Animals are born with instincts which need only circumstances to bring them out. Now a baby is not born with instincts of this character,—it has not even the instinct to help itself; it cannot find the breasts that were made for it; it is more helpless than the baby cat or dog or worm. Therefore a baby in whose brain the potential faculty of reason is slumbering must of necessity begin its career wholly dependent upon the supervision and love of its mother, until such time as it may be capable of reasoning for itself. Motherhood is therefore the supreme privilege of womanhood. It cannot be superseded, hence the fundamental factor in any system of race culture, or in any system of infant mortality, must tend to raise the quality and the intelligence of motherhood as a basic necessity. Motherhood at the present time, though the most important and sacred profession in the world, is almost exclusively carried on by unskilled labor. The maternal instinct is deeply rooted and universal; its absence must be regarded as an abnormality, or as a product of misdirected education. The requisites for the mothers of the future should be absolute physical health and love of children.

If nature endowed a baby with instincts there would be no need for reason or education. Education cannot teach a cat how to nurse or wash a kitten any better than it does,—its instinct is good enough. The mother of a human baby, however, is not born with the instinct which enables her to care for her baby equally as well as the cat cares for her kitten. She must be educated or taught to care for it. She can then care for it better than the cat cares for the kitten, and she can be taught to bake, to sew, to read; to play on the piano, which a cat cannot be taught. So while a baby may be the most helpless living thing at one stage of its career it has in it—in the faculty of reasoning—the ability to become the Lord of all the Earth and of all the animals therein. To limit the environment of a child by imposing instincts upon it, would be to limit its inherent freedom. To be obliged to obey a prescribed instinctive law would rob mankind of his creative or reasoning faculty, and that would be to lower him to the level of the brute creation. Reason is of no use if our acts are already determined for us. There are therefore good reasons why the human baby should be, at the moment of its birth, the most helpless living thing; and as a consequence it is imperative, if the eugenic ideal is worthy of attainment, that every baby should have the benefit of trained and efficient care and education.

THE DELICATE CHILD

There is a certain standard by which we measure the physical and mental development of children. This standard we regard as the evidence of normal development. Some children exceed these requirements; they are bigger and stronger at a given age than the average child at the same age. There are other children who cannot be called sick, but who are physically and mentally inferior to the average standard, whom we designate as "delicate." These children are not as big, or as strong, or as heavy, as other children of the same age. They are born with a reduced vitality, or through mismanagement in early infancy they have acquired a subnormal standard of development. Children born of parents who are not of standard vitality are predisposed to be delicate. If the parents are of average development, and the delicacy of the child is acquired by mismanagement, the proper dietetic and hygienic management will, as a rule, promptly result in a satisfactory restoration to normal health.

TREATMENT.—When a mother awakes to the knowledge that her child is delicate; when she understands that her child's vitality is not what it should be, and when she resolves to "do something" in the interest of her child, she is on the right road, and we hope to encourage her in the good intention. We would however tell her that her effort must be thorough, and that she must be patient and persevering. If she does not falter in well doing she will succeed beyond her expectation, and the satisfaction she will experience in noting the evidences of returning health and strength in the appearance and conduct of her child, should be ample recompense for the effort made and the time bestowed.

She must begin with a definite knowledge of just what she intends doing; she must know, however, what must be done and she must begin at the beginning and build from a sure foundation. It is therefore absolutely essential to ascertain if there is any actual disease underlying the reduced vitality which is responsible for the delicacy of the child; this necessitates a thorough examination by a competent physician. If you are assured there is no disease present, no tuberculosis, no syphilis, no malaria, and that debilitating conditions, such as adenoids, sexual abnormalities, the results of self-abuse, skin disease, do not exist, then certain fixed rules can be laid down, and definite principles followed in the daily management.

WEIGHT, AS A STANDARD OF DEVELOPMENT.—It has been stated elsewhere in this book that one of the safest guides to follow, as to whether a child is thriving, is its weight. This can be relied upon as a general rule. A child should therefore be weighed regularly every week. If it is not gaining an average of four ounces weekly it is not thriving up to standard. When the average is below four ounces there is something wrong with the quality or quantity of the food.

HOW TO FEED THE DELICATE CHILD.—If the child is breast-fed and the weight standard, as evidenced by the weekly averages, is persistently below normal, we must find a substitute for the mother's milk. If the child is bottle-fed and it is demonstrated that it is impossible to maintain normal development on cow's milk, a wet-nurse should be obtained. After the child is weaned, or put upon a more liberal diet, milk should continue to be the chief article of diet. From the first to the third year a child should take one quart of milk daily in addition to the other food. There are some children, however, who seemingly cannot take milk without getting indigestion; they should be put on skimmed milk, to which may be added a small quantity of sugar to make up for the loss of fat. Mothers must be certain that too much milk is not given, or the desire for other necessary food will diminish.

After the first year it is a very good plan to give one teaspoonful of scraped beef daily. If this is well borne, two may be given and later three. It can be given immediately before the regular feeding of cereal and milk. From the twelfth to the sixteenth month eggs may be given: at first one-half, and later a whole egg mixed with bread crumbs. Various vegetables should also be given cooked in the form of a puree. If at any time the child should refuse the food, or act as if it had no appetite, leave the milk out of the diet; this may then restore the appetite and it will take the other food freely; the milk can be resumed later.

As the child grows older, the distaste for milk may grow, or he may be one of those children with whom milk really does not agree; in either event, do not hesitate to leave it out of the child's dietary. These children should be encouraged to eat plenty of good butter on their bread and crackers. Butter will not only agree with them, but it will supply any fat deficiency in the general diet. The diet may now consist of milk (unless it disagrees), cereals cooked three hours, raw or rare meat, poultry, eggs, vegetables, purees, cooked and raw fruit, bread, crackers.

HOW TO BATHE THE DELICATE CHILD.—Regular daily baths are particularly of benefit to the delicate child, despite the prevailing fear that they may catch cold. The salt bath is advised and the time to take it is just before retiring. The room should be warm and the temperature of the water should be 90 deg. F.: it should not last longer than five minutes, and the water should be cooled down to 70 deg. F., before the child is removed from the bath. While the cold water is running in, the surface of the body should be briskly rubbed with the mother's hands and after removal the child should be dried with a fairly coarse bath towel to ensure a good reaction. Very delicate children need not have the temperature of the water reduced; others may stand water of 80 deg. F., but no lower. In the poorly nourished it is frequently advantageous to rub the body, after drying, with olive oil or goose oil. This aids nutrition and because of the massage it aids circulation. In some older children a daily cold spinal douche seems to act particularly well. If the child does not promptly react from the effect of the cold water it is best to discontinue it.

AIRING THE DELICATE CHILD.—Delicate children should, above all things, be assured of the maximum amount of fresh air and sunlight. Many mothers entertain the idea that these children are disposed to take cold easily, if in the open air,—which is not the case. All children need an abundance of fresh air and the delicate need it particularly. The season of the year and the character of the weather will, of course, dictate just how much open-air exercise they may take.

If the weather is very cold and the air damp, or if there is a very cold high wind, it is best to remain indoors; otherwise the child should remain out for four or five hours. Indoor airing is obtained by dressing the child to go out-doors, putting him in his carriage, and leaving him before an open window in a room of good size with all the doors closed so as not to create a draught.

HABITS OF THE DELICATE CHILD.—The amount of sleep necessary for a delicate child is the same as for a normal child of the same age. The room should always be well aired, night and day, and should be devoted to the exclusive use of the child.

These children should never be allowed to sit on the floor. It is always a difficult matter to avoid this, but it must be religiously guarded against; otherwise a cold is the inevitable result.

A change of air is sometimes advisable and essential, especially during the hot, humid weather of July and August. Much better results will be obtained by sending these children to the mountains than to the seashore.

Delicate children should always be clothed warmly, but not too warmly. The feet and legs must always be kept comfortable. Moderate exercise, short of fatigue, is necessary. A midday nap after the noon meal should be taken every day. The child should be undressed and put to bed for two hours and left there, whether it sleeps or not. This applies to delicate children of all ages.

The education of delicate children should be postponed until the health is restored. They should, however, be made to obey and they should be taught good habits. When school work begins it should be made light and easy. They should not go to school before the eighth year, and then not unless physically fit. They should not play at rough games or with rough companions, though it is not wise to shield them too much. Their habits and peculiarities should be studied and every possible effort made to direct them kindly and wisely so that they may contribute to their own upbuilding.

A systematic observance of these suggestions will save many lives and will aid very considerably in producing stronger men and women. Infinite patience, tact and self-sacrifice is necessary, but the results in every case justify the measures adopted.

INDISCRIMINATE FEEDING: POOR APPETITE.—In considering many of the diseases of childhood the term "indiscriminate feeding" is used. An explanation of just what is meant by this will be of decided advantage. There are two fundamental essentials in the successful feeding of infants and children: regularity and suitable food.

A child whose feeding intervals are not regular and whose food is unsuitable is a victim of indiscriminate feeding.

The lack of observance of the regularity rule always leads to loss of appetite and indigestion.

