The Mother's Manual of Children's Diseases

When the nature of these swellings was not understood, they used to be poulticed, and to be opened with a lancet to let out their contents. We know now, however, that we have nothing to do but to let them alone; that by degrees the blood will be absorbed and the tumour will disappear, and as it does so we may trace the gradual transformation of the membrane which covered it into bone, as we feel it crackling like tinsel under the finger. Two, three, or four weeks may be needed for the entire removal of one of these blood-swellings. The doctor will at once recognise its character, and you will then have nothing to do but to wait—often, unhappily, so much harder for the anxious mother than to meddle.

Ruptured Navel.—There is a period some time before the birth of a child when the two halves of its body are not united in front, as they become afterwards; and hare-lip or cleft-palate sometimes remains as the result of the arrest of that development which should have closed the fissured lip or united the two halves of the palate.

In a similar way it happens sometimes that though the skin is closed, the muscles of the stomach (or, more properly speaking, of the belly) are not in the close apposition in which they should be, so that the bowels are not supported by the muscles, but protected only by the skin.

More frequently than this, especially in the case of children who are born before the time, the opening through which the navel string passes is large at birth, and fails to close as speedily and completely as it should do afterwards. When everything goes on as it ought, the gradual contraction of the opening helps to bring about the separation of the navel string and its detachment, and the perfect closure of the opening takes place at the same time, between the fifth and the eighth day after birth.

If this does not occur, the bowels are very apt to protrude through the opening, and if allowed to do so for weeks or months, the opening becomes so dilated that its closure is impossible, and the child grows up afflicted permanently with rupture through the navel. This is always an inconvenience, sometimes even a source of serious danger; but if means are taken to prevent the condition becoming worse, nature seldom fails eventually to bring about a cure, and to effect the complete closure of the opening.

If the muscles on either side do not come into apposition, but leave a cleft between them, the infant should constantly wear a broad bandage of fine flannel round the stomach, not applied too tightly, in order to give support. The circular bandages of vulcanised india-rubber with a pad in the centre are nowise to be recommended. The pad is apt to become displaced, and to press anywhere but over the navel, while its edges irritate the infant's delicate skin, and the pressure which it exerts if it is sufficiently tight to retain its place interferes with respiration.

A pad composed of pieces of plaster spread on wash-leather, and of graduated sizes and kept in place by adhesive strapping,⁷ answers the purpose of preventing the protrusion at the navel, and of thus facilitating the closure of the ring better than any other device with which I am acquainted. They need, however, to be continued even for two or three years, and though they should have been left off it is wise to resume their use if the child should be attacked by whooping-cough, diarrhœa, or any other ailment likely to occasion violent straining.

CHAPTER V.
ON THE DISORDERS AND DISEASES OF CHILDREN AFTER THE FIRST MONTH, AND UNTIL TEETHING IS FINISHED

Infantile Atrophy.—In by far the greater number of instances, the wasting of young children is due to their being fed upon food which they cannot digest, or which when digested fails to yield them proper nourishment. I quoted some figures in my introductory remarks, to show from the evidence obtained at Berlin how much larger was the proportion of deaths under the age of one year among hand-fed infants than among those brought up at the breast. Foundling hospitals on the Continent, in which the children are all drawn from the same class, and subjected in all respects to a similar treatment, except that in some they are fed at the breast, in others brought up by hand, show a mortality in the latter case exactly double of that in the former.

It is as idle to ignore these facts, and to adduce in their disproof the case of some child brought up most successfully by hand, as it would be to deny that a battle-field was a place of danger because some people had been present there and had come away unwounded.

But it is always well not merely to accept a fact, but also to know the reason why a thing is so. The reason is twofold: partly because the different substitutes for the mother's milk, taken for the most part from the vegetable kingdom, are less easy of digestion than the milk, and partly because, even were they digested with the same facility, they do not furnish the elements necessary to support life in due proportion.

