The Mother's Manual of Children's Diseases

CHAPTER VII.
THE DISORDERS AND DISEASES OF THE CHEST

In speaking of the ailments which occur during the first month after birth, I have already noticed the peculiarities of breathing in early infancy, and the difficulties that sometimes attend the complete filling of the air-cells of the lungs, and the readiness with which when once filled they become emptied of air and collapse.

On this ground it is therefore needless for me again to enter, and I may pass at once to consider those ailments which rise in increasing importance from a simple cold or catarrh to inflammation of the air-tubes or bronchitis, inflammation of the lung substance, as pneumonia, and inflammation of the membrane which lines the chest and covers the lungs, or pleurisy.

Catarrh.—A common cold or catarrh is not one of the ailments of very early infancy. The watery eyes, the sneezing, the cough, the slight feverishness and the heavy head are scarcely met with until after the age of three months; nor, indeed, are they often seen till the child is old enough to run about, to go out for a walk, and to encounter in consequence all the variations of temperature and of damp or dryness inseparable from the English climate.

This, however, is not entirely due to the greater exposure of the child to these influences as it grows older, but in part also to the fact that the lining of the air-tubes is less sensitive in early infancy than it afterwards becomes. The young babe if it catches cold gets snuffles, or stoppage of the nostrils, which first become dry, and then pour out an abundant discharge, which sometimes dries and forms crusts, and causes the child to suck with difficulty, and to breathe uncomfortably and with open mouth. In a few days, however, at the worst this discomfort passes away; and the only additional remark I have to make is, that since obstinate snuffles are sometimes a constitutional disease, the doctor's advice should always be sought if they last longer than a week.

It is needless to describe a cold, but it is much more to the purpose to say how its occurrence is to be prevented, and nine times out of ten the observance of two simple rules will suffice for this. First, take care that there is no great difference between the temperature of the day and of the night nursery. The one should never be above 60°, nor the other below 50°, and the undressing and the bath should always take place in the warmer room. Second, never let the child wear the same shoes or boots in the house as it does out of doors. The change should be as much a matter of routine as the taking off its hat or its bonnet.

The domestic management of a cold is simple enough. The usual error is the overdoing precautions, the keeping the room too hot, or overloading the child with extra garments, or its bed with extra covering, by which it is kept in a state of feverishness, or of needlessly profuse perspiration.

If, for the first two days of a bad cold, the child is kept in bed, the room being at a temperature of 60°, with no extra covering on the bed, but a flannel jacket for the child to wear when it sits up in bed to play, a few drops of ipecacuanha wine several times a day, a warm bath, a linseed poultice to the chest, and a little paregoric at night, with a light diet of rice, and arrowroot, and milk, and a roasted apple, and some orange juice; nine times out of ten, or nineteen out of twenty, the cold will pass away with small discomfort to the child and no anxiety to the parents.

Often a child objects to stop all day in its little cot, but move it to its mother's or nurse's big bed; and with a large tray of toys before it, and a little of the tact which love teaches, the day will pass in unclouded content and cheerfulness.

It must of course be borne in mind that measles set in with all the symptoms of a bad cold, followed on the fourth day by the appearance of the eruption; and, moreover, watchfulness must always be alive to detect increase of fever, hurry of breathing, hardness or extreme frequency of cough, the sign of the irritation of the larger air-tubes having extended and become more severe, the evidence that the case from simple catarrh has become one of bronchitis.

Bronchitis and Pneumonia.—It is impossible to enable persons who have not received a medical education to distinguish between a case of bronchitis and one of pneumonia. Neither, indeed, is it of much importance that they should do so, for in both the dangers are of a similar kind, and both call equally for the advice of a skilful doctor.

