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+The Project Gutenberg EBook of The Mother's Manual of Children's Diseases, by 
+Charles West, M.D.
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: The Mother's Manual of Children's Diseases
+
+Author: Charles West, M.D.
+
+Release Date: August 15, 2009 [EBook #29701]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK CHILDREN'S DISEASES ***
+
+
+
+
+Produced by Juliet Sutherland, Erica Pfister-Altschul and
+the Online Distributed Proofreading Team at
+http://www.pgdp.net
+
+
+
+
+
+
+
+
+
+                                  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 a
+small compass, and avoiding all technical detail, such an account of the
+diseases of infancy and childhood, as might be of use and comfort to the
+intelligent mother.
+
+Returning now, with health perfectly restored, to practise my profession
+for the rest of my life exclusively in my own country, I have brought
+with me this little book, in which the comparative leisure of my
+enforced 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 idle
+pretence of telling people how to treat their children's illnesses,
+without the help of a doctor. Its object is to give a description of the
+diseases of early life, such as may help a mother to understand
+something of their nature and symptoms, to save her from needless
+anxiety as to their issue, and to enable her wisely to second the doctor
+in 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, and
+needless repetition best avoided, if we begin by inquiring very briefly
+why so many children die, what general signs indicate that they are ill,
+and what general rules can be laid down for their management in
+sickness.
+
+The first of these inquiries would be as useless as it would be sad, if
+the rate of infant mortality were fixed by determinate laws, such as
+those 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 in
+different countries, in different parts of the same country, and in the
+same country at different times. Thus, while in some parts of Germany
+the 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 10
+per cent. in Norway. Infantile mortality is higher in manufacturing
+districts, lower in those which are agricultural, and varies from 16 per
+cent. in Lancashire to 9 in Dorsetshire. It is then evident that
+mortality in infancy is in part dependent on remediable causes; and of
+this there is no better proof than the fact that the mortality in
+England under one year has been reduced from 15 per cent. in 1872 to 13
+per cent. in 1882.
+
+It would lead us far from any practical purpose if we were to examine
+into all the causes which govern the liability to disease and death
+during infancy and childhood, in the different ranks of society. We must
+therefore limit our inquiry to those conditions which are met with in
+the class to which my readers may fairly be assumed to belong.
+
+_First_ among the causes of sickly infancy and premature death may be
+mentioned the intermarriage of near relatives. The experience of the
+breeders 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 whose
+qualities in these respects are pre-eminent, and eliminate from them all
+who do not occupy the first rank. In family intermarriages, however, it
+is rare that any consideration is regarded, save that of wealth; and the
+fact remains, explain it as we may, that the intermarriage of near
+relatives during several successive generations is followed by a marked
+deterioration of the children, physical, mental, and moral; and by the
+intensifying of any hereditary predisposition to consumption, scrofula,
+and other constitutional ailments which form the _second_ great cause of
+early sickness and mortality.
+
+These are facts known to all, which yet it is not easy to represent by
+figures. All the world is aware that consumption is hereditary, that
+consumptive parents are more likely than others to have consumptive
+children; and a fourth of all the patients admitted into the Hospital
+for Consumption at Brompton stated that the disease had existed in one
+or other of their parents.[1] Scrofula, which is another disease closely
+allied to consumption, is hereditary also; and hip disease, disease of
+the spine, abscesses, and enlarged glands in any members of a family,
+point to risks for the offspring which should not be forgotten, how much
+soever mental endowments, personal beauty, or the charms of disposition
+may be considered, and sometimes reasonably enough, to outweigh them.
+The same liability exists with reference to epilepsy, insanity, and the
+whole class of affections of the nervous system. Parents inquire, with
+no misplaced solicitude, what is her fortune, or what are the pecuniary
+resources of him to whom they are asked to entrust their son's or
+daughter's future. Believe me, the question--what is the health of his
+family, or of hers? is consumption hereditary, or scrofula, or epilepsy,
+or insanity?--is of far greater moment, and touches much more nearly the
+future happiness of those we love.
+
+These two points regard the future parents themselves; but there are
+other conditions on which the health of children to a great degree
+depends; and of these the two most important are the _dwelling_ they
+inhabit, and the _food_ they eat.
+
+I do not refer here to the dwellings of the poor, situated in unhealthy
+localities, where fresh air does not enter, where the rays of the sun do
+not penetrate, with defective drainage and imperfect water-supply; but I
+speak of the nurseries of well-to-do people. 'This will do for our
+bedroom, and that will make a nice spare room, and that will do for the
+children,' is what one often hears. Had you rare plants which cost much
+money to obtain, which needed sunlight, warmth, and air, would you not
+consider anxiously the position of your conservatory, and take much
+pains to insure that nothing should be wanting that could help their
+development, so that you might feast your eyes upon their beauty, or
+delight yourselves with their fragrance? And yet a room at the top of
+the house, one of the attics perhaps, is too often destined for the
+little one and its nurse; or if there are two or three children, one
+small room is set apart for the day nursery, and a second, probably with
+a different aspect, for a sleeping room, and so small that it does not
+furnish the needed five hundred cubic feet of air for each. And as a
+consequence, the children are ailing, any predisposition in them to
+hereditary disease is fostered, they have no strength to battle against
+any acute illness that may befall them, and yet surprise is felt that
+the doctor is never out of the house.[2]
+
+It is needless to dwell on the hand-feeding of infants as one of the
+great causes of mortality in infancy, and of sickliness in later life.
+The statistics of Foundling Hospitals bear sad testimony to the fact of
+its dangers, and the researches of physicians show that a peculiar form
+of disease is produced by it, attended by symptoms, and giving rise to
+appearances after death, peculiar to the form of slow starvation from
+which the infant has perished. I will add, because it is not generally
+known, one fresh illustration of the influence of artificial feeding in
+aggravating the mortality of infants. In Berlin the certificates of
+death of all infants under the age of one year, are required to state
+whether the little one had been brought up at the breast, or on some
+kind or other of artificial food. Of ten thousand children dying under
+the 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 any
+details with reference to the management of children in health. It may,
+therefore, suffice to have pointed out the four great causes of
+preventible disease among the wealthier classes of society; namely, the
+intermarriage of near relatives, the transmission of constitutional
+taint, the insanitary condition of the dwelling, and the injudicious
+selection 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 in
+the 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 little
+tract, _Healthy Nurseries and Bedrooms_, published as one of the Health
+Exhibition Handbooks.
+
+[3] The actual numbers are 2,628 and 7,646. See _Generalbericht ueber
+das 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 of
+three great classes: disorder of function, alteration of temperature,
+complaint of pain.
+
+In the infant it is the last of these which very often calls attention
+to the illness from which it is suffering. Cries are the only language
+which a young baby has to express its distress; as smiles and laughter
+and 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 of
+sick children, will gather from them more, and will be able to judge
+whether its suffering is in the head, or chest, or stomach. The cries of
+a baby with stomach-ache are long and loud and passionate; it sheds a
+profusion 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 a
+quiet sleep. If it has inflammation of the chest it does not cry aloud,
+it sheds no tears, but every few minutes, especially after drawing a
+deeper breath than before, or after each short hacking cough, it gives a
+little cry, which it checks apparently before it is half finished; and
+this, either because it has no breath to waste in cries, or because the
+effort makes its breathing more painful. If disease is going on in the
+head, the child utters sharp piercing shrieks, and then between whiles a
+low moan or wail, or perhaps no sound at all, but lies quiet, apparently
+dozing, 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, but
+the mention of this serves merely as an illustration, which anyone can
+understand, of the different meanings that even a baby's cry will convey
+to different persons.
+
+When a child is taken ill, be the disease from which it is about to
+suffer what it may, there is at once a change from its condition when in
+health, such as soon attracts the attention even of the least observant.
+The child loses its appetite, is fretful and soon tired, and either very
+sleepy or very restless, while most likely it is thirsty, and its skin
+hotter than natural. In many instances, too, it feels sick or actually
+vomits, while its bowels are either much purged or very bound. If old
+enough to talk, it generally complains of feeling ill, or says that it
+has pain in some part or other, though it is by no means certain that a
+little child has described rightly the seat of its pain; for it very
+often says that its head aches or that its stomach aches, just because
+it has heard people when ill complain of pain in the head or in the
+stomach. Some of these signs of illness are, of course, absent in the
+infant, who can describe its feelings even by signs imperfectly; but the
+baby loses its merry laugh and its cheerful look; it ceases to watch its
+mother's or its nurse's eye as it was used to do, though it clings to
+her more closely than ever, and will not be out of her arms even for a
+moment; and if at length rocked to sleep in her lap, will yet wake up
+and cry immediately on being placed in its cot again.
+
+Symptoms such as these are sure to awaken the mother's attention to her
+child, 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 the
+question, 'What is the matter?'
+
+Some mothers send at once to the doctor whenever they see or fancy that
+anything ails their child. But this way of getting rid of responsibility
+is not always possible, nor, indeed, on moral grounds, is it always
+desirable, for the mother who delegates each unpleasant duty to another,
+whether nurse, governess, or doctor, in order to save herself trouble or
+anxiety, performs but half a mother's part, and can expect but half a
+mother's recompense of love.
+
+Whenever a child is unwell, a mother may do much to ascertain what is
+the matter, and may by the exercise of a little patience and common
+sense save herself much needless heart-ache, and her child much
+suffering.
+
+The first point to ascertain is the presence or absence of fever; that
+is to say, whether, and how much, the temperature of the body is higher
+than natural. If the temperature is not higher than natural, it may be
+taken as almost certain that the child neither has any inflammatory
+affection of the chest, nor is about to suffer from any of the eruptive
+fevers. The temperature, however, cannot be judged of merely by the
+sensation conveyed to the hand, but must be ascertained by means of the
+thermometer.[4] In the case of the grown person the thermometer is
+placed either under the tongue, the lips being closed over it, or in the
+armpit, and is kept there five or six minutes. In young children,
+however, neither of these is practicable, and I prefer to place the
+instrument in the groin, and crossing one leg over the other, to
+maintain the thermometer there for the requisite five minutes. The
+temperature of the body in health is about 98.5° Fahr. in the grown
+person, and very slightly higher in childhood; but any heat above 99.5°
+may be regarded as evidence that something is wrong, and the persistence
+for more than twenty-four hours of a temperature of 101° and upwards,
+may be taken as almost conclusive proof of the existence of some serious
+inflammation, or of the onset of one of the eruptive fevers.
+
+At the same time it is well to bear in mind that temporary causes, such
+as especially the disorders produced by over-fatigue, or by an
+over-hearty or indigestible meal, may suddenly raise the temperature as
+high as 102°, or higher, but the needed repose or the action of a
+purgative may be followed in a few hours by an almost equally sudden
+decline of the heat to the natural standard.
+
+It is well to learn to count the pulse and the frequency of the
+breathing; but to do the former accurately, requires practice such as is
+hardly gained except by hospital training; and indeed, with few
+exceptions, the value of the information furnished by the pulse is less
+in the child than in the adult. The reasons for this are obvious, since
+the rapidity of the circulation varies under the slightest causes, and
+the 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 twenty
+in the minute. The place at which to seek the beat of the pulse is at
+the wrist, just inside and below the protuberance of the wrist-bone; but
+if the child is very fat it is often difficult to detect it. When
+detected it is not easy to count it in early infancy, for during the
+first year of life the heart beats between 120 and 130 in the minute,
+diminishing between that age and five years to 100, and gradually
+sinking to 90 at twelve years old. In proportion, moreover, to the
+tender age of the child, is the rapidity of its circulation apt to vary
+under the influence of slight causes, while both its frequency and that
+of the breathing are about a third less during sleep than in the waking
+state.
+
+The frequency of the breathing is less difficult to ascertain, while at
+the same time it furnishes more reliable information than the pulse.
+This is best tested when the child is asleep, remembering always that
+the 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-dress
+on the lower part of the chest and the pit of the stomach. Each heaving
+of 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 two
+years the child breathes from 30 to 40 times in a minute, and this
+frequency 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 would
+thus 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 in
+its chest, and that the doctor should be sent for in order to ascertain
+its exact nature.
+
+It would answer no good purpose to give a description of the information
+to be obtained by listening to the chest. To learn from this, needs the
+well-trained ear; and harm, not good, comes from the half-knowledge
+which serves but to lead astray.
+
+A child may be very suffering, seem very ill, and its suffering and
+illness may depend on pain in the stomach owing to indigestion,
+constipation, or even to an accidental chill. After early infancy it is
+not difficult to make out the seat of the child's suffering: the warm
+hand placed gently on its stomach will soon ascertain whether it is
+tense or tender, whether the tenderness is confined to one particular
+spot, 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 the
+intestines, the pain and tenderness are both relieved by gentle rubbing.
+
+In the young infant the character of the cry will, as I have already
+said, give some clue to the seat of its pain, while, if you lay it down
+in its cot or in its nurse's arms in order to examine its stomach, it
+will often resist and begin to cry. Its stomach then becomes perfectly
+tense, and you cannot tell whether pressure on it causes pain or whether
+the cries are not altogether the consequence of fretfulness and fear. It
+is therefore the best plan to pass your hand beneath the child's clothes
+and to examine its stomach without altering its posture, while at the
+same time the nurse in whose arms it is talks to it to distract its
+attention, or holds it opposite the window, or opposite a bright light,
+which seldom fails to amuse an infant. If there is no tenderness of the
+stomach the child will not cry on pressure; or if during your
+examination 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 of
+children in whom teething is not over, is to examine the mouth and
+ascertain the state of the gums, since some ailments are caused and
+others are aggravated by teething. A wise mother or an intelligent nurse
+will teach the child when well the little trick of putting out its
+tongue and opening its mouth to show its teeth when told to do so; and
+though it may sometimes indulge rather out of place in these
+performances when wished to behave especially prettily before strangers,
+yet when older it will quickly learn the proprieties of behaviour, and
+in the meanwhile you profit much by the lesson when illness really
+comes.
+
+Sometimes, however, infants who when well will open their mouth and
+allow their gums to be felt without difficulty, refuse to do so when
+ill; and it is always desirable that the mother or nurse whose duty it
+is to tend the sick child constantly, should not frighten it, or lose
+its confidence, by doing forcibly that which the doctor who comes
+occasionally may yet be quite right in doing. You will, however,
+generally get a good view of the mouth and throat in young infants by
+gently touching the lips with your finger: the child opens its mouth
+instinctively, and then you can run your finger quickly over its tongue,
+and drawing it slightly forward perfectly see the condition of the
+throat, feel the gums as you withdraw your finger, and notice the
+appearance of the tongue. Sometimes it is important to ascertain whether
+a tooth which was near coming through has actually pierced the gum, and
+yet the child's fretfulness renders it almost impossible to induce it to
+open its mouth. If now, while the nurse holds the child in her arms, you
+go behind her, you can, unseen and unawares, introduce your finger into
+its mouth and ascertain all you wish to know before the little one has
+recovered from its surprise.
+
+I have but little to say here about the general signs of brain disease
+in infancy and childhood, because they will need minute notice
+afterwards. All that I would at present observe is, that you must not at
+once conclude that a child's head is seriously affected, because it is
+heavy and fretful and passionate, and refuses to be amused. The head, as
+we know by our own experience, suffers by sympathy in the course of
+almost every ailment, certainly of every acute ailment, at all ages. If
+the 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 it
+may prefer a darkened room, it does not shrink from the light when
+admitted gradually; if it has no slight twitchings of its fingers or of
+its wrists; if the head, though hot, is not hotter than the rest of the
+body; if the large vessels of the neck, or the open part of the head, or
+fontanelle as it is termed, in an infant in whom the head is not yet
+closed, are not beating violently; and, above all, _if when it cries it
+sheds 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 the
+nurse or the friend who assures you that the child is about to have
+convulsions 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 or
+instrument-maker, and its mode of employment can be learned in five
+minutes. 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 exact
+proportion to whether it has been ill or well managed when in health.
+The mother who lives but little with her children, who contents herself
+with a daily visit to the nursery, and who then scarcely sees her little
+ones until they are brought into the drawing-room in the evening in full
+dress, to be petted and admired and fondled by the visitors, cannot
+expect to take her place by the child's bed in its sickness, to soothe
+its pain, and to expend upon it all the pent-up tenderness which, in
+spite of the calls of business or of pleasure, still dwells within her
+heart. She must be content to see the infant turn from her to the nurse
+with whose face it has all its life been familiar; or to hear the little
+one tell her to go away, for her presence is associated with none of
+those 'familiar acts, made beautiful by love,' which win the young
+heart: the mother is but a stranger who brings no help, who relieves no
+distress. Happy such a mother if she has found a conscientious and
+intelligent nurse to whom she can delegate her office; but she must
+remember that with the child, love follows in the steps of daily, hourly
+kindnesses, that a mother's part must be played in health if it is to be
+undertaken in sickness, that it cannot be laid down and taken up again
+at 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 yielded
+to each wayward wish, and has allowed it to become the petty tyrant of
+the 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 accustomed
+to have its will obeyed in everything, and cannot understand that its
+suffering is not at once taken away. It insists on getting up and on
+being dressed, or on lying in its mother's or nurse's lap, where the
+warmth of another person's body does but aggravate its fever; it screams
+with passion at the approach of the doctor, it will not allow itself to
+be examined, it will take no medicine; the doctor is powerless, the
+mother heart-broken. Sickness is not the time to exercise authority
+which has not been put in force before; and, not once but many times, I
+have watched, a sad spectator, the death of children from an illness not
+necessarily fatal, but rendered so because it was impossible to learn
+the progress of disease, impossible to administer the necessary
+remedies.
+
+
+_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 is
+as to the necessity of perfect truthfulness in dealing with sick
+children. The foolish device of telling a child when ill, that the
+doctor who has been sent for is its uncle or its cousin, is the outcome
+of the still more foolish falsehood of threatening the child with the
+doctor's visit if it does not do this or that. No endeavour should be
+spared by nurse or parent, or by the doctor himself, to render his visit
+popular in the nursery. Three-fourths of the difficulties which attend
+the administration of medicine are commonly the result of previous bad
+management of the child, of foolish over-indulgence, or of still more
+foolish want of truthfulness. It may answer once to tell a child that
+medicine is nice when really it is nasty, but the trick will scarcely
+succeed a second time, and the one success will increase your
+difficulties ever after. If medicine is absolutely necessary, and the
+child is too young to understand reason, it must be given by force, very
+firmly but very kindly, and the grief it occasions will be forgotten in
+an hour or two. If he is old enough, tell him that the medicine is
+ordered to do him good, and firmness combined with gentleness will
+usually succeed in inducing him to take it. The advantage of perfect
+truthfulness extends to every incident in the illness of children, even
+to the not saying, 'Oh, you will soon be well,' if it is not likely so
+to 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 of
+mind is secured to the poor little sufferer!
+
+A little boy three years old was ordered to be cupped. The cupper, a
+kind old man, said to encourage him, 'Oh, dear little boy, it's
+nothing.' 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 try
+to bear it well. And the operation was performed without a cry or a
+sound.
+
+I have spoken of the moral conditions implied in the successful
+management of sick children. There are certain physical conditions no
+less 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 its
+other little inmates. He must (and of course I am speaking not of some
+slight ailment, but of a more serious indisposition) be in a room by
+himself, which should be kept quiet and shaded, and at a temperature
+which should not be allowed to fall below 60° if the chest is in any way
+affected, nor to exceed 55° in other cases, and this temperature should
+always be measured, not by guess, but by the thermometer hung close to
+the child's bed. The room is to be shaded, not by curtains round the
+bed--for, save in special circumstances, curtains should be banished
+from the nursery--nor by closed shutters which exclude both light and
+air, but by letting down the blinds, so as to have a sort of twilight in
+the room, and by shading any light which at night may be burned in the
+apartment; while whether by day or night the child should be so placed
+that his face shall be turned from the light, not directed towards it.
+The room should be kept quiet, and this requires not only general quiet
+in 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; walking
+carefully, 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 more
+than the loudest noise.
+
+Little precautions, so trifling that few think of noticing them, have
+much to do with the quiet of the sick-room, and consequently with the
+patient'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 anyone
+enters the room; and to put a wedge in the window, or to tie back the
+handle, and so quietly open and close the door, may do more than
+medicine towards promoting the child's recovery. There can, however, be
+no abiding quiet without a well-ordered room, and the old proverb
+carried out, 'A place for everything, and everything in its place.' A
+table covered with a cloth so that things may be taken up and put down
+noiselessly, and set apart for the medicine, the drink, the nourishment,
+cups, glasses, spoons, or whatever else the patient is in frequent need
+of; with a _wooden_ bowl and water for rinsing cups and glasses in, and
+a cloth or two for wiping them, will save much trouble and noise, and
+the loud whispers of the attendants to each other, 'Where is the sugar?
+where is the arrowroot? where did you put down the medicine?' of which
+we hear so much in the sick-room, so much especially in the sick-room of
+the 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 the
+doctor in the child's room, do not relate bad symptoms, do not express
+your fears, nor ask the doctor his opinion in the child's hearing. The
+child often understands much more than you would imagine, misunderstands
+still more; and over and over again I have known the thoughtless
+utterance of the mother, nurse, or doctor depress a child's spirits and
+seriously retard his recovery.
+
+It is consoling to bear in mind that how grave soever a child's illness
+may 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 the
+child than it would be from the same disease in the grown person. This
+too is due not simply to the activity of the reparative powers in early
+life, but also in great measure to the mental and moral characteristics
+of childhood.
+
+To make the sick child happy, in order that he may get well, is the
+unwritten lesson which they who have best learnt, know best how to nurse
+sick children. It may seem strange, that from so high a purpose I should
+at once come down to so commonplace a detail as to insist on the
+importance, even on this account, of keeping the sick child in bed.
+
+At the onset of every illness of which the nature is not obvious, during
+the course of any illness in which the chest is affected, or in which
+the temperature is higher than natural, bed is the best and happiest
+place for the child. In it repose is most complete, far more complete
+than after early babyhood it can be in the nurse's or mother's lap, and
+free from the great objection of the increased heat from being in
+contact with another person's body. Nothing is more painful than to
+witness the little child, sick and feverish, with heavy eyes, and aching
+head, up and dressed, trying to amuse itself with its customary toys;
+then, with 'Please nurse me,' begging to be taken in the lap, then
+getting down again; fretful, and sad, and passionate by turns; dragging
+about its misery, wearing out its little strength, in deference to the
+prejudice that bed is so weakening.
+
+
+_The bed does not weaken, but the disease does which renders bed
+necessary._
+
+A child frets sometimes at the commencement of an illness if kept in
+its own little cot. But put it in its nurse's or mother's big bed, set a
+tea tray with some new toys upon it before the child, and a pillow
+behind 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 halved
+your 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 laying
+the baby on a bed, the nurse or mother lying down by its side, and
+soothing it to sleep. Were there no other drawback, it is a waste of
+power to have two persons employed in nursing a sick child; one to keep
+it in her lap, and the other to wait upon her.
+
+It is important in all serious illnesses of children, as well as of a
+grown person, that the bed should be so placed that the attendant can
+pass on either side, and can from either side reach the patient to do
+whatever is necessary. Most cots for young children have a rail round
+them to prevent the child falling out of bed when asleep or at play; but
+nothing can be more inconvenient than the fixed rail over which the
+attendant has to bend in order to give the child food or medicine, or
+for any other purpose. When I founded the Children's Hospital in Ormond
+Street, I introduced children's cots (the idea of which I took from
+those in the Children's Hospital at Frankfort) the sides of which let
+down when needed, while on the top of the rail, or dependent from it, a
+board is placed surrounded by a raised beading on which the toys, the
+food, or drink may be put with great convenience. These bedsteads, with
+probably some improved arrangement for letting down the sides, may be
+seen now in most children's hospitals, but I have been surprised to
+observe how seldom they are employed in private nurseries, and how
+comparatively few bedstead-makers are acquainted with them. The result
+would probably have been very different had a patent been taken out for
+them, and had they been largely advertised as 'Dr. West's improved
+children's bedsteads'! The uninclosed spring mattress, and the
+wedge-shaped horsehair cushion, both of which I introduced in Ormond
+Street, are also very valuable. The latter slightly raises the head and
+shoulders, and renders any other than a thin horsehair pillow for the
+head 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 for
+some very special reason the napkin should be done away with. It heats
+the child, chafes it, and makes it sore; it conceals the inattention of
+the nurse, and at the same time renders it less easy to keep the little
+one 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 a
+piece of macintosh should be placed under the sheet, as is done in the
+lying-in room, and a draw-sheet, as it is termed, over it. The
+draw-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 lying
+on linen that is wet or soiled. It can be drawn away from under the
+child, and a portion still clean and dry brought under it, while the
+soiled part is rolled together and wrapped up in macintosh at one side
+of the bed until a new draw sheet is substituted, which is easily done
+by tacking a fresh sheet to that which is about to be withdrawn, when
+the fresh one is brought under the child's body as that which is soiled
+is removed. The greatest care should always be taken that the under
+sheet is perfectly free from ruck or wrinkle; in long illnesses the skin
+becomes chafed and bed-sores may be produced by neglect of this simple
+precaution. The complaint that a child throws off the bed-clothes is
+easily remedied by a couple of bits of tape tied on either side loosely
+from the sheet or blanket to the sides of the cot.
+
+When children are compelled to remain long in bed, great care is needed
+to prevent the skin from being chafed, which is the first step that
+leads to the occurrence of bed-sores. Careful washing with soap and
+water daily of the whole body, not only of those parts which may be
+soiled by the urine or the evacuations; the washing afterwards with pure
+tepid water; careful drying, and abundant powdering with starch powder,
+will do much to prevent the accident. If, in spite of this care, the
+skin seems anywhere to be red or chafed, it should be sponged over with
+brandy or with sweet spirits of nitre before powdering. Real bed-sores
+must be seen and treated by the doctor.
+
+The warm bath is a great source of comfort to the sick child, and in all
+cases of feverishness, of influenza, or threatening bronchitis, it
+should not be omitted before the child is put to bed, or must be given
+towards evening if the child has not been up during the day. The bath
+may be either warm or hot, the temperature of the former being 90° to
+92°, that of the latter 95° to 96°. The temperature should always be
+ascertained by the thermometer, and the _warm_ bath only should be
+employed, except when the _hot_ bath is ordered by the doctor. The warm
+bath relieves feverishness and quiets the system, and promotes gentle
+perspiration; the hot bath is given when the eruption of scarlet fever
+or of measles fails to come out properly, or in some cases of
+convulsions at the same time that cold is applied to the head, or, in
+some forms of dropsy when it is of importance to excite the action of
+the skin as much as possible. It is not desirable that a child should
+remain less than five or more than ten minutes in the bath, and
+attention must be paid by the addition of warm water to maintain the
+bath at the same temperature during the whole time of the child's
+immersion.
+
+Now and then infants and very young children when ill seem frightened
+at the bath, and then instead of being soothed and relieved by it they
+are 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, he
+very often becomes greatly alarmed, struggles violently, cries
+passionately, and does not become quiet again till he has sobbed himself
+to sleep. All this time, however, he has been exerting his inflamed
+lungs to the utmost, and will probably have thereby done himself ten
+times more harm than the bath has done good. Very different would it
+have been if the bath had been got ready out of the child's sight; if
+when brought to the bedside it had been covered with a blanket so as to
+hide the steam; if the child had been laid upon the blanket, and gently
+let down into the water, and this even without undressing him if he were
+very fearful; and then if you wish to make a baby quite happy in the
+water, 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 the
+much-dreaded bath become a real delight to the little one, and have
+found that if tears were shed at all, it was at being taken out of the
+water, not at being placed in it.
+
+In a great variety of conditions, poultices are of use. They are needed
+in the case of abscesses which it is wished to bring to a head; they are
+sometimes applied over wounds which are in an unhealthy condition, or
+from which it is desired to keep up a discharge. They soothe the pain of
+stomach-ache from any cause, and are of most essential service when
+constantly applied in many forms of chest inflammation. And yet not one
+mother or nurse in ten knows how to make a poultice.[5] When applied
+over a wound they should not be covered with oiled silk or any
+impermeable material, since the edges of the wound and the adjacent skin
+are apt thereby to be rendered irritable and to become covered with
+little itching pimples. When used to relieve pain in the stomach, or as
+a warm application in cases of inflammation of the chest, they should be
+covered with some impermeable material, and will then not require to be
+changed oftener than every six hours. After poultices have been applied
+over the chest or stomach for two or three days the skin is apt to
+become tender, and then it is well to substitute for them what may be
+termed a dry poultice, which is nothing else than a layer of dry cotton
+wool an inch or an inch and a half thick, tacked inside a piece of oiled
+silk.
+
+A handy substitute for a poultice may be made of bran stitched in a
+flannel bag, heated by pouring boiling water on it, then squeezed as dry
+as possible and laid over the painful part. This is especially useful to
+relieve the stomach-ache of infants and young children.
+
+Spongio-piline is a useful substitute for a poultice, especially when it
+is desirable to employ a soothing or stimulating liniment to the
+surface. It retains heat very well when wrung out of hot water, and any
+liniment sprinkled on it is brought into contact with the skin much
+better than if diffused through a poultice. I may just add that its
+edges should be sloped inwards, in order to prevent the moisture from it
+oozing out and wetting the child's night-dress.
+
+When I was young, leeches and bleeding were frequently, no doubt too
+frequently, employed. We have now, however, gone too much to the other
+extreme, for cases are met with from time to time of congestion of the
+brain, or of inflammation of the chest or of the bowels, in which
+leeches bring greater and more speedy relief than any other remedy. In
+applying leeches it is always desirable that they should be put on where
+they will be out of the child's sight if possible, and where it will be
+comparatively easy to stop the bleeding. Hence, in many instances of
+inflammation of the bowels, it is better to apply the leeches at the
+edge of the lower bowel, the anus as it is technically termed, than on
+the front of the stomach, though, of course, this will not always answer
+the purpose. Leeches to the chest may usually be put on just under the
+shoulder-blade; and leeches to the head on one or other side behind the
+ear, where they will be out of the way of any large vein, and where the
+pressure of the finger will easily stop the bleeding. Steady pressure
+with 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 of
+adhesive plaster, will prevent any renewal of the bleeding. In the few
+cases where it is not arrested by these means, the application of a
+little 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 to
+the question of how to manage in the administration of medicine; and
+this is the best way of applying cold to the head. This is often
+ordered, but very seldom efficiently done. Cold is best applied by means
+of a couple of bladders half-filled with pounded ice, and wrapped in two
+large napkins; one of them should be placed under the child's head, the
+corners of the napkin being pinned to the pillow-case to prevent its
+being disturbed, while the other is allowed to rest upon the head, but
+with the corners of the napkin again pinned to the pillow so as to take
+off the greater part of its weight. Thus arranged, the cold application
+will neither get displaced by the child's movements, nor will the child
+itself be wetted, as it too commonly is when wet cloths are employed for
+this purpose, nor irritated by their perpetual removal and renewal.
+
+In London and in large towns there are various contrivances of
+vulcanised rubber, which are, of course, far preferable to the bladders,
+but it is not everyone who lives in London, or who can command the
+resources furnished by a large city.
+
+The difficulties in the administration of medicine to children are in
+great part the fault, either of the doctor in giving needlessly
+unpleasant medicine, or of the parents or nurse who either have failed
+to teach the child obedience, or who are deficient in that tact by which
+hundreds of small troubles are evaded.
+
+As far as the doctor is concerned, all medicines should be prescribed by
+him in small quantities, and as free from taste and smell as possible:
+or where that cannot be, the unpleasant flavour should be covered by
+syrup, or liquorice, or treacle.
+
+Bulky powders should be avoided, and the child who has learned to take
+rhubarb and magnesia, or Gregory's powder without resistance, certainly
+does credit to his training.
+
+Aperients are the medicines most frequently needed in the minor ailments
+of children, and a wise mother will not undertake herself the management
+of serious diseases. Of all aperients castor oil is perhaps the safest,
+the least irritating, the most generally applicable; it acts on the
+bowels and does nothing more. The idea that it tends specially to
+produce constipation afterwards is unfounded; it does not do so more
+than other aperients. All aperients quicken for a time what is termed
+the peristaltic action of the bowels; that is to say, their constant
+movement in a direction from the stomach to the lower bowel, which, as
+well as a contraction on themselves, is constantly going on in every
+living animal, and continues even for some time after death. The bowels
+stimulated to greater activity of movement by the aperient, become for a
+time more sluggish afterwards; they rest for a while, just as after a
+long walk the muscles of the leg are weary and need repose.
+
+There are indeed aperients which do more than this, as grey powder and
+calomel act upon the liver, and so by promoting an increased flow of
+bile cause a more permanent excitement of the bowels, and consequently
+their more prolonged activity; or as Epsom salts or citrate of magnesia,
+which by their action on the blood cause a greater secretion or pouring
+out of fluid from the coats of the intestines, and in this way have in
+addition to their purgative property a special influence in abating
+various feverish conditions.
+
+Castor oil, senna, jalap, jalapine, and scammony are simple aperients.
+They empty the bowels and nothing more, and in cases of simple
+constipation, or where a child is ill either from eating too much or
+from taking indigestible food, are the best purgatives that can be
+given. A dose of castor oil, often one of the great griefs of the
+nursery, may generally be given without the least difficulty if
+previously shaken up in a bottle with a wine-glassful of hot milk
+sweetened and flavoured with a piece of cinnamon boiled in it, by which
+all 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 are
+generally very readily taken by children, but all have the disadvantage
+of being liable to gripe. The German liquorice powder, as it is called,
+which is composed of powdered senna, liquorice powder, fennel, and a
+little sulphur with white sugar, is freer from this drawback than any
+other preparation, and when mixed with a little water is not generally
+objected to. It is important, as senna is often adulterated and loses
+its properties by exposure to the air, that this powder should always be
+obtained from a very good chemist, purchased in small quantities, and
+always kept in a glass-stoppered bottle.
+
+Jalap, in the form in which it is usually sold--as compound jalap
+powder--is in general readily taken; it acts speedily, but often with
+pain, and is not a desirable domestic remedy. Jalapine, which is a sort
+of extract of jalap, is much less apt to gripe, and owing to its small
+bulk is much handier. It may be given in doses of from two to five
+grains to children from two years old and upwards.
+
+Scammony is another powerful simple aperient, apt to be violent in its
+action, and therefore not to be given except when the bowels have long
+been confined, or when it is given to expel worms. The compound scammony
+powder is the form in which it is usually given, and of that five grains
+would be a dose for a child two years old.
+
+Scammony, however, is a costly drug, and therefore the caution given
+with 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 is
+much difficulty in inducing the child to take medicine. It is almost
+tasteless, and a tablespoonful, which would be a proper dose for a child
+of five years old, can be given without being detected.
+
+Much of the difficulty experienced in giving powders arises from their
+being mixed with the arrowroot or jam in which they are administered. A
+very small quantity of arrowroot, bread and milk, or jam, should be put
+in a tea-spoon; the powder then laid upon it, and covered over with the
+arrowroot or jelly, so, in short, as to make a kind of sandwich, with
+the powder, which would thus be untasted, in the middle.
+
+Aloes is a purgative which acts chiefly on the large bowel and to some
+degree also on the liver, and is of most use in the habitual
+constipation of weakly children. In spite of its bitter taste the powder
+is seldom objected to if given between two layers of coarse brown sugar,
+while with most children the addition of a teaspoonful of treacle will
+induce them to take very readily that useful medicine, the compound
+decoction of aloes.
+
+Both rhubarb, aloes, and indeed other remedies which are nauseous if
+given as a liquid and are bulky in the form of powder, may very readily
+be given in extract in the form of very tiny pills. Thus I have
+constantly ordered the extract of rhubarb, which is nearly twice as
+strong as the powder, made up into pills scarcely bigger than what
+children call 'hundreds and thousands' and silver-coated. Ten or a dozen
+of these go down in a teaspoonful of jelly unknown, and with no
+expenditure of temper or tears.
+
+The citrate of magnesia, or Dinneford's Magnesia, taken effervescing
+with lemon juice, or when the effervescence has passed off, or the
+French Limonade Purgative, are almost always very readily taken, and are
+often very useful in the little febrile attacks, or in the slight
+feverish rashes to which children are liable in the spring and autumn.
+
+Mercurials should have no place among domestic remedies. I do not mean
+that the doctor need be called in to prescribe each time that they are
+given, but that the mother should learn from him distinctly with
+reference to each individual child the circumstances which justify their
+employment. They stimulate the liver, as well as produce thereby action
+of the bowels, but they have, especially if often employed, a
+far-reaching influence on the constitution, and that undoubtedly of a
+depressing kind: an influence more than made up for when really needed
+by their other qualities, and especially by their power in doing away
+with the results of many forms of chronic inflammation. They are 'edged
+tools,' however, and we know the proverb about those who play with
+them.[6]
+
+Grey powder, blue pill, and calomel are the three forms in one or other
+of which mercurials are commonly given. Of the three, grey powder is the
+mildest; but it has the inconvenience of not infrequently causing
+nausea, or actual sickness. This objection does not apply to blue pill,
+which can be given either in the tiny pills of which I have already
+spoken, or else broken down, and given in a little jam, or in a
+teaspoonful of syrup or treacle. On the whole I prefer calomel in small
+doses. It has the great advantage of tastelessness, small bulk, and of
+never causing sickness. Half a grain of calomel may be regarded as
+equivalent to two grains of grey powder or blue pill.
+
+I shall speak afterwards of other medicines, which may in various
+circumstances be given, to act upon the bowels; but the above include
+all 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 of
+suppositories and lavements in infancy and childhood. A piece of paper
+rolled up into a conical form and greased, or a bit of soap, is not
+infrequently introduced by nurses just within the bowel, as a means of
+overcoming constipation in infants. The irritation of the muscle at its
+orifice (the sphincter, as it is termed) excites the bowels to action,
+and does away with the necessity for giving an aperient. The drawback
+from this, as well as from the use of the lavement, is that if
+frequently employed they become habitually necessary, and the bowels
+will then never act without their customary stimulus. The lavement, too,
+has the additional disadvantage that while the lower part of the bowel
+is in proportion more capacious in infancy and childhood than in the
+adult, this peculiarity becomes exaggerated by the constant distension
+of the intestine, and a larger and still larger quantity of fluid needs
+to be thrown up in order to produce the requisite action of the bowels.
+
+Opiates and other soothing medicines should never be given except when
+prescribed by the doctor. Thirty-two deaths in England under five years
+of age in 1882 represent but a very small part of the evil wrought by
+the overdose or injudicious use of these remedies. Above all, soothing
+medicines of varying strength, as syrup of poppies, or of unknown
+composition, as Dalby's Carminative or Winslow's Soothing Syrup, should
+never be employed. The only safe preparation, and this to be given only
+by the doctor's orders or with his approval, is the compound tincture of
+camphor, or paregoric elixir, as it is called, of which sixty measured
+drops contain a quarter of a grain of opium. Ten to fifteen measured
+drops of this are a sufficient dose for a child one year old, and this
+ought not to be repeated within twelve hours. The repetition every few
+hours of small doses of opiates is quite as hazardous as the giving of a
+single overdose; and if it does not work serious mischief by stupefying
+the 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 be
+considered in which they may be of service.
+
+There are two points which still remain to be noticed before I leave the
+introductory part of this little book.
+
+The first of these concerns the importance of keeping written notes in
+the course of every case of serious illness. For want of doing this the
+most imperfect and conflicting accounts of what has happened are given
+to the doctor. No person can watch to any good purpose for
+four-and-twenty hours together; and no one's memory, least of all in the
+midst of fatigue and anxiety, can correctly retain all details
+concerning medicine, food, and sleep, which yet it may be of paramount
+importance that the doctor should be made acquainted with. I am
+accustomed to desire a record to be kept on a sheet of paper divided
+into six columns, one for food, a second for medicine, a third for
+sleep, a fourth for the evacuations, and a fifth for any special point
+which the nature of the illness renders it of special moment to observe,
+while the date is entered on the first column of all, indicating when
+food or medicine was given, or when and for how long the child slept. It
+is best to enter the variations of temperature on a separate paper, in
+order that the doctor may at a glance perceive the daily changes in this
+important respect. No one who has not made the experiment can tell the
+relief which the keeping this simple record gives to the anxiety of
+nursing the sick, especially when the sick one is loved most tenderly.
