Chapter I (4)

It has already been observed, that the infant is born with the rudiments of two sets of teeth in the jaw, although neither make their appearance till long after birth. The time when, and the manner in which the first set appear has been pointed out. Now although these admirably answer the purposes for which they were given up to the seventh year, after this period they fail to do so: they are not sufficiently numerous,--in their structure they are not strong or durable,--nor is their power of mastication sufficiently great.

They are not sufficiently large or numerous. If the mouth of a child at this age is examined, it will be seen, that a considerable interval has taken place between the teeth in consequence of the growth and expansion of the face; hence a larger set has become necessary to fill the arch. But it may be asked, do not the teeth grow with the growth of the body? and if not, why is it so? They do not, and for this reason: the important office which these organs are destined to perform requires that they should be composed of a substance too dense and of too low an organization to allow of any subsequent growth and enlargement. Thus the size of the teeth is determined and acquired before they make their appearance through the gums. This being the case, it will be readily seen, that the teeth which would be of appropriate size in the mouth of the infant, would be quite inadequate to the enlarged dimensions of the adult; hence the necessity of a second set, exceeding in number, and size the teeth of the first.

That a necessity also exists at this age, that the weak and delicate teeth of childhood should be exchanged for a set stronger and more durable in their structure, more robust and more powerful, will be sufficiently apparent, if we only recollect the great change which has gradually been taking place in the nature of the food of the two epochs of childhood and adult age.

The second set, or permanent teeth, then, lying under the milk-teeth and hidden in the jaw, undergo in this situation their full developement, before they appear above the gum. This occurrence commences about seven years of age, at which period the first set begin to fall out from their roots becoming absorbed, and no longer retaining their hold of the jaw; to be entirely replaced in the course of a few years by the permanent set, which thus succeeds them. The first teeth of this set which make their appearance are the large double teeth, which emerge from the gum immediately behind the last of the temporary set. Next the two front teeth of the lower jaw fall out, and are succeeded by two others of similar character and form, but of larger size; then the two corresponding teeth of the upper row are cast off, and their place supplied; shortly after the teeth immediately adjoining these; then the double teeth of the first set are exchanged for their smaller successors of the second. The eye-teeth after a time begin to make their appearance; and then more double teeth; making in all twenty-eight teeth, and occupying in their developement from the seventh to the fourteenth year of age. They are not, however, yet complete; for between the latter date and the twenty-first year four more teeth appear, called the wisdom teeth, making the adult set or permanent teeth to amount in all to thirty-two teeth. It should be observed, that whilst this is the most usual course in which this set appear, the line of succession is sometimes different.

THEIR VALUE AND IMPORTANCE.

It would seem almost unnecessary to say a word upon so self-evident a truth, and yet perhaps the full extent of this statement is not generally appreciated. It has not, perhaps, occurred to the minds of all, that upon the right position and arrangement of the teeth the beauty and expression of the countenance much depends. But so it is; for however regular and perfect the general features, if the teeth are irregular or deficient, an unpleasing expression, proportionate to the extent of the displacement, is inevitably produced. Now every mother should be alive to this fact, that she may early apply to the dentist to have any error of the above nature rectified, before it is too late.

On their complete and entire state also depends the perfection of utterance and articulation. The child, for instance, makes no attempt at articulation until it has acquired several teeth; this faculty becomes also exceedingly imperfect during the process of changing them; from this time it continues to improve, until again it is permanently impaired in old age, when they are finally lost. And so again, if a child lose merely a single tooth from the front of its mouth, lisping will result; or if a supernumerary or irregular tooth be present, the articulation will be abrupt and imperfect:--the former plainly showing the importance of the entireness of the series, and the latter, the necessity of regularity in their arrangement and position.

The teeth, however, are chiefly important in relation to the part they sustain in connection with digestion, viz. the mastication of the food. By this act the food, after being received into the mouth, is mixed with the saliva and broken down, till it becomes of an uniform pulpy consistence, fit for being easily swallowed, and acted upon by the gastric juice on its arrival in the stomach. That due mastication of the food is essential to healthy digestion, which will be promoted or retarded in exact proportion as it approaches or falls short of this point, is a fact so generally known as scarcely to need comment. Suffice it to add, that, if food be introduced into the stomach unmasticated, the gastric juice will only act upon its surface; and after a number of hours it will be either rejected by vomiting, or pass on into the intestine, to give rise to cholic, bowel complaints, or flatulence, and very frequently in children to a serious attack of convulsions.

THEIR MANAGEMENT AND PRESERVATION.

IRREGULARITY OF ARRANGEMENT AND POSITION.--Every parent ought to have the mouth of her child inspected occasionally, during the advance of the permanent teeth, that any irregularity in their position or arrangement may be prevented. And it is equally her duty to see to it, that she choose a competent person to do this, since great mistakes are not unfrequently made in this matter, and which themselves become the source of evils far more serious than those they are intended to obviate. "I have known," says Mr. Bell, "no less than eight or even ten firm teeth forcibly removed from the jaws of a child at once, when there was not the slightest reason to apprehend any evil result from their being left alone." Here there was a most cruel, because unnecessary, infliction of pain, as well as great hazard incurred of seriously injuring the permanent teeth by interfering with the secretion of their enamel. And besides all this there is another and yet greater evil, for, if the temporary teeth be removed, before the permanent ones are so advanced as to be ready to occupy their situation, the arch of the jaw will assuredly contract, and when, subsequently, the permanent teeth are fully formed, there will not be room for them to range in their proper situation. Thus the operation which was intended to prevent irregularity becomes the cause of its occurrence, and that in its very worst form, producing a want of accordance between the size of the teeth and that of the jaw.

