The Mother's Manual of Children's Diseases

PART II.

CHAPTER IV.

Drowned people are often resuscitated; the child's case is analogous to theirs; and in both the same measures have to be pursued, namely to try to establish respiration. The degree of the warmth of the child's body, the resistance of its muscles, the red tint or the white colour of its surface, the presence or absence of perceptible beating of its heart, measure the chances of success. Sometimes mere exposure to the cold air produces the necessary effect; at other times breathing is excited by dashing cold water in the child's face, by slapping it, by tickling its nostrils, or by dipping it for a few seconds in a hot bath at 100° or 102°; and then swinging it a few times backwards and forwards in the air.

Much time, however, must not be lost over these proceedings, but the child must be laid on its back, the lower part of its body well wrapped up, the chest slightly raised by a folded napkin placed under it. The two arms must then be taken firmly, raised and slowly extended on either side of the head, then brought down again and gently pressed on either side of the chest; and this movement of alternate raising and extending the arms and bringing them back again beside the chest must be repeated regularly some thirty times in the minute, thus imitating the movements of the chest in breathing. These efforts, too, must not be discontinued so long as the surface retains its warmth, and as an occasional heart-beat shows that life is not absolutely extinct; and I believe that in many instances failure is due to want of perseverance rather than to the absolute uselessness of the measure.

Premature Birth.—In spite of very extraordinary exceptions, it may be laid down as a rule that children born before the completion of six and a half months of pregnancy do not survive. After that date, each additional week adds greatly to the chances of the child living. There is a mistaken idea, founded on a superstition connected with the number seven, that a seven-months child is more likely to survive than one born at the eighth month. But this notion is as destitute of support in fact as it is opposed to common sense, and the nearer any woman has approached the full term of forty weeks of pregnancy, the greater are the chances of her child being born alive and healthy.

The premature child is by no means necessarily still-born. It breathes, but does so imperfectly, so that air does not enter all the smaller air-cells; and its voice is a whimper rather than a cry. Those changes in the heart and large vessels, which prepare, as pregnancy draws to a close, for the altered course of the blood when the child has to breathe through the lungs, are too little advanced for it to bear well the sudden alteration in its mode of being. The feebly beating heart and the not completely developed lungs seem but imperfectly to maintain the bodily heat. The glands of the stomach and intestines are not yet fit to perform digestion properly, while the muscular power is too feeble for the effort at sucking. Everything is sketched out, but to nothing has the finishing touch been put, and hence the frail machinery too often breaks down, in the endeavour to discharge its functions.

It is surprising, however, with what rapidity Nature in some instances perfects the work which she has been called on prematurely to perform.

It is our business to second Nature's endeavours. First of all, and of most importance, is the duty of providing from without the warmth which the child is unable to generate. When very feeble, it must, even without any previous washing or dressing, be at once wrapped in cotton wool, and then in a hot blanket, and surrounded with hot-water bottles. A tin stomach-warmer filled with hot water is very convenient to place under the blanket on which the child lies. Being too feeble to suck, it must be fed, a few drops at a time, from a small spoon; or still better, if it is able to make any effort at sucking, it may draw its nourishment through a quill. The mother after a premature confinement is almost sure to have no milk with which to nourish her child, at any rate for two or three days. It is, therefore, wise to obtain the help of a woman with a healthy baby. She must be allowed to bring her baby with her, since otherwise her supply of milk would fail, especially if she had no other means of getting rid of it than by the breast-pump or by drawing her breast. Even though she may have her own baby, there are few women who can submit, for more than a very few days, to the artificial emptying their breast without the secretion being either greatly lessened or altogether arrested. This, therefore, must be regarded as a resource available only for a few days, and as the child gains strength every effort must be made to get it to take its mother's breast, if she has any supply, or that of the wet-nurse. If this is found impossible, it will be wisest to give up, at any rate for the present, the attempt to nourish the child from the breast, and to obtain for it asses' milk, which is the best substitute. By no means whatever can more than from a sixth to a fourth part of a pint of milk be obtained either by the breast-pump or by drawing the breast; and since a healthy infant of a few weeks old sucks about two pints of milk in twenty-four hours, it is evident that the supply artificially obtained must after the first few days be utterly inadequate.

I have in cases of extreme weakness in premature children succeeded in preserving them by giving them every two hours for two or three days ten measured drops of raw beef juice, five of brandy, and two teaspoonfuls of breast milk. Medicine has no place in the management of these cases; the question is one entirely of warmth, food, and for a time the judicious use of stimulants.

Imperfect Expansion of the Lungs.—Children not premature and perfectly well nourished are yet sometimes feeble, breathe imperfectly, cry weakly, suck difficultly or not at all, and die at the end of a few days. Their lamp of life flickered and went out. Such cases are met with for the most part in conditions similar to those in which children are actually still-born; or now and then they take place when labour has been of unusually short duration, the child hurried into the world too rapidly; while in other instances it is not possible to account for their occurrence.

For a long time the nature of these cases was not understood; but rather more than sixty years ago a German physician discovered that air had entered the lungs but imperfectly; that perhaps a third, perhaps even as much as half, of the lungs had never been dilated, but had remained solid and useless; that in consequence the blood was but half-purified, and vitality therefore but half-sustained. The lungs, however, were found to have undergone no real change; they were not diseased, but if air was blown into them the dark solid patches sunk below the level of the surrounding substance, expanded, grew bright in colour and like a sponge from which the water has been squeezed, and crackled, or crepitated as the technical term is, from the air contained within them.

We breathe in health so without conscious effort that we never realise the fact that, according to the calculation of most competent observers, the mere elasticity of the lungs, independent even of the elasticity of the chest walls, opposes a resistance to each inspiration equal to 150 pounds avoirdupois in the grown man and 120 in the grown woman. The want of breath puts the respiratory muscles into play: the man takes a deep inspiration, and by this unconscious effort, he overcomes the resistance of the chest and the elasticity of the lungs. The new-born infant feels the same want and makes the same effort; but its muscular power is small, and its inspirations are often so feeble as to draw the air in some parts only into the larger tubes, while many of the smaller remain undilated, and much of the lung continues in the state in which it was before birth. The blood being thus but imperfectly purified, all the processes of nutrition go on imperfectly, the vital powers languish, the inspiratory efforts become more and more feeble, while the elasticity of the lung is constantly tending to empty the small cells of air and to oppose its entrance, and next the temperature sinks and the infant dies.

