If a fatal termination does not take place speedily, the disease passes into the chronic stage, the diarrhœa diminishing in frequency, but the pain and straining, and the unhealthy character of the evacuations persisting. Ulceration of the bowels has taken place, emaciation becomes extreme, and the child often sinks at the end of several weeks, worn out by suffering; while recovery, doubtful at the best, is always very slow. But I need not pursue this subject further: enough has already been said to show how little infantile diarrhœa is a disorder for domestic management.
Peritonitis, or inflammation of the membrane covering the bowels and lining the cavity of the belly, is of excessive rarity in its acute form; and is attended by such general illness and such severe local suffering, that it is impossible to overlook it or to misapprehend its gravity. Severe pain in the belly is sometimes complained of by children, and is due to what is termed colic, a spasm of the bowels which is generally associated with constipation. The great test of the cause of the pain is furnished by the presence or absence of tenderness on pressure. The pain of colic is relieved by gentle pressure and gentle rubbing. The pain of inflammation in any degree and of any kind is aggravated by them. This applies also to cases, not indeed very common, in which inflammation is set up by some small body, such as a cherry-stone getting fixed in a little offshoot or appendage of about the size and length of the little finger, connected with the commencement of the large bowel, and producing ulceration. In these circumstances the bowels are confined, there are nausea and sickness, together with pain and tenderness of the belly, especially on the right side. The disease is a very dangerous one, and often proves fatal in the course of a few days. I refer to it because I have often seen it overlooked both by parents and doctors at its outset, since the pain then is often not severe nor the tenderness intense, and because I have seen the patient's condition rendered hopeless by strong aperients being given to overcome the constipation which was supposed to be all that ailed the child. I repeat then the caution, never to overlook the existence of tenderness, never to attempt to treat a case in which it is present; but always to call in medical advice, and above all always to abstain, unless ordered by a medical man, in every such case from the use of aperients.
Large Abdomen.—I must not leave the subject of disorder of the digestive organs without some reference to a condition which often excites much needless anxiety among mothers, namely, the large size of a child's belly. This is sometimes supposed to be a certain evidence of the presence of worms, at other times to be a positive proof of the existence of grave disease, especially of disease of the mesenteric glands, or glands of the bowels as they are popularly termed. It is evidence of neither the one nor the other.
If you go into a gallery of the old masters, and look at any of the pictures of angels which are generally to be seen there in such abundance, you will probably be struck in the case of all the child angels by what will seem to you the undue size of their abdomen. You will notice this even in the works of painters who, like Raphael, most idealise their subjects, while in those of others who, like Rubens, interpret nature more literally, the apparent disproportion becomes grotesque; or, in the coarser hands of Jordaens, even repulsive.
These painters were, after all, true interpreters of nature. In infancy and early childhood the abdomen is much larger comparatively than in the grown person. For this there is a twofold cause; the larger size of the liver on the one hand, and the smaller development of the hips on the other. In a weakly child this appearance is exaggerated by its want of muscular power, which allows the intestines to become much distended with air. If the child is not merely weakly but also ricketty, the contracted chest will leave less room than natural for the lungs, while at the same time the ordinary development of the hips being arrested by the rickets, the disproportion is further increased both by that and by the flatulence due to the imperfect digestion with which the condition is almost always associated.
In no case need the mere size of the abdomen occasion grave anxiety, so long as when the child lies upon its back the abdomen is uniformly soft, nor so long as even if tense it is not tender, and as it everywhere gives out a hollow sound like a drum when tapped with the finger.
It is not for a moment meant that no notice is to be taken, nor opinion asked, as to the cause of excessive size of the abdomen, for its distension may be due to real disease; but it is yet worth while to remember that its mere size is not of itself evidence of disease, nor cause of grave anxiety.
Worms.—There is no mistaking or overlooking the existence of worms when they are really present. Their presence, however, is often suspected without any sufficient reason. Ravenous or uncertain appetite, indigestion, flatulence, undue size of the abdomen, a dark circle round the eyes, itching of the nose and of the entrance of the bowel, a coated tongue, and offensive breath are no real proof of the presence of worms, and do not justify the frequent repetition of violent purgatives or of so-called worm medicines. The only real proof of the presence of worms is their being seen in the evacuations.
The worms commonly found in children are either the round-worm, which resembles the earth-worm, the thread-worm, or the tape-worm; the appearance of each of which is clearly indicated by its name. None of them are spontaneously generated in the body, but they are all introduced from without; their eggs, or, as they are technically called, their ova, being swallowed unperceived in some article of food, or drink. A proof of this is afforded by the fact that an infant, so long as it is nourished exclusively at the breast, never has worms.