The eye-teeth generally occasion most anxiety to a parent, from the prominent position in which they present themselves; but in the majority of cases nothing but time is required to reduce them to their proper station. But, whatever may be the peculiarities of each individual case, the dentist will decide what may be required; only, I would again repeat, do not neglect the occasional inspection of the mouth at this age, if you regard the future comfort and appearance of your child.

THEIR PRESERVATION.--The preservation of the teeth requires attention to several points; the first and principal of which is, to enforce the habit in the child of thoroughly cleaning the teeth by means of water and a brush night and morning, and rinsing out the mouth after each meal. The brush should not be very hard, as it will not only be more difficult to clean the interstices between the teeth, the part in which the tartar[FN#24] is most likely to be deposited, but by its friction, will occasion the gradual absorption of the gum and the exposure of the neck of the teeth. The hair of the brush should be firm and elastic, and not too closely set.

[FN#24] A sort of calcareous substance, which becomes deposited at the roots of the teeth, from a want of proper attention to cleanliness; and, if allowed to remain, will destroy first their beauty, and then the organ itself.

TARTAR.--If there is a tendency to the formation of tartar, then it will be necessary to have recourse to some tooth-powder. Tooth-powders, however, must be chosen with care, as many of them are composed of substances highly injurious to the teeth. "Many of the tooth-powders which are offered for sale, with the promise of rendering the teeth beautifully white, perform, for a time, all that is promised, at the expense of permanent and irremediable injury to the teeth; for they often contain a quantity of tartaric or other acid, which effects a gradual decomposition of the enamel."[FN#25] Prepared chalk is one of the simplest and best tooth-powders.

[FN#25] Bell on the Teeth.

The following form, also, may be used with advantage:--

Prepared chalk, three ounces; Orris root, powdered, half an ounce; Powdered myrrh, half an ounce; Cuttle fish, powdered, one ounce; Essential oil of cinnamon, four drops.--Mix.

The best preservative, then, against the formation of tartar, is to see that the child cleans his teeth thoroughly night and morning with the brush, powder, and water, and also (if possible) that he rinses out the mouth after each meal.

If the gums should be tender, irritable, and bleed (as is frequently the case when an individual gets out of health, or the tartar accumulates) the mouth may be washed night and morning with a tumbler of tepid water, containing from ten to twenty drops of the tincture of myrrh, and the same quantity of spirits of camphor; or the following form may be used:--

Alum, one drachm and a half; Tincture of myrrh, two drachms; Camphor mixture, five ounces and a half.--Mix.

ACIDS.--The use of acids to the teeth cannot be too strongly deprecated: they decompose their substance, and lead to their rapid decay. Hence the whiteness produced by acid tooth-powders and washes is not less deceitful than ruinous in its consequences. As has been just observed, they perform all that their vendors promise, causing the teeth, for a little while, to become very white and beautiful in their appearance, but, at the same time, injuring them irremediably: the enamel becomes gradually decomposed, the bone of the tooth exposed, and its death is the inevitable consequence.

It is therefore of great importance when acid medicines are ordered for children that they should be taken through a glass tube, to prevent their coming in contact with the teeth. From a want of this precaution, I know a lady (and there are many such instances) who once had as sound and fine a set of teeth as any one could boast of, but from this cause has had nearly the whole of the upper row destroyed. She was in delicate health: it was judged requisite that she should take for a considerable time (with other medicines) sulphuric acid; but the glass tube was not thought of, and the consequences followed which have been described.

CALOMEL.--This medicine, as it is frequently given, alone, or in the little white powders, in infancy and childhood, by mothers and nurses, is productive of serious and indeed irremediable injury to the teeth. "The immoderate use of mercury in early infancy produces, more perhaps than any other similar cause, that universal tendency to decay, which, in many instances, destroys almost every tooth at an early age. It is certainly not unimportant to bear this fact in mind, in the administration of this sovereign remedy, this panacea, as many appear to consider it, in infantile diseases."[FN#26]

[FN#26] Bell on the Teeth.

HEAT AND COLD.--The teeth are exceedingly apt to suffer from sudden variations of temperature. Fluids, therefore, should never be taken into the mouth so hot or so cold as to produce the slightest pain; and, for the same reason, the water with which the mouth is cleansed should in winter be always warm or tepid. When ices are taken, the precaution of placing them in the centre of the mouth, so as to prevent contact with the teeth, should be carefully observed.

There are many other causes which might be mentioned as tending to induce decay of the teeth, but their consideration here is purposely avoided.

It is hoped that enough has been said to draw the parent's attention to the subject of the teeth, to prevent their neglect, and yet at the same time to induce a cautious management.

