The Mother's Manual of Children's Diseases

One more case there is in which suckling has to be given up, at any rate in part, and that is when the milk is good in kind, but insufficient in quantity for the child as it grows older. This insufficiency of quantity shows itself at different periods after the infant's birth—at two months, three, or four. The child is not otherwise ill than that it is no longer bright, as it was wont to be, it ceases to gain flesh, it sleeps more than it used to do, though when it wakes it is always eager for the breast, and cries when leaving it, and if the experiment is made of giving it some milk and water immediately on leaving it, it takes that greedily. Mothers are loth to believe this failure of their resources, and in the case of some who have firm and well-formed breasts, there is but little change in their appearance to show that what remains may serve for beauty, not for use. But if while the child is sucking, the nipple is taken suddenly from its mouth, instead of innumerable little jets of milk, spirting out from the openings of the milk-ducts, the nipple will be seen to be barely moistened by its languid flow.

In conditions such as these the question of weaning partially or completely inevitably occurs, and where the mother's weakness is the occasion of the failure to nourish the child, half-measures are of no avail, for so long as she does not entirely give up the attempt to do that to which her health is unequal, her own state will grow worse, that of the child will not improve. When errors of diet or inattention to general rules of health incapacitate the mother from the performance of her duty, there may be hope from the adoption of a wiser course; while when the supply simply fails from its inadequacy, much may be hoped for from a wise combination of hand-feeding with nursing at the breast; the mother perhaps suckling the infant by day, but being undisturbed by demands upon her at night.

Last of all, I must refer to cases in which love has been stronger than reason, as indeed it often is, and in which young people with some pronounced hereditary taint of scrofula or consumption marry and have children. In such cases, if the consumptive taint is on the mother's side, it is, I believe, much wiser, in the inability to obtain a good wet-nurse, to bring up the child by hand rather than at the mother's breast. One word, however, applicable in such circumstances, age and long experience entitle me to add, and it is this. It is essential that, in the absence of that guarantee against the too rapid succession of pregnancies which suckling for a reasonable time presents, there should be self-restraint on both sides, lest the inscription on the young wife's grave should be, as I have too often known it, the same as, in despite of poetry and romance, her biographer assigns as the cause of the death of Petrarch's Laura, that she died worn out crebris partubus, by too many babies.

In all of these cases the rules which I have already given with reference to hand-feeding have to be borne in mind: the preference for asses' milk at first, the careful regulation of the amount of curd in the cows' milk afterwards, increased or diminished by the greater or less proportion of whey mixed with it. Sometimes, however much the quantity of curd or casein may be reduced, the child is yet unable to digest it, for it is firm and not easily acted on by the juices of the stomach. It is then best to omit it altogether, and to supply the necessary albumen by white of egg. A very good food in these circumstances is made of—

White of one raw egg,

Quarter of an ounce of sugar of milk,

Three teaspoonfuls of cream,

Half a pint of whey.

In the course of a few weeks, or when the child seems to need stronger nourishment, one part of veal-tea, made with a pound of veal to a pint of water, may be added to one part of whey, with the white of egg and sugar of milk as before, and one part of white decoction, as it was called some two centuries ago in England. It is composed of—

Half an ounce of hartshorn shavings,

Inside of one French roll,

Three pints of water—boiled to two, strained and sweetened.

This forms an extremely useful way of introducing farinaceous food into the infant's diet, and preparing the way for a larger amount of it which by degrees becomes necessary. Of these, one of the most generally useful is Liebig's or Savory and Moore's food for infants, which has the advantage of not constipating as so many other farinaceous foods do. Chapman's Entire Wheat Flour is an extremely good food; and wheat, as you will remember, excels other farinaceous substances in its nutritive properties, but it is not so easy of digestion as Liebig. There is, however, scarcely any kind of farinaceous food, among which Nestlé's must not be forgotten, which may not answer for an infant; provided always that at first it is not given oftener than twice a day, that it is not made too thick, nor given in larger proportion than one-third of the farinaceous food to two-thirds of the whey, milk, or whatever it is mixed with; and besides, whatever the food may be, it should be prepared each time afresh.

