant and inefficient as they are common. Sixth. Cleanliness is essential in a nurse. A slovenly maid will keep neither her children nor their nurseries clean. Therefore, insist upon the nurse not only washing her face and hands as oc- casion requires, but upon her bathing her whole body frequently, and upon her wearing fresh, well- aired clothing. Seventh. So far as habits are concerned, absolute temperance and early rising are the most desirable. Early rising, however, implies an early hour of retiring, and care must be taken to afford ample facilities for so doing. Eighth. Every nurse-maid should be impressed with the importance of informing the parents of all conditions connected with the health of the child that may demand attention, and of revealing at once any injury that may have been sustained. Having selected a nurse-maid with due care, the mother must remember that she is not absolved from her duty of supervision and assistance in the nursery. The best of nurses will do better work, and be more happy and hence more useful if intelligently not naggingly overlooked, and so 74 HYGIENE OF THE NURSERY assisted as not to be hurried in such necessary sup- plemental work as washing napkins and cleaning the nursery, if her meals can be taken at regular hours and in sufficient leisure, and if she be allowed reasonable time for relaxation and rest. All this may be accomplished if the mother will take charge of her child for a few hours each day, and, by so doing, perform a duty which is of mutual benefit to herself and her baby, and which should be nothing but an extreme pleasure. CHAPTER IV. CLOTHING. In introducing this subject, it may be well to call attention to two important points that are often either unrecognized or overlooked. First. All children, but particularly infants, have little power to resist the depressing influences of continued cold, and on this account require warm clothing. Too much cannot be said against the fashion which, for the sake of supposed beauty, demands that children should be dressed in a way to leave their legs and knees bare. Even in the house, and except in extreme tropical weather, this barbarous practice is injurious, as it exposes a considerable part of the body to constant chilling. The physician knows, and the intelligent layman should be readily convinced of, the bad effects of such protracted abstraction of body-heat. The explanation is sim- ple: every child is supplied by nature with a certain definite quantity of nerve force destined to be ex- pended each day in maintaining what physiologists 75 76 HYGIENE OF THE NURSERY term "the functions of the body," namely, breathing, circulation of the blood, digestion, heat-production, and so on. Now, if an undue proportion of this nerve force be consumed in producing body-heat, as must be the case when so large a surface is left bare, the other functions will be robbed of force. From this robbery the digestion suffers most. With feeble digestion comes constipation or its opposite, diarrhoea. Again, if the surface be chilled, the blood which should circulate in the skin is driven to the interior of the body, and the vessels of the mucous membrane become surcharged. This sur- charging, or congestion, causes the condition known as catarrh, which, affecting the lining membrane of the alimentary tract, causes vomiting and diar- rhoea; and, in the case of the lungs, bronchitis. Mothers who allow their children to have their legs and knees covered with the "hideous" long stockings or drawers, often come to me and complain that Mrs. So-So's children have bare legs, and are even healthier and more robust looking than theirs. Some children are born hardier than others, but no one knows, in the long run, how much better in health, in after life, are those whose vital forces have been husbanded and strengthened in infancy and childhood. I cannot waver in my opinion. I have been too often called to the bedside of these poor little "robust" children whose health, and even CLOTHING 77 life, might have been spared had their clothing been better adapted to their tender years. One great argument advanced by the advocates of bare knees is that in olden times all children were clad with their arms and neck, as well as knees, bare. No one says how many died by the wayside. What mother would, on a winter's day, care to sit on the floor or walk through the halls with her knees un- covered? The mother who protests the loudest I have always observed to be warmly dressed herself. Second. Infants and children have soft tissues. This statement applies as well to the bones as to the muscles. Therefore, the clothing should fit loosely, that it may not interfere with the motion of the limbs, with the rise and fall of the chest in respi- ration, or with the necessary freedom of the muscles of the abdominal wall or intestinal canal, one of which is concerned in respiration, the other in the no less important function of digestion. Let the clothing, then, be warm and loose. Thought for the infant's clothing must begin before its birth, with the filling of the "baby's bas- ket." This should contain the following articles: A nainsook slip. A flannel skirt. A merino shirt, high neck and long sleeves. A flannel band, twenty inches long and five inches wide. 78 HYGIENE OF THE NURSERY A soft woolen shawl, to be used for a wrap in cold weather. Worsted socks. Two linen diapers. Large and small safety-pins. One pair blunt-pointed scissors. Powder box and puff. Soft hair brush. Cold cream or white vaseline. Linen bobbin. Two soft towels. Castile soap. Small soft flannel wash cloths, for washing face and head. Small silk sponge, for bathing body and limbs. Absorbent cotton for cleansing mouth, eyes, genital organs and buttocks. As soon as the child is born and the cutting of the cord frees it from maternal connection, it is the rule to wrap it in a piece of soft flannel and place it in a position of safety until, certain necessary attentions having been rendered to the mother, a convenient time arrives for washing. After this operation, which will be described on a future page, the child is dressed for the first time. Every infant requires knitted worsted shoes, or, as they are popularly called, "socks," a napkin and an abdom- inal band or " binder"; the rest of the dress the CLOTHING 79 body clothing proper consists usually of three garments, which vary in pattern with individual ideas and tastes. The socks are made of silk thread or soft worsted yarn fashioned by needles into the shape of shoes, and of such a size as to fit the foot loosely, while covering the leg two inches or more above the ankle. They are held in position by a loosely tied tape or a narrowed band of stitches the mechanism of which every knitter will understand near the top. Stockings are unnecessary, and are rarely used before the clothes are shortened. The napkin or diaper may be made either of linen or muslin, the former material being preferred, as it is less heating and less liable to cause chafing of the skin when wet. At first the diaper should be half-a-yard wide and one yard long; later, as age advances, larger sizes will be required. When used it is folded into a square and then into a triangle, and must be carefully adjusted to the infant's person so that it may not cause pain by undue pressure upon the back or abdomen. A soiled napkin can never be safely used a second time, even though the soiling medium be simply urine and the subsequent drying be thorough. In consequence, an abundant supply is essential. The least dampness renders its use dangerous, and while insisting upon the washing of all soiled nap- 80 HYGIENE OF THE NURSERY kins, it is equally important that they be aired for at least twelve hours before being used again, that they may be surely dry. One must be most careful, too, to insist upon the laundress washing the napkins in hot suds made with a pure soap, and boiling for twenty minutes. No soda is to be used in washing, and no starch or bluing in ironing as the constant contact of diapers impregnated with irritating substances is sure to produce troublesome excoriation of the buttocks and neighboring deli- cate skin. The band or binder may be of fine, soft flannel or of knitted wool. In either case it should extend from the brim of the pelvis or hip bones to the lower ribs. The flannel band should be five inches wide and twenty inches long, or long enough to go a little more than around the abdomen; it should be cut on the bias to secure elasticity, should be unhemmed, and must be fixed in position by basting, not by safety-pins. This band is to be preferred during the first three weeks of life, for the purpose of holding the dressing of the cord in place, and to protect the navel before it is perfectly healed. After the cord has fallen off and the navel is quite normal, a binder serves merely to prevent abdominal chilling, and it is much better to dis- card the flannel band and substitute a knitted binder; this should be worn until the eighteenth or CLOTHING 8l twentieth month, and sometimes, if the child be subject to intestinal indigestion, until the fourth year or even longer. "Knit Abdominal Bands" can be purchased in the shops or any woman who is apt with her knitting-needles can make one, and the product has the advantages of being readily applied and of keeping its position without the aid of either strings or pins.* Several bands are required to be on hand at the same time for the sake of proper cleanliness, and, as they should be worn well into the second year, it is necessary to replace them, set by set, as the growth of the child demands. The body clothing is usually composed of three separate pieces: a shirt, a petticoat and an outside dress or "slip." The shirt should be long enough to extend from the neck to the lowest part of the trunk and have sleeves reaching to the wrists. It may be made of merino or of soft worsted yarn. In either case it should fit comfortably, be open from top to bottom in front, and be fastened by buttons, * Formula for Crochetted Baby-band. Single zephyr in ridge stitch, that is, half stitch, in which, going back and forth, only the back half of the stitches in the lower row are picked up. Begin on a chain of fifty and crochet forty-eight ridges, hence ninety-six rows. Join by a row of tight stitches or by sewing. Finish off at bottom by a row of plain stitches and at top by a picot-edging (five chains and a tight stitch back into the first). "Babyhood," Vol. in, p. 33- 6 82 HYGIENE OF THE NURSERY with a tape at the neck. The petticoat must be long enough to extend from the waist to six or eight inches below the feet. The proper material for the skirt is light, white flannel. This is gathered at the top into a muslin band, which must be deep enough to reach from the hips to the arm pits, and wide enough to lap over considerably at the back; it is fastened by basting or very care- fully adjusted small safety-pins. The overwidth is to allow for increase in size. An equally good waist can be made with arm- holes and buttoned in the back. The dress or slip is made of fine cambric, cut in one piece, opening well at the back that it may be readily slipped on and off. Another, and I think a preferable outfit, consists, also, of three garments. The first or under gar- ment, made of soft, white flannel, is long enough to extend from the neck to ten inches below the feet about twenty-five inches in total measurement with wide arm-holes. All the seams must be smooth, and the hem at the neck turned outward. The next garment, cut in the same way, but one- half inch larger, and five inches longer, is made of muslin. The slip is also cut Princess, has long sleeves, a longer skirt than either of the other gar- ments, and all are fastened behind by small buttons. When dressing the infant these three coverings CLOTHING 83 are put together, sleeve fitting to sleeve, and the whole drawn over the little one's feet, then but- toned behind, and the process is complete. The advantages of the last method of dressing are 1. Perfect freedom to the organs contained with- in the chest, abdomen and pelvis. 2. Suspension of the clothing from the shoulders. 3. Saving of time to the mother and fatigue to the infant in the process of dressing. 4. A uniform covering of the whole body. So much for the day clothing. At night the dress should consist of the flannel and the outer garment. In the foregoing, my intention has been to lay special stress upon the advantage of holding the garments in place by tape or buttons rather than by pins, and it should be noticed that a baby may be completely dressed with but one pin in its clothing, namely, that fastening the napkin. This, which is allowed only for the sake of convenience, must be a safety-pin, the ordinary pointed pin being an abomination in the nursery. It is hardly necessary to say that, for the sake of cleanliness, an abundant supply of body clothing should be at hand; a mother, particularly, must recognize that " cleanliness is next to godliness," and provide accordingly. Let her remember, too, 84 HYGIENE OF THE NURSERY that fresh clothing must be thoroughly aired or dried before it is put upon the infant. Sometimes, to keep the body clothes dry, a piece of thin rubber cloth is placed over the napkin; this does nothing but harm, for it overheats the parts, and when the diaper is wet with urine, makes a poultice of it, and thus macerates the skin and causes irritating and painful excoriation. At the age of six months in summer and of eight months in winter, provided, in both cases, the health be good, the clothing may be shortened. This change introduces several important questions, namely, the covering of the legs and knees, and the selection of shoes and stockings. The shortening process makes no change in the body clothing except that the skirts end a short dis- tance below the knees, at about the point to which an ordinary shoe top comes; this, of course, prac- tically leaves the legs, from the top of a short stock- ing to the lower edge of the napkin, exposed. As already hinted, it is necessary for the health of the infant to keep this comparatively large surface pro- tected, except, perhaps, during a few extremely hot days in midsummer. There are two ways of accomplishing this : either by drawers or by stockings long enough to extend from the feet to the nap- kin, to which they may be attached by safety- pins or ordinary fasteners. The best drawers are CLOTHING 85 those made in two pieces, one for each leg, as shown in Fig. 12. These, as furnished in the stores, are made of merino, but any clever woman should be able to cut them out of Canton flannel and make them at home. They must fit the legs moderately closely, and have a buttonhole at the top, so that when FIG. 12. DRAWERS. passed over the napkin they may be buttoned to the waist of the skirt on its inner side, and so be held up. These drawers are not readily soiled as they cover the legs only, and the napkin comes be- tween. They must, of course, be made of material to suit the season heavy in winter, light in summer. When stockings alone are used they must be long enough to come well above the knees, and should be held in position by " supporters" instead 86 HYGIENE OF THE NURSERY of garters, since the latter, being necessarily tight, bind the limbs, and often, by interfering with free circulation, cause cold feet. The supporter must be adjusted to make only the required amount of traction, and this always in a direction parallel with the axis of the body. The stocking foot ought to fit easily, but without wrinkling, and at the same time have a roomy and rounded rather than a con- ical-shaped toe. For although the silk, woolen, or cotton material of which the stocking is composed may be yielding, it is elastic, and consequently capable of exerting a certain amount of pressure upon the foot; and there is little doubt that the per- sistent compression made by a short, sharply conical point cramps the toes, crowds them together, and sometimes even forces them to overlap one another. Colored stockings are often preferred to white, but they are only permissible provided the coloring matter be well fixed in the texture and not of such a nature as to cause irritation of the skin. Every stocking should be turned inside out, carefully examined, and all knots and ends removed, the smallest of which hurt the tender little feet, and stockings having seams to be pressed by the shoe into the back, soles or sides of the foot must be avoided. Were these details oftener looked to, many an unexplained tear would be avoided. As with the drawers, so with the hose; several CLOTHING 87 weights should be provided to correspond with the varying demands of .the season for greater or less warmth, and in both cases a sufficient supply must be kept to allow of frequent changing. The shoes are prominent items of the clothing; their shape, size and manner of fastening, and the make-up of the soles being the important matters for consideration. An infant's feet are plumper than those of the adult, and all the tissues, but especially the bones, are softer. They may be readily deformed by protracted pressure from badly constructed shoes, despite the assertions of unhandy shoemakers, who say that the feet are shapeless masses of fat, for which any leathern bag having the semblance of a shoe will serve as a covering. Throwing out the element of fleshiness, the characteristics of the perfectly formed baby and adult foot do not materially differ. In the first place, the inner and outer margins are very different in contour; second, the heel and middle third of the foot is firm and presents little mobility in its component bones, whereas the anterior third, in- cluding the toes, is very mobile. The toes again bear much the same relation to the rest of the foot as the fingers to the hand. This is particularly noticeable in the great toe, which, instead of inclin- ing toward a line passing along the center of the 88 HYGIENE OF THE NURSERY