CHAP. IV.

HINTS FOR THE EARLY DETECTION OF DISEASE IN THE CHILD BY THE MOTHER.

Life is soon extinguished in infancy. At this epoch any disease is formidable, and must be met most promptly. It is either sudden and active in its assaults, or comes with slow and insidious approach. The first signs of its coming on are not always visible to an unpractised eye: it may have made dangerous advances before the mother's mind is awakened to its presence; and medical aid may be solicited when remedies and advice are no longer of any avail.

It is therefore highly important that a mother should possess such information as will enable her to detect disease at its first appearance, and thus insure for her child timely medical assistance. This knowledge it will not be difficult for her to obtain. She has only to bear in mind what are the indications which constitute health, and she will at once see that all deviations from it must denote the presence of disorder, if not of actual disease. With these changes she must to a certain extent make herself acquainted.

Sect. I.--SIGNS OF HEALTH.

The signs of health are to be found, first, in the healthy performance of the various functions of the body; the regular demands made for its supply, neither in excess or deficiency; and a similar regularity in its excretions both in quantity and appearance.

If the figure of the healthy infant is observed, something may be learnt from this. There will be perceived such an universal roundness in all parts of the child's body, that there is no such thing as an angle to be found in the whole figure; whether the limbs are bent or straight, every line forms a portion of a circle. The limbs will feel firm and solid, and unless they are bent, the joints cannot be discovered.

The tongue, even in health, is always white, but it will be free from sores,--the skin cool,--the eye bright,--the complexion clear,--the head cool,--and the abdomen not projecting too far,--the breathing regular, and without effort.

When awake, the infant will be cheerful and sprightly, and, loving to be played with, will often break out into its merry, happy, laugh; whilst, on the other hand, when asleep, it will appear calm, every feature composed, its countenance displaying an expression of happiness, and frequently, perhaps, lit up with a smile.

Sect. II. SIGNS OF DISEASE.

Just in proportion as the above appearances are present and entire, health may be said to exist; and just in proportion to their partial or total absence disease will have usurped its place.

We will, however, for the sake of clearness examine the signs of disease as they are manifested separately by the countenance,--the gestures,--in sleep,--in the stools,--and by the breathing and cough.

OF THE COUNTENANCE.

In health the countenance of a thild is expressive of serenity in mind and body; but if the child be unwell, this expression will be changed, and in a manner which, to a certain extent, will indicate what part of the system is at fault.

The brows will be contracted, if there is pain, and its seat is in the head. This is frequently the very first outward sign of any thing being wrong, and will occur at the very onset of disease; if therefore remarked at an early period, and proper remedies used, its notice may prevent one of the most fearful of infantile complaints--"Water in the Head."

If this sign is passed by unheeded, and the above disease be threatened, soon the eyes will become fixed and staring,--the head hot, and moved uneasily from side to side upon the pillow, or lie heavily upon the nurse's arm,--the child will start in its sleep, grinding its teeth, and awake alarmed and screaming,--its face will be flushed, particularly the cheeks (as if rouged),--its hands hot,--but feet cold, its bowels obstinately costive, or its motions scanty, dark-coloured, and foul.

If the lips are drawn apart, so as to show the teeth or gums, the seat of the pain is in the belly. This sign, however, will only be present during the actual existence of suffering; if, therefore, there be any doubt whether it exist, press upon the stomach, and watch the eifect on the expression of the countenance.

If the pain arise simply from irritation of the bowels excited from indigestion, it will be temporary, and the sign will go and come just as the spasm may occur, and slight remedial measures will give relief.

If, however, the disease be more serious, and inflammation ensue, this sign will be more constantly present, and soon the countenance will become pale, or sallow and sunken,--the child will dread motion, and lie upon its back with the knees bent up to the belly,--the tongue will be loaded,--and in breathing, while the chest will be seen to heave with more than usual effort, the muscles of the belly will remain perfectly quiescent.

If the nostrils are drawn upwards and in quick motion, pain exists in the chest. This sign, however, will generally be the accompaniment of inflammation of the chest, in which case the countenance will be discoloured,--the eyes more or less staring, and the breathing will be difficult and hurried; and if the child's mode of respiring be watched, the chest will be observed to be unmoved, while the belly quickly heaves with every inspiration.

Convulsions are generally preceded by some changes in the countenance. The upper lip will be drawn up, and is occasionally bluish or livid. Then there may be slight squinting, or a singular rotation of the eye upon its own axis; alternate flushing or paleness of the face; and sudden animation followed by languor.

These signs will sometimes manifest themselves many hours, nay days, before the attack occurs; may be looked upon as premonitory; and if timely noticed, and suitable medical aid resorted to, the occurrence of a fit may be altogether prevented.

The state of the eyes should always be attended to. In health they are clear and bright, but in disease they become dull, and give a heavy appearance to the countenance; though after long continued irritation they will assume a degree of quickness which is very remarkable, and a sort of pearly brightness which is better known from observation than it can be from description.

The direction of the eyes, too, should be regarded, for from this we may learn something. When the infant is first brought to the light, both eyes are scarcely ever directed to the same object: this occurs without any tendency to disease, and merely proves, that regarding one object with both eyes is only an acquired habit. But when the child has come to that age when the eyes are by habit directed to the same object, and afterwards it loses that power, this circumstance alone may be looked upon as a frequent prelude to disease affecting the head.

