THE MOTHER'S MANUAL OF CHILDREN'S DISEASES. 

 BY CHARLES WEST, M. D. 

 FELLOW, AND LATE SENIOR CENSOR, OF THE ROYAL COLLEGE OF PHYSICIANS: FOUNDER OF, AND FORMERLY PHYSICIAN TO, THE HOSPITAL FOR SICK CHILDREN:FOREIGN CORRESPONDENT OF THE NATIONAL ACADEMY OF MEDICINE OF PARIS: ETC. 

 AUTHOR OF 'LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. '

 NEW YORK: D. APPLETON AND COMPANY. 1885. 

ADVERTISEMENT. 

I have often asked myself whether it would not be possible to give in asmall compass, and avoiding all technical detail, such an account of thediseases of infancy and childhood, as might be of use and comfort to theintelligent mother. 

Returning now, with health perfectly restored, to practise my professionfor the rest of my life exclusively in my own country, I have broughtwith me this little book, in which the comparative leisure of myenforced sojourn at Nice has enabled me to realise my purpose. 

The book is not intended as a handbook for the nursery; many such exist, and many of them are of great merit. Neither has it the worse than idlepretence of telling people how to treat their children's illnesses, without the help of a doctor. Its object is to give a description of thediseases of early life, such as may help a mother to understandsomething of their nature and symptoms, to save her from needlessanxiety as to their issue, and to enable her wisely to second the doctorin his endeavours for their cure. 

 CHARLES WEST. 

55 HARLEY STREET, CAVENDISH SQUARE. _August 1, 1885. _

CONTENTS. 

 PAGE

ADVERTISEMENT v

_PART I. _

INTRODUCTORY 1

CHAPTER I. 1 Mortality of children and its causes -- Causes fourfold: Intermarriage -- Hereditary taint -- Unhealthy dwellings -- Unwholesome food

CHAPTER II. 5 General signs of disease -- Shown by the cry, the temperature, the pulse and breathing -- Rules for examination as to these points -- Signs of absence of disease of the brain

CHAPTER III. 12 General management of disease -- Mothers who cannot nurse their children when ill -- Importance of truth and keeping child happy -- Rules for management of bed-room and bed -- The bath -- Poultices -- Leeches -- Cold applications -- Medicines -- Note-taking and relation to the doctor

_PART II. _

PLAN PROPOSED TO BE FOLLOWED 31

CHAPTER IV. 32 On the disorders and diseases of children during the first month after birth -- Still-birth -- Premature birth -- Imperfect expansion of lungs -- Jaundice -- Ophthalmia -- Scalp-swellings -- Ruptured navel

CHAPTER V. 45 Disorders and diseases of children after the first month, and until teething is finished -- Infantile atrophy -- Rules for artificial feeding -- Management of indigestion -- Thrush -- Teething -- Affections of the skin -- Eczema

_PART III. _

DISORDERS AND DISEASES INCIDENT TO ALL PERIODS OF CHILDHOOD 85

GENERAL CHARACTERISTICS OF SECOND PERIOD OF CHILDHOOD 85

CHAPTER VI. 88 Disorders and diseases of the brain and nervous system -- Their mortality and its causes -- Convulsions -- Congestion of the brain -- Sunstroke -- Water on the brain -- Inflammation from disease of the ear -- Chronic water on brain -- Brain disorder from exhaustion -- Spasmodic croup -- Epilepsy -- St. Vitus's Dance -- Palsy -- Neuralgia and headache -- Night terrors

CHAPTER VII. 128 Disorders and diseases of the chest -- Catarrh and snuffles -- Bronchitis and pneumonia -- Influenza -- Pleurisy -- Croup -- Diphtheria -- Hooping-cough -- Asthma -- Diseases of the heart

CHAPTER VIII. 151 Diseases of organs of digestion -- Description of process of digestion -- Dyspepsia of weakly children -- Jaundice -- Diarrh[oe]a -- Peritonitis -- Large abdomen -- Worms -- Ulcerated mouth -- Quinsy -- Enlarged tonsils -- Abscess at back of throat -- Diseases of kidneys -- Incontinence of urine

CHAPTER IX. 173 Constitutional diseases -- Their nature -- Chronic constitutional diseases -- Consumption -- Scrofula -- Rickets -- Acute constitutional diseases -- Rheumatic fever -- Ague -- Mumps -- Typhoid fever -- Small-pox -- Inoculation and vaccination -- Chicken-pox -- Measles

APPENDIX. 213 Mental and moral faculties in childhood, and the disorders to which they are liable

INDEX 231

THE MOTHER'S MANUAL

OF

CHILDREN'S DISEASES. 

PART I. 

_INTRODUCTORY. _

CHAPTER I. 

ON THE MORTALITY OF CHILDREN, AND ITS CAUSES. 

The purpose of this little book will probably be best attained, andneedless repetition best avoided, if we begin by inquiring very brieflywhy so many children die, what general signs indicate that they are ill, and what general rules can be laid down for their management insickness. 

The first of these inquiries would be as useless as it would be sad, ifthe rate of infant mortality were fixed by determinate laws, such asthose which limit the stature of man or the age to which he can attain. 

But this is not so; the mortality in early life varies widely indifferent countries, in different parts of the same country, and in thesame country at different times. Thus, while in some parts of Germanythe mortality under one year was recently as high as 25 to 30 per cent. Of the total births, and in England as 15, it was only a little above 10per cent. In Norway. Infantile mortality is higher in manufacturingdistricts, lower in those which are agricultural, and varies from 16 percent. In Lancashire to 9 in Dorsetshire. It is then evident thatmortality in infancy is in part dependent on remediable causes; and ofthis there is no better proof than the fact that the mortality inEngland under one year has been reduced from 15 per cent. In 1872 to 13per cent. In 1882. 

It would lead us far from any practical purpose if we were to examineinto all the causes which govern the liability to disease and deathduring infancy and childhood, in the different ranks of society. We musttherefore limit our inquiry to those conditions which are met with inthe class to which my readers may fairly be assumed to belong. 

_First_ among the causes of sickly infancy and premature death may bementioned the intermarriage of near relatives. The experience of thebreeders of animals, who, by what is termed breeding in and in, undoubtedly obtain certain qualities of speed, or strength, or beauty, does not apply here. They select for their experiments animals whosequalities in these respects are pre-eminent, and eliminate from them allwho do not occupy the first rank. In family intermarriages, however, itis rare that any consideration is regarded, save that of wealth; and thefact remains, explain it as we may, that the intermarriage of nearrelatives during several successive generations is followed by a markeddeterioration of the children, physical, mental, and moral; and by theintensifying of any hereditary predisposition to consumption, scrofula, and other constitutional ailments which form the _second_ great cause ofearly sickness and mortality. 

These are facts known to all, which yet it is not easy to represent byfigures. All the world is aware that consumption is hereditary, thatconsumptive parents are more likely than others to have consumptivechildren; and a fourth of all the patients admitted into the Hospitalfor Consumption at Brompton stated that the disease had existed in oneor other of their parents. [1] Scrofula, which is another disease closelyallied to consumption, is hereditary also; and hip disease, disease ofthe spine, abscesses, and enlarged glands in any members of a family, point to risks for the offspring which should not be forgotten, how muchsoever mental endowments, personal beauty, or the charms of dispositionmay be considered, and sometimes reasonably enough, to outweigh them. The same liability exists with reference to epilepsy, insanity, and thewhole class of affections of the nervous system. Parents inquire, withno misplaced solicitude, what is her fortune, or what are the pecuniaryresources of him to whom they are asked to entrust their son's ordaughter's future. Believe me, the question--what is the health of hisfamily, or of hers? is consumption hereditary, or scrofula, or epilepsy, or insanity?--is of far greater moment, and touches much more nearly thefuture happiness of those we love. 

These two points regard the future parents themselves; but there areother conditions on which the health of children to a great degreedepends; and of these the two most important are the _dwelling_ theyinhabit, and the _food_ they eat. 

I do not refer here to the dwellings of the poor, situated in unhealthylocalities, where fresh air does not enter, where the rays of the sun donot penetrate, with defective drainage and imperfect water-supply; but Ispeak of the nurseries of well-to-do people. 'This will do for ourbedroom, and that will make a nice spare room, and that will do for thechildren, ' is what one often hears. Had you rare plants which cost muchmoney to obtain, which needed sunlight, warmth, and air, would you notconsider anxiously the position of your conservatory, and take muchpains to insure that nothing should be wanting that could help theirdevelopment, so that you might feast your eyes upon their beauty, ordelight yourselves with their fragrance? And yet a room at the top ofthe house, one of the attics perhaps, is too often destined for thelittle one and its nurse; or if there are two or three children, onesmall room is set apart for the day nursery, and a second, probably witha different aspect, for a sleeping room, and so small that it does notfurnish the needed five hundred cubic feet of air for each. And as aconsequence, the children are ailing, any predisposition in them tohereditary disease is fostered, they have no strength to battle againstany acute illness that may befall them, and yet surprise is felt thatthe doctor is never out of the house. [2]

It is needless to dwell on the hand-feeding of infants as one of thegreat causes of mortality in infancy, and of sickliness in later life. The statistics of Foundling Hospitals bear sad testimony to the fact ofits dangers, and the researches of physicians show that a peculiar formof disease is produced by it, attended by symptoms, and giving rise toappearances after death, peculiar to the form of slow starvation fromwhich the infant has perished. I will add, because it is not generallyknown, one fresh illustration of the influence of artificial feeding inaggravating the mortality of infants. In Berlin the certificates ofdeath of all infants under the age of one year, are required to statewhether the little one had been brought up at the breast, or on somekind or other of artificial food. Of ten thousand children dying underthe age of one year, one-fourth had been brought up at the breast, three-fourths by hand. [3]

It is, as I said in the preface, no part of my plan to enter on anydetails with reference to the management of children in health. It may, therefore, suffice to have pointed out the four great causes ofpreventible disease among the wealthier classes of society; namely, theintermarriage of near relatives, the transmission of constitutionaltaint, the insanitary condition of the dwelling, and the injudiciousselection of the food of the infant. 

FOOTNOTES:

[1] This is the proportion stated in Quain's _Dictionary of Medicine_, to which the writer, Dr. Theodore Williams, adds that of 1, 000 cases inthe upper classes 12 per cent. Showed direct hereditary predisposition, and 48 per cent. Family predisposition. 

[2] Many useful suggestions will be found in Mrs. Gladstone's littletract, _Healthy Nurseries and Bedrooms_, published as one of the HealthExhibition Handbooks. 

[3] The actual numbers are 2, 628 and 7, 646. See _Generalbericht ueberdas Medizinal-und Sanitätswesen der Stadt Berlin im Jahre 1881_. 8vo. Berlin 1883, p. 19. 

CHAPTER II. 

THE GENERAL SIGNS OF DISEASE IN INFANCY AND CHILDHOOD. 

The signs of disease at all ages may be referred to one or other ofthree great classes: disorder of function, alteration of temperature, complaint of pain. 

In the infant it is the last of these which very often calls attentionto the illness from which it is suffering. Cries are the only languagewhich a young baby has to express its distress; as smiles and laughterand merry antics tell without a word its gladness. The baby must be ill, is all that its cries tell one person; another, who has seen much ofsick children, will gather from them more, and will be able to judgewhether its suffering is in the head, or chest, or stomach. The cries ofa baby with stomach-ache are long and loud and passionate; it sheds aprofusion of tears; now stops for a moment, and then begins again, drawing up its legs to its stomach; and as the pain passes off, stretches them out again, and with many little sobs passes off into aquiet sleep. If it has inflammation of the chest it does not cry aloud, it sheds no tears, but every few minutes, especially after drawing adeeper breath than before, or after each short hacking cough, it gives alittle cry, which it checks apparently before it is half finished; andthis, either because it has no breath to waste in cries, or because theeffort makes its breathing more painful. If disease is going on in thehead, the child utters sharp piercing shrieks, and then between whiles alow moan or wail, or perhaps no sound at all, but lies quiet, apparentlydozing, till pain wakes it up again. 

It is not, however, by the cry alone, or by any one sign of disease, that it is possible to judge either of its nature or of its degree, butthe mention of this serves merely as an illustration, which anyone canunderstand, of the different meanings that even a baby's cry will conveyto different persons. 

When a child is taken ill, be the disease from which it is about tosuffer what it may, there is at once a change from its condition when inhealth, such as soon attracts the attention even of the least observant. The child loses its appetite, is fretful and soon tired, and either verysleepy or very restless, while most likely it is thirsty, and its skinhotter than natural. In many instances, too, it feels sick or actuallyvomits, while its bowels are either much purged or very bound. If oldenough to talk, it generally complains of feeling ill, or says that ithas pain in some part or other, though it is by no means certain that alittle child has described rightly the seat of its pain; for it veryoften says that its head aches or that its stomach aches, just becauseit has heard people when ill complain of pain in the head or in thestomach. Some of these signs of illness are, of course, absent in theinfant, who can describe its feelings even by signs imperfectly; but thebaby loses its merry laugh and its cheerful look; it ceases to watch itsmother's or its nurse's eye as it was used to do, though it clings toher more closely than ever, and will not be out of her arms even for amoment; and if at length rocked to sleep in her lap, will yet wake upand cry immediately on being placed in its cot again. 

Symptoms such as these are sure to awaken the mother's attention to herchild, and the child's welfare and the parent's happiness alike depend, in many instances, on the way in which she sets about to answer thequestion, 'What is the matter?'

Some mothers send at once to the doctor whenever they see or fancy thatanything ails their child. But this way of getting rid of responsibilityis not always possible, nor, indeed, on moral grounds, is it alwaysdesirable, for the mother who delegates each unpleasant duty to another, whether nurse, governess, or doctor, in order to save herself trouble oranxiety, performs but half a mother's part, and can expect but half amother's recompense of love. 

Whenever a child is unwell, a mother may do much to ascertain what isthe matter, and may by the exercise of a little patience and commonsense save herself much needless heart-ache, and her child muchsuffering. 

The first point to ascertain is the presence or absence of fever; thatis to say, whether, and how much, the temperature of the body is higherthan natural. If the temperature is not higher than natural, it may betaken as almost certain that the child neither has any inflammatoryaffection of the chest, nor is about to suffer from any of the eruptivefevers. The temperature, however, cannot be judged of merely by thesensation conveyed to the hand, but must be ascertained by means of thethermometer. [4] In the case of the grown person the thermometer isplaced either under the tongue, the lips being closed over it, or in thearmpit, and is kept there five or six minutes. In young children, however, neither of these is practicable, and I prefer to place theinstrument in the groin, and crossing one leg over the other, tomaintain the thermometer there for the requisite five minutes. Thetemperature of the body in health is about 98. 5° Fahr. In the grownperson, and very slightly higher in childhood; but any heat above 99. 5°may be regarded as evidence that something is wrong, and the persistencefor more than twenty-four hours of a temperature of 101° and upwards, may be taken as almost conclusive proof of the existence of some seriousinflammation, or of the onset of one of the eruptive fevers. 

At the same time it is well to bear in mind that temporary causes, suchas especially the disorders produced by over-fatigue, or by anover-hearty or indigestible meal, may suddenly raise the temperature ashigh as 102°, or higher, but the needed repose or the action of apurgative may be followed in a few hours by an almost equally suddendecline of the heat to the natural standard. 

It is well to learn to count the pulse and the frequency of thebreathing; but to do the former accurately, requires practice such as ishardly gained except by hospital training; and indeed, with fewexceptions, the value of the information furnished by the pulse is lessin the child than in the adult. The reasons for this are obvious, sincethe rapidity of the circulation varies under the slightest causes, andthe very constraint of holding the sick child's hand makes it struggle, and its efforts raise the frequency of the heart-beats by ten or twentyin the minute. The place at which to seek the beat of the pulse is atthe wrist, just inside and below the protuberance of the wrist-bone; butif the child is very fat it is often difficult to detect it. Whendetected it is not easy to count it in early infancy, for during thefirst year of life the heart beats between 120 and 130 in the minute, diminishing between that age and five years to 100, and graduallysinking to 90 at twelve years old. In proportion, moreover, to thetender age of the child, is the rapidity of its circulation apt to varyunder the influence of slight causes, while both its frequency and thatof the breathing are about a third less during sleep than in the wakingstate. 

The frequency of the breathing is less difficult to ascertain, while atthe same time it furnishes more reliable information than the pulse. This is best tested when the child is asleep, remembering always thatthe breathing is then slower than in the waking state. The open hand, well warmed, should be laid flat and gently over the child's night-dresson the lower part of the chest and the pit of the stomach. Each heavingof the chest, which marks a fresh breath being taken, may be counted, and the information thus obtained is very valuable. Up to the age of twoyears the child breathes from 30 to 40 times in a minute, and thisfrequency gradually declines to from 25 to 30 till the age of twelve, and then settles down to from 20 to 25 as in the grown person. You wouldthus know that a sleeping infant who was breathing more than 30 times, or a child of five who breathes more than 25 times, has some ailment inits chest, and that the doctor should be sent for in order to ascertainits exact nature. 

It would answer no good purpose to give a description of the informationto be obtained by listening to the chest. To learn from this, needs thewell-trained ear; and harm, not good, comes from the half-knowledgewhich serves but to lead astray. 

A child may be very suffering, seem very ill, and its suffering andillness may depend on pain in the stomach owing to indigestion, constipation, or even to an accidental chill. After early infancy it isnot difficult to make out the seat of the child's suffering: the warmhand placed gently on its stomach will soon ascertain whether it istense or tender, whether the tenderness is confined to one particularspot, or whether it is more acute at one spot than at another; and, lastly, whether, as is the case when pain is produced by wind in theintestines, the pain and tenderness are both relieved by gentle rubbing. 

In the young infant the character of the cry will, as I have alreadysaid, give some clue to the seat of its pain, while, if you lay it downin its cot or in its nurse's arms in order to examine its stomach, itwill often resist and begin to cry. Its stomach then becomes perfectlytense, and you cannot tell whether pressure on it causes pain or whetherthe cries are not altogether the consequence of fretfulness and fear. Itis therefore the best plan to pass your hand beneath the child's clothesand to examine its stomach without altering its posture, while at thesame time the nurse in whose arms it is talks to it to distract itsattention, or holds it opposite the window, or opposite a bright light, which seldom fails to amuse an infant. If there is no tenderness of thestomach the child will not cry on pressure; or if during yourexamination the presence of wind in the intestines should occasion pain, gentle friction, instead of increasing suffering, will give relief. 

The one thing which still remains to do, especially in the case ofchildren in whom teething is not over, is to examine the mouth andascertain the state of the gums, since some ailments are caused andothers are aggravated by teething. A wise mother or an intelligent nursewill teach the child when well the little trick of putting out itstongue and opening its mouth to show its teeth when told to do so; andthough it may sometimes indulge rather out of place in theseperformances when wished to behave especially prettily before strangers, yet when older it will quickly learn the proprieties of behaviour, andin the meanwhile you profit much by the lesson when illness reallycomes. 

Sometimes, however, infants who when well will open their mouth andallow their gums to be felt without difficulty, refuse to do so whenill; and it is always desirable that the mother or nurse whose duty itis to tend the sick child constantly, should not frighten it, or loseits confidence, by doing forcibly that which the doctor who comesoccasionally may yet be quite right in doing. You will, however, generally get a good view of the mouth and throat in young infants bygently touching the lips with your finger: the child opens its mouthinstinctively, and then you can run your finger quickly over its tongue, and drawing it slightly forward perfectly see the condition of thethroat, feel the gums as you withdraw your finger, and notice theappearance of the tongue. Sometimes it is important to ascertain whethera tooth which was near coming through has actually pierced the gum, andyet the child's fretfulness renders it almost impossible to induce it toopen its mouth. If now, while the nurse holds the child in her arms, yougo behind her, you can, unseen and unawares, introduce your finger intoits mouth and ascertain all you wish to know before the little one hasrecovered from its surprise. 

I have but little to say here about the general signs of brain diseasein infancy and childhood, because they will need minute noticeafterwards. All that I would at present observe is, that you must not atonce conclude that a child's head is seriously affected, because it isheavy and fretful and passionate, and refuses to be amused. The head, aswe know by our own experience, suffers by sympathy in the course ofalmost every ailment, certainly of every acute ailment, at all ages. Ifthe babe is not sick; if its bowels can be acted on by ordinary means;if, though drowsy, it can be roused without difficulty; if, though itmay prefer a darkened room, it does not shrink from the light whenadmitted gradually; if it has no slight twitchings of its fingers or ofits wrists; if the head, though hot, is not hotter than the rest of thebody; if the large vessels of the neck, or the open part of the head, orfontanelle as it is termed, in an infant in whom the head is not yetclosed, are not beating violently; and, above all, _if when it cries itsheds tears_, you may quiet your mind on the score of the child's brain, at any rate until the doctor's visit, and may turn a deaf ear to thenurse or the friend who assures you that the child is about to haveconvulsions or to be attacked by inflammation of the brain. 

FOOTNOTES:

[4] The thermometer used for this purpose, called a _clinical_thermometer, may be bought for about twelve shillings, of any chemist orinstrument-maker, and its mode of employment can be learned in fiveminutes. No mother should be without it. 

CHAPTER III. 

THE GENERAL MANAGEMENT OF DISEASE IN INFANCY AND CHILDHOOD. 

The management of the child when ill is difficult or easy in exactproportion to whether it has been ill or well managed when in health. The mother who lives but little with her children, who contents herselfwith a daily visit to the nursery, and who then scarcely sees her littleones until they are brought into the drawing-room in the evening in fulldress, to be petted and admired and fondled by the visitors, cannotexpect to take her place by the child's bed in its sickness, to sootheits pain, and to expend upon it all the pent-up tenderness which, inspite of the calls of business or of pleasure, still dwells within herheart. She must be content to see the infant turn from her to the nursewith whose face it has all its life been familiar; or to hear the littleone tell her to go away, for her presence is associated with none ofthose 'familiar acts, made beautiful by love, ' which win the youngheart: the mother is but a stranger who brings no help, who relieves nodistress. Happy such a mother if she has found a conscientious andintelligent nurse to whom she can delegate her office; but she mustremember that with the child, love follows in the steps of daily, hourlykindnesses, that a mother's part must be played in health if it is to beundertaken in sickness, that it cannot be laid down and taken up againat pleasure. 

There is another mother who cannot nurse her child to any good purpose, she who when it was well spoilt it from excess of love, who has yieldedto each wayward wish, and has allowed it to become the petty tyrant ofthe household. The child is ill, it is languid, feverish, and in pain;no position is quite easy to it, no food pleasant to it, bed is irksome, medicine is nasty. It knows only that it suffers, it has been accustomedto have its will obeyed in everything, and cannot understand that itssuffering is not at once taken away. It insists on getting up and onbeing dressed, or on lying in its mother's or nurse's lap, where thewarmth of another person's body does but aggravate its fever; it screamswith passion at the approach of the doctor, it will not allow itself tobe examined, it will take no medicine; the doctor is powerless, themother heart-broken. Sickness is not the time to exercise authoritywhich has not been put in force before; and, not once but many times, Ihave watched, a sad spectator, the death of children from an illness notnecessarily fatal, but rendered so because it was impossible to learnthe progress of disease, impossible to administer the necessaryremedies. 

_What a child has been made when well, such it will be when sick. _

One more point I must insist on before going into details, and that isas to the necessity of perfect truthfulness in dealing with sickchildren. The foolish device of telling a child when ill, that thedoctor who has been sent for is its uncle or its cousin, is the outcomeof the still more foolish falsehood of threatening the child with thedoctor's visit if it does not do this or that. No endeavour should bespared by nurse or parent, or by the doctor himself, to render his visitpopular in the nursery. Three-fourths of the difficulties which attendthe administration of medicine are commonly the result of previous badmanagement of the child, of foolish over-indulgence, or of still morefoolish want of truthfulness. It may answer once to tell a child thatmedicine is nice when really it is nasty, but the trick will scarcelysucceed a second time, and the one success will increase yourdifficulties ever after. If medicine is absolutely necessary, and thechild is too young to understand reason, it must be given by force, veryfirmly but very kindly, and the grief it occasions will be forgotten inan hour or two. If he is old enough, tell him that the medicine isordered to do him good, and firmness combined with gentleness willusually succeed in inducing him to take it. The advantage of perfecttruthfulness extends to every incident in the illness of children, evento the not saying, 'Oh, you will soon be well, ' if it is not likely soto be. If children find you never deceive them, how implicitly they will_trust_ you, what an infinity of trouble is saved, and how much rest ofmind is secured to the poor little sufferer!

A little boy three years old was ordered to be cupped. The cupper, akind old man, said to encourage him, 'Oh, dear little boy, it'snothing. ' The child turned to his mother, saying, 'Mummy, is that true?'His mother said it was not, but that for her sake she hoped he would tryto bear it well. And the operation was performed without a cry or asound. 

I have spoken of the moral conditions implied in the successfulmanagement of sick children. There are certain physical conditions noless important. The sick child should not be left in the common nursery, of which he would taint the air, while he would be disturbed by itsother little inmates. He must (and of course I am speaking not of someslight ailment, but of a more serious indisposition) be in a room byhimself, which should be kept quiet and shaded, and at a temperaturewhich should not be allowed to fall below 60° if the chest is in any wayaffected, nor to exceed 55° in other cases, and this temperature shouldalways be measured, not by guess, but by the thermometer hung close tothe child's bed. The room is to be shaded, not by curtains round thebed--for, save in special circumstances, curtains should be banishedfrom the nursery--nor by closed shutters which exclude both light andair, but by letting down the blinds, so as to have a sort of twilight inthe room, and by shading any light which at night may be burned in theapartment; while whether by day or night the child should be so placedthat his face shall be turned from the light, not directed towards it. The room should be kept quiet, and this requires not only general quietin the house, but quiet in the movements of all persons in the room;speaking, not in a whisper, but in a low and gentle voice; walkingcarefully, not in a silk dress nor in creaky shoes, but not on tiptoe, for there is a fussy sham quietness which disturbs the sick far morethan the loudest noise. 

Little precautions, so trifling that few think of noticing them, havemuch to do with the quiet of the sick-room, and consequently with thepatient's comfort. A rattling window will keep a child awake for hours, or the creaking handle of the door rouse it up again each time anyoneenters the room; and to put a wedge in the window, or to tie back thehandle, and so quietly open and close the door, may do more thanmedicine towards promoting the child's recovery. There can, however, beno abiding quiet without a well-ordered room, and the old proverbcarried out, 'A place for everything, and everything in its place. ' Atable covered with a cloth so that things may be taken up and put downnoiselessly, and set apart for the medicine, the drink, the nourishment, cups, glasses, spoons, or whatever else the patient is in frequent needof; with a _wooden_ bowl and water for rinsing cups and glasses in, anda cloth or two for wiping them, will save much trouble and noise, andthe loud whispers of the attendants to each other, 'Where is the sugar?where is the arrowroot? where did you put down the medicine?' of whichwe hear so much in the sick-room, so much especially in the sick-room ofthe child, who is unable to tell how extremely all this disturbs him. 

One more caution still remains for me to give. Do not talk to thedoctor in the child's room, do not relate bad symptoms, do not expressyour fears, nor ask the doctor his opinion in the child's hearing. Thechild often understands much more than you would imagine, misunderstandsstill more; and over and over again I have known the thoughtlessutterance of the mother, nurse, or doctor depress a child's spirits andseriously retard his recovery. 

It is consoling to bear in mind that how grave soever a child's illnessmay be, the power of repair is greater in early life than in adult age, that with few exceptions the probability of recovery is greater in thechild than it would be from the same disease in the grown person. Thistoo is due not simply to the activity of the reparative powers in earlylife, but also in great measure to the mental and moral characteristicsof childhood. 

To make the sick child happy, in order that he may get well, is theunwritten lesson which they who have best learnt, know best how to nursesick children. It may seem strange, that from so high a purpose I shouldat once come down to so commonplace a detail as to insist on theimportance, even on this account, of keeping the sick child in bed. 

At the onset of every illness of which the nature is not obvious, duringthe course of any illness in which the chest is affected, or in whichthe temperature is higher than natural, bed is the best and happiestplace for the child. In it repose is most complete, far more completethan after early babyhood it can be in the nurse's or mother's lap, andfree from the great objection of the increased heat from being incontact with another person's body. Nothing is more painful than towitness the little child, sick and feverish, with heavy eyes, and achinghead, up and dressed, trying to amuse itself with its customary toys;then, with 'Please nurse me, ' begging to be taken in the lap, thengetting down again; fretful, and sad, and passionate by turns; draggingabout its misery, wearing out its little strength, in deference to theprejudice that bed is so weakening. 

_The bed does not weaken, but the disease does which renders bednecessary. _

A child frets sometimes at the commencement of an illness if kept inits own little cot. But put it in its nurse's or mother's big bed, set atea tray with some new toys upon it before the child, and a pillowbehind it, so that when tired with play it may lie back and go to sleep, and you will have husbanded its strength and saved your own, have halvedyour anxiety and doubled the child's happiness. 

Young infants, indeed, when ill often refuse to be put out of the arms, but over and over again I have found the experiment succeed of layingthe baby on a bed, the nurse or mother lying down by its side, andsoothing it to sleep. Were there no other drawback, it is a waste ofpower to have two persons employed in nursing a sick child; one to keepit in her lap, and the other to wait upon her. 

It is important in all serious illnesses of children, as well as of agrown person, that the bed should be so placed that the attendant canpass on either side, and can from either side reach the patient to dowhatever is necessary. Most cots for young children have a rail roundthem to prevent the child falling out of bed when asleep or at play; butnothing can be more inconvenient than the fixed rail over which theattendant has to bend in order to give the child food or medicine, orfor any other purpose. When I founded the Children's Hospital in OrmondStreet, I introduced children's cots (the idea of which I took fromthose in the Children's Hospital at Frankfort) the sides of which letdown when needed, while on the top of the rail, or dependent from it, aboard is placed surrounded by a raised beading on which the toys, thefood, or drink may be put with great convenience. These bedsteads, withprobably some improved arrangement for letting down the sides, may beseen now in most children's hospitals, but I have been surprised toobserve how seldom they are employed in private nurseries, and howcomparatively few bedstead-makers are acquainted with them. The resultwould probably have been very different had a patent been taken out forthem, and had they been largely advertised as 'Dr. West's improvedchildren's bedsteads'! The uninclosed spring mattress, and thewedge-shaped horsehair cushion, both of which I introduced in OrmondStreet, are also very valuable. The latter slightly raises the head andshoulders, and renders any other than a thin horsehair pillow for thehead to rest on unnecessary. 

A few more hints about the bed may not be out of place. First of all, after early infancy is over, at latest after nine months, except forsome very special reason the napkin should be done away with. It heatsthe child, chafes it, and makes it sore; it conceals the inattention ofthe nurse, and at the same time renders it less easy to keep the littleone absolutely clean than if a folded napkin is placed under the hips, whence it can be at once removed when soiled. In all serious illness apiece of macintosh should be placed under the sheet, as is done in thelying-in room, and a draw-sheet, as it is termed, over it. Thedraw-sheet is, as its name implies, a folded sheet, laid under the hips, and withdrawn in part when needed so as to prevent the child ever lyingon linen that is wet or soiled. It can be drawn away from under thechild, and a portion still clean and dry brought under it, while thesoiled part is rolled together and wrapped up in macintosh at one sideof the bed until a new draw sheet is substituted, which is easily doneby tacking a fresh sheet to that which is about to be withdrawn, whenthe fresh one is brought under the child's body as that which is soiledis removed. The greatest care should always be taken that the undersheet is perfectly free from ruck or wrinkle; in long illnesses the skinbecomes chafed and bed-sores may be produced by neglect of this simpleprecaution. The complaint that a child throws off the bed-clothes iseasily remedied by a couple of bits of tape tied on either side looselyfrom the sheet or blanket to the sides of the cot. 

When children are compelled to remain long in bed, great care is neededto prevent the skin from being chafed, which is the first step thatleads to the occurrence of bed-sores. Careful washing with soap andwater daily of the whole body, not only of those parts which may besoiled by the urine or the evacuations; the washing afterwards with puretepid water; careful drying, and abundant powdering with starch powder, will do much to prevent the accident. If, in spite of this care, theskin seems anywhere to be red or chafed, it should be sponged over withbrandy or with sweet spirits of nitre before powdering. Real bed-soresmust be seen and treated by the doctor. 

The warm bath is a great source of comfort to the sick child, and in allcases of feverishness, of influenza, or threatening bronchitis, itshould not be omitted before the child is put to bed, or must be giventowards evening if the child has not been up during the day. The bathmay be either warm or hot, the temperature of the former being 90° to92°, that of the latter 95° to 96°. The temperature should always beascertained by the thermometer, and the _warm_ bath only should beemployed, except when the _hot_ bath is ordered by the doctor. The warmbath relieves feverishness and quiets the system, and promotes gentleperspiration; the hot bath is given when the eruption of scarlet feveror of measles fails to come out properly, or in some cases ofconvulsions at the same time that cold is applied to the head, or, insome forms of dropsy when it is of importance to excite the action ofthe skin as much as possible. It is not desirable that a child shouldremain less than five or more than ten minutes in the bath, andattention must be paid by the addition of warm water to maintain thebath at the same temperature during the whole time of the child'simmersion. 

Now and then infants and very young children when ill seem frightenedat the bath, and then instead of being soothed and relieved by it theyare only excited and distressed. If the bath is brought into the room, prepared in the child's sight, and he is then taken out of bed, undressed, and put into the water which he sees steaming before him, hevery often becomes greatly alarmed, struggles violently, criespassionately, and does not become quiet again till he has sobbed himselfto sleep. All this time, however, he has been exerting his inflamedlungs to the utmost, and will probably have thereby done himself tentimes more harm than the bath has done good. Very different would ithave been if the bath had been got ready out of the child's sight; ifwhen brought to the bedside it had been covered with a blanket so as tohide the steam; if the child had been laid upon the blanket, and gentlylet down into the water, and this even without undressing him if he werevery fearful; and then if you wish to make a baby quite happy in thewater, put in a couple of bungs or corks with feathers stuck in them, for the baby to play with. Managed thus, I have often seen themuch-dreaded bath become a real delight to the little one, and havefound that if tears were shed at all, it was at being taken out of thewater, not at being placed in it. 

In a great variety of conditions, poultices are of use. They are neededin the case of abscesses which it is wished to bring to a head; they aresometimes applied over wounds which are in an unhealthy condition, orfrom which it is desired to keep up a discharge. They soothe the pain ofstomach-ache from any cause, and are of most essential service whenconstantly applied in many forms of chest inflammation. And yet not onemother or nurse in ten knows how to make a poultice. [5] When appliedover a wound they should not be covered with oiled silk or anyimpermeable material, since the edges of the wound and the adjacent skinare apt thereby to be rendered irritable and to become covered withlittle itching pimples. When used to relieve pain in the stomach, or asa warm application in cases of inflammation of the chest, they should becovered with some impermeable material, and will then not require to bechanged oftener than every six hours. After poultices have been appliedover the chest or stomach for two or three days the skin is apt tobecome tender, and then it is well to substitute for them what may betermed a dry poultice, which is nothing else than a layer of dry cottonwool an inch or an inch and a half thick, tacked inside a piece of oiledsilk. 

A handy substitute for a poultice may be made of bran stitched in aflannel bag, heated by pouring boiling water on it, then squeezed as dryas possible and laid over the painful part. This is especially useful torelieve the stomach-ache of infants and young children. 

Spongio-piline is a useful substitute for a poultice, especially when itis desirable to employ a soothing or stimulating liniment to thesurface. It retains heat very well when wrung out of hot water, and anyliniment sprinkled on it is brought into contact with the skin muchbetter than if diffused through a poultice. I may just add that itsedges should be sloped inwards, in order to prevent the moisture from itoozing out and wetting the child's night-dress. 

When I was young, leeches and bleeding were frequently, no doubt toofrequently, employed. We have now, however, gone too much to the otherextreme, for cases are met with from time to time of congestion of thebrain, or of inflammation of the chest or of the bowels, in whichleeches bring greater and more speedy relief than any other remedy. Inapplying leeches it is always desirable that they should be put on wherethey will be out of the child's sight if possible, and where it will becomparatively easy to stop the bleeding. Hence, in many instances ofinflammation of the bowels, it is better to apply the leeches at theedge of the lower bowel, the anus as it is technically termed, than onthe front of the stomach, though, of course, this will not always answerthe purpose. Leeches to the chest may usually be put on just under theshoulder-blade; and leeches to the head on one or other side behind theear, where they will be out of the way of any large vein, and where thepressure of the finger will easily stop the bleeding. Steady pressurewith the finger will, even where there is no bone to press against, usually effect this; and then a little pad of lint put over the bite, and one or two layers over that, and all fastened on with strips ofadhesive plaster, will prevent any renewal of the bleeding. In the fewcases where it is not arrested by these means, the application of alittle of the solution of muriate of iron will hardly fail of effect. 

There is one more point to which I will refer before passing lastly tothe question of how to manage in the administration of medicine; andthis is the best way of applying cold to the head. This is oftenordered, but very seldom efficiently done. Cold is best applied by meansof a couple of bladders half-filled with pounded ice, and wrapped in twolarge napkins; one of them should be placed under the child's head, thecorners of the napkin being pinned to the pillow-case to prevent itsbeing disturbed, while the other is allowed to rest upon the head, butwith the corners of the napkin again pinned to the pillow so as to takeoff the greater part of its weight. Thus arranged, the cold applicationwill neither get displaced by the child's movements, nor will the childitself be wetted, as it too commonly is when wet cloths are employed forthis purpose, nor irritated by their perpetual removal and renewal. 

In London and in large towns there are various contrivances ofvulcanised rubber, which are, of course, far preferable to the bladders, but it is not everyone who lives in London, or who can command theresources furnished by a large city. 

The difficulties in the administration of medicine to children are ingreat part the fault, either of the doctor in giving needlesslyunpleasant medicine, or of the parents or nurse who either have failedto teach the child obedience, or who are deficient in that tact by whichhundreds of small troubles are evaded. 

As far as the doctor is concerned, all medicines should be prescribed byhim in small quantities, and as free from taste and smell as possible:or where that cannot be, the unpleasant flavour should be covered bysyrup, or liquorice, or treacle. 

Bulky powders should be avoided, and the child who has learned to takerhubarb and magnesia, or Gregory's powder without resistance, certainlydoes credit to his training. 

Aperients are the medicines most frequently needed in the minor ailmentsof children, and a wise mother will not undertake herself the managementof serious diseases. Of all aperients castor oil is perhaps the safest, the least irritating, the most generally applicable; it acts on thebowels and does nothing more. The idea that it tends specially toproduce constipation afterwards is unfounded; it does not do so morethan other aperients. All aperients quicken for a time what is termedthe peristaltic action of the bowels; that is to say, their constantmovement in a direction from the stomach to the lower bowel, which, aswell as a contraction on themselves, is constantly going on in everyliving animal, and continues even for some time after death. The bowelsstimulated to greater activity of movement by the aperient, become for atime more sluggish afterwards; they rest for a while, just as after along walk the muscles of the leg are weary and need repose. 

There are indeed aperients which do more than this, as grey powder andcalomel act upon the liver, and so by promoting an increased flow ofbile cause a more permanent excitement of the bowels, and consequentlytheir more prolonged activity; or as Epsom salts or citrate of magnesia, which by their action on the blood cause a greater secretion or pouringout of fluid from the coats of the intestines, and in this way have inaddition to their purgative property a special influence in abatingvarious feverish conditions. 

Castor oil, senna, jalap, jalapine, and scammony are simple aperients. They empty the bowels and nothing more, and in cases of simpleconstipation, or where a child is ill either from eating too much orfrom taking indigestible food, are the best purgatives that can begiven. A dose of castor oil, often one of the great griefs of thenursery, may generally be given without the least difficulty ifpreviously shaken up in a bottle with a wine-glassful of hot milksweetened and flavoured with a piece of cinnamon boiled in it, by whichall taste of the oil is effectually concealed. 

The domestic remedy, senna tea with prunes which render it palatable, confection of senna, syrup of senna, and the sweet essence of senna aregenerally very readily taken by children, but all have the disadvantageof being liable to gripe. The German liquorice powder, as it is called, which is composed of powdered senna, liquorice powder, fennel, and alittle sulphur with white sugar, is freer from this drawback than anyother preparation, and when mixed with a little water is not generallyobjected to. It is important, as senna is often adulterated and losesits properties by exposure to the air, that this powder should always beobtained from a very good chemist, purchased in small quantities, andalways kept in a glass-stoppered bottle. 

Jalap, in the form in which it is usually sold--as compound jalappowder--is in general readily taken; it acts speedily, but often withpain, and is not a desirable domestic remedy. Jalapine, which is a sortof extract of jalap, is much less apt to gripe, and owing to its smallbulk is much handier. It may be given in doses of from two to fivegrains to children from two years old and upwards. 

Scammony is another powerful simple aperient, apt to be violent in itsaction, and therefore not to be given except when the bowels have longbeen confined, or when it is given to expel worms. The compound scammonypowder is the form in which it is usually given, and of that five grainswould be a dose for a child two years old. 

Scammony, however, is a costly drug, and therefore the caution givenwith reference to German liquorice powder applies here also. 

There is a preparation of scammony, the so-called scammony mixture, which consists of the resin or extract of scammony dissolved in milk, which is extremely useful when the stomach is irritable, or there ismuch difficulty in inducing the child to take medicine. It is almosttasteless, and a tablespoonful, which would be a proper dose for a childof five years old, can be given without being detected. 

Much of the difficulty experienced in giving powders arises from theirbeing mixed with the arrowroot or jam in which they are administered. Avery small quantity of arrowroot, bread and milk, or jam, should be putin a tea-spoon; the powder then laid upon it, and covered over with thearrowroot or jelly, so, in short, as to make a kind of sandwich, withthe powder, which would thus be untasted, in the middle. 

Aloes is a purgative which acts chiefly on the large bowel and to somedegree also on the liver, and is of most use in the habitualconstipation of weakly children. In spite of its bitter taste the powderis seldom objected to if given between two layers of coarse brown sugar, while with most children the addition of a teaspoonful of treacle willinduce them to take very readily that useful medicine, the compounddecoction of aloes. 

Both rhubarb, aloes, and indeed other remedies which are nauseous ifgiven as a liquid and are bulky in the form of powder, may very readilybe given in extract in the form of very tiny pills. Thus I haveconstantly ordered the extract of rhubarb, which is nearly twice asstrong as the powder, made up into pills scarcely bigger than whatchildren call 'hundreds and thousands' and silver-coated. Ten or a dozenof these go down in a teaspoonful of jelly unknown, and with noexpenditure of temper or tears. 

The citrate of magnesia, or Dinneford's Magnesia, taken effervescingwith lemon juice, or when the effervescence has passed off, or theFrench Limonade Purgative, are almost always very readily taken, and areoften very useful in the little febrile attacks, or in the slightfeverish rashes to which children are liable in the spring and autumn. 

Mercurials should have no place among domestic remedies. I do not meanthat the doctor need be called in to prescribe each time that they aregiven, but that the mother should learn from him distinctly withreference to each individual child the circumstances which justify theiremployment. They stimulate the liver, as well as produce thereby actionof the bowels, but they have, especially if often employed, afar-reaching influence on the constitution, and that undoubtedly of adepressing kind: an influence more than made up for when really neededby their other qualities, and especially by their power in doing awaywith the results of many forms of chronic inflammation. They are 'edgedtools, ' however, and we know the proverb about those who play withthem. [6]

Grey powder, blue pill, and calomel are the three forms in one or otherof which mercurials are commonly given. Of the three, grey powder is themildest; but it has the inconvenience of not infrequently causingnausea, or actual sickness. This objection does not apply to blue pill, which can be given either in the tiny pills of which I have alreadyspoken, or else broken down, and given in a little jam, or in ateaspoonful of syrup or treacle. On the whole I prefer calomel in smalldoses. It has the great advantage of tastelessness, small bulk, and ofnever causing sickness. Half a grain of calomel may be regarded asequivalent to two grains of grey powder or blue pill. 

I shall speak afterwards of other medicines, which may in variouscircumstances be given, to act upon the bowels; but the above includeall that are at all fit for common use in the nursery. 

Before leaving this subject I will add a word or two about the use ofsuppositories and lavements in infancy and childhood. A piece of paperrolled up into a conical form and greased, or a bit of soap, is notinfrequently introduced by nurses just within the bowel, as a means ofovercoming constipation in infants. The irritation of the muscle at itsorifice (the sphincter, as it is termed) excites the bowels to action, and does away with the necessity for giving an aperient. The drawbackfrom this, as well as from the use of the lavement, is that iffrequently employed they become habitually necessary, and the bowelswill then never act without their customary stimulus. The lavement, too, has the additional disadvantage that while the lower part of the bowelis in proportion more capacious in infancy and childhood than in theadult, this peculiarity becomes exaggerated by the constant distensionof the intestine, and a larger and still larger quantity of fluid needsto be thrown up in order to produce the requisite action of the bowels. 

Opiates and other soothing medicines should never be given except whenprescribed by the doctor. Thirty-two deaths in England under five yearsof age in 1882 represent but a very small part of the evil wrought bythe overdose or injudicious use of these remedies. Above all, soothingmedicines of varying strength, as syrup of poppies, or of unknowncomposition, as Dalby's Carminative or Winslow's Soothing Syrup, shouldnever be employed. The only safe preparation, and this to be given onlyby the doctor's orders or with his approval, is the compound tincture ofcamphor, or paregoric elixir, as it is called, of which sixty measureddrops contain a quarter of a grain of opium. Ten to fifteen measureddrops of this are a sufficient dose for a child one year old, and thisought not to be repeated within twelve hours. The repetition every fewhours of small doses of opiates is quite as hazardous as the giving of asingle overdose; and if it does not work serious mischief by stupefyingthe child, it renders it impossible to judge of its real condition. 

Thus much may suffice with reference to the more important remedies. Others will necessarily call for notice when the diseases come to beconsidered in which they may be of service. 

There are two points which still remain to be noticed before I leave theintroductory part of this little book. 

The first of these concerns the importance of keeping written notes inthe course of every case of serious illness. For want of doing this themost imperfect and conflicting accounts of what has happened are givento the doctor. No person can watch to any good purpose forfour-and-twenty hours together; and no one's memory, least of all in themidst of fatigue and anxiety, can correctly retain all detailsconcerning medicine, food, and sleep, which yet it may be of paramountimportance that the doctor should be made acquainted with. I amaccustomed to desire a record to be kept on a sheet of paper dividedinto six columns, one for food, a second for medicine, a third forsleep, a fourth for the evacuations, and a fifth for any special pointwhich the nature of the illness renders it of special moment to observe, while the date is entered on the first column of all, indicating whenfood or medicine was given, or when and for how long the child slept. Itis best to enter the variations of temperature on a separate paper, inorder that the doctor may at a glance perceive the daily changes in thisimportant respect. No one who has not made the experiment can tell therelief which the keeping this simple record gives to the anxiety ofnursing the sick, especially when the sick one is loved most tenderly. 

The other point concerns the relations of the mother or of the parentsto the doctor. I have often heard it said, 'Dr. Green always attends myhusband and myself, but we have Dr. White for the servants andchildren, ' implying a lower degree of medical knowledge as required intheir case, and to be acknowledged by a lower rate of remuneration. 

Need I say that the assumption is a mistaken one--that as muchknowledge, as large experience, are needed in the one case as in theother; while over and above, to treat children successfully, a specialtact and a special fondness for children are needed? A man may be a verygood doctor without those special gifts; but their possession, apartfrom real medical knowledge, may make a good children's nurse, but nevera good children's doctor. 

