The Mother's Manual of Children's Diseases

It depends entirely on the parents whether, for the sake of a very great but far-off good, they will strictly observe these rules. The difficulty will not arise on the child's part, for it is not hard for those who have had charge of it from babyhood to bring it up to quiet pursuits and quiet amusements, till it seeks no others, and, like the little cage-bred bird, does not care to emulate the flight of others stronger on the wing.

Inflammation of the Heart.—The above remarks do not comprise all that is to be said about heart-affection in early life. Inflammation may attack the investing or the lining membrane of the heart at all ages, may produce in the child the same suffering as in the grown person, and may tend to destroy life in a similar manner. The causes, indeed, which produce heart disease, are far more frequent in the grown person than in the child, and advancing age brings with it changes which, wholly apart from active inflammation, produce grave forms of disease unknown in early life. There is, however, one cause of heart disease which is far more frequent in childhood and early youth than in later life, namely, rheumatism. Eight out of ten of all cases of heart disease under the age of fifteen are of rheumatic origin, and in eighteen out of twenty cases of acute rheumatism under that age, whether slight or severe, the heart becomes more or less involved. Now and then, though rarely, the heart becomes affected in the course of scarlatina, and still more seldom in the course of the other fevers, and every now and then affection of the heart is associated with some other form of inflammation of the chest.

Pain is by no means a constant attendant on it, but fever, more or less considerable, a quickened pulse, and hurried breathing are all but invariable, and one great reason for seeking the immediate help of the doctor is, that his skilled ear may at once detect by the altered sounds the heart-affection at its very outset, and employ the measures calculated to arrest its progress.

Death in the acute stage of a first attack of inflammation of the heart is of extreme rarity, but the damaged heart is liable to returns of acute mischief, any one of which may prove fatal. Independently of this, life with diseased heart is one of suffering, attended as it is by symptoms similar in kind, though not identical with those which I have already mentioned as attendant on malformation of the organ.

The hopeful element, however, to which I have already referred as present in cases of malformed heart, exists here in even a greater degree; since repair of injury is possible, while the reconstitution of an organ faulty from birth is obviously beyond nature's power.

I can but repeat the directions already given as to the importance of allowing the heart as much rest, and giving it as little work, as is possible with a never-resting organ; and this with the added motive for perseverance furnished by the happy issue which may be hoped for as its reward.

One word I must add about the occasional occurrence of irregular action of the heart during the years of growth, especially from the age of ten to fourteen. This is often quite independent of any disease, and ceases when with added strength the nervous system becomes less impressionable.

CHAPTER VIII.

DISEASES OF THE ORGANS OF DIGESTION

Manner of Performance of Digestion.—The organs situated in what is called in medical language the abdomen, have in the child no other duty to perform than such as subserve the processes of digestion and nutrition. The saliva secreted by the appropriate glands in the mouth, mixing with the food, facilitates the further changes which take place in the stomach. In the stomach the food is acted on and dissolved by the gastric juice or pepsin, which is poured out by an almost infinity of minute tubes, or follicles as they are termed. When the stomach has done its work, its contents in a semi-fluid state pass into the small intestine, and mix there with the bile, the secretions from the intestines themselves, and with those of the large gland, the pancreas (in culinary language known as the sweetbread), which seems to have the special power of dissolving fatty matters. As the food, thus acted on, travels along the intestines, whose constant movement facilitates the passage of their contents from above downwards, its elements are taken up, partly by the blood-vessels, partly by innumerable small vessels, called absorbents from their power of imbibing fluids, and lacteals, from the milky hue of the fluid within them when first absorbed. The fluid taken up by the blood-vessels is conveyed to the liver; that taken up by the absorbents to the mesenteric glands, and in these organs further changes take place in it, which fit it to be received into the mass of the circulating fluid. With this it is carried to the right side of the heart, and thence to the lungs and, lastly, from them to the left side of the heart, whence it is distributed, the great life and health giver, to the rest of the body. The useless inconvertible material, leaving every available element behind, is got rid of, either in a solid form by the bowels, or in a fluid form by the kidneys; and thus as long as life lasts there goes on more or less perfectly the wonderful process of constant change, of constant renewal, and during childhood and youth, of constant increase of size and stature.

