The Mother's Manual of Children's Diseases

The rash often makes its appearance within twenty-four hours after the commencement of the illness, at latest in the course of the second day. It usually shows itself first on the neck, breast, and face, whence it extends in twenty-four hours to the body and limbs, and is then not seldom specially vivid on the inside of the thighs. Its colour is a very bright red, due in part to a general flush of the skin, in part to the presence of innumerable red dots or spots, which do not communicate any sense of roughness to the hand, though now and then extremely minute red pimples are interspersed. For three days the rash usually continues to become of a deeper colour, and more generally diffused over the whole surface; it then slowly declines, but does not wholly disappear until the seventh or eighth day of the disease. As the rash subsides the skin is left rough, and by degrees scales off, often in large flakes from the hands and feet, but elsewhere in a sort of branny scales. Sometimes this process is over in five or six days, while in other cases the skin peels and is reproduced several times in succession, so that it is protracted for three or four weeks or even longer. The degree of this peeling also varies as well as its duration. It is usually most considerable where the rash has been most abundant, while where the rash has been scanty, it is sometimes scarcely apparent except at the tips of the fingers and toes and just around the insertion of the nails.

Besides the rash there are commonly other symptoms not less characteristic of scarlatina, and among them the sore-throat is one of the most invariable. Even in mild cases, it is very rarely absent, and if not present at the beginning, it comes on on the second or third day. The palate and tonsils, in these circumstances are red, and the latter are usually more or less swollen, while swallowing is attended with pain, or at any rate with discomfort. The redness of the palate, which extends also to the back of the throat, is a finely spotted redness closely resembling the rash on the surface. The tongue is coated with a thick white or yellowish coating, through which project numerous bright red points, papillæ as they are called, and this appearance of the tongue is as distinctive of scarlatina as the rash itself. Later, as the rash begins to fade, the coating separates from the tongue, which is left of a bright red colour, looking raw and shining, with the little raised red points projecting beyond its surface, and constituting what has been called in medical language, the strawberry tongue.

When all these symptoms are present, no one can doubt but that the case is one of scarlatina. But the decision is far less easy in mild cases, for in them the rash is sometimes extremely evanescent, the general disturbance of health very slight, and the fever and accompanying rise of temperature small. The risk in such circumstances of the disease being altogether overlooked is even greater than that of its being confounded with some other eruptive fever. The rash of measles cannot be confounded with that of scarlatina, and the distinctly spotty character of the rash of German measles ought, apart even from other differences, to render mistake impossible.

Perhaps the best rule that can be laid down is that every diffused red rash, not obviously formed by distinct spots, even though it be not uniform but appears in patches on the neck, breast, back, or inside of the thighs, and persists for more than twelve hours, is scarlatinal. Further, that in any instance in which even very slight feverishness, or very slight sore-throat, have preceded or accompanied the rash, the nature of the ailment is stamped beyond the possibility of doubt. Mistakes are made from want of careful observation, much more than from any insuperable difficulty in distinguishing one disease from the other. When the least hesitation is felt as to the nature of any rash which may appear on a child, with, or without previous illness, the question should be at once referred to a medical man. People are too apt in these circumstances to wait for a few days, and then to appeal to the doctor when all traces of rash have disappeared, and when the grounds no longer exist on which he could base a positive opinion.

I need not describe the symptoms of severe and dangerous scarlatina, for long before symptoms become really formidable, the patients will have been placed under medical care. It may suffice to say that the danger is almost always in proportion to the severity of the throat-affection and swelling of the glands, and not at all in proportion to the abundance of the rash. Though severe cases usually set in with severe symptoms, yet this is not invariably the case, and medical watching is all the more necessary from the very commencement, since until the end of the first week it is impossible to calculate on the subsequent course of the disease. In malignant scarlatina happily of infrequent occurrence, the child is struck down, as though its blood were poisoned, from the very first; and death takes place often within forty-eight hours, the rash appearing just sufficiently to stamp the nature of the pestilence which has proved so deadly.

It may form a useful conclusion to all that has been said in this little book about the diseases of children, if I endeavour to point out in what consist the duties of parents in cases of scarlatina, or of any disease which resembles it.

1. To watch carefully the commencement of every slight feverish attack in which a diffused red rash appears, even though this should be only in patches, and to bear in mind the possibility of its being due to scarlatina.

2. To remove the child immediately from the others, so long as there is any doubt concerning the nature of the case, and to remove with him his bed, bedding, and all clothes worn by him at the time when the illness began, or the rash appeared.

3. To place the child if possible in a room at the top of the house, so that the other children may not pass by his door.

4. Inasmuch as scarlatina often proves fatal to grown persons who have not already had the disease, to obtain at once the attendance of a skilled nurse, in order to avoid the risk of the disease spreading through the household.