OF THE GESTURES.

The gestures of a healthy child are all easy and natural; but in sickness those deviations occur, which alone will often denote the nature of the disease.

Suppose an infant to have acquired the power to support itself, to hold its head erect; let sickness come, its head will droop immediately, and this power will be lost, only to be regained with the return of health; and during the interval every posture and movement will be that of languor.

The little one that has just taught itself to run alone from chair to chair, having two or three teeth pressing upon and irritating the gums, will for a time be completely taken off its feet, and perhaps lie languidly in its cot, or on its nurse's arm.

The legs being drawn up to the belly, and accompanied by crying, are proofs of disorder and pain in the bowels. Press upon this part, and your pressure will increase the pain. Look to the secretions from the bowels themselves, and by their unhealthy character your suspicions, in reference to the seat of the disorder, are at once confirmed.

The hands of a child in health are rarely carried above its mouth; but let there be any thing wrong about the head and pain present, and the little one's hands will be constantly raised to the head and face.

Sudden starting when awake, as also during sleep, though it occur from trifling causes, should never be disregarded. It is frequently connected with approaching disorder of the brain. It may forebode a convulsive fit, and such suspicion is confirmed, if you find the thumb of the child drawn in and firmly pressed upon the palm, with the fingers so compressed upon it, that the hand cannot be forced open without difficulty. The same condition will exist in the toes, but not to so great a degree; there may also be a puffy state of the back of the hands and feet, and both foot and wrist bent downwards.

There are other and milder signs threatening convulsions and connected with gesture, which should be regarded:--the head being drawn rigidly backwards,--an arm fixed firmly to the side, or near to it,--as also one of the legs drawn stifly upwards. These signs, as also those enumerated above, are confirmed beyond all doubt, if there be present certain alterations in the usual habits of the child:--if the sleep is disturbed,--if there be frequent fits of crying,--great peevishness of temper,--the countenance alternately flushed and pale,--sudden animation followed by as sudden a fit of languor,--catchings of the breath followed by a long and deep inspiration,--all so many premonitory symptoms of an approaching attack.

OF THE SLEEP.

The sleep of the infant in health is quiet, composed, and refreshing. In very early infancy, when not at the breast, it is for the most part asleep in its cot; and although as the months advance it sleeps less, yet when the hour for repose arrives, the child is no sooner laid down to rest, than it drops off into a quiet, peaceful slumber.

Not so, if ill. Frequently it will be unwilling to be put into its cot at all, and the nurse will be obliged to take the infant in her arms; it will then sleep but for a short time, and in a restless and disturbed manner.

If it suffer pain, however slight, the countenance will indicate it; and, as when awake, so now, if there is any thing wrong about the head, the contraction of the eye-brow and grinding of the teeth will appear; if any thing wrong about the belly, the lips will be drawn apart, showing the teeth or gums,--and in both instances there will be great restlessness and frequent startings.

OF THE STOOLS.

In the new-born infant the motions are dark coloured, very much like pitch both in consistence and appearance. The first milk, however, secreted in the mother's breast, acts as an aperient upon the infant's bowels, and thus in about four-and-twenty hours it is cleansed away; or if it should not, a tea-spoonful of castor oil accomplishes this purpose.

From this time, and through the whole of infancy, the stools will be of a lightish yellow colour, the consistence of thin mustard, having little smell, smooth in appearance, and therefore free from lumps or white curded matter, and passed without pain or any considerable quantity of wind. And as long as the child is in health, it will have daily two or three, or even four, of these evacuations. But as it grows older, they will not be quite so frequent; they will become darker in colour, and more solid, though not so much so as in the adult.

Any deviation, then, from the above characters, is of course a sign of something wrong; and as a deranged condition of the bowels is frequently the first indication we have of coming disease, the nurse should daily be directed to watch the evacuations. Their appearance, colour, and the manner in which discharged, are the points principally to be looked to. If the stools have a very curdy appearance, or are too liquid, or green, or dark-coloured, or smell badly, they are unnatural. And in reference to the manner in which they are discharged, it should be borne in mind, that, in a healthy child, the motion is passed with but little wind, and as if squeezed out, but in disease, it will be thrown out with considerable force, which is a sign of great irritation. The number, too, of stools passed within the four-and- twenty hours it is important to note, so that if the child does not have its accustomed relief, (and it must not be forgotten that children, although in perfect health, differ as to the precise number,) a little castor oil may be at once exhibited, and thus mischief be prevented.

This, however, is not the place to discuss the question of disordered bowels, but simply to point out how this circumstance may be known.[FN#27]

[FN#27] See section on Disorders of the Stomach and Bowels, p. 208.

OF THE BREATHING AND COUGH.

The breathing of a child in health is formed of equal inspirations and expirations, and it breathes quietly, regularly, inaudibly, and without effort. But let inflammation of the air-tubes or lungs take place, and the inspiration will become in a few hours so quickened and hurried, and perhaps audible, that the attention has only to be directed to the circumstance to be at once perceived.