Another matter not to be forgotten is the confidence to be reposed inthe doctor--the readiness to acquiesce in his sometimes visiting thechild more frequently in the course of an illness than the symptoms mayseem to you to require. Were you involved in some civil action, in whichyour succession to large property was involved, you would scarcelyexpect your solicitor to give you his opinion on all the questions at asingle interview. In the same way, the doctor, even the mostexperienced, may need to visit his little patient several times beforehe can feel quite certain as to the nature of the disease that isimpending, while he may not wish to alarm you by suggesting all thepossibilities that are present to his mind. The child after a restlessnight may be asleep, and it may be most undesirable to wake him; or hemay be excessively cross and unmanageable, so that it is impossible tolisten to his chest; or it may be very important to ascertain whetherthe high temperature present in the morning has risen still highertowards night, or whether, after free action of the bowels, it hasfallen a degree or two, showing that no fever is impending, but that theundue heat of the body was occasioned by the constipation. Or, again, some remedy may have been ordered, of the effect of which the doctordoes not feel quite sure: he wishes to see for himself whether it isright to continue or wiser to suspend it. The wise physician, like theable general, leaves as little as may be to chance. 

Nearly forty years ago, in addressing a class of medical students, Isaid to them:

'If you are carefully to observe all the points which I have mentioned, and to make yourselves thoroughly masters of a case, you must be lavishof your time; you must be content to turn aside from the direct courseof investigation, which you would pursue uninterruptedly in the adult, in order to soothe the waywardness of the child, to quiet its fears, oreven to cheat it into good humour by joining in its play; and you mustbe ready to do this, not the first time only, but every time that youvisit the child, and must try to win its affections in order to cure itsdisease. If you fail in the former, you will often be foiled in yourattempts at the latter. Nor is this all; you must visit your patientvery often if the disease is serious in its nature and rapid in itscourse. New symptoms succeed each other in infancy and childhood withgreat rapidity; complications occur that call for some change in yourtreatment, or the vital powers falter suddenly when you least expect it. The issues of life and death often hang on the immediate adoption of acertain plan of treatment, or on its timely discontinuance. Do not wait, therefore, for symptoms of great urgency before you visit a child threeor four times a day; but if the disease is one in which changes arelikely to take place rapidly, be frequent in your visits as well aswatchful in your observation. '

Each year has added to my conviction of the perfect truth of each wordwhich I have quoted. If you believe your doctor to be a man of integrityand intelligence, be thankful for his frequent visits, which will ceaseas his anxiety abates. Be convinced that in the mean time they are made, not for his sake, but for yours. If you doubt his integrity, change yourdoctor; but do not say to him in a tone and with an emphasis which thereis no mistaking, 'Well, if you think it _really_ necessary to come'!

FOOTNOTES:

[5] I add in this note a few simple directions for making poultices, though, as I have stated in my preface, it is no part of my purpose toenter into all the details, important though they are, of a sick nurse'sduties. 

For a linseed meal poultice, see that the water is _boiling_, not merelyhot; warm the basin, put the water in _first_; sprinkle the meal on it, stirring the whole time, till it becomes of the uniform consistency ofporridge, then spread it about half an inch thick over the linen, orwhatever it is spread on, and turn up the edges for an inch all round toprevent the poultice crumbling and soiling the night-dress; and thenhaving smeared the surface with a little oil, test its warmth byapplying it to your cheek before putting it on the patient. A broadbandage of some sort or a soft towel must then be put round the body tokeep the poultice in its place, and secured with safety pins. 

Pure mustard poultices are never used in children, on account of thepain they occasion, and the too great irritation which they would causeof the delicate skin of children. A mixture of one part of mustard totwo of linseed meal is, however, often of much use in the chestaffections of children. 

Bread poultices are less generally useful than those of linseed meal. They do not retain the heat nearly so well as those of linseed meal, andare chiefly used in cuts, wounds, or small abscesses; and also becausethey are so easily made. A slice of stale bread without the crust is puton a plate, boiling water is poured over it, and drained off; it is thenplaced on a piece of muslin, pressed between two plates to squeeze outthe remaining water, and its surface is greased before it is appliedwith a little oil or lard. I would refer for details about how to makepoultices, and for many other things well worth the knowing, to MissWood's _Handbook of Nursing_, London, 12mo, 1883. 

[6] I am not ignorant of the doubts which have been raised withreference to the special influence of mercurial remedies on the liver, but prefer in a book written for non-medical readers to leave thepopular opinion unquestioned. 

PART II. 

All that has been said hitherto is only introductory to the greatpurpose of this book, which is to give an account of the nature, symptoms, and course of the more important diseases of infancy andchildhood. 

Any attempt at scientific arrangement of a popular book is useless. Iprefer, therefore, to consult simply the general convenience of myreaders. I think I do so best by considering first the disorders whichbeset the child in the first month of its existence, during what may betermed its transition from the condition of existence in the womb, toits living, breathing state as an inhabitant of this world; and next themore important ailments to which it is liable during that important timeof development which ends with the completion of teething. Afterwardsmay be studied the diseases of the head, the chest, and the bowels; nextconstitutional diseases, such as consumption and scrofula; and lastly, the various fevers, as typhoid, or, as it is popularly called, remittentfever, measles, scarlatina, and small-pox; and last of all I will add afew remarks on the mental and moral characteristics of childhood, andtheir disorders. 

CHAPTER IV. 

ON THE DISORDERS AND DISEASES OF CHILDREN DURING THE FIRST MONTH AFTERBIRTH. 

=Still-birth. =--The infant cries almost as soon as it comes into theworld. The cry is the evidence that air has entered its lungs, that theblood has now begun to take a different course from that which itfollowed before birth, and that the child has entered on a newexistence. The child who does not cry, does not breathe; it is said tobe _still-born_; its quietude means death. 

After a long or a difficult labour, or after the use of instruments, thechild is sometimes still-born in consequence of blood being poured outon its brain, and it is thus killed before birth by apoplexy. This, however, is not usually the case, but the child is generally still-bornbecause some cause or other, generally the protraction of labour, interfered with the due changes of its blood within the womb, and it isborn suffocated before its birth, and consequently unable to make thenecessary efforts to breathe afterwards. 

Drowned people are often resuscitated; the child's case is analogous totheirs; and in both the same measures have to be pursued, namely to tryto establish respiration. The degree of the warmth of the child's body, the resistance of its muscles, the red tint or the white colour of itssurface, the presence or absence of perceptible beating of its heart, measure the chances of success. Sometimes mere exposure to the cold airproduces the necessary effect; at other times breathing is excited bydashing cold water in the child's face, by slapping it, by tickling itsnostrils, or by dipping it for a few seconds in a hot bath at 100° or102°; and then swinging it a few times backwards and forwards in theair. 

Much time, however, must not be lost over these proceedings, but thechild must be laid on its back, the lower part of its body well wrappedup, the chest slightly raised by a folded napkin placed under it. Thetwo arms must then be taken firmly, raised and slowly extended on eitherside of the head, then brought down again and gently pressed on eitherside of the chest; and this movement of alternate raising and extendingthe arms and bringing them back again beside the chest must be repeatedregularly some thirty times in the minute, thus imitating the movementsof the chest in breathing. These efforts, too, must not be discontinuedso long as the surface retains its warmth, and as an occasionalheart-beat shows that life is not absolutely extinct; and I believe thatin many instances failure is due to want of perseverance rather than tothe absolute uselessness of the measure. 

=Premature Birth. =--In spite of very extraordinary exceptions, it may belaid down as a rule that children born before the completion of six anda half months of pregnancy do not survive. After that date, eachadditional week adds greatly to the chances of the child living. Thereis a mistaken idea, founded on a superstition connected with the numberseven, that a seven-months child is more likely to survive than one bornat the eighth month. But this notion is as destitute of support in factas it is opposed to common sense, and the nearer any woman hasapproached the full term of forty weeks of pregnancy, the greater arethe chances of her child being born alive and healthy. 

The premature child is by no means necessarily still-born. It breathes, but does so imperfectly, so that air does not enter all the smallerair-cells; and its voice is a whimper rather than a cry. Those changesin the heart and large vessels, which prepare, as pregnancy draws to aclose, for the altered course of the blood when the child has to breathethrough the lungs, are too little advanced for it to bear well thesudden alteration in its mode of being. The feebly beating heart and thenot completely developed lungs seem but imperfectly to maintain thebodily heat. The glands of the stomach and intestines are not yet fit toperform digestion properly, while the muscular power is too feeble forthe effort at sucking. Everything is sketched out, but to nothing hasthe finishing touch been put, and hence the frail machinery too oftenbreaks down, in the endeavour to discharge its functions. 

It is surprising, however, with what rapidity Nature in some instancesperfects the work which she has been called on prematurely to perform. 

It is our business to second Nature's endeavours. First of all, and ofmost importance, is the duty of providing from without the warmth whichthe child is unable to generate. When very feeble, it must, even withoutany previous washing or dressing, be at once wrapped in cotton wool, andthen in a hot blanket, and surrounded with hot-water bottles. A tinstomach-warmer filled with hot water is very convenient to place underthe blanket on which the child lies. Being too feeble to suck, it mustbe fed, a few drops at a time, from a small spoon; or still better, ifit is able to make any effort at sucking, it may draw its nourishmentthrough a quill. The mother after a premature confinement is almost sureto have no milk with which to nourish her child, at any rate for two orthree days. It is, therefore, wise to obtain the help of a woman with ahealthy baby. She must be allowed to bring her baby with her, sinceotherwise her supply of milk would fail, especially if she had no othermeans of getting rid of it than by the breast-pump or by drawing herbreast. Even though she may have her own baby, there are few women whocan submit, for more than a very few days, to the artificial emptyingtheir breast without the secretion being either greatly lessened oraltogether arrested. This, therefore, must be regarded as a resourceavailable only for a few days, and as the child gains strength everyeffort must be made to get it to take its mother's breast, if she hasany supply, or that of the wet-nurse. If this is found impossible, itwill be wisest to give up, at any rate for the present, the attempt tonourish the child from the breast, and to obtain for it asses' milk, which is the best substitute. By no means whatever can more than from asixth to a fourth part of a pint of milk be obtained either by thebreast-pump or by drawing the breast; and since a healthy infant of afew weeks old sucks about two pints of milk in twenty-four hours, it isevident that the supply artificially obtained must after the first fewdays be utterly inadequate. 

I have in cases of extreme weakness in premature children succeeded inpreserving them by giving them every two hours for two or three days tenmeasured drops of raw beef juice, five of brandy, and two teaspoonfulsof breast milk. Medicine has no place in the management of these cases;the question is one entirely of warmth, food, and for a time thejudicious use of stimulants. 

=Imperfect Expansion of the Lungs. =--Children not premature andperfectly well nourished are yet sometimes feeble, breathe imperfectly, cry weakly, suck difficultly or not at all, and die at the end of a fewdays. Their lamp of life flickered and went out. Such cases are met withfor the most part in conditions similar to those in which children areactually still-born; or now and then they take place when labour hasbeen of unusually short duration, the child hurried into the world toorapidly; while in other instances it is not possible to account fortheir occurrence. 

For a long time the nature of these cases was not understood; butrather more than sixty years ago a German physician discovered that airhad entered the lungs but imperfectly; that perhaps a third, perhapseven as much as half, of the lungs had never been dilated, but hadremained solid and useless; that in consequence the blood was buthalf-purified, and vitality therefore but half-sustained. The lungs, however, were found to have undergone no real change; they were notdiseased, but if air was blown into them the dark solid patches sunkbelow the level of the surrounding substance, expanded, grew bright incolour and like a sponge from which the water has been squeezed, andcrackled, or crepitated as the technical term is, from the air containedwithin them. 

We breathe in health so without conscious effort that we never realisethe fact that, according to the calculation of most competent observers, the mere elasticity of the lungs, independent even of the elasticity ofthe chest walls, opposes a resistance to each inspiration equal to 150pounds avoirdupois in the grown man and 120 in the grown woman. The wantof breath puts the respiratory muscles into play: the man takes a deepinspiration, and by this unconscious effort, he overcomes the resistanceof the chest and the elasticity of the lungs. The new-born infant feelsthe same want and makes the same effort; but its muscular power issmall, and its inspirations are often so feeble as to draw the air insome parts only into the larger tubes, while many of the smaller remainundilated, and much of the lung continues in the state in which it wasbefore birth. The blood being thus but imperfectly purified, all theprocesses of nutrition go on imperfectly, the vital powers languish, theinspiratory efforts become more and more feeble, while the elasticity ofthe lung is constantly tending to empty the small cells of air and tooppose its entrance, and next the temperature sinks and the infant dies. 

Cases in which this condition of the lungs exists usually present thehistory of the child from the very first having failed to utter a strongand loud cry like that of other children. Even after breathing has goneon for some time, such children usually appear feeble, and they suckwith difficulty, although they often make the effort. An infant thusaffected sleeps even more than new-born infants usually do; its voice isvery feeble, and rather a whimper than a cry. In the cry of the healthyinfant you at once detect two parts--the loud cry, suffering orpassionate as the case may be, and the less loud back draught ofinspiration. The French have two words for these two sounds--the _cri_and the _reprise_. The _cri_ is feeble, the _reprise_ is altogetherwanting wherever expansion of the lung has to any considerable extentfailed to take place, and you would hail this second sound as the bestproof of an improvement in the child's condition. 

If you watch the child with a little attention you will see that whilethe chest moves up and down, it is very little, if at all, dilated bythe respiratory movements. The temperature falls, the skin becomes pale, and the lips grow livid, and often slight twitching is observed aboutthe muscles of the face. The difficulty in sucking increases, the crygrows weaker and more whimpering, or even altogether inaudible, whilebreathing is attended with a slight rattle or a feeble cough, and theconvulsive movements return more frequently, and are no longer confinedto the face, but affect also the muscles of the extremities. Any suddenmovement suffices to bring on these convulsive seizures, but even whileperfectly still the child's condition is not uniform, but it willsuddenly become convulsed, and during this seizure the respiration willbe extremely difficult, and death will seem momentarily impending. In afew minutes, however, all this disturbance ceases, and the extremeweakness of the child, its inability to suck, its feeble cry, and itsfrequent and imperfect inspirations, are the only abiding indications ofthe serious disorder from which it suffers. But the other symptomsreturn again and again, until after the lapse of a few days or a fewweeks the infant dies. 

I have dwelt at some length on this condition because it is important toknow that during the first few weeks of life real inflammation of thelungs or air-tubes is of extremely rare occurrence, and that thesymptoms which are not infrequently supposed to depend on it are reallydue to a portion of the lung more or less extensive never having beencalled into proper activity. I may add that we shall hereafter have tonotice a similar condition of the lung--its collapse after having oncebeen inflated--as occurring sometimes in the course of real inflammationof the organs of respiration in early life, and forming a very seriouscomplication of the original disease. 

If the collapse of the lung is not so considerable as to destroy lifewithin the first few hours or days after birth, the babe wastes as wellas grows weaker and weaker, and this wasting coupled with the difficultbreathing not seldom causes the fear that the child has been bornconsumptive and that its death is inevitable. 

No such gloomy view need be taken. Collapse, or at least non-expansionof the lung to some extent, is by no means unusual: consumptive diseaseto such an extent in the new-born infant as to interfere with theestablishment of breathing is extremely rare. The consumptive babe cansuck, it is not so weak as the one whose lungs are imperfectly expanded;it has no convulsive twitchings, nor any of the strange head-symptomswhich we notice in the former. It wastes less rapidly, it is feverishinstead of having a lower temperature than natural, it seems less ill, and yet its death within a few weeks or months is absolutely certain;while the child whose lungs are not diseased but simply unexpanded may, if that accidental condition is removed, grow up to vigorous manhood. 

The treatment of these cases is abundantly simple. The child whobreathes imperfectly but ill maintains its heat. It must be kept warm ata temperature never less than 70°; it may, like the premature child, need stimulants, and all the precautions already mentioned as tofeeding. Twice in the day it should be put for five minutes in a hotbath at 100°, rendered even more stimulating by the addition of a littlemustard. The back and chest may be rubbed from time to time with astimulating liniment, and an emetic of ipecacuanha wine may be giventwice a day. The act of vomiting not only removes any of the mucus whichis apt to accumulate in the larger air tubes, but the powerfulinspirations which follow the effort tend to introduce air into thesmallest vesicles of the lungs, and to do away with their collapse. 

Let these directions be carried out sensibly, patiently, perseveringly, and three times out of four, or oftener still, the mother's ear willbefore many days be greeted by the loud cry, with its _cri_ and_reprise_ of which I have already spoken, and which assures her that herlittle one will live. 

There are no other affections of the lungs so peculiar to the firstmonth of life as to call for notice here. I shall have a fewobservations to make about malformations of the heart, and theprecautions for which they call in the after-life of children; but theywill find their fittest place in the chapter on Affections of the Chest. 

=Jaundice of New-born Children. =--A certain yellow tinge of the skin, unattended by any other sign of jaundice, such as the yellowness of theeye and the dark colour of the urine, is by no means to be confoundedwith real jaundice. It is no real jaundice, but is merely the result ofthe changes which the blood with which the small vessels of the skin areovercharged at birth is undergoing; the redness fading as bruises fade, through shades of yellow into the genuine flesh colour. 

This is no disease, to be treated with the grey powder and the castoroil wherewith the over-busy monthly nurse is always ready. It is anatural process, which the intelligent may watch with interest, withwhich none but the ignorant will try to interfere. 

There is, however, beside this a real jaundice, in which the skin ismore deeply stained, the whites of the eyes are yellow, the urinehigh-coloured, and in which the dark evacuations that carry away thecontents of the bowels before birth are succeeded by white motions, fromwhich the bile is absent. This condition is not very usual, save wherechildren have been exposed to cold, or where the air they breathe isunwholesome. Of this no better proof can be given than is afforded bythe fact that in the Dublin Lying-in Hospital, where the children aredefended with the greatest care both from cold and from a vitiatedatmosphere, infantile jaundice is extremely rare, while it attacksthree-fourths of the children received into the Foundling Hospital ofParis. Still it does sometimes occur when yet no cause can be assignedfor it, and it is noteworthy that it is sometimes met with in successiveinfants in the same family. 

As the respiratory function and that of the skin increase in activity, the jaundice will disappear of its own accord. Great attention must bepaid during its continuance to avoid exposure of the child to cold, while no other food than the mother's milk should be given. If thebowels are at all constipated, half a grain of grey powder or a quarterof a grain of calomel may be given, followed by a small dose of castoroil, and the aperient will often seem to hasten the disappearance of thejaundice; but in a large number of cases even this amount of medicalinterference is not needed. 

There is, indeed, a very grave form of jaundice, happily of excessiverarity, due to malformation of the liver, to absence or obstruction ofthe bile-ducts, and often accompanied with bleeding from the navel. I dobut mention it; the intensity and daily deepening of the jaundice, thefruitlessness of all treatment, and the grave illness of the child, eventhough no bleeding should occur, render it impossible to confound thishopeless condition with the trivial ailment of which I have beenspeaking. 

The next chapter will furnish a fitter place than the present forspeaking fully of the Disorders of the Digestive Organs. 

I will say now but this: that whatever a mother may do eventually, sheavoids grave perils for herself by suckling her infant for the firstmonth; while the health of her child, just launched upon the world, isterribly endangered if fed upon those substitutes for its propernutriment on which after the lapse of a few weeks it may subsist, mayeven manage to thrive. 

There are some local affections incident to the new-born childconcerning which a few words may not be out of place; and first of the

=Ophthalmia of New-born Children. =--It is the cause of the loss of sightof nine-tenths of all persons who, among the poor, are said to have beenborn blind. In the wealthier classes of society it is comparativelyrare, and seldom fails to meet with timely treatment, yet many peoplescarcely realise its dangerous character, or the extreme rapidity of itscourse. 

It generally begins about the third day after birth with swelling ofthe lid of one or other eye, though both are soon involved. The eyelidsswell rapidly, and if the affection is let alone, they soon put on theappearance of two semi-transparent cushions over the eyes. On separatingthe lids, which it is often very difficult to do owing to the spasmodiccontraction of the muscles, their inner surface is seen to be enormouslyswollen, bright red, like scarlet velvet, bathed in an abundantyellowish thin secretion, which often squirts out in a jet as the lidsare forcibly separated. Great care must be taken not to allow any ofthis fluid to enter the eye of a bystander, nor to touch his own eyeuntil the fingers have been most carefully washed, since the dischargeis highly contagious, and may produce most dangerous inflammation of theeyes of any grown person. The discharge being wiped or washed away, theeye itself may be seen at the bottom of the swelling very red, and itssmall vessels very blood-shot. By degrees the surface of the eye assumesa deeper red, it loses its brightness and its polish, while the swellingof the lids lessens, and they can be opened with less difficulty; theirinner surface at the same time becomes softer, but thick and granular, and next the eyes themselves put on likewise a granular condition whichobscures vision. The discharge by this time has become thicker andwhite, and looks like matter from an abscess. By slow degrees theinflammation may subside, the discharge lessen, the swelling diminish, and the eye in the course of weeks may regain its natural condition. Butthe danger is--and when proper treatment is not adopted early the dangeris very great--lest the mischief should extend beyond the surface of theeye, lest ulceration of the eye should take place, the ulceration reachso deep as to perforate it, and not merely interfere with the sight, butdestroy the organ of vision altogether. 

In every instance, then, in which the eyelids of a new-born infantswell, or the slightest discharge appears from them, the attention ofthe doctor must at once be called to the condition. In the meantime, andduring whatever treatment he may think it right to follow, the eye mustbe constantly covered with a piece of folded lint dipped in cold water;and every hour at least the eye must be opened and tepid water squeezedinto it abundantly from a sponge held above, but not touching it, so asto completely wash away all the discharge. A weak solution of alum andzinc, as one grain of the latter to three of the former to an ounce ofwater, may in like manner be dropped from a large camel's-hair brushfour times a day into the eye after careful washing. Simple as thesemeasures are they yet suffice, if adopted at the very beginning, andcarried on perseveringly, to entirely cure in a few days an ailmentwhich if let alone leads almost always to most lamentable results. 

I do not pursue the subject further, for bad cases require all the careof the most skilful oculist for their treatment. 

=Scalp Swellings. =--Almost every new-born child has on one or other sideof its head a puffy swelling, owing to the pressure to which the headhas been subjected in birth, and this swelling disappears at the end oftwenty-four or forty-eight hours. 

Now and then, however, though indeed very seldom, the swelling does notdisappear, but it goes on gradually increasing and becoming moredefinite in its outlines until at the end of three or four days it maybe as big as half a small orange, or sometimes even larger, soft, elastic, painless, under the unchanged scalp, but presenting thepeculiarity of having a hard raised margin with a distinct edge, whichgives to the finger passed over it the sensation of a bony ridge, beyondwhich the bone seems deficient. This tumour is due usually to the samecause as that which produces the other temporary puffy swelling of thescalp, only the pressure having been more severe, blood has actuallybeen forced out from the small vessels under the membrane which coversthe skull, and hence its gradual increase, its definite outline; andhence, too, the bony ridge which surrounds it, and which is due tonature's effort at cure, in the course of which the raised edge of themembrane covering the skull (the _pericranium_) becomes converted intobone. 

When the nature of these swellings was not understood, they used to bepoulticed, and to be opened with a lancet to let out their contents. Weknow now, however, that we have nothing to do but to let them alone;that by degrees the blood will be absorbed and the tumour willdisappear, and as it does so we may trace the gradual transformation ofthe membrane which covered it into bone, as we feel it crackling liketinsel under the finger. Two, three, or four weeks may be needed for theentire removal of one of these blood-swellings. The doctor will at oncerecognise its character, and you will then have nothing to do but towait--often, unhappily, so much harder for the anxious mother than tomeddle. 

=Ruptured Navel. =--There is a period some time before the birth of achild when the two halves of its body are not united in front, as theybecome afterwards; and hare-lip or cleft-palate sometimes remains as theresult of the arrest of that development which should have closed thefissured lip or united the two halves of the palate. 

In a similar way it happens sometimes that though the skin is closed, the muscles of the stomach (or, more properly speaking, of the belly)are not in the close apposition in which they should be, so that thebowels are not supported by the muscles, but protected only by the skin. 

More frequently than this, especially in the case of children who areborn before the time, the opening through which the navel string passesis large at birth, and fails to close as speedily and completely as itshould do afterwards. When everything goes on as it ought, the gradualcontraction of the opening helps to bring about the separation of thenavel string and its detachment, and the perfect closure of the openingtakes place at the same time, between the fifth and the eighth day afterbirth. 

If this does not occur, the bowels are very apt to protrude through theopening, and if allowed to do so for weeks or months, the openingbecomes so dilated that its closure is impossible, and the child growsup afflicted permanently with rupture through the navel. This is alwaysan inconvenience, sometimes even a source of serious danger; but ifmeans are taken to prevent the condition becoming worse, nature seldomfails eventually to bring about a cure, and to effect the completeclosure of the opening. 

If the muscles on either side do not come into apposition, but leave acleft between them, the infant should constantly wear a broad bandage offine flannel round the stomach, not applied too tightly, in order togive support. The circular bandages of vulcanised india-rubber with apad in the centre are nowise to be recommended. The pad is apt to becomedisplaced, and to press anywhere but over the navel, while its edgesirritate the infant's delicate skin, and the pressure which it exerts ifit is sufficiently tight to retain its place interferes withrespiration. 

A pad composed of pieces of plaster spread on wash-leather, and ofgraduated sizes and kept in place by adhesive strapping, [7] answers thepurpose of preventing the protrusion at the navel, and of thusfacilitating the closure of the ring better than any other device withwhich I am acquainted. They need, however, to be continued even for twoor three years, and though they should have been left off it is wise toresume their use if the child should be attacked by whooping-cough, diarrh[oe]a, or any other ailment likely to occasion violent straining. 

FOOTNOTES:

[7] These plasters for ruptured navel in sets of a dozen are to be hadof Ewen, 106 Jermyn Street, St. James's, London, and I dare say at manyother places besides. 

CHAPTER V. 

ON THE DISORDERS AND DISEASES OF CHILDREN AFTER THE FIRST MONTH, ANDUNTIL TEETHING IS FINISHED. 

=Infantile Atrophy. =--In by far the greater number of instances, thewasting of young children is due to their being fed upon food which theycannot digest, or which when digested fails to yield them propernourishment. I quoted some figures in my introductory remarks, to showfrom the evidence obtained at Berlin how much larger was the proportionof deaths under the age of one year among hand-fed infants than amongthose brought up at the breast. Foundling hospitals on the Continent, inwhich the children are all drawn from the same class, and subjected inall respects to a similar treatment, except that in some they are fed atthe breast, in others brought up by hand, show a mortality in the lattercase exactly double of that in the former. 

It is as idle to ignore these facts, and to adduce in their disproof thecase of some child brought up most successfully by hand, as it would beto deny that a battle-field was a place of danger because some peoplehad been present there and had come away unwounded. 

But it is always well not merely to accept a fact, but also to know thereason why a thing is so. The reason is twofold: partly because thedifferent substitutes for the mother's milk, taken for the most partfrom the vegetable kingdom, are less easy of digestion than the milk, and partly because, even were they digested with the same facility, theydo not furnish the elements necessary to support life in due proportion. 

All food has to answer two distinct purposes: the one to furnishmaterials for the growth of the body, the other to afford matter for themaintenance of its temperature; and life cannot be supported except on adiet in which the elements of nutrition and those of respiration bear acertain proportion to each other. Now, in milk, the proper food ofinfants, the elements of the former are to those of the latter about inthe proportion of 1 to 2, while in arrowroot, sago, and tapioca they areonly as 1 to 26, and in wheaten flour only as 1 to 7. If to this we addthe absence in these substances of the oleaginous matters which the milkcontributes to supply the body with fat, and the smaller quantity, andto a certain extent the different kind, of the salts which they contain, it becomes apparent that by such a diet the health if not the life ofthe infant must almost inevitably be sacrificed. 

But these substances are not only less nutritious, they are also lesseasy of digestion than the infant's natural food. We all know howcomplex is the digestive apparatus of the herbivorous animal, of whichthe four stomachs of the ruminants are an instance, and how large is thebulk of food in proportion to his size which the elephant requires, compared with that which suffices for the lion or the tiger. 

The stomach of the infant is the simple stomach of the carnivorousanimal, intended for food which shall not need to stay long in thatreceptacle, but shall be speedily digested; and it is only as the childgrows older, and takes more varied food, that the stomach alterssomewhat in form, that it assumes a more rounded shape, resemblingsomewhat that of the herbivorous animal, and suited to retain the foodlonger. The young of all creatures live upon their mother for a certaintime after birth; but in all the preparation for a different kind offood, and with it for an independent existence, begins much sooner andgoes on more rapidly than in man. Young rabbits are always provided withtwo teeth when born, and the others make their appearance within tendays. In the different ruminants the teeth have either begun to appearbefore birth, or they show themselves a few days afterwards; and ineither case dentition is completed within the first month, and in dogsand cats within the first ten weeks of existence. 

In the human subject the process of teething begins late, between theseventh and the ninth month, and goes on slowly: the first grindingteeth are seldom cut before the beginning of the second year, andteething is not finished until after its end. Until teething has begunthe child ought to live exclusively on the food which nature provides;for until that time the internal organs have not become fitted to digestother sustenance, and the infant deprived of this too often languishesand dies. To get from other food the necessary amount of nourishment, that food has to be taken in larger quantities, and, from the difficultyin digesting it, needs to remain longer in the stomach than the mother'smilk. One of the results of the indigestibility of the food is that thechild is often sick, the stomach getting rid of a part of that foodwhich it is unable to turn to any useful purpose; and so far well. Butthe innutritious substances do not relieve the sense of hunger. Thechild cries in discomfort, and more is given to it, and by degrees theover-distended stomach becomes permanently dilated, and holds a largerquantity than it was originally meant to contain. The undigested masspasses into a state of fermentation, and the infant's breath becomessour and offensive, it suffers from wind and acid eructations, andnurses sometimes express surprise that the child does not thrive sinceit is always hungry. While some of the food is got rid of by vomiting, some passes into the intestines, and there becomes putrid, as thehorribly offensive evacuations prove. They come away, large and solidand white, for the secretion of the bile is inadequate to complete thatsecond digestion which should take place in the intestines; or else theirritation which they excite occasions diarrh[oe]a--a green putty-likematter comes away mixed with a profuse watery discharge. 

What wonder is it that in such circumstances the body should waste mostrapidly; for it is forced from its own tissues to supply those elementsessential to the maintenance of life, which its food contains in far tooscanty a proportion. Every organ of the body contributes to the generalsupport, and life is thus prolonged, if no kind disease curtail it, until each member has furnished all that it can spare, and then deathtakes place from starvation, its approach having been slower, but thesuffering which preceded it not therefore less, than if all food hadbeen withheld. 

Do not suppose that in this description I have been painting too dark apicture, or that children who die thus have been exceptionally weak, andso under the acknowledged difficulties of hand-feeding at length becameconsumptive. They do not die of consumption, and in a large number ofinstances their bodies show no trace of consumptive disease, but presentappearances characteristic of this condition of starvation, and of thisonly. 

Along the whole track of the stomach and intestines are the signs ofirritation and inflammation. The glands of the bowels are enlarged, actual ulceration of the stomach is often met with; while sofar-reaching is the influence of this slow starvation, that even thesubstance of the kidneys and of the brain are often found softened andotherwise altered, though it might not unreasonably have been supposedthat these organs lay quite beyond the reach of any disorder ofdigestion. 

No doubt all these grievous results do not always follow; and sometimeschildren exceptionally strong manage to take and digest enough even ofunsuitable food to maintain their health, and may as they grow up, andthe changes take place in the system which fit it for a varied diet, even become robust. In the majority of instances, however, hand-fedinfants, and those especially who have been brought up chiefly onfarinaceous food, are less strong than others, and are more apt todevelop any latent tendency to hereditary disease, such as scrofula orconsumption, than members of the same family who have been brought up atthe breast. 

Enough has already been said to satisfy all but those who do not wishto be convinced, how incumbent it is on every mother to try to suckleher child. But though it is most desirable that for the first six monthsof their existence children should derive their support entirely fromtheir mother, and that until they are a year or at least nine months oldtheir mother's milk should form the chief part of their food, yet manycircumstances may occur to render the full adoption of this planimpracticable. In some women the supply of milk, although at firstabundant, yet in the course of a few weeks undergoes so considerable adiminution as to become altogether insufficient for the child's support;while in other cases, although its quantity continues undiminished, yetfrom some defect in its quality it does not furnish the infant withproper nutriment. Cases of the former kind are not unusual in young, tolerably healthy, but not robust women; while instances of the latterare met with chiefly among those who have given birth to severalchildren, whose health is bad, or among the poor, who have beenenfeebled by hard living or hard work. The children in the former casethrive well enough for the first six weeks or two months, but then, obtaining the milk in too small a quantity to meet the demands of theirrapid growth, they pine and fret, they lose both flesh and strength, and, unless the food given to supply their wants be judiciouslyselected, their stomach and bowels become disordered, and nutrition, instead of being aided, is more seriously impaired. In the case of themother whose milk disagrees with the child from some defect in itsquality, the signs are in general more pronounced. Either the infantvomits more than that small quantity which a babe who has suckedgreedily or overmuch often rejects immediately on leaving the breast, orit is purged, or it seems never satisfied, does not gain flesh, does notthrive, cries much and is not happy. In these cases, too, the mother'ssupply of milk, though abundant at first, diminishes in a few weeks; shefeels exhausted, and suffers from back-ache, or from pain in the breastseach time after the child's sucking; while, further, her generalweakness leaves her no alternative but to wean the child. 

Knowing the attempt to rear her child entirely at the breast to bevain, the mother may in such cases be tempted to bring it up by handfrom the very first. But how short soever the period may be during whichthe mother may be able to suckle her child, it is very desirable thatshe should nurse it during that period, and also that her milk shouldthen constitute its only food. For the first four or five days after theinfant's birth the milk possesses peculiar qualities, and not merelyabounds in fatty and saccharine matter, but presents its casein or curdin a form in which it is specially easy of digestion. Thesepeculiarities indeed become less marked within a week or two; but notonly is it of moment that the infant should at any rate make its startin life with every advantage, but the mother who nurses her little oneeven for a month avoids thereby almost half the risks which follow herconfinement. For the indolent, among the wealthy, a numerous class whohave but to form a wish in order to have it gratified, a wet-nurse forthe baby suggests itself at once to the mother as a ready means ofsaving herself trouble, and of shirking responsibility. This course, towhich love of pleasure and personal vanity tend alike to prompt her, often finds, in spite of all opposing reasons, the approval of thenurse, to whom it saves trouble, and the too ready acquiescence of thedoctor in a course which pleases his patient. But many circumstancesbesides those moral considerations, which ought never to be forgottenbefore the determination is formed to employ a wet-nurse, may put thisexpedient out of the question, and it becomes therefore of importance tolearn what is the best course for a mother to adopt who is either whollyunable to suckle her child, or who can do so only for a very short time. 

It is obvious that the more nearly the substitute approaches to thecharacter of the mother's milk, the greater will be the prospect of theattempt to rear the child upon it proving successful. There is noargument needed to prove that the milk of some animal more closelyresembles the mother's milk, and is more likely to prove a usefulsubstitute for it than any kind of farinaceous substance. The milk ofall animals, however, differs in many important respects from humanmilk, and differs too very widely in different animals. Thus, the milkof the cow and that of the ewe contain nearly double the quantity ofcurd, and that of the goat more than twice the quantity of butter, andit is only in the milk of the ass that the solid constituents arearranged in the same order as in man. On this account, therefore, asses'milk is regarded, and with propriety, as the best substitute for thechild's natural food. Unfortunately, however, expense is very frequentlya bar to its employment, and compels the use of the less easily digestedcows' milk. But though the cost may be a valid objection to thepermanent employment of asses' milk, it is yet very desirable when ayoung infant cannot have the breast, that it should be supplied withasses' milk for the first four or five weeks, until the first dangers ofthe experiment of bringing it up by hand have been surmounted. Thedeficiency of asses' milk in butter may be corrected by the addition ofabout a twentieth part of cream, and its disposition to act on thebowels may be lessened by heating it to boiling point, not over the firebut in a vessel of hot water; and still more effectually by the additionto it of a fourth part of lime-water or of a teaspoonful of the solutionof saccharated carbonate of lime to two ounces or four tablespoonfuls ofthe milk. 

When cows' milk is given, it must be borne in mind that it containsnearly twice as much curd, and about an eighth less sugar, than humanmilk. It is therefore necessary that it should be given in a dilutedstate and slightly sweetened. The dilution must vary according to theinfant's age; at first the milk may be mixed with an equal quantity ofwater, but as the child grows older the proportion of water may bereduced to one-third. Mere dilution with water, however, leaves theproportion of curd unaltered, and it is precisely the curd which theinfant is unable to digest. Instead, therefore, of diluting the milksimply with water, it is often better to add one part of whey to abouttwo parts of milk, which, according to the child's age, may or may notbe previously diluted. [8]

Attention must be paid to the temperature of the food when given to theinfant, which ought to be as nearly as possible the same as that of themother's milk, namely from 90° to 95° Fahrenheit, and in all cases inwhich care is needed a thermometer should be employed in order to insurethe food being given at the same temperature. Human milk is alkaline, and even if kept for a considerable time it shows little tendency tobecome sour. The milk of animals when in perfect health likewisepresents an alkaline reaction, and that of cows when at grass forms noexception to this rule. Milk even very slightly acid is certain todisagree with an infant; it is therefore always worth while the momentthat a hand-fed infant seems ailing to ascertain this point. Ifalkaline, the milk will deepen the blue colour of litmus paper, which isto be had of any chemist; if acid, it will discharge the colour and turnit red. It is, perhaps, as well to add that, as the oxygen in theatmosphere tends to redden litmus paper, it should not be left exposedto the air, but should always be kept in a glass-stoppered bottle. 

The milk of the cow is very liable to alteration from comparativelyslight causes, and particularly from changes in the animal's diet; whileeven in the most favourable circumstances if the animal is shut up in acity and stall-fed, all the solid constituents of its milk suffer aremarkable diminution; while the secretion further has a great tendencyto become acid, or to undergo even more serious deterioration. Mereacidity of the milk can be counteracted for the moment by the additionof lime-water, or by stirring up with it a small quantity of preparedchalk, which may be allowed to subside to the bottom of the vessel; orif it should happen, though indeed that is rarely the case in thesecircumstances, that the child is constipated, carbonate of magnesia maybe substituted for the chalk or lime-water. If these simple proceedingsare not sufficient to restore the infant's health, it will be wise toseek at once for another source of milk supply, and to place thesuspected milk in the hands of the medical officer of health or of thepublic analyst, in order that it may be submitted to a thorough chemicaland microscopical examination. 

The difficulty sometimes found in obtaining an unvaryingly good milksupply, as well as practical convenience in many respects, has led tothe extensive employment of various forms of condensed milk. They formundoubtedly the best substitute for fresh cows' milk which we possess, and are a great boon especially to the poor in large towns where themilk supply is often scanty, not always fresh, and sometimes of badquality. I should certainly prefer condensed milk for an infant to milkfrom cows living in close dirty stables, such as my experience thirtyyears ago made me familiar with in some parts of London. 

Still all the varieties of condensed milk are far inferior in qualityto good fresh milk. They contain less butter, less albumen, that is tosay less of the main constituents of all animal solids and fluids, and agreater proportion of what are termed the hydro-carbonates, such forinstance as sugar; or, to state the same thing differently, the elementswhich serve for nutrition are in smaller proportion than in fresh milkto those which minister to respiration. They are not only lessnutritious, but the large quantity of sugar which they contain notinfrequently disagrees with the child, and causes bowel complaint. I donot know how far the so-called unsweetened condensed milk which has oflate come into the market is free from this objection; but I have alwayspreferred the Aylesbury condensed milk, which is manufactured withsugar, to the Swiss condensed milk, into which, as I have been given tounderstand, honey largely enters. 

How much food does an infant of a month old require? what intervalsshould be allowed between each time of feeding? and how should the foodbe given? are three questions which call for a moment's notice. Theattempt has been made to determine the first point by two verydistinguished French physicians, who weighed the infants before andafter each time of sucking. Their observations, however, were notsufficiently numerous to be decisive, and their results were veryconflicting; the one estimating the quantity at two pounds and a quarteravoirdupois, which would be equivalent to nearly a quart, the other atnot quite half as much; but the observations of the latter were made onexceptionally weak and sickly infants. Infants no doubt vary, as dogrown people, as to the quantity of food they require. I should estimatefrom my own experience and observation, apart from accurate data, a pintas the minimum needed by an infant a month old; and while Dr. Frankland's estimate of a pint and a half for an infant of five monthsseems to me very reasonable, I should doubt its sufficing for a child ofnine months unless it were supplemented by other food. 

The infant during the first month of life takes food every two hours, and even when asleep should not be allowed to pass more than threehours; and this frequent need of food continues until the age of two, sometimes even until three, months. Afterwards, and until six monthsold, the child does not need to be fed oftener than every three hoursduring the twelve waking hours, and every four hours during the sleepingtime. Later on, five times in the twenty-four hours, namely thrice byday, once the last thing at night, and once again in the early morning, are best for the child's health as well as for the nurse's comfort. 

How is an infant not at the breast to be fed? Certainly not with thecup or spoon; a child so fed has no choice in the matter, but musteither swallow or choke, and is fed as they fatten turkeys for themarket. The infant, on the other hand, sucks the bottle as it would suckits mother's breast; it rests when fatigued, it stops to play, it leavesoff when it has had enough, and many a useful inference may be drawn bythe observant nurse or mother who watches the infant sucking, andnotices if the child sucks feebly, or leaves off panting from want ofbreath, or stops in the midst, and cries because its mouth is sore orits gums are tender. 

But it is not every bottle which an infant should be fed from, andleast of all from those so much in vogue now with the long elastic tube, so handy because they keep the baby quiet, who will lie by the hourtogether with the end in its mouth, sucking, or making as though itsucked, even when the bottle is empty. These bottles, as well as thetubes connected with them, are most difficult to keep clean; and soserious is this evil, that many French physicians not only denouncetheir use, in which they are perfectly justified, but prefer, to the useof any bottle at all, the feeding the infant with a spoon; and here Ithink they are mistaken. The old-fashioned flat bottle, with an openingin the middle, and a short end to which the nipple is attached withoutany tube, the only one known in the time of our grandmothers, continuesstill the best, and very good. My friend, Mr. Edmund Owen, in a lectureat which I presided at the Health Exhibition in August last year, pointed out very humorously the differences between the old bottle andthe new. An infant to be kept in health must not be always sucking, butmust be fed at regular intervals. The careful nurse takes the infant onher knee, feeds it from the old-fashioned feeding-bottle, regulating theflow of the milk according as the infant sucks heartily or slowly, withdraws it for a minute or two, and raises the child into a sittingposture if it seems troubled with flatulence, and then after a pauselets it recommence its meal. This occupies her a quarter of an hour ortwenty minutes of well-spent time, while the lazy nurse, or the motherwho has never given the matter a thought, just puts the tube in theinfant's mouth, and either takes no further trouble or occupies herselfwith something else. And yet, obvious though this is, how constantly onesees infants taken about in the perambulator with the feeding-bottlewrapped up and laid by its side, because it is said the child alwayscries when it is not sucking, and the intelligence and the common senseare wanting, as well as the patient love, that would strive to make outwhich it is of many possible causes that makes the infant cry. One moreobservation with reference to bottle-feeding may not be out of place. Itis this: that no food be left in the bottle after the child has had itsmeal, but that it should be emptied, washed out with a little warm waterand soda, and it and the india-rubber end should be kept in water tillagain needed. To insure the most perfect cleanliness it is always wellto have two bottles in use, and to employ them alternately. 

How strictly soever an infant may be kept at the breast, or howeverexactly the precautions on which I have insisted are observed, sickness, constipation, or diarrh[oe]a may occur, causing much anxiety to theparents, and giving much trouble to the doctor. 

It sometimes happens, without its being possible to assign for it anysufficient reason, that the mother's milk disagrees with her infant, orentirely fails to nourish it, so that, much against her will, she iscompelled to give up suckling it. In some instances this is due toerrors in diet, to the neglect of those rules the observance of which isessential to health, as proper exercise for instance; and then thesecretion is usually deficient in quantity as well as defective in itscomposition. In such cases the child often vomits soon after sucking, itsuffers from stomach-ache, its motions are very sour, of the consistenceof putty, and either green, or become so soon after being passed, instead of presenting the bright yellow colour and semi-fluidconsistence of the evacuations of the healthy infant, and sometimes theyare also lumpy from the presence of masses of undigested curd. Inaddition, also, the child is troubled with griping, which makes it cry;its breath is sour, or actually offensive, and the tongue is much whiterthan it should be, though it must be remembered that the tongue of thesucking child always has a very slight coating of whitish mucus, and isneither as red nor as perfectly free from all coating as it becomes inthe perfectly healthy child of three or four years old. 

In these circumstances, the diminution of stimulants, such as the stoutof which young women are sometimes mistakenly urged to take a quantityto which they were previously quite unaccustomed, is often followed byan increase of the quantity as well as an improvement in the quality ofthe milk. It is true that a nursing mother may often find her strengthmaintained, and her supply of milk increased, by taking a glass of stoutat lunch and another at dinner, instead of, but not in addition to, anyother stimulant; but mere stimulants will no more enable a woman tosuckle her infant better than she otherwise would do, than they wouldfit a man to undergo great fatigue for days together, or to go through awalking tour in Switzerland. A tumbler of one-third milk and two-thirdsgood grit gruel taken three times a day will have greater influence inincreasing the quantity of milk than any conceivable amount ofstimulant. 

There is an entirely opposite condition in which the infant does notthrive at the breast, and this for the most part is met with when themother has already given birth to and suckled several children. In theseinstances the secretion is sometimes, though not always, abundant, butthe infant does not thrive upon it. The babe does not get on, is alwayshungry after leaving the breast, and cries as though it wanted more; inaddition to which it is often purged, either while sucking or within afew minutes afterwards, though the motions, except in being morefrequent and more watery than in health, do not by any means constantlyshow any other change. The mother's history explains the rest. She isconstantly languid, suffers from back-ache, feels exhausted each timeafter the babe has sucked, probably has neuralgia in her face, orabiding headache. In many instances, too, her monthly periods return, though as a rule they do not appear in healthy women while suckling. Allthese symptoms show that her system is not equal to the duty she hasundertaken, and that therefore, for her sake as well as for that of theinfant, she must give up the attempt. 

One more case there is in which suckling has to be given up, at any ratein part, and that is when the milk is good in kind, but insufficient inquantity for the child as it grows older. This insufficiency of quantityshows itself at different periods after the infant's birth--at twomonths, three, or four. The child is not otherwise ill than that it isno longer bright, as it was wont to be, it ceases to gain flesh, itsleeps more than it used to do, though when it wakes it is always eagerfor the breast, and cries when leaving it, and if the experiment is madeof giving it some milk and water immediately on leaving it, it takesthat greedily. Mothers are loth to believe this failure of theirresources, and in the case of some who have firm and well-formedbreasts, there is but little change in their appearance to show thatwhat remains may serve for beauty, not for use. But if while the childis sucking, the nipple is taken suddenly from its mouth, instead ofinnumerable little jets of milk, spirting out from the openings of themilk-ducts, the nipple will be seen to be barely moistened by itslanguid flow. 