Loss of appetite is a serious condition in a growing child and may give infinite trouble. Indigestion in a growing child is unnecessary, unfortunate, and frequently is the one factor that spoils an entire life. It is unnecessary, because it means and is caused by neglect on the part of the mother; it is unfortunate, because it always paves the way for any serious ailment that is epidemic or "in the air"; and it is important, because it very frequently weakens the stomach and renders it unfit for normal digestion for a long period, if not for life.

If for some reason a child's appetite becomes poor and it is not properly managed until the appetite is restored to normal, indiscriminate feeding is always the result.

The reason for the poor appetite may be because the child is kept indoors too long, or because it is being fed on unsuitable food, or is living in unsanitary surroundings, or many other reasons, sometimes trifling reasons, may cause it. When a child will not eat at meal time, the mother feels that it should eat sometime, so she encourages it to eat between meals, and because of a mistaken kindness she breaks the law of regularity,—a law that can never be broken without serious results following. A child in this condition becomes a disturber of the peace; the parents can do nothing with him; he insists on eating just what he likes and when he likes; and he chooses, as a rule, candy, cake, pastries, ice cream, tea, coffee. Indigestion follows, the child loses weight, is languid and listless and constipated.

When finally the physician is called in he finds it necessary to go back to first principles. He lays down the law in a definite, stern way, and the mother and the child must obey. Most parents know and admit they are doing wrong to give in to a whimsical child, and if they would only make up their minds to conquer when conquering is easy they would save themselves many heartaches, many regrets, and the child much suffering and much possible permanent injury as a consequence. Usually one parent is willing to be master but the other lacks the mental equipment to meet the issue, and argues, as he or she imagines, in favor of the child. The parent whose instinct is correct, whose judgment is true, whose interpretation of the situation is just, should not be dissuaded, or argued away from his or her duty. If it is the first real problem in your domestic experience in which a decided stand must be made, make it without fear and without hesitation, and carry it through to the bitter end. Results will justify and vindicate you.

The general treatment of these children will be found outlined in the following paragraph on Loss of Appetite.

LOSS OF APPETITE.—If a child complains of not being hungry, and will not take enough food, and if this condition continues for some time, we must regard the matter as being abnormal and find the cause. This is necessary because a child must eat in order to maintain a certain standard of growth and vitality. These children are not sick; they are active and continue to play as usual and they sleep soundly, but they have no appetite. One of the most frequent causes of this condition is too frequent feedings. Some children are naturally small eaters. They thrive and maintain a satisfactory weight; their system seems not to demand large quantities or even ordinary quantities of food. Parents observe this habit of little eating and begin to coax and bribe the child to eat more at meal time, and to eat between meals. In this way the child really overeats, the appetite becomes capricious, and the stomach rebels. In a very short time the condition of "loss of appetite" is established as a consequence. Another cause is the drinking of too much milk, and yet another and very common cause is indiscriminate eating of candy, cakes crackers, and fruit between meals. Children who are fed at the table with adults eat things they should not eat, and spoil their digestive organs and loss of appetite is the result. The Scotch custom of compelling children to eat at a separate table is an excellent one. They are not tempted to ask for things they cannot have. Lack of fresh air and exercise frequently results in impaired appetite.

TREATMENT.—The very first thing to do with these children is to stop any habit that may be responsible for the loss of appetite. If the child has been eating between meals, stop it absolutely. If too much milk has been taken, stop milk entirely. If the child has not been getting enough fresh air, or if it has been sleeping in a badly ventilated room, or if baths have been too infrequent, rectify the fault. If eating at the family table and fed indiscriminately, change the programme; feed him before the family sits down to meals. Now regulate the time of feeding to suit the age of the child and adhere to strict regularity. It is a pernicious and absolutely wrong custom to force children to eat, or to coax them to eat when they do not want to eat. Loss of appetite will never be cured by forced feeding, or by reducing the interval between feedings, or by giving the child stronger or more concentrated food under the mistaken idea that in this way the loss of appetite can be "made up." The interval of feeding should rather be lengthened than otherwise in order to give the digestive organs an opportunity to regain the normal desire for food. Pay strict attention to the bowels. Be certain the child has a daily satisfactory movement and that he drinks frequently between meals.

If the child does not promptly respond to the proper hygienic and dietary treatment as outlined above there are two things that can be done:

1st: Send the child away. A change of scene and climate will sometimes work like a charm in these cases, and will, after a reasonable length of time, establish a permanently good appetite.

2nd: If this is not possible, as sometimes it may not be with poor patients, then we can give the child suitable tonics.

OVEREATING.—The large majority of individuals eat too much. Most of us would enjoy better health, better spirits, and greater efficiency if we consumed from one-third to one-half less food than we habitually do.

Every living organism requires a certain amount of nourishment according to the work performed and to replenish wear and tear; when food is supplied in excess, the system cannot utilize it, but it is compelled to rid itself of the excess in some way. The work involved in this eliminating process is exceedingly detrimental to the various organs and to the individual. To overeat is to overwork, and to overwork a machine or an animal is not only poor economy but bad judgment. If the digestive apparatus is required to work overtime, it is a self-evident assumption that the various organs will not digest efficiently the food necessary for ordinary existence. If the necessary nourishment is not adequately digested, the general health will suffer as a consequence. If the general health is below standard the individual will not be competent to carry on the requirements of a normal, healthy life.

We must, however, give some thought to the effect which the excess of food exerts upon the human machine.

Nature provides and maintains a standard relationship between the capacity of the individual and his needs. A child has a digestive capacity to digest and assimilate a quantity of food sufficient for his growth and proper nourishment; an adult maintains the same standard according to his requirements. All the other organs are adjusted to harmonize with this scheme. If we overeat, the immediate result is to disorganize this relationship between the various organs; hence we have a multitude of effects which manifest themselves in various ways as a direct result of overeating. The combined general effect expresses itself in the form of what is regarded as poor health and a low standard of efficiency. When a larger quantity of food is taken into the stomach than it can properly digest within a reasonable time, two conditions immediately follow. The stomach itself is dilated and the food is not thoroughly digested. If the habit is persisted in, indigestion, and later chronic gastritis ensues. The direct symptoms of these conditions are given in detail in another part of this book. Very few individuals, however, appreciate the indirect consequences of overeating and of indiscriminate eating on the general health. It is impossible to tabulate in so many words the effect which this habit has on efficiency and temperament. We read and hear a great deal to-day about efficiency. Now, an individual's efficiency is an expression of that individual's health standard or capacity. To be 100 per cent. efficient one must enjoy good health. It would be absurd to expect a high standard of efficiency from an individual with a low standard of health. Poor health means poor vitality. Vitality is the mark of the master. Without vitality one can never dominate. All the great achievements of the race have been consummated by those who conserved their vitality. No single factor contributes a larger percentage of inefficients and failures than overeating. The man or woman who, from habit or experience, has learned the lesson of right eating and living need not be lacking in efficiency, nor need they despair of the attainment of success.

SYMPTOMS OF OVEREATING.—Efficiency depends not only upon one's capacity to perform, but upon the character of the performance. The spirit must be willing to perform. The overeater is heavy, phlegmatic, indifferent, lacking in energy, tact and initiative. She is constantly subjecting her system to needless overwork; she is depressed, nervous, imaginative and she is not ambitious. She is a victim of self-poisoning, of constipation, indigestion, headaches, flatulency, neuralgia, vertigo, and melancholia. An overeater never enjoys good health, never is efficient, and cannot possibly be successful.

To enjoy good health one should know how to select food and how to combine and proportion it. It has been said that the American people are a race of dyspeptics, and it must be admitted that the assertion is more or less true. There are millions of people who suffer from indigestion in some degree, and it may justly be said that indigestion has its beginning in overeating, in some form. It may not be overeating in actual bulk, but it is overeating some article or articles that do not agree with the individual, and the fact that certain articles do not agree is unquestionably dependent upon the nervous temperament of the American people—and the temperament of a people is a product of the kind of existence the people subject themselves to. We are, therefore, unwittingly, victims of our environment.

Correct eating means simple eating—only a few things at a time. Food should be selected according to one's age and occupation, and according to the season of the year. To eat habitually large quantities and at the same time a large variety is suicide pure and simple. If one dared to make the experiment of cutting down one's diet one-half, it is absolutely certain the effect would be immediate benefit. The benefit would not only be manifest in the physical betterment, but the efficiency and general well-being would be greatly enhanced. It is not the kind of food that makes a dyspeptic, but the quantity. A well person need not consider whether a certain kind of food will or will not agree, providing she does not eat too freely of that food, or combine it with other food. The combination of which may in itself form too much of one kind at a time.

Some people imagine, for example, that oatmeal porridge does not agree with them. When the matter is inquired into, however, it is found that they habitually eat bread, eggs, and other articles, with coffee at the the same meal with the porridge. From this combination they experience distress and blame the porridge. If these would take a plate of oatmeal porridge with cream and salt, and some stewed fruit for breakfast they would not experience any trouble, and this would be an ample meal for the ordinary individual. It is not the porridge, but the unsuitable combination, that is at fault. The same may be said of milk. Many people state that they cannot take milk and they deprive themselves of one of the very best articles of diet because of this idea. There are very few people in the world who cannot take milk in some way. It is not the milk that is at fault; it is the combination of it with other less nutritious articles that is the cause of the distress. Even candy is responsible for thousands of cases of indigestion. Anyone may safely take a reasonable quantity of good candy, but if it is taken at a wrong time, or combined with other articles, it may readily produce indigestion.