Now all changes which occur in the breathing from its healthy standard, however slight the shades of difference may be, it is most important should be noticed early. For many of the complaints in the chest, although very formidable in their character, if only seen early by the medical man, may be arrested in their progress; but otherwise, may be beyond the control of art. A parent, therefore, should make herself familiar with the breathing of her child in health, and she will readily mark any change which may arise.

Of cough I should not have said any thing in this chapter, as it can never fail to be noticed, except that it is highly necessary to throw out one caution. Whenever a child has the symptoms of a common cold, attended by hoarseness and a rough cough, always look upon it with suspicion, and never neglect seeking a medical opinion. Hoarseness does not usually attend a common cold in the child, and these symptoms may be premonitory of an attack of "croup;" a disease excessively rapid in its progress, and which, from the importance of the parts affected, carrying on, as they do, a function indispensably necessary to life, requires the most prompt and decided treatment.

The following observations of Dr. Cheyne are so strikingly illustrative, and so pertinent to my present purpose, that I cannot refrain inserting them:--"In the approach of an attack of croup, which almost always takes place in the evening, probably of a day during which the child has been exposed to the weather, and often after catarrhal symptoms have existed for several days, he may be observed to be excited, in variable spirits, more ready than usual to laugh than to cry, a little flushed, occasionally coughing, the sound of the cough being rough, like that which attends the catarrhal stage of the measles. More generally, however, the patient has been for some time in bed and asleep, before the nature of the disease with which he is threatened is apparent; then, perhaps, without waking, he gives a very unusual cough, well known to any one who has witnessed an attack of the croup; it rings as if the child had coughed through a brazen trumpet; it is truly a tussis clangosa; it penetrates the walls and floor of the apartment, and startles the experienced mother,--'Oh! I am afraid our child is taking the croup!' She runs to the nursery, finds her child sleeping softly, and hopes she may be mistaken. But remaining to tend him, before long the ringing cough, a single cough, is repeated again and again; the patient is roused, and then a new symptom is remarked; the sound of his voice is changed; puling, and as if the throat were swelled, it corresponds with the cough," etc.

How important that a mother should be acquainted with the above signs of one of the most terrific complaints to which childhood is subject; for, if she only send for medical assistance during its first stage, the treatment will be almost invariably successful; whereas, if this "golden opportunity" is lost, this disease will seldom yield to the influence of measures, however wisely chosen or perseveringly employed.

SECT. III.--OTHER CIRCUMSTANCES WHICH WILL ASSIST IN THE EARLY DETECTION OF DISEASE.

1. THE INFLUENCE OF THE SEASONS IN PRODUCING PARTICULAR FORMS OF DISORDER.--The recollection of the fact, that at the different seasons of the year some diseases are more prevalent than at other periods, will greatly aid a judicious parent in the early detection of the presence of disorder, and its kind, in her child.

Thus, in the early part of the winter, what is called catarrh, viz. an increased secretion of mucus from the membranes of the nose, fauces, and air-tubes, with fever, and attended with sneezing and cough, thirst, lassitude, and want of appetite, is generally prevalent.

As the winter advances, the air-tubes of the lungs, and the lungs themselves, are liable to become the seat of disorder; and those signs will present themselves, which have been pointed out in the previous section as characteristic of such attacks.

In the spring, we have still the same diseases prevalent, and in addition, measles, scarlet fever, small-pox, and chicken pox, which increase in liability towards the close of this season, and with the first weeks of summer.

In the summer, disease is less prevalent than at any other period of the year; but towards its middle and close, and through the whole of the autumnal months, bowel complaints may be expected, in the forms of diarrhoea, cholera, and dysentery.

2. THE INFLUENCE OF A HEREDITARY PREDISPOSITION TO CERTAIN DISEASES.-- Without entering into this subject at large, still it may be useful to remark, that in some families there is a predisposition to some diseases, which, occurring in the first child, will, as each succeeding child is born, attack at the same age. Amongst other diseases of this class are, croup, hooping-cough, and water in the head.

This observation should not only lead a mother to be alive to the possibility of the successional occurrence of these diseases in her family, and so early note their appearance, and seek medical advice, but should at the same time make her most anxious, on the one hand, to shield her child from all their exciting causes, and on the other, to adopt those measures which may contribute indirectly to overcome the constitutional predisposition to them.

Of the scrofulous constitution, I will merely mention here, that it is of the greatest importance, where a predisposition to this disease exists in a family, that a mother should immediately attend to any alteration in the gait or contour of her child, and give prompt attention also to any complaint made of swelling about a joint, although it may be unattended with pain. The importance of this remark will be seen by contrasting the result of the following cases which occurred in children of the same family.

Case I.

A. B., a female child, having blue eyes, light hair, and a fair complexion, in the early part of the year 1838, being then two years of age, had an enlargement of the left knee joint. For some weeks previous to this time, there had been a degree of heat about the part; but as no pain apparently existed, it was not regarded as of any consequence, and nothing was done. The child, living in the neighbourhood of London, was afterwards placed under medical treatment. Two or three months having elapsed, it was brought to town, and shown to me, in consequence of a slight tumefaction over the lower part of the spine. This soon disappeared under the measures employed, and eventually the disease of the knee (evidently scrofulous) was arrested, so that now the case promises to be cured; but the joint will for ever be stiff, and the limb thus affected shorter than the other.

