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The Maternal Management of Children, in Health and Disease.
by Thomas Bull, M.D.
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If the lips are drawn apart, so as to show the teeth or gums, the seat of the pain is in the belly. This sign, however, will only be present during the actual existence of suffering; if, therefore, there be any doubt whether it exist, press upon the stomach, and watch the eifect on the expression of the countenance.

If the pain arise simply from irritation of the bowels excited from indigestion, it will be temporary, and the sign will go and come just as the spasm may occur, and slight remedial measures will give relief.

If, however, the disease be more serious, and inflammation ensue, this sign will be more constantly present, and soon the countenance will become pale, or sallow and sunken,—the child will dread motion, and lie upon its back with the knees bent up to the belly,—the tongue will be loaded,—and in breathing, while the chest will be seen to heave with more than usual effort, the muscles of the belly will remain perfectly quiescent.

If the nostrils are drawn upwards and in quick motion, pain exists in the chest. This sign, however, will generally be the accompaniment of inflammation of the chest, in which case the countenance will be discoloured,—the eyes more or less staring, and the breathing will be difficult and hurried; and if the child's mode of respiring be watched, the chest will be observed to be unmoved, while the belly quickly heaves with every inspiration.

Convulsions are generally preceded by some changes in the countenance. The upper lip will be drawn up, and is occasionally bluish or livid. Then there may be slight squinting, or a singular rotation of the eye upon its own axis; alternate flushing or paleness of the face; and sudden animation followed by languor.

These signs will sometimes manifest themselves many hours, nay days, before the attack occurs; may be looked upon as premonitory; and if timely noticed, and suitable medical aid resorted to, the occurrence of a fit may be altogether prevented.

The state of the eyes should always be attended to. In health they are clear and bright, but in disease they become dull, and give a heavy appearance to the countenance; though after long continued irritation they will assume a degree of quickness which is very remarkable, and a sort of pearly brightness which is better known from observation than it can be from description.

The direction of the eyes, too, should be regarded, for from this we may learn something. When the infant is first brought to the light, both eyes are scarcely ever directed to the same object: this occurs without any tendency to disease, and merely proves, that regarding one object with both eyes is only an acquired habit. But when the child has come to that age when the eyes are by habit directed to the same object, and afterwards it loses that power, this circumstance alone may be looked upon as a frequent prelude to disease affecting the head.



OF THE GESTURES.



The gestures of a healthy child are all easy and natural; but in sickness those deviations occur, which alone will often denote the nature of the disease.

Suppose an infant to have acquired the power to support itself, to hold its head erect; let sickness come, its head will droop immediately, and this power will be lost, only to be regained with the return of health; and during the interval every posture and movement will be that of languor.

The little one that has just taught itself to run alone from chair to chair, having two or three teeth pressing upon and irritating the gums, will for a time be completely taken off its feet, and perhaps lie languidly in its cot, or on its nurse's arm.

The legs being drawn up to the belly, and accompanied by crying, are proofs of disorder and pain in the bowels. Press upon this part, and your pressure will increase the pain. Look to the secretions from the bowels themselves, and by their unhealthy character your suspicions, in reference to the seat of the disorder, are at once confirmed.

The hands of a child in health are rarely carried above its mouth; but let there be any thing wrong about the head and pain present, and the little one's hands will be constantly raised to the head and face.

Sudden starting when awake, as also during sleep, though it occur from trifling causes, should never be disregarded. It is frequently connected with approaching disorder of the brain. It may forebode a convulsive fit, and such suspicion is confirmed, if you find the thumb of the child drawn in and firmly pressed upon the palm, with the fingers so compressed upon it, that the hand cannot be forced open without difficulty. The same condition will exist in the toes, but not to so great a degree; there may also be a puffy state of the back of the hands and feet, and both foot and wrist bent downwards.

There are other and milder signs threatening convulsions and connected with gesture, which should be regarded:—the head being drawn rigidly backwards,—an arm fixed firmly to the side, or near to it,—as also one of the legs drawn stifly upwards. These signs, as also those enumerated above, are confirmed beyond all doubt, if there be present certain alterations in the usual habits of the child:—if the sleep is disturbed,—if there be frequent fits of crying,—great peevishness of temper,—the countenance alternately flushed and pale,—sudden animation followed by as sudden a fit of languor,—catchings of the breath followed by a long and deep inspiration,—all so many premonitory symptoms of an approaching attack.



OF THE SLEEP.



The sleep of the infant in health is quiet, composed, and refreshing. In very early infancy, when not at the breast, it is for the most part asleep in its cot; and although as the months advance it sleeps less, yet when the hour for repose arrives, the child is no sooner laid down to rest, than it drops off into a quiet, peaceful slumber.

Not so, if ill. Frequently it will be unwilling to be put into its cot at all, and the nurse will be obliged to take the infant in her arms; it will then sleep but for a short time, and in a restless and disturbed manner.

If it suffer pain, however slight, the countenance will indicate it; and, as when awake, so now, if there is any thing wrong about the head, the contraction of the eye-brow and grinding of the teeth will appear; if any thing wrong about the belly, the lips will be drawn apart, showing the teeth or gums,—and in both instances there will be great restlessness and frequent startings.



OF THE STOOLS.



In the new-born infant the motions are dark coloured, very much like pitch both in consistence and appearance. The first milk, however, secreted in the mother's breast, acts as an aperient upon the infant's bowels, and thus in about four-and-twenty hours it is cleansed away; or if it should not, a tea-spoonful of castor oil accomplishes this purpose.

From this time, and through the whole of infancy, the stools will be of a lightish yellow colour, the consistence of thin mustard, having little smell, smooth in appearance, and therefore free from lumps or white curded matter, and passed without pain or any considerable quantity of wind. And as long as the child is in health, it will have daily two or three, or even four, of these evacuations. But as it grows older, they will not be quite so frequent; they will become darker in colour, and more solid, though not so much so as in the adult.

Any deviation, then, from the above characters, is of course a sign of something wrong; and as a deranged condition of the bowels is frequently the first indication we have of coming disease, the nurse should daily be directed to watch the evacuations. Their appearance, colour, and the manner in which discharged, are the points principally to be looked to. If the stools have a very curdy appearance, or are too liquid, or green, or dark-coloured, or smell badly, they are unnatural. And in reference to the manner in which they are discharged, it should be borne in mind, that, in a healthy child, the motion is passed with but little wind, and as if squeezed out, but in disease, it will be thrown out with considerable force, which is a sign of great irritation. The number, too, of stools passed within the four-and- twenty hours it is important to note, so that if the child does not have its accustomed relief, (and it must not be forgotten that children, although in perfect health, differ as to the precise number,) a little castor oil may be at once exhibited, and thus mischief be prevented.

This, however, is not the place to discuss the question of disordered bowels, but simply to point out how this circumstance may be known.[FN#27]



[FN#27] See section on Disorders of the Stomach and Bowels, p. 208.



OF THE BREATHING AND COUGH.



The breathing of a child in health is formed of equal inspirations and expirations, and it breathes quietly, regularly, inaudibly, and without effort. But let inflammation of the air-tubes or lungs take place, and the inspiration will become in a few hours so quickened and hurried, and perhaps audible, that the attention has only to be directed to the circumstance to be at once perceived.

Now all changes which occur in the breathing from its healthy standard, however slight the shades of difference may be, it is most important should be noticed early. For many of the complaints in the chest, although very formidable in their character, if only seen early by the medical man, may be arrested in their progress; but otherwise, may be beyond the control of art. A parent, therefore, should make herself familiar with the breathing of her child in health, and she will readily mark any change which may arise.

Of cough I should not have said any thing in this chapter, as it can never fail to be noticed, except that it is highly necessary to throw out one caution. Whenever a child has the symptoms of a common cold, attended by hoarseness and a rough cough, always look upon it with suspicion, and never neglect seeking a medical opinion. Hoarseness does not usually attend a common cold in the child, and these symptoms may be premonitory of an attack of "croup;" a disease excessively rapid in its progress, and which, from the importance of the parts affected, carrying on, as they do, a function indispensably necessary to life, requires the most prompt and decided treatment.

