complexion, in the early part of the year 1838, being then two years of
age, had an enlargement of the left knee joint. For some weeks previous
to this time, there had been a degree of heat about the part; but as no
pain apparently existed, it was not regarded as of any consequence, and
nothing was done. The child, living in the neighbourhood of London, was
afterwards placed under medical treatment. Two or three months having
elapsed, it was brought to town, and shown to me, in consequence of a
slight tumefaction over the lower part of the spine. This soon
disappeared under the measures employed, and eventually the disease of
the knee (evidently scrofulous) was arrested, so that now the case
promises to be cured; but the joint will for ever be stiff, and the
limb thus affected shorter than the other.
Case II.
G. B., the brother of the above, a handsome boy, with light hair, fine
blue eyes,--indeed, very much like his little sister,--in the year
1836, had enlargements of the glands in his neck, which were relieved
by the treatment resorted to.
In April, 1839, being then eight years old, he was observed by his
mother to limp slightly in walking, but complained of little or no
pain. From the caution, however, which had been given to the parent at
the time I was consulted about the previous case, to notice at an early
period any symptom of this nature in her children, the fact was
immediately attended to. The affection was evidently in the hip; there
was imperfection in the gait, and pain upon pressing over the joint. A
blister was applied, perfect rest to the limb enjoined, and steel
medicines ordered; and in a fortnight the motions of the joint were
restrained more effectually by the application of strips of soap
plaster and a bandage. In three months the child was ordered to the sea-
side, and eventually was able to walk without the slightest limp or
pain, and may be said to be quite well.
I would not say that in the first case, if the disease had been
discovered early, and at that time met by judicious medical treatment,
a stiff knee and shortened limb would have been prevented, although
this is my belief; but in reference to the latter case, I have no
hesitation in saying, that without the disease had been early detected
by the mother, and as promptly attended to by her, the remedial
measures might have failed,--certainly the result would not have been
so highly satisfactory as it was.
Chap. V.
ON WHAT CONSTITUTES THE MATERNAL MANAGEMENT OF THE DISEASES OF CHILDREN.
The especial province of the mother is the prevention of disease, not
its cure. To the establishment and carrying out of this principle,
every word contained in the preceding pages has directly or indirectly
tended.
This, however, is not all. When disease attacks the child, the mother
has then a part to perform, which it is especially important during the
epochs of infancy and childhood should be done well. I refer to those
duties which constitute the maternal part of the management of disease.
Medical treatment, for its successful issue, is greatly dependent upon
a careful, pains-taking, and judicious maternal superintendence. No
medical treatment can avail at any time, if directions be only
partially carried out, or be negligently attended to; and will most
assuredly fail altogether, if counteracted by the erroneous prejudices
of ignorant attendants. But to the affections of infancy and childhood,
this remark applies with great force; since, at this period, disease is
generally so sudden in its assaults, and rapid in its progress, that
unless the measures prescribed are rigidly and promptly administered,
their exhibition is soon rendered altogether fruitless.
The amount of suffering, too, may be greatly lessened by the
thoughtful and discerning attentions of the mother. The wants and
necessities of the young child must be anticipated; the fretfulness
produced by disease, soothed by kind and affectionate persuasion; and
the possibility of the sick and sensitive child being exposed to harsh
and ungentle conduct, carefully provided against.
Again, not only is a firm and strict compliance with medical
directions in the administration of remedies, of regimen, and general
measures, necessary, but an unbiased, faithful, and full report of
symptoms to the physician, when he visits his little patient, is of
the first importance. An ignorant servant or nurse, unless great
caution be exercised by the medical attendant, may, by an unintentional
but erroneous report of symptoms, produce a very wrong impression upon
his mind, as to the actual state of the disease. His judgment may, as a
consequence, be biased in a wrong direction, and the result prove
seriously injurious to the welldoing of the patient. The medical man
cannot sit hour after hour watching symptoms; hence the great
importance of their being faithfully reported. This can alone be done
by the mother, or some person equally competent.
