The Mother's Manual of Children's Diseases

CHAPTER I.

ON THE MORTALITY OF CHILDREN, AND ITS CAUSES

The purpose of this little book will probably be best attained, and needless repetition best avoided, if we begin by inquiring very briefly why so many children die, what general signs indicate that they are ill, and what general rules can be laid down for their management in sickness.

The first of these inquiries would be as useless as it would be sad, if the rate of infant mortality were fixed by determinate laws, such as those which limit the stature of man or the age to which he can attain.

But this is not so; the mortality in early life varies widely in different countries, in different parts of the same country, and in the same country at different times. Thus, while in some parts of Germany the mortality under one year was recently as high as 25 to 30 per cent. of the total births, and in England as 15, it was only a little above 10 per cent. in Norway. Infantile mortality is higher in manufacturing districts, lower in those which are agricultural, and varies from 16 per cent. in Lancashire to 9 in Dorsetshire. It is then evident that mortality in infancy is in part dependent on remediable causes; and of this there is no better proof than the fact that the mortality in England under one year has been reduced from 15 per cent. in 1872 to 13 per cent. in 1882.

It would lead us far from any practical purpose if we were to examine into all the causes which govern the liability to disease and death during infancy and childhood, in the different ranks of society. We must therefore limit our inquiry to those conditions which are met with in the class to which my readers may fairly be assumed to belong.

First among the causes of sickly infancy and premature death may be mentioned the intermarriage of near relatives. The experience of the breeders of animals, who, by what is termed breeding in and in, undoubtedly obtain certain qualities of speed, or strength, or beauty, does not apply here. They select for their experiments animals whose qualities in these respects are pre-eminent, and eliminate from them all who do not occupy the first rank. In family intermarriages, however, it is rare that any consideration is regarded, save that of wealth; and the fact remains, explain it as we may, that the intermarriage of near relatives during several successive generations is followed by a marked deterioration of the children, physical, mental, and moral; and by the intensifying of any hereditary predisposition to consumption, scrofula, and other constitutional ailments which form the second great cause of early sickness and mortality.

These are facts known to all, which yet it is not easy to represent by figures. All the world is aware that consumption is hereditary, that consumptive parents are more likely than others to have consumptive children; and a fourth of all the patients admitted into the Hospital for Consumption at Brompton stated that the disease had existed in one or other of their parents.1 Scrofula, which is another disease closely allied to consumption, is hereditary also; and hip disease, disease of the spine, abscesses, and enlarged glands in any members of a family, point to risks for the offspring which should not be forgotten, how much soever mental endowments, personal beauty, or the charms of disposition may be considered, and sometimes reasonably enough, to outweigh them. The same liability exists with reference to epilepsy, insanity, and the whole class of affections of the nervous system. Parents inquire, with no misplaced solicitude, what is her fortune, or what are the pecuniary resources of him to whom they are asked to entrust their son's or daughter's future. Believe me, the question—what is the health of his family, or of hers? is consumption hereditary, or scrofula, or epilepsy, or insanity?—is of far greater moment, and touches much more nearly the future happiness of those we love.

These two points regard the future parents themselves; but there are other conditions on which the health of children to a great degree depends; and of these the two most important are the dwelling they inhabit, and the food they eat.

I do not refer here to the dwellings of the poor, situated in unhealthy localities, where fresh air does not enter, where the rays of the sun do not penetrate, with defective drainage and imperfect water-supply; but I speak of the nurseries of well-to-do people. 'This will do for our bedroom, and that will make a nice spare room, and that will do for the children,' is what one often hears. Had you rare plants which cost much money to obtain, which needed sunlight, warmth, and air, would you not consider anxiously the position of your conservatory, and take much pains to insure that nothing should be wanting that could help their development, so that you might feast your eyes upon their beauty, or delight yourselves with their fragrance? And yet a room at the top of the house, one of the attics perhaps, is too often destined for the little one and its nurse; or if there are two or three children, one small room is set apart for the day nursery, and a second, probably with a different aspect, for a sleeping room, and so small that it does not furnish the needed five hundred cubic feet of air for each. And as a consequence, the children are ailing, any predisposition in them to hereditary disease is fostered, they have no strength to battle against any acute illness that may befall them, and yet surprise is felt that the doctor is never out of the house.2

It is needless to dwell on the hand-feeding of infants as one of the great causes of mortality in infancy, and of sickliness in later life. The statistics of Foundling Hospitals bear sad testimony to the fact of its dangers, and the researches of physicians show that a peculiar form of disease is produced by it, attended by symptoms, and giving rise to appearances after death, peculiar to the form of slow starvation from which the infant has perished. I will add, because it is not generally known, one fresh illustration of the influence of artificial feeding in aggravating the mortality of infants. In Berlin the certificates of death of all infants under the age of one year, are required to state whether the little one had been brought up at the breast, or on some kind or other of artificial food. Of ten thousand children dying under the age of one year, one-fourth had been brought up at the breast, three-fourths by hand.3

It is, as I said in the preface, no part of my plan to enter on any details with reference to the management of children in health. It may, therefore, suffice to have pointed out the four great causes of preventible disease among the wealthier classes of society; namely, the intermarriage of near relatives, the transmission of constitutional taint, the insanitary condition of the dwelling, and the injudicious selection of the food of the infant.

