I will just mention that symptoms similar to those above described, less severe, though more abiding, yet unattended by gravel in the urine, are sometimes produced in little boys by an unnatural narrowness of the end of the passage for the urine. It is well to bear in mind this possible cause of the child's sufferings, and to consult a doctor with reference to it, since he will be able to relieve it by a trivial operation.
Incontinence of Urine.—The irritation which this mechanical inconvenience produces sometimes has to do with that troublesome infirmity of some children, who wet the bed at night. This may also be induced by a very acid, and consequently irritating, state of urine, either with or without the appearance in it of gravel. Often, however, it is a result of want of care on the part of the nurse, who neglects to cultivate regular habits in a child; and does not pay attention to the quantity of liquid taken at its last meal. Something, too, is due to the fact that the sleep of a child is deeper than that of the grown person, so that the sensation of want, which would arouse the latter to full consciousness, does not have the same effect on the former. It sometimes happens undoubtedly from mere indolence; and this may always be suspected when a child, otherwise healthy, wets itself not at night only, but also in the daytime. Lastly, it does sometimes occur from muscular feebleness in weakly children, the bladder being unable to bear more than a limited degree of distension.
The accident usually happens either soon after going to bed, when the warmth stimulates the action of the bladder, or towards morning, when the bladder has become full. The posture on the back favours its occurrence very much, and it is therefore of importance that the child should lie on its side when in bed. The good effect of a blister on the lower part of the back as a means of cure was largely due to its forcing the child to lie on its side. This object can be attained, however, in a much kindlier way, by tying half a dozen cotton reels together, and fastening them at the child's back. The habit may also often be broken through by arousing the child in the night, and compelling it to empty its bladder, the hour being first ascertained at which the accident usually happens. For this, however, to be of any real use, the child must be awakened thoroughly; since otherwise it will mechanically, and quite unconsciously, empty its bladder while still asleep. The habit in this case is not in the least overcome; only for the time the bed escapes the wetting. The utensil must therefore be placed on different nights at different parts of the room, so that the child, in order to find it, must have been roused to thorough consciousness.
Lastly, I will add that the cases in which the accident is the result of mere indolence are very rare, and though in such cases strictness may be necessary, yet actual punishment is out of place. As a rule, reward answers much better. A penny, or a threepenny-piece every night that the accident does not happen, and a forfeit of a halfpenny or two pence for every night of misfortune, is a very efficacious help to a cure.
When all these domestic means, persevered in for months, fail to produce any result, medical aid must be called in.
CHAPTER IX.
CONSTITUTIONAL DISEASES
There remains for consideration a large class of what may be termed constitutional diseases, in which the local ailment is the outcome of a previous disorder of the whole system. These diseases are either acute or chronic. The acute constitutional diseases belong to the class of fevers. These are marked by certain local characteristics, as the swelling of the joints in acute rheumatism, the sore-throat in scarlatina, or the eruption on the skin in smallpox, and their course is more or less strictly limited by distinct periods of increase, acme, and decline. No such rule obtains in the case of consumption, scrofula, and rickets, which are instances of chronic constitutional diseases. In them too the local manifestations of the general disease vary also: the lungs being affected in one case of consumption, the bowels in another; while scrofula may show itself by affection of the glands in one case, by the formation of abscesses in a second, or by disease of the bones in a third.
Chronic Constitutional Diseases.—It may perhaps be convenient to study first the chronic constitutional diseases; and afterwards to make a few, and they will be but few, remarks on fevers.
Consumption and Scrofula, though similar, are not the same disease. Both, however, depend on some defect in the blood, as the result of which certain materials, incapable of being converted into the natural constituents of the body, are deposited in the substance of different external parts or internal organs. If deposited in small quantities, these materials may be absorbed, as it is termed, that is to say, got rid of, by natural processes, which even now we understand but imperfectly.
If deposited more abundantly, they press upon and gradually spoil the healthy parts in which they are seated, and thereby interfere with the proper performance of their duties. Thus, the deposit of consumption encroaches on the proper substance of the lungs, and so lessens the area in which the blood is exposed to the air and purified: the deposit of scrofula around and in a joint interferes with its powers of movement. Nor is this all; but wherever any deposit has once taken place, it tends especially to increase in that very spot, guided as it were by a certain affinity; and the substance of the previously healthy part is removed as fresh deposit comes to occupy its place. Further, the matter deposited has no power of being changed into healthy substance of lung, or of bone, or of any other part.