The wife belongs to her husband, the husband to his wife; their mutual duties are paramount over even those of the parent; and neither has the right to jeopardise that life which belongs to the other. To say, 'I shall not catch the disease, because I have no fear,' is as idle as it would be for the soldier to say, 'Because I am brave, therefore I am invulnerable.'

I have been accustomed to insist on the absence from the room of father or mother, supposing either of them not to have had scarlatina, so long as I could give the assurance that every thing was going on well; but on the slightest anxiety I have referred to both parents for their mutual decision as to the course which they would choose to adopt.

From a refusal to be guided by this counsel, it has more than once happened to me, to see the child recover from mild scarlatina without a bad symptom, and the mother who had insisted on nursing the little one die of the disease to which she had needlessly exposed herself.

5. So soon as the disease has declared itself as scarlatina, to take up the carpets and remove the curtains from the sick child's room, to empty the drawers of any clothes which may be in them, and to hang up outside the door a sheet moistened with a solution of carbolic acid.

6. To arrange for all food and necessaries to be placed in an adjoining room, or at the head of the stairs, so that there may be no direct communication between the attendants on the sick and the other inmates of the house.

7. To insist on the attendants not wearing either silk or stuff dresses, but dresses of some washable material; and on their changing their garments as well as scrupulously washing themselves before mixing with other inmates of the house, and especially with the children.

8. While in all respects obeying the directions of the doctor, to grease the child all over twice in twenty-four hours with suet or lard, to which a small quantity of carbolic acid has been added. This proceeding both lessens the amount of peeling of the skin in a later stage of the disease; lessens the contagiousness of the scales which are detached; and, by promoting the healthy action of the skin, diminishes the risk of subsequent disorder of the kidneys and consequent dropsy.

9. Even when the case has been of the slightest possible kind, to keep the child always in bed for one-and-twenty days. This was a standing rule at the Children's Hospital, and I am certain that its non-observance will be followed three times out of four by dropsy and kidney-disease.

10. When the disease is over, to destroy, if the parents' means at all permit it, the clothes and bedding of the child. When this is not practicable, to have everything exposed to the heat of superheated steam in a Washington Lyons or other similar disinfector, and to have all linen boiled as well as washed. Lastly, to have the ceiling whitewashed, the paint cleaned, the paper stripped, and the room repapered, as well as the floor washed and rewashed with strong carbolic soap.

These precautions are troublesome and costly, but disease is costlier still; and who shall estimate the cost of death!

APPENDIX

ON THE MENTAL AND MORAL FACULTIES IN CHILDHOOD, AND ON THE DISORDERS TO WHICH THEY ARE LIABLE

Any remarks on the ailments of children would be incomplete if no notice were taken of the mental and moral peculiarities of early life.

For want of giving heed to them, not only are grave mistakes made in the education of children, but in the management of their ailments, both by doctors and by parents: much needless trouble is given to the doctors, much needless distress to the child, much needless anxiety to the parents.

The common mistake committed by those parents who do not make their child an idol to fall down and worship, and thus turn him, to his own misery and theirs, into the most arbitrary of domestic tyrants, is to treat him as though he were in mind, as well as in body, a miniature man; feebler in intellect as he is inferior in strength, but differing in degree only, not in kind.

Now the child differs essentially from the adult in the three respects; that

1. He lives in the present, not in the future.

2. His perceptions are more vivid, and his sensibilities more acute; while the world, on which he has just entered, surrounds him with daily novelties.

3. He has less self-consciousness, less self-dependence, lives as a part of the world by which he is surrounded—a real practical pantheist.

The child lives in the present, not in the future, nor much even in the past, till the world has been some time with him, and he by degrees shares the common heritage of retrospect and anticipation. This is the great secret of the quiet happiness which strikes almost all visitors to a children's hospital.

No one can have watched the sick bed of the child without remarking the almost unvarying patience with which its illness is borne, and the extremity of peril from which apparently, in consequence of that patience, a complete recovery takes place. Much, indeed, is no doubt due to the activity of the reparative powers in early life, but much also to the unruffled quiet of the mind. No sorrow for the past, no gloomy foreboding of the future, no remorse, disappointment, nor anxiety depresses the spirits and enfeebles the vital powers. The prospect of death, even when its approach is realised—and this is not so rare as some may imagine—brings in general but small alarm. This may be from the vagueness of the child's ideas; it may be, as the poet says, that in his short life's journey, 'the heaven that lies about us in our infancy' has been so much with him, that he recognises more clearly than we can do

'The glories he hath known,And that imperial palace whence he came.'