This is not the place for going into all details on the subject of feeding infants, or to explain how if wisely managed the child weans itself by degrees from the bottle or the breast—the best way, be it said, of weaning—or how by degrees it comes to its daily midday meal of beef-tea and bread, and then, when the first grinding teeth have been cut, to a small meat meal daily, finely minced or scraped, and so little by little adopts the modes of living of its elders.

But, last of all, there are instances, though not so many as the public imagine, in which the infant, in spite of most judicious management, fails to thrive, and suffers from various disorders of its digestion.

The most unmanageable and the least hopeful of these cases are those in which the infant is the subject of consumptive disease. It is very rare for its symptoms, even in cases of the most marked tendency to consumption on the part of the parents, to show themselves before the age of three months, and I think I may add, that apart from such tendency consumption never appears in infancy or early childhood, except when it follows on some acute illness, such as inflammation of the lungs, or on typhoid, or, as it is commonly called, remittent fever.

Consumption of the bowels, as it is popularly termed, may be said never to occur in early infancy apart from consumptive disease of the lungs, and is then always accompanied by an increase towards evening of the temperature from its natural standard of 98.5° to 100°. Hence the absence of cough and the persistence of a natural temperature may be taken as almost conclusive evidence that there is no consumptive disease of the bowels. Consumptive disease in infancy is invariably attended with glandular enlargement. The glands of the bowels when irritated always communicate their irritation to the glands in the groin and the bend of the thigh, which are felt hard and enlarged, like little peas, under the finger. But further, if there is real disease of the glands of the bowels, other tiny enlarged glands will be felt, like shot, under the skin of the belly, from which in the general progress of emaciation the layer of fat always present in the healthy baby will already have been removed. Besides this, too, the veins running beneath the skin there, invisible in the healthy infant, will be seen meandering like blue lines, and telling the story that more blood than usual flows through them, because the diseased glands inside interfere with its ready passage through its proper channels.

Two cautions, however, have to be borne in mind with reference to both of these indications of disease. The first is, that the glands in the groin may be enlarged from mere irritation, independent of actual disease communicated to them from the glands inside. If, however, you find the glands at the corner of the lower jaw and those on either side of the neck enlarged too, you are then driven to the conclusion that the glands in the groin are enlarged not from mere local irritation, but from general disease, and that consumption is its cause.

Again, the superficial veins of the belly may be enlarged from any cause which interferes with the proper circulation through the vessels inside. Hence they are often enlarged in grown people in dropsy, and hence too in infants and young children from flatulent distension of the bowels. But in this case the other signs of consumption are wanting; the emaciation, the cough, the increase of evening temperature, and the enlargement of the glands, are all absent.

Sometimes we meet with instances where the child does not digest its food, does not thrive, does not gain flesh, never passes healthy evacuations, at length wastes, loses strength, and dies, without having had any of the signs which I have pointed out as indicative of consumptive disease, and in fact without having suffered from it. Now, these cases are connected with imperfect performance of the function of the liver, and sometimes with an imperfection of its structure. Before birth the functions of the liver are not called into action in the same way nor to the same degree as afterwards, and its structure differs in this respect that it contains a larger amount of fat and a smaller proportion of bile-secreting cells than afterwards. It sometimes happens from causes which we do not understand that the liver structure not only does not undergo that higher development which should take place, but that the fat cells increase at the expense of the bile cells. In these circumstances the food is ill-digested and the health is much impaired, and at last wasting takes place to as great a degree as in the case of consumption, only there are no cough, no glandular enlargement, no big superficial veins, no increased temperature, while on a careful examination the doctor will seldom fail to find the rounded edge of the enlarged liver coming lower down than natural. In these cases too there is a disposition to convulsive affections, and to that peculiar form of convulsion called spasmodic croup, concerning which I shall have something to say later on.

