A Grim ResultBy permission of Henry H. Goddard A Grim Result Isaac is 16, although mentally 10. He is a high-grade moron.
This is one of those all too frequent instances[A]"of a feeble-minded woman with a husband who is alcoholic and the offspring either feeble-minded or miscarriages."
"Isaac is exceedingly dangerous. He is a potential criminal or bad man, or under the best conditions would at least marry and probably become the father of defectives like himself."
This and the succeeding pictures in this volume contrast vividly with the frontispiece. Terrible are the results when we disregard the inevitable laws of nature, and so mate ourselves that our children will be parasites on society.
[A]"Feeble-mindedness; Its Causes and Consequences", Goddard, The Macmillan Company.
[A]"Feeble-mindedness; Its Causes and Consequences", Goddard, The Macmillan Company.
The After-Treatment of Pneumoniais important, and every detail has a distinct bearing on the ultimate recovery and establishment of good health. Careful feeding, a good tonic, and the proper attention to exercise, fresh air and bathing are requisite. A change of air after the fever is gone is more important than all other measures put together. A dry, warm climate where patients can be kept in the open air is preferable. The danger of allowing a slow, long drawn-out convalescence after pneumonia is the development of tuberculosis.
Adenoids are very common, almost popular, in childhood. The condition is one that causes more real trouble and discomfort than any other childhood affliction. Adenoids are associated with, and are responsible for, many of the ailments of childhood. They may be associated with enlarged tonsils or they may be independent of them. They may be present at birth or develop any time thereafter, though they are more frequent between the ages of two and six years. Children who have adenoids invariably suffer from chronic "head-colds" with a discharge from the nose. These chronic colds are caused by the adenoids. Nearly every disease, and every diseased, or abnormal, condition of the nose, throat, larynx, and lungs can be directly caused by the presence of adenoids. They are also responsible for numerous other conditions of very grave importance in the growing child. The accompanying "head-colds" may develop into a bronchitis which may keep the child indoors for a long period. Adenoids always interfere with respiration, thereby depriving the child of a normal quantity of oxygen, thus rendering the blood less pure, and, as a consequence, seriously interfering with the nourishment and general health. The impaired nourishment and poor health thus produced, as a direct result of adenoids, renders the child more liable to disease; he may thus acquire ailments that may affect his whole subsequent life. The mental side of a child's development is also affected by the presence of adenoids, so much so that actual statistics prove that these children cannot keep up with their classes in the public school.
We must therefore regard the presence of adenoids as a serious menace to the health and comfort of the patient. It has already been pointed out in discussing other diseases that before a cure of these diseases could be permanently accomplished it would be absolutely necessary to remove the adenoids, which were, no doubt, the actual cause, or an important contributing cause, of the disease. Such conditions as catarrhal laryngitis, croup, chronic recurring winter coughs, acute catarrhal rhinitis, "snuffles", "cold in the head", chronic catarrh, bronchial asthma, incontinence of urine, "bed-wetting", "nose-bleeding", headaches in growing children, anemia, deafness, night terrors, defective speech, diphtheria, consumption, are frequently caused by the presence of adenoids.
These patients contract certain diseases easier than other children, and when they do, they have them more severely; such diseases are diphtheria, tuberculosis, scarlet fever, measles, and whooping cough.
Adenoid children are, as a rule, in better health during the warm, equable, summer weather than during the changeable, uncertain weather we have in the winter months. If the case is neglected, and if the adenoids have existed for a long time, the growth of the child is impaired. He remains small and stunted, and the expression of the face is dull and stupid. The temperament and disposition are affected also; such children are languid, listless and depressed.
How to Tell When a Child Has Adenoids.—Children with well-developed adenoids are "mouth-breathers." Instead of breathing through the nose they breathe with the mouth open, especially when sound asleep. If a child has a discharge from its nose and a chronic cough, both of which resist treatment, and if in addition it is a mouth-breather, it is safe to investigate the naso-pharynx for adenoids. If a child with these symptoms is not in good health, is listless and depressed, looks stupid, snores at night, has difficulty in breathing and cannot blow its nose satisfactorily, is troubled occasionally with "nose bleeds" and headaches, we may be satisfied that the child has adenoids, as no other condition could produce such a picture.
Adenoids, like enlarged tonsils, are dangerous, apart from the physical distress and disease which they cause, owing to the fact that they harbor deadly bacteria, and from these bacteria, which find a lodgment in the adenoids and tonsils, a fatal attack of diphtheria or consumption may have its beginning.
Treatment of Adenoids.—Absolute removal is the only justifiable treatment. This is rendered imperative for so many reasons that it is unnecessary to go into details in justification of the procedure.
The physical well-being, the mental development, the life of the child depend upon it. Any parent who would wittingly interpose an objection to the removal of his or her child's adenoids, after they have been demonstrated to exist, would be guilty of a grave crime.
The operation itself is not at all dangerous. It is over in a few moments and the child is well in an hour or two, so far as any pain or suffering is concerned.
Physicians are frequently asked if adenoids "grow" again after removal. The answer is, "Yes," they sometimes do. In a very small percentage of the cases they do return. The older the child is when they are removed the less chance there is of a recurrence. A child operated on before it is two years of age is more liable to a recurrence than a child operated on at six years of age. This must not, however, be construed as an excuse for putting an operation off, because if a child needs an operation at two years and it is postponed till later, its health will be permanently injured before it is four years of age.
SUMMARY:—
1. Adenoids cause more trouble and more actual disease than any other condition during childhood.2. It is a crime for a parent to refuse operation if the presence of adenoids has been proved.3. Removal is the only treatment and it should be done in every case as soon as possible.4. The operation is a trivial one and is free from danger.
1. Adenoids cause more trouble and more actual disease than any other condition during childhood.
2. It is a crime for a parent to refuse operation if the presence of adenoids has been proved.
3. Removal is the only treatment and it should be done in every case as soon as possible.
4. The operation is a trivial one and is free from danger.
A hemorrhage from the nose may occur at any time from birth on. It depends upon the rupture of one or more blood vessels. The great majority of "nose-bleeds" are caused by adenoids, or by a small ulcer in the nose, or by an injury, such as a blow or fall. A nasal hemorrhage, however, may be caused by other, more serious conditions, and for that reason may justify a careful inquiry into the cause, especially if bleeding should occur a number of times, or be of a serious character the first time.