The following observations of Dr. Cheyne are so strikingly illustrative, and so pertinent to my present purpose, that I cannot refrain inserting them:—"In the approach of an attack of croup, which almost always takes place in the evening, probably of a day during which the child has been exposed to the weather, and often after catarrhal symptoms have existed for several days, he may be observed to be excited, in variable spirits, more ready than usual to laugh than to cry, a little flushed, occasionally coughing, the sound of the cough being rough, like that which attends the catarrhal stage of the measles. More generally, however, the patient has been for some time in bed and asleep, before the nature of the disease with which he is threatened is apparent; then, perhaps, without waking, he gives a very unusual cough, well known to any one who has witnessed an attack of the croup; it rings as if the child had coughed through a brazen trumpet; it is truly a tussis clangosa; it penetrates the walls and floor of the apartment, and startles the experienced mother,—'Oh! I am afraid our child is taking the croup!' She runs to the nursery, finds her child sleeping softly, and hopes she may be mistaken. But remaining to tend him, before long the ringing cough, a single cough, is repeated again and again; the patient is roused, and then a new symptom is remarked; the sound of his voice is changed; puling, and as if the throat were swelled, it corresponds with the cough," etc.

How important that a mother should be acquainted with the above signs of one of the most terrific complaints to which childhood is subject; for, if she only send for medical assistance during its first stage, the treatment will be almost invariably successful; whereas, if this "golden opportunity" is lost, this disease will seldom yield to the influence of measures, however wisely chosen or perseveringly employed.



SECT. III.—OTHER CIRCUMSTANCES WHICH WILL ASSIST IN THE EARLY DETECTION OF DISEASE.



1. THE INFLUENCE OF THE SEASONS IN PRODUCING PARTICULAR FORMS OF DISORDER.—The recollection of the fact, that at the different seasons of the year some diseases are more prevalent than at other periods, will greatly aid a judicious parent in the early detection of the presence of disorder, and its kind, in her child.

Thus, in the early part of the winter, what is called catarrh, viz. an increased secretion of mucus from the membranes of the nose, fauces, and air-tubes, with fever, and attended with sneezing and cough, thirst, lassitude, and want of appetite, is generally prevalent.

As the winter advances, the air-tubes of the lungs, and the lungs themselves, are liable to become the seat of disorder; and those signs will present themselves, which have been pointed out in the previous section as characteristic of such attacks.

In the spring, we have still the same diseases prevalent, and in addition, measles, scarlet fever, small-pox, and chicken pox, which increase in liability towards the close of this season, and with the first weeks of summer.

In the summer, disease is less prevalent than at any other period of the year; but towards its middle and close, and through the whole of the autumnal months, bowel complaints may be expected, in the forms of diarrhoea, cholera, and dysentery.

2. THE INFLUENCE OF A HEREDITARY PREDISPOSITION TO CERTAIN DISEASES.— Without entering into this subject at large, still it may be useful to remark, that in some families there is a predisposition to some diseases, which, occurring in the first child, will, as each succeeding child is born, attack at the same age. Amongst other diseases of this class are, croup, hooping-cough, and water in the head.

This observation should not only lead a mother to be alive to the possibility of the successional occurrence of these diseases in her family, and so early note their appearance, and seek medical advice, but should at the same time make her most anxious, on the one hand, to shield her child from all their exciting causes, and on the other, to adopt those measures which may contribute indirectly to overcome the constitutional predisposition to them.

Of the scrofulous constitution, I will merely mention here, that it is of the greatest importance, where a predisposition to this disease exists in a family, that a mother should immediately attend to any alteration in the gait or contour of her child, and give prompt attention also to any complaint made of swelling about a joint, although it may be unattended with pain. The importance of this remark will be seen by contrasting the result of the following cases which occurred in children of the same family.



Case I.

A. B., a female child, having blue eyes, light hair, and a fair complexion, in the early part of the year 1838, being then two years of age, had an enlargement of the left knee joint. For some weeks previous to this time, there had been a degree of heat about the part; but as no pain apparently existed, it was not regarded as of any consequence, and nothing was done. The child, living in the neighbourhood of London, was afterwards placed under medical treatment. Two or three months having elapsed, it was brought to town, and shown to me, in consequence of a slight tumefaction over the lower part of the spine. This soon disappeared under the measures employed, and eventually the disease of the knee (evidently scrofulous) was arrested, so that now the case promises to be cured; but the joint will for ever be stiff, and the limb thus affected shorter than the other.



Case II.

G. B., the brother of the above, a handsome boy, with light hair, fine blue eyes,—indeed, very much like his little sister,—in the year 1836, had enlargements of the glands in his neck, which were relieved by the treatment resorted to.

In April, 1839, being then eight years old, he was observed by his mother to limp slightly in walking, but complained of little or no pain. From the caution, however, which had been given to the parent at the time I was consulted about the previous case, to notice at an early period any symptom of this nature in her children, the fact was immediately attended to. The affection was evidently in the hip; there was imperfection in the gait, and pain upon pressing over the joint. A blister was applied, perfect rest to the limb enjoined, and steel medicines ordered; and in a fortnight the motions of the joint were restrained more effectually by the application of strips of soap plaster and a bandage. In three months the child was ordered to the sea- side, and eventually was able to walk without the slightest limp or pain, and may be said to be quite well.

I would not say that in the first case, if the disease had been discovered early, and at that time met by judicious medical treatment, a stiff knee and shortened limb would have been prevented, although this is my belief; but in reference to the latter case, I have no hesitation in saying, that without the disease had been early detected by the mother, and as promptly attended to by her, the remedial measures might have failed,—certainly the result would not have been so highly satisfactory as it was.



Chap. V.

ON WHAT CONSTITUTES THE MATERNAL MANAGEMENT OF THE DISEASES OF CHILDREN.



The especial province of the mother is the prevention of disease, not its cure. To the establishment and carrying out of this principle, every word contained in the preceding pages has directly or indirectly tended.

This, however, is not all. When disease attacks the child, the mother has then a part to perform, which it is especially important during the epochs of infancy and childhood should be done well. I refer to those duties which constitute the maternal part of the management of disease.

Medical treatment, for its successful issue, is greatly dependent upon a careful, pains-taking, and judicious maternal superintendence. No medical treatment can avail at any time, if directions be only partially carried out, or be negligently attended to; and will most assuredly fail altogether, if counteracted by the erroneous prejudices of ignorant attendants. But to the affections of infancy and childhood, this remark applies with great force; since, at this period, disease is generally so sudden in its assaults, and rapid in its progress, that unless the measures prescribed are rigidly and promptly administered, their exhibition is soon rendered altogether fruitless.

The amount of suffering, too, may be greatly lessened by the thoughtful and discerning attentions of the mother. The wants and necessities of the young child must be anticipated; the fretfulness produced by disease, soothed by kind and affectionate persuasion; and the possibility of the sick and sensitive child being exposed to harsh and ungentle conduct, carefully provided against.

Again, not only is a firm and strict compliance with medical directions in the administration of remedies, of regimen, and general measures, necessary, but an unbiased, faithful, and full report of symptoms to the physician, when he visits his little patient, is of the first importance. An ignorant servant or nurse, unless great caution be exercised by the medical attendant, may, by an unintentional but erroneous report of symptoms, produce a very wrong impression upon his mind, as to the actual state of the disease. His judgment may, as a consequence, be biased in a wrong direction, and the result prove seriously injurious to the welldoing of the patient. The medical man cannot sit hour after hour watching symptoms; hence the great importance of their being faithfully reported. This can alone be done by the mother, or some person equally competent.

There are other weighty considerations which might be adduced here, proving how much depends upon efficient maternal management in the time of sickness; but they will be severally dwelt upon, when the diseases with which they are more particularly connected are spoken of.



Sect. 1.—ACCIDENTS AND DISEASES WHICH MAY OCCUR TO THE INFANT AT BIRTH, OR SOON AFTER.

STILL-BORN.



Sometimes the child comes into the world apparently dead, and, unless the most active exertions are made by the attendants, is lost. The superintendence of the means used devolves upon the medical man; but it would be often well if his assistants were already acquainted with the measures pursued under these circumstances, for they would be more likely to be carried into effect with promptitude and success, than they now frequently are. And again, the still-born child is frequently in this state from having been born very rapidly, and before the medical man can have arrived, it will be more especially useful in such a case, that the attendants in the lying-in-room should know how to proceed.

The various causes producing this condition it is unnecessary to mention.