foot, points away from it, in the same manner as the thumb from the hand, although, of course, to a far less degree. An inclination of the great toe toward the mid-line of the foot is undoubtedly often seen in adults, but in them it is a deformity resulting from badly-made shoes, and one that gives a conical contour to the toes, cripples the movements of the great toe, and greatly interferes with the ease of walking, just as a contraction and permanent draw- ing of the thumb toward the palm of the hand would materially lessen the usefulness of that member. The normal position of the toes just described will be readily understood from the tracing of the sole of the foot as shown in Fig. 13. The most striking features of this diagram are, the expanded position of the toes; the width of the anterior part of the foot compared with the heel, and the straight outer and curved inner margins of the foot. The line AB represents the axis of walking, which, while nearly parallel to EF, the inner edge of the foot, forms quite an angle with CD, the center line. In the normal foot the great toe is directly in the axis of walking, a position in which, of course, it is of much greater service than if it were inclined inward toward the line CD. Now, if a line be drawn closely around the mar- CLOTHING 89 gin of the imprint, it will give the exact shape of a perfect shoe sole for the right foot; or taking the imprint of both feet, we get the outlines shown in Fig. 14. B D F\ PIG. 13. TRACING OF NORMAL FOOT. On first sight, one would suppose that a shoe with a sole so shaped would look very awkward, but when made by a skilful shoemaker, it differs very little in appearance from those ordinarily sold in the shop, with the exception that it is broader at the toes. QO HYGIENE OF THE NURSERY Another important fact is clearly demonstrated by Fig. 14, namely, the absolute necessity of having the shoes made "right" and "left," and the fallacy of supposing that one or the other shoe may be used on either foot indiscriminately. Besides having a correct shape, the shoes Left Foot. Right Foot. FIG. 14. SHAPE OF PROPER SHOE SOLES. should be long enough not to cramp the toes and bend them down and backward upon themselves. At the same time it is a mistake to have them too long, allowing the foot to slide back and forth, as this leads to the formation of either blisters or corns. Let the shoe fit snugly about the heel and instep, and easily at the toes, and all is well. I say CLOTHING 91 easily at the toes, because many an otherwise good shoe is ruined by having the uppers at the points too scanty, so that the. toes are forced against the sole and subjected to painful pressure. The best method of fastening is by a lace, since this admits of making one part of the upper tight and another part loose, according to circumstances. Elastic fastenings, as in so-called congress shoes, are not good for children; and when buttons are used, the nurse must not necessarily leave them in the position fixed by the shoemaker, but move one or more as the size of the ankle demands. The thickness of the soles depends upon the age of the child. Before walking is attempted, they may be thin, flexible, and of uniform thickness from heel to toe; afterward they should be made heavier and more resisting, in order to protect the tender feet, and should be decidedly thicker at the heel, that this part of the foot may be elevated. A clear- cut heel, however, as in boots adapted for adults, is not to be recommended in children's shoes before the age of six or eight years. Sometimes a careful mother may notice that, for a short time after stockings and shoes are put upon her baby, the feet are cooler than before. Undue pressure about the ankle, with consequent inter- ference with the blood circulation in the feet, is the cause of this, and the remedy is to remove occa- Q2 HYGIENE OF THE NURSERY sionally the coverings, chafe the feet into warmth, and see that the shoe-top is not so tightly laced or buttoned as to constrict the. ankle. So far, all that has been said of the clothing after shortening refers to the day and house gar- ments. It remains now to consider the night dress and the extra wraps to be worn out of doors. At bedtime, all the clothing worn during the day being removed, the baby is washed, and after the application of a fresh napkin and binder, is ready for the night dress. This consists of a shirt and a special gown. The shirt should be of flannel or merino, a light gauze in summer and a heavier material in winter; its pattern may be the same as that worn by day, though its texture ought to be a trifle lighter. The best pattern of a winter night- gown is a long, plain slip, with a drawing string at the bottom, to prevent exposure of the feet and limbs, should the child kick off the bed covering during sleep. It ought to be made of flannel, or the more easily washed Canton flannel. In summer, a loose muslin slip of the same design, but without the drawing string, may be worn. There is even more temptation by night than by day to use a rubber cloth over the napkin, to protect the body and bed clothing, but never do this. It is a good plan to provide the child with a flannel garment corresponding to the dressing gown of the CLOTHING 93 adult, and with a pair of bedroom shoes. The latter are composed of soft leather or felt soles and knitted uppers, and are fastened around the ankle by a soft elastic. Both of these will be found use- ful in the many occasions when the child has to be taken up at night. When dressing a child for exercise in the open air in cold weather, do not put on the extra outer clothing until immediately before leaving the house, and remove it directly on returning. A long cloak, with or without capes, according to the degree of cold, and a pair of long, warm leggings, constitute the extra covering for the body. Protect the head, in winter, by a close-fitting thick cap; the hands, by worsted gloves or mittens. In summer the child may go out of doors in the same dress worn in the house, the head being pro- tected from the direct rays of the sun by a broad- brimmed, light straw hat. Every mother must decide for herself when her child is to doff the costume of babyhood and assume that of the boy or girl. There are two points that must always be considered, however, namely, the time of dispensing with the napkin and with the abdominal belt. Abandon the napkin, and sub- stitute ordinary drawers, as soon as the child can be trusted to make known the calls of nature a period that varies considerably with the care and 94 HYGIENE OF THE NURSERY skill in training. The binder, as already indicated, should always be worn until about the end of the second year. In clothing the boy or girl, be particular to se- cure warmth, freedom of movement and cleanliness. The first is accomplished by enveloping the whole body no matter what the season in woolen underclothing. This means high-neck and long- sleeve flannel shirts and flannel drawers extending down to the ankles. It is hardly necessary to men- tion that the thickness of these garments must vary with the seasons, but it is quite worth while insisting upon woolen undergarments, except during the very excessively hot days of midsummer. This provision being made, and the shape of the shoes and stockings* looked into, it matters little what may be the fancy of the mother in regard to outer clothing. While securing warmth, we must not go to the other extreme and burden the child with underwear so heavy that constant perspiration is produced. The risk of this is great during the winter in the, so often, over-heated city house, and it is much better to select underclothing of just sufficient * It is impossible for either a stocking or shoe to fit accurately unless the toe-nails be kept in good order. In cutting the toe-nails there is, as in every other affair of life, a right and a wrong way. Cut the nail directly across, without rounding the corners. Should the latter be done, the nail is apt to grow into the flesh and give suffering to the child and work to the surgeon. CLOTHING 95 weight to keep the skin warm without over-activity, depending upon thick overcoats and wraps to conserve the body temperature when out-of-doors. Again it must be remembered that there are a few children who cannot comfortably wear woolen un- derclothing on account of a very sensitive or a very active skin. These either suffer from irritation rashes or, having a constantly moist surface, are readily chilled in passing from warm rooms to a cool outdoor air, and do much better when clothed with some other material, as linen-mesh or cotton stockinet. Freedom of movement refers not only to the limbs, but to the chest and abdomen, which should never be constricted, lest the important organs they contain be crippled in their action. Loose-fitting clothes accomplish this object; but it is to be under- stood that looseness or ease in fit does not necessarily imply that the dress must be awkward, ill-fitting, and a source of mortification to the wearer. On the contrary, clothes must be easy and yet well cut and stylish. To be clean, the child must have a plentiful sup- ply of clothing, so that changes may be made as frequently as required. Clean, cheap clothes look much better than soiled finery. The night dress or a child five or six years old consists, during winter, of a light, high-neck and 96 HYGIENE OF THE NURSERY long-sleeve merino shirt and night drawers of Can- ton flannel; in summer, of a gauze undershirt, with short sleeves and muslin night drawers. Cold weather calls for a warm overcoat, hat, mittens, and leggings, or rubber boots in wet or snowy weather, when the child leaves the warmth of the house. Should the cold be so great as to necessitate ear tabs and a neck wrap for protection, a child under six years is better off in the nursery. As to rainproof clothing and our climate calls often for both rubber boots and a long mackintosh it must be remembered that such coverings, while impervious to moisture from without, are no more pervious to body moisture or, in other words, to perspiration, which secretion they encourage by their warmth. Of course, when perspiration is re- tained, the underclothing becomes moist, and there is a great risk of surface chilling and consequent catarrh. Therefore, it is a good plan, when water- proof garments have been worn for any length of time, to take off the underclothing as soon as shel- ter is reached, to rub the surface into a glow with a coarse towel and then redress the child. Before concluding this chapter, let me advise that the change from winter to spring or summer clothing be not made at any fixed date, under the supposition that it is the time to change, and the weather should be warm, whether it is or not. In CLOTHING 97 our Eastern climate it is unusual to have settled, warm weather until June. May has a certain num- ber of warm days, but they are quickly followed by cooler ones. Consequently the safe plan is to keep on the winter flannels until hot weather surely sets in, changing, in the meanwhile, the outer clothing to suit each day. CHAPTER V. EXERCISE AND AMUSEMENTS. Healthful exercise, especially when taken in the open air and sunshine, invigorates the nerves; se- cures an active performance of such vital functions as circulation, respiration and digestion; maintains a hearty appetite and regular movement of the bowels, and develops the muscles. Symmetry of development is essential, and on this account any exercise or play that brings but one or a few sets of muscles into action must be dis- countenanced. The muscles control the bones, and should one set be comparatively feeble, the bones they move are dragged out of form by stronger opposing sets. Probably the most important groups of muscles to render strong are those of the back which hold the spine in proper position. When these are weak the greatest weight of the trunk being toward the front the backbone has a ten- dency to be drawn forward in such a way that the movements of the chest are crippled, and respira- tion so interfered with that the blood is imperfectly aerated, nutrition fails, and the child becomes a weak, puny invalid. 98 EXERCISE AND AMUSEMENTS 99 M Curvature of the spine the deformity here re- ferred to may also interfere with other functions; for instance, digestion, elimination of urine and the motion of the legs. Bone deformities are more apt to occur in children than in adults, because, in the former, the bones, not being thoroughly set and hardened, are more readily influenced by irregu- lar muscular action. Marking, then, the necessity for equal muscular development, the subject of exercise may be taken up in detail. The first exercise the infant gets will be in the nurse's arms. Shortly (three or four days) after birth the baby may be taken from its crib two or three times a day, and, being placed upon its back on a pillow, carried about the room for ten or fifteen minutes. In the second month, longer walks may be taken, the pillow being discarded and the infant carried in a reclining position in the arms, with the head and body thoroughly supported. By the fourth month the child will have gained sufficient muscular strength to maintain a sitting posture for a short time, provided the head and shoulders be supported by the nurse's hand, and in this way it may be carried about on the right or left arm and it is most important not to use one arm constantly for its daily training. At the end of the eighth month a healthy child 100 HYGIENE OF THE NURSERY ceases to require support to the head and back when carried, but not before. After the infant ceases to be merely a sleeping and eating animal, and begins to show signs of humanity at about the fourth month, for ex- ample he should be laid upon a soft mattress or sofa several times each day and allowed to do as he pleases. Under these circumstances he rolls about and kicks his legs, clasps and unclasps his fists, moves his arms, and crows or cries. All these movements serve a purpose; the legs gain strength for future walking; the hands, for grasping; the arms, for carrying, and the vocal organs, for speaking. A certain class of nurses seems unable to com- prehend that a baby is a tender creature, tender not only in age, but in the texture of all its tissues. They support a young infant upright upon their knees and violently jolt it up and down, under the supposition that it gives pleasure, and should the child cry they add to its torment by a peculiar "song." Gentle movement is as pleasant to the child as riding in an easily running carriage on a smooth road is to an adult; knee-jolting is as un- pleasant and harmful as a journey over the worst corduroy road. The so-called singing must cause only pain. The question of "airing" or subjecting the infant EXERCISE AND AMUSEMENTS IOI to out-door air, arises soon after birth. Airing in-doors consists in taking the child fully dressed as if going out, into a room having a southerly ex- posure, with wide open windows but closed doors to prevent a strong current of air. It may be begun, even in winter, at the age of one month, the first airing lasting for fifteen minutes only, and the time slowly increased, by ten minutes daily, until three or four hours are occupied. This procedure is safe and beneficial in practically all sorts of weather, and with delicate children and those recovering from an illness, should be the only form of airing allowed during the winter months. Airing out-of-doors should be commenced, under normal conditions, as soon as the child has arrived at the proper age, and providing always that the weather be favorable. The fifth month is the proper age for children born in the early fall and winter, and the second month, for those born in summer. In cool weather they should be taken out in a baby carriage or in the nurse's arms, for an hour in the morning and half an hour in the afternoon, while the sun is shining. In summer, they may pass the greater part of their waking hours in the open air. In damp and rainy weather, when there is a strong east or north wind blowing, or when the mercury stands below 20 F., young children are better off in the nursery. The hardening process, in 102 HYGIENE OF THE NURSERY our climate, so far from being successful, usually results in an attack of bronchitis or something worse, which may house the child for a long time, and thus deprive him of the advantage of sub- sequent favorable weather. How shall the baby be taken out? The answer to this question involves the consideration of two points, namely, the clothing and the means of con- veyance. The former has already been refer r ed to. As to the method of conveyance, the arm is to be preferred for very young infants, especially in cold weather, because they are apt to be uncomfort- able in a baby carriage, and because as they must, when carried, be held close to the nurse's body, they are kept warm by the heat given off from the bearer. After the fourth month a carriage may be used. Now there are good and bad baby carriages, as well as a right and a wrong way of trundling them; and here again the mother must not forget that the baby is a tender creature and very easily hurt. The best kind of carriage is none too good for the load it is destined to carry. It should run smoothly, without jolt or jar; its wheels should be provided with rubber tires and kept from creaking by the frequent application of some mineral oil, as sewing-machine oil; the bed must be soft and comfortable, lateral support being given to the body EXERCISE AND AMUSEMENTS 103 by two long, narrow and soft pillows; the infant must never be strapped down, the feet must be kept properly covered and warm, and the parasol always must be at hand, and so arranged as to protect from wind, and shade the tender eyes from bright sunlight. While the carriage is a convenience to the nurse, it is never to be regarded as a place of security for the child, to be left on the sidewalk or in windy places