In conditions such as these the question of weaning partially orcompletely inevitably occurs, and where the mother's weakness is theoccasion of the failure to nourish the child, half-measures are of noavail, for so long as she does not entirely give up the attempt to dothat to which her health is unequal, her own state will grow worse, thatof the child will not improve. When errors of diet or inattention togeneral rules of health incapacitate the mother from the performance ofher duty, there may be hope from the adoption of a wiser course; whilewhen the supply simply fails from its inadequacy, much may be hoped forfrom a wise combination of hand-feeding with nursing at the breast; themother perhaps suckling the infant by day, but being undisturbed bydemands upon her at night. 

Last of all, I must refer to cases in which love has been stronger thanreason, as indeed it often is, and in which young people with somepronounced hereditary taint of scrofula or consumption marry and havechildren. In such cases, if the consumptive taint is on the mother'sside, it is, I believe, much wiser, in the inability to obtain a goodwet-nurse, to bring up the child by hand rather than at the mother'sbreast. One word, however, applicable in such circumstances, age andlong experience entitle me to add, and it is this. It is essential that, in the absence of that guarantee against the too rapid succession ofpregnancies which suckling for a reasonable time presents, there shouldbe self-restraint on both sides, lest the inscription on the youngwife's grave should be, as I have too often known it, the same as, indespite of poetry and romance, her biographer assigns as the cause ofthe death of Petrarch's Laura, that she died worn out _crebrispartubus_, by too many babies. 

In all of these cases the rules which I have already given withreference to hand-feeding have to be borne in mind: the preference forasses' milk at first, the careful regulation of the amount of curd inthe cows' milk afterwards, increased or diminished by the greater orless proportion of whey mixed with it. Sometimes, however much thequantity of curd or casein may be reduced, the child is yet unable todigest it, for it is firm and not easily acted on by the juices of thestomach. It is then best to omit it altogether, and to supply thenecessary albumen by white of egg. A very good food in thesecircumstances is made of--

White of one raw egg, Quarter of an ounce of sugar of milk, Three teaspoonfuls of cream, Half a pint of whey. 

In the course of a few weeks, or when the child seems to need strongernourishment, one part of veal-tea, made with a pound of veal to a pintof water, may be added to one part of whey, with the white of egg andsugar of milk as before, and one part of white decoction, as it wascalled some two centuries ago in England. It is composed of--

Half an ounce of hartshorn shavings, Inside of one French roll, Three pints of water--boiled to two, strained and sweetened. 

This forms an extremely useful way of introducing farinaceous food intothe infant's diet, and preparing the way for a larger amount of it whichby degrees becomes necessary. Of these, one of the most generally usefulis Liebig's or Savory and Moore's food for infants, which has theadvantage of not constipating as so many other farinaceous foods do. Chapman's Entire Wheat Flour is an extremely good food; and wheat, asyou will remember, excels other farinaceous substances in its nutritiveproperties, but it is not so easy of digestion as Liebig. There is, however, scarcely any kind of farinaceous food, among which Nestlé'smust not be forgotten, which may not answer for an infant; providedalways that at first it is not given oftener than twice a day, that itis not made too thick, nor given in larger proportion than one-third ofthe farinaceous food to two-thirds of the whey, milk, or whatever it ismixed with; and besides, whatever the food may be, it should be preparedeach time afresh. 

This is not the place for going into all details on the subject offeeding infants, or to explain how if wisely managed the child weansitself by degrees from the bottle or the breast--the best way, be itsaid, of weaning--or how by degrees it comes to its daily midday meal ofbeef-tea and bread, and then, when the first grinding teeth have beencut, to a small meat meal daily, finely minced or scraped, and so littleby little adopts the modes of living of its elders. 

But, last of all, there are instances, though not so many as the publicimagine, in which the infant, in spite of most judicious management, fails to thrive, and suffers from various disorders of its digestion. 

The most unmanageable and the least hopeful of these cases are those inwhich the infant is the subject of consumptive disease. It is very rarefor its symptoms, even in cases of the most marked tendency toconsumption on the part of the parents, to show themselves before theage of three months, and I think I may add, that apart from suchtendency consumption never appears in infancy or early childhood, exceptwhen it follows on some acute illness, such as inflammation of thelungs, or on typhoid, or, as it is commonly called, remittent fever. 

Consumption of the bowels, as it is popularly termed, may be said neverto occur in early infancy apart from consumptive disease of the lungs, and is then always accompanied by an increase towards evening of thetemperature from its natural standard of 98. 5° to 100°. Hence theabsence of cough and the persistence of a natural temperature may betaken as almost conclusive evidence that there is no consumptive diseaseof the bowels. Consumptive disease in infancy is invariably attendedwith glandular enlargement. The glands of the bowels when irritatedalways communicate their irritation to the glands in the groin and thebend of the thigh, which are felt hard and enlarged, like little peas, under the finger. But further, if there is real disease of the glands ofthe bowels, other tiny enlarged glands will be felt, like shot, underthe skin of the belly, from which in the general progress of emaciationthe layer of fat always present in the healthy baby will already havebeen removed. Besides this, too, the veins running beneath the skinthere, invisible in the healthy infant, will be seen meandering likeblue lines, and telling the story that more blood than usual flowsthrough them, because the diseased glands inside interfere with itsready passage through its proper channels. 

Two cautions, however, have to be borne in mind with reference to bothof these indications of disease. The first is, that the glands in thegroin may be enlarged from mere irritation, independent of actualdisease communicated to them from the glands inside. If, however, youfind the glands at the corner of the lower jaw and those on either sideof the neck enlarged too, you are then driven to the conclusion that theglands in the groin are enlarged not from mere local irritation, butfrom general disease, and that consumption is its cause. 

Again, the superficial veins of the belly may be enlarged from anycause which interferes with the proper circulation through the vesselsinside. Hence they are often enlarged in grown people in dropsy, andhence too in infants and young children from flatulent distension of thebowels. But in this case the other signs of consumption are wanting; theemaciation, the cough, the increase of evening temperature, and theenlargement of the glands, are all absent. 

Sometimes we meet with instances where the child does not digest itsfood, does not thrive, does not gain flesh, never passes healthyevacuations, at length wastes, loses strength, and dies, without havinghad any of the signs which I have pointed out as indicative ofconsumptive disease, and in fact without having suffered from it. Now, these cases are connected with imperfect performance of the function ofthe liver, and sometimes with an imperfection of its structure. Beforebirth the functions of the liver are not called into action in the sameway nor to the same degree as afterwards, and its structure differs inthis respect that it contains a larger amount of fat and a smallerproportion of bile-secreting cells than afterwards. It sometimes happensfrom causes which we do not understand that the liver structure not onlydoes not undergo that higher development which should take place, butthat the fat cells increase at the expense of the bile cells. In thesecircumstances the food is ill-digested and the health is much impaired, and at last wasting takes place to as great a degree as in the case ofconsumption, only there are no cough, no glandular enlargement, no bigsuperficial veins, no increased temperature, while on a carefulexamination the doctor will seldom fail to find the rounded edge of theenlarged liver coming lower down than natural. In these cases too thereis a disposition to convulsive affections, and to that peculiar form ofconvulsion called spasmodic croup, concerning which I shall havesomething to say later on. 

In its less serious form this is both a more frequent and a less gravecondition than consumption, and its existence explains to a great degreethose cases in which young children have failed to be nourished by themilk food which commonly suits their tender age, but have improved onbeef-tea, raw meat or its juice, and food entirely destitute ofsaccharine matter. 

In cases where there is reason to apprehend consumptive disease, theskill and resources of the doctor will often be heavily taxed to meeteach difficulty as it arises. A good wet-nurse, or, in default of her, asses' milk, with the addition of cream to supply the butter in whichthe asses' milk is deficient, a couple of teaspoonfuls of raw meat juicein the course of every twenty-four hours, much care in the introductionof farinaceous substances into the diet, and cod-liver oil twice a day, beginning with ten drops and gradually increasing the dose to ateaspoonful, are all that the mother herself can do. When the cod-liveroil is not borne by the stomach, or when--which, however, is not oftenthe case--the child refuses to take it, glycerine may be substituted forit, though it must be owned that it is a very poor and inefficientsubstitute. The inunction of cod-liver oil is in any case not to be hadrecourse to; it makes the child unpleasant to itself and loathsome toothers, while the power of the skin to absorb oily matters is far toolimited to be worth taking into account. 

Vomiting, though by no means a prominent symptom of either of the twovery grave conditions of which I have been speaking just now, is yet avery common attendant on all disorders of digestion in early life. It isindeed much more frequent in the infant than in the adult, and thegreater irritability of the stomach continues even after the first fewmonths of existence are past, and does not completely cease during theearly years of childhood. In every case of vomiting in childhood, therefore, the first question to set at rest is whether it depends ondisorder of the digestive system, or whether it heralds the onset of oneof the eruptive fevers, or of inflammation of the chest, or of affectionof the brain; and in determining this all the directions given when Iwas speaking of the general symptoms of disease are to be carefullystudied. Vomiting often accompanies infantile diarrh[oe]a, even when thefood taken cannot be regarded as its occasion; and now and then thestomach, with no obvious exciting cause, suddenly becomes too irritableto retain any food, and this indeed may be the case even though attendedby few or no other indications of intestinal disorder. The child in suchcases seems still anxious for the breast; but so great is theirritability of the stomach that the milk is either thrown up unchangedimmediately after it has been swallowed, or it is retained only for afew minutes, and is then rejected in a curdled state; while eachapplication of the child to the breast is followed by the same result. It will generally be found, when this accident takes place in thepreviously healthy child of a healthy mother, that it has beenoccasioned by some act of indiscretion on the part of its mother ornurse. She perhaps has been absent from her nursling longer than usual, and returning tired from a long walk or from some fatiguing occupation, has at once offered it the breast, and allowed it to suck abundantly; orthe infant has been roused from sleep before its customary hour, or ithas been over-excited or over-wearied at play, or in hot weather hasbeen carried about in the sun without proper protection from its rays. 

The infant in whom from any of these causes vomiting has come on, mustat once be taken from the breast, and for a couple of hours neither foodnor medicine should be given to it. It may then be offered a teaspoonfulof cold water; and should the stomach retain this, one or two spoonfulsmay be given in the course of the next half-hour. If this is notrejected, a little isinglass may be dissolved in the water, which muststill be given by a teaspoonful at a time, frequently repeated; or coldbarley-water may be given in the same manner. In eight or ten hours, ifno return of vomiting takes place, the experiment may be tried of givingthe child its mother's milk, or cows' milk diluted with water, in smallquantities from a teaspoon. If the food thus given does not occasionsickness, the infant may in from twelve to twenty-four hours be restoredto the breast: with the precaution, however, of allowing it to suck onlyvery small quantities at a time, lest, the stomach being overloaded, thevomiting should again be produced. 

In many instances when the sickness has arisen from some accidentalcause, such as those above referred to, the adoption of theseprecautions will suffice to restore the child's health. If, however, other signs of disorder of the stomach or bowels have preceded thesickness, or are associated with it, medicine cannot be wholly dispensedwith, and the advice of the doctor must be sought for. Very likely inaddition to directing the rules above laid down to be attended to, hemay lay a tiny dose of calomel, as a quarter, half or a whole grain onthe tongue, which often has a wonderful influence in arresting sickness;while he may further put a small poultice not much bigger than a crownpiece, made half of mustard, half of flour, on the pit of the stomachfor a few minutes, and may give the child a little saline, with a grainor two of carbonate of soda, and perhaps a drop of prussic acid. These, however, are not remedies to be employed by the mother, but must beprescribed, and their effect watched by the medical attendant. 

Sickness, indeed, is not always a solitary symptom unattended by otherevidences of disordered digestion, but is sometimes associated withsigns of its general impairment, and this may be so serious as to leadto great loss of flesh, and even to end in endangering life. In manyinstances, however, the child does not lose much flesh though it digestsill, and its symptoms would be troublesome rather than alarming, if itwere not that they are often the signs of an unhealthy constitution, outof which in the course of a few months consumption is not infrequentlydeveloped. Long-continued indigestion in the infant always warrantsanxiety on the part of the parent. 

In some of these cases there is complete loss of appetite, the infantcaring neither for the breast nor for any other food. It loses the lookof health and grows pale and languid, though it may not have any specialdisorder either of the stomach or of the bowels. It sucks but seldom andis soon satisfied, and even of the small quantity taken, a portion isoften regurgitated almost immediately. This state of things is sometimesbrought on by a mother's over-anxious care, who, fearful of her infanttaking cold, keeps it in a room too hot or too imperfectly ventilated. It follows, also, in delicate infants on attacks of catarrh or ofdiarrh[oe]a, but it is then for the most part a passing evil which timewill cure. In the majority of cases, however, the loss of appetite isassociated with evidence of the stomach's inability to digest even thesmall quantity of food taken, and the bowels are irregular in theiraction, as well as unhealthy in their secretion. Loss of appetite, too, though a frequent is by no means a constant attendant on infantileindigestion, but is replaced sometimes by an unnatural craving, in whichthe child never seems so comfortable as when sucking. It sucks much, butthe milk evidently does not sit well upon the stomach; for soon aftersucking, the child begins to cry and appears to be in much pain until ithas vomited. The rejection of the milk is followed by immediate relief;but at the same time by the desire for more food, and the child oftencan be pacified only by allowing it to suck again. In other casesvomiting is of much less frequent occurrence, and there is neithercraving desire for food, nor much pain after sucking; but the infant isdistressed by frequent acid or offensive eructations; its breath has asour or nauseous smell, and its evacuations have a most f[oe]tid odour. The condition of the bowels that exists in connection with thesedifferent forms of indigestion is variable. In cases of simple loss ofappetite, the debility of the stomach is participated in by theintestines, and constipation is of frequent occurrence, though theevacuations do not always appear unhealthy. In other instances in whichthe desire for food still continues, the bowels may act with dueregularity, but the motions may have a very unnatural appearance. If thechild is brought up entirely at the breast, the motions are usuallyliquid, of a very pale yellow colour, often extremely offensive, andcontain shreds of curdled milk, which not having been digested withinthe stomach, pass unchanged through the whole track of the bowels. Inmany instances, however, the infant having been observed not to thriveat the breast, arrowroot or other farinaceous food is given to it, whichthe stomach is wholly unable to digest, and which gives to the motionsthe appearance of putty or pipe-clay, besmeared more or less abundantlywith slime or mucus. The evacuations are often parti-coloured, andsometimes one or two unhealthy motions are followed by others whichappear perfectly natural; while attacks of diarrh[oe]a often come on, and the matters discharged are then watery, of a dark dirty greencolour, and exceedingly offensive. 

Children, like grown persons suffering from indigestion, often continue, as I have already said, to keep up their flesh much better than could beexpected, and in many cases grow up to be strong and healthy. Still thecondition is one that not merely entails much suffering on the infant, but by its continuance seriously impairs the health, and tends todevelop the seeds of any constitutional predisposition to consumptivedisease. 

In these cases there are many respects in which the mother can mostefficiently second the doctor. All causes unfavourable to health must beexamined into, and as far as possible removed. It must be seen that thenursery is well ventilated, and that its temperature is not too high;while it will often be found that no remedy is half so efficacious aschange of air. Next, it must not be forgotten that the regurgitation ofthe food is due in great measure to the weakness and consequentirritability of the stomach, and care must therefore be taken not tooverload it. If these two points are attended to, benefit may then belooked for from the employment of tonics, and as the general healthimproves the constipated condition of the bowels, so usual in thesecases, will by degrees disappear; while if aperients are needed thosesimple remedies only should be employed of which I spoke in the firstpart of this book, and the use of mercurials is not to be resorted towithout distinct medical order. 

The above mode of treatment is appropriate to cases of what may betermed the indigestion of debility, but a different plan must be adoptedin those instances in which it depends on some other cause. The rule, indeed, which limits the quantity of food to be given at one time is noless applicable here, for the rejection of some of the milk may be theresult of nothing more than of an effort which nature makes to reducethe work that the stomach has to do within the powers of that organ. Butwhen, notwithstanding that due attention is paid to this importantpoint, uneasiness is always produced by taking food, and is not relievedtill after the lapse of some twenty minutes, when vomiting takes place, or when the infant suffers much from flatulence and from frequent acidor nauseous eructations, it is clear that the symptoms are due tosomething more than the mere feebleness of the system. 

It is not, however, the mere fact that the child vomits its food, or ofthe milk so vomited being rejected in a coagulated state, which provesthat the stomach is disordered, but it is the fact of firmly coagulatedmilk being rejected with much pain, and after the lapse of aconsiderable interval from the time of its being taken, which warrantsthis conclusion. The coagulation of the curd is the first change whichthe milk of any animal undergoes when introduced into the stomach. Thecoagulum of human milk is soft and flocculent, and not so thoroughlyseparated from the other elements of the fluid, as the firm hardcoagulum or curd of cow's milk becomes from the whey in which it floats. In a state of health the abundantly secreted gastric juice speedilyredissolves the chief part of the curd in the stomach, while when it haspassed into the intestine the alkaline bile which there becomes mixedwith it, completes its solution, and converts the whole into a fluidwhich closely resembles one of the chief elements of the blood, isconsequently very easily taken up by the minute vessels whose office itis to do so, and thus supplies with nourishment the whole body. 

Milk tends, however, to undergo changes spontaneously, which produceits coagulation, and the occurrence of these changes is greatly favouredby a moderately high temperature, such as that which exists in thestomach. But the alterations of the fluid that accompany thisspontaneous coagulation are very different from those which are broughtabout by the vital processes of digestion. An acid becomes formed withinit, and the acid thus produced has none of the solvent power of gastricjuice, but by its presence impedes rather than favours digestion. Everynurse is aware that a very slight acidity of the milk will suffice togive an infant vomiting, stomach ache, and diarrh[oe]a, and the resultmust be much the same whether fermentation had begun in the milk beforeit was swallowed, or whether it commences afterwards, in consequence ofthe disordered condition of the stomach, and the absence of a healthysecretion of gastric juice. 

The nature of the food is the first point that requires attention in themanagement of these cases of infantile dyspepsia. If the child had beenfed on cow's milk the symptoms may be due to the gastric juice nothaving been able to dissolve the curd, which you will remember is muchfirmer than that of human milk as well as twice as abundant. In thiscase the substitution of asses' milk, the employing whey either entirelyor in part instead of milk, and the adding white of egg in order topresent the elements of the curd in a more easily digestible form, mayall be tried with advantage. Sometimes children refuse whey; and then amixture of cream and veal broth, more or less diluted either with wateror with the white decoction, may be given instead. The addition of soda, potash, chalk or lime water to milk before it is given is also ofservice, since it not only prevents the occurrence of fermentation, butalso renders the curd of cow's milk more easily soluble. 

The indiscriminate and over-free employment of these alkalies, however, as nursery remedies is by all means to be avoided, for the symptoms ofindigestion for which a grown person if suffering would seek the adviceof a skilful doctor require his help no less when the patient is achild. When acids will be of service in promoting the secretion of thegastric juice, when pepsine will be likely to be of use, when stimulantssuch as a little brandy, when aromatics to get rid of flatulence, opiates to relieve pain or check diarrh[oe]a, or when an occasionalmercurial, or some other remedy may be of use by stimulating the liverto increased action, are questions which I would not advise any motherto try to answer for herself. Much care and pains and knowledge andexperience are often required by the doctor to enable him to answer themcorrectly. 

I must not leave the consideration of the ailments of the digestiveorgans in early infancy without some notice of that affection of themouth popularly known as _thrush_ to which an exaggerated importance wasonce attached as the supposed cause of those symptoms of disorderedhealth, of which it is in reality only the accompaniment. Still it is asign of such grave disorder that it needs a careful study. 

THRUSH. --If you examine the mouth of a young infant, in whom the attemptat hand-feeding is not turning out well, you will often observe itslining to be beset with numerous small white spots, that look likelittle bits of curd lying upon its surface, but which on a moreattentive examination are found to be so firmly adherent to it as not tobe removed without some difficulty, when they leave the surface beneathit a deep red colour, and now and then bleeding slightly. These specksappear upon the inner surface of the lips, especially near the angles ofthe mouth, on the inside of the cheeks, and upon the tongue, where theyare more numerous at the tip and edges than towards the centre. They arelikewise seen upon the gums, though less frequently and in smallernumbers. When they first appear they are usually of a circular form, scarcely larger than a small pin's head; but after having existed for aday or two, some of the spots become three or four times as large, whileat the same time they in general lose something of their circular form. By degrees the small white crusts fall off of their own accord, leavingthe surface where they were seated redder than before; a colour whichgradually subsides, as with the infant's improved health the mouthreturns to its natural condition. If the improvement is tardy the whitespecks may be reproduced and again detached several times before themouth resumes its healthy aspect. In the worst cases the speckscoalesce, and coat the mouth as though lined with a membrane which isusually of a yellowish-white tint instead of having the dead whitecolour of the separate spots. Even here, however, though the surface isvery red, it scarcely bleeds if the deposit is removed from it gentlyand with care. 

The popular notion that when the deposit of thrush appears not only inthe mouth, but also at the edge of the bowel, it has passed through thechild is altogether erroneous. The lining membrane of the bowel indeedis red, inflamed, and presents those conditions to which I have alreadyreferred when speaking of the atrophy of hand-fed children, but theactual deposit of thrush can take place only where there exists anappropriate structure for its formation, and that is to be found, not inthe bowels, but only at the inlets and outlets of the digestive canal. The actual deposit at the outlet of the bowel is indeed exceptional, though the edges are often red and sore from the irritation produced bythe acrid motions, and this irritation sometimes extends to the skinover the lower part of the baby's person, which becomes rough, andcovered with a blush of redness. 

Thrush in the child is of far less serious import than in the grownperson. In the latter it indicates the existence of some very serious, almost hopeless disease, and hence it is that we meet with it in thelast stages of dysentery, cancer, and consumption. In the child a slightattack of thrush may occur from causes which are by no means serious, and may disappear under the use of simple means, such as I have alreadydescribed when speaking of the troubles of digestion in early infancy. 

While in any case it must rest with the doctor to regulate as he bestknows how the constitutional treatment of the condition on which thethrush depends, it must be for the mother to see that appropriate localmeasures are adopted. One point of considerable moment, and to whichless care than it deserves is usually paid, is the removing from themouth, each time after the infant has been fed, of all remains of themilk or other food. For this purpose whenever the least sign of thrushappears, the mouth should be carefully wiped out with a piece of softrag dipped in a little warm water every time after food has been given. Supposing the attack to be but slight this precaution will of itselfsuffice in many instances to remove all traces of the affection in twoor three days. If, however, there is much redness of the mouth, or ifthe specks of thrush are numerous, some medicated application isdesirable. 

The once popular honey and borax is not the best application, and thisfor a reason which I will at once explain. The secretion of the mouth ininfants is acid, disease increases this acidity; and it has been foundthat this acid state is not merely favourable to the increase of thrush, but also to the development between the specks of thrush of a sort ofmembrane formed by a peculiar microscopic growth, of whose existence, just as of that of the phylloxera which destroys the vine, or themuscardine which kills the silkworm, we were ignorant till brought tolight by recent scientific research. 

You will therefore at once see why saccharine substances, apt as theyare to pass into a state of fermentation, are not suitable, and why itis better to employ a solution of--

Borax, twenty grainsGlycerine, one teaspoonfulWater, an ounce. 

Now and then the use once or twice a day in addition of a very weaksolution of caustic, as two grains of lunar caustic to an ounce ofwater, in bad cases is necessary; but of this it must be left to thedoctor to decide. 

TEETHING. --The transition is a very natural one by which we pass fromthe study of the dangers and difficulties which attend the feeding andrearing of young infants, to those which accompany _teething_. 

The time of teething is looked forward to by most mothers withundisguised apprehension, nurses attribute to it the most varied formsof constitutional disturbance, and doctors constantly hold forth toanxious parents the expectation that their child will have better healthwhen it has cut all its teeth. The time of teething, too, is in realityone of more than ordinary peril, [9] though why it should be so is notalways rightly understood. It is a time of most active development, atime of transition from one mode of being to another, in respect of allthose important functions by whose due performance the body is nourishedand built up. 

The error which has been committed with reference to this matter, consists not in overrating the hazard of the time, when changes soimportant are being accomplished, but in regarding only one of themanifestations--though that indeed is the most striking one of the manyimportant ends which nature is then labouring to bring about. A child inperfect health usually cuts its teeth at a certain time and in a certainorder, just as a girl at a certain age begins to show signs ofapproaching womanhood; and at length attains it with but slightinconvenience or discomfort. The two processes, however, have this incommon, that during both, constitutional disturbance is more common, andserious diseases are more frequent than at other times, and the cause inboth lies far deeper than the outward manifestation. 

The great changes which nature is constantly bringing about around usand within us are the result of laws operating silently but unceasingly;and hence it is that in her works we see little of the failure whichoften disappoints human endeavours, or of the dangers which often attendon their accomplishment. Thus when her object is to render the child nolonger dependent on the mother for its food, she begins to prepare forthis long beforehand. The first indication of it is furnished by thegreatly increased activity of the salivary glands, which during thefirst few months of existence have scarcely begun to perform theirfunction, a fact which accounts for the tendency to dryness of thetongue of the young infant under the influence of very trivial ailments. About the fourth or fifth month, this condition undergoes a markedalteration; the mouth is now found continually full of saliva, and thechild is constantly drivelling; but no other indication appears of theapproach of the teeth to the surface, except that the ridge of the gumssometimes becomes broader than it was before. No further change may takeplace for many weeks; and it is generally near the end of the seventhmonth before the first teeth make their appearance. The middle cuttingteeth of the lower jaw are in most instances the first to pierce thegum; next the middle cutting teeth of the upper jaw; then usually theside cutting teeth of the lower jaw, and lastly, the corresponding onesof the upper. This, however, is not quite invariable, for sometimes allthe cutting teeth in one jaw precede in their appearance any of those inthe other. The first four grinding teeth next succeed, and often withoutany very definite order as to whether those of the upper or of the lowerjaw are first visible, though in the majority of instances the lower arethe first to appear. The four eye teeth follow, and lastly, theremaining four grinding teeth, which complete the set of first, or asthey are often called, milk teeth. 

We must not, however, picture to ourselves this process as going onuninterruptedly until completed--a mistake into which parents oftenfall, whose anxiety respecting their children is excited by observingthat after several teeth have appeared in rapid succession, the processappears to come to a standstill. Nature has so ordered it that teethingwhich begins at the seventh or eighth month, shall not be completeduntil the twenty-fourth or thirtieth; and has doubtless done so in somemeasure with the view of diminishing the risk of constitutionaldisturbance that might be incurred if the evolution of the teeth went onwithout a pause. As a rule the two lower central incisors or cuttingteeth make their appearance in the course of a week; six weeks or twomonths often intervene before the central upper incisors pierce the gum, but they are in general quickly followed by the lateral incisors. Apause of three or four months most frequently occurs before we see thefirst grinding teeth, another of equal length previous to the appearanceof the eye teeth, and then another still longer before the last grindingteeth are cut. 

Though a perfectly natural process, teething is almost always attendedwith some degree of suffering. This, however, is not always the case, for sometimes we discover that an infant has cut a tooth, who yet hadshown no signs of discomfort, nor any indication that teething wascommencing, with the exception of an increased flow of saliva. Morefrequently indeed, the mouth becomes hot, and the gums look tumid, tense, and shining, while the exact position of each tooth is marked, for some time before its appearance, by the prominence of the gum; orthe eruption of the teeth is preceded by much redness, and great heat ofthe mouth with profuse flow of saliva, and even with little painfululcers of the edge of the tongue, or of the inner surface of either lip. With either of these conditions the child is feverish, fretful, andcries from time to time with pain, while at the same time the bowelsoften are relaxed, or the child coughs and wheezes as if it had caughtcold. 

Symptoms such as these make up what nurses mean when they say that thechild is suffering from its teeth, and this opinion is constantlyfollowed by a request to the doctor to lance the baby's gums. Now thislittle operation when really called for often gives great relief, bothto the local discomfort, and also to the general ailment from which theinfant suffers, but it is often done when there is no occasion for it, and when consequently it causes needless pain, and does no good. 

There are four different conditions in which it may be right to have thechild's gums lanced:

First. When a tooth is very near the surface, and by cutting through thethin gum the child may be spared some needless suffering. 

Second. When the gums are very red and hot and swollen; only in thiscase the gum is scratched or cut, to bleed it, not with the idea ofletting out the imprisoned tooth. 

Third. When the child has for some week or two been feverish andsuffering; while, though the gum is tense and swollen, the tooth doesnot seem to advance. 

Fourth. As an experiment, when during the progress of teething a childis suddenly seized with convulsions for which there is no obvious cause. The irritation of the teeth may have to do with their occurrence; andthe chance of relieving it by so simple a means is not to be thrownaway. 

If the process of teething is going on quite naturally, nointerference, medical or other, is either necessary or proper. Thespecial liability of children to illness at this time must indeed beborne in mind, and care must be taken not to make any alteration in theinfant's food while it is actually cutting its teeth, but rather tochoose the opportunity of some one of those pauses to which referencehas been made, as occurring between the dates of appearance of thesuccessive teeth, for making any such change. If the child is feverish, a little soda or seltzer water sweetened and given after theeffervescence has subsided will be taken eagerly, and avoid the risk ofputting the child too often to the breast, or giving it food toofrequently. It seeks the one or the other because it is thirsty, andcraves for moisture to relieve its hot mouth; not because it is hungryand needs nourishment. If the child has been weaned, still greater carewill be required, for it will often be found that it is no longer ableto digest its ordinary food, which either is at once rejected by thestomach, or else passes through the intestines undigested. Very thinarrowroot made with water, with the addition of one third of milk, willsuit in many cases, or equal parts of milk and water with isinglass, orequal parts of milk and the white decoction. The bowels of course mustbe kept open with very simple and mild aperients, but the bowels are ingeneral more inclined to diarrh[oe]a than to constipation, and thediarrh[oe]a of teething children is often troublesome and requires goodmedical advice. 

The ulcerated state of the mouth is usually connected with specialdisorder of the digestive organs, and that condition of acidity forwhich I have already recommended soda, magnesia, and similar remedies, while locally the mouth needs just that local care which is applicablein cases of thrush. Now and then, severe inflammation of the gumsoccurs, in which they become extremely swollen; and ulceration takesplace of the gum just above where the tooth should come through, andeven around some of those which have already appeared. These are casesin which lancing the gums would do nothing but mischief. They requirethe local care already insisted on, a mild plan of diet, and treatmentto reduce any feverishness; and above all one medicine, the chlorate ofpotass, which in doses of four grains every four hours for a child ayear old, is almost a specific. 

AFFECTIONS OF THE SKIN. --There are a few affections of the skin to whichchildren in early infancy are especially liable, concerning which a fewwords must be said. 

The Latin word _intertrigo_ is used for that _chafing_ of the skin ofthe lower part of the body of an infant which is by no means unusual, and is often very distressing. It is almost invariably due to want ofcare. Either wetted napkins are dried, and put on again without previousrinsing in water, or they have been washed in water containing soda, andnot passed through pure water afterwards, or attention is not paid tochange the infant's napkin immediately that it requires; or a freshnapkin is put on without previous careful ablution of the child; orlastly it occurs almost unavoidably in cases of diarrh[oe]a from theextension of irritation beginning at the edge of the bowel. 

Care is usually all that is needed to remove, as it is to prevent thiscondition. The precautions which I have referred to with regard tocleanliness must be carefully observed, and moreover, each time evenafter passing water, the child should be carefully washed with thingruel, or barley water, then dusted abundantly with starch powder, whilethe napkin must be thickly greased with zinc ointment. After the firstsix or seven months of life the napkin can be almost always dispensedwith, if the child has been brought up in good habits, and in all casesof chafing, it is much the better way to put no napkin on the child whenin bed, but to lay under it a folded towel, which can be removed, and aclean one substituted for it as soon as it becomes soiled. 

There is a very obstinate form of chafing, with great redness of theskin, and disposition to crack about the edge of the bowel which dependson constitutional causes, and calls at once for the interference of thedoctor. 

Besides this purely local ailment, there is another skin affectionwhich is seen over the body generally, and is known popularly by thename of _red gum_, or in Latin _strophulus_. I mention the Latin namebecause I have known persons sometimes, misled by the similarity ofsound, fancy that it had some connection with scrofula. It is met withless commonly now than formerly, when people were accustomed to keepinfants unduly wrapped up, and to be less careful than most arenow-a-days about washing and bathing. It depends on over-irritation ofthe sweat glands of the delicate skin of the infant, the result of whichshows itself in the eruption on the body and face of a number of smalldry pimples sometimes surrounded by a little redness, itchingconsiderably, and when their top has been rubbed off by scratchinghaving a little speck of dried blood at their summit. 

A rash like this, a sort of _nettle rash_, more blotchy and causinglittle lumps on the skin, which in a day or two come and go, sometimesappears in the intervals between the pimples, sometimes takes theirplace, and causes, as they do, much irritation. This nettle rash isusually dependent on some error of diet, on some acidity of the stomach, and, on their being corrected soon passes away, leaving the pimples asthey were before, but sometimes being reproduced if the pimples causeexcessive irritation of the tender skin. 

The matter of chief importance for a mother to know, is that theserashes have no serious signification. Their treatment is very simple. Itconsists in dressing the child very lightly, in bathing it veryfrequently with tepid water, avoiding as far as may be the use of soap, and in sponging it often to relieve the irritation with some simplealkaline lotion; such for instance as one recommended by the late Dr. Tilbury Fox, and which is composed of twenty grains of carbonate ofsoda, two teaspoonfuls of glycerine, and six ounces of rose water. Ofcourse if the stomach is out of order that must be attended to, but alittle fluid magnesia, once or twice a day, is all that is usuallyneeded in the way of medicine. 

One other affection of the skin, very common, very distressing, verytedious, of which there are many varieties, generally known by thetechnical name of _eczema_, from a compound Greek word which signifiesto flow, needs that I should say something about it. It is not limitedin its occurrence to infancy, nor does it of necessity cease whenchildhood is over, but continues to recur even in grown persons, andshows itself still from time to time even in the aged. 

For the most part, however, it makes its appearance between the fifthand twelfth month; sometimes seeming to be induced by the change of foodwhen the child is weaned, and that even though the weaning may have beenwisely managed; at other times showing itself when the irritation ofteething begins, and in every instance being aggravated by the approachof each tooth to the surface, and abating in the intervals. 

It does not occur in all children with equal frequency or severity, andthough there is no doubt but that it is often hereditary, and thisespecially in families some members of which have suffered from gout, yet it is by no means unusual for two or three of the children of thesame parents to be affected by it severely, while no trace of it appearsin the others. 

It shows itself in general first on the cheeks and sides of the face, where the skin becomes red and rough, and slightly puffy. On lookingvery closely--more closely indeed than most persons are wont to do--thisappearance will be seen to be produced by innumerable small pimples, smaller than pins' heads, and which itch violently. Now and then, evenin the course of a few hours, these pimples disappear, leaving the skinrough, and peeling off in branny scales, while the surface beneath isred and irritable, a condition which also in a few days may subside. This, however, is less frequent than the opposite course of theaffection, in which a drop of fluid forms at the top of each tinypimple, and escaping forms a yellowish, thin, transparent, watery, irritating discharge, which reddens still more the raw and weepingsurface of the skin. The fluid when abundant dries at length intoyellowish flakes or crusts, which sometimes assume a brownish colour ifthe surface is made to bleed by irritating or scratching. If the crustsare not removed, the fluid which still continues to be poured outbeneath them soon changes into matter or _pus_ as it is called, andthis, shut up beneath the hard crust above, increases the irritation, and thickens the deposit. After a time the inflammation lessens of itsown accord, the secretion diminishes, the crusts dry up, and at lengthfall off, leaving the skin red, slightly swollen, and its surfacescaling off in flakes, which gradually cease to form, and the skin bydegrees becomes quite sound again, and so remains, until perhaps theirritation caused by the approach of a new tooth to the surface, rekindles the old trouble, to go once again through the same stages asbefore. 

It is on the cheeks, the sides of the face, and the top of the head thatthese changes may be best studied, but there are other situations inwhich the same kind of process often goes on. It may be seen in thecreases of the neck, or the folds of the thigh in fat children, only astwo surfaces of skin are there in contact the fluid never dries to acrust, but the skin, red and sore and swollen, pours out an abundantsecretion which, just as when it occurs behind the ears, gives out astrong and offensive smell. It occurs, too, at the bends of the joints, as under the knee, and at the inside of the elbow joint, as well as onthe front of the chest, the back, and sometimes even over the wholebody, and especially at any part where the pressure of the dressirritates the skin. When thus general, it seldom fails to pass into achronic state such as to call for constant, skilled medical treatment. 

The attack often comes on with general feverishness, a hot skin, fretfulness, and restlessness, which subside when the skin begins todischarge, though the discomfort produced by the local irritation stillcontinues. At other times, and this perhaps more often when the eruptionfirst appears on the head, its onset is more gradual, and slightscurfiness and redness at the top of the head are first noticed, andthen a little crust forms there which is firmly adherent, and is, therefore, often not entirely removed as it should be, and thus bit bybit the mischief extends until its cure becomes tedious and troublesome. When either from neglect, or from the ailment having set in acutely, theaffection of the scalp is severe, the child's state is one of muchsuffering. The whole of the scalp becomes hot and swollen, and coveredover a large surface by a thick dirty crust, through cracks in which athick ill-smelling greenish-yellow matter exudes on pressure. Atdifferent points around, pimples form with mattery heads, --pustules theyare called--while the glands on each side of the neck become swollen andtender. When thus severe on the head it will be found also not merely onthe face, but also on the body, and the poor suffering child is not onlya miserable object to look upon, but, worn by constant restlessness, itloses flesh, and seems almost as though it could not long survive. Happily, however, the condition scarcely ever terminates fatally, thoughfeeble health and stunted growth are not seldom the results of the earlysuffering. But besides, severe eczema in infancy always returns againand again in childhood and in after-life, and there is also a distinctconnection between liability to eczema and to asthma; and this notsimply nor mainly that the disappearance of an attack of eczema may besucceeded by an attack of asthma, but that the child who in infancy hashad severe general eczema is more prone than another to develop adisposition to asthma as he attains the age of five or six, and thiseven though he should not have had any return of the skin affection in asevere form. 

It is evident then, that one cannot take too much pains to guardagainst the occurrence of eczema if possible, and at any rate to preventits becoming severe. The disposition to it is often controlled by verysimple precautions, such as bathing the face, the moment the skin showsany redness or roughness, with thin gruel or barley water, thenpowdering it with starch powder, and when the infant goes out, smearingthe spot very lightly with benzoated zinc ointment, and making the childwear a veil. It will be observed that the exclusion of the air is in allthese cases the object of the application far more than any specificvirtue which it is supposed to possess, and many of the worst cases ofeczema in grown persons are treated, in the great hospital for skindiseases in Paris, by an india-rubber mask, or by india-rubber coveringof the affected part, and benefit thereby without any medicatedapplication whatever. The thin layer of scurf which often forms on aninfant's head should not be allowed to remain there, since its presenceis a source of irritation. If it is very adherent, the surface may bewell greased overnight with a little clarified lard which will softenit, so that it can be readily washed off with weak soap and water in themorning. If, however, the skin is very irritable soap must not be used, but the head must be washed with yelk of egg and warm water, and insteadof a sponge, which would be too harsh, it is better to employ a verylarge camel's hair brush or a soft shaving brush, which is more handy, and the surface after careful drying may be lightly smeared with zincointment. All ointments used must be washed off most scrupulously everyday, otherwise they become rancid, irritate, and make matters worse. 

When eczema sets in acutely, with general feverish disturbance, coolingmedicines are required, and the help of the doctor becomes necessary. These are the cases in which the eruption is not confined to the head orthe face, but extends over the body generally. The child must be dressedas loosely as possible; and when in its cot, should lie there with noother covering than its little shirt; and nothing gives so much reliefto the irritation as the abundant use of powder, either simple starchpowder, or ten parts of starch powder to one of oxide of zinc, orcarbonate of bismuth. All powders must be absolutely free from grit, or, in other words, quite impalpable; otherwise they irritate the surface. On the face and other parts where it can be employed, the puff may beused to apply the powder; but between the creases of the skin--which itis important to keep apart--fine linen, lint, or charpie must beemployed, covered freely with powder, so as to prevent the surfaces fromcoming into contact. If the irritation is very distressing, a weakspirit lotion with a little carbolic acid may sometimes be sponged overthe surface, and the powder renewed immediately; or other forms ofsoothing lotions may be used to abate the irritation. 

When the scalp is affected in the acute form of eczema crusts form veryquickly; or in other cases they collect because people fear to disturbthem when they see the raw surface beneath. It is, however, a grievousmistake to allow them to collect; they are in themselves a source ofirritation, and they entirely prevent any application reaching the skinbeneath. They must always be removed, and never be allowed to formagain. They can be removed either by the employment of a poultice, halfof bread, half of linseed meal, or by the application over-night of ahandkerchief soaked in sweet oil, and covered over with a piece of oiledsilk, which softens the crusts effectually, and allows of their easyremoval by abundant washing with weak soap and water. 

The best applications afterwards vary so much that it is impossible tolay down any positive rule. Sometimes the Carron oil, as it is termed: aliniment compound of equal parts of linseed oil and lime-water--apopular and most useful application in burns--gives most ease to theirritated skin; sometimes the mere exclusion of the air by means of theindia-rubber cap; sometimes the abundant use of powder. In every case, at least once in every twenty-four hours the whole surface must bewashed quite clean with barley water or thin gruel; and when thedischarge lessens or ceases, as it will do in the course of time, then, but not till then, various ointments may be of service. 

When the chronic stage arrives, in which the skin becomes dry and scaly, then is the time for tonics, for iron, sometimes for cod-liver oil, andfor arsenic; of which latter remedy, however, the results are uncertain;while in the acute stage, its influence is simply mischievous. Nothingis more difficult, nor calls for more skill, or larger medicalexperience, than the proper management of the various forms of chroniceczema. 

The question is sometimes asked whether it is safe to cure, or, aspeople call it, to dry up these eruptions in teething children. Therecan be no doubt but that it is very desirable to prevent theiroccurrence as far as may be by the use of the precautionary measureswhich I have explained. But when they have existed for some time, eitherattended with profuse discharge, or causing great irritation by theirextent, there is no doubt but that care must be exercised in attempts attheir cure, that soothing measures such as I have advocated should bechiefly employed, and that the sudden drying up of the discharge by atoo abundant use of dusting powders must be avoided. If, too, thediminution of the rash were followed by a worsening of the child'scondition, by feverishness, by heaviness of the head, or any sign ofdisturbance of the brain, the attempt to cure the rash must at once beabandoned. At the same time I must add that such occurrences are veryrare, and that for one case where I have had to regret my success incuring the rash, I have seen fifty in which I have been mortified by thefailure of my endeavour. 

FOOTNOTES:

[8] The directions given by the distinguished chemist, Dr. Frankland, towhom I am indebted for the suggestion, are as follows: 'One-third of apint of new milk is allowed to stand until the cream has settled; thelatter is removed, and to the blue milk thus obtained about a squareinch of rennet is to be added, and the milk vessel placed in warmwater. ' (I may add that the artificial rennet sold by most chemists maybe substituted for the other. ) 'In about five minutes the rennet, whichmay again be repeatedly used, being removed, the whey is carefullypoured off, and immediately heated to boiling to prevent its becomingsour. A further quantity of curd separates, and must be removed bystraining through calico. In one quarter of a pint of this hot whey isto be dissolved three-eighths of an ounce of milk sugar, and thissolution, along with the cream removed from the one-third of a pint ofmilk, must be added to half a pint of new milk. This will constitute thefood for an infant of from five to eight months old for twelve hours;or, more correctly speaking, it will be one-half of the quantityrequired for twenty-four hours. It is absolutely necessary that a freshquantity should be prepared every twelve hours; and it is scarcelynecessary to add that the strictest cleanliness in all the vessels usedis indispensable. '

[9] In our tables of mortality we find teething registered as havingoccasioned the death of nearly 5 (4. 8) per cent. Of all children whodied in London under one year old; and of 7. 3 per cent. Of those whodied between the age of twelve months and three years. 

PART III. 

_ON THE DISORDERS AND DISEASES INCIDENT TO ALL PERIODS OF CHILDHOOD. _

The ailments hitherto noticed are by no means all that may occur duringinfancy and early childhood, but those only which either happen thenexclusively, or at least with far greater frequency than at other times. 

It will be most convenient to consider the others under the differentsystems to which they belong, as diseases of the head, of the chest, andof the bowels. 

Before entering on these new subjects, however, a few words may not beout of place with reference to what may be termed the second period ofchildhood. It is above all a time of wonderfully lessened sickness andmortality. We have not the means of stating exactly the rate at whichmortality is lessened between the cessation of the first and thecommencement of the second dentition; but we do know that it is tentimes less between the age of one and five, and nearly twenty times lessbetween five and ten than it was in the first year of existence. [10] Amother's anxiety then may safely be quieted after the first year of herinfant's life, and still more after the first set of teeth have beencut, for if her child is strong and healthy then, there will becomparatively little to fear for its future. 

Four years or thereabouts now follow, before any important change takesplace in the child's condition, for it is not until between six andseven years old that the first set of teeth begin to be shed, and thesecond to take their place. This change of teeth too is of far lessmoment as far as the health is concerned, than was the cutting of thefirst set. The first dentition was the preparation for an entirely newmode of life for the child, and was intended to fit it for a lifeindependent of its mother. The second has no such signification; it is amere local alteration rendered necessary by the growth of the jaws, andtakes place quietly, by the gradual absorption of the roots of the firstset of teeth, brought about by the pressure of the others as theyapproach the surface. Four teeth in each jaw are new, and replace noothers, but usually they are cut without much discomfort, and the wisdomteeth do not concern us here, for they do not appear until childhood haslong passed. 

But, though between the age of two years and of ten there is noimportant change, nor even preparation for a change in the constitution, the time is yet one of most active growth of the body, and consolidationof the skeleton. The stature increases from 2 ft. 6 in. To 4 ft. 6 in. , and the weight nearly doubles, while at the same time the ends of thelong bones previously connected with the shafts by means of cartilage orgristle, become firmly united by the conversion of that cartilage intobone, and a similar process goes on, though not completed till later, inthe ribs and the breast bone. 

Rapid increase of height and weight; conversion of the elements of boneinto bone itself, formation of muscle out of the fat, which in the youngchild was stored up as so much building material for an edifice incourse of construction, require for their accomplishment perfect health, and the power of converting to its highest purposes all the nourishmentreceived. What wonder then, if from time to time, the machinery thushardly taxed, fails to be quite equal to the demands upon it, if painsin the limbs--growing pains, as they are commonly called, or head-ache, tell of the inadequate nerve supply. Or if from the same cause, a vaguefeverish condition comes on, in which the temperature is slightlyraised, and the child listless, and yet fretful, loses its cheerfulness, is dull at its easy tasks, and yet indifferent to play. This too is thetime when any unsuspected defects, physical, or mental, or moral, beginto show themselves distinctly; when short sight becomes apparent so soonas the child has to learn its letters, when the dull hearing isperceived which makes it seem inattentive, and gives to its manner anunchildlike nervousness; and the weak intellect is displayed incauseless laughter, causeless mischief, causeless passion, imperfectpower of articulation, or want of words, and by a restless busyness indoing nothing. 

Of all these things I shall have to speak later on more fully. They arethe things however, which only those mothers notice who live much withtheir children, who do not banish them all day long to the nursery orthe school-room, and learn from another whether they fare well or ill. They and only they will notice these things in whom there dwells thatwhich the poet tells us of:

 The mother's love that grows From the soft child, to the strong man; now soft, Now strong as either, and still one sole same love. 

