Hygiene of the Nursery. Part II.
by R. W. Wilson, M.D.
Volume 11, 1900, pgs. 628-633
(Continued from pg. 377.)
But, to return to the means of preventing disease in the nursery, the most prominent place must be given to cleanliness. Owing to the minuteness of most of our living enemies of the germ kind, they may lurk in what might, by many, be termed a clean room. But, however well swept, a room could not be considered clean if there remained on the floor, for example, spilt milk or any other similar organic matter. Bacteria could not exist if they had not a suitable soil to grow upon; and the matters expelled from our own bodies--from lungs, skin, and organs of elimination generally, as well as food stuffs--are the very best media for their cultivation. Cleanliness of the nursery, then, to the extent of completely removing this soil, is a necessity, if bacilli and bacteria are not to grow there. Systematic cleansing with soap and water should be the first thing done, and to facilitate the use of these, where floors are to be washed, all rugs and carpets should be easy to remove, and should themselves be cleansed and occasionally disinfected. So many warm coverings for the floor, of the linoleum class, which can be easily washed, are now obtainable, that very few rugs are really needed. Then, after soap and water, when disease has actually invaded the house, any one of the numerous disinfectants we are all familiar with may be used. Carbolic acid [phenol] in proper dilution and all its kindred products, most of them with an odour of tar, are highly destructive of germ life; boracic acid, in powder or in solution, permanganate of potash, perchloride of mercury, sulphur, chlorine, and many refined proprietary articles with commercial names, such as Sanitas, Izal, Chinosol, etc., have their respective merits. The light of the sun, too, is a disinfectant of great power.
Concerning food in the nursery; milk is often to be seen lying about in readiness for the next meal. It is usually uncovered, and if the weather is warm it may be observed placed on the window-sill for coolness. A worse place than this could hardly be chosen, for the current of air passing in and out must eddy about the vessel, and give the life's opportunity, as a nidus [nest; place of infection] for reproduction, to any bacterium that may be wafted into it. It would be better to put it in the middle of the garden, where the air is less in motion. But, if it must be place in a current of air for cooling purposes, it would be safer to put it in a bottle stoppered with cotton wool than in any ordinary open-mouthed jug without any covering at all. Cotton wool is an excellent filter for air containing possible germs. In the now common practice of sterilizing milk, it is evidently believed by the ignorant that all danger is averted by the simple process of boiling it. The boiling of milk may certainly destroy fully-matured germs, such as the tubercle bacillus, the bacillus of green diarrhoea in children, and the organisms which cause scarlet fever, typhoid, diphtheria, and so forth; but the spores (or seeds) are not destroyed, and the milk, even if they were, could not in any sense be considered sterile then. Sterility, as applied to boiled milk, is another inaccurate expression. Milk may be as fertile a soil as it was before boiling if fresh bacilli or their spores come in its way. Therefore, so-called sterilizers have been devised, which, after boiling, prevent the inroad of any new bacterium. The danger of receiving milk from cows, themselves the victims of tubercle, and containing, therefore, the potential element of phthisis or tuberculosis in us, has recently been taken up by an influential body of men, princes as well as physicians, who have formed themselves into an association for the express purpose of combating it. To destroy every tuberculous cow that exists would be one of the their radical measures, but compensation to the owners for such an act would be costly in the extreme; so legislation will, no doubt, be gradually brought to bear upon it. The association recommends everybody to boil milk before using it, to diminish the risks of tubercle. Milk that is boiled, however, is altered somewhat in composition, and to many is not so digestible as unboiled milk. Scurvy may be induced in certain children by the too exclusive use of it, and this seems to prove that some of its good properties are either modified or destroyed. The boiling of milk, therefore, is not a panacea for every microbic ill that flesh is heir to, but has risks of its own which intelligent people should be fully aware of.
It is not merely through the medium of food that a link is established between the lower animals and ourselves in the propagation of disease. Many of our pets may be active sources of direct infection and admirable agents for its dissemination. No better vehicle for the desquamated scales of scarlet fever, for example, could be found than the fur of a cat; and the presence in the nursery of a favourite tabby may frequently explain obscure attacks of influenza among the children therein. Whoever has sat on the box-seat of an omnibus on a frosty day, with fog prevailing, and watched the volume of condensed steam emitted from each nostril of the panting horses that dragged it, must have realized what possibilities there are for spreading infection from the horse to the man in the street; and, in a lesser degree, the same thing obtains in the nursery. The Englishman's love for his pets will make it, I fear, a more difficult matter for the sanitarian to eliminate diseases connected with them by killing, than tuberculosis in cows by their wholesale destruction.