Incomplete as this sketch is, it may yet suggest how readily one part of this complex machinery may be thrown out of gear, and further how not one part can suffer without all being disordered. Solid food given to the child before it has cut its teeth, enters the stomach unreduced to pulp by the grinders, and unmixed with the saliva, which should help its solution, and which the undeveloped salivary glands do not yet furnish. Too large a quantity of food, or food of an unsuitable character, on which the gastric juice cannot act readily, may pass into a state of fermentation; vomiting, flatulence, sour and offensive breath will be the result, and the food will pass into the intestine unprepared to be acted on by the bile. Exposure to cold, or the opposite condition of excessive heat, may disturb the action of the liver, and interfere with the secretion of bile; and the food will then pass along the intestine in a state unsuitable for absorption. Or, again, the mesenteric glands may be irritated by long-continued imperfect performance of the earlier stages of digestion, or their structure may be altered, and mesenteric disease, or consumption of the bowels, as it has been termed, may result. From want of muscular power, or from want of care on their part who have charge of the child, the bowels may become habitually constipated. Health will then suffer, if the child carries about with it for days together matters which can serve no useful purpose, but which are to the body what an ill-kept dustbin is to the rest of the house. Lastly, if the kidneys perform their duties imperfectly in consequence of exposure to cold, or of the changes which some diseases, such as scarlatina, sometimes bring about in their structure, the blood will be imperfectly purified; dropsy and various forms of inflammation may result; or the brain and nervous system may be disordered, and death in convulsions may attest the dangerous nature of this blood-poisoning.

It would take too long to go in detail through all the phases of disordered digestion in early life. Much has been already anticipated in a former part of this book, especially with reference to the troubles of digestion in infancy and early childhood. There is, indeed, but one form of indigestion whose characters are so special as to require that I should enter into any detail with reference to it.

Dyspepsia of Weakly Children.—Children from the age of about three to ten years, whose health has been impaired by an attack of typhoid, or, as it is commonly called, infantile remittent fever, or who belong to a weakly family, or to one, some of whose members have shown a disposition to consumptive disease, are sometimes martyrs to indigestion. It does not need with them any special error of diet, or any casual exposure to cold to disorder their digestion; but every two or three weeks, even under the most scrupulous care, they lose their appetite, their tongue becomes thickly coated with yellow fur, their breath offensive, their bowels constipated, the evacuations being either very white or very dark, and frequently lumpy, and coated with a thin layer of mucus from the bowel, which also appears in shreds at the bottom of the utensil. With this condition, too, there is some, though not considerable, feverishness, and the urine becomes turbid on cooling, and throws down a reddish-white deposit, which disappears if heated. At the end of two or three days of rest in bed, of a diet of beef-tea and milk, with no solid food, with simple saline medicines, mild aperients, and perhaps a single small dose of calomel, the symptoms pass off; but return again and again at uncertain intervals, and without any obvious cause.

In these cases, the children almost always, when in their ordinary health, have a peculiar patchy condition of the tongue, one part of it being covered with a thin white coating, through which little red points project, while another part is of a vivid red, and looks raw and shining, as though it had been scalded, while the red points, or the papillæ, as they are termed, project above its surface like so many pins' heads. Children in whom this condition exists, require much watching and much care. I have dwelt upon it in order to impress on parents the conviction that it is not a state to be cured, once for all, even by the most skilful doctor, but that years are needed to eradicate a bad habit of the body, as much as to cure a bad habit of the mind.

Jaundice.—I have already spoken of the jaundice of new-born infants; but a sluggish condition of the liver, accompanied by very white or pale evacuations, constipation, and loss of appetite, with a sallow tint of the skin, and sometimes even with actual jaundice, are by no means uncommon during the first ten years of childhood. Neither condition is serious; that of actual jaundice occurs mostly in the summer, and is then connected with the sudden onset of hot weather. When severe, it may be associated with some degree of feverishness, with dizziness, and complaint of headache, and occasionally with vomiting, while the child rests ill at night, or awakes in a state of alarm, and these symptoms sometimes give rise to the fear that the child is about to be attacked by water on the brain. But the following consideration may serve to calm anxiety on that score. The attack is not preceded, as water on the brain is almost invariably, by several days or even weeks of failing health. It is not attended by heat of head, nor by intolerance of light, nor by constant nausea; and the belly is full rather than shrunken. When to these symptoms are added tenderness on the right side, high-coloured urine and white evacuations, you may set your mind at rest, even before the yellow colour of the skin, which appears in a day or two, stamps the case unmistakably as one of jaundice.

My business is, as I have said more than once, the endeavour to describe the symptoms of disease, to explain their nature, to indicate the principles to be observed in attempting their cure, and not to lay down definite rules for their treatment, with the idle expectation that I could thus enable every mother to be her children's doctor.

