to be convinced, how incumbent it is on every mother to try to suckle
her child. But though it is most desirable that for the first six months
of their existence children should derive their support entirely from
their mother, and that until they are a year or at least nine months old
their mother's milk should form the chief part of their food, yet many
circumstances may occur to render the full adoption of this plan
impracticable. In some women the supply of milk, although at first
abundant, yet in the course of a few weeks undergoes so considerable a
diminution as to become altogether insufficient for the child's support;
while in other cases, although its quantity continues undiminished, yet
from some defect in its quality it does not furnish the infant with
proper nutriment. Cases of the former kind are not unusual in young,
tolerably healthy, but not robust women; while instances of the latter
are met with chiefly among those who have given birth to several
children, whose health is bad, or among the poor, who have been
enfeebled by hard living or hard work. The children in the former case
thrive well enough for the first six weeks or two months, but then,
obtaining the milk in too small a quantity to meet the demands of their
rapid growth, they pine and fret, they lose both flesh and strength,
and, unless the food given to supply their wants be judiciously
selected, their stomach and bowels become disordered, and nutrition,
instead of being aided, is more seriously impaired. In the case of the
mother whose milk disagrees with the child from some defect in its
quality, the signs are in general more pronounced. Either the infant
vomits more than that small quantity which a babe who has sucked
greedily or overmuch often rejects immediately on leaving the breast, or
it is purged, or it seems never satisfied, does not gain flesh, does not
thrive, cries much and is not happy. In these cases, too, the mother's
supply of milk, though abundant at first, diminishes in a few weeks; she
feels exhausted, and suffers from back-ache, or from pain in the breasts
each time after the child's sucking; while, further, her general
weakness leaves her no alternative but to wean the child.
Knowing the attempt to rear her child entirely at the breast to be
vain, the mother may in such cases be tempted to bring it up by hand
from the very first. But how short soever the period may be during which
the mother may be able to suckle her child, it is very desirable that
she should nurse it during that period, and also that her milk should
then constitute its only food. For the first four or five days after the
infant's birth the milk possesses peculiar qualities, and not merely
abounds in fatty and saccharine matter, but presents its casein or curd
in a form in which it is specially easy of digestion. These
peculiarities indeed become less marked within a week or two; but not
only is it of moment that the infant should at any rate make its start
in life with every advantage, but the mother who nurses her little one
even for a month avoids thereby almost half the risks which follow her
confinement. For the indolent, among the wealthy, a numerous class who
have but to form a wish in order to have it gratified, a wet-nurse for
the baby suggests itself at once to the mother as a ready means of
saving herself trouble, and of shirking responsibility. This course, to
which love of pleasure and personal vanity tend alike to prompt her,
often finds, in spite of all opposing reasons, the approval of the
nurse, to whom it saves trouble, and the too ready acquiescence of the
doctor in a course which pleases his patient. But many circumstances
besides those moral considerations, which ought never to be forgotten
before the determination is formed to employ a wet-nurse, may put this
expedient out of the question, and it becomes therefore of importance to
learn what is the best course for a mother to adopt who is either wholly
unable to suckle her child, or who can do so only for a very short time.
It is obvious that the more nearly the substitute approaches to the
character of the mother's milk, the greater will be the prospect of the
attempt to rear the child upon it proving successful. There is no
argument needed to prove that the milk of some animal more closely
resembles the mother's milk, and is more likely to prove a useful
substitute for it than any kind of farinaceous substance. The milk of
all animals, however, differs in many important respects from human
milk, and differs too very widely in different animals. Thus, the milk
of the cow and that of the ewe contain nearly double the quantity of
curd, and that of the goat more than twice the quantity of butter, and
it is only in the milk of the ass that the solid constituents are
arranged in the same order as in man. On this account, therefore, asses'
milk is regarded, and with propriety, as the best substitute for the
child's natural food. Unfortunately, however, expense is very frequently
a bar to its employment, and compels the use of the less easily digested
cows' milk. But though the cost may be a valid objection to the
permanent employment of asses' milk, it is yet very desirable when a
young infant cannot have the breast, that it should be supplied with
asses' milk for the first four or five weeks, until the first dangers of
the experiment of bringing it up by hand have been surmounted. The
deficiency of asses' milk in butter may be corrected by the addition of
about a twentieth part of cream, and its disposition to act on the
bowels may be lessened by heating it to boiling point, not over the fire
but in a vessel of hot water; and still more effectually by the addition
to it of a fourth part of lime-water or of a teaspoonful of the solution
of saccharated carbonate of lime to two ounces or four tablespoonfuls of
the milk.
When cows' milk is given, it must be borne in mind that it contains
nearly twice as much curd, and about an eighth less sugar, than human
milk. It is therefore necessary that it should be given in a diluted
state and slightly sweetened. The dilution must vary according to the
infant's age; at first the milk may be mixed with an equal quantity of
water, but as the child grows older the proportion of water may be
reduced to one-third. Mere dilution with water, however, leaves the
proportion of curd unaltered, and it is precisely the curd which the
infant is unable to digest. Instead, therefore, of diluting the milk
simply with water, it is often better to add one part of whey to about
two parts of milk, which, according to the child's age, may or may not
be previously diluted.[8]
Attention must be paid to the temperature of the food when given to the
infant, which ought to be as nearly as possible the same as that of the
mother's milk, namely from 90 deg. to 95 deg. Fahrenheit, and in all cases in
which care is needed a thermometer should be employed in order to insure
the food being given at the same temperature. Human milk is alkaline,
and even if kept for a considerable time it shows little tendency to
become sour. The milk of animals when in perfect health likewise
presents an alkaline reaction, and that of cows when at grass forms no
exception to this rule. Milk even very slightly acid is certain to
disagree with an infant; it is therefore always worth while the moment
that a hand-fed infant seems ailing to ascertain this point. If
alkaline, the milk will deepen the blue colour of litmus paper, which is
to be had of any chemist; if acid, it will discharge the colour and turn
it red. It is, perhaps, as well to add that, as the oxygen in the
atmosphere tends to redden litmus paper, it should not be left exposed
to the air, but should always be kept in a glass-stoppered bottle.
The milk of the cow is very liable to alteration from comparatively
slight causes, and particularly from changes in the animal's diet; while
even in the most favourable circumstances if the animal is shut up in a
city and stall-fed, all the solid constituents of its milk suffer a
remarkable diminution; while the secretion further has a great tendency
to become acid, or to undergo even more serious deterioration. Mere
acidity of the milk can be counteracted for the moment by the addition
of lime-water, or by stirring up with it a small quantity of prepared
chalk, which may be allowed to subside to the bottom of the vessel; or
if it should happen, though indeed that is rarely the case in these
circumstances, that the child is constipated, carbonate of magnesia may
be substituted for the chalk or lime-water. If these simple proceedings
are not sufficient to restore the infant's health, it will be wise to
seek at once for another source of milk supply, and to place the
suspected milk in the hands of the medical officer of health or of the
public analyst, in order that it may be submitted to a thorough chemical
and microscopical examination.
The difficulty sometimes found in obtaining an unvaryingly good milk
supply, as well as practical convenience in many respects, has led to
the extensive employment of various forms of condensed milk. They form
undoubtedly the best substitute for fresh cows' milk which we possess,
and are a great boon especially to the poor in large towns where the
milk supply is often scanty, not always fresh, and sometimes of bad
quality. I should certainly prefer condensed milk for an infant to milk
from cows living in close dirty stables, such as my experience thirty
years ago made me familiar with in some parts of London.
Still all the varieties of condensed milk are far inferior in quality
to good fresh milk. They contain less butter, less albumen, that is to
say less of the main constituents of all animal solids and fluids, and a
greater proportion of what are termed the hydro-carbonates, such for
instance as sugar; or, to state the same thing differently, the elements
which serve for nutrition are in smaller proportion than in fresh milk
to those which minister to respiration. They are not only less
nutritious, but the large quantity of sugar which they contain not
infrequently disagrees with the child, and causes bowel complaint. I do
not know how far the so-called unsweetened condensed milk which has of
late come into the market is free from this objection; but I have always
preferred the Aylesbury condensed milk, which is manufactured with
sugar, to the Swiss condensed milk, into which, as I have been given to
understand, honey largely enters.
How much food does an infant of a month old require? what intervals
should be allowed between each time of feeding? and how should the food
be given? are three questions which call for a moment's notice. The
attempt has been made to determine the first point by two very
distinguished French physicians, who weighed the infants before and
after each time of sucking. Their observations, however, were not
sufficiently numerous to be decisive, and their results were very
conflicting; the one estimating the quantity at two pounds and a quarter
avoirdupois, which would be equivalent to nearly a quart, the other at
not quite half as much; but the observations of the latter were made on
exceptionally weak and sickly infants. Infants no doubt vary, as do
grown people, as to the quantity of food they require. I should estimate
from my own experience and observation, apart from accurate data, a pint
as the minimum needed by an infant a month old; and while Dr.
Frankland's estimate of a pint and a half for an infant of five months
seems to me very reasonable, I should doubt its sufficing for a child of
nine months unless it were supplemented by other food.
The infant during the first month of life takes food every two hours,
and even when asleep should not be allowed to pass more than three
hours; and this frequent need of food continues until the age of two,
sometimes even until three, months. Afterwards, and until six months
old, the child does not need to be fed oftener than every three hours
during the twelve waking hours, and every four hours during the sleeping
time. Later on, five times in the twenty-four hours, namely thrice by
day, once the last thing at night, and once again in the early morning,
are best for the child's health as well as for the nurse's comfort.
How is an infant not at the breast to be fed? Certainly not with the
cup or spoon; a child so fed has no choice in the matter, but must
either swallow or choke, and is fed as they fatten turkeys for the
market. The infant, on the other hand, sucks the bottle as it would suck
its mother's breast; it rests when fatigued, it stops to play, it leaves
off when it has had enough, and many a useful inference may be drawn by
the observant nurse or mother who watches the infant sucking, and
notices if the child sucks feebly, or leaves off panting from want of
breath, or stops in the midst, and cries because its mouth is sore or
its gums are tender.
