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Hygiene of the Nursery.

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 standpoint of the first 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: 1st, from the mother's breast; 2d, from the breast of a foster mother or wet nurse; and 3d, from a bottle, by the method known as artificial or hand-feeding.

1st. 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 babe 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-building food.

It follows, therefore, that every woman who is free from certain contra-indicating diseases, to be 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, so 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 babe gets a small quantity of thin, watery fluid, called colostrum, which affords sufficient nourishment, and at the same time, from its laxative properties, 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 consequent 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 breasts not yield a supply of milk, a little sound cow's milk diluted with double its quantity of water and sweetened with sugar of milk, may be given every fourth hour, the babe being put to the breast in the meanwhile. So soon as the flow begins, however, the artificial feeding is to be discontinued.

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 feeding, and of the importance of regularity. Upon these points the physician should give minute instructions.

When giving the breast, the infant must be held partly on its side, on the right or left arm, according to the gland about to be drawn, 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 run too freely -- a condition very apt to excite vomiting -- the flow is easily regulated by gentle pressure with the supporting fingers. Each of the breasts should be drawn alternately, the contents of one being usually sufficient for a meal; and a healthy child may be allowed to nurse until satisfied, when he will stop of his own accord, drop the nipple and fall asleep with milk still falling over his lips.

During the first six weeks the breast is required every second hour, from 5 A.M. until 11 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 six 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 importance in early than in adult life, on account of the natural feebleness of digestion. To secure this, it is only necessary to have a little perseverance, for infants are such creatures of habit that a short training brings them into the way of expecting food only at certain 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, perhaps, and once or twice at night. In these exceptional cases an appropriate schedule can only be made by close observation of individual characteristics.

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 expression of pleasure, clinches his hands and flexes his limbs. The cry of colic is violent and paroxysmal; the face is livid and wears and expression of suffering; 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 vowels 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 discomfort of indigestion are chiefly due to the accumulation 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 contents of the gastro-intestinal canal, and every nursing is soon followed by more pain, until between crying 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, while medicines are employed to strike at the root of the evil.

After the sixth week the interval between nursings 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 gradually lengthened, 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. Such a plan is perfectly proper, if the babe cease 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 nutriment be required, the food must be selected with due deference to age and prepared in the same manner as in regular hand-feeding.

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, lactation can be prolonged until the tenth or twelfth month. 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.

Change in the manner of feeding may be accomplished gradually or suddenly. In gradual weaning, about four weeks are required to prepare for the absolute withdrawal of the breast. For instance, if suck be given every three hours, from 5 A.M. until 11 P.M., or seven times a day, there should be, during the first week of preparation, one artificial feeding and six nursings daily; during the second, two and five; during the third, four and three; during the fourth, six and one. Then the breast must be entirely withheld. Carefully prepared milk-food, administered from a bottle, is the best substitute. At the age of ten months a mixture that ordinarily agrees well is: --

R. Cream

1 tablespoonful

Milk

8 tablespoonfuls

Sugar of milk

1 teaspoonful

Water

3 tablespoonfuls

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) [1 fluidounce = 2 tablespoonfuls; 1 fluidrachm = 1 teaspoonful] be insufficient to satisfy the child's appetite, all the ingredients except the cream may be increased until the mixture measures eight or even twelve fluidounces, according to the demand.

When such accidents as fever, disordered digestion, with vomiting and diarrhoea, or the actual cutting of one or more teeth occur during the period of preparation, the number of artificial feedings must be reduced, or the breast resumed until the disturbance 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 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 also to be recommended when the mother's health becomes so affected as to render any further suckling a positive peril to the child's life; attacks of erysipelas or of smallpox 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 investigation 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 becomes so. Premature weaning is necessary when the mother is attacked by any acute disease threatening dangerous temporary prostration, such as typhoid or typhus fever. A change must also be made if pulmonary consumption be developed, or, being already present, rapidly advances under the drain of milk secretion. Ordinarily, however, the general condition that leads to withdrawal 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 to wean was 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 atmospheric conditions and eats improper food, she grows weak and thin whether she be nursing or not; and a woman heedless of her health will probably 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 is to be avoided, sufficient exercise must be taken to maintain a healthy appetite and digestion, and abundant time devoted to rest and sleep. Beyond securing a plentiful supply of plain and easily digestible food, with a judicious portion of meat, vegetables, and fruit, it is unnecessary to give special attention to the diet.

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 moderate employment of stimulants, in the form of ale and porter, may be necessary. Such tonics as malt extract, ferrated elixir of cinchona, bitter wine of iron, and the preparation known as "beef, wine, and iron," are useful when there is anaemia, or when the general failure of strength cannot 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.

Fissures 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 in the meantime to keep up secretory activity. Should both sides be affected, weaning may be imperative, on account of the extreme pain produced by sucking, though, even under these circumstances, an effort must be made to maintain the flow of milk by regular pumping. Sometimes 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 various diseases of the delicate skin of the part. They result, also from want of cleanliness or from keeping the nipple too moist, as 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 evening and anointed with cocoa-butter in the morning. At the same time, should the nipples be small and 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 condition without hardening it. The application of alcoholic and astringent lotions are not to be recommended. 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 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 continue 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 ... twenty grains
Mucilage of acacia ... one fluidounce. Mix.

b. On the part of the infant, there are several indications for anticipating the time of withdrawing the mother's breast. It must be done if the occurrence of pregnancy or the recurrence of menstruation renders the milk unwholesome; if the mother contract a dangerous contagious disease, as smallpox, 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 nourishment, 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 babe, 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 likes a long time at the breast and falls asleep there. Consideration of the final indication 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 implied in the old precept, that the child must not be taken from the breast until evolution of the stomach and eye tooth. 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 continuation of the faulty maternal supply.

Upon deciding 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.