+
+The other point concerns the relations of the mother or of the parents
+to the doctor. I have often heard it said, 'Dr. Green always attends my
+husband and myself, but we have Dr. White for the servants and
+children,' implying a lower degree of medical knowledge as required in
+their case, and to be acknowledged by a lower rate of remuneration.
+
+Need I say that the assumption is a mistaken one--that as much
+knowledge, as large experience, are needed in the one case as in the
+other; while over and above, to treat children successfully, a special
+tact and a special fondness for children are needed? A man may be a very
+good doctor without those special gifts; but their possession, apart
+from real medical knowledge, may make a good children's nurse, but never
+a good children's doctor.
+
+Another matter not to be forgotten is the confidence to be reposed in
+the doctor--the readiness to acquiesce in his sometimes visiting the
+child more frequently in the course of an illness than the symptoms may
+seem to you to require. Were you involved in some civil action, in which
+your succession to large property was involved, you would scarcely
+expect your solicitor to give you his opinion on all the questions at a
+single interview. In the same way, the doctor, even the most
+experienced, may need to visit his little patient several times before
+he can feel quite certain as to the nature of the disease that is
+impending, while he may not wish to alarm you by suggesting all the
+possibilities that are present to his mind. The child after a restless
+night may be asleep, and it may be most undesirable to wake him; or he
+may be excessively cross and unmanageable, so that it is impossible to
+listen to his chest; or it may be very important to ascertain whether
+the high temperature present in the morning has risen still higher
+towards night, or whether, after free action of the bowels, it has
+fallen a degree or two, showing that no fever is impending, but that the
+undue heat of the body was occasioned by the constipation. Or, again,
+some remedy may have been ordered, of the effect of which the doctor
+does not feel quite sure: he wishes to see for himself whether it is
+right to continue or wiser to suspend it. The wise physician, like the
+able general, leaves as little as may be to chance.
+
+Nearly forty years ago, in addressing a class of medical students, I
+said 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 lavish
+of your time; you must be content to turn aside from the direct course
+of investigation, which you would pursue uninterruptedly in the adult,
+in order to soothe the waywardness of the child, to quiet its fears, or
+even to cheat it into good humour by joining in its play; and you must
+be ready to do this, not the first time only, but every time that you
+visit the child, and must try to win its affections in order to cure its
+disease. If you fail in the former, you will often be foiled in your
+attempts at the latter. Nor is this all; you must visit your patient
+very often if the disease is serious in its nature and rapid in its
+course. New symptoms succeed each other in infancy and childhood with
+great rapidity; complications occur that call for some change in your
+treatment, or the vital powers falter suddenly when you least expect it.
+The issues of life and death often hang on the immediate adoption of a
+certain plan of treatment, or on its timely discontinuance. Do not wait,
+therefore, for symptoms of great urgency before you visit a child three
+or four times a day; but if the disease is one in which changes are
+likely to take place rapidly, be frequent in your visits as well as
+watchful in your observation.'
+
+Each year has added to my conviction of the perfect truth of each word
+which I have quoted. If you believe your doctor to be a man of integrity
+and intelligence, be thankful for his frequent visits, which will cease
+as 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 your
+doctor; but do not say to him in a tone and with an emphasis which there
+is 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 to
+enter into all the details, important though they are, of a sick nurse's
+duties.
+
+For a linseed meal poultice, see that the water is _boiling_, not merely
+hot; warm the basin, put the water in _first_; sprinkle the meal on it,
+stirring the whole time, till it becomes of the uniform consistency of
+porridge, then spread it about half an inch thick over the linen, or
+whatever it is spread on, and turn up the edges for an inch all round to
+prevent the poultice crumbling and soiling the night-dress; and then
+having smeared the surface with a little oil, test its warmth by
+applying it to your cheek before putting it on the patient. A broad
+bandage of some sort or a soft towel must then be put round the body to
+keep the poultice in its place, and secured with safety pins.
+
+Pure mustard poultices are never used in children, on account of the
+pain they occasion, and the too great irritation which they would cause
+of the delicate skin of children. A mixture of one part of mustard to
+two of linseed meal is, however, often of much use in the chest
+affections 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, and
+are chiefly used in cuts, wounds, or small abscesses; and also because
+they are so easily made. A slice of stale bread without the crust is put
+on a plate, boiling water is poured over it, and drained off; it is then
+placed on a piece of muslin, pressed between two plates to squeeze out
+the remaining water, and its surface is greased before it is applied
+with a little oil or lard. I would refer for details about how to make
+poultices, and for many other things well worth the knowing, to Miss
+Wood's _Handbook of Nursing_, London, 12mo, 1883.
+
+[6] I am not ignorant of the doubts which have been raised with
+reference to the special influence of mercurial remedies on the liver,
+but prefer in a book written for non-medical readers to leave the
+popular opinion unquestioned.
+
+
+
+
+PART II.
+
+
+All that has been said hitherto is only introductory to the great
+purpose of this book, which is to give an account of the nature,
+symptoms, and course of the more important diseases of infancy and
+childhood.
+
+Any attempt at scientific arrangement of a popular book is useless. I
+prefer, therefore, to consult simply the general convenience of my
+readers. I think I do so best by considering first the disorders which
+beset the child in the first month of its existence, during what may be
+termed its transition from the condition of existence in the womb, to
+its living, breathing state as an inhabitant of this world; and next the
+more important ailments to which it is liable during that important time
+of development which ends with the completion of teething. Afterwards
+may be studied the diseases of the head, the chest, and the bowels; next
+constitutional diseases, such as consumption and scrofula; and lastly,
+the various fevers, as typhoid, or, as it is popularly called, remittent
+fever, measles, scarlatina, and small-pox; and last of all I will add a
+few remarks on the mental and moral characteristics of childhood, and
+their disorders.
+
+
+
+
+CHAPTER IV.
+
+ON THE DISORDERS AND DISEASES OF CHILDREN DURING THE FIRST MONTH AFTER
+BIRTH.
+
+
+=Still-birth.=--The infant cries almost as soon as it comes into the
+world. The cry is the evidence that air has entered its lungs, that the
+blood has now begun to take a different course from that which it
+followed before birth, and that the child has entered on a new
+existence. The child who does not cry, does not breathe; it is said to
+be _still-born_; its quietude means death.
+
+After a long or a difficult labour, or after the use of instruments, the
+child is sometimes still-born in consequence of blood being poured out
+on its brain, and it is thus killed before birth by apoplexy. This,
+however, is not usually the case, but the child is generally still-born
+because some cause or other, generally the protraction of labour,
+interfered with the due changes of its blood within the womb, and it is
+born suffocated before its birth, and consequently unable to make the
+necessary efforts to breathe afterwards.
+
+Drowned people are often resuscitated; the child's case is analogous to
+theirs; and in both the same measures have to be pursued, namely to try
+to 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 its
+surface, the presence or absence of perceptible beating of its heart,
+measure the chances of success. Sometimes mere exposure to the cold air
+produces the necessary effect; at other times breathing is excited by
+dashing cold water in the child's face, by slapping it, by tickling its
+nostrils, or by dipping it for a few seconds in a hot bath at 100° or
+102°; and then swinging it a few times backwards and forwards in the
+air.
+
+Much time, however, must not be lost over these proceedings, but the
+child must be laid on its back, the lower part of its body well wrapped
+up, the chest slightly raised by a folded napkin placed under it. The
+two arms must then be taken firmly, raised and slowly extended on either
+side of the head, then brought down again and gently pressed on either
+side of the chest; and this movement of alternate raising and extending
+the arms and bringing them back again beside the chest must be repeated
+regularly some thirty times in the minute, thus imitating the movements
+of the chest in breathing. These efforts, too, must not be discontinued
+so long as the surface retains its warmth, and as an occasional
+heart-beat shows that life is not absolutely extinct; and I believe that
+in many instances failure is due to want of perseverance rather than to
+the absolute uselessness of the measure.
+
+=Premature Birth.=--In spite of very extraordinary exceptions, it may be
+laid down as a rule that children born before the completion of six and
+a half months of pregnancy do not survive. After that date, each
+additional week adds greatly to the chances of the child living. There
+is a mistaken idea, founded on a superstition connected with the number
+seven, that a seven-months child is more likely to survive than one born
+at the eighth month. But this notion is as destitute of support in fact
+as it is opposed to common sense, and the nearer any woman has
+approached the full term of forty weeks of pregnancy, the greater are
+the 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 smaller
+air-cells; and its voice is a whimper rather than a cry. Those changes
+in the heart and large vessels, which prepare, as pregnancy draws to a
+close, for the altered course of the blood when the child has to breathe
+through the lungs, are too little advanced for it to bear well the
+sudden alteration in its mode of being. The feebly beating heart and the
+not completely developed lungs seem but imperfectly to maintain the
+bodily heat. The glands of the stomach and intestines are not yet fit to
+perform digestion properly, while the muscular power is too feeble for
+the effort at sucking. Everything is sketched out, but to nothing has
+the finishing touch been put, and hence the frail machinery too often
+breaks down, in the endeavour to discharge its functions.
+
+It is surprising, however, with what rapidity Nature in some instances
+perfects the work which she has been called on prematurely to perform.
+
+It is our business to second Nature's endeavours. First of all, and of
+most importance, is the duty of providing from without the warmth which
+the child is unable to generate. When very feeble, it must, even without
+any previous washing or dressing, be at once wrapped in cotton wool, and
+then in a hot blanket, and surrounded with hot-water bottles. A tin
+stomach-warmer filled with hot water is very convenient to place under
+the blanket on which the child lies. Being too feeble to suck, it must
+be fed, a few drops at a time, from a small spoon; or still better, if
+it is able to make any effort at sucking, it may draw its nourishment
+through a quill. The mother after a premature confinement is almost sure
+to have no milk with which to nourish her child, at any rate for two or
+three days. It is, therefore, wise to obtain the help of a woman with a
+healthy baby. She must be allowed to bring her baby with her, since
+otherwise her supply of milk would fail, especially if she had no other
+means of getting rid of it than by the breast-pump or by drawing her
+breast. Even though she may have her own baby, there are few women who
+can submit, for more than a very few days, to the artificial emptying
+their breast without the secretion being either greatly lessened or
+altogether arrested. This, therefore, must be regarded as a resource
+available only for a few days, and as the child gains strength every
+effort must be made to get it to take its mother's breast, if she has
+any supply, or that of the wet-nurse. If this is found impossible, it
+will be wisest to give up, at any rate for the present, the attempt to
+nourish 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 a
+sixth to a fourth part of a pint of milk be obtained either by the
+breast-pump or by drawing the breast; and since a healthy infant of a
+few weeks old sucks about two pints of milk in twenty-four hours, it is
+evident that the supply artificially obtained must after the first few
+days be utterly inadequate.
+
+I have in cases of extreme weakness in premature children succeeded in
+preserving them by giving them every two hours for two or three days ten
+measured drops of raw beef juice, five of brandy, and two teaspoonfuls
+of breast milk. Medicine has no place in the management of these cases;
+the question is one entirely of warmth, food, and for a time the
+judicious use of stimulants.
+
+=Imperfect Expansion of the Lungs.=--Children not premature and
+perfectly well nourished are yet sometimes feeble, breathe imperfectly,
+cry weakly, suck difficultly or not at all, and die at the end of a few
+days. Their lamp of life flickered and went out. Such cases are met with
+for the most part in conditions similar to those in which children are
+actually still-born; or now and then they take place when labour has
+been of unusually short duration, the child hurried into the world too
+rapidly; while in other instances it is not possible to account for
+their occurrence.
+
+For a long time the nature of these cases was not understood; but
+rather more than sixty years ago a German physician discovered that air
+had entered the lungs but imperfectly; that perhaps a third, perhaps
+even as much as half, of the lungs had never been dilated, but had
+remained solid and useless; that in consequence the blood was but
+half-purified, and vitality therefore but half-sustained. The lungs,
+however, were found to have undergone no real change; they were not
+diseased, but if air was blown into them the dark solid patches sunk
+below the level of the surrounding substance, expanded, grew bright in
+colour and like a sponge from which the water has been squeezed, and
+crackled, or crepitated as the technical term is, from the air contained
+within them.
+
+We breathe in health so without conscious effort that we never realise
+the fact that, according to the calculation of most competent observers,
+the mere elasticity of the lungs, independent even of the elasticity of
+the chest walls, opposes a resistance to each inspiration equal to 150
+pounds avoirdupois in the grown man and 120 in the grown woman. The want
+of breath puts the respiratory muscles into play: the man takes a deep
+inspiration, and by this unconscious effort, he overcomes the resistance
+of the chest and the elasticity of the lungs. The new-born infant feels
+the same want and makes the same effort; but its muscular power is
+small, and its inspirations are often so feeble as to draw the air in
+some parts only into the larger tubes, while many of the smaller remain
+undilated, and much of the lung continues in the state in which it was
+before birth. The blood being thus but imperfectly purified, all the
+processes of nutrition go on imperfectly, the vital powers languish, the
+inspiratory efforts become more and more feeble, while the elasticity of
+the lung is constantly tending to empty the small cells of air and to
+oppose its entrance, and next the temperature sinks and the infant dies.
+
+Cases in which this condition of the lungs exists usually present the
+history of the child from the very first having failed to utter a strong
+and loud cry like that of other children. Even after breathing has gone
+on for some time, such children usually appear feeble, and they suck
+with difficulty, although they often make the effort. An infant thus
+affected sleeps even more than new-born infants usually do; its voice is
+very feeble, and rather a whimper than a cry. In the cry of the healthy
+infant you at once detect two parts--the loud cry, suffering or
+passionate as the case may be, and the less loud back draught of
+inspiration. The French have two words for these two sounds--the _cri_
+and the _reprise_. The _cri_ is feeble, the _reprise_ is altogether
+wanting wherever expansion of the lung has to any considerable extent
+failed to take place, and you would hail this second sound as the best
+proof of an improvement in the child's condition.
+
+If you watch the child with a little attention you will see that while
+the chest moves up and down, it is very little, if at all, dilated by
+the respiratory movements. The temperature falls, the skin becomes pale,
+and the lips grow livid, and often slight twitching is observed about
+the muscles of the face. The difficulty in sucking increases, the cry
+grows weaker and more whimpering, or even altogether inaudible, while
+breathing is attended with a slight rattle or a feeble cough, and the
+convulsive movements return more frequently, and are no longer confined
+to the face, but affect also the muscles of the extremities. Any sudden
+movement suffices to bring on these convulsive seizures, but even while
+perfectly still the child's condition is not uniform, but it will
+suddenly become convulsed, and during this seizure the respiration will
+be extremely difficult, and death will seem momentarily impending. In a
+few minutes, however, all this disturbance ceases, and the extreme
+weakness of the child, its inability to suck, its feeble cry, and its
+frequent and imperfect inspirations, are the only abiding indications of
+the serious disorder from which it suffers. But the other symptoms
+return again and again, until after the lapse of a few days or a few
+weeks the infant dies.
+
+I have dwelt at some length on this condition because it is important to
+know that during the first few weeks of life real inflammation of the
+lungs or air-tubes is of extremely rare occurrence, and that the
+symptoms which are not infrequently supposed to depend on it are really
+due to a portion of the lung more or less extensive never having been
+called into proper activity. I may add that we shall hereafter have to
+notice a similar condition of the lung--its collapse after having once
+been inflated--as occurring sometimes in the course of real inflammation
+of the organs of respiration in early life, and forming a very serious
+complication of the original disease.
+
+If the collapse of the lung is not so considerable as to destroy life
+within the first few hours or days after birth, the babe wastes as well
+as grows weaker and weaker, and this wasting coupled with the difficult
+breathing not seldom causes the fear that the child has been born
+consumptive and that its death is inevitable.
+
+No such gloomy view need be taken. Collapse, or at least non-expansion
+of the lung to some extent, is by no means unusual: consumptive disease
+to such an extent in the new-born infant as to interfere with the
+establishment of breathing is extremely rare. The consumptive babe can
+suck, it is not so weak as the one whose lungs are imperfectly expanded;
+it has no convulsive twitchings, nor any of the strange head-symptoms
+which we notice in the former. It wastes less rapidly, it is feverish
+instead 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 who
+breathes imperfectly but ill maintains its heat. It must be kept warm at
+a temperature never less than 70°; it may, like the premature child,
+need stimulants, and all the precautions already mentioned as to
+feeding. Twice in the day it should be put for five minutes in a hot
+bath at 100°, rendered even more stimulating by the addition of a little
+mustard. The back and chest may be rubbed from time to time with a
+stimulating liniment, and an emetic of ipecacuanha wine may be given
+twice a day. The act of vomiting not only removes any of the mucus which
+is apt to accumulate in the larger air tubes, but the powerful
+inspirations which follow the effort tend to introduce air into the
+smallest 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 will
+before many days be greeted by the loud cry, with its _cri_ and
+_reprise_ of which I have already spoken, and which assures her that her
+little one will live.
+
+There are no other affections of the lungs so peculiar to the first
+month of life as to call for notice here. I shall have a few
+observations to make about malformations of the heart, and the
+precautions for which they call in the after-life of children; but they
+will 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 the
+eye and the dark colour of the urine, is by no means to be confounded
+with real jaundice. It is no real jaundice, but is merely the result of
+the changes which the blood with which the small vessels of the skin are
+overcharged 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 castor
+oil wherewith the over-busy monthly nurse is always ready. It is a
+natural process, which the intelligent may watch with interest, with
+which none but the ignorant will try to interfere.
+
+There is, however, beside this a real jaundice, in which the skin is
+more deeply stained, the whites of the eyes are yellow, the urine
+high-coloured, and in which the dark evacuations that carry away the
+contents of the bowels before birth are succeeded by white motions, from
+which the bile is absent. This condition is not very usual, save where
+children have been exposed to cold, or where the air they breathe is
+unwholesome. Of this no better proof can be given than is afforded by
+the fact that in the Dublin Lying-in Hospital, where the children are
+defended with the greatest care both from cold and from a vitiated
+atmosphere, infantile jaundice is extremely rare, while it attacks
+three-fourths of the children received into the Foundling Hospital of
+Paris. Still it does sometimes occur when yet no cause can be assigned
+for it, and it is noteworthy that it is sometimes met with in successive
+infants 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 be
+paid during its continuance to avoid exposure of the child to cold,
+while no other food than the mother's milk should be given. If the
+bowels are at all constipated, half a grain of grey powder or a quarter
+of a grain of calomel may be given, followed by a small dose of castor
+oil, and the aperient will often seem to hasten the disappearance of the
+jaundice; but in a large number of cases even this amount of medical
+interference is not needed.
+
+There is, indeed, a very grave form of jaundice, happily of excessive
+rarity, due to malformation of the liver, to absence or obstruction of
+the bile-ducts, and often accompanied with bleeding from the navel. I do
+but mention it; the intensity and daily deepening of the jaundice, the
+fruitlessness of all treatment, and the grave illness of the child, even
+though no bleeding should occur, render it impossible to confound this
+hopeless condition with the trivial ailment of which I have been
+speaking.
+
+The next chapter will furnish a fitter place than the present for
+speaking fully of the Disorders of the Digestive Organs.
+
+I will say now but this: that whatever a mother may do eventually, she
+avoids grave perils for herself by suckling her infant for the first
+month; while the health of her child, just launched upon the world, is
+terribly endangered if fed upon those substitutes for its proper
+nutriment on which after the lapse of a few weeks it may subsist, may
+even manage to thrive.
+
+There are some local affections incident to the new-born child
+concerning 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 sight
+of nine-tenths of all persons who, among the poor, are said to have been
+born blind. In the wealthier classes of society it is comparatively
+rare, and seldom fails to meet with timely treatment, yet many people
+scarcely realise its dangerous character, or the extreme rapidity of its
+course.
+
+It generally begins about the third day after birth with swelling of
+the lid of one or other eye, though both are soon involved. The eyelids
+swell rapidly, and if the affection is let alone, they soon put on the
+appearance of two semi-transparent cushions over the eyes. On separating
+the lids, which it is often very difficult to do owing to the spasmodic
+contraction of the muscles, their inner surface is seen to be enormously
+swollen, bright red, like scarlet velvet, bathed in an abundant
+yellowish thin secretion, which often squirts out in a jet as the lids
+are forcibly separated. Great care must be taken not to allow any of
+this fluid to enter the eye of a bystander, nor to touch his own eye
+until the fingers have been most carefully washed, since the discharge
+is highly contagious, and may produce most dangerous inflammation of the
+eyes of any grown person. The discharge being wiped or washed away, the
+eye itself may be seen at the bottom of the swelling very red, and its
+small vessels very blood-shot. By degrees the surface of the eye assumes
+a deeper red, it loses its brightness and its polish, while the swelling
+of the lids lessens, and they can be opened with less difficulty; their
+inner surface at the same time becomes softer, but thick and granular,
+and next the eyes themselves put on likewise a granular condition which
+obscures vision. The discharge by this time has become thicker and
+white, and looks like matter from an abscess. By slow degrees the
+inflammation may subside, the discharge lessen, the swelling diminish,
+and the eye in the course of weeks may regain its natural condition. But
+the danger is--and when proper treatment is not adopted early the danger
+is very great--lest the mischief should extend beyond the surface of the
+eye, lest ulceration of the eye should take place, the ulceration reach
+so deep as to perforate it, and not merely interfere with the sight, but
+destroy the organ of vision altogether.
+
+In every instance, then, in which the eyelids of a new-born infant
+swell, or the slightest discharge appears from them, the attention of
+the doctor must at once be called to the condition. In the meantime, and
+during whatever treatment he may think it right to follow, the eye must
+be 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 squeezed
+into it abundantly from a sponge held above, but not touching it, so as
+to completely wash away all the discharge. A weak solution of alum and
+zinc, as one grain of the latter to three of the former to an ounce of
+water, may in like manner be dropped from a large camel's-hair brush
+four times a day into the eye after careful washing. Simple as these
+measures are they yet suffice, if adopted at the very beginning, and
+carried on perseveringly, to entirely cure in a few days an ailment
+which if let alone leads almost always to most lamentable results.
+
+I do not pursue the subject further, for bad cases require all the care
+of the most skilful oculist for their treatment.
+
+=Scalp Swellings.=--Almost every new-born child has on one or other side
+of its head a puffy swelling, owing to the pressure to which the head
+has been subjected in birth, and this swelling disappears at the end of
+twenty-four or forty-eight hours.
+
+Now and then, however, though indeed very seldom, the swelling does not
+disappear, but it goes on gradually increasing and becoming more
+definite in its outlines until at the end of three or four days it may
+be as big as half a small orange, or sometimes even larger, soft,
+elastic, painless, under the unchanged scalp, but presenting the
+peculiarity of having a hard raised margin with a distinct edge, which
+gives to the finger passed over it the sensation of a bony ridge, beyond
+which the bone seems deficient. This tumour is due usually to the same
+cause as that which produces the other temporary puffy swelling of the
+scalp, only the pressure having been more severe, blood has actually
+been forced out from the small vessels under the membrane which covers
+the skull, and hence its gradual increase, its definite outline; and
+hence, too, the bony ridge which surrounds it, and which is due to
+nature's effort at cure, in the course of which the raised edge of the
+membrane covering the skull (the _pericranium_) becomes converted into
+bone.
+
+When the nature of these swellings was not understood, they used to be
+poulticed, and to be opened with a lancet to let out their contents. We
+know now, however, that we have nothing to do but to let them alone;
+that by degrees the blood will be absorbed and the tumour will
+disappear, and as it does so we may trace the gradual transformation of
+the membrane which covered it into bone, as we feel it crackling like
+tinsel under the finger. Two, three, or four weeks may be needed for the
+entire removal of one of these blood-swellings. The doctor will at once
+recognise its character, and you will then have nothing to do but to
+wait--often, unhappily, so much harder for the anxious mother than to
+meddle.
+
+=Ruptured Navel.=--There is a period some time before the birth of a
+child when the two halves of its body are not united in front, as they
+become afterwards; and hare-lip or cleft-palate sometimes remains as the
+result of the arrest of that development which should have closed the
+fissured 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 the
+bowels are not supported by the muscles, but protected only by the skin.
+
+More frequently than this, especially in the case of children who are
+born before the time, the opening through which the navel string passes
+is large at birth, and fails to close as speedily and completely as it
+should do afterwards. When everything goes on as it ought, the gradual
+contraction of the opening helps to bring about the separation of the
+navel string and its detachment, and the perfect closure of the opening
+takes place at the same time, between the fifth and the eighth day after
+birth.
+
+If this does not occur, the bowels are very apt to protrude through the
+opening, and if allowed to do so for weeks or months, the opening
+becomes so dilated that its closure is impossible, and the child grows
+up afflicted permanently with rupture through the navel. This is always
+an inconvenience, sometimes even a source of serious danger; but if
+means are taken to prevent the condition becoming worse, nature seldom
+fails eventually to bring about a cure, and to effect the complete
+closure of the opening.
+
+If the muscles on either side do not come into apposition, but leave a
+cleft between them, the infant should constantly wear a broad bandage of
+fine flannel round the stomach, not applied too tightly, in order to
+give support. The circular bandages of vulcanised india-rubber with a
+pad in the centre are nowise to be recommended. The pad is apt to become
+displaced, and to press anywhere but over the navel, while its edges
+irritate the infant's delicate skin, and the pressure which it exerts if
+it is sufficiently tight to retain its place interferes with
+respiration.
+
+A pad composed of pieces of plaster spread on wash-leather, and of
+graduated sizes and kept in place by adhesive strapping,[7] answers the
+purpose of preventing the protrusion at the navel, and of thus
+facilitating the closure of the ring better than any other device with
+which I am acquainted. They need, however, to be continued even for two
+or three years, and though they should have been left off it is wise to
+resume 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 had
+of Ewen, 106 Jermyn Street, St. James's, London, and I dare say at many
+other places besides.
+
+
+
+
+CHAPTER V.
+
+ON THE DISORDERS AND DISEASES OF CHILDREN AFTER THE FIRST MONTH, AND
+UNTIL TEETHING IS FINISHED.
+
+
+=Infantile Atrophy.=--In by far the greater number of instances, the
+wasting of young children is due to their being fed upon food which they
+cannot digest, or which when digested fails to yield them proper
+nourishment. I quoted some figures in my introductory remarks, to show
+from the evidence obtained at Berlin how much larger was the proportion
+of deaths under the age of one year among hand-fed infants than among
+those brought up at the breast. Foundling hospitals on the Continent, in
+which the children are all drawn from the same class, and subjected in
+all respects to a similar treatment, except that in some they are fed at
+the breast, in others brought up by hand, show a mortality in the latter
+case exactly double of that in the former.
+
+It is as idle to ignore these facts, and to adduce in their disproof the
+case of some child brought up most successfully by hand, as it would be
+to deny that a battle-field was a place of danger because some people
+had been present there and had come away unwounded.
+
+But it is always well not merely to accept a fact, but also to know the
+reason why a thing is so. The reason is twofold: partly because the
+different substitutes for the mother's milk, taken for the most part
+from the vegetable kingdom, are less easy of digestion than the milk,
+and partly because, even were they digested with the same facility, they
+do not furnish the elements necessary to support life in due proportion.
+
+All food has to answer two distinct purposes: the one to furnish
+materials for the growth of the body, the other to afford matter for the
+maintenance of its temperature; and life cannot be supported except on a
+diet in which the elements of nutrition and those of respiration bear a
+certain proportion to each other. Now, in milk, the proper food of
+infants, the elements of the former are to those of the latter about in
+the proportion of 1 to 2, while in arrowroot, sago, and tapioca they are
+only as 1 to 26, and in wheaten flour only as 1 to 7. If to this we add
+the absence in these substances of the oleaginous matters which the milk
+contributes to supply the body with fat, and the smaller quantity, and
+to 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 of
+the infant must almost inevitably be sacrificed.
+
+But these substances are not only less nutritious, they are also less
+easy of digestion than the infant's natural food. We all know how
+complex is the digestive apparatus of the herbivorous animal, of which
+the four stomachs of the ruminants are an instance, and how large is the
+bulk 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 carnivorous
+animal, intended for food which shall not need to stay long in that
+receptacle, but shall be speedily digested; and it is only as the child
+grows older, and takes more varied food, that the stomach alters
+somewhat in form, that it assumes a more rounded shape, resembling
+somewhat that of the herbivorous animal, and suited to retain the food
+longer. The young of all creatures live upon their mother for a certain
+time after birth; but in all the preparation for a different kind of
+food, and with it for an independent existence, begins much sooner and
+goes on more rapidly than in man. Young rabbits are always provided with
+two teeth when born, and the others make their appearance within ten
+days. In the different ruminants the teeth have either begun to appear
+before birth, or they show themselves a few days afterwards; and in
+either case dentition is completed within the first month, and in dogs
+and cats within the first ten weeks of existence.
+
+In the human subject the process of teething begins late, between the
+seventh and the ninth month, and goes on slowly: the first grinding
+teeth are seldom cut before the beginning of the second year, and
+teething is not finished until after its end. Until teething has begun
+the child ought to live exclusively on the food which nature provides;
+for until that time the internal organs have not become fitted to digest
+other sustenance, and the infant deprived of this too often languishes
+and dies. To get from other food the necessary amount of nourishment,
+that food has to be taken in larger quantities, and, from the difficulty
+in digesting it, needs to remain longer in the stomach than the mother's
+milk. One of the results of the indigestibility of the food is that the
+child is often sick, the stomach getting rid of a part of that food
+which it is unable to turn to any useful purpose; and so far well. But
+the innutritious substances do not relieve the sense of hunger. The
+child cries in discomfort, and more is given to it, and by degrees the
+over-distended stomach becomes permanently dilated, and holds a larger
+quantity than it was originally meant to contain. The undigested mass
+passes into a state of fermentation, and the infant's breath becomes
+sour and offensive, it suffers from wind and acid eructations, and
+nurses sometimes express surprise that the child does not thrive since
+it is always hungry. While some of the food is got rid of by vomiting,
+some passes into the intestines, and there becomes putrid, as the
+horribly offensive evacuations prove. They come away, large and solid
+and white, for the secretion of the bile is inadequate to complete that
+second digestion which should take place in the intestines; or else the
+irritation which they excite occasions diarrh[oe]a--a green putty-like
+matter comes away mixed with a profuse watery discharge.
+
+What wonder is it that in such circumstances the body should waste most
+rapidly; for it is forced from its own tissues to supply those elements
+essential to the maintenance of life, which its food contains in far too
+scanty a proportion. Every organ of the body contributes to the general
+support, and life is thus prolonged, if no kind disease curtail it,
+until each member has furnished all that it can spare, and then death
+takes place from starvation, its approach having been slower, but the
+suffering which preceded it not therefore less, than if all food had
+been withheld.
+
+Do not suppose that in this description I have been painting too dark a
+picture, or that children who die thus have been exceptionally weak, and
+so under the acknowledged difficulties of hand-feeding at length became
+consumptive. They do not die of consumption, and in a large number of
+instances their bodies show no trace of consumptive disease, but present
+appearances characteristic of this condition of starvation, and of this
+only.
+
+Along the whole track of the stomach and intestines are the signs of
+irritation and inflammation. The glands of the bowels are enlarged,
+actual ulceration of the stomach is often met with; while so
+far-reaching is the influence of this slow starvation, that even the
+substance of the kidneys and of the brain are often found softened and
+otherwise altered, though it might not unreasonably have been supposed
+that these organs lay quite beyond the reach of any disorder of
+digestion.
+
+No doubt all these grievous results do not always follow; and sometimes
+children exceptionally strong manage to take and digest enough even of
+unsuitable food to maintain their health, and may as they grow up, and
+the changes take place in the system which fit it for a varied diet,
+even become robust. In the majority of instances, however, hand-fed
+infants, and those especially who have been brought up chiefly on
+farinaceous food, are less strong than others, and are more apt to
+develop any latent tendency to hereditary disease, such as scrofula or
+consumption, than members of the same family who have been brought up at
+the breast.
+
+Enough has already been said to satisfy all but those who do not wish
+to be convinced, how incumbent it is on every mother to try to suckle
+her child. But though it is most desirable that for the first six months
+of their existence children should derive their support entirely from
+their mother, and that until they are a year or at least nine months old
+their mother's milk should form the chief part of their food, yet many
+circumstances may occur to render the full adoption of this plan
+impracticable. In some women the supply of milk, although at first
+abundant, yet in the course of a few weeks undergoes so considerable a
+diminution as to become altogether insufficient for the child's support;
+while in other cases, although its quantity continues undiminished, yet
+from some defect in its quality it does not furnish the infant with
+proper nutriment. Cases of the former kind are not unusual in young,
+tolerably healthy, but not robust women; while instances of the latter
+are met with chiefly among those who have given birth to several
+children, whose health is bad, or among the poor, who have been
+enfeebled by hard living or hard work. The children in the former case
+thrive 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 their
+rapid growth, they pine and fret, they lose both flesh and strength,
+and, unless the food given to supply their wants be judiciously
+selected, their stomach and bowels become disordered, and nutrition,
+instead of being aided, is more seriously impaired. In the case of the
+mother whose milk disagrees with the child from some defect in its
+quality, the signs are in general more pronounced. Either the infant
+vomits more than that small quantity which a babe who has sucked
+greedily or overmuch often rejects immediately on leaving the breast, or
+it is purged, or it seems never satisfied, does not gain flesh, does not
+thrive, cries much and is not happy. In these cases, too, the mother's
+supply of milk, though abundant at first, diminishes in a few weeks; she
+feels exhausted, and suffers from back-ache, or from pain in the breasts
+each time after the child's sucking; while, further, her general
+weakness leaves her no alternative but to wean the child.
+
+Knowing the attempt to rear her child entirely at the breast to be
+vain, the mother may in such cases be tempted to bring it up by hand
+from the very first. But how short soever the period may be during which
+the mother may be able to suckle her child, it is very desirable that
+she should nurse it during that period, and also that her milk should
+then constitute its only food. For the first four or five days after the
+infant's birth the milk possesses peculiar qualities, and not merely
+abounds in fatty and saccharine matter, but presents its casein or curd
+in a form in which it is specially easy of digestion. These
+peculiarities indeed become less marked within a week or two; but not
+only is it of moment that the infant should at any rate make its start
+in life with every advantage, but the mother who nurses her little one
+even for a month avoids thereby almost half the risks which follow her
+confinement. For the indolent, among the wealthy, a numerous class who
+have but to form a wish in order to have it gratified, a wet-nurse for
+the baby suggests itself at once to the mother as a ready means of
+saving herself trouble, and of shirking responsibility. This course, to
+which love of pleasure and personal vanity tend alike to prompt her,
+often finds, in spite of all opposing reasons, the approval of the
+nurse, to whom it saves trouble, and the too ready acquiescence of the
+doctor in a course which pleases his patient. But many circumstances
+besides those moral considerations, which ought never to be forgotten
+before the determination is formed to employ a wet-nurse, may put this
+expedient out of the question, and it becomes therefore of importance to
+learn what is the best course for a mother to adopt who is either wholly
+unable 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 the
+character of the mother's milk, the greater will be the prospect of the
+attempt to rear the child upon it proving successful. There is no
+argument needed to prove that the milk of some animal more closely
+resembles the mother's milk, and is more likely to prove a useful
+substitute for it than any kind of farinaceous substance. The milk of
+all animals, however, differs in many important respects from human
+milk, and differs too very widely in different animals. Thus, the milk
+of the cow and that of the ewe contain nearly double the quantity of
+curd, and that of the goat more than twice the quantity of butter, and
+it is only in the milk of the ass that the solid constituents are
+arranged in the same order as in man. On this account, therefore, asses'
+milk is regarded, and with propriety, as the best substitute for the
+child's natural food. Unfortunately, however, expense is very frequently
+a bar to its employment, and compels the use of the less easily digested
+cows' milk. But though the cost may be a valid objection to the
+permanent employment of asses' milk, it is yet very desirable when a
+young infant cannot have the breast, that it should be supplied with
+asses' milk for the first four or five weeks, until the first dangers of
+the experiment of bringing it up by hand have been surmounted. The
+deficiency of asses' milk in butter may be corrected by the addition of
+about a twentieth part of cream, and its disposition to act on the
+bowels may be lessened by heating it to boiling point, not over the fire
+but in a vessel of hot water; and still more effectually by the addition
+to it of a fourth part of lime-water or of a teaspoonful of the solution
+of saccharated carbonate of lime to two ounces or four tablespoonfuls of
+the milk.
+
+When cows' milk is given, it must be borne in mind that it contains
+nearly twice as much curd, and about an eighth less sugar, than human
+milk. It is therefore necessary that it should be given in a diluted
+state and slightly sweetened. The dilution must vary according to the
+infant's age; at first the milk may be mixed with an equal quantity of
+water, but as the child grows older the proportion of water may be
+reduced to one-third. Mere dilution with water, however, leaves the
+proportion of curd unaltered, and it is precisely the curd which the
+infant is unable to digest. Instead, therefore, of diluting the milk
+simply with water, it is often better to add one part of whey to about
+two parts of milk, which, according to the child's age, may or may not
+be previously diluted.[8]
+
+Attention must be paid to the temperature of the food when given to the
+infant, which ought to be as nearly as possible the same as that of the
+mother's milk, namely from 90° to 95° Fahrenheit, and in all cases in
+which care is needed a thermometer should be employed in order to insure
+the food being given at the same temperature. Human milk is alkaline,
+and even if kept for a considerable time it shows little tendency to
+become sour. The milk of animals when in perfect health likewise
+presents an alkaline reaction, and that of cows when at grass forms no
+exception to this rule. Milk even very slightly acid is certain to
+disagree with an infant; it is therefore always worth while the moment
+that a hand-fed infant seems ailing to ascertain this point. If
+alkaline, the milk will deepen the blue colour of litmus paper, which is
+to be had of any chemist; if acid, it will discharge the colour and turn
+it red. It is, perhaps, as well to add that, as the oxygen in the
+atmosphere tends to redden litmus paper, it should not be left exposed
+to the air, but should always be kept in a glass-stoppered bottle.
+
+The milk of the cow is very liable to alteration from comparatively
+slight causes, and particularly from changes in the animal's diet; while
+even in the most favourable circumstances if the animal is shut up in a
+city and stall-fed, all the solid constituents of its milk suffer a
+remarkable diminution; while the secretion further has a great tendency
+to become acid, or to undergo even more serious deterioration. Mere
+acidity of the milk can be counteracted for the moment by the addition
+of lime-water, or by stirring up with it a small quantity of prepared
+chalk, which may be allowed to subside to the bottom of the vessel; or
+if it should happen, though indeed that is rarely the case in these
+circumstances, that the child is constipated, carbonate of magnesia may
+be substituted for the chalk or lime-water. If these simple proceedings
+are not sufficient to restore the infant's health, it will be wise to
+seek at once for another source of milk supply, and to place the
+suspected milk in the hands of the medical officer of health or of the
+public analyst, in order that it may be submitted to a thorough chemical
+and microscopical examination.
+
+The difficulty sometimes found in obtaining an unvaryingly good milk
+supply, as well as practical convenience in many respects, has led to
+the extensive employment of various forms of condensed milk. They form
+undoubtedly the best substitute for fresh cows' milk which we possess,
+and are a great boon especially to the poor in large towns where the
+milk supply is often scanty, not always fresh, and sometimes of bad
+quality. I should certainly prefer condensed milk for an infant to milk
+from cows living in close dirty stables, such as my experience thirty
+years ago made me familiar with in some parts of London.
+
+Still all the varieties of condensed milk are far inferior in quality
+to good fresh milk. They contain less butter, less albumen, that is to
+say less of the main constituents of all animal solids and fluids, and a
+greater proportion of what are termed the hydro-carbonates, such for
+instance as sugar; or, to state the same thing differently, the elements
+which serve for nutrition are in smaller proportion than in fresh milk
+to those which minister to respiration. They are not only less
+nutritious, but the large quantity of sugar which they contain not
+infrequently disagrees with the child, and causes bowel complaint. I do
+not know how far the so-called unsweetened condensed milk which has of
+late come into the market is free from this objection; but I have always
+preferred the Aylesbury condensed milk, which is manufactured with
+sugar, to the Swiss condensed milk, into which, as I have been given to
+understand, honey largely enters.
