The Mother's Manual of Children's Diseases

Opiates and other soothing medicines should never be given except when prescribed by the doctor. Thirty-two deaths in England under five years of age in 1882 represent but a very small part of the evil wrought by the overdose or injudicious use of these remedies. Above all, soothing medicines of varying strength, as syrup of poppies, or of unknown composition, as Dalby's Carminative or Winslow's Soothing Syrup, should never be employed. The only safe preparation, and this to be given only by the doctor's orders or with his approval, is the compound tincture of camphor, or paregoric elixir, as it is called, of which sixty measured drops contain a quarter of a grain of opium. Ten to fifteen measured drops of this are a sufficient dose for a child one year old, and this ought not to be repeated within twelve hours. The repetition every few hours of small doses of opiates is quite as hazardous as the giving of a single overdose; and if it does not work serious mischief by stupefying the child, it renders it impossible to judge of its real condition.

Thus much may suffice with reference to the more important remedies. Others will necessarily call for notice when the diseases come to be considered in which they may be of service.

There are two points which still remain to be noticed before I leave the introductory part of this little book.

The first of these concerns the importance of keeping written notes in the course of every case of serious illness. For want of doing this the most imperfect and conflicting accounts of what has happened are given to the doctor. No person can watch to any good purpose for four-and-twenty hours together; and no one's memory, least of all in the midst of fatigue and anxiety, can correctly retain all details concerning medicine, food, and sleep, which yet it may be of paramount importance that the doctor should be made acquainted with. I am accustomed to desire a record to be kept on a sheet of paper divided into six columns, one for food, a second for medicine, a third for sleep, a fourth for the evacuations, and a fifth for any special point which the nature of the illness renders it of special moment to observe, while the date is entered on the first column of all, indicating when food or medicine was given, or when and for how long the child slept. It is best to enter the variations of temperature on a separate paper, in order that the doctor may at a glance perceive the daily changes in this important respect. No one who has not made the experiment can tell the relief which the keeping this simple record gives to the anxiety of nursing the sick, especially when the sick one is loved most tenderly.

The other point concerns the relations of the mother or of the parents to the doctor. I have often heard it said, 'Dr. Green always attends my husband and myself, but we have Dr. White for the servants and children,' implying a lower degree of medical knowledge as required in their case, and to be acknowledged by a lower rate of remuneration.

Need I say that the assumption is a mistaken one—that as much knowledge, as large experience, are needed in the one case as in the other; while over and above, to treat children successfully, a special tact and a special fondness for children are needed? A man may be a very good doctor without those special gifts; but their possession, apart from real medical knowledge, may make a good children's nurse, but never a good children's doctor.

Another matter not to be forgotten is the confidence to be reposed in the doctor—the readiness to acquiesce in his sometimes visiting the child more frequently in the course of an illness than the symptoms may seem to you to require. Were you involved in some civil action, in which your succession to large property was involved, you would scarcely expect your solicitor to give you his opinion on all the questions at a single interview. In the same way, the doctor, even the most experienced, may need to visit his little patient several times before he can feel quite certain as to the nature of the disease that is impending, while he may not wish to alarm you by suggesting all the possibilities that are present to his mind. The child after a restless night may be asleep, and it may be most undesirable to wake him; or he may be excessively cross and unmanageable, so that it is impossible to listen to his chest; or it may be very important to ascertain whether the high temperature present in the morning has risen still higher towards night, or whether, after free action of the bowels, it has fallen a degree or two, showing that no fever is impending, but that the undue heat of the body was occasioned by the constipation. Or, again, some remedy may have been ordered, of the effect of which the doctor does not feel quite sure: he wishes to see for himself whether it is right to continue or wiser to suspend it. The wise physician, like the able general, leaves as little as may be to chance.