But it is not every bottle which an infant should be fed from, and
least of all from those so much in vogue now with the long elastic tube,
so handy because they keep the baby quiet, who will lie by the hour
together with the end in its mouth, sucking, or making as though it
sucked, even when the bottle is empty. These bottles, as well as the
tubes connected with them, are most difficult to keep clean; and so
serious is this evil, that many French physicians not only denounce
their use, in which they are perfectly justified, but prefer, to the use
of any bottle at all, the feeding the infant with a spoon; and here I
think they are mistaken. The old-fashioned flat bottle, with an opening
in the middle, and a short end to which the nipple is attached without
any tube, the only one known in the time of our grandmothers, continues
still the best, and very good. My friend, Mr. Edmund Owen, in a lecture
at which I presided at the Health Exhibition in August last year,
pointed out very humorously the differences between the old bottle and
the new. An infant to be kept in health must not be always sucking, but
must be fed at regular intervals. The careful nurse takes the infant on
her knee, feeds it from the old-fashioned feeding-bottle, regulating the
flow of the milk according as the infant sucks heartily or slowly,
withdraws it for a minute or two, and raises the child into a sitting
posture if it seems troubled with flatulence, and then after a pause
lets it recommence its meal. This occupies her a quarter of an hour or
twenty minutes of well-spent time, while the lazy nurse, or the mother
who has never given the matter a thought, just puts the tube in the
infant's mouth, and either takes no further trouble or occupies herself
with something else. And yet, obvious though this is, how constantly one
sees infants taken about in the perambulator with the feeding-bottle
wrapped up and laid by its side, because it is said the child always
cries when it is not sucking, and the intelligence and the common sense
are wanting, as well as the patient love, that would strive to make out
which it is of many possible causes that makes the infant cry. One more
observation with reference to bottle-feeding may not be out of place. It
is this: that no food be left in the bottle after the child has had its
meal, but that it should be emptied, washed out with a little warm water
and soda, and it and the india-rubber end should be kept in water till
again needed. To insure the most perfect cleanliness it is always well
to have two bottles in use, and to employ them alternately.
How strictly soever an infant may be kept at the breast, or however
exactly the precautions on which I have insisted are observed, sickness,
constipation, or diarrh[oe]a may occur, causing much anxiety to the
parents, and giving much trouble to the doctor.
It sometimes happens, without its being possible to assign for it any
sufficient reason, that the mother's milk disagrees with her infant, or
entirely fails to nourish it, so that, much against her will, she is
compelled to give up suckling it. In some instances this is due to
errors in diet, to the neglect of those rules the observance of which is
essential to health, as proper exercise for instance; and then the
secretion is usually deficient in quantity as well as defective in its
composition. In such cases the child often vomits soon after sucking, it
suffers from stomach-ache, its motions are very sour, of the consistence
of putty, and either green, or become so soon after being passed,
instead of presenting the bright yellow colour and semi-fluid
consistence of the evacuations of the healthy infant, and sometimes they
are also lumpy from the presence of masses of undigested curd. In
addition, also, the child is troubled with griping, which makes it cry;
its breath is sour, or actually offensive, and the tongue is much whiter
than it should be, though it must be remembered that the tongue of the
sucking child always has a very slight coating of whitish mucus, and is
neither as red nor as perfectly free from all coating as it becomes in
the perfectly healthy child of three or four years old.
In these circumstances, the diminution of stimulants, such as the stout
of which young women are sometimes mistakenly urged to take a quantity
to which they were previously quite unaccustomed, is often followed by
an increase of the quantity as well as an improvement in the quality of
the milk. It is true that a nursing mother may often find her strength
maintained, and her supply of milk increased, by taking a glass of stout
at lunch and another at dinner, instead of, but not in addition to, any
other stimulant; but mere stimulants will no more enable a woman to
suckle her infant better than she otherwise would do, than they would
fit a man to undergo great fatigue for days together, or to go through a
walking tour in Switzerland. A tumbler of one-third milk and two-thirds
good grit gruel taken three times a day will have greater influence in
increasing the quantity of milk than any conceivable amount of
stimulant.
There is an entirely opposite condition in which the infant does not
thrive at the breast, and this for the most part is met with when the
mother has already given birth to and suckled several children. In these
instances the secretion is sometimes, though not always, abundant, but
the infant does not thrive upon it. The babe does not get on, is always
hungry after leaving the breast, and cries as though it wanted more; in
addition to which it is often purged, either while sucking or within a
few minutes afterwards, though the motions, except in being more
frequent and more watery than in health, do not by any means constantly
show any other change. The mother's history explains the rest. She is
constantly languid, suffers from back-ache, feels exhausted each time
after the babe has sucked, probably has neuralgia in her face, or
abiding headache. In many instances, too, her monthly periods return,
though as a rule they do not appear in healthy women while suckling. All
these symptoms show that her system is not equal to the duty she has
undertaken, and that therefore, for her sake as well as for that of the
infant, she must give up the attempt.
One more case there is in which suckling has to be given up, at any rate
in part, and that is when the milk is good in kind, but insufficient in
quantity for the child as it grows older. This insufficiency of quantity
shows itself at different periods after the infant's birth--at two
months, three, or four. The child is not otherwise ill than that it is
no longer bright, as it was wont to be, it ceases to gain flesh, it
sleeps more than it used to do, though when it wakes it is always eager
for the breast, and cries when leaving it, and if the experiment is made
of giving it some milk and water immediately on leaving it, it takes
that greedily. Mothers are loth to believe this failure of their
resources, and in the case of some who have firm and well-formed
breasts, there is but little change in their appearance to show that
what remains may serve for beauty, not for use. But if while the child
is sucking, the nipple is taken suddenly from its mouth, instead of
innumerable little jets of milk, spirting out from the openings of the
milk-ducts, the nipple will be seen to be barely moistened by its
languid flow.
In conditions such as these the question of weaning partially or
completely inevitably occurs, and where the mother's weakness is the
occasion of the failure to nourish the child, half-measures are of no
avail, for so long as she does not entirely give up the attempt to do
that to which her health is unequal, her own state will grow worse, that
of the child will not improve. When errors of diet or inattention to
general rules of health incapacitate the mother from the performance of
her duty, there may be hope from the adoption of a wiser course; while
when the supply simply fails from its inadequacy, much may be hoped for
from a wise combination of hand-feeding with nursing at the breast; the
mother perhaps suckling the infant by day, but being undisturbed by
demands upon her at night.
Last of all, I must refer to cases in which love has been stronger than
reason, as indeed it often is, and in which young people with some
pronounced hereditary taint of scrofula or consumption marry and have
children. In such cases, if the consumptive taint is on the mother's
side, it is, I believe, much wiser, in the inability to obtain a good
wet-nurse, to bring up the child by hand rather than at the mother's
breast. One word, however, applicable in such circumstances, age and
long experience entitle me to add, and it is this. It is essential that,
in the absence of that guarantee against the too rapid succession of
pregnancies which suckling for a reasonable time presents, there should
be self-restraint on both sides, lest the inscription on the young
wife's grave should be, as I have too often known it, the same as, in
despite of poetry and romance, her biographer assigns as the cause of
the death of Petrarch's Laura, that she died worn out _crebris
partubus_, by too many babies.
In all of these cases the rules which I have already given with
reference to hand-feeding have to be borne in mind: the preference for
asses' milk at first, the careful regulation of the amount of curd in
the cows' milk afterwards, increased or diminished by the greater or
less proportion of whey mixed with it. Sometimes, however much the
quantity of curd or casein may be reduced, the child is yet unable to
digest it, for it is firm and not easily acted on by the juices of the
stomach. It is then best to omit it altogether, and to supply the
necessary albumen by white of egg. A very good food in these
circumstances is made of--
White of one raw egg,
Quarter of an ounce of sugar of milk,
Three teaspoonfuls of cream,
Half a pint of whey.
In the course of a few weeks, or when the child seems to need stronger
nourishment, one part of veal-tea, made with a pound of veal to a pint
of water, may be added to one part of whey, with the white of egg and
sugar of milk as before, and one part of white decoction, as it was
called some two centuries ago in England. It is composed of--
Half an ounce of hartshorn shavings,
Inside of one French roll,
Three pints of water--boiled to two, strained and sweetened.
This forms an extremely useful way of introducing farinaceous food into
the infant's diet, and preparing the way for a larger amount of it which
by degrees becomes necessary. Of these, one of the most generally useful
is Liebig's or Savory and Moore's food for infants, which has the
advantage of not constipating as so many other farinaceous foods do.
Chapman's Entire Wheat Flour is an extremely good food; and wheat, as
you will remember, excels other farinaceous substances in its nutritive
properties, but it is not so easy of digestion as Liebig. There is,
however, scarcely any kind of farinaceous food, among which Nestle's
must not be forgotten, which may not answer for an infant; provided
always that at first it is not given oftener than twice a day, that it
is not made too thick, nor given in larger proportion than one-third of
the farinaceous food to two-thirds of the whey, milk, or whatever it is
mixed with; and besides, whatever the food may be, it should be prepared
each time afresh.
This is not the place for going into all details on the subject of
feeding infants, or to explain how if wisely managed the child weans
itself by degrees from the bottle or the breast--the best way, be it
said, of weaning--or how by degrees it comes to its daily midday meal of
beef-tea and bread, and then, when the first grinding teeth have been
cut, to a small meat meal daily, finely minced or scraped, and so little
by little adopts the modes of living of its elders.
But, last of all, there are instances, though not so many as the public
imagine, in which the infant, in spite of most judicious management,
fails to thrive, and suffers from various disorders of its digestion.
The most unmanageable and the least hopeful of these cases are those in
which the infant is the subject of consumptive disease. It is very rare
for its symptoms, even in cases of the most marked tendency to
consumption on the part of the parents, to show themselves before the
age of three months, and I think I may add, that apart from such
tendency consumption never appears in infancy or early childhood, except
when it follows on some acute illness, such as inflammation of the
lungs, or on typhoid, or, as it is commonly called, remittent fever.
Consumption of the bowels, as it is popularly termed, may be said never
to occur in early infancy apart from consumptive disease of the lungs,
and is then always accompanied by an increase towards evening of the
temperature from its natural standard of 98.5 deg. to 100 deg.. Hence the
absence of cough and the persistence of a natural temperature may be
taken as almost conclusive evidence that there is no consumptive disease
of the bowels. Consumptive disease in infancy is invariably attended
with glandular enlargement. The glands of the bowels when irritated
always communicate their irritation to the glands in the groin and the
bend of the thigh, which are felt hard and enlarged, like little peas,
under the finger. But further, if there is real disease of the glands of
the bowels, other tiny enlarged glands will be felt, like shot, under
the skin of the belly, from which in the general progress of emaciation
the layer of fat always present in the healthy baby will already have
been removed. Besides this, too, the veins running beneath the skin
there, invisible in the healthy infant, will be seen meandering like
blue lines, and telling the story that more blood than usual flows
through them, because the diseased glands inside interfere with its
ready passage through its proper channels.
