Chapter XXV: The Sick Child

To the mother who has passed through the experience of bringing the child into the world is usually given that intuitiveness which helps her in caring for that child when it is well and in recognizing certain symptoms when it is sick. The newborn baby brings with him a large responsibility, but as the weeks pass by his care becomes less and less of a nervous strain, as the routine duties, so nearly alike each day of his little life, have made the task comparatively easy; but when the baby gets sick, particularly if he is under one year of age, and it is impossible for him clearly to make known his wants, and being unable to tell where it hurts or how badly it hurts, the average mother is likely to become somewhat panicky; and this confusion of mind often renders her quite unfit successfully to nurse the sick baby.

THE NURSE

It is often wise to secure the services of a trained nurse, and if the family purse will allow such services, a good, sincere, capable, practical nurse should be engaged, for her firm kindness will often accomplish much more than the unintentional irritability and anxious solicitude of an overworked and nervous mother.

Usually the mother not only attempts the care of the sick baby with the long night vigil--often not having the opportunity to take a bath or change her raiment day in and day out--but she often attempts to manage the entire household as well, including the getting of the meals and keeping the house cleaned, and it is not to be wondered at that her nerves become overtaxed and in an unlooked for moment she becomes irritable and cross with the sick child.

No matter how low the financial conditions of the family may be, outside help is always essential in cases of severe or long-continued illness of the children. Should the mother insist upon caring for the baby herself, then all household duties should be given over to outside help, and as she takes the rôle of the nurse, the same daily outing and sleep that an outside nurse would receive should be hers to enjoy.

Dr. Griffith has so ably detailed the "features of disease" that we can do no better than to quote the following:[A]

[A] From Griffith's _Care of the Baby_, copyrighted by W. B. Saunders Company.

POSITION

The position assumed in sickness is a matter of importance. A
child feverish or in pain is usually very restless even when
asleep. When awake it desires constantly to be taken up, put down
again, or carried about. Sometimes, however, at the beginning of
an acute disease it lies heavy and stupid for a long time. In
prolonged illnesses and in severe acute disorders the great
exhaustion is shown by the child lying upon its back, with its
face turned toward the ceiling, in a condition of complete
apathy. It may remain like a log, scarcely breathing for days
before death takes place. Perfect immobility may also be seen in
children who are entirely unconscious although not exhausted.

A constant tossing off of the covers at night occurs early in
rickets, but, of course, is seen in many healthy infants,
especially if they are too warmly covered. A baby shows a desire
to be propped up with pillows or to sit erect or to be carried in
the mother's arms with its head over her shoulder whenever
breathing is much interfered with, as in diphtheria of the larynx
and in affections of the heart and lungs. The constant assumption
of one position or the keeping of one part of the body still, may
indicate paralysis. When, however, a cry attends a forcible
change of position, it shows that the child was still because
movement caused pain.

Sleeping with the mouth open and the head thrown back often
attends chronic enlargement of the tonsils and the presence of
adenoid growths in young children, although it may be seen in
other affections which make breathing difficult. In inflammation
of the brain the head is often drawn far back and held stiffly
so. Sometimes, too, in this disease the child lies upon one side
with the back arched, the knees drawn up, and the arms crossed
over the chest. A constant burying of the face in the pillow or
in the mother's lap occurs in severe inflammation of the eyes.

GESTURES

The gestures are often indicative of disease. Babies frequently
place the hands near the seat of pain; thus in slight
inflammation of the mouth they tend to put the hand in the mouth;
in earache to move it to the ear; and in headache to raise it to
the head. In headache or in affections of the brain they
sometimes pluck at the hair or the ears, although they may often
do this when there is no such trouble. Picking at the nose or at
the opening of the bowel is seen in irritation of the intestine
from worms or oftener from other cause. A child with a painful
disease of its chest may sometimes place its hand on its abdomen,
or a hungry child try to put its fists into its mouth.

In approaching convulsions the thumbs are often drawn tightly
into the palms of the hands and the toes are stiffly bent or
straightened. Very young babies, however, tend to do this,
although healthy. The alternate doubling up and straightening of
the body, with squirming movements, making of fists, kicking, and
crying, are indications of colic. This is especially true if the
symptoms come on suddenly and disappear as suddenly, perhaps
attended by the expulsion of gas from the bowel.

