The Maternal Management of Children, in Health and Disease. - Thomas Bull, M.D.
It is therefore highly important that a mother should possess such
information as will enable her to detect disease at its first
appearance, and thus insure for her child timely medical assistance.
This knowledge it will not be difficult for her to obtain. She has only
to bear in mind what are the indications which constitute health, and
she will at once see that all deviations from it must denote the
presence of disorder, if not of actual disease. With these changes she
must to a certain extent make herself acquainted.
Sect. I.--SIGNS OF HEALTH.
The signs of health are to be found, first, in the healthy performance
of the various functions of the body; the regular demands made for its
supply, neither in excess or deficiency; and a similar regularity in
its excretions both in quantity and appearance.
If the figure of the healthy infant is observed, something may be
learnt from this. There will be perceived such an universal roundness
in all parts of the child's body, that there is no such thing as an
angle to be found in the whole figure; whether the limbs are bent or
straight, every line forms a portion of a circle. The limbs will feel
firm and solid, and unless they are bent, the joints cannot be
discovered.
The tongue, even in health, is always white, but it will be free from
sores,--the skin cool,--the eye bright,--the complexion clear,--the head
cool,--and the abdomen not projecting too far,--the breathing regular,
and without effort.
When awake, the infant will be cheerful and sprightly, and, loving to
be played with, will often break out into its merry, happy, laugh;
whilst, on the other hand, when asleep, it will appear calm, every
feature composed, its countenance displaying an expression of
happiness, and frequently, perhaps, lit up with a smile.
Sect. II. SIGNS OF DISEASE.
Just in proportion as the above appearances are present and entire,
health may be said to exist; and just in proportion to their partial or
total absence disease will have usurped its place.
We will, however, for the sake of clearness examine the signs of
disease as they are manifested separately by the countenance,--the
gestures,--in sleep,--in the stools,--and by the breathing and cough.
OF THE COUNTENANCE.
In health the countenance of a thild is expressive of serenity in mind
and body; but if the child be unwell, this expression will be changed,
and in a manner which, to a certain extent, will indicate what part of
the system is at fault.
The brows will be contracted, if there is pain, and its seat is in the
head. This is frequently the very first outward sign of any thing being
wrong, and will occur at the very onset of disease; if therefore
remarked at an early period, and proper remedies used, its notice may
prevent one of the most fearful of infantile complaints--"Water in the
Head."
If this sign is passed by unheeded, and the above disease be
threatened, soon the eyes will become fixed and staring,--the head hot,
and moved uneasily from side to side upon the pillow, or lie heavily
upon the nurse's arm,--the child will start in its sleep, grinding its
teeth, and awake alarmed and screaming,--its face will be flushed,
particularly the cheeks (as if rouged),--its hands hot,--but feet cold,
its bowels obstinately costive, or its motions scanty, dark-coloured,
and foul.
If the lips are drawn apart, so as to show the teeth or gums, the seat
of the pain is in the belly. This sign, however, will only be present
during the actual existence of suffering; if, therefore, there be any
doubt whether it exist, press upon the stomach, and watch the eifect on
the expression of the countenance.
If the pain arise simply from irritation of the bowels excited from
indigestion, it will be temporary, and the sign will go and come just
as the spasm may occur, and slight remedial measures will give relief.
If, however, the disease be more serious, and inflammation ensue, this
sign will be more constantly present, and soon the countenance will
become pale, or sallow and sunken,--the child will dread motion, and
lie upon its back with the knees bent up to the belly,--the tongue will
be loaded,--and in breathing, while the chest will be seen to heave
with more than usual effort, the muscles of the belly will remain
perfectly quiescent.
If the nostrils are drawn upwards and in quick motion, pain exists in
the chest. This sign, however, will generally be the accompaniment of
inflammation of the chest, in which case the countenance will be
discoloured,--the eyes more or less staring, and the breathing will be
difficult and hurried; and if the child's mode of respiring be watched,
the chest will be observed to be unmoved, while the belly quickly
heaves with every inspiration.
Convulsions are generally preceded by some changes in the countenance.
The upper lip will be drawn up, and is occasionally bluish or livid.