In bronchitis inflammation affects the lining of the air-tubes, travelling from the larger towards the smaller, and in bad cases extending even to their termination in the minute air-cells. The inflammation leads to the pouring out of a secretion, which by degrees becomes thick like matter, or even very tenacious, almost as tough as though it were a thin layer of skin. If this is very extensive, and reaches to the small air-cells, it is evident that air cannot enter, while that elasticity of the lung which I have already spoken of tends to drive out from the cells the small quantity of air they contained, and the child dies suffocated, partly from the difficulty in the entrance of air, partly from the collapse of air-cells from which the air has been slowly expelled.

In pneumonia or inflammation of the lung-substance the process is different. A portion of one or other lung, sometimes of both, becomes overfilled with blood, or congested, and though the air-tubes themselves are not the special seat of the congestion, yet the air-cells are pressed on by the surrounding swollen substance, and the entrance of air into them is impeded. If the mischief goes further the substance becomes solid and impervious to air, and lastly it becomes softened, its structure destroyed, and infiltrated with matter; the affected part becomes really an abscess, though not bounded by the distinct limits which would shut in an abscess of the hand or the foot. Inflammation, and the formation of an abscess anywhere is, as we know, attended by fever and much general illness, and inflammation of the lung is of course attended by fever and general illness in proportion to the importance of the organ affected. To these, too, must be added all the disturbance inseparable from any ailment which gravely interferes with breathing.

In the great majority of instances inflammation of the lung-substance does not go on to the last stage, and recovery is not only possible, but probable, from congestion and solidification of the organ. Pneumonia, too, usually attacks only a portion of one lung, while in bronchitis the air-tubes of both are always involved. Hence of the two, serious bronchitis is more to be dreaded than serious pneumonia.

Bronchitis is always developed out of previous catarrh, though there is a wide difference between the duration of the preliminary stage and the occurrence of serious symptoms in different cases; while it may be laid down as a general rule that the severity and danger of an attack are in proportion to the rapidity of its onset. An attack of pneumonia, or inflammation of the lung-substance sets in, as a rule, more suddenly, with fever, a temperature of 103° to 105°, general distress, headache, not unfrequently delirium; the urgency of which symptoms, the hurried breathing and the short, dry, hacking cough, and the tearless eyes are too often misinterpreted, and the state of the chest not examined.

The doctor, of course, skilled in auscultation, will listen to the chest and give to all these symptoms their true signification. The lesson for the parent to bear in mind is never to neglect in a child the symptoms of what may seem to be but a common cold, but to seek for advice the moment the cough shows any disposition to become hard, or the breathing hurried. Next, when any sudden illness sets in with very high temperature and much general ailing, not to let the disorder of the head, or the delirium, make you shut your eyes to the import of the short cough, the dry eyes, the hurried breathing; and lastly, to remember that, grave though the symptoms may be, the tendency in pneumonia is to eventual recovery, and that in early life bronchitis is the graver of the two diseases.

A caution may not be out of place with reference to cases which may occur during the epidemic prevalence of influenza. A child is sometimes struck down by it, just as grown persons are sometimes, with great depression, extreme rapidity of breathing, and very high fever, which, passing off in a couple of days, leave a state of great exhaustion behind. It is well to bear in mind that such symptoms have no such grave meaning when influenza is prevalent as they would have at another time; and the knowledge of this fact may serve in some degree to control your anxiety.

Pleurisy.—It is not possible for anyone, without medical experience, to discriminate between pneumonia, or inflammation of the substance of the lung, and pleurisy, or inflammation of its covering. Some degree of the latter, indeed, very often accompanies the former, and this accounts for the pain which interferes with every attempt of the child to draw a deep breath. When pleurisy comes on independent of affection of the lung-substance, it generally sets in suddenly with severe pain in the chest, and a short hacking cough which causes so much pain that the child tries as much as possible to suppress it. After a few hours the severity of the pain usually subsides, but fever, hurried breathing, and cough continue, and the child, though usually it looks heavy and seems drowsy, yet becomes extremely restless at intervals—cries and struggles as if in pain, and violently resists any attempt to alter its position, since every movement brings on an increase of its sufferings. The posture which it selects varies much; sometimes its breathing seems disturbed in any other position than sitting straight up in bed; at other times it lies on its back, or one side; but whatever be the posture, any alteration of it causes much distress, and is sure to be resisted by the child.