In its less serious form this is both a more frequent and a less grave condition than consumption, and its existence explains to a great degree those cases in which young children have failed to be nourished by the milk food which commonly suits their tender age, but have improved on beef-tea, raw meat or its juice, and food entirely destitute of saccharine matter.

In cases where there is reason to apprehend consumptive disease, the skill and resources of the doctor will often be heavily taxed to meet each difficulty as it arises. A good wet-nurse, or, in default of her, asses' milk, with the addition of cream to supply the butter in which the asses' milk is deficient, a couple of teaspoonfuls of raw meat juice in the course of every twenty-four hours, much care in the introduction of farinaceous substances into the diet, and cod-liver oil twice a day, beginning with ten drops and gradually increasing the dose to a teaspoonful, are all that the mother herself can do. When the cod-liver oil is not borne by the stomach, or when—which, however, is not often the case—the child refuses to take it, glycerine may be substituted for it, though it must be owned that it is a very poor and inefficient substitute. The inunction of cod-liver oil is in any case not to be had recourse to; it makes the child unpleasant to itself and loathsome to others, while the power of the skin to absorb oily matters is far too limited to be worth taking into account.

Vomiting, though by no means a prominent symptom of either of the two very grave conditions of which I have been speaking just now, is yet a very common attendant on all disorders of digestion in early life. It is indeed much more frequent in the infant than in the adult, and the greater irritability of the stomach continues even after the first few months of existence are past, and does not completely cease during the early years of childhood. In every case of vomiting in childhood, therefore, the first question to set at rest is whether it depends on disorder of the digestive system, or whether it heralds the onset of one of the eruptive fevers, or of inflammation of the chest, or of affection of the brain; and in determining this all the directions given when I was speaking of the general symptoms of disease are to be carefully studied. Vomiting often accompanies infantile diarrhœa, even when the food taken cannot be regarded as its occasion; and now and then the stomach, with no obvious exciting cause, suddenly becomes too irritable to retain any food, and this indeed may be the case even though attended by few or no other indications of intestinal disorder. The child in such cases seems still anxious for the breast; but so great is the irritability of the stomach that the milk is either thrown up unchanged immediately after it has been swallowed, or it is retained only for a few minutes, and is then rejected in a curdled state; while each application of the child to the breast is followed by the same result. It will generally be found, when this accident takes place in the previously healthy child of a healthy mother, that it has been occasioned by some act of indiscretion on the part of its mother or nurse. She perhaps has been absent from her nursling longer than usual, and returning tired from a long walk or from some fatiguing occupation, has at once offered it the breast, and allowed it to suck abundantly; or the infant has been roused from sleep before its customary hour, or it has been over-excited or over-wearied at play, or in hot weather has been carried about in the sun without proper protection from its rays.

The infant in whom from any of these causes vomiting has come on, must at once be taken from the breast, and for a couple of hours neither food nor medicine should be given to it. It may then be offered a teaspoonful of cold water; and should the stomach retain this, one or two spoonfuls may be given in the course of the next half-hour. If this is not rejected, a little isinglass may be dissolved in the water, which must still be given by a teaspoonful at a time, frequently repeated; or cold barley-water may be given in the same manner. In eight or ten hours, if no return of vomiting takes place, the experiment may be tried of giving the child its mother's milk, or cows' milk diluted with water, in small quantities from a teaspoon. If the food thus given does not occasion sickness, the infant may in from twelve to twenty-four hours be restored to the breast: with the precaution, however, of allowing it to suck only very small quantities at a time, lest, the stomach being overloaded, the vomiting should again be produced.