Of the more common causes as given above, the adenoids should be removed, and the chronic catarrh which is invariably the cause of the ulcer should be cured.
Treatment of an Acute Attack.—Have the patient sit erect; loosen all tight clothing around neck; fold the hands over the head; apply cold to the back of the neck and the nose. Pieces of ice can be put into the nostril and the ice bag to the nape of the neck, or a piece of ice can be put into a folded napkin and held on the back of the neck. Taking a long breath and holding it as long as possible and repeating it while the ice is being applied is an aid. Placing the feet in hot mustard water is of decided use. Another excellent expedient is to wrap absorbent cotton round a smooth probe (piece of whalebone, for example), dip the cotton in an alum-water mixture (half teaspoonful powdered alum in a half cupful of water), and then push it into the bleeding nostril as far as you can with gentle force. A valuable remedy is Peroxide of Hydrogen used full strength and freely dropped into the nostril. If these measures fail, send for a physician at once.
SUMMARY:—
1st. Nose bleeds may be caused by some serious condition.2nd. If they occur a number of times have the child examined.3rd. If the treatment outlined above does not stop the bleeding in a few moments send immediately for a physician.
1st. Nose bleeds may be caused by some serious condition.
2nd. If they occur a number of times have the child examined.
3rd. If the treatment outlined above does not stop the bleeding in a few moments send immediately for a physician.
Quinsy is not common in childhood. It usually follows tonsilitis when it is seen. The child complains of pain in the neck, extreme pain and difficulty upon swallowing, and inability to open the mouth as much as usual. There is a tendency to hold the head to one side. The treatment is to open the abscess at the earliest moment after pus is present.
Hiccough is, in most cases, in infancy and childhood caused by some irritation of the stomach, may be over-filled with food or gas. In these cases it is an unimportant incident and may be quickly relieved by giving the child an enema of soap-water and a laxative of rhubarb and soda.
Infrequently hiccough may be the result of cold feet, or a surface chill. Simple methods of relief are, to hold the breath, to expire, or blow the breath out as long as possible before taking the next breath; to sip water from a cup held by another person while the tips of the two fore-fingers are in the ears.
Hiccough is quite frequent in hysteria in girls, but it is of no consequence. When hiccoughs set in during the course of any serious disease it is a very unfavorable sign.
Stomatitis is an inflammation of the mucous membrane (inner lining) of the mouth. The gums and the inner surface of the lips and cheeks may be red and angry-looking. There may be small grayish spots on any part of the mouth. If the case is very bad or if it has lasted some time and has been neglected, these spots grow larger and join together forming irregular grayish plaques. A large percentage of the cases never go further than this because the proper care and attention is given them. It is possible, however, for any case to progress further and become ulcerative. This will beobserved first as a faint yellow line at the margin of the teeth and gum. Ulceration never takes place unless the child has teeth. The quantity of saliva is very greatly increased, so much so that it flows out of the mouth soiling the clothes. The saliva is intensely acid and it consequently irritates the skin, causing more or less eczema. The mouth is painful and hot. There is slight fever, but seldom any marked prostration. If, however, the ulceration should be severe, the fever may be quite high.
There is one feature of these cases that sometimes proves vexatious and annoying. Because of the soreness of the mouth, the child cannot draw strongly enough on the nipple to get a normal feeding, and as a result the nutrition of the child is poor. These children are hungry and when offered the nipple grasp it greedily, draw a few mouthfuls then stop because of the pain and begin to cry.
If the ulceration is extensive, there is usually an odor and the gums bleed easily. Sometimes the teeth fall out or have to be drawn out.
Strong, well-fed children are as likely to develop stomatitis as are those who are weakly and ill fed.
The disease is caused by infection and is contagious. Just what the infection is we do not know; we do, however, know that children whose mouths are carefully cleaned after each feeding do not have sore mouths of this character. When cleaning the mouth care must be observed not to injure the tender mucous membrane.
Treatment.—As soon as the condition is observed mouth-washing should be systematically and thoroughly carried out. After each feeding the mouth should be washed with a saturated solution of boric acid in boiled water. (See page626.)
It is not necessary to use any further treatment, as a rule. Patients recover in four to eight days. Strict attention to cleanliness, however, is imperative. The feeding bottle and nipple, or the mother's nipple, if breast fed, must be kept scrupulously clean.
The feeding of these children is sometimes a problem for a day or two, because, as stated above, of the soreness of the mouth. This is best overcome by feeding the baby with a spoon. If breast fed, it is necessary to pump themilk and then feed with the spoon. Children will take the milk better if it is fed cold. Cold boiled water is largely taken and is good for them at this time.
Treatment for Ulcers in Mouth.—The ulcers should be touched with a camel's-hair brush which has been dipped into finely powdered burnt alum. If a stronger caustic is necessary, the solid stick of nitrate of silver may be used.
A mouth wash may also be used in the ulcerative cases, composed of the peroxide of hydrogen diluted with two parts of water. If this is used wash the mouth out afterward with plain, cool, boiled water. The peroxide mouth wash can be used four or five times daily.
In addition to the mouth washing in the ulcerative cases it is advisable to use internally chlorate of potash. The druggist should be requested to make a two-ounce saturated solution, and of this you can give one-half teaspoonful, largely diluted with cool water, every hour during the day for the first twenty-four hours, then every two hours until marked improvement is shown, when it can be further reduced by lengthening the interval between doses.
Sprue is a form of sore mouth. It is seen only during the first six months of life, as a rule. It affects the mucous membrane of the mouth; it appears in the form of small white spots that look like drops of curdled milk. They are on the inner surface of the cheek and may be all over the mouth, and on the tongue. The spots are firmly attached, and if forcibly removed the mucous membrane will bleed.
The disease is caused by infection through lack of cleanliness and it invariably affects poorly nourished children, especially those who are bottle-fed.
There are no symptoms other than those of the mouth; the child frequently refuses to nurse because of evident pain and distress while nursing. The condition is not contagious. It may be cured in from six to eight days without difficulty.