Cases in which this condition of the lungs exists usually present the history of the child from the very first having failed to utter a strong and loud cry like that of other children. Even after breathing has gone on for some time, such children usually appear feeble, and they suck with difficulty, although they often make the effort. An infant thus affected sleeps even more than new-born infants usually do; its voice is very feeble, and rather a whimper than a cry. In the cry of the healthy infant you at once detect two parts—the loud cry, suffering or passionate as the case may be, and the less loud back draught of inspiration. The French have two words for these two sounds—the cri and the reprise. The cri is feeble, the reprise is altogether wanting wherever expansion of the lung has to any considerable extent failed to take place, and you would hail this second sound as the best proof of an improvement in the child's condition.

If you watch the child with a little attention you will see that while the chest moves up and down, it is very little, if at all, dilated by the respiratory movements. The temperature falls, the skin becomes pale, and the lips grow livid, and often slight twitching is observed about the muscles of the face. The difficulty in sucking increases, the cry grows weaker and more whimpering, or even altogether inaudible, while breathing is attended with a slight rattle or a feeble cough, and the convulsive movements return more frequently, and are no longer confined to the face, but affect also the muscles of the extremities. Any sudden movement suffices to bring on these convulsive seizures, but even while perfectly still the child's condition is not uniform, but it will suddenly become convulsed, and during this seizure the respiration will be extremely difficult, and death will seem momentarily impending. In a few minutes, however, all this disturbance ceases, and the extreme weakness of the child, its inability to suck, its feeble cry, and its frequent and imperfect inspirations, are the only abiding indications of the serious disorder from which it suffers. But the other symptoms return again and again, until after the lapse of a few days or a few weeks the infant dies.

I have dwelt at some length on this condition because it is important to know that during the first few weeks of life real inflammation of the lungs or air-tubes is of extremely rare occurrence, and that the symptoms which are not infrequently supposed to depend on it are really due to a portion of the lung more or less extensive never having been called into proper activity. I may add that we shall hereafter have to notice a similar condition of the lung—its collapse after having once been inflated—as occurring sometimes in the course of real inflammation of the organs of respiration in early life, and forming a very serious complication of the original disease.

If the collapse of the lung is not so considerable as to destroy life within the first few hours or days after birth, the babe wastes as well as grows weaker and weaker, and this wasting coupled with the difficult breathing not seldom causes the fear that the child has been born consumptive and that its death is inevitable.

No such gloomy view need be taken. Collapse, or at least non-expansion of the lung to some extent, is by no means unusual: consumptive disease to such an extent in the new-born infant as to interfere with the establishment of breathing is extremely rare. The consumptive babe can suck, it is not so weak as the one whose lungs are imperfectly expanded; it has no convulsive twitchings, nor any of the strange head-symptoms which we notice in the former. It wastes less rapidly, it is feverish instead of having a lower temperature than natural, it seems less ill, and yet its death within a few weeks or months is absolutely certain; while the child whose lungs are not diseased but simply unexpanded may, if that accidental condition is removed, grow up to vigorous manhood.

The treatment of these cases is abundantly simple. The child who breathes imperfectly but ill maintains its heat. It must be kept warm at a temperature never less than 70°; it may, like the premature child, need stimulants, and all the precautions already mentioned as to feeding. Twice in the day it should be put for five minutes in a hot bath at 100°, rendered even more stimulating by the addition of a little mustard. The back and chest may be rubbed from time to time with a stimulating liniment, and an emetic of ipecacuanha wine may be given twice a day. The act of vomiting not only removes any of the mucus which is apt to accumulate in the larger air tubes, but the powerful inspirations which follow the effort tend to introduce air into the smallest vesicles of the lungs, and to do away with their collapse.

Let these directions be carried out sensibly, patiently, perseveringly, and three times out of four, or oftener still, the mother's ear will before many days be greeted by the loud cry, with its cri and reprise of which I have already spoken, and which assures her that her little one will live.

There are no other affections of the lungs so peculiar to the first month of life as to call for notice here. I shall have a few observations to make about malformations of the heart, and the precautions for which they call in the after-life of children; but they will find their fittest place in the chapter on Affections of the Chest.

Jaundice of New-born Children.—A certain yellow tinge of the skin, unattended by any other sign of jaundice, such as the yellowness of the eye and the dark colour of the urine, is by no means to be confounded with real jaundice. It is no real jaundice, but is merely the result of the changes which the blood with which the small vessels of the skin are overcharged at birth is undergoing; the redness fading as bruises fade, through shades of yellow into the genuine flesh colour.

This is no disease, to be treated with the grey powder and the castor oil wherewith the over-busy monthly nurse is always ready. It is a natural process, which the intelligent may watch with interest, with which none but the ignorant will try to interfere.

There is, however, beside this a real jaundice, in which the skin is more deeply stained, the whites of the eyes are yellow, the urine high-coloured, and in which the dark evacuations that carry away the contents of the bowels before birth are succeeded by white motions, from which the bile is absent. This condition is not very usual, save where children have been exposed to cold, or where the air they breathe is unwholesome. Of this no better proof can be given than is afforded by the fact that in the Dublin Lying-in Hospital, where the children are defended with the greatest care both from cold and from a vitiated atmosphere, infantile jaundice is extremely rare, while it attacks three-fourths of the children received into the Foundling Hospital of Paris. Still it does sometimes occur when yet no cause can be assigned for it, and it is noteworthy that it is sometimes met with in successive infants in the same family.

As the respiratory function and that of the skin increase in activity, the jaundice will disappear of its own accord. Great attention must be paid during its continuance to avoid exposure of the child to cold, while no other food than the mother's milk should be given. If the bowels are at all constipated, half a grain of grey powder or a quarter of a grain of calomel may be given, followed by a small dose of castor oil, and the aperient will often seem to hasten the disappearance of the jaundice; but in a large number of cases even this amount of medical interference is not needed.