Indiscriminate eating and overeating are prolific causes of rheumatism, kidney disease, heart disease, liver troubles, obesity, arteriosclerosis, and apoplexy. These diseases are notoriously on the increase and must be construed as a direct consequence of the tendency of the American people to overeat and to eat indiscriminately.

BRAN AS A FOOD.—In the chapter on constipation there may be found a formula for making bran muffins. These muffins are invaluable to children in health, and to the victim of indigestion or constipation, whether child or adult. One muffin with each meal will solve the problem of constipation in growing children without the use of drugs or other aid. They will regulate the bowels of adults in many instances without resorting to drugs.

Raw fruit in season, or stewed fruit, or a baked apple, with a light boiled egg and one bran muffin, is an ample and a nourishing breakfast for a child at school.

For lunch the same child should have a plate of thoroughly done vegetable soup, a bran muffin, and more fruit. After school, a glass of milk with two or three Graham wafers may be given.

For dinner the child at school may have a mixed meal. This meal should not be later than six-thirty o'clock and the child should retire at eight-thirty at the latest. A bran muffin should be taken with this meal unless the child's bowels are too loose.

Mothers should insist on their children eating these muffins. If a child eats only what it likes it will not eat what is good for it. If the mother insists in the right way she will win; if she does not the child will win. If the child wins, the mother is the wrong kind of mother. I do not know of any other single article of diet that is of such value to growing children as these bran muffins. Children who eat them regularly will have less sickness than other children; they will be strong, healthy and full of energy. The bran in itself is not responsible for this list of excellent acquirements, but the regular eating of the bran is. Most ailments of children are of gastro-intestinal origin; bran keeps the entire length of the gastro-intestinal tract sweet and clean; if the child eats a bran muffin with each meal it will not have much desire or much room for any other form of bread or pastry. If white bread or pastry is abstained from the child will not have indigestion, or constipation, and hence it will not be constantly poisoning itself as most children do whose diet is not restricted and whose bowels are more or less constipated.

These muffins should be made of the ordinary unsifted bran. If this is not procurable the sifted bran (Johnstone's) may be employed. This bran may be bought in any good grocery.

Modern milling methods, modern cookery, and modern methods of forced farming, have each contributed their share of rendering food inert and frequently deleterious. The miller has extracted the coarse cellulose from the various flours in the effort to manufacture a product suitable to the super-civilized public demand. This cellulose is absolutely essential to gastric and intestinal digestion, and if children are deprived of it constipation and indigestion are the natural result. Forced farming accomplishes the same effect—the fiber of the vegetable is deficient. Bran is rich in mineral salts, iron, protein, and phosphates, and gives to growing children the ingredients which ordinary food is deficient in. Bran prevents intestinal fermentation and children who eat it are free from intestinal gas and putrefaction. It harmonizes chemically with all other foods. Children should be made to take it every day as a matter of self-preservation and of duty.

HYSTERICAL CHILDREN.—Hysteria is not a disease of infancy or of young children. It is seen as a rule after the eight year. Male as well as female children may be the victims to an equal degree. It is much more frequently seen in the offspring of parents who are themselves nervous, or alcoholic, or who suffer from insanity, or have insanity in the family history. If these children in addition to the hereditary influence suffer from stomach or intestinal disease, or general poor health and are overworked at school, they are very apt to become hysterical.

They are capricious, indifferent, and excitable. Their disposition is irritable; they frequently exhibit fits of great excitability of temper and passion. They cry or weep without cause. They often have hallucinations and while asleep have attacks resembling night terrors. They complain of pains in the joints, and are frequently treated for disease that does not exist. Such condition as hysterical cough, spasm of the muscles of the face, mouth, eyes, and of the neck exist and are difficult to diagnose from real disease. These children complain of painful sensations and sensitive areas and exaggerate all symptoms unnecessarily.

The possibility of curing these patients is good, providing the treatment is faithfully carried out. It is less favorable when marked hereditary influences are strong.

TREATMENT.—In all children of distinctly nervous type and especially those of nervous parents, the first essential duty is to develop their muscular system. Try in every way to make healthy animals of them. Attention and treatment should not be directed toward the nervous system. If the child is made strong by out-door life, good plain, digestible food, early hours, regular sleep in thoroughly aired rooms, regular bathing, and if the school work is conducted with moderation and judgment, the nerves and the nervous temperament will participate in the healthy growth which will follow as a result. Tea and coffee should be forbidden. Exciting books and questionable entertainment as given in picture shows and theaters must not be allowed. If older members of the family, or parents, are excitable and nervous the children should be sent away to the country from them.

They should be put in charge of a person who will exercise firm control over them. It may be necessary to take these patients away from other children, and isolate them under proper control until they are able to control themselves. They should be interested in exercise that compels them to work; they should live and if convenient sleep out of doors; and they should take iron or cod liver oil, or any other indicated tonic. If they complain of pain they should receive cold-water douches, or the cold pack, or the shower bath; and they should be put to bed and treated firmly but kindly. Attention to the bowels is always essential, because these children are as a rule the victims of chronic constipation.

WHAT A MOTHER SHOULD KNOW ABOUT CATHARTICS AND HOW TO GIVE A CHILD A DOSE OF CASTOR OIL.—Broadly speaking there are three kinds of cathartics. I will, in a simple way, explain their action so that a mother may know which one to select under certain circumstances. Frequently a mother is told by her physician to "keep the bowels of her child open." Few mothers know how to keep the bowels open, and as this is an important matter, every mother should know the reason why "any" laxative or cathartic is not always suitable.

CASTOR OIL.—This is one of the oldest and one of the best cathartics we possess for children. It is a mechanical cathartic; it acts in exactly the same way as a street-cleaning machine. It cleans the street by sweeping or pushing everything before it.

CALOMEL—This is a chemical cathartic. It acts through the blood. When it is absorbed by the blood its chemical ingredients act on certain nerves as irritants. These nerves excite the liver and bowel to action and an evacuation is the result.

CITRATE OF MAGNESIA.—This is a saline laxative. It acts by drawing out of the bowel wall enough liquid from the blood to sweep the contents out. It may be likened to the street cleaner who flushes and cleans the street by means of a hose pipe attached to the water hydrant.

Under what condition should a mother use these remedies? Castor oil is ordinarily the best cathartic in childhood; it is not, however, always the best. Most ailments of children are of gastro-intestinal origin—they have either overeaten or they have eaten the wrong kind of food. The stomach and bowel are overloaded: they must be cleaned out. We want a mechanical cathartic, one that will push everything ahead of it, so we use castor oil. When a child needs a cleaning out, use castor oil. By a "cleaning out" we mean, when we know he has eaten too much of a questionable variety of food, as pastries, cakes, fruit, ice cream, etc., as children do at parties; or when he has eaten unripe fruit, as green apples, etc.; or when for some reason he is constipated and complains of not feeling well, use castor oil.

If you decide to use castor oil, use enough. A large dose will act promptly and with less pain and with more certain results than a small dose.

It is always safe and it is always best to decide upon castor oil as the proper remedy, if the child has no fever. If he has a fever he will most likely vomit castor oil when another kind of cathartic would stay on the stomach.

Castor oil works more effectively, more thoroughly, and is less likely to be vomited if given on an empty stomach, so we give it two hours after eating and we give no food for two hours after it is taken.

Castor oil is distinctly of advantage in many chronic diseases of the intestines because of its healing properties. In chronic colitis, for example, when the child is suffering with malnutrition, irregular bowel action with an odor, and mucous or bloody stools, a combination of castor oil and salol, in emulsion, in small doses,—to which a small quantity of opium may be added or withheld according to the frequency of the movements,—with an occasional colon irrigation, is sometimes invaluable.

Mothers must remember that castor oil is not good in the treatment of constipation, because its after effect is to constipate, consequently we would not use it "to keep the bowels open,"—it is only of use to clean the bowel out thoroughly when that is indicated.

HOW TO GIVE A DOSE OF CASTOR OIL—The best way to give a child castor oil is as follows: Place the bottle containing the oil on its side on a piece of ice in the ice box; chill it thoroughly. Take a tablespoon and smear it with butter; pour the ice cold oil into the spoon; it will stick together like a piece of chewing gum and it will slide out of the buttered spoon in one lump. In this way it will not spread over the mouth and teeth and throat, leaving a bad taste, but will go straight and surely into the stomach. The child cannot swallow some and retain enough in the mouth to sputter it all over itself and only get half a dose; it will not nauseate it, because it practically is tasteless if given cold, and the stomach will tolerate the cold oil much better than when given in the ordinary way.