+
+How much food does an infant of a month old require? what intervals
+should be allowed between each time of feeding? and how should the food
+be given? are three questions which call for a moment's notice. The
+attempt has been made to determine the first point by two very
+distinguished French physicians, who weighed the infants before and
+after each time of sucking. Their observations, however, were not
+sufficiently numerous to be decisive, and their results were very
+conflicting; the one estimating the quantity at two pounds and a quarter
+avoirdupois, which would be equivalent to nearly a quart, the other at
+not quite half as much; but the observations of the latter were made on
+exceptionally weak and sickly infants. Infants no doubt vary, as do
+grown people, as to the quantity of food they require. I should estimate
+from my own experience and observation, apart from accurate data, a pint
+as 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 months
+seems to me very reasonable, I should doubt its sufficing for a child of
+nine 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 three
+hours; and this frequent need of food continues until the age of two,
+sometimes even until three, months. Afterwards, and until six months
+old, the child does not need to be fed oftener than every three hours
+during the twelve waking hours, and every four hours during the sleeping
+time. Later on, five times in the twenty-four hours, namely thrice by
+day, 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 the
+cup or spoon; a child so fed has no choice in the matter, but must
+either swallow or choke, and is fed as they fatten turkeys for the
+market. The infant, on the other hand, sucks the bottle as it would suck
+its mother's breast; it rests when fatigued, it stops to play, it leaves
+off when it has had enough, and many a useful inference may be drawn by
+the observant nurse or mother who watches the infant sucking, and
+notices if the child sucks feebly, or leaves off panting from want of
+breath, or stops in the midst, and cries because its mouth is sore or
+its gums are tender.
+
+But it is not every bottle which an infant should be fed from, and
+least 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 hour
+together with the end in its mouth, sucking, or making as though it
+sucked, even when the bottle is empty. These bottles, as well as the
+tubes connected with them, are most difficult to keep clean; and so
+serious is this evil, that many French physicians not only denounce
+their use, in which they are perfectly justified, but prefer, to the use
+of any bottle at all, the feeding the infant with a spoon; and here I
+think they are mistaken. The old-fashioned flat bottle, with an opening
+in the middle, and a short end to which the nipple is attached without
+any tube, the only one known in the time of our grandmothers, continues
+still the best, and very good. My friend, Mr. Edmund Owen, in a lecture
+at which I presided at the Health Exhibition in August last year,
+pointed out very humorously the differences between the old bottle and
+the new. An infant to be kept in health must not be always sucking, but
+must be fed at regular intervals. The careful nurse takes the infant on
+her knee, feeds it from the old-fashioned feeding-bottle, regulating the
+flow of the milk according as the infant sucks heartily or slowly,
+withdraws it for a minute or two, and raises the child into a sitting
+posture if it seems troubled with flatulence, and then after a pause
+lets it recommence its meal. This occupies her a quarter of an hour or
+twenty minutes of well-spent time, while the lazy nurse, or the mother
+who has never given the matter a thought, just puts the tube in the
+infant's mouth, and either takes no further trouble or occupies herself
+with something else. And yet, obvious though this is, how constantly one
+sees infants taken about in the perambulator with the feeding-bottle
+wrapped up and laid by its side, because it is said the child always
+cries when it is not sucking, and the intelligence and the common sense
+are wanting, as well as the patient love, that would strive to make out
+which it is of many possible causes that makes the infant cry. One more
+observation with reference to bottle-feeding may not be out of place. It
+is this: that no food be left in the bottle after the child has had its
+meal, but that it should be emptied, washed out with a little warm water
+and soda, and it and the india-rubber end should be kept in water till
+again needed. To insure the most perfect cleanliness it is always well
+to have two bottles in use, and to employ them alternately.
+
+How strictly soever an infant may be kept at the breast, or however
+exactly the precautions on which I have insisted are observed, sickness,
+constipation, or diarrh[oe]a may occur, causing much anxiety to the
+parents, and giving much trouble to the doctor.
+
+It sometimes happens, without its being possible to assign for it any
+sufficient reason, that the mother's milk disagrees with her infant, or
+entirely fails to nourish it, so that, much against her will, she is
+compelled to give up suckling it. In some instances this is due to
+errors in diet, to the neglect of those rules the observance of which is
+essential to health, as proper exercise for instance; and then the
+secretion is usually deficient in quantity as well as defective in its
+composition. In such cases the child often vomits soon after sucking, it
+suffers from stomach-ache, its motions are very sour, of the consistence
+of putty, and either green, or become so soon after being passed,
+instead of presenting the bright yellow colour and semi-fluid
+consistence of the evacuations of the healthy infant, and sometimes they
+are also lumpy from the presence of masses of undigested curd. In
+addition, also, the child is troubled with griping, which makes it cry;
+its breath is sour, or actually offensive, and the tongue is much whiter
+than it should be, though it must be remembered that the tongue of the
+sucking child always has a very slight coating of whitish mucus, and is
+neither as red nor as perfectly free from all coating as it becomes in
+the perfectly healthy child of three or four years old.
+
+In these circumstances, the diminution of stimulants, such as the stout
+of which young women are sometimes mistakenly urged to take a quantity
+to which they were previously quite unaccustomed, is often followed by
+an increase of the quantity as well as an improvement in the quality of
+the milk. It is true that a nursing mother may often find her strength
+maintained, and her supply of milk increased, by taking a glass of stout
+at lunch and another at dinner, instead of, but not in addition to, any
+other stimulant; but mere stimulants will no more enable a woman to
+suckle her infant better than she otherwise would do, than they would
+fit a man to undergo great fatigue for days together, or to go through a
+walking tour in Switzerland. A tumbler of one-third milk and two-thirds
+good grit gruel taken three times a day will have greater influence in
+increasing the quantity of milk than any conceivable amount of
+stimulant.
+
+There is an entirely opposite condition in which the infant does not
+thrive at the breast, and this for the most part is met with when the
+mother has already given birth to and suckled several children. In these
+instances the secretion is sometimes, though not always, abundant, but
+the infant does not thrive upon it. The babe does not get on, is always
+hungry after leaving the breast, and cries as though it wanted more; in
+addition to which it is often purged, either while sucking or within a
+few minutes afterwards, though the motions, except in being more
+frequent and more watery than in health, do not by any means constantly
+show any other change. The mother's history explains the rest. She is
+constantly languid, suffers from back-ache, feels exhausted each time
+after the babe has sucked, probably has neuralgia in her face, or
+abiding headache. In many instances, too, her monthly periods return,
+though as a rule they do not appear in healthy women while suckling. All
+these symptoms show that her system is not equal to the duty she has
+undertaken, and that therefore, for her sake as well as for that of the
+infant, she must give up the attempt.
+
+One more case there is in which suckling has to be given up, at any rate
+in part, and that is when the milk is good in kind, but insufficient in
+quantity for the child as it grows older. This insufficiency of quantity
+shows itself at different periods after the infant's birth--at two
+months, three, or four. The child is not otherwise ill than that it is
+no longer bright, as it was wont to be, it ceases to gain flesh, it
+sleeps more than it used to do, though when it wakes it is always eager
+for the breast, and cries when leaving it, and if the experiment is made
+of giving it some milk and water immediately on leaving it, it takes
+that greedily. Mothers are loth to believe this failure of their
+resources, and in the case of some who have firm and well-formed
+breasts, there is but little change in their appearance to show that
+what remains may serve for beauty, not for use. But if while the child
+is sucking, the nipple is taken suddenly from its mouth, instead of
+innumerable little jets of milk, spirting out from the openings of the
+milk-ducts, the nipple will be seen to be barely moistened by its
+languid flow.
+
+In conditions such as these the question of weaning partially or
+completely inevitably occurs, and where the mother's weakness is the
+occasion of the failure to nourish the child, half-measures are of no
+avail, for so long as she does not entirely give up the attempt to do
+that to which her health is unequal, her own state will grow worse, that
+of the child will not improve. When errors of diet or inattention to
+general rules of health incapacitate the mother from the performance of
+her duty, there may be hope from the adoption of a wiser course; while
+when the supply simply fails from its inadequacy, much may be hoped for
+from a wise combination of hand-feeding with nursing at the breast; the
+mother perhaps suckling the infant by day, but being undisturbed by
+demands upon her at night.
+
+Last of all, I must refer to cases in which love has been stronger than
+reason, as indeed it often is, and in which young people with some
+pronounced hereditary taint of scrofula or consumption marry and have
+children. In such cases, if the consumptive taint is on the mother's
+side, it is, I believe, much wiser, in the inability to obtain a good
+wet-nurse, to bring up the child by hand rather than at the mother's
+breast. One word, however, applicable in such circumstances, age and
+long experience entitle me to add, and it is this. It is essential that,
+in the absence of that guarantee against the too rapid succession of
+pregnancies which suckling for a reasonable time presents, there should
+be self-restraint on both sides, lest the inscription on the young
+wife's grave should be, as I have too often known it, the same as, in
+despite of poetry and romance, her biographer assigns as the cause of
+the death of Petrarch's Laura, that she died worn out _crebris
+partubus_, by too many babies.
+
+In all of these cases the rules which I have already given with
+reference to hand-feeding have to be borne in mind: the preference for
+asses' milk at first, the careful regulation of the amount of curd in
+the cows' milk afterwards, increased or diminished by the greater or
+less proportion of whey mixed with it. Sometimes, however much the
+quantity of curd or casein may be reduced, the child is yet unable to
+digest it, for it is firm and not easily acted on by the juices of the
+stomach. It is then best to omit it altogether, and to supply the
+necessary albumen by white of egg. A very good food in these
+circumstances 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 stronger
+nourishment, one part of veal-tea, made with a pound of veal to a pint
+of water, may be added to one part of whey, with the white of egg and
+sugar of milk as before, and one part of white decoction, as it was
+called 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 into
+the infant's diet, and preparing the way for a larger amount of it which
+by degrees becomes necessary. Of these, one of the most generally useful
+is Liebig's or Savory and Moore's food for infants, which has the
+advantage of not constipating as so many other farinaceous foods do.
+Chapman's Entire Wheat Flour is an extremely good food; and wheat, as
+you will remember, excels other farinaceous substances in its nutritive
+properties, but it is not so easy of digestion as Liebig. There is,
+however, scarcely any kind of farinaceous food, among which Nestlé's
+must not be forgotten, which may not answer for an infant; provided
+always that at first it is not given oftener than twice a day, that it
+is not made too thick, nor given in larger proportion than one-third of
+the farinaceous food to two-thirds of the whey, milk, or whatever it is
+mixed with; and besides, whatever the food may be, it should be prepared
+each time afresh.
+
+This is not the place for going into all details on the subject of
+feeding infants, or to explain how if wisely managed the child weans
+itself by degrees from the bottle or the breast--the best way, be it
+said, of weaning--or how by degrees it comes to its daily midday meal of
+beef-tea and bread, and then, when the first grinding teeth have been
+cut, to a small meat meal daily, finely minced or scraped, and so little
+by little adopts the modes of living of its elders.
+
+But, last of all, there are instances, though not so many as the public
+imagine, 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 in
+which the infant is the subject of consumptive disease. It is very rare
+for its symptoms, even in cases of the most marked tendency to
+consumption on the part of the parents, to show themselves before the
+age of three months, and I think I may add, that apart from such
+tendency consumption never appears in infancy or early childhood, except
+when it follows on some acute illness, such as inflammation of the
+lungs, or on typhoid, or, as it is commonly called, remittent fever.
+
+Consumption of the bowels, as it is popularly termed, may be said never
+to occur in early infancy apart from consumptive disease of the lungs,
+and is then always accompanied by an increase towards evening of the
+temperature from its natural standard of 98.5° to 100°. Hence the
+absence of cough and the persistence of a natural temperature may be
+taken as almost conclusive evidence that there is no consumptive disease
+of the bowels. Consumptive disease in infancy is invariably attended
+with glandular enlargement. The glands of the bowels when irritated
+always communicate their irritation to the glands in the groin and the
+bend 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 of
+the bowels, other tiny enlarged glands will be felt, like shot, under
+the skin of the belly, from which in the general progress of emaciation
+the layer of fat always present in the healthy baby will already have
+been removed. Besides this, too, the veins running beneath the skin
+there, invisible in the healthy infant, will be seen meandering like
+blue lines, and telling the story that more blood than usual flows
+through them, because the diseased glands inside interfere with its
+ready passage through its proper channels.
+
+Two cautions, however, have to be borne in mind with reference to both
+of these indications of disease. The first is, that the glands in the
+groin may be enlarged from mere irritation, independent of actual
+disease communicated to them from the glands inside. If, however, you
+find the glands at the corner of the lower jaw and those on either side
+of the neck enlarged too, you are then driven to the conclusion that the
+glands in the groin are enlarged not from mere local irritation, but
+from general disease, and that consumption is its cause.
+
+Again, the superficial veins of the belly may be enlarged from any
+cause which interferes with the proper circulation through the vessels
+inside. Hence they are often enlarged in grown people in dropsy, and
+hence too in infants and young children from flatulent distension of the
+bowels. But in this case the other signs of consumption are wanting; the
+emaciation, the cough, the increase of evening temperature, and the
+enlargement of the glands, are all absent.
+
+Sometimes we meet with instances where the child does not digest its
+food, does not thrive, does not gain flesh, never passes healthy
+evacuations, at length wastes, loses strength, and dies, without having
+had any of the signs which I have pointed out as indicative of
+consumptive disease, and in fact without having suffered from it. Now,
+these cases are connected with imperfect performance of the function of
+the liver, and sometimes with an imperfection of its structure. Before
+birth the functions of the liver are not called into action in the same
+way nor to the same degree as afterwards, and its structure differs in
+this respect that it contains a larger amount of fat and a smaller
+proportion of bile-secreting cells than afterwards. It sometimes happens
+from causes which we do not understand that the liver structure not only
+does not undergo that higher development which should take place, but
+that the fat cells increase at the expense of the bile cells. In these
+circumstances 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 of
+consumption, only there are no cough, no glandular enlargement, no big
+superficial veins, no increased temperature, while on a careful
+examination the doctor will seldom fail to find the rounded edge of the
+enlarged liver coming lower down than natural. In these cases too there
+is a disposition to convulsive affections, and to that peculiar form of
+convulsion called spasmodic croup, concerning which I shall have
+something to say later on.
+
+In its less serious form this is both a more frequent and a less grave
+condition than consumption, and its existence explains to a great degree
+those cases in which young children have failed to be nourished by the
+milk food which commonly suits their tender age, but have improved on
+beef-tea, raw meat or its juice, and food entirely destitute of
+saccharine matter.
+
+In cases where there is reason to apprehend consumptive disease, the
+skill and resources of the doctor will often be heavily taxed to meet
+each 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 which
+the asses' milk is deficient, a couple of teaspoonfuls of raw meat juice
+in the course of every twenty-four hours, much care in the introduction
+of farinaceous substances into the diet, and cod-liver oil twice a day,
+beginning with ten drops and gradually increasing the dose to a
+teaspoonful, are all that the mother herself can do. When the cod-liver
+oil is not borne by the stomach, or when--which, however, is not often
+the case--the child refuses to take it, glycerine may be substituted for
+it, though it must be owned that it is a very poor and inefficient
+substitute. The inunction of cod-liver oil is in any case not to be had
+recourse to; it makes the child unpleasant to itself and loathsome to
+others, while the power of the skin to absorb oily matters is far too
+limited to be worth taking into account.
+
+Vomiting, though by no means a prominent symptom of either of the two
+very grave conditions of which I have been speaking just now, is yet a
+very common attendant on all disorders of digestion in early life. It is
+indeed much more frequent in the infant than in the adult, and the
+greater irritability of the stomach continues even after the first few
+months of existence are past, and does not completely cease during the
+early years of childhood. In every case of vomiting in childhood,
+therefore, the first question to set at rest is whether it depends on
+disorder of the digestive system, or whether it heralds the onset of one
+of the eruptive fevers, or of inflammation of the chest, or of affection
+of the brain; and in determining this all the directions given when I
+was speaking of the general symptoms of disease are to be carefully
+studied. Vomiting often accompanies infantile diarrh[oe]a, even when the
+food taken cannot be regarded as its occasion; and now and then the
+stomach, with no obvious exciting cause, suddenly becomes too irritable
+to retain any food, and this indeed may be the case even though attended
+by few or no other indications of intestinal disorder. The child in such
+cases seems still anxious for the breast; but so great is the
+irritability of the stomach that the milk is either thrown up unchanged
+immediately after it has been swallowed, or it is retained only for a
+few minutes, and is then rejected in a curdled state; while each
+application of the child to the breast is followed by the same result.
+It will generally be found, when this accident takes place in the
+previously healthy child of a healthy mother, that it has been
+occasioned by some act of indiscretion on the part of its mother or
+nurse. 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; or
+the infant has been roused from sleep before its customary hour, or it
+has been over-excited or over-wearied at play, or in hot weather has
+been carried about in the sun without proper protection from its rays.
+
+The infant in whom from any of these causes vomiting has come on, must
+at once be taken from the breast, and for a couple of hours neither food
+nor medicine should be given to it. It may then be offered a teaspoonful
+of cold water; and should the stomach retain this, one or two spoonfuls
+may be given in the course of the next half-hour. If this is not
+rejected, a little isinglass may be dissolved in the water, which must
+still be given by a teaspoonful at a time, frequently repeated; or cold
+barley-water may be given in the same manner. In eight or ten hours, if
+no return of vomiting takes place, the experiment may be tried of giving
+the child its mother's milk, or cows' milk diluted with water, in small
+quantities from a teaspoon. If the food thus given does not occasion
+sickness, the infant may in from twelve to twenty-four hours be restored
+to the breast: with the precaution, however, of allowing it to suck only
+very small quantities at a time, lest, the stomach being overloaded, the
+vomiting should again be produced.
+
+In many instances when the sickness has arisen from some accidental
+cause, such as those above referred to, the adoption of these
+precautions will suffice to restore the child's health. If, however,
+other signs of disorder of the stomach or bowels have preceded the
+sickness, or are associated with it, medicine cannot be wholly dispensed
+with, and the advice of the doctor must be sought for. Very likely in
+addition to directing the rules above laid down to be attended to, he
+may lay a tiny dose of calomel, as a quarter, half or a whole grain on
+the tongue, which often has a wonderful influence in arresting sickness;
+while he may further put a small poultice not much bigger than a crown
+piece, made half of mustard, half of flour, on the pit of the stomach
+for a few minutes, and may give the child a little saline, with a grain
+or 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 be
+prescribed, and their effect watched by the medical attendant.
+
+Sickness, indeed, is not always a solitary symptom unattended by other
+evidences of disordered digestion, but is sometimes associated with
+signs of its general impairment, and this may be so serious as to lead
+to great loss of flesh, and even to end in endangering life. In many
+instances, however, the child does not lose much flesh though it digests
+ill, and its symptoms would be troublesome rather than alarming, if it
+were not that they are often the signs of an unhealthy constitution, out
+of which in the course of a few months consumption is not infrequently
+developed. Long-continued indigestion in the infant always warrants
+anxiety on the part of the parent.
+
+In some of these cases there is complete loss of appetite, the infant
+caring neither for the breast nor for any other food. It loses the look
+of health and grows pale and languid, though it may not have any special
+disorder either of the stomach or of the bowels. It sucks but seldom and
+is soon satisfied, and even of the small quantity taken, a portion is
+often regurgitated almost immediately. This state of things is sometimes
+brought on by a mother's over-anxious care, who, fearful of her infant
+taking cold, keeps it in a room too hot or too imperfectly ventilated.
+It follows, also, in delicate infants on attacks of catarrh or of
+diarrh[oe]a, but it is then for the most part a passing evil which time
+will cure. In the majority of cases, however, the loss of appetite is
+associated with evidence of the stomach's inability to digest even the
+small quantity of food taken, and the bowels are irregular in their
+action, as well as unhealthy in their secretion. Loss of appetite, too,
+though a frequent is by no means a constant attendant on infantile
+indigestion, but is replaced sometimes by an unnatural craving, in which
+the child never seems so comfortable as when sucking. It sucks much, but
+the milk evidently does not sit well upon the stomach; for soon after
+sucking, the child begins to cry and appears to be in much pain until it
+has 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 often
+can be pacified only by allowing it to suck again. In other cases
+vomiting is of much less frequent occurrence, and there is neither
+craving desire for food, nor much pain after sucking; but the infant is
+distressed by frequent acid or offensive eructations; its breath has a
+sour or nauseous smell, and its evacuations have a most f[oe]tid odour.
+The condition of the bowels that exists in connection with these
+different forms of indigestion is variable. In cases of simple loss of
+appetite, the debility of the stomach is participated in by the
+intestines, and constipation is of frequent occurrence, though the
+evacuations do not always appear unhealthy. In other instances in which
+the desire for food still continues, the bowels may act with due
+regularity, but the motions may have a very unnatural appearance. If the
+child is brought up entirely at the breast, the motions are usually
+liquid, of a very pale yellow colour, often extremely offensive, and
+contain shreds of curdled milk, which not having been digested within
+the stomach, pass unchanged through the whole track of the bowels. In
+many instances, however, the infant having been observed not to thrive
+at the breast, arrowroot or other farinaceous food is given to it, which
+the stomach is wholly unable to digest, and which gives to the motions
+the appearance of putty or pipe-clay, besmeared more or less abundantly
+with slime or mucus. The evacuations are often parti-coloured, and
+sometimes one or two unhealthy motions are followed by others which
+appear perfectly natural; while attacks of diarrh[oe]a often come on,
+and the matters discharged are then watery, of a dark dirty green
+colour, 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 be
+expected, and in many cases grow up to be strong and healthy. Still the
+condition is one that not merely entails much suffering on the infant,
+but by its continuance seriously impairs the health, and tends to
+develop the seeds of any constitutional predisposition to consumptive
+disease.
+
+In these cases there are many respects in which the mother can most
+efficiently second the doctor. All causes unfavourable to health must be
+examined into, and as far as possible removed. It must be seen that the
+nursery is well ventilated, and that its temperature is not too high;
+while it will often be found that no remedy is half so efficacious as
+change of air. Next, it must not be forgotten that the regurgitation of
+the food is due in great measure to the weakness and consequent
+irritability of the stomach, and care must therefore be taken not to
+overload it. If these two points are attended to, benefit may then be
+looked for from the employment of tonics, and as the general health
+improves the constipated condition of the bowels, so usual in these
+cases, will by degrees disappear; while if aperients are needed those
+simple remedies only should be employed of which I spoke in the first
+part of this book, and the use of mercurials is not to be resorted to
+without distinct medical order.
+
+The above mode of treatment is appropriate to cases of what may be
+termed the indigestion of debility, but a different plan must be adopted
+in 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 no
+less applicable here, for the rejection of some of the milk may be the
+result of nothing more than of an effort which nature makes to reduce
+the work that the stomach has to do within the powers of that organ. But
+when, notwithstanding that due attention is paid to this important
+point, uneasiness is always produced by taking food, and is not relieved
+till after the lapse of some twenty minutes, when vomiting takes place,
+or when the infant suffers much from flatulence and from frequent acid
+or nauseous eructations, it is clear that the symptoms are due to
+something more than the mere feebleness of the system.
+
+It is not, however, the mere fact that the child vomits its food, or of
+the milk so vomited being rejected in a coagulated state, which proves
+that the stomach is disordered, but it is the fact of firmly coagulated
+milk being rejected with much pain, and after the lapse of a
+considerable interval from the time of its being taken, which warrants
+this conclusion. The coagulation of the curd is the first change which
+the milk of any animal undergoes when introduced into the stomach. The
+coagulum of human milk is soft and flocculent, and not so thoroughly
+separated from the other elements of the fluid, as the firm hard
+coagulum or curd of cow's milk becomes from the whey in which it floats.
+In a state of health the abundantly secreted gastric juice speedily
+redissolves the chief part of the curd in the stomach, while when it has
+passed into the intestine the alkaline bile which there becomes mixed
+with it, completes its solution, and converts the whole into a fluid
+which closely resembles one of the chief elements of the blood, is
+consequently very easily taken up by the minute vessels whose office it
+is to do so, and thus supplies with nourishment the whole body.
+
+Milk tends, however, to undergo changes spontaneously, which produce
+its coagulation, and the occurrence of these changes is greatly favoured
+by a moderately high temperature, such as that which exists in the
+stomach. But the alterations of the fluid that accompany this
+spontaneous coagulation are very different from those which are brought
+about by the vital processes of digestion. An acid becomes formed within
+it, and the acid thus produced has none of the solvent power of gastric
+juice, but by its presence impedes rather than favours digestion. Every
+nurse is aware that a very slight acidity of the milk will suffice to
+give an infant vomiting, stomach ache, and diarrh[oe]a, and the result
+must be much the same whether fermentation had begun in the milk before
+it was swallowed, or whether it commences afterwards, in consequence of
+the disordered condition of the stomach, and the absence of a healthy
+secretion of gastric juice.
+
+The nature of the food is the first point that requires attention in the
+management of these cases of infantile dyspepsia. If the child had been
+fed on cow's milk the symptoms may be due to the gastric juice not
+having been able to dissolve the curd, which you will remember is much
+firmer than that of human milk as well as twice as abundant. In this
+case the substitution of asses' milk, the employing whey either entirely
+or in part instead of milk, and the adding white of egg in order to
+present the elements of the curd in a more easily digestible form, may
+all be tried with advantage. Sometimes children refuse whey; and then a
+mixture of cream and veal broth, more or less diluted either with water
+or 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 of
+service, since it not only prevents the occurrence of fermentation, but
+also 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 of
+indigestion for which a grown person if suffering would seek the advice
+of a skilful doctor require his help no less when the patient is a
+child. When acids will be of service in promoting the secretion of the
+gastric juice, when pepsine will be likely to be of use, when stimulants
+such as a little brandy, when aromatics to get rid of flatulence,
+opiates to relieve pain or check diarrh[oe]a, or when an occasional
+mercurial, or some other remedy may be of use by stimulating the liver
+to increased action, are questions which I would not advise any mother
+to try to answer for herself. Much care and pains and knowledge and
+experience are often required by the doctor to enable him to answer them
+correctly.
+
+I must not leave the consideration of the ailments of the digestive
+organs in early infancy without some notice of that affection of the
+mouth popularly known as _thrush_ to which an exaggerated importance was
+once attached as the supposed cause of those symptoms of disordered
+health, of which it is in reality only the accompaniment. Still it is a
+sign of such grave disorder that it needs a careful study.
+
+THRUSH.--If you examine the mouth of a young infant, in whom the attempt
+at hand-feeding is not turning out well, you will often observe its
+lining to be beset with numerous small white spots, that look like
+little bits of curd lying upon its surface, but which on a more
+attentive examination are found to be so firmly adherent to it as not to
+be removed without some difficulty, when they leave the surface beneath
+it a deep red colour, and now and then bleeding slightly. These specks
+appear upon the inner surface of the lips, especially near the angles of
+the mouth, on the inside of the cheeks, and upon the tongue, where they
+are more numerous at the tip and edges than towards the centre. They are
+likewise seen upon the gums, though less frequently and in smaller
+numbers. When they first appear they are usually of a circular form,
+scarcely larger than a small pin's head; but after having existed for a
+day or two, some of the spots become three or four times as large, while
+at the same time they in general lose something of their circular form.
+By degrees the small white crusts fall off of their own accord, leaving
+the surface where they were seated redder than before; a colour which
+gradually subsides, as with the infant's improved health the mouth
+returns to its natural condition. If the improvement is tardy the white
+specks may be reproduced and again detached several times before the
+mouth resumes its healthy aspect. In the worst cases the specks
+coalesce, and coat the mouth as though lined with a membrane which is
+usually of a yellowish-white tint instead of having the dead white
+colour of the separate spots. Even here, however, though the surface is
+very red, it scarcely bleeds if the deposit is removed from it gently
+and with care.
+
+The popular notion that when the deposit of thrush appears not only in
+the mouth, but also at the edge of the bowel, it has passed through the
+child is altogether erroneous. The lining membrane of the bowel indeed
+is red, inflamed, and presents those conditions to which I have already
+referred when speaking of the atrophy of hand-fed children, but the
+actual deposit of thrush can take place only where there exists an
+appropriate structure for its formation, and that is to be found, not in
+the 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 by
+the acrid motions, and this irritation sometimes extends to the skin
+over the lower part of the baby's person, which becomes rough, and
+covered with a blush of redness.
+
+Thrush in the child is of far less serious import than in the grown
+person. In the latter it indicates the existence of some very serious,
+almost hopeless disease, and hence it is that we meet with it in the
+last stages of dysentery, cancer, and consumption. In the child a slight
+attack 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 already
+described when speaking of the troubles of digestion in early infancy.
+
+While in any case it must rest with the doctor to regulate as he best
+knows how the constitutional treatment of the condition on which the
+thrush depends, it must be for the mother to see that appropriate local
+measures are adopted. One point of considerable moment, and to which
+less care than it deserves is usually paid, is the removing from the
+mouth, each time after the infant has been fed, of all remains of the
+milk or other food. For this purpose whenever the least sign of thrush
+appears, the mouth should be carefully wiped out with a piece of soft
+rag dipped in a little warm water every time after food has been given.
+Supposing the attack to be but slight this precaution will of itself
+suffice in many instances to remove all traces of the affection in two
+or three days. If, however, there is much redness of the mouth, or if
+the specks of thrush are numerous, some medicated application is
+desirable.
+
+The once popular honey and borax is not the best application, and this
+for a reason which I will at once explain. The secretion of the mouth in
+infants is acid, disease increases this acidity; and it has been found
+that 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 of
+membrane formed by a peculiar microscopic growth, of whose existence,
+just as of that of the phylloxera which destroys the vine, or the
+muscardine which kills the silkworm, we were ignorant till brought to
+light by recent scientific research.
+
+You will therefore at once see why saccharine substances, apt as they
+are to pass into a state of fermentation, are not suitable, and why it
+is better to employ a solution of--
+
+Borax, twenty grains
+Glycerine, one teaspoonful
+Water, an ounce.
+
+Now and then the use once or twice a day in addition of a very weak
+solution of caustic, as two grains of lunar caustic to an ounce of
+water, in bad cases is necessary; but of this it must be left to the
+doctor to decide.
+
+TEETHING.--The transition is a very natural one by which we pass from
+the study of the dangers and difficulties which attend the feeding and
+rearing of young infants, to those which accompany _teething_.
+
+The time of teething is looked forward to by most mothers with
+undisguised apprehension, nurses attribute to it the most varied forms
+of constitutional disturbance, and doctors constantly hold forth to
+anxious parents the expectation that their child will have better health
+when it has cut all its teeth. The time of teething, too, is in reality
+one of more than ordinary peril,[9] though why it should be so is not
+always rightly understood. It is a time of most active development, a
+time of transition from one mode of being to another, in respect of all
+those important functions by whose due performance the body is nourished
+and built up.
+
+The error which has been committed with reference to this matter,
+consists not in overrating the hazard of the time, when changes so
+important are being accomplished, but in regarding only one of the
+manifestations--though that indeed is the most striking one of the many
+important ends which nature is then labouring to bring about. A child in
+perfect health usually cuts its teeth at a certain time and in a certain
+order, just as a girl at a certain age begins to show signs of
+approaching womanhood; and at length attains it with but slight
+inconvenience or discomfort. The two processes, however, have this in
+common, that during both, constitutional disturbance is more common, and
+serious diseases are more frequent than at other times, and the cause in
+both lies far deeper than the outward manifestation.
+
+The great changes which nature is constantly bringing about around us
+and 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 which
+often disappoints human endeavours, or of the dangers which often attend
+on their accomplishment. Thus when her object is to render the child no
+longer dependent on the mother for its food, she begins to prepare for
+this long beforehand. The first indication of it is furnished by the
+greatly increased activity of the salivary glands, which during the
+first few months of existence have scarcely begun to perform their
+function, a fact which accounts for the tendency to dryness of the
+tongue of the young infant under the influence of very trivial ailments.
+About the fourth or fifth month, this condition undergoes a marked
+alteration; the mouth is now found continually full of saliva, and the
+child is constantly drivelling; but no other indication appears of the
+approach of the teeth to the surface, except that the ridge of the gums
+sometimes becomes broader than it was before. No further change may take
+place for many weeks; and it is generally near the end of the seventh
+month before the first teeth make their appearance. The middle cutting
+teeth of the lower jaw are in most instances the first to pierce the
+gum; next the middle cutting teeth of the upper jaw; then usually the
+side cutting teeth of the lower jaw, and lastly, the corresponding ones
+of the upper. This, however, is not quite invariable, for sometimes all
+the cutting teeth in one jaw precede in their appearance any of those in
+the other. The first four grinding teeth next succeed, and often without
+any very definite order as to whether those of the upper or of the lower
+jaw are first visible, though in the majority of instances the lower are
+the first to appear. The four eye teeth follow, and lastly, the
+remaining four grinding teeth, which complete the set of first, or as
+they are often called, milk teeth.
+
+We must not, however, picture to ourselves this process as going on
+uninterruptedly until completed--a mistake into which parents often
+fall, whose anxiety respecting their children is excited by observing
+that after several teeth have appeared in rapid succession, the process
+appears to come to a standstill. Nature has so ordered it that teething
+which begins at the seventh or eighth month, shall not be completed
+until the twenty-fourth or thirtieth; and has doubtless done so in some
+measure with the view of diminishing the risk of constitutional
+disturbance that might be incurred if the evolution of the teeth went on
+without a pause. As a rule the two lower central incisors or cutting
+teeth make their appearance in the course of a week; six weeks or two
+months often intervene before the central upper incisors pierce the gum,
+but they are in general quickly followed by the lateral incisors. A
+pause of three or four months most frequently occurs before we see the
+first grinding teeth, another of equal length previous to the appearance
+of the eye teeth, and then another still longer before the last grinding
+teeth are cut.
+
+Though a perfectly natural process, teething is almost always attended
+with some degree of suffering. This, however, is not always the case,
+for sometimes we discover that an infant has cut a tooth, who yet had
+shown no signs of discomfort, nor any indication that teething was
+commencing, with the exception of an increased flow of saliva. More
+frequently 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; or
+the eruption of the teeth is preceded by much redness, and great heat of
+the mouth with profuse flow of saliva, and even with little painful
+ulcers of the edge of the tongue, or of the inner surface of either lip.
+With either of these conditions the child is feverish, fretful, and
+cries from time to time with pain, while at the same time the bowels
+often are relaxed, or the child coughs and wheezes as if it had caught
+cold.
+
+Symptoms such as these make up what nurses mean when they say that the
+child is suffering from its teeth, and this opinion is constantly
+followed by a request to the doctor to lance the baby's gums. Now this
+little operation when really called for often gives great relief, both
+to the local discomfort, and also to the general ailment from which the
+infant 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 the
+child's gums lanced:
+
+First. When a tooth is very near the surface, and by cutting through the
+thin gum the child may be spared some needless suffering.
+
+Second. When the gums are very red and hot and swollen; only in this
+case the gum is scratched or cut, to bleed it, not with the idea of
+letting out the imprisoned tooth.
+
+Third. When the child has for some week or two been feverish and
+suffering; while, though the gum is tense and swollen, the tooth does
+not seem to advance.
+
+Fourth. As an experiment, when during the progress of teething a child
+is suddenly seized with convulsions for which there is no obvious cause.
+The irritation of the teeth may have to do with their occurrence; and
+the chance of relieving it by so simple a means is not to be thrown
+away.
+
+If the process of teething is going on quite naturally, no
+interference, medical or other, is either necessary or proper. The
+special liability of children to illness at this time must indeed be
+borne in mind, and care must be taken not to make any alteration in the
+infant's food while it is actually cutting its teeth, but rather to
+choose the opportunity of some one of those pauses to which reference
+has been made, as occurring between the dates of appearance of the
+successive teeth, for making any such change. If the child is feverish,
+a little soda or seltzer water sweetened and given after the
+effervescence has subsided will be taken eagerly, and avoid the risk of
+putting the child too often to the breast, or giving it food too
+frequently. It seeks the one or the other because it is thirsty, and
+craves for moisture to relieve its hot mouth; not because it is hungry
+and needs nourishment. If the child has been weaned, still greater care
+will be required, for it will often be found that it is no longer able
+to digest its ordinary food, which either is at once rejected by the
+stomach, or else passes through the intestines undigested. Very thin
+arrowroot made with water, with the addition of one third of milk, will
+suit in many cases, or equal parts of milk and water with isinglass, or
+equal parts of milk and the white decoction. The bowels of course must
+be kept open with very simple and mild aperients, but the bowels are in
+general more inclined to diarrh[oe]a than to constipation, and the
+diarrh[oe]a of teething children is often troublesome and requires good
+medical advice.
+
+The ulcerated state of the mouth is usually connected with special
+disorder of the digestive organs, and that condition of acidity for
+which I have already recommended soda, magnesia, and similar remedies,
+while locally the mouth needs just that local care which is applicable
+in cases of thrush. Now and then, severe inflammation of the gums
+occurs, in which they become extremely swollen; and ulceration takes
+place of the gum just above where the tooth should come through, and
+even around some of those which have already appeared. These are cases
+in which lancing the gums would do nothing but mischief. They require
+the local care already insisted on, a mild plan of diet, and treatment
+to reduce any feverishness; and above all one medicine, the chlorate of
+potass, which in doses of four grains every four hours for a child a
+year old, is almost a specific.
+
+AFFECTIONS OF THE SKIN.--There are a few affections of the skin to which
+children in early infancy are especially liable, concerning which a few
+words must be said.
+
+The Latin word _intertrigo_ is used for that _chafing_ of the skin of
+the 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 of
+care. Either wetted napkins are dried, and put on again without previous
+rinsing in water, or they have been washed in water containing soda, and
+not passed through pure water afterwards, or attention is not paid to
+change the infant's napkin immediately that it requires; or a fresh
+napkin is put on without previous careful ablution of the child; or
+lastly it occurs almost unavoidably in cases of diarrh[oe]a from the
+extension of irritation beginning at the edge of the bowel.
+
+Care is usually all that is needed to remove, as it is to prevent this
+condition. The precautions which I have referred to with regard to
+cleanliness must be carefully observed, and moreover, each time even
+after passing water, the child should be carefully washed with thin
+gruel, or barley water, then dusted abundantly with starch powder, while
+the napkin must be thickly greased with zinc ointment. After the first
+six or seven months of life the napkin can be almost always dispensed
+with, if the child has been brought up in good habits, and in all cases
+of chafing, it is much the better way to put no napkin on the child when
+in bed, but to lay under it a folded towel, which can be removed, and a
+clean one substituted for it as soon as it becomes soiled.
+
+There is a very obstinate form of chafing, with great redness of the
+skin, and disposition to crack about the edge of the bowel which depends
+on constitutional causes, and calls at once for the interference of the
+doctor.
+
+Besides this purely local ailment, there is another skin affection
+which is seen over the body generally, and is known popularly by the
+name of _red gum_, or in Latin _strophulus_. I mention the Latin name
+because I have known persons sometimes, misled by the similarity of
+sound, fancy that it had some connection with scrofula. It is met with
+less commonly now than formerly, when people were accustomed to keep
+infants unduly wrapped up, and to be less careful than most are
+now-a-days about washing and bathing. It depends on over-irritation of
+the sweat glands of the delicate skin of the infant, the result of which
+shows itself in the eruption on the body and face of a number of small
+dry pimples sometimes surrounded by a little redness, itching
+considerably, and when their top has been rubbed off by scratching
+having a little speck of dried blood at their summit.
+
+A rash like this, a sort of _nettle rash_, more blotchy and causing
+little lumps on the skin, which in a day or two come and go, sometimes
+appears in the intervals between the pimples, sometimes takes their
+place, and causes, as they do, much irritation. This nettle rash is
+usually dependent on some error of diet, on some acidity of the stomach,
+and, on their being corrected soon passes away, leaving the pimples as
+they were before, but sometimes being reproduced if the pimples cause
+excessive irritation of the tender skin.