Two cautions, however, have to be borne in mind with reference to both
of these indications of disease. The first is, that the glands in the
groin may be enlarged from mere irritation, independent of actual
disease communicated to them from the glands inside. If, however, you
find the glands at the corner of the lower jaw and those on either side
of the neck enlarged too, you are then driven to the conclusion that the
glands in the groin are enlarged not from mere local irritation, but
from general disease, and that consumption is its cause.
Again, the superficial veins of the belly may be enlarged from any
cause which interferes with the proper circulation through the vessels
inside. Hence they are often enlarged in grown people in dropsy, and
hence too in infants and young children from flatulent distension of the
bowels. But in this case the other signs of consumption are wanting; the
emaciation, the cough, the increase of evening temperature, and the
enlargement of the glands, are all absent.
Sometimes we meet with instances where the child does not digest its
food, does not thrive, does not gain flesh, never passes healthy
evacuations, at length wastes, loses strength, and dies, without having
had any of the signs which I have pointed out as indicative of
consumptive disease, and in fact without having suffered from it. Now,
these cases are connected with imperfect performance of the function of
the liver, and sometimes with an imperfection of its structure. Before
birth the functions of the liver are not called into action in the same
way nor to the same degree as afterwards, and its structure differs in
this respect that it contains a larger amount of fat and a smaller
proportion of bile-secreting cells than afterwards. It sometimes happens
from causes which we do not understand that the liver structure not only
does not undergo that higher development which should take place, but
that the fat cells increase at the expense of the bile cells. In these
circumstances the food is ill-digested and the health is much impaired,
and at last wasting takes place to as great a degree as in the case of
consumption, only there are no cough, no glandular enlargement, no big
superficial veins, no increased temperature, while on a careful
examination the doctor will seldom fail to find the rounded edge of the
enlarged liver coming lower down than natural. In these cases too there
is a disposition to convulsive affections, and to that peculiar form of
convulsion called spasmodic croup, concerning which I shall have
something to say later on.
In its less serious form this is both a more frequent and a less grave
condition than consumption, and its existence explains to a great degree
those cases in which young children have failed to be nourished by the
milk food which commonly suits their tender age, but have improved on
beef-tea, raw meat or its juice, and food entirely destitute of
saccharine matter.
In cases where there is reason to apprehend consumptive disease, the
skill and resources of the doctor will often be heavily taxed to meet
each difficulty as it arises. A good wet-nurse, or, in default of her,
asses' milk, with the addition of cream to supply the butter in which
the asses' milk is deficient, a couple of teaspoonfuls of raw meat juice
in the course of every twenty-four hours, much care in the introduction
of farinaceous substances into the diet, and cod-liver oil twice a day,
beginning with ten drops and gradually increasing the dose to a
teaspoonful, are all that the mother herself can do. When the cod-liver
oil is not borne by the stomach, or when--which, however, is not often
the case--the child refuses to take it, glycerine may be substituted for
it, though it must be owned that it is a very poor and inefficient
substitute. The inunction of cod-liver oil is in any case not to be had
recourse to; it makes the child unpleasant to itself and loathsome to
others, while the power of the skin to absorb oily matters is far too
limited to be worth taking into account.
Vomiting, though by no means a prominent symptom of either of the two
very grave conditions of which I have been speaking just now, is yet a
very common attendant on all disorders of digestion in early life. It is
indeed much more frequent in the infant than in the adult, and the
greater irritability of the stomach continues even after the first few
months of existence are past, and does not completely cease during the
early years of childhood. In every case of vomiting in childhood,
therefore, the first question to set at rest is whether it depends on
disorder of the digestive system, or whether it heralds the onset of one
of the eruptive fevers, or of inflammation of the chest, or of affection
of the brain; and in determining this all the directions given when I
was speaking of the general symptoms of disease are to be carefully
studied. Vomiting often accompanies infantile diarrh[oe]a, even when the
food taken cannot be regarded as its occasion; and now and then the
stomach, with no obvious exciting cause, suddenly becomes too irritable
to retain any food, and this indeed may be the case even though attended
by few or no other indications of intestinal disorder. The child in such
cases seems still anxious for the breast; but so great is the
irritability of the stomach that the milk is either thrown up unchanged
immediately after it has been swallowed, or it is retained only for a
few minutes, and is then rejected in a curdled state; while each
application of the child to the breast is followed by the same result.
It will generally be found, when this accident takes place in the
previously healthy child of a healthy mother, that it has been
occasioned by some act of indiscretion on the part of its mother or
nurse. She perhaps has been absent from her nursling longer than usual,
and returning tired from a long walk or from some fatiguing occupation,
has at once offered it the breast, and allowed it to suck abundantly; or
the infant has been roused from sleep before its customary hour, or it
has been over-excited or over-wearied at play, or in hot weather has
been carried about in the sun without proper protection from its rays.
The infant in whom from any of these causes vomiting has come on, must
at once be taken from the breast, and for a couple of hours neither food
nor medicine should be given to it. It may then be offered a teaspoonful
of cold water; and should the stomach retain this, one or two spoonfuls
may be given in the course of the next half-hour. If this is not
rejected, a little isinglass may be dissolved in the water, which must
still be given by a teaspoonful at a time, frequently repeated; or cold
barley-water may be given in the same manner. In eight or ten hours, if
no return of vomiting takes place, the experiment may be tried of giving
the child its mother's milk, or cows' milk diluted with water, in small
quantities from a teaspoon. If the food thus given does not occasion
sickness, the infant may in from twelve to twenty-four hours be restored
to the breast: with the precaution, however, of allowing it to suck only
very small quantities at a time, lest, the stomach being overloaded, the
vomiting should again be produced.
In many instances when the sickness has arisen from some accidental
cause, such as those above referred to, the adoption of these
precautions will suffice to restore the child's health. If, however,
other signs of disorder of the stomach or bowels have preceded the
sickness, or are associated with it, medicine cannot be wholly dispensed
with, and the advice of the doctor must be sought for. Very likely in
addition to directing the rules above laid down to be attended to, he
may lay a tiny dose of calomel, as a quarter, half or a whole grain on
the tongue, which often has a wonderful influence in arresting sickness;
while he may further put a small poultice not much bigger than a crown
piece, made half of mustard, half of flour, on the pit of the stomach
for a few minutes, and may give the child a little saline, with a grain
or two of carbonate of soda, and perhaps a drop of prussic acid. These,
however, are not remedies to be employed by the mother, but must be
prescribed, and their effect watched by the medical attendant.
Sickness, indeed, is not always a solitary symptom unattended by other
evidences of disordered digestion, but is sometimes associated with
signs of its general impairment, and this may be so serious as to lead
to great loss of flesh, and even to end in endangering life. In many
instances, however, the child does not lose much flesh though it digests
ill, and its symptoms would be troublesome rather than alarming, if it
were not that they are often the signs of an unhealthy constitution, out
of which in the course of a few months consumption is not infrequently
developed. Long-continued indigestion in the infant always warrants
anxiety on the part of the parent.
In some of these cases there is complete loss of appetite, the infant
caring neither for the breast nor for any other food. It loses the look
of health and grows pale and languid, though it may not have any special
disorder either of the stomach or of the bowels. It sucks but seldom and
is soon satisfied, and even of the small quantity taken, a portion is
often regurgitated almost immediately. This state of things is sometimes
brought on by a mother's over-anxious care, who, fearful of her infant
taking cold, keeps it in a room too hot or too imperfectly ventilated.
It follows, also, in delicate infants on attacks of catarrh or of
diarrh[oe]a, but it is then for the most part a passing evil which time
will cure. In the majority of cases, however, the loss of appetite is
associated with evidence of the stomach's inability to digest even the
small quantity of food taken, and the bowels are irregular in their
action, as well as unhealthy in their secretion. Loss of appetite, too,
though a frequent is by no means a constant attendant on infantile
indigestion, but is replaced sometimes by an unnatural craving, in which
the child never seems so comfortable as when sucking. It sucks much, but
the milk evidently does not sit well upon the stomach; for soon after
sucking, the child begins to cry and appears to be in much pain until it
has vomited. The rejection of the milk is followed by immediate relief;
but at the same time by the desire for more food, and the child often
can be pacified only by allowing it to suck again. In other cases
vomiting is of much less frequent occurrence, and there is neither
craving desire for food, nor much pain after sucking; but the infant is
distressed by frequent acid or offensive eructations; its breath has a
sour or nauseous smell, and its evacuations have a most f[oe]tid odour.
The condition of the bowels that exists in connection with these
different forms of indigestion is variable. In cases of simple loss of
appetite, the debility of the stomach is participated in by the
intestines, and constipation is of frequent occurrence, though the
evacuations do not always appear unhealthy. In other instances in which
the desire for food still continues, the bowels may act with due
regularity, but the motions may have a very unnatural appearance. If the
child is brought up entirely at the breast, the motions are usually
liquid, of a very pale yellow colour, often extremely offensive, and
contain shreds of curdled milk, which not having been digested within
the stomach, pass unchanged through the whole track of the bowels. In
many instances, however, the infant having been observed not to thrive
at the breast, arrowroot or other farinaceous food is given to it, which
the stomach is wholly unable to digest, and which gives to the motions
the appearance of putty or pipe-clay, besmeared more or less abundantly
with slime or mucus. The evacuations are often parti-coloured, and
sometimes one or two unhealthy motions are followed by others which
appear perfectly natural; while attacks of diarrh[oe]a often come on,
and the matters discharged are then watery, of a dark dirty green
colour, and exceedingly offensive.
Children, like grown persons suffering from indigestion, often continue,
as I have already said, to keep up their flesh much better than could be
expected, and in many cases grow up to be strong and healthy. Still the
condition is one that not merely entails much suffering on the infant,
but by its continuance seriously impairs the health, and tends to
develop the seeds of any constitutional predisposition to consumptive
disease.
