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John Roberton, Observations on the Mortality
and Physical Management of Children

Part 2, Section 1

Of the Structure, Functions, and Temperament of the Body, Peculiar to Infancy and Childhood

The formation and growth of the foetus is a subject involving curious and subtle speculations, upon which it is not my intention to touch. The task I propose to myself, is, briefly to describe some of those changes in the conformation and functions of the body, which, beginning at birth, are most striking in infancy and childhood, but yet are to be observed throughout all the stages of life. Indeed, as the infant differs from the foetus, so it may be said do the child, the youth, and the adult, differ from the infant, and from each other: and this difference is not more remarkable in the size and outward figure, than in those minute structural peculiarities, some of them obscure, which pervade the entire body, and give rise to all the phenomena that characterize the several epochs of the life of man.

At the moment the infant is separated from its mother, it enters upon a new mode of existence. Hitherto it had vegetated in a state of comparative inactivity, surrounded by fluid, receiving vital heat from the parent, and nourished in a manner which no one has been able to explain. It now begins to breathe, to generate its own heat, to purify its own blood, to require and desire food, and to perform, in every respect, the functions of an independent animal being.

At this period, we find that the skin is uniformly livid, soon changing, however, to a bright scarlet, as the breathing becomes free and natural: the change in question depends on the astonishingly fine web of blood vessels of which the skin is chiefly composed, beginning to circulate arterial blood, purified for the first time by the process of respiration. The whole surface is tender and irritable, and no part more than the scalp, which is highly red and vascular, and continues to be so for several weeks. Hence it is, perhaps, that the scalp in early infancy is more liable to eruptive complaints than any other part. The cheeks, on the contrary, do not attain their colour until the process of teething draws the blood more abundantly into these parts: this occurs in the fourth or fifth month, and age, at which it may be observed, there is the greatest disposition to small pox, and other contagious diseases of the skin.

At so early a period the softness of the skin is remarkable. It is not until the third year that we perceive much alteration in this respect: and though it then begins to be more firm and fibrous, it is still as unlike that of the adult in the vigour of life, as the skin of the latter is unlike that of old age.

Beneath the skin is spread out another covering of the body, called the cellular substance, which in infancy greatly abounds, producing that smooth rounded plumpness peculiar to early life. This substance is composed of cells of the most delicate texture, containing liquid fat, the quantity of which indicates in general, with great precision, the state of the health. When the health is perfect, the cells are filled, occasioning the skin to feel firm and compact. On the contrary, the slightest deviation from the healthy standard is marked by absorption of some of the fat, and consequent flabbiness of the soft parts. Should disorder continue, the cells become empty, and the skin hangs as if it were loosened from the muscles.

Bedded in the cellular substance and fat are the principle lymphatic vessels and glands, large and in active operation. The glands, it may be observed, are extremely liable to disease.

The muscles, forming layers, which lie deeper than the cellular expanse, are of a rose colour, soft, and feeble; but like the skin, acquiring tension and firmness by age.

The bones are particularly worthy of notice, being soft, spongy, and full of blood. Those which are afterwards single, as the breast-bone and the long bones of the limbs, are generally divided into several portions held together by cartilage. The skull, although more advanced in ossification at this age, than any other part of the osseous system, is yet incomplete in some points, particularly in the fore and upper part, where there is an opening called the anterior fontanelle, through which the pulsation in the brain may be felt, even so late as the fourth year after birth.

When we consider that the bones are the frame work upon which the other parts of the body are built, that they are highly vascular, and that important changes are constantly going on in their structure, by the gradual deposition of ossific matter, until the completion of the growth, we perceive how readily such changes may be interrupted, by general disorder of the system, to the great injury of the symmetry and vigour of the body, or even to the destruction of life itself. In this respect infancy and manhood greatly differ: in the latter, the bones are rarely diseased; whereas, in youth, rickets, various kinds of distortion, and affections of the joints, rank among its most intractable maladies.

In the adult, the heart beats about seventy times during a minute. In the infant, it beats about one hundred and twenty times, [1], propelling the blood with great rapidity into all the tissues of the body; indeed into many, where no red blood circulates in after life. This latter fact shews how numerous are the blood vessels, and accounts well for the redness of the skin, flesh, bones, brain, and every other part: for every part is full of blood. So remarkable a predominance of the arterial system over the venous, nervous, and other systems, seems to be necessary for the gradual increase of the body; for, not only have the arteries to supply the ordinary waste of the juvenile frame, but also to build it up from its feeble and delicate beginning till it attains perfect growth. As their extraordinary duties begin to lessen towards adult age, we find the arteries to diminish in size, number and minuteness of ramification; and the veins, in these respects, to increase. [2] There can be no doubt that the number, frequency, and fatality of infantile diseases, especially of such as are inflammatory, depend, in a great degree, on this extreme vascularity of all the textures. This fact should ever be kept in mind in directing their treatment.