Nearly forty years ago, in addressing a class of medical students, I said to them:

'If you are carefully to observe all the points which I have mentioned, and to make yourselves thoroughly masters of a case, you must be lavish of your time; you must be content to turn aside from the direct course of investigation, which you would pursue uninterruptedly in the adult, in order to soothe the waywardness of the child, to quiet its fears, or even to cheat it into good humour by joining in its play; and you must be ready to do this, not the first time only, but every time that you visit the child, and must try to win its affections in order to cure its disease. If you fail in the former, you will often be foiled in your attempts at the latter. Nor is this all; you must visit your patient very often if the disease is serious in its nature and rapid in its course. New symptoms succeed each other in infancy and childhood with great rapidity; complications occur that call for some change in your treatment, or the vital powers falter suddenly when you least expect it. The issues of life and death often hang on the immediate adoption of a certain plan of treatment, or on its timely discontinuance. Do not wait, therefore, for symptoms of great urgency before you visit a child three or four times a day; but if the disease is one in which changes are likely to take place rapidly, be frequent in your visits as well as watchful in your observation.'

Each year has added to my conviction of the perfect truth of each word which I have quoted. If you believe your doctor to be a man of integrity and intelligence, be thankful for his frequent visits, which will cease as his anxiety abates. Be convinced that in the mean time they are made, not for his sake, but for yours. If you doubt his integrity, change your doctor; but do not say to him in a tone and with an emphasis which there is no mistaking, 'Well, if you think it really necessary to come'!

PART II

All that has been said hitherto is only introductory to the great purpose of this book, which is to give an account of the nature, symptoms, and course of the more important diseases of infancy and childhood.

Any attempt at scientific arrangement of a popular book is useless. I prefer, therefore, to consult simply the general convenience of my readers. I think I do so best by considering first the disorders which beset the child in the first month of its existence, during what may be termed its transition from the condition of existence in the womb, to its living, breathing state as an inhabitant of this world; and next the more important ailments to which it is liable during that important time of development which ends with the completion of teething. Afterwards may be studied the diseases of the head, the chest, and the bowels; next constitutional diseases, such as consumption and scrofula; and lastly, the various fevers, as typhoid, or, as it is popularly called, remittent fever, measles, scarlatina, and small-pox; and last of all I will add a few remarks on the mental and moral characteristics of childhood, and their disorders.

CHAPTER IV.
ON THE DISORDERS AND DISEASES OF CHILDREN DURING THE FIRST MONTH AFTER BIRTH

Still-birth.—The infant cries almost as soon as it comes into the world. The cry is the evidence that air has entered its lungs, that the blood has now begun to take a different course from that which it followed before birth, and that the child has entered on a new existence. The child who does not cry, does not breathe; it is said to be still-born; its quietude means death.

After a long or a difficult labour, or after the use of instruments, the child is sometimes still-born in consequence of blood being poured out on its brain, and it is thus killed before birth by apoplexy. This, however, is not usually the case, but the child is generally still-born because some cause or other, generally the protraction of labour, interfered with the due changes of its blood within the womb, and it is born suffocated before its birth, and consequently unable to make the necessary efforts to breathe afterwards.

Drowned people are often resuscitated; the child's case is analogous to theirs; and in both the same measures have to be pursued, namely to try to establish respiration. The degree of the warmth of the child's body, the resistance of its muscles, the red tint or the white colour of its surface, the presence or absence of perceptible beating of its heart, measure the chances of success. Sometimes mere exposure to the cold air produces the necessary effect; at other times breathing is excited by dashing cold water in the child's face, by slapping it, by tickling its nostrils, or by dipping it for a few seconds in a hot bath at 100° or 102°; and then swinging it a few times backwards and forwards in the air.

Much time, however, must not be lost over these proceedings, but the child must be laid on its back, the lower part of its body well wrapped up, the chest slightly raised by a folded napkin placed under it. The two arms must then be taken firmly, raised and slowly extended on either side of the head, then brought down again and gently pressed on either side of the chest; and this movement of alternate raising and extending the arms and bringing them back again beside the chest must be repeated regularly some thirty times in the minute, thus imitating the movements of the chest in breathing. These efforts, too, must not be discontinued so long as the surface retains its warmth, and as an occasional heart-beat shows that life is not absolutely extinct; and I believe that in many instances failure is due to want of perseverance rather than to the absolute uselessness of the measure.