There are other weighty considerations which might be adduced here,
proving how much depends upon efficient maternal management in the time
of sickness; but they will be severally dwelt upon, when the diseases
with which they are more particularly connected are spoken of.
Sect. 1.--ACCIDENTS AND DISEASES WHICH MAY OCCUR TO THE INFANT AT
BIRTH, OR SOON AFTER.
STILL-BORN.
Sometimes the child comes into the world apparently dead, and, unless
the most active exertions are made by the attendants, is lost. The
superintendence of the means used devolves upon the medical man; but it
would be often well if his assistants were already acquainted with the
measures pursued under these circumstances, for they would be more
likely to be carried into effect with promptitude and success, than
they now frequently are. And again, the still-born child is frequently
in this state from having been born very rapidly, and before the
medical man can have arrived, it will be more especially useful in
such a case, that the attendants in the lying-in-room should know how
to proceed.
The various causes producing this condition it is unnecessary to
mention.
The condition itself may exist in a greater or less degree: the infant
may be completely stillborn, with no indication of life, except,
perhaps, the pulsation of the cord, or a feeble action of the heart;--or
it may make ineffectual efforts at breathing, or even cry faintly, and
yet subsequently perish for want of strength to establish perfectly the
process of respiration. Under all these circumstances, a good deal can
often be effected by art. In every instance, therefore, in which we
have not positive evidence of the child being dead, in the existence of
putrefaction, or of such malformation as is incompatible with life, it
is our duty to give a fair trial to the means for restoring suspended
animation; and as long as the slightest attempt at motion of the
respiratory organs is evinced, or the least pulsation of the heart
continues, we have good grounds for persevering and hoping for ultimate
success.
The measures to be employed to restore a still-born child will be a
little modified by the circumstances present.
IF THERE IS NO PULSATION--NO BEATING IN THE CORD, when the child comes
into the world, it may at once be separated from the mother. This is
to be effected by first tying the navel-string with common sewing
thread (three or four times doubled), about two inches from the body of
the child, and again two inches from the former ligature, and then
dividing the cord with a pair of scissors between the two. And now the
means for its restoration are to be made use of, which are detailed
below, viz. inflation of the lungs, and perhaps the warm bath. If, with
the above circumstances, the child's face be livid and swollen, some
drops of blood should previously be allowed to escape before the
ligature is applied to that part of the navel-string which is now only
attached to the child.
IF THERE IS PULSATION IN THE CORD, BUT RESPIRATION IS NOT FULLY
ESTABLISHED, it must not be divided; and as long as pulsation
continues, and the child does not breathe perfectly and regularly, no
ligature should be applied. The first thing to be done here, is to pass
the finger, covered with the fold of a handkerchief or soft napkin, to
the back of the child's mouth, to remove any mucus which might obstruct
the passage of air into the lungs, and at the same time to tickle
those parts, and thereby excite respiratory movements. The chest
should then be rubbed by the hand, and a gentle shock given to the body
by slapping the back. If these means fail, the chest and soles of the
feet must next be rubbed with spirits, the nostrils and back of the
throat irritated with a feather previously dipped in spirits of wine,
and ammonia or hartshorn may be held to the nose.
INFLATION OF THE LUNGS.--These means not having been successful, and
the pulsation in the cord having ceased, the infant must be separated,
and inflation of the lungs resorted to. This is to be effected gently
and cautiously as follows:--
The child, wrapped in flannel, is to be laid on its back upon a table
placed near the fire. Its head is to be slightly extended, and the
nostrils held between the fingers and thumb of one hand, whilst with
the fingers of the other slight pressure is to be made upon the pit of
the stomach, so as to prevent the air from passing into that organ. The
lungs of the child are now to be filled with air, by the operator
applying his own lips--with a fold of silk or muslin intervening, for
the sake of cleanliness--to those of the child, and then simply blowing
in its mouth, he is to propel the air from his own chest into that of
the infant. Previously, however, to his doing this, he should make
several deep and rapid inspirations, and, finally, a full inspiration,
in order to obtain greater purity of air in his own lungs.