There is another circumstance connected with the distribution of the arteries which assists in discovering the cause of some organs being more liable to disease than others. At an early age, the brain, compared with the face, is more vascular than in the adult; and the same may be remarked of the contents of the thorax and abdomen, compared with the bladder, uterus, and parts in the pelvis generally. The latter, in childhood, are seldom diseased, while the former are the principal seats of its diseases. [3]

At birth, and for a long time after, the brain is soft and easily lacerated. Its bulk is relatively very great, as may be perceived on looking at the head of an infant. [4] The nerves which proceed from it are also proportionately large, and are distributed with surprising minuteness. This indicates the infantile temperament. Infancy is the age of vivid sensations, and of nervous energy. How busily the senses are engaged! how wonderful the rapidity and variety of muscular action! In the young of most of the inferior animals the same may be observed; of which the playfulness of the kitten affords an amusing example. Owing to the size and minute distribution of the nerves; the skin, as well as the stomach and other internal organs, possesses great sensibility to painful impressions, or, as it may be called, irritability. It is not to be understood, however, that the senses generally are so acute as afterwards. They require exercising to attain perfection.

When we look into the infant's mouth at birth, we perceive that its lining is of a deep red colour, and that there are no teeth, nor yet gums. Instead of gums the bony ridge of each jaw is covered by a firm smooth skin. Proceeding downwards to the stomach, the structure of which we can learn only by dissection, we find it to be highly vascular, and its mucous or inner coat of the most soft and delicate consistence. That the irritability of this coat is equal to its vascularity and softness is certain; for we often find that it is unable to bear the stimulus of common panado; and even the mother's milk is frequently returned.

The peculiar qualities remarked as belonging to the inner surface of the stomach, belong equally to the mucous membrane of the intestines throughout its whole extent. The quantity of mucous fluid which it secretes, especially when stimulated by acrid substances, and in certain states of disease, is very great, and characterizes most of the bowel complaints which happen so frequently in early life. As to their healthy functions, the stomach and bowels perform them with great rapidity; the former digesting its proper aliment, and the latter expelling their contents, at shorter intervals than in grown people. If the stomach is irritable and easily excited to vomit, the bowels are still more readily griped and disordered; a truth of which most mothers have painful experience.

In the foetus, and for long after birth, the liver is of extraordinary magnitude. We cannot doubt that it performs an important part in the infantile economy; but what that part is, remains a subject for investigation. The recent experiments and observations of Dr. Lee seem to prove that in the foetus the liver secretes a fluid which serves for the nourishment of the body during the term of foetal life. Should this circumstance receive confirmation it will confer no small honour on the discoverer. [5]

The kidneys in activity equal or surpass the other organs, as appears by the quantity of urine secreted, as well as the frequency of expelling it.

By the end of the fourth month, provided the infant has been healthy, we may, in general, remark diminished redness of the surface, greater firmness and vigour of the muscles, and increased vivacity and restlessness: the senses are also more acute, the affections more developed and lively. About this period, the infant generally becomes fretful and restless, throws up the milk, and in most cases, pours the saliva in a constant stream down the pin-a-fore. There is some cough; various little eruptions appear on the skin; derangement of the bowels takes place; the mouth is hot; the gums, which have lately begun to grow, become perceptibly redder and fuller at one or more points; and the babe conveys every thing it can lay hold of to its mouth, to press the gums upon.

These signs, in the more favourable circumstances, precede, sometimes as long as several weeks, the cutting of the two middle front teeth, called the incisors of the lower jaw. It often happens, however, that the signs of approaching dentition are more severe. Instead of a flow of saliva, there is profuse purging; large blotches appear on different parts of the body, attended with flabbiness of the flesh, or rapid emaciation, and high fever. When there is neither looseness or flow of saliva, and sometimes when there are both in a certain degree, the head becomes affected, and convulsions ensue.