SKIN COLOR

The color of the skin is often altered in disease. It is yellow
in jaundice, and is bluish, especially over the face, in
congenital heart disease. There is a purplish tint around the
eyes and mouth, with a prominence of the veins of the face, in
weakly children or in those with disordered digestion. A pale
circle around the mouth accompanies nausea. The skin frequently
acquires an earthy hue in chronic diarrhea, and is pale in any
condition in which the blood is impoverished, as in Bright's
disease, rickets, consumption, or any exhausted state. Flushing
of the face accompanies fever, but besides this there is often
seen a flushing without fever in older children the subjects of
chronic disorders of digestion. Sudden flushing or paling is
sometimes seen in disease of the brain.

FACIAL EXPRESSION

The expression of the face varies with the disease. In whooping
cough and measles the face is swollen and somewhat flushed,
giving the child a heavy, stupid expression. There is also
swelling of the face, especially about the eyes, in Bright's
disease. Repeated momentary crossing of the eyes often indicates
approaching convulsions. In very severe acute diarrhea it is
astonishing with what rapidity the face will become sunken and
shriveled, and so covered with deep lines that the baby is almost
unrecognizable. The same thing occurs more slowly in the
condition commonly known as marasmus. Often the face has an
expression of distress in the beginning of any serious disease.
If the edges of the nostrils move in and out with breathing, we
may suspect some difficulty of respiration, such as attends
pneumonia. The baby sleeps with its eyes half open in exhausted
conditions or when suffering pain.

THE HEAD

The head exhibits certain noteworthy features. Excessive
perspiration when sleeping is an early symptom of rickets. It
must be remembered, however, that any debilitated child may
perspire more or less when asleep. Both in rickets and in
hydrocephalus (water on the brain) the face seems small and the
head large, but in the former the head is square and flat on top,
while in the latter it is of a somewhat globular shape. The
fontanelle is prominent and throbs forcibly in inflammation of
the brain, is too large in rickets and hydrocephalus, bulges in
the latter affection, and sometimes sinks in conditions with only
slight debility.

THE CHEST

The chest exhibits a heaving movement with a drawing in of the
spaces between the ribs in any disease in which breathing is
difficult. A chicken-breasted chest is seen in Pott's disease of
the spine, and to some extent in bad cases of enlargement of the
tonsillar tissue; a "violin-shaped" chest in rickets; a bulging
of one side in pleurisy with fluid; and a long, narrow chest,
with a general flattening of the upper part, in older children
predisposed to consumption.

THE ABDOMEN

The abdomen is swollen and hard in colic. It is also much
distended with gas in rickets, and is constantly so in chronic
indigestion in later childhood. It is usually much sunken in
inflammation of the brain or in severe exhausting diarrhea or
marasmus. It may be distended with liquid in some cases of
dropsy.

THE CRY

The study of the cry furnishes one of the most valuable means of
learning what ails a baby. A persistent cry may be produced by
the intense, constant itching of eczema.

The paroxysmal cry, very severe for a time and then ceasing
absolutely, is probably due to colic, particularly if accompanied
by the distention of the abdomen and the movements of the body
already referred to. A frequent, peevish, whining cry is heard in
children with general poor health or discomfort. A single shrill
scream uttered now and then is often heard in inflammation of the
brain. In any disease in which there is difficulty in getting
enough air into the lungs, as in pneumonia, the cry is usually
very short and the child cries but little, because it cannot hold
its breath long enough for it. A nasal cry occurs with cold in
the head.

A short cry immediately after coughing indicates that the cough
hurts the chest. Crying when the bowels are moved shows that
there is pain at that time. A child of from two to six years,
waking at night with violent screaming, is probably suffering
from night terrors. In conditions of very great weakness and
exhaustion the baby moans feebly, or it may twist its face into
the position for crying, but emit no sound at all. This latter is
also true in some cases of inflammation of the larynx, while in
other cases the cry is hoarse or croupy. Crying when anything
goes into the mouth makes one suspect some trouble there. If it
occurs with swallowing, it is probable that the throat is
inflamed.