When the chest of the child has been thus distended, it is to be
compressed gently with the hand, so as to empty the lungs; and then the
inflation, with the alternately compressing the chest, must be repeated
again and again, until either the commencement of natural respiration
is announced by a sneeze or deep sigh, or until after long-continued,
steady, persevering, but unavailing, efforts to effect this object
shall have removed all ground of hope for a successful issue.
Whilst these efforts are being made, some other individual must
endeavour to maintain or restore the warmth of the infant's body, by
gently but constantly pressing and rubbing its limbs between his warm
hands. And after respiration is established, the face must still be
freely exposed to the air, whilst the warmth of the limbs and body is
carefully sustained.
It will sometimes happen--and to this circumstance the operator should
be fully alive--that when the child begins to manifest symptoms of
returning animation, its tongue will be drawn backwards and upwards
against the roof of the mouth, filling up the passage to the throat,
and preventing further inflation of the lungs. This is to be remedied
by the introduction of the fore-finger to the upper and back part of
the child's tongue, and gently pressing it downwards and forwards, by
which the difficulty will be removed, and the air again passes.
THE WARM BATH.--More reliance may be placed upon the above measure to
restore animation, than upon the warm bath. Still this is sometimes
useful, and therefore must not be neglected. Whilst inflation is going
on, the bath may be got ready, then resorted to, and if unsuccessful,
inflation may and ought again to be followed up.[FN#28] If the bath is
useful at all, it will be so immediately upon putting the infant into
it; respiration will be excited, followed by a cry; and if this does
not occur at once, it would be wrong to keep the child longer in the
bath, as it would be only losing valuable time which ought to be
devoted to other efforts. The temperature of the bath should be about
100 degrees; and if, upon plunging the infant into it, it fortunately
excite the respiratory effort, it should then be taken out, rubbed with
dry but hot flannels, and, when breathing is fully established, laid in
a warm bed, or, what is still better, in its mother's bosom; letting
it, however, have plenty of air.
[FN#28] We should not relinquish our endeavours at resuscitation
under two or three hours, or even longer; and if ultimately
successful, the state of the infant should be carefully watched for two
or three days.
INJURIES RECEIVED DURING BIRTH.
If a labour be long and tedious, the head and body of the child may be
bruised and disfigured.
The shape of the head is frequently altered by the compression it has
undergone, so that it may be elongated, and measure from the chin to
the back of the head as much as six or seven inches. This always
excites surprise, sometimes apprehension, in the minds of the
attendants: there is no ground for it. It must be allowed to regain its
natural shape without interference.
Tumours or swellings upon the head are very common. They arise from
pressure upon the part during the labour. The only treatment that is
required, or safe, is, freedom from all pressure, and the application
of cold lotions composed of brandy or vinegar and water. The swelling
will gradually subside. It will be right to direct the attention of the
medical man to this circumstance.
The face may be frightfully disfigured from the above cause,
exceedingly black, and the features distorted. Nothing is necessary
here; in a few days the face will recover its proper appearance.
RETENTION OF URINE.
Occasionally an infant will not pass any urine for many hours after
its birth. This most frequently arises from the fact of none being
secreted. In the last case of this kind that I was called to, three
days had elapsed since birth, and no urine had been passed; it proved
that none had been secreted. Sometimes, however, it is the effect of
another cause, which the use of the warm bath will be found to remove,
which should always therefore be employed four and twenty hours after
the birth of the infant, if it has not by that time passed any water.
It now and then happens, but fortunately very rarely, that some
physical obstruction exists. It is always important, therefore, for the
nurse to pay attention to the above point; and it is her duty to direct
the attention of the medical man to the subject, if anything unusual or
unnatural be present. The same observation applies to the bowel also;
and if twelve hours pass without any motion, the parts should be
examined.