A baby can be given oil in the same way, but in smaller doses. When the teaspoon is put into the mouth of a baby it should be immediately turned on its side so that it will keep the mouth open. If the nose is held closed and the mouth wide open for a few seconds the baby cannot spit the oil out—it must swallow, and if the oil sticks together as cold oil will, it gets the whole dose. It usually takes two persons to give a baby a dose of oil—one to open the mouth and give the medicine, the other to hold the nose and arms.

CALOMEL.—The general indication for calomel is fever. When a child develops a disease it immediately gets a temperature, and very frequently the fever is quite high because the slightest ailment gives a child fever. When fever begins, digestion practically stops, it is therefore imperative to clean the whole gastro-intestinal canal; otherwise the undigested material will putrefy and poison the entire system and render the disease more serious than it need be.

Now we select in such conditions calomel for two reasons:

First, because the presence of fever indicates that infection of the blood is taking place; this may come either from the intestinal canal itself, or from the germs of the disease with which the child is suffering. Since calomel acts chemically through the blood it is the cathartic indicated.

Second, because a cathartic like castor oil does not act through the blood and it would most likely be vomited by a fevered stomach.

Certain conditions indicate calomel; biliousness and jaundice, for example, because it has a specific action on the liver and if the liver is at fault calomel is the proper remedy.

Calomel is best given in small divided doses, 1-10 of a grain every half hour, for ten doses. It is best given combined with soda; every drug store carries tablets of calomel and soda for this reason.

Calomel should never be given in the treatment of constipation, nor should it be used indiscriminately by mothers, as much harm may result. It has its specific use as indicated above, but it should never be used under any other circumstances.

CITRATE OF MAGNESIA.—This is a mild laxative. After the bowels have been thoroughly opened with castor oil or calomel, small doses of citrate of magnesia may be given for a few days, "to keep the bowels open." There is no danger or harm in its use if used for this purpose. It must not be used, however, in the treatment of constipation of children for the simple reason that you cannot cure constipation by the use of drugs of any kind. Laxatives of this type have become a national curse. Adults, especially women, use them constantly. All these advertised saline laxative waters work by weakening the blood—when a dose is taken the chemicals in it draw through the bowel wall blood serum, and produce, because of the excess of this watery fluid, large, and frequently many, liquid movements.

If this practice is continued, as it often is every day, the quality of the blood will suffer seriously, and many individuals are the victims of neuralgic pains, headaches, nervousness, insomnia, anemia, and general broken health as a direct consequence of this pernicious habit.

Mothers will try to remember, therefore, that drugs and saline waters have no place in the treatment of constipation in children or themselves. Constipation must be treated by diet, exercise regular living and by the observance of hygienic and sanitary common-sense rules.

VACCINATION

TIME FOR VACCINATION.—The best time to vaccinate a child is during the first three months if he is healthy. The reason for selecting so early a period is because the constitutional disturbances are much less at this time than in later childhood. It should not be done during active dentition. If the child is delicate if his nutrition is bad it should be deferred until a later time. Children suffering from eczema or from any skin disease or those syphilitic should not be vaccinated until it is compulsory, or until exposed to small-pox.

METHODS OF VACCINATING.—It is customary in America to vaccinate at one point rather than to make a number of inoculations as is the custom in some other countries. The leg or the arm is the usual location selected. In infants the sore can be protected better on the leg; in children of the run-about age, the arm is the better location because it can be kept at rest easier.

Before vaccinating the skin should be rendered surgically clean; this can be done by washing with soap and water, drying and then rubbing with alcohol. The wound should be left uncovered for about twenty minutes to dry, it may then be covered with a bandage, or with a vaccine shield. The part should not be washed for twenty-four hours.

THE SYMPTOMS OF SUCCESSFUL VACCINATION.—Nothing is noticed until the third or fourth day, when a red papule appears. In the course of the following day a vesicle appears; this vesicle enlarges until it reaches its full development on the ninth day. The size of the vesicle is about one-half inch in diameter; it is surrounded with a reddish inflammatory area for about two inches. The vesicle begins to dry and is shortly a dark crust which remains from one to three weeks and then falls off. It leaves a bluish scar which soon turns white and the part is roughened and honeycombed. During the period when the vaccination is at its height the child suffers from fever and irritability and loss of appetite.

If vaccination does not "take" in an infant it should be done two or three times and if then unsuccessful it should be repeated every year until it takes. The fact that vaccination does not take does not imply that the child would not take small-pox but rather that the vaccine used is not suitable. There are some children, however, who seem to be immune to vaccination.

Sometimes the symptoms are more severe than those enumerated; this seems to depend upon the susceptibility of the child. The vesicle may be much larger and the area of inflammation much more dense and angry. The fever may be higher and may last longer; there may be a general rash and the degree of depression more profound. Vesicles may be produced on other parts of the body as a result of scratching. Mothers must always remember that vaccination is a surgical wound to begin with and that it is capable of infection in the same way as are other wounds, and that any result coming from such an infection is not due to the vaccine or to the process of vaccination, but to the infection. Many people get unjust ideas about vaccination from just such cases. If the mother is not cleanly or neglects the vaccinated area and permits it to become infected she must not and others should not decry vaccination as a consequence. Anyone who doubts the virtue of vaccination is condemning himself; he is simply ignorant of the accumulation of evidence in favor of it and assumes a position without any possible justification. The mortality of vaccination is stated by Voigt from statistics to be 35 in 2,275,000 cases. In fact, all the deaths are from causes which are preventable and no doubt the result of direct carelessness on the part of the operator or the mother.

TREATMENT.—The mother must understand in what way she may contribute to the successful termination of a case of vaccination. She should see that the part upon which the child is to be vaccinated is absolutely clean so far as she can make it with soap and water. She should see that the part is allowed to dry thoroughly after vaccination. She should not wash the part for at least twenty-four hours. If a vaccine shield is put on she should not disturb it. If the mother is prepared to do her part faithfully a vaccine shield is not necessary from a medical standpoint and in some cases it is objectionable. A simple, clean bandage is all that is necessary. It is very important that the child be kept from scratching the part; most of the troubles of vaccination come from this habit. It is desirable that the limb should be kept at rest during the stage when the process is at its height. If the vesicle discharges it is necessary that the area should be kept clean and dusted with boracic acid. If the wound becomes infected it must be treated by a physician. The mother must not resort to home remedies in such cases unless she is prepared to take the consequences, which may be serious.



CHAPTER XXII

CONSTIPATION IN INFANTS AND CHILDREN

"It is a greater disgrace to be sick than to be in the penitentiary. When you are arrested it is because you have broken a man-made statute, but when you are ill, it is because you have disobeyed one of God's laws."

Constipation—Regularity of Bowel Function—The Function of the Stomach—Fermentation—Incomplete Constipation—Importance of a Clean Bowel—A Daily Movement of the Bowel Necessary—Constipation in Breast-Fed Infants—Treatment of Constipation in Breast-Fed Infants—Constipation in Bottle-Fed Infants—Treatment of Constipation in Bottle-Fed Infants—Constipation in Children Over Two Years of Age—Diet List for Constipation in Children—Bran Muffins in Constipation—Treatment of Obstinate Constipation—Oil Injections in Constipation.

CONSTIPATION. REGULARITY OF BOWEL FUNCTION

The most frequent cause of ill health and inefficiency in the human race is inattention to regulation of the bowel function. Good health depends upon many causes of which good blood is an absolutely necessary requisite. Good blood depends upon what feeds and sustains it. There are other contributing factors, such as the proper kind of exercise, the proper amount and quality of fresh air, the method of living, etc., but these are all food in a sense. The food we take in is acted upon by the various digestive juices until everything is extracted from it that contributes to the building up of the body. Whatever is left, whatever the body does not want, is immediately, or within a reasonable time, passed out in the form of a movement of the bowels.

If any part of the digestive function is deficient, impaired health, or mental and physical inefficiency expressed in the form of indigestion, is the result. If the bowel is at fault, constipation is the usual consequence. A perfectly healthy living machine must maintain a perfect digestion and regular bowel movements.

THE FUNCTION OF THE STOMACH is to mix and churn the food, and to add certain ingredients to the mixture so that before it is carried into the intestines it is (as far as it is the stomach's duty to render it) ready to be absorbed into the system. Before it reaches that part of the intestine which absorbs, it is acted upon again and certain other ingredients are added to it by certain other digestive organs. In time it is in shape to be used and it is sent along on its way. As it passes onward the little sucking glands in the wall of the bowel suck up all the liquid element in the mass of food. The liquid element in the mass is the food itself, rendered liquid by the stomach and other digestive organs and juices. The remaining solid mass is that part of the food which the body cannot use and does not want. By the time the liquid element is absorbed, the solid mass (always kept moving by the bowel wall) has reached the rectum, ready to be passed out at once, or very soon, provided—and upon this provision depends the success of the entire process,—it has all been done within a certain time. If the stomach takes too long to do its work we have indigestion. If the bowel takes too long to do its work we have constipation.