FOOTNOTES:

[10] The exact numbers as given at p. Xiv of the forty-fifth Report ofthe Registrar-General for all England in 1881 are to 1, 000 living underone year 58 deaths; from one to five 6. 1; from five to ten 3. 3. 

CHAPTER VI. 

THE DISORDERS AND DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 

It is stated on good authority[11] that more than half of the deaths atall ages from these causes take place in children under five years, afact which at first sight seems as inexplicable as it is startling. There is, however, a twofold explanation of it: the circulation throughthe much softer tissue of the brain, unenclosed within a _firm bonycase_ as in after-life, varies with far greater rapidity in the infantthan in the grown person, and hence the organ is far more easilyoverfilled with or emptied of its blood. Besides, any organ in whichgrowth is going on with great rapidity is proportionately liable tobecome disordered or diseased. Now the brain doubles its weight in thefirst two years of life, and attains nearly its full size by the end ofthe seventh year. 

These two facts suggest a bright as well as a dark view of disorders ofthe brain and nervous system in early life. If disorder is morefrequent, it is excited by slighter causes, is more likely to betemporary, and even its gravest symptoms, such as convulsions andparalysis, have a less serious import in the one case than in theothers. If the grown man has a fit, and still more, if that fit isfollowed by paralysis, we fear and with reason that some vessel in thebrain-substance has given way, or that some grave, probably irreparabledamage has been inflicted on it. In the child, and especially in theyoung infant, these accidents may mean nothing more than that the brainhas suddenly become over-filled with blood, or that it has beendisturbed by irritation--I know of no better term--in some distantorgan. 

CONVULSIONS. --There are in the body two great nerve masses, the brainand the spinal cord, through which all parts are brought into relationwith each other. The spinal cord or spinal marrow receives impressionsfrom all parts, imparts movement to the limbs, as well as gives activityto the functions of the various internal organs. The brain is thecontrolling power, and governs more or less consciously the movementswhich the spinal cord originates, and hence in proportion as thedevelopment of the brain advances, and its controlling power increases, those involuntary movements, fits or convulsions, which originate inirritation of the spinal cord, become rarer. The brain, at the age ofthree years, is more than twice as large as in the first year of life, and deaths from convulsions have then sunk to a third of their formerfrequency; while from the age of ten to fifteen years, when the brainmay be said to be perfected, only four per cent. , instead of nearlyeighty per cent. As in the first years of life, of all deaths fromdisorders of the nervous system are due to convulsions. [12]

I dwell on this subject the more because there is in a fit of_convulsions_ something so intensely painful to behold that it is easyto exaggerate its danger, and to lose all presence of mind in panic. First, then, it is well to bear in mind that real disease of the brainrarely, very rarely, I do not say never, begins with convulsions; andnext, that their real danger is in general in exactly opposite relationto the frequency of their occurrence. Convulsions now and then returnthirty, forty, or more times in twenty-four hours, and continue to do sosometimes for three or four days together. They are, indeed, not withoutperil, for the perpetually returning disturbance of the circulation maygive rise to an overfilling of the vessels of the brain, or to astagnation of the blood within them, or the spasm may affect the muscleswhich open and close the entrance to the windpipe, and the child may diechoked as in a paroxysm of whooping cough, or in a fit of spasmodiccroup, or lastly the violent and frequently repeated muscular movementsmay at length exhaust its feeble frame. But still, such frequentlyrecurring convulsions are in themselves no evidence that the brain isdiseased; they do but show that the irritability of the spinal cord isincreased to a degree which the brain is no longer able to control, andwhich therefore manifests itself in violent convulsive movements. 

It is thus that the poison of scarlet fever or of small-pox sometimesdisplays its influence over the whole system by producing violentconvulsions at the outset of those diseases; thus that they follow onsome indigestible article of food, or that the mother, over-heated byviolent exertion, or overwhelmed by the news of some unexpectedcalamity, sees her babe, to whom she is in the act of giving the breast, suddenly seized by a violent convulsion. 

In every instance, therefore, the first business is to ascertain thecause of the convulsion, to determine the seat of the irritation whichhas excited the nervous system to such tumultuous reaction. Theconvulsion which ushers in any one of the eruptive fevers in the infantor in the child, is only an exaggeration of the shivering which precedesthe onset of fever in the adult. Has the child been exposed to thecontagion of measles, small-pox, or scarlatina? is it teething, and ifso, when did its last tooth appear? of what did its last meal consist?when were its bowels last open? has it been exposed to the sun with itshead uncovered? or has it, though in the shade, been sitting or playingout of doors in the intense heat of a summer's day? has it had a fall, or been frightened? or is it suffering from whooping-cough which has oflate been very severe? or has its breathing been accompanied with apeculiar catch or crow, the sign of spasmodic croup, and have at thesame time its hands been usually half clenched, and the thumb shut intothe palm, the sign of that disturbance which at length has culminated inan attack of convulsions? Such are the questions, which in less timethan it takes me to write, or others to read, the intelligent motherwill put to herself, and will answer, instead of, in unreasoning alarm, giving all up as lost, or hastening without reflection to do somethingor other that were better left undone. 

The first thing to do in every case of convulsions, be their cause whatit may, is to loosen the dress, so that no string nor band may interferewith respiration, and for this purpose strings must be cut and dressestorn. The next thing is to dash cold water on the face to induce a deepinspiration, for sudden death in a fit almost always takes place frominterruption to breathing. With the same purpose the forefinger shouldbe put into the mouth, and run rapidly to the root of the tongue, whichshould be drawn forward. The object of doing this is twofold; first, toprevent the tongue falling back, as in these circumstances it is apt todo, over the entrance of the windpipe and so producing suffocation, andin the next place the act very frequently puts an end to the spasmodicclosure of the windpipe, and is followed by a deep-drawn breath whichannounces the infant's safety. If the child has cut any teeth, thehandle of a spoon, round which a bit of rag has been wrapped, or a bitof wood, or a thin strip of india-rubber, should be put between theteeth as far back as possible to prevent the tongue being bitten; andoften this is all that can be done. 

There are two circumstances, and two only, in which the warm bath islikely to be of use. At the onset of one of the eruptive fevers, a hotbath is sometimes of great service by stimulating the skin and thusbringing out the rash. In these cases the fit scarcely ever comes on ina child previously in perfect health, but for some hours at least it hasappeared very ill, tossing about with great restlessness, with a dry, hot skin, and twitching of the tendons of the wrists; or, perhaps, witha pale face and cold hands and feet, but with the temperature of thebody as high as 103° or 105°. Here the hot bath at 96° to 98°, evenrendered more stimulating by the addition of mustard, and continued fornot more than five minutes, is sometimes of great service, and isspeedily followed by the cessation of the convulsions and the outbreakof the eruption. 

These, too, are the cases in which the use of the wet sheet, aspractised in hydropathic institutions, is sometimes of great benefit, but I do not advise its employment except under medical advice. 

The second condition in which the bath, and here it is the tepid and notthe hot bath--that is to say, the bath at from 87° to 90°--is ofservice, is where the child is feverish and restless from over-fatigueor over-excitement, or from exposure to the sun or to an excessively hotatmosphere, and convulsions have come on in the course of this ailing. Here the tepid bath for ten or fifteen minutes, coupled with theapplication of cold to the head, will soothe the excitement and preventthe return of the convulsions. 

In neither this case, nor in that in which the hot bath is employed, isthe result of the agent as magical as people sometimes seem to expect. It is rarely that convulsions cease while a child is actually in thebath. For the most part the influence of the bath is limited to abatingtheir severity, shortening their duration, and indisposing to theirreturn. 

The bath, then, is to be used when either a stimulating or a soothinginfluence on the surface is likely to be of service, and only then. Incases where the fits are produced by constipation, by improper food, orby the irritation of a tooth pressing against the gum, it is idle to useit, and equally so in instances where many fits have been recurring inthe course of the same day. Where that is the case it must beself-evident that, be the cause what it may, it must be one over whicheither a hot or a tepid bath can have no influence, and that, painful asit must be to wait a passive spectator, that position is far wiser thanthat of a mischievous meddler. It is some consolation, also, to knowthat unconsciousness to suffering attends convulsions. 

There is one agent, chloroform, which often has a very remarkableinfluence in controlling frequently repeated convulsions. It is anagent, however, too hazardous to be trusted out of medical hands, andeven when the doctor administers it himself, the parents must fullyrecognise the fact that, inasmuch as the child may die during a fitquite independently of breathing chloroform, so the occurrence of thatcatastrophe during its employment is not to be made a subject ofself-reproach to them, or of blame to the doctor. 

But you may ask whether there are no _signs_ of that disturbance of thenervous system, by which you can judge beforehand that the occurrence ofconvulsions is probable. In proportion to the tender age of a babe, thegreater is the probability, as I have already stated, that convulsionswill be induced by slight causes, especially by such as digestivetroubles. Unless you are aware of the phraseology that used at any rateto be common among nurses, you may be much alarmed at being told thatthe child who had seemed scarcely unwell has been very much convulsed, when all that is meant is that the child has shown some of the signsthat threaten convulsions--has had, in short, what in the time of ourgrandmothers used to be called _inward fits_. A child thus affected liesas though it were asleep, winks its imperfectly closed eyes, and gentlytwitches the muscles of its face--a movement especially observable aboutthe lips, which are drawn as though into a smile. Sometimes, too, thismovement of the mouth is seen during sleep, and poets have told us thatit is the angels' whisper which makes the babe to smile--I am sorry thatits meaning in plain prose should be so different. If this conditionincreases, the child breathes with difficulty, its respiration sometimesseems for a moment almost stopped, and a livid ring surrounds the mouth. At every little noise the child wakes up; it makes a gentle moaning, brings up the milk while sleeping, or often passes a great quantity ofwind, especially if the stomach is gently rubbed. When the disorder ofthe digestion, on whatever cause it depended, is removed, these symptomsspeedily subside, nor is there much reason to fear general convulsionsso long as no more serious symptoms show themselves. There is more causefor apprehension, however, when the thumbs are drawn into the palm, either habitually or during sleep; when the eyes are never more thanhalf-closed during sleep; when the twitching of the muscles is no longerconfined to the angles of the mouth, but affects the face andextremities; when the child awakes with a sudden start, its face growingflushed or livid, its eyes turning up under the upper eyelid, or thepupils suddenly dilating, while the countenance wears an expression ofgreat anxiety or alarm, and the child either utters a shriek, orsometimes begins to cry. 

When a fit comes on, the muscles of the face twitch, the body is stiff, immovable, and then in a short time, in a state of twitching motion, thehead and neck are drawn backwards and the limbs violently bent andstretched. Sometimes these movements are confined to certain muscles orare limited to one side, and I may add that such cases are of moreimportance as far as the state of the brain is concerned than those inwhich the convulsions are general. The eye is fixed and does not see;the fingers may be passed over it without its winking, the pupil isimmovably contracted or dilated; the ear is insensible even to loudsounds, the pulse is small, very frequent, often too small, and toofrequent even for the skilled doctor to count it; the breathing hurried, laboured and irregular; the skin bathed in abundant perspiration. 

After this condition has lasted for a minute, or ten minutes, or an houror more, the convulsions cease; and the child either falls asleep, orlies for a short time as if it were bewildered, or bursts out crying, and then returns to its senses, or sinks into a state of stupor, inwhich it may either be perfectly motionless, or twitching of somemuscles may still continue; or, lastly, it may, though this seldomhappens, die in the fit. 

It seems then, from all that has been said, that convulsions, though oneof the most striking, are by no means one of the most conclusive signsof brain disease; that they are even more commonly the result ofdisorders of the nervous system from causes seated elsewhere, than ofactual disease of what may be termed the great nervous centre. 

We may now therefore pass to the examination of these diseases, whichfor the purposes of this book may be considered under the two heads ofcongestion and inflammation. 

I am forced to use these terms in somewhat of a popular sense, for toattempt in a little book like this to define everything with strictscientific accuracy would simply confuse and mislead. 

CONGESTION OF THE BRAIN. --By _congestion of the brain_ is meant acondition in which its vessels are overcharged with blood; a conditionwhich if it exists in an aggravated degree, ends either in the pouringout of blood on, or into the brain, on the one hand, or in inflammationon the other. Either of these terminations, however, is so rare in theprevious healthy child, that I shall confine my remarks entirely tocongestion of the brain, an affection specially liable to occur inchildren during teething. A certain degree of feverishness almost alwaysaccompanies teething. It is, therefore, not difficult to understand how, when the circulation is in a state of permanent excitement, a veryslight cause may suffice to overturn its equilibrium, and occasion agreater flow of blood to the brain than the organ is able to bear. Congestion of the brain, however, is not by any means limited to thisseason, but may occur at other times without any obvious exciting cause, and with no other explanation than is furnished by the well-known factthat all periods of development such as childhood, are periods duringwhich the growing organs are most apt to become disordered. 

In the great majority of cases the symptoms of congestion of the braincome on slowly; and for the most part, general uneasiness, or disorderedstate of the bowels, which are usually, though not invariablyconstipated, and feverishness precede for a few days the more seriousattack. The head by degrees becomes hot, the child grows restless andfretful, and seems distressed by light, or noise, or sudden motion, andchildren who are old enough sometimes complain of their head. Usuallytoo, vomiting occurs repeatedly; a symptom of the greatest importance, since it may exist before there is any well-marked sign of headaffection. Causeless frequently repeated vomiting in a child not ill butailing, is nine times out of ten a sign of mischief in the head. Thedegree of fever which attends this condition varies much, and itsreturns are irregular; but any one who knows how to feel the pulse willfind it permanently quickened, and if the head is unclosed thepulsations of the brain may be seen and felt distinctly. The sleep isdisturbed, the child often waking with a start, while there isoccasional twitching of the muscles of its face, or of the tendons ofits wrist. 

The child may continue in this condition for many days and then recoverits health without any medical interference. This is especially likelyto be the case with children while teething, the fever subsiding, thehead growing cool, and the little one appearing quite well so soon asthe tooth has cut through the gum, but the approach of each tooth to thesurface being attended by the recurrence of the same symptoms. 

The fortunate issue of these cases though frequent, is by no meansinvariable, for sometimes they are but the precursors of thatformidable, I might indeed say, all but hopeless disease, water on thebrain. But even of itself congestion of the brain is by no means atrivial ailment, for it may pass into a stage in which the smallerdiscomforts of the child lead to the sad mistake that the condition ofthe child is improving, instead of which it is really the dulling ofsensibility from approaching death. The head, indeed, becomes less hot, the flush of the face grows slighter and less constant; but thecountenance is heavy and anxious, the indifference to surroundingobjects increases, and the child lies in a state of torpor ordrowsiness, from which indeed it can at first be roused to completeconsciousness The manner on being roused is always fretful, but, if oldenough to talk, the child's answers are natural, though generally veryshort; and murmuring, 'I am so sleepy, so sleepy, ' it subsides into itsformer drowsiness. The bowels generally continue constipated, and thevomiting seldom ceases, though it is sometimes less frequent thanbefore. In this state, without any apparent cause, the child sometimeshas an attack of convulsions, which subsiding, leaves the torpor deeperthan before. The fits return, and death may take place in one of them, or the torpor growing more profound after each convulsive seizure, thechild at length dies insensible. 

Now and then, especially in infants of only five or six months old, recovery takes place even where there seemed almost no ground for hope. The overfull vessels have at length relieved themselves, fluid has beenpoured out into the cavities of the brain, the yielding skull has givenway under the pressure from within, and should the child after allsurvive, its large head, due to chronic water on the brain, tells to allwho know how to interpret the signs, the tale of its past illness, andthe manner of its imperfect recovery. 

Cases such as these are obviously beyond the reach of domesticmanagement, and call for all the resources of medical skill. The mistakecommonly made is that of calling in the doctor too late, because it isnot realised how grave may be the import of symptoms which at firstappear so little alarming; and the so-called experienced nurse havingsaid, 'Oh! it's nothing but the baby's teeth, ' time is lost and dangernot anticipated till too late for remedy. 

The application of two, three, or four leeches at the very outset ofthese cases is often of great service, and sometimes cuts short symptomswhich had seemed very threatening. The doctor, of course, must be thejudge of its expediency, but I refer to it because I have known parentsraise objections to it, and beg to have milder means tried first. Itmust be borne in mind then, that whenever leeches are of use it is atthe beginning of an attack, and that the opportunity once let slip doesnot return. Purgatives, cold to the head, saline medicines, and perhapssome carefully selected sedative, are the measures which will probablybe employed in most cases, but success will in great measure depend onthe minute care with which all the details which I dwelt on in theintroduction, are carried out. 

It is not always, indeed, that active treatment is desirable, andgentle measures then suffice; but nothing except close and frequentwatching can enable the doctor to steer safely between the two oppositedangers of too little and too much. 

When I come to speak of the eruptive fevers, I shall have to mention theconvulsions and other signs of most serious brain disturbance, whichsometimes occur at their outset, and which are due to the condition ofthe blood charged with the fever poison. 

A somewhat similar set of symptoms, attributed with reason to theoverheated state of the blood, occurs in cases of _sunstroke_. It istrue that sunstroke, with the formidable characters that it presents inhot countries, is not seen in England, but even here the mere exposureof an infant or young child to an overheated atmosphere, is by no meansunattended with risk, and I refer to it here, because mothers are by nomeans aware of the danger, and believe that it suffices to guard thechild from the direct rays of the sun. 

Alarm, restlessness, and fretfulness, alternating with drowsiness, hurried, irregular breathing, intense heat of skin, violent beating ofthe open part of the head, twitching of the limbs, and starting of thetendons of the wrists, with a pulse too rapid to be counted, are thesymptoms when the attack is severe. Convulsions are rare, though theysometimes occur. Sickness is almost invariable, the stomach rejectingeverything, and the bowels are almost invariably relaxed, severediarrh[oe]a or dysentery sometimes coming on, as the brain disturbanceabates. The first shock may kill the child in a few hours, or it maysink under the subsequent diarrh[oe]a, but as a rule recovery eventuallytakes place. 

All cases, indeed, are not equally severe, but all require careful andgentle treatment, the cool and darkened room, the quiet, the cold to thehead, the tepid bath, and on the part of everyone the care not to allowthe apparently serious condition of the child to urge them to thoseactive measures which will here be out of place, and destroy the hopeswhich would revive after a few hours of patience and gentle means. 

Really acute inflammation of the brain is of so rare occurrence exceptas the result of accident or injury, and its symptoms are of so seriousa character, even from the first, that medical advice is obviouslyneeded at once. I shall, therefore, pass it over here, and endeavour todescribe two forms of inflammation of the brain which are much morefrequent, and at their commencement more likely to be overlooked. 

=Water on the Brain. =--One of these is the form of inflammation commonlyknown as _water on the brain_, a term which, though incorrect medically, has the advantage of being well understood. This, now, is not a simpledisease, occurring in a previously healthy child, but it is a diseasedependent on the same state of constitution as gives rise in otherchildren to consumption, or scrofula, or disease of the mesentericglands. 

It is this circumstance which renders the disease so serious, andrecovery from it so extremely rare. This it is also which makes it sodesirable to become acquainted with its symptoms, both that you may bealive to the approach of danger, and also not indulge in needless alarmwhen brain symptoms occur from other causes which have no relationwhatever to those which give rise to water on the brain. 

The disease comparatively seldom comes on in a child who had previouslyseemed in perfect health; a state of vague ailing usually precedes itsoutbreak. The child loses flesh and strength, and the look of health, and the lustre of the eye, and the silky softness of the hair. Theappetite becomes uncertain, the bowels irregular, with a tendency toconstipation; there are little feverish attacks for a few hours, subsiding of their own accord. The sleep is not sound, the temperuncertain, the child tires even of its favourite toys; the brightness ofthe little face is changed for a strange, weird, wistful look--anunnatural earnestness; the child sits for moments gazing upward onvacancy, as though it saw, or sought something beyond. 

By degrees these vague premonitions, which may continue for weeks, become more and more marked till they pass into what may be called thefirst stage of the affection, in which there are signs of congestion ofthe brain, such as I have already described, coupled with generalirregular attacks of feverishness. The child becomes more gloomy, morepettish, and slower in its movements, and is little pleased by its usualamusements. Or, at other times, its spirits are very variable; it willsometimes cease suddenly in the midst of its play, and run to hide itshead in its mother's lap, putting its hands to its head, and complainingof headache, or saying merely that it is tired and sleepy, and wants togo to bed. Sometimes, too, it will turn dizzy, as you will know, not somuch from its complaint of dizziness as from its suddenly standingstill, gazing around for a moment as if lost, and then either beginningto cry at the strange sensation, or seeming to awake from a reverie, andat once returning to its play. The infant in its nurse's arms betraysthe same sensation by a sudden look of alarm, a momentary cry, and ahasty clinging to its nurse. If the child can walk it may be observed todrag one leg, halting in its gait, though but slightly, and seldom asmuch at one time as at another, so that both the parents and the medicalattendant may be disposed to attribute it to an ungainly habit which thechild has contracted. The appetite is usually bad, though sometimes veryvariable; and the child, when apparently busy at play, may all at oncethrow down its toys and beg for food, then refuse what is offered; ortaking a hasty bite may seem to nauseate the half-tasted morsel, mayopen its mouth, stretch out its tongue, and heave as if about to vomit. The thirst is seldom considerable, and sometimes there is an actualaversion to drink as well as to food, apparently from its exciting orincreasing the sickness. The stomach, however, seldom rejectseverything; but the same food as occasions sickness at one time isretained at another. Sometimes the child vomits only after taking food, at other times, even when the stomach is empty, it brings up somegreenish phlegm without much effort, and with no relief. These attacksof vomiting seldom occur oftener than two or three times a day, but theymay return for several days together, the child's head probably growingheavier, and its headache more severe. The bowels during this time aredisordered, generally constipated from the very first, though theircondition in this respect sometimes varies at the commencement of thedisease. The evacuations are usually scanty, sometimes pale, often ofdifferent colours, almost always deficient in bile, frequentlymud-coloured and very offensive. The tongue is not dry, generally ratherred at the tip and edges, coated with white fur in the centre andyellowish towards the root, but occasionally very moist, and uniformlycoated with white fur. The skin is harsh, but not very hot, thetemperature seldom above 100° Fahr. , varying causelessly, but usuallyhigher towards evening than in the daytime. The nostrils are dry, theeyes lustreless, and _the child sheds no tears_. It is drowsy, and willsometimes want to be put to bed two or three times in a day; but it isrestless, sleeps ill, grinds its teeth in sleep, lies with its eyespartially open, awakes with the slightest noise, or even starts up inalarm without any apparent cause. At night, too, the existence ofintolerance of light is often first noticed in consequence of thechild's complaints about the presence of the candle in the room. 

I have purposely dwelt long on this preliminary stage because it is onlyin it that treatment is likely to be of any service, while the veryindefiniteness of the symptoms constantly leads to their beingoverlooked, or referred to teething, or thought at any rate to be a meretemporary ailment for which it is not worth while to call in the doctor. 

After four or five days, however, the illness of the child becomes toomarked to escape notice. All cheerfulness has fled, the eyes are closedto shut out the light, the child lies apparently dozing, but answersquestions rationally, in a short quick manner in as few words aspossible, and from time to time complains of its head, or utters ashort, sharp lamentable cry. The night brings with it no other changethan an increase of restlessness, attended sometimes with noisy cries, or with the wandering talk of delirium. Sickness often diminishes, butthe bowels continue constipated, and it is to be noted that whereas infevers the bowels are distended with wind, here all wind has disappearedand the belly is sunken to a striking degree. 

Next comes the last stage. Each stage is distinguished by peculiaritiesof the pulse which tell the expert what is passing; quick and regular inthe first stage; irregular and slower in the second; quick, variable, irregular from time to time in the third; growing more rapid and morefeeble as the end arrives. Squinting, stupor, dilated pupil, difficultyof swallowing, tremulous limbs, convulsions, profound insensibility, such are the series of occurrences which bring on death usually within afortnight, always within three weeks from the appearance of the firstdecided symptoms. 

What are you to do in these cases? Above all save yourselves theheartbreak of feeling that you have overlooked the premonitory symptomsof the disease. Guard with special care the health of any child in whosefamily a disposition to consumptive disease has ever shown itself, andkeep it at any cost from the risk of catching the hooping cough ormeasles. Since, too, it is not in early infancy, but after the age ofone year, and in the majority of instances between the ages of three andsix years that this disease occurs, that is to say, at the time when thebrain begins to be most actively exercised, when the new world on whichthe child is just entering brings with it new wonders every day; be verycareful not to over-stimulate its intelligence, over-excite itsimagination, or over-strain its mental powers. After the age of ten thegreat danger is over; up to that time it is the health of the body whichrequires care; not fuss, not rearing like a hothouse plant, but thehealthy training that may fortify the system. 

When any signs such as I have described indicate the threatening ofdisease, do not look on them as within the scope of domestic management, but place the child at once under the watchful care of a skilful doctor. I have seen but one recovery in all my life, after the disease had fullyset in, and that was a recovery almost worse than death. 

=Earache. =--There is another form of inflammation of the brain which islikewise oftenest met with in children who are of weakly constitution, or of scrofulous habit, or in whom scarlet fever has left behind thatvery troublesome ailment, discharge from the ear. This is so tedious, sodifficult to cure, so apt to return under the influence of very slightcauses, that people are too ready to put up with it as an inconveniencewhich it is useless to try to remedy. 

In addition, however, to the risk of the child's hearing being impairedby the extension of the mischief to the internal ear, there is anotherstill greater danger, namely, that of the _disease passing from the earto the brain_, and producing inflammation of its membranes, or evenabscess of its substance. 

It is therefore of the greatest moment that every case of chronicdischarge from the ear should be looked on as important, and that nopains be spared to bring about its cure; and further, that during itscontinuance the slightest sign of disturbance of the brain--headache, sickness, feverishness, and dulness--should at once be noticed, and theadvice of a competent doctor be immediately sought for. 

These dangers, however, follow almost entirely on long-continueddischarges from the ear, but do not attend that acute inflammation ofthe passage to the ear which is often met with in childhood, and thesymptoms of which sometimes cause needless fear, from being taken forthose of inflammation of the brain. Attacks of _earache_ are mostfrequent before the first set of teeth have been cut, and are by nomeans rare in young children, who are perfectly unable to point out theseat of their sufferings. The attack sometimes comes on quite suddenly, but usually the child is languid and fretful for a period varying from afew hours to one or two days before acute pain is experienced. In thispremonitory stage, however, it will often cry if tossed or movedbriskly; noise seems unpleasant to it, and it does not care to be playedwith; while children who are still at the breast show a disinclinationto suck, though they will take food from a spoon. The infant seeks torest its head on its mother's shoulder, or, if lying in its cot, movesits head uneasily from side to side, and then buries its face in thepillow. If you watch closely, you will see that it is always the sameside of the head which it seeks to bury in the pillow, or to rest on itsnurse's arm, and that no other position seems to give any ease, exceptthis one, which, after much restlessness, the child will take up, and towhich, if disturbed, it will always return. The gentle support to theear seems to soothe the little patient: it cries itself to sleep, butafter a short doze, some fresh twinge of pain arouses it, or someaccidental movement disturbs it, and it awakes crying aloud, andrefusing to be pacified, and may continue so for hours together. Sometimes the ear is red, and the hand is often put to the affected sideof the head, but neither of these symptoms is constant. The intensity ofthe pain seldom lasts for more than a few hours, when, in many instancesa copious discharge of matter takes place from the ear, and the child iswell. In some instances, indeed, the subsidence of the disease on oneside is followed by a similar attack on the opposite side, and the sameacute suffering is once more gone through, and terminates in the samemanner. Sometimes, too, this complete cure does not take place, but theearache abates, or altogether ceases, for a day or two, and thenreturns; no discharge, or but a very scanty discharge, taking place, while, for weeks together, the child has but few intervals of perfectease. In infants, earache seldom follows this chronic course, but itdoes sometimes in older children, and is then of the more importance, since it shows that the disease is no longer confined to the externalpassage, but has extended to the internal ear. 

In children who are too young to express their sufferings by words, theviolence of their cries, coupled with the absence of any sign of diseasein the chest or the bowels, naturally leads to the suspicion ofsomething being wrong in the head. There are several facts, however, which may satisfy you that the case is not one of water on thebrain--the child does not vomit, its bowels are not constipated, thereis but little fever, the cries are loud and passionate, and are attendedwith shedding tears. If you watch closely, you will notice the dread ofmovement and the evident relief afforded by resting one side of thehead, and always the same side, while often the movement of the hand tothe head, and the redness of the ear, with the swelling at its entrance, will all serve to point to that organ as the source of the trouble. Sometimes, when in doubt, you will be able to satisfy yourselves thatthe cause of the suffering is in the ear by pressing the gristle of theorgan slightly inwards, which will produce very evident pain on theaffected side, while on the other side it will not occasion anysuffering. 

The treatment of this painful affection is very simple. In manyinstances the suffering is greatly relieved by warm fomentations, or byapplying to the ear a poultice of hot bran or camomile flowers, while atthe same time a little warm oil and laudanum are dropped into the ear. When these means do not bring relief, a leech applied on the bonedirectly behind the ear seldom fails to give ease; while the dispositionto the frequent return of the attack is often controlled by a series ofsmall blisters, not larger than a sixpence, behind the ear. As soon asthe tendency has sufficiently abated to admit of it, the ear should besyringed out twice a day with warm water, or with equal parts of warmwater and Goulard lotion; but if pain or discharge still continues, medical advice must in all cases be sought for. 

=Chronic Water on the Brain. =--There is still another form ofinflammation of the brain, concerning which a few words will suffice. Itconstitutes what is termed _chronic water on the brain_, and in thisinstance the term is a correct one, for the disease usually depends on aslow form of inflammation of the lining membrane of the cavities of thebrain, often beginning before, still oftener very soon after, birth, which ends in the pouring out of a quantity of fluid into themsufficient to enlarge the head to three or four times its naturaldimensions. 

Such cases are very sad and very hopeless, and the great resource, whichis sometimes adopted by medical men, of puncturing the head and lettingout the fluid, is very seldom successful. 

But there are more hopeful cases sometimes met with, those namely ofchildren in whom, either from simple weakness, or from thatconstitutional disorder called rickets, bone formation has beenbackward, and the head has consequently long remained unclosed. If suchchildren, either from the irritation of teething, or from the strainingduring paroxysms of hooping cough, suffer from congestion of the brain, fluid may be poured out, which, not being compressed by the too yieldingskull, may in consequence enlarge it. These cases, however, may bedistinguished from the other more serious ones by the date of theircommencement, which is always much later than that of the other form, bythe symptoms which attend them being less severe, and by the enlargementof the skull being far slighter. 

Still they require watching, for while with improved health theenlargement ceases, the fluid is in a measure absorbed, and the headdiminishes in size, though always remaining larger than the average;brain mischief is yet more readily set up in children with suchantecedents than in others. 

The anxiety of parents about the size or shape of their child's headafter infancy has passed, is perfectly needless. When the head has onceclosed it always remains so. An odd shape, with an unusual protuberanceof the forehead and the hind head, sometimes remain as the evidence ofthat condition in infancy to which I have just referred. It is, however, an evidence of mischief passed, not of mischief going on. In childrentoo who have suffered from rickets, an affection rarely met with exceptamong the poor in crowded cities, distortion of the limbs is oftenassociated with a peculiar form of the skull, but in this too there isnothing to call for anxiety, still less to excite alarm. It is only apreternaturally small head and shelving forehead, which are foundassociated with mental deficiency; otherwise the greatest varieties ofsize and shape, of symmetry, or of want of it, may be associated with anequal variety of intellectual endowment, which is just as likely to beabove as below the average. 

=Brain Disorder from Exhaustion. =--It may at first sight appear strangethat before leaving the subject of congestion and inflammation of thebrain, I should find it necessary to give a caution against being misledby symptoms which though in some respects similar to those of congestionor inflammation, are in reality due to an exactly opposite condition. 

This mistake, however, is very possible; doctors themselves sometimesfall into it, and some distinguished physicians have thought it worththeir while to lay down very minute rules for distinguishing between thetwo opposite states. Headache we all know attends an overfull conditionof the vessels of the brain, and grown persons usually suffer from itseverely before an attack of apoplexy; but we also know that badheadache accompanies states of great weakness, and that it is one of themost distressing consequences from which a woman suffers who has lostmuch blood in her confinement. In just the same way, the infant who hasbeen exhausted by diarrh[oe]a or by some trying illness, or who afterweaning has been kept on a diet not sufficiently nutritious, may showsymptoms of disorder of the brain. 

It may become irritable, restless, very startlish, with occasionalflushings of the face, moaning in its sleep, and sleeping withhalf-closed eyes. But the head is not hotter than the rest of the body;if the head is not closed, the open part or fontanelle is not tense andpulsating, but flat or even depressed, the hands and feet are cool, andvery readily become cold; there may be occasional vomiting, but nothinglike the constant sickness of real brain-disease, the bowels are notshrunken but distended, constipation is not present, but on the contrarythere is a disposition to diarrh[oe]a. If the symptoms aremisinterpreted and wrongly treated, unmistakable signs of exhaustion atlast come on, and the child may die from its not being borne in mindthat results at first sight much the same may flow from causesdiametrically opposite. 

The moral of this is too obvious for me to need insist upon it. Cold tothe head, low diet, aperients, possibly leeches, are needed in the onecase; increased nourishment, perhaps stimulants, in the other. In everyinstance where symptoms of brain disorder occur in the child, rememberthe grievous consequences of a mistake as to their nature, and seek forfurther help and guidance to preserve you from the possibility of error. 

=Spasmodic Croup. =--I have already tried to explain how, in early life, the brain is often unequal to control the sensitiveness of the nervoussystem to various sources of irritation from without, and how, inconsequence this irritation manifests itself by those involuntarymovements which we call convulsions. But in addition to, or in the placeof those violent contortions or convulsions, the same condition showsitself sometimes in disordered action of the muscles which subserveparts not directly subject to the will, as those for instance which openand close the entrance to the windpipe, or glottis as it is called inmedical phraseology. 

Cases in which this occurs are known in popular language aschild-crowing, or _spasmodic croup_, from the peculiar catch or crowwhich accompanies the entrance of air through the spasmodicallycontracted opening of the windpipe; a spasm which if severe andsufficiently continued closes the opening altogether, so that afterfruitless efforts to get its breath the child dies suffocated. Thisaffection occurs chiefly during teething, just as the fits of ahysterical girl oftenest occur during the transition from girlhood towomanhood; but many other causes besides the local irritation of theteeth may produce it, such as constipation, indigestible food, ordisorder of the bowels. 

It does not often occur in perfectly healthy children; but an infantwho is attacked by it is usually observed to have been drooping for sometime previously, to have lost its appetite, to have become fretful byday and restless at night, and to present many of those ill-definedailments which are popularly ascribed to teething. At length, afterthese symptoms have lasted for a few days or weeks, a slight crowingsound is occasionally heard with the child's respiration, shorter, morehigh-pitched, but less loud than the hoop of hooping cough. Usually itis first noticed on the child awaking out of sleep, but sometimes it isperceived during a fit of crying, or comes on while the infant issucking. The spasm may have been excited by some temporary cause, andthe sound which is its token may not be heard again; but generally itreturns after the lapse of a few hours, or of a day or two, and itsloudness usually increases in proportion as its return becomes morefrequent. It will soon be found that certain conditions favour itsoccurrence; that the child wakes suddenly with an attack of it, thatexcitement induces it, or the act of swallowing, or the effort atsucking, so that the child will drop the nipple, make a peculiar croupysound with its breathing, and then return to the breast again. Throughout the whole course of the affection, its attacks will be foundto be more frequent by night than by day; and to occur mostly soon afterthe child has lain down to sleep, or towards midnight, when the firstsound sleep is drawing to a close. 

At first, the child seems, during the intervals of the attack, much asbefore; except, perhaps, that it is rather more pettish and wilful; butit is not long before graver symptoms than the occasional occurrence ofan unusual sound when the child draws a deep breath excite attention, and give rise to alarm. Fits of difficult breathing occasionally comeon, in which the child throws its head back, while its face and lipsbecome livid, or an ashy paleness surrounds the mouth, slight convulsivemovements pass over the muscles of the face; the chest is motionless, and suffocation seems impending. But in a few seconds the spasm yields, expiration is effected, and a long loud crowing inspiration succeeds, orthe child begins to cry. Breathing now goes on naturally: the crowing isnot repeated, or the crying ceases; a look of apprehension dwells for amoment on the infant's features, but then passes away; it turns oncemore to its playthings, or begins sucking again as if nothing were thematter. A few hours, or even a few days, may pass before this alarmingoccurrence is again observed, but it does recur, and another symptom ofthe disturbance of the nervous system is soon superadded, if it has not, as is often the case, existed from the very beginning. This consists ina peculiar contraction of the hands and feet; a state which may likewisenot infrequently be noticed during infancy, unattended by anypeculiarity in breathing. It differs much in degree; sometimes the thumbis simply drawn into the palm while the fingers are unaffected; at othertimes the fingers are closed more or less firmly, and the thumb is shutinto the palm; or, coupled with this, the hand itself is forcibly flexedon the wrist. In the slightest degree of affection of the foot, thegreat toe is drawn a little away from the other toes; in severer degreesthe toe is drawn away still further, and the whole foot is forcibly bentupon the ankle, and its sole directed a little inwards. Affection of thehands generally precedes the affection of the feet, and may even existwithout it, but the spasmodic contraction of the feet never existswithout the hands being involved likewise. At first this state istemporary, but it does not come on and cease simultaneously with theattacks of crowing breathing, though generally much aggravated duringits paroxysms. Sometimes a child in whom the crowing breathing has beenheard, will awake in the morning with the hands and feet firmly bent, though he may not have had any attack of difficult breathing during thenight. When the contraction is but slight, children still use theirhands; but when considerable they cannot employ them, and they sometimescry, as if the contraction of the muscles were attended with pain. Sometimes, too, there is a degree of puffiness both of hands and feet, asort of dropsical condition, which, whenever it is present, adds much tothe anxiety with reference to the child. 

As the condition becomes more serious, a slight crowing sound is heardeach time the child draws its breath, the fits of difficult breathingare much more severe; they last longer, and sometimes end in generalconvulsions. The breathing now does not return at once to its naturalfrequency, but continues hurried for a few minutes after the occurrenceof each fit of difficult breathing, and is sometimes attended with alittle wheezing. The slightest cause is now sufficient to bring on anattack; it may be produced by a current of air, by a sudden change oftemperature, by slight pressure on the windpipe, by the act ofswallowing, or by momentary excitement. The state of sleep seemsparticularly favourable to its occurrence, and the short fitful dozesare interrupted by the return of impending suffocation, in one paroxysmof which longer and severer than the others the infant may fall backdead. 

It scarcely need be said that the great majority of cases have no suchsad ending as I have described, but still, whenever this spasm exists, even in a slight degree, there is always the possibility, never to beforgotten, of a sudden catastrophe. Usually, after some tooth has beencut which caused special irritation, or as disorder of the bowels hasbeen set right, the symptoms abate by degrees, and then ceasealtogether, though liable to be reproduced by the same causes as thoseto which they were originally due. 

The seeking out and removing the exciting causes must be the care of themedical man, but there are some special precautions which come withinthe mother's own province to observe. 

First of all, as sudden excitement, and especially a fit of crying, arelikely to bring on the attack, and since there is a possibility that anyattack may prove fatal, the greatest care must be taken in themanagement of the child to avoid all unnecessary occasion of annoyanceor of distress. 

Although the benefit that accrues from fresh air, or from a change ofair, is often very great, yet it is very important that the child shouldnot be exposed to the cold or wind, for I have seen such exposurefollowed by a severe attack of difficult breathing, or by the occurrenceof general convulsions. Another reason for caution in this respect isthat the occurrence of catarrh is almost sure to be followed by anaggravation of the spasmodic affection, which, though previously slight, may thereby be rendered serious or even dangerous. 

I have nothing to add to what I have already said with reference to thetreatment of the attack, when actual convulsions come on. Since, however, in this affection convulsions may occur quite unexpectedly atany moment, it is well always to have a basin of cold water and a bunchof feathers handy, in order to be able at once to dash the water on thechild's face, and induce that deep inspiration which saves it from thethreatening danger. If this should not suffice, the finger must be putinto the mouth, and run over the back of the tongue in the way that Ihave already explained when speaking of convulsions. Now and then ithappens, though but very rarely, that violent _general convulsions_ comeon in infancy quite independent of spasmodic croup, not preceded norattended by any sign of disease of the brain, and which end in thecourse of some hours or of a few days in death, the child being partlyworn out by the violence of the muscular movements, partly by thedisturbance of breathing which each fit occasions. Happily, however, inmost of these instances the convulsions by degrees lessen both inviolence and frequency, and the child recovers. 

=Epilepsy. =--There is one other point of view from which convulsions ininfancy and early childhood must be looked on with apprehension, andthat is from their being frequently followed in after years by_epilepsy_. In nearly a fifth of all cases of epilepsy in childhood thathave come under my notice the first occurrence of fits dated back toearly infancy, and this, even though an interval of years had passedbetween the last fit in infancy and the first in childhood. It seems, indeed, as though there were in these cases a peculiar abidingsensitiveness of the nervous system, which, dating back from very earlylife, dependent often on hereditary predisposition, was kindled intoactivity by any special cause, such as the cutting of the second set ofteeth, or the transition from boyhood or girlhood to manhood orwomanhood. 

In the child, just as in the grown person, epilepsy manifests itself intwo different ways; either by momentary unconsciousness, or by violentconvulsions, in which latter there is little distinction from theoccasional fit which may be observed at any period of infancy. 

The attacks of momentary unconsciousness often pass long unnoticed. They occur, perhaps, when the child is at play or at meals; it stops asif dazed, its eye fixed on vacancy; if standing, it does not fall, nordoes it drop the toy or the spoon which it was holding from its hand. Ifspeaking, it just breaks off in the midst of the half-uttered sentence. Then, in less time than it takes to tell, it suddenly looks up again, finishes what it was saying, or goes on with its play, or with its mealas though nothing had happened; or it suffices to call the child and thecloud passes from its face, and it is itself again; and the nurse orperhaps even the mother, thinks that it is some odd trick which thechild has got. By degrees the attacks become more frequent, and maycontinue to recur several times a day without any obvious cause, evenfor months; and this without any change in their character. By degrees, however, under their influence, an alteration takes place slowly in thechild's disposition. It loses its cheerfulness and brightness, its faceassumes a heavy look, it becomes fretful, and its intelligence growsduller. 

Almost invariably after the attacks of this, which has been called the_petit mal_, have continued for some months, a change begins to takeplace, which does not fail to excite attention and to cause alarm. Ifseated, the child's head drops forward for a moment, and strikes againstthe table; if standing, it becomes for an instant dizzy, and staggers, or even falls, and then there is twitching of one limb, or of themuscles of the face, and then the complete fit of epilepsy, ushered insometimes, but not always, by a momentary cry, and then the convulsivetwitching of one limb, followed in a minute or in less time byconvulsions of the whole body as well as of the limbs. The upturnedeyes, which do not see, are horribly distorted, the child foams at themouth, it is insensible, and the insensibility deepens into stupor, oris followed by heavy sleep, for a quarter of an hour, or an hour ormore, from which the patient arouses feeling tired and bruised, andoften with an aching head, but with no remembrance of what has passedduring the seizure so distressing to bystanders. 

It has throughout been my endeavour not to lose sight of those for whomthis little book has been written, and with reference to epilepsy, aswith reference to many other things, I pass over much that would beimportant to the practitioner of medicine, to dwell on those pointswhich mainly interest the parents, and which they are perfectly able toappreciate. 

The question is often put as to the probability of fits terminating inepilepsy; or, on the other hand, as to the ground for hope in any casethat epileptic attacks, which have already often recurred, willeventually cease. In the first place, no conclusion can safely be drawnfrom the severity of a convulsion, nor from its general character, as tothe probability of its frequent recurrence, or of its passing intopermanent epilepsy. The severity of a fit certainly affords no reasonfor this apprehension, nor does its recurrence, so long as a distinctexciting cause can be discovered for each return. The fits, which ceasein the teething child when the gum is lanced, and which, on eachsucceeding return are equally relieved by the same proceeding, do notimply that there is any great tendency on their part to become habitual. In the same way, the attacks which follow on constipation, or onindigestion, or on some other definite exciting cause, may probably withcare be guarded against, and their return prevented. It is not theviolence of a single fit, nor even the frequent return of fits for alimited time, which warrants the gravest apprehension; but it is theirrecurrence when all observable causes of irritation have passed away; itis their return when the child is otherwise apparently in perfecthealth. 

If, on the one hand, the violence of a convulsion does not by any meansimply the greater proportionate risk of its recurrence, so neither canany hopeful conclusion be drawn from the slightness of an attack, orfrom its momentary duration. In childhood, such attacks are at least ascommon preludes to confirmed epilepsy as in the adult, and are the moredeserving of attention from their very liability to be overlooked. Ibelieve, too, that an imperfect suspension of consciousness, the childknowing what passes, though unable to speak, is not very uncommon, andfurther, that it is far from unusual to have the early stage of epilepsyin childhood announced by sudden incoherent talking for a few seconds, or by a wild look; a cry of surprise, or a short fit of sobbing, announcing as in a hysterical girl, the close of the paroxysm. The earlysymptoms of epilepsy in childhood are also the more likely to bemisinterpreted from the circumstance that they are frequentlyaccompanied by a moral perversion much more striking than any loss ofmental power. It is true that in early life there are alternations ofintellectual activity and mental indolence, of quickness and comparativedulness, which all who have had much to do with education are well awareof, and which are perfectly compatible with health of body and health ofmind. But changes in the moral character of a child who is still underthe same influences, have a far deeper meaning than is often attached tothem; a child does not suddenly become wayward, fretful, passionate, ormischievous, except under the pressure of some grave cause. 

One other point there is also to be borne in mind; namely, that thechild is compelled by the vague sensation of hitherto unknown dread, notto conceal the early symptoms of epilepsy as the grown person would do;longing as the child does for love and sympathy, and weakened in itsmoral force, it craves for more love, more sympathy, it exaggerates itssymptoms, it assumes some which do not exist at all. The conclusion is anatural one, but none the less mistaken, that the child who isdiscovered to be shamming has nothing the matter with it--is simply anaughty child. This is a fact of much importance, on which I shall haveoccasion to insist further on. 

In the child, as in the adult, epilepsy blunts the intellect as well asweakens the moral powers; and does both more speedily and moreeffectually in proportion as the child is younger, and its mind and willare less developed. And yet this has its compensation; for as the powersfade quickly, so, if the attacks cease, they recover with surprisingrapidity, and as the moral powers are the first to suffer, so they arethe first to regain--I will not say full vigour, but at least a degreewhich raises the children to be objects of specially tender affection, rather than of pity and compassion. 

The conditions which justify the most hopeful view of any case ofepilepsy are then, first, the absence of any history of frequentlyrecurring convulsions in early infancy; secondly, the existence of adistinct exciting cause for the attacks; thirdly, the rarity of theirreturn far more than their slight severity; and lastly, the more theattacks approach in character to what one knows as hysteria, the lessprofound the insensibility in the fit, the shorter its durationafterwards, the greater are the grounds for hope that the seizures willeventually cease. 

Cases of this last class are to some degree, at any rate, under thechild's control. I have several times seen a fit warded off by thethreat of the shower bath, or even by calling to the child, and sendingit to fetch something in another room. Such cases may indeed pass intoordinary epilepsy, but often, under judicious management, moral ratherthan medical, they cease, so that one can venture on taking a morehopeful view of them than of others. 