Treatment.—Mouth irrigations of boracic acid are allthat are necessary. They are given in the following way: Place the child on its side, roll around the index finger a piece of absorbent cotton, dip this in a saturated solution of boracic acid, and put into the mouth of the child. Let the cotton take up as much of the solution as it will hold, so that when it is lightly pressed on the tongue and cheeks it will flow out of the mouth, thus "irrigating the mouth." Repeat this a number of times, pressing the cotton to a different part each time. This should be gone through from four to six times daily.
If the child is a bottle-fed baby, care should be taken in cleaning the nipples and bottles as directed on page 264. If the patient is breast-fed, care must be taken to note that the mother's nipples are clean. They should be washed with the same solution of boracic acid and not handled. If the child cannot nurse it is necessary to feed it with a spoon.
In obstinate cases the parts may be touched with a one per cent. solution of formalin. Mothers should particularly note not to use honey and borax, as is often recommended by women who know no better, in any disease of the mouth in children.
Inflammation of the Stomach—Acute Gastritis— Persistent Vomiting—Acute Gastric Indigestion—Iced Champagne in Persistent Vomiting—Acute Intestinal Diseases of Children—Conditions Under Which They Exist and Suggestions as to Remedial Measures—Acute Intestinal Indigestion—Symptoms of Acute Intestinal Indigestion—Treatment of Acute Intestinal Indigestion—Children with Whom Milk Does Not Agree—Chronic or Persistent Intestinal Indigestion—Acute Ileo-colitis—Dysentery— Enteritis—Entero-colitis—Inflammatory Diarrhea—Chronic Ileo-colitis—Chronic Colitis—Summer Diarrhea—Cholera Infantum—Gastro-enteritis—Acute Gastro-enteric Infection—Gastro-enteric Intoxication—Colic Appendicitis—Jaundice in Infants—Jaundice in Older Children—Catarrhal Jaundice—Gastro-duodenitis—Intestinal Worms—Worms, Thread, Pin and Tape—Rupture
An infant seldom has real inflammation of the stomach. Gastric, or stomach, indigestion is the better name, because it actually signifies the true condition. It is indigestion that causes a child to vomit, though it is possible to have a true inflammation caused by the taking of irritant or corrosive drugs.
Gastric indigestion causes sudden, repeated vomiting, with prostration and occasional fever. It is caused by unsuitable food, the wrong quantity of food, irregular feeding, and food the quality of which is not good.
Treatment.—The stomach should be immediately washed out. Until the physician arrives the mother can encourage the child to drink a large quantity of cool boiled water. This will be vomited and it will wash out the stomach at the same time. No further treatmentmay be necessary, as the vomiting may stop. All food should be withheld for at least twenty-four hours. A high rectal irrigation should now be given. It is essential to know that the bowel is absolutely clean in all vomiting cases. The normal salt solution is the best agent to use for a high enema in infants. (See page586.)
After twelve or twenty-four hours' abstinence from food, the child can be given teaspoonful doses every twenty minutes of cooled boiled water, or barley or albumen water, weak tea, or chicken broth. Cold liquids are better retained and more readily taken than those that are heated. If the liquid feedings are vomited, another twelve hours must elapse before trying stomach feedings. In these cases we must try to satisfy the thirst by giving cold colon flushings. If the case becomes protracted and we find it impossible to nourish the child by the mouth, we must wash the stomach out once every day with a five per cent. solution of bicarbonate of soda, and feed the child by the rectum. Sometimes we can feed through the stomach tube. Liquids will frequently be retained when put into the stomach through a tube when they will be vomited if swallowed.
The best food by the rectum is plain peptonized milk.
Drugs are absolutely useless. If the vomiting persists, despite the above efforts to stop it, there is nothing to be gained by experimenting. You will not only render the condition worse but you will weaken the child. Morphine given hypodermatically is the only remedy. Given in appropriate doses, according to age, it is absolutely harmless. It will not only stop the vomiting, but it will give the child a much-needed rest, by allowing it to go to sleep. When it wakes up it will be stronger and its stomach will most likely retain small doses of nourishment.
Great care must be exercised, in getting the child back on a normal diet, not to try to go too fast.
In cases of persistent vomiting in children I have found it advisable to use teaspoonful doses of ice-cold champagne. These children will sometimes keep this down when all other liquids will be vomited. It is absolutely necessary to keep the child lying down. If he isrestless or sits up, the vomiting may begin all over again. The champagne not only is excellent nourishment for the child, but it quiets the stomach, allays irritability, and frequently favors sleep, during which time a cure very often results. The champagne must be drawn through a champagne siphon (procured in the drug store), and the bottle must be kept on ice with the mouth downward; otherwise it will get stale very quickly and be of no use. If kept as advised it will remain good to the end.
SUMMARY:—
1st. Persistent vomiting in a child means acute gastritis. Stop all food for twenty-four hours.2nd. Encourage the child to drink large quantities of slightly warm water; this will wash the stomach out and frequently stops the vomiting.3rd. When the child is quiet wash out the bowels.4th. If vomiting persists, use iced champagne as directed.
1st. Persistent vomiting in a child means acute gastritis. Stop all food for twenty-four hours.
2nd. Encourage the child to drink large quantities of slightly warm water; this will wash the stomach out and frequently stops the vomiting.
3rd. When the child is quiet wash out the bowels.
4th. If vomiting persists, use iced champagne as directed.
The large infant mortality that results from intestinal diseases during the summer months is deserving of the most careful consideration, both of the physician and the parent.
Apart from the excessive heat of the summer, there is no doubt that an unfavorable environment, which means bad hygienic surroundings, bad sanitary conditions, bad food and home influences, contributes largely to the enormous number of these serious cases. Education, while it may be expected to influence favorably the sanitary and other conditions in the home, cannot change the home location. The child must continue to live in the same environment. It is in this class of cases that these summer diseases are so very fatal. Children in better circumstances can take advantage of conditions which are denied to the tenement child. The diseases must therefore be faced and treated under these existing conditions.
In addition to the climate and the environment, there are certain factors that occur in all classes which result in intestinal derangement. If the stomach or bowels are not performing their function properly, or if the food or method of feeding is wrong, these, plus very hot, humid weather, invariably result in serious intestinal disease. The mother must be taught to interpret properly the meaning of a green, loose stool in the summertime; she must appreciate that it is the danger signal and must be regarded seriously.
The very best preventive against summer diseases of the intestine is to guard particularly against any trouble with the child's stomach at all seasons of the year. A healthy stomach and bowel will resist disease, even in very hot weather.