Then there may be slight squinting, or a singular rotation of the eye
upon its own axis; alternate flushing or paleness of the face; and
sudden animation followed by languor.
These signs will sometimes manifest themselves many hours, nay days,
before the attack occurs; may be looked upon as premonitory; and if
timely noticed, and suitable medical aid resorted to, the occurrence of
a fit may be altogether prevented.
The state of the eyes should always be attended to. In health they are
clear and bright, but in disease they become dull, and give a heavy
appearance to the countenance; though after long continued irritation
they will assume a degree of quickness which is very remarkable, and a
sort of pearly brightness which is better known from observation than
it can be from description.
The direction of the eyes, too, should be regarded, for from this we
may learn something. When the infant is first brought to the light,
both eyes are scarcely ever directed to the same object: this occurs
without any tendency to disease, and merely proves, that regarding one
object with both eyes is only an acquired habit. But when the child has
come to that age when the eyes are by habit directed to the same
object, and afterwards it loses that power, this circumstance alone may
be looked upon as a frequent prelude to disease affecting the head.
OF THE GESTURES.
The gestures of a healthy child are all easy and natural; but in
sickness those deviations occur, which alone will often denote the
nature of the disease.
Suppose an infant to have acquired the power to support itself, to
hold its head erect; let sickness come, its head will droop
immediately, and this power will be lost, only to be regained with the
return of health; and during the interval every posture and movement
will be that of languor.
The little one that has just taught itself to run alone from chair to
chair, having two or three teeth pressing upon and irritating the gums,
will for a time be completely taken off its feet, and perhaps lie
languidly in its cot, or on its nurse's arm.
The legs being drawn up to the belly, and accompanied by crying, are
proofs of disorder and pain in the bowels. Press upon this part, and
your pressure will increase the pain. Look to the secretions from the
bowels themselves, and by their unhealthy character your suspicions, in
reference to the seat of the disorder, are at once confirmed.
The hands of a child in health are rarely carried above its mouth; but
let there be any thing wrong about the head and pain present, and the
little one's hands will be constantly raised to the head and face.
Sudden starting when awake, as also during sleep, though it occur from
trifling causes, should never be disregarded. It is frequently
connected with approaching disorder of the brain. It may forebode a
convulsive fit, and such suspicion is confirmed, if you find the thumb
of the child drawn in and firmly pressed upon the palm, with the
fingers so compressed upon it, that the hand cannot be forced open
without difficulty. The same condition will exist in the toes, but not
to so great a degree; there may also be a puffy state of the back of the
hands and feet, and both foot and wrist bent downwards.
There are other and milder signs threatening convulsions and connected
with gesture, which should be regarded:--the head being drawn rigidly
backwards,--an arm fixed firmly to the side, or near to it,--as also one
of the legs drawn stifly upwards. These signs, as also those enumerated
above, are confirmed beyond all doubt, if there be present certain
alterations in the usual habits of the child:--if the sleep is
disturbed,--if there be frequent fits of crying,--great peevishness of
temper,--the countenance alternately flushed and pale,--sudden animation
followed by as sudden a fit of languor,--catchings of the breath
followed by a long and deep inspiration,--all so many premonitory
symptoms of an approaching attack.
OF THE SLEEP.
The sleep of the infant in health is quiet, composed, and refreshing.
In very early infancy, when not at the breast, it is for the most
part asleep in its cot; and although as the months advance it sleeps
less, yet when the hour for repose arrives, the child is no sooner laid
down to rest, than it drops off into a quiet, peaceful slumber.
Not so, if ill. Frequently it will be unwilling to be put into its cot
at all, and the nurse will be obliged to take the infant in her arms;
it will then sleep but for a short time, and in a restless and
disturbed manner.
If it suffer pain, however slight, the countenance will indicate it;
and, as when awake, so now, if there is any thing wrong about the head,
the contraction of the eye-brow and grinding of the teeth will appear;
if any thing wrong about the belly, the lips will be drawn apart,
showing the teeth or gums,--and in both instances there will be great
restlessness and frequent startings.
OF THE STOOLS.
In the new-born infant the motions are dark coloured, very much like
pitch both in consistence and appearance. The first milk, however,
secreted in the mother's breast, acts as an aperient upon the infant's
bowels, and thus in about four-and-twenty hours it is cleansed away; or
if it should not, a tea-spoonful of castor oil accomplishes this
purpose.