And this brings me to the question of what can be done, or rather whatcan parents do to promote recovery from epilepsy. First of all, do notlisten to what you may hear about this medicine or the other being aspecific for it. There is no specific whatever for epilepsy, but thereare certain remedies which in skilful hands do have a real thoughlimited power to control the frequency and lessen the severity of theattacks. Next, there are cases in which the attacks depend on somedefinite cause; it may be indigestion, or constipation, or the cuttingof the second set of teeth, and on the irritation produced by thoseteeth being too crowded. Thus, I remember a boy twelve years old, inwhom two severe epileptic fits occurred apparently without cause. He wascutting his back grinding teeth, and in the lower jaw the teeth seemedovercrowded. I had a tooth extracted on either side, the fits ceased, and when I last heard of him many years afterwards they had notreturned. 

Epilepsy often lasts for many years, and no one's memory is retentiveenough to be trusted with all the details between the different attacks, the causes which seemed to produce them, the measures which appeared atdifferent times to be of service. I am therefore accustomed to advisepeople, any of whose children have the misfortune to be epileptic, towrite as brief an account as possible of the child's previous history, and to supplement it by a daily record kept in parallel columns of date, food, state of bowels, sleep, medicine, attacks, specifying theircharacter and duration; and general remarks, which would bear on thechild's temper and general condition, and in which column any probableexciting cause of an attack would be recorded. It is surprising how muchimportant information is gathered in a few months from such a recordkept faithfully. 

The diet should be mild, nutritious, but as a general ruleunstimulating; and should include meat comparatively seldom, and insmall quantities. Some fifty years ago, a very distinguished Americanphysician, Dr. Jackson of Boston, in the United States, insisted verystrongly on the importance of a diet exclusively of milk and vegetablesin greatly lessening the frequency and severity of epileptic attacks. Ibelieve in the great majority of cases of epilepsy in childhood Dr. Jackson's advice is worth following. And I may add that, while I havelittle faith in the influence of mere drugs, I have a yearly increasingconfidence in that of judicious management, mental and moral, as well asphysical. 

The first requisite in all cases is a firm and gentle rule of love onthe part of those who have charge of the child. As violent and suddenexcitement of any kind will often bring on an epileptic seizure, so theinfluence of the opposite condition in warding off its attacks is veryremarkable; and on several occasions I have received patients into theChildren's Hospital who were reported to have epileptic seizures severaltimes in a day, and who nevertheless remained a fortnight or more in theinstitution without any attack coming on. The disorder, however, was notcured, but only kept in check by the gentle rule to which the littleones were subjected. The order goes for much in these cases; the noveltygoes for something too, for almost invariably I have found that after atime the apparent improvement becomes less marked, and though theycontinued better than when they first came to the hospital, the childrenwere still epileptic; the advance of the disease had been retarded, butits progress had not been arrested. The quiet then which suits theepileptic, is not the quiet of listless, apathetic idleness, but thejudicious alternation of tranquil occupation and amusement. The mindmust not be left to slumber from the apprehension of work bringing on afit, but the work must, as far as possible, be such as to interest thechild. In the occupations of epileptics therefore, pursuits which notmerely employ the mental faculties, but also give work to the hands, such as gardening, carpentering, or the tending of animals, arespecially to be recommended; and if by these the mind can be kept awake, the grand object of teaching is answered, and backwardness in reading, writing, or those kinds of knowledge which other children at the sameage have acquired, is of very little moment. Many epileptics have anindistinct articulation, and almost all have a slouching gait, and anawkward manner. The former can often be corrected to a considerabledegree by teaching the child simple chants, which are almost alwayseasily acquired, and practised with pleasure. The latter may berectified by drilling, not carried out into tedious minutiæ, but limitedto simple movements; and the irksomeness of drill is almost completelydone away with by music, while I believe that the accustoming a child tothe strict control and regulation of all its voluntary movements is ofvery great importance indeed as a curative agent. 

It is difficult to carry out these minute precautions on which so muchdepends in the home with other children of the same family. It istherefore, I believe, better for the child, painful though it is to theparents, that he should be placed under the care of some competentperson who will devote the whole of his time to the care of the patient. 

=St. Vitus's Dance. =--A state of unconsciousness, accompanied with moreor less violent involuntary movements, is characteristic of epilepsy. Involuntary movements without loss of consciousness constitute thedisorder commonly known as _St. Vitus's Dance_. It is rare in earlychildhood, becomes more common after the age of five, and attains itsgreatest frequency between the ages of ten and fifteen, girls, owing totheir more impressionable nervous system, being affected by it more thantwice as often as boys. 

It seldom comes on in a child previously in perfect health, andstrangely enough it occurs with special frequency in children who havebefore suffered from rheumatism. Sudden shock or fright is often said tohave been its exciting cause; but even then the symptoms seldom come atonce, but are gradually developed in the course of two or three days. Atfirst, it is noticed that the child has certain odd fidgety movements, usually of one arm, next of the leg of the same side, so that itstumbles in walking, and then the muscles of the face become affected, the child grimacing strangely, and next the limbs of the opposite sidebecome involved, and as things go on from bad to worse, the childbecomes unable to hold anything in its hand, to walk, or even to stand, and even if on the ground still writhes about with the strangestcontortions of its body. If matters grow still worse, the child becomesunable to put out its tongue, it swallows with difficulty, it loses notonly the power of distinct articulation but even the faculty of speech, while the mind itself becomes weakened, the child seems half idiotic, and even though the movements lessen in violence, power over the limbsis lost for the time, and they seem almost paralysed. Happily cases sosevere are very rare, and it is rarer still for them to have a fataltermination. Almost invariably recovery takes place by degrees, themovements lessen, swallowing is performed with less difficulty, thepower of speech, returns, and the intellect regains its brightness: butthe child is left with a special liability to return of the affection, though the first attack is usually the most severe. 

Even at the best, however, the disorder is always tedious, as is shownby the fact that its average duration is seventy days. It is verynatural, therefore, that parents should be anxious when they see thattheir child has some awkward or ungainly habit, some odd trick orgesture never noticed before, lest it should be the beginning of thistedious ailment. Now it is well to remember that St. Vitus's dance doesnot begin with twitching of the muscles of the face, but that itsearliest symptoms are involuntary movements of the arms and twitching ofthe fingers, and that contortions of the face do not come on tillafterwards. Movements of this sort too, even when not limited to theface, vary in the course of a few days in the parts which they affect, and show themselves, now in winking the eyes, then in grimacing, intwitching of the muscles of the face or neck, or in some awkward gait ormanner. These are all best left unnoticed, for they are almostinvariably made worse if the child's attention is called to them. Theyare, or at least before the days of Board Schools they were, scarcelyever met with among the children of the poor, for they almost invariablydepend on mental strain; not of necessity on undue length of the hoursof study, or on the difficulty of the tasks imposed, but often on achild's anxiety to make progress and to keep up with his schoolfellows. In corroboration of this being their cause I may say that, contrary tothe rule which obtains with St. Vitus's dance, these movements are morefrequent in boys than in girls, for the over-mental strain of boys comesearlier; that of girls seldom occurs before the time of transition towomanhood, and its results are then different, though much graver. Incases of this kind, lessening the mental strain is almost alwaysfollowed by a cessation of the movements; change of air, countryamusements, and a generally tonic treatment perfect the cure, anddancing and gymnastics overcome the remains of any awkward habit. 

The movements in real St. Vitus's dance do not shift about as these dofrom one part to another, but tend to involve various parts insuccession, without previously ceasing where they had begun. 

The relative share which the parents and the doctor take in thetreatment of these cases depends to a great extent on their severity. While attention to the state of the bowels, and a generally tonictreatment are almost always needed, gymnastics and drill are often ofvery great service in the slighter cases; and a very distinguished Parisphysician was accustomed to send children thus affected to march roundthe Place Vendôme, keeping step while the band was playing. The utilityof gymnastics turns very much on the degree in which the child is ableby attention to control his movements, and when either as in youngchildren fixed attention cannot be roused, or as in severe cases theeffort only adds to the child's nervousness, and in consequenceincreases the movements, they must be given up. All drill and gymnasticsare best carried out in class with other children, and regulated notsimply by word of mouth, but by a tune or chant. When recovery is inprogress gymnastics will then in almost all instances find their place. 

Even when drill and gymnastics cannot be practised, regulated movementsof the limbs carried out twice a day for ten minutes at a time are ofvery real service. Another's will here takes the place of that of thepatient, and the limbs are thus taught, though far more imperfectly, toact in concert. 

Two or three more cautions may still be of service. Do not keep a childout of bed, and force it to try to exert itself when the movements arevery severe; continued movement, voluntary or involuntary, fatigues. Letthe child lie in bed; it rests there, and the movements, which alwayscease during sleep, become at once greatly lessened. So important indeedis it to avoid the exhaustion caused by incessant violent movement, thatin bad cases it is sometimes necessary to swathe the limbs in flannelbandages, and so to confine them to splints in order to restrain them. Next, do not become over-anxious because the child grows stupid andceases to talk; intelligence and the power of speech will certainly comeback again. And, lastly, do not be impatient and think your medicaladviser incompetent because the disorder lasts so long. An averageduration of seventy days implies that while sometimes it ceases sooner, in others it lasts much longer than the two weary months of watching andwaiting with which in any case you must lay your account. 

=Paralysis, or Palsy. =--When speaking of St. Vitus's dance I said thatthere was a partial loss of power in the limbs as well as an inabilityto control their movements. After a fit of convulsions, or an epilepticseizure, power over some limb is often lost for a time which may varyfrom a few minutes to some hours. In the course of some serious diseasesof the brain, one of the manifestations of the mischief is theimpairment or the loss of power over one arm or leg, rarely over both;and lastly, that terrible disease diphtheria is often followed by aparalysis so general that the patient is sometimes for days unable tomove even a finger, although the condition may eventually pass away. 

There is, however, a very _real paralysis_ which occurs sometimes ininfants and young children. It comes on for the most part quitesuddenly, often unaccompanied by any sign of brain disorder, but tendingnevertheless to issue in great permanent impairment of the power overthe affected limb or limbs, and eventually to interfere with theirgrowth and thus to produce serious deformity. 

It is in general impossible to assign any distinct exciting cause forthe affection, though the fact that in two-thirds of the cases it occursbetween the ages of six months and three years, proves it to be in someway intimately associated with teething. The oldest child in whom I haveever seen it was aged between seven and eight years, and the youngest alittle under six months. It is of excessive rarity for the arm alone tobe affected, but it is by no means unusual for the legs alone to beparalysed; though in the majority of instances power is lost on one sideonly, the leg and arm being both involved. 

A child goes to bed quite well, or at the worst having seemed slightlyailing and feverish for a day or two, and on waking in the morning it issuddenly discovered that power is lost over one leg or both, or overboth arm and leg of one side. The loss of power is at first seldomcomplete, though neither arm nor leg can be used to any good purpose, and during the ensuing twenty-four hours the palsy often grows worse, and sometimes affects one or both limbs of the opposite side. After thattime recovery in general begins. It is now and then speedy, so that inthree or four days all trace of the paralysis may have disappeared. This, however, is a fortunate exception to the general rule, which isthat amendment is very tardy, showing itself first in the arm, afterwards in the leg, and, if both sides have been affected, more onone side than on the other. Unless the improvement is very rapid, it isalmost always only partial, and the palsied limb, though it does notlose sensation, regains but little power; it grows much more slowly thanthe other, is always colder and wastes considerably, while, some musclesstill retaining more power than others, it becomes twisted out of shape, and requires all the skill of the orthopædic surgeon to remedy or atleast to lessen the consequent deformity. 

It has been ascertained that this form of palsy depends on a state ofcongestion, or overfilling of the minute blood-vessels of the spinalmarrow. When the child gets well the congestion has passed away; but itdoes this speedily, and recovery is then rapid as well as complete. Ifit does not soon pass away, other changes take place in the spinalmarrow, and recovery is then slow, incomplete, or even does not takeplace at all. 

Remedies are unfortunately of little avail here, but it is evident thatwhen the palsy is quite recent all movement of the limb must bemischievous, and that the congestion of the spinal marrow to which it isdue will be most likely to abate under the influence of perfect quiet, rest in bed, and soothing or fever medicines, or of such as arecalculated to overcome constipation, or to correct any fault ofdigestion, while the importance of teething, and the possible expediencyof lancing the gums must not be forgotten. 

Afterwards comes the time for exercise of the paralysed limb, forfriction, for shampooing, for galvanism; all continued perhaps formonths or years with unwearied patience, and I must add with reasonableexpectations as to the result. The only additional remark which I haveto make is this, that to gain any real good from galvanism, a batterymust be procured under the direction of some medical man speciallyskilled in the use of electricity, and the mode of employing it must belearned thoroughly from him. It is merely idle to purchase a toymachine, and, giving it to the nurse to turn the handle for ten minutestwice a day, to fancy that you are making a serious trial of the effectsof galvanism. As a mere money question, a costly machine, and severalfees paid in order to be thoroughly instructed in the way to use it, ismuch cheaper than a cripple child. 

A few words may not be out of place with reference to cases in whichparalysis is mistakenly supposed to exist. Much anxiety is sometimesexpressed by parents concerning children who have long passed the usualage without making any attempt to walk; or who having once walked seemto have lost that power. Now it often happens that after any weakeningillness a child ceases for some weeks to walk, just as it ceases totalk. The power in both cases was newly acquired, it called for effortwhich, when strength is regained, will be put forth once more. The sameapplies to other instances in which children are late in learning towalk; or who, having once walked, leave off walking when a back tooth, or when one of the eye teeth is coming near the surface of the gum, andregaining the power lose it again, or lose at least the desire to exertit more than once during the active progress of teething. But, holdingthe child under its arms, you have but to put its feet to the ground, and at once it will draw up its legs though it will make no othermovement; or take it on your lap and tickle the soles of its feet, andlaughing or crying, as the mood takes it, it will move its legs about asfreely as you could wish and show that the power is still there, thoughfor the present the child will not take the trouble to exert it. 

Gradual loss of power over one or other leg, especially if attended withpain either in the back or in the knee or hip, should always call forattention, and induce you to seek at once for medical advice. Such casesgenerally occur later in childhood than the conditions of which I spokein the former paragraph, and may depend on disease of the spine or ofthe hip-joint, two serious conditions which it needs the medical expertto discover and to treat. 

=Neuralgia and Headache. =--In the grown person neuralgia, as many of usknow to our cost, is by no means infrequent; in the child it is veryrare, and when a child complains of severe pain in the head, or ofsevere pain to the knee or hip apart from rheumatism, it is almostinvariably the sign of disease of the brain in the one case, of thehip-joint in the other. To this rule there are indeed exceptions, but itwill always be well to leave it to the doctor to determine--no easymatter by the bye--whether any given case is one of the rare exceptionsor not. 

There is, however, one form of real _neuralgic headache_ which is by nomeans rare in children after the commencement of the second dentition, and which sometimes goes on into early manhood or womanhood, when itbecomes what is commonly known as sick headache. It is essentially anailment of development, incidental to the time when the brain is firstcalled on for the performance of its higher functions. 

It does not by any means always depend on over-study, though I do notremember meeting with it in children who had not yet gone into theschool-room; and I have frequently found it dependent on too continuousapplication, though the number of hours devoted to study in the courseof the day may not have been by any means excessive. 

The child's brain soon tires, and the arrangement, so convenient toparents of morning lessons and afternoon play, works far less well forit than if the time were more equally divided between the two. 

The attacks not infrequently come on on waking in the morning, andrapidly become worse, the pain, which is almost always referred to theforehead, being attended with much intolerance of light and sound, withnausea, and often with actual vomiting. Like the vomiting ofsea-sickness, however, previous stomach disorder has no necessary sharein its production, and I may add, indeed, that it is often difficult toassign any special exciting cause for the attack. The suffering is moreoften relieved by warm or tepid than by cold applications, and notinfrequently pressure or a tight bandage greatly mitigates it. In nocase does the attack last more than twelve hours--usually not more thanhalf that time; it passes off with sleep, and leaves the patient weakand with a degree of tenderness of the head to the touch. 

Such attacks may occur every fortnight, ten days, or even oftener, buttheir very frequent return, instead of increasing apprehension, shoulddiminish anxiety. A first attack, indeed, may seem as though itthreatened mischief, till it is seen how speedily and completely itpasses off, and when afterwards a second or a third attack comes on withthe same severity of onset, the same rapid worsening, and the same quickpassing away, you will feel convinced that the symptoms have no gravemeaning. 

There is a headache of quite a different kind to which I must for amoment refer, that, namely, which depends entirely on imperfect vision, and for which spectacles are the remedy, not physic. The infirmity isnot noticed during the first few years of life, but in later childhood, when a tolerably close attention to study has become necessary. Some ofthe minor degrees of short-sightedness, and want of power of adaptationof the eyes, such as exists in the aged, soon begin to interferesensibly with the child's comfort, and the strain to which the eyes aresubject produces a constant pain over the brow, the cause of which isoften unsuspected. [13]

In all cases, therefore, in which a child complains of constant painover the brow for which there is no obvious cause, it is well to takethe opinion of an oculist, who can best ascertain the power of _readingat different distances_ and with each eye separately, and the real causeof symptoms which had occasioned much anxiety is thus often brought tolight. 

=Night Terrors. =--Before taking leave of the disorders of the nervoussystem, I must briefly mention the Nightmare, or Night Terrors ofchildren, which often cause a degree of alarm quite out of proportion totheir real importance. 

It happens sometimes that a child who has gone to bed apparently well, and who has slept soundly for a short time, awakes suddenly with a sharpand piercing cry. The child will be found sitting up in bed, crying outas if in an agony of fear, 'Oh dear! Oh dear! take it away! father!mother!' while terror is depicted on its countenance, and it does notrecognise its parents, who, alarmed by the shrieks, have come into itsroom, but seems wholly occupied by the fearful impression that hasroused it from sleep. By degrees consciousness returns; the child nowclings to its mother or its nurse, sometimes wants to be taken up andcarried about the room, and by degrees, sometimes in ten minutes, sometimes in half-an-hour, it grows quiet and falls asleep; and thenusually the rest of the night is passed undisturbed, though sometimes asecond or even a third attack may occur before daybreak. 

Seizures of this kind may come on in a great variety of circumstances, and may either happen only two or three times, or may continue to recurat intervals for several weeks. The great point, however, to bear inmind is that they depend invariably on some disorder of the stomach orbowels, and are never an evidence of the commencement of real disease ofthe brain. 

FOOTNOTES:

[11] Reports of the Registrar-General, as quoted at p. 30 of my_Lectures on Diseases of Children_. The actual numbers are 9, 350 underfive years old, out of a total of 16, 258. 

[12] Figures deduced from the 44th Report of the Registrar-General. 

[13] Before I called attention to this form of headache in the lastedition of my lectures, it had already been noticed without myknowledge, by a friend of mine, Dr. Blache, of Paris, in a very valuableessay on the headaches which occur during the period of growth. 

CHAPTER VII. 

THE DISORDERS AND DISEASES OF THE CHEST. 

In speaking of the ailments which occur during the first month afterbirth, I have already noticed the peculiarities of breathing in earlyinfancy, and the difficulties that sometimes attend the complete fillingof the air-cells of the lungs, and the readiness with which when oncefilled they become emptied of air and collapse. 

On this ground it is therefore needless for me again to enter, and I maypass at once to consider those ailments which rise in increasingimportance from a simple cold or catarrh to inflammation of theair-tubes or bronchitis, inflammation of the lung substance, aspneumonia, and inflammation of the membrane which lines the chest andcovers the lungs, or pleurisy. 

=Catarrh. =--A common cold or _catarrh_ is not one of the ailments ofvery early infancy. The watery eyes, the sneezing, the cough, the slightfeverishness and the heavy head are scarcely met with until after theage of three months; nor, indeed, are they often seen till the child isold enough to run about, to go out for a walk, and to encounter inconsequence all the variations of temperature and of damp or drynessinseparable from the English climate. 

This, however, is not entirely due to the greater exposure of the childto these influences as it grows older, but in part also to the fact thatthe lining of the air-tubes is less sensitive in early infancy than itafterwards becomes. The young babe if it catches cold gets _snuffles_, or stoppage of the nostrils, which first become dry, and then pour outan abundant discharge, which sometimes dries and forms crusts, andcauses the child to suck with difficulty, and to breathe uncomfortablyand with open mouth. In a few days, however, at the worst thisdiscomfort passes away; and the only additional remark I have to makeis, that since obstinate snuffles are sometimes a constitutionaldisease, the doctor's advice should always be sought if they last longerthan a week. 

It is needless to describe a cold, but it is much more to the purpose tosay how its occurrence is to be prevented, and nine times out of ten theobservance of two simple rules will suffice for this. First, take carethat there is no great difference between the temperature of the day andof the night nursery. The one should never be above 60°, nor the otherbelow 50°, and the undressing and the bath should always take place inthe warmer room. Second, never let the child wear the same shoes orboots in the house as it does out of doors. The change should be as mucha matter of routine as the taking off its hat or its bonnet. 

The domestic management of a cold is simple enough. The usual error isthe overdoing precautions, the keeping the room too hot, or overloadingthe child with extra garments, or its bed with extra covering, by whichit is kept in a state of feverishness, or of needlessly profuseperspiration. 

If, for the first two days of a bad cold, the child is kept in bed, theroom being at a temperature of 60°, with no extra covering on the bed, but a flannel jacket for the child to wear when it sits up in bed toplay, a few drops of ipecacuanha wine several times a day, a warm bath, a linseed poultice to the chest, and a little paregoric at night, with alight diet of rice, and arrowroot, and milk, and a roasted apple, andsome orange juice; nine times out of ten, or nineteen out of twenty, thecold will pass away with small discomfort to the child and no anxiety tothe parents. 

Often a child objects to stop all day in its little cot, but move it toits mother's or nurse's big bed; and with a large tray of toys beforeit, and a little of the tact which love teaches, the day will pass inunclouded content and cheerfulness. 

It must of course be borne in mind that measles set in with all thesymptoms of a bad cold, followed on the fourth day by the appearance ofthe eruption; and, moreover, watchfulness must always be alive to detectincrease of fever, hurry of breathing, hardness or extreme frequency ofcough, the sign of the irritation of the larger air-tubes havingextended and become more severe, the evidence that the case from simplecatarrh has become one of bronchitis. 

=Bronchitis and Pneumonia. =--It is impossible to enable persons who havenot received a medical education to distinguish between a case ofbronchitis and one of pneumonia. Neither, indeed, is it of muchimportance that they should do so, for in both the dangers are of asimilar kind, and both call equally for the advice of a skilful doctor. 

In _bronchitis_ inflammation affects the lining of the air-tubes, travelling from the larger towards the smaller, and in bad casesextending even to their termination in the minute air-cells. Theinflammation leads to the pouring out of a secretion, which by degreesbecomes thick like matter, or even very tenacious, almost as tough asthough it were a thin layer of skin. If this is very extensive, andreaches to the small air-cells, it is evident that air cannot enter, while that elasticity of the lung which I have already spoken of tendsto drive out from the cells the small quantity of air they contained, and the child dies suffocated, partly from the difficulty in theentrance of air, partly from the collapse of air-cells from which theair has been slowly expelled. 

In _pneumonia_ or inflammation of the lung-substance the process isdifferent. A portion of one or other lung, sometimes of both, becomesoverfilled with blood, or congested, and though the air-tubes themselvesare not the special seat of the congestion, yet the air-cells arepressed on by the surrounding swollen substance, and the entrance of airinto them is impeded. If the mischief goes further the substance becomessolid and impervious to air, and lastly it becomes softened, itsstructure destroyed, and infiltrated with matter; the affected partbecomes really an abscess, though not bounded by the distinct limitswhich would shut in an abscess of the hand or the foot. Inflammation, and the formation of an abscess anywhere is, as we know, attended byfever and much general illness, and inflammation of the lung is ofcourse attended by fever and general illness in proportion to theimportance of the organ affected. To these, too, must be added all thedisturbance inseparable from any ailment which gravely interferes withbreathing. 

In the great majority of instances inflammation of the lung-substancedoes not go on to the last stage, and recovery is not only possible, butprobable, from congestion and solidification of the organ. Pneumonia, too, usually attacks only a portion of one lung, while in bronchitis theair-tubes of both are always involved. Hence of the two, seriousbronchitis is more to be dreaded than serious pneumonia. 

Bronchitis is always developed out of previous catarrh, though there isa wide difference between the duration of the preliminary stage and theoccurrence of serious symptoms in different cases; while it may be laiddown as a general rule that the severity and danger of an attack are inproportion to the rapidity of its onset. An attack of pneumonia, orinflammation of the lung-substance sets in, as a rule, more suddenly, with fever, a temperature of 103° to 105°, general distress, headache, not unfrequently delirium; the urgency of which symptoms, the hurriedbreathing and the short, dry, hacking cough, and the tearless eyes aretoo often misinterpreted, and the state of the chest not examined. 

The doctor, of course, skilled in auscultation, will listen to thechest and give to all these symptoms their true signification. Thelesson for the parent to bear in mind is never to neglect in a child thesymptoms of what may seem to be but a common cold, but to seek foradvice the moment the cough shows any disposition to become hard, or thebreathing hurried. Next, when any sudden illness sets in with very hightemperature and much general ailing, not to let the disorder of thehead, or the delirium, make you shut your eyes to the import of theshort cough, the dry eyes, the hurried breathing; and lastly, toremember that, grave though the symptoms may be, the tendency inpneumonia is to eventual recovery, and that in early life bronchitis isthe graver of the two diseases. 

A caution may not be out of place with reference to cases which mayoccur during the epidemic prevalence of _influenza_. A child issometimes struck down by it, just as grown persons are sometimes, withgreat depression, extreme rapidity of breathing, and very high fever, which, passing off in a couple of days, leave a state of greatexhaustion behind. It is well to bear in mind that such symptoms have nosuch grave meaning when influenza is prevalent as they would have atanother time; and the knowledge of this fact may serve in some degree tocontrol your anxiety. 

=Pleurisy. =--It is not possible for anyone, without medical experience, to discriminate between pneumonia, or inflammation of the substance ofthe lung, and pleurisy, or inflammation of its covering. Some degree ofthe latter, indeed, very often accompanies the former, and this accountsfor the pain which interferes with every attempt of the child to draw adeep breath. When pleurisy comes on independent of affection of thelung-substance, it generally sets in suddenly with severe pain in thechest, and a short hacking cough which causes so much pain that thechild tries as much as possible to suppress it. After a few hours theseverity of the pain usually subsides, but fever, hurried breathing, andcough continue, and the child, though usually it looks heavy and seemsdrowsy, yet becomes extremely restless at intervals--cries and strugglesas if in pain, and violently resists any attempt to alter its position, since every movement brings on an increase of its sufferings. Theposture which it selects varies much; sometimes its breathing seemsdisturbed in any other position than sitting straight up in bed; atother times it lies on its back, or one side; but whatever be theposture, any alteration of it causes much distress, and is sure to beresisted by the child. 

The variations of posture depend on the seat of the inflammation; thepain depends on the two inflamed surfaces of the membrane rubbingagainst each other, and accordingly is relieved not merely by theabatement of the inflammation, but also when either the two surfacesbecome, as they often do, adherent to each other, or when fluid ispoured out into the cavity of the chest, and thus keeps them asunder. 

I dwell on this, because when fluid is poured out, the most distressingsymptoms greatly abate, or even disappear, and parents sometimes put offin consequence sending for the doctor, while yet, if unattended to, thefluid may increase to so large a quantity as to press upon the lung, andso interfere with the entrance of air, or it may, if the mischief is notchecked, change into matter, and then have to be let out by tapping thechest, for just the same reason as it may be necessary to open anabscess in any other situation. 

Whenever, then, symptoms, such as I have described, come on, send atonce for medical advice, and do not let some diminution of suffering, orslight general improvement, lead you to delay. 

=Croup. =--I endeavoured to explain, a few pages back, the cause of thatpeculiar sound which is heard in spasmodic croup. The contraction of theopening of the windpipe changes the sound which passes through it, justas the opening or closing the keys of a wind instrument modifies thesound which it gives forth. But the windpipe is not simply a windinstrument, it is a stringed instrument too, and the strings or vocalcords, as they are termed, give forth, as they vibrate, tones nowdeeper, now more shrill. The action of this delicate apparatus isreadily disturbed, if the nerve-supply to it is disordered by irritationin some distant organ, and then the breathing is accompanied by thepeculiar sound of spasmodic croup, or in older children this may showitself in a different way, as in the loud, barking cough heard in somecases of constipation, or of disordered digestion; or anotherillustration of it is furnished by the loud, long breath--the 'hoop, 'which gives its name to hooping-cough. But there is one sound thatsometimes attends the breathing of children, which more than any othercauses, and justly causes, the greatest anxiety to a mother; and that isthe sound which is characteristic of croup. 

The word croup, which comes from the Lowland Scotch, signifies merelyhoarseness in breathing or coughing, and is therefore, strictlyspeaking, the name of a sign of disease, rather than that of the diseaseitself. The peculiar sound is heard in two different conditions--the onein which a child having caught cold, instead of the air-tubes alonebeing affected, the windpipe, and especially its upper part, becomescongested, and the lining membrane swollen. Partly owing to this, partlyowing to its nerve-supply being disturbed, the child breathes noisilyand hoarsely, and the cough has a peculiar metallic clangor. In theother case there is not merely the congestion of the windpipe, thedisturbed nerve-supply, and the swollen state of the membrane; but inconnection with the influence of the special poison of diphtheria, adeposit takes place at the back of the throat, whence it extends to thewindpipe, and in many instances even far beyond it, blocking up itscanal, and mechanically excluding the entrance of air. 

To determine at once to which class a case of croup belongs is so farfrom easy, that I should advise that on the first sound of voice, orcough, or breathing resembling that of croup, medical advice should atonce be sought. I dwell on the difference between the two: the firstwhich has been called false croup, or better catarrhal croup, and thesecond called true croup, or diphtheritic croup, in order to save muchneedless apprehension to parents, in whose mind the croupy sound isinvariably associated with nothing short of that most dangerousdisease--diphtheria. 

As a general rule catarrhal croup is rarely met with after the age ofsix. Children in whom it occurs have either seemed quite well, or atmost have been a little ailing for a day or two with cold, and cough, and perhaps slight hoarseness. They go to bed and fall asleep as usual, but the cough, which does not wake them, becomes suddenly noisy, ringing, croupy, and the breathing is speedily attended with along-drawn sound, half-hissing, half-ringing, and the child soon wakesalarmed, and fighting for breath, the skin bathed in perspiration, theface flushed and anxious. The cough, the difficult breathing, and thestruggle for air last for an hour or two, or sometimes all night long, though they gradually subside, at any rate towards the approach ofmorning, when the child falls asleep, and, but for a somewhat hoarsesounding cough, and a look of fatigue, there are but few signs of allthat it has endured. 

The attack may not return, or it may recur for two or three successivenights, though in general with lessened severity, the child during thedaytime seeming to suffer only from a slight cold, or now and then, andso rarely that I have not known it to occur above once or twice in allmy experience, it may end in real inflammation of the windpipe; but notin diphtheria. 

Attacks of this kind may recur three, four, or more times even inchildhood, while diphtheria has no tendency to recur, but like measlesor scarlatina seldom appears more than once, though the rule is subjectto more numerous exceptions than are found in the case of the eruptivefevers. Still the fact of an attack of this sort returning should ofitself lessen apprehension and make the parents look forward to itsissue with less anxiety than that with which they regarded its firstoccurrence. 

A fact which shows how large a part is played by disturbance of thenervous system in these cases is the liability of children who havesuffered from it to attacks of asthma, often of great severity as theygrow older, while very often after the transition from childhood toyouth has passed these attacks too lessen in frequency and severity, andoften altogether cease. 

There are two measures which, while waiting for the doctor's arrival, may at once be taken, and which sometimes remove the symptoms almost asif by magic, while even were the case one of diphtheria they would stillbe of some service, and could not possibly do any harm. They are the hotbath, and a full dose of ipecacuanha wine. The former should be as hotas it can be borne, 93° or 94°, and the child should be kept in it forfive minutes, and the latter should be given in a full dose, as ateaspoonful in warm water every quarter of an hour till free vomitingtakes place. How much better soever the child may seem after the use ofthese remedies, it should still be kept for two or three days undercareful medical observation. 

=Diphtheria. =--In _diphtheria_ croup is only one, though the mostfrequent, and one of the most serious, of the many dangerous symptomswhich attend it. The croupal symptoms hardly ever come on quitesuddenly, but are almost always preceded for some days by slightfeverishness, languor, and restlessness, in spite of which the childstill amuses itself; and if too young to express its sensations, theslight degree of sore-throat it experiences is manifested rather by adisinclination to take food than by any obvious difficulty inswallowing. There is no cough, nor any change of voice when the child isawake, but when asleep--and the sleep is generally uneasy--it oftenbreathes with its mouth open, it snores slightly, or there is a littlehoarse sound accompanying the breathing owing to a trivial swelling ofthe throat; while, if sought for, there will generally be found a verylittle enlargement, and a very little tenderness of the glands at thecorner of the lower jaw. The eyes are sometimes tearful, there may beslight running at the nose, and the child is said to have a bad coldwith slight sore-throat--the most remarkable feature of the case beinggenerally that the depression of the patient is out of proportion to theseverity of the local ailment. If now the throat is examined--andexamination of the throat should never be omitted in any case wherethere is the slightest difficulty of swallowing--nothing may at first beseen but a very little swelling, and some redness of one or othertonsil. In a few hours more, white specks like little bits of curd willbe seen first on one tonsil, then on the other, and next these speckswill have united to form one continuous layer of a sort ofyellowish-white membrane over the palate and tonsils. The examination ofthe throat, often so difficult when children are ill, is attended withalmost none, if while they are well they have been taught the littletrick of opening their mouths to show their throat, and of allowing theintroduction of a spoon to keep down the tongue, a proceeding whichthough certainly unpleasant they will almost always readily agree to, like Martha Trapbois, in the 'Fortunes of Nigel, ' 'for a consideration. 'The deposit on the throat may disappear of its own accord, and not bereproduced, and this even though no treatment has been adopted, and intwo or three days the child may be pretty well again, though strength isin general regained less rapidly than might have been expected from thecomparative mildness of the attack. 

In cases so slight it is no easy matter to recognise the features of ahighly dangerous disease; still, out of forerunners so trivial as these, croupal symptoms may be developed, and their advances may be mostinsidious, and unless both parents and doctor have been closely on thewatch they may be surprised all at once by the breathing suddenlybecoming very laboured, by that and the cough becoming attended by thesounds characteristic of croup, and by the child's life being in extremejeopardy, or in danger even beyond the hope of recovery. 

It is not that here, as in cases of catarrhal croup, the ailment hasreally come on suddenly, but that the disease has been silently makingunsuspected progress. Whenever then a child, after a few days of slightcauseless ailing, accompanied with some little discomfort in swallowing, is seen to have white patches at the back of its throat, do not allowyourselves to be lulled even by their disappearance into a feeling ofabsolute security. Watch the child, and beg the doctor to watch itcarefully, until it is perfectly well again, for though the deposit mayhave disappeared from the back of the throat it may continue to beformed in the windpipe, and in the somewhat depressed state of thenervous system which attends diphtheria it may not excite thatirritation which any such cause would produce in a child in perfecthealth, and consequently not announce its presence until its amount hasbecome so considerable as to offer an almost insurmountable obstacle tothe entrance of air. Any, even the slightest, hurry of breathing, ahissing sound when the child draws its breath, hoarseness of voice, or aringing cough, should quicken your apprehension of danger, and make youseek for immediate help. 

It may be as well, however, to mention here, that not every white speckseen at the back of the throat is of necessity due to diphtheria, butthat in some cases of ordinary sore-throat white spots may form on thesurface of the tonsils. These white spots are due to the collection attheir openings of the secretion formed in the minute glands which besetthe surface of the tonsils, and which at these seasons is poured out ingreater abundance than usual. They are distinct from each other, and donot coalesce into a membrane; the surface beneath is not the uniform redshining surface on which the membrane in diphtheria has formed, but theseparate tiny openings from which the white matter has exuded may bedistinctly seen if the surface is wiped with a camel's-hair brush. Itis, of course, wise in every case to leave to the doctor the decision asto the nature of the deposit, but it may sometimes relieve needlessanxiety to know beforehand that there is another cause besidesdiphtheria to which white spots at the back of the throat may be due. 

There are other dangers, indeed, besides those arising from croup, whichaccompany diphtheria, though those just mentioned are of all the mostfrequent. There are cases in which death takes place not from theseverity of any local ailment, but from the intense depression of thenervous system. There are other instances too, in which the case assumeswhat is termed a malignant character; profuse discharge taking placefrom the nostrils, swallowing being from the first exceedinglydifficult, membrane being deposited on the lips, behind the ears, or atthe edge of the bowel; death taking place in twenty-four or thirty-sixhours from the outset of the first serious symptoms, either inconvulsions, or from utter exhaustion. 

But the very urgency of such cases must of necessity call for theimmediate assistance of the doctor; and my business throughout this bookis rather with those points which it is important for a mother tonotice, and those things which it behoves her to do. 

What does diphtheria depend on? is a question more easily asked thananswered. The disease is contagious, as scarlatina is contagious, thoughnot to the same degree. I may add, it is not identical with scarlatina, nor does the one disease protect from the other. It would, perhaps, betoo much to say that it is dependent on an unsanitary condition of atown, a village, or a house, but there is no doubt but that, as is thecase with cholera, scarlet-fever, or typhus, unsanitary conditionsfavour its spread, and increase its severity. 

Being contagious, it is most important to keep cups, glasses, spoons, towels, and bed-linen separate from those of other inmates of the house, and to remove the patient from any room occupied by other children. Great care too is to be observed, if anyone is standing over the childduring a fit of coughing, that none of the membrane which it spits upenters the mouth; and, that if the child's breath is caught, theattendant gargle immediately with a teaspoonful of Condy's fluid in atumbler of water. 

In the next place, as the depression of the nervous system in some casesof diphtheria is quite out of proportion to the local disease, and aschildren who have not seemed very suffering, have yet been known to diesuddenly in an unexpected faint, it is of moment that the child remainconstantly in bed from the commencement of the attack till completeconvalescence. Nor, indeed, in serious cases is even this precautionsufficient; but in such circumstances not only must the child not betaken out of bed for any purpose, but it must even not be suddenlyraised in bed, from a recumbent to a sitting posture. I have, on severaloccasions, known the neglect of these precautions followed immediatelyby what cannot but be regarded as the needless death of the patient. 

During the illness, there is little for the mother to do, except to tryto carry out the doctor's directions, and to give the child constantlylittle bits of ice to suck, which lessen the swelling of the throat, andrelieve the pain and inflammation. If the child knows how to gargle, itshould be induced to do so constantly, and finding the relief which thisaffords, will do so very readily. This is not the time, however, whenthe lesson 'how to gargle' can be learnt. A thoughtful mother teaches itwhile the child is well, and if the gargle is composed of raspberryvinegar and water, the lesson is learnt without tears. There comes atime, however, if the disease is at all severe, when gargling is nolonger possible, for the muscles of the back of the throat lose theirpower; but now some medicated solution, employed by means of thespray-producer, may most efficiently take its place. 

When croupal symptoms have gone on growing worse and worse, and thechild is in the agonies of suffocation, the doctor may propose to openthe windpipe, in the hope of giving the child another chance ofrecovery, and even though the operation fail, of at least lessening itssufferings. 

The operation is sometimes objected to by the parents, on the ground ofthe uncertainty of the result, and the torture of the operation to thechild. Now the anguish of a child dying of croup is due to two causes;first, the actual mechanical impediment to the entrance of air producedby the deposit in the windpipe, and secondly, to the spasm of themuscles in the upper part of the windpipe which that deposit produces. How large an amount of distress the latter may produce, anyone can judgefor himself, to whom it has ever happened to swallow the wrong way, asit is called. The opening made below the seat of the muscles which closethe windpipe, leaves them in perfect rest, and does away with all thesuffering produced by spasm, while there is always a fair prospect ifthe operation is not put off too long, of the deposit being limited tothe part above the artificial opening, and of the good being permanent. 

It is true that we have no certain means of knowing the extent of thedeposit beforehand; it is true also that the operation is not in itselfa cure of the disease, but at any rate, it is a reprieve which givestime for remedies to take effect, and at the worst, it substitutes acomparatively painless death for one of intolerable anguish. It can, too, be performed under the influence of chloroform, so that the ideathat it adds in any way to the child's distress is unfounded. Who thathas seen the calm, happy face, and watched the tranquil sleep of thechild after the operation, who before was struggling, with distortedfeatures and agonised countenance, to get a breath of air, but wouldfeel as I do, that I would have it done in a child of mine for the sakeof a painless death, even though I knew for certain that it would notprolong life even for an hour?

One additional remark I have to make with reference to the loss ofpower, or palsy of various muscles, which frequently follows diphtheria. Almost always there is some impairment of power in the muscles of thethroat on which the deposit had taken place, and there is, inconsequence, a little difficulty in swallowing for a few days. If thisshould get worse, food and especially drink sometimes return by thenose, and next there may be a slight squint, and the sight may becomeweakened, and an uncertain tottering gait; and sometimes for a week ortwo the child may be unable even to stand. In bad cases there is withthese symptoms a general loss of nervous as well as of muscular power, though the child may still be fairly cheerful, and ready to amuse itselfas well as it can. This condition may last for many weeks before itpasses quite away, and if under the mistaken impression that the limbswill gain strength by exercise, the child is allowed to sit up andencouraged to exert itself, recovery will be delayed much longer; anddangerous weakness or fatal exhaustion may suddenly come on. 

The inference is too obvious for me to need dwell on it, that repose isthe great resource, and quiet waiting the true wisdom. 

=Hooping-Cough. =--I need not say much about _hooping-cough_, for thereis scarcely a nursery in which, to everyone's great discomfort, it isnot known as a familiar and most unwelcome visitant. It variesremarkably in its importance, being sometimes so slight as scarcely toamount to an illness, but in other instances one of the most deadly ofdiseases. It causes the death of a fourth of all children who die underthe age of five, and three out of four of these deaths take place ininfants of less than two years old. 

It occurs, however, comparatively seldom during the first three or fourmonths of life, probably because very young children are kept more athome than others, and are thus less exposed to catch it. Thoughhooping-cough is undoubtedly very contagious, it seems to becommunicated only by the breath, and there is absolutely no evidence toshow that the clothes of a child suffering from hooping-cough can carrythe infection as they might were the child suffering from measles, orsmallpox, or scarlet-fever; still less that a person who has visited aroom where children are suffering from hooping-cough can convey thedisease to another house, or to other children. 

The disease derives its name, as everyone knows, from the peculiar soundwhich attends the cough, and which is due, as is the sound of croup, tospasm of the upper part of the windpipe. It is equally characterised bythe cough returning in fits or paroxysms, which end in a long-drawnbreath, attended by the hoop. An occasional sound like a hoop, in ayoung child who has a cold, is not so conclusive of a case being one ofhooping-cough as is the recurrence of the cough in fits; for untilteething is completed, slight and temporary irritation will suffice toproduce a passing spasm of the upper part of the windpipe. 

An ordinary attack of hooping-cough begins like a common cold, but asthe little ailment passes off, the cough still continues, the fits ofcoughing become more frequent, last longer, grow severer and moresuffocative, and end with the loud long breath, the hoop; whilesometimes no sooner is one fit over than another follows it almostimmediately, and quiet breathing does not return until the child istired out by its efforts. Nevertheless, the child's health continuesfairly good, and little or nothing ails it during the intervals of thecough. For about a fortnight the cough usually goes on to increase; andduring this time the night attacks especially become more frequent. Itthen for a week or ten days continues stationary, and then declines, adiminution in the frequency and severity of the night attacks being ingeneral the first sign of amendment, and at the end of six weeks fromthe beginning of the attack the child is in general quite convalescent. Even then, however, a trifling cause will reproduce the characteristiccough for a few days, and not seldom for many months afterwards any coldwhich the child may catch will be attended by a paroxysmal coughundistinguishable save by its milder character and shorter duration fromthe previous hooping-cough, though I believe incapable of communicatingthat disease. 

In mild hooping-cough there is little or nothing to be done, save tofollow the dictates of common sense, and not to neglect them in quest ofsome imaginary specific--some vaunted medicine which is said to be acertain cure; or such as shutting up the child in a room the atmosphereof which is charged with the vapour of tar, or of carbolic acid, or ofsulphur. 

It cannot be too strongly impressed on the minds of parents that thereis no specific whatever for hooping-cough; no remedy which will cut itshort, as quinine cuts short a fit of ague. The domestic treatment ofmild hooping-cough is the domestic treatment of a common cold, implyingthe same precautions as to the equal temperature of the day and nightnursery, the little doses of ipecacuanha at night, but as seldom aspossible during the day, in order not to interfere with the appetite anddigestion, together with special care to insure the regular action ofthe bowels. It sometimes happens that after a week or two the severerfits of coughing are followed by vomiting; and the child may lose fleshand strength from inability to retain its food. In these circumstancesfood must be given, little in quantity, at short intervals, and of akind that need not remain long in the stomach in order to be digested. Good soup, beef-tea, milk, rice milk, or a raw egg beaten up in milk, and biscuit rather than bread, must take the place of the ordinarymeals, and be given twice as often. 

The different liniments, and the favourite Roche's Embrocation, are ofuse when the disease is on the decline, and may also be of service ifbronchitis should occur to complicate the hooping-cough, but nototherwise. 

Change of air when hooping-cough is on the decline is often of greatservice, and change even from good air to one less good appears to besometimes of use; but change in the early stages, or when hooping-coughhas become really severe, is but adding another to the already existingdangers. 

The danger in hooping-cough arises through the medium either of thehead or of the lungs, and through each of them with about equalfrequency. The head becomes affected in consequence of the oftenrecurring congestion of the brain, produced, as in spasmodic croup, bythe constantly returning interruption to the breathing. In these casesthe cough is frequent, and so violent that the child becomes lividduring each paroxysm, and that instead of ending in a loud hoop itfinishes by a fit of convulsions or by the child sinking into a state ofsemi-insensibility. Increased violence of the cough, with suppression ofthe hoop, is always a bad omen in hooping-cough. 

On the other hand, when the cough becomes complicated with bronchitis, it ceases to recur in distinct fits which leave behind them intervals ofcomparative, or of absolute ease. The hurried breathing which precedesand follows a fit of coughing never entirely subsides, while eachreturning cough aggravates the irritation and inflammation of theair-tubes, and the child's condition becomes the very dangerous one ofhooping-cough complicated with bronchitis. 

So long as a child seems pretty well in the intervals between the fitsof coughing, as the hurried breathing subsides after each to a naturalfrequency, as a long loud hoop follows each cough, as vomiting takesplace only after a fit of coughing and never in the intervals, as thechild becomes flushed only and not livid during a cough, and recoversitself perfectly afterwards, as it does not complain of constantheadache, nor spits blood, nor has nose-bleeding, nor is feverish, nordepressed, nor drowsy, you may feel happy about it. When any of thesymptoms just enumerated show themselves you have reason for gravesolicitude, and the child requires daily medical watching. 

One word in conclusion. A child who has recently had hooping-cough ismore liable than another to be attacked by chicken-pox or measles; and, moreover, imperfect recovery from hooping-cough is apt, especially ifthere is any tendency to consumption in the family, to be followed byconsumptive disease. 