SWELLING OF THE BREASTS.
At birth, or two or three days subsequently, the breasts of the infant
will frequently be found swollen, hard, and painful, containing a fluid
much resembling milk. Nurses generally endeavour to squeeze this out,
and thus do great mischief; for by this means inflammation is excited
in the part, and sometimes abscess is the result.
If the breasts are simply slightly enlarged, it is unnecessary to do
any thing more than rub them occasionally and very gently with warm
almond oil, and a little time will restore them to their proper size.
If, however, they are inflamed, hot, painful, with a red surface, and
unusually large, a bread and water poultice must be applied every three
or four hours, which will generally prevent either the formation of
matter, or any other unpleasant consequence. In a few days, under this
treatment, they will usually subside, and be quite well.
INFLAMMATION OF THE EYES.
ITS IMPORTANCE.--About the second or third day after the child's birth,
an inflammation sometimes attacks the eye, which is of considerable
consequence. The more so, from its commencing in a way not calculated
to excite the attention, or alarm the fears, of the mother or nurse.
The child cannot express its sensations, and the swelling of the eye
conceals the progress of the disease, so that serious mischief is
frequently done before the medical man sees the patient. In the first
place, the inflammation is not immediately noticed; and, in the second,
the measures employed are frequently insufficient to check its
progress: hence it causes more blindness (I refer to the lower classes
of society more particularly) than any other inflammatory disorder that
happens to the eye; and the number of children is very considerable,
whose sight is partially or completely destroyed by it. The parent or
nurse is apt to suppose, when this inflammation first appears, that it
is merely a cold in the eye, which will go off; and the consequences
which I have just mentioned take place, in many cases, before they are
aware of the danger, and before the medical man is resorted to for
assistance.
I only desire, in mentioning this complaint, to inform the attendants
of the lying-in-room of its great importance, that it may not be
trifled with, that upon its first approach the physician may be
informed of it, and that the treatment he directs for its cure may be
sedulously and rigidly followed.
SYMPTOMS.--The inflammation commonly comes on about three days after
birth, but it may take place at a later period. It may be known by its
commencing thus:--When the child wakes from sleep, the eyelids will be
observed to stick together a little; their edges will be redder than
natural, and especially at the corners; the child experiences pain from
the access of light, and therefore shuts the eye against it. A little
white matter will also be observed lying on the inside of the lower
lid. After a short time, the lids swell, become red on their external
surface, and a large quantity of matter is secreted, and constantly
poured from the eye; the quantity of discharge increasing until it
becomes very great.
But enough has been said to point out the importance of the disease,
and the signs by which it may be recognised at its first approach.
TREATMENT.--Keeping the eye free from discharge, by the constant
removal of the matter secreted, is what the medical attendant will
chiefly insist upon; and without this is done, any treatment he may
adopt will be useless; with it, there is no doubt of a successful issue
of the case, provided his attention has only been called to it at a
sufficiently early period.
HARE-LIP.
This is a blemish too well known to require a formal description. The
questions most interesting to a mother in relation to it, are,--How is
her child to be nourished, that is born with it? and when ought an
operation to be performed for its removal?
THE MODE OF FEEDING THE INFANT.--If the defect is but trifling, the
infant will be able to suck, provided the mother's nipple is large, and
the milk flows freely from it. If this is not the case, the difficulty
may be obviated by using the cork nipple shield.[FN#29] I have known
this to answer the purpose admirably, when the mother had previously
despaired of nursing her infant, the nipple being too small for it to
grasp.
[FN#29] See p. 41.
If, however, the defect exists in a still greater degree, feeding by
means of the spoon must be resorted to; the greatest care being
necessary as to the quantity, quality, and preparation of the
food.[FN#30]
[FN#30] See "Artificial Feeding," p. 34.
