The Parents' Review

A Monthly Magazine of Home-Training and Culture

Edited by Charlotte Mason.

"Education is an atmosphere, a discipline, a life."
Hygiene of the Nursery

by R. W. Wilson, MD
Volume 11, 1900, pgs. 366-377

"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."

"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."

A letter delivered to the Richmond branch of P.N.E.U.

When I undertook to write a paper fro the P.N.E.U on the subject of Hygiene in the Nursery, I allowed myself a liberal interpretation of the word hygiene, though one not beyond the limits of its real meaning. It is, I am aware, commonly associated in people's minds with a certain few of the general principles upon which the science of public health is founded, such as ventilation and cleanliness; but the idea underlying its root includes everything pertaining to the health of the individual. The architect and sanitary engineer have important work connected with it, no doubt, for the nursery as a room, and the best methods of warming, airing, heating and lighting it, are subjects that lie well within their sphere. But the mere environment, important though it be, is simple in detail and easy to arrange compared with other things in the lives of the environed [environee?]. The constant changes that take place during the growth and development of the young, and the different appearances that present themselves under apparently the same conditions, make this side of the subject one of great complexity. I, shall therefore, be keeping well within the legitimate meaning of the word if, in addition to things intrinsic, I give some consideration to the child itself.

Strange as it may seem, the systematic study of the phenomena of health and disease in children is a thing of comparatively recent date. The constant and rapid changes that take place in youth are most bewildering, and no well-ordered scheme or design seems to have been thought of in past to understand them better. The limited experiences of the few who did compare notes, whether lay or professional, would hardly supply data sufficient to generalise upon and thereby get nearer to the truth. Ancient theories require much contra-evidence for their refutation and overthrow, however false in principle they may be, and free and wide discussion is necessary for progress and enlightenment. Probably the increased facilities we now enjoy for intercommunication--railways to travel by, and cheap literature to spread, broadcast the ideas that occupy the attention of people everywhere, have brought about the change, and rendered it impossible for us to study general principles in a more comprehensive way than ever before. The existence of an educational union like this is testimony enough that a serious study of children in health is taking place. And among experts in the field of disease, union on a wider basis still is also existent. Special treatises on the diseases of children are multiplying rapidly, but they are, nevertheless, all modern. For, whereas it was formerly thought that, though infinite skill and penetration were required for the diagnosis and treatment of disease in mature man, the nurse might be left to deal unaided with sick children in the nursery, now it is becoming recognised that so great are the difficulties that beset the newer task, that the practitioner among children requires a special aptitude for his calling.

The difficulty of treating such a subject as the maintenance of health in the nursery, in a popular way, is the mass of detail that lies before one. To arrange it within the limits of a single paper is no easy matter. It may be best, therefore, to deal only with a few of the first principles involved, and make use of details only to elucidate them.

As striking illustration of how first principles are violated by common consent, and even those of us who know better are forced to perpetuate a fallacy, I may cite the expression "catching a cold." Though we all make use of this phrase, and some of us adopt it as a creed, it is manifestly wrong, and I shall do something now, by exposing the absurdity of it, to clear my own conscience as an aider and abettor of the false doctrine.

Although people know what is meant, vaguely, when a cold is spoken of, it is, none the less, a misapplied term. There is no such entity as "cold" to catch. Cold is a negative quantity, and is merely a relative absence of heat. Heat, on the other hand is an entity, it has a real existence, and the loss of it by the bodies may set up a sensation within us which we term cold. But the excitation of that feeling is not due to the absorption of cold, as the ancient observer who originated the expression may have thought. It is actually due to a loss of heat. And the various symptoms of ill-health described as colds, and which might be more accurately called fevers with catarrh [respiratory inflammation], do not arise coincidentally with, or in consequence of a feeling of chilliness at all. Indeed, the most common symptom of a cold, namely, an excessive flow of mucus from a mucous membrane, may arise without any exposure to cold air whatever. Infectious germs may cause it.

