The Maternal Management of Children, in Health and Disease. - Thomas Bull, M.D.
With regard to the last cause (improper management), it may be well,
in reference to it, to observe, that it sometimes happens that the rash
comes out imperfectly, or, having appeared properly, suddenly
retrocedes and disappears; and that under such circumstances the nurse
will almost certainly, if not well watched, give the child "a good
dose of sulphur in diluted spirit, or a glass of punch containing
saffron," which are considered specifics for bringing out the eruption.
Nothing can be more injurious than such remedies, for generally the
disappearance of the rash will be dependent upon the existence of some
internal inflammation, or of too high a fever; for the removal of
which the medical man ought to be instantly applied to. Sometimes,
however, it may be fairly traced to a careless exposure to cold: under
such circumstances the child should be instantly, and without
hesitation, put into the warm bath.
Measles are frequently followed by cough, and deranged bowels; and
there is always great susceptibility about the child for some time. On
this account he should be carefully screened from a cold or damp
atmosphere; the diet should be carefully regulated; and flannel worn
next to the skin. If the cough should continue, it must not be
neglected on the supposition that it will wear off; for it demands the
skilful and careful attention of the medical man.
In conclusion, it may be remarked that very frequently during infancy
and childhood, and particularly during the period of teething,
eruptions very similar in appearance to this disease occur; unless,
however, they are accompanied by the specific fever, and run the
regular course, they may at once be decided upon as not being the
measles.
Sect. VII.--SMALL-POX.
This disease, the most dreaded of all eruptive fevers, is not so
commonly met with in the present day as formerly; thanks to that
Providence which led to the discovery of Jenner. But although its
occurrence is not so frequent, it still does occasionally present
itself; when it will assume either a mild or severe form. If it attack
a child that has not previously been vaccinated, it is called natural
small-pox; and the chances are that the disorder will be severe in
character;--if, on the other hand, it occur in the vaccinated, the
disease will generally be much modified in its symptoms; the attack
will be mild, and without danger.
NATURAL SMALL-POX.--The infection of small-pox having been received
into the system of a child that has not been vaccinated, fourteen days
(on an average) will transpire before the commencement of the febrile
symptoms, or eruptive fever. A distinct rigor or shivering fit then
takes place, accompanied by pain in the back or in the stomach, with
sickness, giddiness, or headach; as also great drowsiness. And if an
infant be the subject of the disease, a convulsive fit will sometimes
take place, or several in succession.
At the end of eight-and-forty hours from the occurrence of the rigor
(in the majority of cases), the eruption comes out; and shows itself
first on the face and neck in minute flea-bite spots. In the course of
the next four-and-twenty hours in some cases, and in others not until
the expiration of two or three days, it completely covers the body; not
being confined exclusively to the skin, but frequently extending to the
mouth and throat, and even to the external membrane of the eye.
In the course of two or three days from their first appearance the
little pimples, increasing in size, will be found to contain a thin
transparent fluid, to pit or become depressed in their centre, and the
skin in the spaces between them will be found red. On the seventh or
eighth day from the commencement of the fever, the fluid contained in
the pimples will be no longer transparent, but opaque; and they will
consequently appear white, or of a light straw colour. Each pimple or
pock will be no longer depressed in its centre, but will become raised
and pointed, being more fully distended by the increased quantity of
fluid within; and the skin around each pock will now be of a bright
crimson. The head, face, hands, and wherever else the eruption shows
itself, gradually swell; and the eyelids are often so much distended as
to close the eyes and produce temporary blindness. There will always at
this time be some degree of fever present, and its amount will vary
with the circumstances of each individual ease. The skin too will be
very tender, so much so sometimes as greatly to harass and distress the
child.
On the eleventh day the swelling and inflam of the skin of the body
and face subside; the pimples upon these parts dry up and form scabs,
which fall off about the fourteenth or fifteenth day. Those on the
hands, as they come out later, commonly continue a short time longer.
The eruption leaves behind, in some cases, the peculiar marks of the
disease; and in others merely discoloured spots, which disappear in the
progress of a short time.