Premature Birth.—In spite of very extraordinary exceptions, it may be laid down as a rule that children born before the completion of six and a half months of pregnancy do not survive. After that date, each additional week adds greatly to the chances of the child living. There is a mistaken idea, founded on a superstition connected with the number seven, that a seven-months child is more likely to survive than one born at the eighth month. But this notion is as destitute of support in fact as it is opposed to common sense, and the nearer any woman has approached the full term of forty weeks of pregnancy, the greater are the chances of her child being born alive and healthy.

The premature child is by no means necessarily still-born. It breathes, but does so imperfectly, so that air does not enter all the smaller air-cells; and its voice is a whimper rather than a cry. Those changes in the heart and large vessels, which prepare, as pregnancy draws to a close, for the altered course of the blood when the child has to breathe through the lungs, are too little advanced for it to bear well the sudden alteration in its mode of being. The feebly beating heart and the not completely developed lungs seem but imperfectly to maintain the bodily heat. The glands of the stomach and intestines are not yet fit to perform digestion properly, while the muscular power is too feeble for the effort at sucking. Everything is sketched out, but to nothing has the finishing touch been put, and hence the frail machinery too often breaks down, in the endeavour to discharge its functions.

It is surprising, however, with what rapidity Nature in some instances perfects the work which she has been called on prematurely to perform.

It is our business to second Nature's endeavours. First of all, and of most importance, is the duty of providing from without the warmth which the child is unable to generate. When very feeble, it must, even without any previous washing or dressing, be at once wrapped in cotton wool, and then in a hot blanket, and surrounded with hot-water bottles. A tin stomach-warmer filled with hot water is very convenient to place under the blanket on which the child lies. Being too feeble to suck, it must be fed, a few drops at a time, from a small spoon; or still better, if it is able to make any effort at sucking, it may draw its nourishment through a quill. The mother after a premature confinement is almost sure to have no milk with which to nourish her child, at any rate for two or three days. It is, therefore, wise to obtain the help of a woman with a healthy baby. She must be allowed to bring her baby with her, since otherwise her supply of milk would fail, especially if she had no other means of getting rid of it than by the breast-pump or by drawing her breast. Even though she may have her own baby, there are few women who can submit, for more than a very few days, to the artificial emptying their breast without the secretion being either greatly lessened or altogether arrested. This, therefore, must be regarded as a resource available only for a few days, and as the child gains strength every effort must be made to get it to take its mother's breast, if she has any supply, or that of the wet-nurse. If this is found impossible, it will be wisest to give up, at any rate for the present, the attempt to nourish the child from the breast, and to obtain for it asses' milk, which is the best substitute. By no means whatever can more than from a sixth to a fourth part of a pint of milk be obtained either by the breast-pump or by drawing the breast; and since a healthy infant of a few weeks old sucks about two pints of milk in twenty-four hours, it is evident that the supply artificially obtained must after the first few days be utterly inadequate.

I have in cases of extreme weakness in premature children succeeded in preserving them by giving them every two hours for two or three days ten measured drops of raw beef juice, five of brandy, and two teaspoonfuls of breast milk. Medicine has no place in the management of these cases; the question is one entirely of warmth, food, and for a time the judicious use of stimulants.

Imperfect Expansion of the Lungs.—Children not premature and perfectly well nourished are yet sometimes feeble, breathe imperfectly, cry weakly, suck difficultly or not at all, and die at the end of a few days. Their lamp of life flickered and went out. Such cases are met with for the most part in conditions similar to those in which children are actually still-born; or now and then they take place when labour has been of unusually short duration, the child hurried into the world too rapidly; while in other instances it is not possible to account for their occurrence.