Case II.

G. B., the brother of the above, a handsome boy, with light hair, fine blue eyes,--indeed, very much like his little sister,--in the year 1836, had enlargements of the glands in his neck, which were relieved by the treatment resorted to.

In April, 1839, being then eight years old, he was observed by his mother to limp slightly in walking, but complained of little or no pain. From the caution, however, which had been given to the parent at the time I was consulted about the previous case, to notice at an early period any symptom of this nature in her children, the fact was immediately attended to. The affection was evidently in the hip; there was imperfection in the gait, and pain upon pressing over the joint. A blister was applied, perfect rest to the limb enjoined, and steel medicines ordered; and in a fortnight the motions of the joint were restrained more effectually by the application of strips of soap plaster and a bandage. In three months the child was ordered to the sea- side, and eventually was able to walk without the slightest limp or pain, and may be said to be quite well.

I would not say that in the first case, if the disease had been discovered early, and at that time met by judicious medical treatment, a stiff knee and shortened limb would have been prevented, although this is my belief; but in reference to the latter case, I have no hesitation in saying, that without the disease had been early detected by the mother, and as promptly attended to by her, the remedial measures might have failed,--certainly the result would not have been so highly satisfactory as it was.

Chap. V.

ON WHAT CONSTITUTES THE MATERNAL MANAGEMENT OF THE DISEASES OF CHILDREN.

The especial province of the mother is the prevention of disease, not its cure. To the establishment and carrying out of this principle, every word contained in the preceding pages has directly or indirectly tended.

This, however, is not all. When disease attacks the child, the mother has then a part to perform, which it is especially important during the epochs of infancy and childhood should be done well. I refer to those duties which constitute the maternal part of the management of disease.

Medical treatment, for its successful issue, is greatly dependent upon a careful, pains-taking, and judicious maternal superintendence. No medical treatment can avail at any time, if directions be only partially carried out, or be negligently attended to; and will most assuredly fail altogether, if counteracted by the erroneous prejudices of ignorant attendants. But to the affections of infancy and childhood, this remark applies with great force; since, at this period, disease is generally so sudden in its assaults, and rapid in its progress, that unless the measures prescribed are rigidly and promptly administered, their exhibition is soon rendered altogether fruitless.

The amount of suffering, too, may be greatly lessened by the thoughtful and discerning attentions of the mother. The wants and necessities of the young child must be anticipated; the fretfulness produced by disease, soothed by kind and affectionate persuasion; and the possibility of the sick and sensitive child being exposed to harsh and ungentle conduct, carefully provided against.

Again, not only is a firm and strict compliance with medical directions in the administration of remedies, of regimen, and general measures, necessary, but an unbiased, faithful, and full report of symptoms to the physician, when he visits his little patient, is of the first importance. An ignorant servant or nurse, unless great caution be exercised by the medical attendant, may, by an unintentional but erroneous report of symptoms, produce a very wrong impression upon his mind, as to the actual state of the disease. His judgment may, as a consequence, be biased in a wrong direction, and the result prove seriously injurious to the welldoing of the patient. The medical man cannot sit hour after hour watching symptoms; hence the great importance of their being faithfully reported. This can alone be done by the mother, or some person equally competent.

There are other weighty considerations which might be adduced here, proving how much depends upon efficient maternal management in the time of sickness; but they will be severally dwelt upon, when the diseases with which they are more particularly connected are spoken of.

Sect. 1.--ACCIDENTS AND DISEASES WHICH MAY OCCUR TO THE INFANT AT BIRTH, OR SOON AFTER.

STILL-BORN.

Sometimes the child comes into the world apparently dead, and, unless the most active exertions are made by the attendants, is lost. The superintendence of the means used devolves upon the medical man; but it would be often well if his assistants were already acquainted with the measures pursued under these circumstances, for they would be more likely to be carried into effect with promptitude and success, than they now frequently are. And again, the still-born child is frequently in this state from having been born very rapidly, and before the medical man can have arrived, it will be more especially useful in such a case, that the attendants in the lying-in-room should know how to proceed.

The various causes producing this condition it is unnecessary to mention.

The condition itself may exist in a greater or less degree: the infant may be completely stillborn, with no indication of life, except, perhaps, the pulsation of the cord, or a feeble action of the heart;--or it may make ineffectual efforts at breathing, or even cry faintly, and yet subsequently perish for want of strength to establish perfectly the process of respiration. Under all these circumstances, a good deal can often be effected by art. In every instance, therefore, in which we have not positive evidence of the child being dead, in the existence of putrefaction, or of such malformation as is incompatible with life, it is our duty to give a fair trial to the means for restoring suspended animation; and as long as the slightest attempt at motion of the respiratory organs is evinced, or the least pulsation of the heart continues, we have good grounds for persevering and hoping for ultimate success.

The measures to be employed to restore a still-born child will be a little modified by the circumstances present.