The condition itself may exist in a greater or less degree: the infant may be completely stillborn, with no indication of life, except, perhaps, the pulsation of the cord, or a feeble action of the heart;—or it may make ineffectual efforts at breathing, or even cry faintly, and yet subsequently perish for want of strength to establish perfectly the process of respiration. Under all these circumstances, a good deal can often be effected by art. In every instance, therefore, in which we have not positive evidence of the child being dead, in the existence of putrefaction, or of such malformation as is incompatible with life, it is our duty to give a fair trial to the means for restoring suspended animation; and as long as the slightest attempt at motion of the respiratory organs is evinced, or the least pulsation of the heart continues, we have good grounds for persevering and hoping for ultimate success.

The measures to be employed to restore a still-born child will be a little modified by the circumstances present.

IF THERE IS NO PULSATION—NO BEATING IN THE CORD, when the child comes into the world, it may at once be separated from the mother. This is to be effected by first tying the navel-string with common sewing thread (three or four times doubled), about two inches from the body of the child, and again two inches from the former ligature, and then dividing the cord with a pair of scissors between the two. And now the means for its restoration are to be made use of, which are detailed below, viz. inflation of the lungs, and perhaps the warm bath. If, with the above circumstances, the child's face be livid and swollen, some drops of blood should previously be allowed to escape before the ligature is applied to that part of the navel-string which is now only attached to the child.

IF THERE IS PULSATION IN THE CORD, BUT RESPIRATION IS NOT FULLY ESTABLISHED, it must not be divided; and as long as pulsation continues, and the child does not breathe perfectly and regularly, no ligature should be applied. The first thing to be done here, is to pass the finger, covered with the fold of a handkerchief or soft napkin, to the back of the child's mouth, to remove any mucus which might obstruct the passage of air into the lungs, and at the same time to tickle those parts, and thereby excite respiratory movements. The chest should then be rubbed by the hand, and a gentle shock given to the body by slapping the back. If these means fail, the chest and soles of the feet must next be rubbed with spirits, the nostrils and back of the throat irritated with a feather previously dipped in spirits of wine, and ammonia or hartshorn may be held to the nose.

INFLATION OF THE LUNGS.—These means not having been successful, and the pulsation in the cord having ceased, the infant must be separated, and inflation of the lungs resorted to. This is to be effected gently and cautiously as follows:—

The child, wrapped in flannel, is to be laid on its back upon a table placed near the fire. Its head is to be slightly extended, and the nostrils held between the fingers and thumb of one hand, whilst with the fingers of the other slight pressure is to be made upon the pit of the stomach, so as to prevent the air from passing into that organ. The lungs of the child are now to be filled with air, by the operator applying his own lips—with a fold of silk or muslin intervening, for the sake of cleanliness—to those of the child, and then simply blowing in its mouth, he is to propel the air from his own chest into that of the infant. Previously, however, to his doing this, he should make several deep and rapid inspirations, and, finally, a full inspiration, in order to obtain greater purity of air in his own lungs.

When the chest of the child has been thus distended, it is to be compressed gently with the hand, so as to empty the lungs; and then the inflation, with the alternately compressing the chest, must be repeated again and again, until either the commencement of natural respiration is announced by a sneeze or deep sigh, or until after long-continued, steady, persevering, but unavailing, efforts to effect this object shall have removed all ground of hope for a successful issue.

Whilst these efforts are being made, some other individual must endeavour to maintain or restore the warmth of the infant's body, by gently but constantly pressing and rubbing its limbs between his warm hands. And after respiration is established, the face must still be freely exposed to the air, whilst the warmth of the limbs and body is carefully sustained.

It will sometimes happen—and to this circumstance the operator should be fully alive—that when the child begins to manifest symptoms of returning animation, its tongue will be drawn backwards and upwards against the roof of the mouth, filling up the passage to the throat, and preventing further inflation of the lungs. This is to be remedied by the introduction of the fore-finger to the upper and back part of the child's tongue, and gently pressing it downwards and forwards, by which the difficulty will be removed, and the air again passes.

THE WARM BATH.—More reliance may be placed upon the above measure to restore animation, than upon the warm bath. Still this is sometimes useful, and therefore must not be neglected. Whilst inflation is going on, the bath may be got ready, then resorted to, and if unsuccessful, inflation may and ought again to be followed up.[FN#28] If the bath is useful at all, it will be so immediately upon putting the infant into it; respiration will be excited, followed by a cry; and if this does not occur at once, it would be wrong to keep the child longer in the bath, as it would be only losing valuable time which ought to be devoted to other efforts. The temperature of the bath should be about 100 degrees; and if, upon plunging the infant into it, it fortunately excite the respiratory effort, it should then be taken out, rubbed with dry but hot flannels, and, when breathing is fully established, laid in a warm bed, or, what is still better, in its mother's bosom; letting it, however, have plenty of air.



[FN#28] We should not relinquish our endeavours at resuscitation under two or three hours, or even longer; and if ultimately successful, the state of the infant should be carefully watched for two or three days.



INJURIES RECEIVED DURING BIRTH.

If a labour be long and tedious, the head and body of the child may be bruised and disfigured.

The shape of the head is frequently altered by the compression it has undergone, so that it may be elongated, and measure from the chin to the back of the head as much as six or seven inches. This always excites surprise, sometimes apprehension, in the minds of the attendants: there is no ground for it. It must be allowed to regain its natural shape without interference.

Tumours or swellings upon the head are very common. They arise from pressure upon the part during the labour. The only treatment that is required, or safe, is, freedom from all pressure, and the application of cold lotions composed of brandy or vinegar and water. The swelling will gradually subside. It will be right to direct the attention of the medical man to this circumstance.

The face may be frightfully disfigured from the above cause, exceedingly black, and the features distorted. Nothing is necessary here; in a few days the face will recover its proper appearance.



RETENTION OF URINE.



Occasionally an infant will not pass any urine for many hours after its birth. This most frequently arises from the fact of none being secreted. In the last case of this kind that I was called to, three days had elapsed since birth, and no urine had been passed; it proved that none had been secreted. Sometimes, however, it is the effect of another cause, which the use of the warm bath will be found to remove, which should always therefore be employed four and twenty hours after the birth of the infant, if it has not by that time passed any water.

It now and then happens, but fortunately very rarely, that some physical obstruction exists. It is always important, therefore, for the nurse to pay attention to the above point; and it is her duty to direct the attention of the medical man to the subject, if anything unusual or unnatural be present. The same observation applies to the bowel also; and if twelve hours pass without any motion, the parts should be examined.



SWELLING OF THE BREASTS.



At birth, or two or three days subsequently, the breasts of the infant will frequently be found swollen, hard, and painful, containing a fluid much resembling milk. Nurses generally endeavour to squeeze this out, and thus do great mischief; for by this means inflammation is excited in the part, and sometimes abscess is the result.

If the breasts are simply slightly enlarged, it is unnecessary to do any thing more than rub them occasionally and very gently with warm almond oil, and a little time will restore them to their proper size.

If, however, they are inflamed, hot, painful, with a red surface, and unusually large, a bread and water poultice must be applied every three or four hours, which will generally prevent either the formation of matter, or any other unpleasant consequence. In a few days, under this treatment, they will usually subside, and be quite well.



INFLAMMATION OF THE EYES.



ITS IMPORTANCE.—About the second or third day after the child's birth, an inflammation sometimes attacks the eye, which is of considerable consequence. The more so, from its commencing in a way not calculated to excite the attention, or alarm the fears, of the mother or nurse. The child cannot express its sensations, and the swelling of the eye conceals the progress of the disease, so that serious mischief is frequently done before the medical man sees the patient. In the first place, the inflammation is not immediately noticed; and, in the second, the measures employed are frequently insufficient to check its progress: hence it causes more blindness (I refer to the lower classes of society more particularly) than any other inflammatory disorder that happens to the eye; and the number of children is very considerable, whose sight is partially or completely destroyed by it. The parent or nurse is apt to suppose, when this inflammation first appears, that it is merely a cold in the eye, which will go off; and the consequences which I have just mentioned take place, in many cases, before they are aware of the danger, and before the medical man is resorted to for assistance.

I only desire, in mentioning this complaint, to inform the attendants of the lying-in-room of its great importance, that it may not be trifled with, that upon its first approach the physician may be informed of it, and that the treatment he directs for its cure may be sedulously and rigidly followed.