For a long time the nature of these cases was not understood; but rather more than sixty years ago a German physician discovered that air had entered the lungs but imperfectly; that perhaps a third, perhaps even as much as half, of the lungs had never been dilated, but had remained solid and useless; that in consequence the blood was but half-purified, and vitality therefore but half-sustained. The lungs, however, were found to have undergone no real change; they were not diseased, but if air was blown into them the dark solid patches sunk below the level of the surrounding substance, expanded, grew bright in colour and like a sponge from which the water has been squeezed, and crackled, or crepitated as the technical term is, from the air contained within them.

We breathe in health so without conscious effort that we never realise the fact that, according to the calculation of most competent observers, the mere elasticity of the lungs, independent even of the elasticity of the chest walls, opposes a resistance to each inspiration equal to 150 pounds avoirdupois in the grown man and 120 in the grown woman. The want of breath puts the respiratory muscles into play: the man takes a deep inspiration, and by this unconscious effort, he overcomes the resistance of the chest and the elasticity of the lungs. The new-born infant feels the same want and makes the same effort; but its muscular power is small, and its inspirations are often so feeble as to draw the air in some parts only into the larger tubes, while many of the smaller remain undilated, and much of the lung continues in the state in which it was before birth. The blood being thus but imperfectly purified, all the processes of nutrition go on imperfectly, the vital powers languish, the inspiratory efforts become more and more feeble, while the elasticity of the lung is constantly tending to empty the small cells of air and to oppose its entrance, and next the temperature sinks and the infant dies.

Cases in which this condition of the lungs exists usually present the history of the child from the very first having failed to utter a strong and loud cry like that of other children. Even after breathing has gone on for some time, such children usually appear feeble, and they suck with difficulty, although they often make the effort. An infant thus affected sleeps even more than new-born infants usually do; its voice is very feeble, and rather a whimper than a cry. In the cry of the healthy infant you at once detect two parts—the loud cry, suffering or passionate as the case may be, and the less loud back draught of inspiration. The French have two words for these two sounds—the cri and the reprise. The cri is feeble, the reprise is altogether wanting wherever expansion of the lung has to any considerable extent failed to take place, and you would hail this second sound as the best proof of an improvement in the child's condition.

If you watch the child with a little attention you will see that while the chest moves up and down, it is very little, if at all, dilated by the respiratory movements. The temperature falls, the skin becomes pale, and the lips grow livid, and often slight twitching is observed about the muscles of the face. The difficulty in sucking increases, the cry grows weaker and more whimpering, or even altogether inaudible, while breathing is attended with a slight rattle or a feeble cough, and the convulsive movements return more frequently, and are no longer confined to the face, but affect also the muscles of the extremities. Any sudden movement suffices to bring on these convulsive seizures, but even while perfectly still the child's condition is not uniform, but it will suddenly become convulsed, and during this seizure the respiration will be extremely difficult, and death will seem momentarily impending. In a few minutes, however, all this disturbance ceases, and the extreme weakness of the child, its inability to suck, its feeble cry, and its frequent and imperfect inspirations, are the only abiding indications of the serious disorder from which it suffers. But the other symptoms return again and again, until after the lapse of a few days or a few weeks the infant dies.

I have dwelt at some length on this condition because it is important to know that during the first few weeks of life real inflammation of the lungs or air-tubes is of extremely rare occurrence, and that the symptoms which are not infrequently supposed to depend on it are really due to a portion of the lung more or less extensive never having been called into proper activity. I may add that we shall hereafter have to notice a similar condition of the lung—its collapse after having once been inflated—as occurring sometimes in the course of real inflammation of the organs of respiration in early life, and forming a very serious complication of the original disease.

If the collapse of the lung is not so considerable as to destroy life within the first few hours or days after birth, the babe wastes as well as grows weaker and weaker, and this wasting coupled with the difficult breathing not seldom causes the fear that the child has been born consumptive and that its death is inevitable.