while the wheeler exchanges gossip with fellow-nurses or enters a house to visit friends. However good its springs may be, they are never easy enough to allow of rude jolting or of mount- ing a raised curbstone by mere dint of hammering and muscle force. After the age of nine or ten months a healthy child will begin to creep; at the end of a year he will make efforts to stand, and from four to eight months later will be able to walk by himself. Chil- dren, however, present great differences in this respect, and a delay of a few months must not be considered abnormal. Second children are usually more active than those born first, since they imitate and are encouraged by the example of their elders. As soon as efforts at creeping are made there need be no fear that insufficient exercise will be taken; the care should be, rather, to prevent over- fatigue, as the baby, delighted by its new-found IO4 HYGIENE OF THE NURSERY powers, will be inclined to exert them all day long. The question arises at this stage whether or not the nursery floor is a permissible field for exercise. This depends entirely upon the child's health, the state of the weather and the condition of the nursery. Remember always that the stratum of air next to the floor is much lower in temperature than the middle or upper. In some of the biting days of winter it becomes so cold as to make the feet and legs of an adult uncomfortable, and completely to chill a child, who, in creeping, has his whole body in it for long periods. Therefore, should a child be delicate, should he have either bronchitis or catarrh of the digestive tract, should the weather be very cold, or should the heating of the chamber be imperfect, it is better to keep him off the floor and let him take his exercises on the nurse's bed, which may be stripped down to the mattress for the purpose. Colds are contracted and many more are protracted by playing on the floor in winter. Many nurses, and some mothers, have an idea that a child should walk at a certain fixed age, and when this time arrives, put into practice various plans for teaching the process. Beware of this, for go-carts, leading-strings, baby- jumpers and all con- trivances of this ilk have a tendency to flatten the chest, distort the spine, or deform the legs. The EXERCISE AND AMUSEMENTS 105 proper and only safe plan is to let the child teach himself to walk. This he readily does, first through the act of creeping, in which he exercises every muscle of the body without throwing undue weight upon the soft bones. When by this exercise he has sufficiently strengthened the muscles, he will in- stinctively seek to do more; first in an effort to get upon the feet, in which, though failure occurs over and over again, he perseveres until successful in standing with support, then without, and finally ends in walking. The first acquisition of the power of walking should not be overtaxed, and for a month or more the carriage is the best means of airing; but as soon as sufficient strength is acquired for active exercise a somewhat variable age the child should walk out and pass as much time as the weather and nursery requirements permit in the open air. Set walks, however, are an abomination to -the child as well as to the adult. City-bred children suffer in this respect, as they are too frequently sent out merely to walk a certain number of blocks, or for a fixed time, and it is no wonder that they quickly tire of such exercise and prefer their nurseries to the streets. The only way to avoid this is to give an object to the outing, as, for example, a household errand or the purchase of a cheap toy. In the country, on the Bother hand, children run about and amuse 106 HYGIENE OF THE NURSERY themselves according to their own pleasure, visit the garden or the farm, and involuntarily take that kind and degree of exercise best calculated to promote the growth and development of their bodies. Delicate children preeminently require pure air and an outdoor life, although many of them are too feeble to take sufficient exercise on foot. For such, when the parents' purse allows, a donkey or a pony should be provided. Driving may give sufficient exercise at first; but as soon as enough strength is gained, riding is to be preferred, as it keeps the mind more healthfully occupied, strengthens the muscles, expands the chest and produces a healthy appetite and digestion. Children who are " not allowed sufficient out-door life because they take cold easily, should live in cool rooms, wear less heavy underclothing to insure a dry skin, and have the body, particularly the chest and back, sponged once daily with cool water 5o-6o F. or, in the case of young infants, 65-7o F. In the earlier years of life the girl and boy play together and take nearly the same sort and amount of exercise. As time goes on, however, and the girl approaches nearer and nearer to maidenhood, she too frequently begins to look upon her brother's game of ball or romping play as too rough, and spends a constantly increasing time indoors acquir- EXERCISE AND AMUSEMENTS 107 ing the manners and the sedentary habits of her elders of the same sex. This tendency is often encouraged by parents, who prefer polished manners to physical strength, and, above all, dislike their daughters becoming " torn-boys." One must admit that polished man- ners are a great attraction; but as a woman has more important duties than shining in a drawing- room, they are of little intrinsic value when uncom- bined with the fine carriage and good figure which belong to robust health. In regard to the carriage and figure, it is useless to try to assist their formation by the aid of braces and stiff corsets. The latter are especially to be con- demned. Unless most cautiously used, they induce undue contraction of the lower part of the chest and displace the solid organs (liver especially) of the abdomen, interfering primarily with respiration and digestion, and secondarily with the general processes of nutrition. An erect carriage can be better secured by attention to the general health; suitable diet; regulation of the bowels; cold bath- ing and sponging, and exercise short of fatigue, not of particular muscles only, but of the whole frame. My advice, therefore, is to let the girls join in the boys' play. By this plan the latter gain, because they are naturally forced to be more gentle, and the former, because their rapidly-developing frames get I08 HYGIENE OF THE NURSERY the requisite amount of exercise. It is well, how- ever, to curb the ambition of the girls to equal the athletic powers of the boys, for their muscular strength is less. Without letting the subjects know, keep a strict lookout upon the general morals, for it is absurd to shut one's eyes to this risk in mingling the sexes in later childhood and youth. Amusements. A child's life must be devoted to the cultivation of his mind and his body, an undue development of either resulting in an incomplete manhood or womanhood. After writing the above sentence I was called from my desk to the bedside of a little sufferer, and on my way met two boys, both about nine years of age, and both patients of mine. The first had a spirituelle face, and spoke to me with a tip of the hat and the grace of a little Chesterfield; but his features were pinched, so it seemed to me, while his face was anxious and his legs were hardly thick enough to carry his body. Nevertheless, his arms were full of books, which, as I had curiosity enough to examine, I found to be a Greek grammar, Csesar, and the elements of algebra. I felt sorry for the overtaxed little brain, and he showed no symptoms of joy at release from school, for he was on his way home to study all his books, to get the teacher's approval and a high mark on the morrow. Scarcely a block away I met my next little friend; his cheeks EXERCISE AND AMUSEMENTS 1 09 were rosy, his arms and legs sturdy, and his eyes brimful of health and fun. The burden of books he bore was light, and his teacher probably con- sidered him stupid; but his simple "Hello, Doctor, I am off for a game of ball this afternoon," and his jolly smile were more pleasing than all the learning of the first little gentleman. The lesson taught by these two children is very plain to my mind, and the question which will come out ahead in the long run is easily answered ; for health has no handicap in the race of life. It is right, 'of course, to let the children study- after the sixth year; but the brain is not to be cul- tivated at the expense of the body. In other words, our boys and girls must have plenty of play. The subject of childish diversion is a broad one, and it is only possible to outline it here. Let the healthy child play as much as possible in the open air, and let him be as active as he pleases; for his own sensations will tell him when to stop and when to begin again. The only cautions are not to over- look him too much; to let him make as much noise as he wishes out of doors and in his own kingdom the nursery; to make him play those games which will exercise all the muscles of the body equally, and to guard him, when heated, from drink- ing ice-water or from lying on the cold, damp ground, or sitting in a draught. It must be remem- 110 HYGIENE OF THE NURSERY bered, also, that play is the child's business, so that during convalescence from a debilitating disease it must be regulated according to the strength. Before closing this chapter a protest must be entered against roller-skates, as they are dangerous to life and limb. Bicycles with wheels of equal size are not objectionable, if the proper upright position on the seat be insisted upon and if the temptation to too long and too fast riding be resisted. CHAFER VI. SLEEP. FOR some time after birth infants spend the inter- vals between being fed, washed and dressed, in sleep, and thus pass eighteen or twenty out of the twenty-four hours. As age advances, the amount of sleep required becomes less, until at two years fourteen hours, and at three years twelve hours, are enough. The amount of sleep required will, how- ever, vary condiserably in different children, but an observant mother can soon determine this question for herself. Any marked diminution in the average duration of sleep, or any decided restlessness indicate dis- ease, and demand attention from the physician. At the same time, sleep, perhaps more than any other item of nursery regimen, is a matter of training, and many a mother, by want of judicious firmness, has rendered the early years of her child's life not only a burden to himself, but an annoyance to the entire household. One cannot too soon begin to form the good habit of regularity in sleeping hours, and so far as circum- stances admit, the following rules may be enforced : in 112 HYGIENE OF THE NURSERY From the second week to the end of the sixth or eighth month the infant must sleep from 10 p. M. to 6 A. M., and as many hours during the day as nature demands and the exigencies of the nursery permit. This does not mean that the baby is not to be put to bed until nearly midnight; on the contrary, he should practically settle for the night at six o'clock, but the last feeding should be at ten o'clock. After this he must rest undisturbed with the exception, sometimes, of one night feeding, during the first six months, until the early morning hour, when he should be fed and sleep again. During the day, 6 A. M. to 6 P. M., the baby should be trained to sleep between feedings, being promptly roused when the regular hour arrives. From eight months to the end of two and a half years, a morning nap should be taken, say from 12 to 1.30 or 2 p. M., the child being undressed and put to bed. Occasionally an afternoon nap for half an hour or more seems necessary, although, as a rule, sleep at night is more undisturbed and refreshing if this be omitted. The night's rest must begin at 7 P. M. If a late meal be required, the child can be taken up at about ten o'clock, but if past the age for this, he may sleep undisturbed until he wakes of his own accord, sometime between 6 and 8 A. M. As soon as thoroughly awake the child must be taken up, washed and dressed, and given breakfast. SLEEP 113 This is the only way to cultivate the habit of early rising, which promotes both bodily and mental wel- fare, and of all habits is the most conducive to a long and healthy life. By early rising it is not meant that the child shall be roused -from a sound sleep by a rough voice or hand at a certain fixed hour in winter and an ear- lier one in the summer, simply for the whim of a fad- ridden and overprompt parent. Quite the reverse. Let the child wake of his own accord, for he will do so whether it be late or early after he has had enough sleep; and, if he must get up at a certain hour and never fix it before 7 A. M. make the rousing process as gentle and gradual as possible. Sudden rousing excites the brain, quickens the pul- sation of the heart, and, if repeated, may lead to serious consequences. From two and a half to four years, an hour's sleep may or may not be taken in the morning, according to the disposition and needs of the sub- ject, but a child should invariably be put to bed at seven in the evening and not be permitted to rise until six or seven o'clock on the following morn- ing. After the fourth or fifth years, few children will sleep in the daytime; they are ready for bed by 8 p. M., and must be allowed to sleep for ten hours or more. 8 114 HYGIENE OF THE NURSERY A later retiring hour than 9 p. M. ought never to be encouraged until after the twelfth or fifteenth year. Any postponement of the usual hour for going to bed is injurious, and should abridgment of sleep be accompanied by the excitement of a child's party, or the like, the rest obtained is broken and productive of a pale face and nerveless frame on the succeeding day. The position and general features of the night nursery have already been described, and it only remains to say that when occupied by day it must be darkened so as to favor sound sleeping. The bed (and where there are several children in the family each should have its own) must be so situated in the room as to be out of the way of draughts. Curtains, while they protect, prevent the access of fresh air, and it is far better to ward off a draught by a movable, folding screen. The form of bed known as a crib may be occupied until the sixth year. The sides must be high, to prevent the child from falling out and injuring himself, and the movable side should work upon hinges or move up and down in slots. Springs and a soft horsehair mattress, protected by a gum cloth, placed beneath a double sheet, under ordinary circumstances constitute the bed proper. Sometimes a feather mattress is admissi- ble, but this is only when the child is feeble, and SLEEP 115 requires artificial aid to keep up the normal body- heat during sleep. The objection to feathers is, that the body, sink- ing deeply in, is so completely enveloped that it is subjected to an undue degree of heat, which relaxes and weakens the system and renders it very sus- ceptible to the injurious influences of cold. The bed covering is composed of a sheet, one or more blankets according to the weather and a spread. These must be warm enough to maintain a healthy temperature, but, at the same time, not so heavy as to oppress the child. Special care should be taken not to cover the nose or mouth, and it is much better to keep the air of the nursery at a proper, even temperature by an open fire than to secure warmth to the body alone by weighty bed coverings. A pillow ought not to be used with young infants, later it must be small and thin, and made of soft horsehair. The bed should never be made up directly upon the child's leaving it, for then it is saturated with the nocturnal exhalations from the body. When va- cated, the bed coverings must be thrown over the backs of chairs, the mattress shaken up, and, the windows of the chamber being thrown open, allowed to air for an hour or more. In the matter of bed clothing, cleanliness is as Il6 HYGIENE OF THE NURSERY important as in body clothing, and the nurse must never neglect to remake a bed if the sheets become wet with urine or otherwise soiled, no matter at what hour of the night the accident may occur. Much trouble in this direction may be avoided, however, by regularly taking up the child at the time of the last feeding and encouraging a through evacuation of the bladder. Children should never sleep in the same room with persons who are ill, whether the disease be acute or chronic. Sleeping with those having a long-standing cough or consumption of the lungs is especially to be avoided. Do not get the baby into the habit of being rocked or walked to sleep, and do not allow older children to sleep too soon after a meal, as the processes of digestion are apt to produce restlessness and uneasiness. Again, a bright light or loud conversation in the bedroom should never be permitted after the children have settled to rest; but they should be taught to sleep through any ordinary noise, as the sound of foot- steps or low talking. Finally, teach the nurse to make up the bed neatly and smoothly, and direct her to turn the pil- low and smooth out the sheets, should her charge be restless at night. By this latter procedure sound sleep is often brought to a fretful child. Sleeping out-of-doors, in suitable weather, is SLEEP 117 very health giving. In summer, between 7 A. M. and 7 p. M. an infant of one month may sleep in the open air in its coach placed in a sheltered position. In winter, between 9 A. M. and 4 p. M., when the sun is shining and the mercury above 32 F., a baby four months old, being well wrapped up, may sleep in its carriage on a porch or some other protected place. CHAPTER VII. BATHING. A well-known English writer states that "water to the body to the whole body is a necessity of life, of health, and of happiness; it wards off dis- ease, it braces the nerves, it hardens the frame, it is the finest tonic in the