All food has to answer two distinct purposes: the one to furnish materials for the growth of the body, the other to afford matter for the maintenance of its temperature; and life cannot be supported except on a diet in which the elements of nutrition and those of respiration bear a certain proportion to each other. Now, in milk, the proper food of infants, the elements of the former are to those of the latter about in the proportion of 1 to 2, while in arrowroot, sago, and tapioca they are only as 1 to 26, and in wheaten flour only as 1 to 7. If to this we add the absence in these substances of the oleaginous matters which the milk contributes to supply the body with fat, and the smaller quantity, and to a certain extent the different kind, of the salts which they contain, it becomes apparent that by such a diet the health if not the life of the infant must almost inevitably be sacrificed.

But these substances are not only less nutritious, they are also less easy of digestion than the infant's natural food. We all know how complex is the digestive apparatus of the herbivorous animal, of which the four stomachs of the ruminants are an instance, and how large is the bulk of food in proportion to his size which the elephant requires, compared with that which suffices for the lion or the tiger.

The stomach of the infant is the simple stomach of the carnivorous animal, intended for food which shall not need to stay long in that receptacle, but shall be speedily digested; and it is only as the child grows older, and takes more varied food, that the stomach alters somewhat in form, that it assumes a more rounded shape, resembling somewhat that of the herbivorous animal, and suited to retain the food longer. The young of all creatures live upon their mother for a certain time after birth; but in all the preparation for a different kind of food, and with it for an independent existence, begins much sooner and goes on more rapidly than in man. Young rabbits are always provided with two teeth when born, and the others make their appearance within ten days. In the different ruminants the teeth have either begun to appear before birth, or they show themselves a few days afterwards; and in either case dentition is completed within the first month, and in dogs and cats within the first ten weeks of existence.

In the human subject the process of teething begins late, between the seventh and the ninth month, and goes on slowly: the first grinding teeth are seldom cut before the beginning of the second year, and teething is not finished until after its end. Until teething has begun the child ought to live exclusively on the food which nature provides; for until that time the internal organs have not become fitted to digest other sustenance, and the infant deprived of this too often languishes and dies. To get from other food the necessary amount of nourishment, that food has to be taken in larger quantities, and, from the difficulty in digesting it, needs to remain longer in the stomach than the mother's milk. One of the results of the indigestibility of the food is that the child is often sick, the stomach getting rid of a part of that food which it is unable to turn to any useful purpose; and so far well. But the innutritious substances do not relieve the sense of hunger. The child cries in discomfort, and more is given to it, and by degrees the over-distended stomach becomes permanently dilated, and holds a larger quantity than it was originally meant to contain. The undigested mass passes into a state of fermentation, and the infant's breath becomes sour and offensive, it suffers from wind and acid eructations, and nurses sometimes express surprise that the child does not thrive since it is always hungry. While some of the food is got rid of by vomiting, some passes into the intestines, and there becomes putrid, as the horribly offensive evacuations prove. They come away, large and solid and white, for the secretion of the bile is inadequate to complete that second digestion which should take place in the intestines; or else the irritation which they excite occasions diarrhœa—a green putty-like matter comes away mixed with a profuse watery discharge.

What wonder is it that in such circumstances the body should waste most rapidly; for it is forced from its own tissues to supply those elements essential to the maintenance of life, which its food contains in far too scanty a proportion. Every organ of the body contributes to the general support, and life is thus prolonged, if no kind disease curtail it, until each member has furnished all that it can spare, and then death takes place from starvation, its approach having been slower, but the suffering which preceded it not therefore less, than if all food had been withheld.

Do not suppose that in this description I have been painting too dark a picture, or that children who die thus have been exceptionally weak, and so under the acknowledged difficulties of hand-feeding at length became consumptive. They do not die of consumption, and in a large number of instances their bodies show no trace of consumptive disease, but present appearances characteristic of this condition of starvation, and of this only.