The teeth do not cut the gum in a precisely regular time or order. Commonly by the beginning of the fifth month, the two middle incisor teeth of the lower jaw make their appearance. In about a month later, the two opposing teeth in the upper jaw pierce the gum: these, in a couple of months more, are followed by the two lateral incisors of the lower jaw, which in due time have their fellows from above.

When the infant is in its fifteenth or sixteenth month the foremost grinder teeth of the under jaw cut the gum, next the canine or eye teeth of the same jaw. The latter are very troublesome in cutting, and the gum generally requires scarification more than once. In the eighteenth or twentieth month the opposing grinder and canine teeth shoot through the upper gum. About the end of the second year, the last or innermost grinders make their appearance above and below and complete the milk teeth to the number of ten in each jaw.

The completion of the milk teeth is an important epoch in infantile life. The babe is now able to masticate many kinds of solid food; the stomach is more vigorous; and the bowels are somewhat less irritable. The bones are also firmer and stronger, so that the limbs no longer totter with the weight of the body; but are capable of pretty rapid locomotion. All the senses are acute, and in wonderful activity; and, of the members, the tongue is not the least restless.

Generally in the sixth year after birth, though the time varies in different infants, the jaws have grown so much, particularly in length, that the milk teeth, which at first stood closely together, are now at some distance from each other, begin to drop out, and to be succeeded by the permanent teeth. The shedding of the milk teeth, however, and the appearing of the permanent set, take place very gradually: the latter is not completed until the ninth or tenth year. [6]

It is a fanciful distinction, perhaps, to call the interval from birth to the seventh year, when the permanent begin to displace the deciduous teeth, infancy, and the next seven years, childhood. It is adopted however by many writers. The terms infant and child, when they occur in the following work, are generally to be taken as synonymous; or perhaps we should rather say, that infant and infancy are to be understood as referring to the few first years of life merely, without any precise limitation.

After the expiration of infancy, taking it as equivalent to the first seven years, the child becomes of less importance in a medical point of view, as the mortality from seven to fourteen is small compared with that of the preceding years. [7] For one child that dies between the ages of seven and fourteen, ten at least die in the period of infancy. The diseases of childhood are nevertheless highly important: being often of an active inflammatory kind, they select as their victims the healthy and robust, who, having escaped the many perils of infancy, are, on that account, to be the more prized as valuable lives. Indeed in the period referred to the system is still highly irritable; and so delicate as yet is the structure of the brain, and of all the other important organs, that when inflammatory action does commence in any of them, the most destructive effects often rapidly ensue.

The infantile temperament has already been adverted to. It is characterized by great susceptibility of the organs of sense, and through them, of the mind, to powerful impressions from slight causes; that is to say, from causes which would not, in after life, produce the same or nearly the same effects. A pinch of snuff applied to the lining of the nose, or a little cayenne to the tongue, would, in an infant three or four years old, give rise to a degree of irritation more violent and lasting, both as regards the parts acted upon, and the mind, than would happen in an adult subjected to similar operations. The same difference will hold good with reference to stimuli purely mental. Indeed, the excitability of the infantile mind presents an amusing contrast to the grave sang froid of riper years. Tears and smiles, weeping and laughter, love and aversion, curiousity and satiety, succeed each other with wonderful rapidity. The same may be observed in some grown people who are children in spite of their years. One mode of explanation answers for both. In infants, it depends on that extreme delicacy of texture and predominance of the nervous system, which invariably belong to the early stages of life. In the others, the same kind of physical peculiarities have, in a degree, continued from youth upwards.

This subject, although it may appear trifling, is yet worthy of serious attention. In the adaptation of dress to climates and seasons, in the regulation of diet, in the administration of medicine, in the formation of proper tempers and habits; indeed, in the whole detail of the physical and moral education of children, their bodily and mental peculiarities should ever be kept in view.

Footnotes

[1] From Dr. P. Dawson's Practice of Physic:

In a newborn infant placidly sleeping the pulse in a minute, is

140

Toward the first Year

124

-- the second Year

110

-- the third and fourth

96

When the first teeth begin to drop out

86

At Puberty

80

At Manhood

75

About Sixty

60

[2] The rapidity of the growth of an infant is inversely as its age, and so we may suppose is the vascularity of its frame. M. Schwartz, a German philosopher, has given us the dimensions and weight of one [of] his children at different periods after birth.

Age

Length

Weight

At Birth its length was

18 inches 8 lines

6 lb.