Diarrhœa.—I have, therefore, comparatively little to say about diarrhœa in children, important though it is, for its symptoms force themselves on the notice even of the least observant. There are, however, a few points concerning it worth bearing in mind. Before the commencement of teething, diarrhœa is almost always the result of premature weaning, or of a diet in some respect or other unsuitable. As soon as teething begins, the liability to diarrhœa increases greatly, and cases of it are more than twice as frequent, and twice as fatal, between the ages of six and eighteen months as they were in the first six months of life; while, as soon as teething is over, their number immediately declines again to the half of what it was during the continuance of that process. The practical conclusions to be drawn from these facts are that looseness of the bowels during teething is not a desirable occurrence to be promoted, as some mistakenly imagine, but a risk to be by all means avoided, and I may add, when it does take place, far less easy to control than constipation is to remedy. And next, that in order to prevent its occurrence, care should be taken to make changes in the diet of a child, not during the time when a fresh eruption of teeth is taking place, but during one of the pauses in that process. There are certain seasons of the year when diarrhœa is specially prevalent, independent of any change in diet, or alteration, in any respect, of the circumstances in which the child is placed. Thus, in May, June, and July, diarrhœa is twice as prevalent among children at all ages as in November, December, and January; and in August, September, and October, its prevalence is three times as great as during the winter months. The high mortality of children in the summer months is due almost entirely to diarrhœa, and even the bitter Northern winter of a city like Berlin is a third less fatal to infants and young children than the heat of its short summer.

The next point to remember is that mere looseness of the bowels is never to be regarded during the first three years of life as of no importance; for I have seen infants die exhausted from its continuance, even though the examination of the body after death showed almost no sign of disease. Doctors distinguish two forms of diarrhœa: the simple, or, as it is technically called, catarrhal diarrhœa; and inflammatory diarrhœa, or dysentery. The one may pass into the other, just as a common cold, or catarrh, may pass, if unattended to, into a dangerous bronchitis.

Simple diarrhœa usually comes on gradually, and is some days before it grows severe, or passes into the more dangerous dysentery. Simple precautions will often arrest its progress, and, among them, rest in bed is one of the most important. Over and over again I have known a diarrhœa which had continued in spite of all sorts of medicines so long as the child was running about, cease at once when the child was kept for a couple of days in bed. The reason of this is obvious; constant movement of the intestines themselves, which serves so important a part in maintaining due action of the bowels, is increased by the upright position and by movement, and is reduced to a minimum by the horizontal position. A second precaution concerns the diet; solid food and animal broths should for a time be discontinued, and arrowroot, milk and water, and rice substituted for it, for a day or two, with isinglass jelly, and the white decoction of which I have already spoken. It is not always that astringents are suitable at the beginning of an attack, and the sending to the neighbouring chemist for diarrhœa medicine, which often contains an unknown quantity of opium, is always risky, frequently mischievous. In a first attack of diarrhœa, the doctor should always be consulted, for when it is associated with disorder of the liver a mercurial may in the first instance be needed, or possibly very small doses of a saline medicine, such as Epsom salts, with the addition of a few drops of the tincture of rhubarb; or, again, if the diarrhœa sets in with profuse watery discharges, sulphuric acid for the first few hours is often of extreme service. It is at a later time that direct astringents commonly have their use; and the mother, who in her child's first attack of diarrhœa has had the advice of a judicious doctor, will often be helped by him to manage for herself slight returns of the ailment.

Inflammatory diarrhœa, or dysentery, not only follows the continuance of the simpler forms of the disease, but sometimes in the hot months of summer or autumn sets in suddenly with violence. It then frequently commences with vomiting, and the stomach may continue so irritable for twenty-four hours as not to retain even a teaspoonful of cold water. At the same time the over-action of the bowels sets in, and twenty or thirty evacuations may be passed in twenty-four hours. The motions soon lose their natural character, and become watery, slimy, and mixed with blood. They are at first expelled with violence, afterwards with much pain, effort, and often fruitless straining. With these local symptoms, the child, as might be expected, is very ill, feverish, and stupid, though without sound sleep, much exhausted, and its nervous system so disturbed as to occasion frequent twitchings of the fingers and of the corners of the mouth, while sometimes actual convulsions take place. The thirst is intense, the child calling constantly for cold water, and crying out for more the moment the cup is taken away from its lips; while the loss of flesh and the exhaustion are more rapid than in any other disease with which I am acquainted. The fat happy babe of four and twenty hours before is scarcely to be recognised in the miserable little being, with sunken lustreless eyes, and wizened features, and miserable countenance, lying in a state of half-stupor, sensible only to pain, which yet rouses it but to utter a moan, and then sinks again into silent suffering. I can well believe what we are told, that in some countries this, the so-called Summer Complaint of many of the American cities, sometimes carries off children in a few hours.

If a fatal termination does not take place speedily, the disease passes into the chronic stage, the diarrhœa diminishing in frequency, but the pain and straining, and the unhealthy character of the evacuations persisting. Ulceration of the bowels has taken place, emaciation becomes extreme, and the child often sinks at the end of several weeks, worn out by suffering; while recovery, doubtful at the best, is always very slow. But I need not pursue this subject further: enough has already been said to show how little infantile diarrhœa is a disorder for domestic management.