I dwell on this truth, because it is of great practical moment that we should bear in mind to how very large an extent the child lives only in the present; because it follows from it that to keep the sick child happy; to remove from it all avoidable causes of alarm, of suffering, of discomfort; to avoid, as far as may be, any direct struggle with its waywardness; and even if death seems likely to occur, to look at it from a child's point of view—not from that which our larger understanding of good and evil suggests to our minds—are duties of the gravest kind which weigh on the parent and the nurse, no less than on the physician.

But not only does the child live in the present far more than it is possible for the adult, but there are, besides, other important mental differences between the two. Not only is the mind of the child feebler in all respects than that of the adult, but, in proportion to the feebleness of his reasoning power, there is an exaggerated activity of his perceptive faculties, a vividness of his imagination. The child lives at first in the external world, as if it were a part of himself, or he a part of it, and the gladheartedness which it rejoices us to see is as much a result of the vividness with which he realises the things around him, as of that absence of care to which it is often attributed. This peculiarity shows itself in the dreams of childhood, which exceed in the distinctness of their images those which come in later life. It shows itself, too, in the frequency with which, even when awake, the active organs perceive unreal sounds, or in the dark, at night, conjure up ocular spectra; and then not merely colours, but distinct shapes, which pass in long procession before the eyes. This power fades away with advancing life; except under some conditions of disease, the occasional appearance of luminous objects in the dark is the only relic with most of us of the gift of seeing visions with which, at least in some degree, we were endowed in our early years. The child who dreads to be alone, and asserts that he hears sounds, or perceives objects, is not expressing merely a vague apprehension of some unknown danger, but often asserts a literal truth. The sounds have been heard; in the stillness of its nursery the little one has listened to what seemed a voice calling it; or, in the dark, phantasms have risen before its eyes, and the agony of terror with which it calls for a light, or begs for its mother's presence, betrays an impression far too real to be explained away, or to be met by hard words or by unkind treatment.

Impressions such as these are not uncommon in childhood, even during health. Disorder, direct or indirect, of the functions of the brain, more commonly the latter, greatly exaggerates them, and I have known them to outlast for many weeks all other signs of failing health after convalescence from fevers. The unreal sights are far more common than the sounds. The sounds are usually of the simplest kind—as the tinkling of a bell, of which we all remember the exquisite use made by Hans Andersen in one of his nursery tales; or the child's own name, at intervals repeated, just as the little watchful boy heard it in far off Judæa, when it was the prelude to a wondrous communication from the unseen world. It came to him as he woke from sleep, before the morning dawned, while the lamp, lighted overnight, was burning still; and still it is so far the same that these occurrences which suggest to us problems that we cannot attempt to solve, mostly take place at times of transition from the sleeping to the waking state.

The ocular spectra are usually far more vivid and detailed. Those which occur in the waking state are by no means always painful, though their strangeness not infrequently alarms the child, and his horror at the dark arises, not from his seeing nothing, but from his seeing too much.

Some imaginative children amuse themselves with these phantasms, and then, if encouraged to relate them, will constantly transgress the boundary line between truth and falsehood, and weave their little romance. When they happen on waking they are usually preceded by frightful dreams, but the image which the child sees then is not the mere recollection of the dream, but a new, distinct, though painful impression; generally of some animal to which the child points, as now here, now there. These night terrors from the very circumstantial character of the impressions which attend them, often, as I have already said, occasion needless anxiety as to the importance of the cause on which they depend.

Sleep-walking in its smaller degrees of getting out of bed at night, is by no means unusual in childhood; but the greater degrees of somnambulism are certainly rare; and I have always found them dependent on undue mental work; not always, indeed, on the tasks being excessive, but sometimes on the over-anxiety of the child to make progress. I have not yet known a poor person's child a somnambulist.

But not only are the perceptions more acute in childhood than in adult life, the sensibilities are more intense. The child's emotions, indeed, are often transitory—generally very transitory; but while they last they produce results far greater than in the grown person. In the case of the latter, recollection of the past, anticipation of the future, or even the duties of the present, control the overwhelming sorrow, or call forth the energies needed to bear it. The child lives in the present, and this present is but the reflection of the world around, its impressions uncontrolled by experience, ungoverned by reason.

The broken-heartedness of a child on leaving home is not the expression only of intense affection for its friends or relations, it is the shock of separation from the familiar objects which have surrounded it; and I have not infrequently seen children inconsolable when removed from homes that were most wretched, or from relations who were most unkind. Every now and then, indeed, I have been compelled to send children home from the hospital because no love nor care could reconcile them to the change from home; and they have refused to eat, and spent their nights in weeping. The feeling is an unreasoning one, like the home-sickness of the mountaineer.