world." On the word "tonic" the whole subject hinges. Every one knows that food, even in such a simple form as milk, may be given to excess, with the pro- duction of illness, and that medicines are yet more easily abused. Why, then, if the bath be a tonic agent, may it not be often used injudiciously and to the detriment of the child? Intelligent nurses, who have grown gray in ser- vice, often say they have seen babies "washed into heaven." This act has never been actually accom- plished in my experience, but it has been often enough approached to justify introducing this chap- ter with the caution that, should the infant be ailing, the bath had better be discontinued until the phy- sician can be consulted. This, of course, does not preclude ordinary cleanliness, for every part of the 118 BATHING IIQ child's body liable to become soiled can be readily cleaned by the use of a moist sponge, with or with- out soap, and without bringing into play any of the medicinal or, in other words, tonic effects of the bath. The initial bath differs from those that succeed it during infancy in the fact that it involves a special procedure, namely, the removal of the vernioc caseosa, a tenacious, white paste-like material, which usually adheres to the skin of the new-born. This should be removed as soon after birth as the nurse, having made the mother comfortable, can turn her atten- tion to the child, and this process consists in first rubbing the whole surface gently, though thor- oughly, with a bit of soft flannel covered with white vaseline or fresh lard, and next wiping off the softened, greasy coating with a dry piece of absorb- ent cotton, or a very soft towel; especial care being taken to thoroughly clean the arm-pits, and the creases back of the ears and in the groins and buttocks. A dry, sterile dressing is then applied to the cord; a flannel binder adjusted; the face washed with warm water and a soft wash cloth or absoibent cotton; the baby enveloped in a warmed blanket, laid in its crib, on its right side, in a quiet and darkened room, and allowed to sleep for six hours. After this preliminary cleansing, one bath a day I2O HYGIENE OF THE NURSERY should be the rule until the completion of the third year of life. For the first ten days the infant must be bathed on the lap, or "sponged," a full tub-bath never being given until the cord has fallen off and the navel healed. For the first bath the water should have a thermometer measured temperature of 100 F., the same water must not be used in washing the body, and the face and head, or the reverse, and in giving the bath the abdominal binder is neither to be removed nor allowed to become wet. The nurse, seated on a low chair with her gown protected with an upper flannel and an under rubber apron, should take the infant, naked with the excep- tion of the binder and wrapped in a warmed blanket, upon her lap and proceed in the following way: Wash the face and head with warm water no soap and a wash cloth and carefully dry. Clean the eyes by squeezing a solution of boric acid (one teaspoonful to four ounces of water) from a thor- oughly saturated bit of absorbent cotton into the inner corner of each eye letting it run under the lids, the infant being placed on its back and the head turned to the right for the right and the left for the left eye; the cotton must be held quite close, a new piece used for each eye, and after the douching the wet cotton is passed over the eyes so as to gently wipe them. The infant being still on its BATHING 121 back, clear the nose with a little alboline dropped from a medicine dropper into each nostril, this causes sneezing with the expulsion of the softened nasal mucus. Wash the mouth with a small swab of absorbent cotton wet with normal saline solution, passing it gently over the whole surface, including the tongue, gums, cheeks and roof of the mouth; the nurse's finger must never be used. Clean the ears, so far as possible without penetrating the auditory canal, with warm, unsoaped water and a soft wash cloth. Next bathe the body with castile soap and warm water applied by a wash cloth, being careful not to wet the binder, then wash away the soap with a sponge, and, finally, pat the surface dry with a very soft towel. With girl babies, clean the external genitals, each day, with absorbent cotton saturated with boric acid solution. With boys, the foreskin must be retracted every other day and the parts gently bathed to remove all secretions. The daily full tub-bath is, as already stated, begun after the navel has healed, and is in some of its details similar to "sponging." This bath must be given by the monthly nurse so long as she remains in attendance; afterward the mother is the proper person, unless the nurse-maid be excep- tionally careful and experienced; and even in this event the mother should superintend the process. 122 HYGIENE OF THE NURSERY A tub with a supply of water, a piece of soft flannel for a wash-rag, absorbent cotton, a fine sponge, a bit of good soap and several soft towels are the necessary articles. A long apron made of soft flannel is also useful, and it is well to provide a low chair and a piece of oilcloth to place on the floor underneath the tub. The former enables the bather to get more on a level with her work and FIG. 15. BATH TABLE. a, a, elastic tapes for steadying tub. make a deeper lap for the child to rest in, and the latter receives any water that may be splashed about. A stand is now made to hold the baby's bathtub, Fig. 15, and is so contrived that it can be folded up and laid away when not in use. It is convenient, inasmuch as it obviates the necessity of stooping over, by bringing the child more on a level with the bather. It has straps and hooks attached to the sides to hold the tub firmly in place while in use. An ordinary oblong tin tub, painted white inside and large enough to give plenty of room, is to be BATHING 1 23 preferred to either a porcelain basin or a wooden tub. When in use, the tub should be placed on the floor, for the sake of firm support, or on the bath table, and afterward must be well cleaned, dried and aired. Water for the bath ought to be pure and soft, and should it be muddy or otherwise foul, the nurse must take the trouble to filter it. The character of softness is an important one, and when it is impos- sible to obtain anything but hard water from the ordinary sources of supply, a special provision ought to be made for the collection of rain water. The quantity used at a time should be sufficient to cover the child up to the neck when placed in the tub in a semi-reclining position. A matter of great importance is the temperature of the water. Some fortunately very few people use cold water from the first, under the impression that it is strengthening. So far from this being the case, cold water, instead of hardening, depresses the vital forces and frequently produces inflamma- tion of the eyes, nasal catarrh, and inflammation of the lungs and bowels. While cold baths are not to be recommended, one must not go to the other extreme, and use too hot water; for this also weakens the frame and renders it more susceptible to the attacks of disease. The initial temperature of 100 F. must be 124 HYGIENE OF THE NURSERY maintained in subsequent baths until the child is three or four months old, and then slowly reduced, so that by the end of the sixth month it is 95 and through- out the second year from 85 to 90, being somewhat lower in summer than in winter. As the heat of water cannot be estimated by hand with any degree of accuracy, it is essential to use a bath thermometer (Fig. 16). Place this instrument in the water and allow it to remain a few moments, so as to get a full effect upon the mercury. Should the water be too hot, it may be readily cooled by the addition of cold water, or, if too low in temperature, is easily raised to the proper degree by pouring in hot water. It is impossible to insist too strongly upon the necessity of uniformly using the bath thermometer. Several times in my experience a tin bathtub has been filled with water so hot that its sides burned the delicate skin of the little hand placed upon it. Fortu- nately, in such instances, the conse- quent screams led to careful investi- gation, and no serious damage resulted. On the FIG. 16. BATH THERMOMETER. BATHING 125 other hand, I have felt the water cold enough to pain the fingers. Don't neglect the thermometer, then! A piece of flannel is very useful for the first part of the bathing. It readily takes soap, and, being soft, can be thoroughly rubbed over the skin with- out danger of injury. A large, soft sponge, how- ever, is best suited to the finishing of the bath, for it holds more water than a flannel wash-rag, and enables the bather to stream the water over the child's body, and thus get the stimulating effect of a miniature shower bath at the same time that the dirt and superfluous soap are washed away from the surface. The wash-rag and sponge must, by the way, be the child's exclusive property, and are not to be used twice in succession without being thoroughly cleaned and dried in the open air. Unscented Castile or glycerin soaps are the best to use. Common soaps are irritating to the skin, and even the purest and most bland articles must be employed with care, that is, neither too frequently not too profusely, lest they lead to ec- zema or other cutaneous disorders. When any skin disease is present, the physician's advice must be had not only as to the use of soap, but also in refer- ence to the propriety of the bath itself. Two towels are required for each bath. These should be large and composed of fine, soft material. 126 HYGIENE OF THE NURSERY They must be dry and warm, and perfectly clean before they are applied to the surface of the child. The bath apron should be made of two pieces of soft, white flannel; one long enough to extend from the waist almost to the feet of the bather, and broad enough to completely cover the front of her gown; the other quite as broad but about four inches shorter. Both pieces are sewed to a waist belt, forming, in reality, two aprons; the upper of which is thrown over the shoulder when the infant is being lifted from the tub, and then used as a dry and warm covering when he reaches the lap. After the bath, the apron, being more or less wet, must be taken off and thoroughly dried. Several such arti- cles should be provided, as they must be frequently washed to keep then clean and free from odors. Any low chair will do to use in bathing, although as those usually sold have not a sufficiently broad seat to give a comfortable support, it is better to make one by sawing off the legs of an ordinary wooden kitchen chair. The bath must be given at a regular time each day. The best hours are in the morning, midway between two feedings, and in the evening, just before the infant gets his last feeding and goes to bed. The first is perhaps the better hour, but regularity is the more important point. BATHING 127 At the time selected, place the tub containing the water, heated to a proper temperature, in a warm and sheltered part of the room, and around it ar- range, within convenient reach of the hand, the various requisites of the bath. Upon undressing the child, wet his head first; then let the head and shoulders rest on the left forearm and lower the child gently into the water, that his body may be covered as far as his neck. Take a wetted and soaped flannel wash-rag in the right hand and pass it rapidly but thoroughly over the body, avoiding the eyes. Pay particular at- tention to the arm-pits, to the region between the folds of the buttocks and to the groins. This done, take a large, well-filled sponge in the right hand and squeeze the contents over the body. The chief force of this miniature douche must fall upon the back and loins, and the child, during the operation, must be lifted clear of the bath-water by the left arm and hand. The sponge is used simply to clear off the dirt loosened by the wash-rag, and to remove all super- fluous soap; therefore, when this is accomplished, the child shou ] d be lifted from the tub to the lap and enveloped in a towel, or, better still, in the loose folds of the bath-apron. The drying process now begins and consists in absorbing the moisture from the skin. This is done by a series of very 128 HYGIENE OF THE NURSERY gentle patting movements with a towel folded over the palm of the hand. In drying a baby, special attention must be given to those portions of the body where the natural folds form crevices in which water may lodge. Unless these parts be thoroughly dried, serious consequences may ensue. If it be retained in a normal crevice the fold of the but- tocks or behind the ears it causes in a short time troublesome excoriation. "Never allow anything smaller than the elbow to enter the ear" is excellent advice; although during the bath should water get in and be allowed to re- main it may lead to earache and abscesses, and in extreme, though not rare, cases, to deafness. In the event of this a blunt cone formed out of a soft handkerchief or of absorbent cotton will quickly absorb the moisture, and will do no harm if inserted but a very short distance within the orifice. The nose can readily be cleaned by dropping alboline into the nostrils, or by the very careful use of a small cotton swab, especially if a little vaseline be added to facilitate the process. The mouth must be washed in the way already described, with a swab of absorbent cotton, and this is to be done only twice daily, not before or after each feeding. The male and female genitals must receive the same attention as in " sponging," but in regard to the former, after the first year it is BATHING 129 quite sufficient to retract the foreskin and wash the parts, once or at most twice a week. After the infant is patted perfectly dry not rudely rubbed with a towel the whole surface, but es- pecially the region on either side of the spine, should be rubbed with the naked palm until the skin be- comes slightly red. This modified massage ends the bath, and the child must then be dressed as quickly as possible. Several important points yet remain to be men- tioned. Never give a bath immediately after a meal nor when the child is either cold or overheated. Never suddenly or rudely plunge the body into the water; never allow the time of actual immersion to exceed five minutes, and during the first three months limit it to two minutes. Under no circum- stances should the head and face be allowed to dip beneath the surface. Should this happen, the child will become so frightened that it will be difficult to get him to enter the water again. And here, by the way, it may be well to state that if there be repug- nance to the bath, the tub may be covered over with a blanket, and the child, being placed upon it, may be slowly lowered into the water without seeing anything to excite his fears. While the infant's head should be wet before each bath, it must not be washed every day. Too fre- quent cleaning and the too frequent use of soap dry 130 HYGIENE OF THE NURSERY the skin and lead to seborrhoea or other cutaneous disorders; once a week is quite often enough to wash the scalp. The buttocks and thighs require bathing after each bowel movement; this should be done with simple warm water and absorbent cotton, and after the parts are thoroughly cleansed they must be as carefully dried before adjusting a fresh napkin. The question of the propriety of using powder after a bath is often asked by mothers. Powdering has always seemed to me to be a lazy way of absorb- ing the moisture that should be taken up by a dry towel, and unless there be some excoriation or other indication for its use, the skin can be kept cleaner and healthier without it. In cases, too, in which some disorder of the skin would seem to warrant its employment, better and quicker results are ordi- narily obtained by the application of cold cream, oxide of zinc ointment, or vaseline. The rule of one bath a day may be exceeded in very hot weather, when, in addition to the morning full bath, the body may be sponged twice daily with water at a temperature of 85 to 90 F. This, con- trary to what might be expected, has a greater and more permanently cooling effect than bathing with cold water. From what has been written, one might suppose that the details of an infant's bath are endless. So BATHING 131 they must seem when given in full. A skilful bather, however, ought to fulfil every requisite and com- plete the bath in a period of time not exceeding twenty minutes at the very outside, and this must include not only the actual five minutes' immersion, but the preparation of the bath and the drying process. The full bath should be omitted under the follow- ing conditions: in all cases of acute illness until the physician has seen the child; when there is eczema or other skin affection, and in feeble and delicate infants to avoid the risks of exposure^and fatigue. After the third year three full baths a week are quite sufficient. An evening hour is now to be preferred, but the water must be heated to 90 F. in winter, though it may be cooler in the heat of summer. While, at this age, the child has his three full baths weekly, for the purpose of securing absolute cleanliness he must be sponged every day with water, cool or warmed to the season. The sponge bath is best given in the morning, soon after the child has roused himself from sleep and before any food is given. The nurse, for this, must provide herself with a large basin containing water at a temperature of 75 in summer and 85 in winter, a large, fine sponge and several towels. The bath-apron being donned and the child's night- 132 HYGIENE OF THE NURSERY clothes removed, the sponge filled with water is passed rapidly over the whole surface of the body; then the child must be wrapped up in the apron and the skin first dried gently with a soft towel and then rubbed into redness with the open hand. When this process is. completed