FERMENTATION.—Now let us consider the matter from another standpoint. If food stays too long in the stomach it begins to ferment. When anything ferments it makes and evolves gas. You, no doubt, have noticed many times how the cork pops out of a bottle if its contents are "working," or fermenting. If you watch that bottle you will notice that it is quietly or actively evolving air bubbles. That is gas,—gas manufactured by the process of fermentation. This is exactly the process that goes on in the stomach or bowel of a dyspeptic, and it is this collection of foul, poisonous gas that causes the distress and bloated feeling which every dyspeptic suffers from after eating,—if it is this "flatulent" type of indigestion which is present.

THE SIGNIFICANCE OF CONSTIPATION.—If the food takes too long to pass through the bowel it causes, as we have stated, constipation. What is the real significance of constipation? It means that in passing through the bowel the food has given up all its liquid element (which is all its nourishing element), but the bowel has been too slow in passing it along. Consequently it is not ready to be expelled while it is yet a harmless semi-solid mass. It stays in the bowel too long—it begins to putrefy, bacteria attack it, and it is soon a semi-liquid, foul, rotting mass. The sucking glands in the intestinal wall continue to suck—that is their duty. They cannot discriminate between what is good and what is bad—they simply go on absorbing whatever is there to absorb. So there are absorbed into the system liquid and gaseous products which are poison.

This process has been called by a number of names; "self-poisoning" explains the condition thoroughly. The other names are, auto-infection, auto-intoxication, enteric-infection, enteric-toxemia, intestinal indigestion.

The condition is a serious one, because it is absolutely impossible to feel well, or to enjoy good health, while it lasts. The feeling of being constantly sick, yet not sick enough to stop working or to demand a radical cure, affects a woman's efficiency, interferes with her capacity to work, her ability to render the home an abode of contentment, to be an agreeable companion, or to adequately take care of her children.

The constant absorption of intestinal poisons affects the system itself,—the symptoms are headache, neuralgia, loss of appetite, nervousness, insomnia, vertigo, inability to concentrate, lassitude, indigestion. The condition which we name constipation is therefore one of supreme importance. From a medical standpoint, it is the biggest problem in the whole realm of disease. It is the most significant hygienic function of life, and it is becoming more and more important, and more and more a problem. Every modern factor upon which physical efficiency seems to depend is an enemy to the systematic regulation of this function. Our method of hurried and indiscriminate eating, our system of strenuous living, our unsanitary environment, our business activity, our method of pursuing pleasure, take no account of, and resent the time devoted to cultivating, as a hygienic necessity, this toilet requirement. This imperative call of nature is pushed aside by the child at play, by the housewife for a duty which could wait, by the merchant for an engagement. It is particularly an American disease, and it is uniquely an American woman's affliction. It is a curious commentary on the intelligence of the American people, who are ordinarily alert and analytical, to realize how few of them really know how serious a matter constipation is. They don't know because they have given the matter absolutely no thought. They have accepted it as a mere matter of fact, almost of fate.

INCOMPLETE CONSTIPATION.—There is a type of constipation that is not known to the average person and not well understood by those few who know of its existence. In this form of constipation there is a daily bowel movement but the movement is not complete. The bowel does not thoroughly empty itself; it has established this habit because of conditions under which it has had to do its work. If a woman neglects herself, becomes muscularly inactive, does not take proper out-door exercise, grows fat and lazy, eats irregularly and indiscriminately,—the bowel suffers with the rest of the system. The woman may have a healthy appetite, may eat the wrong things at the wrong time, yet the bowel is supposed to go on acting rightly, but it does not. It, too, becomes lazy and acquires bad habits, and this form of incomplete constipation is the result. These patients look healthy and get little sympathy for any pains they may have. They may even gain in weight; they get headaches once in a while, and if they go shopping or visiting they don't feel quite well afterward. They are suffering from the effects of chronic constipation, though their bowels are apparently regular. They are marching onward toward apoplexy or Bright's disease of the kidney.

IMPORTANCE OF A CLEAN BOWEL.—Every mother, sooner or later, observes that a physician always thoroughly cleans out the bowel of a sick child at once, no matter what the character of the sickness is. He does this for two reasons,—first, because he knows that the great majority of children's ailments are of gastro-intestinal origin; second, if the origin of the disease is not in the stomach or bowels, experience has taught him that if the bowels are clean at the beginning of a disease, that disease will run a milder and shorter course than if complicated with a condition of self-poisoning. If a child develops fever the digestive function stops; whatever food is in the stomach or bowel will promptly ferment and putrefy because of the abnormal heat caused by the fever and the arrested digestion. If this is not cleaned out at once the self-poisoning process begins.

The above is a suggestive admission for a physician to make. It simply means that the vast majority of the calls made by a physician on ailing children are caused by errors in diet and can be completely cured by a dose of castor oil or calomel, or, better still, need never occur.

A mother who neglects, who is guilty of inattention to the conditions of her child's bowel, fails in one of the most important duties of motherhood. I know as a father and a physician that if a child's bowel acts regularly and thoroughly, that child is fortified to the highest efficient degree against the multitude of little ailments common to all children. A clean bowel means good blood, good digestion, ability to exercise properly, to sleep soundly and to think clearly. Such a child will resist infection and throw off the minor troubles that pave the way for serious sickness. It is a secret worth knowing.

A DAILY MOVEMENT OF THE BOWEL NECESSARY.—In order to preserve good health one thorough movement of the bowel is necessary daily. A baby may have two or three and enjoy robust health. A larger daily number suggests an abnormal condition of the bowel and an investigation should be made. If a nursing baby's bowels do not move before bedtime it should be given an injection of equal parts of glycerine and hot water, one-half cupful; or an enema of soap and water, or a glycerine suppository. When a child is six months old, in some sooner, it should be put on the stool at a certain time every morning. This will aid in the establishment of the habit, as a child soon understands why it is made to assume this position and acts accordingly.

The condition referred to above and which we termed incomplete constipation may affect the nursing infant. A child's bowels may move daily and yet the child will suffer from constipation. If the movements are watched it will be observed that certain children strain when at stool, and after a time succeed in passing hard, dry lumps or balls of fecal matter. Such a movement is a certain indication that the bowel is not emptying itself satisfactorily and that a constant toxemia or poisoning is going on. Very faithful efforts should be made to remedy this condition by the use of articles of diet that are known to be laxative, otherwise the condition is one that will "grow" with the child and establish an obstinate chronic constipation with all its miseries and dangers.

CONSTIPATION IN BREAST-FED INFANTS.—Many nursing infants thrive and gain in weight, yet they are constipated. Before you drug your baby be sure the fault is not your own. Many mothers are responsible for the constipation with which baby suffers. If the mother is constipated, so will the child be. Cure the constipation of the mother and the baby's bowels will regulate themselves. Nursing mothers who are large tea-drinkers have irregular bowels as a rule. A baby whose mother is lazy or indolent, who does not take a reasonable amount of exercise, whose diet is faulty and whose hours are bad, is a sufferer from constipation. The mother's life must be regulated, her diet and habits corrected, and the instructions carried out as already recommended. The breast milk should be examined and if any cause for constipation exists in it, it should be rectified as suggested elsewhere.

If it is thought advisable to resort to drugs for the immediate relief of the constipation of infants, the best ones are the aromatic fluid extract of cascara sagrada; milk of magnesia with equal parts of the aromatic syrup of rhubarb given in doses of one to three teaspoonfuls daily.

Irrigations, enemas, and suppositories should not be used continuously. The habit is a bad one. The parts become accustomed to their use and fail to act. If the child is passing dry and hard stools it is of advantage to inject two ounces of warm sweet oil at night, allowing it to remain in the bowel until the following morning. See page 312.

CONSTIPATION IN BOTTLE-FED INFANTS.—It is much easier to treat the constipation of bottle-fed babies than of those breast-fed, because the food can be changed to ensure regular bowel movements. The first change to be made in a bottle-fed baby who is habitually constipated is to add more cream to the food. The way to do this is to take out of the bottle of each feeding one tablespoonful of the food and put in its place one tablespoonful pure cream. If this change partly rectifies the bowel ailment, add more cream until the bowels are of the proper consistency. Milk given constipated babies should be raw, never boiled, as boiled milk will always aggravate the trouble.

The use of oatmeal water instead of plain water in making the baby's food may cure the bowel trouble. Taking the sugar of milk out of the baby's food and putting in its place the same quantity of Mellin's food will sometimes cure the constipation.

One or two teaspoonfuls of milk of magnesia put into one feeding daily, or fifteen drops to one tablespoonful of the aromatic fluid extract of cascara sagrada will move the bowels. Orange juice, strained, two teaspoonfuls twice daily, is an excellent remedy and should be tried in every case. Sweet oil and pure cod liver oil, in doses of thirty drops to two teaspoonfuls three times daily after feedings, if the little patient is poorly nourished. If the stools remain hard and dry, an injection of two ounces of warm sweet oil at bedtime is an excellent method of aiding the bowel. The oil should remain in the bowel all night. This lubricates the parts, softens the fecal mass and stimulates the gut to perform its own work. See page 312.

