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V
PRACTICAL TREATISE
ON THE
MANAGEMENT AND DISEASES
OF
CHILDREN.
BY
RICHARD T. EVANSON, M.D.,
PROFESSOR OF MEDICINE,
HENRY MAUNSELL, M . D . ,
PROFESSOR OF MIDWIFERY,
IK THE BOTAL COLLEGE OF SURGEONS IJT IRELAND.
HASWELI., BARRINGTON, AND HASWELI,
ZBO^fi
1838.
Cbr(kt\\ CoU,
PREFACE.
A Preface usually embraces two topics, viz. : — the Author's reasons for publishing ; and such an account as he chooses to give of his qualifications for the task he has undertaken.
With regard to the first, we have only to state, that our publisher informed us that a concise practical work upon the Management and Diseases of Children was a desider- atum in British medical literature. Respecting the second, all that becomes us to say is, that wTe have been con- nected with the Institution for Diseases of Children ever since its establishment in this city: first, as students; and, subsequently, as medical attendants. We had thus, at least, ample opportunity of attaining experience in the subject. If it should now prove that we have profited by this so far as to enable us to render the following chapters (incomplete as we know them to be) in any degree useful to society, we shall be more than recompensed for the labour they have cost us.
H. M. R. T. E.
Dublin, Nov. 1836.
CONTENTS
CHAPTER I.
PECULIARITIES OF THE INFANT STRUCTURE AND CONSTITUTION.
Sect. 1. General Considerations,
2. Digestive Organs,
3. Organs of Respiration, 4. Circulation,
5. Cerebro-spinal System,
6. Locomotive Apparatus,
7. Growth, .
R. T. Evaxson
Page
9 11 13 14 15 18 19
CHAPTER II.
MANAGEMENT AND PHYSICAL EDUCATION OF CHILDREN.
Sect. 1. Management immediately after Birth, . . .26
2. Food and Medicine do. do. ..... 28
3. in First Period, 30
4. Choice of a Nurse, ....... 33
5. Artificial Feeding, ....... 34
6. Weaning, 35
7. Food in Second Period, 30
8. Cleanliness, 39
9. Clothing, 40
10. Sleep, 42
11. Exercise, 44
12. Medicine, 47
13. Light, 49
14. Air, ib.
15. Temperature, 50
16. Mental and Moral Education, ib,
II. Mauxsell
April, 1S3S.— L
6 CONTENTS TO MANAGEMENT, ETC., OF CHILDREN.
CHAPTER III. PECULIARITIES OF DISEASE.
Page
Sect. 1. Etiology, 56
2. Diagnosis, 61
3. Prognosis, 64
R. T. Evanson.
CHAPTER IV. INFANTILE THERAPEUTICS.
Sect. 1. General Observations, ...... 67
2. Mercury, 68
3. Sedatives, ........ 69
4. Alkalies and Alkaline Earths, 72
5. Carminatives, ........ 73
6. Stimulants, ........ 74
7. Tonics, 76
8. Antiphlogistic Plan, 77
9. Blood-letting, 78
10. Blisters, 79
11. Emetics, . 81
12. Expectorants, . 82
13. Diaphoretics, 85
14. Refrigerants, 86
15. Baths, 87
16. Purgatives, . . 88
R. T. Evanson.
CHAPTER V.
ACCIDENTS AND DISEASES OCCURRING AT BIRTH, OR SHORTLY
AFTERWARDS.
Sect. 1. Still-born Children, 95
2. Imperforate Anus, 98
3. Vagina, ib.
4. Penis, .99
5. Spina Bifida, . . . . . . . . ib.
6. Short Frenum Linguae, 101
CONTENTS TO MANAGEMENT, ETC., OF CHILDREN.
7. Hare Lip,
8. Deformed Feet,
9. N«vi Materni,
10. Ruptures,
11. Injuries received during Birth,
12. Blue Disease,
13. Trismus Nascentium, 1 1. Infantile Erysipelas, . 13. Abscesses,
16. Induration of Cellular Tissue.
17. Jaundice,
18. Purulent Ophthalmia,
19. Red Gum,
20. Swelling of the Breasts,
H. Maunsell.
CHAPTER VI.
DENTITION.
Page
101
ib
103 105 107 108 109 111 112 113 114 115 116 117
117
R. T. E vanson.
CHAPTER VII.
DISEASES OF DIGESTIVE ORGANS Sect. 1. General Observations,
2. Affections of Mouth, &c.
3. Stomach and Bowels,
4. Mesenteric Disease,
5. Worms, .
6. Remittent Fever,
R. T. Evanson.
CHAPTER VIII.
DISEASES OF THE RESPIRATORY ORGANS. Sect. 1. Catarrh,
2. Bronchitis, .......
3. Pneumonia,
4. Pleuritis,
5. Cronn. ........
125 126 137 168 177 183
191 192
195 196
S CONTENTS TO MANAGEMENT, ETC., OF CHILDREN.
Page
6. Laryngitis, 202
7. Foreign Bodies in Larynx, 204
8. Spasm of the Glottis, 205
9. Hooping Cough, 209
H. Maunsell.
CHAPTER IX. ERUPTIVE FEVERS.
Sect. 1. Measles, 214
2. Scarlet Fever, 219
3. Small-Pox, 230
4. Chicken-Pox, 237
H. Maunsell.
CHAPTER X.
VACCINATION, 238
H. Maunsell.
CHAPTER XL
CONSTITUTIONAL DISEASES.
Sect. 1. Scrofula, . . . 260
2. Rickets, . 269
3. Syphilis, 271
4. Purpura, . . . 275
5. Pemphigus, 277
H. Maunsell.
CHAPTER XII.
DISEASES OF THE CEREBRAL SYSTEM.
Sect. 1. Functional Diseases, 280
2. Inflammatory Affections, 286
R. T. Evanson.
PRACTICAL TREATISE,
&C. <fec.
CHAPTER I.
PECULIARITIES OF THE INFANT STRUCTURE AND CONSTITUTION. I. GENERAL CONSIDERATIONS.
In considering our present subject, as well as in the observations which we propose to make upon the diseases of children, we mean to regard the period of childhood as consisting of two epochs — the first commencing at birth, and continuing until the twelfth month ; the second commencing at the termination of the first year, and continuing until the eighth.
This division, which has been generally adopted, possesses the merit of being nearly in accordance with one definitely marked out by nature herself. About the tenth or twelfth month, the child, by its acquisition of teeth, becomes fitted for the use of other nourish- ment than the mother's milk ; and the stomach and bowels receive, not merely with impunity, but advantage, kinds of food, which, during the earlier months, would have been productive of serious derangements of the digestive functions : at the same time, very obvious external changes have their commencement, and indicate marked alterations, both bodily and mental.'* During the first period, also, the child is subject to some peculiar diseases and dangers, to which the attention of the physician requires to be specially- directed, and the diminished liability to which, upon the commence- ment of the second epoch, appears materially to increase the chances of existence.
Beyond the eighth year, we would not employ the term, child — though sometimes continued until the age of puberty ; but before then, the peculiarities characteristic of childhood have been merging into the attributes of adult age; while the influence of sex begins to be discernible, and the individual may thenceforward be designated boy or girl.
The infant, at birth, is endowed with the same organs as the adult ; but so different, for the most part, in structure or development, as to constitute those essential characters which distinguish childhood,
*" At this time," says Wend t, "the hitherto projecting forehead hecomeB flattened, the countenance receives expression, the eyes intelligence, the limbs firmness." — Die Kinderkrankheiten systematise?! dar^estcllt von Dr. J. Wendt, Wien 1827.
March, 1S38. — E 3
10 MANAGEMENT AND DISEASES OF CHILDREN.
and without a knowledge of which, neither the management nor diseases of children can be correctly understood.
Infancy may be emphatically termed the period of growth. We find the infant, at birth, fully provided with the organs of nutritive or organic life — those which are essential for the sustenance and nutrition of the individual ; while the organs of animal life or rela- tion,— those which connect man with the external world, and make him, on their completion, the superior being that he is, — are as yet but imperfect in development or structure — herein being to be found the basis of that great difference observable between the infant and the adult. In the former, we have the organs of nutritive life alone, fully developed, and actively employed; but in the latter, we have both classes of organs, relative as well as nutritive, brought to com- pletion and in full activity, constituting the period of maturity or perfect growth.
To speak in general terms, we may say, that the anatomical struc- tures in the infant differ from those in the adult, by their greater softness or want of consistency ; being surcharged with fluids, and many of them as yet unfitted for the full discharge of their appro- priate functions: while in advanced life, on the contrary, the quan- tity of fluids diminishes, and the structures become condensed, so that the organs, instead of being too soft, have become too rigid,, as we find them to be in old age.
In the infant, the capillary system, in particular, predominates ; absorption and deposition are active, and the processes of interstitial growth most vigorous; secretion is abundant,and excretion frequent; the nervous sensibility being acute, and the membranes remarkable for their vascularity ; all which phenomena depend, not- merely on the abundance of blood present, but on the preponderance of the arterial over the venous vessels.
Before proceeding to a particular review of the several organs, and the properties by which they are characterized in childhood, it may be well to take a glance at the general appearance of the newly born infant.
The length of the body varies from about one foot and a half to less than two feet. Baudelocque states sixteen inches, and twenty- two, (or at most twenty-three) inches, as the extreme limits. The average weight is from about six to seven pounds and a half ; more has been assigned, but is not common : six pounds is by far the most common weight, according to Camus's Tables.
The skin is thin, tender, and of a reddish hue: but covered at birth with a whitish unctuous matter, called vernix caseosa. There is some hair upon the scalp, and the nails reach to the ends of the fingers : the articulations are commonly flexed, the limbs round, and the body plump.
The relative dimensions of various parts differ materially from those observed in after life. The lower extremities are less deve- loped than the upper ; the median point, — that lying midway between the two extremes of the body, — -being found at the umbili- cus, or a line or two below it.
DIGESTIVE ORGANS. 11
The pelvis in the infant is small and contracted, being less deve- loped in proportion than the thorax, which is flattened at the sides, but prominent in front ; while the abdomen and head present dimen- sions, not only very large in comparison with the other cavities, but also as compared with their own dimensions in after life.
The newly born infant possesses little power of motion ; none of independent support. Sensation and perception are dull or absent. Its cries and movements may be looked on as involuntary — its search for food as instinctive. One third of its time is chiefly occupied in taking nourishment, the remainder is passed in sleep.
Peculiarities not less striking or important, arrest our attention, on turning to the consideration of the internal organs ; and these we shall briefly notice in succession, commencing with those of or- ganic life, as being first called into action ; and of these the digestive organs naturally claim precedence, and will be found in a high state of development.
II. DIGESTIVE ORGANS.
The mouth of the infant is fully formed, and in some respects particularly adapted to the performance of its proper office of suc- tion, as we see in the disposition of the palate and lips and the obli- quity of the posterior nares ;■ yet appearing to be imperfect from the want of teeth, which, however, can hardly be said to be want- ing— only absent ; as they already exist within the gum, in due time to make their appearance and mark a new era, when the child becomes fitted for a different aliment, from that hitherto provided by nature for its sustenance.
The mucous membrane lining the fauces, pharynx, stomach, and the whole tract of the intestinal tube, is thick and villous ; being more sensitive and vascular than in after periods of life ; softer in texture, and more bedewed with mucus, which is abundant, but thin ; becoming viscid, however, and much increased in quantity, on the occurrence of any irritation.
The sensibility of the mucous membrane is adapted to the mild and unirritating fluid provided by nature as the suitable nourishment for the infant : any other substance proves irritating in a greater or lesser degree, and is therefore to be avoided.
The stomach and duodenum are fully formed, their mucous mem- brane being thick, villous, and of a rosy tint.
The small intestines in the infant are a third longer in propor- tion to the length of the whole intestinal tract, than in the adult ; and the large intestines are longer in proportion to the small, but their calibre is relatively less. The val vulae conniventes are scarcely apparent ; the vermiform process is very long, and the coecum is largely developed.
The salivary glands and the pancreas are very large, and seem particularly active.
Digestion is rapid and incessant ; the child frequently requiring
12 MANAGEMENT AND DISEASES OF CHILDREN.
food, which, if permitted, will be often taken to repletion ; so as to be ejected without effort from the overloaded stomach, which is not capable of containing more than a few ounces of fluid at a time.
The chyle, which is rapidly eliminated, is quickly absorbed, the tract of the small intestines being long, as we have seen ; while the lacteal vessels and mesenteric glands are largely developed, and in a high state of activity.
The gall bladder, though small at birth, soon enlarges ; and is found to contain bile, bitter in taste, and green in colour: but bile, in the infant, is less viscid and less charged with the principles pecu- liar to this fluid, than at a more advanced age, when concretions are liable to form.
The liver undergoes a remarkable alteration in function and form after birth. The mode of circulation is changed ; the left lobe diminishes, the umbilical vein and canalis venosus are obliter- ated ; while the vena portae is developed, and the secretion of bile becomes the peculiar function.
The parenchyma of the liver becomes darker as life advances ; and the size of the organ diminishes relatively in volume — but instances are recorded, where the proportions of the liver remained through life as in the foetus.
The spleen presents little peculiarity that we are as yet able to notice; too little is known of its functions to enable us to appreciate any changes that may occur ; but we have observed, that it is sub- ject to disease at a very early period.
The bowels, at birth, are found to contain a dark coloured, inodo- rous, insipid substance, which is called meconium* and appears to result from the accumulation of intestinal secretion, for which pas- sage had not before been provided. This is, however, soon expelled, and its place occupied by the residue of the food ; which, from the nature of the infant's aliment, we might conjecture, would be but little characterized by the properties of fecal matter. Accordingly, we find the contents of the bowels in infants, much less feculent than they afterwards become ; being thin, charged with mucus, and of a yellowish colour ; possessing little fetor, but abundant and fre- quently expelled, the infant passing a stool three or four times each day.
In a similar manner we find the other excretions less odorous, more watery, and not so largely charged with their peculiar princi- ples, saline or otherwise, as in the adult ; but they are quickly ex- pelled, though not very abundantly secreted.
The perspiration is less saline and odorous, but more watery, though not copious. The urine differs in like manner from that of the adult (in particular, the quantity of urea is much less); and it is retained a much shorter time, being, like the feces, quickly expelled.
This does not depend merely on the constant supply of food, or less relative capacity of the containing viscus ; but is connected with the peculiar sensibility of the lining membranes and irritability of the muscular coats of these viscera; which, like the other involuntary
ORGANS OF RESPIRATION. 13
muscles, are more irritable in the infant, than they are subsequently found to be. In their tissue, they are softer and of a paler hue, nor has command over their actions been yet acquired.
This latter character in particular, attaches to the urinary bladder in the child, and occasionally continues to give annoyance for some time, by leading to frequent wetting of the dress or bed-clothes. The bladder, in the infant, is more elongated in shape, and situated higher up, than that of the adult ; but is less capacious in proportion, while the ureters are particularly large. But it is upon its differ- ence of anatomical structure, as regards the position of the urethra, more than perhaps other circumstances, that this difficulty of retain- ing the urine depends ; for the pouch or fundus of the bladder ('bas fond') does not exist in the foetus, the cervix or urethral opening being then most dependent ; and this state of parts still obtains to a certain degree in the young subject ; probably in some more than others.
The kidneys undergo remarkable alteration; their lobular forma- tion disappearing, and the supra-renal capsules rapidly diminishing; but the relation which these changes bear to the functions of the organ, is not very obvious.
III. ORGANS OF RESPIRATION.
Having considered the digestive organs, or those which generate the materials for the biood, we shall now notice the respiratory organs, or those by which the blood is regenerated, and fitted again for the purposes of the circulation.
In no organs do more important changes occur, at birth, than in the lungs; in nothing does the infant more remarkably differ from the foetus, than in being a respiratory animal. The lungs, which before birth had been condensed, of a brownish red hue, very vas- cular, and not as yet permeated by air, now suddenly augment in size, becoming, after respiration, of a rosy colour, soft and vesicular in structure, and crepitant to the touch.
The respiratory process is carried on with rapidity and force, consonant with the general activity observable throughout the sys- tem ; and in particular, the constant demand for fresh supplies of blood.
The inspirations are frequent, counting from 35 to 40 in the minute, or nearly double those of the healthy man ; while the sound emitted on the passage of the air, is so peculiar, from its force and clearness, as to obtain the distinguishing appellation of puerile respiration. This character, respiration in the adult occa- sionally assumes, when the healthy portion of a lung is obliged to take on a compensatory action, in consequence of obstruction in the diseased portion (as in Pneumonia), — when the respiration in the sound part is said to be puerile, as significant of its force.
Notwithstanding this activity in the process of respiration, it would appear that less oxygen is consumed in the infant than the
3*
14 MANAGEMENT AND DISEASES OF CHILDREN.
adult, and that the power of generating heat (a process closely re- lated to respiration,) is also less.
The thymus gland, which occupied a large and conspicuous space within the upper and anterior part of the thorax in the foetus, gradu- ally diminishes after birth, and is hardly to be recognized in the adult. It is freely supplied with veins and arteries, and contains at first a whitish fluid somewhat like chyle, which shows the gland to have a secreting power; but no excretory ducts have been discovered. Its supply of blood-vessels and softness of texture, seem to allow of sudden augmentation of size; and this, in instances where the gland is larger than ordinary after birth, may cause, by the pressure exerted on subjacent and important parts, very distressing or dan- gerous symptoms. To such cause has been attributed a spasmodic affection to which some children are liable, and which often proves fatal; at least, the thymus gland has been found distended or en- larged in such instances. In common, it does not exceed a couple of inches in length, one and a half in breadth, and a quarter of an inch in thickness.
IV. ORGANS OF CIRCULATION.
The blood, having undergone the requisite changes in the lungs, is conveyed again to the heart, thence to be sent throughout the system. From the moment the act of respiration is performed, the circulation undergoes a total change; and the heart is altered ac- cordingly, becoming complete in its functions, but still retaining some remarkable peculiarities. Its volume is proportionably large; but the relative capacity of its cavities differs from what is after- wards observed, those of the left side, — or the ventricles, and, in connection, the arteries, — preponderating decidedly at first: the balance, however, is gradually altered, until we find, in the adult, the cavities of the right side of the heart nearly three times the size of those of the left.
The thickness of the parietes of these cavities, however, changes inversely with their capacity; for, from being nearly equal, the parietes of the left ventricle become almost four times as thick as those of the right — a change which rapidly proceeds after the obli- teration of the ductus arteriosus, and the closure of the foramen ovale, when the left ventricle has the sole conduct of the circula- tion through the system.
The parietes of the heart are softer and paler than in after life, when the relative bulk is less, but the texture firmer, and colour deeper; this organ being then called upon to propel its contents with greater force, as they have to traverse a longer space. In the infant, the large volume but feebler power of the heart fits it for the propulsion of a larger quantity of blood, but through a less dis- tance; while the peculiar irritability of this, as well as the other hollow muscles during infantile life, ensures more active contrac- tility, and so, more rapid action, suited to the constant demand for
CEREBROSPINAL SYSTEM. ] 5
fresh supply. Accordingly, we often find the pulse in the infant, like the respiration, nearly double in frequency that of the adult, varying from 120 to 140 beats in a minute.
That part of the nervous system more immediately connected with the class of organs which we have just been considering, should naturally be in a high state of development, to allow of the fulness of function which we have seen these organs to possess : and accord- ingly, we find the ganglions, or system of the sympathetic nerve, very perfectly formed at birth ; while the brain, and its nervous connections, on the contrary, are very imperfectly formed, though largely developed — more especially the brain itself.
We now come to the consideration of the second class of organs, — those of animal life, or relation to external objects; and here we shall find remarkable changes manifested in the advance of organs from a state of essential imperfections, to one of completeness — this advance in organization, and successive development of func- tion, constituting the most interesting eras of infantile life, looked forward to with eagerness, and remembered with pleasure as the periods of dawning intelligence, and independent muscular exertion — when the infant first begins to take notice, to walk alone, and to speak.
V. CEREBRO-SPINAL SYSTEM.
The brain, though large in volume, is very imperfect in structure in the infant, being so soft as to be almost fluid, and of a reddish hue, but with the cortical portion less deeply coloured than in adult age, and the convolutions less deeply marked.
The brain is altogether inadequate to perform, on first entrance into life, those exalted functions which afterwards render it so im- portant an organ, and so characteristic of the superiority of man ; and accordingly, we find the newly born child incapable of thought, and apparently devoid of perception.
The precise changes which the brain undergoes, in its progress towards perfection of structure, are not accurately determined; but those appear to be as important which regard alterations in the quality, as in the quantity of the cerebral substance. The increase in size is not perhaps so remarkable as that in the density of the organ; which, according to Wenzel, does not attain its greatest weight until the seventh year, — the size and weight of the brain at that time being said to differ little from what they are at mature age, when the power of function is so far superior.
Whatever may be the case as to the density, however, it will be found that alteration does occur in the size, and even form of the brain, long after this age; and that to an extent and with a fre- quency, now little known, and the importance of which is as yet but little noticed.