and it should be done in at least ten minutes the clothing is put on rapidly, and the child is ready and usually hungry for his morning meal. No soap need be used in these baths. In the tri-weekly cleansing bath the process of washing is much the same as in infancy. That is, the bathtub being filled with water at a temperature of about 90, the child is put into it up to his neck and thoroughly soaped with a wash-rag, and next douched clean with a large sponge. Here, also, the head must be wet first; the body immersion must not last longer than five minutes, and the dry- ing must be done quickly and with a patting rather than a rubbing movement. Ample reaction of the skin must be secured by gently rubbing with the palm of the hand, especially over the spine. The washing of the head is a most important matter, as it cleanses the scalp, prevents the for- mation of scurf, and adds beauty to the hair. At the same time the nurse must be careful how she dries the hair. To rub it gently with a soft towel and then brush it out with a fine hair brush is the BATHING 133 proper plan. Combing, in so far as it means dress- ing the hair and cleansing the scalp with a fine comb, must never be allowed, as it not only thins the hair by pulling it out by the roots, but also irritates the scalp and produces eruptions upon it. As the child approaches puberty he must gradu- ally be taught to wash himself, and should be en- couraged to form the habit of bathing every day. The bath at this age should be a sponging rather than a soaking process; it is best taken in the morn- ing directly after rising, and the temperature of the water may range from 65 to 75, though delicate children may require it warmer, especially during winter weather. When childhood merges into youth, while the sponge is still preferable to the plunge, water may be used, all the year round, just as it flows from the faucet. The temperature will be, of course, quite low at times, but so long as the bath is taken in a warm room, completed quickly, and followed by a sense of stimulation and warmth, nothing but good results. Whatever room be used for the purpose of the toilet, the child, if he be old enough to bathe him- self, should occupy it alone, so that the whole body may be stripped naked; otherwise washing cannot be thoroughly or effectually accomplished. A boy should wash his head each morning; a 134 HYGIENE OF THE NURSERY girl, who has long hair, at least once a week. Any loitering over the bath is attended with the danger of chilling. Never occupy more time than fifteen minutes in the whole process. These daily sponge baths are ordinarily quite sufficient to keep the person perfectly clean. Some- times, however, it is necessary to take, in addition, a full warm bath at intervals of a week. These baths are relaxing if too prolonged; ten minutes is the maximum time for remaining in the water. After leaving the tub there must be no exposure to draughts. The best hour for such a bath is in the evening; some time after the last meal and just before going to bed. Sea-water baths are useful for a child of any age, although ordinary sea bathing is not to be recom- mended until the child is old enough and strong enough to hold his own in a moderate surf after the eighth year, for instance. A younger subject may, when at the seaside, be dressed daily in a bathing suit and allowed to splash for a time at the edge of the surf. The process of carrying a child against his will into the waves and immersing his head, as is often done, is cruel and productive of so much terror that more harm than good results. In our climate, the proper season for sea bathing is from the middle of June until the middle of September. - BATHING 135 On arriving at the coast, it is always well to pre- pare for the plunge in the sea by giving, on the first day, a warm salt-water bath. On the day following, about three hours after breakfast, the child may don his bathing dress. Immediately on entering the water, the head must be thoroughly wetted. After this, the bath may be protracted for fifteen, or at most twenty, minutes. To get the invigorating effects of a surf bath, it should never be repeated oftener than once a day, and in some cases it is better to allow a day to intervene, or even to enter the water only twice a week. Drying and dressing should be rapidly performed, and a half- hour's brisk walk is very useful in promoting re- action and causing free circulation of the blood. Should the bather feel faint after coming out of the water, he must be wrapped in towels and given half a tumblerful of milk containing one or more tea- spoonfuls of brandy or whisky, and the succeeding baths should be at longer intervals and for shorter periods, or the} must be discontinued if their effect is uniformly depressant, and a daily sponge bath of equal quantities of salt and fresh water substi- tuted. When the child is either cold or perspiring freely, the bath must not be undertaken. The bathing suit should be of light flannel, made in one piece like a pair of moderately loose night drawers, but with short arms and legs; it should 136 HYGIENE OF THE NURSERY open only over the shoulders, where, when put on, it is fastened by buttons. This arrangement permits of easy removal after the bath when the flannel is saturated with sea water, and is, in consequence, heavy and sticky. The question of sea bathing suggests that of swimming. Boys, and girls too, should early learn to swim. The art is not only a safeguard, but a means of most pleasant and invigorating exercise. It develops the muscles, expands the chest, aids digestion, strengthens the whole frame, and pro- motes energy, courage and self-reliance. Swimming, like every other exercise, must be taken in moderation. Even with this care it is not always beneficial. The bather should leave the water experiencing a pleasant glow over the whole surface of the body; the spirits and appetite should be increased, and there ought to be a sensation of augmented strength. If, on the contrary, it should disagree, there is a sense of chilliness, with lassi- tude and depression of spirits; the face is pinched and pale, and the lips and finger-nails are apt to look blue. Swimming in salt water is more invigorating than in fresh. Apart from the different quality of the two waters, the battling with the waves in the former case is more exhilarating, and the sea breezes, blowing upon the body, carry with them health BATHING 137 and strength. Every one must have noticed the increased softness and beauty of the skin and the greater lustre of the hair after a sojourn at the sea- side. It may be serviceable next briefly to detail the different baths in common use as well as those most often directed by physicians, with some reference to their effects upon the system. Concerning temperature, the bath may be: 1. Cold, temperature 50 to 65 F. 2. Cool, temperature 65 to 75 F. 3. Temperate, temperature 75 to 85 F. 4. Tepid, temperature 85 to 92 F. 5. Warm, temperature 92 to 98 F. 6. Hot, temperature 98 to 112 F. When giving a cold bath, strip the child in a warm room, and rub him thoroughly with the palm of the hand until the whole body, especially the spinal region, is warm. Let him then stand in a tub con- taining enough hot water to cover the feet, and sponge him rapidly with cold water. The tempera- ture of the latter must never be below 50 F., and 65 is usually cold enough. The addition of half an ounce of rock salt or a tablespoonful of concen- trated sea water to the gallon, renders it more stimu- lating and insures a complete reaction. After sponging, the surface must be thoroughly and quickly dried with a soft towel and rubbed with the open hand until aglow. 138 HYGIENE OF THE NURSERY This bath, provided the degree of cold does not exceed the resisting powers of the child, is a power- ful tonic, producing rapid tissue changes and in- creasing nutrition. Should the water be too cold, or the sponging continued too long, reaction does not follow the primary shock, and the result is fa- tigue, exhaustion, or even dangerous prostration. This bath, therefore, must be used with caution and only under a physician's advice. The cases in which it is of most service are those in which there is a sluggish circulation with poor appetite and feeble digestion; in which the nutrition is impaired, as in rickets, and in certain spasmodic nervous disorders. A cooled bath is sometimes prescribed, and may be employed with advantage in conditions attended with very high fever. The child is first immersed in water at 95, and this is gradually lowered to 70 by the addition of cold water, the process occupy- ing from fifteen to thirty minutes. Analogous to this bath is the cold pack. Fold a sheet in such a way as to be long enough to extend from the child's arm-pit to his feet, and wide enough to encircle completely his body; dip it in water at 90 and lay it smoothly upon a cot, the mattress of which must be protected by a rubber mackintosh. When all is in readiness, place the child upon the sheet, and wrap it around his body and legs. A BATHING 139 blanket must then be thrown over the sheet and the pack left undisturbed for ten minutes. Then lift the child out quickly and envelop him in a warm blanket and allow him to remain at rest for some little time. In the absence of the physician, sponging with water at a temperature of 85 to 95 is the only safe bath to employ to reduce temperature. In giving this bath, strip the child and place him in bed between blankets, while the nurse, inserting her hand between, must pass a damp sponge slowly over the surface. Five to ten minutes may be con- sumed in this operation, although if the child com- plain of chilliness, discontinue the sponging at once; a sensation of cold, too, indicates the use of warmer water. The operation may be repeated several times daily, or as often as every two hours in urgent cases, and when the heat reduction is of short duration. The hot bath, 98 to 112, is employed for vari- ous purposes to relieve nervous irritability, to promote sleep, to produce sweating, and to draw the blood to the surface in the event of congestion of some internal organ. Whether a full bath or merely a foot bath be required, five minutes is suf- ficient time for immersion; then, with or without drying, according to the degree of sweating desired, the whole body, or only the feet and legs in case 140 HYGIENE OF THE NURSERY of a foot bath, must be enveloped in a blanket, and the child put to bed. To render these baths more stimulating, a teaspoonful to a tablespoonful of mus- tard flour may be added, and the child held in the water until the arms of the nurse begin to tingle. The hot bath is purely stimulating, and it is impor- tant not to continue it too long, lest the primary and only desirable effect be followed by depression. The blanket bath is useful in producing perspira- tion. Wring a blanket out of hot water and wrap it around the child: then throw three or four dry blankets over him and leave him for half an hour. Rub the body then with a soft towel to absorb the moisture thoroughly, and keep the child in bed. There are several medicated baths in frequent domestic use, which it may be useful to describe. Mustard Bath. Take from two teaspoonfuls to two tablespoonfuls of mustard flour; hot water, two to four gallons. In the form of a foot bath it produces sweating and determines the blood to the surface. As a general bath it acts as a powerful stimulant. Salt-water Bath. Take four tablespoonfuls of rock salt, or Ditman's sea salt, or concentrated sea water; water, warm or cool, according to season, four gallons. To be used as a general bath every morning in chronic tuberculosis, scrofula, rickets, and general BATHING 141 debility. Bath to be followed by thorough rubbing of the surface, especially over the spine. Bran Bath. Take one pint of bran; tie up in a muslin bag, place in a quart of water, boil for an hour, squeeze bag thoroughly into the water, and add to four gallons of warm water. Useful in eczema and other skin diseases. Soda Bath. Take one tablespoonful of bicar- bonate of sodium; warm water, four gallons. Used in skin affections. Hot air or Vapor Bath. The body-clothing being removed the child is laid upon a bed, the bed- clothing is pinned tightly about the neck so that the head only is outside, and raised about a foot above the body by an arrangement of hoops or a wicker support. Hot air or vapor is then introduced be- neath the raised bed-covering from a croup-kettle. This bath causes free perspiration in from ten to twenty minutes, and may be continued for twenty or thirty minutes unless f aintness or giddiness be pro- duced, when it should be stopped at once. Such baths are especially useful in case of suppression of the urine, and in uremia. Disinfectant Bath.* Take six and one-half ounces of liquid carbolic acid (90%), four ounces of glycerin, and four gallons of warm water (98 F.) ; or six ounces of solution of chlorinated soda and *See Chapter XI. 142 HYGIENE OF THE NURSERY six quarts of warm water. Applicable for disinfec- tion of the person after an attack of scarlatina or other contagious disease. Neither of these solutions is as efficient as bichloride of mercury in the pro- portion of i to 5000, but this is such a poisonous substance that it should never be used without a physician's oversight. Compresses are often useful. The wet compress consists simply of a roll of flannel or soft linen dipped in cold or hot water, according to circum- stances, and wrung out and then applied to the part indicated. Cover this with a piece of oiled silk rather larger than the compress. There are several matters that bear a more or less close relation to the subject of bathing. These are the care of the teeth, nails and hair. The teeth must be cleaned morning and evening, and the cleaning process must be begun with the appearance of the first tooth. Ordinarily, a soft wash rag folded over the forefinger, or swab of absorbent cotton dipped in cool water and thor- oughly rubbed over the teeth, is sufficient to keep the early teeth clean, and does not injure the tender gums. Should a dark-colored scum form at the junction of the tooth and gum, a little prepared chalk or other bland tooth powder may be used in addition. If it be impossible to get at the point of discoloration in this way, shape with a penknife a BATHING 143 moderately hard bit of wood into the form shown in Fig. 17, then rub the woody fibres at the ex- treme end into a sort of brush, wet this, dip it in the toothpowder and gently rub at the discolor- ation until it disappears, taking care not to make the gum bleed. Over a piece of wood so shaped one may also wrap a bit of soft cambric and use water and powder as before. Take good care of the milk teeth, for if they become decayed and broken off or lost, their permanent substitutes are apt to come in ir- regularly and produce a lasting , FIG. 17 STICK FOR deformity. CLEANING TEETH. The tooth brush can be used after a number of the milk teeth have been cut. The bristles should be very soft and fine, and it must be employed with gentleness. Unless there should be some discoloration, no powder need be used. The child should early learn to clean his own teeth. The importance of taking care of the toe-nails has already been referred to in the chapter on cloth- ing. The finger-nails should not be allowed to grow too long; at the same time it is a bad plan to cut them close to the quick. In trimming them, use a moderately dull pair of scissors, and do not 144 HYGIENE OF THE NURSERY round them too much. When hang-nails appear, they must be cut close with sharp scissors. The fingers and toes should be inspected carefully after each bath, to see if they require attention. Directions have already been given in regard to washing the hair. All that remains to be said now is to repeat the caution against the use of a fine comb, and to protest against the employment of hair oil and hair washes. The best scent for the hair is an occasional dressing of soap and water; the best beautifier is a thorough brushing with good brushes, and the latter should be employed every morning and evening. Besides keeping the long hair of a girl free from scent and grease, do not dress it over the ears or tie it up tight and make it " like a cap of iron over the skull." If the hair be well brushed and the scalp thus sufficiently stimulated, there will be enough natural oil secreted to keep it tidy; artificial oily applications only act temporarily, and by blocking up the pores of the skin tend to make the hair drier and harder to keep in order. Should there be a tendency for the hair to fall out, wash the scalp thoroughly and frequently with soap and water, and stimulate it by firm brushing and the use of a wash such as the follow- ing: BATHING 145 Take of Aromatic spirit of ammonia i fluidounce. Tincture of cantharides i| fluidrachms. Glycerin | fluidounce. Rose water 7 fluidounces. Mix. A tablespoonful of this may be rubbed into the scalp once every day, the rubbing to be followed by washing with a sponge and vigorous brushing. In such cases, however, it is best to seek the advice of a physician, for falling out of the hair may be due to a variety of causes. CHAPTER VIII. FOOD. The choice of food and the method of feeding bear so close a relation to age that it is necessary, in studying these questions, to regard them from the stand-point of the two stages of a child's life mentioned in the first chapter; that is to say, the periods of infancy and childhood. Infancy. An infant may be fed in one of three ways: i, from the mother's breast; 2, from the breast of a foster-mother or wet-nurse; and, 3, from a bottle, by the method known as artificial or hand-feeding. i. Feeding from the maternal breast. There can be no doubt that this, being the natural, is at the same time the proper method of nourishing the human infant; and fortunate is the baby that, in our day of advanced civilization and city living, can