SYMPTOMS.—The inflammation commonly comes on about three days after birth, but it may take place at a later period. It may be known by its commencing thus:—When the child wakes from sleep, the eyelids will be observed to stick together a little; their edges will be redder than natural, and especially at the corners; the child experiences pain from the access of light, and therefore shuts the eye against it. A little white matter will also be observed lying on the inside of the lower lid. After a short time, the lids swell, become red on their external surface, and a large quantity of matter is secreted, and constantly poured from the eye; the quantity of discharge increasing until it becomes very great.

But enough has been said to point out the importance of the disease, and the signs by which it may be recognised at its first approach.

TREATMENT.—Keeping the eye free from discharge, by the constant removal of the matter secreted, is what the medical attendant will chiefly insist upon; and without this is done, any treatment he may adopt will be useless; with it, there is no doubt of a successful issue of the case, provided his attention has only been called to it at a sufficiently early period.



HARE-LIP.



This is a blemish too well known to require a formal description. The questions most interesting to a mother in relation to it, are,—How is her child to be nourished, that is born with it? and when ought an operation to be performed for its removal?

THE MODE OF FEEDING THE INFANT.—If the defect is but trifling, the infant will be able to suck, provided the mother's nipple is large, and the milk flows freely from it. If this is not the case, the difficulty may be obviated by using the cork nipple shield.[FN#29] I have known this to answer the purpose admirably, when the mother had previously despaired of nursing her infant, the nipple being too small for it to grasp.



[FN#29] See p. 41.



If, however, the defect exists in a still greater degree, feeding by means of the spoon must be resorted to; the greatest care being necessary as to the quantity, quality, and preparation of the food.[FN#30]



[FN#30] See "Artificial Feeding," p. 34.



CAUTION IN REFERENCE TO THE OPERATION.—With regard to the operation for the removal of this deformity, I would strongly warn parents against desiring its too early performance. Various considerations contribute to make the distressed parents anxious for this. But very seldom indeed—except the deformity be very great, and implicating other parts beside the lip—will the operation be required, or ought it to be resorted to, before the second year and a half of the infant's life; and for this very cogent reasons exist. For instance, convulsions may thus be induced, which often terminate fatally.

The most proper age for removing this deformity by operation, is from that of two years and a half to four years.



BLEEDING FROM THE NAVEL-STRING.



Bleeding from the navel-string will sometime take place hours after it has been supposed to be carefully secured. This will arise, either from the cord being carelessly tied, or from its being unusually large at birth, and in a few hours shrinking so much that the ligature no longer sufficiently presses on the vessels. In either case, it is of importance that the attendants in the lying-in-room should understand how to manage this accident when it occurs, that it may not prove injurious or fatal to the child.

THE MODE OF ARRESTING THE BLEEDING.—The clothes of the child and the flannel roller must be taken off;—the whole cord without delay must be unwrapped, and then a second ligature be applied below the original one, (viz. nearer to the body of the infant,) taking great care that it shall not cut through the cord when drawn very tight, but at the same time drawing it sufficiently tight to compress the vessels.

The ligature should be composed of fine linen threads, three or four thicknesses, and not of tape or bobbin, or any substance of this nature, as it cannot be relied on for this purpose.



ULCERATION OR IMPERFECT HEALING OF THE NAVEL.



The cord separates from the navel generally some time between the fifth and fifteenth day from delivery, and the part usually heals without giving the slightest trouble.

This, however, is not always the case, for sometimes a thin discharge will take place, which, if the part be examined, will be found to proceed from a small growth about the size, perhaps, of a pea, or even less. This must be removed by applying a little powdered alum,—or, if this fail, it should be once or twice slightly touched with blue-stone, and afterwards dressed with calamine cerate.

At other times, though fortunately very rarely, excoriation of the navel and the parts around takes place, which quickly spreads, and assumes an angry and threatening character. If, however, the attention of the medical man is called to it early, it will always do well: until his directions are given, apply a nicely made bread and water poultice.



BLEEDING FROM THE NAVEL.



Sometimes, a day or two after the cord separates, or at the time of separation, bleeding takes place from the navel: fortunately, this very seldom occurs; indeed, it is very rarely met with; and I only mention it, to observe that, upon its occurrence, the point of the finger should be placed over the part, and pressure steadily applied until medical assistance is obtained.

Now and then, in these cases, a growth sprouts up and bleeds. Let this be touched with lunar caustic, or any other astringent application, or let pressure be employed, still it will bleed,—not freely or in a stream, but there will be a constant drain from the part, and the infant, as a consequence, will waste, and be brought to death's door. Excise it, it will only make matters worse. The treatment in this case consists in simply winding a piece of very narrow tape round the growth, and then leaving it untouched. The bleeding will soon cease; the fungus will sprout over the upper margin of the tape; in a very short time it will, as it were, strangle the disease, which subsequently falling off, a complete cure is accomplished.



JAUNDICE.



It frequently happens, during the first or second week after birth, that the skin of the child becomes very yellow, and it has all the appearance of having the jaundice. This gives rise to great distress to the parent when she perceives it, and she becomes very anxious for the medical man's next visit.

Now, ordinarily, it is of no consequence; commonly disappearing spontaneously, and requiring no medical treatment. If, however, it does not go off in two or three days, a tea-spoonful of castor oil should be given once, or oftener, if necessary.

It is, of course, possible for an attack of real jaundice to occur at this early period, and a disease of a very serious nature will then have to be dealt with; but, except as a consequence of malformation (a very infrequent occurrence), it is not likely to arise; and therefore jaundice during the first and second week after delivery need not create alarm.



Tongue-tied.



FROM WHAT IT ARISES.—This arises from the bridle under the tongue being so short, or its attachment to the tongue extended so near the tip, as to interfere with the motions of the organ in sucking, and, in after years, in speaking. It is a rare occurrence, although nothing is more common than for medical men to have infants brought to them supposed to be labouring under the above defect.

HOW ITS EXISTENCE MAY BE DETERMINED.—The best guide for a parent to determine whether it exist or not, is for her to watch whether the infant can protrude the tip of the tongue beyond the lips: if so, it will be able to suck a good nipple readily, and nothing need or ought to be done. No mother will unnecessarily expose her infant to an operation, which, unless very carefully performed, is not altogether unattended with danger; and, if she suspects any defect of this kind to exist, she has only to observe the circumstance mentioned above, to satisfy her mind upon the subject.



MOLES AND MARKS ON THE SKIN, ETC.



The supposed influence of the imagination of the mother, in the production of the above appearances in the texture of the skin of her infant, has been fully discussed in the author's work "Hints to Mothers, etc." This part of the subject is, however, foreign to the present inquiry, which chiefly has reference to the probable effect of their presence upon the health of the child.

They may be divided into two classes: the brownish mole, and claret- stain; and small but somewhat elevated tumours, either of a dark blue, livid colour, or of a bright vermilion hue.

MOLES AND STAINS.—They are of no importance, as far as the health of the infant is concerned. If situated in the face, however, they frequently cause great disfigurement, as the claret-stain, which may be seen sometimes to occupy nearly half the face. But they happily do not increase in size, remaining stationary through life; and as any operation that might be proposed for their removal, would only cause an equal, if not greater, deformity, they ought to be left alone.

COLOURED SPOTS OR TUMOURS.—These vary in their number, size, and situation. The same child is sometimes born with many of them. They may be as small as a pea, or as large as a crown piece. They are not only found on the skin, but on the lips, in the mouth, etc. etc.

These, also, sometimes remain stationary in their size, having no tendency to enlarge, unless, indeed, they are subjected to friction or pressure. But as they frequently require surgical aid, in which case, the earlier the application of remedial measures, the less severe in their kind, and the greater the probability of a speedy and successful result,—so is it always important for the mother early to obtain a medical opinion, that the measure of interference or non-interference may be decided.



Sect. II. DISORDERS OF THE STOMACH AND BOWELS OF THE INFANT.



INDIGESTION, FLATULENCE, VOMITING, GRIPING, AND LOOSENESS.



Disorder of the stomach and bowels is one of the most fruitful sources of the diseases of infancy. Only prevent their derangement, and, all things being equal, the infant will be healthy and flourish, and need not the aid of physic or physicians. Experience daily proves, that a large proportion of the children who die in infancy are lost from derangement of these organs, as the primary cause.