The variations of posture depend on the seat of the inflammation; the pain depends on the two inflamed surfaces of the membrane rubbing against each other, and accordingly is relieved not merely by the abatement of the inflammation, but also when either the two surfaces become, as they often do, adherent to each other, or when fluid is poured out into the cavity of the chest, and thus keeps them asunder.

I dwell on this, because when fluid is poured out, the most distressing symptoms greatly abate, or even disappear, and parents sometimes put off in consequence sending for the doctor, while yet, if unattended to, the fluid may increase to so large a quantity as to press upon the lung, and so interfere with the entrance of air, or it may, if the mischief is not checked, change into matter, and then have to be let out by tapping the chest, for just the same reason as it may be necessary to open an abscess in any other situation.

Whenever, then, symptoms, such as I have described, come on, send at once for medical advice, and do not let some diminution of suffering, or slight general improvement, lead you to delay.

Croup.—I endeavoured to explain, a few pages back, the cause of that peculiar sound which is heard in spasmodic croup. The contraction of the opening of the windpipe changes the sound which passes through it, just as the opening or closing the keys of a wind instrument modifies the sound which it gives forth. But the windpipe is not simply a wind instrument, it is a stringed instrument too, and the strings or vocal cords, as they are termed, give forth, as they vibrate, tones now deeper, now more shrill. The action of this delicate apparatus is readily disturbed, if the nerve-supply to it is disordered by irritation in some distant organ, and then the breathing is accompanied by the peculiar sound of spasmodic croup, or in older children this may show itself in a different way, as in the loud, barking cough heard in some cases of constipation, or of disordered digestion; or another illustration of it is furnished by the loud, long breath—the 'hoop,' which gives its name to hooping-cough. But there is one sound that sometimes attends the breathing of children, which more than any other causes, and justly causes, the greatest anxiety to a mother; and that is the sound which is characteristic of croup.

The word croup, which comes from the Lowland Scotch, signifies merely hoarseness in breathing or coughing, and is therefore, strictly speaking, the name of a sign of disease, rather than that of the disease itself. The peculiar sound is heard in two different conditions—the one in which a child having caught cold, instead of the air-tubes alone being affected, the windpipe, and especially its upper part, becomes congested, and the lining membrane swollen. Partly owing to this, partly owing to its nerve-supply being disturbed, the child breathes noisily and hoarsely, and the cough has a peculiar metallic clangor. In the other case there is not merely the congestion of the windpipe, the disturbed nerve-supply, and the swollen state of the membrane; but in connection with the influence of the special poison of diphtheria, a deposit takes place at the back of the throat, whence it extends to the windpipe, and in many instances even far beyond it, blocking up its canal, and mechanically excluding the entrance of air.

To determine at once to which class a case of croup belongs is so far from easy, that I should advise that on the first sound of voice, or cough, or breathing resembling that of croup, medical advice should at once be sought. I dwell on the difference between the two: the first which has been called false croup, or better catarrhal croup, and the second called true croup, or diphtheritic croup, in order to save much needless apprehension to parents, in whose mind the croupy sound is invariably associated with nothing short of that most dangerous disease—diphtheria.

As a general rule catarrhal croup is rarely met with after the age of six. Children in whom it occurs have either seemed quite well, or at most have been a little ailing for a day or two with cold, and cough, and perhaps slight hoarseness. They go to bed and fall asleep as usual, but the cough, which does not wake them, becomes suddenly noisy, ringing, croupy, and the breathing is speedily attended with a long-drawn sound, half-hissing, half-ringing, and the child soon wakes alarmed, and fighting for breath, the skin bathed in perspiration, the face flushed and anxious. The cough, the difficult breathing, and the struggle for air last for an hour or two, or sometimes all night long, though they gradually subside, at any rate towards the approach of morning, when the child falls asleep, and, but for a somewhat hoarse sounding cough, and a look of fatigue, there are but few signs of all that it has endured.