A fractured limb may be completely mended; a fluid is poured out around and between the edges of the broken bone; by degrees this hardens, it undergoes changes which convert it into solid bone, and the limb is once more as serviceable as before, though some indications of the fracture may still be perceptible in the texture of the bone itself. Or, a person receives a severe blow on his arm or leg; in course of time the blood which had flowed from the ruptured vessels, and had formed a big bruise, is absorbed, and all is as before the injury was inflicted. If more serious damage has been done, the fibres of some muscles may have been torn, even though the skin remains unbroken. Inflammation is set up, the injured parts die, and are melted down into the matter of an abscess. The abscess discharges itself, its walls contract, the opposite surfaces come into contact, and are welded together again, so that there is no loss of substance, nor anything save a scar on the surface to indicate what has happened.
In the case of the deposits of consumption or scrofula these changes cannot take place. In technical language the matter is said to be incapable of organisation; that is to say, it cannot be transformed by nature's alchemy into anything good or useful. It is rubbish to be got rid of; and the patient's recovery depends on the possibility of getting rid of it. If there is much of it, so as to be removed from the vivifying influence which adjacent living structures still maintain about it, the deposit softens at its centre. This softening gradually extends to the circumference; the mass irritates more and more the parts around it, and where the irritation is greatest the structures yield, and are removed to make a way for its escape, and the patient spits up the contents of the abscess.
But the abscess of the lungs is not like an abscess which follows an injury. It has not formed in the midst of previously healthy parts which are capable of reproducing the original structure; its walls are themselves involved in the disease, and, in accordance with the rule I have already mentioned, 'much will have more,' and the patient goes on spitting up the perpetually renewed contents of the abscess for months or years; until by its gradually increasing size, and the more and more abundant discharge of matter, and further and further destruction of lung-substance, death takes place.
This fatal issue, however, is not invariable. In favourable circumstances, and especially in childhood, the radical constitutional defect may be amended, and with a healthier condition of the blood the unhealthy deposit may cease to take place. The lung-substance, however, with all its curious structure of air-cells and their network of minute vessels where, as in nature's laboratory, the blood receives its due supply of oxygen, is not reproduced. The lung shrinks, the sides of the abscess come together, and by slow degrees a dense material cuts it off from the adjacent healthy structure, but the most complete recovery leaves the patient with his breathing power lessened, and with his vigour consequently more or less impaired.
When the deposit is less considerable, a different change takes place. The material dries by degrees, and is at last converted by a purely chemical change into a hard chalky substance, which in the course of time becomes of more than stony hardness.
Last of all; when the deposit is smallest in quantity, it may be completely got rid of; and a lung in which consumptive disease once existed, may eventually regain perfect soundness.
I have dwelt on these processes as they take place in the lungs; but, allowing for differences of locality, they resemble such as take place elsewhere.
Three important conclusions follow from what has been said.
First. It is only in quite the early stage of consumptive disease that absolutely perfect recovery can be hoped for. There is a euphemism, more amiable than honest, which doctors not seldom make use of, saying that a child's lungs are not diseased, but only tender. They mean by this, that on listening to the chest, they detect such changes in the sounds of breathing as their experience tells them are usually produced in the early stage of consumptive disease of the lungs. If the opinion is confirmed by a second competent medical man, then, and not later, is the time for precautions, for removing the child from school, and for selecting, as far as may be, a suitable winter climate. When the signs of disease are well marked, a reprieve, perhaps a long one, is all that can be confidently reckoned on.
Second. When softening of the consumptive deposit has taken place, of which certain sounds attending breathing are all but conclusive, recovery, even the most complete, always implies loss of a certain amount of lung-substance, and consequently loss of a certain amount of breathing power.
Third, and this is most important, as well as most cheering; consumption, which is at no age the absolutely hopeless disease that it was once supposed to be, admits of far more cheerful anticipations in children than in grown persons, or, for that matter, than in the youth or maiden.
The principal causes of consumptive disease are, hereditary predisposition, and improper feeding in infancy. There are besides two diseases incidental to childhood, and one of them almost peculiar to it, namely typhoid fever and measles, which are more apt than any others to develop a tendency to consumption. During convalescence from either of them, therefore, special care is needed.
In the grown person, consumption almost always attacks the lungs, and this often to the exclusion of other organs. In the child, however, this is not so, and though the lungs are indeed oftener affected than other parts, yet in nearly half of the cases some one or other of the digestive organs is likewise involved, and in about one in seven instances the lungs are free and the digestive organs alone are attacked.