CHAPTER II.

THE GENERAL SIGNS OF DISEASE IN INFANCY AND CHILDHOOD

The signs of disease at all ages may be referred to one or other of three great classes: disorder of function, alteration of temperature, complaint of pain.

In the infant it is the last of these which very often calls attention to the illness from which it is suffering. Cries are the only language which a young baby has to express its distress; as smiles and laughter and merry antics tell without a word its gladness. The baby must be ill, is all that its cries tell one person; another, who has seen much of sick children, will gather from them more, and will be able to judge whether its suffering is in the head, or chest, or stomach. The cries of a baby with stomach-ache are long and loud and passionate; it sheds a profusion of tears; now stops for a moment, and then begins again, drawing up its legs to its stomach; and as the pain passes off, stretches them out again, and with many little sobs passes off into a quiet sleep. If it has inflammation of the chest it does not cry aloud, it sheds no tears, but every few minutes, especially after drawing a deeper breath than before, or after each short hacking cough, it gives a little cry, which it checks apparently before it is half finished; and this, either because it has no breath to waste in cries, or because the effort makes its breathing more painful. If disease is going on in the head, the child utters sharp piercing shrieks, and then between whiles a low moan or wail, or perhaps no sound at all, but lies quiet, apparently dozing, till pain wakes it up again.

It is not, however, by the cry alone, or by any one sign of disease, that it is possible to judge either of its nature or of its degree, but the mention of this serves merely as an illustration, which anyone can understand, of the different meanings that even a baby's cry will convey to different persons.

When a child is taken ill, be the disease from which it is about to suffer what it may, there is at once a change from its condition when in health, such as soon attracts the attention even of the least observant. The child loses its appetite, is fretful and soon tired, and either very sleepy or very restless, while most likely it is thirsty, and its skin hotter than natural. In many instances, too, it feels sick or actually vomits, while its bowels are either much purged or very bound. If old enough to talk, it generally complains of feeling ill, or says that it has pain in some part or other, though it is by no means certain that a little child has described rightly the seat of its pain; for it very often says that its head aches or that its stomach aches, just because it has heard people when ill complain of pain in the head or in the stomach. Some of these signs of illness are, of course, absent in the infant, who can describe its feelings even by signs imperfectly; but the baby loses its merry laugh and its cheerful look; it ceases to watch its mother's or its nurse's eye as it was used to do, though it clings to her more closely than ever, and will not be out of her arms even for a moment; and if at length rocked to sleep in her lap, will yet wake up and cry immediately on being placed in its cot again.

Symptoms such as these are sure to awaken the mother's attention to her child, and the child's welfare and the parent's happiness alike depend, in many instances, on the way in which she sets about to answer the question, 'What is the matter?'

Some mothers send at once to the doctor whenever they see or fancy that anything ails their child. But this way of getting rid of responsibility is not always possible, nor, indeed, on moral grounds, is it always desirable, for the mother who delegates each unpleasant duty to another, whether nurse, governess, or doctor, in order to save herself trouble or anxiety, performs but half a mother's part, and can expect but half a mother's recompense of love.

Whenever a child is unwell, a mother may do much to ascertain what is the matter, and may by the exercise of a little patience and common sense save herself much needless heart-ache, and her child much suffering.

The first point to ascertain is the presence or absence of fever; that is to say, whether, and how much, the temperature of the body is higher than natural. If the temperature is not higher than natural, it may be taken as almost certain that the child neither has any inflammatory affection of the chest, nor is about to suffer from any of the eruptive fevers. The temperature, however, cannot be judged of merely by the sensation conveyed to the hand, but must be ascertained by means of the thermometer.4 In the case of the grown person the thermometer is placed either under the tongue, the lips being closed over it, or in the armpit, and is kept there five or six minutes. In young children, however, neither of these is practicable, and I prefer to place the instrument in the groin, and crossing one leg over the other, to maintain the thermometer there for the requisite five minutes. The temperature of the body in health is about 98.5° Fahr. in the grown person, and very slightly higher in childhood; but any heat above 99.5° may be regarded as evidence that something is wrong, and the persistence for more than twenty-four hours of a temperature of 101° and upwards, may be taken as almost conclusive proof of the existence of some serious inflammation, or of the onset of one of the eruptive fevers.