But, moreover, sudden shocks may sometimes overthrow the whole moral equilibrium, and disarrange the balance of the nervous system so seriously as to cause the death of a child previously free from any important ailment. Thus, I remember a little boy five years of age who died sixteen days after his father's funeral. The strange sad scene overcame him, though there had been no special tie between him and his father. He shivered violently, became very sick, complained by signs of pain in the head, for he had lost his speech, which he regained by slow degrees in the course of four or five days. Improvement in other respects did not take place, he lay in a drowsy state save when he called for his mother, and at length the drowsiness deepened into stupor, and so he died. I suppose his mother was right; she said his heart was broken.

It behoves us to bear in mind that the heart may break, or the reason fail, under causes that seem to us quite insufficient; that the griefs of childhood may be, in proportion to the child's powers of bearing them, as overwhelming as those which break the strong man down. Every now and then we are shocked by the tale that some young child has committed suicide, and for reasons which to our judgment seem most trivial—from fear of punishment, or even from mere dread of reproof. These facts deserve special attention, they show how much more the susceptibility and sensitiveness of children need to be taken into consideration than is commonly done.

This keenness of the emotions in children displays itself in other ways, and has constantly to be borne in mind in our management of them. The child loves intensely, or dislikes strongly; craves most earnestly for sympathy, clings most tenaciously to the stronger, better, higher around it, or to what it fancies so; or shrinks, in often causeless but unconquerable dread, from things or persons that have made on it an unpleasant impression. Reason as yet does not govern its caprices, nor the more intelligent selfishness of later years hinder their manifestation. The waywardness of the most wilful child is determined by some cause near at hand; and those who love children, and can read their thoughts, will not in general be long in discovering their motives and seeing through their conduct.

One word more must be said with reference to that intense craving for sympathy so characteristic of the child. It is this which often underlies the disposition to exaggerate its ailments, or even to feign such as do not exist, and in such attempts at deception it often perseveres with almost incredible resolution. Over and over again I have met with instances where the motives to such deception were neither the increase of comfort nor the gratification of mere indolence; but the monopolising the love and sympathy which during some bygone illness had been extended to it, and which it could not bear to share again with its brothers and sisters. This feeling, too, sometimes becomes quite uncontrollable, and the child then needs as much care and as judicious management, both bodily and mental, to bring it back to health, as would be called for in the case of some adult hypochondriac or monomaniac.

A caution may not be out of place as to the importance of not ministering to this tendency to exaggerated self-consciousness by talking of children's ailments in their hearing, or by seeming to notice the complaints they make as though they were something out of the common way.

It will be observed that throughout I have dwelt more on disorders of the moral faculties than of the intellectual powers in childhood, and I have done so because I believe them to be the more common and the more important. In the feeble-minded the moral sense almost invariably participates in the weakness of the intellect; but it is by no means unusual for the former to be grievously perverted, while the intelligence is in no respect deficient. The moral element in the child seems to me to assert its superiority in this, that it is the most keenly sensitive, the soonest disordered—

'Like sweet bells jangled, out of tune, and harsh,'

and the discord is first perceived in the finest notes.

To a very great extent, a mixture of vanity and of a morbid craving for sympathy lie at the root of many of those perversions of character which excite a parent's anxiety. One of these consists in an over-scrupulousness with reference to the right or wrong of actions in themselves quite indifferent; in doubts as to whether the morning or evening prayer has been properly said, whether something was or was not absolutely true, whether this or that peccadillo was a grievous offence against God, and so on; and all these little cases of conscience are brought by the child several times a day to his mother or to his nurse for solution. If listened to readily the child's truthfulness becomes inevitably destroyed, and he grows up with a morbid frame of mind, which after-life will aggravate almost infinitely.

One knows indeed the history of child saints; but it must be remembered that one great characteristic of pre-eminent sanctity at all ages of life is reticence, while these little people are perpetually seeking to interest others in themselves, their doubts, and feelings. If wisely dealt with, not by direct ridicule, but by a wholesome neglect of the child's revelations, treating them as of no special interest or importance, and discouraging that minute introspection which, of doubtful good at any age, is absolutely destructive of the simplicity of childhood, this unnatural condition will soon pass away. It will help this object very much, if the child is sent on a visit to judicious friends, and change of scene, of pursuits, of playmates, and amusements will be of all the more service since these morbid states of mind seldom come on in children whose bodily health is robust.

Another mode in which the same perverted feelings display themselves is in the disposition occasionally noticed to exaggerate some real ailment, or to complain of some ailment which is altogether imaginary. So far is this from being rare that my experience coincides entirely with that of the French physician M. Roger, who has had larger opportunities than anyone else in France for observing the diseases of children, and who says, 'It must be borne in mind that simulated ailments are much more common in the children's hospital than in a hospital for adults.'