+
+The matter of chief importance for a mother to know, is that these
+rashes have no serious signification. Their treatment is very simple. It
+consists in dressing the child very lightly, in bathing it very
+frequently with tepid water, avoiding as far as may be the use of soap,
+and in sponging it often to relieve the irritation with some simple
+alkaline lotion; such for instance as one recommended by the late Dr.
+Tilbury Fox, and which is composed of twenty grains of carbonate of
+soda, two teaspoonfuls of glycerine, and six ounces of rose water. Of
+course if the stomach is out of order that must be attended to, but a
+little fluid magnesia, once or twice a day, is all that is usually
+needed in the way of medicine.
+
+One other affection of the skin, very common, very distressing, very
+tedious, of which there are many varieties, generally known by the
+technical name of _eczema_, from a compound Greek word which signifies
+to flow, needs that I should say something about it. It is not limited
+in its occurrence to infancy, nor does it of necessity cease when
+childhood is over, but continues to recur even in grown persons, and
+shows itself still from time to time even in the aged.
+
+For the most part, however, it makes its appearance between the fifth
+and twelfth month; sometimes seeming to be induced by the change of food
+when the child is weaned, and that even though the weaning may have been
+wisely managed; at other times showing itself when the irritation of
+teething begins, and in every instance being aggravated by the approach
+of each tooth to the surface, and abating in the intervals.
+
+It does not occur in all children with equal frequency or severity, and
+though there is no doubt but that it is often hereditary, and this
+especially 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 the
+same parents to be affected by it severely, while no trace of it appears
+in 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 looking
+very closely--more closely indeed than most persons are wont to do--this
+appearance will be seen to be produced by innumerable small pimples,
+smaller than pins' heads, and which itch violently. Now and then, even
+in the course of a few hours, these pimples disappear, leaving the skin
+rough, and peeling off in branny scales, while the surface beneath is
+red and irritable, a condition which also in a few days may subside.
+This, however, is less frequent than the opposite course of the
+affection, in which a drop of fluid forms at the top of each tiny
+pimple, and escaping forms a yellowish, thin, transparent, watery,
+irritating discharge, which reddens still more the raw and weeping
+surface of the skin. The fluid when abundant dries at length into
+yellowish flakes or crusts, which sometimes assume a brownish colour if
+the surface is made to bleed by irritating or scratching. If the crusts
+are not removed, the fluid which still continues to be poured out
+beneath them soon changes into matter or _pus_ as it is called, and
+this, shut up beneath the hard crust above, increases the irritation,
+and thickens the deposit. After a time the inflammation lessens of its
+own accord, the secretion diminishes, the crusts dry up, and at length
+fall off, leaving the skin red, slightly swollen, and its surface
+scaling off in flakes, which gradually cease to form, and the skin by
+degrees becomes quite sound again, and so remains, until perhaps the
+irritation caused by the approach of a new tooth to the surface,
+rekindles the old trouble, to go once again through the same stages as
+before.
+
+It is on the cheeks, the sides of the face, and the top of the head that
+these changes may be best studied, but there are other situations in
+which the same kind of process often goes on. It may be seen in the
+creases of the neck, or the folds of the thigh in fat children, only as
+two surfaces of skin are there in contact the fluid never dries to a
+crust, but the skin, red and sore and swollen, pours out an abundant
+secretion which, just as when it occurs behind the ears, gives out a
+strong 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 on
+the front of the chest, the back, and sometimes even over the whole
+body, and especially at any part where the pressure of the dress
+irritates the skin. When thus general, it seldom fails to pass into a
+chronic 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 to
+discharge, though the discomfort produced by the local irritation still
+continues. At other times, and this perhaps more often when the eruption
+first appears on the head, its onset is more gradual, and slight
+scurfiness and redness at the top of the head are first noticed, and
+then a little crust forms there which is firmly adherent, and is,
+therefore, often not entirely removed as it should be, and thus bit by
+bit the mischief extends until its cure becomes tedious and troublesome.
+When either from neglect, or from the ailment having set in acutely, the
+affection of the scalp is severe, the child's state is one of much
+suffering. The whole of the scalp becomes hot and swollen, and covered
+over a large surface by a thick dirty crust, through cracks in which a
+thick ill-smelling greenish-yellow matter exudes on pressure. At
+different points around, pimples form with mattery heads,--pustules they
+are called--while the glands on each side of the neck become swollen and
+tender. When thus severe on the head it will be found also not merely on
+the face, but also on the body, and the poor suffering child is not only
+a miserable object to look upon, but, worn by constant restlessness, it
+loses flesh, and seems almost as though it could not long survive.
+Happily, however, the condition scarcely ever terminates fatally, though
+feeble health and stunted growth are not seldom the results of the early
+suffering. But besides, severe eczema in infancy always returns again
+and again in childhood and in after-life, and there is also a distinct
+connection between liability to eczema and to asthma; and this not
+simply nor mainly that the disappearance of an attack of eczema may be
+succeeded by an attack of asthma, but that the child who in infancy has
+had severe general eczema is more prone than another to develop a
+disposition to asthma as he attains the age of five or six, and this
+even though he should not have had any return of the skin affection in a
+severe form.
+
+It is evident then, that one cannot take too much pains to guard
+against the occurrence of eczema if possible, and at any rate to prevent
+its becoming severe. The disposition to it is often controlled by very
+simple precautions, such as bathing the face, the moment the skin shows
+any redness or roughness, with thin gruel or barley water, then
+powdering it with starch powder, and when the infant goes out, smearing
+the spot very lightly with benzoated zinc ointment, and making the child
+wear a veil. It will be observed that the exclusion of the air is in all
+these cases the object of the application far more than any specific
+virtue which it is supposed to possess, and many of the worst cases of
+eczema in grown persons are treated, in the great hospital for skin
+diseases in Paris, by an india-rubber mask, or by india-rubber covering
+of the affected part, and benefit thereby without any medicated
+application whatever. The thin layer of scurf which often forms on an
+infant's head should not be allowed to remain there, since its presence
+is a source of irritation. If it is very adherent, the surface may be
+well greased overnight with a little clarified lard which will soften
+it, so that it can be readily washed off with weak soap and water in the
+morning. 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 instead
+of a sponge, which would be too harsh, it is better to employ a very
+large camel's hair brush or a soft shaving brush, which is more handy,
+and the surface after careful drying may be lightly smeared with zinc
+ointment. All ointments used must be washed off most scrupulously every
+day, otherwise they become rancid, irritate, and make matters worse.
+
+When eczema sets in acutely, with general feverish disturbance, cooling
+medicines are required, and the help of the doctor becomes necessary.
+These are the cases in which the eruption is not confined to the head or
+the face, but extends over the body generally. The child must be dressed
+as loosely as possible; and when in its cot, should lie there with no
+other covering than its little shirt; and nothing gives so much relief
+to the irritation as the abundant use of powder, either simple starch
+powder, or ten parts of starch powder to one of oxide of zinc, or
+carbonate 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 be
+used to apply the powder; but between the creases of the skin--which it
+is important to keep apart--fine linen, lint, or charpie must be
+employed, covered freely with powder, so as to prevent the surfaces from
+coming into contact. If the irritation is very distressing, a weak
+spirit lotion with a little carbolic acid may sometimes be sponged over
+the surface, and the powder renewed immediately; or other forms of
+soothing lotions may be used to abate the irritation.
+
+When the scalp is affected in the acute form of eczema crusts form very
+quickly; or in other cases they collect because people fear to disturb
+them when they see the raw surface beneath. It is, however, a grievous
+mistake to allow them to collect; they are in themselves a source of
+irritation, and they entirely prevent any application reaching the skin
+beneath. They must always be removed, and never be allowed to form
+again. They can be removed either by the employment of a poultice, half
+of bread, half of linseed meal, or by the application over-night of a
+handkerchief soaked in sweet oil, and covered over with a piece of oiled
+silk, which softens the crusts effectually, and allows of their easy
+removal by abundant washing with weak soap and water.
+
+The best applications afterwards vary so much that it is impossible to
+lay down any positive rule. Sometimes the Carron oil, as it is termed: a
+liniment compound of equal parts of linseed oil and lime-water--a
+popular and most useful application in burns--gives most ease to the
+irritated skin; sometimes the mere exclusion of the air by means of the
+india-rubber cap; sometimes the abundant use of powder. In every case,
+at least once in every twenty-four hours the whole surface must be
+washed quite clean with barley water or thin gruel; and when the
+discharge 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, and
+for arsenic; of which latter remedy, however, the results are uncertain;
+while in the acute stage, its influence is simply mischievous. Nothing
+is more difficult, nor calls for more skill, or larger medical
+experience, than the proper management of the various forms of chronic
+eczema.
+
+The question is sometimes asked whether it is safe to cure, or, as
+people call it, to dry up these eruptions in teething children. There
+can be no doubt but that it is very desirable to prevent their
+occurrence as far as may be by the use of the precautionary measures
+which I have explained. But when they have existed for some time, either
+attended with profuse discharge, or causing great irritation by their
+extent, there is no doubt but that care must be exercised in attempts at
+their cure, that soothing measures such as I have advocated should be
+chiefly employed, and that the sudden drying up of the discharge by a
+too abundant use of dusting powders must be avoided. If, too, the
+diminution of the rash were followed by a worsening of the child's
+condition, by feverishness, by heaviness of the head, or any sign of
+disturbance of the brain, the attempt to cure the rash must at once be
+abandoned. At the same time I must add that such occurrences are very
+rare, and that for one case where I have had to regret my success in
+curing the rash, I have seen fifty in which I have been mortified by the
+failure of my endeavour.
+
+FOOTNOTES:
+
+[8] The directions given by the distinguished chemist, Dr. Frankland, to
+whom I am indebted for the suggestion, are as follows: 'One-third of a
+pint of new milk is allowed to stand until the cream has settled; the
+latter is removed, and to the blue milk thus obtained about a square
+inch of rennet is to be added, and the milk vessel placed in warm
+water.' (I may add that the artificial rennet sold by most chemists may
+be substituted for the other.) 'In about five minutes the rennet, which
+may again be repeatedly used, being removed, the whey is carefully
+poured off, and immediately heated to boiling to prevent its becoming
+sour. A further quantity of curd separates, and must be removed by
+straining through calico. In one quarter of a pint of this hot whey is
+to be dissolved three-eighths of an ounce of milk sugar, and this
+solution, along with the cream removed from the one-third of a pint of
+milk, must be added to half a pint of new milk. This will constitute the
+food for an infant of from five to eight months old for twelve hours;
+or, more correctly speaking, it will be one-half of the quantity
+required for twenty-four hours. It is absolutely necessary that a fresh
+quantity should be prepared every twelve hours; and it is scarcely
+necessary to add that the strictest cleanliness in all the vessels used
+is indispensable.'
+
+[9] In our tables of mortality we find teething registered as having
+occasioned the death of nearly 5 (4.8) per cent. of all children who
+died in London under one year old; and of 7.3 per cent. of those who
+died 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 during
+infancy and early childhood, but those only which either happen then
+exclusively, or at least with far greater frequency than at other times.
+
+It will be most convenient to consider the others under the different
+systems to which they belong, as diseases of the head, of the chest, and
+of the bowels.
+
+Before entering on these new subjects, however, a few words may not be
+out of place with reference to what may be termed the second period of
+childhood. It is above all a time of wonderfully lessened sickness and
+mortality. We have not the means of stating exactly the rate at which
+mortality is lessened between the cessation of the first and the
+commencement of the second dentition; but we do know that it is ten
+times less between the age of one and five, and nearly twenty times less
+between five and ten than it was in the first year of existence.[10] A
+mother's anxiety then may safely be quieted after the first year of her
+infant's life, and still more after the first set of teeth have been
+cut, for if her child is strong and healthy then, there will be
+comparatively little to fear for its future.
+
+Four years or thereabouts now follow, before any important change takes
+place in the child's condition, for it is not until between six and
+seven years old that the first set of teeth begin to be shed, and the
+second to take their place. This change of teeth too is of far less
+moment as far as the health is concerned, than was the cutting of the
+first set. The first dentition was the preparation for an entirely new
+mode of life for the child, and was intended to fit it for a life
+independent of its mother. The second has no such signification; it is a
+mere local alteration rendered necessary by the growth of the jaws, and
+takes place quietly, by the gradual absorption of the roots of the first
+set of teeth, brought about by the pressure of the others as they
+approach the surface. Four teeth in each jaw are new, and replace no
+others, but usually they are cut without much discomfort, and the wisdom
+teeth do not concern us here, for they do not appear until childhood has
+long passed.
+
+But, though between the age of two years and of ten there is no
+important change, nor even preparation for a change in the constitution,
+the time is yet one of most active growth of the body, and consolidation
+of 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 the
+long bones previously connected with the shafts by means of cartilage or
+gristle, become firmly united by the conversion of that cartilage into
+bone, and a similar process goes on, though not completed till later, in
+the ribs and the breast bone.
+
+Rapid increase of height and weight; conversion of the elements of bone
+into bone itself, formation of muscle out of the fat, which in the young
+child was stored up as so much building material for an edifice in
+course of construction, require for their accomplishment perfect health,
+and the power of converting to its highest purposes all the nourishment
+received. What wonder then, if from time to time, the machinery thus
+hardly taxed, fails to be quite equal to the demands upon it, if pains
+in 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 vague
+feverish condition comes on, in which the temperature is slightly
+raised, and the child listless, and yet fretful, loses its cheerfulness,
+is dull at its easy tasks, and yet indifferent to play. This too is the
+time when any unsuspected defects, physical, or mental, or moral, begin
+to show themselves distinctly; when short sight becomes apparent so soon
+as the child has to learn its letters, when the dull hearing is
+perceived which makes it seem inattentive, and gives to its manner an
+unchildlike nervousness; and the weak intellect is displayed in
+causeless laughter, causeless mischief, causeless passion, imperfect
+power of articulation, or want of words, and by a restless busyness in
+doing nothing.
+
+Of all these things I shall have to speak later on more fully. They are
+the things however, which only those mothers notice who live much with
+their children, who do not banish them all day long to the nursery or
+the school-room, and learn from another whether they fare well or ill.
+They and only they will notice these things in whom there dwells that
+which 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 of
+the Registrar-General for all England in 1881 are to 1,000 living under
+one 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 at
+all ages from these causes take place in children under five years, a
+fact which at first sight seems as inexplicable as it is startling.
+There is, however, a twofold explanation of it: the circulation through
+the much softer tissue of the brain, unenclosed within a _firm bony
+case_ as in after-life, varies with far greater rapidity in the infant
+than in the grown person, and hence the organ is far more easily
+overfilled with or emptied of its blood. Besides, any organ in which
+growth is going on with great rapidity is proportionately liable to
+become disordered or diseased. Now the brain doubles its weight in the
+first two years of life, and attains nearly its full size by the end of
+the seventh year.
+
+These two facts suggest a bright as well as a dark view of disorders of
+the brain and nervous system in early life. If disorder is more
+frequent, it is excited by slighter causes, is more likely to be
+temporary, and even its gravest symptoms, such as convulsions and
+paralysis, have a less serious import in the one case than in the
+others. If the grown man has a fit, and still more, if that fit is
+followed by paralysis, we fear and with reason that some vessel in the
+brain-substance has given way, or that some grave, probably irreparable
+damage has been inflicted on it. In the child, and especially in the
+young infant, these accidents may mean nothing more than that the brain
+has suddenly become over-filled with blood, or that it has been
+disturbed by irritation--I know of no better term--in some distant
+organ.
+
+CONVULSIONS.--There are in the body two great nerve masses, the brain
+and the spinal cord, through which all parts are brought into relation
+with each other. The spinal cord or spinal marrow receives impressions
+from all parts, imparts movement to the limbs, as well as gives activity
+to the functions of the various internal organs. The brain is the
+controlling power, and governs more or less consciously the movements
+which the spinal cord originates, and hence in proportion as the
+development of the brain advances, and its controlling power increases,
+those involuntary movements, fits or convulsions, which originate in
+irritation of the spinal cord, become rarer. The brain, at the age of
+three 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 former
+frequency; while from the age of ten to fifteen years, when the brain
+may be said to be perfected, only four per cent., instead of nearly
+eighty per cent. as in the first years of life, of all deaths from
+disorders 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 easy
+to 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 brain
+rarely, very rarely, I do not say never, begins with convulsions; and
+next, that their real danger is in general in exactly opposite relation
+to the frequency of their occurrence. Convulsions now and then return
+thirty, forty, or more times in twenty-four hours, and continue to do so
+sometimes for three or four days together. They are, indeed, not without
+peril, for the perpetually returning disturbance of the circulation may
+give rise to an overfilling of the vessels of the brain, or to a
+stagnation of the blood within them, or the spasm may affect the muscles
+which open and close the entrance to the windpipe, and the child may die
+choked as in a paroxysm of whooping cough, or in a fit of spasmodic
+croup, or lastly the violent and frequently repeated muscular movements
+may at length exhaust its feeble frame. But still, such frequently
+recurring convulsions are in themselves no evidence that the brain is
+diseased; they do but show that the irritability of the spinal cord is
+increased to a degree which the brain is no longer able to control, and
+which therefore manifests itself in violent convulsive movements.
+
+It is thus that the poison of scarlet fever or of small-pox sometimes
+displays its influence over the whole system by producing violent
+convulsions at the outset of those diseases; thus that they follow on
+some indigestible article of food, or that the mother, over-heated by
+violent exertion, or overwhelmed by the news of some unexpected
+calamity, 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 the
+cause of the convulsion, to determine the seat of the irritation which
+has excited the nervous system to such tumultuous reaction. The
+convulsion which ushers in any one of the eruptive fevers in the infant
+or in the child, is only an exaggeration of the shivering which precedes
+the onset of fever in the adult. Has the child been exposed to the
+contagion of measles, small-pox, or scarlatina? is it teething, and if
+so, 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 its
+head uncovered? or has it, though in the shade, been sitting or playing
+out 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 of
+late been very severe? or has its breathing been accompanied with a
+peculiar catch or crow, the sign of spasmodic croup, and have at the
+same time its hands been usually half clenched, and the thumb shut into
+the palm, the sign of that disturbance which at length has culminated in
+an attack of convulsions? Such are the questions, which in less time
+than it takes me to write, or others to read, the intelligent mother
+will put to herself, and will answer, instead of, in unreasoning alarm,
+giving all up as lost, or hastening without reflection to do something
+or other that were better left undone.
+
+The first thing to do in every case of convulsions, be their cause what
+it may, is to loosen the dress, so that no string nor band may interfere
+with respiration, and for this purpose strings must be cut and dresses
+torn. The next thing is to dash cold water on the face to induce a deep
+inspiration, for sudden death in a fit almost always takes place from
+interruption to breathing. With the same purpose the forefinger should
+be put into the mouth, and run rapidly to the root of the tongue, which
+should be drawn forward. The object of doing this is twofold; first, to
+prevent the tongue falling back, as in these circumstances it is apt to
+do, over the entrance of the windpipe and so producing suffocation, and
+in the next place the act very frequently puts an end to the spasmodic
+closure of the windpipe, and is followed by a deep-drawn breath which
+announces the infant's safety. If the child has cut any teeth, the
+handle of a spoon, round which a bit of rag has been wrapped, or a bit
+of wood, or a thin strip of india-rubber, should be put between the
+teeth as far back as possible to prevent the tongue being bitten; and
+often this is all that can be done.
+
+There are two circumstances, and two only, in which the warm bath is
+likely to be of use. At the onset of one of the eruptive fevers, a hot
+bath is sometimes of great service by stimulating the skin and thus
+bringing out the rash. In these cases the fit scarcely ever comes on in
+a child previously in perfect health, but for some hours at least it has
+appeared very ill, tossing about with great restlessness, with a dry,
+hot skin, and twitching of the tendons of the wrists; or, perhaps, with
+a pale face and cold hands and feet, but with the temperature of the
+body as high as 103° or 105°. Here the hot bath at 96° to 98°, even
+rendered more stimulating by the addition of mustard, and continued for
+not more than five minutes, is sometimes of great service, and is
+speedily followed by the cessation of the convulsions and the outbreak
+of the eruption.
+
+These, too, are the cases in which the use of the wet sheet, as
+practised 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 not
+the hot bath--that is to say, the bath at from 87° to 90°--is of
+service, is where the child is feverish and restless from over-fatigue
+or over-excitement, or from exposure to the sun or to an excessively hot
+atmosphere, and convulsions have come on in the course of this ailing.
+Here the tepid bath for ten or fifteen minutes, coupled with the
+application of cold to the head, will soothe the excitement and prevent
+the return of the convulsions.
+
+In neither this case, nor in that in which the hot bath is employed, is
+the result of the agent as magical as people sometimes seem to expect.
+It is rarely that convulsions cease while a child is actually in the
+bath. For the most part the influence of the bath is limited to abating
+their severity, shortening their duration, and indisposing to their
+return.
+
+The bath, then, is to be used when either a stimulating or a soothing
+influence on the surface is likely to be of service, and only then. In
+cases where the fits are produced by constipation, by improper food, or
+by the irritation of a tooth pressing against the gum, it is idle to use
+it, and equally so in instances where many fits have been recurring in
+the course of the same day. Where that is the case it must be
+self-evident that, be the cause what it may, it must be one over which
+either a hot or a tepid bath can have no influence, and that, painful as
+it must be to wait a passive spectator, that position is far wiser than
+that of a mischievous meddler. It is some consolation, also, to know
+that unconsciousness to suffering attends convulsions.
+
+There is one agent, chloroform, which often has a very remarkable
+influence in controlling frequently repeated convulsions. It is an
+agent, however, too hazardous to be trusted out of medical hands, and
+even when the doctor administers it himself, the parents must fully
+recognise the fact that, inasmuch as the child may die during a fit
+quite independently of breathing chloroform, so the occurrence of that
+catastrophe during its employment is not to be made a subject of
+self-reproach to them, or of blame to the doctor.
+
+But you may ask whether there are no _signs_ of that disturbance of the
+nervous system, by which you can judge beforehand that the occurrence of
+convulsions is probable. In proportion to the tender age of a babe, the
+greater is the probability, as I have already stated, that convulsions
+will be induced by slight causes, especially by such as digestive
+troubles. Unless you are aware of the phraseology that used at any rate
+to be common among nurses, you may be much alarmed at being told that
+the 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 signs
+that threaten convulsions--has had, in short, what in the time of our
+grandmothers used to be called _inward fits_. A child thus affected lies
+as though it were asleep, winks its imperfectly closed eyes, and gently
+twitches the muscles of its face--a movement especially observable about
+the lips, which are drawn as though into a smile. Sometimes, too, this
+movement of the mouth is seen during sleep, and poets have told us that
+it is the angels' whisper which makes the babe to smile--I am sorry that
+its meaning in plain prose should be so different. If this condition
+increases, the child breathes with difficulty, its respiration sometimes
+seems 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 of
+wind, especially if the stomach is gently rubbed. When the disorder of
+the digestion, on whatever cause it depended, is removed, these symptoms
+speedily subside, nor is there much reason to fear general convulsions
+so long as no more serious symptoms show themselves. There is more cause
+for apprehension, however, when the thumbs are drawn into the palm,
+either habitually or during sleep; when the eyes are never more than
+half-closed during sleep; when the twitching of the muscles is no longer
+confined to the angles of the mouth, but affects the face and
+extremities; when the child awakes with a sudden start, its face growing
+flushed or livid, its eyes turning up under the upper eyelid, or the
+pupils suddenly dilating, while the countenance wears an expression of
+great anxiety or alarm, and the child either utters a shriek, or
+sometimes 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, the
+head and neck are drawn backwards and the limbs violently bent and
+stretched. Sometimes these movements are confined to certain muscles or
+are limited to one side, and I may add that such cases are of more
+importance as far as the state of the brain is concerned than those in
+which the convulsions are general. The eye is fixed and does not see;
+the fingers may be passed over it without its winking, the pupil is
+immovably contracted or dilated; the ear is insensible even to loud
+sounds, the pulse is small, very frequent, often too small, and too
+frequent 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 hour
+or more, the convulsions cease; and the child either falls asleep, or
+lies 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, in
+which it may either be perfectly motionless, or twitching of some
+muscles may still continue; or, lastly, it may, though this seldom
+happens, die in the fit.
+
+It seems then, from all that has been said, that convulsions, though one
+of the most striking, are by no means one of the most conclusive signs
+of brain disease; that they are even more commonly the result of
+disorders of the nervous system from causes seated elsewhere, than of
+actual disease of what may be termed the great nervous centre.
+
+We may now therefore pass to the examination of these diseases, which
+for the purposes of this book may be considered under the two heads of
+congestion and inflammation.
+
+I am forced to use these terms in somewhat of a popular sense, for to
+attempt in a little book like this to define everything with strict
+scientific accuracy would simply confuse and mislead.
+
+CONGESTION OF THE BRAIN.--By _congestion of the brain_ is meant a
+condition in which its vessels are overcharged with blood; a condition
+which if it exists in an aggravated degree, ends either in the pouring
+out of blood on, or into the brain, on the one hand, or in inflammation
+on the other. Either of these terminations, however, is so rare in the
+previous healthy child, that I shall confine my remarks entirely to
+congestion of the brain, an affection specially liable to occur in
+children during teething. A certain degree of feverishness almost always
+accompanies teething. It is, therefore, not difficult to understand how,
+when the circulation is in a state of permanent excitement, a very
+slight cause may suffice to overturn its equilibrium, and occasion a
+greater 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 this
+season, but may occur at other times without any obvious exciting cause,
+and with no other explanation than is furnished by the well-known fact
+that all periods of development such as childhood, are periods during
+which the growing organs are most apt to become disordered.
+
+In the great majority of cases the symptoms of congestion of the brain
+come on slowly; and for the most part, general uneasiness, or disordered
+state of the bowels, which are usually, though not invariably
+constipated, and feverishness precede for a few days the more serious
+attack. The head by degrees becomes hot, the child grows restless and
+fretful, and seems distressed by light, or noise, or sudden motion, and
+children who are old enough sometimes complain of their head. Usually
+too, vomiting occurs repeatedly; a symptom of the greatest importance,
+since it may exist before there is any well-marked sign of head
+affection. Causeless frequently repeated vomiting in a child not ill but
+ailing, is nine times out of ten a sign of mischief in the head. The
+degree of fever which attends this condition varies much, and its
+returns are irregular; but any one who knows how to feel the pulse will
+find it permanently quickened, and if the head is unclosed the
+pulsations of the brain may be seen and felt distinctly. The sleep is
+disturbed, the child often waking with a start, while there is
+occasional twitching of the muscles of its face, or of the tendons of
+its wrist.
+
+The child may continue in this condition for many days and then recover
+its health without any medical interference. This is especially likely
+to be the case with children while teething, the fever subsiding, the
+head growing cool, and the little one appearing quite well so soon as
+the tooth has cut through the gum, but the approach of each tooth to the
+surface being attended by the recurrence of the same symptoms.
+
+The fortunate issue of these cases though frequent, is by no means
+invariable, for sometimes they are but the precursors of that
+formidable, I might indeed say, all but hopeless disease, water on the
+brain. But even of itself congestion of the brain is by no means a
+trivial ailment, for it may pass into a stage in which the smaller
+discomforts of the child lead to the sad mistake that the condition of
+the child is improving, instead of which it is really the dulling of
+sensibility from approaching death. The head, indeed, becomes less hot,
+the flush of the face grows slighter and less constant; but the
+countenance is heavy and anxious, the indifference to surrounding
+objects increases, and the child lies in a state of torpor or
+drowsiness, from which indeed it can at first be roused to complete
+consciousness The manner on being roused is always fretful, but, if old
+enough to talk, the child's answers are natural, though generally very
+short; and murmuring, 'I am so sleepy, so sleepy,' it subsides into its
+former drowsiness. The bowels generally continue constipated, and the
+vomiting seldom ceases, though it is sometimes less frequent than
+before. In this state, without any apparent cause, the child sometimes
+has an attack of convulsions, which subsiding, leaves the torpor deeper
+than before. The fits return, and death may take place in one of them,
+or the torpor growing more profound after each convulsive seizure, the
+child 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 been
+poured out into the cavities of the brain, the yielding skull has given
+way under the pressure from within, and should the child after all
+survive, its large head, due to chronic water on the brain, tells to all
+who know how to interpret the signs, the tale of its past illness, and
+the manner of its imperfect recovery.
+
+Cases such as these are obviously beyond the reach of domestic
+management, and call for all the resources of medical skill. The mistake
+commonly made is that of calling in the doctor too late, because it is
+not realised how grave may be the import of symptoms which at first
+appear so little alarming; and the so-called experienced nurse having
+said, 'Oh! it's nothing but the baby's teeth,' time is lost and danger
+not anticipated till too late for remedy.
+
+The application of two, three, or four leeches at the very outset of
+these cases is often of great service, and sometimes cuts short symptoms
+which had seemed very threatening. The doctor, of course, must be the
+judge of its expediency, but I refer to it because I have known parents
+raise objections to it, and beg to have milder means tried first. It
+must be borne in mind then, that whenever leeches are of use it is at
+the beginning of an attack, and that the opportunity once let slip does
+not return. Purgatives, cold to the head, saline medicines, and perhaps
+some carefully selected sedative, are the measures which will probably
+be employed in most cases, but success will in great measure depend on
+the minute care with which all the details which I dwelt on in the
+introduction, are carried out.
+
+It is not always, indeed, that active treatment is desirable, and
+gentle measures then suffice; but nothing except close and frequent
+watching can enable the doctor to steer safely between the two opposite
+dangers of too little and too much.
+
+When I come to speak of the eruptive fevers, I shall have to mention the
+convulsions and other signs of most serious brain disturbance, which
+sometimes occur at their outset, and which are due to the condition of
+the blood charged with the fever poison.
+
+A somewhat similar set of symptoms, attributed with reason to the
+overheated state of the blood, occurs in cases of _sunstroke_. It is
+true that sunstroke, with the formidable characters that it presents in
+hot countries, is not seen in England, but even here the mere exposure
+of an infant or young child to an overheated atmosphere, is by no means
+unattended with risk, and I refer to it here, because mothers are by no
+means aware of the danger, and believe that it suffices to guard the
+child from the direct rays of the sun.
+
+Alarm, restlessness, and fretfulness, alternating with drowsiness,
+hurried, irregular breathing, intense heat of skin, violent beating of
+the open part of the head, twitching of the limbs, and starting of the
+tendons of the wrists, with a pulse too rapid to be counted, are the
+symptoms when the attack is severe. Convulsions are rare, though they
+sometimes occur. Sickness is almost invariable, the stomach rejecting
+everything, and the bowels are almost invariably relaxed, severe
+diarrh[oe]a or dysentery sometimes coming on, as the brain disturbance
+abates. The first shock may kill the child in a few hours, or it may
+sink under the subsequent diarrh[oe]a, but as a rule recovery eventually
+takes place.
+
+All cases, indeed, are not equally severe, but all require careful and
+gentle treatment, the cool and darkened room, the quiet, the cold to the
+head, the tepid bath, and on the part of everyone the care not to allow
+the apparently serious condition of the child to urge them to those
+active measures which will here be out of place, and destroy the hopes
+which would revive after a few hours of patience and gentle means.
+
+Really acute inflammation of the brain is of so rare occurrence except
+as the result of accident or injury, and its symptoms are of so serious
+a character, even from the first, that medical advice is obviously
+needed at once. I shall, therefore, pass it over here, and endeavour to
+describe two forms of inflammation of the brain which are much more
+frequent, and at their commencement more likely to be overlooked.
+
+=Water on the Brain.=--One of these is the form of inflammation commonly
+known as _water on the brain_, a term which, though incorrect medically,
+has the advantage of being well understood. This, now, is not a simple
+disease, occurring in a previously healthy child, but it is a disease
+dependent on the same state of constitution as gives rise in other
+children to consumption, or scrofula, or disease of the mesenteric
+glands.
+
+It is this circumstance which renders the disease so serious, and
+recovery from it so extremely rare. This it is also which makes it so
+desirable to become acquainted with its symptoms, both that you may be
+alive to the approach of danger, and also not indulge in needless alarm
+when brain symptoms occur from other causes which have no relation
+whatever to those which give rise to water on the brain.
+
+The disease comparatively seldom comes on in a child who had previously
+seemed in perfect health; a state of vague ailing usually precedes its
+outbreak. The child loses flesh and strength, and the look of health,
+and the lustre of the eye, and the silky softness of the hair. The
+appetite becomes uncertain, the bowels irregular, with a tendency to
+constipation; there are little feverish attacks for a few hours,
+subsiding of their own accord. The sleep is not sound, the temper
+uncertain, the child tires even of its favourite toys; the brightness of
+the little face is changed for a strange, weird, wistful look--an
+unnatural earnestness; the child sits for moments gazing upward on
+vacancy, 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 the
+first stage of the affection, in which there are signs of congestion of
+the brain, such as I have already described, coupled with general
+irregular attacks of feverishness. The child becomes more gloomy, more
+pettish, and slower in its movements, and is little pleased by its usual
+amusements. Or, at other times, its spirits are very variable; it will
+sometimes cease suddenly in the midst of its play, and run to hide its
+head in its mother's lap, putting its hands to its head, and complaining
+of headache, or saying merely that it is tired and sleepy, and wants to
+go to bed. Sometimes, too, it will turn dizzy, as you will know, not so
+much from its complaint of dizziness as from its suddenly standing
+still, gazing around for a moment as if lost, and then either beginning
+to cry at the strange sensation, or seeming to awake from a reverie, and
+at once returning to its play. The infant in its nurse's arms betrays
+the same sensation by a sudden look of alarm, a momentary cry, and a
+hasty clinging to its nurse. If the child can walk it may be observed to
+drag one leg, halting in its gait, though but slightly, and seldom as
+much at one time as at another, so that both the parents and the medical
+attendant may be disposed to attribute it to an ungainly habit which the
+child has contracted. The appetite is usually bad, though sometimes very
+variable; and the child, when apparently busy at play, may all at once
+throw down its toys and beg for food, then refuse what is offered; or
+taking a hasty bite may seem to nauseate the half-tasted morsel, may
+open its mouth, stretch out its tongue, and heave as if about to vomit.
+The thirst is seldom considerable, and sometimes there is an actual
+aversion to drink as well as to food, apparently from its exciting or
+increasing the sickness. The stomach, however, seldom rejects
+everything; but the same food as occasions sickness at one time is
+retained at another. Sometimes the child vomits only after taking food,
+at other times, even when the stomach is empty, it brings up some
+greenish phlegm without much effort, and with no relief. These attacks
+of vomiting seldom occur oftener than two or three times a day, but they
+may return for several days together, the child's head probably growing
+heavier, and its headache more severe. The bowels during this time are
+disordered, generally constipated from the very first, though their
+condition in this respect sometimes varies at the commencement of the
+disease. The evacuations are usually scanty, sometimes pale, often of
+different colours, almost always deficient in bile, frequently
+mud-coloured and very offensive. The tongue is not dry, generally rather
+red at the tip and edges, coated with white fur in the centre and
+yellowish towards the root, but occasionally very moist, and uniformly
+coated with white fur. The skin is harsh, but not very hot, the
+temperature seldom above 100° Fahr., varying causelessly, but usually
+higher towards evening than in the daytime. The nostrils are dry, the
+eyes lustreless, and _the child sheds no tears_. It is drowsy, and will
+sometimes want to be put to bed two or three times in a day; but it is
+restless, sleeps ill, grinds its teeth in sleep, lies with its eyes
+partially open, awakes with the slightest noise, or even starts up in
+alarm without any apparent cause. At night, too, the existence of
+intolerance of light is often first noticed in consequence of the
+child's complaints about the presence of the candle in the room.
+
+I have purposely dwelt long on this preliminary stage because it is only
+in it that treatment is likely to be of any service, while the very
+indefiniteness of the symptoms constantly leads to their being
+overlooked, or referred to teething, or thought at any rate to be a mere
+temporary 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 too
+marked to escape notice. All cheerfulness has fled, the eyes are closed
+to shut out the light, the child lies apparently dozing, but answers
+questions rationally, in a short quick manner in as few words as
+possible, and from time to time complains of its head, or utters a
+short, sharp lamentable cry. The night brings with it no other change
+than an increase of restlessness, attended sometimes with noisy cries,
+or with the wandering talk of delirium. Sickness often diminishes, but
+the bowels continue constipated, and it is to be noted that whereas in
+fevers the bowels are distended with wind, here all wind has disappeared
+and the belly is sunken to a striking degree.
+
+Next comes the last stage. Each stage is distinguished by peculiarities
+of the pulse which tell the expert what is passing; quick and regular in
+the first stage; irregular and slower in the second; quick, variable,
+irregular from time to time in the third; growing more rapid and more
+feeble as the end arrives. Squinting, stupor, dilated pupil, difficulty
+of swallowing, tremulous limbs, convulsions, profound insensibility,
+such are the series of occurrences which bring on death usually within a
+fortnight, always within three weeks from the appearance of the first
+decided symptoms.
+
+What are you to do in these cases? Above all save yourselves the
+heartbreak of feeling that you have overlooked the premonitory symptoms
+of the disease. Guard with special care the health of any child in whose
+family a disposition to consumptive disease has ever shown itself, and
+keep it at any cost from the risk of catching the hooping cough or
+measles. Since, too, it is not in early infancy, but after the age of
+one year, and in the majority of instances between the ages of three and
+six years that this disease occurs, that is to say, at the time when the
+brain begins to be most actively exercised, when the new world on which
+the child is just entering brings with it new wonders every day; be very
+careful not to over-stimulate its intelligence, over-excite its
+imagination, or over-strain its mental powers. After the age of ten the
+great danger is over; up to that time it is the health of the body which
+requires care; not fuss, not rearing like a hothouse plant, but the
+healthy training that may fortify the system.
+
+When any signs such as I have described indicate the threatening of
+disease, 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 fully
+set in, and that was a recovery almost worse than death.
+
+=Earache.=--There is another form of inflammation of the brain which is
+likewise oftenest met with in children who are of weakly constitution,
+or of scrofulous habit, or in whom scarlet fever has left behind that
+very troublesome ailment, discharge from the ear. This is so tedious, so
+difficult to cure, so apt to return under the influence of very slight
+causes, that people are too ready to put up with it as an inconvenience
+which it is useless to try to remedy.
+
+In addition, however, to the risk of the child's hearing being impaired
+by the extension of the mischief to the internal ear, there is another
+still greater danger, namely, that of the _disease passing from the ear
+to the brain_, and producing inflammation of its membranes, or even
+abscess of its substance.
+
+It is therefore of the greatest moment that every case of chronic
+discharge from the ear should be looked on as important, and that no
+pains be spared to bring about its cure; and further, that during its
+continuance the slightest sign of disturbance of the brain--headache,
+sickness, feverishness, and dulness--should at once be noticed, and the
+advice of a competent doctor be immediately sought for.
+
+These dangers, however, follow almost entirely on long-continued
+discharges from the ear, but do not attend that acute inflammation of
+the passage to the ear which is often met with in childhood, and the
+symptoms of which sometimes cause needless fear, from being taken for
+those of inflammation of the brain. Attacks of _earache_ are most
+frequent before the first set of teeth have been cut, and are by no
+means rare in young children, who are perfectly unable to point out the
+seat of their sufferings. The attack sometimes comes on quite suddenly,
+but usually the child is languid and fretful for a period varying from a
+few hours to one or two days before acute pain is experienced. In this
+premonitory stage, however, it will often cry if tossed or moved
+briskly; noise seems unpleasant to it, and it does not care to be played
+with; while children who are still at the breast show a disinclination
+to suck, though they will take food from a spoon. The infant seeks to
+rest its head on its mother's shoulder, or, if lying in its cot, moves
+its head uneasily from side to side, and then buries its face in the
+pillow. If you watch closely, you will see that it is always the same
+side of the head which it seeks to bury in the pillow, or to rest on its
+nurse's arm, and that no other position seems to give any ease, except
+this one, which, after much restlessness, the child will take up, and to
+which, if disturbed, it will always return. The gentle support to the
+ear seems to soothe the little patient: it cries itself to sleep, but
+after a short doze, some fresh twinge of pain arouses it, or some
+accidental movement disturbs it, and it awakes crying aloud, and
+refusing to be pacified, and may continue so for hours together.