This part of our subject would be very incomplete, however, if the question of artificial feeding of infants were left unnoticed. In some few cases we know that the infant cannot be nursed by its mother--in many more, I regret to say, the mother, from selfish motives, prefers to leave the feeding of her child to somebody else. Wet-nursing is not in vogue here, and the question of how to artificially feed an infant arises so often under these conditions, that it may not be superfluous to point out some general principles that ought to guide on in the answer to it.
Though the food provided by Nature for the infant cow and that intended for the infant man both bear the name of "milk," there is a very great difference between them in chemical composition. The cow's milk is richer in proteids (that is, the element which roughly corresponds to the white of the egg), but it is poorer in cream and in sugar that the human milk. To convert cow's milk, then, into a food which more closely resembles the human variety--and which seems, surely, to be the right line to pursue--it should, for a newly-born child, have two parts of water added to each part of milk, and a little cream and sugar supplied in addition. A very little soda and a grain or two of salt should also be put into each bottleful. The sugar might preferably be of the kind known as lactose, or milk sugar; for that is the sort present in human milk. But cane-sugar, when it can be obtained, should always be used in preference to the product of beet-root, with which our country is at present supplied so cheaply from Germany. And the proportion of milk to water should be increased gradually with the increasing age of the child, until about the end of the first year is reached, when the milk may be given undiluted. None of the many foods which are so widely advertised should ever be used in the feeding of a newly-born child. Later on they may be useful adjuncts to the food which Nature has specially provided; but, at first, they ought not to be given if milk and cream can be obtained. This is now the accepted belief of all who have seriously studied this matter. The composition of the many artificial foods for infants at the present in the market varies widely. The worst, perhaps, among them contain unaltered starch granules; some, very little better, are composed of the flour of wheat and barley changed into dextrine; another kind contains condensed milk with the addition of dextrine and sugar; and yet another is formed of proteids, partially peptonized, with fat added. Now, a child has hardly any power to digest starch until the tenth or eleventh month of life; therefore the starchy varieties should not be given till this amylolytic function has developed; and the proteids of the last-named kind are of vegetable origin, and not so digestible as the proteids of milk. When diluted with water only, they are deficient in nearly every nutritional element that the body requires; and when milk is added, there is little need for them. Indeed, these food may be positively injurious if continued for long, and the chief defect of the majority of them is the small quantity of fat they contain. But, as before said, they may be useful and pleasant additions to the food of children later than the first few months of life.
Having taken a rapid survey of the surroundings of early life in the home, the conditions under which children live, and certain possible ways in which health may be affected, chiefly by things outside of them, we may not briefly allude to certain things connected directly with their bodies and coming from within, which are equally harmful. The human organism is so complex and the health of one department depends so much upon the health of another, that it is wonderful that harmony is preserved at all in the whole. There is not merely the danger of giving the wrong food to the body--foods that may contain deficiency or excess of what it needs; but there exists within it, also, organs which give out secretions that are of vital necessity to its other parts. As an example of what I mean, I will very shortly, refer to that curious disease known as myxaedema. In it there is perverted function of the thyroid gland and the consequence is the development of a new substance in the body which gives it the appearance of gross fatness. The sufferer from it looks heavy; his muscular and mental functions are impaired; and the whole individual is changed. Give to such a person part of the healthy thyroid gland of a sheep; and the disease will gradually disappear. That which ought to have been secreted by the patient's own thyroid, and was not, had far-reaching consequences, even to the brain itself. Fortunately, this has found to be remediable by help of the corresponding gland of one of the lower animals, and so the healthy balance can be restored.
The case is only here referred to in order to place us in a proper mental attitude towards this subject of the dire effects of the body on withholding one kind of physiological product, or of thrusting up it another. The products of fermentation, which are the products of microbic life, maybe considered to be thrust upon the body; they are often formed within it, and in quantity may be small, but many of them may be deadly in their effects.
The cavities of the mouth and nostrils contain possibilities in this respect which are appalling when we come to look into them. Despite the cleansing action of the tongue in its movements during mastication there is always a certain amount of food left in the interstices of the teeth, and this forms the pabulum upon which innumerable micro-organisms grow, some of them capable of destroying us by their toxines.