No such gloomy view need be taken. Collapse, or at least non-expansion of the lung to some extent, is by no means unusual: consumptive disease to such an extent in the new-born infant as to interfere with the establishment of breathing is extremely rare. The consumptive babe can suck, it is not so weak as the one whose lungs are imperfectly expanded; it has no convulsive twitchings, nor any of the strange head-symptoms which we notice in the former. It wastes less rapidly, it is feverish instead of having a lower temperature than natural, it seems less ill, and yet its death within a few weeks or months is absolutely certain; while the child whose lungs are not diseased but simply unexpanded may, if that accidental condition is removed, grow up to vigorous manhood.

The treatment of these cases is abundantly simple. The child who breathes imperfectly but ill maintains its heat. It must be kept warm at a temperature never less than 70°; it may, like the premature child, need stimulants, and all the precautions already mentioned as to feeding. Twice in the day it should be put for five minutes in a hot bath at 100°, rendered even more stimulating by the addition of a little mustard. The back and chest may be rubbed from time to time with a stimulating liniment, and an emetic of ipecacuanha wine may be given twice a day. The act of vomiting not only removes any of the mucus which is apt to accumulate in the larger air tubes, but the powerful inspirations which follow the effort tend to introduce air into the smallest vesicles of the lungs, and to do away with their collapse.

Let these directions be carried out sensibly, patiently, perseveringly, and three times out of four, or oftener still, the mother's ear will before many days be greeted by the loud cry, with its cri and reprise of which I have already spoken, and which assures her that her little one will live.

There are no other affections of the lungs so peculiar to the first month of life as to call for notice here. I shall have a few observations to make about malformations of the heart, and the precautions for which they call in the after-life of children; but they will find their fittest place in the chapter on Affections of the Chest.

Jaundice of New-born Children.—A certain yellow tinge of the skin, unattended by any other sign of jaundice, such as the yellowness of the eye and the dark colour of the urine, is by no means to be confounded with real jaundice. It is no real jaundice, but is merely the result of the changes which the blood with which the small vessels of the skin are overcharged at birth is undergoing; the redness fading as bruises fade, through shades of yellow into the genuine flesh colour.

This is no disease, to be treated with the grey powder and the castor oil wherewith the over-busy monthly nurse is always ready. It is a natural process, which the intelligent may watch with interest, with which none but the ignorant will try to interfere.

There is, however, beside this a real jaundice, in which the skin is more deeply stained, the whites of the eyes are yellow, the urine high-coloured, and in which the dark evacuations that carry away the contents of the bowels before birth are succeeded by white motions, from which the bile is absent. This condition is not very usual, save where children have been exposed to cold, or where the air they breathe is unwholesome. Of this no better proof can be given than is afforded by the fact that in the Dublin Lying-in Hospital, where the children are defended with the greatest care both from cold and from a vitiated atmosphere, infantile jaundice is extremely rare, while it attacks three-fourths of the children received into the Foundling Hospital of Paris. Still it does sometimes occur when yet no cause can be assigned for it, and it is noteworthy that it is sometimes met with in successive infants in the same family.

As the respiratory function and that of the skin increase in activity, the jaundice will disappear of its own accord. Great attention must be paid during its continuance to avoid exposure of the child to cold, while no other food than the mother's milk should be given. If the bowels are at all constipated, half a grain of grey powder or a quarter of a grain of calomel may be given, followed by a small dose of castor oil, and the aperient will often seem to hasten the disappearance of the jaundice; but in a large number of cases even this amount of medical interference is not needed.

There is, indeed, a very grave form of jaundice, happily of excessive rarity, due to malformation of the liver, to absence or obstruction of the bile-ducts, and often accompanied with bleeding from the navel. I do but mention it; the intensity and daily deepening of the jaundice, the fruitlessness of all treatment, and the grave illness of the child, even though no bleeding should occur, render it impossible to confound this hopeless condition with the trivial ailment of which I have been speaking.

The next chapter will furnish a fitter place than the present for speaking fully of the Disorders of the Digestive Organs.