The round-worm occasions the fewest symptoms, and is rather an object of disgust than of grave importance, at least in this country, where it seldom happens that more than two or three are present. In other countries, as some parts of Italy, for instance, where the drinking water is bad and stagnant, they are sometimes found in great numbers, as thirty or forty, and it is then not easy to determine whether the symptoms which accompany them are produced by the worms, or by the unwholesome character of the water in other respects.
They appear to live on the contents of the intestines, and do not adhere to them, as the tape-worm does, and hence their comparative harmlessness, and they have no power, as has sometimes been mistakenly imagined, of perforating the bowels, and of thus producing grave mischief.
The thread-worm is the commonest variety of these creatures, and has the peculiarity of inhabiting the lowest twelve inches of the bowel, where it produces much irritation and causes very distressing itching. It is often present in great numbers, and is so rapidly reproduced, that in a week or two after it has been apparently got rid of, it may again be found as numerous as before. Certain articles of food seem to favour its development, such as pastry, sugar, sweets, beer, fruit, and anything which is apt to undergo fermentation, and thereby to impart to the evacuations a specially acid character. These worms are often accompanied with more or less marked symptoms of indigestion, but otherwise the local irritation is usually the only indication of their presence. They produce, indeed, such disturbance of the nervous system as may attend indigestion in any of its forms, but I have never but once known convulsions occur apparently due to their presence in great numbers, and ceasing on their expulsion; and this was in a child between eighteen months and two years old.
The tape-worm is developed in the human body from a minute germ or ovum; one form of which exists in the flesh of the bullock, the other in that of the pig; and which seems to require for its growth the favouring conditions of warmth and moisture which are found in the intestines. It fixes itself to the lining of the bowels by means of its mouth, which is furnished with minute tentacles, and it thus derives its support from the juices which it imbibes. The head is so small as not to be seen distinctly without a magnifying glass; and immediately beyond it the jointed body begins; at first, scarcely bigger than a thread of worsted, but gradually enlarging, till at the distance of three inches it is an eighth of an inch wide, and thence rapidly widens till each joint is half an inch wide, and from a third to half an inch apart. It does not exceed these dimensions, even though it may grow to the length of four or six yards. Portions of it, sometimes a yard or two in length, are thrown off from its lower end occasionally, and this occurrence often gives the first indication of its presence, the worm continuing to grow as before, and fresh portions being detached from time to time. It does not appear that the worm has the power of reproducing itself; hence its French name of ver solitaire, and the occasional presence of two or three would seem to be due to the development of two or three distinct ova within the intestine.
Deriving as it does its support from the system of the child, and not as the other worms do from the contents of the bowel, the tape-worm often produces graver inconveniences. It sometimes causes uncomfortable colicky sensations, which may even be very distressing, and the disorders of digestion which accompany it are often very considerable; certainly more so than in the case of the other varieties of worms; but I have seen no instance of convulsions which could be attributed to them, notwithstanding the generally received opinion to the contrary.
When the existence of worms is suspected, one or two doses of a simple aperient, such as castor oil, repeated two days successively, seldom fail to produce evidence of their presence; which in the case of tape-worm is also furnished by the spontaneous detachment of some of the joints. It must be remembered, however, that until the head has been detached from its connection with the bowel, nothing has been gained, and the tape-worm will in a short time grow again. To obtain the detachment of the head it is necessary that any worm medicine should be given when the intestines are empty. I am, therefore, always accustomed to give a dose of castor oil about two hours after the child's mid-day meal; and to send the child to bed as soon as the aperient begins to act, and to give it no more food except a biscuit and a little milk and water during the rest of the day. In the early morning, the special worm medicine is given, and over and over again I have known the worm to be brought away completely after many previous failures. When the smallness of the joints shows that the greater part of the worm has been thrown off, and that little more than the head remains, it is necessary to have recourse to the unpleasant proceeding of mixing the evacuations with water, and then straining them through muslin, in order that the doctor may by means of the microscope make out whether or no the head has been really detached. This is no question of mere curiosity, but a matter of the gravest moment, since nothing has been really gained so long as the head of the worm remains adherent to the bowel.
Precautions such as these are not needed in the case of the other kinds of worms. Thread-worms, however, are best attacked in their habitation; that is to say, in the lower bowel, by means of lavements. It is, therefore, desirable before they are administered that the bowels should be emptied by a dose of castor oil.
The only other caution which remains for me to give refers to the peculiar effect which salicine, a very valuable medicine, especially in the case of thread-worms, has upon the urine. It sometimes turns the urine of a greenish-yellow, often of a red colour, as though it were mixed with blood. The appearance, however, has no grave meaning, but is due simply to a chemical action of the medicine on the colouring matter and salts of the urine.
There still remain some local ailments of parts connected with the process of digestion, concerning which a few words must be said.
Ulcerated Mouth.—First, with reference to the sore-mouth of children. I have already noticed a form of inflammation and ulceration of the gums sometimes met with during teething, but the sore-mouth of which I am now about to speak is often quite independent of that process; though it may sometimes be found associated with it, and is indeed rarely met with after five years of age. In almost all instances it is preceded and attended with symptoms of indigestion, during the course of which the mouth becomes inflamed, hot and red, and small very painful shallow ulcers with sharp-cut edges, and a little yellowish deposit on their surface, appear at the edge of the tongue, on the inside of the mouth, and especially on the inside of the lower lip, and the adjacent surface of the gum. Successive crops of these little ulcerations not unfrequently appear, so that for many weeks the child may be kept by them in a state of extreme discomfort; swallowing, and even speaking being the occasions of considerable suffering.
It is seldom that nursery remedies, and the so-called cooling medicines, though often of some service, suffice to get rid of the ailment, which for the most part needs judicious medical treatment, and local as well as constitutional measures. Now and then this condition comes on in the course of measles, and is then sometimes of serious importance.
In the other form, the disease is usually limited to the gums, and affects especially those of the front of the lower jaw, which become swollen, ulcerated at their edges, where a very ill-smelling deposit takes place of a dirty white or greyish colour, the surface beneath being spongy, swollen, raw, and bleeding. The ulceration sometimes extends so as to lay bare a large part of the sockets of the teeth; but though loosened they seldom drop out. Coupled with this, the glands at the angle of the jaw are swollen, and the child dribbles constantly a large quantity of horribly offensive saliva. In the children of the well-to-do classes the condition is seldom seen except in a slight degree; but even when severe it is rarely accompanied by any grave disorder of the general health. It seems to tend, whether treated or left to itself, slowly to get well; but its progress to a natural cure is extremely tedious, and the gums are left by it for a long time spongy, bleeding easily, and only very imperfectly covering the teeth.
Anxiety is sometimes excited by this condition; it being supposed that the white deposit on the edge of the gum implies some relation between it and diphtheria. This is not so, for though this peculiar ulceration of the gums has now and then been found associated with diphtheria, the nature of the two diseases is essentially different. It is, however, always wise to call in medical advice in order to settle this important question, and the more so, since there is one remedy, the chlorate of potass, which, in appropriate doses, acts upon the condition almost as a charm.
I say nothing about a dreadful form of inflammation of the mouth which ends in mortification, because it is of infinite rarity except among the destitute poor, and even among them it is very seldom seen except as a consequence of measles, or of some kind of fever. It is only among the very poor that I have seen it, and even among them it has come under my notice only ten times in the whole course of my life.
There is a very common but inaccurate opinion that sore-mouth in childhood is often produced by the employment of mercury. I never yet saw a sore mouth due to the administration of mercury in any child before the first set of teeth were entirely cut; and never but once out of 70,000 cases which have come under my notice in hospital or dispensary practice, have I seen in children of any age under twelve any affection of the mouth from mercury sufficiently severe to cause me a moment's anxiety.
Quinsey, or inflammatory sore-throat, has in it nothing specially peculiar to the child, but occurs at all ages with the same symptoms. It is, however, comparatively rare under twelve years of age, and is almost always less severe in childhood than at or after puberty, while I scarcely remember to have met with it under five years of age. This circumstance attaches special importance to sore-throat in young children, since it will usually be found to betoken the approach of scarlet fever, or of diphtheria, rather than the existence of simple inflammation, or quinsey.
While this fact affords a reason for most scrupulous attention to every case of sore-throat in children, and this in proportion to the tender age of the child, needless alarm is sometimes caused by the appearance on the inflamed tonsils of numerous white specks, which are at once supposed to be diphtheritic. I have already pointed out the distinction between the two conditions when speaking of diphtheria, but the matter is so important that I will repeat what I then said. These spots are not in the form of a uniform white patch or membrane, which, on being removed, leaves the surface beneath red, raw, and often slightly bleeding; but they are rather distinct circular spots, firmly adherent to the tonsil, wiped off with difficulty, and evidently exuding from the openings of little pits, blind pouches, or glands, with which the surface of the tonsil is beset. I do not advise any parent to rest satisfied with his or her judgment on this matter the first time that they notice this appearance; but there are children with whom slight sore-throat is always attended by this condition, and others in whom the tonsils are habitually enlarged, and seldom free from these white spots flecking their surface.