The most important food product which has a direct relationship to this class of diseases is milk. In a large city like New York it will remain impossible to solve the milk problem, despite the splendid efforts of the Health Department and the members of the medical profession, until the city itself shall establish milk depots and ice stations where safe milk, and ice to keep it safe, may be obtained at a nominal cost, or free, if the parents cannot afford to buy it. We, therefore, must recognize that the vast majority of children to-day are taking milk that is not suited to them, that is really not fit as a food for children. The mothers do not know this and no steps are taken to render the milk more safe for them to feed to their children. These mothers are willing to do what is essential in the interest of their children, but they do not know what should be done. These people cannot afford a physician or a nurse to teach them, nor do they even know that their methods are wrong or that they need any instruction. We must carry the information and the explanation to them. We must show them the need for a change of methods. This is the work for those charitably disposed women who desire some worthy purpose in life, who really wish to do some real good. All the equipment they need is good common sense. They will tell these mothers why it is necessary to pasteurize the milk before feeding it to the baby. Theywill show how to keep the nursing bottles clean, and the nipples sweet and fresh. They will instruct them how to dress the baby in the hot weather and impress them with the need of giving it all the cool, fresh air possible. In short, they will gain the confidence and the good will of these mothers in a tactful and diplomatic way, and they will tell them all they know in language which they will understand regarding the care of the baby. In every city in the country this work is needed and is waiting for the missionaries who will volunteer. To teach mothers the need for boiled water as a necessary drink for baby and older children is alone a worthy avocation. To impress upon one of these willing but ignorant mothers the absolute necessity for washing her hands before she prepares her baby's food, that she must keep a covered vessel in which the soiled napkins are placed until washed, that she should frequently sponge her baby in the hot weather, and explain thoroughly why these are important details, is a work of true religious charity. They should be specially taught to immediately discontinue milk at the first sign of intestinal trouble, to give a suitable dose of castor oil and to put the child on barley water as a food until the danger is passed. They should be taught to know the significance of a green, watery stool, they should know that is the one danger signal in the summer time that no mother can ignore without wilfully risking the life of her baby. They should be taught to prepare special articles of diet when they are needed. If every mother were educated to the extent as indicated in the above outline the appalling infant mortality would fall into insignificance. It is not a difficult task nor would it take a long time to carry it out; it is the work for willing women who have time and who perhaps spend that time in less desirable but more dramatic ways.
It is the knowledge that aids in catching disease in its inception that counts. The worst infections begin as a mild condition and prompt treatment robs them of their sting. When treatment is delayed and the child is fed for twenty-four hours too long on milk, the condition which in the beginning could have been stopped promptly has developed and it becomes a fight for life.
It will be seen from the above that all we need is education. Education of the mother primarily, but education of the missionary, the nurse, the physician, the municipality, and the State, each co-operating, each willing to work in the interest of a great cause, for the benefit of the human race and for the brotherhood of man.
Causes.—Overfeeding, unsuitable and improper food, irregular and indiscriminate feeding, sudden change from one food to another, as at weaning time, a change from a poor quality to a rich food, or vice versa. Conditions affecting the health of the child, especially the nervous system, such as hot weather, extreme cold, fatigue, or at the beginning of any of the acute diseases. Children sometimes are predisposed to attacks of intestinal indigestion; these children are delicate in health and have weak digestive ability. The slightest irregularity or error in diet will cause an attack in these children.
Symptoms.—The attack may come on suddenly or it may develop slowly. The important constitutional symptoms are fever, prostration, and a general nervous irritability. The child is seized with pain in the abdomen. The pain is referred to the region around the navel. It is sharp, colicky, and severe, causing the child to cry out and draw up its legs in an effort to lessen its severity. The child is exceedingly restless and acts as if it were on the verge of a dangerous illness. Gas in the bowel is not present as a rule as frequently as it is in infants under the same circumstances. In a few hours diarrhea sets in, the stools may number from four to twelve or more in twenty-four hours. The stools are acid, sour, and the odor may be very foul. They are thinner than usual and frothy from the presence of gas.
In very young infants suffering from a sudden attack of intestinal indigestion, the stomach, as well as the bowels, is invariably upset. If the indigestion is the result of a slower process, the stomach does not participate in the process. The color of the stools in infancy is yellow, then yellowish-green, and later grass-green.Undigested food is always present and in infants the curdled casein of the milk appears as white specks or lumps in the movements.
The fever is high in the sudden cases and lower in the cases of gradual onset. The prostration is more severe when the onset is sudden and in infants may be very marked.
The termination of the disease depends upon the cause, the treatment, and the previous health of the child. In healthy children promptly and properly treated it may be all over in a week. In delicate, poorly nourished children, and especially in the summer time, it may be the beginning of trouble that may eventuate in death.
Treatment.—There is no condition in the whole realm of diseases of childhood where the knowledge of the mother may have such important results as this condition. The most effective time to treat these cases of intestinal indigestion is before the physician is called. There are few diseases in which time is so valuable, so far as final results are concerned, as it is here. Every mother should know the significance of a loose, green stool. She should be taught that it means danger and consequently demands prompt treatment. The first indication is to empty, thoroughly, the bowel. The best means for this purpose, if it is immediately procurable, is calomel. If calomel is not procurable at once give castor oil, two teaspoonfuls to an infant, one tablespoonful to an older child. Calomel should be given in one-eighth-grain doses, repeated every three-quarters of an hour for eight or twelve doses, until the bowel is thoroughly cleaned out. Don't be afraid of a few extra movements at the beginning. Better clean out thoroughly at the start than to be compelled to do it all over again after the child is weak and suffering from the poison of the disease. The next important thing to do is to stop milk at once. The thirst is usually intense and if vomiting is not present it can be moderately relieved by giving small quantities frequently of cool boiled water or mineral water or strained albumen or barley water. We quite often have to stop all food and liquids by the mouth for twenty-four hours.
If the prostration is very great and the child looks as though it might collapse, it can be given brandy in cracked ice from time to time.
After the bowels have been thoroughly cleaned out, never before, some medicinal agent may be given to stop the unnecessary diarrhea. In a very large number of promptly and properly treated cases this is not needed. If it is thought best to use it the physician will select the agent according to the conditions present and prescribe it.