There are many causes which may give rise to these affections; many of them appertain to the mother's system, some to that of the infant. All are capable, to a great extent, of being prevented or remedied. It is, therefore, most important that a mother should not be ignorant or misinformed upon this subject. It is the prevention of these affections, however, that will be principally dwelt upon in this chapter; for let the mother ever bear in mind, and act upon the principle, that the prevention of disease alone belongs to her; the cure to the physician.

For the sake of clearness and reference, these disorders will be spoken of as they occur:—

To the infant at the breast. At the period of weaning. And to the infant brought up by hand.



1. TO THE INFANT AT THE BREAST.



UNHEALTHY MILK.—The infant's stomach and bowels may become deranged from the breast-milk becoming unwholesome.

This may arise from the parent getting out of health, a circumstance which will be so manifest to herself, and to those more immediately interested in her welfare, that it is only necessary just to allude to it here. Suffice it to say, that there are many causes of a general kind to which it may owe its origin; but that the most frequent is undue lactation, a subject to which reference has already been made, and the effects both upon mother and child fully dwelt upon.[FN#31] To cure derangement of the bowels from this cause, a wet-nurse is the only remedy.



[FN#31] See page 15.



Anxiety of mind in the mother will cause her milk to be unhealthy in its character, and deficient in quantity, giving rise to flatulence, griping, and sometimes even convulsions in the infant.[FN#32] A fit of passion in the nurse will frequently be followed by a fit of bowel complain in the child.[FN#33] These causes of course are temporary, and when removed the milk becomes a healthy and sufficient for the child as before.



[FN#32] See page 25.

[FN#33] See page 33.



Sudden and great mental disturbance, however, will occasionally drive away the milk altogether, and in a few hours. A Mrs. S., aet. 21, a fine healthy woman, of a blonde complexion, was confined of a boy in October, 1836. She had a good time, and a plentiful supply of milk for the child, which she continued to suckle till the following January, a period of three months, when her milk suddenly disappeared. This circumstance puzzled the medical attendant, for he could not trace it to any physical ailment; but the milk never returned, and a wet-nurse became necessary. In the following spring the husband of this lady failed, an adversity which had been impending since the date when the breast-milk disappeared, upon which day the deranged state of the husband's affairs was made known to the wife,—a fact which at once explained the mysterious disappearance of the milk.

Unwholesome articles of diet will affect the mother's milk, and derange the infant's bowels. On the 25th May, 1836, I was called to see an infant at the breast with diarrhoea. The remedial measures had but little effect so long as the infant was allowed the breast-milk; but this being discontinued, and arrow-root made with water only allowed, the complaint was quickly put a stop to. Believing that the mother's milk was impaired from some accidental cause which might now be passed, the infant was again allowed the breast. In less than four-and-twenty hours, however, the diarrhoea returned. The mother being a very healthy woman, it was suspected that some unwholesome article in her diet might be the cause. The regimen was accordingly carefully inquired into, when it appeared that porter from a neighbouring publican's had been substituted for their own for some little time past. This proved to be bad, throwing down, when left to stand a few hours, a considerable sediment; it was discontinued; good sound ale taken instead; the infant again put to the breast, upon the milk of which it flourished, and never had another attack.

In the same way aperient medicine, taken by the mother, will act on the child's bowels, through the effect which it produces upon her milk. This, however, is not the case with all kinds of purgative medicine, nor does the same purgative produce a like effect upon all children. It is well, therefore, for a parent to notice what aperient acts thus through her system upon that of her child, and what does not, and when an aperient becomes necessary for herself, unless she desire that the infant's bowels be moved, to avoid the latter; if otherwise, she may take the former with good effect.

Again; the return of the monthly periods whilst the mother is a nurse always affects the properties of the milk, more or less, deranging the stomach and bowels of the infant. It will thus frequently happen, that a few days before the mother is going to be unwell, the infant will become fretful and uneasy; its stomach will throw up the milk, and its motions will be frequent, watery, and greenish. And then, when the period is fully over, the milk will cease to purge. It is principally in the early months, however, that the infant seems to be affected by this circumstance; for it will be generally found that although the milk is certainly impaired by it, being less abundant and nutritious, still, after the third or fourth month it ceases to affect the infant. Is then a mother, because her monthly periods return after her delivery, to give up nursing? Certainly not, unless the infant's health is seriously affected by it; for she will generally find that, as the periods come round, by keeping the infant pretty much from the breast, during its continuance, and feeding him upon artificial food, she will prevent disorder of the child's health, and be able in the intervals to nurse her infant with advantage. It must be added, however, that a wet- nurse is to be resorted to rather than any risk incurred of injuring the child's health; and that, in every case, partial feeding will be necessary at a much earlier period than when a mother is not thus affected.

The milk may also be rendered less nutritive, and diminished in quantity, by the mother again becoming pregnant. In this case, however, the parent's health will chiefly suffer, if she persevere in nursing; this, however, will again act prejudicially to the child. It will be wise, therefore, if pregnancy should occur, and the milk disagree with the infant, to resign the duties of a nurse, and to put the child upon a suitable artificial diet;—if, however, pregnancy should take place before the infant is six month's old, a wet-nurse ought to be procured.

FROM IRREGULAR NURSING.—This is one of the most frequent sources of derangement of the stomach and bowels of the child. The infant that is constantly at the breast will always be suffering, more or less, from flatulence, griping, looseness of the bowels, and vomiting. This is caused by a sufficient interval not being allowed between the meals for digestion. The milk, therefore, passes on from the stomach into the bowels undigested, and the effects just alluded to follow. Time must not only be given for the proper digestion of the milk, but the stomach itself must be allowed a season of repose. This evil, then, must be avoided most carefully by the mother strictly adhering to those rules for nursing which have been already laid down.[FN#34]



[FN#34] See page 5.



FROM TEETHING.—The bowels of the infant at the breast, as well as after it is weaned, are generally affected by teething. And it is fortunate that this is the case, for it prevents more serious affections. Indeed, the diarrhoea that occurs during dentition, except it be violent, must not be subdued; if, however, this is the case, attention must be paid to it. It will generally be found to be accompanied by a swollen gum; the freely lancing of which will sometimes alone put a stop to the looseness: further medical aid may, however, be necessary.

FROM COLD AND DAMP, ETC.—Of course there are other causes besides these already alluded to, giving rise to bowel complaints, during this epoch,—causes not cognisable by the mother, however, and not mentioned therefore here. It is right, however, that she should be aware that these affections are sometimes the result simply of impressions of cold or damp, particularly at certain seasons of the year; in the autumn, for instance, when, as is well known, bowel complaints are very frequent. When thus produced, it is important early to seek medical aid, as inflammation is generally the result.



2. AT THE PERIOD OF WEANING.



There is great susceptibility to derangements of the stomach and bowels of the child at the period when weaning ordinarily takes place, so that great care and judgment must be exercised in effecting this object. Usually, however, the bowels are deranged during this process from one of these causes; from weaning too early, from effecting it too suddenly and abruptly, or from over-feeding and the use of improper and unsuitable food. There is another cause which also may give rise to diarrhoea at this time, independently of weaning, viz. the irritation of difficult teething.

WEANING TOO EARLY.—The substitution of artificial food for the breast- milk of the mother, at a period when the digestive organs of the infant are too delicate for this change, is a frequent source of the affections now under consideration.

The attempt to wean a delicate child, for instance, when only six months old, will inevitably be followed by disorder of the stomach and bowels. Unless, therefore, a mother is obliged to resort to this measure, from becoming pregnant, or any other unavoidable cause, if she consult the welfare of her child, she will not give up nursing at this early period. But if she should be no longer competent to suckle, and her infant be delicate, a wet-nurse must be obtained; for, the infant's bowels becoming disordered, medicine or remedies will avail little without healthy breast milk.

The age at which weaning ought to take place must ever depend upon circumstances; the ninth month would not be too early for some, the twelfth would be for others.[FN#35]



[FN#35] See page 51.



FOR SUDDEN AND ABRUPT ALTERATION OF DIET.—Depriving the child at once of the breast, and substituting artificial food, however proper under due regulations such food may be, will invariably cause bowel complaints. Certain rules and regulations must be adopted to effect weaning safely, the details of which are given elsewhere.[FN#36]



[FN#36] See page 52.