draw from the breast of a robust mother an abundant supply of pure, health-giving, tissue-build- ing food. It follows, therefore, that every woman who is free from certain contraindicating diseases, to be 146 FOOD 147 mentioned later, should nourish her child solely from her breast up to the age of eight months, and partially to the end of the first year, or, failing in either limit, as long as possible. The infant should be put to the breast as soon as the mother has recovered somewhat from the fatigue of labor some four or eight hours after birth. Of course no milk can be drawn at this early date, but the baby gets a small quantity of thin, watery fluid, called colostrum, which affords sufficient nourish- ment, and at the same time, from its laxative prop- erties, clears away the greenish or black viscid material that collects in the infant's intestinal canal during intra-uterine life. This procedure, too, is of great advantage to the mother, for it insures proper contraction of the womb, draws out the nipples, and encourages the formation of milk. As the secretion of milk is never fully established until the third day after labor, it stands to reason that no food other than the colostrum is required before that time. Hence, the practice of filling the infant's stomach with gruel, sugar and water, and other sweetened mixtures, is more than useless, for it diminishes the activity of sucking and the conse- quent stimulation of milk production. Put the child to the breast every two hours while the mother is awake, and there need be no fear of starvation. After the third day, should the breast not yield 148 HYGIENE OF THE NURSERY a supply of milk, a mixture of cream, two teaspoon- fuls, whey and water each three teaspoonfuls, and one-fourth of a teaspoonful of sugar of milk, may be given every fourth hour, the baby being put to the breast in the meanwhile. When the flow begins, however, the artificial feeding is to be dis- continued. Usually on the fourth day milk is secreted and regular lactation commences. Many untrained mothers make a failure of nursing because they know nothing of the manner of giving suck; of the length of time the child should be kept at the breast; of the proper time for and interval between feed- ing, and the importance of regularity. Upon these points the physician should give minute in- structions. When giving the breast, the infant must be held partly on its side, on the right or left arm, accord- ing to the gland about to be drawn from, while the mother must bend her body forward, so that the nipple may fall easily into the child's mouth, and steady the breast with the first and second finger of the disengaged hand, placed above and below the nipple. In case the milk runs too freely a condi- tion very apt to excite vomiting the flow is easily regulated by gentle pressure with the supporting fingers. Each of the breasts should be drawn alter- nately, the contents of one being usually sufficient FOOD 149 for a meal; and a healthy child may be allowed to nurse for fifteen minutes or until satisfied, when he will stop of his own accord, drop the nipple and fall asleep with milk still flowing over his lips. During the first six weeks the breast is required every second hour, from 6 A. M. until 10 p. M. At night the infant should be put in a crib by the mother's bed, or in an adjoining room, under the care of a competent nurse, and there remain quietly until the morning feeding. This secures the mother eight hours of uninterrupted repose, a matter of great importance to her general health and consequent capacity for prolonged lactation. As to the infant, he may rebel at first, and wake and cry, so that it is necessary to quiet him with a little milk and water administered from a bottle; but often, after a few days and certainly at the end of a week or two, the good custom of sleeping at night is formed, and there is no further trouble. Regularity in meal hours is even of more impor- tance in early than in adult life, on account of the natural feebleness of digestion, and, further, regular nursing has a marked influence upon the maternal food supply, for it is a fact that breasts which are emptied at fixed intervals produce more and better milk, than those called upon irregularly and too frequently. To secure regularity, it is only neces- sary to have a little perseverance, for infants are 150 HYGIENE OF THE NURSERY such creatures of habit that a short training brings them into the way of expecting food only at cer- tain times, and, when healthy, they wake to suck the breast with almost the precision of the clock. While insisting upon this rule, one must recognize the fact that, although in the vast majority of instances a two-hours' interval is most suitable up to the second month, there is no absolute law as to the number of daily nursings. Some infants seem to need food less frequently, and it is best to respect their peculiarity and not force the breast upon them so long as they sleep well, do not fret when awake, and thrive generally. Others, again, may require it oftener, every hour and a half, per- haps, and once or twice at night. In these excep- tional cases an appropriate schedule can only be made by close observation of individual character- istics. A common and most ruinous mistake is to resort to constant feeding as a means of pacifying crying. Babies certainly do cry from hunger, but just as frequently the crying results from colic, or from the discomfort and pain of indigestion. Every mother should be able to recognize the difference. The cry from hunger usually begins after a sound sleep. It is not peevish, and stops at the sight of the breast, when the infant rouses himself, presents an expres- sion of pleasure, clinches his hands and flexes his FOOD 151 limbs. The cry of colic is violent and paroxysmal; the face is livid and wears an expression of suffer- ing; the abdomen is distended and hard; the hands and feet are cold; the legs are drawn up or kicked violently about ; and an explosion of wind from the mouth or bowels ends the attack. A peevish cry, hot skin and sour breath attend indigestion. It stands without saying that the cry of hunger must be relieved by giving food; but this is the very worst thing to do under other circumstances, for it both breaks up good habits and produces serious mischief. The pain of colic and the discom- fort of indigestion are chiefly due to the accumula- tion of flatus resulting from the fermentation of food. Mothers soon learn, and unfortunately infants too, that the breast milk temporarily relieves suffering. This it does in the same way as any other warm liquid; but, unlike a simple fluid, milk only adds more material to the already fermenting con- tents of the gastro-intestinal canal, and every nurs- ing is soon followed by more pain, until between cry- ing and sucking and sucking and crying, the infant's life is passed in misery, if not cut short altogether. Instead of continuous feeding, the plan for relief is to decrease the quantity of food by increasing the intervals between nursing and by abridging the time of lying at the breast. After the sixth week the interval between nurs- 152 HYGIENE OF THE NURSERY ings may be slowly increased until, by the fourth month, it reaches three hours. During this period, also, the time of lying at the breast may be gradu- ally lengthened to twenty minutes, for the quantity of milk secreted and the child's appetite and capacity for food are all augmented as the days pass by. At the end of the sixth month, feeding every fourth hour suits some children well, but as a rule the three-hour interval must be adhered to from the fourth month to the end of lactation. Many authorities recommend additional artificial feeding, alternating with nursing, after the sixth or eighth month. This plan of mixed feeding is perfectly proper, if the baby ceases to gain strength and flesh while on the breast. If otherwise, the maxim of not interfering with any course that is doing well is as applicable here as elsewhere, and the breast may be relied upon entirely until the time comes for weaning. Should additional nutri- ment be required, the food must be selected with due reference to age and prepared in the same manner as in regular bottle-feeding, and employed only to supplement the breast milk, which must be conserved as long as possible, since even a little natural food is of great value in insuring proper growth and development during the earlier months of life. It is a good plan, however, even when breast- FOOD 153 feeding is progressing satisfactorily to begin, about the fifth month, to substitute one nursing daily by a bottle; this allows the mother more freedom for rest and recreation, and, at the same time, accus- toms the infant to being artificially fed, and in- creases the ease of weaning when this becomes necessary. Another means of facilitating the substitution of the bottle for the breast is to begin early to use it in giving the drinking water, which every baby requires three or four times daily. The date of weaning cannot be fixed for all cases, since it must depend upon two conditions the health of the mother and the development of the child. When the former continues to be robust and the child steadily grows and gains flesh, lacta- tion can be prolonged until the tenth month. Usually if persevered in longer, the mother's strength begins to fail, her milk is lessened in quantity or becomes poor in quality, the child's nutrition suffers, and he grows pale, thin and flabby, and may develop the disease known as rickets. Not- withstanding the age, the beginning of summer is a bad time to wean an infant, and unless the indi- cations for withdrawing the breast are very urgent, it is better to postpone the change until the hot months have passed, resorting, in the meantime, to artificial feeding as a supplement to any deficiency in the maternal supply. 154 HYGIENE OF THE NURSERY Change in the manner of feeding may be accom- plished gradually or suddenly. In gradual wean- ing, about four weeks are required to prepare for the absolute withdrawal of the breast. For instance, if suck be given every three hours, or six times a day, there should be, during the first week of prepa- ration, one artificial feeding and five nursings daily; during the second, two and four; during the third, four and two; during the fourth, five and one. Then the breast must be entirely withheld. Care- fully prepared milk-food, administered from a bottle, is the best substitute. At the age of ten months a mixture that ordinarily agrees well is: 1$. Cream i tablespoonful (fld. oz. J). Milk 8 tablespoonfuls (fld. oz. 4 ). Sugar of milk i teaspoonful. Water 3 tablespoonfuls (fld. oz. i). This is to be poured into a perfectly clean bottle, warmed in a water-bath, and taken through a clean, plain rubber tip. Should the quantity (six fluid- ounces*) be insufficient to satisfy the child's appe- tite, the milk and water may be increased until the mixture measures eight fluidounces. When such accidents as fever or disordered diges- tion, with vomiting and diarrhoea, occur during the period of preparation, the number of artificial * One fluidounce = two tablespoonfuls. One fluidrachm = one teaspoonful. FOOD 155 feedings must be reduced, or the breast resumed until the disturbance be passed; then the course may be begun again and carried to its completion. Usually there is little trouble in weaning infants in this way. Sometimes they become fretful under the change and may refuse food entirely for a day or more; but a little determination on the part of the mother and the cravings of hunger will soon overcome this difficulty. Occasionally the child refuses to suck milk from a bottle or to drink it from a cup or spoon in fact seems to object to any form of liquid food except that drawn from the mother while at the same time he is eager for bread or other solid food. Under these circumstances prepare for each meal a moderate portion of either rice pudding or junket. After these have been taken for a day or two, add to each meal a little milk, reducing the amount of pudding or junket; stir the whole together and feed from a spoon; next day still further reduce the solid and increase the liquid, and so proceed until finally a taste for milk is cultivated. Sudden weaning is not advisable unless, while the breast is being presented, there is an absolute refusal to take artificial food from either a bottle or a spoon. This is most apt to occur when food has been given too frequently, and when the breast has been used as a means to quiet crying. The plan is 156 HYGIENE OF THE NURSERY also to be recommended when the mother's health becomes so affected as to render any further suck- ling a positive peril to the child's life; attacks of erysipelas or of small-pox are instances in point. The physician is often forced to decide upon the advisability of premature weaning. His decision must be made cautiously and after thorough in- vestigation of two propositions, namely: a, the effect of further lactation upon the health of the mother, and b, the requirements of the child. a. Lactation being a physiological process is not a drain upon the systemic strength so long as the functions of nutrition are actively performed, but under other circumstances it very frequently be- comes so. A mother must make no attempt to nurse if she has tuberculosis, advanced cardiac or active kidney disease, hysteria, epilepsy, marked anaemia, cancer, goiter, or is septic or convulsed after child-birth. Premature weaning is necessary when the mother is attacked by a contagious disease or by any acute disease threatening dangerous temporary prostration, such as typhoid fever. Ordinarily, however, the general condition that leads to with- drawal of the breast is one of simple loss of strength and flesh on the part of the mother. Undoubtedly these indications often warrant the procedure, but every one who has seen much of children's practice must have met with many cases in which the advice FOOD 157 to wean has been given carelessly and unnecessarily, and in which the child might have had its natural food had proper attention been given to the health of the mother. If a woman be worn out by household cares; if she wear herself out by a round of dinners, balls or shopping, or if she expose herself to injurious at- mospheric conditions and eat improper food, she grows weak and thin whether she be nursing or not; and a woman heedless of her health will prob- ably care little whether she suckles her child or gives it up to a wet-nurse or to the bottle. In addition to making nursing the important duty of her life for the time being, a mother must be as free from household cares as possible. Mental and physical fatigue must be avoided, sufficient exercise must be taken to maintain a healthy appetite and digestion, abundant time devoted to rest and sleep, and regular evacuations of the bowels secured. As to diet, the nursing mother requires a plentiful supply of fluids and of plain and easily digestible food, with a judicious portion of meat, vegetables, and fruit. She should eat three regular meals daily, with a cup of milk, cocoa or gruel at early bed-time, and in some cases between meals. She may be allowed eggs, plainly cooked; cereals and nearly all soups and vegetables; sweet fruits, and meat, usually once and never more than twice a 158 HYGIENE OF THE NURSERY day; but must avoid acid fruits, salads, pastry and rich desserts; tea and coffee, except in extreme moderation, and wine or beer absolutely. Should the secretion of milk be scanty, it may often be increased by the free use of animal broths, chocolate, gruel, or milk, and sometimes the em- ployment of a good malt extract may be necessary. Such tonics as ferrated elixir of cinchona, bitter wine of iron, and the preparation known as "beef, wine and iron," are useful when there is anae- mia, or when the general failure of strength can- not be overcome by food and attention to hygienic rules. The ordinary local conditions indicating the necessity of premature weaning, on the mother's account, are fissures of the nipple, and mammary abscess. Fissure being usually a unilateral condition, it is only necessary to retire the affected side from duty and nourish the child alternately from the unaffected gland and from the bottle until healing takes place, the disabled breast being pumped or massaged in the meantime to keep up secretory activity. Should both sides be affected, weaning may be imperative, on account of the extreme pain pro- duced by sucking, although, even under these circumstances, an effort must be made to maintain the flow of milk by regular pumping. Sometimes FOOD 159 women are able to struggle through the attack by taking advantage of the relief and protection afforded by a nipple-shield. Fissures of the nipple may be preceded by vari- ous diseases of the delicate skin of the part. They result, also, from want of cleanliness or from keep- ing the nipple too moist, and when constant sucking is allowed or when there is a continual flow of milk. They may be prevented by proper attention to the nipple before confinement. During the latter months of pregnancy the clothing covering the breast must be loose, and the wearing of a wire tea- strainer over the nipple to prevent pressure has been recommended by one authority. Each day, for three months before labor, the nipples should be washed thoroughly with hot water in the even- ing and anointed with cocoa-butter in the morn- ing. At the same time, should the nipples be small or retracted, the woman must be taught to use her thumb and finger to draw them out. This process is not only an advantage in giving proper size and shape, but brings the skin into good con- dition without hardening it. The application of alcoholic and astringent lotions is not to be recom- mended. They tend to harden the tissue, which should be soft and pliable rather than tanned, and render the nipples liable to crack. When a fissure exists, it is best first