In these cases there are many respects in which the mother can most
efficiently second the doctor. All causes unfavourable to health must be
examined into, and as far as possible removed. It must be seen that the
nursery is well ventilated, and that its temperature is not too high;
while it will often be found that no remedy is half so efficacious as
change of air. Next, it must not be forgotten that the regurgitation of
the food is due in great measure to the weakness and consequent
irritability of the stomach, and care must therefore be taken not to
overload it. If these two points are attended to, benefit may then be
looked for from the employment of tonics, and as the general health
improves the constipated condition of the bowels, so usual in these
cases, will by degrees disappear; while if aperients are needed those
simple remedies only should be employed of which I spoke in the first
part of this book, and the use of mercurials is not to be resorted to
without distinct medical order.
The above mode of treatment is appropriate to cases of what may be
termed the indigestion of debility, but a different plan must be adopted
in those instances in which it depends on some other cause. The rule,
indeed, which limits the quantity of food to be given at one time is no
less applicable here, for the rejection of some of the milk may be the
result of nothing more than of an effort which nature makes to reduce
the work that the stomach has to do within the powers of that organ. But
when, notwithstanding that due attention is paid to this important
point, uneasiness is always produced by taking food, and is not relieved
till after the lapse of some twenty minutes, when vomiting takes place,
or when the infant suffers much from flatulence and from frequent acid
or nauseous eructations, it is clear that the symptoms are due to
something more than the mere feebleness of the system.
It is not, however, the mere fact that the child vomits its food, or of
the milk so vomited being rejected in a coagulated state, which proves
that the stomach is disordered, but it is the fact of firmly coagulated
milk being rejected with much pain, and after the lapse of a
considerable interval from the time of its being taken, which warrants
this conclusion. The coagulation of the curd is the first change which
the milk of any animal undergoes when introduced into the stomach. The
coagulum of human milk is soft and flocculent, and not so thoroughly
separated from the other elements of the fluid, as the firm hard
coagulum or curd of cow's milk becomes from the whey in which it floats.
In a state of health the abundantly secreted gastric juice speedily
redissolves the chief part of the curd in the stomach, while when it has
passed into the intestine the alkaline bile which there becomes mixed
with it, completes its solution, and converts the whole into a fluid
which closely resembles one of the chief elements of the blood, is
consequently very easily taken up by the minute vessels whose office it
is to do so, and thus supplies with nourishment the whole body.
Milk tends, however, to undergo changes spontaneously, which produce
its coagulation, and the occurrence of these changes is greatly favoured
by a moderately high temperature, such as that which exists in the
stomach. But the alterations of the fluid that accompany this
spontaneous coagulation are very different from those which are brought
about by the vital processes of digestion. An acid becomes formed within
it, and the acid thus produced has none of the solvent power of gastric
juice, but by its presence impedes rather than favours digestion. Every
nurse is aware that a very slight acidity of the milk will suffice to
give an infant vomiting, stomach ache, and diarrh[oe]a, and the result
must be much the same whether fermentation had begun in the milk before
it was swallowed, or whether it commences afterwards, in consequence of
the disordered condition of the stomach, and the absence of a healthy
secretion of gastric juice.
The nature of the food is the first point that requires attention in the
management of these cases of infantile dyspepsia. If the child had been
fed on cow's milk the symptoms may be due to the gastric juice not
having been able to dissolve the curd, which you will remember is much
firmer than that of human milk as well as twice as abundant. In this
case the substitution of asses' milk, the employing whey either entirely
or in part instead of milk, and the adding white of egg in order to
present the elements of the curd in a more easily digestible form, may
all be tried with advantage. Sometimes children refuse whey; and then a
mixture of cream and veal broth, more or less diluted either with water
or with the white decoction, may be given instead. The addition of soda,
potash, chalk or lime water to milk before it is given is also of
service, since it not only prevents the occurrence of fermentation, but
also renders the curd of cow's milk more easily soluble.
The indiscriminate and over-free employment of these alkalies, however,
as nursery remedies is by all means to be avoided, for the symptoms of
indigestion for which a grown person if suffering would seek the advice
of a skilful doctor require his help no less when the patient is a
child. When acids will be of service in promoting the secretion of the
gastric juice, when pepsine will be likely to be of use, when stimulants
such as a little brandy, when aromatics to get rid of flatulence,
opiates to relieve pain or check diarrh[oe]a, or when an occasional
mercurial, or some other remedy may be of use by stimulating the liver
to increased action, are questions which I would not advise any mother
to try to answer for herself. Much care and pains and knowledge and
experience are often required by the doctor to enable him to answer them
correctly.
I must not leave the consideration of the ailments of the digestive
organs in early infancy without some notice of that affection of the
mouth popularly known as _thrush_ to which an exaggerated importance was
once attached as the supposed cause of those symptoms of disordered
health, of which it is in reality only the accompaniment. Still it is a
sign of such grave disorder that it needs a careful study.
THRUSH.--If you examine the mouth of a young infant, in whom the attempt
at hand-feeding is not turning out well, you will often observe its
lining to be beset with numerous small white spots, that look like
little bits of curd lying upon its surface, but which on a more
attentive examination are found to be so firmly adherent to it as not to
be removed without some difficulty, when they leave the surface beneath
it a deep red colour, and now and then bleeding slightly. These specks
appear upon the inner surface of the lips, especially near the angles of
the mouth, on the inside of the cheeks, and upon the tongue, where they
are more numerous at the tip and edges than towards the centre. They are
likewise seen upon the gums, though less frequently and in smaller
numbers. When they first appear they are usually of a circular form,
scarcely larger than a small pin's head; but after having existed for a
day or two, some of the spots become three or four times as large, while
at the same time they in general lose something of their circular form.
By degrees the small white crusts fall off of their own accord, leaving
the surface where they were seated redder than before; a colour which
gradually subsides, as with the infant's improved health the mouth
returns to its natural condition. If the improvement is tardy the white
specks may be reproduced and again detached several times before the
mouth resumes its healthy aspect. In the worst cases the specks
coalesce, and coat the mouth as though lined with a membrane which is
usually of a yellowish-white tint instead of having the dead white
colour of the separate spots. Even here, however, though the surface is
very red, it scarcely bleeds if the deposit is removed from it gently
and with care.
The popular notion that when the deposit of thrush appears not only in
the mouth, but also at the edge of the bowel, it has passed through the
child is altogether erroneous. The lining membrane of the bowel indeed
is red, inflamed, and presents those conditions to which I have already
referred when speaking of the atrophy of hand-fed children, but the
actual deposit of thrush can take place only where there exists an
appropriate structure for its formation, and that is to be found, not in
the bowels, but only at the inlets and outlets of the digestive canal.
The actual deposit at the outlet of the bowel is indeed exceptional,
though the edges are often red and sore from the irritation produced by
the acrid motions, and this irritation sometimes extends to the skin
over the lower part of the baby's person, which becomes rough, and
covered with a blush of redness.
Thrush in the child is of far less serious import than in the grown
person. In the latter it indicates the existence of some very serious,
almost hopeless disease, and hence it is that we meet with it in the
last stages of dysentery, cancer, and consumption. In the child a slight
attack of thrush may occur from causes which are by no means serious,
and may disappear under the use of simple means, such as I have already
described when speaking of the troubles of digestion in early infancy.
While in any case it must rest with the doctor to regulate as he best
knows how the constitutional treatment of the condition on which the
thrush depends, it must be for the mother to see that appropriate local
measures are adopted. One point of considerable moment, and to which
less care than it deserves is usually paid, is the removing from the
mouth, each time after the infant has been fed, of all remains of the
milk or other food. For this purpose whenever the least sign of thrush
appears, the mouth should be carefully wiped out with a piece of soft
rag dipped in a little warm water every time after food has been given.
Supposing the attack to be but slight this precaution will of itself
suffice in many instances to remove all traces of the affection in two
or three days. If, however, there is much redness of the mouth, or if
the specks of thrush are numerous, some medicated application is
desirable.
The once popular honey and borax is not the best application, and this
for a reason which I will at once explain. The secretion of the mouth in
infants is acid, disease increases this acidity; and it has been found
that this acid state is not merely favourable to the increase of thrush,
but also to the development between the specks of thrush of a sort of
membrane formed by a peculiar microscopic growth, of whose existence,
just as of that of the phylloxera which destroys the vine, or the
muscardine which kills the silkworm, we were ignorant till brought to
light by recent scientific research.
You will therefore at once see why saccharine substances, apt as they
are to pass into a state of fermentation, are not suitable, and why it
is better to employ a solution of--
Borax, twenty grains
Glycerine, one teaspoonful
Water, an ounce.
Now and then the use once or twice a day in addition of a very weak
solution of caustic, as two grains of lunar caustic to an ounce of
water, in bad cases is necessary; but of this it must be left to the
doctor to decide.
TEETHING.--The transition is a very natural one by which we pass from
the study of the dangers and difficulties which attend the feeding and
rearing of young infants, to those which accompany _teething_.
The time of teething is looked forward to by most mothers with
undisguised apprehension, nurses attribute to it the most varied forms
of constitutional disturbance, and doctors constantly hold forth to
anxious parents the expectation that their child will have better health
when it has cut all its teeth. The time of teething, too, is in reality
one of more than ordinary peril,[9] though why it should be so is not
always rightly understood. It is a time of most active development, a
time of transition from one mode of being to another, in respect of all
those important functions by whose due performance the body is nourished
and built up.
The error which has been committed with reference to this matter,
consists not in overrating the hazard of the time, when changes so
important are being accomplished, but in regarding only one of the
manifestations--though that indeed is the most striking one of the many
important ends which nature is then labouring to bring about. A child in
perfect health usually cuts its teeth at a certain time and in a certain
order, just as a girl at a certain age begins to show signs of
approaching womanhood; and at length attains it with but slight
inconvenience or discomfort. The two processes, however, have this in
common, that during both, constitutional disturbance is more common, and
serious diseases are more frequent than at other times, and the cause in
both lies far deeper than the outward manifestation.
The great changes which nature is constantly bringing about around us
and within us are the result of laws operating silently but unceasingly;
and hence it is that in her works we see little of the failure which
often disappoints human endeavours, or of the dangers which often attend
on their accomplishment. Thus when her object is to render the child no
longer dependent on the mother for its food, she begins to prepare for
this long beforehand. The first indication of it is furnished by the
greatly increased activity of the salivary glands, which during the
first few months of existence have scarcely begun to perform their
function, a fact which accounts for the tendency to dryness of the
tongue of the young infant under the influence of very trivial ailments.