At the same time it is well to bear in mind that temporary causes, such as especially the disorders produced by over-fatigue, or by an over-hearty or indigestible meal, may suddenly raise the temperature as high as 102°, or higher, but the needed repose or the action of a purgative may be followed in a few hours by an almost equally sudden decline of the heat to the natural standard.

It is well to learn to count the pulse and the frequency of the breathing; but to do the former accurately, requires practice such as is hardly gained except by hospital training; and indeed, with few exceptions, the value of the information furnished by the pulse is less in the child than in the adult. The reasons for this are obvious, since the rapidity of the circulation varies under the slightest causes, and the very constraint of holding the sick child's hand makes it struggle, and its efforts raise the frequency of the heart-beats by ten or twenty in the minute. The place at which to seek the beat of the pulse is at the wrist, just inside and below the protuberance of the wrist-bone; but if the child is very fat it is often difficult to detect it. When detected it is not easy to count it in early infancy, for during the first year of life the heart beats between 120 and 130 in the minute, diminishing between that age and five years to 100, and gradually sinking to 90 at twelve years old. In proportion, moreover, to the tender age of the child, is the rapidity of its circulation apt to vary under the influence of slight causes, while both its frequency and that of the breathing are about a third less during sleep than in the waking state.

The frequency of the breathing is less difficult to ascertain, while at the same time it furnishes more reliable information than the pulse. This is best tested when the child is asleep, remembering always that the breathing is then slower than in the waking state. The open hand, well warmed, should be laid flat and gently over the child's night-dress on the lower part of the chest and the pit of the stomach. Each heaving of the chest, which marks a fresh breath being taken, may be counted, and the information thus obtained is very valuable. Up to the age of two years the child breathes from 30 to 40 times in a minute, and this frequency gradually declines to from 25 to 30 till the age of twelve, and then settles down to from 20 to 25 as in the grown person. You would thus know that a sleeping infant who was breathing more than 30 times, or a child of five who breathes more than 25 times, has some ailment in its chest, and that the doctor should be sent for in order to ascertain its exact nature.

It would answer no good purpose to give a description of the information to be obtained by listening to the chest. To learn from this, needs the well-trained ear; and harm, not good, comes from the half-knowledge which serves but to lead astray.

A child may be very suffering, seem very ill, and its suffering and illness may depend on pain in the stomach owing to indigestion, constipation, or even to an accidental chill. After early infancy it is not difficult to make out the seat of the child's suffering: the warm hand placed gently on its stomach will soon ascertain whether it is tense or tender, whether the tenderness is confined to one particular spot, or whether it is more acute at one spot than at another; and, lastly, whether, as is the case when pain is produced by wind in the intestines, the pain and tenderness are both relieved by gentle rubbing.

In the young infant the character of the cry will, as I have already said, give some clue to the seat of its pain, while, if you lay it down in its cot or in its nurse's arms in order to examine its stomach, it will often resist and begin to cry. Its stomach then becomes perfectly tense, and you cannot tell whether pressure on it causes pain or whether the cries are not altogether the consequence of fretfulness and fear. It is therefore the best plan to pass your hand beneath the child's clothes and to examine its stomach without altering its posture, while at the same time the nurse in whose arms it is talks to it to distract its attention, or holds it opposite the window, or opposite a bright light, which seldom fails to amuse an infant. If there is no tenderness of the stomach the child will not cry on pressure; or if during your examination the presence of wind in the intestines should occasion pain, gentle friction, instead of increasing suffering, will give relief.

The one thing which still remains to do, especially in the case of children in whom teething is not over, is to examine the mouth and ascertain the state of the gums, since some ailments are caused and others are aggravated by teething. A wise mother or an intelligent nurse will teach the child when well the little trick of putting out its tongue and opening its mouth to show its teeth when told to do so; and though it may sometimes indulge rather out of place in these performances when wished to behave especially prettily before strangers, yet when older it will quickly learn the proprieties of behaviour, and in the meanwhile you profit much by the lesson when illness really comes.

Sometimes, however, infants who when well will open their mouth and allow their gums to be felt without difficulty, refuse to do so when ill; and it is always desirable that the mother or nurse whose duty it is to tend the sick child constantly, should not frighten it, or lose its confidence, by doing forcibly that which the doctor who comes occasionally may yet be quite right in doing. You will, however, generally get a good view of the mouth and throat in young infants by gently touching the lips with your finger: the child opens its mouth instinctively, and then you can run your finger quickly over its tongue, and drawing it slightly forward perfectly see the condition of the throat, feel the gums as you withdraw your finger, and notice the appearance of the tongue. Sometimes it is important to ascertain whether a tooth which was near coming through has actually pierced the gum, and yet the child's fretfulness renders it almost impossible to induce it to open its mouth. If now, while the nurse holds the child in her arms, you go behind her, you can, unseen and unawares, introduce your finger into its mouth and ascertain all you wish to know before the little one has recovered from its surprise.

