The Mother's Manual of Children's Diseases
This is no disease, to be treated with the grey powder and the castor oil wherewith the over-busy monthly nurse is always ready. It is a natural process, which the intelligent may watch with interest, with which none but the ignorant will try to interfere.
There is, however, beside this a real jaundice, in which the skin is more deeply stained, the whites of the eyes are yellow, the urine high-coloured, and in which the dark evacuations that carry away the contents of the bowels before birth are succeeded by white motions, from which the bile is absent. This condition is not very usual, save where children have been exposed to cold, or where the air they breathe is unwholesome. Of this no better proof can be given than is afforded by the fact that in the Dublin Lying-in Hospital, where the children are defended with the greatest care both from cold and from a vitiated atmosphere, infantile jaundice is extremely rare, while it attacks three-fourths of the children received into the Foundling Hospital of Paris. Still it does sometimes occur when yet no cause can be assigned for it, and it is noteworthy that it is sometimes met with in successive infants in the same family.
As the respiratory function and that of the skin increase in activity, the jaundice will disappear of its own accord. Great attention must be paid during its continuance to avoid exposure of the child to cold, while no other food than the mother's milk should be given. If the bowels are at all constipated, half a grain of grey powder or a quarter of a grain of calomel may be given, followed by a small dose of castor oil, and the aperient will often seem to hasten the disappearance of the jaundice; but in a large number of cases even this amount of medical interference is not needed.
There is, indeed, a very grave form of jaundice, happily of excessive rarity, due to malformation of the liver, to absence or obstruction of the bile-ducts, and often accompanied with bleeding from the navel. I do but mention it; the intensity and daily deepening of the jaundice, the fruitlessness of all treatment, and the grave illness of the child, even though no bleeding should occur, render it impossible to confound this hopeless condition with the trivial ailment of which I have been speaking.
The next chapter will furnish a fitter place than the present for speaking fully of the Disorders of the Digestive Organs.
I will say now but this: that whatever a mother may do eventually, she avoids grave perils for herself by suckling her infant for the first month; while the health of her child, just launched upon the world, is terribly endangered if fed upon those substitutes for its proper nutriment on which after the lapse of a few weeks it may subsist, may even manage to thrive.
There are some local affections incident to the new-born child concerning which a few words may not be out of place; and first of the
Ophthalmia of New-born Children.—It is the cause of the loss of sight of nine-tenths of all persons who, among the poor, are said to have been born blind. In the wealthier classes of society it is comparatively rare, and seldom fails to meet with timely treatment, yet many people scarcely realise its dangerous character, or the extreme rapidity of its course.
It generally begins about the third day after birth with swelling of the lid of one or other eye, though both are soon involved. The eyelids swell rapidly, and if the affection is let alone, they soon put on the appearance of two semi-transparent cushions over the eyes. On separating the lids, which it is often very difficult to do owing to the spasmodic contraction of the muscles, their inner surface is seen to be enormously swollen, bright red, like scarlet velvet, bathed in an abundant yellowish thin secretion, which often squirts out in a jet as the lids are forcibly separated. Great care must be taken not to allow any of this fluid to enter the eye of a bystander, nor to touch his own eye until the fingers have been most carefully washed, since the discharge is highly contagious, and may produce most dangerous inflammation of the eyes of any grown person. The discharge being wiped or washed away, the eye itself may be seen at the bottom of the swelling very red, and its small vessels very blood-shot. By degrees the surface of the eye assumes a deeper red, it loses its brightness and its polish, while the swelling of the lids lessens, and they can be opened with less difficulty; their inner surface at the same time becomes softer, but thick and granular, and next the eyes themselves put on likewise a granular condition which obscures vision. The discharge by this time has become thicker and white, and looks like matter from an abscess. By slow degrees the inflammation may subside, the discharge lessen, the swelling diminish, and the eye in the course of weeks may regain its natural condition. But the danger is—and when proper treatment is not adopted early the danger is very great—lest the mischief should extend beyond the surface of the eye, lest ulceration of the eye should take place, the ulceration reach so deep as to perforate it, and not merely interfere with the sight, but destroy the organ of vision altogether.
In every instance, then, in which the eyelids of a new-born infant swell, or the slightest discharge appears from them, the attention of the doctor must at once be called to the condition. In the meantime, and during whatever treatment he may think it right to follow, the eye must be constantly covered with a piece of folded lint dipped in cold water; and every hour at least the eye must be opened and tepid water squeezed into it abundantly from a sponge held above, but not touching it, so as to completely wash away all the discharge. A weak solution of alum and zinc, as one grain of the latter to three of the former to an ounce of water, may in like manner be dropped from a large camel's-hair brush four times a day into the eye after careful washing. Simple as these measures are they yet suffice, if adopted at the very beginning, and carried on perseveringly, to entirely cure in a few days an ailment which if let alone leads almost always to most lamentable results.