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 continued -- a matter of moment in all cases, and of inestimable 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 mental or physical disease and from taint of syphilis, consumption, or scrofula. 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 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 breasts, 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, prominent 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, and show, when placed under the microscope, a number of minute, equal-sized, fat globules. 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 development 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 be found fulfilling in her single person all the required conditions -- a rare thing, indeed -- it does not necessarily follow that her milk will suit the babe 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 weaning, 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 almost given up the employment of wet-nurses, preferring to regulate the artificial food myself rather than allow an ignorant woman to supplement sub rosa her deficient supply of breast milk by an unskillfully proportioned food, -- an event of not uncommon occurrence.

3d. 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 which 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 displayed in carrying it out.

There is no artificial food equal to the milk of a robust woman. The fluid, however, secreted from 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 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 inherently 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 handling is necessary.

To insure success in hand-feeding, it must be remembered than 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 that will be applicable to every case, or one that needs no change from month to month of progressing growth. As age and strength increase, there is a corresponding development of the gastro-intestinal functions and a demand for more and stronger food. On the other hand, should the system be accidentally reduced by disease, the digestion, sympathizing 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 completely assimilated and not by forcing down strong food merely because it is strong; for the latter, when not vomited, passes through the bowels undigested, 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 alimentary canal. On these accounts many changes in diet; as to quality and quantity, must be anticipated 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 administration; and, e, the the means of preservation.

a. Healthy breast milk must be taken as the type of infant's food, and the nearer an artificial substance 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 somewhat animal, usually disagreeable, and very rarely sweetish taste. It is bluish-white in color and thin and watery in consistence.

According to Leeds' very thorough analysis, it contains:--

Water

86.766 per cent

Total solids

13.234 per cent.

Total solids not fat

9.221 per cent.

Fat

4.013 per cent.

Milk sugar

6.997 per cent.

Albuminoids

2.058 per cent.

Ash

0.21 per cent.

It contains, then, nitrogenous material, carbohydrates, 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 combination as to most easily and completely meet the demands.

It must not be supposed, however, that the elements are uniformly present in the same proportion. On the contrary, the fluid varies both at different periods of lactation and in different individuals.

This fact is the most striking feature of the above observer's work, which shows that the most changeable constituent is the albumen, varying from a maximum of 4.86 per cent. to a minimum of 0.85; the next are the fats 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 albumen is nutritive; that of milk sugar calorifacient; 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 naturally 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, though, perhaps, asses' milk resembles that of a woman a little more closely than the others; nevertheless, cows' milk is usually selected, because, being plentiful, it is easily obtained and cheap.

Cows' milk [1] (market milk) as a specific gravity of 1.029, is richer looking -- that is, whiter and more opaque than human milk, and is slightly acid in reaction unless perfectly fresh from pasture-fed animals, when it may be neutral or alkaline, and contains--

Water

87.7 per cent.

Total solids

12.3 per cent.

Total solids not fat

8.48 per cent.

Fat

3.75 per cent.

Milk sugar

4.42 per cent.

Albuminoids

3.42 per cent.

Ash

0.64 per cent.

Comparing this analysis with that previously given, it is readily seen that the two fluids differ in specific gravity and reaction, and that cows' milk contains more nitrogenous material, but less fat and much less sugar than woman's milk.

 

Figure 18. Lactometer (see [1]).

The nitrogenous material differs in quality as well as in quantity. König, in a number of analyses that closely correspond to those of Leeds, divides the nitrogenous constituent into three groups; namely, caseine, albumen and albuminoids, basing the division upon the different effects of coagulating agents.

Upon this point Leeds remarks: "Whilst by present modes of analysis the separation of the so-called caseine from the so-called albumen is not accurately performed, yet the results are approximately correct (König's), and have a very great value in pointing out the most important of all the differences between the two secretions, which is, that the fraction of the total albuminoids in cows' milk which is coagulable by acids is far greater (perhaps four times) than the non-coagulable part.

"In woman's milk, on the contrary, the reverse is true, and the non-coagulable part much exceeds (perhaps by more than twice) the coagulable portion."

This difference is readily tested by adding rennet to the two fluids. In the case of cows' milk the caseine is coagulated into two 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 instance a coagulum most difficult to digest; in the other, one 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 preparation, and unless this be done there are few instances 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 mistaken one, and arises from the overlooked fact that condensed milk is always dissolved in a large proportion of water, while cows' milk is too frequently used insufficiently diluted or otherwise improperly 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 babies; sugar also counteracts the tendency to constipation -- often a troublesome complaint in hand-feeding. These advantages are unquestioned, and, together with the ease of preparation, are those which place it so high in the esteem of monthly nurses. It is equally true, however, that, as a food, it does not contain enough nutrient material to supply the wants of a growing baby.

Again, more than half of the saccharine ingredient 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 alimentary 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; 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 infrequently undergoes decomposition, and thus becomes utterly unfit for use.

For a temporary change of diet, and as a substitute during traveling or under circumstances in which sound cows' milk cannot be obtained, it may be resorted to with advantage.

The farinaceous substances so often selected, especially by the poor, to replace breast-milk, are not only bad foods, but have both directly and indirectly 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. Secondly, 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 pancreatic juice, -- secretions that are not fully established until the fourth month.

While the starch lies undigested in the gastrointestinal canal, it is subject to fermentation, resulting in the formation of irritant products that rapidly induce catarrh of the mucous membrane; a condition directly interfering with the digestion and adsorption of food. Again, perfect nutrition demands 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 albuminates, and when the diet consists of farinaceous material, the little sugar formed and absorbed appropriates oxygen that otherwise would go toward the removal of waste, and so retards the necessary changes.

Farinaceous food, as such, is never permissible before the fourth month; earlier, it is only to be employed for its mechanical action, as an additive to milk preparations. This will be mentioned later.