The attack may not return, or it may recur for two or three successive nights, though in general with lessened severity, the child during the daytime seeming to suffer only from a slight cold, or now and then, and so rarely that I have not known it to occur above once or twice in all my experience, it may end in real inflammation of the windpipe; but not in diphtheria.

Attacks of this kind may recur three, four, or more times even in childhood, while diphtheria has no tendency to recur, but like measles or scarlatina seldom appears more than once, though the rule is subject to more numerous exceptions than are found in the case of the eruptive fevers. Still the fact of an attack of this sort returning should of itself lessen apprehension and make the parents look forward to its issue with less anxiety than that with which they regarded its first occurrence.

A fact which shows how large a part is played by disturbance of the nervous system in these cases is the liability of children who have suffered from it to attacks of asthma, often of great severity as they grow older, while very often after the transition from childhood to youth has passed these attacks too lessen in frequency and severity, and often altogether cease.

There are two measures which, while waiting for the doctor's arrival, may at once be taken, and which sometimes remove the symptoms almost as if by magic, while even were the case one of diphtheria they would still be of some service, and could not possibly do any harm. They are the hot bath, and a full dose of ipecacuanha wine. The former should be as hot as it can be borne, 93° or 94°, and the child should be kept in it for five minutes, and the latter should be given in a full dose, as a teaspoonful in warm water every quarter of an hour till free vomiting takes place. How much better soever the child may seem after the use of these remedies, it should still be kept for two or three days under careful medical observation.

Diphtheria.—In diphtheria croup is only one, though the most frequent, and one of the most serious, of the many dangerous symptoms which attend it. The croupal symptoms hardly ever come on quite suddenly, but are almost always preceded for some days by slight feverishness, languor, and restlessness, in spite of which the child still amuses itself; and if too young to express its sensations, the slight degree of sore-throat it experiences is manifested rather by a disinclination to take food than by any obvious difficulty in swallowing. There is no cough, nor any change of voice when the child is awake, but when asleep—and the sleep is generally uneasy—it often breathes with its mouth open, it snores slightly, or there is a little hoarse sound accompanying the breathing owing to a trivial swelling of the throat; while, if sought for, there will generally be found a very little enlargement, and a very little tenderness of the glands at the corner of the lower jaw. The eyes are sometimes tearful, there may be slight running at the nose, and the child is said to have a bad cold with slight sore-throat—the most remarkable feature of the case being generally that the depression of the patient is out of proportion to the severity of the local ailment. If now the throat is examined—and examination of the throat should never be omitted in any case where there is the slightest difficulty of swallowing—nothing may at first be seen but a very little swelling, and some redness of one or other tonsil. In a few hours more, white specks like little bits of curd will be seen first on one tonsil, then on the other, and next these specks will have united to form one continuous layer of a sort of yellowish-white membrane over the palate and tonsils. The examination of the throat, often so difficult when children are ill, is attended with almost none, if while they are well they have been taught the little trick of opening their mouths to show their throat, and of allowing the introduction of a spoon to keep down the tongue, a proceeding which though certainly unpleasant they will almost always readily agree to, like Martha Trapbois, in the 'Fortunes of Nigel,' 'for a consideration.' The deposit on the throat may disappear of its own accord, and not be reproduced, and this even though no treatment has been adopted, and in two or three days the child may be pretty well again, though strength is in general regained less rapidly than might have been expected from the comparative mildness of the attack.

In cases so slight it is no easy matter to recognise the features of a highly dangerous disease; still, out of forerunners so trivial as these, croupal symptoms may be developed, and their advances may be most insidious, and unless both parents and doctor have been closely on the watch they may be surprised all at once by the breathing suddenly becoming very laboured, by that and the cough becoming attended by the sounds characteristic of croup, and by the child's life being in extreme jeopardy, or in danger even beyond the hope of recovery.