With the act of crying there ought always to be tears in children
over three or four months of age. If there are none, serious
disease is indicated, and their reappearance is then a good sign.

COUGHING

The character of the cough is also instructive. A frequent, loud,
nearly painless cough, at first tight and later loose, is heard
in bronchitis. A short, tight, suppressed cough, which is
followed by a grimace, and, perhaps, by a cry, indicates some
inflammation about the chest, often pneumonia. There is a brazen,
barking, "croupy" cough in spasmodic croup. In inflammation of
the larynx, including true croup, the cough may be hoarse,
croupy, or sometimes almost noiseless.

The cough of whooping cough is so peculiar that it must be
described separately when considering this disease. Then there
are certain coughs which are purely nervous or dependent upon
remote affections. Thus the so-called "stomach cough" is caused
by some irritation of the stomach or bowels. It is not nearly so
frequent as mothers suppose. Irritation about the nose or the
canal of the ears sometimes induces a cough in a similar way.
Enlarged tonsils or elongated palate or throat irritation may
also produce a cough.

THE BREATHING

The breathing of a young child, particularly if under one year of
age and awake, is always slightly irregular. If it becomes very
decidedly so, we suspect disease, particularly of the brain. A
combination of long pauses, lasting half a minute or a minute,
with breathing which is at first very faint, gradually becomes
more and more deep, and then slowly dies away entirely, goes by
the name of "Cheyne-Stokes respiration," and is found in
affections of the brain. It is one of the worst of symptoms
except in infancy, and even then it is very serious.

The rate of respiration is increased in fever in proportion to
the height of the temperature. It is increased also by pain in
rickets, and especially in some affections of the lungs. Sixty
respirations a minute are not at all excessive for a child of two
years with pneumonia, and the speed is frequently decidedly
greater than this.

Breathing is often very slow in disease of the brain,
particularly tubercular meningitis. Poisoning by opiates produces
the same effect. Frequent deep sighing or yawning occurs in
affections of the brain, in faintness, or in great exhaustion,
and may be a very unfavorable symptom. Breathing entirely through
the mouth shows that the nose is completely blocked, while
snuffling breathing is the result of a partial catarrhal
obstruction. A gurgling in the throat not accompanied by cough
may indicate that there is mucus in the back part of it, the
result of an inflammation, sometimes slight, sometimes serious.

"Labored" breathing, in which the chest is pulled up with each
breath while the muscles of the neck become tense, the pit of the
stomach and the spaces between the ribs sink in, and the edges of
the nostrils move in and out, is seen in conditions where the
natural ease of respiration is greatly interfered with, as in
pneumonia, diphtheria of the larynx, asthma, and the like.
Long-drawn, noisy inspirations and expirations are heard in
obstruction of the larynx, as from laryngeal diphtheria or
spasmodic croup.

THE PULSE

The rate of the pulse is subject to such variations in infants
that its examination is of less value than it would otherwise be.
In early childhood its observation is of more service, although
even then deceptive. Slight irregularity is not uncommon. Unusual
irregularity is an important symptom in affections of the brain
or heart. Fever produces an increase in the pulse rate, the
degree of which depends, as a rule, upon the height of the
temperature. Slowing of the pulse is a very significant symptom,
seen particularly in affections of the brain, and sometimes in
Bright's disease and jaundice.

THE TEMPERATURE

The temperature is of all things important to remember in infancy
and childhood because fever is easily produced and runs high from
slight causes.

Even slight cold or the presence of constipation or slight
disturbances of digestion may in babies sometimes produce a
temperature of 103 F. or more. We do not speak of fever unless
the elevation reaches 100 F. A temperature of 102 or 103 F.
constitutes moderate fever, while that of 104 or 105 F. is high
fever, and above 105 F. very high. A temperature of 107 F. is
very dangerous, and is usually not recovered from. The danger
from fever depends not only upon its height, but upon its
duration also. An elevation of 105 F. may be easily borne for a
short time, but it becomes alarming if much prolonged.