In many instances when the sickness has arisen from some accidental cause, such as those above referred to, the adoption of these precautions will suffice to restore the child's health. If, however, other signs of disorder of the stomach or bowels have preceded the sickness, or are associated with it, medicine cannot be wholly dispensed with, and the advice of the doctor must be sought for. Very likely in addition to directing the rules above laid down to be attended to, he may lay a tiny dose of calomel, as a quarter, half or a whole grain on the tongue, which often has a wonderful influence in arresting sickness; while he may further put a small poultice not much bigger than a crown piece, made half of mustard, half of flour, on the pit of the stomach for a few minutes, and may give the child a little saline, with a grain or two of carbonate of soda, and perhaps a drop of prussic acid. These, however, are not remedies to be employed by the mother, but must be prescribed, and their effect watched by the medical attendant.

Sickness, indeed, is not always a solitary symptom unattended by other evidences of disordered digestion, but is sometimes associated with signs of its general impairment, and this may be so serious as to lead to great loss of flesh, and even to end in endangering life. In many instances, however, the child does not lose much flesh though it digests ill, and its symptoms would be troublesome rather than alarming, if it were not that they are often the signs of an unhealthy constitution, out of which in the course of a few months consumption is not infrequently developed. Long-continued indigestion in the infant always warrants anxiety on the part of the parent.

In some of these cases there is complete loss of appetite, the infant caring neither for the breast nor for any other food. It loses the look of health and grows pale and languid, though it may not have any special disorder either of the stomach or of the bowels. It sucks but seldom and is soon satisfied, and even of the small quantity taken, a portion is often regurgitated almost immediately. This state of things is sometimes brought on by a mother's over-anxious care, who, fearful of her infant taking cold, keeps it in a room too hot or too imperfectly ventilated. It follows, also, in delicate infants on attacks of catarrh or of diarrhœa, but it is then for the most part a passing evil which time will cure. In the majority of cases, however, the loss of appetite is associated with evidence of the stomach's inability to digest even the small quantity of food taken, and the bowels are irregular in their action, as well as unhealthy in their secretion. Loss of appetite, too, though a frequent is by no means a constant attendant on infantile indigestion, but is replaced sometimes by an unnatural craving, in which the child never seems so comfortable as when sucking. It sucks much, but the milk evidently does not sit well upon the stomach; for soon after sucking, the child begins to cry and appears to be in much pain until it has vomited. The rejection of the milk is followed by immediate relief; but at the same time by the desire for more food, and the child often can be pacified only by allowing it to suck again. In other cases vomiting is of much less frequent occurrence, and there is neither craving desire for food, nor much pain after sucking; but the infant is distressed by frequent acid or offensive eructations; its breath has a sour or nauseous smell, and its evacuations have a most fœtid odour. The condition of the bowels that exists in connection with these different forms of indigestion is variable. In cases of simple loss of appetite, the debility of the stomach is participated in by the intestines, and constipation is of frequent occurrence, though the evacuations do not always appear unhealthy. In other instances in which the desire for food still continues, the bowels may act with due regularity, but the motions may have a very unnatural appearance. If the child is brought up entirely at the breast, the motions are usually liquid, of a very pale yellow colour, often extremely offensive, and contain shreds of curdled milk, which not having been digested within the stomach, pass unchanged through the whole track of the bowels. In many instances, however, the infant having been observed not to thrive at the breast, arrowroot or other farinaceous food is given to it, which the stomach is wholly unable to digest, and which gives to the motions the appearance of putty or pipe-clay, besmeared more or less abundantly with slime or mucus. The evacuations are often parti-coloured, and sometimes one or two unhealthy motions are followed by others which appear perfectly natural; while attacks of diarrhœa often come on, and the matters discharged are then watery, of a dark dirty green colour, and exceedingly offensive.

Children, like grown persons suffering from indigestion, often continue, as I have already said, to keep up their flesh much better than could be expected, and in many cases grow up to be strong and healthy. Still the condition is one that not merely entails much suffering on the infant, but by its continuance seriously impairs the health, and tends to develop the seeds of any constitutional predisposition to consumptive disease.

In these cases there are many respects in which the mother can most efficiently second the doctor. All causes unfavourable to health must be examined into, and as far as possible removed. It must be seen that the nursery is well ventilated, and that its temperature is not too high; while it will often be found that no remedy is half so efficacious as change of air. Next, it must not be forgotten that the regurgitation of the food is due in great measure to the weakness and consequent irritability of the stomach, and care must therefore be taken not to overload it. If these two points are attended to, benefit may then be looked for from the employment of tonics, and as the general health improves the constipated condition of the bowels, so usual in these cases, will by degrees disappear; while if aperients are needed those simple remedies only should be employed of which I spoke in the first part of this book, and the use of mercurials is not to be resorted to without distinct medical order.

The above mode of treatment is appropriate to cases of what may be termed the indigestion of debility, but a different plan must be adopted in those instances in which it depends on some other cause. The rule, indeed, which limits the quantity of food to be given at one time is no less applicable here, for the rejection of some of the milk may be the result of nothing more than of an effort which nature makes to reduce the work that the stomach has to do within the powers of that organ. But when, notwithstanding that due attention is paid to this important point, uneasiness is always produced by taking food, and is not relieved till after the lapse of some twenty minutes, when vomiting takes place, or when the infant suffers much from flatulence and from frequent acid or nauseous eructations, it is clear that the symptoms are due to something more than the mere feebleness of the system.

It is not, however, the mere fact that the child vomits its food, or of the milk so vomited being rejected in a coagulated state, which proves that the stomach is disordered, but it is the fact of firmly coagulated milk being rejected with much pain, and after the lapse of a considerable interval from the time of its being taken, which warrants this conclusion. The coagulation of the curd is the first change which the milk of any animal undergoes when introduced into the stomach. The coagulum of human milk is soft and flocculent, and not so thoroughly separated from the other elements of the fluid, as the firm hard coagulum or curd of cow's milk becomes from the whey in which it floats. In a state of health the abundantly secreted gastric juice speedily redissolves the chief part of the curd in the stomach, while when it has passed into the intestine the alkaline bile which there becomes mixed with it, completes its solution, and converts the whole into a fluid which closely resembles one of the chief elements of the blood, is consequently very easily taken up by the minute vessels whose office it is to do so, and thus supplies with nourishment the whole body.

Milk tends, however, to undergo changes spontaneously, which produce its coagulation, and the occurrence of these changes is greatly favoured by a moderately high temperature, such as that which exists in the stomach. But the alterations of the fluid that accompany this spontaneous coagulation are very different from those which are brought about by the vital processes of digestion. An acid becomes formed within it, and the acid thus produced has none of the solvent power of gastric juice, but by its presence impedes rather than favours digestion. Every nurse is aware that a very slight acidity of the milk will suffice to give an infant vomiting, stomach ache, and diarrhœa, and the result must be much the same whether fermentation had begun in the milk before it was swallowed, or whether it commences afterwards, in consequence of the disordered condition of the stomach, and the absence of a healthy secretion of gastric juice.

The nature of the food is the first point that requires attention in the management of these cases of infantile dyspepsia. If the child had been fed on cow's milk the symptoms may be due to the gastric juice not having been able to dissolve the curd, which you will remember is much firmer than that of human milk as well as twice as abundant. In this case the substitution of asses' milk, the employing whey either entirely or in part instead of milk, and the adding white of egg in order to present the elements of the curd in a more easily digestible form, may all be tried with advantage. Sometimes children refuse whey; and then a mixture of cream and veal broth, more or less diluted either with water or with the white decoction, may be given instead. The addition of soda, potash, chalk or lime water to milk before it is given is also of service, since it not only prevents the occurrence of fermentation, but also renders the curd of cow's milk more easily soluble.