Along the whole track of the stomach and intestines are the signs of irritation and inflammation. The glands of the bowels are enlarged, actual ulceration of the stomach is often met with; while so far-reaching is the influence of this slow starvation, that even the substance of the kidneys and of the brain are often found softened and otherwise altered, though it might not unreasonably have been supposed that these organs lay quite beyond the reach of any disorder of digestion.

No doubt all these grievous results do not always follow; and sometimes children exceptionally strong manage to take and digest enough even of unsuitable food to maintain their health, and may as they grow up, and the changes take place in the system which fit it for a varied diet, even become robust. In the majority of instances, however, hand-fed infants, and those especially who have been brought up chiefly on farinaceous food, are less strong than others, and are more apt to develop any latent tendency to hereditary disease, such as scrofula or consumption, than members of the same family who have been brought up at the breast.

Enough has already been said to satisfy all but those who do not wish to be convinced, how incumbent it is on every mother to try to suckle her child. But though it is most desirable that for the first six months of their existence children should derive their support entirely from their mother, and that until they are a year or at least nine months old their mother's milk should form the chief part of their food, yet many circumstances may occur to render the full adoption of this plan impracticable. In some women the supply of milk, although at first abundant, yet in the course of a few weeks undergoes so considerable a diminution as to become altogether insufficient for the child's support; while in other cases, although its quantity continues undiminished, yet from some defect in its quality it does not furnish the infant with proper nutriment. Cases of the former kind are not unusual in young, tolerably healthy, but not robust women; while instances of the latter are met with chiefly among those who have given birth to several children, whose health is bad, or among the poor, who have been enfeebled by hard living or hard work. The children in the former case thrive well enough for the first six weeks or two months, but then, obtaining the milk in too small a quantity to meet the demands of their rapid growth, they pine and fret, they lose both flesh and strength, and, unless the food given to supply their wants be judiciously selected, their stomach and bowels become disordered, and nutrition, instead of being aided, is more seriously impaired. In the case of the mother whose milk disagrees with the child from some defect in its quality, the signs are in general more pronounced. Either the infant vomits more than that small quantity which a babe who has sucked greedily or overmuch often rejects immediately on leaving the breast, or it is purged, or it seems never satisfied, does not gain flesh, does not thrive, cries much and is not happy. In these cases, too, the mother's supply of milk, though abundant at first, diminishes in a few weeks; she feels exhausted, and suffers from back-ache, or from pain in the breasts each time after the child's sucking; while, further, her general weakness leaves her no alternative but to wean the child.

Knowing the attempt to rear her child entirely at the breast to be vain, the mother may in such cases be tempted to bring it up by hand from the very first. But how short soever the period may be during which the mother may be able to suckle her child, it is very desirable that she should nurse it during that period, and also that her milk should then constitute its only food. For the first four or five days after the infant's birth the milk possesses peculiar qualities, and not merely abounds in fatty and saccharine matter, but presents its casein or curd in a form in which it is specially easy of digestion. These peculiarities indeed become less marked within a week or two; but not only is it of moment that the infant should at any rate make its start in life with every advantage, but the mother who nurses her little one even for a month avoids thereby almost half the risks which follow her confinement. For the indolent, among the wealthy, a numerous class who have but to form a wish in order to have it gratified, a wet-nurse for the baby suggests itself at once to the mother as a ready means of saving herself trouble, and of shirking responsibility. This course, to which love of pleasure and personal vanity tend alike to prompt her, often finds, in spite of all opposing reasons, the approval of the nurse, to whom it saves trouble, and the too ready acquiescence of the doctor in a course which pleases his patient. But many circumstances besides those moral considerations, which ought never to be forgotten before the determination is formed to employ a wet-nurse, may put this expedient out of the question, and it becomes therefore of importance to learn what is the best course for a mother to adopt who is either wholly unable to suckle her child, or who can do so only for a very short time.