In advanced life it has been ascertained, according to Desmoulin and Cruvelhier, that the brain diminishes in specific gravity, as most probably it does also in general or in relative size. It grows
16 MANAGEMENT AND DISEASES OF CHILDREN.
rigid in its quality, becomes again unequal to the due performance of its functions, as it had before been in infancy, though from an opposite cause, and second childishness is said to take place.
The cerebellum is at birth somewhat more advanced in organiz- ation than the brain ; but it is about the period of puberty that the relation between the cerebrum and cerebellum undergoes the most remarkable change, the latter becoming considerably augmented in relative size, being then nearly twice as large, in proportion as it had been at birth.
The spinal marrow is largely developed, like the brain in the infant, but appears to be more matured in structure, and farther ad- vanced in the performance of its functions.
The general sensibility is acute, and the nervous susceptibility in the infant remarkable; so that all impressions are violently felt, and sympathetic affections are presented in a very aggravated form, and are very prone to occur, constituting a peculiar feature in the infant constitution, which may be emphatically said to be nervous. The large endowment of nervous matter, and its peculiar susceptibility of impression from the softness of its texture, appear to confer this quality, which is never to be lost sight of in the treatment of in- fantile disease — a remark as old as the time of Boerhaave, but which is nevertheless too frequently forgotten.
As the infant grows older, the brain becomes capable of perceiv- ing impressions made through the senses. Signs of intelligence begin to be manifested: the infant takes notice, and becomes sensi- ble of the qualities of bodies, recognizing them and exhibiting symptoms of gratification or annoyance. The nerves of sensation, however, though freely developed, are as yet but imperfect in their functions, and inadequate to the conveyance of their appropriate impressions; while we find that the apparatus by which the exter- nal sources of these sensations are supplied, is more or less imper- fect, and destined to undergo much alteration.
To notice particular senses, we shall commence with vision, which does not appear to exist in the newly-born babe, though the eye is fully developed : and it has been ascertained, that perfect images are formed on the retina. Vividly illuminated objects seem soon to attract notice; but the eye follows, or is fixed on them, at first, in an apparently passive manner, little dependent on the will. Light is at all times agreeable to the infant, which seems naturally to dislike darkness; but a very bright light is injurious, as well as annoying to the eye.
The sense of hearing is as little exercised as that of sight, in the first instance. It is doubtful if the young infant can hear at all ; at least, for some time it does so but very imperfectly : and that this must be so, is manifest, from the deficiency of structure in the ex- ternal ear, which is as yet ill calculated to collect or receive vibra- tions of sound, the pinna being very inelastic, the tympanum small, and its membrane oblique, while a soft matter, little favourable to vibration, covers all.
CEREBRO-SPINAL SYSTEM. 17
Taste early exists, and provision is made for its exercise in the full development of the mouth ; but probably perception of flavours is en- joyed to a less extent than we might at first suppose. The apparatus connected with the sense of smell, is much lc*s fully formed ; and although this sense be manifested early, there is little probability that delicacy of perception is early enjoyed by it.
The absence of speech, or of the capability of uttering articulate sounds, is a deficiency characteristic of infancy, but not to be ac- counted for by mere anatomical examination of the organs of voice, though these certainly are but imperfectly developed. The larynx is small, and nearly circular; the lips of the glottis, and the superior ligaments, being, therefore, very short. This, combined with an immature muscular endowment, sufficiently accounts for the shrill, feeble tone, and wailing cry, peculiar to the infant : but the acqui- sition of the power of speech is connected with the advance of intel- lect, rather than alteration of mechanical structure, in this part of the apparatus of voice.
The gradual alteration going on in the larynx, does not become very evident until the period of puberty, when the rima glottidis enlarges, the thyroid cartilage, and thyro-arytenoid muscle, become elongated, and achangeinthetoneof voice is consequently occasioned. In the male it assumes the deep and grave sound, which characterizes the full-toned voice of manhood : while in the female little change takes place in the larynx ; and the acute tones still remain charac- teristic of the female voice, which always more or less resembles that of childhood.
The mechanism on which depends the power of articulating intel- ligible sounds, is more connected with the increased growth and power of the muscles of the mouth and pharynx, which, even before intellect begins to dawn, become, by a happy provision, early developed, being necessary both for sucking and deglutition.
The infant begins to articulate at from half a year to a year old ; and usually speaks plainly, or so as to be understood by a stranger, at from two to three years of age.
The general sense of tact, or perception of contact, makes us con- scious of the presence of external bodies ; and, to a certain extent, is exercised by the whole cutaneous surface, though not in like de- gree. In the young infant, however, the skin does not seem well disposed for the active exercise of this power, the papillae being less developed, and its structure more gelatinous than in after life. The sense of touch, strictly so called, — or that perception by contact, in virtue of which we not only recognise the presence, but certain of the qualities of bodies, exists only in some organs — almost solely in the hands — and is but little developed in the infant.
Whether the skin be less sensitive or not, the muscularendowment necessary for the exercise of this sense is but very imperfect, — the use of the fingers for this purpose being as yet unknown, or the at- tempts to employ them sufficiently awkward.
The assistance of muscles is necessary for the exercise of all the
18 MANAGEMENT AND DISEASES OF CHILDREN.
special senses ; and the imperfection of the muscular apparatus, is a principal cause of the deficiencies of these senses in the infant.
VI. LOCOMOTIVE APPARATUS.
The organs of locomotion are those that enable us voluntarily to come into contact with external objects; and these organs are but little developed in the child, in either of their chief component parts, bone or muscle.
The osseous system, in particular, is imperfectly and unequally developed, varying according to the purposes of its different parts.
The bones necessary to contain and protect important organs, as the bones of the head or chest, are much more advanced in ossification than those destined merely for muscular support, or locomotion, — which are but imperfectly ossified, or exist as yet only in the form of cartilage.* The bones in general are characterized by their small- ness of size, redness of colour, and softness of texture, being very vascular, and the earthy part not only much less in proportion than in the adult bone, but even the animal portion being less firm, in consequence of the larger proportion of gelatine.
The bones in the infant, then, are little calculated, from their for- mation or structure, for the support of the body in the erect posture, or the endurance of strong muscular exertion : nor are the muscles themselves better prepared for such efforts.
We have already noticed the characters of the muscular tissues of organic life, or the involuntary muscles in the infant.
Similar characters of structure belong to the voluntary muscles. They are pale in colour, and easily torn, being soft in .consistence* and slender in shape, the bellies of the muscles not being yet formed. They contain less fibrine than in after life, and have their fibres but loosely united, the fasciculi not being embraced by fasciae or apo- neuroses. Similarly imperfect are the tendons and ligaments, or muscular appendages.
In the child, the irritability of the muscles, or tendency to contract, is more easily excited, but less easily sustained, than in after life. Hence, the motions of the child are quick or sudden, and frequent, but fail in capability of effecting powerful action, or sustaining con- tinued exertion.
The first efforts of the infant at voluntary movements are thus necessarily imperfect. It begins to attempt walking at about twelve months of age, and has generally acquired the power of walking
* "The most striking fact of this kind," to use the words of Dr. Symonds, in his able article 'Age,' Cyclopaedia of Anatomy and Physiology, "is presented in the spinal column. The annular portions of the vertebrae, which form the canal of the medulla spinalis, are found strongly ossified at birth ; but the bodies of these bones, which are to be used hereafter in supporting the weight of the head and trunk, are very slightly expanded, and all but devoid of earthy particles ; while the processes to which the muscles employed in the flexion, and extension of the column, afterwards contract attachments, are either only shaped in cartilage, or may be said to have no existence."
GROWTH. 19
alone between the second and third year. But many are the mis- chances which such efforts entail ; foreseeing which, nature has pro- vidently furnished a shield of defence in the yielding and elastic cellular tissue, in which the body of the child is so liberally encased.
VII. GROWTH.
We have already designated infancy as the period of growth ; and this character, which continues during childhood, is sufficiently manifested by the progressive and rapid advance made in the body at large, and its several organs in detail. The progress of this advance is uniform ; so that the successive developments of differ- ent parts observe stated periods, and a well known order.
In this progress we are most attracted by the advance made in the organs of animal life : but the changes which take place in the organic functions are not less remarkable, though less noticed ; con- sisting principally of a decrease in activity, if not power, and occur- ring out of sight, so as to be little obnoxious to observation.
As the infant grows older, digestion ceases to be so active, and the digestive tube so sensitive. Food is less frequently required ; and the kind of food may be more varied, a more stimulating variety being borne and necessary. The secretions begin more to resemble those of adult life, and the evacuations require less frequently to be voided, being no longer passed independently of the will.
The involuntary muscles generally acquire more tone, grow firmer in structure, and deeper in colour, losing their puerile irritability.
Respiration becomes slower, and the pulsations of the heart less frequent, — the respiration gradually parting with the attributes of puerility, and the pulse diminishing in rapidity.
The activity of secretion becomes abated, and the membranes are not so vascular or sensitive. Less mucus is secreted naturally, or poured out on the occurrence of irritation.
The capillary vessels are no longer so abundant, nor do the arte- rial branches preponderate so much over the venous.
As the child advances in age, the activity of the ganglionic system of nerves is less manifested, while that of the cerebro-spinal system comes more into play ; and the body, gradually losing the characters of infancy, begins to assume the attributes of adult age.
In these various stages of advance, we are particularly struck by the progress made in the powers of sensation, perception, and vo- luntary motion, or in the organs of animal life.
Sensation awakens,and thesenses successively and rapidly expand. Perception is manifested, and reflection in due time succeeds. Thus endowed, the child is competent to voluntary efforts ; and muscular power is proportionably developed, and brought into action.
The several senses improve as they are exercised, and mutually aid each other by corroborating orcorrectingthe impressions received by each.
Our perceptive faculties are thus brought first into action, and we
20 MANAGEMENT AND DISEASES OF CHILDREN.
obtain a knowledge of the existenceand propertiesof external objects. Memory/' the store-houseof the understanding," becomes furnished, and the intellect is supplied with the materials of knowledge and business for thought.
The progress of growth in the organs devoted to the exercise of the senses, the intellect and voluntary motion, is remarkable and characteristic, but unequal in advance, and tardy in completion. The perfecting of these organs finishes the process of growth : and is not fully completed until the period of maturity, or near to the meridian of life.
Full development of the bones and muscles connected wilh the apparatus of the organs of sense, is necessary for the full exercise of the several senses, and is not finally completed until long after the period of childhood ; nor are the powers of sensation brought to perfection before then. The acuteness of the early impressions is probably great, whether in consequence of their novelty, or the sensibility of the nerves ; and such impressions seem tobe recollected as peculiarly pleasurable. But it is only by practised experience that the perfection of sensation can be attained, as is remarkably exemplified in the sense of touch.
The advance in the organs of voluntary motion, — the knitting of the frame, and development of the muscular power, — constitute the most noted feature of growth ; and the completion of these organs, the most characteristic attribute of manhood.
The form of the skeleton, and its several parts, alters much ; and the chemical constitution of the osseous system, also, undergoes change. The relative development of the pelvis and lower extremi- ties, comes to bear a better proportion to that of the thorax and the rest of the body. The form of the spine assumes more of the alter- nate curvatures of full growth. The shafts of the bones become firmer, and more closely united to their heads, and the processes shootout; while the quantity of calcareous matter gradually increases, until the completion of bony growth, when the frame-work of the muscular system is brought to perfection.
The muscles are not stationary, as the bones advance. Their colour deepens, and the fibres become well defined and firm, being developed so as to form the belly or central fulness : more fibrine enters into their composition. The aponeurotic sheaths, and tendi- nous appendages, have become necessary, and are added.
Muscular exertion now comes into busy operation, but continues to be characterized by activity rather than power. The child has a constant tendency to muscular movement, and loves exercise ; but the power is soon expended, and rest is required, — well-concerted, or long-sustained, muscular exertion being beyond its capability. This is an important moral as well as physical check, the corporeal power being limited, and full strength not acquired, until the con- trolling influence of a matured intellect has been provided.
This brings us to consider the progress of growth in the cerebro- spinal portion of the nervous system ; particularly the brain, the
GROWTH. 21
organ of thought and feeling, and that in which remarkable changes take place.
As the body elongates, the spinal marrow of course becomes enlarged, until it bears to the brain a greater proportion in size than it did at birth ; but having been more forward in structure from the first, its advance in this respect is less remarkable.
The brain grows, and the head enlarges remarkably, within the first year after birth — particularly, during the first few months. The imperfect state of ossification in the bones of the skull at this period, admits readily of the rapid enlargement of the cranium and its contents ; this being one of the uses of the fontanelles, in addition to the facility which they can afford in delivery, by allowing the bones to overlap each other, and so diminishing the bulk of the head.
Six of these deficiencies in ossification are found at birth, the spaces being covered by membrane : nor have the sutures yet begun to form. The principal of these openings is called the bregma, and is situated at the top of the head, between the frontal and parietal bones ; another is found behind, between the occipital and parietal bones ; and of the remaining two, (each of which is double, thus constituting six in all,) one is found in the temporal fossa, at each side, the other above each mastoid process.
The presence of these fontanelles (particularly that on the top of the head,) is a source of uneasiness to the ignorant, imparting to the hand an uncomfortable sensation, as if the brain were devoid of pro- tection ; and improper, and often injurious attempts are accordingly made to remove them, by compressing the head, for the purpose of bringing the bones together. But so far from being a cause for alarm, these openings are a source of advantage. The effects of blows or falls on the head (to which the infant is so liable,) are thus mitigated, the shockbeing intercepted before it has affected the brain ; while, in cases of disease, the danger from effusion is lessened by the possibility of quick expansion thus permitted, and which dimin- ishes the effects of compression. The full or sunk state of thebregma is an important point in diagnosis.
These openings gradually close by a natural process, and will be found completely united by the fifth year, when the sutures are well marked and formed. Occasionally, the fontanelles are later in closing, the process of ossification being slow or imperfect; and this is a just cause for uneasiness, having its source usually in a general delicacy of constitution, often connected with a strumous taint.
The brain not only increases much in size in the child, but also alters sensibly in structure, advancing towards more complete organ- ization ; and this remarkably, at the time when signs of intelligence begin to be displayed. From about the period when the first teeth appear, this advance in structure is striking, that in size having been before more remarkable.
The brain now becomes firmer, more consistent, and less vascular ; the difference between the medullary and cortical portions is more March, 1838.— F 4
22 MANAGEMENT AND DISEASES OF CHILDREN.
pronounced ; the former is less red, the latter deeper coloured ; the convolutions are better marked, and so the peripheral surface more extended.
The advance in quantity and quality continues manifest to the age of seven years, or about the period of second dentition, which appears to be on many accounts remarkable.
The brain has now assumed considerable volume, and its structure apparently resembles that of adult life ; but after this period, advance in structure, and increase of size, may still be observed, though not so remarkably.*
The character begins now to be defined, and some indications of the mental endowments of the future man are afforded ; the features form, and the physiognomy begins to exhibit traces of a marked dis- position. But in regarding the countenance, we must take into ac- count the development of the bones and muscles connected with the head and face, which occurs about this age : yet, the general enlarge- ment of the head is not so much connected with the expansion of the skull and its integuments, as some insist.
When the circumference of the head, taken above the orbits, does not exceed thirteen inches in the adult, idiocy always attends, accord- ing to Gall : and Dr. Voisin found, on careful examination, that idiocy was complete, when this measurement varied from eleven to thirteen inches: while that from the root of the nose over the head, to the occipital spine, measured only between eight and nine inches. In the full-sized head, the former measurement averages two and twenty inches ; the latter fourteen.
A very small head is usually accompanied by feebleness of cha- racter ; but the head may be large,and the person dull, or even idiotic, — the deficiency existing in the structure, not size of the brain.
The advance of growth in the brain does not seem to proceed equally, either as to size or structure, in all parts. Vimont notices, that the increase of size, during the first months, is most remarkable in the parts situated at the base of the skull, and occupying the ante- rior and inferior regions of the frontal bone: while, of the cerebral convolutions, those soonest acquiring firmness of structure are placed in the lateral and middle parts of the base. All know that the cere- bellum does not acquire its full development, until about the period of puberty.
The head varies with the progress of growth not only in size, but shape, — the different regions of the brain being found to bear a differ- ent relative proportion at different ages — particularly during youth ; while at all periods there exists a certain degree of individual pecu- liarity.
Not less remarkably do we observe a certain order or relation in the successive development of the several moral and intellectual powers : which is, doubtless, dependant upon this relative advance
* The concretions of the pineal glands have begun to form about this period ; and they are redder in colour, but fewer in number, than in afterlife : but in some instances they never form.
GROWTH. 23
in size or structure in different parts of the brain, though not yet directly connected therewith — observations for determining this point having been but partially made, and the importance of the subject not yet duly appreciated.
However this may be, it is certain, that the disposition and intel- lect are gradually unfolded : and that attempts to force the one or the other before its appointed time and proper progression, are sure to be attended with injurious, if not dangerous consequences. The rea- son is obvious and physiological ; because, what is called the culti- vation of the mind, is in truth but the exercise of the brain ; and this, like every other organ, if overtasked, will be worn out or des- troyed.
In noticing the development of the intellectual powers, we see that the child observes before he reasons — that the perceptive faculties come into play before the reflective. The child early observes and recollects things, and the qualities and relations of things ; and is in- quisitive about events. He constantly asks what this or that is.
But the senses advance still more rapidly than the perceptive fa- culties, and are thus prepared to furnish these faculties with know- ledge of the various properties of matter. The differences to be observed, however, in the power of appreciating these qualities of bodies depend on differences in the constitution of the perceptive faculties — not of the senses.
The eye may see well, and clearly perceive differences in size or form, and yet not be able to distinguish differences in colours: the ear that hears best, is not that which best appreciates those vari- ations in sound that constitute melody.
The various degrees of talent exhibited by some children more than others, depend much on the different degrees with which they are endowed with those faculties that take cognizance of the physical properties of things.
In these qualities and relations of bodies we have the foundation of the physical and natural sciences; and for these sciences, (espe- cially the latter,) mental capacity exists at a much earlier age than seems commonly supposed.
The gift of language as a mental power, is that which earliest attracts attention, and is first cultivated. Hence, facility in this respect, with a quick observation, are taken as indications of great intellectual capacity. But the reflective faculties must be in full operation, to constitute a really good understanding; and these are always the latest to be developed, and often not very liberally bestowed.
It is, indeed, upon a due balance between the reasoning and per- ceptive faculties, that the superiority of the intellect will depend. Where the latter preponderate, they early show themselves, and give a quickness of apprehension, which, in a child, is often taken for superior talent. But the smartest boy does not necessarily make the cleverest man ; there must be a full endowment of the reflective faculties, to give depth of thought, or soundness of under- standing.
24 MANAGEMENT AND DISEASES OF CHILDREN.
When these faculties early preponderate, however, the child will be slow in apprehension, and may be esteemed dull ; but when the period for their exercise arrives, powers will be exhibited which had not been anticipated. Peculiarities of disposition, moreover, will affect these results as much as differences in talent, though sel- dom, if at all, taken into the account. The child often exhibits (from the earliest age,) a marked disposition, as it occasionally does some peculiar talent. Almost from the moment of birth some in- fants are observed to be peevish, passionate, or obstinate; while others are gentle and affectionate, or timid.
A determined infant may be seen to rule a weak parent, and even exercise an influence over a whole family. A very gentle child may never acquire sufficient force of character to make his way in the world, no matter how intellectual he may be.
The higher sentiments, generally speaking, are the more slowly developed ; and superior moral powers, as the sense of justice and religion, are among the latest to come into operation, requiring some assistance from the understanding for their direction and support.
No doubt can exist that the child is endowed with certain powers, moral and intellectual, varying in different individuals, and consti- tuting natural differences of character; but this militates not against the necessity for education or training, and the vast influence exer- cised thereby ; on the contrary, it serves as a guide and a limitation, — pointing out what requires to be cultivated, and what to be re- pressed ; and shows us what is possible to be done.
How important, then, to acquire a knowledge of the primitive faculties of man, and the laws by which they are regulated in their natural development, or influenced by artificial training. Nor is the necessity for such knowledge confined to the system more im- mediately connected with mental manifestation. The same holds good respecting all the other systems in the body ; for without due attention to each, we shall not be able to do justice to any, or secure for the whole its best advantages during the period of development or growth.
With regard to the general growth of the body, and the advance in height, weight, and strength, differences arise from age and sex; and these have been accurately investigated by M. Quetelet.*
According to him, the average weight of the male infant at birth is about half a pound more than that of the female, and the length about an inch more; and the annual growth of the female infant is less than that of the male, but her development is more early com- pleted.
The growth of the stature is most rapid during the first year, when it amounts to nearly eight inches: it is less rapid as the child approaches the fourth or fifth year, but afterwards increases with a tolerably regular progression.
A remarkable difference is often to be observed in the degree of
* See Eclectic Journal of Medicine, February, 1838. — Ed.