=Asthma. =--_Asthma_, attended by distress of breathing quite asconsiderable as in the grown person, is by no means unusual in thechild. Recovery from it is far more likely to take place in the latter, since it is almost always independent of those diseases of the heart orlungs, which in the former occasion or aggravate it. It belongs to theclass of what has been termed nervous asthma and is observed withspecial frequency in children who, when younger, had been liable tocatarrhal croup; spasm of the air-tubes having taken the place of theprevious spasm of the windpipe. Independently of that antecedent itcomes on sometimes about the time of the second teething in nervous andimpressionable children, in whom an attack may be produced byindigestion, constipation, or over-fatigue. It is also by no means rarein children in whom that skin affection, eczema, of which I have alreadyspoken, outlasts the time of infancy, and becomes general and severe. The improper performance of the functions of the skin seems to cause apeculiar sensitiveness of the air-tubes, and to render them liable tothe occasional occurrence of that spasm which produces asthma. Thesecases are less hopeful than others, and the liability to the attacksceases only when the skin-affection has been completely cured; a reasonthis for not neglecting eczema in infancy and early childhood. Sometimes, too, it follows frequently-recurring attacks of bronchitis, and, though less often than might be expected, it succeeds severehooping-cough, and in these two conditions the prospects of recovery areless hopeful than in the others. 

When asthma occurs in childhood, the first point is to ascertain thecause on which the attack depends; and it is worth any amount of care todiscover and remove it; for if what may be called the asthmatic habit isnot formed, the attacks will, in the majority of instances, ceasebetween the ages of twelve and fifteen. Bad habits of the body are, however, as difficult to get rid of as bad habits of the mind, and theboy who grows up an asthmatic youth is very unlikely to get rid of thedisorder in later life. 

It is in that form of asthma which succeeds to frequent attacks ofcatching cold, and in which bronchitis precedes or accompanies eachseizure, that change of climate is most useful. In the majority ofinstances a moderately sheltered seaside place, with a sandy soil suchas Bournemouth, is the best, and a few years' residence there notinfrequently overcomes every disposition to asthma through the wholeremainder of the patient's life. To this, however, there are exceptions, and I have seen instances in which residence at Bournemouth and in theRiviera have failed, but where a perfect cure has been wrought by thecold, still air of Davos. 

=Diseases of the Heart. =--=Malformed Heart. =--Every now and then onesees a little babe, carefully wrapped up in its nurse's arms to shieldit, even on a warm day, from the air; and, on removing the shawl whichcovered it, one is struck by the sight of a little pale pinched face, with a livid ring around the mouth, and a blue instead of a rosy tint oflips and fingertips, as though perished with cold. The babe wakes onbeing disturbed, and gives a faint short cry of distress; the livid hueof its surface deepens, it struggles feebly, its mouth twitches asthough convulsions might be coming on. Soon, however, these symptomssubside, the babe smiles again, is cheerful, and save for the tints ofits face and lips, it looks like other infants, but frailer. 

This condition has a name in medical writings, from a Greek wordexpressive of the blue tint which characterises it, and is called_cyanosis_. It depends on the blood not having undergone completelythose changes in the lungs which take place in the healthy state. Theblood, as it returns through the veins to the right side of the heart, is of a deep purple hue. The right side of the heart contracting sendsit to the lungs, where, in the minute vessels of the air-cells, it ispurified, and returns vivified by the oxygen a bright scarlet stream, tobe distributed by the arteries over the whole body; and thence to returnonce more for fresh purification to the right side of the heart. Beforebirth, the blood does not run the same course, but is purified withinthe mother's body, the blood running through channels which close withthe first breath the infant draws. The previously existing communicationbetween the two sides of the heart ceases at the same time as the newchannels are opened, by the shutting of a thin valve which had hithertoallowed the blood to pass from one side to the other. 

Sometimes this closure fails to take place, or takes place butimperfectly; sometimes, in addition, the channels which should bedisused after birth remain open still; and sometimes also the heart isotherwise imperfectly formed, and a large communication exists betweenthe two sides of the heart, which long before birth ought to have beenfirmly partitioned off from each other. 

According to the freedom of communication between the two sides of theheart, there is more or less ready intermingling of the impure bloodwith that which is already purified; and this is betokened by thegreater or less severity of the symptoms which I have described. Whenthe heart is very malformed, and the blood consequently is very impure, life is but a short agony which ends in a few weeks; some slightmovement, some little accidental cold deranging altogether the imperfectmachinery, and bringing it to a sudden standstill. Between this and theslightest cases there are all shades of difference, till, in the latter, a smaller power to maintain warmth, a less rapid growth, a smallermuscular development, a feebler power, a hurry of breathing on exertion, or in ascending a hill, or in going up a staircase, are all, except thesounds which the educated ear detects of the blood passing through itsdevious course, that tell of nature having, in this instance, ill doneher handiwork. 

The one most natural question to which, in every instance, the doctorhas to reply is this: 'Will he or she outgrow it?' To this the answeris, '_Yes_, ' and '_No_. ' In the worst cases the answer is obviously_no_; and in none does _yes_ imply a recovery so complete as to leave notrace behind, and to make the child heartwhole. But short of this, inmany instances much may be hoped for. There is, as I shall have occasionagain to repeat, a power in the growing heart to adapt itself in largemeasure to conditions other than those of perfect health. The channels, through which the blood ought not to flow, may shrink though they maynot entirely close; the valve may shut more completely than at first theopening between the two sides of the heart; all inconveniences maylessen, and the child may at last become scarcely aware of thedifference between himself and others. But for any such result, or foranything approaching it to be attained, certain conditions areabsolutely essential which it is seldom easy to induce parents toobserve. Whatever can hurry the circulation is most carefully to beavoided. The child must be kept strictly out of the way ofhooping-cough, measles, or any other fever; must be shielded from everyrisk of catching cold, and having smaller power of maintaining itswarmth than others have, must be specially warmly clad, and must live inrooms at a temperature of 60 deg. Fahr. , all the year round. Greatattention must be paid to the state of the bowels, so that constipationmay not necessitate violent efforts to relieve them. 

Moreover, for years the child must be carried upstairs; when old enoughto take part in games, it must not be allowed to join in any which callfor violent exertion, such as cricket, or lawn tennis, nor ride anyother than a quiet pony at a gentle pace. 

It depends entirely on the parents whether, for the sake of a very greatbut far-off good, they will strictly observe these rules. The difficultywill not arise on the child's part, for it is not hard for those whohave had charge of it from babyhood to bring it up to quiet pursuits andquiet amusements, till it seeks no others, and, like the littlecage-bred bird, does not care to emulate the flight of others strongeron the wing. 

=Inflammation of the Heart. =--The above remarks do not comprise allthat is to be said about heart-affection in early life. _Inflammation_may attack the investing or the lining membrane of the heart at allages, may produce in the child the same suffering as in the grownperson, and may tend to destroy life in a similar manner. The causes, indeed, which produce heart disease, are far more frequent in the grownperson than in the child, and advancing age brings with it changeswhich, wholly apart from active inflammation, produce grave forms ofdisease unknown in early life. There is, however, one cause of heartdisease which is far more frequent in childhood and early youth than inlater life, namely, rheumatism. Eight out of ten of all cases of heartdisease under the age of fifteen are of rheumatic origin, and ineighteen out of twenty cases of acute rheumatism under that age, whetherslight or severe, the heart becomes more or less involved. Now and then, though rarely, the heart becomes affected in the course of scarlatina, and still more seldom in the course of the other fevers, and every nowand then affection of the heart is associated with some other form ofinflammation of the chest. 

Pain is by no means a constant attendant on it, but fever, more or lessconsiderable, a quickened pulse, and hurried breathing are all butinvariable, and one great reason for seeking the immediate help of thedoctor is, that his skilled ear may at once detect by the altered soundsthe heart-affection at its very outset, and employ the measurescalculated to arrest its progress. 

Death in the acute stage of a first attack of inflammation of the heartis of extreme rarity, but the damaged heart is liable to returns ofacute mischief, any one of which may prove fatal. Independently of this, life with diseased heart is one of suffering, attended as it is bysymptoms similar in kind, though not identical with those which I havealready mentioned as attendant on malformation of the organ. 

The hopeful element, however, to which I have already referred aspresent in cases of malformed heart, exists here in even a greaterdegree; since repair of injury is possible, while the reconstitution ofan organ faulty from birth is obviously beyond nature's power. 

I can but repeat the directions already given as to the importance ofallowing the heart as much rest, and giving it as little work, as ispossible with a never-resting organ; and this with the added motive forperseverance furnished by the happy issue which may be hoped for as itsreward. 

One word I must add about the occasional occurrence of _irregularaction of the heart_ during the years of growth, especially from the ageof ten to fourteen. This is often quite independent of any disease, andceases when with added strength the nervous system becomes lessimpressionable. 

CHAPTER VIII. 

DISEASES OF THE ORGANS OF DIGESTION. 

=Manner of Performance of Digestion. =--The organs situated in what iscalled in medical language the abdomen, have in the child no other dutyto perform than such as subserve the processes of digestion andnutrition. The saliva secreted by the appropriate glands in the mouth, mixing with the food, facilitates the further changes which take placein the stomach. In the stomach the food is acted on and dissolved by thegastric juice or pepsin, which is poured out by an almost infinity ofminute tubes, or follicles as they are termed. When the stomach has doneits work, its contents in a semi-fluid state pass into the smallintestine, and mix there with the bile, the secretions from theintestines themselves, and with those of the large gland, the pancreas(in culinary language known as the sweetbread), which seems to have thespecial power of dissolving fatty matters. As the food, thus acted on, travels along the intestines, whose constant movement facilitates thepassage of their contents from above downwards, its elements are takenup, partly by the blood-vessels, partly by innumerable small vessels, called absorbents from their power of imbibing fluids, and lacteals, from the milky hue of the fluid within them when first absorbed. Thefluid taken up by the blood-vessels is conveyed to the liver; that takenup by the absorbents to the mesenteric glands, and in these organsfurther changes take place in it, which fit it to be received into themass of the circulating fluid. With this it is carried to the right sideof the heart, and thence to the lungs and, lastly, from them to the leftside of the heart, whence it is distributed, the great life and healthgiver, to the rest of the body. The useless inconvertible material, leaving every available element behind, is got rid of, either in a solidform by the bowels, or in a fluid form by the kidneys; and thus as longas life lasts there goes on more or less perfectly the wonderful processof constant change, of constant renewal, and during childhood and youth, of constant increase of size and stature. 

Incomplete as this sketch is, it may yet suggest how readily one partof this complex machinery may be thrown out of gear, and further how notone part can suffer without all being disordered. Solid food given tothe child before it has cut its teeth, enters the stomach unreduced topulp by the grinders, and unmixed with the saliva, which should help itssolution, and which the undeveloped salivary glands do not yet furnish. Too large a quantity of food, or food of an unsuitable character, onwhich the gastric juice cannot act readily, may pass into a state offermentation; vomiting, flatulence, sour and offensive breath will bethe result, and the food will pass into the intestine unprepared to beacted on by the bile. Exposure to cold, or the opposite condition ofexcessive heat, may disturb the action of the liver, and interfere withthe secretion of bile; and the food will then pass along the intestinein a state unsuitable for absorption. Or, again, the mesenteric glandsmay be irritated by long-continued imperfect performance of the earlierstages of digestion, or their structure may be altered, and mesentericdisease, or consumption of the bowels, as it has been termed, mayresult. From want of muscular power, or from want of care on their partwho have charge of the child, the bowels may become habituallyconstipated. Health will then suffer, if the child carries about with itfor days together matters which can serve no useful purpose, but whichare to the body what an ill-kept dustbin is to the rest of the house. Lastly, if the kidneys perform their duties imperfectly in consequenceof exposure to cold, or of the changes which some diseases, such asscarlatina, sometimes bring about in their structure, the blood will beimperfectly purified; dropsy and various forms of inflammation mayresult; or the brain and nervous system may be disordered, and death inconvulsions may attest the dangerous nature of this blood-poisoning. 

It would take too long to go in detail through all the phases ofdisordered digestion in early life. Much has been already anticipated ina former part of this book, especially with reference to the troubles ofdigestion in infancy and early childhood. There is, indeed, but one formof indigestion whose characters are so special as to require that Ishould enter into any detail with reference to it. 

=Dyspepsia of Weakly Children. =--Children from the age of about three toten years, whose health has been impaired by an attack of typhoid, or, as it is commonly called, infantile remittent fever, or who belong to aweakly family, or to one, some of whose members have shown a dispositionto consumptive disease, are sometimes martyrs to indigestion. It doesnot need with them any special error of diet, or any casual exposure tocold to disorder their digestion; but every two or three weeks, evenunder the most scrupulous care, they lose their appetite, their tonguebecomes thickly coated with yellow fur, their breath offensive, theirbowels constipated, the evacuations being either very white or verydark, and frequently lumpy, and coated with a thin layer of mucus fromthe bowel, which also appears in shreds at the bottom of the utensil. With this condition, too, there is some, though not considerable, feverishness, and the urine becomes turbid on cooling, and throws down areddish-white deposit, which disappears if heated. At the end of two orthree days of rest in bed, of a diet of beef-tea and milk, with no solidfood, with simple saline medicines, mild aperients, and perhaps a singlesmall dose of calomel, the symptoms pass off; but return again and againat uncertain intervals, and without any obvious cause. 

In these cases, the children almost always, when in their ordinaryhealth, have a peculiar patchy condition of the tongue, one part of itbeing covered with a thin white coating, through which little red pointsproject, while another part is of a vivid red, and looks raw andshining, as though it had been scalded, while the red points, or thepapillæ, as they are termed, project above its surface like so manypins' heads. Children in whom this condition exists, require muchwatching and much care. I have dwelt upon it in order to impress onparents the conviction that it is not a state to be cured, once for all, even by the most skilful doctor, but that years are needed to eradicatea bad habit of the body, as much as to cure a bad habit of the mind. 

=Jaundice. =--I have already spoken of the jaundice of new-born infants;but a sluggish condition of the liver, accompanied by very white or paleevacuations, constipation, and loss of appetite, with a sallow tint ofthe skin, and sometimes even with actual _jaundice_, are by no meansuncommon during the first ten years of childhood. Neither condition isserious; that of actual jaundice occurs mostly in the summer, and isthen connected with the sudden onset of hot weather. When severe, it maybe associated with some degree of feverishness, with dizziness, andcomplaint of headache, and occasionally with vomiting, while the childrests ill at night, or awakes in a state of alarm, and these symptomssometimes give rise to the fear that the child is about to be attackedby water on the brain. But the following consideration may serve to calmanxiety on that score. The attack is not preceded, as water on the brainis almost invariably, by several days or even weeks of failing health. It is not attended by heat of head, nor by intolerance of light, nor byconstant nausea; and the belly is full rather than shrunken. When tothese symptoms are added tenderness on the right side, high-colouredurine and white evacuations, you may set your mind at rest, even beforethe yellow colour of the skin, which appears in a day or two, stamps thecase unmistakably as one of jaundice. 

My business is, as I have said more than once, the endeavour to describethe symptoms of disease, to explain their nature, to indicate theprinciples to be observed in attempting their cure, and not to lay downdefinite rules for their treatment, with the idle expectation that Icould thus enable every mother to be her children's doctor. 

=Diarrh[oe]a. =--I have, therefore, comparatively little to say about_diarrh[oe]a_ in children, important though it is, for its symptomsforce themselves on the notice even of the least observant. There are, however, a few points concerning it worth bearing in mind. Before thecommencement of teething, diarrh[oe]a is almost always the result ofpremature weaning, or of a diet in some respect or other unsuitable. Assoon as teething begins, the liability to diarrh[oe]a increases greatly, and cases of it are more than twice as frequent, and twice as fatal, between the ages of six and eighteen months as they were in the firstsix months of life; while, as soon as teething is over, their numberimmediately declines again to the half of what it was during thecontinuance of that process. The practical conclusions to be drawn fromthese facts are that looseness of the bowels during teething is not adesirable occurrence to be promoted, as some mistakenly imagine, but arisk to be by all means avoided, and I may add, when it does take place, far less easy to control than constipation is to remedy. And next, thatin order to prevent its occurrence, care should be taken to make changesin the diet of a child, not during the time when a fresh eruption ofteeth is taking place, but during one of the pauses in that process. There are certain seasons of the year when diarrh[oe]a is speciallyprevalent, independent of any change in diet, or alteration, in anyrespect, of the circumstances in which the child is placed. Thus, inMay, June, and July, diarrh[oe]a is twice as prevalent among children atall ages as in November, December, and January; and in August, September, and October, its prevalence is three times as great as duringthe winter months. The high mortality of children in the summer monthsis due almost entirely to diarrh[oe]a, and even the bitter Northernwinter of a city like Berlin is a third less fatal to infants and youngchildren than the heat of its short summer. 

The next point to remember is that mere looseness of the bowels isnever to be regarded during the first three years of life as of noimportance; for I have seen infants die exhausted from its continuance, even though the examination of the body after death showed almost nosign of disease. Doctors distinguish two forms of diarrh[oe]a: thesimple, or, as it is technically called, catarrhal diarrh[oe]a; andinflammatory diarrh[oe]a, or dysentery. The one may pass into the other, just as a common cold, or catarrh, may pass, if unattended to, into adangerous bronchitis. 

_Simple diarrh[oe]a_ usually comes on gradually, and is some daysbefore it grows severe, or passes into the more dangerous dysentery. Simple precautions will often arrest its progress, and, among them, restin bed is one of the most important. Over and over again I have known adiarrh[oe]a which had continued in spite of all sorts of medicines solong as the child was running about, cease at once when the child waskept for a couple of days in bed. The reason of this is obvious;constant movement of the intestines themselves, which serves soimportant a part in maintaining due action of the bowels, is increasedby the upright position and by movement, and is reduced to a minimum bythe horizontal position. A second precaution concerns the diet; solidfood and animal broths should for a time be discontinued, and arrowroot, milk and water, and rice substituted for it, for a day or two, withisinglass jelly, and the white decoction of which I have already spoken. It is not always that astringents are suitable at the beginning of anattack, and the sending to the neighbouring chemist for diarrh[oe]amedicine, which often contains an unknown quantity of opium, is alwaysrisky, frequently mischievous. In a first attack of diarrh[oe]a, thedoctor should always be consulted, for when it is associated withdisorder of the liver a mercurial may in the first instance be needed, or possibly very small doses of a saline medicine, such as Epsom salts, with the addition of a few drops of the tincture of rhubarb; or, again, if the diarrh[oe]a sets in with profuse watery discharges, sulphuricacid for the first few hours is often of extreme service. It is at alater time that direct astringents commonly have their use; and themother, who in her child's first attack of diarrh[oe]a has had theadvice of a judicious doctor, will often be helped by him to manage forherself slight returns of the ailment. 

_Inflammatory diarrh[oe]a_, or dysentery, not only follows thecontinuance of the simpler forms of the disease, but sometimes in thehot months of summer or autumn sets in suddenly with violence. It thenfrequently commences with vomiting, and the stomach may continue soirritable for twenty-four hours as not to retain even a teaspoonful ofcold water. At the same time the over-action of the bowels sets in, andtwenty or thirty evacuations may be passed in twenty-four hours. Themotions soon lose their natural character, and become watery, slimy, andmixed with blood. They are at first expelled with violence, afterwardswith much pain, effort, and often fruitless straining. With these localsymptoms, the child, as might be expected, is very ill, feverish, andstupid, though without sound sleep, much exhausted, and its nervoussystem so disturbed as to occasion frequent twitchings of the fingersand of the corners of the mouth, while sometimes actual convulsions takeplace. The thirst is intense, the child calling constantly for coldwater, and crying out for more the moment the cup is taken away from itslips; while the loss of flesh and the exhaustion are more rapid than inany other disease with which I am acquainted. The fat happy babe of fourand twenty hours before is scarcely to be recognised in the miserablelittle being, with sunken lustreless eyes, and wizened features, andmiserable countenance, lying in a state of half-stupor, sensible only topain, which yet rouses it but to utter a moan, and then sinks again intosilent suffering. I can well believe what we are told, that in somecountries this, the so-called Summer Complaint of many of the Americancities, sometimes carries off children in a few hours. 

If a fatal termination does not take place speedily, the disease passesinto the chronic stage, the diarrh[oe]a diminishing in frequency, butthe pain and straining, and the unhealthy character of the evacuationspersisting. Ulceration of the bowels has taken place, emaciation becomesextreme, and the child often sinks at the end of several weeks, worn outby suffering; while recovery, doubtful at the best, is always very slow. But I need not pursue this subject further: enough has already been saidto show how little infantile diarrh[oe]a is a disorder for domesticmanagement. 

=Peritonitis=, or inflammation of the membrane covering the bowels andlining the cavity of the belly, is of excessive rarity in its acuteform; and is attended by such general illness and such severe localsuffering, that it is impossible to overlook it or to misapprehend itsgravity. Severe pain in the belly is sometimes complained of bychildren, and is due to what is termed colic, a spasm of the bowelswhich is generally associated with constipation. The great test of thecause of the pain is furnished by the presence or absence of tendernesson pressure. The pain of colic is relieved by gentle pressure and gentlerubbing. The pain of inflammation in any degree and of any kind isaggravated by them. This applies also to cases, not indeed very common, in which inflammation is set up by some small body, such as acherry-stone getting fixed in a little offshoot or appendage of aboutthe size and length of the little finger, connected with thecommencement of the large bowel, and producing ulceration. In thesecircumstances the bowels are confined, there are nausea and sickness, together with pain and tenderness of the belly, especially on the rightside. The disease is a very dangerous one, and often proves fatal in thecourse of a few days. I refer to it because I have often seen itoverlooked both by parents and doctors at its outset, since the painthen is often not severe nor the tenderness intense, and because I haveseen the patient's condition rendered hopeless by strong aperients beinggiven to overcome the constipation which was supposed to be all thatailed the child. I repeat then the caution, never to overlook theexistence of tenderness, never to attempt to treat a case in which it ispresent; but always to call in medical advice, and above all always toabstain, unless ordered by a medical man, in every such case from theuse of aperients. 

=Large Abdomen. =--I must not leave the subject of disorder of thedigestive organs without some reference to a condition which oftenexcites much needless anxiety among mothers, namely, the large size of achild's belly. This is sometimes supposed to be a certain evidence ofthe presence of worms, at other times to be a positive proof of theexistence of grave disease, especially of disease of the mesentericglands, or glands of the bowels as they are popularly termed. It isevidence of neither the one nor the other. 

If you go into a gallery of the old masters, and look at any of thepictures of angels which are generally to be seen there in suchabundance, you will probably be struck in the case of all the childangels by what will seem to you the undue size of their abdomen. Youwill notice this even in the works of painters who, like Raphael, mostidealise their subjects, while in those of others who, like Rubens, interpret nature more literally, the apparent disproportion becomesgrotesque; or, in the coarser hands of Jordaens, even repulsive. 

These painters were, after all, true interpreters of nature. In infancyand early childhood the abdomen is much larger comparatively than in thegrown person. For this there is a twofold cause; the larger size of theliver on the one hand, and the smaller development of the hips on theother. In a weakly child this appearance is exaggerated by its want ofmuscular power, which allows the intestines to become much distendedwith air. If the child is not merely weakly but also ricketty, thecontracted chest will leave less room than natural for the lungs, whileat the same time the ordinary development of the hips being arrested bythe rickets, the disproportion is further increased both by that and bythe flatulence due to the imperfect digestion with which the conditionis almost always associated. 

In no case need the mere size of the abdomen occasion grave anxiety, solong as when the child lies upon its back the abdomen is uniformly soft, nor so long as even if tense it is not tender, and as it everywheregives out a hollow sound like a drum when tapped with the finger. 

It is not for a moment meant that no notice is to be taken, nor opinionasked, as to the cause of excessive size of the abdomen, for itsdistension may be due to real disease; but it is yet worth while toremember that its mere size is not of itself evidence of disease, norcause of grave anxiety. 

=Worms. =--There is no mistaking or overlooking the existence of _worms_when they are really present. Their presence, however, is oftensuspected without any sufficient reason. Ravenous or uncertain appetite, indigestion, flatulence, undue size of the abdomen, a dark circle roundthe eyes, itching of the nose and of the entrance of the bowel, a coatedtongue, and offensive breath are no real proof of the presence of worms, and do not justify the frequent repetition of violent purgatives or ofso-called worm medicines. The only real proof of the presence of wormsis their being seen in the evacuations. 

The worms commonly found in children are either the round-worm, whichresembles the earth-worm, the thread-worm, or the tape-worm; theappearance of each of which is clearly indicated by its name. None ofthem are spontaneously generated in the body, but they are allintroduced from without; their eggs, or, as they are technically called, their ova, being swallowed unperceived in some article of food, ordrink. A proof of this is afforded by the fact that an infant, so longas it is nourished exclusively at the breast, never has worms. 

The _round-worm_ occasions the fewest symptoms, and is rather an objectof disgust than of grave importance, at least in this country, where itseldom happens that more than two or three are present. In othercountries, as some parts of Italy, for instance, where the drinkingwater is bad and stagnant, they are sometimes found in great numbers, asthirty or forty, and it is then not easy to determine whether thesymptoms which accompany them are produced by the worms, or by theunwholesome character of the water in other respects. 

They appear to live on the contents of the intestines, and do not adhereto them, as the tape-worm does, and hence their comparativeharmlessness, and they have no power, as has sometimes been mistakenlyimagined, of perforating the bowels, and of thus producing gravemischief. 

The _thread-worm_ is the commonest variety of these creatures, and hasthe peculiarity of inhabiting the lowest twelve inches of the bowel, where it produces much irritation and causes very distressing itching. It is often present in great numbers, and is so rapidly reproduced, thatin a week or two after it has been apparently got rid of, it may againbe found as numerous as before. Certain articles of food seem to favourits development, such as pastry, sugar, sweets, beer, fruit, andanything which is apt to undergo fermentation, and thereby to impart tothe evacuations a specially acid character. These worms are oftenaccompanied with more or less marked symptoms of indigestion, butotherwise the local irritation is usually the only indication of theirpresence. They produce, indeed, such disturbance of the nervous systemas may attend indigestion in any of its forms, but I have never but onceknown convulsions occur apparently due to their presence in greatnumbers, and ceasing on their expulsion; and this was in a child betweeneighteen months and two years old. 

The _tape-worm_ is developed in the human body from a minute germ orovum; one form of which exists in the flesh of the bullock, the other inthat of the pig; and which seems to require for its growth the favouringconditions of warmth and moisture which are found in the intestines. Itfixes itself to the lining of the bowels by means of its mouth, which isfurnished with minute tentacles, and it thus derives its support fromthe juices which it imbibes. The head is so small as not to be seendistinctly without a magnifying glass; and immediately beyond it thejointed body begins; at first, scarcely bigger than a thread of worsted, but gradually enlarging, till at the distance of three inches it is aneighth of an inch wide, and thence rapidly widens till each joint ishalf an inch wide, and from a third to half an inch apart. It does notexceed these dimensions, even though it may grow to the length of fouror six yards. Portions of it, sometimes a yard or two in length, arethrown off from its lower end occasionally, and this occurrence oftengives the first indication of its presence, the worm continuing to growas before, and fresh portions being detached from time to time. It doesnot appear that the worm has the power of reproducing itself; hence itsFrench name of _ver solitaire_, and the occasional presence of two orthree would seem to be due to the development of two or three distinctova within the intestine. 

Deriving as it does its support from the system of the child, and not asthe other worms do from the contents of the bowel, the tape-worm oftenproduces graver inconveniences. It sometimes causes uncomfortablecolicky sensations, which may even be very distressing, and thedisorders of digestion which accompany it are often very considerable;certainly more so than in the case of the other varieties of worms; butI have seen no instance of convulsions which could be attributed tothem, notwithstanding the generally received opinion to the contrary. 

When the existence of worms is suspected, one or two doses of a simpleaperient, such as castor oil, repeated two days successively, seldomfail to produce evidence of their presence; which in the case oftape-worm is also furnished by the spontaneous detachment of some of thejoints. It must be remembered, however, that until the head has beendetached from its connection with the bowel, nothing has been gained, and the tape-worm will in a short time grow again. To obtain thedetachment of the head it is necessary that any worm medicine should begiven when the intestines are empty. I am, therefore, always accustomedto give a dose of castor oil about two hours after the child's mid-daymeal; and to send the child to bed as soon as the aperient begins toact, and to give it no more food except a biscuit and a little milk andwater during the rest of the day. In the early morning, the special wormmedicine is given, and over and over again I have known the worm to bebrought away completely after many previous failures. When the smallnessof the joints shows that the greater part of the worm has been thrownoff, and that little more than the head remains, it is necessary to haverecourse to the unpleasant proceeding of mixing the evacuations withwater, and then straining them through muslin, in order that the doctormay by means of the microscope make out whether or no the head has beenreally detached. This is no question of mere curiosity, but a matter ofthe gravest moment, since nothing has been really gained so long as thehead of the worm remains adherent to the bowel. 

Precautions such as these are not needed in the case of the other kindsof worms. Thread-worms, however, are best attacked in their habitation;that is to say, in the lower bowel, by means of lavements. It is, therefore, desirable before they are administered that the bowels shouldbe emptied by a dose of castor oil. 

The only other caution which remains for me to give refers to thepeculiar effect which salicine, a very valuable medicine, especially inthe case of thread-worms, has upon the urine. It sometimes turns theurine of a greenish-yellow, often of a red colour, as though it weremixed with blood. The appearance, however, has no grave meaning, but isdue simply to a chemical action of the medicine on the colouring matterand salts of the urine. 

There still remain some local ailments of parts connected with theprocess of digestion, concerning which a few words must be said. 

=Ulcerated Mouth. =--First, with reference to the _sore-mouth_ ofchildren. I have already noticed a form of inflammation and ulcerationof the gums sometimes met with during teething, but the sore-mouth ofwhich I am now about to speak is often quite independent of thatprocess; though it may sometimes be found associated with it, and isindeed rarely met with after five years of age. In almost all instancesit is preceded and attended with symptoms of indigestion, during thecourse of which the mouth becomes inflamed, hot and red, and small verypainful shallow ulcers with sharp-cut edges, and a little yellowishdeposit on their surface, appear at the edge of the tongue, on theinside of the mouth, and especially on the inside of the lower lip, andthe adjacent surface of the gum. Successive crops of these littleulcerations not unfrequently appear, so that for many weeks the childmay be kept by them in a state of extreme discomfort; swallowing, andeven speaking being the occasions of considerable suffering. 

It is seldom that nursery remedies, and the so-called coolingmedicines, though often of some service, suffice to get rid of theailment, which for the most part needs judicious medical treatment, andlocal as well as constitutional measures. Now and then this conditioncomes on in the course of measles, and is then sometimes of seriousimportance. 

In the other form, the disease is usually limited to the gums, andaffects especially those of the front of the lower jaw, which becomeswollen, ulcerated at their edges, where a very ill-smelling deposittakes place of a dirty white or greyish colour, the surface beneathbeing spongy, swollen, raw, and bleeding. The ulceration sometimesextends so as to lay bare a large part of the sockets of the teeth; butthough loosened they seldom drop out. Coupled with this, the glands atthe angle of the jaw are swollen, and the child dribbles constantly alarge quantity of horribly offensive saliva. In the children of thewell-to-do classes the condition is seldom seen except in a slightdegree; but even when severe it is rarely accompanied by any gravedisorder of the general health. It seems to tend, whether treated orleft to itself, slowly to get well; but its progress to a natural cureis extremely tedious, and the gums are left by it for a long timespongy, bleeding easily, and only very imperfectly covering the teeth. 

Anxiety is sometimes excited by this condition; it being supposed thatthe white deposit on the edge of the gum implies some relation betweenit and diphtheria. This is not so, for though this peculiar ulcerationof the gums has now and then been found associated with diphtheria, thenature of the two diseases is essentially different. It is, however, always wise to call in medical advice in order to settle this importantquestion, and the more so, since there is one remedy, the chlorate ofpotass, which, in appropriate doses, acts upon the condition almost as acharm. 

I say nothing about a dreadful form of inflammation of the mouth whichends in mortification, because it is of infinite rarity except among thedestitute poor, and even among them it is very seldom seen except as aconsequence of measles, or of some kind of fever. It is only among thevery poor that I have seen it, and even among them it has come under mynotice only ten times in the whole course of my life. 

There is a very common but inaccurate opinion that sore-mouth inchildhood is often produced by the employment of mercury. I never yetsaw a sore mouth due to the administration of mercury in any childbefore the first set of teeth were entirely cut; and never but once outof 70, 000 cases which have come under my notice in hospital ordispensary practice, have I seen in children of any age under twelve anyaffection of the mouth from mercury sufficiently severe to cause me amoment's anxiety. 

=Quinsey=, or inflammatory sore-throat, has in it nothing speciallypeculiar to the child, but occurs at all ages with the same symptoms. Itis, however, comparatively rare under twelve years of age, and is almostalways less severe in childhood than at or after puberty, while Iscarcely remember to have met with it under five years of age. Thiscircumstance attaches special importance to sore-throat in youngchildren, since it will usually be found to betoken the approach ofscarlet fever, or of diphtheria, rather than the existence of simpleinflammation, or quinsey. 

While this fact affords a reason for most scrupulous attention to everycase of sore-throat in children, and this in proportion to the tenderage of the child, needless alarm is sometimes caused by the appearanceon the inflamed tonsils of numerous white specks, which are at oncesupposed to be diphtheritic. I have already pointed out the distinctionbetween the two conditions when speaking of diphtheria, but the matteris so important that I will repeat what I then said. These spots are notin the form of a uniform white patch or membrane, which, on beingremoved, leaves the surface beneath red, raw, and often slightlybleeding; but they are rather distinct circular spots, firmly adherentto the tonsil, wiped off with difficulty, and evidently exuding from theopenings of little pits, blind pouches, or glands, with which thesurface of the tonsil is beset. I do not advise any parent to restsatisfied with his or her judgment on this matter the first time thatthey notice this appearance; but there are children with whom slightsore-throat is always attended by this condition, and others in whom thetonsils are habitually enlarged, and seldom free from these white spotsflecking their surface. 

=Enlarged Tonsils. =--I have said that quinsey or acute inflammation ofthe tonsils is unusual in early childhood; but a sort of chronicinflammation of those glands which leads to their very considerableenlargement is far from uncommon; and is sometimes the cause of veryserious discomfort. It is seldom traceable to any acute attack ofsore-throat, but usually comes on imperceptibly in children who arefeeble or out of health, or takes place slowly during the cutting of thefirst set of grinding teeth; the irritation which that produces being insome cases its only apparent exciting cause. Not seldom the enlargementhas become considerable before it attracts attention; one of the firstsymptoms that indicate it being the loud snoring of the child duringsleep, who is compelled by the obstruction at the back of the nostrilsto breathe with its mouth open. The voice at the same time becomesthick, and this and the snoring breathing are both greatly aggravatedwhen the child catches cold. 

A greater degree of enlargement of the tonsils occasions deafness frompressure on the passage leading to the internal ear, and is also apt togive rise to a troublesome hacking cough which sometimes excitesapprehension lest the child's lungs should be diseased. When still moreconsiderable the enlarged tonsils block up the passage through thenostrils, and air consequently enters the lungs but very imperfectly. The nostrils thus disused become extremely small, narrow, andcompressed, the upper jaw does not undergo its proper development, theteeth are crowded and overlap each other, the palate remains narrow andunusually high-arched, and the face assumes something of a bird-likecharacter. Besides this the child grows pigeon-breasted, owing to thelungs not being filled sufficiently at each inspiration to overcome thepressure of the external air on the yielding sides of the chest. 

When any considerable enlargement of the tonsils exists, each cold thatthe child may catch aggravates it, and if diphtheria, scarlatina, orsevere sore-throat should occur, the temporary increase of the swellingmay become the occasion of serious danger. The question arises, what arethe chances that a child whose tonsils are enlarged will outgrow thecondition, or when is it necessary to have the enlarged tonsils removed?

It scarcely ever happens that any such enlargement of the tonsils existsin children under six years of age as to call for their removal. Thereis almost always ground for the hope that after the irritation caused bycutting the first four permanent grinding teeth has completely ceased, the tonsils may return by degrees to their former size. A similarshrinking of the enlarged tonsil sometimes takes place, especially inthe boy, at the time of approach to manhood, when the vocal organsundergo full development. This can be counted on, however, only in caseswhere the tonsils are not of extreme size, and have not undergonefrequent attacks of inflammation. Whenever the hearing is habituallydull, and the voice always thick, when cough is frequent, the nostrilsnarrow, the chest pigeon-breasted, and the child feeble and ill-thriven, removal of the tonsils is absolutely necessary. In cases where thequestion is doubtful, its decision must turn on whether the tonsils haveoften been inflamed. So long as their surface is smooth, and theirsubstance soft and elastic, delay is permissible. When their substanceis hard, like gristle, and their surface uneven and corrugated, theyhave undergone such changes that absorption is impossible, and theirremoval absolutely necessary. 

I dwell thus particularly on the question of removal of the tonsils, because there is among many persons an unreasoning dread of theoperation, which is entirely devoid of danger, requiring only a fewseconds for its performance, and which may even be done underchloroform. The painting tincture of iodine behind the angle of the jaw, or the touching the tonsils with caustic, iodine, alum, tannin, or sweetspirits of nitre are utterly futile proceedings. They diminish theunhealthy and often offensive secretion from the glands which beset thetonsils, and restore the surface to a more healthy condition, but theyare absolutely without influence in lessening their size. 

Now and then all the symptoms of enlarged tonsils are present, but yetmost careful examination fails to discover any increase of their size. When this is the case the symptoms are due to a thickening of themembrane at the back part of the nostrils, often attended with spongyoutgrowths from their surface, which obstruct just as completely asenlarged tonsils would do the free entrance of air. It will, in any casewhere this condition is suspected, be absolutely necessary to seek theadvice of some of those gentlemen who make a specialty of diseases ofthe throat, and who will have the necessary technical dexterity todiscover the condition, and to treat it skilfully. 

=Abscess at back of the Throat. =--I should pass unnoticed, on account ofits rarity, the occasional formation of an abscess at the back of thethroat, behind the gullet, interfering both with breathing and withswallowing, but that the description of it in my Lectures once enabled alady in the wilds of Russia to detect it, to point out the nature of thecase to her puzzled doctor, to urge him to open the abscess, and thus tosave her child's life. 

This abscess may form at any age, sometimes after fever, sometimeswithout any obvious cause. It shows itself by difficulty in swallowingand breathing, unattended by cough, but accompanied by a sound similarto that of croup, but not so harsh or ringing. The neck is stiff, thehead thrown back, and often there is a distinct swelling on one or otherside of the neck. The finger introduced into the mouth, and carried overthe tongue to the back of the throat, feels there a swelling whichprojects over the top of the windpipe, and causes the difficulty both inswallowing and breathing. This swelling is the abscess; a prick with thesurgeon's lancet lets out the matter, and saves the child. 

=Diseases of the Kidneys. =--The _kidneys_ perform very important dutiesin carrying off from the system a large amount of useless material, andthus supplement in many respects the action of the skin, and thepurifying influence which is exercised by the air on the blood, as itpasses through the lungs. 

It is evident, therefore, that their disorder in any way must be amatter of serious moment, though at the same time the knowledge of theskilled doctor is needed to determine the nature and degree of theailment from which they are suffering, since that requires anexamination of the urine, both chemically and by means of themicroscope. My remarks on these diseases must consequently be few andfragmentary. 

In the grown person, what is known as _Bright's disease_ is of frequentoccurrence, assumes different forms, and depends on various causes. Inthe child it is comparatively rare, and is scarcely ever met with exceptas a consequence of a chill, or as a result of scarlatina. In theseconditions the kidneys become overfilled with blood or congested, andthe congestion may pass into inflammation, by which their structure maybe irreparably damaged. Dropsy is the great outward sign of theaffection--either slight swelling of the face, eyelids, and ankles, orvery great swelling of all the limbs, and even the abundant pouring outof fluid into the belly. The degree of dropsy is, however, by no meansan absolute measure of the amount of kidney mischief. It thereforebehoves every parent to follow out all directions most scrupulously evenin cases of very slight dropsy, in order to guard against the risk ofpermanent injury to the kidneys being left behind; and especially toremember the liability to the occurrence of dropsy and disease of thekidneys after scarlatina. Any check to the action of the skin while itis peeling or desquamating, as it is termed, is especially liable to befollowed by these accidents. To avoid all risks as far as possible, Ihave been accustomed for many years to insist on a child remaining inbed for one-and-twenty days after the first appearance of the rash ineven the mildest case of scarlatina, and I am absolutely sure that it isthe height of imprudence ever to neglect this precaution. 

It will suffice to mention the fact that _diabetes_, though very rare, may yet occur in childhood, and that as a rule it is more dangerous inchildhood than in the grown person. Whenever a child loses flesh withoutobvious cause, suffers much from thirst, and at the same time passesurine in greater abundance than in health, the possibility that it maysuffer from diabetes must be borne in mind. 

Of far greater frequency than any other affection of the kidney is thatin which the child passes _gravel_ with the urine, either in the form ofa reddish-white sediment, which collects at the bottom of the vessel asthe urine cools, or of minute glistening red particles, which resemblegrains of cayenne pepper. 

These deposits, when abundant in the male child, have a tendency tocollect in the bladder, and there to form a stone. This painful disease, too, is so much more frequent in childhood than at a later age, thatmore than a third--indeed, nearly half--of all the operations for stoneperformed in English hospitals are done on boys under ten years old. 

Even when this grave consequence does not follow the presence of gravelin the kidneys, and its passage into the bladder, it is oftenaccompanied with much suffering. The pain is like that of stomach-acheor colic, the child crying and drawing up its legs on every attempt topass water, which sometimes is voided only in a few drops at a time, andnow and then is completely suppressed for some hours. The very acuteform of the ailment seldom occurs, except in infants who inherit fromtheir parents a disposition to gouty or rheumatic affections. In them, however, a trifling cold, slight disorder of the digestion, a state ofconstipation, or the feverishness and general irritation which sometimesattend on teething, not infrequently produce these deposits and giverise to all these painful symptoms, the deposit disappearing and thepain ceasing so soon as the brief constitutional disturbance subsides. 

The very acute attacks seldom occur after the first two years of life, but similar symptoms, though less severe, are by no means unusual inolder children, and continue to recur from very trifling causes, especially from errors in diet and disorders of digestion. 

In spite of the suffering which for the time attends it, there is nocause for anxiety with reference to the issue of each attack. The warmbath, a castor oil aperient, and soothing medicine soon relieve thepain, and the children return to their former state of health. It is thefrequent return of the attack, even in a comparatively mild form, thepersistent disposition to the formation of gravel, the remote risk inthe case of male children of stone in the bladder, and the habituallyimperfect performance of the digestive functions which call for specialcare. The avoidance of sugar, sweets, and whatever tends to impartacidity to the urine, the maintaining the due action of the skin bywearing flannel, and the judicious use of alkaline remedies, sometimescombined with iron, are the measures on which the doctor is sure toinsist. 

The difficulty usually encountered in the treatment of these casesarises from the reluctance of the parents to continue for months andyears the observance of the necessary rules. It seems so hard to denytheir little one the small gratifications in which other children mayindulge with impunity; and they fail to realise the heavy penalty, inthe shape of gout, rheumatism, gravel, and stone, which in after-lifetheir darling may have to pay for their over-indulgence in his earlyyears. 

I will just mention that symptoms similar to those above described, lesssevere, though more abiding, yet unattended by gravel in the urine, aresometimes produced in little boys by an unnatural narrowness of the endof the passage for the urine. It is well to bear in mind this possiblecause of the child's sufferings, and to consult a doctor with referenceto it, since he will be able to relieve it by a trivial operation. 

=Incontinence of Urine. =--The irritation which this mechanicalinconvenience produces sometimes has to do with that troublesomeinfirmity of some children, who wet the bed at night. This may also beinduced by a very acid, and consequently irritating, state of urine, either with or without the appearance in it of gravel. Often, however, it is a result of want of care on the part of the nurse, who neglects tocultivate regular habits in a child; and does not pay attention to thequantity of liquid taken at its last meal. Something, too, is due to thefact that the sleep of a child is deeper than that of the grown person, so that the sensation of want, which would arouse the latter to fullconsciousness, does not have the same effect on the former. It sometimeshappens undoubtedly from mere indolence; and this may always besuspected when a child, otherwise healthy, wets itself not at nightonly, but also in the daytime. Lastly, it does sometimes occur frommuscular feebleness in weakly children, the bladder being unable to bearmore than a limited degree of distension. 

The accident usually happens either soon after going to bed, when thewarmth stimulates the action of the bladder, or towards morning, whenthe bladder has become full. The posture on the back favours itsoccurrence very much, and it is therefore of importance that the childshould lie on its side when in bed. The good effect of a blister on thelower part of the back as a means of cure was largely due to its forcingthe child to lie on its side. This object can be attained, however, in amuch kindlier way, by tying half a dozen cotton reels together, andfastening them at the child's back. The habit may also often be brokenthrough by arousing the child in the night, and compelling it to emptyits bladder, the hour being first ascertained at which the accidentusually happens. For this, however, to be of any real use, the childmust be awakened thoroughly; since otherwise it will mechanically, andquite unconsciously, empty its bladder while still asleep. The habit inthis case is not in the least overcome; only for the time the bedescapes the wetting. The utensil must therefore be placed on differentnights at different parts of the room, so that the child, in order tofind it, must have been roused to thorough consciousness. 

Lastly, I will add that the cases in which the accident is the result ofmere indolence are very rare, and though in such cases strictness may benecessary, yet actual punishment is out of place. As a rule, rewardanswers much better. A penny, or a threepenny-piece every night that theaccident does not happen, and a forfeit of a halfpenny or two pence forevery night of misfortune, is a very efficacious help to a cure. 

When all these domestic means, persevered in for months, fail toproduce any result, medical aid must be called in. 

CHAPTER IX. 

CONSTITUTIONAL DISEASES. 

There remains for consideration a large class of what may be termed_constitutional diseases_, in which the local ailment is the outcome ofa previous disorder of the whole system. These diseases are either acuteor chronic. The acute constitutional diseases belong to the class offevers. These are marked by certain local characteristics, as theswelling of the joints in acute rheumatism, the sore-throat inscarlatina, or the eruption on the skin in smallpox, and their course ismore or less strictly limited by distinct periods of increase, acme, anddecline. No such rule obtains in the case of consumption, scrofula, andrickets, which are instances of chronic constitutional diseases. In themtoo the local manifestations of the general disease vary also: the lungsbeing affected in one case of consumption, the bowels in another; whilescrofula may show itself by affection of the glands in one case, by theformation of abscesses in a second, or by disease of the bones in athird. 

=Chronic Constitutional Diseases. =--It may perhaps be convenient tostudy first the chronic constitutional diseases; and afterwards to makea few, and they will be but few, remarks on fevers. 

=Consumption= and Scrofula, though similar, are not the same disease. Both, however, depend on some defect in the blood, as the result ofwhich certain materials, incapable of being converted into the naturalconstituents of the body, are deposited in the substance of differentexternal parts or internal organs. If deposited in small quantities, these materials may be absorbed, as it is termed, that is to say, gotrid of, by natural processes, which even now we understand butimperfectly. 

If deposited more abundantly, they press upon and gradually spoil thehealthy parts in which they are seated, and thereby interfere with theproper performance of their duties. Thus, the deposit of consumptionencroaches on the proper substance of the lungs, and so lessens the areain which the blood is exposed to the air and purified: the deposit ofscrofula around and in a joint interferes with its powers of movement. Nor is this all; but wherever any deposit has once taken place, it tendsespecially to increase in that very spot, guided as it were by a certainaffinity; and the substance of the previously healthy part is removed asfresh deposit comes to occupy its place. Further, the matter depositedhas no power of being changed into healthy substance of lung, or ofbone, or of any other part. 