Enlarged Tonsils.—I have said that quinsey or acute inflammation of the tonsils is unusual in early childhood; but a sort of chronic inflammation of those glands which leads to their very considerable enlargement is far from uncommon; and is sometimes the cause of very serious discomfort. It is seldom traceable to any acute attack of sore-throat, but usually comes on imperceptibly in children who are feeble or out of health, or takes place slowly during the cutting of the first set of grinding teeth; the irritation which that produces being in some cases its only apparent exciting cause. Not seldom the enlargement has become considerable before it attracts attention; one of the first symptoms that indicate it being the loud snoring of the child during sleep, who is compelled by the obstruction at the back of the nostrils to breathe with its mouth open. The voice at the same time becomes thick, and this and the snoring breathing are both greatly aggravated when the child catches cold.
A greater degree of enlargement of the tonsils occasions deafness from pressure on the passage leading to the internal ear, and is also apt to give rise to a troublesome hacking cough which sometimes excites apprehension lest the child's lungs should be diseased. When still more considerable the enlarged tonsils block up the passage through the nostrils, and air consequently enters the lungs but very imperfectly. The nostrils thus disused become extremely small, narrow, and compressed, the upper jaw does not undergo its proper development, the teeth are crowded and overlap each other, the palate remains narrow and unusually high-arched, and the face assumes something of a bird-like character. Besides this the child grows pigeon-breasted, owing to the lungs not being filled sufficiently at each inspiration to overcome the pressure of the external air on the yielding sides of the chest.
When any considerable enlargement of the tonsils exists, each cold that the child may catch aggravates it, and if diphtheria, scarlatina, or severe sore-throat should occur, the temporary increase of the swelling may become the occasion of serious danger. The question arises, what are the chances that a child whose tonsils are enlarged will outgrow the condition, or when is it necessary to have the enlarged tonsils removed?
It scarcely ever happens that any such enlargement of the tonsils exists in children under six years of age as to call for their removal. There is almost always ground for the hope that after the irritation caused by cutting the first four permanent grinding teeth has completely ceased, the tonsils may return by degrees to their former size. A similar shrinking of the enlarged tonsil sometimes takes place, especially in the boy, at the time of approach to manhood, when the vocal organs undergo full development. This can be counted on, however, only in cases where the tonsils are not of extreme size, and have not undergone frequent attacks of inflammation. Whenever the hearing is habitually dull, and the voice always thick, when cough is frequent, the nostrils narrow, the chest pigeon-breasted, and the child feeble and ill-thriven, removal of the tonsils is absolutely necessary. In cases where the question is doubtful, its decision must turn on whether the tonsils have often been inflamed. So long as their surface is smooth, and their substance soft and elastic, delay is permissible. When their substance is hard, like gristle, and their surface uneven and corrugated, they have undergone such changes that absorption is impossible, and their removal absolutely necessary.
I dwell thus particularly on the question of removal of the tonsils, because there is among many persons an unreasoning dread of the operation, which is entirely devoid of danger, requiring only a few seconds for its performance, and which may even be done under chloroform. The painting tincture of iodine behind the angle of the jaw, or the touching the tonsils with caustic, iodine, alum, tannin, or sweet spirits of nitre are utterly futile proceedings. They diminish the unhealthy and often offensive secretion from the glands which beset the tonsils, and restore the surface to a more healthy condition, but they are absolutely without influence in lessening their size.
Now and then all the symptoms of enlarged tonsils are present, but yet most careful examination fails to discover any increase of their size. When this is the case the symptoms are due to a thickening of the membrane at the back part of the nostrils, often attended with spongy outgrowths from their surface, which obstruct just as completely as enlarged tonsils would do the free entrance of air. It will, in any case where this condition is suspected, be absolutely necessary to seek the advice of some of those gentlemen who make a specialty of diseases of the throat, and who will have the necessary technical dexterity to discover the condition, and to treat it skilfully.
Abscess at back of the Throat.—I should pass unnoticed, on account of its rarity, the occasional formation of an abscess at the back of the throat, behind the gullet, interfering both with breathing and with swallowing, but that the description of it in my Lectures once enabled a lady in the wilds of Russia to detect it, to point out the nature of the case to her puzzled doctor, to urge him to open the abscess, and thus to save her child's life.
This abscess may form at any age, sometimes after fever, sometimes without any obvious cause. It shows itself by difficulty in swallowing and breathing, unattended by cough, but accompanied by a sound similar to that of croup, but not so harsh or ringing. The neck is stiff, the head thrown back, and often there is a distinct swelling on one or other side of the neck. The finger introduced into the mouth, and carried over the tongue to the back of the throat, feels there a swelling which projects over the top of the windpipe, and causes the difficulty both in swallowing and breathing. This swelling is the abscess; a prick with the surgeon's lancet lets out the matter, and saves the child.
Diseases of the Kidneys.—The kidneys perform very important duties in carrying off from the system a large amount of useless material, and thus supplement in many respects the action of the skin, and the purifying influence which is exercised by the air on the blood, as it passes through the lungs.
It is evident, therefore, that their disorder in any way must be a matter of serious moment, though at the same time the knowledge of the skilled doctor is needed to determine the nature and degree of the ailment from which they are suffering, since that requires an examination of the urine, both chemically and by means of the microscope. My remarks on these diseases must consequently be few and fragmentary.
In the grown person, what is known as Bright's disease is of frequent occurrence, assumes different forms, and depends on various causes. In the child it is comparatively rare, and is scarcely ever met with except as a consequence of a chill, or as a result of scarlatina. In these conditions the kidneys become overfilled with blood or congested, and the congestion may pass into inflammation, by which their structure may be irreparably damaged. Dropsy is the great outward sign of the affection—either slight swelling of the face, eyelids, and ankles, or very great swelling of all the limbs, and even the abundant pouring out of fluid into the belly. The degree of dropsy is, however, by no means an absolute measure of the amount of kidney mischief. It therefore behoves every parent to follow out all directions most scrupulously even in cases of very slight dropsy, in order to guard against the risk of permanent injury to the kidneys being left behind; and especially to remember the liability to the occurrence of dropsy and disease of the kidneys after scarlatina. Any check to the action of the skin while it is peeling or desquamating, as it is termed, is especially liable to be followed by these accidents. To avoid all risks as far as possible, I have been accustomed for many years to insist on a child remaining in bed for one-and-twenty days after the first appearance of the rash in even the mildest case of scarlatina, and I am absolutely sure that it is the height of imprudence ever to neglect this precaution.
It will suffice to mention the fact that diabetes, though very rare, may yet occur in childhood, and that as a rule it is more dangerous in childhood than in the grown person. Whenever a child loses flesh without obvious cause, suffers much from thirst, and at the same time passes urine in greater abundance than in health, the possibility that it may suffer from diabetes must be borne in mind.
Of far greater frequency than any other affection of the kidney is that in which the child passes gravel with the urine, either in the form of a reddish-white sediment, which collects at the bottom of the vessel as the urine cools, or of minute glistening red particles, which resemble grains of cayenne pepper.
These deposits, when abundant in the male child, have a tendency to collect in the bladder, and there to form a stone. This painful disease, too, is so much more frequent in childhood than at a later age, that more than a third—indeed, nearly half—of all the operations for stone performed in English hospitals are done on boys under ten years old.
Even when this grave consequence does not follow the presence of gravel in the kidneys, and its passage into the bladder, it is often accompanied with much suffering. The pain is like that of stomach-ache or colic, the child crying and drawing up its legs on every attempt to pass water, which sometimes is voided only in a few drops at a time, and now and then is completely suppressed for some hours. The very acute form of the ailment seldom occurs, except in infants who inherit from their parents a disposition to gouty or rheumatic affections. In them, however, a trifling cold, slight disorder of the digestion, a state of constipation, or the feverishness and general irritation which sometimes attend on teething, not infrequently produce these deposits and give rise to all these painful symptoms, the deposit disappearing and the pain ceasing so soon as the brief constitutional disturbance subsides.
The very acute attacks seldom occur after the first two years of life, but similar symptoms, though less severe, are by no means unusual in older children, and continue to recur from very trifling causes, especially from errors in diet and disorders of digestion.
In spite of the suffering which for the time attends it, there is no cause for anxiety with reference to the issue of each attack. The warm bath, a castor oil aperient, and soothing medicine soon relieve the pain, and the children return to their former state of health. It is the frequent return of the attack, even in a comparatively mild form, the persistent disposition to the formation of gravel, the remote risk in the case of male children of stone in the bladder, and the habitually imperfect performance of the digestive functions which call for special care. The avoidance of sugar, sweets, and whatever tends to impart acidity to the urine, the maintaining the due action of the skin by wearing flannel, and the judicious use of alkaline remedies, sometimes combined with iron, are the measures on which the doctor is sure to insist.
The difficulty usually encountered in the treatment of these cases arises from the reluctance of the parents to continue for months and years the observance of the necessary rules. It seems so hard to deny their little one the small gratifications in which other children may indulge with impunity; and they fail to realise the heavy penalty, in the shape of gout, rheumatism, gravel, and stone, which in after-life their darling may have to pay for their over-indulgence in his early years.