GROWTH. 25
development, or proportional growth of one organ or system of organs more than another. In some children the head is very large, and great liveliness and intelligence are early displayed, the cerebro-spinal system of nerves being that which preponderates; and this lays the foundation for a particular temperament, which, according to the rational view of M. Thomas, would, in this instance, be the nervous temperament.
In other children, great muscular power is early displayed, the chest is large, the body well nourished, and the complexion florid. This constitutes the thoracic, or, as it is more commonly called, the sanguineous temperament — the circulatory system predominating. The child is strong and active, but not particularly intelligent.
When the abdomen is very large, and the circulation languid, — the child being pale, indolent, and dull, with a large appetite, but little activity of mind or body, — the abdominal organs preponderate, and the temperament is abdominal or lymphatic.
Other varieties of temperament exist, and in some individuals no temperament is strongly marked, or more than one are mixed together. But attention to the subject is important, as modifying our plan of management both in health and disease.
These varieties of constitution may be born with the child, and looked on as hereditary: but they will be much influenced by the manner in which the individual is managed; according as one sys- tem of organs, or another, is exercised or neglected.
The great principle that should guide us, is to afford to all and each its proper or appropriate share of exercise or occupation, so as to strengthen the weak or ill-developed organs ; while we repress those that arc disproportionately developed, or over active, by con- signing them to quiescence. To be enabled to do this, however, we must study the subject as physiologists.
Thus have we, in a brief and summary manner, sketched those peculiarities of infancy, a knowledge of which must, serve as our guide in understanding aright the management of children in health or disease. This object we have kept exclusively in view, and re- sisted the temptation of pursuing any of these subjects, however interesting, further than the object proposed would warrant.
We have seen the infant presented to us, in the first instance,. as a mere vegetative being, with the organs of nutritive life prepon- derating in development and activity.
As growth proceeds, however, the little being asserts its claim to a higher order of existence. The organs of organic life dimininish relatively in importance, while those of animal life advance, and ultimately preponderate — the infant becomes a rational being.
To promote this preponderance, and ensure the mens sana in corpore sano, is the great end proposed in the rearing and manage- ment of children. The principles by which we are to be guided in our attempts to attain this object, have been already pointed out ; and the manner in which these principles are to be carried into effect, will constitute a chief part of the ensuing chapter.
4*
26 MANAGEMENT AND DISEASES OF CHILDREN.
CHAPTER II. MANAGEMENT AND PHYSICAL EDUCATION OF CHILDREN.
In the consideration of the subject of this chapter, we shall adopt the division, already made into the two epochs of infancy and child- hood ; and shall, therefore, at once proceed to consider the manage- ment of the infant directly after its birth.
I. MANAGEMENT IMMEDIATELY AFTER BIRTH.
Let us suppose, then, a child to be placed in our hands immediately after birth; any mucus obstructing its breathing has been removed from its mouth, the cord has been tied and divided three or four inches from its navel, it is crying stoutly, and moving its limbs in such a manner as forcibly to convey to us the impression that it is suffering pain. That such is really the case, we can readily admit, when we recollect the sudden transition of temperature which it has experienced, from about 98°, the heat of the mother's body, to that of the atmosphere, which, at the highest, will seldom exceed 70°. The production of pain, however, is but a necessary consequence of the access of air to the surface of the body ; the vivifying influence of which, as we learn from the ingenious researches of Dr. Edwards,* is calculated powerfully to counteract the greater or lesser degree of insensibility induced during birth. The pain, also, by exciting the infant to cry, contributes materially to the perfect expansion of the lungs by air ; the non-effecting of which, as we shall subsequently find, is notunfrequently attended by fatal results. The good effects, however, of exposure to cold are but momentary.
"Instinct," says Dr. Edwards, "leads mothers to keep their in- fants warm, though philosophers, by more or less specious reasoning, have at different times, and in different countries, induced them to abandon this guide, by persuading them that external cold would for- tify the constitutions of their children, as it does those of adults." To this distinguished physiologist we are indebted for the observa- tions, that the heat of mature infants at birth is from 3° to 5° less than , that of adults — varying between 93° and 95°; that the heat of prema- ture infants is still less ; and that the power of producing heat being in all young animals at. its minimum at birth, they have not the same capability of resisting a diminution of their temperature, from expo- sure to cold, as adults. From Dr. E.'s discoveries, indeed, we are fully warranted in concluding that the philosophers of whom he speaks are in the wrong; and that nature, as she usually does, has conferred a proper instinct upon mothers, in teaching them to keep
* Dr. Edwards on the Influence of Physical Agents on Life. Translated by Doctors Hodokin and Fisher.
MANAGEMENT IMMEDIATELY AFTER BIRTH. 27
their offspring warm. It is for us, therefore, immediately upon taking charge of the newly-born child, to have it warmly wrapped up in flannel, and to take care that, in cold weather, it shall be dressed in the neighbourhood of a comfortable fire, and lhat, during the operation, it shall not be unnecessarily exposed to cold.* When we examine more carefully the body of the infant, we shall find that it is more or less covered with a white, greasy, or curd-like substance. This is the vernix caseosa, and appears to be provided for the pur- pose of defending the tender skin from the injurious effects of the warm, watery fluid in which it floats while in its mother's womb. After birth, however, this coating has no useful purpose to serve, and would be injurious by intercepting the vivifying influence of the air of which we have already spoken. t It is, therefore, advis- able to remove it ; and, accordingly, the first act of the nurse is, to wash the new-born child. The washing should be performed with warm water, and a fine sponge. Particular care should be taken to remove all extraneous matters from the eyes, and from the folds of the skin, in the arm-pits, &c. ; but no force likely to hurt the sur- face should be employed : and we have not found soap to be re- quired, although it is recommended by many writers. In this country, where whiskey is of universal use, the nurses generally employ a little of it for washing the child's head, under the idea that it prevents the taking of cold. This practice is certainly not a necessary one in ordinary cases ; but at the same time, it does not appear to be attended with any injurious consequences : and when we can say so much for any popular custom, it is as well to let people have their way, and direct our own attention the more closely to the prevention of what may be really prejudicial.
The washing being accomplished with as little delay as possible, and the surface having been carefully dried with a soft napkin, the next business of the nurse is, to dress her charge. This process is commenced by an arrangement for the protection of the remnant of the navel string. The surface of this should be carefully exa- mined, lest, as frequently happens, secondary bleeding should take place, in consequence of the loosening of the ligature — dependent on the oozing out of the gelatinous fluid, which makes up the bulk of the cord. If such an occurrence has taken place, a fresh ligature must be applied firmly, and its ends cut off close to the knot. The
* The views of Dr. Edwards have been practically confirmed by some observa- tions of Dr. Milne Edwards, and Dr. Villerme. It is the custom in France, to convey infants, within a few hours of their birth, to the office of the mayor of the commune, in order that their birth may be registered; and Drs. E. and V. discovered, that the proportion of deaths, within a very limited period after birth, compared with the total births, was much greater in winter than in summer — in the northern and colder, than in the southern and warmer departments, and in parishes where the inhabitants were scattered over a large surface of ground, than in others, where they were more closely congregated round the mayor.
f If any authority were wanting for the removal of the vernix caseosa, we have it in the practice, which obtains universally among animals, of licking their off- spring immediately after birth.
28 MANAGEMENT AND DISEASES OF CHILDREN,
cord is then to be drawn through a circular hole, cut in a piece of old linen, about four or five inches in diameter, which is to be gently folded round it. In the preparation of this envelope, the nurses are particularly anxious to have it extremely dry and warm. It is always held carefully to the fire, and sometimes even scorched, before they will permit its application — a prejudice which is cer- tainly harmless, and probably but one indication of the general instinct which teaches them that a new-born infant requires its heat to be carefully husbanded.* The cord, thus enveloped, is to be placed flat upon the child's abdomen, and secured there by a band of thin flannel, five or six inches broad, and long enough to go twice round the body. The chief use of this band appears to be, to sup- port the navel string and its covering; and we cannot think that it is required, as Dr. Deweest supposes, as a support to the abdomen: it never should be applied so as to make any pressure upon that cavity ; and on that account, it is well to have it made of the thin- nest flannel, cut diagonally or bias, so as that it may be perfectly elastic. In fastening it, pins are usually employed ; but the fewer of these used in dressing an infant, the better: and it would be well, if we could have strings substituted for them in every possible case. The further dressing of the body of the child, is very much a mat- ter of fashion, with which the physician has little to do further than to see that its clothing is sufficiently warm, and not calculated to place any restrictions upon the movements of the limbs. The ar- rangement of the headdress must be conducted upon similar princi- ples as that of the other clothing : the head is to be protected from the cold air by a moderately thick muslin cap, but so as that it shall suffer no compression, and not be placed in a constrained position. Over all, a thin flannel shawl is to be wrapped in such a way as neither to impede free access of air to the mouth, nor to hamper the extremities, so as to prevent their spontaneous movements. The infant is then to be placed in a cradle or bed, so situated, as that it shall not be exposed to draughts of cold air ; and that, without being in the dark, its eyes may be protected from a strong light, which, as yet, they are unable to endure : thus placed, it will usually fall asleep, and remain so for several hours, until awakened by the calls of hunger.
II. FOOD AND MEDICINE IMMEDIATELY AFTER BIRTH.
During fcetal existence, the various organs designed for the per- formance of digestion, produce a greater or lesser quantity of their
♦As a curious instance of this dread of abstracting heat from the child, we often find the peasants of this country carefully warming- the scissors, before using it for the division of the cord. It is easy, and no doubt appears scientific, to ridicule popular customs and superstitions ; but would it not be more discreet and philosophical, to endeavour to discover their origin from some instinct to which they may generally be traced 1
f On Physical and Medical Treatment of Children. London. 18*26.
FOOD AND MEDICINE IMMEDIATELY AFTER BIRTH. 09
peculiar secretions; and, as there is no exit provided for these, they accumulate in the intestines of the child, constituting the dark green or brownish, pitch-like substance denominated meconium. By many persons, even at the present day, this meconium is supposed to exert a most baneful influence upon the health of the child ; and it is believed that no time should be lost in effecting its speedy removal. Accordingly, very few children, in this country, are fortunate enough to escape being dosed with castor oil, immediately upon their arrival in the world ; and many are obliged to undergo the additional peril of having a quantity of calomel forced down their throats. Neither of these practices, however, is constantly necessary, and the last is positively injurious : the delicate mucous membrane of the child's intestines, only fitted for the reception of the mildest nutriment, is always injured by the operation of a medi- cine so active and so irritating as calomel. To the milder action of castor oil, the same objection does not apply ; and where the abdomen of the child is full, and no evacuation takes place for three or four hours after birth, it will usually be found advantageous to administer half a drachm of oil, provided we can procure it fresh and free from rancidity. We are, however, decidedly of opinion, that it is better and more natural to allow an infant to sleep quietly for three or four hours after birth ; and not before that period to disturb it, or irritate its stomach, by the administration of anything whatsoever. Those who advise the immediate employment of pur- gatives, assert that such practice is consistent with the plans of nature,* inasmuch as they suppose the milk first secreted by the mother (or colostrum, as it is termed,) to possess a purgative pro- perty. The argument is obviously a contradictory one ; for, if nature herself provides a purgative, why should we seek to super- sede her efforts by artificial means? The fact, however, of the first milk being purgative, is not proved, and is altogether denied by some.t It is probable that it possesses no distinct purgative quality, but excites the intestines merely by mechanical distention, and so in effect produces expulsion of the meconium, as other food is found to do in cases in which the secretion of milk is not established, for two or three days after labour. So much for medicine immediately after birth ; and upon the same principle, viz. that sleep is what the infant most requires, we do not think it necessary to give any food for some hours. Should the mother be able to supply the natural nutriment at the end of eight or ten hours, as is often the case, we think the infant should be then applied to the breast ; and that it is highly desirable to avoid giving, in the interim, any other food whatsoever. Should the secretion of milk not be perfectly esta- blished for two or three days, as sometimes happens, the child will be cross, and evince signs of hunger, and we shall generally find it necessary to give a small quantity of thin gruel with a little milk.
* Dewees.
I Jorg. Handbuch zum Erkennen u. Heilen der Kinderkrankheiten.
30 MANAGEMENT AND DISEASES OF CHILDREN.
Even in these cases Professor Jorg recommends, that nothing should be given but a few tea-spoonfulls of lukewarm water ; and we happen to know that such is his practice, without any bad results, in the Lying-in-Hospital of Leipzig. Notwithstanding this, should it not be practicable to have the child suckled within ten or twelve hours after birth, we think it advisable to give, every five or six hours, a few tea-spoonfulls of such food as has been mentioned above, but to stop this immediately upon a nurse being procured, or the mother becoming herself capable of supplying sufficient nourishment.
The infant being now established as a denizen of the nurser}7, we shall proceed to consider its further management with regard to food, cleanliness, clothing, sleep, exercise, medicine, and the action upon it of physical agents, as light, air, and temperature.
III. FOOD IN THE FIRST PERIOD.
It is unnecessary to go at any length into the question of the pro- priety of mothers nursing their own children. The weight of the moral and physical considerations which leave no choice as to the propriety of obeying the dictates of nature, is now universally acknowledged. Women are not, at least at the present time, the unnatural deserters of their offspring that systematic writers would lead us to suppose ; and we think most experienced physicians will join us in declaring that our duty is less frequently to urge maternal nursing, than to explain* and even enforce, in individual instances, the exceptions whereby nature herself does sometimes render it impossible or inexpedient to comply with her general law. We are, in fact, oftener obliged to save an infant from destruction, and a delicate mother from injury, by forbidding ineffectual attempts at nursing on the part of the latter, than we are called upon to remind a stout and healthy parent of the urgency of the claims upon her. We shall therefore assume, as a general rule, that all mothers should nurse their own children, and merely indicate those cases in which it becomes necessary to substitute another mode of rearing the child. Women who labour under any mortal or- weakening disease, — as phthisis, haemorrhages) epilepsy, &c, — are obviously disqualified for the office of nurses ; some who are in other respects healthy have breasts incapable of secreting a sufficient supply of milk, and this may be temporarily the case with one child (especially the first), while upon other occasions the same individuals make excellent nurses ; in other cases, the breast may perform its functions well, but the nipple may be naturally so small, or may be so completely obliterated by the pressure of tight stays, as not to admit of its being laid hold of by the child. These are actual, physical hindrances to nursing. Women may, and the higher classes frequently do pos- sess such extremely sensitive and excitable temperaments as will render it imprudent for them to suckle their own children. Fright- ened and excited by every accidental change in the infant's counte- nance, and inordinately moved by the common agitations of life,auch
FOOD IN THE FIRST PERIOD. 31
persons are kept by their own tenderness, and over-anxious desire to do their duty well, in a state of continual fever, which materially interferes with the formation of milk, both as to quantity and quality. Women, also, who become mothers for the first time at a late period of life, have seldom the flexibility of disposition, or the physical aptitude for secretion of milk, required to constitute a good nurse. Another disqualification for nursing we must notice, although we hope and believe that it is rarely observable among our country- women : if women of fashion are not contented to give up their engagements in society in favour of their domestic duties, it is better for them not to undertake the latter — " In this matter/' says Wcndt, " it is better to do nothing, than only half."
We have already stated, that the child should be put to the breast as soon as the latter contains any thing for it to extract ; this generally happens when the mother's system has been relieved, by sleep and ten or twelve hours' rest, from the fever, which is always more or less attendant upon labour. Unless there has been some se- cretion of milk, it is better not to apply the child, as it becomes disap- pointed by continued ineffectual attempts at obtaining nourishment, and there may subsequently be some difficulty in getting it to en- gage seriously in the business of sucking. As soon, however, as it has fairly commenced, it will require no other food ; and if the mother be a good nurse, she should be able to support her infant inde- pendently of any other nutriment, during at least two-thirds of the period of infancy, — that is to say, until the sixth or seventh month. About that time the teeth usually begin to appear, and to indicate that the digestive system is assuming a capability of doing more work than it was adequate to at first ; and, accordingly, we should then take the hint from nature, and begin gradually to train and exercise its powers. The suckling of the infant, which during the first months should be performed at regular intervals of about four hours, should now be repeated not more than three or four times during the day and night ; and twice during the same period some artificial food should be given. This at first may consist of soft bread, steeped in hot water, with the addition of a little sugar and fresh cow's milk ; subsequently some light broth, free from fat and vegetable matters, may be given once during the day. With re- spect to the mode of feeding at this period, the spoon will be the best vehicle, as it is an object to give food somewhat more solid than could be drawn through the sucking bottle. The child, how- ever, should not be placed horizontally on its back, and gorged until it is filled to the throat, as is often done; but its head should be kept elevated, and its actions be carefully attended to, so that we may know, and at once stop, the moment it appears to be satisfied.
During the first five or six months, the infant must be suckled during the night as well as day, but this should be done at regular intervals of four hours; and if it sleeps with the mother or nurse, the nipple should not be allowed to remain in its mouth, as it is not our object to keep the stomach constantly full, but to give it time,
32 MANAGEMENT AND DISEASES OF CHILDREN.
when filled, to digest its contents. A child nursed as we have re- commended, will be found to awaken, with a good deal of regularity, at the proper periods for its meals. During the process of weaning, the intervals between the times of suckling at night, may be first gradually lengthened; and it is desirable, not to accustom the child to receive any artificial nourishment during the hours proper for sleep.
We have been hitherto supposing the mother to be a perfect nurse, and the relative supply and demand to be well adjusted be- tween her and her infant; but these are not exactly the cases which we always meet in practice. We shall frequently have a demand greater than the supply, long before the sixth or seventh month ; and in such instances, we shall be obliged to give food at an earlier period, and will often find it to agree well, if its kind and administration be regulated upon the rules just laid down. The great maxim to be observed is, not to let the infant want nourish- ment which will agree with it. If this can be furnished by the mother alone, so much the better, if the deficiency can be supplied by artificial food, without the infant suffering, there will be no ne- cessity for making any further change: but if neither of these con- ditions obtain, we must have recourse to a strange nurse.
As we have stated it to be desirable, that as much as possible of the infant's nourishment should be derived from the nurse, it of course becomes an object to render our source of supply as available as may be ; and we are, therefore, legitimately called upon to con- sider how this may be done most efficiently. The grand secret is, in a word, to keep the nurse in good health; if we succeed in this, we render the milk, both as to quantity and quality, as good as it can beproduced by the individual. Now, how is this to be done? Is it by overloading the stomach with a mass of indigestible food and drinks, and keeping the system under a continued fever of diges- tion ? or is it not rather by allowing the person to live, as much as possible, in the manner customary with her, supposing that to be one which has hitherto preserved her in good health, — permitting her to eat her usual meals, which she will probably do with in- creased appetite, and not inculcating upon her the necessity of taking drinks more stimulating or in larger quantities (relatively with her probably increased consumption of food,) than she has been in the habit of using ? With hired nurses, it is especially necessary to act upon the principle just laid down ; for these persons coming from the scanty table of their own homes, are apt to indulge their appetites from mere novelty, if, as is usually the case, their employ- ers show any disposition towards a stall-feeding system. Nurses should not be kept upon any one description of food exclusively, but should have, as is natural, a wholesome, mixed, animal and vegetable diet, with or without wine, according as they have been accustomed to live ; but we may, perhaps allow them, with advan- tage, somewhat of an extra, though never an unreasonable quantity
CHOICE OF A NURSE. 33
of malt drink, providing always that it will agree with their digest- ive system.
Irritability of temper, and indulgence in passion, interfere with the secretion of milk to such an extent, that a child has been known to be attacked with convulsions immediately after being suckled by a nurse, while suffering under the effects of a fit of anger. A know- ledge of this circumstance influences many persons to indulge nurses in the most extravagant whims, lest their temper should be crossed, and the child thereby injured. Irritable persons are unquestionably unfitted to nurse or manage children ; but we apprehend, that over- indulgence is not the way to improve temper: and as we fear that the most learned diatribe from us, would have little efficacy in sup- plying a good disposition where Providence has not created it, we shall not pursue this subject farther.