It is not that here, as in cases of catarrhal croup, the ailment has really come on suddenly, but that the disease has been silently making unsuspected progress. Whenever then a child, after a few days of slight causeless ailing, accompanied with some little discomfort in swallowing, is seen to have white patches at the back of its throat, do not allow yourselves to be lulled even by their disappearance into a feeling of absolute security. Watch the child, and beg the doctor to watch it carefully, until it is perfectly well again, for though the deposit may have disappeared from the back of the throat it may continue to be formed in the windpipe, and in the somewhat depressed state of the nervous system which attends diphtheria it may not excite that irritation which any such cause would produce in a child in perfect health, and consequently not announce its presence until its amount has become so considerable as to offer an almost insurmountable obstacle to the entrance of air. Any, even the slightest, hurry of breathing, a hissing sound when the child draws its breath, hoarseness of voice, or a ringing cough, should quicken your apprehension of danger, and make you seek for immediate help.

It may be as well, however, to mention here, that not every white speck seen at the back of the throat is of necessity due to diphtheria, but that in some cases of ordinary sore-throat white spots may form on the surface of the tonsils. These white spots are due to the collection at their openings of the secretion formed in the minute glands which beset the surface of the tonsils, and which at these seasons is poured out in greater abundance than usual. They are distinct from each other, and do not coalesce into a membrane; the surface beneath is not the uniform red shining surface on which the membrane in diphtheria has formed, but the separate tiny openings from which the white matter has exuded may be distinctly seen if the surface is wiped with a camel's-hair brush. It is, of course, wise in every case to leave to the doctor the decision as to the nature of the deposit, but it may sometimes relieve needless anxiety to know beforehand that there is another cause besides diphtheria to which white spots at the back of the throat may be due.

There are other dangers, indeed, besides those arising from croup, which accompany diphtheria, though those just mentioned are of all the most frequent. There are cases in which death takes place not from the severity of any local ailment, but from the intense depression of the nervous system. There are other instances too, in which the case assumes what is termed a malignant character; profuse discharge taking place from the nostrils, swallowing being from the first exceedingly difficult, membrane being deposited on the lips, behind the ears, or at the edge of the bowel; death taking place in twenty-four or thirty-six hours from the outset of the first serious symptoms, either in convulsions, or from utter exhaustion.

But the very urgency of such cases must of necessity call for the immediate assistance of the doctor; and my business throughout this book is rather with those points which it is important for a mother to notice, and those things which it behoves her to do.

What does diphtheria depend on? is a question more easily asked than answered. The disease is contagious, as scarlatina is contagious, though not to the same degree. I may add, it is not identical with scarlatina, nor does the one disease protect from the other. It would, perhaps, be too much to say that it is dependent on an unsanitary condition of a town, a village, or a house, but there is no doubt but that, as is the case with cholera, scarlet-fever, or typhus, unsanitary conditions favour its spread, and increase its severity.

Being contagious, it is most important to keep cups, glasses, spoons, towels, and bed-linen separate from those of other inmates of the house, and to remove the patient from any room occupied by other children. Great care too is to be observed, if anyone is standing over the child during a fit of coughing, that none of the membrane which it spits up enters the mouth; and, that if the child's breath is caught, the attendant gargle immediately with a teaspoonful of Condy's fluid in a tumbler of water.

In the next place, as the depression of the nervous system in some cases of diphtheria is quite out of proportion to the local disease, and as children who have not seemed very suffering, have yet been known to die suddenly in an unexpected faint, it is of moment that the child remain constantly in bed from the commencement of the attack till complete convalescence. Nor, indeed, in serious cases is even this precaution sufficient; but in such circumstances not only must the child not be taken out of bed for any purpose, but it must even not be suddenly raised in bed, from a recumbent to a sitting posture. I have, on several occasions, known the neglect of these precautions followed immediately by what cannot but be regarded as the needless death of the patient.