There is, indeed, a very grave form of jaundice, happily of excessive rarity, due to malformation of the liver, to absence or obstruction of the bile-ducts, and often accompanied with bleeding from the navel. I do but mention it; the intensity and daily deepening of the jaundice, the fruitlessness of all treatment, and the grave illness of the child, even though no bleeding should occur, render it impossible to confound this hopeless condition with the trivial ailment of which I have been speaking.

The next chapter will furnish a fitter place than the present for speaking fully of the Disorders of the Digestive Organs.

I will say now but this: that whatever a mother may do eventually, she avoids grave perils for herself by suckling her infant for the first month; while the health of her child, just launched upon the world, is terribly endangered if fed upon those substitutes for its proper nutriment on which after the lapse of a few weeks it may subsist, may even manage to thrive.

There are some local affections incident to the new-born child concerning which a few words may not be out of place; and first of the

Ophthalmia of New-born Children.—It is the cause of the loss of sight of nine-tenths of all persons who, among the poor, are said to have been born blind. In the wealthier classes of society it is comparatively rare, and seldom fails to meet with timely treatment, yet many people scarcely realise its dangerous character, or the extreme rapidity of its course.

It generally begins about the third day after birth with swelling of the lid of one or other eye, though both are soon involved. The eyelids swell rapidly, and if the affection is let alone, they soon put on the appearance of two semi-transparent cushions over the eyes. On separating the lids, which it is often very difficult to do owing to the spasmodic contraction of the muscles, their inner surface is seen to be enormously swollen, bright red, like scarlet velvet, bathed in an abundant yellowish thin secretion, which often squirts out in a jet as the lids are forcibly separated. Great care must be taken not to allow any of this fluid to enter the eye of a bystander, nor to touch his own eye until the fingers have been most carefully washed, since the discharge is highly contagious, and may produce most dangerous inflammation of the eyes of any grown person. The discharge being wiped or washed away, the eye itself may be seen at the bottom of the swelling very red, and its small vessels very blood-shot. By degrees the surface of the eye assumes a deeper red, it loses its brightness and its polish, while the swelling of the lids lessens, and they can be opened with less difficulty; their inner surface at the same time becomes softer, but thick and granular, and next the eyes themselves put on likewise a granular condition which obscures vision. The discharge by this time has become thicker and white, and looks like matter from an abscess. By slow degrees the inflammation may subside, the discharge lessen, the swelling diminish, and the eye in the course of weeks may regain its natural condition. But the danger is—and when proper treatment is not adopted early the danger is very great—lest the mischief should extend beyond the surface of the eye, lest ulceration of the eye should take place, the ulceration reach so deep as to perforate it, and not merely interfere with the sight, but destroy the organ of vision altogether.

In every instance, then, in which the eyelids of a new-born infant swell, or the slightest discharge appears from them, the attention of the doctor must at once be called to the condition. In the meantime, and during whatever treatment he may think it right to follow, the eye must be constantly covered with a piece of folded lint dipped in cold water; and every hour at least the eye must be opened and tepid water squeezed into it abundantly from a sponge held above, but not touching it, so as to completely wash away all the discharge. A weak solution of alum and zinc, as one grain of the latter to three of the former to an ounce of water, may in like manner be dropped from a large camel's-hair brush four times a day into the eye after careful washing. Simple as these measures are they yet suffice, if adopted at the very beginning, and carried on perseveringly, to entirely cure in a few days an ailment which if let alone leads almost always to most lamentable results.

I do not pursue the subject further, for bad cases require all the care of the most skilful oculist for their treatment.

Scalp Swellings.—Almost every new-born child has on one or other side of its head a puffy swelling, owing to the pressure to which the head has been subjected in birth, and this swelling disappears at the end of twenty-four or forty-eight hours.

Now and then, however, though indeed very seldom, the swelling does not disappear, but it goes on gradually increasing and becoming more definite in its outlines until at the end of three or four days it may be as big as half a small orange, or sometimes even larger, soft, elastic, painless, under the unchanged scalp, but presenting the peculiarity of having a hard raised margin with a distinct edge, which gives to the finger passed over it the sensation of a bony ridge, beyond which the bone seems deficient. This tumour is due usually to the same cause as that which produces the other temporary puffy swelling of the scalp, only the pressure having been more severe, blood has actually been forced out from the small vessels under the membrane which covers the skull, and hence its gradual increase, its definite outline; and hence, too, the bony ridge which surrounds it, and which is due to nature's effort at cure, in the course of which the raised edge of the membrane covering the skull (the pericranium) becomes converted into bone.

When the nature of these swellings was not understood, they used to be poulticed, and to be opened with a lancet to let out their contents. We know now, however, that we have nothing to do but to let them alone; that by degrees the blood will be absorbed and the tumour will disappear, and as it does so we may trace the gradual transformation of the membrane which covered it into bone, as we feel it crackling like tinsel under the finger. Two, three, or four weeks may be needed for the entire removal of one of these blood-swellings. The doctor will at once recognise its character, and you will then have nothing to do but to wait—often, unhappily, so much harder for the anxious mother than to meddle.

Ruptured Navel.—There is a period some time before the birth of a child when the two halves of its body are not united in front, as they become afterwards; and hare-lip or cleft-palate sometimes remains as the result of the arrest of that development which should have closed the fissured lip or united the two halves of the palate.

In a similar way it happens sometimes that though the skin is closed, the muscles of the stomach (or, more properly speaking, of the belly) are not in the close apposition in which they should be, so that the bowels are not supported by the muscles, but protected only by the skin.

More frequently than this, especially in the case of children who are born before the time, the opening through which the navel string passes is large at birth, and fails to close as speedily and completely as it should do afterwards. When everything goes on as it ought, the gradual contraction of the opening helps to bring about the separation of the navel string and its detachment, and the perfect closure of the opening takes place at the same time, between the fifth and the eighth day after birth.

If this does not occur, the bowels are very apt to protrude through the opening, and if allowed to do so for weeks or months, the opening becomes so dilated that its closure is impossible, and the child grows up afflicted permanently with rupture through the navel. This is always an inconvenience, sometimes even a source of serious danger; but if means are taken to prevent the condition becoming worse, nature seldom fails eventually to bring about a cure, and to effect the complete closure of the opening.