IV. CHOICE OF A NURSE.
When circumstances prevent a parent from sucklingherown child, it is important that we should have some principle to guide us in our selection of a strange nurse. Medical men are constantly asked for an opinion upon this subject, and we shall therefore offer a few rules, which may be useful in enabling us to form one. The great thing we have to look to is, to ascertain that both woman and child are in good health ; and of this, we must endeavour to judge from the following signs : — The woman's general appearance and form should be observed ; and they ought to be such as betoken a sound constitution. Her skin should be free from eruptions ; her tongue clean, and indicating a healthy digestion ; her gums and teeth sound and perfect ; the breasts should be firm, and well formed, — not too large, or flabby, — and with perfect, well-developed nipples. We should see that the milk flows from them freely, upon slight pres- sure ; and we should allow a little of the latter to remain in a glass, in order that we may judge of its quality. It should be thin, and of a bluish-white colour; sweet to the taste ; and when allowed to stand, should throw up a considerable quantity of cream. A nurse should not be old ; but it is better that she should have had one or two children before, as she will then be likely to have more milk, and may also be supposed to have acquired experience in the man- agement of infants. Having examined the mother, we must next turn to the child, which should be well nourished, clean and free from eruption, especially on the head and buttocks. We should carefully examine its mouth, to ascertain that it is free from sores or aphthae. If both woman and child bear such an examination as we have mentioned, we may, with tolerable security, pronounce the former as likely to prove a good nurse.*
* The following is the beau ideal of a good nurse, according to Wendt. Some of its Germanisms may amuse. "Youth, fulness of health, plenty of milk, and a good build of breasts and nipples — a rather phlegmatic temperament, a quiet disposition, and no inclination to sensuality or dissolute habits, a white delicate
March, 1838.— G 5
34 MANAGEMENT AND DISEASES OF CHILDREN.
V. ARTIFICIAL FEEDING.
What we have already stated as to the management of an infant's food, negatives altogether the question of the propriety of ever choosing to rear a child entirely by artificial feeding. Certain cases occur, however, in which we have no alternative. Peculiar circum- stances may preclude the possibility of procuring a nurse ; or an infant, whose mother is incapable of nourishing it, may be the sub- ject of some contagious disease, to contamination from which, we cannot, in common honesty, permit a stranger to be exposed. The necessity of resorting occasionally to artificial feeding, obliges us, therefore, to consider how we can render it least injurious, for such is really the question ; although, we do not mean to deny, that in certain instances extremely healthy children have been reared in this way. These are, notwithstanding, but exceptions ; for a very ex- tended experience, in different countries, has proved that spoon-feed- ing is generally unsuccessful. — The kind of artificial food proper to be employed, forms the subject of our first inquiry ; and, as a general rule, we may say, that it should be as like the natural nutriment as possible. This rule, however, is easier laid down than acted upon ; "for nature," says Dr. Prout, "will not permit the chemist to officiate as her journeyman, even in the most trifling degree."* In the present state of our knowledge, then, it is vain to attempt any preparation, upon chemical principles, of a food resembling human milk. It will be better to be satisfied with employing the food of some other young animal, and modifying it, so as to make its sensible properties as nearly similar as we can to the milk in question. For this purpose, good cow's milk is usually the most convenient ; and as it is thicker and whiter, and not so sweet as human milk, we may add to two parts of it, one of very thin barley water, and sufficient white sugar to make the necessary increase in sweetness. Asses' milk approaches more nearly, in sensible pro- perties, to what we require ; but it is richer, and requires to be diluted with about a third part of water. So modified, it may be used, if the cow's milk disagrees, or if it can be conveniently pro- cured. As the child becomes a little older, thin bread pap, made as we have already directed,! may be advantageously employed ; and it will also be advisable to give, occasionally, some light beef or chicken tea. In managing spoon-feeding, all our ingenuity will fre- quently be required for varying the kinds of food ; as a description
skin, traversed by blue veins, and covered with freckles, — fair or reddish hair, large blue eyes, sound teeth, a fresh breath, a clean skin, no disagreeable odour, no unnatural discharges, a bluish-white, — rather thin, than thick and tenacious milk, which, dropped upon the thumb nail, flows off rather quickly, — it should have no smell, and a mildy sweet taste, — along with these^ large and firm nip- ples, a cleanly person, and a harmless temper, — form the ideal of a good nurse." — Die Kxnderkrankheitcn systematisch dargestellt von Dr. Johann Wendt. Wien. 1827. 2te ausgabe. * Gulstonian Lecture, 1831. f p. 31.
WEANING. 35
which agrees well with the infant at first, may, after a little, derange the bowels, producing acidity, gripes, and purging, or perhaps cos- tiveness. Thus, prepared barley dressed with water and unboiled milk, will sometimes purge, — an effect which may be obviated by having the milk boiled. In other cases, we must have recourse to the use of arrow-root, for a short time, for the purpose of restraining the bowels, and again recur to the barley when costiveness is pro- duced. A great matter is accomplished, if we can prevent the production of acid fermentation in the stomach and bowels; and, on this account, we must be most particular in requiring every article of food to be freshly prepared before use, and in enforcing the strict- est attention to cleanliness with respect to every vessel employed. Every kind of food should be tepid or lukewarm.
Our second inquiry relates to the mode of administering artificial food. This may be accomplished either with the spoon or sucking bottle.* The former has the advantage of leaving less opportunity for uncleanliness, as a spoon is easily washed, and its condition at once perceptible ; while the bottle may appear clean, and yet con- tain a leaven of acidity, which will do material injury. On the other hand, the bottle has the advantage of giving out the food in a mode somewhat analogous to that employed by nature ; the child has some trouble in procuring what it wants, and will therefore not be likely to take too much ; the action of sucking is also practised, whereby a degree of pressure is made upon the child's salivary glands, and the necessary secretion from those organs, in all probability, usefully promoted. In the earlier periods, we think, the bottle possesses, on these points, decided advantages : but while using it, too much precaution cannot be taken against uncleanliness. No food should ever be allowed to remain in it after the infant has been fed ; and there should be always two in the nursery, in order that one may be exposed to the air, and dried, while the other is in use.t
VI. WEANING.
The time of weaning, we have already intimated, should be that indicated by nature, (that is to say, between the seventh and twelfth months in ordinary cases,) when by providing the child with teeth she furnishes it with the means of obtaining nourishment from sub- stances of a somewhat solid nature. The mode of weaning may be easily deduced from the rules which we have laid down for the feeding of the infant. If it has been gradually accustomed to a diminished supply of maternal, and an increase of artificial food,
• These bottles have a narrow neck, about the size of the nipple, with a small orifice, covered with a teat of washed shammy leather, through which the infant sucks the food. They can be had at any druggist's, ready for use.
| Dr. Zwierlein of Briickenau, has written a book to prove that goats are the best and cheapest wet nurses. We fear it would be difficult to introduce the practice in this country. — Die Ziege els heste u.wohlfe.ilste Saidgamme, 1816. 2r theiL 1819.
36 DISEASES AND MANAGEMENT OF CHILDREN.
weaning will be an easy process, and a great deal of suffering will be spared both to parent and offspring. No violent change should be made ; and by proceeding gradually, the child will come to pre- fer artificial food contemporaneously with the failure of the mater- nal supply. This is what the term weaning imports, and this is the mode in which it should be accomplished.
VII. FOOD IN THE SECOND PERIOD.
For some time after weaning, the child's food should consist of those materials which we have mentioned as proper during the latter months of suckling. Regularity in the times of feeding, is pro- bably of nearly as much importance as the quality of the food itself. No definite rules, however, can be laid down in this respect, as muchrnust be dependent upon the habits of the child, and its guar- dianSj as to sleep, &c. ; but the general principle should, under all circumstances, be observed, of permitting no variation, from day to day, in the time for the different meals, and of not breaking in upon these by giving food at irregular periods : while, at the same time, too long fasting must not be allowed. During the day-time, about four hours is quite sufficient interval between any two meals : this will give time enough, in children, for the stomach, and com- mencement of the small intestines, to perform their offices in the process of digestion, and allow the former an opportunity of recov- ering energy after the discharge of its function.* It is better not to allow a child to acquire a habit of being fed during the night, as uninterrupted sleep is what they then require most ; to ensure which, it is necessary that the stomach should be in a state of comparative rest. Perhaps, the best mode in which we can illustrate our ideas with respect to the plan upon which a child should be fed, will be to describe specifically a day's feeding of a healthy child, — premis- ing that we do not mean to enforce a literal observance of certain hours, &c. specified, but merely to give an example of the working of the principles we have laid down. A healthy child, of two or three years old, commonly awakes, hungry and thirsty, at five or six o'clock in the morning ; sometimes even earlier. Immediately after awaking, a little bread and sweet milk should be given to it, or (when the child is too young to eat bread,) a little bread pap. The latter should be warm ; but in the former case the bread may be eaten from the hand, and the milk allowed to be drunk cold, as it is as well, at this meal, to furnish no inducement for eating, beyond that of hunger. After eating, the child will generally sleep again for an hour or two ; and about nine o'clock, it should get its second meal, of bread softened in hot water, which latter is to be drained
* The importance of not setting the stomach to work during the latter stages of digestion, is well put by Dr. Paris, in his able article on Dietetics, in the Cyc. of Pract. Med. The maxim should be carefully attended to in feeding children.
FOOD IN THE SECOND PERIOD. 37
off, and fresh milk, and a little sugar added to the bread. Be- tween one and two, the child may have dinner, consisting, at the younger ages, of beef, mutton, or chicken broth, (deprived of all fat,) and bread. When a sufficient number of teeth are developed to admit of chewing being performed, a little animal food, as chicken, roast or boiled mutton or beef, not too much dressed, should be allowed, with a potatoe or bread, and some fresh, well-dressed, vege- table, as turnips or cauliflower. After dinner, some drink will be requisite ; and a healthy child requires, or indeed wishes for nothing but water. Light, fresh table beer would not be injurious to a child of four or five years old ; but it is unnecessary, and no advantage would, in this instance, result from the creation of a new want. Be- tween six and seven o'clock, the child may have its last meal, of bread steeped in water, &c, as at nine o'clock in the morning. A healthy child who has been in the open air during the greater part of the day, will be ready for bed shortly after this last mentioned supply, and will require nothing further until morning. Similar regimen and hours may be adopted throughout the whole period of child- hood ; only, as the fourth or fifth year approaches, giving, for break- fast and supper, bread and milk, without water, and either warm or cold, according to the weather, or the child's inclination. The supply of food, upon first waking in the morning, may also be gra- dually discontinued, and breakfast given somewhat earlier.
The foregoing, we conceive, may fairly be offered as a model of a suitable diet for childhood ; but, as Dr. Barlow* very judiciously observes, " No exclusive system can be right, nor can any precise rule of diet be possibly laid down, as this requires to be adapted, in every case, to the particular constitution concerned." With the sto- mach of one child, for example, so much milk as we have recom- mended may disagree, and produce acidity, and it may be advisa- ble to substitute for it tea or cocoa ; with another, a meat dinner every day may produce plethora, and it may be necessary to alter- nate it with rice, or some other vegetable substance.
The constitution of the child, its habits of exposure to the air, and its residence in a city or the country must be taken into account : and something must also be allowed for the customs of the commu- nity in which it is being brought up. A judicious parent or physi- cian will recollect all these matters : and while, as we hope, they will be able to derive something like a foundation of principles from our recommendations, they will yet recognize the expediency of occasional modifications in matters of detail. It is of great im- portance, than no pre-conceived system or theory, with respect to diet, should be assumed and adhered to with unreflecting obstinacy, as is but too often the case. Thus one class of persons, arguing that the growth of a child requires an active nutrition, adopt the theory that an excess either in the quantity or quality of nutritious matter cannot be committed ; and then, by cramming and overloading the
♦See his excellent article on Physical Education, in the Cyc. Pract. Med.
5*
38 DISEASES AND MANAGEMENT OF CHILDREN.
stomach, impair the digestive powers, and produce the defect in supply of new material which it is their object to prevent. Others, observing a healthy remnant of potatoe-fed children in an Irish cabin, and hearing, that the Hindoos live and thrive upon rice, instantly infer that scanty vegetable food is the true panacea for health and longevity ; and, accordingly, condemn their offspring or patients to the miseries and perils of an insufficient* non-animal diet. Most unfounded prejudices are also taken up from exparte observations as to the wholesomeness or unwholesomeness of indi- vidual articles of food. Fruits, for instance, are under a general interdict from the dietary of children ; and the consequence is, that the schoolboy, impelled by his instinct* on the one hand, and restrained by the soi-disant science of his managers on the other, devours in secret, the unripe, ill-cultivated, and pernicious trash of the fruit-stall, instead of being permitted a moderate use of* the wholesome, cooling, and antiseptic produce of the garden. Much learned trifling has also escaped from writers with respect to the propriety and necessity of " living naturally and on such food as is presented to us by nature :" and we are often told that children should be fed upon bread and milk alone : because the former is prepared by the simplest cookery, and the latter in what they call the laboratory of nature. Dr. Fordyce, however, has met the ques- tion, and settled it at once, by declaring that " man has no natural food/' Let those who may be startled by this proposition, call to their recollection the difference between the milk afforded by a cowr kept alive upon the weeds and scanty vegetation of a neglected waste, and one fed upon the riches of a pasture which has experienced the transforming power of cultivation ; let them recollect that the wheat, of which their so-called natural diet is composed, is itself the result of a long course of cultivation, and a full employment of all the resources of the complicated art of agriculture. " The potatoe," says Dr. Paris, among many other examples — " the potatoe, whose introduction has added so many millions to our population, derives its origin from a small and bitter root which grows wild in Chili, and at Monte Video."! The science of Dietetics is, in truth, an uncertain one, — any facts that we know respecting it being liable to be influenced by many varying conditions, all of which should be taken into the consideration of every individual case ; and after all, no theory should be permitted the slightest weight in a particu- lar instance in which it may be contradicted by experience. If an article of food, in favour of whose wholesomeness we have universal testimony, should disagree with a certain individual, its use with that person must not be insisted upon.
* We have the authority of Dr. Paris for the fact, " that artisans and labourers in the confined manufactories of large towns, suffer prodigiously in their health, whenever a failure occurs in the crops of common fruits. This fact was remark- ably striking in the years 1804 and 1805." — Art. Dietetics, hi Cyc. Pract. Med.
f Op. citat.
CLEANLINESS. 39
VIII. CLEANLINESS.
The importance of the excretion from the skin is universally ac- knowledged, and is sufficiently proved by the amount of the daily perspiration', which was estimated by Lavoisier and Seguin at an average of lib. 14 oz. in the adult.* This will probably render obvious enough the necessity of removing from the body of the child any obstructions to this discharge which might be offered by the adhesion of extraneous matters. The beneficial action of the physical agents upon the system (of which we shall again speak), as these agents must act through the medium of the skin-, leads us to infer a similar necessity. The accumulation of dirt upon the sur- face will also be observed to produce very distressing excoriations, and even permanent cutaneous diseases; which, when once esta- blished, are often with difficulty removed. With these considera- tions in view, we therefore feel authorised to advance the dogma, that too much attention cannot be paid to the subject of cleanliness, during both periods of childhood. The infant's body, we have already stated, requires to be carefully washed immediately after birth ; and the same operation should be performed daily, until the child becomes old enough to attend to its own comforts. Washing should at first be performed with warm water and a fine sponge — taking care, in the early periods, that no exposure be permitted long enough to produce an impression of cold. As the infant grows stronger, and when the weather is warm, we may gradually lessen the temperature of the water, until at length it may be used nearly quite cold. It i^ better, however, for the reasons assigned in p. 26, to be in no hurry about employing a perfectly cold bath ; and under any circumstances, we would not recommend water to be used with- out allowing it to remain during the night in the nursery, and so acquire a slight increase of temperature. It is not necessary to use soap, except with parts of the body (as the hands and arms,) which are particularly exposed to the reception of dirt, and with these only occasionally. Brown soap is better than white, as being less likely to cause cracking of the skin, which is often a source of much annoyance to the child. In all cases, great care should be taken to dry the surface well with a soft napkin, especially where there are folds of skin, as between the nates, on the front of the neck, arm- pits, &c. A neglect of this precaution will be sure to occasion, ex- coriation, and often troublesome sores; to make matters more secure, we shall do well in fat children, after careful drying, to dust over the skin in such situations with some fine dry powder, as hair-pow- der, or starch finely levigated, and contained in a muslin bag. This will absorb the secretions from the surface, and prevent friction. When the infant is being washed, during the first few days of its life, attention must be paid to the condition of the navel string. In
* Lavoisier's Traite Elcmcntairede Chimie.
40 MANAGEMENT AND DISEASES OF CHILDREN.
ordinary cases, this dries up and falls off between the sixth and tenth days, ulceration taking place at the navel. A small healthy sore remains for a few days longer, which will heal up without any interference, except the daily application of a piece of dry old linen. The linen in which we have at first enveloped the navel string, commonly adheres firmly to it; and if it remains dry, we need not disturb it, but merely raise it gently, so as to have the abdomen underneath carefully washed and dried. The frequency of the dis- charges from the bowels and bladder of an infant, requires us to enforce especial care in changing the napkin placed for the recep- tion of those matters — otherwise the skin will be injured, and dis- agreeable excoriations produced. We are to recollect, that, in the natural state, those evacuations are regularly periodical ; and an ob- servant nurse will soon discover the periods when they are about to take place, and not only anticipate them, but teach the child, at a very early age, to give intelligible warning of its necessities ; the complaint is often made to us of a child's being dirty, but it may be relied upon that the fault is almost always with the nurse. Indeed, we have no doubt that an orderly education of these functions com- menced in the earliest infancy, will be the means of establishing a regularity of the bowels which will continue throughout the whole of life, — and the more tenaciously, as in such training we are not altering or improving nature, but merely working in unison with her tendency to periodicity. As the child advances, we must con- tinue an unabated attention to cleanliness ; the hair must be care- fully combed and brushed ; and the ears, eyes, and all other open- ings of passages from the interior of the body, must be kept per- fectly clean, as well as the skin itself. By adopting such a line of conduct, we may count upon certainly preventing most of the erup- tions upon the scalp or skin which have not been directly commu- nicated by contagion, and of materially diminishing any tendency that may exist to scrofula, marasmus, or rickets. Mere washing would, of course, have little effect, if scrupulous exactness was not observed in making frequent changes of the child's clothes : an infant and young child should have a complete change of dress every day ; and the linen of elder children should be changed very frequently, — so often as never to allow the accumulation of the slightest quantity of dirt.
IX. CLOTHING.
We have already dwelt at sufficient length upon the principles which guide us in the clothing of an infant immediately after birth. They are, simply, to preserve a sufficient quantity of heat, and to do so without setting any restrictions to the free movements of all parts of the child's body and limbs, or irritating its tender skin. Although the discoveries of Dr. Edwards, to which we have refer- red at the commencement of this chapter, lead directly to the esta- blishment of the first principle now laid down, yet the subject is one of such great importance, and so much mystified by the phan-
CLOTHING. 4 1
tasies of systematic writers, that we shall make no apology for the following long quotation. " It (mortality from cold) is not con- fined to children whom the misery of their parents cannot guard from the rigour of the weather, but it operates to a great extent, without being either perceived or suspected, in families enjoying affluence, and in which it is believed that the necessary precautions are taken, — because, cold being relative, it is difficult from our own feelings to judge of its effects on others, and because it does not always manifest itself by determinate and uniform sensations. They do not feel the cold, but they have an uneasiness or an indisposition which arises from it :. their constitution becomes deteriorated by- passing through the alternations of health and disease, and they sink under the action of an unknown cause. It is the more likely to be unknown, because the injurious effects of cold do not always manifest themselves during or immediately after its application. The changes are at first insensible : they increase by the repetition of the impression, or by its long duration : and the constitution is altered, without the effect being suspected. "* We wish we could, as a commentary upon the foregoing passages, adequately depict one of those miserable victims of parental vanity, whose appearance in our streets will sometimes, upon a March or November day, strike cold into our hearts. The cap and feathers set upon, not covering the child's head, and probably of a colour and richness contrasting mournfully with blue eyes, sharpened nose, and shrunken cheeks, in which cold has- assumed the features of starvation — the short kilt and Highland hose, exposing between them cracked and quivering knees — altogether require for their description more graphic power than we presume to lay claim to. We hope, how- ever, that we have said enough to call attention to the absurdity of the " hardening" system, as it is called, and to show that a clothing regulated so as to obviate the rigours of our climate is both demand- ed by our sensations and sanctioned by our knowledge. The ma- terial of clothing is not, we conceive, of very great consequence. We are rather inclined to discourage the use of flannel next the skin in children ; it is liable to injure the tender and irritable sur- face, and it is more likely than linen to permit the concealed accu- mulation of dirt. Upon these accounts, and as children need not be exposed to wet, we think flannel next the skin had better be avoid- ed. The feet should be protected in winter by warm stockings, and sufficiently strong shoes; and when the weather is particularly cold, woollen gaiters should be drawn over the legs when the child is about to be exposed to the air. It has latterly been a good deal the fashion to allow children, when a little advanced, to sleep with- out night-caps; and this, we think, may be permitted without injury, as the non-confinement of the hair certainly promotes its growth, and in this instance we may safely leave nature to herself. In every article of dress the principle should be carefully followed, of placing
* Edwards, op. chat.