to see whether l6o HYGIENE OF THE NURSERY or not nursing can be continued by means of a nipple-shield. Should the child refuse this, a good plan is to fill the shield with warm milk and invert it over the nipple. The infant then draws the fluid at once and without difficulty, and will often con- tinue sucking until the breast milk follows. After nursing and removing the shield, the nipple must be dried thoroughly with absorbent cotton, and the following lotion applied with a camel's-hair brush : Take of Boracic acid 20 grains. Mucilage of acacia i fluidounce. Mix. Mammary abscess requires careful surgical attention. b. On the part of the infant, there are several in- dications for anticipating the time of withdrawing the mother's breast, but this is always a serious matter and must never be advised without most careful consideration. The occurrence of pregnancy during lactation necessitates immediate weaning, but this is by no means the case with the re-establishment of men- struation. Usually the function of the breasts stops on the return of the monthly flow, and sometimes, while secretion continues, the milk is so altered in quality as to be unfit for food; but, at others, though the quantity may be diminished, the quality is unchanged and the infant keeps well and gains FOOD l6l steadily between the periods. Under these con- ditions the baby should be kept at the breast, though it may be advisable, during the first day or two of menstruation, to feed partially or entirely from a bottle. Premature weaning is also necessary if the mother contracts a dangerous contagious disease, as small-pox, scarlet fever, or erysipelas; if the mammary glands become inflamed; if the breast does not afford sufficient nourishment and artificial food be refused; and, finally, if dentition be markedly delayed and the premonitory symptoms of rickets appear. As to the amount of nourish- ment, it must be remembered that the breast milk may be of good quality, but so diminished in quantity that it is insufficient; or, while abundant in quantity, so poor in quality that it does not meet the demands of nutrition. Even without a minute examination of the milk, it is possible to form a good idea of which condition is present from the behavior of the infant in the act of sucking. If the milk be good in quality but deficient in quantity, the baby, when put to the breast, seizes the nipple as if famished and draws upon it vigorously for a time, and then drops it with a scream of rage. On the contrary, should there be an abundant supply of poor milk, the nipple is grasped languidly, the child lies a long time at the breast and falls asleep there. Consideration of the final indication 1 62 HYGIENE OF THE NURSERY opens the question of the propriety of regulating weaning by the progress of dentition. This is certainly a good guide, but not in the way im- plied in the old precept, that the child must not be taken from the breast until evolution of the stomach and eye teeth. Insufficient food is one of the chief causes of rickets, and rickets more than any other disease delays dentition; consequently, should the teeth not pierce the gum in time, the inference is for other food rather than a continuance of the faulty maternal supply. In this connection one must remember what has already been stated in regard to " mixed feeding," and if the breast secretes only enough milk of good quality to serve for two or three daily feedings, even so little must be carefully conserved during the earlier months of life and the deficiency made up by a properly modi- fied cow's milk mixture administered from a bottle. When the mother's milk so disagrees as to war- rant withdrawal of the breast, the baby does not thrive, ceases to gain weight or loses steadily, and presents the evidences of disordered digestion. It may vomit or eructate, though the symptoms being, as a rule, intestinal rather than gastric, there are, usually, discomfort, constant crying, poor and restless sleep, distention of the abdomen, colic, frequent expulsion of flatus from the bowel, sometimes constipation but usually diarrhoea, with FOOD 163 loose green evacuations containing mucus and passed with much gas. Habitual vomiting does not necessarily indicate weaning. In such cases an effort must be made to overcome the trouble before resorting to extreme measures. If vomiting occurs soon after jiursing, it may simply mean that the infant has taken too much food, therefore, shorten the time of lying at the breast, give one breast only, and interrupt the sucking by short periods of rest, thus preventing too rapid feeding. Vomiting taking place some- time after nursing and repeated, is often due to the milk being too rich in fat, and may be overcome by increasing the intervals between nursings, or by giving, from a feeding bottle, immediately before each meal one or two tablespoonfuls of pure boiled water, lime-water and water, or barley- water. When there is constant colic the milk is too rich in proteids, and the mother should take more exercise in the fresh air, eat less meat, avoid worry and control her emotions. The element of constipa- tion associated with colic can be but little influenced through the mother's milk. Where all expedients fail and one is reasonably sure that the only proper course is to anticipate the time of weaning, the next point to consider is whether the infant shall be brought up by hand or by a wet-nurse. 164 HYGIENE OF THE NURSERY 2. Feeding by a wet-nurse. The advantage of feeding from the breast of a wet-nurse is that the mother's milk is substituted by the milk of another woman; in other words, that natural feeding is con- tinued a matter of moment in all cases, and of in- estimable importance with delicate children. The disadvantage consists in the difficulty of finding, in a woman belonging to the class from which wet- nurses come, all the moral and physical characters essential to a good substitute, and the fact that a stranger is introduced into the household, often to deceive and annoy the family, and on the slightest provocation to leave her charge to fate or to the tender mercies of another of her kind. For these reasons it is preferable, in the majority of instances, to trust to careful bottle-feeding. Nevertheless, as some children must have human milk if their lives are to be saved, the rules for selecting a wet-nurse must be understood. The woman chosen must be strong and robust, but rather spare than fat. Her bill of health must be perfectly free from hereditary tendency to men- tal or physical disease and from taint of syphilis or tuberculosis. She must be cheerful, good-natured, active, careful, and temperate in habits. Her age should be between twenty and thirty years; she should understand the care of an infant and the manner of giving suck; her child ought to be of FOOD 165 nearly the same age as the infant to be adopted, and she must be able to afford an abundant supply of good milk. The last quality can be estimated by inspecting the breast, by examining some of the milk drawn by a pump, and by ascertaining the condition of the woman's own child. The breasts of a good nurse are not necessarily large, but are firm to the touch and pyriform in shape, with well developed, promi- nent nipples, and with the skin distinctly marbled with large blue veins. The milk, which ought to flow readily on pressure or on suction, should be opaque and dull white in color, have a specific gravity of 1.031, an alkaline reaction, show, when placed under the microscope, a number of minute, equal-sized, fat globules, and yield on analysis a normal percentage of fat, proteids and sugar. Its quantity may be ascertained by weighing the child before and after sucking, the normal gain being from three to six ounces. There is, however, no better or more readily applied test of the quality of a nurse than the size, weight, and general devel- opment of her own child; and if it be weak and ill- nourished, no amount of fitness in other respects can warrant her engagement. Even when a woman is found fulfilling in her single person all the required conditions a rare thing, indeed it does not necessarily follow that 1 66 HYGIENE OF THE NURSERY her milk will suit the baby to be suckled. Then changes and new trials must be made until the desired end be attained. The diet of a wet-nurse and the manner of wean- ing must be governed by the rules already given for maternal feeding. Personally, I have had such good results from carefully regulated bottle feeding that I have, as far as possible, given up the emloyment of wet- nurses, preferring to regulate the artificial food myself rather than allow an ignorant woman to supplement surreptitiously her deficient supply of breast milk by an unskilfully proportioned food an event of not uncommon occurrence. 3. Artificial feeding. In my experience there are few American women, especially in the well-to- do classes, who do not look upon the duty of nursing their babies as a pleasant one; but there are many who are completely unable to do so, and a vast number in whom the secretion of milk fails after a few weeks or months of lactation. They must, therefore, through no fault of their own, resort to a wet-nurse or to artificial feeding. Usually they select the last method, with results that vary in direct proportion to the care and intelligence dis- played in carrying it out. There is no artificial food equal to the milk of a robust woman. The fluid, however, secreted from FOOD 167 the glands of a feeble or unhealthy mother, though often sufficient in quantity to fill the suckling's stomach and satisfy the cravings of hunger, does not contain enough pabulum to meet the demands of nutrition. In such unfortunate cases, good cows' milk, properly prepared, is a better food than the bad breast milk. More care and trouble, though, are involved in bottle- than in breast- feeding. If the child has been nourished in the natural way i. e., breast-fed even for a few weeks, or when the powers of digestion are inher- ently active, the task is far easier to accomplish. In these cases the stomach and intestinal canal, inactive in foetal life, are trained to their new duties under normal conditions, and so prepared for the digestion of properly selected artificial food. On the contrary, if digestion be naturally feeble, or if the infant must be bottle-fed from the first, great difficulty may be expected, and most skilful hand- ling is necessary. To insure success in hand-feeding, it must be remembered that an infant is not nourished alone by the food he swallows, but by that portion of it he digests and assimilates. The best diet, therefore, is one so adapted to age and digestive power that everything eaten will be digested and absorbed. But as children differ as much in constitution as in feature, it is impossible to formulate exactly a food 1 68 HYGIENE OF THE NURSERY that will be applicable to every case, or one that needs no change from month to month of progress- ing growth. As age and strength increase, there is a corresponding development of the gastro-intes- tinal functions and a demand for more and stronger food. On the other hand, should the system be accidentally reduced by disease, the digestion, sym- pathizing in the general debility, temporarily loses its normal activity and assumes that of an earlier age. In such a case more nourishment is certainly needed to build up the failing strength, but it is to be supplied by giving such food as can be com- pletely assimilated, and not by forcing down strong food merely because it is strong; for the latter, when not vomited, passes through the bowels un- digested, and the little creature starves to death in the midst of plenty, or dies from the ill effects of the constant presence of fermenting food in the ali- mentary canal. On these accounts many changes in diet, as to quality and quantity, must be antici- pated and made. Important matters, therefore, to be studied in detail are: a, the selection of a proper substitute for the breast milk; b, the quantity to be given; c, the method of preparation; d, the mode of administra- tion; and, e, the means of preservation. a. Healthy breast milk must be taken as the type of infant's food, and the nearer an artificial FOOD 169 substitute can be made to approach it in chemical composition and physical properties, the more perfect it is. Normal breast milk has a specific gravity of 1.031. It is a persistently alkaline fluid, having a some- what animal, usually disagreeable, and very rarely sweetish taste. It is bluish- white in color, thin and watery in consistence, and contains no bacteria. According to recent analyses, its average com- position is: Fat 4.00 per cent. Milk sugar (lactose) 7 .00 per cent. Proteids i . 50 per cent. Salts o . 20 per cent. Water 87 .30 per cent. Some authorities give a higher albuminoid average, namely, 2 per cent.; but, as will be detailed later, the proportion of this ingre- dient varies greatly, and it is safe to assert that a range from i. oo to 2.25 per cent, is perfectly normal. Human milk contains, then, fat, nitrogenous material, sugar, salts and water all the elements essential to repair tissue waste, to supply new material for growth, and to maintain body heat, or, in other words, to constitute a perfect aliment; and these, too, are so proportioned in the combi- nation as to most easily and completely meet the demands. It must not be supposed, however, that the 1 70 HYGIENE OF THE NURSERY elements are uniformly present in the same pro- portion. On the contrary, the fluid varies both at different periods of lactation and in different individuals. This fact is the most striking feature of Professor Leeds' experimental work, which shows that the most changeable constituent is the proteids, vary- ing from a maximum of 4.86 per cent, to a minimum of 0.85; the next are the fat and salts, the maximum being about three times the minimum, and the least the sugar. The latter, in fact, varies but little from a standard of about 7 per cent. The function of the proteids is nutritive, that of milk sugar calori- facient; hence, the point seems to be that nature, while allowing a wide range of oscillation in the rapidity of tissue building, carefully provides an available fuel for the constant maintenance of animal heat the supply of caloric due to cerebral impulses and self-originated locomotion being extremely small in early infancy. In seeking a substitute for human milk, one natur- ally turns to the domestic animals for the source of supply. Between the milk of the ass, cow, goat and ewe there is little choice, so far as composition is concerned, although, perhaps, asses' milk resembles that of women a little more closely than the others; nevertheless, cows' milk is usually selected, because, being plentiful, it is easily obtained and cheap. FOOD 171 Cows' milk* (market milk) has a specific gravity of 1.027 to 1.035, i s richer looking, that is, whiter and more opaque than human milk, is slightly acid in reaction unless perfectly fresh from pasture-fed animals, when it may be neutral or alkaline, and always contains bacteria. It has the following average composition: Fat 4.0 per cent. Milk sugar 5 -o per cent. Proteids 3.5 per cent. Salts 0.7 per cent. Water 87 .o per cent. * The character of cows' milk may be determined with sufficient accuracy in the following way: Provide a specific gravity glass, such as is shown in Fig. 18, and which can be obtained at any chemist's, or a lactometer may be used. To obtain the specific gravity, fill a beaker to such a point with milk that it will float the specific gravity glass or lactometer, and read the degree of density from the scale at a level with the surface of the milk. The chemical reaction is found by inserting a piece of blue litmus paper, which should turn slightly red a few moments after being wet. In applying this test small pieces of litmus paper should be examined under and in the milk, as exposure to air may redden paper dipped in milk, although the fluid itself may not be acid. To ascertain the proportion of cream, cut a narrow strip of paper four inches long, and divide the upper half-inch, by cross-markings, into twelve equal parts; paste this on a beaker (Fig. 18) with the marked portion uppermost, and the lower edge coming accurately to the bottom of the beaker; then pour in enough milk to come just to the top of the paper, and place the whole aside for twenty- four hours. During this time the cream rises and appears as 172 HYGIENE OF THE NURSERY Comparing -this analysis with that previously given for human milk, it is readily seen that the two fluids differ in specific gravity and reaction, and that cow's milk contains more nitrogenous material but much less sugar than woman's milk. While the sugar of human and cows' milk is chemically identical, and the fats are quite similar, there are important differences in the quality as well as the quantity of the nitrogenous material. This in both fluids is complex, being made up of casein, lactalbumin, and peptones. The peptones are pres- ent in very small quantities only, and to what extent they exist naturally, and to what, in cows' milk, they are formed by bacterial action, is not known. Casein is an acid substance, and is present in combination with an alkali, chiefly as potassium caseinate. The casein of cows' milk is readily pre- cipitated by dilute acid, and is thrown down in large firm masses; that of human milk requires more acid a yellow layer at the top; this layer should have the depth of ten or twelve spaces. Beakers with a scale cut in the glass are now sold in instrument shops under the name of "creamometers." FIG. 1 8. SPECIFIC GRAVITY GLASS AND CREAM BEAKER. FOOD 173 and is precipitated in fine, soft particles, which are dissolved by an excess of acid. After the separation of the casein, the lactalbumin is left in solution in the whey. Lactalbumin closely resembles serum albumin, is unaffected by acid, but is precipitated by boiling. The relative proportions of casein