It is obvious that the more nearly the substitute approaches to the character of the mother's milk, the greater will be the prospect of the attempt to rear the child upon it proving successful. There is no argument needed to prove that the milk of some animal more closely resembles the mother's milk, and is more likely to prove a useful substitute for it than any kind of farinaceous substance. The milk of all animals, however, differs in many important respects from human milk, and differs too very widely in different animals. Thus, the milk of the cow and that of the ewe contain nearly double the quantity of curd, and that of the goat more than twice the quantity of butter, and it is only in the milk of the ass that the solid constituents are arranged in the same order as in man. On this account, therefore, asses' milk is regarded, and with propriety, as the best substitute for the child's natural food. Unfortunately, however, expense is very frequently a bar to its employment, and compels the use of the less easily digested cows' milk. But though the cost may be a valid objection to the permanent employment of asses' milk, it is yet very desirable when a young infant cannot have the breast, that it should be supplied with asses' milk for the first four or five weeks, until the first dangers of the experiment of bringing it up by hand have been surmounted. The deficiency of asses' milk in butter may be corrected by the addition of about a twentieth part of cream, and its disposition to act on the bowels may be lessened by heating it to boiling point, not over the fire but in a vessel of hot water; and still more effectually by the addition to it of a fourth part of lime-water or of a teaspoonful of the solution of saccharated carbonate of lime to two ounces or four tablespoonfuls of the milk.

When cows' milk is given, it must be borne in mind that it contains nearly twice as much curd, and about an eighth less sugar, than human milk. It is therefore necessary that it should be given in a diluted state and slightly sweetened. The dilution must vary according to the infant's age; at first the milk may be mixed with an equal quantity of water, but as the child grows older the proportion of water may be reduced to one-third. Mere dilution with water, however, leaves the proportion of curd unaltered, and it is precisely the curd which the infant is unable to digest. Instead, therefore, of diluting the milk simply with water, it is often better to add one part of whey to about two parts of milk, which, according to the child's age, may or may not be previously diluted⁸.

Attention must be paid to the temperature of the food when given to the infant, which ought to be as nearly as possible the same as that of the mother's milk, namely from 90° to 95° Fahrenheit, and in all cases in which care is needed a thermometer should be employed in order to insure the food being given at the same temperature. Human milk is alkaline, and even if kept for a considerable time it shows little tendency to become sour. The milk of animals when in perfect health likewise presents an alkaline reaction, and that of cows when at grass forms no exception to this rule. Milk even very slightly acid is certain to disagree with an infant; it is therefore always worth while the moment that a hand-fed infant seems ailing to ascertain this point. If alkaline, the milk will deepen the blue colour of litmus paper, which is to be had of any chemist; if acid, it will discharge the colour and turn it red. It is, perhaps, as well to add that, as the oxygen in the atmosphere tends to redden litmus paper, it should not be left exposed to the air, but should always be kept in a glass-stoppered bottle.

The milk of the cow is very liable to alteration from comparatively slight causes, and particularly from changes in the animal's diet; while even in the most favourable circumstances if the animal is shut up in a city and stall-fed, all the solid constituents of its milk suffer a remarkable diminution; while the secretion further has a great tendency to become acid, or to undergo even more serious deterioration. Mere acidity of the milk can be counteracted for the moment by the addition of lime-water, or by stirring up with it a small quantity of prepared chalk, which may be allowed to subside to the bottom of the vessel; or if it should happen, though indeed that is rarely the case in these circumstances, that the child is constipated, carbonate of magnesia may be substituted for the chalk or lime-water. If these simple proceedings are not sufficient to restore the infant's health, it will be wise to seek at once for another source of milk supply, and to place the suspected milk in the hands of the medical officer of health or of the public analyst, in order that it may be submitted to a thorough chemical and microscopical examination.