From this time, and through the whole of infancy, the stools will be
of a lightish yellow colour, the consistence of thin mustard, having
little smell, smooth in appearance, and therefore free from lumps or
white curded matter, and passed without pain or any considerable
quantity of wind. And as long as the child is in health, it will have
daily two or three, or even four, of these evacuations. But as it grows
older, they will not be quite so frequent; they will become darker in
colour, and more solid, though not so much so as in the adult.
Any deviation, then, from the above characters, is of course a sign of
something wrong; and as a deranged condition of the bowels is
frequently the first indication we have of coming disease, the nurse
should daily be directed to watch the evacuations. Their appearance,
colour, and the manner in which discharged, are the points principally
to be looked to. If the stools have a very curdy appearance, or are too
liquid, or green, or dark-coloured, or smell badly, they are unnatural.
And in reference to the manner in which they are discharged, it should
be borne in mind, that, in a healthy child, the motion is passed with
but little wind, and as if squeezed out, but in disease, it will be
thrown out with considerable force, which is a sign of great
irritation. The number, too, of stools passed within the four-and-
twenty hours it is important to note, so that if the child does not
have its accustomed relief, (and it must not be forgotten that
children, although in perfect health, differ as to the precise number,)
a little castor oil may be at once exhibited, and thus mischief be
prevented.
This, however, is not the place to discuss the question of disordered
bowels, but simply to point out how this circumstance may be
known.[FN#27]
[FN#27] See section on Disorders of the Stomach and Bowels, p. 208.
OF THE BREATHING AND COUGH.
The breathing of a child in health is formed of equal inspirations and
expirations, and it breathes quietly, regularly, inaudibly, and without
effort. But let inflammation of the air-tubes or lungs take place, and
the inspiration will become in a few hours so quickened and hurried,
and perhaps audible, that the attention has only to be directed to the
circumstance to be at once perceived.
Now all changes which occur in the breathing from its healthy
standard, however slight the shades of difference may be, it is most
important should be noticed early. For many of the complaints in the
chest, although very formidable in their character, if only seen early
by the medical man, may be arrested in their progress; but otherwise,
may be beyond the control of art. A parent, therefore, should make
herself familiar with the breathing of her child in health, and she
will readily mark any change which may arise.
Of cough I should not have said any thing in this chapter, as it can
never fail to be noticed, except that it is highly necessary to throw
out one caution. Whenever a child has the symptoms of a common cold,
attended by hoarseness and a rough cough, always look upon it with
suspicion, and never neglect seeking a medical opinion. Hoarseness does
not usually attend a common cold in the child, and these symptoms may
be premonitory of an attack of "croup;" a disease excessively rapid in
its progress, and which, from the importance of the parts affected,
carrying on, as they do, a function indispensably necessary to life,
requires the most prompt and decided treatment.
The following observations of Dr. Cheyne are so strikingly
illustrative, and so pertinent to my present purpose, that I cannot
refrain inserting them:--"In the approach of an attack of croup, which
almost always takes place in the evening, probably of a day during
which the child has been exposed to the weather, and often after
catarrhal symptoms have existed for several days, he may be observed to
be excited, in variable spirits, more ready than usual to laugh than to
cry, a little flushed, occasionally coughing, the sound of the cough
being rough, like that which attends the catarrhal stage of the
measles. More generally, however, the patient has been for some time in
bed and asleep, before the nature of the disease with which he is
threatened is apparent; then, perhaps, without waking, he gives a very
unusual cough, well known to any one who has witnessed an attack of the
croup; it rings as if the child had coughed through a brazen trumpet;
it is truly a tussis clangosa; it penetrates the walls and floor of the
apartment, and startles the experienced mother,--'Oh! I am afraid our
child is taking the croup!' She runs to the nursery, finds her child
sleeping softly, and hopes she may be mistaken. But remaining to tend
him, before long the ringing cough, a single cough, is repeated again
and again; the patient is roused, and then a new symptom is remarked;
the sound of his voice is changed; puling, and as if the throat were
swelled, it corresponds with the cough," etc.