I do not pursue the subject further, for bad cases require all the care of the most skilful oculist for their treatment.
Scalp Swellings.—Almost every new-born child has on one or other side of its head a puffy swelling, owing to the pressure to which the head has been subjected in birth, and this swelling disappears at the end of twenty-four or forty-eight hours.
Now and then, however, though indeed very seldom, the swelling does not disappear, but it goes on gradually increasing and becoming more definite in its outlines until at the end of three or four days it may be as big as half a small orange, or sometimes even larger, soft, elastic, painless, under the unchanged scalp, but presenting the peculiarity of having a hard raised margin with a distinct edge, which gives to the finger passed over it the sensation of a bony ridge, beyond which the bone seems deficient. This tumour is due usually to the same cause as that which produces the other temporary puffy swelling of the scalp, only the pressure having been more severe, blood has actually been forced out from the small vessels under the membrane which covers the skull, and hence its gradual increase, its definite outline; and hence, too, the bony ridge which surrounds it, and which is due to nature's effort at cure, in the course of which the raised edge of the membrane covering the skull (the pericranium) becomes converted into bone.
When the nature of these swellings was not understood, they used to be poulticed, and to be opened with a lancet to let out their contents. We know now, however, that we have nothing to do but to let them alone; that by degrees the blood will be absorbed and the tumour will disappear, and as it does so we may trace the gradual transformation of the membrane which covered it into bone, as we feel it crackling like tinsel under the finger. Two, three, or four weeks may be needed for the entire removal of one of these blood-swellings. The doctor will at once recognise its character, and you will then have nothing to do but to wait—often, unhappily, so much harder for the anxious mother than to meddle.
Ruptured Navel.—There is a period some time before the birth of a child when the two halves of its body are not united in front, as they become afterwards; and hare-lip or cleft-palate sometimes remains as the result of the arrest of that development which should have closed the fissured lip or united the two halves of the palate.
In a similar way it happens sometimes that though the skin is closed, the muscles of the stomach (or, more properly speaking, of the belly) are not in the close apposition in which they should be, so that the bowels are not supported by the muscles, but protected only by the skin.
More frequently than this, especially in the case of children who are born before the time, the opening through which the navel string passes is large at birth, and fails to close as speedily and completely as it should do afterwards. When everything goes on as it ought, the gradual contraction of the opening helps to bring about the separation of the navel string and its detachment, and the perfect closure of the opening takes place at the same time, between the fifth and the eighth day after birth.
If this does not occur, the bowels are very apt to protrude through the opening, and if allowed to do so for weeks or months, the opening becomes so dilated that its closure is impossible, and the child grows up afflicted permanently with rupture through the navel. This is always an inconvenience, sometimes even a source of serious danger; but if means are taken to prevent the condition becoming worse, nature seldom fails eventually to bring about a cure, and to effect the complete closure of the opening.
If the muscles on either side do not come into apposition, but leave a cleft between them, the infant should constantly wear a broad bandage of fine flannel round the stomach, not applied too tightly, in order to give support. The circular bandages of vulcanised india-rubber with a pad in the centre are nowise to be recommended. The pad is apt to become displaced, and to press anywhere but over the navel, while its edges irritate the infant's delicate skin, and the pressure which it exerts if it is sufficiently tight to retain its place interferes with respiration.
A pad composed of pieces of plaster spread on wash-leather, and of graduated sizes and kept in place by adhesive strapping,7 answers the purpose of preventing the protrusion at the navel, and of thus facilitating the closure of the ring better than any other device with which I am acquainted. They need, however, to be continued even for two or three years, and though they should have been left off it is wise to resume their use if the child should be attacked by whooping-cough, diarrhœa, or any other ailment likely to occasion violent straining.
CHAPTER V.
ON THE DISORDERS AND DISEASES OF CHILDREN AFTER THE FIRST MONTH, AND UNTIL TEETHING IS FINISHED
Infantile Atrophy.—In by far the greater number of instances, the wasting of young children is due to their being fed upon food which they cannot digest, or which when digested fails to yield them proper nourishment. I quoted some figures in my introductory remarks, to show from the evidence obtained at Berlin how much larger was the proportion of deaths under the age of one year among hand-fed infants than among those brought up at the breast. Foundling hospitals on the Continent, in which the children are all drawn from the same class, and subjected in all respects to a similar treatment, except that in some they are fed at the breast, in others brought up by hand, show a mortality in the latter case exactly double of that in the former.
It is as idle to ignore these facts, and to adduce in their disproof the case of some child brought up most successfully by hand, as it would be to deny that a battle-field was a place of danger because some people had been present there and had come away unwounded.
But it is always well not merely to accept a fact, but also to know the reason why a thing is so. The reason is twofold: partly because the different substitutes for the mother's milk, taken for the most part from the vegetable kingdom, are less easy of digestion than the milk, and partly because, even were they digested with the same facility, they do not furnish the elements necessary to support life in due proportion.