IF THERE IS NO PULSATION--NO BEATING IN THE CORD, when the child comes into the world, it may at once be separated from the mother. This is to be effected by first tying the navel-string with common sewing thread (three or four times doubled), about two inches from the body of the child, and again two inches from the former ligature, and then dividing the cord with a pair of scissors between the two. And now the means for its restoration are to be made use of, which are detailed below, viz. inflation of the lungs, and perhaps the warm bath. If, with the above circumstances, the child's face be livid and swollen, some drops of blood should previously be allowed to escape before the ligature is applied to that part of the navel-string which is now only attached to the child.

IF THERE IS PULSATION IN THE CORD, BUT RESPIRATION IS NOT FULLY ESTABLISHED, it must not be divided; and as long as pulsation continues, and the child does not breathe perfectly and regularly, no ligature should be applied. The first thing to be done here, is to pass the finger, covered with the fold of a handkerchief or soft napkin, to the back of the child's mouth, to remove any mucus which might obstruct the passage of air into the lungs, and at the same time to tickle those parts, and thereby excite respiratory movements. The chest should then be rubbed by the hand, and a gentle shock given to the body by slapping the back. If these means fail, the chest and soles of the feet must next be rubbed with spirits, the nostrils and back of the throat irritated with a feather previously dipped in spirits of wine, and ammonia or hartshorn may be held to the nose.

INFLATION OF THE LUNGS.--These means not having been successful, and the pulsation in the cord having ceased, the infant must be separated, and inflation of the lungs resorted to. This is to be effected gently and cautiously as follows:--

The child, wrapped in flannel, is to be laid on its back upon a table placed near the fire. Its head is to be slightly extended, and the nostrils held between the fingers and thumb of one hand, whilst with the fingers of the other slight pressure is to be made upon the pit of the stomach, so as to prevent the air from passing into that organ. The lungs of the child are now to be filled with air, by the operator applying his own lips--with a fold of silk or muslin intervening, for the sake of cleanliness--to those of the child, and then simply blowing in its mouth, he is to propel the air from his own chest into that of the infant. Previously, however, to his doing this, he should make several deep and rapid inspirations, and, finally, a full inspiration, in order to obtain greater purity of air in his own lungs.

When the chest of the child has been thus distended, it is to be compressed gently with the hand, so as to empty the lungs; and then the inflation, with the alternately compressing the chest, must be repeated again and again, until either the commencement of natural respiration is announced by a sneeze or deep sigh, or until after long-continued, steady, persevering, but unavailing, efforts to effect this object shall have removed all ground of hope for a successful issue.

Whilst these efforts are being made, some other individual must endeavour to maintain or restore the warmth of the infant's body, by gently but constantly pressing and rubbing its limbs between his warm hands. And after respiration is established, the face must still be freely exposed to the air, whilst the warmth of the limbs and body is carefully sustained.

It will sometimes happen--and to this circumstance the operator should be fully alive--that when the child begins to manifest symptoms of returning animation, its tongue will be drawn backwards and upwards against the roof of the mouth, filling up the passage to the throat, and preventing further inflation of the lungs. This is to be remedied by the introduction of the fore-finger to the upper and back part of the child's tongue, and gently pressing it downwards and forwards, by which the difficulty will be removed, and the air again passes.

THE WARM BATH.--More reliance may be placed upon the above measure to restore animation, than upon the warm bath. Still this is sometimes useful, and therefore must not be neglected. Whilst inflation is going on, the bath may be got ready, then resorted to, and if unsuccessful, inflation may and ought again to be followed up.[FN#28] If the bath is useful at all, it will be so immediately upon putting the infant into it; respiration will be excited, followed by a cry; and if this does not occur at once, it would be wrong to keep the child longer in the bath, as it would be only losing valuable time which ought to be devoted to other efforts. The temperature of the bath should be about 100 degrees; and if, upon plunging the infant into it, it fortunately excite the respiratory effort, it should then be taken out, rubbed with dry but hot flannels, and, when breathing is fully established, laid in a warm bed, or, what is still better, in its mother's bosom; letting it, however, have plenty of air.

[FN#28] We should not relinquish our endeavours at resuscitation under two or three hours, or even longer; and if ultimately successful, the state of the infant should be carefully watched for two or three days.

INJURIES RECEIVED DURING BIRTH.

If a labour be long and tedious, the head and body of the child may be bruised and disfigured.

The shape of the head is frequently altered by the compression it has undergone, so that it may be elongated, and measure from the chin to the back of the head as much as six or seven inches. This always excites surprise, sometimes apprehension, in the minds of the attendants: there is no ground for it. It must be allowed to regain its natural shape without interference.

Tumours or swellings upon the head are very common. They arise from pressure upon the part during the labour. The only treatment that is required, or safe, is, freedom from all pressure, and the application of cold lotions composed of brandy or vinegar and water. The swelling will gradually subside. It will be right to direct the attention of the medical man to this circumstance.

The face may be frightfully disfigured from the above cause, exceedingly black, and the features distorted. Nothing is necessary here; in a few days the face will recover its proper appearance.

RETENTION OF URINE.