Peritonitis, or inflammation of the membrane covering the bowels and lining the cavity of the belly, is of excessive rarity in its acute form; and is attended by such general illness and such severe local suffering, that it is impossible to overlook it or to misapprehend its gravity. Severe pain in the belly is sometimes complained of by children, and is due to what is termed colic, a spasm of the bowels which is generally associated with constipation. The great test of the cause of the pain is furnished by the presence or absence of tenderness on pressure. The pain of colic is relieved by gentle pressure and gentle rubbing. The pain of inflammation in any degree and of any kind is aggravated by them. This applies also to cases, not indeed very common, in which inflammation is set up by some small body, such as a cherry-stone getting fixed in a little offshoot or appendage of about the size and length of the little finger, connected with the commencement of the large bowel, and producing ulceration. In these circumstances the bowels are confined, there are nausea and sickness, together with pain and tenderness of the belly, especially on the right side. The disease is a very dangerous one, and often proves fatal in the course of a few days. I refer to it because I have often seen it overlooked both by parents and doctors at its outset, since the pain then is often not severe nor the tenderness intense, and because I have seen the patient's condition rendered hopeless by strong aperients being given to overcome the constipation which was supposed to be all that ailed the child. I repeat then the caution, never to overlook the existence of tenderness, never to attempt to treat a case in which it is present; but always to call in medical advice, and above all always to abstain, unless ordered by a medical man, in every such case from the use of aperients.

Large Abdomen.—I must not leave the subject of disorder of the digestive organs without some reference to a condition which often excites much needless anxiety among mothers, namely, the large size of a child's belly. This is sometimes supposed to be a certain evidence of the presence of worms, at other times to be a positive proof of the existence of grave disease, especially of disease of the mesenteric glands, or glands of the bowels as they are popularly termed. It is evidence of neither the one nor the other.

If you go into a gallery of the old masters, and look at any of the pictures of angels which are generally to be seen there in such abundance, you will probably be struck in the case of all the child angels by what will seem to you the undue size of their abdomen. You will notice this even in the works of painters who, like Raphael, most idealise their subjects, while in those of others who, like Rubens, interpret nature more literally, the apparent disproportion becomes grotesque; or, in the coarser hands of Jordaens, even repulsive.

These painters were, after all, true interpreters of nature. In infancy and early childhood the abdomen is much larger comparatively than in the grown person. For this there is a twofold cause; the larger size of the liver on the one hand, and the smaller development of the hips on the other. In a weakly child this appearance is exaggerated by its want of muscular power, which allows the intestines to become much distended with air. If the child is not merely weakly but also ricketty, the contracted chest will leave less room than natural for the lungs, while at the same time the ordinary development of the hips being arrested by the rickets, the disproportion is further increased both by that and by the flatulence due to the imperfect digestion with which the condition is almost always associated.

In no case need the mere size of the abdomen occasion grave anxiety, so long as when the child lies upon its back the abdomen is uniformly soft, nor so long as even if tense it is not tender, and as it everywhere gives out a hollow sound like a drum when tapped with the finger.

It is not for a moment meant that no notice is to be taken, nor opinion asked, as to the cause of excessive size of the abdomen, for its distension may be due to real disease; but it is yet worth while to remember that its mere size is not of itself evidence of disease, nor cause of grave anxiety.

Worms.—There is no mistaking or overlooking the existence of worms when they are really present. Their presence, however, is often suspected without any sufficient reason. Ravenous or uncertain appetite, indigestion, flatulence, undue size of the abdomen, a dark circle round the eyes, itching of the nose and of the entrance of the bowel, a coated tongue, and offensive breath are no real proof of the presence of worms, and do not justify the frequent repetition of violent purgatives or of so-called worm medicines. The only real proof of the presence of worms is their being seen in the evacuations.

The worms commonly found in children are either the round-worm, which resembles the earth-worm, the thread-worm, or the tape-worm; the appearance of each of which is clearly indicated by its name. None of them are spontaneously generated in the body, but they are all introduced from without; their eggs, or, as they are technically called, their ova, being swallowed unperceived in some article of food, or drink. A proof of this is afforded by the fact that an infant, so long as it is nourished exclusively at the breast, never has worms.

The round-worm occasions the fewest symptoms, and is rather an object of disgust than of grave importance, at least in this country, where it seldom happens that more than two or three are present. In other countries, as some parts of Italy, for instance, where the drinking water is bad and stagnant, they are sometimes found in great numbers, as thirty or forty, and it is then not easy to determine whether the symptoms which accompany them are produced by the worms, or by the unwholesome character of the water in other respects.

They appear to live on the contents of the intestines, and do not adhere to them, as the tape-worm does, and hence their comparative harmlessness, and they have no power, as has sometimes been mistakenly imagined, of perforating the bowels, and of thus producing grave mischief.