42 MANAGEMENT AND DISEASES OF CHILDREN.
no constraint upon the motions of any part. For the boy tight- waisted trowsers or braces, and for the girl stays of all kinds, must be forbidden during the whole period of childhood. The injuries that may be committed upon the organs in the chest and abdomen, by the latter article, are well known to be of the most serious nature ; the chest may be completely altered in shape by a conti- nued pressure, and the lungs diminished in their capacity, while at the same time the stomach and liver are driven from their natural position, and made to press upon the other organs of the abdomen. Derangements of the functions of respiration, circulation, and di- gestion follow as natural consequences, and but too often lead to an early grave, or, what is perhaps worse, a life of prolonged delicacy and ill-health. After all these risks, the object held in view in the use of stays is not attainable by their means. By active and con- tinued compression upon the lower part of the chest, its shape may no doubt, be altered, — the ribs may be brought together, so as to form a narrower circle, and a shape be produced which however it may be fancied to constitute the ideal of beauty, yet bears no re- semblance to the human form, either as it comes from the hands of nature, or exists in the conception of the artist. The only way in which we can assist in the production of a really fine figure is, to remove all restrictions, and secure, as far as possible, so^free an action of the muscles as will lead to their perfect development. By such a course, also, we shall best promote the acquisition of a good carriage, which is infinitely more likely to be the result of a perfect balance of the muscles, than of any mechanical support whatsoever. If the principle of avoiding constraint be held in view in the man- agement of a child's feet, much suffering wTould be spared in after life. Corns and tumours upon the toes are almost always the results of tight or ill-fitting shoes; and therefore it is highly desirable, that we should have these articles so constructed as to protect the foot equally, and not injure it by any undue pressure upon particular parts.
x. SLEEP.
For several weeks after birth, the infant is disposed to sleep con- tinuously, only awaking when pressed by the demands of hunger, and we should certainly not disturb its repose. As its senses become more capable of bearing external impressions ; and probably as its sensorium begins to elaborate these latter into ideas, the waking intervals become gradually longer, and after some time, the chief portion of sleep is taken during the night. Throughout the whole period of childhood, however, more sleep is required than in adult age ; and up to the third or fourth year, the child will be disposed, and ought to be. allowed, to sleep for an hour or two during the day. In regulating the periods for sleep, as in other matters, we should not forget the periodical plan almost universally adopted by nature ; and by a little training, or rather by permitting that plan to
SLEEP. 43
operate undisturbedly, the nurse will be saved many a sleepless night. Matters should be arranged in the nursery, so as to have no obstacle opposed to the child's sleeping about the middle of theday,an hour or two before its time of dinner ; it will thus be again sufliciently tired in the evening to ensure its sleeping soundly from seven or eighto'clock, until the following morning. On the other hand, if we defer its daily rest, and keep it awake until later, by amusing it, its night's sleep will not commence so early, and (the child being less fatigued,) it will probably be interrupted before morning. A question is often, put to a physician : should the child sleep with its mother or nurse? For a month or two after birth, it is unquestionably desirable that it should ; for the infant, as we have seen, possessing a low temperature, and but a small power of generating heat, requires to be kept warm by contact with another being. In support of this conclusion, we may allude to the care which is taken by birds and other warm- blooded animals, to preserve heat in their young offspring by the almost continual application of their own bodies. In our care for the infant, however, we must not forget the mother : and as her health would be likely to suffer from the anxiety and disturbance occasioned by being obliged to attend to a child during the night, we need not prolong unnecessarily the period of its sleeping with her. At the expiration of a month or six weeks, especially when the weather is warm, the infant, if healthy, will, with due precau- tions, be able to maintain its own heat, and we may then allow it to sleep in a cradle or bed by itself. A sufficiency of bed-clothes should be employed, and the temperature of the room during the first few months, should not be allowed to fall below 60° F. While we are anxious to keep it warm, we must be equally careful to per- mit a free access of air to its mouth, which should also be strictly attended to while it sleeps with the mother or nurse. There has been at all times a considerable expenditure of words, and much learned trifling with regard to the question of the salubrity or in- salubrity of cradles. It appears to us that their employment or non- employment, is a matter very safely to be left to the fancy or con- venience of the parents. A cradle makes a clean, airy, and, from the facility of moving it about, a convenient bed, and, as such, has advantages over more ponderous pieces of furniture. As to the injury likely to be inflicted upon the cerebral system, by rocking, we have not the shadow of a proof of such a species of motion being ever injurious to the brain, of either infants or adults ; if it were so, how would the sensorium of the infant escape the effects of the thousand shocks to which it is exposed, and that too in an inverted position, before birth ; or, among adults, what sort of brains would the veteran sailor possess ? Throughout all our views respecting the management of children, we wish to avoid speculating or dogma- tising in the absence of any basis of facts, and to lean to popular opinions, whose antiquity, we are not ashamed to confess, is in our minds primd facie evidence of their having originated in observation, rather than to affect a pretension to science by abusing, upon a theory, practices which possess the sanction of long and general use. We
44 MANAGEMENT AND DISEASES OF CHILDREN.
cannot therefore agree that u rocking must be utterly disallowed,'' or that the reason for its disallowance, viz. that : " Sleep here en- sues, because the motion promotes a congestive state of the vessels of the brain, inducing a degree of vertigo"* — is anything more than a very shadowy hypothesis. During the whole of the second period, a child should decidedly sleep alone, in a bed without any hangings which might impede the free access of air, and in a room as large,! as can conveniently be procured ; not cold, or admitting draughts of wind, but possessing the means of a free ventilation. As few persons as possible should be allowed to sleep in the nursery, and in winter, a fire is an essential requisite, both for the preservation of a sufficient temperature, which should be permitted to fall as little below 60° F. as possible ; and also for the promotion of a free circulation of air. With respect to early rising, we are ready to admit, to the fullest extent, the great advantages, physical and moral, of the habit, but still we must protest against a child being, under any circumstances, curtailed of the due proportion of sleep. The way to bring about early rising safely and usefully, is to train the child to habits of retiring early to bed, and then to encourage it to rise immediately upon its spontaneous awaking, but by no means to force it from its bed before the latter occurrence. No definite rules can or ought to be laid down as to the number of hours' sleep to be allowed : one child will require more or less than another ; and our only safe guide will be, to train it to go to bed shortly after its last meal in the evening, and then to permit it to sleep without disturb- ance until it awakes of its own accord upon the following morning.
The composition of the infant's or child's bed is a matter of some moment — it should be firm and elastic, and of such material as can readily be dried, or changed altogether, when wet. To answer these ends, a small tick, stuffed with straw, forms the best bed for the infant and young child; the straw should be frequently changed, and the tick as often washed and well exposed to the air. For a more ad- vanced child, a hair-mattress answers all purposes. It should be exposed daily to a draught of air : and in summer, placed for an hour or two in the sunshine, when that is practicable.
XI. EXERCISE.
From the very earliest periods of infancy, some degree of muscu lar motion is necessary for the well-being of the child ; and as Dr. Barlow judiciously observes, " it is advisable to suffer them to ex-
* Cyc. Pract. Med. art. Physical Education.
| According to Dr. Edwards's views, the advantages of large rooms are not merely owing to the greater purity of the air, but he also thinks that the slight agitation of the atmosphere, caused by the space being extended, produces such a feeling of well-being, that the chest dilates in consequence, and admits a larger proportion of air. The agreeable sensation which is experienced on breathing in the country is, he says, principally due to that cause. Henke refers short- sightedness to the narrow circle of vision rendered customary in confined nurseries. — Zdolphe Henke Handbuch dtr Kinderkrankheiten, Fkt. a. m. 1813.
EXERCISE. 45
ercise their limbs freely, by laying them frequently on a bed, sofa, or carpet, and allowing them to roll and kick at their good pleasure." This, and being carried about in the nurse's arms, is all the exer- cise a mere infant requires.* It may be well to advert to a hazard noticed by Dr. Barlow, as likely to attend the practice oUioisting, as it is termed ; it is the danger of the child's chest being compres- sed by the hand of the person holding it, being placed with the thumb and fingers on each side of the sternum. That some impres- sion is likely to be made in this way upon the chest of a young infant, appears to us extremely probable, and we should therefore caution the nurse against allowing it to be so grasped. The act of hoisting, itself, appears to be always attended with pleasure to a healthy child ; probably in consequence of that sense of well-being which is produced by agitation of the atmosphere; and if no risk of a fall be run, it need not be interdicted. With respect to the period of the child's walking, we conceive that it should be left entirely to nature. Spontaneous efforts will not be made to an extent likely to produce injury; but go-carts, &c. should be banished from the nursery, as by such contrivances, the child will be supported, and induced prematurely to walk, before its limbs have acquired suffi- cient firmness to enable them to support the weight of the body. By these attempts at anticipating the child's strength, its legs may be made crooked, but we need scarcely dread such a result, when the commencement of walking is a voluntary act. In early child- hood, the taking of exercise may in like manner be left altogether to nature ; all we have to do is to provide opportunity, by allowing the free and unrestrained use of a garden or field, in fine weather, or of a large nursery at other times. The active and restless spirits of the child will then prompt it to do all that is required for its health, and its own sense of fatigue will be the best monitor as to the proper duration of its exertions. When the child grows into the boy or girl, more consideration becomes due to the management of its muscular system, as the necessity for the dedication of definite por- tions of time to mental education then first arises. It then becomes an object to economise the hours of exercise, and for this purpose the gymnasium and dancing-school are sought by parents, and re- commended by physicians. The latter is generally considered rather as a place for acquiring an accomplishment than for exercise ; but under a judicious master, who avoids constrained positions and restrictive machinery, it may do excellent service, by giving vent to the buoyant spirits of youth, and exercising almost all the muscles. The gymnasium has certainly been an improvement in modern education, but it too has its evils and hazards. In it also a skilful teacher is required, whose knowledge of muscular anatomy will enable him to contrive means of generally exercising the frame,
* Nurses are in the habit of rubbing the infant's body gently with their hand, during the time of dressing. This friction appears to be agreeable to the child, and is probably useful, by stimulating the surface, and promoting the cutaneous circulation. It may be considered as a species of exercise.
March, 1S38.— // 6
46 MANAGEMENT AND DISEASES OF CHILDREN.
and whose judgment will constantly interfere to prevent the youth from being carried on by spirit and emulation to an overtaxing of his own powers. When practised to too great an extent, gymnastic exercises certainly stop the growth,* by directing all the energy of the individual towards a development of the muscular system ^ if improperly directed, they also occasion ruptures and injuries to the joints ; but under a skilful teacher, such abuses may be certainly and safely prevented. Neither gymnastics nor dancing ought, however, to supersede the daily play in the green fields, and both parents and children are fortunate, when not called upon by cir- cumstances to sacrifice this, the most healthful and most invigo- rating of exercises. Our plan, restricting our observations to the management of childhood, does not warrant us in considering at any greater length the exercises of youth, — a full view of the merits, &c. of the different kinds of which, belong more to the province of the physiologist, than of the child's physician. With respect to the quantity of exercise to be permitted to the child, we can give no rules more definite than to allow the dictates of nature to be followed as to fatigue, and to adopt the views already put forward as to sleep and food; whereby, of course, will be provided, regular inter- ruptions to play, or continuance in the open air.
It is much to be desired that public gardens should be established in our large towns, to which the inhabitants of all classes, and their children, could have access. They should be planted with shrubs and trees, so as to afford moderate shelter, — and be provided with a large shed, in which refuge might be taken from the vicissitudes of our variable climate. Most large continental towns have a pro- vision of the kind, as well as numerous private gardens, to which the poorest can resort at no greater expense than the price of a cup of coffee. We know that it will be objected, that in our country such places would become scenes of drunkenness and riot ; but we are sanguine enough to hope, that the opportunity of enjoying temperate amusements in the presence of their fellow-citizens of a better rank, would be appreciated by our artisans, and ultimately tend to restrain their ferocity, and elevate them in their own opinions. The lower classes of these countries are too much thrown upon the one brutal indulgence of drinking; and it is an absurdity to suppose that the strictest revenue laws will have any effect, ex- cept to aggravate the evil. Make spirits dearer, and the labourer will certainly diminish his allowance of food and clothing to pro- cure the only means within his reach of relieving his mind from the pressure of toil and want. Give him an opportunity of being amused, when his day's labour is ended, with music, and of en- joying the pleasures of a public garden in the presence of his supe- riors, and we hope (perhaps too sanguinely,) that he would be gradually led to lessen his allowance of spirits, in order to enable
* Any person who recollects the stunted stature of a boy, servant in a gym- nasium in this city, will admit the truth of the above statement.
MEDICINE. 47
him to procure dress sufficiently decent to admit of his partaking in those amusements without a sense of degradation.
xn. MEDICINE.
There is no subject connected with the management of children, in which such fatal errors have prevailed, as in the treatment of their bowels ; and unfortunately, the influence of certain medical theories has, of late years, tended rather to the increase than dimi- nution of those mistakes. The importance which has, in many re- spects very justly, been attached to the digestive system in disease, has attracted much attention to its state in health ; but, unhappily, the great majority of persons fall into the grievous fallacy of sup- posing that what is useful as a remedy, must also be useful as a pre- ventative : and as the multitude has, in the case of the system in question, but one idea cognate with either remedy or preventative, viz., the idea of purging, the propriety of adopting a regular system of purgation with healthy children, has been admitted almost with- out question. There cannot, however, be a more dangerous ab- surdity than such a system ; and in proof of our opinion, we shall ask a single question, and bring forward one fact. What is the mode of action and effect of every aperient drug in the pharma- copoeia ? Is it not irritation, direct or indirect, of the intestinal mucous membrane, in a greater or lesser degree ; and does it not produce, as a necessary effect, in every instance, a larger or smaller quantity of increased secretion ? So much for our question. We presume that no person, but a devoted disciple of St. John Long, will maintain that irritation producing increase of secretion, can ever be necessary in the healthy body. With respect to our fact — let any person with regular, or moderately regular bowels, take an aperient, and he will certainly find that after its immediate effects have passed away, a state of costiveness will remain. The ten- dency of nature to periodical movements, has been interrupted by the production of evacuations at irregular periods, and she requires some time to enable her to recur to the simplicity of her original design. We wish it to be distinctly understood, that what we are now advancing has no reference to the use of purgatives in disease, but solely to their abuse during health ; and we are the more par- ticular in endeavouring to convey our own views upon the subject, because we know that the impropriety of a needless resort to medi- cines of this kind, is not sufficiently thought of by medical men. We have, indeed, too often had occasion to lament over the display of drugs upon the mantel-piece of even a medical man's nursery, not to feel special interest in this matter. The least judicious would surely grieve, did he see an ointment of cantharides rubbed to a healthy skin with no other apparent intention than that it might be followed by a healing salve ; yet, what less absurd, is portended by the accumulation, in such a situation as we have
4S MANAGEMENT AND DISEASES OF CHILDREN.
alluded to, of packets of aperient draughts, bundles of restraining powders, and bottles of carminative mixture — all designed for the same unlucky children. This is no imaginary description, we have but too often seen its original ; yet, better and more merciful would it be, towards many of the victims, to destroy them in the birth, than, by such a course, to provide for them the enduring miseries of an irritable intestinal mucous membrane.
The bowels of a healthy infant, after the meconium has passed away, should be opened from two to four times in the twenty-four hours. The discharge should be fluid, of a lightish-yellow colour, free from any fetid or acid smell, and destitute of lumps, or white curdy matter : it should pass without pain, or any considerable quantity of wind. As long as these conditions exist, there is no occasion for medicine ; should they be materially deviated from, a state of disease must be present, and will be indicated by other symptoms, the nature and treatment of which will be considered in the proper place. The infant may, however, labour under a degree of costiveness which can scarcely be called disease, and yet requires medical interference. Having less than two stools, for example, in the twenty-four hours, calls for an aperient : and so also does a lumpy, or partially solid, condition of the discharge. The medicine, in such cases, should be of the mildest nature. For an infant, from half a drachm to a drachm of fresh castor oil, will generally answer every purpose ; or a dessert spoonful of a mix- ture formed of a couple of drachms of manna dissolved in an ounce of fennel or carraway water, may be given, and repeated every hour until the bowels are opened. These are probably the only safe nursery medicines. Calomel, which is but too commonly the first article in the list, should be banished from it altogether, and never given for the mere removal of, what we may perhaps call, healthy costiveness. Its use seldom fails to produce motions of a green colour, mixed with gelatinous mucus ; thereby showing that it is likely to do much more than what we want, when our object is merely to empty the bowels of their contents.
During childhood, the bowels should be regularly freed once or twice a day (some difference existing in individuals as to the precise number of theirperiodical motions). The discharge should be rather of a darker yellow than in the infant, and more solid, but less so than in the adult ; it should have a feculent smell, and be free from mucus or lumps of indigested matter. When a healthy child has been treated upon the principles which we have indicated, — under the heads of food, exercise, and cleanliness, — it will seldom require any purgative medicine ; but occasionally, from some error of diet, or other accidental circumstance, costiveness will occur, and we must then be prepared to recommend a mild aperient. A couple of drachms of castor oil will usually answer very well ; or, if that should disagree with the stomach, a table-spoonful of the mixture directed below, may be given every second or third hour, until it
LIGHT.— AIR. 49
operates.* In childhood, as in infancy, the domestic use of calomel cannot be too strongly interdicted.
XIII. LIGHT.
The influence of this physical agent, in the vegetable kingdom, is known to every one who has observed the bleached appearance of a plant growing in the dark, or has noticed the efforts made by flowers placed near a window ta turn towardsthe light, even though they may not be led to grow in that direction by the direct in- fluence of the solar rays. Dr. Edwards has made some ingenious experiments to show the influence of light upon the development of animals; in the course of which, he found that those which naturally change their form, as tadpoles, were prevented from doing so by the withdrawal of light. In man it is not easy to obtain any information as to the specific effect of light unaided by air and temperature ; but from the facts just alluded to, we are warranted in inferring analogically that light must materially influence deve- lopment of form. The infant, therefore, as soon as its eyes lose their extreme sensibility, should be freely exposed to light. The nursery should never be darkened during the day ; and at night, it is better that the shutters should be left unclosed, and no window curtains used.
XIV. AIR.
We hope that the stress which we have laid upon the propriety of keeping up a due degree of warmth in the nursery, will not be interpreted as warranting any measure likely to interfere with a free access of air. Both objects are perfectly compatible. The purity of the air in which, the child resides and sleeps should be secured, by providing means for ventilation, in a sufficient number of windows, and a chimney, which latter is absolutely essential to the establishment of a current of air ; and also by restricting the number of individuals residing in the apartment within the nar- rowest limits. It has been already stated, that a certain agitation in the atmosphere is healthful ; and, therefore, the nursery should be as large as possible, in order to favour motion of the air contained within it. But our attentions with regard to air, should not be confined to the nursery ; the vivifying influence which it has been shown to produce upon the system, by contact with the surface of the body, furnishes us with a reason for the advantages, shown by experience, to be derivable from an exposure of the child to the open air as freely as possible, consistently with an observance of
* R Infusi Sennas Compositi, 517.
Aquae Carui, 3 i i . Tartratis Potassoe, 5ii- Mannae Optima;, %i. M
Fiat mistura.
50 MANAGEMENT AND DISEASES OF CHILDREN.
the principles already inculcated under other heads. It is this vivifying influence which renders the play in the open fields so much more useful than the most carefully directed exercises of the gymnasium.
XV. TEMPERATURE.
We have already incidentally said so much upon this subject, that any thing farther would be merely repetition. We may, however, take the opportunity of controverting a very common fallacy, viz., that exposure to heat renders the body more sus- ceptible of the ill effects of cold. Dr. Edwards found, that ;< in ex- posing animals to successive applications of cold, their temperature will fall the more slowly, the longer they shall have been subjected to the influence of warmth. Hence, that those who are liable to frequent exposure to severe cold, are rendered more capable of supporting it, by subjecting themselves, in the intervals, to a high temperature." We find, in point of fact, that the Russians, and other northern nations, preserve, by means of stoves, and double doors and windows, a very high temperature in their dwellings during winter, and yet leave them with impunity to pursue their occupations in the open air.* This should make us hesitate in denying access to a fire to a cold and shivering child, under the idea that we should render him, by the prohibition, hardier, and less likely in future to suffer from cold.
XVI. MENTAL AND MORAL EDUCATION.
The connexion between these subjects and physical management is so close, and the action and re-action of one upon the other so constant and influential, that we cannot conclude this chapter with- out noticing them. In doing so, however, we feel considerable embarrassment, both from the difficulties incidental to the subject, and from the narrowness of the limits within which the nature of our present plan obliges us to confine ourselves in our observations. A moment's reflection will be sufficient to convince us, that the infant is scarcely born when it commences a process of learning. , Its senses first receive a knowledge of the agents which act speci- fically upon them ; the eye becomes acquainted with light, the ear with sound, &c; and subsequently the infant learns to compare the different sensations, and to derive inferences from this com- parison. Thus, the mother's nipple is soon recognized by the sense of sight ; but it is at a later period that the information conveyed by the eye is corrected by the touch, so far as to enable the mouth or hands to be directed with certainty towards the object in ques- tion. After a short period, the power of perceiving external ob-
* The common winter temperature of houses in St. Petersburg, is 64° F. ; while out of doors, it is frequently so low as 20° Dr. Granville's Travels.