If the muscles on either side do not come into apposition, but leave a cleft between them, the infant should constantly wear a broad bandage of fine flannel round the stomach, not applied too tightly, in order to give support. The circular bandages of vulcanised india-rubber with a pad in the centre are nowise to be recommended. The pad is apt to become displaced, and to press anywhere but over the navel, while its edges irritate the infant's delicate skin, and the pressure which it exerts if it is sufficiently tight to retain its place interferes with respiration.

A pad composed of pieces of plaster spread on wash-leather, and of graduated sizes and kept in place by adhesive strapping,[7] answers the purpose of preventing the protrusion at the navel, and of thus facilitating the closure of the ring better than any other device with which I am acquainted. They need, however, to be continued even for two or three years, and though they should have been left off it is wise to resume their use if the child should be attacked by whooping-cough, diarrhœa, or any other ailment likely to occasion violent straining.

CHAPTER V.

All food has to answer two distinct purposes: the one to furnish materials for the growth of the body, the other to afford matter for the maintenance of its temperature; and life cannot be supported except on a diet in which the elements of nutrition and those of respiration bear a certain proportion to each other. Now, in milk, the proper food of infants, the elements of the former are to those of the latter about in the proportion of 1 to 2, while in arrowroot, sago, and tapioca they are only as 1 to 26, and in wheaten flour only as 1 to 7. If to this we add the absence in these substances of the oleaginous matters which the milk contributes to supply the body with fat, and the smaller quantity, and to a certain extent the different kind, of the salts which they contain, it becomes apparent that by such a diet the health if not the life of the infant must almost inevitably be sacrificed.

But these substances are not only less nutritious, they are also less easy of digestion than the infant's natural food. We all know how complex is the digestive apparatus of the herbivorous animal, of which the four stomachs of the ruminants are an instance, and how large is the bulk of food in proportion to his size which the elephant requires, compared with that which suffices for the lion or the tiger.

The stomach of the infant is the simple stomach of the carnivorous animal, intended for food which shall not need to stay long in that receptacle, but shall be speedily digested; and it is only as the child grows older, and takes more varied food, that the stomach alters somewhat in form, that it assumes a more rounded shape, resembling somewhat that of the herbivorous animal, and suited to retain the food longer. The young of all creatures live upon their mother for a certain time after birth; but in all the preparation for a different kind of food, and with it for an independent existence, begins much sooner and goes on more rapidly than in man. Young rabbits are always provided with two teeth when born, and the others make their appearance within ten days. In the different ruminants the teeth have either begun to appear before birth, or they show themselves a few days afterwards; and in either case dentition is completed within the first month, and in dogs and cats within the first ten weeks of existence.

In the human subject the process of teething begins late, between the seventh and the ninth month, and goes on slowly: the first grinding teeth are seldom cut before the beginning of the second year, and teething is not finished until after its end. Until teething has begun the child ought to live exclusively on the food which nature provides; for until that time the internal organs have not become fitted to digest other sustenance, and the infant deprived of this too often languishes and dies. To get from other food the necessary amount of nourishment, that food has to be taken in larger quantities, and, from the difficulty in digesting it, needs to remain longer in the stomach than the mother's milk. One of the results of the indigestibility of the food is that the child is often sick, the stomach getting rid of a part of that food which it is unable to turn to any useful purpose; and so far well. But the innutritious substances do not relieve the sense of hunger. The child cries in discomfort, and more is given to it, and by degrees the over-distended stomach becomes permanently dilated, and holds a larger quantity than it was originally meant to contain. The undigested mass passes into a state of fermentation, and the infant's breath becomes sour and offensive, it suffers from wind and acid eructations, and nurses sometimes express surprise that the child does not thrive since it is always hungry. While some of the food is got rid of by vomiting, some passes into the intestines, and there becomes putrid, as the horribly offensive evacuations prove. They come away, large and solid and white, for the secretion of the bile is inadequate to complete that second digestion which should take place in the intestines; or else the irritation which they excite occasions diarrhœa—a green putty-like matter comes away mixed with a profuse watery discharge.

What wonder is it that in such circumstances the body should waste most rapidly; for it is forced from its own tissues to supply those elements essential to the maintenance of life, which its food contains in far too scanty a proportion. Every organ of the body contributes to the general support, and life is thus prolonged, if no kind disease curtail it, until each member has furnished all that it can spare, and then death takes place from starvation, its approach having been slower, but the suffering which preceded it not therefore less, than if all food had been withheld.

Do not suppose that in this description I have been painting too dark a picture, or that children who die thus have been exceptionally weak, and so under the acknowledged difficulties of hand-feeding at length became consumptive. They do not die of consumption, and in a large number of instances their bodies show no trace of consumptive disease, but present appearances characteristic of this condition of starvation, and of this only.

Along the whole track of the stomach and intestines are the signs of irritation and inflammation. The glands of the bowels are enlarged, actual ulceration of the stomach is often met with; while so far-reaching is the influence of this slow starvation, that even the substance of the kidneys and of the brain are often found softened and otherwise altered, though it might not unreasonably have been supposed that these organs lay quite beyond the reach of any disorder of digestion.

No doubt all these grievous results do not always follow; and sometimes children exceptionally strong manage to take and digest enough even of unsuitable food to maintain their health, and may as they grow up, and the changes take place in the system which fit it for a varied diet, even become robust. In the majority of instances, however, hand-fed infants, and those especially who have been brought up chiefly on farinaceous food, are less strong than others, and are more apt to develop any latent tendency to hereditary disease, such as scrofula or consumption, than members of the same family who have been brought up at the breast.

Enough has already been said to satisfy all but those who do not wish to be convinced, how incumbent it is on every mother to try to suckle her child. But though it is most desirable that for the first six months of their existence children should derive their support entirely from their mother, and that until they are a year or at least nine months old their mother's milk should form the chief part of their food, yet many circumstances may occur to render the full adoption of this plan impracticable. In some women the supply of milk, although at first abundant, yet in the course of a few weeks undergoes so considerable a diminution as to become altogether insufficient for the child's support; while in other cases, although its quantity continues undiminished, yet from some defect in its quality it does not furnish the infant with proper nutriment. Cases of the former kind are not unusual in young, tolerably healthy, but not robust women; while instances of the latter are met with chiefly among those who have given birth to several children, whose health is bad, or among the poor, who have been enfeebled by hard living or hard work. The children in the former case thrive well enough for the first six weeks or two months, but then, obtaining the milk in too small a quantity to meet the demands of their rapid growth, they pine and fret, they lose both flesh and strength, and, unless the food given to supply their wants be judiciously selected, their stomach and bowels become disordered, and nutrition, instead of being aided, is more seriously impaired. In the case of the mother whose milk disagrees with the child from some defect in its quality, the signs are in general more pronounced. Either the infant vomits more than that small quantity which a babe who has sucked greedily or overmuch often rejects immediately on leaving the breast, or it is purged, or it seems never satisfied, does not gain flesh, does not thrive, cries much and is not happy. In these cases, too, the mother's supply of milk, though abundant at first, diminishes in a few weeks; she feels exhausted, and suffers from back-ache, or from pain in the breasts each time after the child's sucking; while, further, her general weakness leaves her no alternative but to wean the child.