Occasionally an infant will not pass any urine for many hours after its birth. This most frequently arises from the fact of none being secreted. In the last case of this kind that I was called to, three days had elapsed since birth, and no urine had been passed; it proved that none had been secreted. Sometimes, however, it is the effect of another cause, which the use of the warm bath will be found to remove, which should always therefore be employed four and twenty hours after the birth of the infant, if it has not by that time passed any water.

It now and then happens, but fortunately very rarely, that some physical obstruction exists. It is always important, therefore, for the nurse to pay attention to the above point; and it is her duty to direct the attention of the medical man to the subject, if anything unusual or unnatural be present. The same observation applies to the bowel also; and if twelve hours pass without any motion, the parts should be examined.

SWELLING OF THE BREASTS.

At birth, or two or three days subsequently, the breasts of the infant will frequently be found swollen, hard, and painful, containing a fluid much resembling milk. Nurses generally endeavour to squeeze this out, and thus do great mischief; for by this means inflammation is excited in the part, and sometimes abscess is the result.

If the breasts are simply slightly enlarged, it is unnecessary to do any thing more than rub them occasionally and very gently with warm almond oil, and a little time will restore them to their proper size.

If, however, they are inflamed, hot, painful, with a red surface, and unusually large, a bread and water poultice must be applied every three or four hours, which will generally prevent either the formation of matter, or any other unpleasant consequence. In a few days, under this treatment, they will usually subside, and be quite well.

INFLAMMATION OF THE EYES.

ITS IMPORTANCE.--About the second or third day after the child's birth, an inflammation sometimes attacks the eye, which is of considerable consequence. The more so, from its commencing in a way not calculated to excite the attention, or alarm the fears, of the mother or nurse. The child cannot express its sensations, and the swelling of the eye conceals the progress of the disease, so that serious mischief is frequently done before the medical man sees the patient. In the first place, the inflammation is not immediately noticed; and, in the second, the measures employed are frequently insufficient to check its progress: hence it causes more blindness (I refer to the lower classes of society more particularly) than any other inflammatory disorder that happens to the eye; and the number of children is very considerable, whose sight is partially or completely destroyed by it. The parent or nurse is apt to suppose, when this inflammation first appears, that it is merely a cold in the eye, which will go off; and the consequences which I have just mentioned take place, in many cases, before they are aware of the danger, and before the medical man is resorted to for assistance.

I only desire, in mentioning this complaint, to inform the attendants of the lying-in-room of its great importance, that it may not be trifled with, that upon its first approach the physician may be informed of it, and that the treatment he directs for its cure may be sedulously and rigidly followed.

SYMPTOMS.--The inflammation commonly comes on about three days after birth, but it may take place at a later period. It may be known by its commencing thus:--When the child wakes from sleep, the eyelids will be observed to stick together a little; their edges will be redder than natural, and especially at the corners; the child experiences pain from the access of light, and therefore shuts the eye against it. A little white matter will also be observed lying on the inside of the lower lid. After a short time, the lids swell, become red on their external surface, and a large quantity of matter is secreted, and constantly poured from the eye; the quantity of discharge increasing until it becomes very great.

But enough has been said to point out the importance of the disease, and the signs by which it may be recognised at its first approach.

TREATMENT.--Keeping the eye free from discharge, by the constant removal of the matter secreted, is what the medical attendant will chiefly insist upon; and without this is done, any treatment he may adopt will be useless; with it, there is no doubt of a successful issue of the case, provided his attention has only been called to it at a sufficiently early period.

HARE-LIP.

This is a blemish too well known to require a formal description. The questions most interesting to a mother in relation to it, are,--How is her child to be nourished, that is born with it? and when ought an operation to be performed for its removal?

THE MODE OF FEEDING THE INFANT.--If the defect is but trifling, the infant will be able to suck, provided the mother's nipple is large, and the milk flows freely from it. If this is not the case, the difficulty may be obviated by using the cork nipple shield.[FN#29] I have known this to answer the purpose admirably, when the mother had previously despaired of nursing her infant, the nipple being too small for it to grasp.

[FN#29] See p. 41.

If, however, the defect exists in a still greater degree, feeding by means of the spoon must be resorted to; the greatest care being necessary as to the quantity, quality, and preparation of the food.[FN#30]

[FN#30] See "Artificial Feeding," p. 34.

CAUTION IN REFERENCE TO THE OPERATION.--With regard to the operation for the removal of this deformity, I would strongly warn parents against desiring its too early performance. Various considerations contribute to make the distressed parents anxious for this. But very seldom indeed--except the deformity be very great, and implicating other parts beside the lip--will the operation be required, or ought it to be resorted to, before the second year and a half of the infant's life; and for this very cogent reasons exist. For instance, convulsions may thus be induced, which often terminate fatally.

The most proper age for removing this deformity by operation, is from that of two years and a half to four years.

BLEEDING FROM THE NAVEL-STRING.

Bleeding from the navel-string will sometime take place hours after it has been supposed to be carefully secured. This will arise, either from the cord being carelessly tied, or from its being unusually large at birth, and in a few hours shrinking so much that the ligature no longer sufficiently presses on the vessels. In either case, it is of importance that the attendants in the lying-in-room should understand how to manage this accident when it occurs, that it may not prove injurious or fatal to the child.