About the fourth or fifth month, this condition undergoes a marked
alteration; the mouth is now found continually full of saliva, and the
child is constantly drivelling; but no other indication appears of the
approach of the teeth to the surface, except that the ridge of the gums
sometimes becomes broader than it was before. No further change may take
place for many weeks; and it is generally near the end of the seventh
month before the first teeth make their appearance. The middle cutting
teeth of the lower jaw are in most instances the first to pierce the
gum; next the middle cutting teeth of the upper jaw; then usually the
side cutting teeth of the lower jaw, and lastly, the corresponding ones
of the upper. This, however, is not quite invariable, for sometimes all
the cutting teeth in one jaw precede in their appearance any of those in
the other. The first four grinding teeth next succeed, and often without
any very definite order as to whether those of the upper or of the lower
jaw are first visible, though in the majority of instances the lower are
the first to appear. The four eye teeth follow, and lastly, the
remaining four grinding teeth, which complete the set of first, or as
they are often called, milk teeth.
We must not, however, picture to ourselves this process as going on
uninterruptedly until completed--a mistake into which parents often
fall, whose anxiety respecting their children is excited by observing
that after several teeth have appeared in rapid succession, the process
appears to come to a standstill. Nature has so ordered it that teething
which begins at the seventh or eighth month, shall not be completed
until the twenty-fourth or thirtieth; and has doubtless done so in some
measure with the view of diminishing the risk of constitutional
disturbance that might be incurred if the evolution of the teeth went on
without a pause. As a rule the two lower central incisors or cutting
teeth make their appearance in the course of a week; six weeks or two
months often intervene before the central upper incisors pierce the gum,
but they are in general quickly followed by the lateral incisors. A
pause of three or four months most frequently occurs before we see the
first grinding teeth, another of equal length previous to the appearance
of the eye teeth, and then another still longer before the last grinding
teeth are cut.
Though a perfectly natural process, teething is almost always attended
with some degree of suffering. This, however, is not always the case,
for sometimes we discover that an infant has cut a tooth, who yet had
shown no signs of discomfort, nor any indication that teething was
commencing, with the exception of an increased flow of saliva. More
frequently indeed, the mouth becomes hot, and the gums look tumid,
tense, and shining, while the exact position of each tooth is marked,
for some time before its appearance, by the prominence of the gum; or
the eruption of the teeth is preceded by much redness, and great heat of
the mouth with profuse flow of saliva, and even with little painful
ulcers of the edge of the tongue, or of the inner surface of either lip.
With either of these conditions the child is feverish, fretful, and
cries from time to time with pain, while at the same time the bowels
often are relaxed, or the child coughs and wheezes as if it had caught
cold.
Symptoms such as these make up what nurses mean when they say that the
child is suffering from its teeth, and this opinion is constantly
followed by a request to the doctor to lance the baby's gums. Now this
little operation when really called for often gives great relief, both
to the local discomfort, and also to the general ailment from which the
infant suffers, but it is often done when there is no occasion for it,
and when consequently it causes needless pain, and does no good.
There are four different conditions in which it may be right to have the
child's gums lanced:
First. When a tooth is very near the surface, and by cutting through the
thin gum the child may be spared some needless suffering.
Second. When the gums are very red and hot and swollen; only in this
case the gum is scratched or cut, to bleed it, not with the idea of
letting out the imprisoned tooth.
Third. When the child has for some week or two been feverish and
suffering; while, though the gum is tense and swollen, the tooth does
not seem to advance.
Fourth. As an experiment, when during the progress of teething a child
is suddenly seized with convulsions for which there is no obvious cause.
The irritation of the teeth may have to do with their occurrence; and
the chance of relieving it by so simple a means is not to be thrown
away.
If the process of teething is going on quite naturally, no
interference, medical or other, is either necessary or proper. The
special liability of children to illness at this time must indeed be
borne in mind, and care must be taken not to make any alteration in the
infant's food while it is actually cutting its teeth, but rather to
choose the opportunity of some one of those pauses to which reference
has been made, as occurring between the dates of appearance of the
successive teeth, for making any such change. If the child is feverish,
a little soda or seltzer water sweetened and given after the
effervescence has subsided will be taken eagerly, and avoid the risk of
putting the child too often to the breast, or giving it food too
frequently. It seeks the one or the other because it is thirsty, and
craves for moisture to relieve its hot mouth; not because it is hungry
and needs nourishment. If the child has been weaned, still greater care
will be required, for it will often be found that it is no longer able
to digest its ordinary food, which either is at once rejected by the
stomach, or else passes through the intestines undigested. Very thin
arrowroot made with water, with the addition of one third of milk, will
suit in many cases, or equal parts of milk and water with isinglass, or
equal parts of milk and the white decoction. The bowels of course must
be kept open with very simple and mild aperients, but the bowels are in
general more inclined to diarrh[oe]a than to constipation, and the
diarrh[oe]a of teething children is often troublesome and requires good
medical advice.
The ulcerated state of the mouth is usually connected with special
disorder of the digestive organs, and that condition of acidity for
which I have already recommended soda, magnesia, and similar remedies,
while locally the mouth needs just that local care which is applicable
in cases of thrush. Now and then, severe inflammation of the gums
occurs, in which they become extremely swollen; and ulceration takes
place of the gum just above where the tooth should come through, and
even around some of those which have already appeared. These are cases
in which lancing the gums would do nothing but mischief. They require
the local care already insisted on, a mild plan of diet, and treatment
to reduce any feverishness; and above all one medicine, the chlorate of
potass, which in doses of four grains every four hours for a child a
year old, is almost a specific.
AFFECTIONS OF THE SKIN.--There are a few affections of the skin to which
children in early infancy are especially liable, concerning which a few
words must be said.
The Latin word _intertrigo_ is used for that _chafing_ of the skin of
the lower part of the body of an infant which is by no means unusual,
and is often very distressing. It is almost invariably due to want of
care. Either wetted napkins are dried, and put on again without previous
rinsing in water, or they have been washed in water containing soda, and
not passed through pure water afterwards, or attention is not paid to
change the infant's napkin immediately that it requires; or a fresh
napkin is put on without previous careful ablution of the child; or
lastly it occurs almost unavoidably in cases of diarrh[oe]a from the
extension of irritation beginning at the edge of the bowel.
Care is usually all that is needed to remove, as it is to prevent this
condition. The precautions which I have referred to with regard to
cleanliness must be carefully observed, and moreover, each time even
after passing water, the child should be carefully washed with thin
gruel, or barley water, then dusted abundantly with starch powder, while
the napkin must be thickly greased with zinc ointment. After the first
six or seven months of life the napkin can be almost always dispensed
with, if the child has been brought up in good habits, and in all cases
of chafing, it is much the better way to put no napkin on the child when
in bed, but to lay under it a folded towel, which can be removed, and a
clean one substituted for it as soon as it becomes soiled.
There is a very obstinate form of chafing, with great redness of the
skin, and disposition to crack about the edge of the bowel which depends
on constitutional causes, and calls at once for the interference of the
doctor.
Besides this purely local ailment, there is another skin affection
which is seen over the body generally, and is known popularly by the
name of _red gum_, or in Latin _strophulus_. I mention the Latin name
because I have known persons sometimes, misled by the similarity of
sound, fancy that it had some connection with scrofula. It is met with
less commonly now than formerly, when people were accustomed to keep
infants unduly wrapped up, and to be less careful than most are
now-a-days about washing and bathing. It depends on over-irritation of
the sweat glands of the delicate skin of the infant, the result of which
shows itself in the eruption on the body and face of a number of small
dry pimples sometimes surrounded by a little redness, itching
considerably, and when their top has been rubbed off by scratching
having a little speck of dried blood at their summit.
A rash like this, a sort of _nettle rash_, more blotchy and causing
little lumps on the skin, which in a day or two come and go, sometimes
appears in the intervals between the pimples, sometimes takes their
place, and causes, as they do, much irritation. This nettle rash is
usually dependent on some error of diet, on some acidity of the stomach,
and, on their being corrected soon passes away, leaving the pimples as
they were before, but sometimes being reproduced if the pimples cause
excessive irritation of the tender skin.
The matter of chief importance for a mother to know, is that these
rashes have no serious signification. Their treatment is very simple. It
consists in dressing the child very lightly, in bathing it very
frequently with tepid water, avoiding as far as may be the use of soap,
and in sponging it often to relieve the irritation with some simple
alkaline lotion; such for instance as one recommended by the late Dr.
Tilbury Fox, and which is composed of twenty grains of carbonate of
soda, two teaspoonfuls of glycerine, and six ounces of rose water. Of
course if the stomach is out of order that must be attended to, but a
little fluid magnesia, once or twice a day, is all that is usually
needed in the way of medicine.
One other affection of the skin, very common, very distressing, very
tedious, of which there are many varieties, generally known by the
technical name of _eczema_, from a compound Greek word which signifies
to flow, needs that I should say something about it. It is not limited
in its occurrence to infancy, nor does it of necessity cease when
childhood is over, but continues to recur even in grown persons, and
shows itself still from time to time even in the aged.
For the most part, however, it makes its appearance between the fifth
and twelfth month; sometimes seeming to be induced by the change of food
when the child is weaned, and that even though the weaning may have been
wisely managed; at other times showing itself when the irritation of
teething begins, and in every instance being aggravated by the approach
of each tooth to the surface, and abating in the intervals.
It does not occur in all children with equal frequency or severity, and
though there is no doubt but that it is often hereditary, and this
especially in families some members of which have suffered from gout,
yet it is by no means unusual for two or three of the children of the
same parents to be affected by it severely, while no trace of it appears
in the others.
It shows itself in general first on the cheeks and sides of the face,
where the skin becomes red and rough, and slightly puffy. On looking
very closely--more closely indeed than most persons are wont to do--this
appearance will be seen to be produced by innumerable small pimples,
smaller than pins' heads, and which itch violently. Now and then, even
in the course of a few hours, these pimples disappear, leaving the skin
rough, and peeling off in branny scales, while the surface beneath is
red and irritable, a condition which also in a few days may subside.