Breast-fed infants rarely have intestinal diseases of a severe type. If they should develop diarrhea they must be taken off the mother's milk for twenty-four hours. They should be given a dose of castor oil or calomel and fed on barley water in the interval. The feedings should be reduced in quantity and the interval doubled. The two-hour interval will become a four-hour feeding: the three or four ounces at each feeding can be reduced to two ounces. The intention is to simply give as little as possible while the diarrhea is under way.
The mother's breasts must be pumped at the regular feeding time in order to preserve the flow, release the pressure, and keep the milk fresh.
It is sometimes a problem to renew feedings of milk without exciting a relapse of the diarrhea. It should not be tried until the stools are normal in color and consistency. This may not be for three or four days. In resuming the milk it should be given in smaller amounts and diluted with lime water or barley water for the first day. Gruels may be given to which skimmed milk may be added: later add the ordinary milk. If it is well digested and does not cause any return of the diarrhea, the quantity of milk can be slowly increased until the former feedings are resumed. It is often of very great advantage to boil the milk for some time. Peptonized milk is safe and can be used in bottle-fed infants after diarrhea. In older children, meat, broths, eggs, boiled milk, and dry toast bread may be used sparingly for some time. Cereals, vegetables, fruits, should be withheld for a considerable time and watched carefully when resumed. Kumyss, buttermilk, matzoon, bacillac, andother fermented milks are better borne than plain milk. All of these children need rest, fresh air, change of air, frequent bathing, and tonics, as an attack of this kind leaves them depressed, weak, languid, and anemic.
SUMMARY:—
1st. When a child complains of sharp, colicky, severe pains in the abdomen, around navel, which are shortly followed by foul, sour, frothy diarrhea,—greenish in color, it has acute intestinal indigestion.2nd. Every mother should know that a green stool means danger. She should know to give at once a cathartic,—castor oil is good, but give a good large dose—then stop all food for twenty-four hours. If she learns this lesson she will have time to wait for the doctor; meantime, she may have saved her child's life.
1st. When a child complains of sharp, colicky, severe pains in the abdomen, around navel, which are shortly followed by foul, sour, frothy diarrhea,—greenish in color, it has acute intestinal indigestion.
2nd. Every mother should know that a green stool means danger. She should know to give at once a cathartic,—castor oil is good, but give a good large dose—then stop all food for twenty-four hours. If she learns this lesson she will have time to wait for the doctor; meantime, she may have saved her child's life.
Contrary to the general belief, there are quite a large number of children in whom milk seems to act as a poison. These children are not necessarily constipated. They suffer, however, from a slow, continuous intestinal toxemia or poison. The symptoms of this condition are headache, disorders of speech, habitual sleep-talking, sleep-walking, and general nervous irritability without cause: they are listless, languid, and constantly tired. They may be bright in the morning and sleepy in the afternoon. They are irritable and cross and touchy.
Treatment.—Milk must be wholly discontinued. Eggs must be restricted to one every second day, and meat but once daily. The use of green vegetables is particularly suitable and should be given daily. Cereals and fruit also are good. Malted milk, kumyss, or matzoon may be given in place of milk. If constipation is present, rhubarb and soda mixture is an excellent laxative in these cases. A tonic should be prescribed for all these children.
Cause.—Any cause which has been mentioned as acause of ordinary diarrhea may result in this disease. It may occur at any time of the year and at any age. It may follow the infectious diseases. It may follow any other disease of the intestines.
Symptoms.—It may begin like an ordinary attack of acute intestinal indigestion. There is usually vomiting, fever, pain, and frequent yellow or green stools. The passages may be blood-stained and there may be little or much mucus. The stools at the beginning have no odor as a rule. The bowels move very frequently, often with little or nothing to pass. There may be pain with each movement. The blood may disappear in a few days, but the mucus remains, often in large quantity in each stool.
At the beginning the fever is high, but it soon falls and remains low during the attack. The child loses weight, is irritable, has no appetite, and looks and acts sick. When the attack is over these children do not gain their strength as readily as we would like; recovery is slow.
The acute symptoms usually last about one week, after this time the child begins to recover, but the process is a tedious one and one in which much care has to be exercised. It is an encouraging sign to note the disappearance of the blood in the stools and the return of the movements to the normal brown color. When these favorable signs are wanting the bowel is probably ulcerated and it will take a much longer time to return to normal and to be free from blood and mucus.
The above is the ordinary form of this disease and it ends in recovery as a rule. There is a more severe form, however, which differs from the above in the following way:
The fever is high and remains high; the stools are more frequent and there is more blood and more mucus in them; the child is much more irritable and is more profoundly sick. Death may occur at any time from the second day. If the little patient survives, the return to health is a very slow process; it often takes months and frequently years before a reasonable degree of strength is regained. Relapses are common, and theyare very difficult to treat and care for. In some cases the child never wholly regains its former strength.
There are children who have been the victims of other intestinal diseases or conditions who develop colitis. The colitis in these cases may come on suddenly with vomiting and high fever, or it begins slowly, with no vomiting and with little fever. Their appetite is poor, their digestion is feeble, their prostration is pronounced. They lose flesh rapidly and may be emaciated to a remarkable degree. Very few of these cases recover completely. Serious and sometimes fatal relapses may take place. The feeding of these children is a difficult task and the greatest care must be constantly taken; a very little mistake may cost the life of the child.
Treatment.—All diseases of the intestine in childhood should be promptly and efficiently treated. If any form of diarrhea is neglected, it may result in the development of ileo-colitis with all its risks and uncertainty. When a child is seized with sudden bowel trouble, no matter what variety it is, it should be treated with the greatest care because "sudden" bowel trouble usually means plenty of trouble if it is neglected.
Fresh air is essential in all these cases. A change of air is of decided value as soon as the immediate symptoms have abated. The diet is the same as for children who have gastro-enteric intoxication. Later, much difficulty will be met because these patients have absolutely no appetite,—peptonized skimmed milk is always good, beef broths are often well borne, liquid beef peptonoids may be tried. The food should be given every three hours. Boiled water and stimulants may be given between the feedings. Later in older children, raw beef, eggs, boiled milk, kumyss, or matzoon and gruels may be given. Great care has to be taken for months after an attack; relapses may be caused by changes of temperature, by fatigue, and, of course, by improper feeding. These children should avoid potatoes, tomatoes, fruits, corn, oatmeal, and a great many other things which an intelligent mother would not give any sick child, as candy, cakes, pastries, etc.