OVERFEEDING, AND THE USE OF IMPROPER AND UNWHOLESOME FOOD.—These causes are more productive of disorder of the stomach and bowels at the time of weaning than any yet referred to.

If too large a quantity of food is given at each meal, or the meals are too frequently repeated, in both instances the stomach will become oppressed, wearied, and deranged; part of the food, perhaps, thrown up by vomiting, whilst the remainder, not having undergone the digestive process, will pass on into the bowels, irritate its delicate lining membrane, and produce flatulence, with griping, purging, and perhaps convulsions.

Then, again, improper and unsuitable food will be followed by precisely the same effects; and unless a judicious alteration be quickly made, remedies will not only have no influence over the disease, but the cause being continued, the disease will become most seriously aggravated.

It is, therefore, of the first importance to the well-doing of the child, that at this period, when the mother is about to substitute an artificial food for that of her own breast, she should first ascertain what kind of food suits the child best, and then the precise quantity which nature demands. Many cases might be cited, where children have never had a prescription written for them, simply because, these points having been attended to, their diet has been managed with judgment and care; whilst, on the other hand, others might be referred to, whose life has been hazarded, and all but lost, simply from injudicious dietetic management. Over-feeding, and improper articles of food, are more frequently productive, in their result, of anxious hours and distressing scenes to the parent, and of danger and loss of life to the child, than almost any other causes.

TEETHING.—The irritation caused by difficult teething may give rise to diarrhoea at the period when the infant is weaned, independently of the weaning itself. Such disorder of the bowels, if it manifestly occur from this cause, is a favourable circumstance, and should not be interfered with, unless indeed the attack be severe and aggravated, when medical aid becomes necessary. Slight diarrhoea then, during weaning, when it is fairly traceable to the cutting of a tooth (the heated and inflamed state of the gum will at once point to this as the source of the derangement), is of no consequence, but it must not be mistaken for disorder arising from other causes. Lancing the gum will at once, then, remove the cause, and generally cure the bowel complaint.



3. TO THE CHILD BROUGHT UP BY HAND.



Children brought up on an artificial diet are very liable to indigestion and bowel complaints; indeed none more so: and it is from these affections that so many of these infants perish. When, then, it is absolutely necessary from untoward circumstances to have recourse to this mode of nourishing the child, the rules and regulations laid down in the section on "Artificial Feeding" must be most strictly followed out, if the parent would hope to avoid disease and rear her child.[FN#37] And if these affections should at any time unfortunately manifest themselves, the mother ought carefully and diligently to examine whether the plan of feeding pursued is in every particular correct, particularly bearing in mind that the two causes most frequently productive of disorder in the child are overfeeding and the exhibition of unsuitable food—the two grand errors of the nursery. These results, however, have already been sufficiently dwelt upon as likely to take place at weaning, and they may of course occur to a child who is brought up on an artificial diet at any period.



[FN#37] See page 34.



MATERNAL TREATMENT OF THE DISORDERS OF THE STOMACH AND BOWELS.



As must have been already seen, the maternal treatment chiefly consists in the removal of the cause of the disorder; medicine may occasionally be exhibited by the mother, but its use in her hands must be very limited indeed.

Unfortunately the general resource and only remedy of most mothers in affections of the stomach and bowels is an aperient, and a combination containing calomel is the one too frequently selected. The primary cause of the disorder is undetected, and consequently no measures taken for its removal, but purgative powder after purgative powder is given, the evil being supposed to rest in the bowels alone, and that such means must eventually get rid of it. The mother is not aware all this time that the real source of the derangement is probably in the diet itself; that there is some error here, and that unless this is corrected, the remedies must be worse than useless. The consequence of such a plan of proceeding is usually very sad; a confirmed and obstinate diarrhoea but too commonly ensues, and the infant is sometimes reduced to the last extremity.

The removal of the cause of the disorder, then, in a large number of instances of derangement of the stomach and bowels, if effected early, will cure the disease, and without further remedy. But it will be asked, by what method is this cause to be detected? In this way. In all human probability the primary cause of the disorder is connected with the diet; this is the case in ninety-nine instances out of a hundred. Well, then, is the sick child at the breast? If so, ascertain whether the breast-milk is healthy and wholesome, or whether any circumstances exist which have rendered it otherwise? If nothing faulty is found here, the next question would naturally be, whether the rules and regulations laid down for suckling have been strictly adhered to? Or, whether the infant is sufficiently old to render it at all probable that a tooth may be irritating the gum?

Perhaps the child is being weaned; well, is there any error here? Is the change being attempted too early? or too suddenly and abruptly? If this is not the case, then, has the child been overfed, or is the food given of the proper description?

Is the child being brought up by hand? Then, there is every reason to suspect, either that the quality of the food given is not the most suitable, or, that the quantity exhibited is too great; in fact, that the rules laid down for "artificial feeding" have not been strictly acted upon.

By a mode of investigation like this, any defect or error in the dietetic management of the infant producing the disorder will be easily detected by a careful mother; and its correction alone will, in very many instances, be all that is necessary to remove the symptoms.

For example, if flatulence and griping, followed by diarrhoea, occur to an infant at the breast; if at the same time it becomes pale, its flesh flabby, its disposition fretful, always crying until it is put to the breast, the nipple of which it grasps eagerly, sucking eagerly, yet never satisfied, for its hunger continues, it is not nourished; if, too, the more it sucks, the more the stomach and bowels are deranged, the more it vomits and is purged; depend upon it the cause of all the evil will be found to be unwholesome milk. No medicine will avail any thing here; the cause must be removed; the best medicine, and the only remedy, is a breast of healthy milk. And if this is not procured early, there will be great danger of a diarrhoea setting in, which may probably prove fatal to the child.

Again; if there is simply vomiting of the breast-milk almost immediately after the child has been suckled, the milk coming up pure and unchanged, and discharged without any apparent effort, and the moment after the child is cheerful and happy, this will be found to depend upon repletion, and not upon unwholesome milk; in fact, the stomach has received too much. This must be prevented in future, not by giving medicine, but simply by removing the infant from the nipple immediately it ceases to draw strongly, the moment it begins to dally with the breast.

Again; if flatulence and griping occur to the child brought up by handy this derangement will generally be found to result from overfeeding: abstinence and diminution of the quantity of the food will generally be all that is necessary here. It will be well, however, for the mother in this case, and she may do it with the utmost safety, to unload the bowels of their indigestible contents by the exhibition of a tea-spoonful of castor oil. A dose or two of this medicine will effectually clear them out, without increasing the irritation, or weakening the child, whilst it will in most instances altogether remove the symptoms. If the flatulence, however, should continue, four or five grains of magnesia may be mixed with the last meal at night, and a little warm water thrown up into the bowel as an injection the next morning.

Diarrhoea occurring in a child brought up by hand, if it be not the result of overfeeding, will very frequently be found to arise from unsuitable diet, the food given not being of a kind suited to the infant's stomach; for what will agree with one child often disagrees with another. Alteration of diet will sometimes alone suffice in these cases to cure, if this alteration is only made early enough, before any considerable irritation of the stomach and bowels has been induced. Thin arrow-root made with water (prepared very carefully, or the child will refuse it,) should be given for five or six days; the warm bath used every night for the same period, a new flannel bandage rolled round the body, and the child cautiously protected from a damp atmosphere. The arrow-root, upon the cessation of the diarrhoea, may have cows' milk added to it, if milk is not found to disagree: when this is the case, chicken or weak mutton broth, free from fat, or beef- tea, thickened with farinaceous food, with a little salt added, are the best substitutes. Should not the diarrhoea yield to the foregoing measures, and that readily, medical aid ought to be sought. Diarrhoea is very frequent from the time of weaning to the third year of age, and certainly in its effects forms so important a disease, that, unless in the slight form noticed above, a mother is not justified in attempting its relief.

In conclusion, I would observe, that I do not think a mother justified in attempting more than what has been laid down here for her guidance. It is believed that the few and plain common-sense directions given, if followed, will do much to prevent disease, and even to relieve it in its milder forms; they will not, however, cure disease itself when really established: and again I would repeat, let the mother recollect that to prevent disease is her province—to cure it, is the physician's.



Sect. III.—COSTIVENESS.