And a stranger thing still, in face of this expression, is the fact that one may take into his lungs air more than a hundred degrees colder than his body, and yet not catch cold from that cause. The temperature of the body is about 98 degrees Fahrenheit, freezing point 32 degrees, and a temperature below zero of this scale is not unfrequently reached, even in England; but we do not of a surety catch cold on that account by breathing such an atmosphere. More than this, men go into the Arctic regions and breathe air 50 degrees below freezing point, and still remain unaffected by it. Dr. Nansen and his companions in the Fram, during an Arctic winter, suffered practically neither from coughs or colds. I will not say that it is quite impossible for anyone to have congestion set up in his air-passages by breathing very cold air, for it would appear that there are some highly susceptible individuals who may have acute laryngitis or acute bronchitis induced by it without either mechanical irritants or morbific [unhealthy] organisms being present, but they are few and far between. The provisions of Nature for warming the air as it enters our breathing organs are so perfect, that even children may, in this climate, almost neglect the temperature of the air they breathe.

But, on the other hand, during the mildest weather whilst sitting at an open window, with the thermometer at 60 degrees or higher, a sneezing fit comes on, a neuralgia or lumbago is set up, and, as the expression goes, "a cold is caught."

Now it would matter little, if people were not misled by it--but, in consequence of this false conception, which has crystallized into a phrase, found its way into dictionaries, and has taken firm root in the English mind, much harm has been done. People shut themselves up in rooms with doors closed and windows hermetically sealed, breathe the same air over and over again, and get into a state of ill-health which is the outcome of their pet fallacy.

A reaction against this vicious doctrine of cold-catching has at last set in, however, and the quarter from which it comes is one the least expected. It is actually in the treatment of a disease which was too often attributed to cold, namely, phthisis [lung disease] or consumption, that this more enlightened view has found acceptance. What is now popularly known as the "Nordrach System" of treatment of this dreadful complaint, is based in great measure upon the beneficial effects of fresh air. [Dr. Otto Walther used open windows and lots of fresh air in his 'open air cure' at his sanitariums for tuberculosis] Properly regulated but very liberal diet plays also a part, but the open-air life, both in sleeping and waking hours, is the basis of the treatment. Patients sleep freely exposed to the outer air, so far as breathing is concerned, though their bodies are kept perfectly warm the while, and such success has been attained by Dr. Walther, at Nordrach, on these lines, that there are in England already a few, and soon will be many more institutions, public and private, wherein this widespread disease will be combated according to Walther's method. It is worthy of a trial, for the number of victims yearly to consumption in the United Kingdom is about 60,000.

Now all this confutation of cherished beliefs has only been preliminary to the statement that it does not matter to the bulk of mankind what the temperature is of the air they breathe. But that the body should be kept warm is quite another matter, and a word may be said in this connection upon the risk that children sometimes run, in having one part of their bodies unduly clothed and another quite unprotected. Parents sometimes expose the legs and arms of their children designedly, with the object of hardening them; or sometimes, in a spirit of vanity, to compel admiration of their beautiful contour and proportions.

Within certain limits, varying with the strength of the child, the season of the year and other circumstances, it may, perhaps, be done with impunity, but it is risky if permitted at all times, and causes like this may have far-reaching effects which do not declare themselves at the moment. To act on the safe side, it appears to be as well to conserve body-heat by help of gaiters and mittens in very cold weather, whilst there are so many demands otherwise upon the growing organism. Even with active exercise, a child may be cold at the knees, and in hands and feet, and his happiness is not increased thereby any more than his health. But, whilst all this is perfectly true, it must be conceded that an even greater risk may be run by coddling, and as no rule can be laid down to apply rigidly to all children alike, the good nurse will soon decide, by observing effects, whether a particular child requires special care and protection or not. This conservation of body-heat, by means of proper clothing, needs as much attention within the nursery as out of doors.

Leaving, then, the subject of heat and cold, which is so curiously misunderstood, the atmosphere itself must be considered. It may be assumed that no one, now, believes the air to be a simple element and a thing to be classified along with fire and water in the sense that the ancients classified them. The air, we all know now to be a mixture of gases, chiefly nitrogen, oxygen, and carbonic acid gas. And living things upon the earth require, for their very existence, the two last-named constituents. In general terms it may be said that the Animal Kingdom absorbs O, and gives out CO2; and the Vegetable Kingdom absorbs CO2 and gives out O, a beautiful balance in Nature being thus established. But there are other constituents in the atmosphere, besides nitrogen, oxygen, and carbonic acid, and some of them are highly deleterious to man. In the nursery, which we are now concerned with, there may be found traces of chlorine, sulphuretted hydrogen, epithalial scales from the skin, and fibres of sorts, also hair, dust, and even fine particles of arsenic given off from certain green wall-papers, together with effluvia of various kinds, all of which things the nursery would be better without.