CAUTION IN REFERENCE TO THE OPERATION.--With regard to the operation
for the removal of this deformity, I would strongly warn parents
against desiring its too early performance. Various considerations
contribute to make the distressed parents anxious for this. But very
seldom indeed--except the deformity be very great, and implicating other
parts beside the lip--will the operation be required, or ought it to be
resorted to, before the second year and a half of the infant's life;
and for this very cogent reasons exist. For instance, convulsions may
thus be induced, which often terminate fatally.
The most proper age for removing this deformity by operation, is from
that of two years and a half to four years.
BLEEDING FROM THE NAVEL-STRING.
Bleeding from the navel-string will sometime take place hours after it
has been supposed to be carefully secured. This will arise, either from
the cord being carelessly tied, or from its being unusually large at
birth, and in a few hours shrinking so much that the ligature no
longer sufficiently presses on the vessels. In either case, it is of
importance that the attendants in the lying-in-room should understand
how to manage this accident when it occurs, that it may not prove
injurious or fatal to the child.
THE MODE OF ARRESTING THE BLEEDING.--The clothes of the child and the
flannel roller must be taken off;--the whole cord without delay must be
unwrapped, and then a second ligature be applied below the original
one, (viz. nearer to the body of the infant,) taking great care that
it shall not cut through the cord when drawn very tight, but at the
same time drawing it sufficiently tight to compress the vessels.
The ligature should be composed of fine linen threads, three or four
thicknesses, and not of tape or bobbin, or any substance of this
nature, as it cannot be relied on for this purpose.
ULCERATION OR IMPERFECT HEALING OF THE NAVEL.
The cord separates from the navel generally some time between the
fifth and fifteenth day from delivery, and the part usually heals
without giving the slightest trouble.
This, however, is not always the case, for sometimes a thin discharge
will take place, which, if the part be examined, will be found to
proceed from a small growth about the size, perhaps, of a pea, or even
less. This must be removed by applying a little powdered alum,--or, if
this fail, it should be once or twice slightly touched with blue-stone,
and afterwards dressed with calamine cerate.
At other times, though fortunately very rarely, excoriation of the
navel and the parts around takes place, which quickly spreads, and
assumes an angry and threatening character. If, however, the attention
of the medical man is called to it early, it will always do well: until
his directions are given, apply a nicely made bread and water poultice.
BLEEDING FROM THE NAVEL.
Sometimes, a day or two after the cord separates, or at the time of
separation, bleeding takes place from the navel: fortunately, this very
seldom occurs; indeed, it is very rarely met with; and I only mention
it, to observe that, upon its occurrence, the point of the finger
should be placed over the part, and pressure steadily applied until
medical assistance is obtained.
Now and then, in these cases, a growth sprouts up and bleeds. Let this
be touched with lunar caustic, or any other astringent application, or
let pressure be employed, still it will bleed,--not freely or in a
stream, but there will be a constant drain from the part, and the
infant, as a consequence, will waste, and be brought to death's door.
Excise it, it will only make matters worse. The treatment in this case
consists in simply winding a piece of very narrow tape round the
growth, and then leaving it untouched. The bleeding will soon cease;
the fungus will sprout over the upper margin of the tape; in a very
short time it will, as it were, strangle the disease, which
subsequently falling off, a complete cure is accomplished.
JAUNDICE.
It frequently happens, during the first or second week after birth,
that the skin of the child becomes very yellow, and it has all the
appearance of having the jaundice. This gives rise to great distress to
the parent when she perceives it, and she becomes very anxious for the
medical man's next visit.
Now, ordinarily, it is of no consequence; commonly disappearing
spontaneously, and requiring no medical treatment. If, however, it
does not go off in two or three days, a tea-spoonful of castor oil
should be given once, or oftener, if necessary.
It is, of course, possible for an attack of real jaundice to occur at
this early period, and a disease of a very serious nature will then
have to be dealt with; but, except as a consequence of malformation (a
very infrequent occurrence), it is not likely to arise; and therefore
jaundice during the first and second week after delivery need not
create alarm.
Tongue-tied.