1. IN INFANCY.



The principle to act upon in the management of the infant's bowels is this,—that they should be kept free, and by the mildest and least irritating means.

If therefore they become accidentally confined (less than two stools in the four-and-twenty hours), and the infant is suckled, the mother may ascertain whether an aperient taken by herself will render her milk of a sufficiently purgative quality to act upon the bowels of her child. This is the mildest mode of all.

If, however, this does not answer, or is not practicable from the child being fed artificially, then the mildest aperient medicines must be chosen to accomplish this purpose. The kind of medicine to be selected, and the doses in which to be adminstered, will be found in the section on "Aperient Medicine."[FN#39]



[FN#39] See page 97.



If, however, the bowels of the infant are disposed to be habitually confined, it should be ascertained whether this may not be dependent upon its diet. The same food that agrees perfectly well with one child will frequently cause costiveness in another. An intelligent and observing mother will soon discover whether this is the source of the mischief, or not. Boiled milk, for instance, will invariably cause confined bowels in some children; the same result will follow sago boiled in beef tea, with others; whilst, on the other hand, the bowels may frequently be brought into regular order, and their confined state overcome, by changing the food to Leman's tops and bottoms steeped in hot water, and a small quantity of unboiled milk added; or prepared barley, mixed in warm water and unboiled milk, will have the same effect.

Sometimes children are constitutionally costive, that is, the bowels are relieved every third or fourth day, not oftener, and yet perfect health is enjoyed. This occasionally will happen in large families, all the children, though perfectly healthy and robust, being similarly affected. When such is found by a mother to be really the habit of her child, it would be very unwise, because injurious to its health, to attempt by purgatives to obtain more frequent relief. At the same time it will be prudent and necessary for her to watch that the regular time is not exceeded. This condition seldom occurs to the very young infant.



2. IN CHILDHOOD.



Children of sound health, who are judiciously fed, and have sufficient exercise, very seldom need aperient medicine. Errors in diet, a want of proper attention to the state of the skin, insufficiency of air and exercise, in fine, a neglect of those general principles which have been laid down for the management of health, and upon the observance of which the due and healthy performance of every function of the body depends, are the sources of bowel derangements, and particularly, at this age, of costiveness.

I feel assured, however, that some children are more troubled with costiveness than others, from the simple but important circumstance of their not being early taught the habit of relieving the bowels daily, and at a certain hour. There is a natural tendency to this periodical relief of the system, and it exists at the earliest age. And if the mother only cause this habit to be fairly established in infancy, she will do much towards promoting regularity of her child's bowels throughout life. The recollection of this fact, and the mother's acting upon it, is of the greatest importance to the future health and comfort of her children.

If the bowels are accidentally confined at this age, castor oil is certainly the best aperient that can be given: it acts mildly but efficiently, clearing out the bowels without irritating them. The dose must be regulated by the age, as also by the effect that aperients generally have upon the individual. Great care must in future be taken to avoid the cause or accidental circumstance which produced the irregularity.

When the bowels are habitually costive, much care and judgment is necessary for their relief and future management. Fortunately this condition is very rare in youth. The activity and exposure to the air, usual at this period of life, render purgatives unnecessary, unless, indeed (as just mentioned), some error in diet, or some unusual circumstance, render them accidentally confined. Should, however, the foregoing state exist, medicine alone will avail little; there are certain general measures which must also be acted up to, and most strictly, if the end is to be accomplished. They consist, principally, in an observance of great regularity with respect to the time of taking food, its quality, quantity, and due mastication; regular and sufficient exercise, horse exercise being particularly serviceable; the shower-bath, or daily ablution; early rising (the indulgence in the habit of lying in bed always predisposing to constipation); and, lastly, the patient habituating himself to evacuate the bowels at a certain hour of the day. After breakfast appears to be the time when the bowels are more disposed to act than at any other part of the day; this is the time, then, that should be chosen.

All these points must be sedulously observed, and upon the principles laid down in the various chapters upon these subjects, if habitual costiveness is expected to be overcome.



SECT. IV.—WORMS.



NOT SO FREQUENT AS POPULARLY SUPPOSED; AN ERROR PRODUCTIVE OF MISCHIEF.—Almost all diseases have been, at one time or other, attributed to the generation of worms in the intestines. And at the present day it is not at all an uncommon occurrence for medical men to be called in to prescribe for children, to whom the strongest purgative quack medicines have been previously exhibited by parents, for the removal of symptoms which, upon investigation, are found in no way connected with or produced by worms. The results of such errors are always, more or less, mischievous, and sometimes of so serious a nature as to lay the foundation of disease which ultimately proves fatal. This observation, moreover, it behoves a mother carefully to regard, since the symptoms, popularly supposed to indicate the existence of worms, are so deceptive, (and none more so than that which is usually so much depended upon—the picking of the nose,) that it may be positively asserted to be impossible for an unprofessional person to form a correct and sound opinion in any of these cases.

It was at one time imagined, and the idea is still popularly current, that worms were the occasion of a troublesome and lingering species of fever, which was therefore designated worm-fever. This notion is now entirely exploded; for if worms be present under such circumstances, it is a mere accidental complication; the fever referred to being generally of a remitting character, and neither caused by or causing the generation of worms. The symptoms of this fever, however, have led and continue to lead very many astray. This is not surprising, since they so closely resemble those which characterise the presence of worms, that an unprofessional person is almost sure to be misled by them. Amongst other symptoms, there is the picking of the nose and lips, offensive breath, occasional vomiting, deranged bowels, pain in the head and belly, with a tumid and swollen condition of the latter, a short dry cough, wasting of the flesh, etc.; symptoms continually attendant upon the disorder now under consideration. These cases have hitherto been perpetually looked upon by mothers as worm-cases, and after having been treated by them as such, by the use of the popular worm-powders of the day, have, as perpetually, presented themselves to the physician greatly and grievously aggravated by such injudicious treatment. It is folly, at any time, for an unprofessional person to prescribe for a case where worms are actually known to exist: surely where there is any doubt upon the latter point it must be greater folly still.

The infant at the breast is seldom, if ever, the subject of this disorder, whilst an artificial diet, or bringing up by hand, predisposes to it. Worms most frequently occur, however, during childhood; much more so at this epoch than in adult age. They do not invariably occasion indisposition, for they are now and then passed without pain or distress by children who are in the enjoyment of perfect health, and in whom previously there was not the slightest suspicion of their existence. The idea, formerly so prevalent, of their being attended with danger, is without foundation; for unless the case be mismanaged, they rarely give rise to serious consequences.

HOW PRODUCED, AND HOW BEST PREVENTED.—The causes of worms it is not very easy to explain; at the same time it is very certain that some known circumstances favour their production.

If the general health of a child be enfeebled, particularly if the child be strumous, such a condition will favour the generation of these animals. The protracted use of unwholesome and innutritious articles of food, or a deficient supply of salt (the most necessary stimulant to the digestive organs), or other condiments, predisposes to worms. This observation is strikingly illustrated by an occurrence which formerly took place in Holland, where an ancient law existed forbidding salt in the bread of certain criminals; they were in consequence horribly infested with worms, and quickly died. Sugar, too, whilst a necessary condiment for the food of children, if given in the form of sweetmeats, and their indulgence, long persisted in, may so enfeeble the organs of digestion as to cause worms. And, lastly, (though many other causes might be referred to) the injudicious means occasionally employed to effect the removal of these animals, by the debility produced in the intestinal canal, favours not only their re-appearance but their increase.

These, then, are so many causes which may occasion worms in the child, and of course the best and most effectual method to prevent their production is their avoidance. A mother, therefore, should at all times be careful in the regulation of the diet and general management of her child's habits and health, even if no stronger obligations existed than the dread of this disorder; and she must be more than ordinarily vigilant on this head, when the slightest disposition to such disorder is manifested. Again; she must not forget that the symptoms so commonly ascribed as characteristic of worms are much more frequently caused by other diseases; that at no time, therefore, is she justified in giving worm powders, or strong doses of medicine for such symptoms; for if they do exist, their use is always attended with risk, and if they do not, the debility which they occasion in the stomach and bowels may itself become the source of their production.



Sect. V. SCARLET FEVER.



There are several varieties of this disease; it will be more perspicuous, however, for our purpose to speak of it under the two following forms:—

Mild scarlet fever;

Scarlet fever, with sore throat.