But vitiation comes from the inmates themselves. In exchange for the five parts of oxygen absorbed by the blood in each act of breathing, four parts of carbonic acid are given out from the lungs; an adult man gives off in repose from 12 to 16 cubic feet of CO2 in 24 hours, and this CO2 does not sink down to the floor or rise to the ceiling, but diffuses through every part of the air within the room, the rate of diffusion being fairly rapid.

In addition to this expired air, there is the CO2 which comes from that other constant source of vitiation, the illuminating agents--gas, candles, and lamps. One cubic foot of coal-gas consumes the O of about eight cubic feet of air, and produces two cubic feet of CO2. The disappearance of the entire candle when lighted, or of the oil in a lamp, should assist us in realizing the degree of vitiation that goes on with them in action. Neither the candle nor the oil are annihilated, they have only undergone a change of state; and the change from the solid or liquid to the gaseous state results in enormous expansion and increase of bulk. A candle, harmless enough as a solid stick of greasy matter, becomes a harmful thing when burnt into carbonic acid gas. The best of all illuminants, therefore, is the electric light, which has no products of combustion. But an even greater source of danger to health than these inanimate constituents of the air, being within and without the nursery, are certain minute living organisms, which, from their smallness, are popularly known as microbes; and about these I shall have more hereafter to say.

So, when we come to analyze the things pertaining to the atmosphere which may and do cause languor, feebleness, and disease within us, and even death itself, it may seem wonderful that any but the strongest has ever reached maturity.

Nature is very bountiful, however, and has wide margins of health-giving principles, far beyond the needs of man, as he exists at present. For instance, the oxygen of the air is one of man's vital necessities, and it may seem strange on a superficial view of the matter that the nitrogen which flows in and out of his lungs unused, should be four times as plentiful as the oxygen which is life to him. But we find on examination that the O, even though less in quantity than the N, is far in excess of his needs, and the dilution of it to so high a degree is also beneficent. Some figures may be instructive, and I shall quote from Parkes:--Pure air out-of-doors represents about 210 of oxygen in 1000 volumes of air. In a crowded part of Manchester, where plenty of smoke existed, the amount of oxygen was 208.68 to about 202 parts per 1000. In London, in the open spaces, the O amounted to 209.5; and in the crowded districts of the East End to about 208.5 in a 1000 volumes. In a foggy and frosty day in Manchester it was 209 per 1000. (Parkes, p. 154.)

Whilst dealing with percentages of gases in the air, I may as well give here also a few figures representing the amount of carbonic acid present. And though these are in decimal points, they are probably more important, and better worth remembering than the bigger figures of oxygen. The usual amount of carbonic acid present in pure air is 0'3 to 0'45 per 1000 volumes. Roscoe's experiments on the air of London showed 0'37 per 1000 volumes. Angus Smith in Manchester found 0'413 per 1000, during fogs 0'679. In the neighborhood of Gower Street, London, in damp weather, De Chaumont found 0'736 per 1000. This may seem to be a small amount to lay stress upon, and the variation from the highest to the lowest but trifling, yet it is true that a fractional increase if carbonic acid gas in the air we breathe, has an appreciable effect on health. The increase of CO2 rather than O in the outer air, should receive our first attention.