The nutrient value of the cereals and their products as they exist in so-called "infant's foods," has been imperfectly determined. They are undoubtedly useful as mechanical attenuants, but it is very questionable whether any of them, unless prepared with milk, can permanently meet the demand of nutrition. At the same time it is quite probably that the soluble albuminoid substances 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 and-a-half to sixteen fluidounces of food; in the second and third months, about twenty-four fluidounces, and from this time to the twelfth month from two to two and-a-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 capacity of the stomach is usually attained, and the greater demand for nutriment, as growth advances 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 has recently written an important paper upon the subject. He states that, by actual measurement, the stomach of an infant five days old holds 25 c.c., or six and-a-quarter fluidrachms, an quantity very far short of that usually forced upon the babe 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.

While the author has been unable to verify the above measurements, and has, on the contrary, found no uniformity in the size of the stomach for given ages, yet the following table (Rotch) is a useful one, and corresponds closely with conclusions drawn from clinical experience.

General Rules for Feeding.

Age.

Intervals of Feeding.

Average Amount at Each Feeding.

Average Amount in 24 Hours.

First week.

2 hours.

1 ounce.

10 ounces.

One to six weeks.

2 1/2 hours.

1 1/2 to 2 ounces.

21 to 16 ounces.

Six to twelve weeks and possibly to fifth or sixth month.

3 hours.

3 to 4 ounces.

18 to 24 ounces.

At six months.

3 hours.

6 ounces.

36 ounces.

At ten months.

3 hours.

8 ounces.

40 ounces.

c. The object to be accomplished in the preparation of cows' milk is to make it resemble human milk as much as possible in chemical composition and physical properties. To do this, it is necessary to reduce the proportion of casein, to increase the proportion of fat and sugar, and to overcome the tendency of the caseine to coagulate into large, firm masses upon entering the stomach.

Dilution with water is all that need be done to reduce the amount of caseine to the proper level; but as this diminishes the already insufficient fat and sugar, it is essential to add these materials to the mixture of milk and water. Fat is best added in the form of cream, and of the sugars, either pure white loaf sugar or sugar of milk may be used. The latter is greatly preferable, as it is little apt to ferment, and contains some of the salts of milk, which are of nutritive value.

Firm clotting may be prevented by the addition of an alkali or a small quantity of some thickening substance.

Lime water is the alkali usually selected. It acts by partially neutralizing the acid of the gastric juice, so that the caseine is coagulated gradually and in small masses, or passes, in great part, unchanged into the intestine, to be there digested by the alkaline secretions. As it contains only half a grain of lime to the fluidounce, the desired result cannot be attained, unless at least a third part of the milk mixture be lime water. The quantity often used -- one or two teaspoonfuls to the bottle of food -- has no effect beyond neutralizing the natural acidity of the milk itself. When lime water is constantly employed, it becomes quite an item of expense if procured from the drug shop; this outlay is unnecessary, as it can be made quite as well in the nursery. Take a piece of unslaked lime as large as a walnut, drop it into two quarts of filtered water contained in an earthen vessel, stir thoroughly, allow to settle, and use only from the top, replacing the water and stirring as consumed.

Instead of lime water, two to four grains of bicarbonate of soda may be added to each bottle, or, better still, from five to fifteen drops of the saccharated solution of lime.

This solution is made in the following way:--

Take of--
Slaked lime, one ounce.

Refined sugar, in powder, 2 ounces.

Distilled water, 1 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, such as barley-water, gelatine, or one of the digestible prepared foods -- act purely mechanically by getting, as it were, between the particles of casein during coagulation, preventing their running together and forming a large, compact mass.

When an "infant's food" is used to act mechanically, care should be taken to select one in which the starch has been converted into dextrine and grape sugar by the process of manufacture. The articles known as "Mellin's Food" and "Horlick's Food" can be relied upon. One teaspoonful of either dissolved in a tablespoonful of hot water and added to each portion of food, makes a very easily digested mixture.

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:--

Cream

2 teaspoonfuls

Whey

3 teaspoonfuls

Water (hot)

3 teaspoonfuls

Milk sugar

1/4 teaspoonful

For each portion; to be given every two hours from 5 A.M. to 11 P.M.; and in some cases once or twice a night; amounting to twelve fluidounces of food per diem.

Diet from the second to the sixth week:--

Milk

1 tablespoonful

Cream

2 teaspoonfuls

Milk sugar

1/4 teaspoonful

Water

2 tablespoonfuls

For one portion; to be given every two hours from 5 A.M. to 11 P.M.; amounting to seventeen fluidounces of food per diem.

Diet from the sixth week to the end of the second month:--

Milk

2 1/2 tablespoonfuls

Cream

1 tablespoonful

Milk sugar

1/2 teaspoonful

Water

2 1/2 tablespoonfuls

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:--

Milk

5 tablespoonfuls

Cream

1 tablespoonful

Milk sugar

1 teaspoonful

Water

2 tablespoonfuls

For each portion; to be given every two and a half hours, or thirty-two fluidounces per diem.

Diet during the sixth month; six meals daily from 6 or 7 A.M. to 9 or 10 P.M.

Morning and midday bottles each:--

Milk

9 tablespoonfuls

Cream

1 tablespoonful

Mellin's Food

1 teaspoonful

Hot water

2 tablespoonfuls

Dissolve the Mellin's Food in the hot water and add, with stirring, to the previously mixed milk and cream.

Other bottles each:--

Milk

9 tablespoonfuls

Cream

1 tablespoonful

Milk sugar

1 teaspoonful

Hot water

2 tablespoonfuls

This gives an equivalent of thirty-six fluidounces of food in a day.

In the seventh month the Mellin's Food may be increased to two teaspoonfuls and given three times day.

Throughout the eighth and ninth months five meals a day will be sufficient.