A fractured limb may be completely mended; a fluid is poured out aroundand between the edges of the broken bone; by degrees this hardens, itundergoes changes which convert it into solid bone, and the limb is oncemore as serviceable as before, though some indications of the fracturemay still be perceptible in the texture of the bone itself. Or, a personreceives a severe blow on his arm or leg; in course of time the bloodwhich had flowed from the ruptured vessels, and had formed a big bruise, is absorbed, and all is as before the injury was inflicted. If moreserious damage has been done, the fibres of some muscles may have beentorn, even though the skin remains unbroken. Inflammation is set up, theinjured parts die, and are melted down into the matter of an abscess. The abscess discharges itself, its walls contract, the opposite surfacescome into contact, and are welded together again, so that there is noloss of substance, nor anything save a scar on the surface to indicatewhat has happened. 

In the case of the deposits of consumption or scrofula these changescannot take place. In technical language the matter is said to beincapable of organisation; that is to say, it cannot be transformed bynature's alchemy into anything good or useful. It is rubbish to be gotrid of; and the patient's recovery depends on the possibility of gettingrid of it. If there is much of it, so as to be removed from thevivifying influence which adjacent living structures still maintainabout it, the deposit softens at its centre. This softening graduallyextends to the circumference; the mass irritates more and more the partsaround it, and where the irritation is greatest the structures yield, and are removed to make a way for its escape, and the patient spits upthe contents of the abscess. 

But the abscess of the lungs is not like an abscess which follows aninjury. It has not formed in the midst of previously healthy parts whichare capable of reproducing the original structure; its walls arethemselves involved in the disease, and, in accordance with the rule Ihave already mentioned, 'much will have more, ' and the patient goes onspitting up the perpetually renewed contents of the abscess for monthsor years; until by its gradually increasing size, and the more and moreabundant discharge of matter, and further and further destruction oflung-substance, death takes place. 

This fatal issue, however, is not invariable. In favourablecircumstances, and especially in childhood, the radical constitutionaldefect may be amended, and with a healthier condition of the blood theunhealthy deposit may cease to take place. The lung-substance, however, with all its curious structure of air-cells and their network of minutevessels where, as in nature's laboratory, the blood receives its duesupply of oxygen, is not reproduced. The lung shrinks, the sides of theabscess come together, and by slow degrees a dense material cuts it offfrom the adjacent healthy structure, but the most complete recoveryleaves the patient with his breathing power lessened, and with hisvigour consequently more or less impaired. 

When the deposit is less considerable, a different change takes place. The material dries by degrees, and is at last converted by a purelychemical change into a hard chalky substance, which in the course oftime becomes of more than stony hardness. 

Last of all; when the deposit is smallest in quantity, it may becompletely got rid of; and a lung in which consumptive disease onceexisted, may eventually regain perfect soundness. 

I have dwelt on these processes as they take place in the lungs; but, allowing for differences of locality, they resemble such as take placeelsewhere. 

Three important conclusions follow from what has been said. 

First. It is only in quite the early stage of consumptive disease thatabsolutely perfect recovery can be hoped for. There is a euphemism, moreamiable than honest, which doctors not seldom make use of, saying that achild's lungs are not diseased, but only tender. They mean by this, thaton listening to the chest, they detect such changes in the sounds ofbreathing as their experience tells them are usually produced in theearly stage of consumptive disease of the lungs. If the opinion isconfirmed by a second competent medical man, _then, and not later_, isthe time for precautions, for removing the child from school, and forselecting, as far as may be, a suitable winter climate. When the signsof disease are well marked, a reprieve, perhaps a long one, is all thatcan be confidently reckoned on. 

Second. When softening of the consumptive deposit has taken place, ofwhich certain sounds attending breathing are all but conclusive, recovery, even the most complete, always implies loss of a certainamount of lung-substance, and consequently loss of a certain amount ofbreathing power. 

Third, and this is most important, as well as most cheering;consumption, which is at no age the absolutely hopeless disease that itwas once supposed to be, admits of far more cheerful anticipations inchildren than in grown persons, or, for that matter, than in the youthor maiden. 

The principal _causes_ of consumptive disease are, hereditarypredisposition, and improper feeding in infancy. There are besides twodiseases incidental to childhood, and one of them almost peculiar to it, namely typhoid fever and measles, which are more apt than any others todevelop a tendency to consumption. During convalescence from either ofthem, therefore, special care is needed. 

In the grown person, consumption almost always attacks the lungs, andthis often to the exclusion of other organs. In the child, however, thisis not so, and though the lungs are indeed oftener affected than otherparts, yet in nearly half of the cases some one or other of thedigestive organs is likewise involved, and in about one in seveninstances the lungs are free and the digestive organs alone areattacked. 

Fever, cough, and wasting are the three sets of symptoms which in somedegree or other are always present in consumptive disease of the lungs. The fever in the early stages of consumption is not in general severe;but so long as the evening temperature of a child never exceeds 99°, there is no cause for anxiety. On the other hand, if the eveningtemperature for a week or ten days together always amounts to 100°, there is grave presumption that consumptive disease is present. Inadvanced consumption the evening temperature is constantly 103° to 105°, while in the morning it may fall to 101° or 100°. 

Cough is but rarely absent even in cases where the lungs are butslightly involved, for the irritation of the digestive organs oftenexcites a sympathetic cough, and in these circumstances observation ofthe evening temperature will often furnish a clue to the rightinterpretation of the symptoms. 

There is a form of cough which is oftenest observed in children betweenthe ages of two and five years, which comes in fits closely resemblingthose of hooping-cough, and each fit ends in a sort of imperfect 'hoop. 'This may depend on a particular form of consumption in which the _glandsconnected with the lungs_ (the bronchial glands as they are called) _arediseased_, and not the lung-substance itself. The enlarged glands presson some of the nerves connected with the upper part of the windpipe, andthus occasion the spasmodic cough. Always suspect this when a coughpersists for weeks together, not getting rapidly worse as hooping-coughwould do, but at the same time not growing better, as would be the casewith mild hooping-cough. The doctor on listening to the chest will solveyour doubts; the thermometer will help you to decide whether his visitis necessary. I may add that this form of consumptive disease is lessserious than that in which the lung-substance is involved. 

Consumption sometimes follows bronchitis, especially when a child hasbeen subject to frequent attacks of it. A very slow and imperfectrecovery from an attack of bronchitis which had not been speciallysevere is always a reason for solicitude. 

Now and then infants are born with consumptive disease. In that case thelungs are always affected; and the symptoms of fever, cough, and wastingusually show themselves within the first three or four months, and theinfants almost invariably die within the year. Now and then, however, aninfant thus affected may continue apparently in good health for a fewmonths, and then be suddenly attacked by symptoms of acute inflammationor of severe bronchitis which prove rapidly fatal; and it may be foundafter death that the acute attack destroyed life because the lungs werealready the seat of extensive consumptive disease. 

No infant in whose mother's family a predisposition to consumptionexists ought to be nursed by its mother, but by a healthy wet nurse; or, if that is impossible, it should be brought up on a milk diet, with buta small admixture of farinaceous food. 

There is a form of very rapid, or so-called galloping consumption, whichis seldom observed before the age of seven years; generally two or threeyears later. Its symptoms so closely resemble those of typhoid fever, that it may readily be mistaken for it. I refer to it in order to saythat the doctor who mistakes the one for the other can scarcely beregarded as blameworthy; and the mistake is of the less importance sincethe treatment applicable to the one case would do no harm in the other. 

I have already noticed the connection between water on the brain andconsumption. It is indeed nothing else than inflammation excited by thepresence of the deposit of consumptive matter in the brain or itsmembranes. 

Little has been said hitherto about the wasting which was referred to asone of the characteristics of consumption. When the disease is limited, or nearly so, to the lungs, the wasting is not considerable until themischief in the chest is far advanced. It must be remembered, however, in order to judge of this, that while in the full-grown man the bestsign of health is the persistence for years together of the same weight, the case of the child is different. The child ought to grow in height, and increase in weight, and during these changes the plump infant growsthinner, not by real wasting but by conversion of its fat into bone andmuscle. The child is thinner, but is taller and weighs heavier. The onlyreal test therefore of the condition of the child is afforded by itsincrease in height and in weight. One need not be solicitous about thechild who increases in height, and maintains his previous weight, norabout him who while he does not grow yet becomes heavier; but the childwho neither gains in weight, nor in height, or who loses weight out ofproportion to his increased height, is in a condition that warrantsanxiety. I have long been accustomed, in the case of children whoseparents were resident in India, to instruct those who have charge ofthem to send every three months a statement of the height and weight ofthe children, as the best evidence of their state of health. 

=Consumptive Disease of the Bowels. =--Consumptive disease sometimesinvades the whole system from the very first, while in other instancesit attacks from the outset the organs of digestion, and continuesthroughout to affect them chiefly, and loss of flesh is then one of itsearliest symptoms. In instances where there is a strong familypredisposition to the disease, consumption of the bowels or mesentericdisease, or disease of the glands of the bowels, all three popular namesfor the affection, sometimes shows itself at the time of weaning. In themajority of cases, however, it comes on later, after the completion ofteething, and between the age of three and ten years. Indigestion suchas I have already spoken of sometimes precedes it, with the irregularcondition of bowels, and the patchy state of the tongue. But this is byno means constant, scarcely I think general; and not infrequentlymomentary, causeless, colicky pains precede for a short time any othersymptom. In a few weeks after their occurrence, sometimes indeedindependently of them, the appetite fails, or becomes capricious; thebowels begin to act irregularly, being alternately constipated andrelaxed; and the motions are unnatural in character, being, for the mostpart, dark, loose, and slimy. Sometimes indeed, they are solid, and thenoften white, as if from complete inactivity of the liver, and sometimeshalf-liquid, frothy, and like yeast. One peculiarity which they alwayspresent, be their other characters what they may, is their extremeabundance, quite out of proportion to the quantity of food taken, anddue to their admixture with the unhealthy secretions from the bowels. The child next becomes restless and feverish at night, its thirst isconsiderable, and the colicky pains become both more severe and morefrequent. Sometimes the stomach grows very irritable, and the food takenis occasionally vomited, while the tongue, in the early stages of theaffection, continues for the most part clean and moist, and except thatit is often unnaturally red deviates but little from its appearance inhealth. Next comes a change in the condition of the belly, the date ofwhich varies considerably. It becomes larger than natural, owing to thefilling of the bowels with wind, but at the same time it is tense andtender on pressure--two points of great importance to be noticed, andthe glands in the groin, which in a healthy child cannot be felt, becomeenlarged, and are felt and perhaps even seen like tiny beans under theskin. 

As in other forms of consumptive disease, so here the progress from badto worse seldom goes on uninterruptedly. Pauses take place in itscourse, though each time they become shorter; and signs of amendment nowand then appear, but they too promise less and less with each return. The child wastes rapidly; is always more or less feverish; the abdomenis constantly tender, but does not in general go on increasing in size;the pains become more frequent and more severe, and the bowels arealmost always habitually relaxed. Life is sometimes cut short by thelungs becoming affected, but when this is not the case the patient maylinger on for weeks, or months, or even for two or three years, until, worn to a skeleton, death at last takes place from exhaustion. 

Much apprehension is often needlessly excited in the minds of parents, with reference to any child whose digestion is imperfect, who losesflesh, and has a large abdomen; and the words mesenteric disease, sometimes uttered thoughtlessly by the doctors, seem to them to sealtheir little one's doom. Now, first of all, it must be remembered thatmesenteric disease, due to consumption, plays but a very small part inthe production of the symptoms just described, but that the covering andthe lining of the bowels are chiefly involved. Next, enlargement of themesenteric glands and disorder of their functions take place from manycauses other than consumption. They are always more or less enlarged intyphoid fever; they become enlarged when irritated by unwholesome foodin infancy, or they may swell in the course of chronic indigestion. Inall these cases too, the glands in the groin may be enlarged bysympathy, and this without the existence of any actual abiding disease. A big abdomen is, of itself, no evidence of it, nor even when associatedwith indigestion and frequent stomach-ache; but when to these you addabiding tenderness, and an evening temperature always at least onedegree above that in the morning, there is every reason to fear thatconsumptive disease has attacked the organs of digestion. 

Even then, however, there is no ground for despair; for, whileconsumptive disease in any form is less seldom recovered from inchildhood than in after-life, such recovery oftener takes place in casesof affection of the digestive organs than when the disease is seatedelsewhere. 

=Scrofula. =--With this word of comfort I leave the subject ofconsumption, and pass to that of the allied disease _scrofula_. Brieflystated, two of the great differences between it and consumption are thatscrofula is almost entirely limited to childhood and youth, whileconsumption may occur at any age; and next, that while scrofula attacksthe bones and the glands, the skin and the membranes adjacent to it, consumption has its seat in the lungs, the brain, and the internalorgans. 

Scrofulous diseases of the bones come so exclusively under theobservation of the surgeon, that I do not feel myself competent to sayanything about them. I would however warn all parents to be very muchalive to the importance of noticing the early symptoms of any suchdiseases, as shown by slight lameness, complaint of pain in the back, ordifficulty in moving the hand or arm, or in turning the head or bendingthe neck. They may be but temporary accidents, due to cold, or to slightmuscular rheumatism, or to some sprain not noticed at the time; but theymay also be signs of the commencement of scrofulous disease of somebone; and in no disease whatever is early judicious treatment of greatervalue, or the result of neglect less remediable. 

Besides these graver ailments which seldom appear until after the timeof infancy has passed, there are others of a less serious nature whichoften show themselves within the first year of life. One of theseconsists in the formation beneath the skin of numerous small lumps of arounded form, and of the size of a kidney-bean, slightly movable, andnot tender. By degrees such lumps become adherent to the skin, thesurface of which above them grows red, they project slightly above it, and at last open by a small circular aperture, discharge a littlematter, and then subside. They collapse and disappear; a slightdepression and a degree of lividity of the skin mark for a considerabletime the situation they had occupied. I refer to them, because whilethey are a sign of a scrofulous constitution, which may require specialcare in diet and preparations of iron and cod-liver oil, they are bestleft absolutely alone--neither poulticed nor lanced. The same principleof non-intervention applies equally to the swellings which sometimesform on two or three of the fingers in infancy, not involving the jointsbut producing great thickening and a hard swelling around the bone. These swellings disappear by degrees as the constitutional vigourimproves, and this is especially promoted by a long stay at the seaside;but they tend, if the health fails, to affect the bones themselves, andthus to occasion deformities of the hand. 

Glandular swelling, discharges from the ear, offensive secretion fromthe nose, and in female children, even of very tender age, a dischargeof whites, are all common signs of a scrofulous constitution, and alltedious and troublesome. They all, however, are very much under theinfluence of judicious medical treatment. It must at the same time beborne in mind that none of these ailments admit of what may be calledactive treatment. There are no royal means of dispersing scrofulousglands, or of curing discharges from the ear, or of doing away with theoffensive smell which in some cases proceeds from the nostrils. Freshair, suitable diet, preparations of iron, residence at the seaside, andsea-bathing, measures directed to improve the general health, are ofchief value, and without them local treatment is of small avail. 

A few words, however, may with propriety be added with reference to thelocal treatment of the minor ailments to which I have just referred. 

No local application is of use in the _scrofulous swellings of thefingers_. Tincture of iodine, indeed, may be painted over them whenquite small, while at the same time the joints are kept quiet by a smallgutta-percha splint. When they become considerable, iodine is useless;and even if matter forms in the swelling it is much better to let itmake its way out by a small opening spontaneously than to make apuncture with a lancet, since the edges of the wound would not heal, andthe risk of the disease affecting the bone would be increased. 

The _glandular swellings_ of the neck or about the lower jaw arelikewise best let alone, or merely covered with a layer of cotton wool, stitched inside a piece of oiled silk to maintain a uniform temperature. If they become suddenly painful and more swollen, a cooling lotion ofGoulard water and spirits of wine, constantly applied, will reduce theswelling and lessen the discomfort. When stationary, a mild iodineointment may be smeared over the gland at bedtime, and covered withoiled silk. Applications of iodine, however, need careful watching, forsometimes they over-irritate the gland, and cause an abscess. If thegland were out of sight there would be no objection to this, whichwould probably be a rapid mode of getting rid of the swelling; but thescar left behind, if the abscess burst or were opened, is an objectionwhen the swelling is situated in the neck or at the jaw. 

If the skin over the top of the swelling becomes red, and its substancebegins to feel soft, then, but not till then, it is desirable to apply awarm poultice constantly. At the same time the progress must be dailywatched by the doctor, in order that he may seize the proper moment tomake a small puncture and let out the matter. The small cut leaves aless puckered scar than the natural opening. The subsequent managementof the case must be superintended by the doctor. 

_Offensive discharge from the nostrils_ does not depend, in by far themajority of cases, on disease of the bones, but on an unhealthycondition of their lining membrane. It is exceedingly obstinate anddifficult of cure, is four times more frequent in girls than in boys, and unfortunately often lasts into womanhood, and continues even whenthe general health is perfect. 

Much may be done to abate the annoyance by diligent sniffing up thenostrils some weak disinfectant; or by regularly irrigating the nostrilsby means of a simple apparatus, to be obtained from anyinstrument-maker. In spite of this, however, it is often necessary tointroduce a little plug of cotton wool dipped in the fluid some distanceup the nostrils, with a thread attached by which it can be withdrawn, and a fresh one substituted twice a day. 

The discharge of _whites_ is sometimes very troublesome, and apt toreturn from the commencement of teething up even to womanhood. It is amere sign of debility, usually also connected with a scrofulous habit, but has no further or graver meaning. Locally, constant cold ablution bymeans of a sponge held above the child, not touching it, is the greatremedy, and this may have to be repeated every hour or two if the caseis severe. Astringent lotions of different kinds may be used in the samemanner; while care must be taken that the child's drawers are large andloose, so as not to irritate her when sitting. General treatment, however, sea air and sea bathing are especially in these cases the greatremedy. 

It must not be forgotten that all these ailments have a special tendencyto recur; and that when people say 'Dr. A. Or Dr. B. Did the child goodfor the time, but this or that symptom returned as soon as the treatmentwas discontinued, ' as though this were the doctor's fault, they areunjust; for the tendency to return of every form of scrofulous diseaseis one of the great characteristics of the malady. Patience andperseverance on the parents' part, even for months and years, are oftenas much needed as skill on the part of the doctor. 

One more remark may not be out of place. Some persons have an impressionthat there is something specially shameful in scrofulous disease, andwhile they will readily admit the existence of a consumptive tendency intheir family, they almost resent the suggestion that their child'sailment is scrofulous. For this prejudice there is absolutely nofoundation. There is no more reason for connecting scrofula in a childwith any antecedent wrong-doing on the part of its progenitors, thanthere is for attaching that idea to the red hair or black eyes which achild may have in common with the rest of its family. 

=Rickets. =--We sometimes see, especially in the poorer quarters of agreat city, persons dwarfed in stature, with large hands, bowed legs, bent arms, swollen wrists and ankles, walking with an awkward gait, though usually holding themselves remarkably upright, with the face of agrown person on the body of a child, and we know that they suffered from_rickets_ when young. 

Rickets is essentially a disease of childhood, and of early childhood, in which proper bone-formation does not take place, the soft material, or gristle, which should turn to bone, remaining long in the soft state. When, therefore, the child begins to walk, or to use its limbs, theybend under the weight of the body, or under their own weight, and withevery slight movement which its feeble muscular power enables it tomake. It does more, however, than interfere with the hardening of thelimbs: it arrests growth to a great degree, interferes withdevelopment, retards teething, postpones the closure of the open part ofthe head, or fontanelle, weakens constitutional vigour, and impairsmuscular power. To this feeble muscular power it is due that the childcannot make the effort to fill its lungs completely, and hence thepressure of the external air forces the soft ribs inwards, and gives tothe chest the peculiar form of pigeon-breast. In the course of time thedelayed bone-formation takes place, and the bones themselves become ashard as ivory, but the limbs do not straighten, and the deformityproduced in infancy is but confirmed in after-life. 

The greater degrees of rickets are scarcely ever seen among the childrenof the wealthier classes, but over-crowded and ill-ventilated nurseries, cots from which the air is well-nigh shut out by closed sides andoverhanging curtains; injudicious feeding, with undue preponderance offarinaceous food, often produce its slighter forms. I never yet sawrickets in a child while brought up exclusively at its mother's breast. 

The slighter forms of rickets show themselves in a tardy closure of theinfant's head, which sweats profusely when the child is laid down tosleep; in big wrists, which contrast with the attenuated arms; in ageneral limpness of the whole body, and a bowing of the back under theweight of the head, which bends as a green stick would bend if a weightwere placed upon it. They are further marked by backwardness inteething, and by the irregular order in which the teeth appear, and, further, by the peculiar narrowness of the chest, and by what has beentermed the beading of the ends of the ribs: little round prominences dueto a heaping up of gristle just where the ribs join on to thebreastbone, marking the spots at which the tardy bone-making has come toa standstill. 

Children who bear these stamps of rickets are far more apt than othersto suffer from spasmodic croup, and in them it is also specially likelyto be severe and to be accompanied by convulsions. They will also bemore liable than others to attacks of bronchitis, they will suffer moreduring teething, they will be often constipated, and will be troubled byvarious forms of indigestion. Now and then, too, they will havecauseless attacks of feverishness lasting for a few days, or for two orthree weeks, attended with general tenderness of the surface, and adisposition to perspiration, which brings no relief but serves only toweaken. 

It is true that these symptoms do not often become immediately dangerousto life, though spasmodic croup and bronchitis both have their perils;but they interfere with health, and growth, and good looks, andcheerfulness, and quick intelligence. 

If mothers would but ask themselves the real signification of thesesymptoms, and change the conditions which surround the child, and altertheir mode of feeding it, they would many and many a time be spared theheart-ache of seeing their little ones grow up weakly, ugly, ill-thriven. 

Unfortunately, it is so much easier to give cod-liver oil and iron thanto turn the best spare room into a night nursery, and to uglify the cotby taking away the curtains which made it so pretty, and to give up someof the pleasures of society in order to superintend the preparation ofthe baby's food; that the doctor is called in to correct by drugs theevil which drugs cannot reach. Iron and cod-liver oil are very useful inthe second place; fresh air, good ventilation, and a wise diet mustalways occupy the first. 

=Acute Constitutional Diseases. =--It still remains for us to glancerapidly at the characters of the _acute constitutional diseases_, all ofwhich belong, as has already been stated, to the class of fevers. Ofthem all but two are contagious--that is to say, are capable of beingcommunicated directly from person to person. They are likewiseinfectious, or, in other words, articles of bedding or clothes whichhave been worn by the sick, retain a something--an exhalation from thebreath, an emanation from the skin, or a secretion from thebowels--which may reproduce the same disease in a person previouslyhealthy. 

To this contagious and infectious property there are two exceptions; theone is furnished by acute rheumatism, or rheumatic fever, the other byintermittent fever, or ague. 

=Rheumatic Fever. =--The main features of _rheumatic fever_ are the sameat all ages. Fever, pain in the limbs, swelling of the joints, sweatsunattended by that relief which usually accompanies abundant action ofthe skin in fevers, are its characteristics. In the child all thesesymptoms are usually less even than in the adult. The swelling of thejoints in particular is less considerable, and both the pain and theswelling are apt to wander from one to another joint, or to a differentlimb, instead of remaining fixed as they do in the grown person forseveral days in the same joint, even though fresh joints may beimplicated in the course of the disease. 

These circumstances tend to make people look on rheumatic fever in thechild too often as a comparatively trivial ailment; and this not onlybecause the suffering which attends the disease is slighter, but becauseits duration is also shorter. But there is one fact which forbids thislow estimate of its importance, and that is the great tendency toaffection of the heart even in cases of comparatively mild rheumatism inthe child; while in the grown person there is a direct relation betweenthe general severity of the rheumatic symptoms and the liability of theheart to be involved. I have already stated that nine out of ten of allcases of heart disease in early life, not due to original malformation, are of rheumatic origin, and further that heart disease comes on in thecourse of four out of five cases of rheumatic fever in the child, slightas well as severe. It seldom occurs before the third or fourth day ofthe illness, so that if parents take the alarm at the very outset, it isusually though not invariably possible for the doctor by judicioustreatment to anticipate and to prevent its occurrence, or at any rategreatly to control its progress. 

Every threatening of rheumatism, therefore, is to be watched with themost anxious care, since so serious a complication as disease of theheart may accompany extremely slight general symptoms. It is wise too, to place any child in whom general feverish symptoms come on at onceunder medical observation, for though it does not usually happen, yet itdoes sometimes occur, that rheumatic inflammation attacks the heartbefore any other local signs of the malady have manifested themselves. It is scarcely necessary to add that tenfold precautions are needed whenrheumatism has once occurred, since the liability to its return is verygreat, and the heart which escaped in the first attack may suffer in thesecond; or the comparatively small mischief done the first time maybecome an incurable disorder. 

=Ague. =--_Intermittent fever_ or _ague_ is very rare in childhood inLondon; or at any rate it is very rare among children of the wealthierclasses. I believe it is everywhere rarer among children than amonggrown persons, probably because they are as a rule less exposed to thosemalarious influences which produce it. In the child it generally takesthe form of tertian ague, that is to say the attack recurs every secondday; one day of freedom intervening between two attacks. 

The three stages of shivering, heat, and sweating are less marked in thechild than in the grown person, and this indistinctness of its symptomsis greater in proportion to the tenderer age of the child. Shivering isscarcely ever well-marked, a condition of unaccountable depressionusually taking its place, while once or twice I have known convulsionsoccur which gave rise to the apprehension that disease of the brainexisted. The hot stage is long, and passes off gradually without theprofuse perspiration that occurs in the grown person, and the child evenbetween the attacks is almost always more or less ailing. 

A first and even a second attack may puzzle not the parents only, butalso the doctor; but after the symptoms have returned a few times, thechild being neither better nor worse in the intervals, it becomesevident that no serious disease is impending. The risk of an overhastyconclusion is that the depression and disturbance of the nervous systemmay be supposed to imply the existence of brain disease; and lead tounsuitable treatment, instead of the administration of quinine, whichnine times out of ten proves a specific for ague. The rapid increase oftemperature in the attack, and its equally rapid subsidence afterwards, will, if carefully noted, preserve from error. 

There is much that is obscure with reference to the nature both ofrheumatic and intermittent fever. They differ from other fevers not onlyby being neither contagious nor infectious but also by their readinessto return, while a single attack of any of the others furnishes aguarantee, and often a complete guarantee, against its recurrence. Inaddition to these peculiarities, the fevers of which I have now to speakare characterised by running a certain definite course, beingaccompanied by certain peculiar appearances on the surface (generallyrashes on the skin, whence their name of eruptive fevers); beingattended each with its own peculiar dangers, and all having a tendencyto what is termed epidemic prevalence; that is to say to occur one year, and without obvious cause with vastly greater frequency than in otheryears. 

=Mumps. =--It has been questioned whether that painful but not dangerousailment the _mumps_, ought or ought not to be classed with these fevers. I think it should, for it is contagious, infectious, runs a fairlydefinite course, is attended with invariable external appearances, oftenprevails epidemically, and one attack preserves in most instances from asecond. 

It very seldom befalls children under seven years of age, and is morefrequent in early youth than in childhood. It sets in with the ordinarysymptoms of a cold, which are followed in about twenty-four hours bystiffness of the neck, and pain about the lower jaw, which is increasedby speaking or swallowing. At the same time a swelling appears, sometimes on one side sometimes on both of the lower jaw, and increasesvery rapidly so as to occasion great disfigurement of the face. Theswelling goes on to increase, and to become more tense, attended withmore head-ache, fever, and discomfort for some forty-eight hours, butthen it begins to lessen, and the general illness subsides rapidly, though the enlarged gland, for that is the cause of the swelling, sometimes does not return to its natural size for a week, ten days, ormore; and now and then, though very rarely, an abscess forms, which isboth tedious and troublesome. 

The treatment suitable for a severe common cold, together with theconstant application of a warm poultice to the swollen gland, is allthat is usually required, though the doctor's help is often needed torelieve the suffering which for the first day or two in many instancesattends the ailment. 

=Typhoid Fever. =--There is no question as to the place which should beoccupied by typhoid fever, smallpox, measles, and scarlatina, for allbelong to the class of eruptive fevers. They are all specific diseases, each due to its own peculiar poison, and not capable of being producedby any mere unsanitary conditions, though such may aggravate theirseverity and facilitate their spread. 

The belief in the special character of each of these diseases hasreceived strong confirmation from the researches of the eminentFrenchman, M. Pasteur, and others who have followed in his track. Theyhave discovered in the blood and other secretions, and in some of thetissues both of men and animals, minute microscopic organisms whichdiffer in their characters in different diseases. Experiment has furthershown that in some mysterious way these organisms are the cause of thesediseases, for on inoculating animals with them the peculiar disease ofwhich each was the accompaniment, and no other, was reproduced in theinoculated animal. 

As far as our knowledge goes at present then, we are forced to regardeach of these as a separate disease, measles never passing intoscarlatina, nor that into smallpox, but each, whether slight or severe, retaining throughout its distinct character. 

We have already seen how, in the course of various diseases, the pulseis quickened, and the temperature raised, constituting that state whichwe commonly call fever, but as the local ailment subsides the feverdisappears. There is, apart from smallpox, measles, and the otherso-called eruptive fevers, only one real essential fever commonly metwith in childhood, and that is what the doctors call _typhoid fever_. The name, from the similarity of sound to _typhus_, from which, however, it is essentially different, has long been a name of terror in thenursery, and all sorts of epithets have been substituted for it, asgastric fever, and infantile remittent fever, and so on. Name it as youmay, the fever is one and the same with the typhoid fever, which onehears of as prevailing constantly in many continental cities, andproving dangerous and fatal in any district almost in direct relation tothe neglect of drainage and of proper sanitary precautions. 

It is extremely rare in infancy, though I saw it once in a babe eightmonths old, and is comparatively seldom met with before the age of fiveyears. From five to ten years old it is more frequent than from ten tofifteen, but it is consolatory to know that it is less fatal in earlychildhood than at any subsequent time of life, and that cases of suchexceedingly mild character that the child's condition can be moreproperly described as ailing rather than ill, are then far fromuncommon. The symptoms, however, are in all instances similar in kind, though widely varying in degree, and the duration of the fever is, asnearly as may be, three weeks. By this it is not meant that at threeweeks' end the child who has had typhoid fever is well again, but onlythat the temperature, which had hitherto been high, and always higher atnight than in the morning, has subsided, that the skin has become lessdry, the tongue slightly moist, the intelligence more clear, that thefever has run its course. For the first week or ten days, the symptomshave probably become every day more grave; and for the next ten thedoctor could find no better consolation than the assurance--happy if hecould give it--that the condition was not worse, but that you must havepatience, for the time for improvement had not yet arrived. If theattack has been severe, the child will be left greatly exhausted, sadlyemaciated, and suffering from the effects of that ulceration of thebowels which accompanies the fever, and from which life may still be inimminent danger. But the fire is quenched; the question is no longer howto put out the conflagration, but how to repair the mischief it hascaused. 

When mild, the disease usually comes on very gradually, the child losesits cheerfulness, the appearance of health leaves it, the appetitefails, and the thirst becomes troublesome; in the daytime it is listlessand fretful, and drowsy towards evening, but the nights are oftenrestless, and the slumber broken and unrefreshing. The skin is hotter, and almost always drier than natural, or if there is any perspiration, it comes on at irregular times, lasts but an hour or two and brings norefreshing. The thermometer will quite, in the early days, solve alldoubt as to the nature of the case. In the morning the thermometer willbe natural, or nearly so, but at seven o'clock in the evening it willhave risen to 101° or 102°, and will continue so during the early partof the unquiet night. After midnight it will begin to fall, and by sixo'clock in the morning, or even earlier, will have regained its naturalstandard. There is no other disease but typhoid fever, and now and thensome forms of galloping consumption, in which these oscillations oftemperature take place regularly. Other symptoms attend typhoid feverbesides these, and serve to stamp upon it its distinctive character. Thebowels are usually loose, or if not, a moderate aperient acts on themexcessively, the evacuations being loose, often watery, of a lightyellow-ochrey colour. The abdomen is full, the bowels being more or lessdistended with wind, sometimes tender, especially at the right side, andboth tender and painful in all cases where the disease is severe. Towards the end of the first, or at the latest by the middle of thesecond week, small rose-red spots or pimples appear on the abdomen, sometimes also on the chest and back. They disappear for the moment ifpressure is made on them, but reappear the moment the pressure iswithdrawn. Now and then they are numerous, and sometimes two or threesuccessive crops appear, the old ones fading as the others showthemselves; but in childhood they are often scanty, though whether fewor many, they are the external characteristic of the disease just as therash is in scarlatina or measles. 

Whenever a child of whatever age begins without obvious cause to loseappetite and health, to become feverish, with marked increase oftemperature towards evening for several days together, and more or lessdisposition to diarrh[oe]a, it is all but absolutely certain that thechild has contracted typhoid fever. 

When the disease comes on gradually, it seldom becomes dangerous, thoughuntil the end of the first week there is always considerable uncertaintyon this point. The amount of diarrh[oe]a and the degree of disorder ofthe brain, as shown by restlessness, delirium, and stupor are themeasure of the gravity of any case. There is, however, scarcely anydisease from which even when most severe recovery so often takes placein childhood, and this not as persons so often imagine from somecritical occurrence but by a process of gradual amendment. The firstsigns of amendment, too, may be taken as giving almost certain promiseof complete recovery; but it is well to bear in mind that there is nodisease of early life in which the mental faculties, though time bringsthem back at length uninjured, remain so long in a state of feeblenessand torpor as in typhoid fever. Though the first signs of improvement, too, are very seldom deceptive, yet the patient's convalescence isalmost always slow, and interrupted by many fluctuations. 

Though contagious, still typhoid fever is far less directly contagiousthan measles or scarlatina. It seems as if with this disease, just aswith cholera, the contagious element were present in its most activeform in the discharges from the bowels. These should therefore bedisinfected by carbolic acid or some other disinfectant immediately; andshould never be emptied in a closet used by other members of the family, and more particularly by children. Special precautions also should betaken with the bed-linen, and night-dresses of the patient; and it mustbe remembered that wise precautions have nothing in common withexaggerated alarm. One more hint will not be out of place. In typhoidfever, and still more in the highly contagious measles and scarlatina, the person who sleeps in the patient's room is much more likely tocontract the disease than she who sits up and watches at night keepingwide awake. Whoever takes charge of a fever patient during the nightshould therefore sit up and watch, not lie down and doze, and this notfor the patient's sake only, but for her own. 

It can scarcely be necessary to say that in every, even the mildest, attack of typhoid fever the attendance of the doctor is needed fromfirst to last. He may come every day, and may daily do nothing butmerely watch. The disease will run its course, the greatest skill cannotcut it short, though now and then instead of lasting for three or evenfour weeks it comes to an end spontaneously in fourteen days. Skilledwatching is what the competent doctor gives. You would not despise orunderestimate the pilot's skill, who steered your barque through adangerous sea in smoothest water, because he knew each hidden rock orunseen quicksand on which but for his guidance you might have madeshipwreck. 

=Small-pox. =--At the present day, thanks to vaccination, and tore-vaccination, _small-pox_ is rarely met with in the well-to-do classesof society, though it is not yet a century ago since it found itsvictims not only among the poor, but among the highest in the land. Itdoes, however, occur sometimes after vaccination, and sometimes, thoughvery rarely, an attack of small-pox fails to furnish an absoluteguarantee against the occurrence of a second. 

Small-pox, unmodified by previous vaccination, sets in in the child withviolent sickness; vomiting, sometimes recurring frequently forforty-eight hours, with much depression, or even stupor; in someinstances even actual convulsions, and fever; but neither with thesore-throat of scarlatina, nor with the sneezing, cough, and running atthe nose of measles. At the end of from forty-eight to sixty hours, aneruption of pimples appears on the face, forehead, forearms and wrists, whence it extends to the body and the lower limbs. They are reddish incolour, rather pointed in form, and at first scarcely raised above thesurface; so that the eruption looks at first like the very earlyeruption of measles; though the tiny pimples felt as if beneath the skinserve even then to distinguish the one disease from the other. Inanother forty-eight hours the character of the pimples has changed intothat of little vesicles or pocks, depressed instead of pointed at theircentre, and containing a little watery milky fluid. They next enlarge, and become once more prominent at their centre as they fill more andmore with fluid, which becomes thicker, yellowish-white--looks like, andindeed is, matter. Four or five days are occupied with this process;the matter in the pocks then begins to dry, and scabs to form, whichgradually by the end of another week drop off, and leave the skinspotted with red or even scarred if the pocks went deep enough todestroy the skin, and to leave the indelible marks, the so-calledpitting of small-pox. 

The danger of the disease is in childhood the nervous disorder at theoutset, and then the exhaustion produced by the so-called maturation ofthe pocks when the thin watery fluid changes to the thicker matter, anddepresses the patient in the same way as he would be depressed by anenormous abscess. 

The first outbreak of the eruption is followed always by a mostremarkable abatement in the disturbance of the constitution, and forthree or four days, even though the eruption is abundant, the patientmay seem so well that it is almost impossible to realise the imminentperil to which he will be exposed in a few days' time. 

=Inoculation and Vaccination. =--The danger of small-pox is in directproportion to the abundance of the eruption; and the great advantage ofinoculation for the small-pox consisted in the much scantier eruptionwhich followed it, as compared with that which commonly took place inthe natural small-pox. 

The same advantage in a greater degree is obtained by vaccination, evenin the exceptional instances in which it fails to render the personaltogether insusceptible to the disease. 

The great advantage which inoculation secured was counterbalanced ingreat measure by the fact that it always maintained small-pox rifethroughout the whole country, and that consequently all who either hadneglected inoculation, or young children on whom, on account of theirtender age, it had not yet been practised, were more than ever exposedto constant risk of infection. 

This very real danger led to the almost unanimous welcome which thepractice of vaccination received towards the end of the last century, since it was hoped that by it not only would the risk attendingsmall-pox be lessened, and the disease when it did occur be even milderin character than inoculated small-pox, but that small-pox itself wouldeventually be extirpated. 

These anticipations have not hitherto been fully realised; but the goodeffected by vaccination has been such as to render it, in the opinion ofnearly everyone qualified to form an opinion on the subject, one of thegreatest boons ever conferred on the human race. 

Small-pox, like other eruptive fevers, has the peculiarity of occurringfor the most part only once in a person's life. We do not know in theleast on what this protecting influence depends. We know the fact, butare the less able to offer an explanation, since there are otherconstitutional diseases, such as gout and rheumatism, in which the localsymptoms are equally the outcome of previous constitutional disorder, where exactly the opposite rule obtains, and in which their occurrencedoes but increase the liability to their return. 

The protective power is apparently possessed by the mild form of thedisease communicated by inoculation as much as by the severer form ofsmall-pox which is contracted by direct contagion or infection. Thisknowledge has been applied in the treatment of some of the diseases ofanimals, and it has been found in the case of the so-called small-pox insheep (a disease which, however, is quite distinct from human small-pox)that while one in two of the animals who contracted it in the ordinaryway died, death took place in only three per cent, or not one in thirty, of those in whom it was produced by inoculation; and the inoculatedsheep were thereby safeguarded from subsequent attacks as completely asthe others. 

This knowledge was more recently applied by the distinguished Frenchmanwhom I have already mentioned, M. Pasteur, in the case of a fatalpestilence among sheep in many parts of France, known by the name of_charbon_. The inoculated sheep died, however, in such large numbers, though in a somewhat smaller proportion than those who had been directlyinfected, that he found it necessary to weaken the matter which heemployed by admixture with other innocuous materials. This experiment, however, again yielded unsatisfactory results; slight symptoms of thedisease were produced, but the protection thus afforded was inadequateand uncertain. Some few resisted the disease, but others contracted itand died. With that clear insight which constitutes genius, M. Pasteurnext tried the experiment of inoculating the sheep first with a weakmatter which produced but slight symptoms, but at the same time enabledthe animal to support a second inoculation with a stronger matter; andthis second inoculation enabled them to bear, unharmed, subsequentexposure to the disease. A grateful country has given a pension, andconferred well-merited honours on the man who has preserved their flocksfrom pestilence, but whom the silly sentimentality of theanti-vivisectionists in England would have mulcted in a fine, and, ifpossible, have sent to prison. 

That weakening of the poisonous element which Pasteur strove to attainby art, is already provided by nature in the cow-pox. The cow-pox isnothing else than small-pox modified in character, diminished inseverity by passing through the system of the animal; but giving, whenintroduced into the system, a safeguard against natural small-pox atleast as complete as that furnished by the inoculated disease. 

More than 70, 000 children have come under my observation, either inhospital or in private practice; and I need not say that a physicianhaving much consulting practice sees far more than the average ofunusual and severe cases. Twice, and only twice, I have seen infants diefrom vaccination, and in both instances death took place from erysipelasbeginning at the puncture. The one case I saw twice in consultation withthe family practitioner. The other which I watched throughout was thatof a little boy, the fifth child of a nobleman of high rank, both hisparents being perfectly healthy. He was vaccinated by the family doctorin the country, direct from the arm of another perfectly healthy infant, from whom ten other infants were vaccinated immediately afterwards. Thelittle boy was seized with convulsions within twenty-four hours, andalmost at the same time erysipelas appeared on the punctured arm. Theerysipelas extended rapidly, convulsions returned more than once, and onthe fourth day from the vaccination the child died. One of the otherchildren vaccinated at the same time died in the country in the samemanner; all the others passed through vaccination regularly, and withouta single bad symptom. I have no explanation to offer; this case standsby itself just as do those of death from the sting of a bee or deathfrom cutting a corn. 

That some people die of other diseases since the introduction ofvaccination, is undoubtedly true, for many of those who would have diedin early infancy of small-pox are cut off later by measles orbronchitis, or die during teething; since it is obvious that vaccinationdoes not protect against any other disease than small-pox. 

That protection, indeed, is not absolute, nor was the protectionafforded by inoculation absolute; but small-pox after vaccination, evenwhen it does occur, is very rarely severe, and still more seldom fatal. 

There seems good reason for believing that the protecting power ofvaccination tends to diminish with the lapse of time; though apparentlythis is not always the case, nor can any direct statement be made as tothe conditions which favour this in one case, or prevent it in another. As a matter of fact, however, we do know that such a tendency doesexist, and that this tendency calls for the repetition of vaccinationfrom time to time; such re-vaccination carefully performed being asnearly as possible an absolute guarantee against small-pox. All personsengaged as nurses or attendants at the Small-Pox Hospital during thepast thirty-two years, have been vaccinated or re-vaccinated beforeentering on their duties, and during this period not a single case ofthe disease has occurred among the whole staff. The experience of othersmall-pox hospitals for a shorter period is identical. As far as weknow, every seventh year is a reasonable interval at whichre-vaccination should be performed. 

One great cause of the failure of the protective power of vaccinationis the unintelligent and careless manner in which it is too oftenperformed, especially among the poor. To this same cause it is also duethat in some cases of almost infinite rarity one special constitutionaldisease has been known to be communicated. I have never seen such acase, but I know there are such. They are, however, no more a reasonagainst vaccination than the occasional death from an overdose of opiumis a reason against the use of that drug. 

To avoid any risk of this kind, and also with the idea that the power ofthe vaccine matter may have become weakened by transmission through manythousands of persons, vaccination direct from the calf has beenintroduced of late years, especially in America and on the Continent. The time, however, that has as yet elapsed is scarcely sufficient totest the comparative preservative power of this as compared withvaccination from the human subject. Its immediate local effects aresomewhat more severe; I do not know any reason why its influence shouldnot be equally abiding. 

There is absolutely no foundation for the idea that scrofula, consumption, or any similar disease can be transmitted by vaccination. In some infants, whose skin is very delicate, and especially in those, some members of whose family have been liable to eruptions on the skin, vaccination has seemed to act as an irritant, and to give occasion to aneruption, or aggravate an eruption already existing. Such cases, however, are not frequent, and the eruption is not more troublesome thanthose which often appear in teething children. The occurrence of actualerysipelas around the puncture, while very dangerous, is, as I havealready stated, of excessive rarity. 

A thoroughly dispassionate review of the whole subject appears to me towarrant the following conclusions:--

1st. That vaccination, though not a perfect guarantee against small-pox, diminishes immensely the risk of its occurrence; and that by periodicalrevaccination, this guarantee is rendered all but absolute. 

2nd. That a very large proportion of the failures of vaccination are dueto its careless and imperfect performance. 

3rd. That to such careless performance and to the introduction of theblood and not of the vaccine matter alone, from one child to another aredue the extremely rare instances in which one special disease has beentransmitted by vaccination. 

4th. That there is absolutely no evidence of the transmission ofscrofula, consumption, or any similar disease by vaccination. 

5th. That vaccination direct from the calf appears to present somedecided advantages; but it has not yet been practised for a sufficienttime to admit of a comparison between its preservative power and that ofvaccination from one child to another. 

6th. That in either case it is expedient that vaccination be performedwithin the first three months after birth, so as to avoid the irritationof teething which is unfavourable to successful vaccination, and alsobecause the disposition to those skin diseases which vaccination tendsto aggravate is never so considerable before the age of three months asit becomes subsequently. 

Even when vaccination fails to protect against small-pox it tends toproduce a modified and so much milder form of the disease, that whileone patient died out of every two in the Homerton Small Pox Hospital whohad the disease naturally, the deaths were only one in four of those whohad been imperfectly vaccinated, and one in forty-three of those whosearms bore evidence of perfectly good and successful vaccination. 

The influence of previous vaccination often scarcely shows itself in thestage which precedes the appearance of the eruption of small-pox, thefever being often just as intense, and the general symptoms just assevere as in the unmodified disease. The difference, however, becomes atonce obvious with the appearance of the rash. The pocks are always muchfewer than even in mild small-pox, sometimes even not more than twenty. They never attain above half the size of the ordinary small-poxpustules; they run their course and dry off in half the time, andconsequently the dangerous fever which accompanies their development inthe natural disease is almost or altogether absent in the vast majorityof instances. 

If vaccination did no more than this it would be hard to overestimateits value, or to praise as it deserves the merit of its discoverer. 

=Chicken-Pox= is an ailment of such slight importance that it wouldscarcely call for notice if it were not that the resemblance of theeruption to that of small-pox sometimes leads to its being mistaken forthat disease. 

It is highly contagious, and for this reason perhaps it is usually metwith in infancy and early childhood. Sometimes, though by no meansconstantly, the eruption is preceded for twenty-four or thirty-six hoursby slight feverishness; but oftener the appearance of the rash is thefirst indication of anything being the matter. It shows itself in theform of small pimples, which in a few hours change into small circularpocks containing a little slightly turbid fluid. They appear on theforehead, face, and body, but very rarely on the limbs; they enlarge forsome two or at most three days, then shrivel and dry up; and at the endof a week the crusts or scabs fall off, scarcely ever causing anypermanent pitting of the skin. They are usually not above twenty orthirty in number, though every now and then they are much more numerouswithout any obvious reason. Their distinction from the small-poxeruption consists not only in the smaller size of the pocks, and in theentirely different course which they run, but also in the fact that twoor three successive crops of the eruption appear in the course of fiveor six days, so that new ones, those at maturity, and those on which thecrusts have already formed, or from which they have already fallen, maybe seen on the child at the same time. This is sufficient of itself toestablish the difference between the two diseases, and also todistinguish between chicken-pox and the milder variety of small-poxwhich is sometimes observed in children who have been alreadyvaccinated. 