MENTAL AND MORAL EDUCATION. 51
jects, and the memory, is so far educated, that the infant can deter- mine the differences between persons, and becomes capable of recog- nizing its mother or nurse. All this is really mental education, and that too of the most important kind: for what a small proportion does the learning of the schools bear to the knowledge of external agents, and of our own powers and relations, which we must acquire during the period of childhood, and without which we should be incapable of supporting our own existence. We cannot, however, materially aid id the communication of such knowledge ; the demands of the senses for their proper excitements will force it upon the young being ; and we refer to it, here, only to show that the young child who is permitted to use its eyes and ears, is always busily employed in learning, and that the hours of play are not to be considered as periods of intellectual idleness. At what time the business of formally instructing the intellect should be com- menced, becomes an interesting question, and one upon which much difference of opinion exists : if we begin too early, we shall certainly injure the health ; and if we delay too long, we shall often experience much difficulty in restraining the habits of bodily acti- vity, (which in such cases will generally be acquired,) within limits favourable to the necessary exertion of the mental powers. In this, as in most other matters, we shall probably find our best guide, if we carefully observe the plans of nature. She seldom fails to im- plant in the child a most restless and prying curiosity, which is in reality the appetite for knowledge, and should never be denied its gratification. Books and pictures never fail to attract the attention of very young children; and allowing them to apply it, at their own pleasure, to these, and especially to the latter, is precisely doing for the mind what we do for the body when we place it in the garden or field — it is giving it an opportunity of taking whole- some exercise, which it will cease from doing upon the first ap- proach of fatigue. In the one case the child will, itself, learn to walk and run with firmness ; and as its muscles and bones become stronger, it will usually desire to learn the more artificial exercises of riding and swimming. In the other case, an acquaintance will be imperceptibly acquired with the forms of letters, and of animals and other external objects ; and the uses of the one being gradually learned, and a curiosity respecting the others being excited, a growing desire for information will lead the child to devote more and more time to its acquirement, until at length we shall find it no difficult matter to include among our periodical arrangements, a daily allotment of a short portion of time for the purposes of in- struction. The precise age for adopting this latter arrangement cannot be exactly defined — it must differ a little, according to the strength of the child, but we conceive it should not be before the sixth year. The time to be allotted for instruction is also a matter of moment ; it should never be long enough to produce fatigue, and we think should not exceed two hours daily during any part of the period of childhood. By adopting such a plan as we have recom-
52 MANAGEMENT AND DISEASES OF CHILDREN.
mended, we allow a child to learn to think, which in reality is superior to knowledge, and we also give it an opportunity of ob- taining materials for thought, by making an acquaintance, at its leisure, with the sensible properties of many objects. " We do not/' however, to borrow the words of an ingenious writer, " at- tempt to force their intellectual growth. Do not feed them with meat, until they have teeth to masticate it. There is a great deal which they ought to learn, can learn, and must learn, before they can or ought to understand it."*
So much for intellectual education ; during the period to which our consideration is restricted, viz., the first eight years of life, it should scarcely^ in our opinion, be made a matter of formal business, but the foundation of it should rather be laid by such playful exer- cise of the faculties as we have sketched. — A more important sub- ject, however, is what we have designated as moral education. This commences at the earliest period of infancy, and wTe almost believe, is finished, for good or for evil, before the individual passes from the period of childhood. In moral qualities, the child is, in- deed, father to the man ; and the education of these requires the most anxious attention, even during the earliest periods of infancy. No one who is familiar with the habits of infants can avoid ob- serving, that from the moment of birth they display obvious marks of being endowed with active passions and affections, and that, too, in very varying proportions in different individuals. Anger is perhaps the first which is displayed to our notice, but shame and jealousy soon make their appearance, and also some of a more amiable character, as compassion and brotherly affection. Now, we must recollect that these, and all the other elements of our moral constitution, are originally implanted in us, and designed for good. " It is very true," says Dr. Chalmers/!" " that the anger, and the shame, and the emulation, and the parental affection, and the compassion, and the love of reputation, and the sense of pro- perty, and the conscience or moral sense, are so many forces of a mechanism, which, if not thus furnished, and that too within certain proportions, would run into a disorder that might have proved de- structive both of the individual and of the species." We shall give an example of our meaning, and again in the words of the ex- cellent writer just quoted: — "The more patent view of anger is, that it is an instrument of defence against the aggressions of violence or injustice, and by which they are kept in check from desolating, as they otherwise would, the face of society."^ In like manner, all the passions and affections are designed for good ; and we conceive, therefore, that our object in morally educating a child should be, not to obliterate those forcesof his moral mechanism, but to guide them into a system of harmonious operation with each
* "The Doctor," generally (we believe,) attributed to the pen of Southey. f Bridgewater Treatise, vol. i. p. 196. j Op. citat. p. 208.
MENTAL AND MORAL EDUCATION. 53
other. Now, how is this most likely to be accomplished ? Is it not by cultivating those affections which are obviously good, and by their influence lessening the violence of others, whose unre- strained indulgence would certainly lead to evil ? Thus, the anger of even a very young infant will be best restrained, not by B dis- play of anger upon the part of its parent, but by a steady exhibition of parental affection, and by showing it a practical example of calm- ness. Causes likely to excite irritability should be carefully re- moved from the infant, as a habit of indulgence in anger will readily be acquired before the counteracting affections can be cor- respondingly excited. As the child advances in age, new passions and affections call daily for our notice ; and as its mental education simultaneously progresses, and it is constantly acquiring an in- creased knowledge of external objects, we are furnished by this progress and knowledge with additional and powerful instruments for influencing its moral nature. He displays but a small ac- quaintance with the human heart, who hopes by an apothegm to ex- tinguish the passion of jealousy, or to repress the cravings of am- bition by a dry statement of the unquestionable truth that all is vanity. But still, the natural feeling of emulation, which is the commencement of jealousy, can be restrained within just and whole- some limits, by calling into play the family affection, and com- passion, which are equally original elements of the moral consti- tution ; and the love of reputation may be prevented from growing into a dangerous ambition, by encouraging, along with the affec- tions just mentioned, a development of the conscience or moral sense, and of the sense of property, both of which we conceive to be inherent in our nature.* The child may in this way be prac- tically shown, that while a generous rivalry in its sports and lessons is not forbidden, still that benevolence and natural affection for its brothers and playmates teach it to stop short, in every instance, of carrying this so far as to wound the persons or feelings of others ; and, again, that while it may be lawfully anxious to obtain credit and praise from its teachers, still that its sense of property forbid it to seek for either by making an unpermitted use of the labour of others, and its conscience peremptorily interdicts any advantage which might be attained by the assertion of an untruth. In this way we avoid overtaxing nature ; — we do not vainly denounce, or attempt to obliterate, forces which are as much part of our moral frame, as hunger is of our physical ; — we do not tell the hungry man he shall not eat, because gluttony is a vice, but we furnish him with a guide as to the quantity and quality of food which is whole- some and necessary. Above all the restraining principles (if one may be preferred to another), we would be inclined to endeavour with most care to bring into activity the sense of property, and conscience or the moral sense, as Dr. Chalmers terms it. Upeo these the well-being of society mainly depends : if not encouraged
* See Chalmers in Bridgewater Treatise, passim.
54 MANAGEMENT AND DISEASES OF CHILDREN.
in early childhood, they are of all others the most likely to remain dormant ; but if once well developed in the child, they require a long course of vice for their overthrow.
The progress of mental knowledge may be brought into useful operation in our work, by directing the growing faculties of the child to such portions of the general plan of nature as may be within its comprehension. Admiration for the skill of Providence may, at a very early age, be excited, by calling attention to the more obvious adaptations of means to ends in the forms of animals, in the benefits conferred by the mode of distribution of water over the earth, &c. &c. ; and a perception of beauty can be called up in a very young mind, by the colours and fragrance of flowers, and the influence of music. From all these the watchful parent can derive practical lessons of humility and love, which would be sought in vain in the maxims of a dry morality. To work out in practice the principles which we have attempted to lay down,, we are well aware, would require qualifications, on the part of the parent or teacher, of no ordinary kind ; but the nearer we can approach to them, the more likely are we to produce the mens sana, which we feel con- fident is fully as certain of producing, as of inhabiting, the corpus sanum.
Our limits forbid us to enter at greater length into this most interesting subject ; but one word we must add, to prevent miscon- ception. We have not yet spoken of religious instruction as a part of moral education, because we have been considering the manage- ment of the moral faculties as they exist in the natural man; we are deeply convinced, however, of its necessity and importance ; and we are firmly of opinion, that in no way can we promote the interests of an individual, both as regards himself and his relations with society, so effectually, as by encouraging in him early habits of religious observances ; in no way can we so surely call forth and strengthen his best affections, as by early setting before his view the living truths of revelation.
As general conclusions from the views we have put forward, we would say, that during childhood (t. e. until the eighth year), education should have for its main object the cultivation of the moral qualities ; and that, during the same period, the intellect will be pretty fully occupied in obtaining such most necessary informa- tion as can be acquired by the use of the senses without much formal assistance, and therefore that schooling, properly so called, should not be commenced, at the very earliest, before the termina- tion of the sixth year. Until then, the confinement of a school is injurious to the bodily health, and not required for the mental im- provement of the child. In coming to these conclusions, we may appear to undervalue those useful inventions of late years, — infant schools. We conceive, however, that they have a specific purpose, and that, when well-regulated, they effect that purpose usefully — viz. to take charge of the children of the poor in large cities, when their parents are engaged in their daily labour, and unable to at-
MENTAL AND MORAL EDUCATION. 55
tend to their wants. In this view, their value is inestimable ; but still they are but the substitution of a lesser for a greater evil: all the ties of social affection, of well-regulated obedience, and of mutual co-operation, which constitute the bonds of society, are learned by the infant in the domestic circle, and can be learned no where else; and if we can leave it in the care of an intelligent mother, and in the society of its brothers and sisters, we should not send it to an infant school, where it is governed by and associated with strangers, with none of whom it is likely to have natural sym- pathies. What the child may be expected to gain specifically in these schools, beyond mere protection, can only be regularity of habits, which certainly is of great importance, but not so great as to countervail the advantages of a well-regulated domestic circle. For the reasons we have advanced, we conceive that infant schools, though most serviceable in large cities for the poor, are totally un- fitted for children of more opulent parents. With the latter the system might be characterized, as Dr. Chalmers has done another artificial system, as " a taking to pieces of the actual framework of society, and re-constructing it in a new way or on new principles — which is altogether fruitless of good, and often fruitful of sorest evil, both to the happiness and virtue of the commonwealth."
[Since writing the above, we have had the pleasure of reading an interesting little treatise on Infant Education, published in Chambers' Educational Course. Edinburgh, 1836. At the same time that we are most gratified to find that the principles which we have at- tempted to lay down for early education, are those sanctioned by the experience of Mr. Wilderspin and others, still we cannot change our opinion with respect to the class of society for which the infant school is really adapted; and we must be excused for pre- ferring the family circle, as a place of education for the very young, in all cases in which it can be made use of without important sacri- fices. We do not agree that the element of numbers, as Messrs. Chambers assert, is indispensable for exercising the social virtues of the child, particularly of the female child; but we acutely feel, that a tenderness, not less than parental, is required to keep unceasingly awake the sense of responsibility which ought to be felt by the in- fant's instructor: and we conceive that this responsibility is intended, by a wise Providence, not merely for the child's advantage, but also for a strong and wholesome check upon the morality of the parent, which it would not be beneficial to society to weaken by division, in any case admitting of its being left whole and undivided.]
56 MANAGEMENT AND DISEASES OF CHILDREN.
CHAPTER III. PECULIARITIES OF DISEASE IN INFANCY AND CHILDHOOD.
I. ETIOLOGY.
The great activity which pervades the whole hody in the child, united in the peculiar susceptibility of the nervous system, and the abundant supply of blood-vessels, more especially arterial capilla- ries, predispose, in a particular manner, to the sudden occurrence of disease, its rapid progress, and frequently fatal termination, — organic change readily taking place.
If one source of diseased action be zplus of vitality in any organ, as Broussais has taught, or an over-exercise of the natural function, in no subject is disease from such a source so likely to be found as in the child. This great activity of all organs and functions, however, while it predisposes parts so much to take on diseased action, con- fers at the same time a peculiar energy or power of reparation, in virtue of which the danger in infantile disease is in a particular man- ner diminished, when once the acute stage of the disorder has been subdued or has subsided. Thus the danger in infantile complaints is principally from the rapid occurrence of organic change, with fatal result, in the first instance, — the establishment of chronic disease being less liable to occur than in the adult, and more easily prevented; while, should such take place, the child has more chance of recovery, no matter to what extremity it may have been reduced.
The great nervous sensibility of the infant, and consequent irrita- bility, is a prime source of disease, and gives a particular character to all disorders occurring in the child. Irritation is easily set up in any organ, directly or indirectly ; and indirect or sympathetic irri- tation is very liable to occur in the child, particularly in certain organs, and is often presented in a very severe form. The most common seat of direct irritation is in some part of the alimentary canal, and this generally arises from the ingestion of unwholesome aliment. The presence of any irritating matter there gives rise to symptoms often very formidable, particularly when it occasions sympathetic disturbance in the brain. The intestinal mucous mem- brane itself soon takes on the irritative action, and becomes the seat of disease ; the attendant symptoms generally assuming the type of remittent fever. The suffering caused by difficult dentition is a familiar example of direct irritation, which, though slight in itself, may lead to most serious results.
The lungs may be directly irritated ; but often are sympathetically so, as when disease has existed in the abdomen, or occasionally in
ETIOLOGY. 57
the head. The cough in the first case will be irritative, and may be violent ; it is in the second usually spasmodic.
The brain is less liable to direct irritation, but often takes on this state, sympathetically, from disease in the digestive organs, or during the existence of protracted thoracic disease, especially if the cough be violent, as in pertussis.
Thus we see that the head sympathises most directly with the digestive apparatus, less so with the chest. The lungs sympathise frequently with disordered states of the bowels, less frequently with disorders of the head. The digestive organs sympathise rea- dily with all the others, — remittent fever arising during almost all protracted diseases of childhood, as we see in most of the severe forms of pulmonary complaint: and the stomach and bowels are immediately affected on the occurrence of irritation or inflam- mation of the brain. The mucous membrane of the bowels, parti- cularly, sympathises with the cutaneous surface, many diseases of which arise from disorders of the digestive tube.
In the child, irritation, which is of such frequent occurrence, readily passes into congestion or inflammation. In the brain, in particular, congestion often arises suddenly during states of irritation.
Inflammation in the child is generally very severe, and runs its course rapidly, leading to organic change. Exudations of lymph, or other matters, are quickly thrown out, and occur in situations where they are not liable to be found in the adult — on the mucous membrane, for example, as we see in croup. Effusions readily occur in serous membranes, as the arachnoid ; and softening or ulcerations are frequent in the mucous membranes, as we find through- out the whole tract of the intestinal canal.
Plethora is frequently present in the child, and is often the result of over-feeding ; but does not necessarily give rise to disease, as it does in the adult, the redundant material being consumed in the active processes of growth.
The full fat child is a natural and wholesome object, and not so prone to disease as the pale, slender subject of misguided solicitude, that has been doctored into delicacy, and which, though not so violently affected by inflammatory disease when attacked, is more ex- posed to illness, and more liable to protracted affections and relapse.
Metastasis, or transference of diseased action from one part to another, is particularly liable to occur in the child — hence the popular dread of the disappearance, or going in, as it is called, of eruptions, exanthems, &c, &c, — which apprehension, however, is commonly carried too far, and leads to very erroneous practice. The sudden suppression of inflammatory action going on in the skin, whether attended with fever or not, — as the eruption of mea- sles, scarlet fever, extensive itch or other cutaneous disease, — is often followed by morbid action set up in the alimentary canal, chest, or head. The first is perhaps most common ; but in mea- sles, the chest is often attacked under such circumstances, and at the close of scarlatina, the head. The suppression of an accus-
March, 1838.—/ ' 7
58 MANAGEMENT AND DISEASES OF CHILDREN.
tomed discharge, as chronic diarrhoea, may have the same effect ; and this appears natural, when we recollect the great susceptibility of the system, and the power of counter-irritation in the child.
Disorders strictly to be called nervous do not occur in the child, though the nervous system is so susceptible and so subject to dis- turbance; but this usually displays itself in spasm or convulsion, and arises directly from morbid action going on in the brain or spinal marrow, or sympathetically, in consequence of disorder of the digestive organs. Convulsions occur in the infant, and epilepsy or chorea in the child ; but nervous affections such as hysteria or hypochondriasis are not to be seen at this age, neither do we often meet with neuralgic pains.
Mental impressions, so fertile a source of disorders of the nervous system in the adult, scarcely if at all affect the child, with the exception of fear or anger, which, if sudden or violent, may pro- duce serious consequences. We have seen dangerous cerebral irri- tation thus excited; and fatal convulsions, or idiocy for life, have been caused in the child by a sudden fright.
Some disorders are congenital, or may be born with the infant, as syphilis, and occasionally hydrocephalus. Some are peculiarly liable to occur immediately after birth, as purulent ophthalmia; while trismus nascentium is restricted in its period of invasion to the first nine days, never appearing after that period.
There seems to be an hereditary predisposition to the occurrence of certain disorders, as croup, and hydrocephalus, among the children of some families ; all or most of whom are in succession attacked, and that often about the same age.
The common causes of disease affect the child with more severity, in general, than the adult; but from some the infant is perhaps free.
Irregularities of diet, or improper food, is one of the most fre- quent sources of illness in childhood; and derangement of the sto- mach and bowels, which are so liable to be thus induced, lead to serious results at this period of life. We have noticed the liability to dangerous sympathetic affections, particularly those of the head. Fever of an obstinate character, and generally of remittent form, is thus induced ; and inflammatory affections of the abdominal viscera have their frequent origin in this cause. A single indigestible meal will cause flatulency and acidity to an inordinate degree, soon to be followed by diarrhoea and more serious consequences. Such occur- rences take place frequently at the time of weaning; and we should always make inquiries on this point, when an infant suffering under such symptoms is brought to us. Indeed, so common a cause of infantile disease is disorder of the bowels, that many have regarded it as the sole source of children's disorders.*
* Etmuller, in 'his " Valetudinarium Infantile," attributes the diseases of the first year to some peculiar alteration in the digestive system; Harris regarded acidity as the chief cause of infantile disease; and Sydenham attributed much to this cause, combined with debility. The increase of mucus consequent on intes- tinal irritation, we have already noticed; and this, Dr. Armstrong assigns as a prime source of infantile disease.
ETIOLOGY. 59
Impressions of cold and damp, or vicissitudes of temperature, the most fertile source of disease at all periods of life, is particularly so with the child: this we were prepared to expect, having seen that the infant has hut low powers of generating heat, and so of resisting the injurious effects of cold, especially when associated with damp- ness. During sleep, in particular, there is a susceptibility of the injurious influence of sudden alternations of temperature; and to such the infant is especially exposed, much of its time being passed in sleep, frequently in the open air; and, when in bed, it often throws off the clothes, while warm or even perspiring. Here we have the origin of many inflammatory affections, particularly of the throat, chest, and abdomen.
Some forms of disease are said to arise often, in certain situations, in consequence of the lowness and dampness of the place, as croup, or even hydrocephalus, which latter is looked upon as almost epi- demic in the Valais, where the best effects result from the removal of children from the district.
Want of light and air is an abundant source of ill-health in children, and consequent delicacy of constitution in the adult. Thus is scrofula commonly generated or called forth, and all epi- demic diseases aggravated or spread. To such sources of malady, however, the children of the poor, especially in large cities, are sure to be exposed; and the detriment to the commonweal arising from this cause, though now little noticed, is such as well to deserve national consideration.*
The influence of season, or states of the atmosphere, in generating or modifying particular forms of complaint, is most remarkable in the child, — so much so, as to cause an established uniformity in the variety of inflammatory affections prevailing at different periods of the year. This variety generally arises from a different tract of the mucous membrane being affected at different seasons; and a degree of order seems to be observed in the course of this morbid migra- tion, which may be seen to commence with the nose and mouth, coryza and catarrh prevailing generally among children at the be- ginning of winter. Bronchitis, and the severer forms of pulmonary inflammation, appear as the winter advances, and prevail during the spring, especially the earlier months. As summer approaches, dis- ease lessens, and pulmonary affections nearly disappear; but as the season advances, the seat of disorder again changes; and now the gastro-intestinal mucous membrane becomes engaged, and on the arrival of autumn, we have diarrhoea, dysentery, or cholera, con- stantly presented to us in the sick child. From attention to these particulars, we may derive some information as to the nature of a child's disease, when it is only complaining or out of order.
Autumn and winter seem to be the most unhealthy seasons — sum- mer and spring, less so ; but this rule does not hold good alike in all towns, and occasionally much illness obtains during spring. At
* See p. 46.
60 MANAGEMENT AND DISEASES OF CHILDREN.
this season some epidemic usually prevails, and we most generally meet with one of the exanthematous disorders to which children are subject. It is a more favourable time for the occurrence of such, however, than the winter months, — the approach of summer facili- tating recovery during convalescence.
It has been doubted whether the very young child is susceptible of contagion ; but infants have been born covered with small-pox, and are said to have come into the world affected with hooping-cough: and we have seen the youngest infants at the breast attacked by cholera.