THE MOUTH

The tongue of newborn infants is generally whitish and continues
to be so until the saliva becomes plentiful. After this we
usually find it coated in disturbances of the stomach and bowels
and in nearly any disorder accompanied by fever. In scarlet fever
the tongue becomes bright red after a few days, and in measles
and whooping cough it is often faintly bluish. In the latter
affection an ulcer may sometimes be found directly under the
tongue, where the thin membrane binds it to the floor of the
mouth. In thrush the tongue is covered with white patches like
curdled milk. A pale, flabby tongue, marked by the teeth at its
edges, indicates debility or impaired digestion. In prolonged or
very high fever the tongue grows dry, and in some diseases of the
stomach or bowels it may look like raw beef.

Grinding of the teeth is a frequent symptom in infants in whom
dentition has commenced. It generally indicates an irritated
nervous system. Most often this depends upon some disturbance of
digestion; less often upon the presence of worms. The symptom is
present during or preceding a convulsion, and may occur, too, in
disease of the brain. In some babies it appears to be only a
nervous habit.

NURSING

The manner of nursing or swallowing frequently affords important
information. A baby whose nose is much obstructed or who has
pneumonia can nurse but for a moment, and then has to let the
nipple go in order to breathe more satisfactorily. If it gives a
few sucks and then drops the nipple with a cry, we must suspect
that the mouth is sore and that nursing is painful. If it
swallows with a gurgling noise, often stops to cough, and does as
little nursing as possible, we suspect that the throat may be
sore. The ceasing to nurse at all, in the case of a very sick
baby, is an evidence of great weakness or increasing stupor, and
is a most unfavorable symptom.

THE URINE

Urine that is high-colored and stains the diaper, or that shows a
thick, reddish cloud after standing, may accompany fever or
indigestion. Sometimes the urine under these conditions is milky
when first passed. In some babies a diet containing beef juice or
other highly nitrogenous food will produce the reddish cloud, or
even actual, red, sandlike particles. A decidedly yellow stain on
the diaper occurs when there is jaundice. A faint reddish stain
seldom indicates blood. The amount of urine passed is scanty in
fever, in diarrhea, and especially in acute Bright's disease. In
the latter disease the urine is often of a smoky or even a muddy
appearance. The possibility of the occurrence of this symptom
after scarlet fever must always be kept in mind, in order that a
physician may be summoned very quickly, since it is a serious
matter.

THE STOOLS

We find that the passages are often putty-colored in disorders of
the liver, frequently bloody or tarry in appearance in bleeding
within the bowel, and liable to be black after taking bismuth,
charcoal, or iron, and red after krameria, kino, or haematoxylon.
Infants who are receiving more milk than they can digest
constantly have whitish lumps in their stools, or even entirely
formed but almost white passages. The presence of a certain
amount of greenish coloration of the passages is not infrequent.
This is usually an evidence of indigestion, but passages which
are yellow when passed and turn to a faint pea green some time
later are not an indication of disease.

WHEN BABY GETS SICK

When baby shows that he is sick, take his temperature as directed elsewhere, cut down the feeding to at least one half, or, if his temperature is around 102 F. give him nothing but rice water or barley water. If he is constipated give him a cleansing enema, and if hot and feverish a sponge bath may be administered. He should then be put into a bed with light covers and wait further orders which the doctor will give on his arrival. Give the baby no medicine unless ordered to do so by the physician.

Known to every physician who undertakes the care of children, is the failure of many well-meaning mothers to call him early. The mother attempts the care of the baby herself, and not until the condition gets beyond her knowledge and wisdom does she seek medical advice. In the early hours of an approaching cold, the beginning of intestinal indigestion, or at the beginning of bronchitis, if the physician can see the child early, prolonged illness may be avoided as well as unnecessary expense and many heart-breaking experiences.

FEEDING THE SICK BABY

Feeding the sick baby differs somewhat with the character of the individual disease, but in the outset of any and all diseases the intestinal tract should not be overburdened with food. At the approach of any illness, the food should at least be cut down one half; for instance, in the case of a serious acute illness accompanied by fever, not only should the strength of the food be reduced one half, but water should be given plentifully between feedings. It is better never to urge the baby to eat at such times--for the ability to digest food is very much reduced.

In cases of acute attacks with much vomiting and fever, all milk should be immediately stopped and rice water or barley water substituted. When vomiting ceases and the fever approaches normal and food is desired, begin with boiled skim milk in small amounts, well diluted with cereal water, and do not approach the normal amount of milk for twenty-four to forty-eight hours. In this way the weak digestive organs are not overtaxed and they gradually resume their usual work of good digestion. When a baby seems to have no appetite for food, lengthen the intervals from three to four or five hours, for feeding when food is not desired usually aggravates disease disturbances.

EXAMINING SICK CHILDREN

And now, above all times, the early seed sowing of teaching the child self-control, teaching him to gargle if he is sufficiently old enough, to open his mouth and allow observation without resistance, brings sure results. The great harm of making the doctor and his medicine a threat to obtain obedience also brings its harvest at this time; for the doctor, of all people, ought to be regarded as the child's best friend. When baby is sick, the doctor is needed, his daily visits must not be resisted, his medicines must not be feared--these and such other matters should be made a part of every child's early education.

Under no circumstances or conditions should we directly falsify to a child. Nothing is accomplished by telling a child it will not hurt when you know that it will hurt, or that the medicine tastes good when you know it is bad-tasting. Every physician can recall unnecessary disturbances in the office because a mother has allowed a child to acquire a wrong mental attitude toward the family physician.

One mother told her little girl in my office when I wished to make an examination for adenoids which necessitated my putting my finger back of the child's uvula, "Now Mary, the doctor won't hurt you at all, it will feel nice." I turned to the little girl and said: "Mary, it will not feel nice, it really won't hurt you, but it will feel uncomfortable." It was a grave mistake to tell her that it would feel nice. The child resisted, and, while the examination was successfully made, the greatest of tact had to be used in securing the friendship of the child after the examination.

It is far better when the throat is to be examined to wrap the child in a shawl or a sheet with his arms placed at his side, and for a member of the family to take him in her lap and hold him securely while the physician quickly makes the observation. And while we appreciate that sickness is not the time to introduce new methods of training, in instances where children have been spoiled, it is far better quietly and firmly to go about the task in a manner that you know can be carried through to a successful finish.

TREATMENT OF SICK CHILDREN

A sick child should be encouraged to lie in his bed much of the time, and the bed should be kept clean and cool. He should never be set up suddenly or laid back quickly. In the case of a broken leg, all rapid movements should be avoided. A simple story or a soothing lullaby, or the giving of a toy, will often divert attention when some painful movement must be made or some disagreeable task performed.

Both cleanliness of the body and cleanliness of the mouth are exceedingly necessary in sickness. In all instances of disease or indisposition, the mouth must receive daily care, for stomatitis or gangrene of the mouth often follows neglect. A listerine wash in proportion of one to four, or a magnesia wash, or the addition of a few drops of essence of cinnamon to the mouth wash will do much to prevent such conditions, as well as to relieve them.

Applications of medicine to the throat may be made without resistance if the tactful nurse watches her time. She should slowly introduce the tongue depressor which may be a flat stick or a spoon, when the application of medicine with a camel's-hair brush is quickly made to the rolled-out throat as the child gags, and if the nurse then quickly diverts his attention to some beautiful story or a picture or a new toy, the treatment is soon forgotten. Under no circumstances argue with or scold a sick child. Get everything ready, if possible behind his back or in another room, and then with plenty of help make the application or the observation without words, always with gentleness and firmness.

NURSING RECORDS

Whether the nurse be the mother, caretaker, practical or professional nurse, a record should always be kept of the condition of the patient. The temperature should be reported at different periods designated by the physician. The pulse should be recorded, the amount of urine passed and the time it was passed, the number of bowel movements, all feedings and the general well being of the child--whether it is restless or comfortable, sleeping or awake, together with the water that he drinks.

The record may be kept, if necessary, on a piece of common letter paper, and should read something like this:

March 26, 1916

7 A. M. Temperature 102; pulse 132; respiration 40; morning
toilet; took 4 ounces of milk; 2 ounces of barley water; 1 ounce
of lime water.

9 A. M. Enema given; good bowel movement; mustard paste applied
to chest, front and back, and oil-silk jacket applied; drank
boiled water, 4 ounces.

11 A. M. Took the juice of one orange; temperature 103; pulse
135.

12 Noon. Very listless and nervous; temperature 104. Has coughed
a great deal. Gave mustard paste to chest, front and back, and
wet-sheet pack.

1:30 P. M. Temperature 101.8; 4 ounces of water to drink; looks
better.

3 P. M. Has slept 1½ hours; temperature 102.5; pulse 134;
respiration 40; 6 ounces of food given (3 ounces of milk, 2
ounces of barley water and 1 ounce of lime water).

A record like this is a great help to the physician, and such a record may be kept by anyone who can read and write. There are printed record blanks which may be procured from any medical supply house and most drug stores.

BAD-TASTING MEDICINES

Castor oil has neither a pleasant smell nor taste, and nothing is accomplished by telling the child that it does smell good or taste good. If the patient is old enough to drink from a cup, put in a layer of orange juice and then the castor oil and then another layer of orange juice, and in this way it often can be easily taken. Someone has suggested that a piece of ice held in the mouth just before the medicine is taken will often make a bad dose go down without so much forcing. A taste of currant jelly, or a bit of sweet chocolate, or the chewing of a stick of cinnamon is a great adjunct to the administration of bad-tasting medicines. All oily medicines must be kept in a cool place and should always be given in spoons or from medicine glasses that have first been dipped in very cold water. Very often the addition of sugar to bad-tasting medicines will in no wise interfere with their action, while it often facilitates the administration of the disagreeable dose. The majority of bad-tasting medicines are now put up in the form of chocolate-flavored candy tablets.

TEMPERATURES AND PULSE

The normal temperature of a baby is 98.5 to 99 F. in the rectum. After shaking the mercury of the thermometer down below the 97 mark it is well lubricated with vaseline and then carefully, gently, pushed into the rectum for about an inch and a half or two inches, and left there for three minutes before removing.

Mothers should exercise self-control in taking the temperature, for nothing is gained by allowing a panicky fear to seize you should the mercury register higher than you anticipated. Notify your physician when the temperature registers above 100 F.

The respirations of a child are fairly regular and rhythmic and occur about forty times per minute during the first month of life and about thirty times per minute during the remainder of the year. From one to two years, twenty-six to twenty-eight is the average. Breathing is somewhat irregular when the child is awake and may be a bit slower when asleep. Before the baby is born the fetal pulse is about 150. At birth it ranges from 130 to 140. During the first month the pulse is found to be from 120 to 140. By the sixth month it gets down to 120 or 130, and from that on to a year the normal pulse beat of the baby is about 120. The pulse is influenced very much by exercise and is often increased by crying or nursing or any other excitement.

FEVER

Children get fever very easily--the digestive disturbance of overeating, constipation, a slight bilious attack--all produce fever which disappears quite as suddenly as it came. The first thing to do under such circumstances is to withhold food, give plenty of water to drink, produce a brisk movement of the bowel by giving a dose of castor oil, give a cleansing enema, and treat the fever as follows:

After removing all of the clothes from the child, place him in a warm blanket and then prepare a sponge bath which may be equal parts of alcohol and water; expose one portion of the body at a time and apply the water and alcohol first to one arm and then to the other arm, the chest, one leg, the other leg, the back and then the buttocks. Do not dry the part but allow evaporation to take place, and this, accompanied by the cooling of the blood which is brought to the skin by the friction, readily reduces the fever. Another procedure which may be employed if the fever registers high is the wet-sheet pack which is administered as follows:

Three thicknesses of wool blankets are placed on the bed and a sheet as long as the baby and just enough to wrap around him once, is wrung out of cool water and spread over these blankets. With a hot-water bottle to the feet, the child is then laid down in the wet sheet which is now brought in contact with every portion of his body, then the blankets are quickly brought around, and he is allowed to warm up the sheet--which lowers his temperature.

Another valuable procedure is the cooling enema. Water the same temperature as that of the body, is allowed to enter the bowel and is then quickly cooled down to 90 or 85 F.; in this manner much heat is taken out of the body and the fever quickly reduced. (For further treatment of fevers see Appendix.)