The Mother's Manual of Children's Diseases Part 11

=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 p.u.b.erty, while I scarcely remember to have met with it under five years of age. This circ.u.mstance 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 pa.s.sage 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 pa.s.sage 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 a.s.sumes 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 pa.s.s 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 p.r.i.c.k 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 pa.s.ses 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, a.s.sumes 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 pa.s.s 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 pa.s.ses 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 pa.s.ses _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 pa.s.sage 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 pa.s.s 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 const.i.tutional 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.

I will just mention that symptoms similar to those above described, less severe, though more abiding, yet unattended by gravel in the urine, are sometimes produced in little boys by an unnatural narrowness of the end of the pa.s.sage for the urine. It is well to bear in mind this possible cause of the child's sufferings, and to consult a doctor with reference to it, since he will be able to relieve it by a trivial operation.

=Incontinence of Urine.=--The irritation which this mechanical inconvenience produces sometimes has to do with that troublesome infirmity of some children, who wet the bed at night. This may also be induced by a very acid, and consequently irritating, state of urine, either with or without the appearance in it of gravel. Often, however, it is a result of want of care on the part of the nurse, who neglects to cultivate regular habits in a child; and does not pay attention to the quant.i.ty of liquid taken at its last meal. Something, too, is due to the fact that the sleep of a child is deeper than that of the grown person, so that the sensation of want, which would arouse the latter to full consciousness, does not have the same effect on the former. It sometimes happens undoubtedly from mere indolence; and this may always be suspected when a child, otherwise healthy, wets itself not at night only, but also in the daytime. Lastly, it does sometimes occur from muscular feebleness in weakly children, the bladder being unable to bear more than a limited degree of distension.

The accident usually happens either soon after going to bed, when the warmth stimulates the action of the bladder, or towards morning, when the bladder has become full. The posture on the back favours its occurrence very much, and it is therefore of importance that the child should lie on its side when in bed. The good effect of a blister on the lower part of the back as a means of cure was largely due to its forcing the child to lie on its side. This object can be attained, however, in a much kindlier way, by tying half a dozen cotton reels together, and fastening them at the child's back. The habit may also often be broken through by arousing the child in the night, and compelling it to empty its bladder, the hour being first ascertained at which the accident usually happens. For this, however, to be of any real use, the child must be awakened thoroughly; since otherwise it will mechanically, and quite unconsciously, empty its bladder while still asleep. The habit in this case is not in the least overcome; only for the time the bed escapes the wetting. The utensil must therefore be placed on different nights at different parts of the room, so that the child, in order to find it, must have been roused to thorough consciousness.

Lastly, I will add that the cases in which the accident is the result of mere indolence are very rare, and though in such cases strictness may be necessary, yet actual punishment is out of place. As a rule, reward answers much better. A penny, or a threepenny-piece every night that the accident does not happen, and a forfeit of a halfpenny or two pence for every night of misfortune, is a very efficacious help to a cure.

When all these domestic means, persevered in for months, fail to produce any result, medical aid must be called in.

CHAPTER IX.

CONSt.i.tUTIONAL DISEASES.

There remains for consideration a large cla.s.s of what may be termed _const.i.tutional diseases_, in which the local ailment is the outcome of a previous disorder of the whole system. These diseases are either acute or chronic. The acute const.i.tutional diseases belong to the cla.s.s of fevers. These are marked by certain local characteristics, as the swelling of the joints in acute rheumatism, the sore-throat in scarlatina, or the eruption on the skin in smallpox, and their course is more or less strictly limited by distinct periods of increase, acme, and decline. No such rule obtains in the case of consumption, scrofula, and rickets, which are instances of chronic const.i.tutional diseases. In them too the local manifestations of the general disease vary also: the lungs being affected in one case of consumption, the bowels in another; while scrofula may show itself by affection of the glands in one case, by the formation of abscesses in a second, or by disease of the bones in a third.

=Chronic Const.i.tutional Diseases.=--It may perhaps be convenient to study first the chronic const.i.tutional diseases; and afterwards to make a few, and they will be but few, remarks on fevers.

=Consumption= and Scrofula, though similar, are not the same disease.

Both, however, depend on some defect in the blood, as the result of which certain materials, incapable of being converted into the natural const.i.tuents of the body, are deposited in the substance of different external parts or internal organs. If deposited in small quant.i.ties, these materials may be absorbed, as it is termed, that is to say, got rid of, by natural processes, which even now we understand but imperfectly.

If deposited more abundantly, they press upon and gradually spoil the healthy parts in which they are seated, and thereby interfere with the proper performance of their duties. Thus, the deposit of consumption encroaches on the proper substance of the lungs, and so lessens the area in which the blood is exposed to the air and purified: the deposit of scrofula around and in a joint interferes with its powers of movement.

Nor is this all; but wherever any deposit has once taken place, it tends especially to increase in that very spot, guided as it were by a certain affinity; and the substance of the previously healthy part is removed as fresh deposit comes to occupy its place. Further, the matter deposited has no power of being changed into healthy substance of lung, or of bone, or of any other part.