Knowing the attempt to rear her child entirely at the breast to be vain, the mother may in such cases be tempted to bring it up by hand from the very first. But how short soever the period may be during which the mother may be able to suckle her child, it is very desirable that she should nurse it during that period, and also that her milk should then constitute its only food. For the first four or five days after the infant's birth the milk possesses peculiar qualities, and not merely abounds in fatty and saccharine matter, but presents its casein or curd in a form in which it is specially easy of digestion. These peculiarities indeed become less marked within a week or two; but not only is it of moment that the infant should at any rate make its start in life with every advantage, but the mother who nurses her little one even for a month avoids thereby almost half the risks which follow her confinement. For the indolent, among the wealthy, a numerous class who have but to form a wish in order to have it gratified, a wet-nurse for the baby suggests itself at once to the mother as a ready means of saving herself trouble, and of shirking responsibility. This course, to which love of pleasure and personal vanity tend alike to prompt her, often finds, in spite of all opposing reasons, the approval of the nurse, to whom it saves trouble, and the too ready acquiescence of the doctor in a course which pleases his patient. But many circumstances besides those moral considerations, which ought never to be forgotten before the determination is formed to employ a wet-nurse, may put this expedient out of the question, and it becomes therefore of importance to learn what is the best course for a mother to adopt who is either wholly unable to suckle her child, or who can do so only for a very short time.

It is obvious that the more nearly the substitute approaches to the character of the mother's milk, the greater will be the prospect of the attempt to rear the child upon it proving successful. There is no argument needed to prove that the milk of some animal more closely resembles the mother's milk, and is more likely to prove a useful substitute for it than any kind of farinaceous substance. The milk of all animals, however, differs in many important respects from human milk, and differs too very widely in different animals. Thus, the milk of the cow and that of the ewe contain nearly double the quantity of curd, and that of the goat more than twice the quantity of butter, and it is only in the milk of the ass that the solid constituents are arranged in the same order as in man. On this account, therefore, asses' milk is regarded, and with propriety, as the best substitute for the child's natural food. Unfortunately, however, expense is very frequently a bar to its employment, and compels the use of the less easily digested cows' milk. But though the cost may be a valid objection to the permanent employment of asses' milk, it is yet very desirable when a young infant cannot have the breast, that it should be supplied with asses' milk for the first four or five weeks, until the first dangers of the experiment of bringing it up by hand have been surmounted. The deficiency of asses' milk in butter may be corrected by the addition of about a twentieth part of cream, and its disposition to act on the bowels may be lessened by heating it to boiling point, not over the fire but in a vessel of hot water; and still more effectually by the addition to it of a fourth part of lime-water or of a teaspoonful of the solution of saccharated carbonate of lime to two ounces or four tablespoonfuls of the milk.

When cows' milk is given, it must be borne in mind that it contains nearly twice as much curd, and about an eighth less sugar, than human milk. It is therefore necessary that it should be given in a diluted state and slightly sweetened. The dilution must vary according to the infant's age; at first the milk may be mixed with an equal quantity of water, but as the child grows older the proportion of water may be reduced to one-third. Mere dilution with water, however, leaves the proportion of curd unaltered, and it is precisely the curd which the infant is unable to digest. Instead, therefore, of diluting the milk simply with water, it is often better to add one part of whey to about two parts of milk, which, according to the child's age, may or may not be previously diluted.[8]

Attention must be paid to the temperature of the food when given to the infant, which ought to be as nearly as possible the same as that of the mother's milk, namely from 90° to 95° Fahrenheit, and in all cases in which care is needed a thermometer should be employed in order to insure the food being given at the same temperature. Human milk is alkaline, and even if kept for a considerable time it shows little tendency to become sour. The milk of animals when in perfect health likewise presents an alkaline reaction, and that of cows when at grass forms no exception to this rule. Milk even very slightly acid is certain to disagree with an infant; it is therefore always worth while the moment that a hand-fed infant seems ailing to ascertain this point. If alkaline, the milk will deepen the blue colour of litmus paper, which is to be had of any chemist; if acid, it will discharge the colour and turn it red. It is, perhaps, as well to add that, as the oxygen in the atmosphere tends to redden litmus paper, it should not be left exposed to the air, but should always be kept in a glass-stoppered bottle.

The milk of the cow is very liable to alteration from comparatively slight causes, and particularly from changes in the animal's diet; while even in the most favourable circumstances if the animal is shut up in a city and stall-fed, all the solid constituents of its milk suffer a remarkable diminution; while the secretion further has a great tendency to become acid, or to undergo even more serious deterioration. Mere acidity of the milk can be counteracted for the moment by the addition of lime-water, or by stirring up with it a small quantity of prepared chalk, which may be allowed to subside to the bottom of the vessel; or if it should happen, though indeed that is rarely the case in these circumstances, that the child is constipated, carbonate of magnesia may be substituted for the chalk or lime-water. If these simple proceedings are not sufficient to restore the infant's health, it will be wise to seek at once for another source of milk supply, and to place the suspected milk in the hands of the medical officer of health or of the public analyst, in order that it may be submitted to a thorough chemical and microscopical examination.

The difficulty sometimes found in obtaining an unvaryingly good milk supply, as well as practical convenience in many respects, has led to the extensive employment of various forms of condensed milk. They form undoubtedly the best substitute for fresh cows' milk which we possess, and are a great boon especially to the poor in large towns where the milk supply is often scanty, not always fresh, and sometimes of bad quality. I should certainly prefer condensed milk for an infant to milk from cows living in close dirty stables, such as my experience thirty years ago made me familiar with in some parts of London.