The difficulty sometimes found in obtaining an unvaryingly good milk supply, as well as practical convenience in many respects, has led to the extensive employment of various forms of condensed milk. They form undoubtedly the best substitute for fresh cows' milk which we possess, and are a great boon especially to the poor in large towns where the milk supply is often scanty, not always fresh, and sometimes of bad quality. I should certainly prefer condensed milk for an infant to milk from cows living in close dirty stables, such as my experience thirty years ago made me familiar with in some parts of London.

Still all the varieties of condensed milk are far inferior in quality to good fresh milk. They contain less butter, less albumen, that is to say less of the main constituents of all animal solids and fluids, and a greater proportion of what are termed the hydro-carbonates, such for instance as sugar; or, to state the same thing differently, the elements which serve for nutrition are in smaller proportion than in fresh milk to those which minister to respiration. They are not only less nutritious, but the large quantity of sugar which they contain not infrequently disagrees with the child, and causes bowel complaint. I do not know how far the so-called unsweetened condensed milk which has of late come into the market is free from this objection; but I have always preferred the Aylesbury condensed milk, which is manufactured with sugar, to the Swiss condensed milk, into which, as I have been given to understand, honey largely enters.

How much food does an infant of a month old require? what intervals should be allowed between each time of feeding? and how should the food be given? are three questions which call for a moment's notice. The attempt has been made to determine the first point by two very distinguished French physicians, who weighed the infants before and after each time of sucking. Their observations, however, were not sufficiently numerous to be decisive, and their results were very conflicting; the one estimating the quantity at two pounds and a quarter avoirdupois, which would be equivalent to nearly a quart, the other at not quite half as much; but the observations of the latter were made on exceptionally weak and sickly infants. Infants no doubt vary, as do grown people, as to the quantity of food they require. I should estimate from my own experience and observation, apart from accurate data, a pint as the minimum needed by an infant a month old; and while Dr. Frankland's estimate of a pint and a half for an infant of five months seems to me very reasonable, I should doubt its sufficing for a child of nine months unless it were supplemented by other food.

The infant during the first month of life takes food every two hours, and even when asleep should not be allowed to pass more than three hours; and this frequent need of food continues until the age of two, sometimes even until three, months. Afterwards, and until six months old, the child does not need to be fed oftener than every three hours during the twelve waking hours, and every four hours during the sleeping time. Later on, five times in the twenty-four hours, namely thrice by day, once the last thing at night, and once again in the early morning, are best for the child's health as well as for the nurse's comfort.

How is an infant not at the breast to be fed? Certainly not with the cup or spoon; a child so fed has no choice in the matter, but must either swallow or choke, and is fed as they fatten turkeys for the market. The infant, on the other hand, sucks the bottle as it would suck its mother's breast; it rests when fatigued, it stops to play, it leaves off when it has had enough, and many a useful inference may be drawn by the observant nurse or mother who watches the infant sucking, and notices if the child sucks feebly, or leaves off panting from want of breath, or stops in the midst, and cries because its mouth is sore or its gums are tender.