+Sometimes the ear is red, and the hand is often put to the affected side
+of the head, but neither of these symptoms is constant. The intensity of
+the pain seldom lasts for more than a few hours, when, in many instances
+a copious discharge of matter takes place from the ear, and the child is
+well. In some instances, indeed, the subsidence of the disease on one
+side is followed by a similar attack on the opposite side, and the same
+acute suffering is once more gone through, and terminates in the same
+manner. Sometimes, too, this complete cure does not take place, but the
+earache abates, or altogether ceases, for a day or two, and then
+returns; no discharge, or but a very scanty discharge, taking place,
+while, for weeks together, the child has but few intervals of perfect
+ease. In infants, earache seldom follows this chronic course, but it
+does sometimes in older children, and is then of the more importance,
+since it shows that the disease is no longer confined to the external
+passage, but has extended to the internal ear.
+
+In children who are too young to express their sufferings by words, the
+violence of their cries, coupled with the absence of any sign of disease
+in the chest or the bowels, naturally leads to the suspicion of
+something being wrong in the head. There are several facts, however,
+which may satisfy you that the case is not one of water on the
+brain--the child does not vomit, its bowels are not constipated, there
+is but little fever, the cries are loud and passionate, and are attended
+with shedding tears. If you watch closely, you will notice the dread of
+movement and the evident relief afforded by resting one side of the
+head, and always the same side, while often the movement of the hand to
+the 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 that
+the cause of the suffering is in the ear by pressing the gristle of the
+organ slightly inwards, which will produce very evident pain on the
+affected side, while on the other side it will not occasion any
+suffering.
+
+The treatment of this painful affection is very simple. In many
+instances the suffering is greatly relieved by warm fomentations, or by
+applying to the ear a poultice of hot bran or camomile flowers, while at
+the 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 bone
+directly behind the ear seldom fails to give ease; while the disposition
+to the frequent return of the attack is often controlled by a series of
+small blisters, not larger than a sixpence, behind the ear. As soon as
+the tendency has sufficiently abated to admit of it, the ear should be
+syringed out twice a day with warm water, or with equal parts of warm
+water 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 of
+inflammation of the brain, concerning which a few words will suffice. It
+constitutes what is termed _chronic water on the brain_, and in this
+instance the term is a correct one, for the disease usually depends on a
+slow form of inflammation of the lining membrane of the cavities of the
+brain, often beginning before, still oftener very soon after, birth,
+which ends in the pouring out of a quantity of fluid into them
+sufficient to enlarge the head to three or four times its natural
+dimensions.
+
+Such cases are very sad and very hopeless, and the great resource, which
+is sometimes adopted by medical men, of puncturing the head and letting
+out the fluid, is very seldom successful.
+
+But there are more hopeful cases sometimes met with, those namely of
+children in whom, either from simple weakness, or from that
+constitutional disorder called rickets, bone formation has been
+backward, and the head has consequently long remained unclosed. If such
+children, either from the irritation of teething, or from the straining
+during paroxysms of hooping cough, suffer from congestion of the brain,
+fluid may be poured out, which, not being compressed by the too yielding
+skull, may in consequence enlarge it. These cases, however, may be
+distinguished from the other more serious ones by the date of their
+commencement, which is always much later than that of the other form, by
+the symptoms which attend them being less severe, and by the enlargement
+of the skull being far slighter.
+
+Still they require watching, for while with improved health the
+enlargement ceases, the fluid is in a measure absorbed, and the head
+diminishes in size, though always remaining larger than the average;
+brain mischief is yet more readily set up in children with such
+antecedents than in others.
+
+The anxiety of parents about the size or shape of their child's head
+after infancy has passed, is perfectly needless. When the head has once
+closed it always remains so. An odd shape, with an unusual protuberance
+of the forehead and the hind head, sometimes remain as the evidence of
+that condition in infancy to which I have just referred. It is, however,
+an evidence of mischief passed, not of mischief going on. In children
+too who have suffered from rickets, an affection rarely met with except
+among the poor in crowded cities, distortion of the limbs is often
+associated with a peculiar form of the skull, but in this too there is
+nothing to call for anxiety, still less to excite alarm. It is only a
+preternaturally small head and shelving forehead, which are found
+associated with mental deficiency; otherwise the greatest varieties of
+size and shape, of symmetry, or of want of it, may be associated with an
+equal variety of intellectual endowment, which is just as likely to be
+above as below the average.
+
+=Brain Disorder from Exhaustion.=--It may at first sight appear strange
+that before leaving the subject of congestion and inflammation of the
+brain, I should find it necessary to give a caution against being misled
+by symptoms which though in some respects similar to those of congestion
+or inflammation, are in reality due to an exactly opposite condition.
+
+This mistake, however, is very possible; doctors themselves sometimes
+fall into it, and some distinguished physicians have thought it worth
+their while to lay down very minute rules for distinguishing between the
+two opposite states. Headache we all know attends an overfull condition
+of the vessels of the brain, and grown persons usually suffer from it
+severely before an attack of apoplexy; but we also know that bad
+headache accompanies states of great weakness, and that it is one of the
+most distressing consequences from which a woman suffers who has lost
+much blood in her confinement. In just the same way, the infant who has
+been exhausted by diarrh[oe]a or by some trying illness, or who after
+weaning has been kept on a diet not sufficiently nutritious, may show
+symptoms of disorder of the brain.
+
+It may become irritable, restless, very startlish, with occasional
+flushings of the face, moaning in its sleep, and sleeping with
+half-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 and
+pulsating, but flat or even depressed, the hands and feet are cool, and
+very readily become cold; there may be occasional vomiting, but nothing
+like the constant sickness of real brain-disease, the bowels are not
+shrunken but distended, constipation is not present, but on the contrary
+there is a disposition to diarrh[oe]a. If the symptoms are
+misinterpreted and wrongly treated, unmistakable signs of exhaustion at
+last come on, and the child may die from its not being borne in mind
+that results at first sight much the same may flow from causes
+diametrically opposite.
+
+The moral of this is too obvious for me to need insist upon it. Cold to
+the head, low diet, aperients, possibly leeches, are needed in the one
+case; increased nourishment, perhaps stimulants, in the other. In every
+instance where symptoms of brain disorder occur in the child, remember
+the grievous consequences of a mistake as to their nature, and seek for
+further 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 nervous
+system to various sources of irritation from without, and how, in
+consequence this irritation manifests itself by those involuntary
+movements which we call convulsions. But in addition to, or in the place
+of those violent contortions or convulsions, the same condition shows
+itself sometimes in disordered action of the muscles which subserve
+parts not directly subject to the will, as those for instance which open
+and close the entrance to the windpipe, or glottis as it is called in
+medical phraseology.
+
+Cases in which this occurs are known in popular language as
+child-crowing, or _spasmodic croup_, from the peculiar catch or crow
+which accompanies the entrance of air through the spasmodically
+contracted opening of the windpipe; a spasm which if severe and
+sufficiently continued closes the opening altogether, so that after
+fruitless efforts to get its breath the child dies suffocated. This
+affection occurs chiefly during teething, just as the fits of a
+hysterical girl oftenest occur during the transition from girlhood to
+womanhood; but many other causes besides the local irritation of the
+teeth may produce it, such as constipation, indigestible food, or
+disorder of the bowels.
+
+It does not often occur in perfectly healthy children; but an infant
+who is attacked by it is usually observed to have been drooping for some
+time previously, to have lost its appetite, to have become fretful by
+day and restless at night, and to present many of those ill-defined
+ailments which are popularly ascribed to teething. At length, after
+these symptoms have lasted for a few days or weeks, a slight crowing
+sound is occasionally heard with the child's respiration, shorter, more
+high-pitched, but less loud than the hoop of hooping cough. Usually it
+is first noticed on the child awaking out of sleep, but sometimes it is
+perceived during a fit of crying, or comes on while the infant is
+sucking. The spasm may have been excited by some temporary cause, and
+the sound which is its token may not be heard again; but generally it
+returns after the lapse of a few hours, or of a day or two, and its
+loudness usually increases in proportion as its return becomes more
+frequent. It will soon be found that certain conditions favour its
+occurrence; that the child wakes suddenly with an attack of it, that
+excitement induces it, or the act of swallowing, or the effort at
+sucking, so that the child will drop the nipple, make a peculiar croupy
+sound with its breathing, and then return to the breast again.
+Throughout the whole course of the affection, its attacks will be found
+to be more frequent by night than by day; and to occur mostly soon after
+the child has lain down to sleep, or towards midnight, when the first
+sound sleep is drawing to a close.
+
+At first, the child seems, during the intervals of the attack, much as
+before; except, perhaps, that it is rather more pettish and wilful; but
+it is not long before graver symptoms than the occasional occurrence of
+an unusual sound when the child draws a deep breath excite attention,
+and give rise to alarm. Fits of difficult breathing occasionally come
+on, in which the child throws its head back, while its face and lips
+become livid, or an ashy paleness surrounds the mouth, slight convulsive
+movements 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, or
+the child begins to cry. Breathing now goes on naturally: the crowing is
+not repeated, or the crying ceases; a look of apprehension dwells for a
+moment on the infant's features, but then passes away; it turns once
+more to its playthings, or begins sucking again as if nothing were the
+matter. A few hours, or even a few days, may pass before this alarming
+occurrence is again observed, but it does recur, and another symptom of
+the disturbance of the nervous system is soon superadded, if it has not,
+as is often the case, existed from the very beginning. This consists in
+a peculiar contraction of the hands and feet; a state which may likewise
+not infrequently be noticed during infancy, unattended by any
+peculiarity in breathing. It differs much in degree; sometimes the thumb
+is simply drawn into the palm while the fingers are unaffected; at other
+times the fingers are closed more or less firmly, and the thumb is shut
+into the palm; or, coupled with this, the hand itself is forcibly flexed
+on the wrist. In the slightest degree of affection of the foot, the
+great toe is drawn a little away from the other toes; in severer degrees
+the toe is drawn away still further, and the whole foot is forcibly bent
+upon the ankle, and its sole directed a little inwards. Affection of the
+hands generally precedes the affection of the feet, and may even exist
+without it, but the spasmodic contraction of the feet never exists
+without the hands being involved likewise. At first this state is
+temporary, but it does not come on and cease simultaneously with the
+attacks of crowing breathing, though generally much aggravated during
+its paroxysms. Sometimes a child in whom the crowing breathing has been
+heard, will awake in the morning with the hands and feet firmly bent,
+though he may not have had any attack of difficult breathing during the
+night. When the contraction is but slight, children still use their
+hands; but when considerable they cannot employ them, and they sometimes
+cry, as if the contraction of the muscles were attended with pain.
+Sometimes, too, there is a degree of puffiness both of hands and feet, a
+sort of dropsical condition, which, whenever it is present, adds much to
+the anxiety with reference to the child.
+
+As the condition becomes more serious, a slight crowing sound is heard
+each time the child draws its breath, the fits of difficult breathing
+are much more severe; they last longer, and sometimes end in general
+convulsions. The breathing now does not return at once to its natural
+frequency, but continues hurried for a few minutes after the occurrence
+of each fit of difficult breathing, and is sometimes attended with a
+little wheezing. The slightest cause is now sufficient to bring on an
+attack; it may be produced by a current of air, by a sudden change of
+temperature, by slight pressure on the windpipe, by the act of
+swallowing, or by momentary excitement. The state of sleep seems
+particularly favourable to its occurrence, and the short fitful dozes
+are interrupted by the return of impending suffocation, in one paroxysm
+of which longer and severer than the others the infant may fall back
+dead.
+
+It scarcely need be said that the great majority of cases have no such
+sad ending as I have described, but still, whenever this spasm exists,
+even in a slight degree, there is always the possibility, never to be
+forgotten, of a sudden catastrophe. Usually, after some tooth has been
+cut which caused special irritation, or as disorder of the bowels has
+been set right, the symptoms abate by degrees, and then cease
+altogether, though liable to be reproduced by the same causes as those
+to which they were originally due.
+
+The seeking out and removing the exciting causes must be the care of the
+medical man, but there are some special precautions which come within
+the mother's own province to observe.
+
+First of all, as sudden excitement, and especially a fit of crying, are
+likely to bring on the attack, and since there is a possibility that any
+attack may prove fatal, the greatest care must be taken in the
+management of the child to avoid all unnecessary occasion of annoyance
+or of distress.
+
+Although the benefit that accrues from fresh air, or from a change of
+air, is often very great, yet it is very important that the child should
+not be exposed to the cold or wind, for I have seen such exposure
+followed by a severe attack of difficult breathing, or by the occurrence
+of general convulsions. Another reason for caution in this respect is
+that the occurrence of catarrh is almost sure to be followed by an
+aggravation 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 the
+treatment of the attack, when actual convulsions come on. Since,
+however, in this affection convulsions may occur quite unexpectedly at
+any moment, it is well always to have a basin of cold water and a bunch
+of feathers handy, in order to be able at once to dash the water on the
+child's face, and induce that deep inspiration which saves it from the
+threatening danger. If this should not suffice, the finger must be put
+into the mouth, and run over the back of the tongue in the way that I
+have already explained when speaking of convulsions. Now and then it
+happens, though but very rarely, that violent _general convulsions_ come
+on in infancy quite independent of spasmodic croup, not preceded nor
+attended by any sign of disease of the brain, and which end in the
+course of some hours or of a few days in death, the child being partly
+worn out by the violence of the muscular movements, partly by the
+disturbance of breathing which each fit occasions. Happily, however, in
+most of these instances the convulsions by degrees lessen both in
+violence and frequency, and the child recovers.
+
+=Epilepsy.=--There is one other point of view from which convulsions in
+infancy and early childhood must be looked on with apprehension, and
+that is from their being frequently followed in after years by
+_epilepsy_. In nearly a fifth of all cases of epilepsy in childhood that
+have come under my notice the first occurrence of fits dated back to
+early infancy, and this, even though an interval of years had passed
+between the last fit in infancy and the first in childhood. It seems,
+indeed, as though there were in these cases a peculiar abiding
+sensitiveness of the nervous system, which, dating back from very early
+life, dependent often on hereditary predisposition, was kindled into
+activity by any special cause, such as the cutting of the second set of
+teeth, or the transition from boyhood or girlhood to manhood or
+womanhood.
+
+In the child, just as in the grown person, epilepsy manifests itself in
+two different ways; either by momentary unconsciousness, or by violent
+convulsions, in which latter there is little distinction from the
+occasional 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 as
+if dazed, its eye fixed on vacancy; if standing, it does not fall, nor
+does it drop the toy or the spoon which it was holding from its hand. If
+speaking, 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 meal
+as though nothing had happened; or it suffices to call the child and the
+cloud passes from its face, and it is itself again; and the nurse or
+perhaps even the mother, thinks that it is some odd trick which the
+child has got. By degrees the attacks become more frequent, and may
+continue to recur several times a day without any obvious cause, even
+for months; and this without any change in their character. By degrees,
+however, under their influence, an alteration takes place slowly in the
+child's disposition. It loses its cheerfulness and brightness, its face
+assumes a heavy look, it becomes fretful, and its intelligence grows
+duller.
+
+Almost invariably after the attacks of this, which has been called the
+_petit mal_, have continued for some months, a change begins to take
+place, which does not fail to excite attention and to cause alarm. If
+seated, the child's head drops forward for a moment, and strikes against
+the table; if standing, it becomes for an instant dizzy, and staggers,
+or even falls, and then there is twitching of one limb, or of the
+muscles of the face, and then the complete fit of epilepsy, ushered in
+sometimes, but not always, by a momentary cry, and then the convulsive
+twitching of one limb, followed in a minute or in less time by
+convulsions of the whole body as well as of the limbs. The upturned
+eyes, which do not see, are horribly distorted, the child foams at the
+mouth, it is insensible, and the insensibility deepens into stupor, or
+is followed by heavy sleep, for a quarter of an hour, or an hour or
+more, from which the patient arouses feeling tired and bruised, and
+often with an aching head, but with no remembrance of what has passed
+during the seizure so distressing to bystanders.
+
+It has throughout been my endeavour not to lose sight of those for whom
+this little book has been written, and with reference to epilepsy, as
+with reference to many other things, I pass over much that would be
+important to the practitioner of medicine, to dwell on those points
+which mainly interest the parents, and which they are perfectly able to
+appreciate.
+
+The question is often put as to the probability of fits terminating in
+epilepsy; or, on the other hand, as to the ground for hope in any case
+that epileptic attacks, which have already often recurred, will
+eventually cease. In the first place, no conclusion can safely be drawn
+from the severity of a convulsion, nor from its general character, as to
+the probability of its frequent recurrence, or of its passing into
+permanent epilepsy. The severity of a fit certainly affords no reason
+for this apprehension, nor does its recurrence, so long as a distinct
+exciting cause can be discovered for each return. The fits, which cease
+in the teething child when the gum is lanced, and which, on each
+succeeding return are equally relieved by the same proceeding, do not
+imply that there is any great tendency on their part to become habitual.
+In the same way, the attacks which follow on constipation, or on
+indigestion, or on some other definite exciting cause, may probably with
+care be guarded against, and their return prevented. It is not the
+violence of a single fit, nor even the frequent return of fits for a
+limited time, which warrants the gravest apprehension; but it is their
+recurrence when all observable causes of irritation have passed away; it
+is their return when the child is otherwise apparently in perfect
+health.
+
+If, on the one hand, the violence of a convulsion does not by any means
+imply the greater proportionate risk of its recurrence, so neither can
+any hopeful conclusion be drawn from the slightness of an attack, or
+from its momentary duration. In childhood, such attacks are at least as
+common preludes to confirmed epilepsy as in the adult, and are the more
+deserving of attention from their very liability to be overlooked. I
+believe, too, that an imperfect suspension of consciousness, the child
+knowing what passes, though unable to speak, is not very uncommon, and
+further, that it is far from unusual to have the early stage of epilepsy
+in 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 early
+symptoms of epilepsy in childhood are also the more likely to be
+misinterpreted from the circumstance that they are frequently
+accompanied by a moral perversion much more striking than any loss of
+mental power. It is true that in early life there are alternations of
+intellectual activity and mental indolence, of quickness and comparative
+dulness, which all who have had much to do with education are well aware
+of, and which are perfectly compatible with health of body and health of
+mind. But changes in the moral character of a child who is still under
+the same influences, have a far deeper meaning than is often attached to
+them; a child does not suddenly become wayward, fretful, passionate, or
+mischievous, except under the pressure of some grave cause.
+
+One other point there is also to be borne in mind; namely, that the
+child is compelled by the vague sensation of hitherto unknown dread, not
+to conceal the early symptoms of epilepsy as the grown person would do;
+longing as the child does for love and sympathy, and weakened in its
+moral force, it craves for more love, more sympathy, it exaggerates its
+symptoms, it assumes some which do not exist at all. The conclusion is a
+natural one, but none the less mistaken, that the child who is
+discovered to be shamming has nothing the matter with it--is simply a
+naughty child. This is a fact of much importance, on which I shall have
+occasion to insist further on.
+
+In the child, as in the adult, epilepsy blunts the intellect as well as
+weakens the moral powers; and does both more speedily and more
+effectually in proportion as the child is younger, and its mind and will
+are less developed. And yet this has its compensation; for as the powers
+fade quickly, so, if the attacks cease, they recover with surprising
+rapidity, and as the moral powers are the first to suffer, so they are
+the first to regain--I will not say full vigour, but at least a degree
+which 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 of
+epilepsy are then, first, the absence of any history of frequently
+recurring convulsions in early infancy; secondly, the existence of a
+distinct exciting cause for the attacks; thirdly, the rarity of their
+return far more than their slight severity; and lastly, the more the
+attacks approach in character to what one knows as hysteria, the less
+profound the insensibility in the fit, the shorter its duration
+afterwards, the greater are the grounds for hope that the seizures will
+eventually cease.
+
+Cases of this last class are to some degree, at any rate, under the
+child's control. I have several times seen a fit warded off by the
+threat of the shower bath, or even by calling to the child, and sending
+it to fetch something in another room. Such cases may indeed pass into
+ordinary epilepsy, but often, under judicious management, moral rather
+than medical, they cease, so that one can venture on taking a more
+hopeful view of them than of others.
+
+And this brings me to the question of what can be done, or rather what
+can parents do to promote recovery from epilepsy. First of all, do not
+listen to what you may hear about this medicine or the other being a
+specific for it. There is no specific whatever for epilepsy, but there
+are certain remedies which in skilful hands do have a real though
+limited power to control the frequency and lessen the severity of the
+attacks. Next, there are cases in which the attacks depend on some
+definite cause; it may be indigestion, or constipation, or the cutting
+of the second set of teeth, and on the irritation produced by those
+teeth being too crowded. Thus, I remember a boy twelve years old, in
+whom two severe epileptic fits occurred apparently without cause. He was
+cutting his back grinding teeth, and in the lower jaw the teeth seemed
+overcrowded. I had a tooth extracted on either side, the fits ceased,
+and when I last heard of him many years afterwards they had not
+returned.
+
+Epilepsy often lasts for many years, and no one's memory is retentive
+enough to be trusted with all the details between the different attacks,
+the causes which seemed to produce them, the measures which appeared at
+different times to be of service. I am therefore accustomed to advise
+people, any of whose children have the misfortune to be epileptic, to
+write 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 their
+character and duration; and general remarks, which would bear on the
+child's temper and general condition, and in which column any probable
+exciting cause of an attack would be recorded. It is surprising how much
+important information is gathered in a few months from such a record
+kept faithfully.
+
+The diet should be mild, nutritious, but as a general rule
+unstimulating; and should include meat comparatively seldom, and in
+small quantities. Some fifty years ago, a very distinguished American
+physician, Dr. Jackson of Boston, in the United States, insisted very
+strongly on the importance of a diet exclusively of milk and vegetables
+in greatly lessening the frequency and severity of epileptic attacks. I
+believe in the great majority of cases of epilepsy in childhood Dr.
+Jackson's advice is worth following. And I may add that, while I have
+little faith in the influence of mere drugs, I have a yearly increasing
+confidence in that of judicious management, mental and moral, as well as
+physical.
+
+The first requisite in all cases is a firm and gentle rule of love on
+the part of those who have charge of the child. As violent and sudden
+excitement of any kind will often bring on an epileptic seizure, so the
+influence of the opposite condition in warding off its attacks is very
+remarkable; and on several occasions I have received patients into the
+Children's Hospital who were reported to have epileptic seizures several
+times in a day, and who nevertheless remained a fortnight or more in the
+institution without any attack coming on. The disorder, however, was not
+cured, but only kept in check by the gentle rule to which the little
+ones were subjected. The order goes for much in these cases; the novelty
+goes for something too, for almost invariably I have found that after a
+time the apparent improvement becomes less marked, and though they
+continued better than when they first came to the hospital, the children
+were still epileptic; the advance of the disease had been retarded, but
+its progress had not been arrested. The quiet then which suits the
+epileptic, is not the quiet of listless, apathetic idleness, but the
+judicious alternation of tranquil occupation and amusement. The mind
+must not be left to slumber from the apprehension of work bringing on a
+fit, but the work must, as far as possible, be such as to interest the
+child. In the occupations of epileptics therefore, pursuits which not
+merely employ the mental faculties, but also give work to the hands,
+such as gardening, carpentering, or the tending of animals, are
+specially 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 same
+age have acquired, is of very little moment. Many epileptics have an
+indistinct articulation, and almost all have a slouching gait, and an
+awkward manner. The former can often be corrected to a considerable
+degree by teaching the child simple chants, which are almost always
+easily acquired, and practised with pleasure. The latter may be
+rectified by drilling, not carried out into tedious minutiæ, but limited
+to simple movements; and the irksomeness of drill is almost completely
+done away with by music, while I believe that the accustoming a child to
+the strict control and regulation of all its voluntary movements is of
+very great importance indeed as a curative agent.
+
+It is difficult to carry out these minute precautions on which so much
+depends in the home with other children of the same family. It is
+therefore, I believe, better for the child, painful though it is to the
+parents, that he should be placed under the care of some competent
+person who will devote the whole of his time to the care of the patient.
+
+=St. Vitus's Dance.=--A state of unconsciousness, accompanied with more
+or less violent involuntary movements, is characteristic of epilepsy.
+Involuntary movements without loss of consciousness constitute the
+disorder commonly known as _St. Vitus's Dance_. It is rare in early
+childhood, becomes more common after the age of five, and attains its
+greatest frequency between the ages of ten and fifteen, girls, owing to
+their more impressionable nervous system, being affected by it more than
+twice as often as boys.
+
+It seldom comes on in a child previously in perfect health, and
+strangely enough it occurs with special frequency in children who have
+before suffered from rheumatism. Sudden shock or fright is often said to
+have been its exciting cause; but even then the symptoms seldom come at
+once, but are gradually developed in the course of two or three days. At
+first, 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 it
+stumbles in walking, and then the muscles of the face become affected,
+the child grimacing strangely, and next the limbs of the opposite side
+become involved, and as things go on from bad to worse, the child
+becomes unable to hold anything in its hand, to walk, or even to stand,
+and even if on the ground still writhes about with the strangest
+contortions of its body. If matters grow still worse, the child becomes
+unable to put out its tongue, it swallows with difficulty, it loses not
+only 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 limbs
+is lost for the time, and they seem almost paralysed. Happily cases so
+severe are very rare, and it is rarer still for them to have a fatal
+termination. Almost invariably recovery takes place by degrees, the
+movements lessen, swallowing is performed with less difficulty, the
+power of speech, returns, and the intellect regains its brightness: but
+the 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 shown
+by the fact that its average duration is seventy days. It is very
+natural, therefore, that parents should be anxious when they see that
+their child has some awkward or ungainly habit, some odd trick or
+gesture never noticed before, lest it should be the beginning of this
+tedious ailment. Now it is well to remember that St. Vitus's dance does
+not begin with twitching of the muscles of the face, but that its
+earliest symptoms are involuntary movements of the arms and twitching of
+the fingers, and that contortions of the face do not come on till
+afterwards. Movements of this sort too, even when not limited to the
+face, 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, in
+twitching of the muscles of the face or neck, or in some awkward gait or
+manner. These are all best left unnoticed, for they are almost
+invariably made worse if the child's attention is called to them. They
+are, or at least before the days of Board Schools they were, scarcely
+ever met with among the children of the poor, for they almost invariably
+depend on mental strain; not of necessity on undue length of the hours
+of study, or on the difficulty of the tasks imposed, but often on a
+child's anxiety to make progress and to keep up with his schoolfellows.
+In corroboration of this being their cause I may say that, contrary to
+the rule which obtains with St. Vitus's dance, these movements are more
+frequent in boys than in girls, for the over-mental strain of boys comes
+earlier; that of girls seldom occurs before the time of transition to
+womanhood, and its results are then different, though much graver. In
+cases of this kind, lessening the mental strain is almost always
+followed by a cessation of the movements; change of air, country
+amusements, and a generally tonic treatment perfect the cure, and
+dancing and gymnastics overcome the remains of any awkward habit.
+
+The movements in real St. Vitus's dance do not shift about as these do
+from one part to another, but tend to involve various parts in
+succession, without previously ceasing where they had begun.
+
+The relative share which the parents and the doctor take in the
+treatment of these cases depends to a great extent on their severity.
+While attention to the state of the bowels, and a generally tonic
+treatment are almost always needed, gymnastics and drill are often of
+very great service in the slighter cases; and a very distinguished Paris
+physician was accustomed to send children thus affected to march round
+the Place Vendôme, keeping step while the band was playing. The utility
+of gymnastics turns very much on the degree in which the child is able
+by attention to control his movements, and when either as in young
+children fixed attention cannot be roused, or as in severe cases the
+effort only adds to the child's nervousness, and in consequence
+increases the movements, they must be given up. All drill and gymnastics
+are best carried out in class with other children, and regulated not
+simply by word of mouth, but by a tune or chant. When recovery is in
+progress gymnastics will then in almost all instances find their place.
+
+Even when drill and gymnastics cannot be practised, regulated movements
+of the limbs carried out twice a day for ten minutes at a time are of
+very real service. Another's will here takes the place of that of the
+patient, and the limbs are thus taught, though far more imperfectly, to
+act in concert.
+
+Two or three more cautions may still be of service. Do not keep a child
+out of bed, and force it to try to exert itself when the movements are
+very severe; continued movement, voluntary or involuntary, fatigues. Let
+the child lie in bed; it rests there, and the movements, which always
+cease during sleep, become at once greatly lessened. So important indeed
+is it to avoid the exhaustion caused by incessant violent movement, that
+in bad cases it is sometimes necessary to swathe the limbs in flannel
+bandages, and so to confine them to splints in order to restrain them.
+Next, do not become over-anxious because the child grows stupid and
+ceases to talk; intelligence and the power of speech will certainly come
+back again. And, lastly, do not be impatient and think your medical
+adviser incompetent because the disorder lasts so long. An average
+duration of seventy days implies that while sometimes it ceases sooner,
+in others it lasts much longer than the two weary months of watching and
+waiting with which in any case you must lay your account.
+
+=Paralysis, or Palsy.=--When speaking of St. Vitus's dance I said that
+there was a partial loss of power in the limbs as well as an inability
+to control their movements. After a fit of convulsions, or an epileptic
+seizure, power over some limb is often lost for a time which may vary
+from a few minutes to some hours. In the course of some serious diseases
+of the brain, one of the manifestations of the mischief is the
+impairment or the loss of power over one arm or leg, rarely over both;
+and lastly, that terrible disease diphtheria is often followed by a
+paralysis so general that the patient is sometimes for days unable to
+move even a finger, although the condition may eventually pass away.
+
+There is, however, a very _real paralysis_ which occurs sometimes in
+infants and young children. It comes on for the most part quite
+suddenly, often unaccompanied by any sign of brain disorder, but tending
+nevertheless to issue in great permanent impairment of the power over
+the affected limb or limbs, and eventually to interfere with their
+growth and thus to produce serious deformity.
+
+It is in general impossible to assign any distinct exciting cause for
+the affection, though the fact that in two-thirds of the cases it occurs
+between the ages of six months and three years, proves it to be in some
+way intimately associated with teething. The oldest child in whom I have
+ever seen it was aged between seven and eight years, and the youngest a
+little under six months. It is of excessive rarity for the arm alone to
+be affected, but it is by no means unusual for the legs alone to be
+paralysed; though in the majority of instances power is lost on one side
+only, the leg and arm being both involved.
+
+A child goes to bed quite well, or at the worst having seemed slightly
+ailing and feverish for a day or two, and on waking in the morning it is
+suddenly discovered that power is lost over one leg or both, or over
+both arm and leg of one side. The loss of power is at first seldom
+complete, 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 that
+time recovery in general begins. It is now and then speedy, so that in
+three or four days all trace of the paralysis may have disappeared.
+This, however, is a fortunate exception to the general rule, which is
+that amendment is very tardy, showing itself first in the arm,
+afterwards in the leg, and, if both sides have been affected, more on
+one side than on the other. Unless the improvement is very rapid, it is
+almost always only partial, and the palsied limb, though it does not
+lose sensation, regains but little power; it grows much more slowly than
+the other, is always colder and wastes considerably, while, some muscles
+still retaining more power than others, it becomes twisted out of shape,
+and requires all the skill of the orthopædic surgeon to remedy or at
+least to lessen the consequent deformity.
+
+It has been ascertained that this form of palsy depends on a state of
+congestion, or overfilling of the minute blood-vessels of the spinal
+marrow. When the child gets well the congestion has passed away; but it
+does this speedily, and recovery is then rapid as well as complete. If
+it does not soon pass away, other changes take place in the spinal
+marrow, and recovery is then slow, incomplete, or even does not take
+place at all.
+
+Remedies are unfortunately of little avail here, but it is evident that
+when the palsy is quite recent all movement of the limb must be
+mischievous, and that the congestion of the spinal marrow to which it is
+due will be most likely to abate under the influence of perfect quiet,
+rest in bed, and soothing or fever medicines, or of such as are
+calculated to overcome constipation, or to correct any fault of
+digestion, while the importance of teething, and the possible expediency
+of lancing the gums must not be forgotten.
+
+Afterwards comes the time for exercise of the paralysed limb, for
+friction, for shampooing, for galvanism; all continued perhaps for
+months or years with unwearied patience, and I must add with reasonable
+expectations as to the result. The only additional remark which I have
+to make is this, that to gain any real good from galvanism, a battery
+must be procured under the direction of some medical man specially
+skilled in the use of electricity, and the mode of employing it must be
+learned thoroughly from him. It is merely idle to purchase a toy
+machine, and, giving it to the nurse to turn the handle for ten minutes
+twice a day, to fancy that you are making a serious trial of the effects
+of galvanism. As a mere money question, a costly machine, and several
+fees paid in order to be thoroughly instructed in the way to use it, is
+much cheaper than a cripple child.
+
+A few words may not be out of place with reference to cases in which
+paralysis is mistakenly supposed to exist. Much anxiety is sometimes
+expressed by parents concerning children who have long passed the usual
+age without making any attempt to walk; or who having once walked seem
+to have lost that power. Now it often happens that after any weakening
+illness a child ceases for some weeks to walk, just as it ceases to
+talk. The power in both cases was newly acquired, it called for effort
+which, when strength is regained, will be put forth once more. The same
+applies to other instances in which children are late in learning to
+walk; 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, and
+regaining the power lose it again, or lose at least the desire to exert
+it more than once during the active progress of teething. But, holding
+the 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 other
+movement; or take it on your lap and tickle the soles of its feet, and
+laughing or crying, as the mood takes it, it will move its legs about as
+freely as you could wish and show that the power is still there, though
+for the present the child will not take the trouble to exert it.
+
+Gradual loss of power over one or other leg, especially if attended with
+pain either in the back or in the knee or hip, should always call for
+attention, and induce you to seek at once for medical advice. Such cases
+generally occur later in childhood than the conditions of which I spoke
+in the former paragraph, and may depend on disease of the spine or of
+the hip-joint, two serious conditions which it needs the medical expert
+to discover and to treat.
+
+=Neuralgia and Headache.=--In the grown person neuralgia, as many of us
+know to our cost, is by no means infrequent; in the child it is very
+rare, and when a child complains of severe pain in the head, or of
+severe pain to the knee or hip apart from rheumatism, it is almost
+invariably the sign of disease of the brain in the one case, of the
+hip-joint in the other. To this rule there are indeed exceptions, but it
+will always be well to leave it to the doctor to determine--no easy
+matter by the bye--whether any given case is one of the rare exceptions
+or not.
+
+There is, however, one form of real _neuralgic headache_ which is by no
+means rare in children after the commencement of the second dentition,
+and which sometimes goes on into early manhood or womanhood, when it
+becomes what is commonly known as sick headache. It is essentially an
+ailment of development, incidental to the time when the brain is first
+called on for the performance of its higher functions.
+
+It does not by any means always depend on over-study, though I do not
+remember meeting with it in children who had not yet gone into the
+school-room; and I have frequently found it dependent on too continuous
+application, though the number of hours devoted to study in the course
+of the day may not have been by any means excessive.
+
+The child's brain soon tires, and the arrangement, so convenient to
+parents of morning lessons and afternoon play, works far less well for
+it than if the time were more equally divided between the two.
+
+The attacks not infrequently come on on waking in the morning, and
+rapidly become worse, the pain, which is almost always referred to the
+forehead, being attended with much intolerance of light and sound, with
+nausea, and often with actual vomiting. Like the vomiting of
+sea-sickness, however, previous stomach disorder has no necessary share
+in its production, and I may add, indeed, that it is often difficult to
+assign any special exciting cause for the attack. The suffering is more
+often relieved by warm or tepid than by cold applications, and not
+infrequently pressure or a tight bandage greatly mitigates it. In no
+case does the attack last more than twelve hours--usually not more than
+half that time; it passes off with sleep, and leaves the patient weak
+and with a degree of tenderness of the head to the touch.
+
+Such attacks may occur every fortnight, ten days, or even oftener, but
+their very frequent return, instead of increasing apprehension, should
+diminish anxiety. A first attack, indeed, may seem as though it
+threatened mischief, till it is seen how speedily and completely it
+passes off, and when afterwards a second or a third attack comes on with
+the same severity of onset, the same rapid worsening, and the same quick
+passing away, you will feel convinced that the symptoms have no grave
+meaning.
+
+There is a headache of quite a different kind to which I must for a
+moment refer, that, namely, which depends entirely on imperfect vision,
+and for which spectacles are the remedy, not physic. The infirmity is
+not noticed during the first few years of life, but in later childhood,
+when a tolerably close attention to study has become necessary. Some of
+the minor degrees of short-sightedness, and want of power of adaptation
+of the eyes, such as exists in the aged, soon begin to interfere
+sensibly with the child's comfort, and the strain to which the eyes are
+subject produces a constant pain over the brow, the cause of which is
+often unsuspected.[13]
+
+In all cases, therefore, in which a child complains of constant pain
+over the brow for which there is no obvious cause, it is well to take
+the opinion of an oculist, who can best ascertain the power of _reading
+at different distances_ and with each eye separately, and the real cause
+of symptoms which had occasioned much anxiety is thus often brought to
+light.
+
+=Night Terrors.=--Before taking leave of the disorders of the nervous
+system, I must briefly mention the Nightmare, or Night Terrors of
+children, which often cause a degree of alarm quite out of proportion to
+their 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 sharp
+and piercing cry. The child will be found sitting up in bed, crying out
+as 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 not
+recognise its parents, who, alarmed by the shrieks, have come into its
+room, but seems wholly occupied by the fearful impression that has
+roused it from sleep. By degrees consciousness returns; the child now
+clings to its mother or its nurse, sometimes wants to be taken up and
+carried about the room, and by degrees, sometimes in ten minutes,
+sometimes in half-an-hour, it grows quiet and falls asleep; and then
+usually the rest of the night is passed undisturbed, though sometimes a
+second 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 recur
+at intervals for several weeks. The great point, however, to bear in
+mind is that they depend invariably on some disorder of the stomach or
+bowels, and are never an evidence of the commencement of real disease of
+the 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 under
+five 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 last
+edition of my lectures, it had already been noticed without my
+knowledge, by a friend of mine, Dr. Blache, of Paris, in a very valuable
+essay 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 after
+birth, I have already noticed the peculiarities of breathing in early
+infancy, and the difficulties that sometimes attend the complete filling
+of the air-cells of the lungs, and the readiness with which when once
+filled they become emptied of air and collapse.
+
+On this ground it is therefore needless for me again to enter, and I may
+pass at once to consider those ailments which rise in increasing
+importance from a simple cold or catarrh to inflammation of the
+air-tubes or bronchitis, inflammation of the lung substance, as
+pneumonia, and inflammation of the membrane which lines the chest and
+covers the lungs, or pleurisy.
+
+=Catarrh.=--A common cold or _catarrh_ is not one of the ailments of
+very early infancy. The watery eyes, the sneezing, the cough, the slight
+feverishness and the heavy head are scarcely met with until after the
+age of three months; nor, indeed, are they often seen till the child is
+old enough to run about, to go out for a walk, and to encounter in
+consequence all the variations of temperature and of damp or dryness
+inseparable from the English climate.
+
+This, however, is not entirely due to the greater exposure of the child
+to these influences as it grows older, but in part also to the fact that
+the lining of the air-tubes is less sensitive in early infancy than it
+afterwards becomes. The young babe if it catches cold gets _snuffles_,
+or stoppage of the nostrils, which first become dry, and then pour out
+an abundant discharge, which sometimes dries and forms crusts, and
+causes the child to suck with difficulty, and to breathe uncomfortably
+and with open mouth. In a few days, however, at the worst this
+discomfort passes away; and the only additional remark I have to make
+is, that since obstinate snuffles are sometimes a constitutional
+disease, the doctor's advice should always be sought if they last longer
+than a week.