Fever, cough, and wasting are the three sets of symptoms which in some degree or other are always present in consumptive disease of the lungs. The fever in the early stages of consumption is not in general severe; but so long as the evening temperature of a child never exceeds 99°, there is no cause for anxiety. On the other hand, if the evening temperature for a week or ten days together always amounts to 100°, there is grave presumption that consumptive disease is present. In advanced consumption the evening temperature is constantly 103° to 105°, while in the morning it may fall to 101° or 100°.
Cough is but rarely absent even in cases where the lungs are but slightly involved, for the irritation of the digestive organs often excites a sympathetic cough, and in these circumstances observation of the evening temperature will often furnish a clue to the right interpretation of the symptoms.
There is a form of cough which is oftenest observed in children between the ages of two and five years, which comes in fits closely resembling those of hooping-cough, and each fit ends in a sort of imperfect 'hoop.' This may depend on a particular form of consumption in which the glands connected with the lungs (the bronchial glands as they are called) are diseased, and not the lung-substance itself. The enlarged glands press on some of the nerves connected with the upper part of the windpipe, and thus occasion the spasmodic cough. Always suspect this when a cough persists for weeks together, not getting rapidly worse as hooping-cough would do, but at the same time not growing better, as would be the case with mild hooping-cough. The doctor on listening to the chest will solve your doubts; the thermometer will help you to decide whether his visit is necessary. I may add that this form of consumptive disease is less serious than that in which the lung-substance is involved.
Consumption sometimes follows bronchitis, especially when a child has been subject to frequent attacks of it. A very slow and imperfect recovery from an attack of bronchitis which had not been specially severe is always a reason for solicitude.
Now and then infants are born with consumptive disease. In that case the lungs are always affected; and the symptoms of fever, cough, and wasting usually show themselves within the first three or four months, and the infants almost invariably die within the year. Now and then, however, an infant thus affected may continue apparently in good health for a few months, and then be suddenly attacked by symptoms of acute inflammation or of severe bronchitis which prove rapidly fatal; and it may be found after death that the acute attack destroyed life because the lungs were already the seat of extensive consumptive disease.
No infant in whose mother's family a predisposition to consumption exists ought to be nursed by its mother, but by a healthy wet nurse; or, if that is impossible, it should be brought up on a milk diet, with but a small admixture of farinaceous food.
There is a form of very rapid, or so-called galloping consumption, which is seldom observed before the age of seven years; generally two or three years later. Its symptoms so closely resemble those of typhoid fever, that it may readily be mistaken for it. I refer to it in order to say that the doctor who mistakes the one for the other can scarcely be regarded as blameworthy; and the mistake is of the less importance since the treatment applicable to the one case would do no harm in the other.
I have already noticed the connection between water on the brain and consumption. It is indeed nothing else than inflammation excited by the presence of the deposit of consumptive matter in the brain or its membranes.
Little has been said hitherto about the wasting which was referred to as one of the characteristics of consumption. When the disease is limited, or nearly so, to the lungs, the wasting is not considerable until the mischief in the chest is far advanced. It must be remembered, however, in order to judge of this, that while in the full-grown man the best sign of health is the persistence for years together of the same weight, the case of the child is different. The child ought to grow in height, and increase in weight, and during these changes the plump infant grows thinner, not by real wasting but by conversion of its fat into bone and muscle. The child is thinner, but is taller and weighs heavier. The only real test therefore of the condition of the child is afforded by its increase in height and in weight. One need not be solicitous about the child who increases in height, and maintains his previous weight, nor about him who while he does not grow yet becomes heavier; but the child who neither gains in weight, nor in height, or who loses weight out of proportion to his increased height, is in a condition that warrants anxiety. I have long been accustomed, in the case of children whose parents were resident in India, to instruct those who have charge of them to send every three months a statement of the height and weight of the children, as the best evidence of their state of health.