First meal at 7 A.M.:--

Milk

13 tablespoonfuls

Cream

1 tablespoonful

Milk sugar

1 teaspoonful

Hot water

2 tablespoonfuls

Second meal at 10.30 A.M. Milk, cream, and water in the same proportion; Mellin's food, one tablespoonful.

Third meal at 2 P.M. -- Same as second.

Fourth meal at 6 P.M. -- Same as second.

Fifth meal at 10 P.M. -- Same as first.

This gives forty fluidounces of food per diem.

Instead of Mellin's Food, a teaspoonful of "flour-ball" [2] may be added.

Two meals of flour-ball daily -- the second and fourth -- are all that can be digested. To prepare these, rub one teaspoonful of the powder with a tablespoonful of milk into a smooth paste, then add a second tablespoonful of milk, constantly rubbing until a cream-like mixture is obtained. Pour this into eight ounces of hot milk, stirring well, and it is then ready for use. The other meals should be composed of milk, cream, sugar of milk and water, as already given.

Mellin's Food and flour-ball may be substituted by oatmeal or barley, or any one of the infants' foods in which the starch has been converted, by Liebig's process, into dextrine and grape sugar.

Diet for the tenth and eleventh months:

First meal, 7 A.M.:--

Milk

17 tablespoonfuls

Cream

1 tablespoonful

Mellin's Food

1 tablespoonful

(Or flour-ball or barley-jelly [3])

2 teaspoonfuls

Water (used only with Mellin's Food)

2 tablespoonfuls

Second meal, 10.30 A.M. -- A breakfast-cupful of warm milk (eight fluidounces).

Third meal, 2 P.M. -- The yelk of an egg lightly boiled, with stale bread crumbs.

Fourth meal, 6 P.M. -- Same as first.

Fifth meal, 10 P.M. -- Same as second.

On alternate days the third meal may consist of a teacupful (six fluidounces) of beef tea containing a few stale bread crumbs.

A further variation can be made by occasionally using mutton, chicken or veal broth instead of beef tea. [4]

As much more difficulty is experienced feeding infants during the first twelve months than during the second, it would be well to pause here to consider what had best be done in case the food described should disagree.

If, after feeding, vomiting occur, with the expulsion of large, firm clots of caseine, the effect of adding lime water or barley water must be tried.

For instance, at the age of six weeks make each bottle of:

Milk

2 1/2 tablespoonfuls

Cream

1 tablespoonful

Milk sugar

1/2 teaspoonful

Lime water

2 1/2 tablespoonfuls

Or of:--

Milk

2 1/2 tablespoonfuls

Cream

1 tablespoonful

Milk sugar

1/2 teaspoonful

Barley water

2 1/2 tablespoonfuls

Sometimes, particularly if there be diarrhoea, boiling makes the milk more tolerable, and in this condition it may be used instead of fresh milk in either of the above mixtures. Condensed milk, too, can be employed temporarily, making each portion of:--

 

Condensed milk

1 teaspoonful

Cream

1 tablespoonful

Hot water

5 tablespoonfuls

Should further alteration be necessary, goats' or asses' milk may be substituted for cows' milk, the strong odor of the former and the laxative properties of the latter being removed by boiling. One ass is capable of nourishing three children for the first three months of life, two children for the fourth or fifth months, and one child after this period to the ninth month. The milk should be used warm from the udder.

"Strippings" is another good substitute for cows' milk. It is obtained by re-milking the cow after the ordinary daily supply has been drawn, and contains much cream but little curd. Assimilable portions of this are:--

Strippings

2 tablespoonfuls

Water

4 tablespoonfuls

And if the small amount of caseine, in such a mixture, be still undigested:--

Strippings

3 tablespoonfuls

Barley water

3 tablespoonfuls

Another good food is that recommended by Dr. A. V. Meigs. It consists of a combination of two parts of the cream, containing from fourteen to sixteen per cent. of fat; one part average milk; two parts lime water, and three parts sugar water, the latter consisting of seventeen and three-fourths drachms [5] of milk sugar to one pint of water. This makes an alkaline mixture with the percentage of its ingredients closely corresponding to human milk.

When, in spite of careful preparation, all of these foods give rise to indigestion with fever, and the expulsion, by vomiting and diarrhoea, of hard curds from the stomach and intestines, the expedient of predigesting the milk must be resorted to.

The best method is to peptonize the milk by pancreatin [6]. That manufactured under the name of extractum pancreatis, by Fairchild Brother & Foster, of New York, has proved most efficient in my hands. To accomplish this artificial digestion, put into a clean quart bottle five grains of extractum pancreatis, fifteen grains of bicarbonate of sodium, and four fluidounces of cool, filtered water; shake thoroughly together, and add a pint of fresh, cool milk. Place the bottle in water, not so hot but that the whole hand can be held in it for a minute without discomfort, and keep the bottle there for exactly thirty minutes. At the end of that time put the bottle on ice to check further digestion and to keep the milk from spoiling. The fluid obtained, while somewhat less white in color than milk, does not differ from it in taste; if, however, an acid be added, the caseine, instead of being coagulated into large, firm curds, takes the form of minute, soft flakes, or readily broken-down feathery masses of small size. When the process is carried just to the point described, the caseine is only partly converted into peptone; but every succeeding moment of continued warmth lessens the amount of caseine until peptonization is complete. Then the liquid is grayish yellow in color; has a distinctly bitter taste, and shows no coagulation whatever on the addition of an acid. This artificial digestion, therefore, may be carried just as far as circumstances indicate, although it is ordinarily best to stop it short of complete conversion, as children object to the markedly bitter taste, and often, on account of it, absolutely refuse the food. Partial peptonization, too, is usually sufficient to adapt the milk to ready assimilation. To seize the proper moment for arresting the process, the person conducting it must be told to taste the milk from time to time, and as soon as the least bitterness is appreciable, to remove the bottle from the hot water and place it upon ice for cooling and use. Such milk may be sweetened with sugar of milk, and given pure or diluted with water. For an infant of six weeks each meal may consist of:--

Peptonized milk

6 tablespoonfuls

Milk sugar

1/2 teaspoonful

Water

2 tablespoonfuls

To this, cream may be added when desirable, and by diminishing the quantity of water and increasing that of milk the strength of the food may be made greater at any time.

Although every precaution be taken, the last of a quantity of predigested food is apt to grow bitter; and if the attendants will take the trouble, it is much better to peptonize every meal separately. This is readily done by obtaining a number of powders of pancreatin and bicarbonate of sodium, so proportioned that each packet shall contain the proper amount for one bottle of food.

For example:--

Take of--

Extractum pancreatis, nine grains.

Bicarbonate of sodium, twenty-four grains.

Mix and divide into twelve powders, and dispense in waxed papers.

Directions. -- Put one powder into a nursing bottle with two fluidounces of filtered water and two fluidounces of fresh sweet milk; shake together and keep warm in a water-bath for about half an hour before feeding; sweeten with half a teaspoonful of milk sugar.

The great advantages of partial peptonization are that the necessity for lime water, barley water and thickening substances to keep apart the curd is done away with, and that, when the digestive disturbance requiring a careful preparation of food is removed, an ordinary milk diet can be gradually resumed by regularly diminishing the time artificial digestion is allowed to progress. This changes the caseine in a less and less degree, until, finally, it is taken in its natural form.

Instead of this ordinary peptonizing process, I have for the past yea or more employed the "Peptogenic milk powder," prepared by the chemists already referred to. This powder contains a digestive ferment, pancreatin; an alkali, bicarbonate of sodium, and a due proportion of milk sugar.

The mode of employment is as follows:--

Take of--

Milk, 4 tablespoonfuls.

Water, 4 tablespoonfuls.

Cream, 1 tablespoonful.

Peptogenic milk powder, 1 measure. [7]

This mixture is to be heated over a brisk flame to a point that can be comfortably sipped by the preparer (about 115° F.) and kept at this heat for six minutes. When properly prepared, the resultant, so-called "humanized milk," presents the albuminoids in a minutely coagulable and digestible form; has an alkaline reaction; contains the proper proportion of salts, milk sugar and fat, and has the appearance of human milk.

Leeds gives the following analysis of this prepared milk:--

Water, 86.2 per cent.

Fat, 4.5 per cent.

Milk sugar, 7 per cent.

Albuminoids, 2 per cent.

Ash (salts), 0.3 per cent.

This corresponds very closely with his average analysis of human milk.

In using this powder, too, one can readily return to a plain milk diet by gradually shortening the time of heating; in other words, by slowly diminishing predigestion.

Great and deserving stress has recently been placed upon a method of preparing, or rather preserving, cows' milk, known as "Sterilization."

As milk exists in the healthy cows' udder it is aseptic, i.e., free from any poisonous or dangerous ingredient, but during milking, and subsequent handling and transportation, particles of manure or various forms of dirt get into it and are apt to set up fermentation or other injurious change. To deprive these accidentally introduced organic impurities of their activity, or, in other words, to sterilize, it is necessary to subject the fluid to high heat under pressure.

Several admirable implements have been devised for conducting the process; one of the most simple, made after a design of my own, is shown in the accompanying figure.

This apparatus is made of tin, and consists of an oblong case provided with a well fitting cover, and having a movable perforated false bottom (D), which stands a short distance above the true one and has attached a framework capable of holding ten, six-ounce, nursing bottles. On the outside of the case is a row of supports (B) for holding inverted bottles while drying, and at the proper distance below these a gradually inclining gutter (C) for carrying off the drip. A movable water bottle (A) is hung to the side; in this each bottle of food may be heated at the time of administration.

The bottles are made of flint glass and according to the design described on page 203, the graduated markings being especially convenient for measurement and rendering the use of a separate measuring glass unnecessary, a matter of no little moment, as every implement that comes in contact with the milk in sterilization must be kept chemically clean. Ten bottles are used, so that the whole supply of milk intended for a day's consumption can be prepared at once. Each bottle is provided with a perforated rubber cork, which in turn is closed by a well fitting glass stopper.

Sterilization should be performed in the morning as soon as possible after the milk has been served. The process is as follows: First, see that the ten bottles are perfectly clean and dry; pour into each six fluidounces (12 tablespoonfuls) of milk; insert the perforated rubber corks, without the glass toppers, however; remove the false bottom and place the bottles in the frame; pour into the case enough water to fill it to the height of about two inches; replace the the false bottom carrying the bottles; adjust lid, and put the whole on the kitchen range. Allow the water to boil and, by occasionally removing the lid, ascertain that the expansion that immediately precedes boiling has taken place in the milk, then press the glass stoppers into the perforated corks, and thus hermetically close each bottle. After this, keep the apparatus on the fire and the water boiling for twenty minutes. Finally, remove the false bottom with the bottles; pour out the water, replace and carry the whole, covered with the lid, to the nursery.

When the hour of feeding arrives, put one of the bottles into the attached water bath and heat it to the proper point for administration. The milk may, of course, be diluted with filtered water, or receive the additions ordinary made to adapt it to children of different ages. The tip used -- and a tube must not be employed even here -- should be thoroughly cleaned and immersed for a few minutes in boiling water before it is attached to the bottle.

So soon as a bottle is emptied -- and if the whole of its contents be not taken the remainder must be thrown away -- it is washed in the ordinary manner with a solution of bicarbonate or salicylate of sodium (see p. 204) and placed in the rack (B) to drain and dry.

Milk sterilized by the above process will remain sound for several days, according to some authorities as many as eighteen, [8] when the heating is continued for thirty minutes.

Sterilized milk is especially useful in travelling, when fresh milk cannot be obtained; for use in cities during the heat of summer, when milk is most apt to undergo injurious changes; for the feeding of delicate children, or for those suffering from disease of the stomach of intestinal canal.

Sometimes milk, in every form and however carefully prepared, ferments soon after being swallowed and excites vomiting, or causes great flatulence and discomfort, while it affords little nourishment. With these cases the best plan is to withhold milk entirely for a time and try some other form of food. The following are good substitutes:--

Mellin's food, 1 teaspoonful.
Hot water, 6 tablespoonfuls.

For each portion; to be given every two hours at the age of six weeks.

Veal broth (1/2 lb of meat to the pint), 3 tablespoonfuls
Barley water, 3 tablespoonfuls

For one portion.

Whey, 3 tablespoonfuls
Barley water, 3 tablespoonfuls
Milk sugar, 1/2 teaspoonful

A teaspoonful of the juice of raw beef [9] every two hours will usually be retained when everything else is rejected.

Such foods are only to be used temporarily until the tendency to fermentation within the alimentary canal ceases; then milk may be gradually and cautiously resumed.

When infants approaching the end of the first year become affected with digestion, it is often sufficient to reduce the strength and quantity of the food to a point compatible with digestive powers. For instance, at eight months the food may be reduced to that proper for a healthy child of six months, or even less. Here, too, predigestion of the food is very serviceable.

If a few grains of extractum pancreatis be added to a gobletful of thick, well-boiled starch gruel, at a temperature of 100° F., the gelatinous mucilage quickly grows thinner and soon is transformed into a fluid, the starch having been rendered soluble by the action of the pancreatin; by still longer contact, the hydrated starch is converted into dextrine and sugar. Advantage may be taken of this property to render the foods containing starch assimilable. Thus, to a mixture of barley jelly and milk, e.g.:--

Barley jelly, 2 teaspoonfuls
Milk sugar, 1 teaspoonful
Warm milk, 16 tablespoonfuls

Add three grains of extractum pancreatis, and five grains of bicarbonate of sodium, and keep warm for half an hour before administering.

The same process may be employed with food containing oatmeal, arrowroot or wheaten flour, with a view of converting the starchy elements into digestible elements without materially altering the taste.

When the infant has arrived at an age to take meat broths, these too, when digestion is enfeebled, may be readily peptonized. [9]

Returning to the regime of the healthy infant, it will be found that after the first year far less change is required in the food from month to month.

Diet from the twelfth to the eighteenth month, five meals per day:--

First meal, 7 A.M. -- A slice of stale bread, broken and soaked in a breakfast-cup (eight fluidounces) of new milk.

Second meal, 10 A.M. -- A teacup of milk (six fluidounces) with a soda biscuit or thin slice of buttered bread.

Third meal, 2 P.M. -- A teacup of beef tea (six fluidounces) with a slice of bread. One good tablespoonful of rice-and-milk pudding.

Fourth meal, 6 P.M. -- Same as first.

Fifth meal, 10 P.M. -- One tablespoonful of Mellen's Food with a breakfast-cupful of milk.

To alternate with this:--

First meal, 7 A.M. -- The yelk of an egg lightly boiled, with bread crumbs; a teacupful of new milk.

Second meal, 10 A.M. -- A teacupful of milk with a thin slice of buttered bread.

Third meal, 2 P.M. -- A mashed, baked potato, moistened with four tablespoonfuls of beef tea; two good tablespoonfuls of junket.

Fourth meal, 6 P.M. -- A breakfast-cupful of new milk with a slice of bread broken up and soaked in it.

Fifth meal, 10 P.M. -- Same as second.

The fifth meal is often unnecessary, and sleep should never be disturbed for it; at the same time, should the child awake an hour or more before the first meal, he must break his fast upon a cup of warm milk, and not be allowed to go hungry until the set breakfast hour.

Diet from eighteen months to the end of two and one-half years, four meals a day:--

First meal, 7 A.M. -- A breakfast-cupful of new milk; the yelk of an egg lightly boiled; two thin slices of bread and butter.

Second meal, 11 A.M. -- A teacupful of milk with a soda-biscuit.

Third meal, 2 P.M. -- A breakfast-cupful of beef tea, mutton or chicken broth; a thin slice of stale bread; a saucer of rice-and-milk pudding.

Fourth meal, 6.30 P.M. -- A breakfast-cupful of milk with bread and butter.

On alternate days:--

First meal, 7 A.M. -- Two tablespoonfuls of thoroughly cooked oatmeal or wheaten grits with sugar and cream; a teacupful of new milk.

Second meal, 11 A.M. -- A teacupful of milk with a slice of bread and butter.

Third meal, 2 P.M. -- One tablespoonful of underdone mutton pounded to a paste; bread and butter, or mashed baked potato, moistened with good plain dish gravy; a saucer of junket.

Fourth meal, 6.30 P.M. -- A breakfast-cupful of milk, a slice of soft milk toast, or a slice or two of bread and butter.

When sickness supervenes, all that is ordinarily necessary is a reduction of the diet to plain milk, or milk with Mellin's Food.

An important point, often neglected, is the matter of drink. Even the youngest infant requires water several times daily, and the demand increases with age. The water must be as pure as possible and should not be too cold. In the heat of summer, however, bits of ice and water moderately cooled by ice can be allowed without harm.

The foregoing schedule must, of course, be regarded only as an average. Many children can bear nothing but milk food up to the age of two or even three years, and, provided enough be taken, no fear for their nutrition need be entertained. If a child be thriving on milk, he is never to be forced to take additional food merely because a certain age has been reached; let the healthy appetite be the guide.

A young mother, in her solicitude to do her best, often finds great difficulty in adhering to simple rules in the diet of her child. Mrs. A., who has had great experience with children, having had some herself, tells her that the child would thrive far better if it ate such and such a thing, and did not keep to weak milk foods. Mrs. B. assures her that her cousin's last child grew much healthier after eating a chop with vegetables and pudding each day. Aunt. C. comes with the announcement -- which she breaks gently -- that she knows the child is simply starving, and the ignorant nurse confirms the statement.

All their seeming convincing theories are very upsetting to a mother who wants only to do what is right. She must bear in mind, however, that some children can eat anything and live; but she does not know how much better, more robust, and disease-resisting they would be, did they adhere to a simple diet. Let her remember that the so-called "weak milk foods" contain those nourishing qualities to which nature, in her wisdom, has limited the child's powers of digestion. Therefore, young mothers, let well enough alone.

d. Success in hand-feeding depends quite as much on the administration as upon the preparation of the food.

From birth up to such time as broth, bread, and eggs are added to the diet, all the food should be taken from a bottle. Even after this, as the bottle is a comfort and insures slow feeding, it may be allowed for milk preparations, until the child, of his own accord, tires of it. The only feeding apparatus to be admitted to the nursery is the simple bottle and tip. The bottle represented in Figure 20 is made, by my suggestion, by Mr. J. J. Ottenger, of Philadelphia. Its interior surface presents no angles for the collection of milk; it is easily cleaned, and the graduated scale is convenient for nursery use.

All complicated arrangements of rubber and glass tubing are not only an abomination, but a fruitful source of sickness and death. Rather than use them, it is far better to feed the infant with a spoon. In England, a bottle with a long rubber tube is almost universally employed. Should this be abandoned and a simple bottle and rubber tip used, the objections of some authors to bottle-feeding would vanish.

The bottle shaped as above must be of transparent flint glass, so that the slightest foulness can be detected at a glance, and may vary in capacity from six to twelve fluidounces, according to the age of the child. Two should be on hand at a time, to be used alternately. Immediately after a meal the bottle must be thoroughly washed out with scalding water, filled with a solution of bicarbonate or salicylate of sodium -- one teaspoonful of either to a pint of water -- and thus allowed to stand until next required; then the soda solution being emptied, it must be thoroughly rinsed with cold water before receiving the food. The tips or nipples of which there should also be two, must be composed of soft, flexible India-rubber, and a conical shape is to be preferred, as being more readily everted and cleaned; the opening at the point must be free, but not large enough to permit the milk to flow in a stream without suction. At the end of each feeding the nipple must be removed at once from the bottle, cleansed externally by rubbing with a stiff brush wet with cold water, everted and treated in the same way, and then placed in cold water and allowed to stand in a cool place until again wanted.

 While taking these precautions for perfect cleanliness, the nurse must satisfy herself of their efficacy by smelling both the bottle and the tip just before they are used, to be sure of the absence of any sour odor.

Next to cleanliness of the feeding apparatus, it is important to insist upon the separate preparation of each meal immediately before it is given. The practice of making, in the morning, the whole day's supply of food, though it save trouble, is a most dangerous one. Changes almost invariably take place in the mixture, and by the close of the day it becomes unfit for consumption.

When the graduated bottle is not at hand, a common glass graduate, marked for fluidrachms and ounces and holding a pint, should be provided for the nursery. Some moments before meal-time, so as to avoid hurry, measure the different fluid ingredients of the food in this, one after the other; add the requisite quantity of milk sugar, and mix the whole thoroughly, by stirring with a spoon, and pour into the feeding bottle. When the graduated bottle is employed, thorough shaking is sufficient. The food must now be heated to a temperature of about 95° F. This can be done by steeping the bottle in hot water, or by placing it in a water-bath over an alcohol lamp or gas jet. Finally, apply the tip and the meal is ready.

When feeding, the child must occupy a half-reclining position in the nurse's lap. The bottle should be held by the nurse, at first horizontally, but gradually more and more tilted up as it is emptied, the object being to keep the neck always full and prevent the drawing in and swallowing of air. Ample time, say five, ten or fifteen minutes, according to the quantity of food, should be allowed for the meal. It is best to withdraw the bottle occasionally for a brief rest, and after the meal is over, sucking from the empty bottle must not be allowed, even for a moment.

e. For children residing in cities, an honest dairyman must be found, who will serve sound milk and cream from country cows once every day in winter, and twice during the day in the heat of summer. The milk of ordinary stock cows is more suitable than that from Alderney or Durham breed, as the latter is too rich, and, therefore, more difficult to digest. The mixed milk of a good herd is to be preferred to that from a single animal. It is less likely to be affected by peculiarities of feeding, and less liable to variation from alterations in health or different stages of lactation.

The care of the herd and of the milk is of great consequence. The cows should be healthy, and the milk of any animal that seems indisposed should not be mixed with that from perfectly healthy animals. The cows must not be fed upon swill or the refuse of breweries, glucose factories, or any other fermented food. They must not be allowed to drink stagnant water, and must not be heated or worried before being milked. The pasture must be free from noxious weeds, and the barn and yard must be kept clean. The udder should be washed, if dirty, before the milking. The milk must be at once thoroughly cooled. This is best accomplished by placing the can in a tank of cold spring water, or in ice water, the water being of the same depth as the milk in the can. It is well to keep the water in the tank flowing; indeed, this is necessary unless ice water be used. The can should remain uncovered during the cooling and the milk should be gently stirred. The temperature should be reduced to 60° F. within an hour, and the can must remain in the cold water until the time for delivering.

In summer, when ready for delivery, the top should be placed in position and a cloth wet in cold water spread over the can, or refrigerator cans may be used. At no season should the milk be frozen, and at the same time no buyer should receive milk having a temperature over 65° F.