How important that a mother should be acquainted with the above signs
of one of the most terrific complaints to which childhood is subject;
for, if she only send for medical assistance during its first stage,
the treatment will be almost invariably successful; whereas, if this
"golden opportunity" is lost, this disease will seldom yield to the
influence of measures, however wisely chosen or perseveringly employed.
SECT. III.--OTHER CIRCUMSTANCES WHICH WILL ASSIST IN THE EARLY DETECTION
OF DISEASE.
1. THE INFLUENCE OF THE SEASONS IN PRODUCING PARTICULAR FORMS OF
DISORDER.--The recollection of the fact, that at the different seasons
of
the year some diseases are more prevalent than at other periods, will
greatly aid a judicious parent in the early detection of the presence
of disorder, and its kind, in her child.
Thus, in the early part of the winter, what is called catarrh, viz. an
increased secretion of mucus from the membranes of the nose, fauces,
and air-tubes, with fever, and attended with sneezing and cough,
thirst, lassitude, and want of appetite, is generally prevalent.
As the winter advances, the air-tubes of the lungs, and the lungs
themselves, are liable to become the seat of disorder; and those signs
will present themselves, which have been pointed out in the previous
section as characteristic of such attacks.
In the spring, we have still the same diseases prevalent, and in
addition, measles, scarlet fever, small-pox, and chicken pox, which
increase in liability towards the close of this season, and with the
first weeks of summer.
In the summer, disease is less prevalent than at any other period of
the year; but towards its middle and close, and through the whole of
the autumnal months, bowel complaints may be expected, in the forms of
diarrhoea, cholera, and dysentery.
2. THE INFLUENCE OF A HEREDITARY PREDISPOSITION TO CERTAIN DISEASES.--
Without entering into this subject at large, still it may be useful to
remark, that in some families there is a predisposition to some
diseases, which, occurring in the first child, will, as each succeeding
child is born, attack at the same age. Amongst other diseases of this
class are, croup, hooping-cough, and water in the head.
This observation should not only lead a mother to be alive to the
possibility of the successional occurrence of these diseases in her
family, and so early note their appearance, and seek medical advice,
but should at the same time make her most anxious, on the one hand, to
shield her child from all their exciting causes, and on the other, to
adopt those measures which may contribute indirectly to overcome the
constitutional predisposition to them.
Of the scrofulous constitution, I will merely mention here, that it is
of the greatest importance, where a predisposition to this disease
exists in a family, that a mother should immediately attend to any
alteration in the gait or contour of her child, and give prompt
attention also to any complaint made of swelling about a joint,
although it may be unattended with pain. The importance of this remark
will be seen by contrasting the result of the following cases which
occurred in children of the same family.
Case I.
A. B., a female child, having blue eyes, light hair, and a fair
complexion, in the early part of the year 1838, being then two years of
age, had an enlargement of the left knee joint. For some weeks previous
to this time, there had been a degree of heat about the part; but as no
pain apparently existed, it was not regarded as of any consequence, and
nothing was done. The child, living in the neighbourhood of London, was
afterwards placed under medical treatment. Two or three months having
elapsed, it was brought to town, and shown to me, in consequence of a
slight tumefaction over the lower part of the spine. This soon
disappeared under the measures employed, and eventually the disease of
the knee (evidently scrofulous) was arrested, so that now the case
promises to be cured; but the joint will for ever be stiff, and the
limb thus affected shorter than the other.
Case II.
G. B., the brother of the above, a handsome boy, with light hair, fine
blue eyes,--indeed, very much like his little sister,--in the year
1836, had enlargements of the glands in his neck, which were relieved
by the treatment resorted to.
In April, 1839, being then eight years old, he was observed by his
mother to limp slightly in walking, but complained of little or no
pain. From the caution, however, which had been given to the parent at
the time I was consulted about the previous case, to notice at an early
period any symptom of this nature in her children, the fact was
immediately attended to. The affection was evidently in the hip; there
was imperfection in the gait, and pain upon pressing over the joint. A
blister was applied, perfect rest to the limb enjoined, and steel
medicines ordered; and in a fortnight the motions of the joint were
restrained more effectually by the application of strips of soap
plaster and a bandage. In three months the child was ordered to the sea-
side, and eventually was able to walk without the slightest limp or
pain, and may be said to be quite well.