Ozone, present in the air in the country and at the seaside, is practically absent from the air in towns. But a consideration of such fact and figures will make clear to us the reason why the multitudes who live in towns and who cannot afford to take a change of air, live as long as those who do, the reason being that they always have enough and more than enough, of oxygen for their needs if they merely open their doors and windows, or, better still, take exercise in the outer air. The expression "change of air" therefore, seems to be very much more to the point than that other one about "catching cold." The air, through the agency of the winds, is always changing around us! I cannot refrain from citing some interesting facts, bearing on this subject, which were brought to light by Professor Mosso, of Turrin recently. He, with a few assistants, investigated this problem of the needs of O by the body in a series of experiments conducted on the top of the Alps. Professor Mosso found that after a short sojourn at those high altitudes he became accustomed to the rarefaction of the air (which implies a lessened quantity of O) and could do hard work without pulse or respiration being quickened more than at sea-level. And his conclusion was that the disturbance of breathing of the heart's action which everyone experiences at climbing at great heights, and which is known as mountain sickness, are due to a diminution of carbonic acid rather than a deficiency of oxygen. Once more of the whole amount of oxygen taken in at each inspiration, only a quarter of it is absorbed by the lungs, and we might breathe the same air over and over again four times if we could, at each act, lay hold of the requisite amount which is really there. The law of diffusion of gases, however, prevents this. Enough has been said to show that if we can get a good supply of air from the outside of our houses, we need not be troubled in mind about its deficiency in oxygen--it always contains enough--the thing to aim at is to produce as little carbonic acid as possible. And get rid of it as fast as we can.

Having drawn attention to these essential points connected with the air, what has to be said about the ventilation of the nursery may, not inappropriately, be introduced here. And I will admit, at the outset, that the proper airing of any room is not always easy to accomplish without producing draughts that may be no less dangerous than foul air itself. Strong draughts act by carrying off too much heat from the bodies of the inmates, and catarrhs and other ailments result. For, although one can breathe air at very low temperatures without harm, the play of cold air upon the surface of the body is full of danger in many ways. The body, by its oxidation processes, keeps up its own uniform temperature--its furnaces within are sufficient up to a certain point, but a current of cold air passing over it may carry off more heat than the healthy oxidation of the tissues can supply. And this loss will be greatly increased if the surface of the body is wetted either from without, as by rain, or from within, by perspiration. How cold or chilling of the body acts in the production of catarrhs and inflammations is too complex a subject to enter upon here. It is not simply the driving away of blood from the skin to internal organs; there is a grater perturbation in the physiological economy than that, and the nervous system plays an important part in it. But the fact remains, that congestions of internal organs, neuralgias, and rheumatism may be caused by loss of body heat, either locally or generally, and morbific agencies which might otherwise be kept at bay, come into operation then.

The experience of Pasteur, in his investigation of Chicken Cholera, proves that the cooling of the body is a factor in the causation of that disease. He found, in the course of his experiments, that certain strong chickens were able to resist the disease when he injected the virus into them. But, on putting their feet into cold water, and thereby chilling their bodies at the same time, he found that even the strongest of them became victims. Probably, therefore, what acts in the case of this infectious disease among fowls, acts also among men in their infectious diseases. Our predecessors, accordingly, believed that the chilling was the chief element in the case--having not yet discovered bacteria--and they conceived the ideas of humours and evil influences, to explain what they suspected, but which was still obscure.

As draughts in a nursery may act in the same way as the cold water to the feet of the recalcitrant chickens, the great question that arises when ventilation has to be considered, is: How can sufficient fresh air be introduced without producing too great a draught?

One need not hesitate to answer that the best system is, to bring it in from the outside by tubes, through numerous openings in the wall, about the breathing line as to height, or a little above it, and in a direction upwards; it should flow in naturally, and not be driven by any machinery, for by mechanical propulsion it may be forced in at too great a velocity. To avoid draughts, its rate of ingress should not be more than 2 ft. per second. But propulsion is not likely to be resorted to in the nursery. Tubes are so easily arranged for natural ventilation by the sanitary engineer, that those who have a proper regard for health in the nursery should not hesitate to take the advice of such experts.