During the illness, there is little for the mother to do, except to try to carry out the doctor's directions, and to give the child constantly little bits of ice to suck, which lessen the swelling of the throat, and relieve the pain and inflammation. If the child knows how to gargle, it should be induced to do so constantly, and finding the relief which this affords, will do so very readily. This is not the time, however, when the lesson 'how to gargle' can be learnt. A thoughtful mother teaches it while the child is well, and if the gargle is composed of raspberry vinegar and water, the lesson is learnt without tears. There comes a time, however, if the disease is at all severe, when gargling is no longer possible, for the muscles of the back of the throat lose their power; but now some medicated solution, employed by means of the spray-producer, may most efficiently take its place.

When croupal symptoms have gone on growing worse and worse, and the child is in the agonies of suffocation, the doctor may propose to open the windpipe, in the hope of giving the child another chance of recovery, and even though the operation fail, of at least lessening its sufferings.

The operation is sometimes objected to by the parents, on the ground of the uncertainty of the result, and the torture of the operation to the child. Now the anguish of a child dying of croup is due to two causes; first, the actual mechanical impediment to the entrance of air produced by the deposit in the windpipe, and secondly, to the spasm of the muscles in the upper part of the windpipe which that deposit produces. How large an amount of distress the latter may produce, anyone can judge for himself, to whom it has ever happened to swallow the wrong way, as it is called. The opening made below the seat of the muscles which close the windpipe, leaves them in perfect rest, and does away with all the suffering produced by spasm, while there is always a fair prospect if the operation is not put off too long, of the deposit being limited to the part above the artificial opening, and of the good being permanent.

It is true that we have no certain means of knowing the extent of the deposit beforehand; it is true also that the operation is not in itself a cure of the disease, but at any rate, it is a reprieve which gives time for remedies to take effect, and at the worst, it substitutes a comparatively painless death for one of intolerable anguish. It can, too, be performed under the influence of chloroform, so that the idea that it adds in any way to the child's distress is unfounded. Who that has seen the calm, happy face, and watched the tranquil sleep of the child after the operation, who before was struggling, with distorted features and agonised countenance, to get a breath of air, but would feel as I do, that I would have it done in a child of mine for the sake of a painless death, even though I knew for certain that it would not prolong life even for an hour?

One additional remark I have to make with reference to the loss of power, or palsy of various muscles, which frequently follows diphtheria. Almost always there is some impairment of power in the muscles of the throat on which the deposit had taken place, and there is, in consequence, a little difficulty in swallowing for a few days. If this should get worse, food and especially drink sometimes return by the nose, and next there may be a slight squint, and the sight may become weakened, and an uncertain tottering gait; and sometimes for a week or two the child may be unable even to stand. In bad cases there is with these symptoms a general loss of nervous as well as of muscular power, though the child may still be fairly cheerful, and ready to amuse itself as well as it can. This condition may last for many weeks before it passes quite away, and if under the mistaken impression that the limbs will gain strength by exercise, the child is allowed to sit up and encouraged to exert itself, recovery will be delayed much longer; and dangerous weakness or fatal exhaustion may suddenly come on.

The inference is too obvious for me to need dwell on it, that repose is the great resource, and quiet waiting the true wisdom.

Hooping-Cough.—I need not say much about hooping-cough, for there is scarcely a nursery in which, to everyone's great discomfort, it is not known as a familiar and most unwelcome visitant. It varies remarkably in its importance, being sometimes so slight as scarcely to amount to an illness, but in other instances one of the most deadly of diseases. It causes the death of a fourth of all children who die under the age of five, and three out of four of these deaths take place in infants of less than two years old.

It occurs, however, comparatively seldom during the first three or four months of life, probably because very young children are kept more at home than others, and are thus less exposed to catch it. Though hooping-cough is undoubtedly very contagious, it seems to be communicated only by the breath, and there is absolutely no evidence to show that the clothes of a child suffering from hooping-cough can carry the infection as they might were the child suffering from measles, or smallpox, or scarlet-fever; still less that a person who has visited a room where children are suffering from hooping-cough can convey the disease to another house, or to other children.