This, however, is less frequent than the opposite course of the
affection, in which a drop of fluid forms at the top of each tiny
pimple, and escaping forms a yellowish, thin, transparent, watery,
irritating discharge, which reddens still more the raw and weeping
surface of the skin. The fluid when abundant dries at length into
yellowish flakes or crusts, which sometimes assume a brownish colour if
the surface is made to bleed by irritating or scratching. If the crusts
are not removed, the fluid which still continues to be poured out
beneath them soon changes into matter or _pus_ as it is called, and
this, shut up beneath the hard crust above, increases the irritation,
and thickens the deposit. After a time the inflammation lessens of its
own accord, the secretion diminishes, the crusts dry up, and at length
fall off, leaving the skin red, slightly swollen, and its surface
scaling off in flakes, which gradually cease to form, and the skin by
degrees becomes quite sound again, and so remains, until perhaps the
irritation caused by the approach of a new tooth to the surface,
rekindles the old trouble, to go once again through the same stages as
before.
It is on the cheeks, the sides of the face, and the top of the head that
these changes may be best studied, but there are other situations in
which the same kind of process often goes on. It may be seen in the
creases of the neck, or the folds of the thigh in fat children, only as
two surfaces of skin are there in contact the fluid never dries to a
crust, but the skin, red and sore and swollen, pours out an abundant
secretion which, just as when it occurs behind the ears, gives out a
strong and offensive smell. It occurs, too, at the bends of the joints,
as under the knee, and at the inside of the elbow joint, as well as on
the front of the chest, the back, and sometimes even over the whole
body, and especially at any part where the pressure of the dress
irritates the skin. When thus general, it seldom fails to pass into a
chronic state such as to call for constant, skilled medical treatment.
The attack often comes on with general feverishness, a hot skin,
fretfulness, and restlessness, which subside when the skin begins to
discharge, though the discomfort produced by the local irritation still
continues. At other times, and this perhaps more often when the eruption
first appears on the head, its onset is more gradual, and slight
scurfiness and redness at the top of the head are first noticed, and
then a little crust forms there which is firmly adherent, and is,
therefore, often not entirely removed as it should be, and thus bit by
bit the mischief extends until its cure becomes tedious and troublesome.
When either from neglect, or from the ailment having set in acutely, the
affection of the scalp is severe, the child's state is one of much
suffering. The whole of the scalp becomes hot and swollen, and covered
over a large surface by a thick dirty crust, through cracks in which a
thick ill-smelling greenish-yellow matter exudes on pressure. At
different points around, pimples form with mattery heads,--pustules they
are called--while the glands on each side of the neck become swollen and
tender. When thus severe on the head it will be found also not merely on
the face, but also on the body, and the poor suffering child is not only
a miserable object to look upon, but, worn by constant restlessness, it
loses flesh, and seems almost as though it could not long survive.
Happily, however, the condition scarcely ever terminates fatally, though
feeble health and stunted growth are not seldom the results of the early
suffering. But besides, severe eczema in infancy always returns again
and again in childhood and in after-life, and there is also a distinct
connection between liability to eczema and to asthma; and this not
simply nor mainly that the disappearance of an attack of eczema may be
succeeded by an attack of asthma, but that the child who in infancy has
had severe general eczema is more prone than another to develop a
disposition to asthma as he attains the age of five or six, and this
even though he should not have had any return of the skin affection in a
severe form.
It is evident then, that one cannot take too much pains to guard
against the occurrence of eczema if possible, and at any rate to prevent
its becoming severe. The disposition to it is often controlled by very
simple precautions, such as bathing the face, the moment the skin shows
any redness or roughness, with thin gruel or barley water, then
powdering it with starch powder, and when the infant goes out, smearing
the spot very lightly with benzoated zinc ointment, and making the child
wear a veil. It will be observed that the exclusion of the air is in all
these cases the object of the application far more than any specific
virtue which it is supposed to possess, and many of the worst cases of
eczema in grown persons are treated, in the great hospital for skin
diseases in Paris, by an india-rubber mask, or by india-rubber covering
of the affected part, and benefit thereby without any medicated
application whatever. The thin layer of scurf which often forms on an
infant's head should not be allowed to remain there, since its presence
is a source of irritation. If it is very adherent, the surface may be
well greased overnight with a little clarified lard which will soften
it, so that it can be readily washed off with weak soap and water in the
morning. If, however, the skin is very irritable soap must not be used,
but the head must be washed with yelk of egg and warm water, and instead
of a sponge, which would be too harsh, it is better to employ a very
large camel's hair brush or a soft shaving brush, which is more handy,
and the surface after careful drying may be lightly smeared with zinc
ointment. All ointments used must be washed off most scrupulously every
day, otherwise they become rancid, irritate, and make matters worse.
When eczema sets in acutely, with general feverish disturbance, cooling
medicines are required, and the help of the doctor becomes necessary.
These are the cases in which the eruption is not confined to the head or
the face, but extends over the body generally. The child must be dressed
as loosely as possible; and when in its cot, should lie there with no
other covering than its little shirt; and nothing gives so much relief
to the irritation as the abundant use of powder, either simple starch
powder, or ten parts of starch powder to one of oxide of zinc, or
carbonate of bismuth. All powders must be absolutely free from grit, or,
in other words, quite impalpable; otherwise they irritate the surface.
On the face and other parts where it can be employed, the puff may be
used to apply the powder; but between the creases of the skin--which it
is important to keep apart--fine linen, lint, or charpie must be
employed, covered freely with powder, so as to prevent the surfaces from
coming into contact. If the irritation is very distressing, a weak
spirit lotion with a little carbolic acid may sometimes be sponged over
the surface, and the powder renewed immediately; or other forms of
soothing lotions may be used to abate the irritation.
When the scalp is affected in the acute form of eczema crusts form very
quickly; or in other cases they collect because people fear to disturb
them when they see the raw surface beneath. It is, however, a grievous
mistake to allow them to collect; they are in themselves a source of
irritation, and they entirely prevent any application reaching the skin
beneath. They must always be removed, and never be allowed to form
again. They can be removed either by the employment of a poultice, half
of bread, half of linseed meal, or by the application over-night of a
handkerchief soaked in sweet oil, and covered over with a piece of oiled
silk, which softens the crusts effectually, and allows of their easy
removal by abundant washing with weak soap and water.
The best applications afterwards vary so much that it is impossible to
lay down any positive rule. Sometimes the Carron oil, as it is termed: a
liniment compound of equal parts of linseed oil and lime-water--a
popular and most useful application in burns--gives most ease to the
irritated skin; sometimes the mere exclusion of the air by means of the
india-rubber cap; sometimes the abundant use of powder. In every case,
at least once in every twenty-four hours the whole surface must be
washed quite clean with barley water or thin gruel; and when the
discharge lessens or ceases, as it will do in the course of time, then,
but not till then, various ointments may be of service.
When the chronic stage arrives, in which the skin becomes dry and scaly,
then is the time for tonics, for iron, sometimes for cod-liver oil, and
for arsenic; of which latter remedy, however, the results are uncertain;
while in the acute stage, its influence is simply mischievous. Nothing
is more difficult, nor calls for more skill, or larger medical
experience, than the proper management of the various forms of chronic
eczema.
The question is sometimes asked whether it is safe to cure, or, as
people call it, to dry up these eruptions in teething children. There
can be no doubt but that it is very desirable to prevent their
occurrence as far as may be by the use of the precautionary measures
which I have explained. But when they have existed for some time, either
attended with profuse discharge, or causing great irritation by their
extent, there is no doubt but that care must be exercised in attempts at
their cure, that soothing measures such as I have advocated should be
chiefly employed, and that the sudden drying up of the discharge by a
too abundant use of dusting powders must be avoided. If, too, the
diminution of the rash were followed by a worsening of the child's
condition, by feverishness, by heaviness of the head, or any sign of
disturbance of the brain, the attempt to cure the rash must at once be
abandoned. At the same time I must add that such occurrences are very
rare, and that for one case where I have had to regret my success in
curing the rash, I have seen fifty in which I have been mortified by the
failure of my endeavour.
FOOTNOTES:
[8] The directions given by the distinguished chemist, Dr. Frankland, to
whom I am indebted for the suggestion, are as follows: 'One-third of a
pint of new milk is allowed to stand until the cream has settled; the
latter is removed, and to the blue milk thus obtained about a square
inch of rennet is to be added, and the milk vessel placed in warm
water.' (I may add that the artificial rennet sold by most chemists may
be substituted for the other.) 'In about five minutes the rennet, which
may again be repeatedly used, being removed, the whey is carefully
poured off, and immediately heated to boiling to prevent its becoming
sour. A further quantity of curd separates, and must be removed by
straining through calico. In one quarter of a pint of this hot whey is
to be dissolved three-eighths of an ounce of milk sugar, and this
solution, along with the cream removed from the one-third of a pint of
milk, must be added to half a pint of new milk. This will constitute the
food for an infant of from five to eight months old for twelve hours;
or, more correctly speaking, it will be one-half of the quantity
required for twenty-four hours. It is absolutely necessary that a fresh
quantity should be prepared every twelve hours; and it is scarcely
necessary to add that the strictest cleanliness in all the vessels used
is indispensable.'
[9] In our tables of mortality we find teething registered as having
occasioned the death of nearly 5 (4.8) per cent. of all children who
died in London under one year old; and of 7.3 per cent. of those who
died between the age of twelve months and three years.
PART III.
_ON THE DISORDERS AND DISEASES INCIDENT TO ALL PERIODS OF CHILDHOOD._
The ailments hitherto noticed are by no means all that may occur during
infancy and early childhood, but those only which either happen then
exclusively, or at least with far greater frequency than at other times.
It will be most convenient to consider the others under the different
systems to which they belong, as diseases of the head, of the chest, and
of the bowels.
Before entering on these new subjects, however, a few words may not be
out of place with reference to what may be termed the second period of
childhood. It is above all a time of wonderfully lessened sickness and
mortality. We have not the means of stating exactly the rate at which
mortality is lessened between the cessation of the first and the
commencement of the second dentition; but we do know that it is ten
times less between the age of one and five, and nearly twenty times less
between five and ten than it was in the first year of existence.[10] A
mother's anxiety then may safely be quieted after the first year of her
infant's life, and still more after the first set of teeth have been
cut, for if her child is strong and healthy then, there will be
comparatively little to fear for its future.