Cases which begin with free vomiting, thin stools;and fever should be treated at once. The bowels must be thoroughly cleaned out, the colon should be thoroughly irrigated, and all food should be stopped. When there are bloody stools with mucus and pain we must depend upon castor oil, irrigations of the colon, and opium and bismuth by the mouth. A good big dose of oil at the beginning is always necessary. If, however, the stomach is irritable and will not tolerate castor oil, we may substitute calomel in one-fourth-grain doses every hour for six doses, to be followed by citrate of magnesium. Irrigation of the colon in these cases is one of the essential means of successful treatment; it should be done twice a day during the first few days of the disease.
Stimulants are needed in all the cases. They help the heart, act as a food, and tend to quiet the general nervousness by favoring sleep. Good brandy given in boiled cool water is the best stimulant.
After the child is over the worst of the acute symptoms all medicine should be withdrawn and the proper kind of food given. Tonics will aid in restoring the strength. Cod Liver Oil during the following winter is a very good plan to aid in building up the vitality of the weakened bowel, but it must not be given too soon.
Chronic Ileo-colitis fellows the acute variety. Cases which are unusually severe or which have been badly managed are likely to become chronic. A child suffering from this disease presents the following picture: The patient is emaciated, the abdomen is usually enlarged with gas, the feet are cold, the circulation of the blood is poor, the fever is low or absent altogether except when the child is having a relapse, when it jumps up suddenly. The bowels are loose and contain mucus, frequently in large quantities. The mucus may stop for a few days; then it appears again with a rise of temperature accompanied with loose stools with foul odor. These children are exceedingly nervous and irritable and are very poor sleepers.
Parents should be told it will be impossible to effect a rapid cure of these cases. It often takes months to get them started on the safe road. The slightest mistake or change in the weather will upset the progress of the cure and it will be necessary to begin all over again. The entire hope of cure rests with the mother. She must be faithful, patient, and must carry out the physician's instructions implicitly. The management consists in diet, change of climate, and such other treatment as the physician finds necessary in each individual case.
Treatment.—In children under one year of age the only hope is breast milk, which must be given in small quantities. They do not do well on any starch food for a considerable period.
Where breast milk is not available the whites of two or three eggs may be given daily. They may be beaten up and given in skimmed milk, or in plain water with a little salt added. Zwieback or bread crumbs may be given in small quantities. They should be fed at four-hour intervals.
Older children may take skimmed milk, raw scraped beef, junket, and coddled white of egg or raw egg, bread crumbs, toasted, or zwieback.
A rectal enema must be given every twenty-four hours if the bowels have not moved. If constipation is the habit a laxative should be given; the aromatic fluid extract of cascara sagrada or magnesia are suitable. At least one free movement every day is essential to success.
Colon irrigations are only to be used when there is a rise of temperature, irrespective of whether the bowels have moved or not.
When convalescence is established these children should be given a maximum of fresh air and should be treated as recommended in cases of malnutrition.
As the name implies, this is the form of diarrhea that is so common, especially in cities, in summer. It is always preceded by some milder condition which paves the way for the more serious diarrhea. Acuteindigestion is, as a general rule, the forerunner of cholera infantum. The influence of hot weather must always be kept in mind as the underlying factor which no doubt conduces to gastro-intestinal disease of infancy and childhood. The depression incident to a spell of hot and possibly humid weather tends to interfere with the digestive process of babies and children. When this function is carried on imperfectly, the strength and vitality of the child fails, and if immediate steps are not taken to check the process, diarrhea makes its appearance. If these children are improperly fed, or if their surroundings are not sanitary; if they are not getting fresh air enough, or if they suffer because of lack of attention, and have at the same time a little indigestion, it is only a step further to develop a full-fledged cholera infantum.
The outcome of any case of summer diarrhea is questionable. It is not safe to make any promise. An apparently mild attack may prove quickly fatal. Much depends upon the previous history of the child. If it has been a strong, healthy child it has a very good chance if treated energetically and correctly. If it has previously suffered from bad nutrition, is not robust, has had trouble with its stomach, etc., the chances are against it.
The one lesson to be learned by all mothers is, as stated above, to act quickly; to be on the watch all through the summer months for any trouble with the baby's stomach or bowels. It is much easier to treat and cure a little trouble than to battle against an established gastro-enteric intoxication. Overfeeding and indiscriminate feeding must be religiously avoided,—they are the two most prolific causes of stomach and intestinal troubles in childhood.
Symptoms.—The onset is sudden and pronounced. The child begins to vomit and continues vomiting and retching persistently. The bowels are loose, and large, watery, greenish stools are frequent. The prostration is very marked, the child looks seriously sick, respiration is quick and shallow, the eyes sunken, the skin becomes ashen gray in color, and the pulse is soft and veryrapid. The fever may be very high or it may remain low. The low febrile cases are the worst.
If taken in hand quickly and if the treatment is energetic and if the child reacts, the case may go rapidly on to recovery and the child be wholly well in a few days; or it may not react, but be overwhelmed by the poison and sink and die in twenty-four hours.
Treatment.—In the treatment of cholera infantum it must not be forgotten that the dangerous element is the poisoning of the system that is constantly going on. It is difficult for the non-medical mind to estimate the importance of this element. It is, of course, caused by the bacteria present in the gastro-intestinal canal. There are numberless millions of bacteria in the normal healthy bowel. A very large percentage of those germs are good for us, are there for a beneficent purpose, and can and do protect us from other germs which occasionally find their way into the bowel and whose purpose is not a peaceful one. When the bowel condition changes, as during an attack of summer diarrhea, it is invaded by multitudes of evil-intentioned germs. These germs find conditions in the diseased bowel exceedingly favorable to them, so they begin work in an active, energetic way. The result of their activity is highly poisonous, and, as the good germs are virtually out of business and are consequently not working in our interest, we are absolutely in the hands of the enemy. There is soon manufactured, by these invading germs, enough poison to poison the entire system of the child. It is this feature that we must combat in summer diarrhea.
It is absolutely essential to keep these cases as much in the open fresh air as possible. No matter how sick they may be, this rule must be observed. Light clothing is advisable.