Still all the varieties of condensed milk are far inferior in quality to good fresh milk. They contain less butter, less albumen, that is to say less of the main constituents of all animal solids and fluids, and a greater proportion of what are termed the hydro-carbonates, such for instance as sugar; or, to state the same thing differently, the elements which serve for nutrition are in smaller proportion than in fresh milk to those which minister to respiration. They are not only less nutritious, but the large quantity of sugar which they contain not infrequently disagrees with the child, and causes bowel complaint. I do not know how far the so-called unsweetened condensed milk which has of late come into the market is free from this objection; but I have always preferred the Aylesbury condensed milk, which is manufactured with sugar, to the Swiss condensed milk, into which, as I have been given to understand, honey largely enters.

How much food does an infant of a month old require? what intervals should be allowed between each time of feeding? and how should the food be given? are three questions which call for a moment's notice. The attempt has been made to determine the first point by two very distinguished French physicians, who weighed the infants before and after each time of sucking. Their observations, however, were not sufficiently numerous to be decisive, and their results were very conflicting; the one estimating the quantity at two pounds and a quarter avoirdupois, which would be equivalent to nearly a quart, the other at not quite half as much; but the observations of the latter were made on exceptionally weak and sickly infants. Infants no doubt vary, as do grown people, as to the quantity of food they require. I should estimate from my own experience and observation, apart from accurate data, a pint as the minimum needed by an infant a month old; and while Dr. Frankland's estimate of a pint and a half for an infant of five months seems to me very reasonable, I should doubt its sufficing for a child of nine months unless it were supplemented by other food.

The infant during the first month of life takes food every two hours, and even when asleep should not be allowed to pass more than three hours; and this frequent need of food continues until the age of two, sometimes even until three, months. Afterwards, and until six months old, the child does not need to be fed oftener than every three hours during the twelve waking hours, and every four hours during the sleeping time. Later on, five times in the twenty-four hours, namely thrice by day, once the last thing at night, and once again in the early morning, are best for the child's health as well as for the nurse's comfort.

How is an infant not at the breast to be fed? Certainly not with the cup or spoon; a child so fed has no choice in the matter, but must either swallow or choke, and is fed as they fatten turkeys for the market. The infant, on the other hand, sucks the bottle as it would suck its mother's breast; it rests when fatigued, it stops to play, it leaves off when it has had enough, and many a useful inference may be drawn by the observant nurse or mother who watches the infant sucking, and notices if the child sucks feebly, or leaves off panting from want of breath, or stops in the midst, and cries because its mouth is sore or its gums are tender.

But it is not every bottle which an infant should be fed from, and least of all from those so much in vogue now with the long elastic tube, so handy because they keep the baby quiet, who will lie by the hour together with the end in its mouth, sucking, or making as though it sucked, even when the bottle is empty. These bottles, as well as the tubes connected with them, are most difficult to keep clean; and so serious is this evil, that many French physicians not only denounce their use, in which they are perfectly justified, but prefer, to the use of any bottle at all, the feeding the infant with a spoon; and here I think they are mistaken. The old-fashioned flat bottle, with an opening in the middle, and a short end to which the nipple is attached without any tube, the only one known in the time of our grandmothers, continues still the best, and very good. My friend, Mr. Edmund Owen, in a lecture at which I presided at the Health Exhibition in August last year, pointed out very humorously the differences between the old bottle and the new. An infant to be kept in health must not be always sucking, but must be fed at regular intervals. The careful nurse takes the infant on her knee, feeds it from the old-fashioned feeding-bottle, regulating the flow of the milk according as the infant sucks heartily or slowly, withdraws it for a minute or two, and raises the child into a sitting posture if it seems troubled with flatulence, and then after a pause lets it recommence its meal. This occupies her a quarter of an hour or twenty minutes of well-spent time, while the lazy nurse, or the mother who has never given the matter a thought, just puts the tube in the infant's mouth, and either takes no further trouble or occupies herself with something else. And yet, obvious though this is, how constantly one sees infants taken about in the perambulator with the feeding-bottle wrapped up and laid by its side, because it is said the child always cries when it is not sucking, and the intelligence and the common sense are wanting, as well as the patient love, that would strive to make out which it is of many possible causes that makes the infant cry. One more observation with reference to bottle-feeding may not be out of place. It is this: that no food be left in the bottle after the child has had its meal, but that it should be emptied, washed out with a little warm water and soda, and it and the india-rubber end should be kept in water till again needed. To insure the most perfect cleanliness it is always well to have two bottles in use, and to employ them alternately.

How strictly soever an infant may be kept at the breast, or however exactly the precautions on which I have insisted are observed, sickness, constipation, or diarrhœa may occur, causing much anxiety to the parents, and giving much trouble to the doctor.

It sometimes happens, without its being possible to assign for it any sufficient reason, that the mother's milk disagrees with her infant, or entirely fails to nourish it, so that, much against her will, she is compelled to give up suckling it. In some instances this is due to errors in diet, to the neglect of those rules the observance of which is essential to health, as proper exercise for instance; and then the secretion is usually deficient in quantity as well as defective in its composition. In such cases the child often vomits soon after sucking, it suffers from stomach-ache, its motions are very sour, of the consistence of putty, and either green, or become so soon after being passed, instead of presenting the bright yellow colour and semi-fluid consistence of the evacuations of the healthy infant, and sometimes they are also lumpy from the presence of masses of undigested curd. In addition, also, the child is troubled with griping, which makes it cry; its breath is sour, or actually offensive, and the tongue is much whiter than it should be, though it must be remembered that the tongue of the sucking child always has a very slight coating of whitish mucus, and is neither as red nor as perfectly free from all coating as it becomes in the perfectly healthy child of three or four years old.

In these circumstances, the diminution of stimulants, such as the stout of which young women are sometimes mistakenly urged to take a quantity to which they were previously quite unaccustomed, is often followed by an increase of the quantity as well as an improvement in the quality of the milk. It is true that a nursing mother may often find her strength maintained, and her supply of milk increased, by taking a glass of stout at lunch and another at dinner, instead of, but not in addition to, any other stimulant; but mere stimulants will no more enable a woman to suckle her infant better than she otherwise would do, than they would fit a man to undergo great fatigue for days together, or to go through a walking tour in Switzerland. A tumbler of one-third milk and two-thirds good grit gruel taken three times a day will have greater influence in increasing the quantity of milk than any conceivable amount of stimulant.