But it is not every bottle which an infant should be fed from, and least of all from those so much in vogue now with the long elastic tube, so handy because they keep the baby quiet, who will lie by the hour together with the end in its mouth, sucking, or making as though it sucked, even when the bottle is empty. These bottles, as well as the tubes connected with them, are most difficult to keep clean; and so serious is this evil, that many French physicians not only denounce their use, in which they are perfectly justified, but prefer, to the use of any bottle at all, the feeding the infant with a spoon; and here I think they are mistaken. The old-fashioned flat bottle, with an opening in the middle, and a short end to which the nipple is attached without any tube, the only one known in the time of our grandmothers, continues still the best, and very good. My friend, Mr. Edmund Owen, in a lecture at which I presided at the Health Exhibition in August last year, pointed out very humorously the differences between the old bottle and the new. An infant to be kept in health must not be always sucking, but must be fed at regular intervals. The careful nurse takes the infant on her knee, feeds it from the old-fashioned feeding-bottle, regulating the flow of the milk according as the infant sucks heartily or slowly, withdraws it for a minute or two, and raises the child into a sitting posture if it seems troubled with flatulence, and then after a pause lets it recommence its meal. This occupies her a quarter of an hour or twenty minutes of well-spent time, while the lazy nurse, or the mother who has never given the matter a thought, just puts the tube in the infant's mouth, and either takes no further trouble or occupies herself with something else. And yet, obvious though this is, how constantly one sees infants taken about in the perambulator with the feeding-bottle wrapped up and laid by its side, because it is said the child always cries when it is not sucking, and the intelligence and the common sense are wanting, as well as the patient love, that would strive to make out which it is of many possible causes that makes the infant cry. One more observation with reference to bottle-feeding may not be out of place. It is this: that no food be left in the bottle after the child has had its meal, but that it should be emptied, washed out with a little warm water and soda, and it and the india-rubber end should be kept in water till again needed. To insure the most perfect cleanliness it is always well to have two bottles in use, and to employ them alternately.

How strictly soever an infant may be kept at the breast, or however exactly the precautions on which I have insisted are observed, sickness, constipation, or diarrhœa may occur, causing much anxiety to the parents, and giving much trouble to the doctor.

It sometimes happens, without its being possible to assign for it any sufficient reason, that the mother's milk disagrees with her infant, or entirely fails to nourish it, so that, much against her will, she is compelled to give up suckling it. In some instances this is due to errors in diet, to the neglect of those rules the observance of which is essential to health, as proper exercise for instance; and then the secretion is usually deficient in quantity as well as defective in its composition. In such cases the child often vomits soon after sucking, it suffers from stomach-ache, its motions are very sour, of the consistence of putty, and either green, or become so soon after being passed, instead of presenting the bright yellow colour and semi-fluid consistence of the evacuations of the healthy infant, and sometimes they are also lumpy from the presence of masses of undigested curd. In addition, also, the child is troubled with griping, which makes it cry; its breath is sour, or actually offensive, and the tongue is much whiter than it should be, though it must be remembered that the tongue of the sucking child always has a very slight coating of whitish mucus, and is neither as red nor as perfectly free from all coating as it becomes in the perfectly healthy child of three or four years old.

In these circumstances, the diminution of stimulants, such as the stout of which young women are sometimes mistakenly urged to take a quantity to which they were previously quite unaccustomed, is often followed by an increase of the quantity as well as an improvement in the quality of the milk. It is true that a nursing mother may often find her strength maintained, and her supply of milk increased, by taking a glass of stout at lunch and another at dinner, instead of, but not in addition to, any other stimulant; but mere stimulants will no more enable a woman to suckle her infant better than she otherwise would do, than they would fit a man to undergo great fatigue for days together, or to go through a walking tour in Switzerland. A tumbler of one-third milk and two-thirds good grit gruel taken three times a day will have greater influence in increasing the quantity of milk than any conceivable amount of stimulant.

There is an entirely opposite condition in which the infant does not thrive at the breast, and this for the most part is met with when the mother has already given birth to and suckled several children. In these instances the secretion is sometimes, though not always, abundant, but the infant does not thrive upon it. The babe does not get on, is always hungry after leaving the breast, and cries as though it wanted more; in addition to which it is often purged, either while sucking or within a few minutes afterwards, though the motions, except in being more frequent and more watery than in health, do not by any means constantly show any other change. The mother's history explains the rest. She is constantly languid, suffers from back-ache, feels exhausted each time after the babe has sucked, probably has neuralgia in her face, or abiding headache. In many instances, too, her monthly periods return, though as a rule they do not appear in healthy women while suckling. All these symptoms show that her system is not equal to the duty she has undertaken, and that therefore, for her sake as well as for that of the infant, she must give up the attempt.