I would not say that in the first case, if the disease had been
discovered early, and at that time met by judicious medical treatment,
a stiff knee and shortened limb would have been prevented, although
this is my belief; but in reference to the latter case, I have no
hesitation in saying, that without the disease had been early detected
by the mother, and as promptly attended to by her, the remedial
measures might have failed,--certainly the result would not have been
so highly satisfactory as it was.
Chap. V.
ON WHAT CONSTITUTES THE MATERNAL MANAGEMENT OF THE DISEASES OF CHILDREN.
The especial province of the mother is the prevention of disease, not
its cure. To the establishment and carrying out of this principle,
every word contained in the preceding pages has directly or indirectly
tended.
This, however, is not all. When disease attacks the child, the mother
has then a part to perform, which it is especially important during the
epochs of infancy and childhood should be done well. I refer to those
duties which constitute the maternal part of the management of disease.
Medical treatment, for its successful issue, is greatly dependent upon
a careful, pains-taking, and judicious maternal superintendence. No
medical treatment can avail at any time, if directions be only
partially carried out, or be negligently attended to; and will most
assuredly fail altogether, if counteracted by the erroneous prejudices
of ignorant attendants. But to the affections of infancy and childhood,
this remark applies with great force; since, at this period, disease is
generally so sudden in its assaults, and rapid in its progress, that
unless the measures prescribed are rigidly and promptly administered,
their exhibition is soon rendered altogether fruitless.
The amount of suffering, too, may be greatly lessened by the
thoughtful and discerning attentions of the mother. The wants and
necessities of the young child must be anticipated; the fretfulness
produced by disease, soothed by kind and affectionate persuasion; and
the possibility of the sick and sensitive child being exposed to harsh
and ungentle conduct, carefully provided against.
Again, not only is a firm and strict compliance with medical
directions in the administration of remedies, of regimen, and general
measures, necessary, but an unbiased, faithful, and full report of
symptoms to the physician, when he visits his little patient, is of
the first importance. An ignorant servant or nurse, unless great
caution be exercised by the medical attendant, may, by an unintentional
but erroneous report of symptoms, produce a very wrong impression upon
his mind, as to the actual state of the disease. His judgment may, as a
consequence, be biased in a wrong direction, and the result prove
seriously injurious to the welldoing of the patient. The medical man
cannot sit hour after hour watching symptoms; hence the great
importance of their being faithfully reported. This can alone be done
by the mother, or some person equally competent.
There are other weighty considerations which might be adduced here,
proving how much depends upon efficient maternal management in the time
of sickness; but they will be severally dwelt upon, when the diseases
with which they are more particularly connected are spoken of.
Sect. 1.--ACCIDENTS AND DISEASES WHICH MAY OCCUR TO THE INFANT AT
BIRTH, OR SOON AFTER.
STILL-BORN.
Sometimes the child comes into the world apparently dead, and, unless
the most active exertions are made by the attendants, is lost. The
superintendence of the means used devolves upon the medical man; but it
would be often well if his assistants were already acquainted with the
measures pursued under these circumstances, for they would be more
likely to be carried into effect with promptitude and success, than
they now frequently are. And again, the still-born child is frequently
in this state from having been born very rapidly, and before the
medical man can have arrived, it will be more especially useful in
such a case, that the attendants in the lying-in-room should know how
to proceed.
The various causes producing this condition it is unnecessary to
mention.
The condition itself may exist in a greater or less degree: the infant
may be completely stillborn, with no indication of life, except,
perhaps, the pulsation of the cord, or a feeble action of the heart;--or
it may make ineffectual efforts at breathing, or even cry faintly, and
yet subsequently perish for want of strength to establish perfectly the
process of respiration. Under all these circumstances, a good deal can
often be effected by art. In every instance, therefore, in which we
have not positive evidence of the child being dead, in the existence of
putrefaction, or of such malformation as is incompatible with life, it
is our duty to give a fair trial to the means for restoring suspended
animation; and as long as the slightest attempt at motion of the
respiratory organs is evinced, or the least pulsation of the heart
continues, we have good grounds for persevering and hoping for ultimate
success.