The natural small-pox is sometimes much more severe in its character
than the foregoing, and what is called confluent small-pox is said to
exist. This form will be marked by great constitutional disturbance,
and the eruption coming out earlier than in the milder form; instead of
being distinct, that is, each pimple standing distinct and separate
one from the other, they will coalesce, and appear flat and doughy, not
prominent: they will more particularly run into each other on the face,
where they will form one continuous bag, which soon becoming a sore,
will discharge copiously.
SMALL-POX IN THE VACCINATED.--When small-pox occurs to those that have
been formerly vaccinated, the disease, in almost every instance, is
much altered or modified in its character. Indeed in children, in whom
of course vaccination has been but comparatively lately performed,
small-pox when it occurs will, in the majority of cases, be so mild
that the real nature of the disease will be with difficulty determined:
so mild, that again and again has a parent been heard to exclaim,
"Surely these few scattered pimples cannot be the small-pox!" If,
however, as the pimples progress, they are narrowly watched, and are
seen to become depressed in their centre; if there has been the
precursory rigor, etc.; and if the source of the disorder can be traced
to some case of undoubted small-pox, the child in fact having been
exposed to contagion, no doubt ought to exist in reference to the
nature of such a case, however slight may be the character of the
disease.
The usual progress, however, of small-pox modified by vaccination is
as follows. The first stage is the same usually as in the natural form
of the disease. As soon, however, as the eruption appears, the
modifying power of the vaccination becomes apparent. The eruption will
be found to be generally both less in quantity and more limited in its
extent; or if even it should come out profusely, and cover a large
extent of the surface of the body, still the controuling power of the
vaccination will immediately show itself after its appearance,--first,
in the complete subsidence of all the febrile symptoms which will now
take place; and, secondly, in reference to the eruption, part of which
will die away at once, and the remainder will by the fifth day be
filled with the opaque yellowish fluid, then dry up, becoming hard and
horny, and falling off will leave a mottled red appearance of the skin,
and now and then slight pitting.
Such is the usual progress of the disease: subsequent to vaccination,
it is a mild and tractable disorder. It is right, however, to mention
that small-pox has occurred even to the vaccinated in almost as severe
a form as the confluent natural small-pox, and running its regular
course unaltered or unmodified. Such instances, however, are extremely
rare, and form the exceptions to the general rule; for "no reasonable
doubt can be entertained, from the abundance of facts now before the
world, that such modification is the law of the animal economy, and
that the regular or natural progress is the exception."
MATERNAL MANAGEMENT.--The grand principle in the treatment of small-pox
is to moderate and keep under the fever; and however the plans adopted
by different medical men may vary in particular points to accomplish
this purpose, they uniformly make this principle their chief aim and
object. To carry out this intention, however, the medical adviser is
greatly dependent upon the aid and assistance of a judicious parent,
and without this it is impossible to hope for a successful issue to
the case. A clear knowledge, therefore, of those points of general
management in which in fact a great part of the above principle
consists (few and simple as these directions are), it must be
all-important for the mother to be acquainted with: for the rest,
she must and ought to look to the medical man.
In the more rare and severe form of this disease, viz. the confluent
small-pox, although in some instances it runs the same course as the
milder form, the distinct or natural small-pox, still, usually, the
constitutional symptoms are much more aggravated, and the medical and
general treatment required will so much depend upon the character of
the individual case, that we do not think it well to notice it here.
BED AND BED-ROOM.--It will not be necessary at first for the child to
be confined to his bed, but generally about the third or fourth day he
will gladly resort to it; and if he does not, it will be prudent to
keep him there. He must not, however, be loaded with bed-clothes, but
lightly covered; and the bed and body linen should be changed daily, if
possible.
The bed-room should be capacious and well ventilated; fresh air
frequently admitted; and if the season of the year permit, and there is
no dampness of atmosphere, a window should be constantly open during
the day: it is also desirable to keep the chamber darkened in all
cases, as there is always a tendency to inflammation of the eyes.
If these directions are not regarded, and a great heat of the
apartment is permitted, with abundance of bed-clothes heaped upon the
child, the hot bath is used, and hot and stimulating regimen given
(upon the old and erroneous notion of bringing out the eruption), the
mildest case will inevitably be converted into one of the most severe
and dangerous. Facts have abundantly shown that such measures
invariably prove the most effectual means of exasperating the disease,
and endangering life.
REGIMEN.--This must be most sparing. Cold water may be given whenever
the child asks for it. Lemonade should form the common drink during the
fever; and gruel, barley-water, and roasted apples are all else that is
required during this period, and not until the disease is going off
must any change be made in the diet.
The above period having arrived, mildly nutritious food should be
given, as chicken or mutton broth, beef-tea, arrow-root, tapioca, or
sago; to be followed in a few days by the wing of a chicken or a mutton
chop; remembering always, that solid animal food must at first be given
cautiously and sparingly. Wine or stimulants must be positively
forbidden; unless, indeed, ordered by the medical man, for
circumstances may arise which render them advisable.
The state of the bowels must be carefully attended to at this time.
THE ERUPTION.--In the natural and mild form of this disorder the
pustules generally break from the sixth to the eighth day; dry scabs
succeed; and in about nine or ten days the parts heal perfectly,
requiring no treatment. In the more aggravated cases, however, in which
the pustules are very numerous, running one into the other, and,
bursting, discharge greatly, the whole surface of the body should be
frequently and liberally dusted over with dried flour, or, what is
better, starch powder. The sores in this instance are always tedious in
healing, and followed by the well-known pits or marks: these arise from
a loss of substance in the true skin, and occur more particularly on
the face, from the great vascularity of this part causing the pustules
to be more numerous here than elsewhere. It is a popular error to
suppose that by wearing masks of fine linen or cambric illined with
particular ointments, these scars or pits may be prevented: it is
impossible to prevent them; and any local application, except a little
cold cream or oil of almonds applied to the scabs when they harden,
will prove more injurious than useful. The child's hands, however,
should always be muffled to prevent its scratching or breaking the
sores, for otherwise he will not be kept from thus attempting to allay
the excessive itching which they occasion.
The hair should be closely cut at an early period of the disease, and
so kept throughout its continuance. This will contribute very much to
the comfort of the child, by preventing the hair becoming matted
together with the discharge from the pustules when they break, which
gives rise to great pain and irritation. In the confluent and worst
forms of this disease, this measure it is particularly necessary to
attend to, as also to the application of cold lotions to the head when
hot and dry (with other remedial means), as there is always a tendency
in these cases to the formation of abscesses, the healing of which is
troublesome and attended with difficulty.
CAUTIONS, ETC.--It has already been stated that a free ventilation of
the bed-room is necessary to the well-doing of the patient. This
measure, however, must not be confined to the chamber of the sick, but
acted upon through the whole house.
In conjunction with ventilation, fumigations by means of aromatic
substances kept slowly burning should be resorted to. A solution of the
chloride of lime too, a most powerful disinfectant, should be used to
purify the different apartments. This is best accomplished by steeping
in the solution pieces of linen, and hanging them about the rooms, as
also frequently and freely sprinkling the walls themselves; and as soon
as the invalid is removed, the chamber should be white-washed, the
various articles of furniture well scoured with soap and water, and the
room be well and freely ventilated prior to its being again occupied.
The clothes of the patient and the bed linen should be frequently
removed, and when taken away immediately immersed in boiling water, and
whilst hung up in the open air sprinkled occasionally with a weak
solution of the chloride of lime. If these directions are not observed,
and the clothes are closely wrapped up, they will retain and give out
the disease to others at a great distance of time.
Again: as the contagious property of smallpox hangs about the child as
long as any scabs remain (which indeed may be said to retain the poison
in its concentrated form), a parent must be most careful that the
invalid is not too early brought in contact with the healthy members of
the family.
An observance of these precautions is imperatively demanded; they not
only protect the healthy, but aid the infected.
Sect. VIII.--HOOPING-COUGH.
My chief inducement to notice the above disorder arises out of the
well-known fact, that there is no complaint of childhood more
frequently subjected to quackery and mismanagement than is this.
Indeed, there are few maladies against which a greater array and
variety of means have been recommended, than against hooping-cough.
I suppose from the circumstance of the simple and mild form of the
complaint being so tractable (provided it remain such) that the
simplest and mildest measures effect its cure, parents are tempted to
undertake its management in the more severe and complicated forms; and
the result is but too often the establishment of disease dangerous to
life, and sometimes fatal to it.
But although most imprudent for a parent to assume the office of the
physician, her aid is essentially necessary in carrying out the
measures prescribed. By her watchfulness and care the duration of the
disease may not only be abridged, but, what is of much greater
importance, a more serious and aggravated form of disease prevented;
for although hooping-cough in itself is not a dangerous disorder, still
the most simple and slight case, if neglected or mismanaged, may
quickly be converted into one both complicated and dangerous.
DESCRIPTION OF THE DISEASE.--Hooping-cough commences with the symptoms
of a common cold, which is more or less frequent. These symptoms
continue from five days to fifteen; at the end of which time the cough
changes its character, and assumes the convulsive form, which
distinguishes the disorder. It occurs in paroxysms, varying with the
severity of the disease from five to six in the twenty-four hours to
one every ten or fifteen minutes; being generally more severe and
frequent during the night than in the day.
During a paroxysm the expirations are made with such violence, and
repeated in such quick succession, that the child cannot breathe, and
seems in danger of suffocation. The face and neck become swollen and
purple from suffusion; and the eyes prominent, injected, arid full of
tears. The little one, with a forewarning of the attack, which it
dreads, falls on his knees, or clings closely to any thing near him.
The paroxysm terminates with one or two long inspirations, attended
with that peculiar noise, or "whoop," from which the disease has
derived its designation.
Sometimes the fit of coughing is interrupted for a minute or two, so
that a little rest is obtained; and is then succeeded by another fit
of coughing and another hoop, until after a succession of these actions
the paroxysm terminates by vomiting, or a discharge of mucus from the
lungs, or both.
The disease having continued at its height for two or three weeks, it
begins naturally to decline; the paroxysms become less frequent and
violent; the expectoration increases; the cough loses its
characteristic hoop, and gradually wears away altogether; until at
length, in two or three months from the first onset of the disease, the
child is restored to perfect health. Sometimes, however, particularly
in the autumn, and at other seasons on the occurrence of easterly
winds, the paroxysms of cough will return,--it will assume its
spasmodic character, and be accompanied with the "whoop," after a
month, or even two or three months, of perfect and apparent recovery.
Errors in diet will sometimes alone have a similar effect.
It is a disease which usually occurs during childhood, rarely affects
the same individual twice, and is seldom seen in the very young infant.
In reference to the probable result of the disease, when it occurs in
its mild and simple form in a healthy child, the termination is usually
favourable; but it may at first assume this form, and afterwards become
complicated, and consequently more or less dangerous, owing to
injudicious management, or to various influences over which the mother
has no control.
It generally appears as an epidemic, and at those seasons when
catarrhal complaints are most prevalent, and affects many or several at
the same time. Isolated cases, however, frequently occur, which seem to
prove the disease to be infectious. Some persons deny that it is so.
Mothers and nurses, however, who have not had the disease, will often
contract it from the child under such circumstances, and thus it will
be quickly propagated through the family. The nursing mother will
occasionally take it from the infant at her breast. The child who has
caught it from others whilst at school, and brought home in
consequence, will communicate it readily to his brothers and sisters,
although the disease did not exist previously in the family or
neighbourhood, and was brought from a distant part of the country. All
these instances are surely proofs of its infectious character, and
point out the necessity of caution whenever hooping-cough may present
itself in a family, and the necessity which exists for an early removal
of the unaffected children from the sphere of its contagious influence.
The infectious property diminishes as the disease declines.
MATERNAL MANAGEMENT.--In the mild and simple form of this disease the
medical treatment is one rather of prevention than cure, and the
maternal management consists in assisting, by watchfulness and care,
the fulfilment of this design.
In these slighter cases little more is required of the mother during
the Jirst stage of the disorder (that is, before the cough becomes
spasmodic) than attention to diet, regimen, and the excretions. The
diet should be farinaceous, with milk, or as may be otherwise directed.
The child must be confined to a mild equable temperature; in fact, to
his apartment. It is a popular error to suppose that at this time
change of air is beneficial to the disease: at a later period it
certainly is so, but now injurious, and attended with great risk.
Should the weather be cold, the little patient must be warmly clad, and
flannel worn next the skin; this latter precaution should always be
taken in the winter, spring, and autumn. Purgatives and other medicines
will be required, and ordered by the medical attendant; the chief
attention, however, of the parent must be directed to any change she
may observe in the symptoms, breathing, etc.; she must be all on the
alert to notice the first signs of local inflammation. Of this,
however, we shall speak presently.
During the early part of the second stage, that is, when the cough
becomes spasmodic, assuming its peculiar sound, the same diet and
regimen must be continued, and the same watchfulness observed, lest
any inflammatory symptoms manifest themselves.
Under the foregoing treatment the disease generally runs its course
without any untoward event, and the child recovers perfectly.
Sometimes, however, although the patient is quite well, and the disease
on the decline, the cough still continues. In these cases, and at this
time, it is that change of air often proves so very serviceable. The
sea-side is preferable, if the season of the year permit; and salt-
water bathing, commencing with the warm or tepid bath, and passing
gradually to the cold-bath (if no complication forbid it), will also
prove certainly and rapidly remedial.
Crying, mental irritation, or opposition, frequently bring on a fit;
and even the sight of another in a paroxysm will induce it in those
affected by the disease. Running or other active exercise will
generally cause the fits to be more severe. Young children, too, must
be carefully watched at night, and be raised up by the nurse as soon as
the fit is threatened. These hints the mother should bear in mind.
So much for the simple form of the disease, and that in which it most
frequently and commonly presents itself to our notice: a mild disease;
and, if carefully managed and watched over, certainly not a dangerous
one.
Of what, then, is a parent to be afraid, or against what is she to
guard? Lest other disease insidiously come on, and advance to an
irremediable degree, masked by the cough, without attracting her
attention. This is the great source of danger in hooping-cough. The
physician, in a case of simple hooping-cough, is not in daily
attendance upon his patient, and therefore not present to notice the
commencement or first symptoms of those diseases which so frequently
occur at this time, and the successful treatment of which will mainly
depend upon their early detection, and the decision with which they are
treated. When you hear of a child or several children in a family dying
of hooping-cough, it is not this disease which proves fatal; but death
is caused by some disease of lungs or brain, which has been super-added
to the hooping-cough. The progress of hooping-cough, then, must be
closely attended to by the parent, even in the most favourable cases.
The most frequent complication with hooping-cough is inflammation of
the air-tubes of the lungs. This is extremely frequent during spring
and winter, especially in the months of February, March, and April,
owing to the prevalence of easterly winds at this season. It is not my
intention to detail the symptoms of this affection, only to point out
those which will enable a parent to recognise its approach. A parent
then may take warning, and fear the approach of mischief, when she
observes the fits of coughing become more frequent and more distressing
to the child, and the breathing hurried in the intervals of the
paroxysm; when any exertion or speaking causes increased difficulty of
breathing or panting; when the expectoration becomes less abundant, and
difficult to get up; when there is no longer, or at all events less
frequent, vomiting after the cough, and more or less febrile symptoms
present.
If the lungs themselves are attacked by inflammation, most of the
symptoms already pointed out will occur; the cough will be frequent,
in short paroxysms; the vomiting will not take place; the breathing
will be very quick and hurried; and as the disease advances the hoop
will cease.
If hooping-cough attack a child whilst teething, or from six months to
two or three years of age, it is very common for the brain to suffer,
and convulsions and water on the head to occur, particularly if the
latter disease prevails in the family. Whenever the paroxysm of cough
is increased in violence, the characteristic hoop disappearing, and the
face becomes very livid; the hands clenched, and the thumbs drawn into
the palms; the head hot, and marked fits of drowsiness and languor; and
the child, during sleep, screaming out, or grinding its teeth,--
something wrong about the head ought to be anticipated. Of the
treatment we have here nothing to say, except that the gums must be
carefully examined, and scarified if they require it, and the
temperature of the head reduced by cold sponging, or the application of
a bag of ice when necessary. The chief duty, however, of the parent is
to be alive to these symptoms, and early to detect the incipient
mischief, that by a prompt application of efficient means the accession
of so formidable a malady may be prevented.