and lactalbumin have been determined with sufficient accuracy to point out the most important of all the differences between the two secretions, which is, that the frac- tion of the total albuminoids in cows' milk which is coagulable by acids (casein) is far greater than the non-coagulable part (lactalbumin). In woman's milk, on the contrary, the reverse is true, and the non-coagulable part much exceeds the coagulable portion. The following table shows this difference: Human Cow's milk. milk. Total proteids... i. 80 3-50 Casein 0.60 3 .OO Lactalbumin .... i .20 0.50 Taking weight for weight of each secretion, the coagulum of human milk is only one-fifth that of cows' milk. This difference is readily tested by 174 HYGIENE OF THE NURSERY adding rennet to the two fluids. In the case of cow's milk the casein is coagulated into large, firm masses, while with human milk a light, loose curd is formed. In the stomach the acid gastric juice has the same effect, producing in the first in- stance a coagulum most difficult to digest; in the other, one of vastly less bulk and readily attacked and broken down by the gastro-intestinal solvents. These chemical and physical properties of cows' milk can be altered by various methods of prepa- ration, and unless this be done there are few in- stances in which it will not prove a poor substitute for the natural food. Condensed milk is frequently recommended by physicians and largely used by the laity on their own responsibility. It keeps better than cows' milk and is supposed to be more readily digested by young infants. The latter supposition is a mis- taken one, and arises from the overlooked fact that condensed milk is always given dissolved in a large proportion of water (i part to 12-10-8 or 6, according to the age of the child), while cows' milk is too fre- quently used insufficiently diluted or otherwise im- properly prepared. The author is convinced of the accuracy of this statement from a number of years' close study of the subject. Condensed milk contains a large proportion of sugar, forms fat quickly, and thus makes large FOOD 175 babies; sugar also counteracts in some degree the tendency to constipation often a troublesome complaint in hand-feeding. These advantages are unquestioned, and, together with the ease of prepa- ration and the fact that, when in good condition, it is sterile or free from bacteria, are those which place it so high in the esteem of monthly nurses. It is equally true, however, that prepared as a food it does not contain enough nutrient material, either in the form of fat or proteids, to supply the wants of a growing baby. Again, more than half of the saccharine ingre- dient of this preparation is cane sugar, added for the purpose of preservation, and this material is very liable, when in excess, to ferment in the ali- mentary canal, giving rise to irritant products that impede digestion. Infants fed upon condensed milk, though fat, are pale, lethargic and flabby; although large, are far from strong; have little power to resist diseases; frequently develop scurvy; often cut their teeth late, and are very likely to drift into rickets. It must be remembered also that condensed milk, when long kept, or when packed in imperfect cans, not unfre- quently undergoes decomposition, and thus becomes utterly unfit for use. For a temporary change of diet, and as a sub- stitute during traveling or under circumstances in 176 HYGIENE OF THE NURSERY which sound cows' milk cannot be obtained, it may be resorted to with advantage. Again, for feeding very young infants when a sterile food of low albuminoid percentage is indicated, it may some- times prove useful, but the necessity of adding fat, in the form of cream, must always be insisted upon. The farinaceous substances so often selected, especially by the poor, to replace breast milk, are not only bad foods, but have both directly and in- directly a deleterious effect upon the processes of nutrition. They are bad for two reasons. First, they differ materially in chemical composition from human milk. For example, in arrowroot, which is the favorite, the proportion of the tissue-building to the heat-producing element is as one to twenty, while in human milk it is about one to five. Second, the heat-producing principle, starch, must be converted into sugar before it can be absorbed. This change is accomplished in the body by the saliva and pan- creatic juice secretions that are not fully estab- lished until the fourth month. While the starch lies undigested in the gastro- intestinal canal, it is subject to fermentation, result- ing in the formation of irritant products that rapidly induce catarrh of the mucous membrane a con- dition directly interfering with the digestion and FOOD 177 absorption of food. Again, perfect nutrition de- mands rapid waste and removal of effete tissues as well as repair of the same. This is effected by oxidation. Now, sugars are known to have a much greater affinity for oxygen than albuminoids, and when the diet consists of farinaceous material, the small amount of sugar formed and absorbed appro- priates oxygen that otherwise would go toward the removal of waste, and so retards the necessary changes. The persistent and exclusive use of this class of food always leads to a condition of mal- nutrition which may result in simple atrophy, scurvy or rickets, while the irritant products of fermenta- tion often produce sufficient gastro-intestinal dis- turbance to cause death. Farinaceous food, as such, is therefore never per- missible before the later months of infancy, and then only as an adjunct to properly modified milk mixtures. It may be employed earlier for its mechanical action, with milk mixtures, and in properly selected cases proves very useful in this way. The purpose of this method of employment will be considered later under the head of Atten- uants. The nutrient value of the cereals and their prod- ucts, as they exist in so-called "infants' foods," has been imperfectly determined. They are un- doubtedly useful as mechanical attenuants, but it 12 178 HYGIENE OF THE NURSERY is very certain that none of them, unless prepared with milk, can permanently meet the demand of nutrition. At the same time it is quite probable that the albuminoids with the soluble carbohy- drates (maltose) obtained by Liebig's process have a food value of their own, making them more serviceable than the starches. b. The quantity of food to be allowed each day varies with the appetite and age. Some infants habitually eat little, others much; as both thrive, the question of the correct amount in a given case must be answered by observation. So long as the child develops with normal rapidity and keeps well he may be allowed to eat as much or as little as he wants; for, if food of proper strength be given at proper intervals, the instinctive cravings of hunger, since they represent the wants of the system, rarely lead to excess in either direction. Nevertheless, it is well to have some guide. During the first four weeks, infants generally require from twelve to seventeen fluidounces of food; in the second and third months, about thirty fluidounces, and from this time to the twelfth month from two to two and one-half or even three pints. After the twelfth month the quantity depends upon whether additions be made to the diet, or milk food be used exclusively. When the daily amount reaches three pints, the limit of the FOOD 179 capacity of the stomach is usually attained, and the greater demand for nutriment, as growth ad- vances month by month, must be met by adding to the strength of the food rather than by increasing its bulk. These two factors, strength and quantity, are intimately associated throughout the whole period of infancy, and in the earlier months a mere increase in the latter is not always sufficient to maintain the balance of nutrition. As a rule, infants are overfed, and this opens the very interesting question of the normal capacity of the stomach at different ages. Rotch states that, by actual measurement, the stomach of an infant five days old holds 25 c.c., or six and one-quarter fluidrachms, a quantity very far short of that usu- ally forced upon the baby during the first week. Frowlowsky's investigations show that there is a very rapid increase in the capacity of the stomach during the first two months of life, while in the third, fourth and fifth months the increase is slight. Guided by these data, the quantity of food should be rapidly augmented during the first six or eight weeks of life and then held at the same quantity up to the fifth or sixth month. Another considerable increase is also demanded between the sixth and the tenth months. The author has been unable to verify the above measurements, and has, on the contrary, found no I$0 HYGIENE OF THE NURSERY uniformity in the size of the stomach for given ages; still clinical experience is a sufficient guide, and upon this the following table is based: TABLE OF INTERVALS OF FEEDING AND AVERAGE AMOUNTS OF FOOD. Age. Intervals of feeding. Average amount at each feeding. Average amount in 24 hours. During first week. . . . 2 hours. i ounce. 12 ounces. From second to sixth week. 2 hours. ii to 2 ounces. 12 to 17 ounces. From sixth week to third month. 2 hours. 3 to 4 ounces. 24 to 30 ounces. From third to sixth month. z\ hours. 4 to 6 ounces. 32 to 36 ounces. At ten months 3 hours. 8 ounces. 40 ounces. c. The object to be accomplished in the prepara- tion or modification of cows' milk is to make it re- semble human milk as much as possible in chemical composition and physical properties. To do this it is necessary to reduce the proportion of proteids, to increase the proportion of sugar, and to overcome the tendency of the casein to coagulate into large, firm masses upon entering the stomach and coming in contact with the acid gastric juice. FOOD l8l Dilution with water is all that need be done to reduce the amount of proteids to the proper level; but as this diminishes the already insufficient sugar, and also the fat, it is essential to add these materials to the mixture of milk and water. Fat is best added in the form of gravity cream which contains approx- imately 1 6 per cent, of fat; and of the sugars, either pure white loaf sugar or sugar of milk of good quality may be used. The latter is greatly pref- erable, because it is the natural sugar, is directly assimilable, in the process of digestion is converted into lactic acid, and, unlike cane sugar, is not readily fermented. One ounce of milk sugar to twenty ounces of food properly proportioned for the first four months, gives a sugar percent- age similar to human milk, i. e., 6 to 7 per cent. If cane sugar be used, one-half the quantity is required. Firm clotting may be prevented by the addition of an alkali or a small quantity of some thickening substance or attenuant. Lime-water is the alkali usually selected. It neutralizes the slightly acid reaction which usually characterizes market milk and has a further chemi- cal action which is variously explained. Some authorities claim that to the extent of the quantity of lime-water added a soluble calcium caseinate is formed which is not acted upon by the acid gastric 1 82 HYGIENE OF THE NURSERY juice with the precipitation of firm curds. Others, that lime-water causes the mucoid proteids (Storch) of the milk to swell up and become viscid, thus tending to gelatinize the curd, and by its alkaline properties to retard the curdling action of the gas- tric secretion. Whichever theory is accepted the result is the same, the total bulk of casein coagulum is diminished and the ease of digestion increased. To produce measurable results the quantity of lime-water to be used must always be in the propor- tion of one part to twenty of milk mixture. When lime-water is constantly employed, it becomes quite an item of expense if procured from the chemist's. This outlay is unnecessary, for it can be made quite as well in the nursery. Take one heaping teaspoon- ful of slaked lime and put it with one quart of boiled or distilled water into a bottle, cork securely, and shake thoroughly two or three times, at intervals of half an hour; then allow to settle and after twenty-four hours siphon off for use the upper clear fluid; this must be kept in a well-stopped, perfectly clean bottle. Instead of lime-water, bicarbonate of sodium may be added to each bottle in the proportion of one grain to each fluidounce of milk mixture; or, better still, from five to fifteen drops of the saccharated solution of lime. This solution is made in the following way : FOOD 183 Take of Slaked lime i ounce. Refined sugar, in powder 2 ounces. Distilled water i pint. Mix the lime and sugar by trituration in a mortar. Transfer the mixture to a bottle containing the water, and having closed this with a cork, shake it occasionally for a few hours. Finally, separate the clear solution with a siphon and keep it in a stoppered bottle. Thickening substances, attenuants, are employed to act in the main mechanically by getting, as it were, between the particles of casein during coagu- lation, preventing their running together and form- ing a large compact mass. This class embraces gummy materials like dextrin, gelatin, the various infants' foods prepared by Liebig's process (in which the starch of wheat and barley is converted into maltose and dextrin), and finely divided starch as it exists in barley- or oatmeal- water; and it is for this purpose only that starch is permissible as an element of diet in infancy. Barley-water and gela- tin* are the attenuants usually employed. When an "infant's food" is used to act mechanic- ally, care should be taken to select a reliable one, that is, one in which the starch has been converted into maltose and dextrin by the process of manu- facture. The articles known as Mellin's Food and Horlick's Food can be relied upon. One teaspoon- *See Chapter IX. 184 HYGIENE OF THE NURSERY ful of either dissolved in a tablespoonful of hot water and added to each portion of food, makes a very easily digested mixture. Dry malt extracts also act well mechanically, being especially useful when desirable to reinforce the fat-building elements of the food. It must not be inferred from what has been stated in regard to the use of lime-water and attenuants that these are essentials in the artificial feeding of infants. On the contrary, the majority of healthy babies require only sound cows' milk, properly modified by the addition of cream, milk sugar, and water. It is best to leave the addition of lime- water, bicarbonate of sodium, or an attenuant, to the'judgment of the physician. For the successful management of children, the mother or nurse must not only be familiar with the theory of feeding, but must practically understand the methods of preparing food. To this end a schedule of the diet of an infant from birth upward, with a sketch of the modifications that have to be made most frequently, will serve as a useful guide. Diet during the first week: Gravity cream* (16%) . . 2 teaspoonfuls. Whey 3 teaspoonfuls. Water, 98-ioo F 3 teaspoonfuls. Milk sugar teaspoonful. * Gravity cream is obtained by skimming after milk has stood for twenty-four hours. Ordinary centrifugal cream has 18-20 per cent. fat. Heavy centrifugal cream has 35-40 per cent. fat. FOOD 185 For each portion; to be given every two hours from 5 A.M. to ii P.M., and in some cases once or twice at night; amounting to twelve fluidounces of food per diem. Diet from the second to the sixth week: Gravity cream (16%) ... 2 teaspoonfuls (fid. oz. J). Milk i tablespoonful (fld. oz. ). Milk sugar $ teaspoonf ul. Water 2 tablespoonfuls (fld. oz. i). For one portion; to be given every two hours from 6 A.M. to 10 P.M. and once during the night; amounting to seventeen fluid- ounces of food per diem. Diet from the sixth week to the end of the second month : Gravity cream (16%) . . . i tablespoonful (fld. oz. $). Milk 2 J tablespoonfuls (fld. oz. i). Milk sugar teaspoonf ul. Water z\ tablespoonfuls (fld. oz. i|). For each portion; to be given every two hours; amounting to thirty fluidounces per diem. Diet from the beginning of the third month to the sixth month: Gravity cream (16%) ... i tablespoonful (fld. oz. ). Milk 4 tablespoonfuls (fld. oz. 2 ) . Milk sugar i teaspoonf ul. Water 3 tablespoonfuls (fld. oz. ij). For each portion; to be given every two and one-half hours; thirty-two fluidounces per diem. 1 86 HYGIENE OF THE NURSERY Diet during the sixth and seventh months; six meals daily: Gravity cream (16%) . . . i tablespoonful (fld. oz. J). Milk 7 tablespoonfuls (fld. oz. 3^). Milk sugar i teaspoonful. Water 4 tablespoonfuls (fld. oz. 2 ). For each portion; to be given every three hours from 6 or 7 A.M. to 9 or 10 P.M.; thirty-six fluidounces per diem. Often a pinch gr. 2 to 5 of table salt is of service, and may be added, after the second week, to each portion of food. A table of the dietary, as far as it has been carried, may be useful for convenience of reference (page 187). Throughout the eighth and ninth months five meals a day will be sufficient, each meal composed of Gravity cream (16%) . . . i tablespoonful (fld. oz. ). Milk 12 tablespoonfuls (fld. oz. 6 ). Milk sugar i teaspoonful. Water 3 tablespoonfuls (fld. oz. ij). This allows forty fluidounces of food per diem. At this age it is sometimes advisable to supple- ment the milk mixture with one of the reliable in- fants' foods (Liebig foods); thus, two teaspoonfuls of Mellin's food may be added to the second, third, and fourth meals, the milk sugar being then omitted. Instead of Liebig food, one of the wheat or barley FOOD I8 7 -3 A s? X ^ *>* 1 "o rt H MO X MO X MO MO MO .1 cr H-l <+H <4-. VM 13 .3 g g d 2 1 J 1 J9 1 HM J 1 a a r bO a fl s - g' g X j_, en <; (_, Pi OH Pt ^ 2 &b H g ,J O O O M ll il l|l 5 >s 2 2 H- 1 10 H vO t- g y A | A S 1 i to- MO to MO MO MM 3 i 1 43 Tt U TO C -1 l L o C/3 H 5, a a, u 1 & M PI d a to to to 11 ^ In M- bO ^8 J 8 M A en t 3 MO to MO :S <*H >J * M <+-! <-M MO NH H_^ ^ .^ 3