I have but little to say here about the general signs of brain disease in infancy and childhood, because they will need minute notice afterwards. All that I would at present observe is, that you must not at once conclude that a child's head is seriously affected, because it is heavy and fretful and passionate, and refuses to be amused. The head, as we know by our own experience, suffers by sympathy in the course of almost every ailment, certainly of every acute ailment, at all ages. If the babe is not sick; if its bowels can be acted on by ordinary means; if, though drowsy, it can be roused without difficulty; if, though it may prefer a darkened room, it does not shrink from the light when admitted gradually; if it has no slight twitchings of its fingers or of its wrists; if the head, though hot, is not hotter than the rest of the body; if the large vessels of the neck, or the open part of the head, or fontanelle as it is termed, in an infant in whom the head is not yet closed, are not beating violently; and, above all, if when it cries it sheds tears, you may quiet your mind on the score of the child's brain, at any rate until the doctor's visit, and may turn a deaf ear to the nurse or the friend who assures you that the child is about to have convulsions or to be attacked by inflammation of the brain.

CHAPTER III.

THE GENERAL MANAGEMENT OF DISEASE IN INFANCY AND CHILDHOOD

The management of the child when ill is difficult or easy in exact proportion to whether it has been ill or well managed when in health. The mother who lives but little with her children, who contents herself with a daily visit to the nursery, and who then scarcely sees her little ones until they are brought into the drawing-room in the evening in full dress, to be petted and admired and fondled by the visitors, cannot expect to take her place by the child's bed in its sickness, to soothe its pain, and to expend upon it all the pent-up tenderness which, in spite of the calls of business or of pleasure, still dwells within her heart. She must be content to see the infant turn from her to the nurse with whose face it has all its life been familiar; or to hear the little one tell her to go away, for her presence is associated with none of those 'familiar acts, made beautiful by love,' which win the young heart: the mother is but a stranger who brings no help, who relieves no distress. Happy such a mother if she has found a conscientious and intelligent nurse to whom she can delegate her office; but she must remember that with the child, love follows in the steps of daily, hourly kindnesses, that a mother's part must be played in health if it is to be undertaken in sickness, that it cannot be laid down and taken up again at pleasure.

There is another mother who cannot nurse her child to any good purpose, she who when it was well spoilt it from excess of love, who has yielded to each wayward wish, and has allowed it to become the petty tyrant of the household. The child is ill, it is languid, feverish, and in pain; no position is quite easy to it, no food pleasant to it, bed is irksome, medicine is nasty. It knows only that it suffers, it has been accustomed to have its will obeyed in everything, and cannot understand that its suffering is not at once taken away. It insists on getting up and on being dressed, or on lying in its mother's or nurse's lap, where the warmth of another person's body does but aggravate its fever; it screams with passion at the approach of the doctor, it will not allow itself to be examined, it will take no medicine; the doctor is powerless, the mother heart-broken. Sickness is not the time to exercise authority which has not been put in force before; and, not once but many times, I have watched, a sad spectator, the death of children from an illness not necessarily fatal, but rendered so because it was impossible to learn the progress of disease, impossible to administer the necessary remedies.

One more point I must insist on before going into details, and that is as to the necessity of perfect truthfulness in dealing with sick children. The foolish device of telling a child when ill, that the doctor who has been sent for is its uncle or its cousin, is the outcome of the still more foolish falsehood of threatening the child with the doctor's visit if it does not do this or that. No endeavour should be spared by nurse or parent, or by the doctor himself, to render his visit popular in the nursery. Three-fourths of the difficulties which attend the administration of medicine are commonly the result of previous bad management of the child, of foolish over-indulgence, or of still more foolish want of truthfulness. It may answer once to tell a child that medicine is nice when really it is nasty, but the trick will scarcely succeed a second time, and the one success will increase your difficulties ever after. If medicine is absolutely necessary, and the child is too young to understand reason, it must be given by force, very firmly but very kindly, and the grief it occasions will be forgotten in an hour or two. If he is old enough, tell him that the medicine is ordered to do him good, and firmness combined with gentleness will usually succeed in inducing him to take it. The advantage of perfect truthfulness extends to every incident in the illness of children, even to the not saying, 'Oh, you will soon be well,' if it is not likely so to be. If children find you never deceive them, how implicitly they will trust you, what an infinity of trouble is saved, and how much rest of mind is secured to the poor little sufferer!