I will say now but this: that whatever a mother may do eventually, she avoids grave perils for herself by suckling her infant for the first month; while the health of her child, just launched upon the world, is terribly endangered if fed upon those substitutes for its proper nutriment on which after the lapse of a few weeks it may subsist, may even manage to thrive.

There are some local affections incident to the new-born child concerning which a few words may not be out of place; and first of the

Ophthalmia of New-born Children.—It is the cause of the loss of sight of nine-tenths of all persons who, among the poor, are said to have been born blind. In the wealthier classes of society it is comparatively rare, and seldom fails to meet with timely treatment, yet many people scarcely realise its dangerous character, or the extreme rapidity of its course.

It generally begins about the third day after birth with swelling of the lid of one or other eye, though both are soon involved. The eyelids swell rapidly, and if the affection is let alone, they soon put on the appearance of two semi-transparent cushions over the eyes. On separating the lids, which it is often very difficult to do owing to the spasmodic contraction of the muscles, their inner surface is seen to be enormously swollen, bright red, like scarlet velvet, bathed in an abundant yellowish thin secretion, which often squirts out in a jet as the lids are forcibly separated. Great care must be taken not to allow any of this fluid to enter the eye of a bystander, nor to touch his own eye until the fingers have been most carefully washed, since the discharge is highly contagious, and may produce most dangerous inflammation of the eyes of any grown person. The discharge being wiped or washed away, the eye itself may be seen at the bottom of the swelling very red, and its small vessels very blood-shot. By degrees the surface of the eye assumes a deeper red, it loses its brightness and its polish, while the swelling of the lids lessens, and they can be opened with less difficulty; their inner surface at the same time becomes softer, but thick and granular, and next the eyes themselves put on likewise a granular condition which obscures vision. The discharge by this time has become thicker and white, and looks like matter from an abscess. By slow degrees the inflammation may subside, the discharge lessen, the swelling diminish, and the eye in the course of weeks may regain its natural condition. But the danger is—and when proper treatment is not adopted early the danger is very great—lest the mischief should extend beyond the surface of the eye, lest ulceration of the eye should take place, the ulceration reach so deep as to perforate it, and not merely interfere with the sight, but destroy the organ of vision altogether.

In every instance, then, in which the eyelids of a new-born infant swell, or the slightest discharge appears from them, the attention of the doctor must at once be called to the condition. In the meantime, and during whatever treatment he may think it right to follow, the eye must be constantly covered with a piece of folded lint dipped in cold water; and every hour at least the eye must be opened and tepid water squeezed into it abundantly from a sponge held above, but not touching it, so as to completely wash away all the discharge. A weak solution of alum and zinc, as one grain of the latter to three of the former to an ounce of water, may in like manner be dropped from a large camel's-hair brush four times a day into the eye after careful washing. Simple as these measures are they yet suffice, if adopted at the very beginning, and carried on perseveringly, to entirely cure in a few days an ailment which if let alone leads almost always to most lamentable results.

I do not pursue the subject further, for bad cases require all the care of the most skilful oculist for their treatment.

Scalp Swellings.—Almost every new-born child has on one or other side of its head a puffy swelling, owing to the pressure to which the head has been subjected in birth, and this swelling disappears at the end of twenty-four or forty-eight hours.

Now and then, however, though indeed very seldom, the swelling does not disappear, but it goes on gradually increasing and becoming more definite in its outlines until at the end of three or four days it may be as big as half a small orange, or sometimes even larger, soft, elastic, painless, under the unchanged scalp, but presenting the peculiarity of having a hard raised margin with a distinct edge, which gives to the finger passed over it the sensation of a bony ridge, beyond which the bone seems deficient. This tumour is due usually to the same cause as that which produces the other temporary puffy swelling of the scalp, only the pressure having been more severe, blood has actually been forced out from the small vessels under the membrane which covers the skull, and hence its gradual increase, its definite outline; and hence, too, the bony ridge which surrounds it, and which is due to nature's effort at cure, in the course of which the raised edge of the membrane covering the skull (the pericranium) becomes converted into bone.