Four years or thereabouts now follow, before any important change takes
place in the child's condition, for it is not until between six and
seven years old that the first set of teeth begin to be shed, and the
second to take their place. This change of teeth too is of far less
moment as far as the health is concerned, than was the cutting of the
first set. The first dentition was the preparation for an entirely new
mode of life for the child, and was intended to fit it for a life
independent of its mother. The second has no such signification; it is a
mere local alteration rendered necessary by the growth of the jaws, and
takes place quietly, by the gradual absorption of the roots of the first
set of teeth, brought about by the pressure of the others as they
approach the surface. Four teeth in each jaw are new, and replace no
others, but usually they are cut without much discomfort, and the wisdom
teeth do not concern us here, for they do not appear until childhood has
long passed.
But, though between the age of two years and of ten there is no
important change, nor even preparation for a change in the constitution,
the time is yet one of most active growth of the body, and consolidation
of the skeleton. The stature increases from 2 ft. 6 in. to 4 ft. 6 in.,
and the weight nearly doubles, while at the same time the ends of the
long bones previously connected with the shafts by means of cartilage or
gristle, become firmly united by the conversion of that cartilage into
bone, and a similar process goes on, though not completed till later, in
the ribs and the breast bone.
Rapid increase of height and weight; conversion of the elements of bone
into bone itself, formation of muscle out of the fat, which in the young
child was stored up as so much building material for an edifice in
course of construction, require for their accomplishment perfect health,
and the power of converting to its highest purposes all the nourishment
received. What wonder then, if from time to time, the machinery thus
hardly taxed, fails to be quite equal to the demands upon it, if pains
in the limbs--growing pains, as they are commonly called, or head-ache,
tell of the inadequate nerve supply. Or if from the same cause, a vague
feverish condition comes on, in which the temperature is slightly
raised, and the child listless, and yet fretful, loses its cheerfulness,
is dull at its easy tasks, and yet indifferent to play. This too is the
time when any unsuspected defects, physical, or mental, or moral, begin
to show themselves distinctly; when short sight becomes apparent so soon
as the child has to learn its letters, when the dull hearing is
perceived which makes it seem inattentive, and gives to its manner an
unchildlike nervousness; and the weak intellect is displayed in
causeless laughter, causeless mischief, causeless passion, imperfect
power of articulation, or want of words, and by a restless busyness in
doing nothing.
Of all these things I shall have to speak later on more fully. They are
the things however, which only those mothers notice who live much with
their children, who do not banish them all day long to the nursery or
the school-room, and learn from another whether they fare well or ill.
They and only they will notice these things in whom there dwells that
which the poet tells us of:
The mother's love that grows
From the soft child, to the strong man; now soft,
Now strong as either, and still one sole same love.
FOOTNOTES:
[10] The exact numbers as given at p. xiv of the forty-fifth Report of
the Registrar-General for all England in 1881 are to 1,000 living under
one year 58 deaths; from one to five 6.1; from five to ten 3.3.
CHAPTER VI.
THE DISORDERS AND DISEASES OF THE BRAIN AND NERVOUS SYSTEM.
It is stated on good authority[11] that more than half of the deaths at
all ages from these causes take place in children under five years, a
fact which at first sight seems as inexplicable as it is startling.
There is, however, a twofold explanation of it: the circulation through
the much softer tissue of the brain, unenclosed within a _firm bony
case_ as in after-life, varies with far greater rapidity in the infant
than in the grown person, and hence the organ is far more easily
overfilled with or emptied of its blood. Besides, any organ in which
growth is going on with great rapidity is proportionately liable to
become disordered or diseased. Now the brain doubles its weight in the
first two years of life, and attains nearly its full size by the end of
the seventh year.
These two facts suggest a bright as well as a dark view of disorders of
the brain and nervous system in early life. If disorder is more
frequent, it is excited by slighter causes, is more likely to be
temporary, and even its gravest symptoms, such as convulsions and
paralysis, have a less serious import in the one case than in the
others. If the grown man has a fit, and still more, if that fit is
followed by paralysis, we fear and with reason that some vessel in the
brain-substance has given way, or that some grave, probably irreparable
damage has been inflicted on it. In the child, and especially in the
young infant, these accidents may mean nothing more than that the brain
has suddenly become over-filled with blood, or that it has been
disturbed by irritation--I know of no better term--in some distant
organ.
CONVULSIONS.--There are in the body two great nerve masses, the brain
and the spinal cord, through which all parts are brought into relation
with each other. The spinal cord or spinal marrow receives impressions
from all parts, imparts movement to the limbs, as well as gives activity
to the functions of the various internal organs. The brain is the
controlling power, and governs more or less consciously the movements
which the spinal cord originates, and hence in proportion as the
development of the brain advances, and its controlling power increases,
those involuntary movements, fits or convulsions, which originate in
irritation of the spinal cord, become rarer. The brain, at the age of
three years, is more than twice as large as in the first year of life,
and deaths from convulsions have then sunk to a third of their former
frequency; while from the age of ten to fifteen years, when the brain
may be said to be perfected, only four per cent., instead of nearly
eighty per cent. as in the first years of life, of all deaths from
disorders of the nervous system are due to convulsions.[12]
I dwell on this subject the more because there is in a fit of
_convulsions_ something so intensely painful to behold that it is easy
to exaggerate its danger, and to lose all presence of mind in panic.
First, then, it is well to bear in mind that real disease of the brain
rarely, very rarely, I do not say never, begins with convulsions; and
next, that their real danger is in general in exactly opposite relation
to the frequency of their occurrence. Convulsions now and then return
thirty, forty, or more times in twenty-four hours, and continue to do so
sometimes for three or four days together. They are, indeed, not without
peril, for the perpetually returning disturbance of the circulation may
give rise to an overfilling of the vessels of the brain, or to a
stagnation of the blood within them, or the spasm may affect the muscles
which open and close the entrance to the windpipe, and the child may die
choked as in a paroxysm of whooping cough, or in a fit of spasmodic
croup, or lastly the violent and frequently repeated muscular movements
may at length exhaust its feeble frame. But still, such frequently
recurring convulsions are in themselves no evidence that the brain is
diseased; they do but show that the irritability of the spinal cord is
increased to a degree which the brain is no longer able to control, and
which therefore manifests itself in violent convulsive movements.
It is thus that the poison of scarlet fever or of small-pox sometimes
displays its influence over the whole system by producing violent
convulsions at the outset of those diseases; thus that they follow on
some indigestible article of food, or that the mother, over-heated by
violent exertion, or overwhelmed by the news of some unexpected
calamity, sees her babe, to whom she is in the act of giving the breast,
suddenly seized by a violent convulsion.
In every instance, therefore, the first business is to ascertain the
cause of the convulsion, to determine the seat of the irritation which
has excited the nervous system to such tumultuous reaction. The
convulsion which ushers in any one of the eruptive fevers in the infant
or in the child, is only an exaggeration of the shivering which precedes
the onset of fever in the adult. Has the child been exposed to the
contagion of measles, small-pox, or scarlatina? is it teething, and if
so, when did its last tooth appear? of what did its last meal consist?
when were its bowels last open? has it been exposed to the sun with its
head uncovered? or has it, though in the shade, been sitting or playing
out of doors in the intense heat of a summer's day? has it had a fall,
or been frightened? or is it suffering from whooping-cough which has of
late been very severe? or has its breathing been accompanied with a
peculiar catch or crow, the sign of spasmodic croup, and have at the
same time its hands been usually half clenched, and the thumb shut into
the palm, the sign of that disturbance which at length has culminated in
an attack of convulsions? Such are the questions, which in less time
than it takes me to write, or others to read, the intelligent mother
will put to herself, and will answer, instead of, in unreasoning alarm,
giving all up as lost, or hastening without reflection to do something
or other that were better left undone.
The first thing to do in every case of convulsions, be their cause what
it may, is to loosen the dress, so that no string nor band may interfere
with respiration, and for this purpose strings must be cut and dresses
torn. The next thing is to dash cold water on the face to induce a deep
inspiration, for sudden death in a fit almost always takes place from
interruption to breathing. With the same purpose the forefinger should
be put into the mouth, and run rapidly to the root of the tongue, which
should be drawn forward. The object of doing this is twofold; first, to
prevent the tongue falling back, as in these circumstances it is apt to
do, over the entrance of the windpipe and so producing suffocation, and
in the next place the act very frequently puts an end to the spasmodic
closure of the windpipe, and is followed by a deep-drawn breath which
announces the infant's safety. If the child has cut any teeth, the
handle of a spoon, round which a bit of rag has been wrapped, or a bit
of wood, or a thin strip of india-rubber, should be put between the
teeth as far back as possible to prevent the tongue being bitten; and
often this is all that can be done.
There are two circumstances, and two only, in which the warm bath is
likely to be of use. At the onset of one of the eruptive fevers, a hot
bath is sometimes of great service by stimulating the skin and thus
bringing out the rash. In these cases the fit scarcely ever comes on in
a child previously in perfect health, but for some hours at least it has
appeared very ill, tossing about with great restlessness, with a dry,
hot skin, and twitching of the tendons of the wrists; or, perhaps, with
a pale face and cold hands and feet, but with the temperature of the
body as high as 103 deg. or 105 deg.. Here the hot bath at 96 deg. to 98 deg., even
rendered more stimulating by the addition of mustard, and continued for
not more than five minutes, is sometimes of great service, and is
speedily followed by the cessation of the convulsions and the outbreak
of the eruption.
These, too, are the cases in which the use of the wet sheet, as
practised in hydropathic institutions, is sometimes of great benefit,
but I do not advise its employment except under medical advice.
The second condition in which the bath, and here it is the tepid and not
the hot bath--that is to say, the bath at from 87 deg. to 90 deg.--is of
service, is where the child is feverish and restless from over-fatigue
or over-excitement, or from exposure to the sun or to an excessively hot
atmosphere, and convulsions have come on in the course of this ailing.
Here the tepid bath for ten or fifteen minutes, coupled with the
application of cold to the head, will soothe the excitement and prevent
the return of the convulsions.
In neither this case, nor in that in which the hot bath is employed, is
the result of the agent as magical as people sometimes seem to expect.
It is rarely that convulsions cease while a child is actually in the
bath. For the most part the influence of the bath is limited to abating
their severity, shortening their duration, and indisposing to their
return.