There is an entirely opposite condition in which the infant does not thrive at the breast, and this for the most part is met with when the mother has already given birth to and suckled several children. In these instances the secretion is sometimes, though not always, abundant, but the infant does not thrive upon it. The babe does not get on, is always hungry after leaving the breast, and cries as though it wanted more; in addition to which it is often purged, either while sucking or within a few minutes afterwards, though the motions, except in being more frequent and more watery than in health, do not by any means constantly show any other change. The mother's history explains the rest. She is constantly languid, suffers from back-ache, feels exhausted each time after the babe has sucked, probably has neuralgia in her face, or abiding headache. In many instances, too, her monthly periods return, though as a rule they do not appear in healthy women while suckling. All these symptoms show that her system is not equal to the duty she has undertaken, and that therefore, for her sake as well as for that of the infant, she must give up the attempt.

One more case there is in which suckling has to be given up, at any rate in part, and that is when the milk is good in kind, but insufficient in quantity for the child as it grows older. This insufficiency of quantity shows itself at different periods after the infant's birth—at two months, three, or four. The child is not otherwise ill than that it is no longer bright, as it was wont to be, it ceases to gain flesh, it sleeps more than it used to do, though when it wakes it is always eager for the breast, and cries when leaving it, and if the experiment is made of giving it some milk and water immediately on leaving it, it takes that greedily. Mothers are loth to believe this failure of their resources, and in the case of some who have firm and well-formed breasts, there is but little change in their appearance to show that what remains may serve for beauty, not for use. But if while the child is sucking, the nipple is taken suddenly from its mouth, instead of innumerable little jets of milk, spirting out from the openings of the milk-ducts, the nipple will be seen to be barely moistened by its languid flow.

In conditions such as these the question of weaning partially or completely inevitably occurs, and where the mother's weakness is the occasion of the failure to nourish the child, half-measures are of no avail, for so long as she does not entirely give up the attempt to do that to which her health is unequal, her own state will grow worse, that of the child will not improve. When errors of diet or inattention to general rules of health incapacitate the mother from the performance of her duty, there may be hope from the adoption of a wiser course; while when the supply simply fails from its inadequacy, much may be hoped for from a wise combination of hand-feeding with nursing at the breast; the mother perhaps suckling the infant by day, but being undisturbed by demands upon her at night.

Last of all, I must refer to cases in which love has been stronger than reason, as indeed it often is, and in which young people with some pronounced hereditary taint of scrofula or consumption marry and have children. In such cases, if the consumptive taint is on the mother's side, it is, I believe, much wiser, in the inability to obtain a good wet-nurse, to bring up the child by hand rather than at the mother's breast. One word, however, applicable in such circumstances, age and long experience entitle me to add, and it is this. It is essential that, in the absence of that guarantee against the too rapid succession of pregnancies which suckling for a reasonable time presents, there should be self-restraint on both sides, lest the inscription on the young wife's grave should be, as I have too often known it, the same as, in despite of poetry and romance, her biographer assigns as the cause of the death of Petrarch's Laura, that she died worn out crebris partubus, by too many babies.

In all of these cases the rules which I have already given with reference to hand-feeding have to be borne in mind: the preference for asses' milk at first, the careful regulation of the amount of curd in the cows' milk afterwards, increased or diminished by the greater or less proportion of whey mixed with it. Sometimes, however much the quantity of curd or casein may be reduced, the child is yet unable to digest it, for it is firm and not easily acted on by the juices of the stomach. It is then best to omit it altogether, and to supply the necessary albumen by white of egg. A very good food in these circumstances is made of—

White of one raw egg,
Quarter of an ounce of sugar of milk,
Three teaspoonfuls of cream,
Half a pint of whey.

In the course of a few weeks, or when the child seems to need stronger nourishment, one part of veal-tea, made with a pound of veal to a pint of water, may be added to one part of whey, with the white of egg and sugar of milk as before, and one part of white decoction, as it was called some two centuries ago in England. It is composed of—

Half an ounce of hartshorn shavings,
Inside of one French roll,
Three pints of water—boiled to two, strained and sweetened.

This forms an extremely useful way of introducing farinaceous food into the infant's diet, and preparing the way for a larger amount of it which by degrees becomes necessary. Of these, one of the most generally useful is Liebig's or Savory and Moore's food for infants, which has the advantage of not constipating as so many other farinaceous foods do. Chapman's Entire Wheat Flour is an extremely good food; and wheat, as you will remember, excels other farinaceous substances in its nutritive properties, but it is not so easy of digestion as Liebig. There is, however, scarcely any kind of farinaceous food, among which Nestlé's must not be forgotten, which may not answer for an infant; provided always that at first it is not given oftener than twice a day, that it is not made too thick, nor given in larger proportion than one-third of the farinaceous food to two-thirds of the whey, milk, or whatever it is mixed with; and besides, whatever the food may be, it should be prepared each time afresh.

This is not the place for going into all details on the subject of feeding infants, or to explain how if wisely managed the child weans itself by degrees from the bottle or the breast—the best way, be it said, of weaning—or how by degrees it comes to its daily midday meal of beef-tea and bread, and then, when the first grinding teeth have been cut, to a small meat meal daily, finely minced or scraped, and so little by little adopts the modes of living of its elders.

But, last of all, there are instances, though not so many as the public imagine, in which the infant, in spite of most judicious management, fails to thrive, and suffers from various disorders of its digestion.

The most unmanageable and the least hopeful of these cases are those in which the infant is the subject of consumptive disease. It is very rare for its symptoms, even in cases of the most marked tendency to consumption on the part of the parents, to show themselves before the age of three months, and I think I may add, that apart from such tendency consumption never appears in infancy or early childhood, except when it follows on some acute illness, such as inflammation of the lungs, or on typhoid, or, as it is commonly called, remittent fever.

Consumption of the bowels, as it is popularly termed, may be said never to occur in early infancy apart from consumptive disease of the lungs, and is then always accompanied by an increase towards evening of the temperature from its natural standard of 98.5° to 100°. Hence the absence of cough and the persistence of a natural temperature may be taken as almost conclusive evidence that there is no consumptive disease of the bowels. Consumptive disease in infancy is invariably attended with glandular enlargement. The glands of the bowels when irritated always communicate their irritation to the glands in the groin and the bend of the thigh, which are felt hard and enlarged, like little peas, under the finger. But further, if there is real disease of the glands of the bowels, other tiny enlarged glands will be felt, like shot, under the skin of the belly, from which in the general progress of emaciation the layer of fat always present in the healthy baby will already have been removed. Besides this, too, the veins running beneath the skin there, invisible in the healthy infant, will be seen meandering like blue lines, and telling the story that more blood than usual flows through them, because the diseased glands inside interfere with its ready passage through its proper channels.

Two cautions, however, have to be borne in mind with reference to both of these indications of disease. The first is, that the glands in the groin may be enlarged from mere irritation, independent of actual disease communicated to them from the glands inside. If, however, you find the glands at the corner of the lower jaw and those on either side of the neck enlarged too, you are then driven to the conclusion that the glands in the groin are enlarged not from mere local irritation, but from general disease, and that consumption is its cause.

Again, the superficial veins of the belly may be enlarged from any cause which interferes with the proper circulation through the vessels inside. Hence they are often enlarged in grown people in dropsy, and hence too in infants and young children from flatulent distension of the bowels. But in this case the other signs of consumption are wanting; the emaciation, the cough, the increase of evening temperature, and the enlargement of the glands, are all absent.

Sometimes we meet with instances where the child does not digest its food, does not thrive, does not gain flesh, never passes healthy evacuations, at length wastes, loses strength, and dies, without having had any of the signs which I have pointed out as indicative of consumptive disease, and in fact without having suffered from it. Now, these cases are connected with imperfect performance of the function of the liver, and sometimes with an imperfection of its structure. Before birth the functions of the liver are not called into action in the same way nor to the same degree as afterwards, and its structure differs in this respect that it contains a larger amount of fat and a smaller proportion of bile-secreting cells than afterwards. It sometimes happens from causes which we do not understand that the liver structure not only does not undergo that higher development which should take place, but that the fat cells increase at the expense of the bile cells. In these circumstances the food is ill-digested and the health is much impaired, and at last wasting takes place to as great a degree as in the case of consumption, only there are no cough, no glandular enlargement, no big superficial veins, no increased temperature, while on a careful examination the doctor will seldom fail to find the rounded edge of the enlarged liver coming lower down than natural. In these cases too there is a disposition to convulsive affections, and to that peculiar form of convulsion called spasmodic croup, concerning which I shall have something to say later on.

In its less serious form this is both a more frequent and a less grave condition than consumption, and its existence explains to a great degree those cases in which young children have failed to be nourished by the milk food which commonly suits their tender age, but have improved on beef-tea, raw meat or its juice, and food entirely destitute of saccharine matter.

In cases where there is reason to apprehend consumptive disease, the skill and resources of the doctor will often be heavily taxed to meet each difficulty as it arises. A good wet-nurse, or, in default of her, asses' milk, with the addition of cream to supply the butter in which the asses' milk is deficient, a couple of teaspoonfuls of raw meat juice in the course of every twenty-four hours, much care in the introduction of farinaceous substances into the diet, and cod-liver oil twice a day, beginning with ten drops and gradually increasing the dose to a teaspoonful, are all that the mother herself can do. When the cod-liver oil is not borne by the stomach, or when—which, however, is not often the case—the child refuses to take it, glycerine may be substituted for it, though it must be owned that it is a very poor and inefficient substitute. The inunction of cod-liver oil is in any case not to be had recourse to; it makes the child unpleasant to itself and loathsome to others, while the power of the skin to absorb oily matters is far too limited to be worth taking into account.

Vomiting, though by no means a prominent symptom of either of the two very grave conditions of which I have been speaking just now, is yet a very common attendant on all disorders of digestion in early life. It is indeed much more frequent in the infant than in the adult, and the greater irritability of the stomach continues even after the first few months of existence are past, and does not completely cease during the early years of childhood. In every case of vomiting in childhood, therefore, the first question to set at rest is whether it depends on disorder of the digestive system, or whether it heralds the onset of one of the eruptive fevers, or of inflammation of the chest, or of affection of the brain; and in determining this all the directions given when I was speaking of the general symptoms of disease are to be carefully studied. Vomiting often accompanies infantile diarrhœa, even when the food taken cannot be regarded as its occasion; and now and then the stomach, with no obvious exciting cause, suddenly becomes too irritable to retain any food, and this indeed may be the case even though attended by few or no other indications of intestinal disorder. The child in such cases seems still anxious for the breast; but so great is the irritability of the stomach that the milk is either thrown up unchanged immediately after it has been swallowed, or it is retained only for a few minutes, and is then rejected in a curdled state; while each application of the child to the breast is followed by the same result. It will generally be found, when this accident takes place in the previously healthy child of a healthy mother, that it has been occasioned by some act of indiscretion on the part of its mother or nurse. She perhaps has been absent from her nursling longer than usual, and returning tired from a long walk or from some fatiguing occupation, has at once offered it the breast, and allowed it to suck abundantly; or the infant has been roused from sleep before its customary hour, or it has been over-excited or over-wearied at play, or in hot weather has been carried about in the sun without proper protection from its rays.

The infant in whom from any of these causes vomiting has come on, must at once be taken from the breast, and for a couple of hours neither food nor medicine should be given to it. It may then be offered a teaspoonful of cold water; and should the stomach retain this, one or two spoonfuls may be given in the course of the next half-hour. If this is not rejected, a little isinglass may be dissolved in the water, which must still be given by a teaspoonful at a time, frequently repeated; or cold barley-water may be given in the same manner. In eight or ten hours, if no return of vomiting takes place, the experiment may be tried of giving the child its mother's milk, or cows' milk diluted with water, in small quantities from a teaspoon. If the food thus given does not occasion sickness, the infant may in from twelve to twenty-four hours be restored to the breast: with the precaution, however, of allowing it to suck only very small quantities at a time, lest, the stomach being overloaded, the vomiting should again be produced.