If it is a city child that is affected and it does not show decided improvement in three or four days, it should, if possible, be sent to the country. There is always distinct danger of a relapse in every case, so the little victim should be given a change of air as soon as convalescence permits. The seashore is preferable to the mountains in all intestinal cases.
In the care of these patients cleanliness is an important factor and counts much in the ultimate cure. The child, as well as the clothing, should be kept scrupulously clean. Napkins as soon as soiled should be removed and put into a disinfecting solution. The buttocks should be well powdered after each movement to prevent sores developing.
Feeding must be stopped at once. No food of any kind should be given for at least twenty-four hours, or until the tendency to vomit subsides. The thirst must be allayed, however, so we give frequently small quantities of thin barley water or albumen water or cold boiled water. If these are vomited we must stop giving them altogether for twenty-four hours. If the fever is high and the skin dry, the child should be given a cool pack, 85° to 90° F., which can be moistened every half hour with water at this temperature; this will often control the fever satisfactorily. Hot-water bottles should be placed at the feet if they are cold.
If, on the other hand, the fever is very low (below normal), the child's circulation poor, the skin blue and cold, a hot-water bath at 108° F., for five minutes (rubbing the surface of the body while in the bath), will be of very great service. The bath may be repeated at half-hour intervals.
If the patient is a breast-fed infant it can be allowed to nurse after the twenty-four-hour rest. The length of time it is permitted to stay at the breast should be about one-quarter of the time it was allowed before the attack began. If it does not vomit, the nursing can be repeated every four hours. As the case progresses toward recovery the interval between feedings can be shortened. Care, however, must be taken not to shorten the interval too rapidly.
If the patient is artificially fed and is not over four months old, a substitute for the milk must be found. The best substitutes are rice or barley water, either plain or dextrinized, the malted foods, chicken or beef broths, liquid peptonoids or bovinine. Water (boiled and cooled) may be allowed at all times if not vomited.
Older children are treated in the same way. All foodis withheld while there is any vomiting. When vomiting stops begin with small quantities of beef broth, or chicken, or veal broth. Later kumyss or matzoon can be tried, and finally thin gruels made with milk.
If vomiting persists the stomach must be washed out; this can be done by giving the infant or child a large drink of cool boiled water. This will be immediately vomited and it will clean the stomach at the same time. The stomach-pump may be used to better advantage. One washing is usually sufficient. The vomiting will stop after the stomach has been washed out and the patient may then be given, frequently, small quantities of cold albumen water or barley water.
The bowel should be thoroughly cleaned out at the beginning of every summer diarrhea. Castor oil or calomel are the two best cathartics for this purpose. If the stomach is not upset use castor oil. If the stomach is upset use calomel; one-fourth of a grain every hour for eight doses will be sufficient. Give enough, however,—there is no danger at the beginning of the attack of too free movements of the bowel. Whatever cathartic is given, it should produce green, watery stools.
Irrigation of the bowel is an exceedingly effective way of cleaning out the poison-laden large intestine. It should be done in every instance unless the movements are watery and of such frequency as to render irrigation unnecessary. Once or twice daily will be sufficient in even the worst cases. The irrigation should be given at the temperature of 100° F, and should be the normal saline solution; a long rectal tube is used to give the irrigation.
SUMMARY:—
1st. Cholera infantum is one of the most dangerous, one of the most treacherous, and one of the quickest acting diseases of childhood.2nd. Don't temporize, don't delay, don't regard lightly any diarrhea during the summer time.3rd. Give a large dose of castor oil and withhold all nourishment until the doctor sees the littlepatient in every case of diarrhea during the warm weather.4th. Keep the child in a cool, quiet place and don't handle or annoy it.5th. Follow, your doctor's directions implicitly. The fight may be short, sharp, and decisive. Don't pave the way for regrets afterward. Do everything while you have the chance.
1st. Cholera infantum is one of the most dangerous, one of the most treacherous, and one of the quickest acting diseases of childhood.
2nd. Don't temporize, don't delay, don't regard lightly any diarrhea during the summer time.
3rd. Give a large dose of castor oil and withhold all nourishment until the doctor sees the littlepatient in every case of diarrhea during the warm weather.
4th. Keep the child in a cool, quiet place and don't handle or annoy it.
5th. Follow, your doctor's directions implicitly. The fight may be short, sharp, and decisive. Don't pave the way for regrets afterward. Do everything while you have the chance.
Colic is a common condition in infancy. Very few children escape more or less colic during the first few months of life. It does not seem to injure permanently some infants; they go on growing according to standard, eat and sleep, and seem contented and happy despite occasional severe attacks of colic. Other children suffer seriously; the degree of indigestion is considerable, and the nutrition of the child is interfered with.
Colic is much more frequent in bottle-fed infants than in those fed on breast milk. Cow's milk, no matter how skillfully it is prepared for their use, is at best an unsuitable diet and taxes the digestive ability of robust children. It is quite natural for an infant whose digestive organs are not strong to develop colic and intestinal indigestion if put on artificial food. Any condition that causes indigestion may likewise cause colic. Those children who are always overfeeding,—taking too much milk, too strong milk, or who are fed irregularly,—are the colicky babies.
Constipation is frequently associated with colic and may be the actual cause. A daily movement of the bowel does not necessarily mean that the bowels are emptying themselves satisfactorily. Despite the daily movement, there may be considerable fecal matter left in the bowel which undergoes decomposition. This results in the evolution of large quantities of gas and severe attacks of colic. Indigestion is very often caused by conditions which effect the stability of the child's nervous organism; such conditions are fright, anger, fatigue, exhaustion, excitement.
The origin of the colic in breast-fed children is veryoften caused by some nervous condition of the mother that affects her milk. Constipation in the mother may cause colic in the child.
Symptoms.—A baby having an attack of colic will cry loudly from time to time and whine during the interval; it will pull up its legs and bear down. Its abdomen is tense and hard and distended with gas. With the expulsion of the gas the pain ceases and the child falls asleep. If the attack is very severe the prostration and exhaustion is marked; the feet are cold and the body is bathed in perspiration.
If the colic is constant the child may be fretful and restless most of the time, being seemingly comfortable for only an hour or two in the twenty-four.