The milk and cream must be transported from the dairy in perfectly clean vessels. To insure this it is best to provide two sets of small cans; one set to be thoroughly cleansed and aired while the other is taken away by the milkman to bring back the next supply. So soon as this arrives in the morning, or in the morning and evening in hot weather, the milk should be emptied into separate and absolutely clean earthenware or glass pitchers, and these put at once into a refrigerator reserved exclusively for them. This may stand in some convenient spot near the nursery, but not in it, and especially not in an adjoining bath room. With a good refrigerator there is no difficulty in keeping milk perfectly sweet for twenty-four hours in winter and for twelve hours in summer, except on intensely hot days; then it may be necessary to scald, lightly boil or sterilize the whole of the supply when received, in order to prevent change.

It is a well-known fact that milk is a fluid having active powers of absorption, and that it frequently acts as the medium of transmission of the contagion of such diseases as scarlatina, diphtheria and typhoid fever. Doctor V. C. Vaughan has also lately discovered in milk a special poison which he terms tyrotoxicon (cheese poison).

The clinical elements of interest in these discoveries is the close analogy between the symptoms produced by the experimental use of tyrotoxicon and those observed in cholera infantum -- an analogy suggestive of the possibility of the latter disease being chiefly due to poisoned milk. This causal relation is scarcely more than a theory, though certain well-known features of the disease seem to bear it out. Thus, the affection occurs at a season when decomposition of the milk takes place most rapidly; it occurs at places where absolutely fresh milk cannot be obtained; it prevails among classes of people whose surroundings are most favorable to fermentative changes; it is most fatal at an age when there is the greatest dependence upon milk as a food, when the gastro-intestinal mucous membrane is most susceptible to irritants, and when irritation and nervous fevers are most easily produced.

Drs. Newton and Wallace, of the New Jersey State Board of Health, have reported a number of cases of poisoning by milk that occurred in different hotels in Long Branch. These observers found that the affected milk was all obtained from one milkman, and that the cows furnishing it were all milked at the unusual hours of midnight and noon. The noon milking was immediately placed in cans without being cooled, and "carted eight miles through the warmest part of the day in a very hot month." It was this milk that produced the poisonous effects, the morning's milk being always good. No statement is made as to the health of the cows or the nature of the poison, but there is a probability of its having been tyrotoxicon, and of this material or its ferment having been generated by the careless collection and transportation of the milk, combined with the high atmospheric temperature.

Childhood. -- Children who have cut their milk teeth may be fed for a twelvemonth -- namely, up to the age of three and a half years -- in the following way:--

First meal, 7 A.M. -- One or two tumblerfuls of milk, a saucer of thoroughly cooked oatmeal or wheaten grits, and a slice of bread and butter.

Second meal, 11 A.M. (if hungry) -- A tumblerful of milk or a teacupful of beef tea with a biscuit.

Third meal, 2 P.M. -- A slice of underdone roast beef or mutton or a bit of roast chicken or turkey, minced as fine as possible; a baked potato thoroughly mashed with a fork and moistened with gravy; a slice of bread and butter; a saucer of junket or rice-and-milk pudding.

Fourth meal, 7 P.M. -- A tumblerful of milk and one or two slices of well-moistened milk toast.

From three and a half years up the child must take his meals at the table with his parents, or with some reliable attendant who will see that he eats leisurely. The diet, while plain, must be varied. The following list will give an idea of the food to be selected:--

Breakfast.

Every Day.
One Dish Only Each Day.

Milk.

Fresh Fish.

Eggs, plain omelette.

Porridge and cream.

Eggs, lightly boiled.

Chicken hash.

Bread and butter.

Eggs, poached.

Stewed kidney.

Eggs, scrambled.

Stewed liver.

 Sound fruits may be allowed before and after the meal, according to taste, as oranges, grapes without pulp (seeds not to be swallowed), peaches, thoroughly ripe pears, cantaloupes and strawberries.

Dinner.

Every Day.
Two Dishes Each Day.

Clear soup.

Potatoes, baked.

Hominy.

Meat, roasted or broiled, and cut into small pieces.

Potatoes, mashed.

Macaroni, plain.

Bread and butter.

Spinach.

Peas.

Stewed celery.

String-beans, young.

Cauliflower.

Green corn, grated.

Junket, rice-and-milk or other light pudding, and occasionally ice cream, may be allowed for dessert.

Supper.

Every Day.

Milk.
Milk toast or bread and butter.
Stewed fruit.

Fried food, highly-seasoned or made-up dishes are to be excluded, and no condiment but salt is to be used.

Eating, however little, between meals, must be absolutely avoided. Keep a young child from knowing the taste of cakes or bonbons, or, having learned it, let him feel that they are as unattainable as the thousand other things beyond his reach, and he soon ceases to ask for them. Even a piece of bread between meals should be forbidden. His appetite then remains natural, and he will eat proper food at his regular meal hours.

Filtered or spring water should be the only drink; tea, coffee, wine or beer being entirely forbidden.

As to the quantity, a healthy child may be permitted to satisfy his appetite at each meal, under the one condition that he eats slowly and masticates thoroughly.

In the case of illness, the diet must be reduced in quantity and quality, according to the rules that are applicable to adults.


[1] The character of cows' milk may be determined with sufficient accuracy in the following way:--

Prepare a urinometer, such as shown in Fig. 18, and which can be obtained at any drug shop. To obtain the specific gravity, fill the beaker to such a point with milk that it will float the specific gravity glass, and read the degree of density from the scale at the 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 though 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 the beaker 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 cream rises and appears as a yellow layer at the top; this layer should have the depth of ten or twelve spaces.

[2] See Chap. IX.

[3] See Chap. IX.

[4] Ibid.

[5] About eighteen teaspoonfuls.

[6] The subject of peptonization is further considered in Chapter IX.

[7] Measure provided with each can of powder.

[8] Since writing the above, this statement has been verified by my own experiments.

[9] See Chapter IX.


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