In lieu of tubes, a very good means of ventilating a room is by fitting a piece of wood, two or three inches deep, beneath the lower sash of the window, and by this means creating a space in the middle of it, at the junction of upper and lower frames. This gives a good amount and a right direction to the incoming air. And the point of outlet to select for the air when vitiated, should always be in or near the ceiling; or, in some cases, near the floor as well. The common practice of making an outlet into the chimney-flue is bad, for it permits a backward flow of smoke and soot. A better plan would be to have a separate shaft passing up by the side of the chimney stack unconnected with smoke or fire-grates. Failing that, the contrivance known as Dr. Arnott's ventilator can be fitted into an outer wall by removing a brick. About 5 ft. from the floor, then, would be a suitable lever for air ingress, and some one of the many contrivances for purifying it as it enters, and valves for regulating its flow, might be adopted. The ideal nursery would have an open fire to provide the necessary radiant heat, and this should be fed by a 3-inch pipe communicating with the outer air to give a direct supply to the grate. The drawing down of hot, vitiated air from near the ceiling to the level of the respiring occupants would thus be prevented.

As the ventilation of every room has to be studied on its own merits or demerits, one cannot do more in a paper like this than express the almost universally accepted opinion, that air should flow in naturally from without through a system of tubes; and that the walls of the room should be warmed either from a heating apparatus situated within themselves, or by the radiant heat of a coal fire. As to cost: in the building of a new house, it would be insignificant compared to the advantages gained; but in many old houses, the difficulties of adaptation would be considerable.

Sources of foul air, like drain pipes, or sinks, should be searched for outside the nursery windows, and a jealous eye kept upon them. The point of inlet for fresh air should be nowhere near such sources of danger.

When nurseries are left unoccupied, it should be the invariable custom during the day, except perhaps in a London fog, to leave the windows widely open, and I may here remark that less draught is produced by a widely-opened window than by a slightly opened one, and more air enters.

Sunshine as well as air is highly important also, from the health point of view, and a south aspect should be chosen if possible.

Could we but find a simple and effectual means of keeping the walls of our dwelling-places warm, we might sit in them with the doors and windows removed altogether, even though frosts prevailed without, and yet we would not suffer. We get chilled by our bodies radiating heat to surrounding objects which are eat a lower temperature than they are, and if a room is kept at about 60 degrees F., the loss from our bodies is not greater than can be compensated from within them.

But, to return to the elements of vitiation, there is one, more dangerous to life than any we have yet discussed, and that is the organic matter which is thrown off from the persons of the inmates themselves. It comes away as mucus and other effete matters, and may be charged with the microbes of disease. Mucus from the bronchial tubes may contain the bacilli of tubercle; from the throat, those of diphtheria; from the intestines, the germs of enteric fever. Thus cast out, it may dry upon walls, floor or furniture, and the solid residuum, finally resolved into dust, may get wafted about in the air and become a source of danger. Soiled clothes, for instance, should always be removed at once from the nursery.

The air, then, which enters our houses from without, already bearing bacteria in plenty, may receive considerable additions from within, where infectious diseases prevail among the inmates.

Parkes gives some figures bearing upon this point which I will quote from. He says, "When the moulds and bacteria in the external air were as 2 to 6, in houses of four rooms and upwards they were as 4 to 85; in two-roomed houses as 22 to 430; and in one-roomed houses as 12 to 580. These are the actual numbers found per 10 litres of air." Ten litres are equal, roughly, to about ten quarts.

This shews the evil effects of overcrowding; and what happens when many people are forced to live in few rooms, occurs also when many children are crowded into one small nursery. According to the number of children, so should the cubic space of the room be.

Now it would be a mistake to suppose that all those bacteria, counted by Parkes, were harmful. On the contrary, the vast majority of them found upon the earth or in the air, are beneficial in the highest degree. They are, for the most part, the agents of public health, the scavengers for the human race. Without them, man would not be able to live upon this planet, its surface would be unclean from the accumulations of the dead of both the animal and the vegetable kingdoms; the leaves of autumn would not disappear as they do, but for them. And if they claim as compensation some human sacrifices, even the pestilences that are due to them would not outweigh their beneficent work. Those among us, therefore, who have not been accustomed to look upon these agents of decomposition in any light but that of horror and loathing, should dwell upon this phase of their existence. They are even now being called into requisition by man to help him, in an orderly way, towards the disposal of sewage and the purification of towns. The few among the many, however, which are, undoubtedly, factors of disease in the human race, we are justified in trying to exterminate, if we can. Coming to us through the channel of the air we breathe, through the food we eat, and the water we drink, there are some kinds of hostile bacteria which find our bodies their best dwelling-places. Once they have found an entry, they may do irreparable mischief before we can destroy them and cast them out. Therefore, to prevent their finding access to the nursery should be our first line of defence; and this is a field of operation for mothers and nurses. We need not fear that in our constant warfare against the pathogenic kinds, we may destroy greater numbers of the non-pathogenic and benignant. Nature has been so prodigal in her provision of the good, that we need not hesitate to include them with the bad in our sweepings from the nursery. But when they have already produced disease, the sphere of treatment belongs to the doctor; and the exhibition of anti-toxines to neutralize the poisons which they produce within the body, will be for him to undertake.