If cleanliness is desirable for the outside of the body, it is still more so for within. And yet, many people most particular about the face and hands will never think of looking into the ears, mouths, and nostrils of children to see if they are clean. Besides the mucus membranes at the back of the nostrils, which so commonly now becomes the seat of adenoids growths, there is another more complicated and delicate organ, namely, the parts composing the middle ear which are in direct communication with it through the Eustachain tubes. These tubes permit the passage of air through the inner side of the drum, for the drum of the ear would not vibrate unless it had air on both sides of it. Well, by neglecting to clean the back of the nostrils in certain catarrhal states, like that of ordinary influenza, these tubes maybe blocked, an abscess of the middle ear may be set up, and besides the acuteness of the pain whilst it lasts, deafness may result for the remainder of the life.
To reduce all such risks to a minimum, a child might easily be taught to make use of a nasal douche, or simply to sniff up any warm antiseptic fluid, from the hollow of the hand. A little common salt in water, borax and water, or boracic lotion is all that would be required. Yet, strange as it may seem, there are many children, quite grown up and attending school who do not know how to use a handkerchief.
Though nurses should hardly undertake the syringing of ears blocked with cerunem, they ought to certainly be able to douche the nostrils when there is a need for it. Speech, breathing, singing, hearing would all be improved by attention to this necessary form of cleanliness.
Natural secretions poured out in excess may thus, in themselves, be a source of danger; but the risk does not end there; for, wherever organic matter exists and air has access to it, there will be microbes to flourish and inflammatory action take place if it is allowed to remain.
In the mouth and throughout the alimentary canal, microorganisms are present always, and, if left unheeded, they may tend to evil consequences in many ways. Their effects upon the teeth, for example, results in caries, owing to the acids produced by them. These acids penetrate any cracks in the enamel, and dissolve out the lime salts of the dentine. The ground is then prepared for a very living colony of living microbes, which liberate occasionally some exceeding unpleasant compounds of the phosphorus class.
Not only is the pain of toothache a thing to be prevented if possible, but the destruction of our pearly ornaments is a blemish which even the skill of the dentist cannot always repair, and carries with it a loss of more than aesthetic value. A boy may be rejected for army and navy on account of bad teeth.
Much has been said and written about the causes of decay in teeth among civilized peoples. The consumption of sugar, jams, and sugar-producers have been blamed, among ourselves, for it. And the evils of what we consider advanced civilization, the mental strain and struggle for existence, over-crowding, bad water to drink, unsuitable food to eat, which gives too little work for the jaws, have all been cited as probable causes. Travellers visit remote parts of the earth, and find savages living simply and frugally with teeth intact up to a ripe old age, and this is quoted as an argument in favour of the dirt theories. I suspect, however, that the death rate in early life amongst savages is very high, and only a very strong remnant survives. And as to sugar, we know that the negro, in countries where the sugar-cane grows, delights in sucking and nibbling at the cane, consuming thereby quite a lot of saccharine matter, but his teeth remain good in spite of it. And the rice-eaters of India, as another example, have starchy food enough, yet their teeth are good. I am bound to say about them, however, that they do take pains to clean their teeth, mostly with bits of cane. How far this is part of their religion, I am not prepared to say. But cleanliness in many of the religions of the world is equal to godliness--with us, it only comes next to it.
People of by-gone ages--even the mummies of Egypt--are all dragged in to show that so far as teeth are concerned, the present races of civilized man are decadent. Now, it is probably, that no single explanation is sufficient to account for teeth-caries in every instance. Good teeth, are, upon the whole, fair evidence of an inherited sound constitution. There are, certainly, inherited diseases which show evidence of their existence in the teeth; and even in the course of temporary illness in those whose teeth are good, a groove or weak place will appear, which marks the period of the disease and the consequent mal-nutrition. The nails and hair are also affected in the same way. So that, to speculate upon the possible causes which produce bad teeth--if they are as remote as the illnesses and physique of our ancestors--will not help us much in dealing with them in the nursery. Practically, the general principles for us to go upon must be--to maintain all round the highest standard of health in a child; to pay most particular attention to the cleansing of the mouth; and to feed with food that contains all the elements of nutrition that the body requires. And when disease appears, do not put off, but go to the dentist at once to have the cracks and fissures attended to. A hint as to the method of brushing the teeth may be given, and it is this--brush the teeth vertically as well as horizontally, and do not let it be only in the morning that this is done, but use the tooth-brush after every meal, and especially after the last one of the day.