The bath, then, is to be used when either a stimulating or a soothing
influence on the surface is likely to be of service, and only then. In
cases where the fits are produced by constipation, by improper food, or
by the irritation of a tooth pressing against the gum, it is idle to use
it, and equally so in instances where many fits have been recurring in
the course of the same day. Where that is the case it must be
self-evident that, be the cause what it may, it must be one over which
either a hot or a tepid bath can have no influence, and that, painful as
it must be to wait a passive spectator, that position is far wiser than
that of a mischievous meddler. It is some consolation, also, to know
that unconsciousness to suffering attends convulsions.
There is one agent, chloroform, which often has a very remarkable
influence in controlling frequently repeated convulsions. It is an
agent, however, too hazardous to be trusted out of medical hands, and
even when the doctor administers it himself, the parents must fully
recognise the fact that, inasmuch as the child may die during a fit
quite independently of breathing chloroform, so the occurrence of that
catastrophe during its employment is not to be made a subject of
self-reproach to them, or of blame to the doctor.
But you may ask whether there are no _signs_ of that disturbance of the
nervous system, by which you can judge beforehand that the occurrence of
convulsions is probable. In proportion to the tender age of a babe, the
greater is the probability, as I have already stated, that convulsions
will be induced by slight causes, especially by such as digestive
troubles. Unless you are aware of the phraseology that used at any rate
to be common among nurses, you may be much alarmed at being told that
the child who had seemed scarcely unwell has been very much convulsed,
when all that is meant is that the child has shown some of the signs
that threaten convulsions--has had, in short, what in the time of our
grandmothers used to be called _inward fits_. A child thus affected lies
as though it were asleep, winks its imperfectly closed eyes, and gently
twitches the muscles of its face--a movement especially observable about
the lips, which are drawn as though into a smile. Sometimes, too, this
movement of the mouth is seen during sleep, and poets have told us that
it is the angels' whisper which makes the babe to smile--I am sorry that
its meaning in plain prose should be so different. If this condition
increases, the child breathes with difficulty, its respiration sometimes
seems for a moment almost stopped, and a livid ring surrounds the mouth.
At every little noise the child wakes up; it makes a gentle moaning,
brings up the milk while sleeping, or often passes a great quantity of
wind, especially if the stomach is gently rubbed. When the disorder of
the digestion, on whatever cause it depended, is removed, these symptoms
speedily subside, nor is there much reason to fear general convulsions
so long as no more serious symptoms show themselves. There is more cause
for apprehension, however, when the thumbs are drawn into the palm,
either habitually or during sleep; when the eyes are never more than
half-closed during sleep; when the twitching of the muscles is no longer
confined to the angles of the mouth, but affects the face and
extremities; when the child awakes with a sudden start, its face growing
flushed or livid, its eyes turning up under the upper eyelid, or the
pupils suddenly dilating, while the countenance wears an expression of
great anxiety or alarm, and the child either utters a shriek, or
sometimes begins to cry.
When a fit comes on, the muscles of the face twitch, the body is stiff,
immovable, and then in a short time, in a state of twitching motion, the
head and neck are drawn backwards and the limbs violently bent and
stretched. Sometimes these movements are confined to certain muscles or
are limited to one side, and I may add that such cases are of more
importance as far as the state of the brain is concerned than those in
which the convulsions are general. The eye is fixed and does not see;
the fingers may be passed over it without its winking, the pupil is
immovably contracted or dilated; the ear is insensible even to loud
sounds, the pulse is small, very frequent, often too small, and too
frequent even for the skilled doctor to count it; the breathing hurried,
laboured and irregular; the skin bathed in abundant perspiration.
After this condition has lasted for a minute, or ten minutes, or an hour
or more, the convulsions cease; and the child either falls asleep, or
lies for a short time as if it were bewildered, or bursts out crying,
and then returns to its senses, or sinks into a state of stupor, in
which it may either be perfectly motionless, or twitching of some
muscles may still continue; or, lastly, it may, though this seldom
happens, die in the fit.
It seems then, from all that has been said, that convulsions, though one
of the most striking, are by no means one of the most conclusive signs
of brain disease; that they are even more commonly the result of
disorders of the nervous system from causes seated elsewhere, than of
actual disease of what may be termed the great nervous centre.
We may now therefore pass to the examination of these diseases, which
for the purposes of this book may be considered under the two heads of
congestion and inflammation.
I am forced to use these terms in somewhat of a popular sense, for to
attempt in a little book like this to define everything with strict
scientific accuracy would simply confuse and mislead.
CONGESTION OF THE BRAIN.--By _congestion of the brain_ is meant a
condition in which its vessels are overcharged with blood; a condition
which if it exists in an aggravated degree, ends either in the pouring
out of blood on, or into the brain, on the one hand, or in inflammation
on the other. Either of these terminations, however, is so rare in the
previous healthy child, that I shall confine my remarks entirely to
congestion of the brain, an affection specially liable to occur in
children during teething. A certain degree of feverishness almost always
accompanies teething. It is, therefore, not difficult to understand how,
when the circulation is in a state of permanent excitement, a very
slight cause may suffice to overturn its equilibrium, and occasion a
greater flow of blood to the brain than the organ is able to bear.
Congestion of the brain, however, is not by any means limited to this
season, but may occur at other times without any obvious exciting cause,
and with no other explanation than is furnished by the well-known fact
that all periods of development such as childhood, are periods during
which the growing organs are most apt to become disordered.
In the great majority of cases the symptoms of congestion of the brain
come on slowly; and for the most part, general uneasiness, or disordered
state of the bowels, which are usually, though not invariably
constipated, and feverishness precede for a few days the more serious
attack. The head by degrees becomes hot, the child grows restless and
fretful, and seems distressed by light, or noise, or sudden motion, and
children who are old enough sometimes complain of their head. Usually
too, vomiting occurs repeatedly; a symptom of the greatest importance,
since it may exist before there is any well-marked sign of head
affection. Causeless frequently repeated vomiting in a child not ill but
ailing, is nine times out of ten a sign of mischief in the head. The
degree of fever which attends this condition varies much, and its
returns are irregular; but any one who knows how to feel the pulse will
find it permanently quickened, and if the head is unclosed the
pulsations of the brain may be seen and felt distinctly. The sleep is
disturbed, the child often waking with a start, while there is
occasional twitching of the muscles of its face, or of the tendons of
its wrist.
The child may continue in this condition for many days and then recover
its health without any medical interference. This is especially likely
to be the case with children while teething, the fever subsiding, the
head growing cool, and the little one appearing quite well so soon as
the tooth has cut through the gum, but the approach of each tooth to the
surface being attended by the recurrence of the same symptoms.
The fortunate issue of these cases though frequent, is by no means
invariable, for sometimes they are but the precursors of that
formidable, I might indeed say, all but hopeless disease, water on the
brain. But even of itself congestion of the brain is by no means a
trivial ailment, for it may pass into a stage in which the smaller
discomforts of the child lead to the sad mistake that the condition of
the child is improving, instead of which it is really the dulling of
sensibility from approaching death. The head, indeed, becomes less hot,
the flush of the face grows slighter and less constant; but the
countenance is heavy and anxious, the indifference to surrounding
objects increases, and the child lies in a state of torpor or
drowsiness, from which indeed it can at first be roused to complete
consciousness The manner on being roused is always fretful, but, if old
enough to talk, the child's answers are natural, though generally very
short; and murmuring, 'I am so sleepy, so sleepy,' it subsides into its
former drowsiness. The bowels generally continue constipated, and the
vomiting seldom ceases, though it is sometimes less frequent than
before. In this state, without any apparent cause, the child sometimes
has an attack of convulsions, which subsiding, leaves the torpor deeper
than before. The fits return, and death may take place in one of them,
or the torpor growing more profound after each convulsive seizure, the
child at length dies insensible.
Now and then, especially in infants of only five or six months old,
recovery takes place even where there seemed almost no ground for hope.
The overfull vessels have at length relieved themselves, fluid has been
poured out into the cavities of the brain, the yielding skull has given
way under the pressure from within, and should the child after all
survive, its large head, due to chronic water on the brain, tells to all
who know how to interpret the signs, the tale of its past illness, and
the manner of its imperfect recovery.
Cases such as these are obviously beyond the reach of domestic
management, and call for all the resources of medical skill. The mistake
commonly made is that of calling in the doctor too late, because it is
not realised how grave may be the import of symptoms which at first
appear so little alarming; and the so-called experienced nurse having
said, 'Oh! it's nothing but the baby's teeth,' time is lost and danger
not anticipated till too late for remedy.
The application of two, three, or four leeches at the very outset of
these cases is often of great service, and sometimes cuts short symptoms
which had seemed very threatening. The doctor, of course, must be the
judge of its expediency, but I refer to it because I have known parents
raise objections to it, and beg to have milder means tried first. It
must be borne in mind then, that whenever leeches are of use it is at
the beginning of an attack, and that the opportunity once let slip does
not return. Purgatives, cold to the head, saline medicines, and perhaps
some carefully selected sedative, are the measures which will probably
be employed in most cases, but success will in great measure depend on
the minute care with which all the details which I dwelt on in the
introduction, are carried out.
It is not always, indeed, that active treatment is desirable, and
gentle measures then suffice; but nothing except close and frequent
watching can enable the doctor to steer safely between the two opposite
dangers of too little and too much.
When I come to speak of the eruptive fevers, I shall have to mention the
convulsions and other signs of most serious brain disturbance, which
sometimes occur at their outset, and which are due to the condition of
the blood charged with the fever poison.
A somewhat similar set of symptoms, attributed with reason to the
overheated state of the blood, occurs in cases of _sunstroke_. It is
true that sunstroke, with the formidable characters that it presents in
hot countries, is not seen in England, but even here the mere exposure
of an infant or young child to an overheated atmosphere, is by no means
unattended with risk, and I refer to it here, because mothers are by no
means aware of the danger, and believe that it suffices to guard the
child from the direct rays of the sun.
Alarm, restlessness, and fretfulness, alternating with drowsiness,
hurried, irregular breathing, intense heat of skin, violent beating of
the open part of the head, twitching of the limbs, and starting of the
tendons of the wrists, with a pulse too rapid to be counted, are the
symptoms when the attack is severe. Convulsions are rare, though they
sometimes occur. Sickness is almost invariable, the stomach rejecting
everything, and the bowels are almost invariably relaxed, severe
diarrh[oe]a or dysentery sometimes coming on, as the brain disturbance
abates. The first shock may kill the child in a few hours, or it may
sink under the subsequent diarrh[oe]a, but as a rule recovery eventually
takes place.