=Measles= is a disease with which almost everyone is familiar, and onewhich with proper care is not generally attended with danger. Its greatrisks are twofold; first, that of its being complicated with bronchitis, or inflammation of the lungs during its progress, and next of its beingfollowed by an imperfect recovery, and by the awakening into activityany tendency to scrofulous or consumptive disease. On these two accountsthe disease is not to be made light of, and special watchfulness is tobe exercised during the whole time of convalescence. It is also unwisewhen one child in a family is attacked by measles to expose the others, as is often done, to its contagion, in order, as people say, 'to get itover;' for its mildness in one case furnishes no guarantee of itsmildness in another, and the danger of the disease is almost in exactproportion to the tender age of those who are attacked by it. 

The early symptoms of measles are those of a bad feverish cold; the eyesgrow red, weak, and watery, and are unable to bear the light, the childsneezes very frequently, sometimes almost every five minutes, and istroubled by a constant short dry cough. About the fourth day, a rashmakes its appearance on the face, forehead, and behind the ears, and inthe course of the next forty-eight hours travels downwards over the bodyand limbs, and then in another forty-eight hours it fades in the sameway, being at its height on the body when it has already begun todisappear from the face. It first shows itself in the form of small redcircular spots, not unlike fleabites, but very slightly raised above thesomewhat reddened skin, and looking for a few hours not unlike the veryearly stages of small-pox, before the eruption has lost the character ofminute pimples. On the face the spots sometimes run together, and thenform irregular blotches about a third of an inch long by half thatbreadth; while elsewhere they present an irregular crescenticarrangement. As the rash fades it puts on a dirty yellowish redappearance; the surface of the skin often becomes slightly scurfy, andit continues somewhat stained of a reddish hue for some days after theeruption has disappeared. 

The only other point on which it is necessary to dwell is this, that thesymptoms do not, as in small-pox, become less severe immediately on theappearance of the eruption, but continue just as troublesome as beforefor twenty-four hours or more, the voice being hoarse, the cough evenmore incessant, and the throat often slightly sore and red. Soon, however, improvement becomes apparent, the fever lessens, the coughgrows looser; and in less than a fortnight the patient is usuallyconvalescent. 

The above is pretty nearly the ordinary course of measles, for we do notmeet with that extreme variation in its severity which is observed inscarlatina, where one child will seem scarcely to ail at all, while itsbrother or sister may be in a state of extreme peril. It is not wise, however, to trust a case even of apparently mild measles to domesticmanagement, for while the cough is troublesome in almost every case, theear of the experienced doctor is needed to ascertain whether it ismerely the cough of irritation which attends the measles, or the gravercough due to bronchitis. 

One other caution will not be out of place. The danger of exposure tocold is very real, but that does not necessitate the loading the childwith excessive covering, or the abstaining from washing its hands andface. The child should be kept moderately cool; and sponging its handsand face frequently with tepid water soothes it and relieves the painfulirritation and itching. 

=German Measles. =--There is a disorder which seems to hold a middleplace between measles and scarlatina, akin to both, identical withneither, and furnishing no sort of protection from their occurrence. 

It is known in this country by the name of _German measles_, orsometimes by its German name of _Rötheln_; the first clear descriptionof its character having been given by German writers. 

It is unfortunate that a very slight resemblance of some of its symptomsto those of scarlet fever has led to its being sometimes mistaken forit, and as the ailment is almost always very trivial, doctors anxious toavoid alarming their patients' friends, too often allow the error to gounrectified, and the disease to pass as one of mild scarlet fever. 

The resemblance of German measles to scarlet fever is, however, extremely slight, and is almost entirely limited to the existence of aslight sore-throat, unaccompanied with glandular swelling. The rash inno respect resembles the uniform redness of the scarlatinal eruption, and there is no peeling of the skin, nor even any roughness of thesurface left behind. 

Slight feverishness sometimes precedes the appearance of the rash fortwenty-four hours; but the cough, and sneezing, and running at the eyesand nose, which usher in measles are entirely absent. The rash usuallyappears in the course of twenty-four hours, is never postponed beyondthe second day; it begins, like that of measles, on the face, and, likeit, travels downwards, but always disappears on the third day, whilethat of measles is not entirely gone before the eighth or ninth. Therash itself also has a different character. It consists of small, slightly elevated, round red spots which now and then coalesce intosmall patches, but never have the somewhat crescentic arrangementobserved in the rash of measles. The colour of the spots is somewhatdarker than that of the eruption of measles, while the _skin betweenthem remains pale_, and does not assume the flush of measles. As itdisappears it simply fades, and does not at all change its tint as thatof measles does, and it leaves the skin unroughened. 

Now and then German measles are severe, and are attended with a gooddeal of fever for a day or two, and even with symptoms of bronchitis. These cases are, however, very unusual, are seen only at times when thedisease prevails epidemically; and even then the symptoms of theaffection are sufficiently marked to preserve from error all but thosewho wish to be deceived, and to flatter themselves that their child ishenceforth protected from scarlatina. 

=Scarlatina=, or =Scarlet Fever=, for the two names mean the same thing, the former being only the Latin term, and not implying any greatermildness of the disease, is one of the most formidable ailments ofchildhood, and especially of early childhood, since the highestmortality from it takes place during the third year of life. 

It is more dreaded in a household, and justly so, than any otherdisease of childhood, though, indeed, it is not limited in itsoccurrence to early life, and instances are familiar to us all in whichthe mother, devoting herself to the care of her little ones, has herselffallen a victim to the poison. 

I do not think it so directly contagious, from person to person, assmall-pox, chicken-pox, or measles, but its infection appears to bespecially abiding in its character, and to cling longer to the clothes, the bedding, and even the room of a scarlet fever patient, than that ofthe other eruptive fevers, except perhaps small-pox. 

It is an object of special dread also for two other reasons. One ofthese reasons is the extreme and causeless variations in its severity;so that I have known more than one or two children in the same family tohave it so slightly as scarcely to be ill, two to have their livesplaced in jeopardy, and two to die. The other reason for special dreadis that the mildness of the disease at its outset affords but a slightguarantee against the occurrence of serious complications in its course, and still slighter against secondary diseases which may follow in itstrain, and either destroy life directly, or leave behind someirremediable mischief. 

Scarlatina has been divided by medical men into three classes, accordingto its different degrees of severity; the mild--that accompanied withbad sore-throat--and the malignant variety. 

We have specially to do with the first of the three; for it is in itonly that there is danger of the disease being overlooked, or mistaken. 

The symptoms of scarlatina usually appear within three days afterexposure to its contagion, and there is very good authority forbelieving that the interval never exceeds six days. I should not, however, feel quite secure until after the lapse of ten days, and duringthis time the child ought to be isolated from his brothers and sisters. In the mildest form of the disease the appearance of the rash upon thesurface, usually with, but sometimes even without slight sore-throat andfeverishness, may be the first indication of an affection which issometimes so deadly. In the majority of cases, however, it is usheredin by vomiting once or oftener, accompanied by headache, heaviness, ofhead, great heat of skin, and some measure of sore-throat. The brain iseasily disturbed in children, as has already been said, and delirium atnight during the first twenty-four hours of an attack of scarlet feverneed not excite anxiety, for it then often passes away, and the diseaseruns a perfectly favourable course. The continuance of delirium later isan attendant only on the graver forms of scarlet fever. 

The rash often makes its appearance within twenty-four hours after thecommencement of the illness, at latest in the course of the second day. It usually shows itself first on the neck, breast, and face, whence itextends in twenty-four hours to the body and limbs, and is then notseldom specially vivid on the inside of the thighs. Its colour is a verybright red, due in part to a general flush of the skin, in part to thepresence of innumerable red dots or spots, which do not communicate anysense of roughness to the hand, though now and then extremely minute redpimples are interspersed. For three days the rash usually continues tobecome of a deeper colour, and more generally diffused over the wholesurface; it then slowly declines, but does not wholly disappear untilthe seventh or eighth day of the disease. As the rash subsides the skinis left rough, and by degrees scales off, often in large flakes from thehands and feet, but elsewhere in a sort of branny scales. Sometimes thisprocess is over in five or six days, while in other cases the skin peelsand is reproduced several times in succession, so that it is protractedfor three or four weeks or even longer. The degree of this peeling alsovaries as well as its duration. It is usually most considerable wherethe rash has been most abundant, while where the rash has been scanty, it is sometimes scarcely apparent except at the tips of the fingers andtoes and just around the insertion of the nails. 

Besides the rash there are commonly other symptoms not lesscharacteristic of scarlatina, and among them the sore-throat is one ofthe most invariable. Even in mild cases, it is very rarely absent, andif 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 latterare usually more or less swollen, while swallowing is attended withpain, or at any rate with discomfort. The redness of the palate, whichextends also to the back of the throat, is a finely spotted rednessclosely resembling the rash on the surface. The tongue is coated with athick white or yellowish coating, through which project numerous brightred points, papillæ as they are called, and this appearance of thetongue is as distinctive of scarlatina as the rash itself. Later, as therash begins to fade, the coating separates from the tongue, which isleft of a bright red colour, looking raw and shining, with the littleraised red points projecting beyond its surface, and constituting whathas been called in medical language, the strawberry tongue. 

When all these symptoms are present, no one can doubt but that the caseis one of scarlatina. But the decision is far less easy in mild cases, for in them the rash is sometimes extremely evanescent, the generaldisturbance of health very slight, and the fever and accompanying riseof temperature small. The risk in such circumstances of the diseasebeing altogether overlooked is even greater than that of its beingconfounded with some other eruptive fever. The rash of measles cannot beconfounded with that of scarlatina, and the distinctly spotty characterof 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 redrash, not obviously formed by distinct spots, even though it be notuniform but appears in patches on the neck, breast, back, or inside ofthe thighs, and persists for more than twelve hours, is scarlatinal. Further, that in any instance in which even very slight feverishness, orvery slight sore-throat, have preceded or accompanied the rash, thenature of the ailment is stamped beyond the possibility of doubt. Mistakes are made from want of careful observation, much more than fromany insuperable difficulty in distinguishing one disease from the other. When the least hesitation is felt as to the nature of any rash whichmay appear on a child, with, or without previous illness, the questionshould be at once referred to a medical man. People are too apt in thesecircumstances to wait for a few days, and then to appeal to the doctorwhen all traces of rash have disappeared, and when the grounds no longerexist on which he could base a positive opinion. 

I need not describe the symptoms of severe and dangerous scarlatina, forlong before symptoms become really formidable, the patients will havebeen placed under medical care. It may suffice to say that the danger isalmost always in proportion to the severity of the throat-affection andswelling of the glands, and not at all in proportion to the abundance ofthe rash. Though severe cases usually set in with severe symptoms, yetthis is not invariably the case, and medical watching is all the morenecessary from the very commencement, since until the end of the firstweek it is impossible to calculate on the subsequent course of thedisease. In malignant scarlatina happily of infrequent occurrence, thechild is struck down, as though its blood were poisoned, from the veryfirst; and death takes place often within forty-eight hours, the rashappearing just sufficiently to stamp the nature of the pestilence whichhas proved so deadly. 

It may form a useful conclusion to all that has been said in this littlebook about the diseases of children, if I endeavour to point out in whatconsist the duties of parents in cases of scarlatina, or of any diseasewhich resembles it. 

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

2. To remove the child immediately from the others, so long as there isany doubt concerning the nature of the case, and to remove with him hisbed, bedding, and all clothes worn by him at the time when the illnessbegan, or the rash appeared. 

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

4. Inasmuch as scarlatina often proves fatal to grown persons who havenot already had the disease, to obtain at once the attendance of askilled nurse, in order to avoid the risk of the disease spreadingthrough the household. 

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

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

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

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

6. To arrange for all food and necessaries to be placed in an adjoiningroom, or at the head of the stairs, so that there may be no directcommunication between the attendants on the sick and the other inmatesof 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 theirgarments as well as scrupulously washing themselves before mixing withother inmates of the house, and especially with the children. 

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

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

10. When the disease is over, to destroy, if the parents' means at allpermit it, the clothes and bedding of the child. When this is notpracticable, to have everything exposed to the heat of superheated steamin a Washington Lyons or other similar disinfector, and to have alllinen boiled as well as washed. Lastly, to have the ceiling whitewashed, the paint cleaned, the paper stripped, and the room repapered, as wellas the floor washed and rewashed with strong carbolic soap. 

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

APPENDIX

_ON THE MENTAL AND MORAL FACULTIES IN CHILDHOOD, AND ON THE DISORDERS TOWHICH THEY ARE LIABLE. _

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

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

The common mistake committed by those parents who do not make theirchild an idol to fall down and worship, and thus turn him, to his ownmisery and theirs, into the most arbitrary of domestic tyrants, is totreat him as though he were in mind, as well as in body, a miniatureman; feebler in intellect as he is inferior in strength, but differingin 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 dailynovelties. 

3. He has less self-consciousness, less self-dependence, lives as apart 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 thepast, till the world has been some time with him, and he by degreesshares the common heritage of retrospect and anticipation. This is thegreat secret of the quiet happiness which strikes almost all visitors toa children's hospital. 

No one can have watched the sick bed of the child without remarking thealmost unvarying patience with which its illness is borne, and theextremity of peril from which apparently, in consequence of thatpatience, a complete recovery takes place. Much, indeed, is no doubt dueto the activity of the reparative powers in early life, but much also tothe unruffled quiet of the mind. No sorrow for the past, no gloomyforeboding of the future, no remorse, disappointment, nor anxietydepresses the spirits and enfeebles the vital powers. The prospect ofdeath, even when its approach is realised--and this is not so rare assome may imagine--brings in general but small alarm. This may be fromthe vagueness of the child's ideas; it may be, as the poet says, that inhis 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 cando

 '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 weshould bear in mind to how very large an extent the child lives only inthe present; because it follows from it that to keep the sick childhappy; to remove from it all avoidable causes of alarm, of suffering, ofdiscomfort; to avoid, as far as may be, any direct struggle with itswaywardness; and even if death seems likely to occur, to look at it froma child's point of view--not from that which our larger understanding ofgood and evil suggests to our minds--are duties of the gravest kindwhich 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 ispossible for the adult, but there are, besides, other important mentaldifferences between the two. Not only is the mind of the child feeblerin all respects than that of the adult, but, in proportion to thefeebleness of his reasoning power, there is an exaggerated activity ofhis perceptive faculties, a vividness of his imagination. The childlives 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 seeis as much a result of the vividness with which he realises the thingsaround him, as of that absence of care to which it is often attributed. This peculiarity shows itself in the dreams of childhood, which exceedin the distinctness of their images those which come in later life. Itshows itself, too, in the frequency with which, even when awake, theactive organs perceive unreal sounds, or in the dark, at night, conjureup ocular spectra; and then not merely colours, but distinct shapes, which pass in long procession before the eyes. This power fades awaywith advancing life; except under some conditions of disease, theoccasional appearance of luminous objects in the dark is the only relicwith most of us of the gift of seeing visions with which, at least insome degree, we were endowed in our early years. The child who dreads tobe alone, and asserts that he hears sounds, or perceives objects, is notexpressing merely a vague apprehension of some unknown danger, but oftenasserts a literal truth. The sounds have been heard; in the stillness ofits nursery the little one has listened to what seemed a voice callingit; or, in the dark, phantasms have risen before its eyes, and the agonyof terror with which it calls for a light, or begs for its mother'spresence, betrays an impression far too real to be explained away, or tobe met by hard words or by unkind treatment. 

Impressions such as these are not uncommon in childhood, even duringhealth. Disorder, direct or indirect, of the functions of the brain, more commonly the latter, greatly exaggerates them, and I have knownthem to outlast for many weeks all other signs of failing health afterconvalescence from fevers. The unreal sights are far more common thanthe sounds. The sounds are usually of the simplest kind--as the tinklingof a bell, of which we all remember the exquisite use made by HansAndersen in one of his nursery tales; or the child's own name, atintervals repeated, just as the little watchful boy heard it in far offJudæa, when it was the prelude to a wondrous communication from theunseen world. It came to him as he woke from sleep, before the morningdawned, while the lamp, lighted overnight, was burning still; and stillit is so far the same that these occurrences which suggest to usproblems that we cannot attempt to solve, mostly take place at times oftransition from the sleeping to the waking state. 

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

Some imaginative children amuse themselves with these phantasms, andthen, if encouraged to relate them, will constantly transgress theboundary line between truth and falsehood, and weave their littleromance. When they happen on waking they are usually preceded byfrightful dreams, but the image which the child sees then is not themere recollection of the dream, but a new, distinct, though painfulimpression; generally of some animal to which the child points, as nowhere, now there. These night terrors from the very circumstantialcharacter of the impressions which attend them, often, as I have alreadysaid, occasion needless anxiety as to the importance of the cause onwhich they depend. 

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

But not only are the perceptions more acute in childhood than in adultlife, the sensibilities are more intense. The child's emotions, indeed, are often transitory--generally very transitory; but while they lastthey produce results far greater than in the grown person. In the caseof the latter, recollection of the past, anticipation of the future, oreven the duties of the present, control the overwhelming sorrow, or callforth the energies needed to bear it. The child lives in the present, and this present is but the reflection of the world around, itsimpressions uncontrolled by experience, ungoverned by reason. 

The broken-heartedness of a child on leaving home is not the expressiononly of intense affection for its friends or relations, it is the shockof separation from the familiar objects which have surrounded it; and Ihave not infrequently seen children inconsolable when removed from homesthat were most wretched, or from relations who were most unkind. Everynow and then, indeed, I have been compelled to send children home fromthe hospital because no love nor care could reconcile them to the changefrom home; and they have refused to eat, and spent their nights inweeping. The feeling is an unreasoning one, like the home-sickness ofthe mountaineer. 

But, moreover, sudden shocks may sometimes overthrow the whole moralequilibrium, and disarrange the balance of the nervous system soseriously as to cause the death of a child previously free from anyimportant ailment. Thus, I remember a little boy five years of age whodied sixteen days after his father's funeral. The strange sad sceneovercame him, though there had been no special tie between him and hisfather. He shivered violently, became very sick, complained by signs ofpain in the head, for he had lost his speech, which he regained by slowdegrees in the course of four or five days. Improvement in otherrespects did not take place, he lay in a drowsy state save when hecalled for his mother, and at length the drowsiness deepened intostupor, and so he died. I suppose his mother was right; she said hisheart was broken. 

It behoves us to bear in mind that the heart may break, or the reasonfail, under causes that seem to us quite insufficient; that the griefsof childhood may be, in proportion to the child's powers of bearingthem, as overwhelming as those which break the strong man down. Everynow and then we are shocked by the tale that some young child hascommitted suicide, and for reasons which to our judgment seem mosttrivial--from fear of punishment, or even from mere dread of reproof. These facts deserve special attention, they show how much more thesusceptibility and sensitiveness of children need to be taken intoconsideration 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. Thechild loves intensely, or dislikes strongly; craves most earnestly forsympathy, clings most tenaciously to the stronger, better, higher aroundit, or to what it fancies so; or shrinks, in often causeless butunconquerable dread, from things or persons that have made on it anunpleasant impression. Reason as yet does not govern its caprices, northe more intelligent selfishness of later years hinder theirmanifestation. The waywardness of the most wilful child is determined bysome cause near at hand; and those who love children, and can read theirthoughts, will not in general be long in discovering their motives andseeing through their conduct. 

One word more must be said with reference to that intense craving forsympathy so characteristic of the child. It is this which oftenunderlies the disposition to exaggerate its ailments, or even to feignsuch as do not exist, and in such attempts at deception it oftenperseveres with almost incredible resolution. Over and over again I havemet with instances where the motives to such deception were neither theincrease of comfort nor the gratification of mere indolence; but themonopolising the love and sympathy which during some bygone illness hadbeen extended to it, and which it could not bear to share again with itsbrothers and sisters. This feeling, too, sometimes becomes quiteuncontrollable, and the child then needs as much care and as judiciousmanagement, both bodily and mental, to bring it back to health, aswould be called for in the case of some adult hypochondriac ormonomaniac. 

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

It will be observed that throughout I have dwelt more on disorders ofthe moral faculties than of the intellectual powers in childhood, and Ihave done so because I believe them to be the more common and the moreimportant. In the feeble-minded the moral sense almost invariablyparticipates in the weakness of the intellect; but it is by no meansunusual for the former to be grievously perverted, while theintelligence is in no respect deficient. The moral element in the childseems to me to assert its superiority in this, that it is the mostkeenly 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 forsympathy lie at the root of many of those perversions of characterwhich excite a parent's anxiety. One of these consists in anover-scrupulousness with reference to the right or wrong of actions inthemselves quite indifferent; in doubts as to whether the morning orevening prayer has been properly said, whether something was or was notabsolutely true, whether this or that peccadillo was a grievous offenceagainst God, and so on; and all these little cases of conscience arebrought by the child several times a day to his mother or to his nursefor solution. If listened to readily the child's truthfulness becomesinevitably destroyed, and he grows up with a morbid frame of mind, whichafter-life will aggravate almost infinitely. 

One knows indeed the history of child saints; but it must be rememberedthat one great characteristic of pre-eminent sanctity at all ages oflife is reticence, while these little people are perpetually seeking tointerest others in themselves, their doubts, and feelings. If wiselydealt with, not by direct ridicule, but by a wholesome neglect of thechild's revelations, treating them as of no special interest orimportance, and discouraging that minute introspection which, ofdoubtful good at any age, is absolutely destructive of the simplicity ofchildhood, this unnatural condition will soon pass away. It will helpthis object very much, if the child is sent on a visit to judiciousfriends, and change of scene, of pursuits, of playmates, and amusementswill be of all the more service since these morbid states of mind seldomcome on in children whose bodily health is robust. 

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

It is difficult to assign any sufficient reason for this conduct. Mereindolence seems sometimes to be the chief reason for it, oftener vanity;the sense of importance in finding everything in the household arrangedwith exclusive reference to itself appears to be the motive for it; andthis may sometimes be observed to be very powerful even at anexceedingly early age. In many instances a morbid craving for sympathyis mingled with the love of importance, and both these sentiments arenot infrequently exaggerated by the conduct of a foolishly fond mother. Real illness, however, in almost all these cases exists at thecommencement, though the child persists in complaining of its oldsymptoms long after their cause has disappeared. 

The great difficulty which the doctor meets with in the management ofthese cases arises from the incredulity with which his opinion isreceived. Candour is looked upon as so eminently characteristic ofchildhood, that deceit seems impossible; the case is thought by theparents to be an obscure one which the doctor does not understand; andtherefore it is said, he, with want of straightforwardness and ofkindness, throws doubts on the existence of disease, and on thetruthfulness of a most loving, most suffering child. The vagaries of ahysterical girl, the fits, the palsy, the half-unconsciousness have allbeen assumed within my own observation by children from ten to fifteenyears old, and I have more than once had to give place to the ignorantand impudent pretender who traded successfully on the feelings of theparents. Sometimes, one knows not why, except that the child has gottired of the part he was playing, the symptoms that had caused so muchanxiety suddenly disappear, but even then the habit of mind left behindis anything but healthy. Indeed in all cases of this kind it is muchless the state of the body than that of the mind which excites myapprehension. The constant watching its own sensations, the habit ofconstantly gratifying every wayward wish and temper under the plea ofillness, and the constant indulgence which it too often meets with inthis from the over-kindness of its parents, exert a most injuriousinfluence on its character, and it grows up a juvenile hypochondriac. 

A doctor is very unlikely to throw doubt recklessly on the reality of achild's illness. His hesitation should certainly not be attributed tounworthy motives; the parents should co-operate with him heartily in anycourse of observation which he desires to follow, and if necessaryanother medical man of experience should be associated with the first, and allowed to visit the child two or three times. One does notassociate the idea of moral delinquency with hysteria; the child whoshams belongs to the same class with the hysterical patient. It is onlythe strangeness of the occurrence in the eyes of non-medical people, that makes them fancy it something worse. 

If now the suspicion is justified that the child is either greatlyexaggerating or altogether feigning illness, it does not by any meansalways follow that he should at once be charged with it, since it isoften of much importance that his self-respect should not be destroyed. It must be remembered that there is in all these cases a measure of realailment underlying all the half-unconscious exaggeration, and that ifspoiling and over-indulgence do much to foster it, sternness andpunishment interfere with recovery. To turn the thoughts away from self, to occupy the mind with new scenes, new amusements, new pursuits, tocall forth by degrees self-control, and to let the child perceive ratherby your manner than by what is actually said that the parents have notbeen duped by all his past vagaries; such are the simple means by whichthe little one will be brought round again to health of mind and healthof body. Unhappily, in the minds of too many people the idea of thedoctor is associated with the administration of drugs and with nothingelse; the treatment of disease is of much wider scope; and many of ourbest remedies are those which do not admit of being weighed or measured, and whose names are not inscribed on the drawers or bottles inApothecaries' Hall. 

Another phase of mental disorder in childhood sometimes presents itselfas the result of overtasking the intellectual powers. This over-work toois by no means due in all cases to the parents' unwisely urging thechild forward, but it is often quite voluntary on his part. Theprecaution too of limiting the hours of work is often inadequate fromthe want of some provision for turning the thoughts and energies duringplay hours into some perfectly different channel. 

In many of these cases Nature happily takes matters into her ownmanagement. For a year or two, or more, the mind has grown apparently atthe expense of the body; the parents take a fearful joy in theirdarling's acquirements; and if it should live, think they, of whatremarkable talents will it not be the possessor! By degrees, the extremequickness of intellect becomes less remarkable; but the body begins toincrease in robustness; and a year will sometimes suffice to transmutethe little fairy, so quick, so clever, but so fragile, into a verycommonplace, merry, rosy, romping child. I may add that it is well tobear in mind the converse of this; to remember that body and mindrarely grow in equal proportion at one time; that the incorrigiblelittle dunce, though not likely to prove a genius as he grows older, will yet very probably be found at twelve or fourteen to know as much ashis playmates. A dull mind, and a sickly or ill-developed frame may makeus anxious: but if the physical development is good, the mind will notbe likely to remain long below the average standard. 

But sometimes, the over-tasked mind leads to mischief which Naturecannot rectify; an attack of water on the brain destroys the child, orif not it sinks under almost any accidental disease. In other instancesneither of these results takes place, but the whole nervous system seemsprofoundly shaken, and the moral character of the child seriously, andeven permanently injured. I remember a quick and clever little girl agedfive and a half years who was urged on by her governess to work whichshe delighted in, till at length the signs of over-taxed brain showedthemselves in frequent extreme irritability, and occasional attacks ofcauseless fury amounting almost to madness. It was fully a year duringwhich almost all mental work was suspended, while the child was sent tohave complete change under most judicious management in the country, before her mind quite recovered its balance and she became able toresume her studies in a very moderate degree. 

Cases such as this are instances of the slightest degree of a conditionwhich if not remedied may pass into confirmed insanity. I believe thegradations to be almost imperceptible by which the one state passes intothe other; and I have known instances in which the ungovernable temperand occasional fury of the child have passed in youth into abidinginsanity which rendered the patient the inmate, and I fear the permanentinmate, of a lunatic asylum. 

In whatever circumstances insanity comes on in childhood, and it doessometimes, though very seldom, come on independently of any obviousexciting cause, it always assumes the character of what has been termedmoral insanity, or of that condition in which the moral system ratherthan the mental power is chiefly disordered. 

Idiocy is unquestionably of much more frequent occurrence in childhood, than any of those forms of mental or moral disorder of which I have beenspeaking hitherto. The term idiocy, however, is a very wide one, including conditions differing remarkably from each other both in kindand degree, while not seldom it is misapplied to cases in which there ismere backwardness of intellectual power. 

=Backward Children. =--_Enfants arriérés_--as the French callthem--constitute a class by no means seldom met with. They generallyattain their bodily development slowly, and the development of theirmind is equally tardy. They cut their teeth late, walk late, talk late, are slow in learning to wash and dress themselves, are generally dull intheir perceptions, and do not lay aside the habits of infancy till faradvanced in childhood. When the time comes for positive instruction, their slowness almost wears out everyone's patience; and among the poorindeed the attempt at teaching such children is at length given up indespair, and growing up in absolute ignorance, it is no wonder that theyshould be regarded as idiots. Still, dull as such children are, there isbetween them and the idiot an essential difference. The backward child, unlike the idiot, does not remain stationary; his development goes on, but more slowly than that of other children, he is behind them in thewhole course of their progress, and his delay increasing every day, places at length an enormous distance between him and them--a distancewhich in fact becomes insurmountable. 

In some of its minor degrees even, this backwardness not infrequentlyexcites the solicitude of parents. It is sometimes observed in childrenwho had been ill-nourished in infancy or who had been weakened by someserious or protracted illness, even though unattended by any specialaffection of the brain; but it is also met with independent of anyspecial cause. The distinction, however, between such a case and one ofidiocy is this, that though at four years old the child may not seem tobe intellectually superior to most children at two, yet in manners, habits, and intelligence it does agree with what might be expected fromthe child at two; less bright perhaps, less joyous, but stillpresenting nothing which if it were but younger would awakenapprehension. 

It is well in all cases of unusual backwardness to ascertain thecondition of the sense of hearing, and of the power of speech, for Ihave known the existence of deafness long overlooked, and the child'sdulness and inability to speak referred to intellectual deficiency; andhave also observed mere difficulty of articulation, dependent partly onmalformation of the mouth, lead to a similar misapprehension. In bothinstances I have seen this inability to keep up ready intercourse withother children cast a shadow over the mind, and the little ones inconsequence be dull, suspicious, unchild-like. I have already referredto a similar result as sometimes following serious illnesses. The childwill for months cease to walk, or forget to talk, if these had been butcomparatively recent acquirements; or will continue dull and unequal toany mental effort for weeks or months together, and then the mind willbegin to develop itself once more, though slowly, possibly so slowly asnever altogether to make up for lost ground. 

=Idiocy. =--In _idiocy_, however, there is much more than the mere arrestof the intellect at any period. The idiot of eight years old does notcorrespond in his mental development to the child at six, or four, ortwo; his mind is not only dwarfed but deformed; while feebleness of willis often as remarkable as mere deficiency of power of apprehension. Evenin earliest infancy there is usually a something in the child idioticfrom birth which marks him as different from babies of his own age. Heis unable to support his head, which rolls about from side to side, almost without an effort on his part to prevent it. Next it is perceivedthat the child, though he can see, does not notice; that his eye doesnot meet his mother's with the fond look of recognition, accompaniedwith the dimpling smile, with which the infant, even of three monthsold, greets his mother. Then it is found to have no notion of graspinganything, though that is usually almost the first accomplishment ofbabyhood; if tossed in its nurse's arms there seems to be no spring inits limbs; and though a strange vacant smile sometimes passes over itsface, yet the merry ringing laugh of infancy or joyous chuckle ofirrepressible glee is not heard. As time passes on, the child shows nopleasure at being put down 'to feel its feet, ' as nurses term it; iflaid on the floor it probably cries, but does not attempt to turn round, nor try to crawl about as other babies do. It does not learn to stand orwalk till late, and then stands awkwardly, walks with difficulty, crossing its legs immediately on assuming the erect posture, aninfirmity which it often takes years to overcome. Just, too, as theidiot is slow to notice, slow in learning to grasp anything, or to standor walk, so he is late in learning to talk, he often acquires but fewwords, for his ideas are few. He learns even these few with difficulty, and employs the same to express many different things; he generallyarticulates them indistinctly, often indeed so imperfectly as to bealmost unintelligible. 

In other instances the evidences of idiocy are not present at birth, orat any rate are not then noticed, but succeed to some attack ofconvulsions or to some illness attended with serious affection of thebrain. Sometimes too there is no point in the child's history which canbe laid hold on as marking the commencement of the weakening of hisintellect, but as the body grows the mind remains stationary, or itspowers retrocede, until by degrees the painful conviction that the childhas become idiotic forces itself upon the unwilling parents. Here wehave sometimes the sad spectacle of the body perfectly developed, haleand strong, but the mind obscured; the child in constant unrest, perpetually chattering, laughing without cause, destroying its clothes, or the furniture of its room, for no purpose; or sitting silent, with aweird smile upon its face, looking at its spread-out fingers, orstroking a piece of cloth for a quarter of an hour together as thoughthe sensation yielded it a kind of pleasure. It would be almost endlessto describe the various degrees of mental weakness; from the slightsilliness down to the condition in which the child is, and remains alllife long, below the level of the brute. 

Parents as a rule are anxious to persuade themselves, and to persuadethe doctor that their idiot child was once as bright and intelligent asothers; and that the mind was darkened by some grave illness. We have, however, the highest authority, that of Dr. Down, for saying that as arule which has but few exceptions idiocy from birth is more amenable totraining than that which comes on afterwards, that in fact it is morehopeful to have to do with an ill-developed than with a damaged brain. 

The one great question which still remains is what can the parents dofor best and wisest whom the affliction has befallen of having an idiotchild. 

First. To moderate their expectations as to the results of any, even thebest devised and most successful treatment. The child who has been bornof weak intellect, or who has become so as the result of illness, willalways remain at a lower level than others, and this, even though someone faculty, as the musical faculty, or the power of calculation, shouldbe above the average. 

Secondly. From the child's earliest infancy to occupy themselves inperfecting as far as possible the physical powers and aptitudes, and thehabits of cleanliness and order. Development of mind waits ondevelopment of body: to stand, to sit, to walk, to grasp an object putinto the hand, are essential to bringing the idiot child into relationwith the world around it; are its elementary education, to be givenpatiently, cheerfully, lovingly, even for years together. To attend toits natural wants, and by fixed routine to accustom it at stated hoursto empty its bowels and its bladder is a lesson hard to teach; and notless difficult is it to make the child learn to masticate its food, todrink without slobbering, and then to use the spoon and fork, and tofeed itself; and afterwards to dress itself, to wash itself, to tie itsshoestrings; for idiots almost without exception are awkward as well aslazy. 

The common class of nurses, even the very kindest, find it so mucheasier to feed the child, to wash it, and to dress it, than to teach itto do any of these things for itself, that it too often grows up, tilltoo old to remain in the nursery, without having made the slightestadvance above the condition of completest babyhood. It is absolutelyessential either that the mother should devote herself solely to thecare and teaching of the idiot, or that she should engage a nurse whowill have no other duty. Such a person must be above the average ineducation and intelligence, and of course will command more than theordinary wages. The mother, too, must resign herself to the little one'saffection being transferred in a great degree from herself to the personwho has constant charge of it--a hard trial this, but one to which, forher child's good, she must bring herself to submit. 

Thirdly. So soon as the child has been taught at home to exercise theselower powers, and the question of what is termed its education arises, it is a matter of absolute necessity that he be sent to an institutionspecially set apart for the feeble-minded. It is absolutely impossiblewith the most devoted love and the most lavish expenditure of money, todo at home what can be, and is constantly, accomplished even in a pauperidiot asylum. The imitative faculty, which is usually very stronglymarked in the idiot, furnishes one great means of his improvement; whilebesides there are many of the moral powers which cannot be brought outexcept in the society of other children of his own age and not differingtoo widely from him in mental power. 

I have warned, and I repeat the warning, against exaggeratedexpectations as to the results of even the wisest treatment. To teachcleanliness, order, and neatness; to impart knowledge enough to enablethe idiot to take care of himself; to develop his affections; to enablehim to read and write; to practise some easy handicraft; to partake ofsome simple pleasures, and so at length to return to the shelter of hisown home, and to be there, not an object to be hidden away, too painfulto look upon, but an object rather of special tenderness, repaying withhis guileless love the sad self-sacrifice of his parents for many ayear; these are endeavours almost sure of accomplishment in awell-conducted institution, sure never to be realised in a home. 

I have often sent afflicted parents, who shrank from parting with theirchildren, to one institution near London; and I doubt not there areothers in England, where pains, and care, and skill, and untiring loveawake the slumbering intellect, arouse the dormant affections, and workmiracles of healing on these helpless little ones. 

INDEX. 

Abdomen, large, its importance exaggerated, 158 ---- tenderness of, very important, 158

Acute constitutional diseases, 187

Aperients, 23

Artificial feeding, its dangers, 45 ---- ---- rules for, 50 ---- ---- sometimes necessary, 49, 58 ---- ---- substitutes for milk, 59

Asses' milk best substitute for human, 51

Asthma, 145

Atrophy, infantile, 45 ---- its causes and symptoms, 47 ---- symptoms essentially different from consumption, 48, 62 ---- may depend on consumption, 61

Backwardness, 224

Bath, warm, management of, 19 ---- ---- when to be used in convulsions, 91

Bed, importance of, in illness, 16

Bedsores, how to prevent, and treat, 18

Bedstead, best form of, for children, 17

Brain, disease of, cry in, 5 ---- ---- proofs of absence of, 10 ---- and nervous system, mortality from diseases of, 88 ---- ---- convulsions as a sign of, 89 ---- congestion of, 95 ---- disorder of, from exhaustion, 106 ---- inflammation of, 99. _See_ Water on the Brain. ---- disease from disease of the ear, 102 ---- ---- symptoms of, 103 ---- ---- treatment of, 105

Breathing, frequency of, in health and disease, 8

Bright's disease of the kidneys, 169

Bronchitis, 130 ---- more serious than pneumonia, 131 ---- its symptoms, 131

Catarrh, 128 ---- its prevention and treatment, 129

Chafing, 77

Chest, cry in disease of, 5

Chicken-pox, 202

Childhood, characters of second period of, 85 ---- mental and moral faculties, peculiarities in, 213 ---- difference between child and adult, 213 ---- patience of child, 214 ---- vividness of imagination, 215 ---- phantasms and sounds, 216 ---- sensibility intense, 217 ---- craving for sympathy in, 218

Children and infants, mortality of, 1; _see_ Mortality. ---- diseases of, their signs, 5; _see_ Diseases of Children. ---- management, 12 ---- spoiled, 13 ---- sick, importance of truth with them, 13 ---- keeping happy, 16

Chloroform in convulsions, 92

Chronic constitutional diseases, 173

Cold to the head, how to apply, 22

Colic, characters of, 158

Congestion of the brain, 95 ---- fatal termination of, 96 ---- chronic water on brain from, 97 ---- treatment of, 97

Constitutional diseases, 173

Consumption, how distinguished from non-expansion of lungs, 38 ---- its symptoms when cause of infantile atrophy, 61 ---- its nature, 174 ---- recovery from, 176 ---- causes of, 176 ---- symptoms, 177 ---- dependent on disease of glands of lungs, 177 ---- in infancy, 178 ---- galloping, 178 ---- of the bowels, 179

Convulsions, as sign of brain disorder, 88 ---- less serious than in grown person, 89 ---- signs of their approach, 93 ---- causes of, various, 90 ---- description of a fit of, 94 ---- treatment of, 91 ---- now and then without apparent cause, 111

Cough, from disease of glands of lungs, 177

Cow's milk, excess of curd in, 51 ---- ---- easily deteriorated, 52

Cow-pox, its nature, 198

Croup, its nature, 133 ---- its two kinds, 134 ---- catarrhal, 134 ---- distinction from diphtheria, 135 ---- treatment of, 135 ---- spasmodic, 107. _See_ Spasmodic Croup. 

Cry in illness, various meanings of, 5 ---- when lungs are imperfectly expanded, 36

Diabetes, 169

Diarrh[oe]a in childhood, 154 ---- simple, 156 ---- inflammatory, 157

Digestion, how performed, 151

Digestive organs, peculiarities of, in infancy, 46

Diphtheria, 136 ---- its gradual progress, 136 ---- caution not to overlook it, 137. ---- various dangers of, 138 ---- management of, 139 ---- opening windpipe in, 140 ---- paralysis after, 141

Diseases of infants and children, their signs, 5 ---- management, 12

Doctor, proper relation of parents to, 28

Dream images vivid in childhood, 215

Dyspepsia of weakly children, 153

Earache, symptoms of, 103 ---- treatment of, 105 ---- inflammation of brain from disease of ear, 102

Eczema, 79 ---- its symptoms and course, 79 ---- treatment, 81 ---- alleged dangers of curing, 84

Epilepsy, its two forms, 112 ---- prospects of recovery from, 113 ---- moral perversion, from, 114 ---- treatment of, 116 ---- moral management of, 117

Exhaustion a cause of brain disorder, 106

Farinaceous food, why unsuitable, 46 ---- ---- results of its excess, 47 ---- ---- best forms of, 60

Feeding-bottle, best form of, 55

Feigned illness, 221

Fingers, scrofulous disease of bones of, 183

Food, quantity required by an infant, 54 ---- best mode of giving, 54

Galvanism, in cases of paralysis, 123

German measles, 204

Glandular enlargement in infantile consumption, 61 ---- swellings from scrofula, 183

Gravel, 170

Grimacing, distinct from St. Vitus's dance, 119

Gums in teething, when to be lanced, 75 ---- management when ulcerated, 76

Head, varieties in shape of, unimportant, 106

Headache, neuralgic, 124 ---- from defective sight, 126

Heart, malformation of, 146 ---- ---- management of, 148 ---- frequency of disease of, from rheumatic fever, 149, 188 ---- inflammation of, 148

Hooping-cough, 141 ---- management of, 143 ---- its dangers, 144

Hysteria, relation of, to epilepsy, 115

Idiocy, 224, 225 ---- its management, 227

Incontinence of urine, 171

Indigestion in infancy, 47, 56 ---- its management, 65

Infants and children, mortality of. _See_ Mortality ---- rules for artificial feeding of, 50 ---- substitutes for mother's milk, 51 ---- quantity of food required, 54 ---- feeding-bottles, 55

Influenza, 132

Inoculation and vaccination, 196

Jaundice of new-born children, 39 ---- in childhood, 154

Kidneys, disease of, 168

Lavements, their use and abuse, 26

Leeches very useful in some cases, 21 ---- how to apply, 21

Liver, disease of, a cause of infantile atrophy, 62

Lungs, imperfect expansion of, 35 ---- ---- ---- ---- its symptoms, 36 ---- ---- ---- ---- ---- treatment, 38 ---- inflammation of, rare in early infancy, 37

Measles, 202 ---- its symptoms and dangers, 203 ---- ---- management, 204

Medicine, choice and administration of, 23

Mercury, not cause of sore-mouth in children, 165

Mesenteric disease, 179 ---- ---- its importance exaggerated, 181

Milk, why proper food of infants, 46 ---- mother's, peculiarities of, soon after birth of child, 50 ---- ---- best substitutes for, 50 ---- ---- and that of animals compared, 50 ---- substitutes for, 59 ---- condensed, inferior to fresh milk, 53

Moral insanity in childhood, 219-223 ---- perversion from epilepsy, 114

Mortality of infants and children, 1 ---- varies in different places and times, 1 ---- causes of, 2 ---- ---- intermarriage and hereditary taint, 2 ---- ---- unhealthy dwellings, 3 ---- ---- unwholesome food, 4 ---- increased during teething, 72 note

Mother not always good nurse, 12

Mouth, how to examine, 10 ---- sore, 163

Mumps, 190

Napkins, inconvenience of, 18

Navel, rupture of, 43

Nettle-rash, 78

Neuralgia and headache, 124

Night terrors, 126

Nose, offensive discharge from, 184

Notes, importance of keeping in illness, 28

Ophthalmia of new-born children, 40

Opiates, 27

Palsy, 121 ---- form of, peculiar to childhood, 122 ---- its cause, 123 ---- ---- treatment, 123 ---- cases mistaken for it, 124

Peritonitis, 158 ---- local, often overlooked, 158

Phantasms in childhood, 215

Pleurisy, 132

Pneumonia, 130 ---- its symptoms, 131

Poultices, uses of, 20 ---- how made, 20 note

Premature birth, 33 ---- ---- its management, 34

Pulse, frequency of, in health and disease, 8

Quinsy, 165

Red-gum, 77

Respiration, frequency of, in health and disease, 8 ---- artificial, 33

Rheumatic fever, 188

Rheumatism, connection of, with St. Vitus's dance, 118 ---- chief cause of heart inflammation, 149

Rickets, 185

Round-worm, 160

Rupture of navel, 43

Scalp-swellings, 42

Scarlatina, 205 ---- its dangers and symptoms, 206 ---- characters of rash, 207 ---- sore-throat of, 208 ---- how recognised, 208 ---- management of; duties of parents, 209

Scrofula, 181 ---- abscesses under skin, 182 ---- disease of bones of fingers, 183 ---- glandular swellings, 183 ---- offensive discharge from nostrils, 184

Shamming does not disprove illness, 115

Sick-room, management of, 14

Sleep-walking, 216

Small-pox, 195 ---- after vaccination, 201

Snuffles, 128

Sore-mouth, 163 ---- ---- not diphtheritic, 164 ---- ---- not due to mercury, 165 ---- throat of scarlatina, 208

Spasmodic croup, 107 ---- ---- its nature and symptoms, 108 ---- ---- ---- treatment, 111

Still-birth, 32

Stomach, how to examine, 9 ---- ache, cry in, characteristic, 5

St. Vitus's dance, 118 ---- ---- ---- its connection with rheumatism, 118 ---- ---- ---- its symptoms, 118 ---- ---- ---- distinct from mere grimacing, 119 ---- ---- ---- its treatment, 120

Suckling, importance of, to mother and child, 40, 50 ---- unfitness of some mothers for it, 49 ---- sometimes has to be abandoned, 57

Sunstroke, 98

Tape-worm, 161

Tears, their value as a sign of disease, 11, 101

Teething, takes place later in man than in other animals, 47 ---- order in which teeth appear, 73 ---- when the gums should be lanced, 75 ---- rules for management of, 76

Temperature, in health and disease, 7 ---- of sick-room, 14 ---- increase of, in infantile consumption, 61

Thermometer, importance of use of, 7, 28

Thread-worms, 160

Throat, white spots on, not always diphtheritic, 137 ---- sore, inflammatory, or quinsey, 165 ---- abscess at back of, 168

Thrush, 70

Tonsils, enlarged, 166 ---- inflamed, 165 ---- when to be removed, 167

Typhoid fever, 191 ---- ---- its symptoms, 192 ---- ---- ---- management, 194

Urine, incontinence of, 171

Vaccination, 196 ---- M. Pasteur's experiments, 197 ---- death from, 198 ---- re-vaccination, 199 ---- animal, 200 ---- alleged transmission of disease by, 200 ---- conclusions with reference to it, 200 ---- small-pox after, 201

Vomiting in infancy, 63 ---- its treatment, 64 ---- as sign of congestion of brain, 95

Water on the brain, acute, its early symptoms, 99 ---- ---- ---- ---- symptoms of its progress, 101 ---- ---- ----- ---- chronic, two kinds of, 97, 105

Whey, Dr. Frankland's rules for preparing, 51 note ---- its uses, 51

White decoction, 59

Whites in children, 184

Worms, 160 ---- the round, and the thread-worm, 160 ---- tape-worm, 161 ---- treatment of, 162

PRINTED BYSPOTTISWOODE AND CO. , NEW-STREET SQUARELONDON

[Transcriber's Notes: Printer's errors have been corrected as follows: Page 2--thoes corrected to those (to those conditions) Page 2--do corrected to does (The experience ... Does not apply) Page 99--added comma (more gloomy, more pettish) Page 107--removed space (distinguished) Page 119--fidgetty corrected to fidgety (odd fidgety movements) Page 160--added hyphen to round worm (round-worm) Page 220--added quotation mark (a hospital for adults. ') Page 231--203 corrected to 202 (Chicken-pox, 202)All other spelling, hyphenation, and punctuation has been left as written. 

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The medical knowledge represented in this book is over a century old. The publication of this book is for historical interest only, and is not