MILD SCARLET FEVER.—In this form of the disease there is only the rash with fever.

SYMPTOMS.—The anticipating symptoms are those of fever: they precede the eruption. The degree of fever, however, is variable; for the symptoms are sometimes so moderate as scarcely to attract attention, slight and irregular shivering, nausea, perhaps vomiting, thirst, and heat of skin; whilst, at others, there is considerable constitutional disturbance, indicated by pungent heat of skin, flushing of the face, suffusion of the eyes, pain in the head, great anxiety and restlessness, and occasionally slight delirium.

These symptoms are followed on the second day (in the majority of instances) by the rash. This first appears in numerous specks or minute patches of a vivid red colour on the face, neck, and chest. In about four-and-twenty hours it becomes gradually diffused over the whole trunk. On the following day (the third) it extends to the upper and lower extremities, so that at this period the whole surface of the body is of a bright red colour, hot and dry. The efflorescence, too, is not always confined to the skin, but occasionally tinges the inside of the lips, cheeks, palate, throat, nostrils, and even the internal surface of the eyelids. Sometimes the efflorescence is continuous and universal; but more generally on the trunk of the body there are intervals of a natural hue between the patches, with papulous dots scattered over them, the colour being most deep on the loins and neighbouring parts, at the flexure of the joints, and upon those parts of the body which are subjected to pressure. It is also generally most vivid in the evening, gradually becoming paler towards morning.

The eruption is at its height on the fourth day;—it begins to decline on the fifth, when the interstices widen, and the florid hue fades;—on the sixth, the rash is very indistinct; and on the eighth day it is wholly gone.

The various symptoms with which the eruption is accompanied, gradually disappear with the efflorescence; but the tongue still remains morbidly red and clean. The peeling off of the cuticle (the outer layer of the skin), which begins about the end of the fifth day on the parts on which the eruption first appeared, proceeds; so that about the eighth or ninth, portions of the cuticle are thrown off, the thickest and largest being those detached from the skin of the hands and feet.



SCARLET FEVER, WITH SORE THROAT.—In this form of the disease, the fever and rash are accompanied with inflammation of the throat.

SYMPTOMS.—The symptoms are more severe than in the mild form of this disease, and, in the majority of instances, the inflammation of the throat appears with the eruption, and goes through its progress of increase and decline with the cutaneous eruption. Sometimes, however, it precedes the fever; whilst at others it does not appear until the rash is at its height.

It is generally in the course of the second day that the child complains of considerable stiffness in the muscles of the neck, extending to the lower jaw, and under the ears;—of a roughness of the throat, and difficulty in swallowing;—and some degree of hoarseness will be noticed: all so many indications that the throat is affected. Very shortly, an increased secretion of the mucus of these parts occurs, and, collecting about the tonsils, aggravates the child's sufferings, from the frequent and ineffectual efforts made to expel it. If the inflammatory action be more severe, exudations of lymph will also be poured out, and intermingling with the mucus, greatly augment the difficulty of swallowing. At this time the lining membrane of the mouth, as also the tongue, assume a florid red colour; the red points of the latter becoming much elongated.

The febrile symptoms are severe from the first; amongst others, there will be headach, sometimes accompanied by slight delirium, nausea, intense heat of skin, languor, and considerable inquietude and anxiety: and as the inflammation approaches its height, the fever increases, the pulse rises, the breathing becomes oppressed, the skin becomes more pungently hot and dry, and the thirst urgent. All these symptoms being increased towards evening, when the febrile restlessness is often succeeded by delirium.

The rash is seldom perceptible before the third day, and then comes out in irregular patches on various parts of the body, particularly about the elbows and wrists; thus differing as to the time and mode of its appearance, from the mild form of the disease. It frequently recedes, or entirely vanishes, the day after it first comes out, and then reappears partially, and at uncertain times. This generally protracts the duration of the disorder, without, however, producing any perceptible change in the other symptoms. On the fifth or sixth day of the disease, the fever and inflammation of the throat begin to abate; at the same time the rash declines, and the peeling off of the cuticle soon follows.

This is the ordinary course of scarlet fever with sore throat; but in many cases the symptoms run still higher, and the disease is alarmingly dangerous from its commencement. In some instances, there is an acrid discharge from the nostrils or ears, often accompanied with deafness; as also enlargements of the glands in the neck, followed by the formation of abscesses in their immediate neighbourhood. It is unnecessary, however, to follow out the symptoms of scarlet fever more fully; as all that has been attempted here, has been so to sketch out the more prominent symptoms of this disease, that the directions upon the parental management may be readily comprehended: they will be very brief, but a strict attention thereto will be found all-important to the well-doing and comfort of the child.

CHARACTER OF SCARLET FEVER COMPARED WITH THAT OF MEASLES.—It will be seldom difficult to distinguish this disease from other acute eruptive disorders. The one to which it bears the greatest resemblance is the measles; but from this it is readily distinguished by the absence of the cough, the inflamed and watery eye, running at the nose and sneezing, which are the predominant symptoms in the early stage of the measles; but which do not usually attend on scarlet fever—at least, in any high degree. In measles, also, there is an absence of that restlessness, anxiety, and depression of spirits, by which scarlet fever is peculiarly distinguished.—The rash, too, in measles, does not appear till two or three days later than that of scarlet fever. It also differs in its characters. In scarlet fever, the eruption consists of innumerable minute dots or points, diffused in patches with uneven edges of various sizes and forms; and gives to those portions of the skin on which it appears, a diffused bright red colour. In measles, the rash comes out in irregular semi-lunar or crescentic shaped patches, distinctly elevated; the spots being of a deeper red in the centre than in the circumference, and leaving intervening spaces in which the skin retains its natural pale colour.

MATERNAL MANAGEMENT.—The chief points to which the parent's attention must be directed, irrespective of a strict attention to the more immediate medical treatment directed by the physician, are the following:—

VENTILATION OF THE BED-ROOM.—Even in the mildest cases, the child must be kept in bed from the first accession of the fever. He must not be loaded, however, as was formerly the practice, with a quantity of bed-clothes, in order to encourage the fever and increase the quantity of eruption. A moderate quantity of clothing is all that is required, adapted to the heat of skin and feelings of the patient.

The bed-room must be kept cool and well ventilated. This is of importance in the mildest cases; but in the more severe forms of this disease, in which the throat is much affected, the constant and free admission of pure air will have a most decided and marked good effect upon the symptoms. The air should be renewed, therefore, from time to time. The linen, both of the bed and the patient, should also be frequently changed daily,—if practicable.

However mild the symptoms of this disease may be at the commencement, the child must always be carefully and vigilantly watched by the parent, as inflammation of some internal organ may suddenly arise (which is generally indicated by symptoms sufficiently obvious), and thus change an apparently mild form of this disease into one of an alarming character.

COLD SPONGING.—Whenever the skin is pungently hot and dry, the whole surface of the body should be sponged with cold water, or with vinegar and water. The heat is by this means rapidly abstracted, and the child refreshed; and this may again and again be resorted to, as the heat again returns. By this application alone, "the pulse has been diminished in frequency, the thirst has abated, the tongue has become moist, a general free per spiration has broken forth, the skin has become soft and cool, and the eyes have brightened; and these indications of relief have been speedily followed by a calm and refreshing sleep. In all these respects, the condition of the patient presented a complete contrast to that which preceded the cold washing; and his languor was exchanged for a considerable share of vigour. The morbid heat, it is true, when thus removed, is liable to return, and with it the distressing symptoms; but a repetition of the remedy is followed by the same beneficial effects as at first."[FN#40]



[FN#40] Bateman's Practical Synopsis of Cutaneous Diseases.



GARGLES AND THE INHALATION OF WARM WATER.—When the throat is affected, gargles are sometimes ordered; but the pain and inconvenience which their employment gives rise to, frequently precludes their use: and children seldom understand how to employ them, even if the state of the throat permitted it. Under these circumstances, the inhalation of the steam of hot water, or hot vinegar and water, may be substituted, and with decided benefit. Mudge's inhaler is a good contrivance to effect this.

When the throat is found by the mother to be early affected, an immediate application to the medical adviser is especially important. For, if he be called upon to treat this form of scarlet fever at its very commencement, by judicious treatment, the duration and violence of the disease may be both shortened and greatly mitigated.

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