CONSTIPATION IN CHILDREN OVER TWO YEARS OF AGE.—Most children when put upon a varied diet after the nursing days are over are relieved of any constipation which may have existed up to that time. There are a few, however, whose condition does not seem to improve. These children need attention. We should first insist on regular habits. A child should be told that its bowels must move every morning after breakfast. If this is absolutely insisted upon the child will soon recognize the uselessness of fighting the proposition and submit. If at any time a conscientious effort is made to move the bowel without result after fifteen minutes it is wise to use a glycerine suppository so that the bowel will empty itself.

It has been stated in another part of this book that there are children with whom milk does not agree. Experience has taught us that milk, especially milk that has been boiled, causes more cases of constipation in growing children than all other causes combined. Find out if it is milk that is the cause in any individual case. While these children cannot take whole milk just as it comes from the dairy without suffering in a great many ways, they can take milk and water, or milk and oatmeal water, prepared in the following way, without becoming constipated. A bottle of fresh milk is allowed to stand in a cool place for five hours, when the top ten ounces are skimmed off with a Chapin dipper and mixed with twelve ounces of oatmeal gruel or plain water. This can be used as a drink.

Parents can select from the following list of articles such combinations as may be suitable to constitute the regular meals of a constipated child:

Lamb chops. Rare steak. Rare roast beef. Hashed chicken. Soft boiled eggs. Cracked wheat. Hominy. Cornmeal. Oatmeal, Scotch. Bran biscuits. Oatmeal crackers. Graham wafers. Stewed or baked apple. Apple sauce. Plain vanilla ice cream. Animal broths, purees of peas. Beans, and lentils. Peas. String beans. Spinach. Cauliflower. Asparagus. Stewed tomatoes, strained. Whole wheat bread. Zwieback. Custard. Stewed prunes. Junket. Cornstarch.

Malted milk is agreeable and advisable as a drink.

Orange juice or a scraped raw apple is allowable at this time. Constipated children should eat plenty of good butter. Olive oil, two or three teaspoonfuls after each meal, is excellent. It can be kept up for months to advantage. Older children may eat raw and cooked fruits, figs, dates, baked potatoes, poultry, and fish. One or two raw apples or a peach or orange may be given daily. A strict observance of the above rules and diet will result in normal movements of the bowel if persisted in for a reasonable time. It may be necessary occasionally to use a suppository or an enema now and again until the habit is established.

In children from five to fifteen years of age the use of bran muffins, with fruit, etc., as described above, will effect a cure of constipation without having to resort to drugs. I have cured many cases of constipation in growing children with these muffins without making any other change in their diet or habits.

RECIPE FOR BRAN MUFFINS

Take one pint of best flour, one quart unsifted bran, one teaspoonful bicarbonate of soda (baking soda), a pinch of salt. Mix these thoroughly together, then add: six to eight tablespoonfuls good, New Orleans molasses, one pint of milk. Mix together very thoroughly. Put in muffin rings and bake in oven. About one ounce should be put in each ring as they raise easily. Eat with plenty of good butter. They should be given to children before each meal, when they are hungry, not after their stomachs are full. Put bran in dish first. Sift in flour, soda and salt. Mix these thoroughly together, then add one pint of milk (two cupfuls) and six to eight tablespoonfuls of New Orleans molasses. The quantity of molasses depends upon the individual taste. They are good for any child or adult whether constipation exists or not.

Drugs may be of temporary service in some cases. A pill of cascara sagrada is the best for this purpose. It should not be continued for more than two weeks. Castor oil, calomel, and other frequently-used cathartics should never be used in simple constipation.

TREATMENT OF OBSTINATE CONSTIPATION

There are cases that resist treatment of the kind described above. Diet and drugs do not succeed in establishing the habit of daily bowel movements. In these cases radical treatment is imperative. The diet should be the same as that described above, but it will be found advisable to cut out milk altogether. Cereals can be taken with sugar and butter instead of milk. The oil injection plan of Professor Kerley has given me excellent results. I quote his comments upon and method of giving it:—

"OIL INJECTIONS."—"For this purpose a soft-bulb syringe of four ounces' capacity is ordered. Over the hard rubber tip is place a small sized adult rectal tube or a No. 18 American catheter. The catheter or tube is cut so that but nine inches remain for use. The cut end is forced over the small, hard rubber tip of the syringe. A fountain syringe is impracticable for this purpose, as it is soon destroyed by the oil and rendered unfit for use. Besides, sufficient pressure is not produced to force the oil into the gut even with a high elevation of the bag. The child is placed on his back or on his left side. The syringe is filled with oil, the tube is lubricated, and passed through the rectum as far as it can go. When it has been passed to the full nine inches, as may readily be done with a little practice, the syringe is emptied and the tube withdrawn. The injection should be given after the child has been placed in bed for the night. It is our object to have the oil retained during the night. If a passage of the bowels is produced at the time, or if the oil leaks out during the night, a small quantity should be used. In some of my patients I have been able to use but one ounce. In very few, indeed, does it cause an evacuation at the time. If there is a tendency to leakage a napkin should be worn to avoid soiling the bed-linen. The following morning after breakfast, the child is placed on the vessel and kept there until a bowel movement results or until fifteen minutes have elapsed. In a great many cases if the constipation has been obstinate for months, the bowel will be at once evacuated. When this does not occur in fifteen minutes, a glycerine suppository is inserted, which invariably produces an evacuation. This use of the suppository, according to my observation, can usually be dispensed with in a very few days; the use of the oil, however, may have to be continued for several weeks. When the child has had the oil nightly and an evacuation the next morning without assistance for two weeks, I direct that the oil be omitted for a night and the effect noted. If the usual passage occurs after breakfast, the oil is given for five nights and then omitted. If the case progresses satisfactorily the use of the oil is gradually omitted, being given at first every second night, then every third, fourth, or fifth night, etc. A considerable number of cases have been completely relieved in two months. In the event of no passage following the omission of the oil, its use is continued for two weeks longer, when it is again omitted for a night." To illustrate this point the following case is cited.

"ILLUSTRATIVE CASE.—A boy three years of age had never had a bowel evacuation without drugs, soap enemas, or suppositories since birth, and finally these were no longer effective. The mother, thoroughly frightened, brought the child to me. Eight months of diet and the use of the oil were required before he was entirely well. It is now three months since the local treatment was discontinued and the bowel function remains normal.

"The diet with the absence of milk must be continued for months after the patient is apparently well, and he must not be allowed to pass a single morning without an evacuation at the usual time. In assuming the management of one of these cases I explain to the mother or nurse that the treatment is not pleasant for the child or the attendant, and that it may have to be persisted in for weeks, and unless she is willing to carry it out to the end, it would better not be undertaken. I assure her, however, that with her cooeperation, which is usually readily given, the child will make a complete recovery. Cases that are slow in responding to treatment, I usually give the additional advantage of abdominal massage from twenty minutes to one-half hour, before the child is placed at stool. The massage should practiced by one skilled in the work.

"The above local measures apply particularly to children after the eighteenth month. They may be used earlier, however, following out the diet along the lines laid down for bottle-fed children who suffer from constipation. In very young children a smaller amount of oil should be used, never more than two ounces, usually one ounce is all that is required. When the oil treatment is under way, whatever the age of the patient, laxative drugs should not be given."



CHAPTER XXIII

CONSTIPATION IN WOMEN

Chief Cause of Constipation in Women—Constipation a Cause of Domestic Unhappiness—The Requirements of Good Health—The Cost of Constipation—Constipation and Social Exigencies—One of the Important Duties of Mothers—Constipation and Diseases of Women—Constipation is Always Harmful—Constipation and Pregnancy—Explanation of Incomplete Constipation—Causes of Constipation—Negligence—Lack of Exercise—Lack of Water—Lack of Bulk in the Food Taken—Abuse of Cathartic Drugs and Aperient Waters—Overeating—Treatment of Constipation in Women.

It has been stated that constipation is almost universal among the women of America. It is a fact that very few American women enjoy, to a reasonable degree, a permanently satisfactory bowel condition. Constipation is an acquired habit and unquestionably negligence is the primary and the chief cause of it. The negligence, no doubt, begins at a very early age; it is at least an established habit before any intelligent, consecutive effort is made to remedy it. Inasmuch as women are the mothers of the race, and as their part in the scheme of life is the supreme one; and as constipation has been shown to be a serious, far-reaching, significant disease, a very sincere and persistent crusade should be made to educate women as to its importance. For a less altruistic purpose, tremendous popular movements have been carried to success. For a less service rendered to the race names have achieved renown. In addition to the symptoms stated in the preceding paper, the condition which we now desire to emphasize is the effect of the constant self-poisoning on the general health and its effect upon a woman's reproductive efficiency.

The poison being constantly absorbed, means general bad health, bad health to a degree depending upon the degree of constipation which is the cause of the poisoning. It may be simply that the woman does not wholly enjoy good health, or that she is completely incapacitated because of chronic bad health, or any degree of indifferent health between these two extremes.

If the degree of poison is sufficient to cause habitual poor health, its effect upon the blood must be bad, and the effect of the bad blood upon the nervous system and the other vital organs cannot be good. Now if this process has been going on for many years, the condition of the woman, who is its victim, as an efficient machine, compared with the woman in whom this condition never did exist, must be very different indeed. This condition of affairs—inasmuch as constipation is so common in women—must have a tremendous significance when estimating the vitality and efficiency of the coming generation.