All food has to answer two distinct purposes: the one to furnish materials for the growth of the body, the other to afford matter for the maintenance of its temperature; and life cannot be supported except on a diet in which the elements of nutrition and those of respiration bear a certain proportion to each other. Now, in milk, the proper food of infants, the elements of the former are to those of the latter about in the proportion of 1 to 2, while in arrowroot, sago, and tapioca they are only as 1 to 26, and in wheaten flour only as 1 to 7. If to this we add the absence in these substances of the oleaginous matters which the milk contributes to supply the body with fat, and the smaller quantity, and to a certain extent the different kind, of the salts which they contain, it becomes apparent that by such a diet the health if not the life of the infant must almost inevitably be sacrificed.
But these substances are not only less nutritious, they are also less easy of digestion than the infant's natural food. We all know how complex is the digestive apparatus of the herbivorous animal, of which the four stomachs of the ruminants are an instance, and how large is the bulk of food in proportion to his size which the elephant requires, compared with that which suffices for the lion or the tiger.
The stomach of the infant is the simple stomach of the carnivorous animal, intended for food which shall not need to stay long in that receptacle, but shall be speedily digested; and it is only as the child grows older, and takes more varied food, that the stomach alters somewhat in form, that it assumes a more rounded shape, resembling somewhat that of the herbivorous animal, and suited to retain the food longer. The young of all creatures live upon their mother for a certain time after birth; but in all the preparation for a different kind of food, and with it for an independent existence, begins much sooner and goes on more rapidly than in man. Young rabbits are always provided with two teeth when born, and the others make their appearance within ten days. In the different ruminants the teeth have either begun to appear before birth, or they show themselves a few days afterwards; and in either case dentition is completed within the first month, and in dogs and cats within the first ten weeks of existence.
In the human subject the process of teething begins late, between the seventh and the ninth month, and goes on slowly: the first grinding teeth are seldom cut before the beginning of the second year, and teething is not finished until after its end. Until teething has begun the child ought to live exclusively on the food which nature provides; for until that time the internal organs have not become fitted to digest other sustenance, and the infant deprived of this too often languishes and dies. To get from other food the necessary amount of nourishment, that food has to be taken in larger quantities, and, from the difficulty in digesting it, needs to remain longer in the stomach than the mother's milk. One of the results of the indigestibility of the food is that the child is often sick, the stomach getting rid of a part of that food which it is unable to turn to any useful purpose; and so far well. But the innutritious substances do not relieve the sense of hunger. The child cries in discomfort, and more is given to it, and by degrees the over-distended stomach becomes permanently dilated, and holds a larger quantity than it was originally meant to contain. The undigested mass passes into a state of fermentation, and the infant's breath becomes sour and offensive, it suffers from wind and acid eructations, and nurses sometimes express surprise that the child does not thrive since it is always hungry. While some of the food is got rid of by vomiting, some passes into the intestines, and there becomes putrid, as the horribly offensive evacuations prove. They come away, large and solid and white, for the secretion of the bile is inadequate to complete that second digestion which should take place in the intestines; or else the irritation which they excite occasions diarrhœa—a green putty-like matter comes away mixed with a profuse watery discharge.
What wonder is it that in such circumstances the body should waste most rapidly; for it is forced from its own tissues to supply those elements essential to the maintenance of life, which its food contains in far too scanty a proportion. Every organ of the body contributes to the general support, and life is thus prolonged, if no kind disease curtail it, until each member has furnished all that it can spare, and then death takes place from starvation, its approach having been slower, but the suffering which preceded it not therefore less, than if all food had been withheld.
Do not suppose that in this description I have been painting too dark a picture, or that children who die thus have been exceptionally weak, and so under the acknowledged difficulties of hand-feeding at length became consumptive. They do not die of consumption, and in a large number of instances their bodies show no trace of consumptive disease, but present appearances characteristic of this condition of starvation, and of this only.
Along the whole track of the stomach and intestines are the signs of irritation and inflammation. The glands of the bowels are enlarged, actual ulceration of the stomach is often met with; while so far-reaching is the influence of this slow starvation, that even the substance of the kidneys and of the brain are often found softened and otherwise altered, though it might not unreasonably have been supposed that these organs lay quite beyond the reach of any disorder of digestion.
No doubt all these grievous results do not always follow; and sometimes children exceptionally strong manage to take and digest enough even of unsuitable food to maintain their health, and may as they grow up, and the changes take place in the system which fit it for a varied diet, even become robust. In the majority of instances, however, hand-fed infants, and those especially who have been brought up chiefly on farinaceous food, are less strong than others, and are more apt to develop any latent tendency to hereditary disease, such as scrofula or consumption, than members of the same family who have been brought up at the breast.
Enough has already been said to satisfy all but those who do not wish 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.