However this may be, certain diseases which spread epidemically if not by contagion, as measles, hooping-cough, &c, are particularly liable to occur during childhood, and generally prevail among many children at the same time. These complaints are sometimes repre- sented as peculiar to infancy and childhood, and the individual once affected is said never to have the disorder again. The same indi- vidual, however, may have any of these complaints a second time ; but this is rare, though it occasionally happens, as with scarlet fever. There is certainly less liability of their being taken by the adult than the child ; but we have seen a person of seventy in hooping- cough, and a mother will occasionally take measles from her own offspring. Hence it is desirable that such diseases should have been passed through ; and we may be consulted as to the prudence of leaving a child exposed to any of these complaints, or removing it for security. If the child be healthy, and the type of the prevailing epidemic mild, it will in general be best to allow it to take its chance ; but when the infant is delicate, or only recovering from a former illness, and under any circumstances, when the type of the prevail- ing disorder is severe or malignant, it will be advisable to take every precaution against the malady.
Scrofula is much a disease of childhood, though not confined to that period of life. In the child it is particularly liable to display itself by attacking the glands of the neck. Glandular disease is fre- quent at this age ; mumps, an affection of the parotid gland, occurs usually in childhood ; and it is liable to be transferred by metastasis to the testicle. Enlargement of the mesenteric glands leading to disorganization, and the establishment of tabes mesenterica, usually commences during childhood. The bones are often engaged in disease at this period. The scrofulous diathesis, which then so often obtains, doubtless contributes to this ; but their great vascularity of structure, also acts its part. If this contributes to occurrence of dis- ease, it also aids materially in its reparation ; for recoveries may be looked for in early life, that could not be expected at a later period.
In consequence of the great vitality of bone, fractures unite with certainty and rapidity : and the greater softness of the osseous mat- ter, also imparts the peculiarity, that partial fracture, or only bend- ing of the bone, may take place. * From anatomical peculiarities
♦See paper by Dr. Hart, in the Dub. Med. Jour. vol. i.
DIAGNOSIS. 61
some fractures can scarcely occur e. g. of the neck of the femur. This power of yielding without being fractured, is remarkably ex- emplified in the hones of the head ; for a depression will occasion- ally be foqnd in the skull of the child from injury, which is in truth a mere bulging in, not fracture, — but which could not have taken place in the adult, without the bone giving way. The power of spontaneous rectification in cases of fracture, is also remarkable ; for however crookedly united, the bone has a tendency in the child to become straight, and will occasionally do so completely, even in bad cases.
A similar power of reparation exists in the soft parts ; but great losses of blood are ill borne by the child ; and the peculiar suscep- tibility of the nervous system, makes the shock from operations and injuries always dangerous — it may be fatal. Hence, surgical opera- tions are generally objected to, until after the third month.
^ II. DIAGNOSIS.
It is particularly necessary to be versed in the diagnosis of infan- tile disease, as our chief chance of success in acute cases, depends on an early discrimination, so as to be able promptly to apply the necessary remedies ; while the little patient cannot in general give any information itself, or only such as is likely to lead astray.
This loss, however, will be the less felt, if we pay sufficient atten- tion to the information conveyed by the physical signs in infantile disease, — one look at the sick child often imparting more know- ledge to the experienced eye, than any account given by attendants could convey. We shall always have occasion, however, to inquire from them the history of the case.
The healthy child is cool, plump, and lively, the flesh firm, and movements free. It likes to be played writh, and carried about. The abdomen is full and soft, and pressure upon it seems rather to please than annoy the child. It sleeps quietly on its side, with the limbs flexed, generally, going to rest at the same hour ; and awaking cheerfully, soon demands food. It is scarcely necessary to add, that the secretions are natural and regular. Not so with the child when ill : it is more or less peevish — dislikes being stirred/or even cries when handled ; its hour of sleep is uncertain, and it rests ill, or awakes startled or crying. The skin is hot and dry, particu- larly of the hands, feet, and head. The flesh is soft or wasted. There is thirst, with unnatural appetite and depraved secretions.
^ hen a sick child is brought to us, or we visit it, our attention should first be directed to the expression of the countenance, then to the attitude, state of the limbs, and skin. We next proceed to examine more minutely into the several symptoms, — to determine the seat of the disorder, whether in the head, chest, or abdomen, — and its nature, or the particular lesion on which it depends.
When the brows are knit, the eves fixed and staring, or looking
7*
62 MANAGEMENT AND DISEASES OF CHILDREN.
wild or vacant, our attention is at once directed to the head. We try whether it is unusually hot, the vessels full or in over-action, and examine the fontanelle, to see if it be depressed or in a state of distention. We now observe the attitude, and see whether the child's head hangs heavily on the nurse's arm, or rolls from side to side, sunk upon the pillow.* We examine the limbs, to see whether they be rigid or relaxed, — lying motionless, or tossed about, and affected with spasm — in particular, we try whether the hands are clenched, and the thumb turned in, or toes bent. According as the upper or lower extremities are affected,one or both, we judge of the seat and ex- tent of the disease. The state of the pupil next demands investigation. It may be found contracted, and the child will start, as if frightened, or scream out, on being touched ; or the pupil may be dilated and insensible to light, — the child being motionless or unconscious. We will hear that the child has had starting in its sleep, grinding of the teeth, or movements of the lips ; and when awakened, it started up affrighted or screamed out ; the bowels are obstinately costive, or the evacuations very foul and dark-coloured. The hands are usually hot, but the feet cold ; and one cheek is often deeply flushed. No doubt can now exist that the head is the seat of disease ; but what that particular disease may be, and whether a primary or secondary affection, is to be determined by symptoms hereafter to be detailed in their proper place.
Occasionally we see a child lying completely prostrate, — the limbs relaxed and motionless, the belly sunk, and the eyes fixed, with the lids half-closed ; we are told that it is much better than it Avas, having been affected with convulsions; and no suspicion seems to exist that it is in the last stage of cerebral disease, — the attendants actually congratulating themselves on its quietness. It is not un- common to find one or more of the extremities quite paralytic in the young infant, without any notice having been taken of the circumstance.
There is another expression of countenance, very different from that last described, but which denotes much suffering. The lips are retracted, or drawn, so as to show the teeth or gums ; the counte- nance is pale, or sallow and sunk ; the child seems to dread motion, lies on its back with the knees bent or drawn up, and is pained by pressure on the abdomen. Here neither the brow is knit, nor the pupil of the eye affected. The skin is very hot, shrivelled, and harsh; there is much wasting, great thirst, particularly for cold water, and a distinct diurnal exacerbation. The tongue is much loaded, or dry, red, and pointed ; aphthae may be present ; and di- arrhoea constantly attends, — the stools being generally thin, green or dark brown, and fetid. The abdomen is here obviously the seat of disease ; and such a state of things often occurs at the period of weaning, as the' state before depicted does during dentition.
During the autumnal season, we often see an infant lying sunk in
* Occasionally the neck is stiff or retracted.
DIAGNOSIS. 63
the nurse's arms — the face is pale, the features sharp, the counte- nance betokens distress ; it may be that the eyes are sunk, and the skin around them, as also the lips, dark-coloured. On our first query, we will be told that the child lias vomiting and purging ; but a look was suilicient to tell us the nature of the case.
When a child coughs, the eyes are red, and the nose runs, with sneezing or snullles, we know that it has a catarrh, but cannot say whether it may not be getting measles, or some epidemic then pre- vailing : we will therefore be cautious in our diagnosis, until the case has shown some more determinate symptoms.
Cough is a usual attendant on affections of the chest, and cough in the child is often violent or spasmodic. In the young infant, we must recollect that pertussis may be present without any whoop. When the larynx is the seat of disease, the cough will be acute or hoarse, according as inflammation or ulceration be present, — but almost always spasmodic. The peculiar crowing cough of croup is well known, but cannot be too early recognized.
The young child almost always swallows any matter expectorated, and therefore this can scarcely become an object of diagnosis. Some of the false membrane in croup, however, is occasionally coughed up. We should always recollect the influence which ex- pectoration swallowed may have on the stomach and bowels, and allow for the effect which it must produce on the appearance of the stools.
The quantity of mucus thrown out, on even slight irritation of j. the mucous membranes, sufficiently accounts for the loud wheezing, Jj or rr//e, heard during the existence of pulmonary inflammation in /' the child ; and this circumstance alone need not cause the alarm it often does.
Antecedent to the information to be derived from auscultation, we have intimation from the expression of the countenance, and at- titude of the child, as to the chest being the seat of disease. When acute or extensive inflammation is present, the respiration is hurried, the countenance discoloured, the eyes more or less staring, and the alae nasi in quick motion. Respiration is carried on more or less by the aid of the diaphragm and abdominal muscles; while the thorax remains comparatively quiescent. On the contrary, when the abdomen is the seat of the inflammation, it is by the thoracic muscles that respiration is carried on, the abdominal remaining quiet, and the alae nasi unaffected, though the breathing be hurried. The deep depression noticed at the scrobiculis cordis and the upper part of the sternum, when respiration is very difficult, indicate a severe degree of pleuro-pneumony; but our intention here is not to forestal the diagnostics of particular diseases of the chest, but to furnish a general sketch by which thoracic disease in the child may readily be recognized and distinguished from disease of the other cavities.
It is very necessary, but often difficult, to determine the existence of pain and its seat in the child. Having ascertained that uneasi-
64 MANAGEMENT AND DISEASES OF CHILDREN.
ness or crying does not originate in consequence of the child being hurt by any part of its dress, — we observe whether it puts its hand to the head, throat, or other place, as if indicating distress; and if this indication be corroborated by other symptoms, we may con- sider that part to be a seat of suffering. We have thus been led to detect otitis in the infant, when its cries could not otherwise be ac- counted for. Picking of the lips and nose is, however, a well- known indication of intestinal irritation. We must be cautious not to credit a child's statement of its having pain (or, as it generally expresses it, 'being sick,') in the head or stomach, without getting it to point to the part it complains of, but which it often misnames. The peculiar expression of the countenance also assists us: the brows being contracted, when the uneasiness has its seat in the head ; the lips drawn and apart, when in the abdomen ; and the alse nasi in motion, when the respiration is impeded and painful.
The softness of the muscles or degree of emaciation to which a child is reduced, are important in diagnosis, but not to be judged of by merely regarding the face : this may appear full and firm, and yet the rest of the body be much reduced.
In mesenteric disease, the emaciation proceeds steadily, but may be slow in progress. Derangement of the intestinal mucous mem- brane is soon attended with softness and wasting of the muscles ; and in protracted cases the emaciation becomes extreme — the skin being harsh, dry, and wrinkled — the countenance assuming an ap- pearance of old age that looks almost unearthly.
We are often consulted respecting cutaneous disorders in children, which, from the delicacy of their skin, are very liable to occur, and often assume a very formidable aspect. It will be particularly necessary to be familiar with the forms in which itch or psora may be presented, as it appears often in a very severe form, and has been taken for a syphilitic eruption ; while syphilis is at times over- looked, and the child perishes before the true nature of the disease is discovered.
III. PROGNOSIS.
Determining the nature of a disease will often at once decide our prognosis. Thus trismus nascentium is almost necessarily fatal ; and a particular form of hydrocephalus generally so ; while syphilis, however severe in the infant, may almost certainly be cured : and so of other diseases.
In no class of complaints is correct diagnosis of more importance than in children's, as so much of the danger arises from their not being distinguished in sufficient time to allow of a prompt employ- ment of remedies. Thus all acute inflammatory affections are highly- dangerous in themselves; but if seen sufficiently early and detected, our prognosis may be favourable — so influential is adequately active treatment.
When the acute stage has passed by, or been subdued, we have
PROGNOSIS. 65
again excuse for a hopeful prognosis, even though some organic change may have taken place ; so vigorous in general is the infant constitution, and such powers of reparation does it possess.
In general we may say that, however severely a child may be affected in the first stage of an acute disorder, or to whatever extre- mity it may be reduced in the progress of a protracted one, it will be wise not absolutely to give it up, however guarded be our prog- nosis. Few who had not witnessed it, would credit the immediate benefit to be derived from sufficiently energetic means in the early stages of the severest forms of infantile disease, or the apparently moribund state from which a child may be restored by judicious management. One evil arises from early despairing of a child, which the practitioner should keep in mind and guard against. The attendants, who are always ready to give up administering medicines, which they often look on as only a source of annoyance, will from that time do nothing ; and thus children are allowed to perish for want of proper perseverance in the administration of the remedies prescribed.
On the other hand, we should inquire carefully as to the plan of treatment that has been pursued with a child which has been long ill, and which may be brought to us in an apparently hopeless state, and, before we pronounce an opinion, see whether that state be not owing more to the remedies employed than the original disorder. Thus we often see children run down to the last extremity by incessant purging, which will almost of itself cease, if the little powders which it has been for so long taking be but discontinued : these powders almost invariably consisting of calomel, or some other highly irritating medicine. Or, a child which appears to be in the last stage of hydrocephalus, may be found, on examination, to have been brought into this state by the excessive evacuations to which it has been subjected : and of course, the mistake being dis- covered, our prognosis may be more favourable than it otherwise would be.
Again, if we find our efforts to subdue inflammatory action inef- fectual, though apparently sufficient for the object proposed — that in fact the child, though relieved after each application, is again quickly thrown back, — we may suspect improper interference on the part of attendants, who are usually in dread of the little patient being too much weakened. By at once charging them with the delinquency, or expressing our opinion that now some stimulant would be beneficial, we shall in general obtain a confession, made either in contrition or exultation — the attendants owning their fault, or boasting of their sagacity in knowing that wine or spirits was required, and having administered it accordingly. Having thus discovered the source of failure in our remedies, our prognosis may improve accordinglv.
W e have noticed the liability to the occurrence of sympathetic affections in the child. In them there is less danger than the same symptoms would indicate did they belong to a primary disease,
66 MANAGEMENT AND DISEASES OF CHILDREN.
particularly when the true nature of the case is early detected, and the primary source of disease removable.
We must keep in mind, however, that functional disorder, if con- tinued, will change into organic disease (particularly liable to occur in the child), and guard our prognosis accordingly.
This tendency to sympathetic affection, or disease arising seconda- rily during the progress of any disorder, in the child, is itself a par- ticular source of uncertainty and danger ; and must make us always guarded in promising absolute recovery in any complaint that has to run a certain course, or shows a tendency to become protracted. Thus remittent fever, however slight at the commencement, is liable to be tedious in its course — and so time is allowed for the occurrence of sympathetic affections of the head or chest, which but too often supervene. In no disease is the necessity for this precaution better exemplified than in pertussis.
We have already pointed out the greater liability of some of those sympathetic affections to occur than others. It now remains to no- tice the degree of danger with which these complications are liable to be attended. This will mainly depend on the facility with which the original disease may be removed, or the degree of inter- ference with treatment which the complication involves. Thus the combination of pulmonary inflammation with gastro-enteritis, or the occurrence of either during the existence of the other, is particularly dangerous from both sources. When the head becomes engaged during the existence of pertussis, the danger is augmented in con- sequence of the persistence of the primary disease, which has to run its course ; — and the occurrence of gastric, or intestinal irritation, during affections of the head, adds much to the danger by embar- rassing the treatment.
The type of the prevailing epidemic will give us an early inti- mation as to the liability of danger, in many instances. There are times when measles and hooping-cough are comparatively mild complaints ; while, again, a most dangerous character, or malignant type, will prevail — and to be attacked, is to be in danger.
When an hereditary disposition to the occurrence of particular diseases of childhood exists, such diseases when they occur must be looked on unfavourably, and all preventive means should be adopted to avert them. The same rule holds good with respect to disorders arising from particular situations.
One peculiarity in the symptoms of disease, as it approaches a fatal termination, is often manifested in the child in so remarkable a degree, as in a special manner to call for precaution, to prevent our being signally misled in our prognosis.
We allude to the remission, or at times total absence, of severe symptoms, which in truth ushers in death, but by the unwary will be taken as the harbinger of recovery. In no instance is this more striking, than in affections of the head in the child. Consciousness or even intelligence may be suddenly restored, just as death was expected — but they come only to mark the fatal moment.
GENERAL OBSERVATIO.'n G7
CHAPTER IV.
INFANTILE THERAPEUTICS. I. GENERAL OBSERVATIONS.
In nothing are the peculiarities of infancy more remarkable than in the influence which they exercise over the action and uses of medicines. Most medicines act with great energy on the child, and some have a peculiarity of action differing from that on the adult ; while all require to be given in diminished doses, regulated by the age. If attention be not directed to these points, the practi- tioner can hardly fail to meet with embarrassment in treating infantile disease.
An attempt was long since made by Gaubius to express with arithmetical precision the difference of dose according to the age ; and his table is useful, though not always implicitly to be followed. According to his arrangement, if the dose for an adult be 1, half the quantity will be the dose at fourteen years of age (or puberty), half this, or a fourth, at four years of age, and half this again, or an eighth, at two years. Expressed in a tabular form, with the inter- mediate ages from childhood, the table will stand thus :
Dose for an adult, 1 say 1 drachm,
For a child 7 years old, ... £ — 1 scruple,
4 years old, ... £ — 15 grains,
3 ... 1-6 — 10 grains,
2 ... i — 8 grains,
1 and under, 1-12 to 1-15 — 5 or 4 grains.
We have here a useful general index; but to attain facility in prescribing, attention must be paid to the several medicines; and, as it may prove convenient, we shall subjoin formulae for them.
The number of medicines given to the child is not great, and we are restricted in administering them to the liquid form or that of powder: when insoluble, the powder should be given in some ve- hicle sufficiently thick for its suspension, so as to ensure its being swallowed.
Sugar is usually added to medicines for children, to render them more palatable ; and we should try to select such drugs as are free from strong taste or smell. — The dose should not be bulky: hence very light powders (as pulvis sennae) are inconvenient.
The dose of liquid medicines varies from a tea-spoonful or drachm to a dessert-spoonful or two drachms, and a powder should not ex- ceed ten grains.
Medicine is not required in all cases of illness in the child, alter- ation of diet or in the mode of management being often sufficient,
68 MANAGEMENT AND DISEASES OF CHILDRExN.
and in many instances very mild remedies will suffice. This is no excuse, however, for giving nothing but ptisans or syrups to infants, and so letting them perish in acute disorders through fear of using adequate means. When obliged to employ active measures, it is necessary to be prompt in their application, and carefully to look for the earliest moment when their use may be suspended, and milder means resorted to, or the case left to the resources of nature, which in infancy are so powerful when the strength is not too much broken by the protracted use of depletion.
We must be attentive to support the child by suitable nourish- ment during illness; at least, it must not be left too long without some kind of sustenance, as the infant cannot exist many hours without food. During febrile or inflammatory complaints, this must be restricted to barley-water, whey, or very thin gruel ; even the breast milk may be too stimulating, and will require to be mixed with water or exchanged for lighter drink; but this must be sup- plied at sufficiently short intervals.
During depression or convalescence, change to a more nourishing food than usual will serve, to a certain degree, as a substitute for stimulant or tonic medicines: so susceptible of excitement is the child.
Change of air exercises the most beneficial influence in infantile disease, often putting an end to protracted illness in a few days. With the child we can avail ourselves of this measure at an earlier stage of acute disorders than with the adult. Being brought abroad or changed to another room in the same house (if more elevated and airy), will always be useful ; and we cannot be too particular in insisting on the apartments of a sick child being kept cool and airy, at least sufficiently ventilated and of an equable temperature.
II. mercury.
Of the medicines which have a peculiar action, one of the most remarkable is mercury, which is often given in an empirical manner to the child.
Mercury does not seem capable of salivating an infant. We have never seen it do so, nor do we know of any such case upon re- cord. Our experience agrees with that of Dr. J. Clarke, as we never succeeded in salivating a child under three years of age. The pushing of mercury, then, in inflammatory diseases, so as to induce salivation, as we do with the adult, cannot be practised with the young child ; and on this account we are impeded in the employ- ment of one of our most important agents in the treatment of acute inflammations — as croup, meningitis, hydrocephalus, &c. &c. This is the greater loss in consequence of the liability to gastric or intes- tinal irritation in the child, which, when occurring during the ex- istence of pulmonic inflammation, prevents our being able to employ tartar emetic.
Some consider that mercury exerts a special influence in con-
SEDATIVES. 69
trolling inflammatory action, independently of salivation ; and on some such ground, calomel is constantly administered to the sick child.
It is more rational, however, to look to the influence which mercury is acknowledged to exercise upon the secretions, and which is particularly manifested in the child ; hut this, though hene- ficial, falls far short of a specific influence in arresting inflammation, and is liable to do mischief, if not cautiously resorted to.
In connexion with this power, mercury has the character of quickening the action of other medicines, and so ensuring their effects; and hence it is often joined with diaphoretics, expectorants, cathartics, &c.
It is its action on the intestinal canal, and particularly the biliary secretion, that is most manifest in the child ; and some give a pre- ference to calomel as a purgative for infants. No mistake can be greater: though occasionally useful, it is at all times liable to create intestinal irritation, and its continued use is certain to cause it, — producing griping, diarrhoea, and green stools.