We might go much further and yet be sure of our position, and maintain that it is this national autotoxemia, this scourge of womanhood, that is to a great extent responsible for the characteristic American "vice of neurasthenia," and of the domestic infelicity and unhappiness which are so common in the large cities of this country. If we add to the intestinal autotoxemia of constipation, the tendency to, or vice of, indiscriminate eating and drinking—of which the American people are particularly guilty—we would be on firmer ground. In fact we would feel that we had pointed out the one underlying cause of most of the domestic irritability prevalent to-day, which is of serious importance, and which is, fortunately, capable of correction. It is a matter of everlasting and continuous education.

THE REQUIREMENTS OF GOOD HEALTH.—There are certain fundamental basic requirements which are essential to good health: fresh air, good water, a reasonable amount of physical and mental exercise, nutritious food, freedom from unnecessary and unreasonable worry, frequent bathing, and a daily movement of the bowels. The reason why constipation is of such serious importance is because it is the only basic requirement of good health that afflicts a large majority of the race at the same time. The health of so many is being undermined by this one affliction, that it dominates all other factors that have any bearing upon posterity. A woman may enjoy all the essential conditions necessary to good health, yet she may be constipated, and the presence of this condition will undermine, in her constitution, all the benefits she derives from her advantageous environments. It will do more; it will be responsible for the disposition,—the temperament,—of that woman. The natural disposition of that woman may be an amicable one; if it were allowed to express itself naturally it would be kind, gentle, considerate, affectionate. No woman, however, the victim of chronic constipation, can preserve an equable temperament or an amicable disposition. It is impossible—with her nerves being constantly poisoned—that she can hold the symptoms of that condition in abeyance. She must be irritable and nervous and sick of herself and everything and everybody. The home as a direct result suffers; its atmosphere is not one of contentment and peace and affection. Constipation, therefore, blights the home and the influence of one blighted home may have a far-reaching effect on the story of the human race. It is responsible also for that woman's mental attitude outside the home. Instead of exerting an optimistic influence, her whole existence is a message of pessimism and discouragement. Multiply these influences and messages to correspond with the prevalence of the disease and we have a condition that is tremendously significant, a condition that is really a pressing economic issue. A constipated woman is an anti-eugenist—a eugenic atrocity.

We have no desire to create a false impression or to build up a foolish fear. Are we justified in regarding this as one of the most important, if not the most important, disease condition; the most menacing physical vice, which the human race has to combat? Let us offer the following brief facts in witness of our stand:

THE COST OF CONSTIPATION.—It has been estimated that consumption (the great white plague) kills one-tenth of all the human race. Cancer kills half as many, or one in every twenty. Constipation, and the diseases which are caused directly by it, kills one in every three of all the people on the civilized globe.

Constipation has been responsible for the expenditure of millions of dollars in advertising in the newspapers alone,—more, probably, than has been spent in advertising remedies for all other diseases combined. Do you suppose this money was a donation? Do you suppose these keen, alert interpreters of the spirit of the times, the up-to-date business men, were not and are not aware that constipation is the "universal disease"?

Every drug store, in every civilized spot on earth, has its shelves loaded down with constipation remedies; dinner pills, liver pills, cathartic pills, tablets in all possible coatings and combinations, mineral waters from a multitude of springs, aperient drinks by the dozen, laxative teas and cordials, cathartic oils and emulsions. If the demand for these articles should cease most of the drug stores would close up.

Many millions of dollars have been made and are being made by various men and concerns, who have devised ingenious mechanical agencies which are supposed to cure, and in curing renew the lost health caused by constipation. We have in mind in this connection, a man who conceived the ingenious plan of putting the opening of an ordinary fountain syringe in the middle instead of at the end and made a fortune out of it. In this opening he places an upright nozzle, and instead of hanging the bag up and allowing the water to run into the bowel, he has the patient sit on the bag and thereby the water is forced into the bowel. He has written a two-hundred page book on the advantages of this idea, and his "literature" contains the names of famous men and women in all walks of life who use his device. The name of one of the famous judges of the Supreme Court of the United States was there; another was the name of a popular operatic beauty who writes for the daily press little essays on "How to be beautiful!" and "How to keep well!" He deserves his success. He is an emancipator and has doubtless done a great deal of good. His success demonstrates, beyond contradiction, the prevalence of the malady under discussion, and it must be remembered that he is only one of hundreds who garner from the same ample harvest.

If we could estimate in value the economic loss sustained by the race because of the inefficiency of the victims of intestinal intoxication, due to constipation, the sum would be colossal. Even then it would only represent the direct economic deficiency—it would not express, nor could any figure adequately represent, the indirect loss sustained by the race because of the temperamental characteristics, which are the products of intestinal poisoning, and which produce domestic tragedies and economic failures.

Has this array of evidence any meaning, or does it just happen to be so? We leave it to the reader; if it stimulates thought, or pricks a conscience it will have done its duty.

CONSTIPATION AND SOCIAL EXIGENCIES.—The cause of constipation in women, whose social station commands every sanitary, hygienic, and dietary luxury, is their method of living, the food they eat, and the negligence which is almost obligatory because of social exactions. If constipation did not so frequently accompany "good" living (which is the modern name for overeating and drinking) we would have thousands and thousands of healthy, robust, contented women, fit and willing to assume the onerous duties concomitant with motherhood. All their enthusiasm, however, is expended in the effort to keep "in the ring," to overcome the effects of the poison of constipation, to preserve their youth and freshness, to undo what neglect has accomplished. It is because of the failure of this simple function that my lady seeks the masseur, the facial artist, the society doctor, the beauty expert, and the thousand and one agencies, which an extravagant and profligate age has made necessary to foster the efficiency of its votaries.

I am optimistic, however, regarding the future. I believe the human race is improving, despite the disadvantageous surroundings and conditions which hamper honest effort and stultify truth. A higher efficiency is the goal, and the intention is to obtain this desideratum by fair and by just means. There is an awakening, an unrest, a groping for knowledge in almost every field of human endeavor, and there is none in which the yearning for fact, for truth, for instruction, is stronger and keener, than in the world-wide movement in the interest of a better motherhood, and in a more serious study of child life. It is an encouraging sign, a hopeful promise, of what the future has in store.

ONE OF THE IMPORTANT DUTIES OF MOTHERS.—The immediate lesson to be learnt from the facts just recounted is to instruct mothers in their duty toward their daughters. If each mother would retain the confidence of her daughter sufficient to instruct her in the duties which are important, how much needless suffering would be saved. To know as a matter of fact whether the daughter's bowels are in good condition will appeal to all who read this as being of very great importance. It is not only necessary to know if they have a movement every day, it is necessary to know the character of the daily movement; whether it is hard and dry and necessitates straining,—the evil consequences of which, in young girls, is very serious indeed,—or if it is habitually loose and suggestive of what has been described as incomplete constipation.

If the mothers of America would consecrate themselves to this simple task, who could tell in mere words the effect it would have on the race yet unborn? There are problems of scientific intent, and of fancy names, that engage the attention of philanthropically inclined ladies, and which are emblazoned on the society columns of the daily press, of much less importance to the human family than the homely duty we ask mothers to devote themselves to.

CONSTIPATION AND DISEASES OF WOMEN.—Constipation is present in a very large majority of the cases of diseases of women. It may be caused by disease of the womb, or it may cause disease of the womb. There is no question about the bad effect constipation has upon all diseases of this type. In many cases it is absolutely impossible to effect a cure without first curing the accompanying constipation.

We seldom appreciate how severe a degree of constipation a growing girl will submit to without seeking relief. Some of the worst cases of constipation that have been known, have been in girls between the ages of sixteen and twenty. The mechanical effects of such a condition can well be imagined. The constant, severe straining, necessary to evacuate the bowel, has, in very many instances, produced congestion and displacement of the womb and ovaries. It is not observed at this time, or if observed it is not understood, and thus is laid the foundation for years of neurasthenia, helplessness, and disease.

The more we investigate the ramifications of constipation the more we learn of its seriousness and of its significance.

CONSTIPATION IS ALWAYS HARMFUL.—There is no period in life when constipation can be borne with impunity. Youth, with its virility and vitality, will endure its consequences with an apparent negation, so far as positive or specific results are concerned, but it is only an apparent impunity. There is always a certain amount of strength built up, held in reserve as a heritage of youth, which will withstand a certain amount of physical license, but if this reserve is assailed by an unnecessary imposition, and is successfully undermined, there will be infinitely less reserve to call upon in the legitimate battle of life. Life is too real, too concentrated, too strenuous, and health is too precious to be wilfully wasted in any form of self-abuse.