It is a matter for congratulation that so sure a basis of rational treatment as this, has been evolved within the short period of our better acquaintance with them.

This part of our subject is one of increasing importance, and, being comparatively new as a scientific study, is so little understood by the general public that to dilate upon it may be permissible, within certain limits. Those diseases which have been known popularly as zymotic or infectious, are probably due, each and all of them, to specific organisms. When once they gain admittance to the human body, and conditions within are favourable, their powers of reproduction are marvellous. As a result of their life-work, poisons are produced which give rise to the varied signs and symptoms of infectious diseases. But the generating of these poisons, or toxines, takes a variable time, according to the nature of the organism at work. And from the time of invasion of the body by these organisms till they have increased and multiplied, and let loose their toxines in quantity sufficient to set up fever and inflammation, is called the "period of incubation" of these diseases. The periods of incubation vary, and, though they are not very definite always, as we might suppose when we think of the differences in individuals, they are still sufficiently well-defined as to be worth remembering by parents and nurses; for quarantine regulations have to be founded upon them. Incubation periods, dates of appearance and fading of skin eruptions, periods of quarantine after exposure to the infection, and periods of isolation after suffering from the disease, should be as well known to the guardians of children as the multiplication table.

But there is one disease in this group which is dreaded more, perhaps, than any other, namely diphtheria, and even at the risk of being wearisome I must give particulars about it, for it is the belief of most medical men now, that we have found its remedy. The suddenness with which it may carry off children in the full bloom of health and vigour, and the tracheotomies, paralyses, and horrors that follow in its wake, all fill us with a dread of it, so that the discovery of anything approaching to a cure we naturally hail with delight.

The remedy I refer to is the anti-diphtheric serum, and the method of employment is injection under the skin. It should be done with the least possible delay, as soon, indeed, as the disease has declared itself; for every hour that is lost means increase of jeopardy.

Now, every mother or nurse who would do her duty and keep her conscience clear, should be prepared to report at once to the doctor that a throat has become diphtheric in character. It ought to be a part of the duty of a nurse, as of a mother, to know what a healthy throat looks like, and how to examine it.

It ought to be a part of the education of a child to shew its throat without fear, and without the fuss that commonly attends to a throat examination. It is a matter that should give no trouble to child, nurse, or doctor; and, so far as diphtheria is concerned, it would certainly be the means of saving many a life.

If nurse or mother has never seen a real case of diphtheria, I do not know why she should not get a pictorial illustration of it; for it is very characteristic with its white or grey patch of membrane lying on a dark red surface. And surely chromo-lithography might supply the want.

A nursery book of reference of this class would be infinitely safer than many of the little hand-books of disease, with imperfect descriptions, that are so commonly used.

And, as education on these lines proceeds, and people who have the care of children become aware of their responsibilities, when new developments on this anti-toxine line of treatment come about--as they are sure to do in the near future--the death-rate in nurseries will sensibly diminish, and the nurse, with her increased knowledge and importance, will have risen in the social scale. It may be then, also, that unemployed young ladies of the middle class, who do not think it derogatory now to nurse the sick, may neither think it an unworthy thing to enter the nursery, and watch and guide, with intelligence, the budding lives of happy children. The influence of their own acquired refinements in thought, speech, and manner, would have an educational value of a very high degree.

(To be continued).

Hygiene of the Nursery. Part II
BY R.W. Wilson, M.D.
Parents Review Volume 11 1900 pgs 628-633

(continued from page 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 May 2011, LNL