Consumptive Disease of the Bowels.—Consumptive disease sometimes invades the whole system from the very first, while in other instances it attacks from the outset the organs of digestion, and continues throughout to affect them chiefly, and loss of flesh is then one of its earliest symptoms. In instances where there is a strong family predisposition to the disease, consumption of the bowels or mesenteric disease, or disease of the glands of the bowels, all three popular names for the affection, sometimes shows itself at the time of weaning. In the majority of cases, however, it comes on later, after the completion of teething, and between the age of three and ten years. Indigestion such as I have already spoken of sometimes precedes it, with the irregular condition of bowels, and the patchy state of the tongue. But this is by no means constant, scarcely I think general; and not infrequently momentary, causeless, colicky pains precede for a short time any other symptom. In a few weeks after their occurrence, sometimes indeed independently of them, the appetite fails, or becomes capricious; the bowels begin to act irregularly, being alternately constipated and relaxed; and the motions are unnatural in character, being, for the most part, dark, loose, and slimy. Sometimes indeed, they are solid, and then often white, as if from complete inactivity of the liver, and sometimes half-liquid, frothy, and like yeast. One peculiarity which they always present, be their other characters what they may, is their extreme abundance, quite out of proportion to the quantity of food taken, and due to their admixture with the unhealthy secretions from the bowels. The child next becomes restless and feverish at night, its thirst is considerable, and the colicky pains become both more severe and more frequent. Sometimes the stomach grows very irritable, and the food taken is occasionally vomited, while the tongue, in the early stages of the affection, continues for the most part clean and moist, and except that it is often unnaturally red deviates but little from its appearance in health. Next comes a change in the condition of the belly, the date of which varies considerably. It becomes larger than natural, owing to the filling of the bowels with wind, but at the same time it is tense and tender on pressure—two points of great importance to be noticed, and the glands in the groin, which in a healthy child cannot be felt, become enlarged, and are felt and perhaps even seen like tiny beans under the skin.
As in other forms of consumptive disease, so here the progress from bad to worse seldom goes on uninterruptedly. Pauses take place in its course, though each time they become shorter; and signs of amendment now and then appear, but they too promise less and less with each return. The child wastes rapidly; is always more or less feverish; the abdomen is constantly tender, but does not in general go on increasing in size; the pains become more frequent and more severe, and the bowels are almost always habitually relaxed. Life is sometimes cut short by the lungs becoming affected, but when this is not the case the patient may linger on for weeks, or months, or even for two or three years, until, worn to a skeleton, death at last takes place from exhaustion.
Much apprehension is often needlessly excited in the minds of parents, with reference to any child whose digestion is imperfect, who loses flesh, and has a large abdomen; and the words mesenteric disease, sometimes uttered thoughtlessly by the doctors, seem to them to seal their little one's doom. Now, first of all, it must be remembered that mesenteric disease, due to consumption, plays but a very small part in the production of the symptoms just described, but that the covering and the lining of the bowels are chiefly involved. Next, enlargement of the mesenteric glands and disorder of their functions take place from many causes other than consumption. They are always more or less enlarged in typhoid fever; they become enlarged when irritated by unwholesome food in infancy, or they may swell in the course of chronic indigestion. In all these cases too, the glands in the groin may be enlarged by sympathy, and this without the existence of any actual abiding disease. A big abdomen is, of itself, no evidence of it, nor even when associated with indigestion and frequent stomach-ache; but when to these you add abiding tenderness, and an evening temperature always at least one degree above that in the morning, there is every reason to fear that consumptive disease has attacked the organs of digestion.
Even then, however, there is no ground for despair; for, while consumptive disease in any form is less seldom recovered from in childhood than in after-life, such recovery oftener takes place in cases of affection of the digestive organs than when the disease is seated elsewhere.
Scrofula.—With this word of comfort I leave the subject of consumption, and pass to that of the allied disease scrofula. Briefly stated, two of the great differences between it and consumption are that scrofula is almost entirely limited to childhood and youth, while consumption may occur at any age; and next, that while scrofula attacks the bones and the glands, the skin and the membranes adjacent to it, consumption has its seat in the lungs, the brain, and the internal organs.
Scrofulous diseases of the bones come so exclusively under the observation of the surgeon, that I do not feel myself competent to say anything about them. I would however warn all parents to be very much alive to the importance of noticing the early symptoms of any such diseases, as shown by slight lameness, complaint of pain in the back, or difficulty in moving the hand or arm, or in turning the head or bending the neck. They may be but temporary accidents, due to cold, or to slight muscular rheumatism, or to some sprain not noticed at the time; but they may also be signs of the commencement of scrofulous disease of some bone; and in no disease whatever is early judicious treatment of greater value, or the result of neglect less remediable.
Besides these graver ailments which seldom appear until after the time of infancy has passed, there are others of a less serious nature which often show themselves within the first year of life. One of these consists in the formation beneath the skin of numerous small lumps of a rounded form, and of the size of a kidney-bean, slightly movable, and not tender. By degrees such lumps become adherent to the skin, the surface of which above them grows red, they project slightly above it, and at last open by a small circular aperture, discharge a little matter, and then subside. They collapse and disappear; a slight depression and a degree of lividity of the skin mark for a considerable time the situation they had occupied. I refer to them, because while they are a sign of a scrofulous constitution, which may require special care in diet and preparations of iron and cod-liver oil, they are best left absolutely alone—neither poulticed nor lanced. The same principle of non-intervention applies equally to the swellings which sometimes form on two or three of the fingers in infancy, not involving the joints but producing great thickening and a hard swelling around the bone. These swellings disappear by degrees as the constitutional vigour improves, and this is especially promoted by a long stay at the seaside; but they tend, if the health fails, to affect the bones themselves, and thus to occasion deformities of the hand.