At the end of 8 days

20 - 2 -

7 1/2

--- 3 weeks

20 - 8 -

8 1/4

--- 4 weeks

20 - 11 -

8 3/4

--- 5 weeks

21 - 3 -

9 1/4

--- 7 weeks

21 - 8 -

9 3/4

--- 10 weeks

22 - 0 -

11

--- 11 weeks

23 - 3 -

11 1/4

--- 13 weeks

23 - 7 -

11 5/6

In 5 Months

24 - 0 -

13 1/2

In 9 ditto

27 - 7 -

14

and so on. At the end of one year, the length of the body was from 28 to 29 inches, and the weight 20 pounds. Other infants of three years were 2 feet and a half, and weighed from 25 to 30 pounds. This observation implies that, by the 3rd year a child generally attains to three-fourths more than its original length. Of course the rapidity of the growth becomes constantly less.

See Friedlander de l'education physique &c.

[3] The activity of the blood vessels in advancing the growth of some parts more quickly than others, and many curious phenomena to be observed in the developement of the body generally, are worthy of careful study, but do not come within the scope of the concise sketch here attempted. There is one circumstance, however, which may be noticed for its singularity. The age of a child, we are informed, is to be known by finding out the central point of the body: for instance, M. Chaussier ascertained that at the age of six months, it was the inferior point of the sternum: at nine months, it was a little above the navel: and at the end of 40 weeks exactly at the navel. The idea is certainly curious, but further observations of a similar kind are desirable.

[4] While the body of an adult may weigh thirty times more than it did at birth, the brain does not quite quadruple its original weight. According to Soemmering, the brain which, at birth, weighs about 13 ounces, will, at the end of two years, weigh 23 ounces; in six years about 36 1/'2 ounces; and at adult age, about 50 ounces.

[5] Dr. Lee "ascertained that the stomach of the foetus, from three to nine months old, always contains a transparent mucous and acid fluid, but never the smallest admixture of albuminous or nutritious matter -- while on the other hand the upper half of the small intestines always contains a yellowish pultacious mass which, in appearance and chemical properties exactly resembles the chyme of the adult -- in a word, pure albumen. The lower half of the small intestines contains very little of this substance. The meconium is confined solely to the large intestines. But the most remarkable fact is that a fluid, resembling that in the duodenum, viz, pure albumen, is found in the hepatic duct of the foetus -- Hence, it may be inferred that the liver secretes the nutriment of the foetus which is taken up from the small intestines." -- Med. Chirur. Review p. 504, 1827.

[6] There are many curious deviations, from the order in which the teeth usually appear. Such deviations are thus classed by Dr. Dewees, -- "1. Sometimes children are born with teeth ready cut, but this precocity is no proof of vigour or constitution. 2. Sometimes the lateral cut themselves before the middle ones; at other times the canines may be seen before the incisors. 3. Now and then the teeth are very tardy in showing themselves. We have several times seen the first tooth make its appearance after the 14th month; And Van Swisten mentions an instance where this did not happen until the 18th month, though the child was perfectly healthy; and a child is now under our care who has not yet cut a tooth, though rather beyond 17 months old. 4. Rayer mentions a case where the teeth did not appear until the child was 13 years old. 5. Fouchard relates an instance where at six years old the child had none but the fore teeth. 6. Brouzet gives an instance where only one half of the proper number of the teeth was present at the 12th year of the child's life and whose gums had acquired the hardness of an old person's. 7. Professor Baumes gives the history of a man in whom no teeth ever appeared." Dr. Dewees on the Physical treatment &c. of Children.

[7] Cheetham's Blue Coat Hospital in this town contains 80 children, all boys; 40 are from Manchester; the others from the surrounding townships. None are admitted under the age of six years, nor in general remain in, above the age of 14. During the last 8 years there has been no death in the Hospital; and within the long term of 26 years 4 only, as I am informed, have died, and one of these was drowned. This small amount of mortality is at the rate of one death annually in every 520 boys.

The Warrington Blue Coat School contains 14 boys and 10 girls, who are admitted at, from 8 to 10 years of age. During the last 12 years the School has always had its full number; and within that period none have died.

The great seminary at Ackworth, belonging to the Society of Friends contains not fewer than 300 children who enter at the age of 10 and leave at the age of 14. The sexes are generally in the proportion of 160 boys to 120 girls. A gentlemen who resided 4 years in this school informs me that during that period only 3 died; which is at the rate of 1 in 400 annually.


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