CONSTIPATION AND PREGNANCY.—Mothers will appreciate from the foregoing explanation why constipation is eugenically a crime during pregnancy. The evils which result from constipation mechanically, frequently have serious consequences by interfering with the circulation of the blood to the womb, by forcing the womb to assume wrong positions, by straining at stool, and by preventing the kidneys from functionating properly; these may render the life of the pregnant woman miserable, and may be the direct cause of a painful, prolonged, difficult labor. The evils which result from constipation because of the absorption of poisons by the bowel are of the gravest importance during pregnancy. These poisons affect the general health; the victim is tired, listless, and apathetic, and is thereby disinclined to exercise adequately; the appetite is poor; there are headaches, neuralgias, insomnia, nervousness, melancholia, and general mental and physical inertness. What hope may a pregnant woman entertain of having "an easy confinement," or of bringing a healthy child into the world under these circumstances? Who is to blame? Sometimes it is necessary to tell the unadorned truth,—the woman is to blame. No woman has a right to assume the responsibilities of maternity who has not had enough respect for herself to discontinue habits which caused this failing, or who has not had strength of will enough to begin its successful cure. Get busy,—do something,—it is never "too late," but do it now.

Before we take up the treatment of constipation in women, it is necessary to explain more fully the type of constipation which we referred to as "incomplete" constipation. There is a condition of the bowel, in which we find its wall coated with hard fecal matter. The size of the bowel may be dilated as a consequence. This condition may occupy part, or most, of the entire length of the large intestine. In the middle of this hard mass there is a small channel through which semi-liquid matter passes. When the bowel moves, it is this semi-liquid matter that passes out, and this constitutes the daily movement. We have consequently a condition in which we have a daily movement but not a complete emptying of the bowel. The character of the stools from such a bowel must necessarily be more or less of a semi-liquid consistency, because the intestine, being coated with a hard dried out layer of old fecal substance, is prevented from absorbing the liquid part of the fresh fecal mass passing through it. This condition may exist for a considerable time, but it will slowly undermine the health and vitality of any person in whom it exists. The symptoms which a patient in this condition complains of are,—a feeling of being tired and languid, no energy or vim, headache, loss of appetite, loss of flesh, neuralgic pains, nausea, vertigo (dizziness), insomnia, frequent colds, cold hands and feet, biliousness, sallow skin and muddy complexion, liver spots, coated tongue and a "bad breath," nervousness, melancholia, various abnormal conditions and diseases of the skin, pimples, blackheads, eruptions, eczema, piles, appendicitis, diseases of the intestinal wall as a result of the constipation, Bright's disease of the kidney, and many other morbid conditions. Any physician could name many symptoms, which were never properly understood but which are now known to be caused by the absorption of poisons resulting from inactivity of the bowels. Patients may not necessarily have all of the above symptoms; they may have a number of them, or they may have all of them, and they may have others not mentioned at all.

TREATMENT OF CONSTIPATION IN WOMEN.—To effect a movement of the bowels in a patient who is a victim of constipation is not a cure. We can indefinitely cause bowel action by drugs, etc., but the condition will remain the same or worse. When habitual constipation exists there is an underlying condition affecting the entire system which indicates that something is radically wrong. It may be necessary to change the whole routine of the patient's life. It will certainly be necessary at the very beginning to inquire into the daily diet, exercise, and surroundings.

During the past ten years there has been born every few days a new medical "ism," a new religious cult. Why? Because human nature is an unstable equation. We are never satisfied with the old order of things and there will always be a following wherever there is a leader. These "isms" and cults do not survive. Some seem to thrive, others die a natural death. There is a law, as old as the hills, that you cannot get something for nothing in this world. We learn its bitter truth as the years pass, and when we get over the day dreams and the sentiment of youth we settle down to real work. If we desire to retain good health, or regain lost health, we must do something. No one can hand it to us on a silver plate, nor can anyone work a miracle in our behalf. We cannot buy health, we must deserve it.

This is the secret of the success of all schemes to cure disease. The human family will not knuckle down and swallow the truth. The man or woman in poor health is looking for Aladdin's lamp everywhere and always. A new bait, dressed up in lubricated, oily words, promising impossible results, will be accepted as the simple unadorned truth, and will be bought and paid for, in the end forgotten. The royal road, the easy road, which they are looking for is impossible. There is no way by which any one of us may continue to break the laws of nature and retain or regain our lost health. Miracles are impossible. Prayers without deeds are empty mouthings and a waste of time. Let us see how this works out in the treatment of constipation. We must find the cause of the constipation. I will name the causes in their order of frequency.

NEGLIGENCE.—This is unquestionably the primary cause of almost all cases of bowel inactivity. As has been already noted, the exigencies of modern life are of such a strenuous nature that we do not find the time to devote to this function the degree of systematic attention which it demands in order to preserve a healthy condition of intestinal regularity. The bowel is simply a complex muscle controlled by an elaborate system of nerves of an involuntary type. In order to preserve the highest degree of efficiency of this complicated mechanism, it must be permitted to obey the laws nature endowed it with and which it must obey. When the fecal mass reaches the rectum the nerve centers, acting through the spinal cord, send a message to the rectum something like this: "Empty yourself of your contents, we have made all preparations and everything is ready." The rectum obeys to the extent of notifying you that it wants to be relieved; you feel the desire to evacuate the bowels. If you obey, all is well, nature is appeased, you encourage the systematic regularity necessary to good health. If you do not obey, you upset the delicate mechanism, and frequent negligence of this character will result in the complete disarrangement of this complex machinery so that it will fail to warn you that a bowel movement is necessary and constipation is established. We must therefore retrace our steps and re-educate the bowel systematically to empty itself at a certain time every day. This can be done in nearly every case without artificial assistance. It may take time but it is worth a little methodical persistence. The point is, you must do it; no "ism" or esoteric agency can do it for you.

Mothers will recognize from this explanation the necessity of establishing the habit in children at the earliest possible moment.

LACK OF EXERCISE.—What does the word exercise imply? It implies movement, better circulation of the blood, better health and tone to every part of the body, more oxygen, and a richer, better quality of blood, and because of a better quality of blood, which is the fuel of the body machine, we have a better, smoother working machine. Every human being requires a certain amount of exercise; otherwise the machine will not run smoothly. If this exercise is not obtained, things begin to go wrong. One of the very first signs to indicate that the machine is not running as it ought to run, is a sluggish condition of the whole digestive apparatus and a certain degree of bowel inactivity (constipation) follows. There is no substitute for this need. Drugs will not help you, mechanical devices will not do the work for you, though they may aid you. You must do the work yourself. If you fail or hesitate to recognize the truth, if you temporize or procrastinate, you are only deferring the issue. The argument that you have not the time, that your work will not permit you, is no argument at all. You must do it or reap the consequences; you certainly cannot escape them. The wise woman accepts the situation, the fool goes to an early grave.

LACK OF WATER.—Constipation may be due to a deficiency of water in the system. Women who suffer from this type do not drink enough water. The bowel may be willing and able to do its duty, but is handicapped because a certain amount of liquid is essential to proper digestion and natural bowel activity. At least six glasses of water should be taken by every healthy adult human being in each twenty-four hours. The best time to take this water is as follows: one glass on arising, two between breakfast and lunch, two between lunch and dinner, and one on retiring. Between meals means one hour after a meal and at least one-half hour before the following meal. No liquid should be taken during a meal, or immediately after, or before a meal. All water taken may be hot or cold, according to the fancy of the taker. It is of advantage to squeeze the juice of half a lemon into the water taken on arising if there is any tendency to constipation or if the liver is lazy or torpid. It is also good for the complexion.

LACK OF BULK IN THE FOOD TAKEN.—Sometimes the character of the food taken is such that there is no body to it. The process of digestion so completely liquefies it that the bowel has no solid matter to manipulate. To excite the peculiar movements of the intestinal wall there must be substance in the contents. The variety of the daily food must be so arranged as to provide this. A list of these foods is provided elsewhere in this book. Certain other foods stimulate intestinal activity, not because of their bulk, but because of the chemical elements they contain. All forms of sugar, the sugars of fruits, the acids of fruits and vegetables, are excellent natural laxatives. Sour milk and buttermilk, oils and fats, are also of distinct value in this respect.

On the other hand, soups, gruels, porridges, and purees are constipating because the digestive process reduces them to liquids and leaves no bulk for the bowel to act upon. New bread, hot biscuits, "noodles," and doughy foods are also objectionable, especially to children. Hot baths, hot drinks, hot enemas, and sweating are also constipating because they extract so much liquid from the bowel leaving the contents excessively dry.

ABUSE OF CATHARTIC DRUGS AND APERIENT WATERS.—This is a widespread evil; it may justly be regarded as a national curse. The victims of this custom do not realize that they are addicted to a habit which must be rightly regarded as equally as bad as the drink habit, so far as its ultimate effect on the general health and the prospect of longevity is concerned. Its popularity is a product of our national vice of indiscriminate eating and drinking. It is more common among the class who live in restaurants, hotels, and boarding houses, who keep late hours, eat late suppers and who do not exercise enough. These individuals eat too much and live too high. After a time the liver becomes sluggish, the stomach fails to digest properly, the bowels lose their tone, and flatulent indigestion or some other more or less serious condition follows; to maintain the pace, to feel and keep fit, they discover that a glass of some advertised aperient or laxative water before breakfast works wonders, tides them over for the time being and keeps them "in the ring." They compliment themselves and push the specter of age aside.