Glandular swelling, discharges from the ear, offensive secretion from the nose, and in female children, even of very tender age, a discharge of whites, are all common signs of a scrofulous constitution, and all tedious and troublesome. They all, however, are very much under the influence of judicious medical treatment. It must at the same time be borne in mind that none of these ailments admit of what may be called active treatment. There are no royal means of dispersing scrofulous glands, or of curing discharges from the ear, or of doing away with the offensive smell which in some cases proceeds from the nostrils. Fresh air, suitable diet, preparations of iron, residence at the seaside, and sea-bathing, measures directed to improve the general health, are of chief value, and without them local treatment is of small avail.
A few words, however, may with propriety be added with reference to the local treatment of the minor ailments to which I have just referred.
No local application is of use in the scrofulous swellings of the fingers. Tincture of iodine, indeed, may be painted over them when quite small, while at the same time the joints are kept quiet by a small gutta-percha splint. When they become considerable, iodine is useless; and even if matter forms in the swelling it is much better to let it make its way out by a small opening spontaneously than to make a puncture with a lancet, since the edges of the wound would not heal, and the risk of the disease affecting the bone would be increased.
The glandular swellings of the neck or about the lower jaw are likewise best let alone, or merely covered with a layer of cotton wool, stitched inside a piece of oiled silk to maintain a uniform temperature. If they become suddenly painful and more swollen, a cooling lotion of Goulard water and spirits of wine, constantly applied, will reduce the swelling and lessen the discomfort. When stationary, a mild iodine ointment may be smeared over the gland at bedtime, and covered with oiled silk. Applications of iodine, however, need careful watching, for sometimes they over-irritate the gland, and cause an abscess. If the gland were out of sight there would be no objection to this, which would probably be a rapid mode of getting rid of the swelling; but the scar left behind, if the abscess burst or were opened, is an objection when the swelling is situated in the neck or at the jaw.
If the skin over the top of the swelling becomes red, and its substance begins to feel soft, then, but not till then, it is desirable to apply a warm poultice constantly. At the same time the progress must be daily watched by the doctor, in order that he may seize the proper moment to make a small puncture and let out the matter. The small cut leaves a less puckered scar than the natural opening. The subsequent management of the case must be superintended by the doctor.
Offensive discharge from the nostrils does not depend, in by far the majority of cases, on disease of the bones, but on an unhealthy condition of their lining membrane. It is exceedingly obstinate and difficult of cure, is four times more frequent in girls than in boys, and unfortunately often lasts into womanhood, and continues even when the general health is perfect.
Much may be done to abate the annoyance by diligent sniffing up the nostrils some weak disinfectant; or by regularly irrigating the nostrils by means of a simple apparatus, to be obtained from any instrument-maker. In spite of this, however, it is often necessary to introduce a little plug of cotton wool dipped in the fluid some distance up the nostrils, with a thread attached by which it can be withdrawn, and a fresh one substituted twice a day.
The discharge of whites is sometimes very troublesome, and apt to return from the commencement of teething up even to womanhood. It is a mere sign of debility, usually also connected with a scrofulous habit, but has no further or graver meaning. Locally, constant cold ablution by means of a sponge held above the child, not touching it, is the great remedy, and this may have to be repeated every hour or two if the case is severe. Astringent lotions of different kinds may be used in the same manner; while care must be taken that the child's drawers are large and loose, so as not to irritate her when sitting. General treatment, however, sea air and sea bathing are especially in these cases the great remedy.
It must not be forgotten that all these ailments have a special tendency to recur; and that when people say 'Dr. A. or Dr. B. did the child good for the time, but this or that symptom returned as soon as the treatment was discontinued,' as though this were the doctor's fault, they are unjust; for the tendency to return of every form of scrofulous disease is one of the great characteristics of the malady. Patience and perseverance on the parents' part, even for months and years, are often as much needed as skill on the part of the doctor.
One more remark may not be out of place. Some persons have an impression that there is something specially shameful in scrofulous disease, and while they will readily admit the existence of a consumptive tendency in their family, they almost resent the suggestion that their child's ailment is scrofulous. For this prejudice there is absolutely no foundation. There is no more reason for connecting scrofula in a child with any antecedent wrong-doing on the part of its progenitors, than there is for attaching that idea to the red hair or black eyes which a child may have in common with the rest of its family.
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