+
+It is needless to describe a cold, but it is much more to the purpose to
+say how its occurrence is to be prevented, and nine times out of ten the
+observance of two simple rules will suffice for this. First, take care
+that there is no great difference between the temperature of the day and
+of the night nursery. The one should never be above 60°, nor the other
+below 50°, and the undressing and the bath should always take place in
+the warmer room. Second, never let the child wear the same shoes or
+boots in the house as it does out of doors. The change should be as much
+a matter of routine as the taking off its hat or its bonnet.
+
+The domestic management of a cold is simple enough. The usual error is
+the overdoing precautions, the keeping the room too hot, or overloading
+the child with extra garments, or its bed with extra covering, by which
+it is kept in a state of feverishness, or of needlessly profuse
+perspiration.
+
+If, for the first two days of a bad cold, the child is kept in bed, the
+room 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 to
+play, 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 a
+light diet of rice, and arrowroot, and milk, and a roasted apple, and
+some orange juice; nine times out of ten, or nineteen out of twenty, the
+cold will pass away with small discomfort to the child and no anxiety to
+the parents.
+
+Often a child objects to stop all day in its little cot, but move it to
+its mother's or nurse's big bed; and with a large tray of toys before
+it, and a little of the tact which love teaches, the day will pass in
+unclouded content and cheerfulness.
+
+It must of course be borne in mind that measles set in with all the
+symptoms of a bad cold, followed on the fourth day by the appearance of
+the eruption; and, moreover, watchfulness must always be alive to detect
+increase of fever, hurry of breathing, hardness or extreme frequency of
+cough, the sign of the irritation of the larger air-tubes having
+extended and become more severe, the evidence that the case from simple
+catarrh has become one of bronchitis.
+
+=Bronchitis and Pneumonia.=--It is impossible to enable persons who have
+not received a medical education to distinguish between a case of
+bronchitis and one of pneumonia. Neither, indeed, is it of much
+importance that they should do so, for in both the dangers are of a
+similar 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 cases
+extending even to their termination in the minute air-cells. The
+inflammation leads to the pouring out of a secretion, which by degrees
+becomes thick like matter, or even very tenacious, almost as tough as
+though it were a thin layer of skin. If this is very extensive, and
+reaches to the small air-cells, it is evident that air cannot enter,
+while that elasticity of the lung which I have already spoken of tends
+to drive out from the cells the small quantity of air they contained,
+and the child dies suffocated, partly from the difficulty in the
+entrance of air, partly from the collapse of air-cells from which the
+air has been slowly expelled.
+
+In _pneumonia_ or inflammation of the lung-substance the process is
+different. A portion of one or other lung, sometimes of both, becomes
+overfilled with blood, or congested, and though the air-tubes themselves
+are not the special seat of the congestion, yet the air-cells are
+pressed on by the surrounding swollen substance, and the entrance of air
+into them is impeded. If the mischief goes further the substance becomes
+solid and impervious to air, and lastly it becomes softened, its
+structure destroyed, and infiltrated with matter; the affected part
+becomes really an abscess, though not bounded by the distinct limits
+which would shut in an abscess of the hand or the foot. Inflammation,
+and the formation of an abscess anywhere is, as we know, attended by
+fever and much general illness, and inflammation of the lung is of
+course attended by fever and general illness in proportion to the
+importance of the organ affected. To these, too, must be added all the
+disturbance inseparable from any ailment which gravely interferes with
+breathing.
+
+In the great majority of instances inflammation of the lung-substance
+does not go on to the last stage, and recovery is not only possible, but
+probable, from congestion and solidification of the organ. Pneumonia,
+too, usually attacks only a portion of one lung, while in bronchitis the
+air-tubes of both are always involved. Hence of the two, serious
+bronchitis is more to be dreaded than serious pneumonia.
+
+Bronchitis is always developed out of previous catarrh, though there is
+a wide difference between the duration of the preliminary stage and the
+occurrence of serious symptoms in different cases; while it may be laid
+down as a general rule that the severity and danger of an attack are in
+proportion to the rapidity of its onset. An attack of pneumonia, or
+inflammation 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 hurried
+breathing and the short, dry, hacking cough, and the tearless eyes are
+too often misinterpreted, and the state of the chest not examined.
+
+The doctor, of course, skilled in auscultation, will listen to the
+chest and give to all these symptoms their true signification. The
+lesson for the parent to bear in mind is never to neglect in a child the
+symptoms of what may seem to be but a common cold, but to seek for
+advice the moment the cough shows any disposition to become hard, or the
+breathing hurried. Next, when any sudden illness sets in with very high
+temperature and much general ailing, not to let the disorder of the
+head, or the delirium, make you shut your eyes to the import of the
+short cough, the dry eyes, the hurried breathing; and lastly, to
+remember that, grave though the symptoms may be, the tendency in
+pneumonia is to eventual recovery, and that in early life bronchitis is
+the graver of the two diseases.
+
+A caution may not be out of place with reference to cases which may
+occur during the epidemic prevalence of _influenza_. A child is
+sometimes struck down by it, just as grown persons are sometimes, with
+great depression, extreme rapidity of breathing, and very high fever,
+which, passing off in a couple of days, leave a state of great
+exhaustion behind. It is well to bear in mind that such symptoms have no
+such grave meaning when influenza is prevalent as they would have at
+another time; and the knowledge of this fact may serve in some degree to
+control your anxiety.
+
+=Pleurisy.=--It is not possible for anyone, without medical experience,
+to discriminate between pneumonia, or inflammation of the substance of
+the lung, and pleurisy, or inflammation of its covering. Some degree of
+the latter, indeed, very often accompanies the former, and this accounts
+for the pain which interferes with every attempt of the child to draw a
+deep breath. When pleurisy comes on independent of affection of the
+lung-substance, it generally sets in suddenly with severe pain in the
+chest, and a short hacking cough which causes so much pain that the
+child tries as much as possible to suppress it. After a few hours the
+severity of the pain usually subsides, but fever, hurried breathing, and
+cough continue, and the child, though usually it looks heavy and seems
+drowsy, yet becomes extremely restless at intervals--cries and struggles
+as if in pain, and violently resists any attempt to alter its position,
+since every movement brings on an increase of its sufferings. The
+posture which it selects varies much; sometimes its breathing seems
+disturbed in any other position than sitting straight up in bed; at
+other times it lies on its back, or one side; but whatever be the
+posture, any alteration of it causes much distress, and is sure to be
+resisted by the child.
+
+The variations of posture depend on the seat of the inflammation; the
+pain depends on the two inflamed surfaces of the membrane rubbing
+against each other, and accordingly is relieved not merely by the
+abatement of the inflammation, but also when either the two surfaces
+become, as they often do, adherent to each other, or when fluid is
+poured out into the cavity of the chest, and thus keeps them asunder.
+
+I dwell on this, because when fluid is poured out, the most distressing
+symptoms greatly abate, or even disappear, and parents sometimes put off
+in consequence sending for the doctor, while yet, if unattended to, the
+fluid may increase to so large a quantity as to press upon the lung, and
+so interfere with the entrance of air, or it may, if the mischief is not
+checked, change into matter, and then have to be let out by tapping the
+chest, for just the same reason as it may be necessary to open an
+abscess in any other situation.
+
+Whenever, then, symptoms, such as I have described, come on, send at
+once for medical advice, and do not let some diminution of suffering, or
+slight general improvement, lead you to delay.
+
+=Croup.=--I endeavoured to explain, a few pages back, the cause of that
+peculiar sound which is heard in spasmodic croup. The contraction of the
+opening of the windpipe changes the sound which passes through it, just
+as the opening or closing the keys of a wind instrument modifies the
+sound which it gives forth. But the windpipe is not simply a wind
+instrument, it is a stringed instrument too, and the strings or vocal
+cords, as they are termed, give forth, as they vibrate, tones now
+deeper, now more shrill. The action of this delicate apparatus is
+readily disturbed, if the nerve-supply to it is disordered by irritation
+in some distant organ, and then the breathing is accompanied by the
+peculiar sound of spasmodic croup, or in older children this may show
+itself in a different way, as in the loud, barking cough heard in some
+cases of constipation, or of disordered digestion; or another
+illustration of it is furnished by the loud, long breath--the 'hoop,'
+which gives its name to hooping-cough. But there is one sound that
+sometimes attends the breathing of children, which more than any other
+causes, and justly causes, the greatest anxiety to a mother; and that is
+the sound which is characteristic of croup.
+
+The word croup, which comes from the Lowland Scotch, signifies merely
+hoarseness in breathing or coughing, and is therefore, strictly
+speaking, the name of a sign of disease, rather than that of the disease
+itself. The peculiar sound is heard in two different conditions--the one
+in which a child having caught cold, instead of the air-tubes alone
+being affected, the windpipe, and especially its upper part, becomes
+congested, and the lining membrane swollen. Partly owing to this, partly
+owing to its nerve-supply being disturbed, the child breathes noisily
+and hoarsely, and the cough has a peculiar metallic clangor. In the
+other case there is not merely the congestion of the windpipe, the
+disturbed nerve-supply, and the swollen state of the membrane; but in
+connection with the influence of the special poison of diphtheria, a
+deposit takes place at the back of the throat, whence it extends to the
+windpipe, and in many instances even far beyond it, blocking up its
+canal, and mechanically excluding the entrance of air.
+
+To determine at once to which class a case of croup belongs is so far
+from easy, that I should advise that on the first sound of voice, or
+cough, or breathing resembling that of croup, medical advice should at
+once be sought. I dwell on the difference between the two: the first
+which has been called false croup, or better catarrhal croup, and the
+second called true croup, or diphtheritic croup, in order to save much
+needless apprehension to parents, in whose mind the croupy sound is
+invariably associated with nothing short of that most dangerous
+disease--diphtheria.
+
+As a general rule catarrhal croup is rarely met with after the age of
+six. Children in whom it occurs have either seemed quite well, or at
+most 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 a
+long-drawn sound, half-hissing, half-ringing, and the child soon wakes
+alarmed, and fighting for breath, the skin bathed in perspiration, the
+face flushed and anxious. The cough, the difficult breathing, and the
+struggle for air last for an hour or two, or sometimes all night long,
+though they gradually subside, at any rate towards the approach of
+morning, when the child falls asleep, and, but for a somewhat hoarse
+sounding cough, and a look of fatigue, there are but few signs of all
+that it has endured.
+
+The attack may not return, or it may recur for two or three successive
+nights, though in general with lessened severity, the child during the
+daytime seeming to suffer only from a slight cold, or now and then, and
+so rarely that I have not known it to occur above once or twice in all
+my experience, it may end in real inflammation of the windpipe; but not
+in diphtheria.
+
+Attacks of this kind may recur three, four, or more times even in
+childhood, while diphtheria has no tendency to recur, but like measles
+or scarlatina seldom appears more than once, though the rule is subject
+to more numerous exceptions than are found in the case of the eruptive
+fevers. Still the fact of an attack of this sort returning should of
+itself lessen apprehension and make the parents look forward to its
+issue with less anxiety than that with which they regarded its first
+occurrence.
+
+A fact which shows how large a part is played by disturbance of the
+nervous system in these cases is the liability of children who have
+suffered from it to attacks of asthma, often of great severity as they
+grow older, while very often after the transition from childhood to
+youth has passed these attacks too lessen in frequency and severity, and
+often 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 as
+if by magic, while even were the case one of diphtheria they would still
+be of some service, and could not possibly do any harm. They are the hot
+bath, and a full dose of ipecacuanha wine. The former should be as hot
+as it can be borne, 93° or 94°, and the child should be kept in it for
+five minutes, and the latter should be given in a full dose, as a
+teaspoonful in warm water every quarter of an hour till free vomiting
+takes place. How much better soever the child may seem after the use of
+these remedies, it should still be kept for two or three days under
+careful medical observation.
+
+=Diphtheria.=--In _diphtheria_ croup is only one, though the most
+frequent, and one of the most serious, of the many dangerous symptoms
+which attend it. The croupal symptoms hardly ever come on quite
+suddenly, but are almost always preceded for some days by slight
+feverishness, languor, and restlessness, in spite of which the child
+still amuses itself; and if too young to express its sensations, the
+slight degree of sore-throat it experiences is manifested rather by a
+disinclination to take food than by any obvious difficulty in
+swallowing. There is no cough, nor any change of voice when the child is
+awake, but when asleep--and the sleep is generally uneasy--it often
+breathes with its mouth open, it snores slightly, or there is a little
+hoarse sound accompanying the breathing owing to a trivial swelling of
+the throat; while, if sought for, there will generally be found a very
+little enlargement, and a very little tenderness of the glands at the
+corner of the lower jaw. The eyes are sometimes tearful, there may be
+slight running at the nose, and the child is said to have a bad cold
+with slight sore-throat--the most remarkable feature of the case being
+generally that the depression of the patient is out of proportion to the
+severity of the local ailment. If now the throat is examined--and
+examination of the throat should never be omitted in any case where
+there is the slightest difficulty of swallowing--nothing may at first be
+seen but a very little swelling, and some redness of one or other
+tonsil. In a few hours more, white specks like little bits of curd will
+be seen first on one tonsil, then on the other, and next these specks
+will have united to form one continuous layer of a sort of
+yellowish-white membrane over the palate and tonsils. The examination of
+the throat, often so difficult when children are ill, is attended with
+almost none, if while they are well they have been taught the little
+trick of opening their mouths to show their throat, and of allowing the
+introduction of a spoon to keep down the tongue, a proceeding which
+though 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 be
+reproduced, and this even though no treatment has been adopted, and in
+two or three days the child may be pretty well again, though strength is
+in general regained less rapidly than might have been expected from the
+comparative mildness of the attack.
+
+In cases so slight it is no easy matter to recognise the features of a
+highly dangerous disease; still, out of forerunners so trivial as these,
+croupal symptoms may be developed, and their advances may be most
+insidious, and unless both parents and doctor have been closely on the
+watch they may be surprised all at once by the breathing suddenly
+becoming very laboured, by that and the cough becoming attended by the
+sounds characteristic of croup, and by the child's life being in extreme
+jeopardy, or in danger even beyond the hope of recovery.
+
+It is not that here, as in cases of catarrhal croup, the ailment has
+really come on suddenly, but that the disease has been silently making
+unsuspected progress. Whenever then a child, after a few days of slight
+causeless ailing, accompanied with some little discomfort in swallowing,
+is seen to have white patches at the back of its throat, do not allow
+yourselves to be lulled even by their disappearance into a feeling of
+absolute security. Watch the child, and beg the doctor to watch it
+carefully, until it is perfectly well again, for though the deposit may
+have disappeared from the back of the throat it may continue to be
+formed in the windpipe, and in the somewhat depressed state of the
+nervous system which attends diphtheria it may not excite that
+irritation which any such cause would produce in a child in perfect
+health, and consequently not announce its presence until its amount has
+become so considerable as to offer an almost insurmountable obstacle to
+the entrance of air. Any, even the slightest, hurry of breathing, a
+hissing sound when the child draws its breath, hoarseness of voice, or a
+ringing cough, should quicken your apprehension of danger, and make you
+seek for immediate help.
+
+It may be as well, however, to mention here, that not every white speck
+seen at the back of the throat is of necessity due to diphtheria, but
+that in some cases of ordinary sore-throat white spots may form on the
+surface of the tonsils. These white spots are due to the collection at
+their openings of the secretion formed in the minute glands which beset
+the surface of the tonsils, and which at these seasons is poured out in
+greater abundance than usual. They are distinct from each other, and do
+not coalesce into a membrane; the surface beneath is not the uniform red
+shining surface on which the membrane in diphtheria has formed, but the
+separate tiny openings from which the white matter has exuded may be
+distinctly seen if the surface is wiped with a camel's-hair brush. It
+is, of course, wise in every case to leave to the doctor the decision as
+to the nature of the deposit, but it may sometimes relieve needless
+anxiety to know beforehand that there is another cause besides
+diphtheria to which white spots at the back of the throat may be due.
+
+There are other dangers, indeed, besides those arising from croup, which
+accompany diphtheria, though those just mentioned are of all the most
+frequent. There are cases in which death takes place not from the
+severity of any local ailment, but from the intense depression of the
+nervous system. There are other instances too, in which the case assumes
+what is termed a malignant character; profuse discharge taking place
+from the nostrils, swallowing being from the first exceedingly
+difficult, membrane being deposited on the lips, behind the ears, or at
+the edge of the bowel; death taking place in twenty-four or thirty-six
+hours from the outset of the first serious symptoms, either in
+convulsions, or from utter exhaustion.
+
+But the very urgency of such cases must of necessity call for the
+immediate assistance of the doctor; and my business throughout this book
+is rather with those points which it is important for a mother to
+notice, and those things which it behoves her to do.
+
+What does diphtheria depend on? is a question more easily asked than
+answered. The disease is contagious, as scarlatina is contagious, though
+not 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, be
+too much to say that it is dependent on an unsanitary condition of a
+town, a village, or a house, but there is no doubt but that, as is the
+case with cholera, scarlet-fever, or typhus, unsanitary conditions
+favour 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 child
+during a fit of coughing, that none of the membrane which it spits up
+enters the mouth; and, that if the child's breath is caught, the
+attendant gargle immediately with a teaspoonful of Condy's fluid in a
+tumbler of water.
+
+In the next place, as the depression of the nervous system in some cases
+of diphtheria is quite out of proportion to the local disease, and as
+children who have not seemed very suffering, have yet been known to die
+suddenly in an unexpected faint, it is of moment that the child remain
+constantly in bed from the commencement of the attack till complete
+convalescence. Nor, indeed, in serious cases is even this precaution
+sufficient; but in such circumstances not only must the child not be
+taken out of bed for any purpose, but it must even not be suddenly
+raised in bed, from a recumbent to a sitting posture. I have, on several
+occasions, known the neglect of these precautions followed immediately
+by 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 try
+to carry out the doctor's directions, and to give the child constantly
+little bits of ice to suck, which lessen the swelling of the throat, and
+relieve the pain and inflammation. If the child knows how to gargle, it
+should be induced to do so constantly, and finding the relief which this
+affords, will do so very readily. This is not the time, however, when
+the lesson 'how to gargle' can be learnt. A thoughtful mother teaches it
+while the child is well, and if the gargle is composed of raspberry
+vinegar and water, the lesson is learnt without tears. There comes a
+time, however, if the disease is at all severe, when gargling is no
+longer possible, for the muscles of the back of the throat lose their
+power; but now some medicated solution, employed by means of the
+spray-producer, may most efficiently take its place.
+
+When croupal symptoms have gone on growing worse and worse, and the
+child is in the agonies of suffocation, the doctor may propose to open
+the windpipe, in the hope of giving the child another chance of
+recovery, and even though the operation fail, of at least lessening its
+sufferings.
+
+The operation is sometimes objected to by the parents, on the ground of
+the uncertainty of the result, and the torture of the operation to the
+child. Now the anguish of a child dying of croup is due to two causes;
+first, the actual mechanical impediment to the entrance of air produced
+by the deposit in the windpipe, and secondly, to the spasm of the
+muscles in the upper part of the windpipe which that deposit produces.
+How large an amount of distress the latter may produce, anyone can judge
+for himself, to whom it has ever happened to swallow the wrong way, as
+it is called. The opening made below the seat of the muscles which close
+the windpipe, leaves them in perfect rest, and does away with all the
+suffering produced by spasm, while there is always a fair prospect if
+the operation is not put off too long, of the deposit being limited to
+the 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 the
+deposit beforehand; it is true also that the operation is not in itself
+a cure of the disease, but at any rate, it is a reprieve which gives
+time for remedies to take effect, and at the worst, it substitutes a
+comparatively painless death for one of intolerable anguish. It can,
+too, be performed under the influence of chloroform, so that the idea
+that it adds in any way to the child's distress is unfounded. Who that
+has seen the calm, happy face, and watched the tranquil sleep of the
+child after the operation, who before was struggling, with distorted
+features and agonised countenance, to get a breath of air, but would
+feel as I do, that I would have it done in a child of mine for the sake
+of a painless death, even though I knew for certain that it would not
+prolong life even for an hour?
+
+One additional remark I have to make with reference to the loss of
+power, or palsy of various muscles, which frequently follows diphtheria.
+Almost always there is some impairment of power in the muscles of the
+throat on which the deposit had taken place, and there is, in
+consequence, a little difficulty in swallowing for a few days. If this
+should get worse, food and especially drink sometimes return by the
+nose, and next there may be a slight squint, and the sight may become
+weakened, and an uncertain tottering gait; and sometimes for a week or
+two the child may be unable even to stand. In bad cases there is with
+these symptoms a general loss of nervous as well as of muscular power,
+though the child may still be fairly cheerful, and ready to amuse itself
+as well as it can. This condition may last for many weeks before it
+passes quite away, and if under the mistaken impression that the limbs
+will gain strength by exercise, the child is allowed to sit up and
+encouraged to exert itself, recovery will be delayed much longer; and
+dangerous weakness or fatal exhaustion may suddenly come on.
+
+The inference is too obvious for me to need dwell on it, that repose is
+the great resource, and quiet waiting the true wisdom.
+
+=Hooping-Cough.=--I need not say much about _hooping-cough_, for there
+is scarcely a nursery in which, to everyone's great discomfort, it is
+not known as a familiar and most unwelcome visitant. It varies
+remarkably in its importance, being sometimes so slight as scarcely to
+amount to an illness, but in other instances one of the most deadly of
+diseases. It causes the death of a fourth of all children who die under
+the age of five, and three out of four of these deaths take place in
+infants of less than two years old.
+
+It occurs, however, comparatively seldom during the first three or four
+months of life, probably because very young children are kept more at
+home than others, and are thus less exposed to catch it. Though
+hooping-cough is undoubtedly very contagious, it seems to be
+communicated only by the breath, and there is absolutely no evidence to
+show that the clothes of a child suffering from hooping-cough can carry
+the infection as they might were the child suffering from measles, or
+smallpox, or scarlet-fever; still less that a person who has visited a
+room where children are suffering from hooping-cough can convey the
+disease to another house, or to other children.
+
+The disease derives its name, as everyone knows, from the peculiar sound
+which attends the cough, and which is due, as is the sound of croup, to
+spasm of the upper part of the windpipe. It is equally characterised by
+the cough returning in fits or paroxysms, which end in a long-drawn
+breath, attended by the hoop. An occasional sound like a hoop, in a
+young child who has a cold, is not so conclusive of a case being one of
+hooping-cough as is the recurrence of the cough in fits; for until
+teething is completed, slight and temporary irritation will suffice to
+produce a passing spasm of the upper part of the windpipe.
+
+An ordinary attack of hooping-cough begins like a common cold, but as
+the little ailment passes off, the cough still continues, the fits of
+coughing become more frequent, last longer, grow severer and more
+suffocative, and end with the loud long breath, the hoop; while
+sometimes no sooner is one fit over than another follows it almost
+immediately, and quiet breathing does not return until the child is
+tired out by its efforts. Nevertheless, the child's health continues
+fairly good, and little or nothing ails it during the intervals of the
+cough. For about a fortnight the cough usually goes on to increase; and
+during this time the night attacks especially become more frequent. It
+then for a week or ten days continues stationary, and then declines, a
+diminution in the frequency and severity of the night attacks being in
+general the first sign of amendment, and at the end of six weeks from
+the beginning of the attack the child is in general quite convalescent.
+Even then, however, a trifling cause will reproduce the characteristic
+cough for a few days, and not seldom for many months afterwards any cold
+which the child may catch will be attended by a paroxysmal cough
+undistinguishable save by its milder character and shorter duration from
+the previous hooping-cough, though I believe incapable of communicating
+that disease.
+
+In mild hooping-cough there is little or nothing to be done, save to
+follow the dictates of common sense, and not to neglect them in quest of
+some imaginary specific--some vaunted medicine which is said to be a
+certain cure; or such as shutting up the child in a room the atmosphere
+of which is charged with the vapour of tar, or of carbolic acid, or of
+sulphur.
+
+It cannot be too strongly impressed on the minds of parents that there
+is no specific whatever for hooping-cough; no remedy which will cut it
+short, as quinine cuts short a fit of ague. The domestic treatment of
+mild hooping-cough is the domestic treatment of a common cold, implying
+the same precautions as to the equal temperature of the day and night
+nursery, the little doses of ipecacuanha at night, but as seldom as
+possible during the day, in order not to interfere with the appetite and
+digestion, together with special care to insure the regular action of
+the bowels. It sometimes happens that after a week or two the severer
+fits of coughing are followed by vomiting; and the child may lose flesh
+and strength from inability to retain its food. In these circumstances
+food must be given, little in quantity, at short intervals, and of a
+kind 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 ordinary
+meals, and be given twice as often.
+
+The different liniments, and the favourite Roche's Embrocation, are of
+use when the disease is on the decline, and may also be of service if
+bronchitis should occur to complicate the hooping-cough, but not
+otherwise.
+
+Change of air when hooping-cough is on the decline is often of great
+service, and change even from good air to one less good appears to be
+sometimes of use; but change in the early stages, or when hooping-cough
+has become really severe, is but adding another to the already existing
+dangers.
+
+The danger in hooping-cough arises through the medium either of the
+head or of the lungs, and through each of them with about equal
+frequency. The head becomes affected in consequence of the often
+recurring congestion of the brain, produced, as in spasmodic croup, by
+the constantly returning interruption to the breathing. In these cases
+the cough is frequent, and so violent that the child becomes livid
+during each paroxysm, and that instead of ending in a loud hoop it
+finishes by a fit of convulsions or by the child sinking into a state of
+semi-insensibility. Increased violence of the cough, with suppression of
+the 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 of
+comparative, or of absolute ease. The hurried breathing which precedes
+and follows a fit of coughing never entirely subsides, while each
+returning cough aggravates the irritation and inflammation of the
+air-tubes, and the child's condition becomes the very dangerous one of
+hooping-cough complicated with bronchitis.
+
+So long as a child seems pretty well in the intervals between the fits
+of coughing, as the hurried breathing subsides after each to a natural
+frequency, as a long loud hoop follows each cough, as vomiting takes
+place only after a fit of coughing and never in the intervals, as the
+child becomes flushed only and not livid during a cough, and recovers
+itself perfectly afterwards, as it does not complain of constant
+headache, nor spits blood, nor has nose-bleeding, nor is feverish, nor
+depressed, nor drowsy, you may feel happy about it. When any of the
+symptoms just enumerated show themselves you have reason for grave
+solicitude, and the child requires daily medical watching.
+
+One word in conclusion. A child who has recently had hooping-cough is
+more liable than another to be attacked by chicken-pox or measles; and,
+moreover, imperfect recovery from hooping-cough is apt, especially if
+there is any tendency to consumption in the family, to be followed by
+consumptive disease.
+
+=Asthma.=--_Asthma_, attended by distress of breathing quite as
+considerable as in the grown person, is by no means unusual in the
+child. 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 or
+lungs, which in the former occasion or aggravate it. It belongs to the
+class of what has been termed nervous asthma and is observed with
+special frequency in children who, when younger, had been liable to
+catarrhal croup; spasm of the air-tubes having taken the place of the
+previous spasm of the windpipe. Independently of that antecedent it
+comes on sometimes about the time of the second teething in nervous and
+impressionable children, in whom an attack may be produced by
+indigestion, constipation, or over-fatigue. It is also by no means rare
+in children in whom that skin affection, eczema, of which I have already
+spoken, outlasts the time of infancy, and becomes general and severe.
+The improper performance of the functions of the skin seems to cause a
+peculiar sensitiveness of the air-tubes, and to render them liable to
+the occasional occurrence of that spasm which produces asthma. These
+cases are less hopeful than others, and the liability to the attacks
+ceases only when the skin-affection has been completely cured; a reason
+this 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 severe
+hooping-cough, and in these two conditions the prospects of recovery are
+less hopeful than in the others.
+
+When asthma occurs in childhood, the first point is to ascertain the
+cause on which the attack depends; and it is worth any amount of care to
+discover and remove it; for if what may be called the asthmatic habit is
+not formed, the attacks will, in the majority of instances, cease
+between 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 the
+boy who grows up an asthmatic youth is very unlikely to get rid of the
+disorder in later life.
+
+It is in that form of asthma which succeeds to frequent attacks of
+catching cold, and in which bronchitis precedes or accompanies each
+seizure, that change of climate is most useful. In the majority of
+instances a moderately sheltered seaside place, with a sandy soil such
+as Bournemouth, is the best, and a few years' residence there not
+infrequently overcomes every disposition to asthma through the whole
+remainder of the patient's life. To this, however, there are exceptions,
+and I have seen instances in which residence at Bournemouth and in the
+Riviera have failed, but where a perfect cure has been wrought by the
+cold, still air of Davos.
+
+=Diseases of the Heart.=--=Malformed Heart.=--Every now and then one
+sees a little babe, carefully wrapped up in its nurse's arms to shield
+it, even on a warm day, from the air; and, on removing the shawl which
+covered 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 of
+lips and fingertips, as though perished with cold. The babe wakes on
+being disturbed, and gives a faint short cry of distress; the livid hue
+of its surface deepens, it struggles feebly, its mouth twitches as
+though convulsions might be coming on. Soon, however, these symptoms
+subside, the babe smiles again, is cheerful, and save for the tints of
+its face and lips, it looks like other infants, but frailer.
+
+This condition has a name in medical writings, from a Greek word
+expressive of the blue tint which characterises it, and is called
+_cyanosis_. It depends on the blood not having undergone completely
+those changes in the lungs which take place in the healthy state. The
+blood, 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 sends
+it to the lungs, where, in the minute vessels of the air-cells, it is
+purified, and returns vivified by the oxygen a bright scarlet stream, to
+be distributed by the arteries over the whole body; and thence to return
+once more for fresh purification to the right side of the heart. Before
+birth, the blood does not run the same course, but is purified within
+the mother's body, the blood running through channels which close with
+the first breath the infant draws. The previously existing communication
+between the two sides of the heart ceases at the same time as the new
+channels are opened, by the shutting of a thin valve which had hitherto
+allowed the blood to pass from one side to the other.
+
+Sometimes this closure fails to take place, or takes place but
+imperfectly; sometimes, in addition, the channels which should be
+disused after birth remain open still; and sometimes also the heart is
+otherwise imperfectly formed, and a large communication exists between
+the two sides of the heart, which long before birth ought to have been
+firmly partitioned off from each other.
+
+According to the freedom of communication between the two sides of the
+heart, there is more or less ready intermingling of the impure blood
+with that which is already purified; and this is betokened by the
+greater or less severity of the symptoms which I have described. When
+the heart is very malformed, and the blood consequently is very impure,
+life is but a short agony which ends in a few weeks; some slight
+movement, some little accidental cold deranging altogether the imperfect
+machinery, and bringing it to a sudden standstill. Between this and the
+slightest cases there are all shades of difference, till, in the latter,
+a smaller power to maintain warmth, a less rapid growth, a smaller
+muscular development, a feebler power, a hurry of breathing on exertion,
+or in ascending a hill, or in going up a staircase, are all, except the
+sounds which the educated ear detects of the blood passing through its
+devious course, that tell of nature having, in this instance, ill done
+her handiwork.
+
+The one most natural question to which, in every instance, the doctor
+has to reply is this: 'Will he or she outgrow it?' To this the answer
+is, '_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 no
+trace behind, and to make the child heartwhole. But short of this, in
+many instances much may be hoped for. There is, as I shall have occasion
+again to repeat, a power in the growing heart to adapt itself in large
+measure to conditions other than those of perfect health. The channels,
+through which the blood ought not to flow, may shrink though they may
+not entirely close; the valve may shut more completely than at first the
+opening between the two sides of the heart; all inconveniences may
+lessen, and the child may at last become scarcely aware of the
+difference between himself and others. But for any such result, or for
+anything approaching it to be attained, certain conditions are
+absolutely essential which it is seldom easy to induce parents to
+observe. Whatever can hurry the circulation is most carefully to be
+avoided. The child must be kept strictly out of the way of
+hooping-cough, measles, or any other fever; must be shielded from every
+risk of catching cold, and having smaller power of maintaining its
+warmth than others have, must be specially warmly clad, and must live in
+rooms at a temperature of 60 deg. Fahr., all the year round. Great
+attention must be paid to the state of the bowels, so that constipation
+may not necessitate violent efforts to relieve them.
+
+Moreover, for years the child must be carried upstairs; when old enough
+to take part in games, it must not be allowed to join in any which call
+for violent exertion, such as cricket, or lawn tennis, nor ride any
+other than a quiet pony at a gentle pace.
+
+It depends entirely on the parents whether, for the sake of a very great
+but far-off good, they will strictly observe these rules. The difficulty
+will not arise on the child's part, for it is not hard for those who
+have had charge of it from babyhood to bring it up to quiet pursuits and
+quiet amusements, till it seeks no others, and, like the little
+cage-bred bird, does not care to emulate the flight of others stronger
+on the wing.
+
+=Inflammation of the Heart.=--The above remarks do not comprise all
+that is to be said about heart-affection in early life. _Inflammation_
+may attack the investing or the lining membrane of the heart at all
+ages, may produce in the child the same suffering as in the grown
+person, and may tend to destroy life in a similar manner. The causes,
+indeed, which produce heart disease, are far more frequent in the grown
+person than in the child, and advancing age brings with it changes
+which, wholly apart from active inflammation, produce grave forms of
+disease unknown in early life. There is, however, one cause of heart
+disease which is far more frequent in childhood and early youth than in
+later life, namely, rheumatism. Eight out of ten of all cases of heart
+disease under the age of fifteen are of rheumatic origin, and in
+eighteen out of twenty cases of acute rheumatism under that age, whether
+slight 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 now
+and then affection of the heart is associated with some other form of
+inflammation of the chest.
+
+Pain is by no means a constant attendant on it, but fever, more or less
+considerable, a quickened pulse, and hurried breathing are all but
+invariable, and one great reason for seeking the immediate help of the
+doctor is, that his skilled ear may at once detect by the altered sounds
+the heart-affection at its very outset, and employ the measures
+calculated to arrest its progress.
+
+Death in the acute stage of a first attack of inflammation of the heart
+is of extreme rarity, but the damaged heart is liable to returns of
+acute mischief, any one of which may prove fatal. Independently of this,
+life with diseased heart is one of suffering, attended as it is by
+symptoms similar in kind, though not identical with those which I have
+already mentioned as attendant on malformation of the organ.
+
+The hopeful element, however, to which I have already referred as
+present in cases of malformed heart, exists here in even a greater
+degree; since repair of injury is possible, while the reconstitution of
+an organ faulty from birth is obviously beyond nature's power.
+
+I can but repeat the directions already given as to the importance of
+allowing the heart as much rest, and giving it as little work, as is
+possible with a never-resting organ; and this with the added motive for
+perseverance furnished by the happy issue which may be hoped for as its
+reward.
+
+One word I must add about the occasional occurrence of _irregular
+action of the heart_ during the years of growth, especially from the age
+of ten to fourteen. This is often quite independent of any disease, and
+ceases when with added strength the nervous system becomes less
+impressionable.
+
+
+
+
+CHAPTER VIII.
+
+DISEASES OF THE ORGANS OF DIGESTION.
+
+
+=Manner of Performance of Digestion.=--The organs situated in what is
+called in medical language the abdomen, have in the child no other duty
+to perform than such as subserve the processes of digestion and
+nutrition. The saliva secreted by the appropriate glands in the mouth,
+mixing with the food, facilitates the further changes which take place
+in the stomach. In the stomach the food is acted on and dissolved by the
+gastric juice or pepsin, which is poured out by an almost infinity of
+minute tubes, or follicles as they are termed. When the stomach has done
+its work, its contents in a semi-fluid state pass into the small
+intestine, and mix there with the bile, the secretions from the
+intestines themselves, and with those of the large gland, the pancreas
+(in culinary language known as the sweetbread), which seems to have the
+special power of dissolving fatty matters. As the food, thus acted on,
+travels along the intestines, whose constant movement facilitates the
+passage of their contents from above downwards, its elements are taken
+up, 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. The
+fluid taken up by the blood-vessels is conveyed to the liver; that taken
+up by the absorbents to the mesenteric glands, and in these organs
+further changes take place in it, which fit it to be received into the
+mass of the circulating fluid. With this it is carried to the right side
+of the heart, and thence to the lungs and, lastly, from them to the left
+side of the heart, whence it is distributed, the great life and health
+giver, to the rest of the body. The useless inconvertible material,
+leaving every available element behind, is got rid of, either in a solid
+form by the bowels, or in a fluid form by the kidneys; and thus as long
+as life lasts there goes on more or less perfectly the wonderful process
+of 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 part
+of this complex machinery may be thrown out of gear, and further how not
+one part can suffer without all being disordered. Solid food given to
+the child before it has cut its teeth, enters the stomach unreduced to
+pulp by the grinders, and unmixed with the saliva, which should help its
+solution, and which the undeveloped salivary glands do not yet furnish.
+Too large a quantity of food, or food of an unsuitable character, on
+which the gastric juice cannot act readily, may pass into a state of
+fermentation; vomiting, flatulence, sour and offensive breath will be
+the result, and the food will pass into the intestine unprepared to be
+acted on by the bile. Exposure to cold, or the opposite condition of
+excessive heat, may disturb the action of the liver, and interfere with
+the secretion of bile; and the food will then pass along the intestine
+in a state unsuitable for absorption. Or, again, the mesenteric glands
+may be irritated by long-continued imperfect performance of the earlier
+stages of digestion, or their structure may be altered, and mesenteric
+disease, or consumption of the bowels, as it has been termed, may
+result. From want of muscular power, or from want of care on their part
+who have charge of the child, the bowels may become habitually
+constipated. Health will then suffer, if the child carries about with it
+for days together matters which can serve no useful purpose, but which
+are to the body what an ill-kept dustbin is to the rest of the house.
+Lastly, if the kidneys perform their duties imperfectly in consequence
+of exposure to cold, or of the changes which some diseases, such as
+scarlatina, sometimes bring about in their structure, the blood will be
+imperfectly purified; dropsy and various forms of inflammation may
+result; or the brain and nervous system may be disordered, and death in
+convulsions may attest the dangerous nature of this blood-poisoning.
+
+It would take too long to go in detail through all the phases of
+disordered digestion in early life. Much has been already anticipated in
+a former part of this book, especially with reference to the troubles of
+digestion in infancy and early childhood. There is, indeed, but one form
+of indigestion whose characters are so special as to require that I
+should enter into any detail with reference to it.
+
+=Dyspepsia of Weakly Children.=--Children from the age of about three to
+ten years, whose health has been impaired by an attack of typhoid, or,
+as it is commonly called, infantile remittent fever, or who belong to a
+weakly family, or to one, some of whose members have shown a disposition
+to consumptive disease, are sometimes martyrs to indigestion. It does
+not need with them any special error of diet, or any casual exposure to
+cold to disorder their digestion; but every two or three weeks, even
+under the most scrupulous care, they lose their appetite, their tongue
+becomes thickly coated with yellow fur, their breath offensive, their
+bowels constipated, the evacuations being either very white or very
+dark, and frequently lumpy, and coated with a thin layer of mucus from
+the 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 a
+reddish-white deposit, which disappears if heated. At the end of two or
+three days of rest in bed, of a diet of beef-tea and milk, with no solid
+food, with simple saline medicines, mild aperients, and perhaps a single
+small dose of calomel, the symptoms pass off; but return again and again
+at uncertain intervals, and without any obvious cause.