A biscuit given to a child before he is put to bed is an excellent way of filling up the spaces between the teeth with starchy food; and, as starch is converted into sugar by the action of saliva, the best of breeding-grounds for bacteria is thus provided for the long hours of the night, when there are few movements and little secretion within the mouth, to remove it. Lactic acid is frequently formed under these conditions, and the dentine acted upon by it.
As to sugar itself--when given at proper times and in suitable quantity, being highly nutritious, it is beneficial rather than harmful. It promotes a free flow of saliva, which thoroughly dissolves it in the mouth, and so it is passed on to the stomach. There, of course, if taken in great excess, it may undoubtedly produce catarrh [inflammation, congestion]; and catarrh of the stomach may, in a roundabout way, produce decay in the teeth; but by its direct action upon sound teeth, there seems to be less chance of corrosive effects than by the fermenting starch.
There seems to be too great a tendency, perhaps, at the present time to bestow thought only upon digestion in the stomach, and to provide soft and highly-concentrated pulps and fluids, that require no mastication. The over-crowding of teeth in small jaw-bones, leading up to decay, is, in some degree, due to the little need there now is for chewing, with consequent atrophy of the organs of mastication. The savages who do not feed on peptonized foods, and have excellent teeth withal, probably give their jaw-bones better exercise than civilized people do. It might, therefore, be to the advantage of the civilized, if, during the growing period of life, they munched more crusts and hard biscuits, and were given the drumstick of a fowl now and then to sharpen their teeth upon.
It is not merely that carious [having cavities] teeth will impair digestion through deficient mastication; they will, under certain conditions, set up serious disturbances also in the nervous system. Epileptic fits have even been produced by the irritation of decayed teeth.
The first teeth should be as carefully attended to as the permanent set, for they minister to the needs of the body at an important stage of development, and if allowed to become carious, they may affect the health of the secondary set.
The practical suggestions that I have to make in this connection are: that the nurse should frequently cleanse the mouth of a baby with a little boric lotion, or borax and glycerine, before the teeth appear; that after the eruption of the primary teeth, whilst the child is still very young, a piece of flannel moistened in warm water should be employed to wipe away any particles of food from them; and, when the child is old enough to use a brush, and has learned to rinse his mouth out with water without swallowing it, a little soap and precipitated chalk may be used by him. Probably, too, a regular visit to the dentist for inspection is the safest, and in the end, the most economical procedure.
As there will always be those among the custodians of children who aspire to the higher realms of treatment by drugs, a few words for guidance, and intended rather as a warning than as an encouragement to them, may not be out of place. If the diagnosis of disease in children is more difficult than in the adult, so is the treatment of their diseases. The laws which govern dosage in the one case do not always apply in the other. Opium, for example, should be given to children with the greatest caution and in minute doses. Children are also very susceptible to the action of carbolic acid, iodoform and chlorate of potash. But a very large number of drugs are tolerated as well by children as by grown-up people, and some even better. Among this class are belladonna, mercury, the bromides, chloral, bismuth and quinine. When drugs are required, however, the case would be best left in the hands of the family doctor.
In nearly every nursery now, a clinical thermometer is to be found, and it is a source of comfort or distress, according to the natural temperament of the person who uses it. Its use ought to be preceded by a knowledge of the normal range of body heat. In children, it is more variable than in adults; and during the first two years, a variation anywhere within the limits of 98 degrees and 99.3 degrees F. may be considered normal. The best place to take temperature is in the groin, for there the two skin surfaces come into more perfect contact than in the armpit. The period of highest temperature is from 8 to 10 a.m., and it fluctuates throughout the 24 hours, which shows how highly sensitive the nervous system of children is. When the temperature rises above the normal point, the wisest thing for mothers or nurses to do, on their own initiative, is to sponge the body with tepid water rather than give an antipyretic medicine, and no risks will be run.
In bringing this too lengthy paper to a close, I will confess that one of my objects has been to avoid giving tips and wrinkles for amateur doctoring in the nursery. I have deemed it wiser to try to throw a little light upon the dark places of hygiene that continue to be obscured by traditional fallacies; and if I have succeeded in arresting attention and arousing thought in some who have been content to merely drift along as their forefathers did, or if I shall have provoked a spirit of controversy among those who have not been contented to drift, but have been striking out for terra firma, viewing the land ahead in a different light to that which it appears to myself, in either case I shall consider that my labour has not been in vain in writing it.
Proofread by LNL, May 2011