The indiscriminate and over-free employment of these alkalies, however, as nursery remedies is by all means to be avoided, for the symptoms of indigestion for which a grown person if suffering would seek the advice of a skilful doctor require his help no less when the patient is a child. When acids will be of service in promoting the secretion of the gastric juice, when pepsine will be likely to be of use, when stimulants such as a little brandy, when aromatics to get rid of flatulence, opiates to relieve pain or check diarrhœa, or when an occasional mercurial, or some other remedy may be of use by stimulating the liver to increased action, are questions which I would not advise any mother to try to answer for herself. Much care and pains and knowledge and experience are often required by the doctor to enable him to answer them correctly.

I must not leave the consideration of the ailments of the digestive organs in early infancy without some notice of that affection of the mouth popularly known as thrush to which an exaggerated importance was once attached as the supposed cause of those symptoms of disordered health, of which it is in reality only the accompaniment. Still it is a sign of such grave disorder that it needs a careful study.

Thrush.—If you examine the mouth of a young infant, in whom the attempt at hand-feeding is not turning out well, you will often observe its lining to be beset with numerous small white spots, that look like little bits of curd lying upon its surface, but which on a more attentive examination are found to be so firmly adherent to it as not to be removed without some difficulty, when they leave the surface beneath it a deep red colour, and now and then bleeding slightly. These specks appear upon the inner surface of the lips, especially near the angles of the mouth, on the inside of the cheeks, and upon the tongue, where they are more numerous at the tip and edges than towards the centre. They are likewise seen upon the gums, though less frequently and in smaller numbers. When they first appear they are usually of a circular form, scarcely larger than a small pin's head; but after having existed for a day or two, some of the spots become three or four times as large, while at the same time they in general lose something of their circular form. By degrees the small white crusts fall off of their own accord, leaving the surface where they were seated redder than before; a colour which gradually subsides, as with the infant's improved health the mouth returns to its natural condition. If the improvement is tardy the white specks may be reproduced and again detached several times before the mouth resumes its healthy aspect. In the worst cases the specks coalesce, and coat the mouth as though lined with a membrane which is usually of a yellowish-white tint instead of having the dead white colour of the separate spots. Even here, however, though the surface is very red, it scarcely bleeds if the deposit is removed from it gently and with care.

The popular notion that when the deposit of thrush appears not only in the mouth, but also at the edge of the bowel, it has passed through the child is altogether erroneous. The lining membrane of the bowel indeed is red, inflamed, and presents those conditions to which I have already referred when speaking of the atrophy of hand-fed children, but the actual deposit of thrush can take place only where there exists an appropriate structure for its formation, and that is to be found, not in the bowels, but only at the inlets and outlets of the digestive canal. The actual deposit at the outlet of the bowel is indeed exceptional, though the edges are often red and sore from the irritation produced by the acrid motions, and this irritation sometimes extends to the skin over the lower part of the baby's person, which becomes rough, and covered with a blush of redness.

Thrush in the child is of far less serious import than in the grown person. In the latter it indicates the existence of some very serious, almost hopeless disease, and hence it is that we meet with it in the last stages of dysentery, cancer, and consumption. In the child a slight attack of thrush may occur from causes which are by no means serious, and may disappear under the use of simple means, such as I have already described when speaking of the troubles of digestion in early infancy.

While in any case it must rest with the doctor to regulate as he best knows how the constitutional treatment of the condition on which the thrush depends, it must be for the mother to see that appropriate local measures are adopted. One point of considerable moment, and to which less care than it deserves is usually paid, is the removing from the mouth, each time after the infant has been fed, of all remains of the milk or other food. For this purpose whenever the least sign of thrush appears, the mouth should be carefully wiped out with a piece of soft rag dipped in a little warm water every time after food has been given. Supposing the attack to be but slight this precaution will of itself suffice in many instances to remove all traces of the affection in two or three days. If, however, there is much redness of the mouth, or if the specks of thrush are numerous, some medicated application is desirable.