+
+In these cases, the children almost always, when in their ordinary
+health, have a peculiar patchy condition of the tongue, one part of it
+being covered with a thin white coating, through which little red points
+project, while another part is of a vivid red, and looks raw and
+shining, as though it had been scalded, while the red points, or the
+papillæ, as they are termed, project above its surface like so many
+pins' heads. Children in whom this condition exists, require much
+watching and much care. I have dwelt upon it in order to impress on
+parents 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 eradicate
+a 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 pale
+evacuations, constipation, and loss of appetite, with a sallow tint of
+the skin, and sometimes even with actual _jaundice_, are by no means
+uncommon during the first ten years of childhood. Neither condition is
+serious; that of actual jaundice occurs mostly in the summer, and is
+then connected with the sudden onset of hot weather. When severe, it may
+be associated with some degree of feverishness, with dizziness, and
+complaint of headache, and occasionally with vomiting, while the child
+rests ill at night, or awakes in a state of alarm, and these symptoms
+sometimes give rise to the fear that the child is about to be attacked
+by water on the brain. But the following consideration may serve to calm
+anxiety on that score. The attack is not preceded, as water on the brain
+is 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 by
+constant nausea; and the belly is full rather than shrunken. When to
+these symptoms are added tenderness on the right side, high-coloured
+urine and white evacuations, you may set your mind at rest, even before
+the yellow colour of the skin, which appears in a day or two, stamps the
+case unmistakably as one of jaundice.
+
+My business is, as I have said more than once, the endeavour to describe
+the symptoms of disease, to explain their nature, to indicate the
+principles to be observed in attempting their cure, and not to lay down
+definite rules for their treatment, with the idle expectation that I
+could 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 symptoms
+force themselves on the notice even of the least observant. There are,
+however, a few points concerning it worth bearing in mind. Before the
+commencement of teething, diarrh[oe]a is almost always the result of
+premature weaning, or of a diet in some respect or other unsuitable. As
+soon 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 first
+six months of life; while, as soon as teething is over, their number
+immediately declines again to the half of what it was during the
+continuance of that process. The practical conclusions to be drawn from
+these facts are that looseness of the bowels during teething is not a
+desirable occurrence to be promoted, as some mistakenly imagine, but a
+risk 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, that
+in order to prevent its occurrence, care should be taken to make changes
+in the diet of a child, not during the time when a fresh eruption of
+teeth is taking place, but during one of the pauses in that process.
+There are certain seasons of the year when diarrh[oe]a is specially
+prevalent, independent of any change in diet, or alteration, in any
+respect, of the circumstances in which the child is placed. Thus, in
+May, June, and July, diarrh[oe]a is twice as prevalent among children at
+all ages as in November, December, and January; and in August,
+September, and October, its prevalence is three times as great as during
+the winter months. The high mortality of children in the summer months
+is due almost entirely to diarrh[oe]a, and even the bitter Northern
+winter of a city like Berlin is a third less fatal to infants and young
+children than the heat of its short summer.
+
+The next point to remember is that mere looseness of the bowels is
+never to be regarded during the first three years of life as of no
+importance; for I have seen infants die exhausted from its continuance,
+even though the examination of the body after death showed almost no
+sign of disease. Doctors distinguish two forms of diarrh[oe]a: the
+simple, or, as it is technically called, catarrhal diarrh[oe]a; and
+inflammatory 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 a
+dangerous bronchitis.
+
+_Simple diarrh[oe]a_ usually comes on gradually, and is some days
+before it grows severe, or passes into the more dangerous dysentery.
+Simple precautions will often arrest its progress, and, among them, rest
+in bed is one of the most important. Over and over again I have known a
+diarrh[oe]a which had continued in spite of all sorts of medicines so
+long as the child was running about, cease at once when the child was
+kept for a couple of days in bed. The reason of this is obvious;
+constant movement of the intestines themselves, which serves so
+important a part in maintaining due action of the bowels, is increased
+by the upright position and by movement, and is reduced to a minimum by
+the horizontal position. A second precaution concerns the diet; solid
+food and animal broths should for a time be discontinued, and arrowroot,
+milk and water, and rice substituted for it, for a day or two, with
+isinglass jelly, and the white decoction of which I have already spoken.
+It is not always that astringents are suitable at the beginning of an
+attack, and the sending to the neighbouring chemist for diarrh[oe]a
+medicine, which often contains an unknown quantity of opium, is always
+risky, frequently mischievous. In a first attack of diarrh[oe]a, the
+doctor should always be consulted, for when it is associated with
+disorder 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, sulphuric
+acid for the first few hours is often of extreme service. It is at a
+later time that direct astringents commonly have their use; and the
+mother, who in her child's first attack of diarrh[oe]a has had the
+advice of a judicious doctor, will often be helped by him to manage for
+herself slight returns of the ailment.
+
+_Inflammatory diarrh[oe]a_, or dysentery, not only follows the
+continuance of the simpler forms of the disease, but sometimes in the
+hot months of summer or autumn sets in suddenly with violence. It then
+frequently commences with vomiting, and the stomach may continue so
+irritable for twenty-four hours as not to retain even a teaspoonful of
+cold water. At the same time the over-action of the bowels sets in, and
+twenty or thirty evacuations may be passed in twenty-four hours. The
+motions soon lose their natural character, and become watery, slimy, and
+mixed with blood. They are at first expelled with violence, afterwards
+with much pain, effort, and often fruitless straining. With these local
+symptoms, the child, as might be expected, is very ill, feverish, and
+stupid, though without sound sleep, much exhausted, and its nervous
+system so disturbed as to occasion frequent twitchings of the fingers
+and of the corners of the mouth, while sometimes actual convulsions take
+place. The thirst is intense, the child calling constantly for cold
+water, and crying out for more the moment the cup is taken away from its
+lips; while the loss of flesh and the exhaustion are more rapid than in
+any other disease with which I am acquainted. The fat happy babe of four
+and twenty hours before is scarcely to be recognised in the miserable
+little being, with sunken lustreless eyes, and wizened features, and
+miserable countenance, lying in a state of half-stupor, sensible only to
+pain, which yet rouses it but to utter a moan, and then sinks again into
+silent suffering. I can well believe what we are told, that in some
+countries this, the so-called Summer Complaint of many of the American
+cities, sometimes carries off children in a few hours.
+
+If a fatal termination does not take place speedily, the disease passes
+into the chronic stage, the diarrh[oe]a diminishing in frequency, but
+the pain and straining, and the unhealthy character of the evacuations
+persisting. Ulceration of the bowels has taken place, emaciation becomes
+extreme, and the child often sinks at the end of several weeks, worn out
+by suffering; while recovery, doubtful at the best, is always very slow.
+But I need not pursue this subject further: enough has already been said
+to show how little infantile diarrh[oe]a is a disorder for domestic
+management.
+
+=Peritonitis=, or inflammation of the membrane covering the bowels and
+lining the cavity of the belly, is of excessive rarity in its acute
+form; and is attended by such general illness and such severe local
+suffering, that it is impossible to overlook it or to misapprehend its
+gravity. Severe pain in the belly is sometimes complained of by
+children, and is due to what is termed colic, a spasm of the bowels
+which is generally associated with constipation. The great test of the
+cause of the pain is furnished by the presence or absence of tenderness
+on pressure. The pain of colic is relieved by gentle pressure and gentle
+rubbing. The pain of inflammation in any degree and of any kind is
+aggravated by them. This applies also to cases, not indeed very common,
+in which inflammation is set up by some small body, such as a
+cherry-stone getting fixed in a little offshoot or appendage of about
+the size and length of the little finger, connected with the
+commencement of the large bowel, and producing ulceration. In these
+circumstances the bowels are confined, there are nausea and sickness,
+together with pain and tenderness of the belly, especially on the right
+side. The disease is a very dangerous one, and often proves fatal in the
+course of a few days. I refer to it because I have often seen it
+overlooked both by parents and doctors at its outset, since the pain
+then is often not severe nor the tenderness intense, and because I have
+seen the patient's condition rendered hopeless by strong aperients being
+given to overcome the constipation which was supposed to be all that
+ailed the child. I repeat then the caution, never to overlook the
+existence of tenderness, never to attempt to treat a case in which it is
+present; but always to call in medical advice, and above all always to
+abstain, unless ordered by a medical man, in every such case from the
+use of aperients.
+
+=Large Abdomen.=--I must not leave the subject of disorder of the
+digestive organs without some reference to a condition which often
+excites much needless anxiety among mothers, namely, the large size of a
+child's belly. This is sometimes supposed to be a certain evidence of
+the presence of worms, at other times to be a positive proof of the
+existence of grave disease, especially of disease of the mesenteric
+glands, or glands of the bowels as they are popularly termed. It is
+evidence of neither the one nor the other.
+
+If you go into a gallery of the old masters, and look at any of the
+pictures of angels which are generally to be seen there in such
+abundance, you will probably be struck in the case of all the child
+angels by what will seem to you the undue size of their abdomen. You
+will notice this even in the works of painters who, like Raphael, most
+idealise their subjects, while in those of others who, like Rubens,
+interpret nature more literally, the apparent disproportion becomes
+grotesque; or, in the coarser hands of Jordaens, even repulsive.
+
+These painters were, after all, true interpreters of nature. In infancy
+and early childhood the abdomen is much larger comparatively than in the
+grown person. For this there is a twofold cause; the larger size of the
+liver on the one hand, and the smaller development of the hips on the
+other. In a weakly child this appearance is exaggerated by its want of
+muscular power, which allows the intestines to become much distended
+with air. If the child is not merely weakly but also ricketty, the
+contracted chest will leave less room than natural for the lungs, while
+at the same time the ordinary development of the hips being arrested by
+the rickets, the disproportion is further increased both by that and by
+the flatulence due to the imperfect digestion with which the condition
+is almost always associated.
+
+In no case need the mere size of the abdomen occasion grave anxiety, so
+long 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 everywhere
+gives 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 opinion
+asked, as to the cause of excessive size of the abdomen, for its
+distension may be due to real disease; but it is yet worth while to
+remember that its mere size is not of itself evidence of disease, nor
+cause of grave anxiety.
+
+=Worms.=--There is no mistaking or overlooking the existence of _worms_
+when they are really present. Their presence, however, is often
+suspected without any sufficient reason. Ravenous or uncertain appetite,
+indigestion, flatulence, undue size of the abdomen, a dark circle round
+the eyes, itching of the nose and of the entrance of the bowel, a coated
+tongue, and offensive breath are no real proof of the presence of worms,
+and do not justify the frequent repetition of violent purgatives or of
+so-called worm medicines. The only real proof of the presence of worms
+is their being seen in the evacuations.
+
+The worms commonly found in children are either the round-worm, which
+resembles the earth-worm, the thread-worm, or the tape-worm; the
+appearance of each of which is clearly indicated by its name. None of
+them are spontaneously generated in the body, but they are all
+introduced from without; their eggs, or, as they are technically called,
+their ova, being swallowed unperceived in some article of food, or
+drink. A proof of this is afforded by the fact that an infant, so long
+as it is nourished exclusively at the breast, never has worms.
+
+The _round-worm_ occasions the fewest symptoms, and is rather an object
+of disgust than of grave importance, at least in this country, where it
+seldom happens that more than two or three are present. In other
+countries, as some parts of Italy, for instance, where the drinking
+water is bad and stagnant, they are sometimes found in great numbers, as
+thirty or forty, and it is then not easy to determine whether the
+symptoms which accompany them are produced by the worms, or by the
+unwholesome character of the water in other respects.
+
+They appear to live on the contents of the intestines, and do not adhere
+to them, as the tape-worm does, and hence their comparative
+harmlessness, and they have no power, as has sometimes been mistakenly
+imagined, of perforating the bowels, and of thus producing grave
+mischief.
+
+The _thread-worm_ is the commonest variety of these creatures, and has
+the 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, that
+in a week or two after it has been apparently got rid of, it may again
+be found as numerous as before. Certain articles of food seem to favour
+its development, such as pastry, sugar, sweets, beer, fruit, and
+anything which is apt to undergo fermentation, and thereby to impart to
+the evacuations a specially acid character. These worms are often
+accompanied with more or less marked symptoms of indigestion, but
+otherwise the local irritation is usually the only indication of their
+presence. They produce, indeed, such disturbance of the nervous system
+as may attend indigestion in any of its forms, but I have never but once
+known convulsions occur apparently due to their presence in great
+numbers, and ceasing on their expulsion; and this was in a child between
+eighteen months and two years old.
+
+The _tape-worm_ is developed in the human body from a minute germ or
+ovum; one form of which exists in the flesh of the bullock, the other in
+that of the pig; and which seems to require for its growth the favouring
+conditions of warmth and moisture which are found in the intestines. It
+fixes itself to the lining of the bowels by means of its mouth, which is
+furnished with minute tentacles, and it thus derives its support from
+the juices which it imbibes. The head is so small as not to be seen
+distinctly without a magnifying glass; and immediately beyond it the
+jointed body begins; at first, scarcely bigger than a thread of worsted,
+but gradually enlarging, till at the distance of three inches it is an
+eighth of an inch wide, and thence rapidly widens till each joint is
+half an inch wide, and from a third to half an inch apart. It does not
+exceed these dimensions, even though it may grow to the length of four
+or six yards. Portions of it, sometimes a yard or two in length, are
+thrown off from its lower end occasionally, and this occurrence often
+gives the first indication of its presence, the worm continuing to grow
+as before, and fresh portions being detached from time to time. It does
+not appear that the worm has the power of reproducing itself; hence its
+French name of _ver solitaire_, and the occasional presence of two or
+three would seem to be due to the development of two or three distinct
+ova within the intestine.
+
+Deriving as it does its support from the system of the child, and not as
+the other worms do from the contents of the bowel, the tape-worm often
+produces graver inconveniences. It sometimes causes uncomfortable
+colicky sensations, which may even be very distressing, and the
+disorders of digestion which accompany it are often very considerable;
+certainly more so than in the case of the other varieties of worms; but
+I have seen no instance of convulsions which could be attributed to
+them, notwithstanding the generally received opinion to the contrary.
+
+When the existence of worms is suspected, one or two doses of a simple
+aperient, such as castor oil, repeated two days successively, seldom
+fail to produce evidence of their presence; which in the case of
+tape-worm is also furnished by the spontaneous detachment of some of the
+joints. It must be remembered, however, that until the head has been
+detached from its connection with the bowel, nothing has been gained,
+and the tape-worm will in a short time grow again. To obtain the
+detachment of the head it is necessary that any worm medicine should be
+given when the intestines are empty. I am, therefore, always accustomed
+to give a dose of castor oil about two hours after the child's mid-day
+meal; and to send the child to bed as soon as the aperient begins to
+act, and to give it no more food except a biscuit and a little milk and
+water during the rest of the day. In the early morning, the special worm
+medicine is given, and over and over again I have known the worm to be
+brought away completely after many previous failures. When the smallness
+of the joints shows that the greater part of the worm has been thrown
+off, and that little more than the head remains, it is necessary to have
+recourse to the unpleasant proceeding of mixing the evacuations with
+water, and then straining them through muslin, in order that the doctor
+may by means of the microscope make out whether or no the head has been
+really detached. This is no question of mere curiosity, but a matter of
+the gravest moment, since nothing has been really gained so long as the
+head of the worm remains adherent to the bowel.
+
+Precautions such as these are not needed in the case of the other kinds
+of 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 should
+be emptied by a dose of castor oil.
+
+The only other caution which remains for me to give refers to the
+peculiar effect which salicine, a very valuable medicine, especially in
+the case of thread-worms, has upon the urine. It sometimes turns the
+urine of a greenish-yellow, often of a red colour, as though it were
+mixed with blood. The appearance, however, has no grave meaning, but is
+due simply to a chemical action of the medicine on the colouring matter
+and salts of the urine.
+
+There still remain some local ailments of parts connected with the
+process of digestion, concerning which a few words must be said.
+
+=Ulcerated Mouth.=--First, with reference to the _sore-mouth_ of
+children. I have already noticed a form of inflammation and ulceration
+of the gums sometimes met with during teething, but the sore-mouth of
+which I am now about to speak is often quite independent of that
+process; though it may sometimes be found associated with it, and is
+indeed rarely met with after five years of age. In almost all instances
+it is preceded and attended with symptoms of indigestion, during the
+course of which the mouth becomes inflamed, hot and red, and small very
+painful shallow ulcers with sharp-cut edges, and a little yellowish
+deposit on their surface, appear at the edge of the tongue, on the
+inside of the mouth, and especially on the inside of the lower lip, and
+the adjacent surface of the gum. Successive crops of these little
+ulcerations not unfrequently appear, so that for many weeks the child
+may be kept by them in a state of extreme discomfort; swallowing, and
+even speaking being the occasions of considerable suffering.
+
+It is seldom that nursery remedies, and the so-called cooling
+medicines, though often of some service, suffice to get rid of the
+ailment, which for the most part needs judicious medical treatment, and
+local as well as constitutional measures. Now and then this condition
+comes on in the course of measles, and is then sometimes of serious
+importance.
+
+In the other form, the disease is usually limited to the gums, and
+affects especially those of the front of the lower jaw, which become
+swollen, ulcerated at their edges, where a very ill-smelling deposit
+takes place of a dirty white or greyish colour, the surface beneath
+being spongy, swollen, raw, and bleeding. The ulceration sometimes
+extends so as to lay bare a large part of the sockets of the teeth; but
+though loosened they seldom drop out. Coupled with this, the glands at
+the angle of the jaw are swollen, and the child dribbles constantly a
+large quantity of horribly offensive saliva. In the children of the
+well-to-do classes the condition is seldom seen except in a slight
+degree; but even when severe it is rarely accompanied by any grave
+disorder of the general health. It seems to tend, whether treated or
+left to itself, slowly to get well; but its progress to a natural cure
+is extremely tedious, and the gums are left by it for a long time
+spongy, bleeding easily, and only very imperfectly covering the teeth.
+
+Anxiety is sometimes excited by this condition; it being supposed that
+the white deposit on the edge of the gum implies some relation between
+it and diphtheria. This is not so, for though this peculiar ulceration
+of the gums has now and then been found associated with diphtheria, the
+nature of the two diseases is essentially different. It is, however,
+always wise to call in medical advice in order to settle this important
+question, and the more so, since there is one remedy, the chlorate of
+potass, which, in appropriate doses, acts upon the condition almost as a
+charm.
+
+I say nothing about a dreadful form of inflammation of the mouth which
+ends in mortification, because it is of infinite rarity except among the
+destitute poor, and even among them it is very seldom seen except as a
+consequence of measles, or of some kind of fever. It is only among the
+very poor that I have seen it, and even among them it has come under my
+notice only ten times in the whole course of my life.
+
+There is a very common but inaccurate opinion that sore-mouth in
+childhood is often produced by the employment of mercury. I never yet
+saw a sore mouth due to the administration of mercury in any child
+before the first set of teeth were entirely cut; and never but once out
+of 70,000 cases which have come under my notice in hospital or
+dispensary practice, have I seen in children of any age under twelve any
+affection of the mouth from mercury sufficiently severe to cause me a
+moment's anxiety.
+
+=Quinsey=, or inflammatory sore-throat, has in it nothing specially
+peculiar to the child, but occurs at all ages with the same symptoms. It
+is, however, comparatively rare under twelve years of age, and is almost
+always less severe in childhood than at or after puberty, while I
+scarcely remember to have met with it under five years of age. This
+circumstance attaches special importance to sore-throat in young
+children, since it will usually be found to betoken the approach of
+scarlet fever, or of diphtheria, rather than the existence of simple
+inflammation, or quinsey.
+
+While this fact affords a reason for most scrupulous attention to every
+case of sore-throat in children, and this in proportion to the tender
+age of the child, needless alarm is sometimes caused by the appearance
+on the inflamed tonsils of numerous white specks, which are at once
+supposed to be diphtheritic. I have already pointed out the distinction
+between the two conditions when speaking of diphtheria, but the matter
+is so important that I will repeat what I then said. These spots are not
+in the form of a uniform white patch or membrane, which, on being
+removed, leaves the surface beneath red, raw, and often slightly
+bleeding; but they are rather distinct circular spots, firmly adherent
+to the tonsil, wiped off with difficulty, and evidently exuding from the
+openings of little pits, blind pouches, or glands, with which the
+surface of the tonsil is beset. I do not advise any parent to rest
+satisfied with his or her judgment on this matter the first time that
+they notice this appearance; but there are children with whom slight
+sore-throat is always attended by this condition, and others in whom the
+tonsils are habitually enlarged, and seldom free from these white spots
+flecking their surface.
+
+=Enlarged Tonsils.=--I have said that quinsey or acute inflammation of
+the tonsils is unusual in early childhood; but a sort of chronic
+inflammation of those glands which leads to their very considerable
+enlargement is far from uncommon; and is sometimes the cause of very
+serious discomfort. It is seldom traceable to any acute attack of
+sore-throat, but usually comes on imperceptibly in children who are
+feeble or out of health, or takes place slowly during the cutting of the
+first set of grinding teeth; the irritation which that produces being in
+some cases its only apparent exciting cause. Not seldom the enlargement
+has become considerable before it attracts attention; one of the first
+symptoms that indicate it being the loud snoring of the child during
+sleep, who is compelled by the obstruction at the back of the nostrils
+to breathe with its mouth open. The voice at the same time becomes
+thick, and this and the snoring breathing are both greatly aggravated
+when the child catches cold.
+
+A greater degree of enlargement of the tonsils occasions deafness from
+pressure on the passage leading to the internal ear, and is also apt to
+give rise to a troublesome hacking cough which sometimes excites
+apprehension lest the child's lungs should be diseased. When still more
+considerable the enlarged tonsils block up the passage through the
+nostrils, and air consequently enters the lungs but very imperfectly.
+The nostrils thus disused become extremely small, narrow, and
+compressed, the upper jaw does not undergo its proper development, the
+teeth are crowded and overlap each other, the palate remains narrow and
+unusually high-arched, and the face assumes something of a bird-like
+character. Besides this the child grows pigeon-breasted, owing to the
+lungs not being filled sufficiently at each inspiration to overcome the
+pressure of the external air on the yielding sides of the chest.
+
+When any considerable enlargement of the tonsils exists, each cold that
+the child may catch aggravates it, and if diphtheria, scarlatina, or
+severe sore-throat should occur, the temporary increase of the swelling
+may become the occasion of serious danger. The question arises, what are
+the chances that a child whose tonsils are enlarged will outgrow the
+condition, or when is it necessary to have the enlarged tonsils removed?
+
+It scarcely ever happens that any such enlargement of the tonsils exists
+in children under six years of age as to call for their removal. There
+is almost always ground for the hope that after the irritation caused by
+cutting the first four permanent grinding teeth has completely ceased,
+the tonsils may return by degrees to their former size. A similar
+shrinking of the enlarged tonsil sometimes takes place, especially in
+the boy, at the time of approach to manhood, when the vocal organs
+undergo full development. This can be counted on, however, only in cases
+where the tonsils are not of extreme size, and have not undergone
+frequent attacks of inflammation. Whenever the hearing is habitually
+dull, and the voice always thick, when cough is frequent, the nostrils
+narrow, the chest pigeon-breasted, and the child feeble and ill-thriven,
+removal of the tonsils is absolutely necessary. In cases where the
+question is doubtful, its decision must turn on whether the tonsils have
+often been inflamed. So long as their surface is smooth, and their
+substance soft and elastic, delay is permissible. When their substance
+is hard, like gristle, and their surface uneven and corrugated, they
+have undergone such changes that absorption is impossible, and their
+removal absolutely necessary.
+
+I dwell thus particularly on the question of removal of the tonsils,
+because there is among many persons an unreasoning dread of the
+operation, which is entirely devoid of danger, requiring only a few
+seconds for its performance, and which may even be done under
+chloroform. The painting tincture of iodine behind the angle of the jaw,
+or the touching the tonsils with caustic, iodine, alum, tannin, or sweet
+spirits of nitre are utterly futile proceedings. They diminish the
+unhealthy and often offensive secretion from the glands which beset the
+tonsils, and restore the surface to a more healthy condition, but they
+are absolutely without influence in lessening their size.
+
+Now and then all the symptoms of enlarged tonsils are present, but yet
+most careful examination fails to discover any increase of their size.
+When this is the case the symptoms are due to a thickening of the
+membrane at the back part of the nostrils, often attended with spongy
+outgrowths from their surface, which obstruct just as completely as
+enlarged tonsils would do the free entrance of air. It will, in any case
+where this condition is suspected, be absolutely necessary to seek the
+advice of some of those gentlemen who make a specialty of diseases of
+the throat, and who will have the necessary technical dexterity to
+discover the condition, and to treat it skilfully.
+
+=Abscess at back of the Throat.=--I should pass unnoticed, on account of
+its rarity, the occasional formation of an abscess at the back of the
+throat, behind the gullet, interfering both with breathing and with
+swallowing, but that the description of it in my Lectures once enabled a
+lady in the wilds of Russia to detect it, to point out the nature of the
+case to her puzzled doctor, to urge him to open the abscess, and thus to
+save her child's life.
+
+This abscess may form at any age, sometimes after fever, sometimes
+without any obvious cause. It shows itself by difficulty in swallowing
+and breathing, unattended by cough, but accompanied by a sound similar
+to that of croup, but not so harsh or ringing. The neck is stiff, the
+head thrown back, and often there is a distinct swelling on one or other
+side of the neck. The finger introduced into the mouth, and carried over
+the tongue to the back of the throat, feels there a swelling which
+projects over the top of the windpipe, and causes the difficulty both in
+swallowing and breathing. This swelling is the abscess; a prick with the
+surgeon's lancet lets out the matter, and saves the child.
+
+=Diseases of the Kidneys.=--The _kidneys_ perform very important duties
+in carrying off from the system a large amount of useless material, and
+thus supplement in many respects the action of the skin, and the
+purifying influence which is exercised by the air on the blood, as it
+passes through the lungs.
+
+It is evident, therefore, that their disorder in any way must be a
+matter of serious moment, though at the same time the knowledge of the
+skilled doctor is needed to determine the nature and degree of the
+ailment from which they are suffering, since that requires an
+examination of the urine, both chemically and by means of the
+microscope. My remarks on these diseases must consequently be few and
+fragmentary.
+
+In the grown person, what is known as _Bright's disease_ is of frequent
+occurrence, assumes different forms, and depends on various causes. In
+the child it is comparatively rare, and is scarcely ever met with except
+as a consequence of a chill, or as a result of scarlatina. In these
+conditions the kidneys become overfilled with blood or congested, and
+the congestion may pass into inflammation, by which their structure may
+be irreparably damaged. Dropsy is the great outward sign of the
+affection--either slight swelling of the face, eyelids, and ankles, or
+very great swelling of all the limbs, and even the abundant pouring out
+of fluid into the belly. The degree of dropsy is, however, by no means
+an absolute measure of the amount of kidney mischief. It therefore
+behoves every parent to follow out all directions most scrupulously even
+in cases of very slight dropsy, in order to guard against the risk of
+permanent injury to the kidneys being left behind; and especially to
+remember the liability to the occurrence of dropsy and disease of the
+kidneys after scarlatina. Any check to the action of the skin while it
+is peeling or desquamating, as it is termed, is especially liable to be
+followed by these accidents. To avoid all risks as far as possible, I
+have been accustomed for many years to insist on a child remaining in
+bed for one-and-twenty days after the first appearance of the rash in
+even the mildest case of scarlatina, and I am absolutely sure that it is
+the 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 in
+childhood than in the grown person. Whenever a child loses flesh without
+obvious cause, suffers much from thirst, and at the same time passes
+urine in greater abundance than in health, the possibility that it may
+suffer from diabetes must be borne in mind.
+
+Of far greater frequency than any other affection of the kidney is that
+in which the child passes _gravel_ with the urine, either in the form of
+a reddish-white sediment, which collects at the bottom of the vessel as
+the urine cools, or of minute glistening red particles, which resemble
+grains of cayenne pepper.
+
+These deposits, when abundant in the male child, have a tendency to
+collect 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, that
+more than a third--indeed, nearly half--of all the operations for stone
+performed in English hospitals are done on boys under ten years old.
+
+Even when this grave consequence does not follow the presence of gravel
+in the kidneys, and its passage into the bladder, it is often
+accompanied with much suffering. The pain is like that of stomach-ache
+or colic, the child crying and drawing up its legs on every attempt to
+pass water, which sometimes is voided only in a few drops at a time, and
+now and then is completely suppressed for some hours. The very acute
+form of the ailment seldom occurs, except in infants who inherit from
+their parents a disposition to gouty or rheumatic affections. In them,
+however, a trifling cold, slight disorder of the digestion, a state of
+constipation, or the feverishness and general irritation which sometimes
+attend on teething, not infrequently produce these deposits and give
+rise to all these painful symptoms, the deposit disappearing and the
+pain 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 in
+older 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 no
+cause for anxiety with reference to the issue of each attack. The warm
+bath, a castor oil aperient, and soothing medicine soon relieve the
+pain, and the children return to their former state of health. It is the
+frequent return of the attack, even in a comparatively mild form, the
+persistent disposition to the formation of gravel, the remote risk in
+the case of male children of stone in the bladder, and the habitually
+imperfect performance of the digestive functions which call for special
+care. The avoidance of sugar, sweets, and whatever tends to impart
+acidity to the urine, the maintaining the due action of the skin by
+wearing flannel, and the judicious use of alkaline remedies, sometimes
+combined with iron, are the measures on which the doctor is sure to
+insist.
+
+The difficulty usually encountered in the treatment of these cases
+arises from the reluctance of the parents to continue for months and
+years the observance of the necessary rules. It seems so hard to deny
+their little one the small gratifications in which other children may
+indulge with impunity; and they fail to realise the heavy penalty, in
+the shape of gout, rheumatism, gravel, and stone, which in after-life
+their darling may have to pay for their over-indulgence in his early
+years.
+
+I will just mention that symptoms similar to those above described, less
+severe, though more abiding, yet unattended by gravel in the urine, are
+sometimes produced in little boys by an unnatural narrowness of the end
+of the passage for the urine. It is well to bear in mind this possible
+cause of the child's sufferings, and to consult a doctor with reference
+to it, since he will be able to relieve it by a trivial operation.
+
+=Incontinence of Urine.=--The irritation which this mechanical
+inconvenience produces sometimes has to do with that troublesome
+infirmity of some children, who wet the bed at night. This may also be
+induced 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 to
+cultivate regular habits in a child; and does not pay attention to the
+quantity of liquid taken at its last meal. Something, too, is due to the
+fact 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 full
+consciousness, does not have the same effect on the former. It sometimes
+happens undoubtedly from mere indolence; and this may always be
+suspected when a child, otherwise healthy, wets itself not at night
+only, but also in the daytime. Lastly, it does sometimes occur from
+muscular feebleness in weakly children, the bladder being unable to bear
+more than a limited degree of distension.
+
+The accident usually happens either soon after going to bed, when the
+warmth stimulates the action of the bladder, or towards morning, when
+the bladder has become full. The posture on the back favours its
+occurrence very much, and it is therefore of importance that the child
+should lie on its side when in bed. The good effect of a blister on the
+lower part of the back as a means of cure was largely due to its forcing
+the child to lie on its side. This object can be attained, however, in a
+much kindlier way, by tying half a dozen cotton reels together, and
+fastening them at the child's back. The habit may also often be broken
+through by arousing the child in the night, and compelling it to empty
+its bladder, the hour being first ascertained at which the accident
+usually happens. For this, however, to be of any real use, the child
+must be awakened thoroughly; since otherwise it will mechanically, and
+quite unconsciously, empty its bladder while still asleep. The habit in
+this case is not in the least overcome; only for the time the bed
+escapes the wetting. The utensil must therefore be placed on different
+nights at different parts of the room, so that the child, in order to
+find it, must have been roused to thorough consciousness.
+
+Lastly, I will add that the cases in which the accident is the result of
+mere indolence are very rare, and though in such cases strictness may be
+necessary, yet actual punishment is out of place. As a rule, reward
+answers much better. A penny, or a threepenny-piece every night that the
+accident does not happen, and a forfeit of a halfpenny or two pence for
+every night of misfortune, is a very efficacious help to a cure.
+
+When all these domestic means, persevered in for months, fail to
+produce 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 of
+a previous disorder of the whole system. These diseases are either acute
+or chronic. The acute constitutional diseases belong to the class of
+fevers. These are marked by certain local characteristics, as the
+swelling of the joints in acute rheumatism, the sore-throat in
+scarlatina, or the eruption on the skin in smallpox, and their course is
+more or less strictly limited by distinct periods of increase, acme, and
+decline. No such rule obtains in the case of consumption, scrofula, and
+rickets, which are instances of chronic constitutional diseases. In them
+too the local manifestations of the general disease vary also: the lungs
+being affected in one case of consumption, the bowels in another; while
+scrofula may show itself by affection of the glands in one case, by the
+formation of abscesses in a second, or by disease of the bones in a
+third.
+
+=Chronic Constitutional Diseases.=--It may perhaps be convenient to
+study first the chronic constitutional diseases; and afterwards to make
+a 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 of
+which certain materials, incapable of being converted into the natural
+constituents of the body, are deposited in the substance of different
+external parts or internal organs. If deposited in small quantities,
+these materials may be absorbed, as it is termed, that is to say, got
+rid of, by natural processes, which even now we understand but
+imperfectly.
+
+If deposited more abundantly, they press upon and gradually spoil the
+healthy parts in which they are seated, and thereby interfere with the
+proper performance of their duties. Thus, the deposit of consumption
+encroaches on the proper substance of the lungs, and so lessens the area
+in which the blood is exposed to the air and purified: the deposit of
+scrofula around and in a joint interferes with its powers of movement.
+Nor is this all; but wherever any deposit has once taken place, it tends
+especially to increase in that very spot, guided as it were by a certain
+affinity; and the substance of the previously healthy part is removed as
+fresh deposit comes to occupy its place. Further, the matter deposited
+has no power of being changed into healthy substance of lung, or of
+bone, or of any other part.
+
+A fractured limb may be completely mended; a fluid is poured out around
+and between the edges of the broken bone; by degrees this hardens, it
+undergoes changes which convert it into solid bone, and the limb is once
+more as serviceable as before, though some indications of the fracture
+may still be perceptible in the texture of the bone itself. Or, a person
+receives a severe blow on his arm or leg; in course of time the blood
+which had flowed from the ruptured vessels, and had formed a big bruise,
+is absorbed, and all is as before the injury was inflicted. If more
+serious damage has been done, the fibres of some muscles may have been
+torn, even though the skin remains unbroken. Inflammation is set up, the
+injured parts die, and are melted down into the matter of an abscess.
+The abscess discharges itself, its walls contract, the opposite surfaces
+come into contact, and are welded together again, so that there is no
+loss of substance, nor anything save a scar on the surface to indicate
+what has happened.
+
+In the case of the deposits of consumption or scrofula these changes
+cannot take place. In technical language the matter is said to be
+incapable of organisation; that is to say, it cannot be transformed by
+nature's alchemy into anything good or useful. It is rubbish to be got
+rid of; and the patient's recovery depends on the possibility of getting
+rid of it. If there is much of it, so as to be removed from the
+vivifying influence which adjacent living structures still maintain
+about it, the deposit softens at its centre. This softening gradually
+extends to the circumference; the mass irritates more and more the parts
+around it, and where the irritation is greatest the structures yield,
+and are removed to make a way for its escape, and the patient spits up
+the contents of the abscess.
+
+But the abscess of the lungs is not like an abscess which follows an
+injury. It has not formed in the midst of previously healthy parts which
+are capable of reproducing the original structure; its walls are
+themselves involved in the disease, and, in accordance with the rule I
+have already mentioned, 'much will have more,' and the patient goes on
+spitting up the perpetually renewed contents of the abscess for months
+or years; until by its gradually increasing size, and the more and more
+abundant discharge of matter, and further and further destruction of
+lung-substance, death takes place.
+
+This fatal issue, however, is not invariable. In favourable
+circumstances, and especially in childhood, the radical constitutional
+defect may be amended, and with a healthier condition of the blood the
+unhealthy deposit may cease to take place. The lung-substance, however,
+with all its curious structure of air-cells and their network of minute
+vessels where, as in nature's laboratory, the blood receives its due
+supply of oxygen, is not reproduced. The lung shrinks, the sides of the
+abscess come together, and by slow degrees a dense material cuts it off
+from the adjacent healthy structure, but the most complete recovery
+leaves the patient with his breathing power lessened, and with his
+vigour 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 purely
+chemical change into a hard chalky substance, which in the course of
+time becomes of more than stony hardness.
+
+Last of all; when the deposit is smallest in quantity, it may be
+completely got rid of; and a lung in which consumptive disease once
+existed, 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 place
+elsewhere.
+
+Three important conclusions follow from what has been said.
+
+First. It is only in quite the early stage of consumptive disease that
+absolutely perfect recovery can be hoped for. There is a euphemism, more
+amiable than honest, which doctors not seldom make use of, saying that a
+child's lungs are not diseased, but only tender. They mean by this, that
+on listening to the chest, they detect such changes in the sounds of
+breathing as their experience tells them are usually produced in the
+early stage of consumptive disease of the lungs. If the opinion is
+confirmed by a second competent medical man, _then, and not later_, is
+the time for precautions, for removing the child from school, and for
+selecting, as far as may be, a suitable winter climate. When the signs
+of disease are well marked, a reprieve, perhaps a long one, is all that
+can be confidently reckoned on.
+
+Second. When softening of the consumptive deposit has taken place, of
+which certain sounds attending breathing are all but conclusive,
+recovery, even the most complete, always implies loss of a certain
+amount of lung-substance, and consequently loss of a certain amount of
+breathing power.
+
+Third, and this is most important, as well as most cheering;
+consumption, which is at no age the absolutely hopeless disease that it
+was once supposed to be, admits of far more cheerful anticipations in
+children than in grown persons, or, for that matter, than in the youth
+or maiden.
+
+The principal _causes_ of consumptive disease are, hereditary
+predisposition, and improper feeding in infancy. There are besides two
+diseases incidental to childhood, and one of them almost peculiar to it,
+namely typhoid fever and measles, which are more apt than any others to
+develop a tendency to consumption. During convalescence from either of
+them, therefore, special care is needed.
+
+In the grown person, consumption almost always attacks the lungs, and
+this often to the exclusion of other organs. In the child, however, this
+is not so, and though the lungs are indeed oftener affected than other
+parts, yet in nearly half of the cases some one or other of the
+digestive organs is likewise involved, and in about one in seven
+instances the lungs are free and the digestive organs alone are
+attacked.
+
+Fever, cough, and wasting are the three sets of symptoms which in some
+degree 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 evening
+temperature for a week or ten days together always amounts to 100°,
+there is grave presumption that consumptive disease is present. In
+advanced 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 but
+slightly involved, for the irritation of the digestive organs often
+excites a sympathetic cough, and in these circumstances observation of
+the evening temperature will often furnish a clue to the right
+interpretation of the symptoms.
+
+There is a form of cough which is oftenest observed in children between
+the ages of two and five years, which comes in fits closely resembling
+those 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 _glands
+connected with the lungs_ (the bronchial glands as they are called) _are
+diseased_, and not the lung-substance itself. The enlarged glands press
+on some of the nerves connected with the upper part of the windpipe, and
+thus occasion the spasmodic cough. Always suspect this when a cough
+persists for weeks together, not getting rapidly worse as hooping-cough
+would do, but at the same time not growing better, as would be the case
+with mild hooping-cough. The doctor on listening to the chest will solve
+your doubts; the thermometer will help you to decide whether his visit
+is necessary. I may add that this form of consumptive disease is less
+serious than that in which the lung-substance is involved.
+
+Consumption sometimes follows bronchitis, especially when a child has
+been subject to frequent attacks of it. A very slow and imperfect
+recovery from an attack of bronchitis which had not been specially
+severe is always a reason for solicitude.
+
+Now and then infants are born with consumptive disease. In that case the
+lungs are always affected; and the symptoms of fever, cough, and wasting
+usually show themselves within the first three or four months, and the
+infants almost invariably die within the year. Now and then, however, an
+infant thus affected may continue apparently in good health for a few
+months, and then be suddenly attacked by symptoms of acute inflammation
+or of severe bronchitis which prove rapidly fatal; and it may be found
+after death that the acute attack destroyed life because the lungs were
+already the seat of extensive consumptive disease.
+
+No infant in whose mother's family a predisposition to consumption
+exists 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 but
+a small admixture of farinaceous food.
+
+There is a form of very rapid, or so-called galloping consumption, which
+is seldom observed before the age of seven years; generally two or three
+years 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 say
+that the doctor who mistakes the one for the other can scarcely be
+regarded as blameworthy; and the mistake is of the less importance since
+the treatment applicable to the one case would do no harm in the other.