This irritation, however, is sometimes resorted to in the treat- ment of cerebral affections, as a source of counter-irritation.
On the other hand, the occasional use of a mild mercurial is serviceable, by restoring the natural functions, when the stools are very foul and unnatural in appearance.
Calomel is the preparation of mercury most frequently employed with the child. Blue pill is an inconvenient form, but might be given bruised down in some liquid. Hydrargyrum cum creta vel magnesia are mild mercurials — and from their mildness and combina- tion with an antacid, are peculiarly suited to the bowels of children, when acidity is present, with or without diarrhoea.
Calomel may be given alone to act on the bowels, in doses of from one-fourth to one or two grains at most, and usually requires to be followed, in two or three hours, by a dose of castor oil, or other aperient.
Calomel is more usually given in combination with other medi- cines, as purgatives, to quicken their operation; or with ipecacuan, as an expectorant or diaphoretic. The dose is usually i or \ a grain, or at most a grain, repeated every second or third hour. Its value in such combinations has been already alluded to.
The hydrargyrum cum creta is particularly given when diarrhoea is present, and a mercurial indicated ; but in this case the dose must be small (not exceeding one grain), or combined with an opiate. Hydrargyrum cum creta alone is by no means to be taken as a cure for diarrhoea, as some seem to suppose; and even when guarded by an opiate, any mercurial is, in certain cases, injurious.
III. SEDATIVES.
Irritation is a usual attendant on infantile disease, which often arises directly from this source; and in all cases, nervous suscepti- March, 1S3S.— K S
70 MANAGEMENT AND DISEASES OF CHILDREN.
bility to a greater or less degree is present. Hence we are prepared to expect much good from the employment of sedatives, which are often indicated, but concerning the use of which a very general apprehension appears to prevail. This has probably arisen from the injurious, or even fatal results, which have followed the admin- istration of soothing syrups, &c. to young children by ignorant at- tendants. The ingredients of such compounds, or at least the quan- tity of narcotic which they contain, are seldom known ; so that their employment, even by the regular practitioner, is dangerous, inde- pendently of the objection that recommending such fosters popular prejudice respecting the ignorance or indifference of medical men about infantile disease. Hence the physician should d\\\ ays formally prescribe them ; and from no class of medicines does more signal service arise, when judiciously administered to the child.
Opium acts with much energy and rapidity, particularly within the first few months after birth, and due caution must be exercised in prescribing it. But when once the proper dose with which to begin is known, and we are aware of the quickness with which it acts, and the length of time during which its influence lasts, we can avoid the danger of an over-dose, or one too frequently repeated. Conditional orders should be always given to suspend the medicine while the child sleeps, or until the symptoms have returned. The in- fant frequently begins to slumber immediately on the administration of the first dose of the medicine, and continues to sleep for several hours,— the effect lasting from four to five hours or more at a time. Hence an opiate should not be renewed oftener than every third or fourth hour, — twice or thrice a day being in general sufficiently often. In some cases, however, it may be required so often as every hour or half-hour, until the desired result is attained, as in severe cholera, but its effects much in such cases be narrowly watched. The in- fluence of opium is more immediate and remarkable when the tinc- ture of opium, or the pulvis cretae comp. c. opio, are exhibited, than the syrup of white poppy, or Dover's powder, though the doses be equivalent. Syrup of poppy is generally preferred as the opiate for children ; but it is uncertain in its strength, being liable to spoil or be adulterated. When genuine and well-preserved, one ounce is considered equivalent to a grain of opium ; so that thirty drops, or half a tea-spoonful, would be equal to 1-16 of a grain of opium, or about a drop of laudanum : this would be the dose for a child two or three months old. During the first month, however, we would not advise more thon 5 or i of a drop of laudanum to be given at once until the effect was tried, — even this minute quantity occasion- ally producing more of a narcotic effect than a much larger dose of syrup of poppy. The best and safest form for exhibiting opium to the young infant is by diffusing a given quantity of laudanum in a mixture with simple syrup, so that the dose will be always definite, however minute, as in the following formula, which we name the simple sedative syrup.
SEDATIVES. 71
No. 1. Syrupus Sedalivus Simplex.
R Aqua; Distillata? ^i Mucil. Gum. ac. ,^ss Syrupi Simplicis ,^ss Tincture Opii gnttam. M.
A tea-spoonful will be the dose, repeated every half hour till rest be procured ; but after the first month, double that quantity may be begun with. At the third month, half a drop of laudanum may be given for a dose, — one drop at six months old, — and two after the first year.
The sedative influence of lettuce or orange-flower water would point them out as eligible vehicles, instead of the distilled water in this mixture ; but not being officinal in our Pharmacopoeias, they are not always to be obtained.
Laurel water, however, can always be procured, and it is a seda- tive peculiarly serviceable in allaying pain, spasm, or convulsion, arising from intestinal irritation in the child. Hence we propose another sedative mixture to be called
No. 2. Syrupus Sedativus Compositus.
R. Mucil. Gum. ac. ^ss Aquae $i
Aquae Lauro-cerasi gtts. iv. Syrupi Aurantii ^ss Tincturae Opii guttam. M.
If we wish to obviate costiveness while using this mixture, syrup of violets may be used instead of simple syrup, or a drachm of rhu- barb wine added. If, on the contrary, we wish to check diarrhoea, allay pain, or remove flatulency, — arornatics, alkalies, or astringents, may be combined.
Dover's powder is a mild and safe opiate for the child, and less liable to disagree than perhaps any other. From ^ to \ a grain may be given at a dose, during the first three months ; and from one grain to two, after a year old. The compound powder of chalk with opium acts more energetically, and must be used with greater caution. The very small quantity of opium present, however, enables us to give it apparently more freely: from half a grain to a grain will be borne during the first six months, and two grains after that period, three times a day, or four grains by a child two years old.
Narcotics readily produce their effect when applied to the skin of the child, so delicate and susceptible is the cutaneous surface. In this manner, tincture of digitalis is often used in continental practice ; and an English practitioner, Dr. Bow, extols the use of opiate fric- tions in the inflammatory affections of children. The form he em- ploys is as follows ; and he relates many cures effected in this way.
No. 3. Dr. Bow's Opiate Liniment.
R Opii 31
Linim. Camph. comp. £i Digere per dies aliquot et effunde linimentum.
72 MANAGEMENT AND DISEASES OF CHILDREN.
Sleep being almost as essential to the child as food, we can scarcely fail to benefit it by inducing a state of rest during illness, and this the use of opium seldom fails to do. Many alarming symptoms, as screaming, spasm, or convulsion, may be thus mitigated, or at once removed, if dependent on irritation alone. When using narcotics for such a purpose, however, we should examine into the cause of irritation, and try to remove it, while we palliate the symptoms, — as, for example, by dividing the gums, or freeing out the bowels, if required ; and in inflammatory cases, depletion should always pre- cede or accompany the use of sedatives. After blood-letting, opium appears to possess, in some instances, a distinct influence in con- trolling inflammatory action, more especially when seated in a serous membrane. In cerebral irritation, or in meningitis, after depletion, the beneficial effects of an opiate in procuring rest and tranquillity is often very remarkable; but in this case judgment and experience are particularly required, as cerebral irritation is very liable to pass into congestion in the child, and inflammation to end in effusion ; and the narcotic effects of an opiate would tend to obscure or aggravate the symptoms, and might increase the liability to congestion. The irritable or spasmodic character which often belongs to the cough or breathing, in the pulmonary affections of children, is generally miti- gated, and at times removed, by the use of an opiate; and some tincture of opium, or Dover's powder, is a useful adjunct to expec- torant medicines, which are also better borne by the stomach when thus combined.
In all cases of gastric or intestinal irritation, whether sympathetic or not, opium is a chief resource, and must in severe cases be ad- ministered in a decisive manner. An injection containing one, two, or three drops of laudanum, according as the child is three, six, or twelve months old, will often at once check a diarrhoea which had lasted long, and been in vain treated otherwise.
IV. ALKALIES AND ALKALINE EARTHS.
These exert a decided sedative influence, especially upon the mu- cous membranes, when in a state of irritation or chronic inflamma- tory action ;. while they, at the same time, alter and improve their secretions. Their antacid properties, in addition, render them pe- culiarly eligible in the treatment of infantile disease; and we have often experienced their utility, more especially in controlling gastric or intestinal irritation. The stomach may be thus often quieted, and many of the more distressing attendants on diarrhoea or dysen- tery removed. They mitigate pain and spasm, appearing to restore or equalise the peristaltic motion. Tenesmus is often speedily re- moved by the use of one of these alkalies, and the character of the stools altered, their fetor being destroyed. In pertussis, or in spas- modic cough, they tend much to mitigate the severity of the symp- toms ; and in the advanced stages of bronchitis, &c, the alkalies, in addition, exercise an influence over the morbid action, causing the phlegm to be less viscid, and consequently more easily excreted.
CARMINATIVES. 73
In prescribing these medicines, however, we must not employ them in the early Btagei of inflammation, and we must be careful to exhibit them sufficiently diluted or guarded by some mucilaginous men- struum. Combination with opium, or its alternate use, adds much to their efficacy, and is generally adopted.
According to the object in view, will we combine, or select, the alkali we would employ. In general, the bi-carbonates are prefer- able to the carbonates, as being less caustic; and, for this reason,
- carbonate of soda is preferable to carbonate of potash, as well as because it is not dilequescent, and therefore may be given in the
■ form of powder ; but these objections do not apply to the bi-carbo-
, nate of potash, which should therefore be preferred to the carbonate. When the stomach is very irritable, the liquor of potash, or lime
1 water, will often answer best, or magnesia, if the bowels be confined.
i When the bowels arc irritable, chalk in the form of pulvis cretae compositus, with or without opium, is usually selected ; or chalk mixture instead. Where the stomach is at the same time irritable,
: however, carbonate of lime will not be borne ; and we choose car- bonate of soda, or better, bi-carbonate of soda or potash. If much flatulency be present, with acidity, any carbonate is objectionable : the additional extrication of gas, caused by its decomposition, adding to the distress and oppression. A few drops of liquor of ammonia, or of its aromatic or fetid spirits, will answer best in this case — often putting an end at once to the flatulency, as well as acidity, by its stimulant or alkaline properties. Should the action of a stimu- lant be objectionable, calcined magnesia should be preferred.
V. CARMINATIVES.
A stimulant action is often looked to as a principal agent in restoring the mucous membrane to a healthy tone. For this pur- pose, an aromatic stimulant is usually preferred, and some of the distilled waters, or a few drops of an aromatic oil, diffused through • the mixture selected. Indeed, with some, no medicine is prescribed for a child, without the intervention of dill or fennel water ; but this is objectionable, when unnecessary, as their strong odour is always offensive, and adds much to the disgust for medicine. To all these aromatic waters is attributed an anti-flatulent or anti-spasmodic action ; but to some, peculiar properties are ascribed. Thus mint water is selected when the stomach is irritable ; but in such cases the simple or compound infusion of mint, or fresh mint tea, is pre- ferable. Cinnamon water is chosen when the bowels are the seat of irritation. On such principles are constructed the carminative mixtures so commonly given to children when affected with gripings, acidity, flatulency, or convulsions ; and when these arise independ- ently of inflammatory action, those mixtures arc often of great uti- lity. But we must be careful to avoid stimulants when such symp- toms are connected with inflammation of the stomach, bowels, or any other organ.
S*
74 MANAGEMENT AND DISEASES OF CHILDREN.
The most celebrated compound of this description is Dalby's car- minative,* the prescription for which we give in a note ; but some of the following formulae, which are more simple, will be found
convenient :
No. 4. Mistura Jlnti-emetica.
R Infusi Menthas ^i Mucil. Gum. ac. ^ss Liquor Potassas gtts. vi Syrupi Aurantii §ss Spir. Lavendulae c. ^ss Tinct. Opii gtts ij M.
3i — Jij nor^ quaque 2da sumat.
In irritability of stomach with flatulency and acidity, or diarrhoea, when much griping or spasm is present without inflammatory action, the following mixture is to be employed — to which a drachm of tincture of rhubarb can be added, to ensure a purgative effect, if desired :
No. 5. Mistura Carminaliva.
R Aquae Carui §i
Mncil. Gum. ac. Sjss Magnesias ustas gr. xxiv. Olei Cajeputi gtts. iv. Syrupi Croci ,^ss
Spir. Ammonias Fcetid. Jss ]\f t
2jss — 5'J ter indies sumat.
The stimulant effect of this mixture can be increased, when depression attends, by the addition of half a drachm of compound spirit of lavender, or one scruple of nitrous spirit of ether, or Hoff- man's anodyne liquor. Four drops of laudanum may be added to the foregoing mixture, when an anodyne effect is desired.
VI. STIMULANTS.
Much caution is required in administering stimulants to the child, as excitement is easily induced, and the depression often attendant on local disease increased, instead of being diminished. Great mis- chief is thus done by the improper administration of stimulants to infants, to whom they are commonly given to expel flatus, allay pain or spasm, and throw out eruptions, or stimulate the child when thought to be debilitated during the progress of inflammatory affec-
* Dalby^s Carminative.
R Aquas Mentha? Piperita? 51J Carbonatis Magnesias ^ij Olei Menthas guttam — Anisi guttas iii Tincturas Castorei $ss
Cardam. Comp. 5ss
Assafcetidae gtts. xv.
Spiritus Pulegii gtts. xv. Tincturas Opii guttas v M.
STIMULANTS. 75
tions, particularly of the alimentary canal. When exhibited in such . all the .symptoms become aggravated : and vet their use is often persevered in to the last.
\\ e must not fall into the popular notion that the diseases of children arise from debility — an error of which even Sydenham seems to have partaken, often prescribing ammonia in infantile disease.
When a stimulant is required, as in cases of sudden sinking or much depression, such as attends severe vomiting and purging, the volatile alkali is one of our best for children, being quick and tran- sient in its action — not likely to disturb the head, or give rise to continued excitement, as alcoholic preparations do. Hence aro- matic tinctures, wines, &c. should seldom be given to the child ; but the aromatic waters, volatile oils, or some of the milder aro- matic spirits, may be commonly employed as vehicles or adjuncts.
During the course of the eruptive fevers, when the eruption has receded, or come but scantily out, some stimulant may be required ; and when these fevers assume the typhoid type, stimulants must be employed ; but their universal use in measles, small-pox, &c. &c. as practised by some, cannot be too strongly reprobated.
When restlessness, spasm, or convulsions, arise from exhaustion, as in cases where depletion has been carried too far, or illness has been long protracted, a stimulant is most beneficial ; but if used as an anti-spasmodic where such symptoms arise from an opposite cause, as they generally do, an aggravation of every symptom will be induced.
The following will be found a good general stimulant for the child :
No. 6. Mistura Excitans.
R Aquae Menthac 5iss
Spir. Ammonia? Arom. 5s9 Spir. (Etheris nitrosi gtts. xij Spir. Lavendulae Comp. ^l Syrupi Caryophilloruin Jss M.
5i hora quaque secundd.
Turpentine, as a stimulant and anti-spasmodic, is peculiarly adapted for children — one or two drops often at once removing flatulency or spasm. In protracted diarrhoea, its action is most serviceable : and it has also anthelmintic powers, which recom- mend it in particular cases.
The following formula will be found convenient :
No. 7. Mistura Tercbinihinata.
R Aqua? Anisi 51
Mucil. Gum. ac. ^ss Olei Terebinth. Rect. $ss Olei Limon. volat. gtts. iv Syrupi Caryophill. 5iv M.
5* — 5'J hora quaque 3tid.
76 MANAGEMENT AND DISEASES OF CHILDREN.
VII. TONICS.
Children often require tonics during convalescence, or in" the advanced stages of inflammatory and febrile disorders ; but they must be tried with caution, and used very moderately, as they are much more liable to induce excitement than in the adult. A prin- cipal object in giving tonics to the child is to restore appetite, as when once that is established, strength will soon be renewed by the use of nutritious food. For this purpose any of the simple bitters, or sulphate of quinine, may be used. The infusions of columba, gentian, hop, or chamomile, given in doses of two drachms or half an ounce, twice or thrice daily, appear to be the bitters best adapted to the child ; but sulphate of quinine may be looked on as a substi- tute for all — and in sufficiently small doses can be given to the youngest infant, as in the following formula :
No. 8. Mistura Corroborates*
R Aquae Distillatss ^iss Snlphatis Quiniae gr. ij Acidi Sulphur, arom. gtts. xvi Syrupi Caryophillorum gss M.
5i — 3'J ter indies sumat.
Iron and iodine are tonics of peculiar power, especially in the treatment of scrofula ; and hence often employed in infantile medi- cine. Their power in restoring appetite, when properly adminis- tered, is constant and remarkable, particularly so with iron. Iodine is liable to cause colicky pains, griping, or purging, with febrile excitement. It must be discontinued when such occur ; and so must all tonics, when excitement or fever attend their use.
The tartrate of iron, which has little of the chalybeate taste and is very soluble, is the preparation generally given to children ; but the muriated or acetated tinctures will be found convenient, parti- cularly the latter. If the form of powder be preferred, the carbonate of iron can be exhibited ; but unless recently made, this preparation will probably be inert when given in the small quantity suited to a child. The black oxide or scales of iron are hence a better prepar- ation, though seldom prescribed. The tartrate is deliquescent ; but may be given in form of powder, (as follows) if not too long kept. No. 9. Fulvis Chalybeatus.
R Tartratis Ferri et Potassae gr. ij Pulveris Aromatici gr. iss Sacchari duri gr. ij. M.
Unum pulverem talem ter quaterve indies sumat.
The tartrate will, however, be best given in solution : and we are provided in the Pharmacopoeia with such a preparation, in the vinum ferri, which may be given in doses of from five to twenty drops.
In similar doses we may give the tinctura ferri acetatis, which, however, has a strong chalybeate taste, but this is somewhat con- cealed by giving it in whey or asses' milk. The tinctura muriatis ferri is still more styptic in taste, but a very powerful preparation,
ANTIPHLOGISTIC PLAN OF TREATMENT. 77
and therefore to be given in but half the dose and well diluted. It may be combined with the muriate of lime of baryta ; and hence its utility in scrofula is enhanced.
/ot/inr, HO the form of tincture or hydriodatcd solution, can be safely administered to the youngest child. From one to five drops of either preparation may be given at a dose, in some sweetened water ; but sugar should not be added until the dose is about being taken, as decomposition would otherwise occur ; and distilled water alone should be ordered for the solution of iodine. The tincture when recent, is precipitated on being added to water : but this does not occur when it has been some time kept ; and it is altogether one of our best preparations of iodine.
No. 10. Solutio Iodinii Hydriodata.
R Aquae Distillatce 51J Iodinii gr. v Hydriodatis Potassas gr. x. M
In cachectic states of the system, such as we often see in children which have been neglected or mismanaged, iodine is most useful as a stimulating tonic, especially if unhealthy inflammation, or ulcera- tion, tending to sloughing, be present, as in pemphigus, &c. In glandular enlargements, which occur so generally at a young age, it is unnecessary to point out the utility of iodine.
VIII. ANTIPHLOGISTIC PLAN OF TREATMENT.
The class of remedies which we shall have most occasion to use in the treatment of infantile disease, is that which is employed to combat acute inflammation: and hence called antiphlogistic. These remedies act principally by depletion, or as evacuants ; but we must not forget that a certain part of their action is stimulant, — especially exciting some organ or tissue, as the kidneys or skin, and so produ- cing a diuretic or diaphoretic effect. This is most manifest in the case of cathartics, which often irritate the bowels, as well as purge, — thus acting more or less as counter-irritants, some of their reme- dial power arising from this source. This action may, however, be carried too far, so as to do injury by the special irritation thus pro- duced, which may also prevent the expected evacuation, and aggra- vate, or even create, locaL inflammation. Much mischief arises from overlooking these circumstances in the treatment of childrens' dis- eases ; for in consequence of the susceptibility of their organs, this irritative action is peculiarly liable to be carried to an injurious degree. Thus it is that we see intestinal irritation induced by pur- gatives given to children, until nothing but a little bloody mucus is evacuated ;. or stimulating expectorants employed, until expectora- tion has been suppressed, and a slight catarrh changed into a severe bronchitis.
These, errors we shall avoid by recollecting that the use of evacu- ant medicines is not necessarily followed by evacuation, as their
78 MANAGEMENT AND DISEASES OF CHILDREN.
names (purgatives, diaphoretics, &c. &c.) would imply, unless the necessary precautions be taken to ensure such results. These are, to employ only the least stimulating in the earlier stages of inflam- matory disease, and to premise direct depletion when required.
IX. BLOOD-LETTING
Is the first step in the antiphlogistic plan of treatment, and the most powerful, not only in subduing inflammation, but in ensuring the beneficial results of the other remedies — most evacuants acting with more speed and certainty when blood-letting has been premised. In the child, more particularly, bleeding is required in the first stage of all acute inflammations. It may be practised with safety in the youngest infant, provided we hold in view the relation between the necessities of the case and the strength of the patient — the only true rule applicable