In older children who cry because of severe pain in the abdomen the possibility of appendicitis must not be forgotten.
Treatment.—Find out the cause of the colic if possible. If the cause is located in the mother, the remedy naturally must affect her. Regulation of her bowel, restriction of her diet, and proper exercise, may be sufficient to effect a cure of the colic in the infant.
The object of treatment is to help the child get rid of the gas. The best and quickest means to effect this is to apply massage or give a rectal injection. An injection of two ounces of cold water in which a half or one teaspoonful of glycerine has been put, will act quickly. Dry heat applied to the abdomen in the form of the hot-water bottle or woolen cloths will aid in the expulsion of the gas. The feet should be kept warm.
In cases of habitual colic in breast-fed babies the cause may be in the quality of the mother's milk. It should be examined and if found too strong should be diluted. This can be done by giving the child an ounce of plain boiled water or barley water before each feeding. If the child gets an ounce of liquid before each feeding he will not want as much of the breast milk; so we shall have the same total quantity, but a reduced quality, which may cure the colic at once.
It is necessary, in order to cure colic, that the bowels move every day in a satisfactory manner. If any aidis needed, milk of magnesia is the best laxative. It may be given in teaspoonful doses in water previous to a feeding. Aromatic cascara sagrada in from ten to thirty-drop doses is a very good laxative, if a stronger remedy is needed.
To relieve the acute attack, three drops of Hoffman's anodyne may be given in two teaspoonfuls of warm water and repeated in ten-minute intervals until relieved, to a baby under one year of age. From five to ten drops of gin, given in three teaspoonfuls of warm water, and repeated in fifteen minutes, is also satisfactory and harmless. A very good remedy which may be used with the above for quick relief, and to stop the child from crying, is the following: Fold a piece of flannel cloth (two thicknesses) the size of the baby's abdomen; wring out of very hot water and drop ten drops of turpentine over the surface,—at different spots,—of the flannel and lay on abdomen,—turpentine side next skin. Cover this with another piece of flannel,—two or three thicknesses, that has been dry-heated and allow to remain in place for about ten minutes.
Colic, as a rule, disappears completely about the third month.
Appendicitis is mentioned here merely to acquaint mothers with its prominent symptoms.
When a child has what seems to be an attack of indigestion, but complains of pain and tenderness in the abdomen, vomits, and develops a fever, and is constipated, appendicitis may be suspected.
The pain and tenderness are not referred to the region of the appendix but are more centrally located. If, however, the finger point is pressed over the appendix, distinct tenderness will be elicited in inflammation of that region. Constipation is the rule in appendicitis, but diarrhea occasionally accompanies it.
The abdominal muscles may be rigid, that is, the abdomen does not feel soft as is usual; there is a feeling if they are pressed, as if they were hard and unyielding.
Treatment.—Put the child in bed and send for the family physician at once. The condition is too seriousand too uncertain to delay, or for a parent to make any effort at treatment. Appendicitis is a much more serious condition in infancy and childhood than it is in an adult.
There are two types of jaundice in infants that deserve brief consideration.
1st. There is a form of jaundice caused by a defect in the development of the bile or gall tubes. These infants develop jaundice a day or two after birth and become intensely jaundiced within a very brief time. They lose flesh and strength to a marked degree and die in a few weeks. It is not possible to affect this condition favorably by any method of treatment. This type of jaundice is not very common.
2nd. There is a type of jaundice that appears between the second and fifth day of life that is very common. It lasts from one to two weeks and then disappears. It is never fatal and is not serious. It requires no treatment.
Symptoms.—This form of jaundice begins like an attack of ordinary indigestion. There are, as a rule, pain, fever, vomiting, and prostration. The pain is located in the upper part of the abdomen and may be quite severe. The vomiting may continue for a number of days. The bowels are usually constipated. After a few days the jaundice sets in and may be quite intense. After the jaundice is established the stools are gray or white in color and there is much gas in the bowel. The urine is very dark and may be yellow or yellowish-green in color. The child complains of headache, is dull and listless, and appears sick and weak. The condition lasts about two weeks, but the jaundice may last much longer. It is not a serious disease.
Treatment.—The diet should be cut down in quantity and should consist of rare meat, fruit, and a small quantity of milk. If vomiting continues the milk may diluted with lime water or vichy water. The childshould drink water or vichy water freely. No starchy foods, or fats, or sugars should be allowed. The bowels should be kept open with calomel, one-tenth of a grain every hour until ten are taken, to be followed by citrate of magnesia every morning. If the pain is severe it may be relieved by a mustard paste or a turpentine poultice. The child should be given acid hydrochloric diluted, eight drops in one-half glass of water, ten minutes before each meal—and kept on it for at least one month.
There are three types of intestinal worms; they are known as the round-worm, the thread-worm, and the tape worm.
Round-Worm.—The round-worm is usually found in children of the run-about age. It is never seen in infancy. It occupies the small or upper intestine, and is from four to ten inches long. If there are round-worms in the bowel, there are usually a number of them and there may be hundreds.
Symptoms.—Round-worms give no definite symptoms. The only possible way to tell if they are present is actually to see them in the stools of the child. They are of a light gray color.
It is reasonable to expect that a child suffering from worms will have symptoms of abdominal distress from time to time; indigestion with colic and much gas may be present; children lose their appetites and are nervous and restless; sleep is disturbed; they may grind their teeth and talk in their sleep, and they may pick their noses unnecessarily during the day. These symptoms may, however, accompany other conditions when no worms are present in the bowel. My observation has been that in children in whom worms were present the nervous symptoms were distinctly accentuated. They are unreliable children; they seem well to-day and peevish to-morrow; they complain of headaches, dizziness, and chilly feelings. They are hysterical, noisy, uncontrollable. A child with these symptoms should be suspected of having worms and if no cause can be found to explain his temperamental vagaries he shouldbe treated for worms. I have cured a number of children of excessive nervousness by giving them medicine for worms when no worms were present. Such results can only be explained on the assumption that these children were suffering from intestinal auto-toxemia or self-poisoning, and the thorough disinfection of the bowel apparently stopped the process by ridding the child's system of a mass of bacteria, which were undoubtedly causing the auto-toxemia and consequent nervousness.
Treatment.—The most efficient remedy for removing round-worms is Santonin. The quantity necessary for the various ages is as follows: