Children's Health.
by Florence A. Stoney, M.D., B.S. (Lond.)
Volume 15, 1904, pgs. 910-918
(A lecture delivered before the Kew Branch of the P.N.E.U.)
There is a great deal with regard to children which of necessity you must all know a great deal more about than I can possibly pretend to do. It is some of the medical aspects of many questions connected with children that I am venturing to bring before you, since that is the side of child life with which I have come most in contact.
In medicine you cannot wholly consider one class of disease by itself; for the breathing reacts upon the heart and both upon nutrition and so on all round. To take breathing first, there are two factors in breathing: --
1. Good air.
2. Good breathing apparatus.
The first--that is good air--is hard to obtain in London, still open windows go a long way towards it. In a room of this size the air will not be fresh with shut windows if more than about four people are breathing in it at a time; 3,000 cubic feet of air are needed by each person every hour.
At night every child will be much hardier if accustomed to sleep with open windows, the child wearing a warm long nightgown and jacket, especially if inclined to throw off the blankets; if more heat is required in the room it should be supplied by extra clothing and by a fire, but not by shut windows--to sleep in impure air, that is, to spend at least one-third of one's life in impure air, is not the way to get strong.
Next as to the breathing apparatus. Normally, air should enter the lungs by way of the nose, *the mouth being kept closed.* The air on its passage through the nose gets filtered from some of its impurities as it passes over the mucous membrane, and becomes warmed and takes up moisture before passing into the throat and so to the larynx and down the windpipe to the lungs.
In the mouth the entrance to the throat is guarded on either side by the tonsils, that is, by glands which help to arrest injurious products which are in the air and prevent their travelling further. Similar glands are placed just behind the nose above the soft palate, and these if enlarged constitute what are called "adenoids." In children these glandular masses are always more marked than in adults, in fact both tonsils and adenoids become smaller in adult age. Now owing to irritation, as by impure air, these tonsils and adenoids are apt to enlarge unduly and become unhealthy, especially with children brought up in the impure air of town, with the joys of fogs and smoke and dust to be breathed as well as air. The consequences of such enlargement are far-reaching--much more than you would imagine. For instance, the adenoids partially blocking up the nose make it difficult for the child to breathe through the nose, and cause it to keep the mouth open. The unhealthy tissue at the back of the nose gives rise to chronic irritation of the mucous membrane of the nose, which shows itself in discharge from the nostrils, otherwise a chronic cold in the head, aggravated by fresh colds caught on top of the prevailing unhealthy condition. The discharge causes cracking round the nostrils and leads to a very ugly thickening of the upper lip. Mouth breathing--since the nose is blocked--leads to snoring at night, in fact snoring in a child is an easy way of diagnosing the presence of adenoids. Owing to breathing through the mouth the air reaches the chest cold and unfiltered, instead of warmed and filtered as it ought to be, the result of this is that the air passages all get frequently irritated.
The tonsils among other parts get larger and larger with each attack of sore throat. Quinsy, which is an abscess in the tonsil, is quite unknown except where the tonsil is already unhealthy. Any child with growing pains or other rheumatic tendency, or even rheumatic heredity, is much more liable to attacks of tonsillitis, and in them especially the tonsils should be looked after.
Sore throats always leave the mucous membrane a little more unhealthy than they found it Extending further down inflammation of the larynx ensues, leaving the mucous membrane, as before, unhealthy, a condition giving rise to much trouble in after life if the voice has to be used much, as for instance in following many professions, such as singing or teaching. The mischief in many cases goes even further and reaches the lungs, giving rise to bronchitis. In a young child where the ribs are quite yielding and the chest wall very soft, the air-way being obstructed by tonsils and adenoids results in the air being unable to enter freely, with the consequence that the ribs sink in and the chest cavity containing the lungs fails to grow and expand, leaving the child with a permanently small chest and therefore with permanently small lungs and breathing capacity.
The obstruction of the air-way at night causes the condition known as "night terrors," when the child wakes in a fright, really owing to partial asphyxiation, a condition completely cured by the removal of the obstruction.
If a child shows a marked tendency to catch cold on the least provocation, it nearly always means that its mucous membrane is in a thickened unhealthy condition. This chronic unhealthy condition of the mucous membrane, aggravated by every cold, is exactly the condition which predisposes to consumption, especially when added to poor lung expansion and the irritation of dust and cold air passing down direct to the lungs. In these days when the germs of consumption and other diseases are spread broadcast by men spitting about everywhere in the streets, trains, tramcars, and so on, so that the germs are continually flying about in the dust and being inhaled, it is essential to check any unhealthy condition of the air passages which could allow the child to more easily fall a victim to consumption, therefore we should aim at constantly keeping the upper air passages in a clean and healthy condition.
We have not yet done with the possible after effects of tonsils and adenoids. You are all I expect familiar with the phrase "throat deafness," but what exactly is meant by that term? Where the nose opens posteriorly above the soft palate there is the opening of the eustachian tube, which is the tube communicating between the throat and the ear. Every time a healthy person swallows there is a click in each ear, showing that air has passed up the eustachian tube and into the ear chamber. The drum or tympanic membrane of the ear requires air equally on each side of it in order to allow it to vibrate freely and convey the sound to the three little bones of the ear and so to the brain. The outer side of the drum is in contact with the external ear. The inner is in contact with the air through the eustachian tube. If adenoids are present and enlarge so as to block the eustachian tube, one of two things happens. Firstly, inflammation extends to the ear, suppuration occurs and there is discharge which comes through the membrane and appears externally as running at the ear. Unless this inflammation is very rapidly stopped there will be permanent damage to the delicate parts inside the ear and some resulting permanent deafness, besides that, the ear is so close to the brain that there is always risk of serious extension to that organ. This running of the ear can as a rule be quickly stopped if treated energetically at the very commencement, but the case is quite different if allowed to go on unchecked for a couple of weeks, still more where untreated for months or years.
As serious, even more so as regards deafness, is the other condition which arises when the eustachian tube is blocked without corresponding inflammation, and this is a condition which is very commonly not attended to till the ear is so damaged that full function is never recovered again. The growth of adenoids blocks the end of the eustachian tube, hence air no longer enters the ear and the drum gets drawn in or rather pushed in by the atmospheric pressure outside. This causes slight deafness, insidious at first, but a deafness which tends to constantly increase. The mother or teacher frequently thinks the child is merely tiresome or inattentive or dull when he does not answer or says "What?" every time he is spoken to, and the mischief is allowed to continue. I had a child of about ten brought to me lately--she was dull and sullen, had night terrors, frequent colds, great fits of bad temper and they always had to shout to make her hear. The poor child had both membranes indrawn, causing considerable deafness; when the adenoids were removed she became quite a different child, bright and elert, she lost her fits of temper and sullenness, her hearing having become normal, she also lost her night terrors and her tendency to catch cold. This is a typical case where treatment is started before it is too late.
Adenoids are often said to cause mental dulness. They do not necessarily do so, but if they cut off a child from hearing what is going on around, they necessarily greatly narrow their world of thought and interfere with a large part of their education; at the same time poor physical development adds to the injury. I know one lady who is also a very typical case; she is very deaf and gets bad noises always ringing in her ears. This is the result of old-standing throat deafness which was never attended to at the time and now it is too late for anything to be done. She overworks badly, as she says if she is not busy she gets so depressed about her hearing. These are just the cases which go on to delusions of hearing voices and even may end in an asylum. The point that I want to lay stress on is that throat deafness which does not clear up *absolutely* in a couple of weeks is a thing needing imperatively to be attended to quickly, or life-long deafness will ensue, getting gradually worse and worse as time goes on.
Then there is yet another view of the result of adenoids--the aesthetic effect. The shape of the face is very substantially altered. The effect of mouth breathing, whether partial or entire, leads to a narrow formation of the nose, the nostrils look pinched in while the upper part is thickened. The mouth, always open, gives a silly look to the face. A mouth which is always used for breathing enlarges with that use just as the nose gets narrower and smaller from want of use. The upper lip is affected in three ways. It may become very short so that the front teeth look unduly prominent; or it becomes thickened and wider than it ought to be, which is also very ugly; the third way it changes the upper lip some people take as a type of beauty, this is to give it a full double arch such as you always see in the women in Burne Jones' pictures. Then where deafness ensues the face has a "wooden" expression and you see a marked line down either side of the nose. The palate also becomes more arched, the soft palate does not move freely so that there is a thickness and want of clearness in the speaking or singing voice, with some nasal tone in it.
This gives us some idea of the far-reaching results of tonsils and adenoids. To some slight extent the condition cures itself, for the growth gets smaller in adults, but the consequences of chronic catarrh, poor physical development and deafness all remain. The treatment where only slight is to encourage the child in every way to breathe through the nose and to keep the mouth shut. A great deal can be attained by the habit of breathing through the correct channel, every breath taken in through the nostrils tends to enlarge that cavity and make nose-breathing more easy, while every breath through the mouth has just the reverse effect.
Physical exercises, *where this point is attended to,* will greatly help. Many children may thus learn not to breathe in a lazy way; they too often take very shallow breaths instead of expanding the lungs fully. Care is required to let nothing impede the movements of the chest. I do not think many children tight-lace, but some have stiff clothing put round them which does help to make good lung expansion more difficult. I often notice women breathing much more rapidly than they ought to do, showing how small a part of their lungs is being expanded with each breath.
Another preventive measure we are only beginning to live up to, and that is to avoid catching clod. A cold is certainly infectious, the infection being in the air near the sufferer. Such a person, whether child or adult, ought to remain isolated for a few days so as not to spread infection, and not live in the room with other children, especially those liable to cold. Cold is caught much more from someone else than from draughts. Is it fair to other people to go about amongst them giving them disease?
Where there is any considerable obstruction present from tonsils and adenoids, or any deafness or ear-discharge whatsoever, the sooner the tonsils and adenoids are removed the better. The operation is a very slight one, only occupying a minute or two, but has to be done under laughing gas or other anaesthetic, as adenoids in children always need removal as well as the tonsils--it is such a pity to wait, as so often happens, till the damage is permanent before doing anything.
Now to take another condition of childhood that requires attention, and that is eyesight. Every young child is at first long-sighted owing to the shape of the eyeball. As the eye develops in a normal case this is corrected and vision is what we call normal. There are two great groups of cases in childhood where the vision departs from this normal. In one of these, far the most common one, the child is too long sighted; this means that they see objects perfectly at a distance, but when they attempt to look at a near object, as in reading a book, they have to strain the eye muscles, both those that accommodate the eyes to near vision and also those which converge the two eyes so as to focus them on the book.
It is a reason against a child being allowed to read or do fine kindergarten work, which is just as bad, at an early age, that undue strain is put on the eye muscles just at the time that the eye is of such a shape as to be more strained. If such work is persisted in one of two things happens. In the worse case the eye muscles give way and cease to try and work the two eyes together. The child therefore looks with one eye at the object and the other eye is turned in, causing a squint. Now a squint does not look nice, but if it were only a case of appearance it would not so much matter, but the squinting eye is seeing a different set of objects to the straight eye, and therefore the child sees everything double; when it looks at a pencil, instead of seeing one it sees two pencils; the brain dislikes this doubling of the image, and if this condition is allowed to go on, the brain learns to attend only to the better of the two images seen, that means that only one eye is used at a time and the squinting eye from want of use becomes to all practical intents blind. This condition therefore disfigures the child with a squint, gives it only one eye instead of two to see with, and destroys all binocular vision. The child thus loses the delights of stereoscopic vision, everything looks flat, things do not stand out in clear relief one behind the other. Also if any accident deprives it of sight in the good eye it is very badly off. This condition of squint, if taken in time, can be completely cured by suitable glasses and the eyes come straight again. If left too long the vision of the squinting eye is never recovered. The child cannot attend to its own eyesight and to see a child growing up with a squint is almost equal to labelling the parents as either ignorant or careless.
Slighter degrees of long-sight also require care. Children sometimes complain of a headache over the forehead whenever they read, or that everything goes misty after they have been studying a short time. Such a case is probably long-sighted, and the headaches are due to the strain on the eyes. Another indication is where styes appear on the lids or there is redness all round the lids, or the lids are stuck together on waking in the morning; all these conditions clear up absolutely and in a most delightful way as soon as the child is given suitable glasses.
The opposite extreme is short-sight. This condition is never hereditary, though the tendency to it may be. It is caused by the tissues of the eyeball being weak and giving way under strain. Any debility in general health will aid this weakening of the tissues; if added to this is habitual overstrain of holding the paper too close to the eyes, then the mischief is done. Here again is a reason for not allowing a young child, say under six, to do any fine eye work. Their little arms are not long enough to hold the work at a sufficient distance. Where a child is debilitated, as after rheumatic fever, influenza or any other infectious disease, very special care must be taken to avoid eye strain; short-sight often dates from an attack of measles or fever, the eyeball being weak and easily yielding if not carefully kept from any work at that time. To prevent short-sight the paper when the child is writing should always be strictly in front of it; the reason for this being that the two eyes may be equally used, and the child must not be allowed to hold the head on one side. In writing it is important to make sure that the writing pad is placed at an angle while the child sits absolutely straight on the chair and straight at the table. It can then write comfortably keeping its body symmetrical, with the two eyes at an equal distance from the paper, which distance should never be less than ten inches. It is thus constant care and watchfulness which are necessary to prevent short-sight--to allow a child to read curled up in a chair or on a sofa or with its head on one side is no real kindness to it.
Just one thing more about eyesight and that is that if a child has the misfortune to become short-sighted, let him have suitable glasses. It opens up a new world of beauty of which he has no conception until then, and from the very fact of not having perfect vision without glasses he values the delights of being able to see if possible more than normal people.
This brings me to a movement which is steadily growing in favour, namely the frequent medical examination of children so as to detect the beginning of any mischief and to be able to correct it in time. This systematic examination should be done about three times a year and by the same doctor, so as to get a comparative record. The child is examined as to chest capacity, the condition of the lungs and heart; the spine is examined for lateral curvature, this is specially needed with girls, partly because it shows more on a woman's figure, but also and much more important because with curvature of the spine, the pelvis or hip bone also changes in shape, and when the girl becomes a woman one of the chief causes of difficulty in childbirth is this crookedness of the pelvis; it is for this reason that one lays such great stress on lateral curvature in a girl and on giving exercises to rectify it during the early stages. The advantage of this systematic examination of children is that errors in vision, throat troubles, hollow teeth, lateral curvature, flat foot, &c., are detected early, and taken together these conditions make a great difference as to whether the child's future life is to be a sound healthy one or no.
Typed by Lacy Reagan, May 2024