A fractured limb may be completely mended; a fluid is poured out around and between the edges of the broken bone; by degrees this hardens, it undergoes changes which convert it into solid bone, and the limb is once more as serviceable as before, though some indications of the fracture may still be perceptible in the texture of the bone itself. Or, a person receives a severe blow on his arm or leg; in course of time the blood which had flowed from the ruptured vessels, and had formed a big bruise, is absorbed, and all is as before the injury was inflicted. If more serious damage has been done, the fibres of some muscles may have been torn, even though the skin remains unbroken. Inflammation is set up, the injured parts die, and are melted down into the matter of an abscess.

The abscess discharges itself, its walls contract, the opposite surfaces come into contact, and are welded together again, so that there is no loss of substance, nor anything save a scar on the surface to indicate what has happened.

In the case of the deposits of consumption or scrofula these changes cannot take place. In technical language the matter is said to be incapable of organisation; that is to say, it cannot be transformed by nature's alchemy into anything good or useful. It is rubbish to be got rid of; and the patient's recovery depends on the possibility of getting rid of it. If there is much of it, so as to be removed from the vivifying influence which adjacent living structures still maintain about it, the deposit softens at its centre. This softening gradually extends to the circ.u.mference; the ma.s.s irritates more and more the parts around it, and where the irritation is greatest the structures yield, and are removed to make a way for its escape, and the patient spits up the contents of the abscess.

But the abscess of the lungs is not like an abscess which follows an injury. It has not formed in the midst of previously healthy parts which are capable of reproducing the original structure; its walls are themselves involved in the disease, and, in accordance with the rule I have already mentioned, 'much will have more,' and the patient goes on spitting up the perpetually renewed contents of the abscess for months or years; until by its gradually increasing size, and the more and more abundant discharge of matter, and further and further destruction of lung-substance, death takes place.

This fatal issue, however, is not invariable. In favourable circ.u.mstances, and especially in childhood, the radical const.i.tutional defect may be amended, and with a healthier condition of the blood the unhealthy deposit may cease to take place. The lung-substance, however, with all its curious structure of air-cells and their network of minute vessels where, as in nature's laboratory, the blood receives its due supply of oxygen, is not reproduced. The lung shrinks, the sides of the abscess come together, and by slow degrees a dense material cuts it off from the adjacent healthy structure, but the most complete recovery leaves the patient with his breathing power lessened, and with his vigour consequently more or less impaired.

When the deposit is less considerable, a different change takes place.

The material dries by degrees, and is at last converted by a purely chemical change into a hard chalky substance, which in the course of time becomes of more than stony hardness.

Last of all; when the deposit is smallest in quant.i.ty, it may be completely got rid of; and a lung in which consumptive disease once existed, may eventually regain perfect soundness.

I have dwelt on these processes as they take place in the lungs; but, allowing for differences of locality, they resemble such as take place elsewhere.

Three important conclusions follow from what has been said.

First. It is only in quite the early stage of consumptive disease that absolutely perfect recovery can be hoped for. There is a euphemism, more amiable than honest, which doctors not seldom make use of, saying that a child's lungs are not diseased, but only tender. They mean by this, that on listening to the chest, they detect such changes in the sounds of breathing as their experience tells them are usually produced in the early stage of consumptive disease of the lungs. If the opinion is confirmed by a second competent medical man, _then, and not later_, is the time for precautions, for removing the child from school, and for selecting, as far as may be, a suitable winter climate. When the signs of disease are well marked, a reprieve, perhaps a long one, is all that can be confidently reckoned on.

Second. When softening of the consumptive deposit has taken place, of which certain sounds attending breathing are all but conclusive, recovery, even the most complete, always implies loss of a certain amount of lung-substance, and consequently loss of a certain amount of breathing power.

Third, and this is most important, as well as most cheering; consumption, which is at no age the absolutely hopeless disease that it was once supposed to be, admits of far more cheerful antic.i.p.ations in children than in grown persons, or, for that matter, than in the youth or maiden.

The princ.i.p.al _causes_ of consumptive disease are, hereditary predisposition, and improper feeding in infancy. There are besides two diseases incidental to childhood, and one of them almost peculiar to it, namely typhoid fever and measles, which are more apt than any others to develop a tendency to consumption. During convalescence from either of them, therefore, special care is needed.

In the grown person, consumption almost always attacks the lungs, and this often to the exclusion of other organs. In the child, however, this is not so, and though the lungs are indeed oftener affected than other parts, yet in nearly half of the cases some one or other of the digestive organs is likewise involved, and in about one in seven instances the lungs are free and the digestive organs alone are attacked.

Fever, cough, and wasting are the three sets of symptoms which in some degree or other are always present in consumptive disease of the lungs.

The fever in the early stages of consumption is not in general severe; but so long as the evening temperature of a child never exceeds 99, there is no cause for anxiety. On the other hand, if the evening temperature for a week or ten days together always amounts to 100, there is grave presumption that consumptive disease is present. In advanced consumption the evening temperature is constantly 103 to 105, while in the morning it may fall to 101 or 100.