+
+I have already noticed the connection between water on the brain and
+consumption. It is indeed nothing else than inflammation excited by the
+presence of the deposit of consumptive matter in the brain or its
+membranes.
+
+Little has been said hitherto about the wasting which was referred to as
+one of the characteristics of consumption. When the disease is limited,
+or nearly so, to the lungs, the wasting is not considerable until the
+mischief 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 best
+sign 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 grows
+thinner, not by real wasting but by conversion of its fat into bone and
+muscle. The child is thinner, but is taller and weighs heavier. The only
+real test therefore of the condition of the child is afforded by its
+increase in height and in weight. One need not be solicitous about the
+child who increases in height, and maintains his previous weight, nor
+about him who while he does not grow yet becomes heavier; but the child
+who neither gains in weight, nor in height, or who loses weight out of
+proportion to his increased height, is in a condition that warrants
+anxiety. I have long been accustomed, in the case of children whose
+parents were resident in India, to instruct those who have charge of
+them to send every three months a statement of the height and weight of
+the children, as the best evidence of their state of health.
+
+=Consumptive Disease of the Bowels.=--Consumptive disease sometimes
+invades the whole system from the very first, while in other instances
+it attacks from the outset the organs of digestion, and continues
+throughout to affect them chiefly, and loss of flesh is then one of its
+earliest symptoms. In instances where there is a strong family
+predisposition to the disease, consumption of the bowels or mesenteric
+disease, or disease of the glands of the bowels, all three popular names
+for the affection, sometimes shows itself at the time of weaning. In the
+majority of cases, however, it comes on later, after the completion of
+teething, and between the age of three and ten years. Indigestion such
+as I have already spoken of sometimes precedes it, with the irregular
+condition of bowels, and the patchy state of the tongue. But this is by
+no means constant, scarcely I think general; and not infrequently
+momentary, causeless, colicky pains precede for a short time any other
+symptom. In a few weeks after their occurrence, sometimes indeed
+independently of them, the appetite fails, or becomes capricious; the
+bowels begin to act irregularly, being alternately constipated and
+relaxed; and the motions are unnatural in character, being, for the most
+part, dark, loose, and slimy. Sometimes indeed, they are solid, and then
+often white, as if from complete inactivity of the liver, and sometimes
+half-liquid, frothy, and like yeast. One peculiarity which they always
+present, be their other characters what they may, is their extreme
+abundance, quite out of proportion to the quantity of food taken, and
+due to their admixture with the unhealthy secretions from the bowels.
+The child next becomes restless and feverish at night, its thirst is
+considerable, and the colicky pains become both more severe and more
+frequent. Sometimes the stomach grows very irritable, and the food taken
+is occasionally vomited, while the tongue, in the early stages of the
+affection, continues for the most part clean and moist, and except that
+it is often unnaturally red deviates but little from its appearance in
+health. Next comes a change in the condition of the belly, the date of
+which varies considerably. It becomes larger than natural, owing to the
+filling of the bowels with wind, but at the same time it is tense and
+tender on pressure--two points of great importance to be noticed, and
+the glands in the groin, which in a healthy child cannot be felt, become
+enlarged, and are felt and perhaps even seen like tiny beans under the
+skin.
+
+As in other forms of consumptive disease, so here the progress from bad
+to worse seldom goes on uninterruptedly. Pauses take place in its
+course, though each time they become shorter; and signs of amendment now
+and then appear, but they too promise less and less with each return.
+The child wastes rapidly; is always more or less feverish; the abdomen
+is constantly tender, but does not in general go on increasing in size;
+the pains become more frequent and more severe, and the bowels are
+almost always habitually relaxed. Life is sometimes cut short by the
+lungs becoming affected, but when this is not the case the patient may
+linger 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 loses
+flesh, and has a large abdomen; and the words mesenteric disease,
+sometimes uttered thoughtlessly by the doctors, seem to them to seal
+their little one's doom. Now, first of all, it must be remembered that
+mesenteric disease, due to consumption, plays but a very small part in
+the production of the symptoms just described, but that the covering and
+the lining of the bowels are chiefly involved. Next, enlargement of the
+mesenteric glands and disorder of their functions take place from many
+causes other than consumption. They are always more or less enlarged in
+typhoid fever; they become enlarged when irritated by unwholesome food
+in infancy, or they may swell in the course of chronic indigestion. In
+all these cases too, the glands in the groin may be enlarged by
+sympathy, and this without the existence of any actual abiding disease.
+A big abdomen is, of itself, no evidence of it, nor even when associated
+with indigestion and frequent stomach-ache; but when to these you add
+abiding tenderness, and an evening temperature always at least one
+degree above that in the morning, there is every reason to fear that
+consumptive disease has attacked the organs of digestion.
+
+Even then, however, there is no ground for despair; for, while
+consumptive disease in any form is less seldom recovered from in
+childhood than in after-life, such recovery oftener takes place in cases
+of affection of the digestive organs than when the disease is seated
+elsewhere.
+
+=Scrofula.=--With this word of comfort I leave the subject of
+consumption, and pass to that of the allied disease _scrofula_. Briefly
+stated, two of the great differences between it and consumption are that
+scrofula is almost entirely limited to childhood and youth, while
+consumption may occur at any age; and next, that while scrofula attacks
+the bones and the glands, the skin and the membranes adjacent to it,
+consumption has its seat in the lungs, the brain, and the internal
+organs.
+
+Scrofulous diseases of the bones come so exclusively under the
+observation of the surgeon, that I do not feel myself competent to say
+anything about them. I would however warn all parents to be very much
+alive to the importance of noticing the early symptoms of any such
+diseases, as shown by slight lameness, complaint of pain in the back, or
+difficulty in moving the hand or arm, or in turning the head or bending
+the neck. They may be but temporary accidents, due to cold, or to slight
+muscular rheumatism, or to some sprain not noticed at the time; but they
+may also be signs of the commencement of scrofulous disease of some
+bone; and in no disease whatever is early judicious treatment of greater
+value, or the result of neglect less remediable.
+
+Besides these graver ailments which seldom appear until after the time
+of infancy has passed, there are others of a less serious nature which
+often show themselves within the first year of life. One of these
+consists in the formation beneath the skin of numerous small lumps of a
+rounded form, and of the size of a kidney-bean, slightly movable, and
+not tender. By degrees such lumps become adherent to the skin, the
+surface of which above them grows red, they project slightly above it,
+and at last open by a small circular aperture, discharge a little
+matter, and then subside. They collapse and disappear; a slight
+depression and a degree of lividity of the skin mark for a considerable
+time the situation they had occupied. I refer to them, because while
+they are a sign of a scrofulous constitution, which may require special
+care in diet and preparations of iron and cod-liver oil, they are best
+left absolutely alone--neither poulticed nor lanced. The same principle
+of non-intervention applies equally to the swellings which sometimes
+form on two or three of the fingers in infancy, not involving the joints
+but producing great thickening and a hard swelling around the bone.
+These swellings disappear by degrees as the constitutional vigour
+improves, and this is especially promoted by a long stay at the seaside;
+but they tend, if the health fails, to affect the bones themselves, and
+thus to occasion deformities of the hand.
+
+Glandular swelling, discharges from the ear, offensive secretion from
+the nose, and in female children, even of very tender age, a discharge
+of whites, are all common signs of a scrofulous constitution, and all
+tedious and troublesome. They all, however, are very much under the
+influence of judicious medical treatment. It must at the same time be
+borne in mind that none of these ailments admit of what may be called
+active treatment. There are no royal means of dispersing scrofulous
+glands, or of curing discharges from the ear, or of doing away with the
+offensive smell which in some cases proceeds from the nostrils. Fresh
+air, suitable diet, preparations of iron, residence at the seaside, and
+sea-bathing, measures directed to improve the general health, are of
+chief value, and without them local treatment is of small avail.
+
+A few words, however, may with propriety be added with reference to the
+local treatment of the minor ailments to which I have just referred.
+
+No local application is of use in the _scrofulous swellings of the
+fingers_. Tincture of iodine, indeed, may be painted over them when
+quite small, while at the same time the joints are kept quiet by a small
+gutta-percha splint. When they become considerable, iodine is useless;
+and even if matter forms in the swelling it is much better to let it
+make its way out by a small opening spontaneously than to make a
+puncture with a lancet, since the edges of the wound would not heal, and
+the risk of the disease affecting the bone would be increased.
+
+The _glandular swellings_ of the neck or about the lower jaw are
+likewise 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 of
+Goulard water and spirits of wine, constantly applied, will reduce the
+swelling and lessen the discomfort. When stationary, a mild iodine
+ointment may be smeared over the gland at bedtime, and covered with
+oiled silk. Applications of iodine, however, need careful watching, for
+sometimes they over-irritate the gland, and cause an abscess. If the
+gland were out of sight there would be no objection to this, which
+would probably be a rapid mode of getting rid of the swelling; but the
+scar left behind, if the abscess burst or were opened, is an objection
+when the swelling is situated in the neck or at the jaw.
+
+If the skin over the top of the swelling becomes red, and its substance
+begins to feel soft, then, but not till then, it is desirable to apply a
+warm poultice constantly. At the same time the progress must be daily
+watched by the doctor, in order that he may seize the proper moment to
+make a small puncture and let out the matter. The small cut leaves a
+less puckered scar than the natural opening. The subsequent management
+of the case must be superintended by the doctor.
+
+_Offensive discharge from the nostrils_ does not depend, in by far the
+majority of cases, on disease of the bones, but on an unhealthy
+condition of their lining membrane. It is exceedingly obstinate and
+difficult of cure, is four times more frequent in girls than in boys,
+and unfortunately often lasts into womanhood, and continues even when
+the general health is perfect.
+
+Much may be done to abate the annoyance by diligent sniffing up the
+nostrils some weak disinfectant; or by regularly irrigating the nostrils
+by means of a simple apparatus, to be obtained from any
+instrument-maker. In spite of this, however, it is often necessary to
+introduce a little plug of cotton wool dipped in the fluid some distance
+up 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 to
+return from the commencement of teething up even to womanhood. It is a
+mere sign of debility, usually also connected with a scrofulous habit,
+but has no further or graver meaning. Locally, constant cold ablution by
+means of a sponge held above the child, not touching it, is the great
+remedy, and this may have to be repeated every hour or two if the case
+is severe. Astringent lotions of different kinds may be used in the same
+manner; while care must be taken that the child's drawers are large and
+loose, so as not to irritate her when sitting. General treatment,
+however, sea air and sea bathing are especially in these cases the great
+remedy.
+
+It must not be forgotten that all these ailments have a special tendency
+to recur; and that when people say 'Dr. A. or Dr. B. did the child good
+for the time, but this or that symptom returned as soon as the treatment
+was discontinued,' as though this were the doctor's fault, they are
+unjust; for the tendency to return of every form of scrofulous disease
+is one of the great characteristics of the malady. Patience and
+perseverance on the parents' part, even for months and years, are often
+as much needed as skill on the part of the doctor.
+
+One more remark may not be out of place. Some persons have an impression
+that there is something specially shameful in scrofulous disease, and
+while they will readily admit the existence of a consumptive tendency in
+their family, they almost resent the suggestion that their child's
+ailment is scrofulous. For this prejudice there is absolutely no
+foundation. There is no more reason for connecting scrofula in a child
+with any antecedent wrong-doing on the part of its progenitors, than
+there is for attaching that idea to the red hair or black eyes which a
+child may have in common with the rest of its family.
+
+=Rickets.=--We sometimes see, especially in the poorer quarters of a
+great 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 a
+grown 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, they
+bend under the weight of the body, or under their own weight, and with
+every slight movement which its feeble muscular power enables it to
+make. It does more, however, than interfere with the hardening of the
+limbs: it arrests growth to a great degree, interferes with
+development, retards teething, postpones the closure of the open part of
+the head, or fontanelle, weakens constitutional vigour, and impairs
+muscular power. To this feeble muscular power it is due that the child
+cannot make the effort to fill its lungs completely, and hence the
+pressure of the external air forces the soft ribs inwards, and gives to
+the chest the peculiar form of pigeon-breast. In the course of time the
+delayed bone-formation takes place, and the bones themselves become as
+hard as ivory, but the limbs do not straighten, and the deformity
+produced in infancy is but confirmed in after-life.
+
+The greater degrees of rickets are scarcely ever seen among the children
+of the wealthier classes, but over-crowded and ill-ventilated nurseries,
+cots from which the air is well-nigh shut out by closed sides and
+overhanging curtains; injudicious feeding, with undue preponderance of
+farinaceous food, often produce its slighter forms. I never yet saw
+rickets in a child while brought up exclusively at its mother's breast.
+
+The slighter forms of rickets show themselves in a tardy closure of the
+infant's head, which sweats profusely when the child is laid down to
+sleep; in big wrists, which contrast with the attenuated arms; in a
+general limpness of the whole body, and a bowing of the back under the
+weight of the head, which bends as a green stick would bend if a weight
+were placed upon it. They are further marked by backwardness in
+teething, and by the irregular order in which the teeth appear, and,
+further, by the peculiar narrowness of the chest, and by what has been
+termed the beading of the ends of the ribs: little round prominences due
+to a heaping up of gristle just where the ribs join on to the
+breastbone, marking the spots at which the tardy bone-making has come to
+a standstill.
+
+Children who bear these stamps of rickets are far more apt than others
+to suffer from spasmodic croup, and in them it is also specially likely
+to be severe and to be accompanied by convulsions. They will also be
+more liable than others to attacks of bronchitis, they will suffer more
+during teething, they will be often constipated, and will be troubled by
+various forms of indigestion. Now and then, too, they will have
+causeless attacks of feverishness lasting for a few days, or for two or
+three weeks, attended with general tenderness of the surface, and a
+disposition to perspiration, which brings no relief but serves only to
+weaken.
+
+It is true that these symptoms do not often become immediately dangerous
+to life, though spasmodic croup and bronchitis both have their perils;
+but they interfere with health, and growth, and good looks, and
+cheerfulness, and quick intelligence.
+
+If mothers would but ask themselves the real signification of these
+symptoms, and change the conditions which surround the child, and alter
+their mode of feeding it, they would many and many a time be spared the
+heart-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 than
+to turn the best spare room into a night nursery, and to uglify the cot
+by taking away the curtains which made it so pretty, and to give up some
+of the pleasures of society in order to superintend the preparation of
+the baby's food; that the doctor is called in to correct by drugs the
+evil which drugs cannot reach. Iron and cod-liver oil are very useful in
+the second place; fresh air, good ventilation, and a wise diet must
+always occupy the first.
+
+=Acute Constitutional Diseases.=--It still remains for us to glance
+rapidly at the characters of the _acute constitutional diseases_, all of
+which belong, as has already been stated, to the class of fevers. Of
+them all but two are contagious--that is to say, are capable of being
+communicated directly from person to person. They are likewise
+infectious, or, in other words, articles of bedding or clothes which
+have been worn by the sick, retain a something--an exhalation from the
+breath, an emanation from the skin, or a secretion from the
+bowels--which may reproduce the same disease in a person previously
+healthy.
+
+To this contagious and infectious property there are two exceptions; the
+one is furnished by acute rheumatism, or rheumatic fever, the other by
+intermittent fever, or ague.
+
+=Rheumatic Fever.=--The main features of _rheumatic fever_ are the same
+at all ages. Fever, pain in the limbs, swelling of the joints, sweats
+unattended by that relief which usually accompanies abundant action of
+the skin in fevers, are its characteristics. In the child all these
+symptoms are usually less even than in the adult. The swelling of the
+joints in particular is less considerable, and both the pain and the
+swelling are apt to wander from one to another joint, or to a different
+limb, instead of remaining fixed as they do in the grown person for
+several days in the same joint, even though fresh joints may be
+implicated in the course of the disease.
+
+These circumstances tend to make people look on rheumatic fever in the
+child too often as a comparatively trivial ailment; and this not only
+because the suffering which attends the disease is slighter, but because
+its duration is also shorter. But there is one fact which forbids this
+low estimate of its importance, and that is the great tendency to
+affection of the heart even in cases of comparatively mild rheumatism in
+the child; while in the grown person there is a direct relation between
+the general severity of the rheumatic symptoms and the liability of the
+heart to be involved. I have already stated that nine out of ten of all
+cases of heart disease in early life, not due to original malformation,
+are of rheumatic origin, and further that heart disease comes on in the
+course of four out of five cases of rheumatic fever in the child, slight
+as well as severe. It seldom occurs before the third or fourth day of
+the illness, so that if parents take the alarm at the very outset, it is
+usually though not invariably possible for the doctor by judicious
+treatment to anticipate and to prevent its occurrence, or at any rate
+greatly to control its progress.
+
+Every threatening of rheumatism, therefore, is to be watched with the
+most anxious care, since so serious a complication as disease of the
+heart may accompany extremely slight general symptoms. It is wise too,
+to place any child in whom general feverish symptoms come on at once
+under medical observation, for though it does not usually happen, yet it
+does sometimes occur, that rheumatic inflammation attacks the heart
+before any other local signs of the malady have manifested themselves.
+It is scarcely necessary to add that tenfold precautions are needed when
+rheumatism has once occurred, since the liability to its return is very
+great, and the heart which escaped in the first attack may suffer in the
+second; or the comparatively small mischief done the first time may
+become an incurable disorder.
+
+=Ague.=--_Intermittent fever_ or _ague_ is very rare in childhood in
+London; or at any rate it is very rare among children of the wealthier
+classes. I believe it is everywhere rarer among children than among
+grown persons, probably because they are as a rule less exposed to those
+malarious influences which produce it. In the child it generally takes
+the form of tertian ague, that is to say the attack recurs every second
+day; one day of freedom intervening between two attacks.
+
+The three stages of shivering, heat, and sweating are less marked in the
+child than in the grown person, and this indistinctness of its symptoms
+is greater in proportion to the tenderer age of the child. Shivering is
+scarcely ever well-marked, a condition of unaccountable depression
+usually taking its place, while once or twice I have known convulsions
+occur which gave rise to the apprehension that disease of the brain
+existed. The hot stage is long, and passes off gradually without the
+profuse perspiration that occurs in the grown person, and the child even
+between the attacks is almost always more or less ailing.
+
+A first and even a second attack may puzzle not the parents only, but
+also the doctor; but after the symptoms have returned a few times, the
+child being neither better nor worse in the intervals, it becomes
+evident that no serious disease is impending. The risk of an overhasty
+conclusion is that the depression and disturbance of the nervous system
+may be supposed to imply the existence of brain disease; and lead to
+unsuitable treatment, instead of the administration of quinine, which
+nine times out of ten proves a specific for ague. The rapid increase of
+temperature 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 of
+rheumatic and intermittent fever. They differ from other fevers not only
+by being neither contagious nor infectious but also by their readiness
+to return, while a single attack of any of the others furnishes a
+guarantee, and often a complete guarantee, against its recurrence. In
+addition to these peculiarities, the fevers of which I have now to speak
+are characterised by running a certain definite course, being
+accompanied by certain peculiar appearances on the surface (generally
+rashes on the skin, whence their name of eruptive fevers); being
+attended each with its own peculiar dangers, and all having a tendency
+to what is termed epidemic prevalence; that is to say to occur one year,
+and without obvious cause with vastly greater frequency than in other
+years.
+
+=Mumps.=--It has been questioned whether that painful but not dangerous
+ailment the _mumps_, ought or ought not to be classed with these fevers.
+I think it should, for it is contagious, infectious, runs a fairly
+definite course, is attended with invariable external appearances, often
+prevails epidemically, and one attack preserves in most instances from a
+second.
+
+It very seldom befalls children under seven years of age, and is more
+frequent in early youth than in childhood. It sets in with the ordinary
+symptoms of a cold, which are followed in about twenty-four hours by
+stiffness of the neck, and pain about the lower jaw, which is increased
+by speaking or swallowing. At the same time a swelling appears,
+sometimes on one side sometimes on both of the lower jaw, and increases
+very rapidly so as to occasion great disfigurement of the face. The
+swelling goes on to increase, and to become more tense, attended with
+more head-ache, fever, and discomfort for some forty-eight hours, but
+then 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, or
+more; and now and then, though very rarely, an abscess forms, which is
+both tedious and troublesome.
+
+The treatment suitable for a severe common cold, together with the
+constant application of a warm poultice to the swollen gland, is all
+that is usually required, though the doctor's help is often needed to
+relieve the suffering which for the first day or two in many instances
+attends the ailment.
+
+=Typhoid Fever.=--There is no question as to the place which should be
+occupied by typhoid fever, smallpox, measles, and scarlatina, for all
+belong to the class of eruptive fevers. They are all specific diseases,
+each due to its own peculiar poison, and not capable of being produced
+by any mere unsanitary conditions, though such may aggravate their
+severity and facilitate their spread.
+
+The belief in the special character of each of these diseases has
+received strong confirmation from the researches of the eminent
+Frenchman, M. Pasteur, and others who have followed in his track. They
+have discovered in the blood and other secretions, and in some of the
+tissues both of men and animals, minute microscopic organisms which
+differ in their characters in different diseases. Experiment has further
+shown that in some mysterious way these organisms are the cause of these
+diseases, for on inoculating animals with them the peculiar disease of
+which each was the accompaniment, and no other, was reproduced in the
+inoculated animal.
+
+As far as our knowledge goes at present then, we are forced to regard
+each of these as a separate disease, measles never passing into
+scarlatina, 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 pulse
+is quickened, and the temperature raised, constituting that state which
+we commonly call fever, but as the local ailment subsides the fever
+disappears. There is, apart from smallpox, measles, and the other
+so-called eruptive fevers, only one real essential fever commonly met
+with 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 the
+nursery, and all sorts of epithets have been substituted for it, as
+gastric fever, and infantile remittent fever, and so on. Name it as you
+may, the fever is one and the same with the typhoid fever, which one
+hears of as prevailing constantly in many continental cities, and
+proving dangerous and fatal in any district almost in direct relation to
+the neglect of drainage and of proper sanitary precautions.
+
+It is extremely rare in infancy, though I saw it once in a babe eight
+months old, and is comparatively seldom met with before the age of five
+years. From five to ten years old it is more frequent than from ten to
+fifteen, but it is consolatory to know that it is less fatal in early
+childhood than at any subsequent time of life, and that cases of such
+exceedingly mild character that the child's condition can be more
+properly described as ailing rather than ill, are then far from
+uncommon. The symptoms, however, are in all instances similar in kind,
+though widely varying in degree, and the duration of the fever is, as
+nearly as may be, three weeks. By this it is not meant that at three
+weeks' end the child who has had typhoid fever is well again, but only
+that the temperature, which had hitherto been high, and always higher at
+night than in the morning, has subsided, that the skin has become less
+dry, the tongue slightly moist, the intelligence more clear, that the
+fever has run its course. For the first week or ten days, the symptoms
+have probably become every day more grave; and for the next ten the
+doctor could find no better consolation than the assurance--happy if he
+could give it--that the condition was not worse, but that you must have
+patience, for the time for improvement had not yet arrived. If the
+attack has been severe, the child will be left greatly exhausted, sadly
+emaciated, and suffering from the effects of that ulceration of the
+bowels which accompanies the fever, and from which life may still be in
+imminent danger. But the fire is quenched; the question is no longer how
+to put out the conflagration, but how to repair the mischief it has
+caused.
+
+When mild, the disease usually comes on very gradually, the child loses
+its cheerfulness, the appearance of health leaves it, the appetite
+fails, and the thirst becomes troublesome; in the daytime it is listless
+and fretful, and drowsy towards evening, but the nights are often
+restless, 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 no
+refreshing. The thermometer will quite, in the early days, solve all
+doubt as to the nature of the case. In the morning the thermometer will
+be natural, or nearly so, but at seven o'clock in the evening it will
+have risen to 101° or 102°, and will continue so during the early part
+of the unquiet night. After midnight it will begin to fall, and by six
+o'clock in the morning, or even earlier, will have regained its natural
+standard. There is no other disease but typhoid fever, and now and then
+some forms of galloping consumption, in which these oscillations of
+temperature take place regularly. Other symptoms attend typhoid fever
+besides these, and serve to stamp upon it its distinctive character. The
+bowels are usually loose, or if not, a moderate aperient acts on them
+excessively, the evacuations being loose, often watery, of a light
+yellow-ochrey colour. The abdomen is full, the bowels being more or less
+distended with wind, sometimes tender, especially at the right side, and
+both 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 the
+second week, small rose-red spots or pimples appear on the abdomen,
+sometimes also on the chest and back. They disappear for the moment if
+pressure is made on them, but reappear the moment the pressure is
+withdrawn. Now and then they are numerous, and sometimes two or three
+successive crops appear, the old ones fading as the others show
+themselves; but in childhood they are often scanty, though whether few
+or many, they are the external characteristic of the disease just as the
+rash is in scarlatina or measles.
+
+Whenever a child of whatever age begins without obvious cause to lose
+appetite and health, to become feverish, with marked increase of
+temperature towards evening for several days together, and more or less
+disposition to diarrh[oe]a, it is all but absolutely certain that the
+child has contracted typhoid fever.
+
+When the disease comes on gradually, it seldom becomes dangerous, though
+until the end of the first week there is always considerable uncertainty
+on this point. The amount of diarrh[oe]a and the degree of disorder of
+the brain, as shown by restlessness, delirium, and stupor are the
+measure of the gravity of any case. There is, however, scarcely any
+disease from which even when most severe recovery so often takes place
+in childhood, and this not as persons so often imagine from some
+critical occurrence but by a process of gradual amendment. The first
+signs of amendment, too, may be taken as giving almost certain promise
+of complete recovery; but it is well to bear in mind that there is no
+disease of early life in which the mental faculties, though time brings
+them back at length uninjured, remain so long in a state of feebleness
+and torpor as in typhoid fever. Though the first signs of improvement,
+too, are very seldom deceptive, yet the patient's convalescence is
+almost always slow, and interrupted by many fluctuations.
+
+Though contagious, still typhoid fever is far less directly contagious
+than measles or scarlatina. It seems as if with this disease, just as
+with cholera, the contagious element were present in its most active
+form in the discharges from the bowels. These should therefore be
+disinfected by carbolic acid or some other disinfectant immediately; and
+should never be emptied in a closet used by other members of the family,
+and more particularly by children. Special precautions also should be
+taken with the bed-linen, and night-dresses of the patient; and it must
+be remembered that wise precautions have nothing in common with
+exaggerated alarm. One more hint will not be out of place. In typhoid
+fever, and still more in the highly contagious measles and scarlatina,
+the person who sleeps in the patient's room is much more likely to
+contract the disease than she who sits up and watches at night keeping
+wide awake. Whoever takes charge of a fever patient during the night
+should therefore sit up and watch, not lie down and doze, and this not
+for 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 from
+first to last. He may come every day, and may daily do nothing but
+merely watch. The disease will run its course, the greatest skill cannot
+cut it short, though now and then instead of lasting for three or even
+four weeks it comes to an end spontaneously in fourteen days. Skilled
+watching is what the competent doctor gives. You would not despise or
+underestimate the pilot's skill, who steered your barque through a
+dangerous sea in smoothest water, because he knew each hidden rock or
+unseen quicksand on which but for his guidance you might have made
+shipwreck.
+
+=Small-pox.=--At the present day, thanks to vaccination, and to
+re-vaccination, _small-pox_ is rarely met with in the well-to-do classes
+of society, though it is not yet a century ago since it found its
+victims not only among the poor, but among the highest in the land. It
+does, however, occur sometimes after vaccination, and sometimes, though
+very rarely, an attack of small-pox fails to furnish an absolute
+guarantee against the occurrence of a second.
+
+Small-pox, unmodified by previous vaccination, sets in in the child with
+violent sickness; vomiting, sometimes recurring frequently for
+forty-eight hours, with much depression, or even stupor; in some
+instances even actual convulsions, and fever; but neither with the
+sore-throat of scarlatina, nor with the sneezing, cough, and running at
+the nose of measles. At the end of from forty-eight to sixty hours, an
+eruption of pimples appears on the face, forehead, forearms and wrists,
+whence it extends to the body and the lower limbs. They are reddish in
+colour, rather pointed in form, and at first scarcely raised above the
+surface; so that the eruption looks at first like the very early
+eruption of measles; though the tiny pimples felt as if beneath the skin
+serve even then to distinguish the one disease from the other. In
+another forty-eight hours the character of the pimples has changed into
+that of little vesicles or pocks, depressed instead of pointed at their
+centre, and containing a little watery milky fluid. They next enlarge,
+and become once more prominent at their centre as they fill more and
+more with fluid, which becomes thicker, yellowish-white--looks like, and
+indeed is, matter. Four or five days are occupied with this process;
+the matter in the pocks then begins to dry, and scabs to form, which
+gradually by the end of another week drop off, and leave the skin
+spotted with red or even scarred if the pocks went deep enough to
+destroy the skin, and to leave the indelible marks, the so-called
+pitting of small-pox.
+
+The danger of the disease is in childhood the nervous disorder at the
+outset, and then the exhaustion produced by the so-called maturation of
+the pocks when the thin watery fluid changes to the thicker matter, and
+depresses the patient in the same way as he would be depressed by an
+enormous abscess.
+
+The first outbreak of the eruption is followed always by a most
+remarkable abatement in the disturbance of the constitution, and for
+three or four days, even though the eruption is abundant, the patient
+may seem so well that it is almost impossible to realise the imminent
+peril to which he will be exposed in a few days' time.
+
+=Inoculation and Vaccination.=--The danger of small-pox is in direct
+proportion to the abundance of the eruption; and the great advantage of
+inoculation for the small-pox consisted in the much scantier eruption
+which followed it, as compared with that which commonly took place in
+the natural small-pox.
+
+The same advantage in a greater degree is obtained by vaccination, even
+in the exceptional instances in which it fails to render the person
+altogether insusceptible to the disease.
+
+The great advantage which inoculation secured was counterbalanced in
+great measure by the fact that it always maintained small-pox rife
+throughout the whole country, and that consequently all who either had
+neglected inoculation, or young children on whom, on account of their
+tender age, it had not yet been practised, were more than ever exposed
+to constant risk of infection.
+
+This very real danger led to the almost unanimous welcome which the
+practice of vaccination received towards the end of the last century,
+since it was hoped that by it not only would the risk attending
+small-pox be lessened, and the disease when it did occur be even milder
+in character than inoculated small-pox, but that small-pox itself would
+eventually be extirpated.
+
+These anticipations have not hitherto been fully realised; but the good
+effected by vaccination has been such as to render it, in the opinion of
+nearly everyone qualified to form an opinion on the subject, one of the
+greatest boons ever conferred on the human race.
+
+Small-pox, like other eruptive fevers, has the peculiarity of occurring
+for the most part only once in a person's life. We do not know in the
+least on what this protecting influence depends. We know the fact, but
+are the less able to offer an explanation, since there are other
+constitutional diseases, such as gout and rheumatism, in which the local
+symptoms are equally the outcome of previous constitutional disorder,
+where exactly the opposite rule obtains, and in which their occurrence
+does but increase the liability to their return.
+
+The protective power is apparently possessed by the mild form of the
+disease communicated by inoculation as much as by the severer form of
+small-pox which is contracted by direct contagion or infection. This
+knowledge has been applied in the treatment of some of the diseases of
+animals, and it has been found in the case of the so-called small-pox in
+sheep (a disease which, however, is quite distinct from human small-pox)
+that while one in two of the animals who contracted it in the ordinary
+way 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 inoculated
+sheep were thereby safeguarded from subsequent attacks as completely as
+the others.
+
+This knowledge was more recently applied by the distinguished Frenchman
+whom I have already mentioned, M. Pasteur, in the case of a fatal
+pestilence 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 directly
+infected, that he found it necessary to weaken the matter which he
+employed by admixture with other innocuous materials. This experiment,
+however, again yielded unsatisfactory results; slight symptoms of the
+disease were produced, but the protection thus afforded was inadequate
+and uncertain. Some few resisted the disease, but others contracted it
+and died. With that clear insight which constitutes genius, M. Pasteur
+next tried the experiment of inoculating the sheep first with a weak
+matter which produced but slight symptoms, but at the same time enabled
+the animal to support a second inoculation with a stronger matter; and
+this second inoculation enabled them to bear, unharmed, subsequent
+exposure to the disease. A grateful country has given a pension, and
+conferred well-merited honours on the man who has preserved their flocks
+from pestilence, but whom the silly sentimentality of the
+anti-vivisectionists in England would have mulcted in a fine, and, if
+possible, have sent to prison.
+
+That weakening of the poisonous element which Pasteur strove to attain
+by art, is already provided by nature in the cow-pox. The cow-pox is
+nothing else than small-pox modified in character, diminished in
+severity by passing through the system of the animal; but giving, when
+introduced into the system, a safeguard against natural small-pox at
+least as complete as that furnished by the inoculated disease.
+
+More than 70,000 children have come under my observation, either in
+hospital or in private practice; and I need not say that a physician
+having much consulting practice sees far more than the average of
+unusual and severe cases. Twice, and only twice, I have seen infants die
+from vaccination, and in both instances death took place from erysipelas
+beginning at the puncture. The one case I saw twice in consultation with
+the family practitioner. The other which I watched throughout was that
+of a little boy, the fifth child of a nobleman of high rank, both his
+parents being perfectly healthy. He was vaccinated by the family doctor
+in the country, direct from the arm of another perfectly healthy infant,
+from whom ten other infants were vaccinated immediately afterwards. The
+little boy was seized with convulsions within twenty-four hours, and
+almost at the same time erysipelas appeared on the punctured arm. The
+erysipelas extended rapidly, convulsions returned more than once, and on
+the fourth day from the vaccination the child died. One of the other
+children vaccinated at the same time died in the country in the same
+manner; all the others passed through vaccination regularly, and without
+a single bad symptom. I have no explanation to offer; this case stands
+by itself just as do those of death from the sting of a bee or death
+from cutting a corn.
+
+That some people die of other diseases since the introduction of
+vaccination, is undoubtedly true, for many of those who would have died
+in early infancy of small-pox are cut off later by measles or
+bronchitis, or die during teething; since it is obvious that vaccination
+does not protect against any other disease than small-pox.
+
+That protection, indeed, is not absolute, nor was the protection
+afforded by inoculation absolute; but small-pox after vaccination, even
+when it does occur, is very rarely severe, and still more seldom fatal.
+
+There seems good reason for believing that the protecting power of
+vaccination tends to diminish with the lapse of time; though apparently
+this is not always the case, nor can any direct statement be made as to
+the 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 does
+exist, and that this tendency calls for the repetition of vaccination
+from time to time; such re-vaccination carefully performed being as
+nearly as possible an absolute guarantee against small-pox. All persons
+engaged as nurses or attendants at the Small-Pox Hospital during the
+past thirty-two years, have been vaccinated or re-vaccinated before
+entering on their duties, and during this period not a single case of
+the disease has occurred among the whole staff. The experience of other
+small-pox hospitals for a shorter period is identical. As far as we
+know, every seventh year is a reasonable interval at which
+re-vaccination should be performed.
+
+One great cause of the failure of the protective power of vaccination
+is the unintelligent and careless manner in which it is too often
+performed, especially among the poor. To this same cause it is also due
+that in some cases of almost infinite rarity one special constitutional
+disease has been known to be communicated. I have never seen such a
+case, but I know there are such. They are, however, no more a reason
+against vaccination than the occasional death from an overdose of opium
+is a reason against the use of that drug.
+
+To avoid any risk of this kind, and also with the idea that the power of
+the vaccine matter may have become weakened by transmission through many
+thousands of persons, vaccination direct from the calf has been
+introduced of late years, especially in America and on the Continent.
+The time, however, that has as yet elapsed is scarcely sufficient to
+test the comparative preservative power of this as compared with
+vaccination from the human subject. Its immediate local effects are
+somewhat more severe; I do not know any reason why its influence should
+not 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 an
+eruption, or aggravate an eruption already existing. Such cases,
+however, are not frequent, and the eruption is not more troublesome than
+those which often appear in teething children. The occurrence of actual
+erysipelas around the puncture, while very dangerous, is, as I have
+already stated, of excessive rarity.
+
+A thoroughly dispassionate review of the whole subject appears to me to
+warrant the following conclusions:--
+
+1st. That vaccination, though not a perfect guarantee against small-pox,
+diminishes immensely the risk of its occurrence; and that by periodical
+revaccination, this guarantee is rendered all but absolute.
+
+2nd. That a very large proportion of the failures of vaccination are due
+to its careless and imperfect performance.
+
+3rd. That to such careless performance and to the introduction of the
+blood and not of the vaccine matter alone, from one child to another are
+due the extremely rare instances in which one special disease has been
+transmitted by vaccination.
+
+4th. That there is absolutely no evidence of the transmission of
+scrofula, consumption, or any similar disease by vaccination.
+
+5th. That vaccination direct from the calf appears to present some
+decided advantages; but it has not yet been practised for a sufficient
+time to admit of a comparison between its preservative power and that of
+vaccination from one child to another.
+
+6th. That in either case it is expedient that vaccination be performed
+within the first three months after birth, so as to avoid the irritation
+of teething which is unfavourable to successful vaccination, and also
+because the disposition to those skin diseases which vaccination tends
+to aggravate is never so considerable before the age of three months as
+it becomes subsequently.
+
+Even when vaccination fails to protect against small-pox it tends to
+produce a modified and so much milder form of the disease, that while
+one patient died out of every two in the Homerton Small Pox Hospital who
+had the disease naturally, the deaths were only one in four of those who
+had been imperfectly vaccinated, and one in forty-three of those whose
+arms bore evidence of perfectly good and successful vaccination.
+
+The influence of previous vaccination often scarcely shows itself in the
+stage which precedes the appearance of the eruption of small-pox, the
+fever being often just as intense, and the general symptoms just as
+severe as in the unmodified disease. The difference, however, becomes at
+once obvious with the appearance of the rash. The pocks are always much
+fewer than even in mild small-pox, sometimes even not more than twenty.
+They never attain above half the size of the ordinary small-pox
+pustules; they run their course and dry off in half the time, and
+consequently the dangerous fever which accompanies their development in
+the natural disease is almost or altogether absent in the vast majority
+of instances.
+
+If vaccination did no more than this it would be hard to overestimate
+its value, or to praise as it deserves the merit of its discoverer.
+
+=Chicken-Pox= is an ailment of such slight importance that it would
+scarcely call for notice if it were not that the resemblance of the
+eruption to that of small-pox sometimes leads to its being mistaken for
+that disease.
+
+It is highly contagious, and for this reason perhaps it is usually met
+with in infancy and early childhood. Sometimes, though by no means
+constantly, the eruption is preceded for twenty-four or thirty-six hours
+by slight feverishness; but oftener the appearance of the rash is the
+first indication of anything being the matter. It shows itself in the
+form of small pimples, which in a few hours change into small circular
+pocks containing a little slightly turbid fluid. They appear on the
+forehead, face, and body, but very rarely on the limbs; they enlarge for
+some two or at most three days, then shrivel and dry up; and at the end
+of a week the crusts or scabs fall off, scarcely ever causing any
+permanent pitting of the skin. They are usually not above twenty or
+thirty in number, though every now and then they are much more numerous
+without any obvious reason. Their distinction from the small-pox
+eruption consists not only in the smaller size of the pocks, and in the
+entirely different course which they run, but also in the fact that two
+or three successive crops of the eruption appear in the course of five
+or six days, so that new ones, those at maturity, and those on which the
+crusts have already formed, or from which they have already fallen, may
+be seen on the child at the same time. This is sufficient of itself to
+establish the difference between the two diseases, and also to
+distinguish between chicken-pox and the milder variety of small-pox
+which is sometimes observed in children who have been already
+vaccinated.
+
+=Measles= is a disease with which almost everyone is familiar, and one
+which with proper care is not generally attended with danger. Its great
+risks are twofold; first, that of its being complicated with bronchitis,
+or inflammation of the lungs during its progress, and next of its being
+followed by an imperfect recovery, and by the awakening into activity
+any tendency to scrofulous or consumptive disease. On these two accounts
+the disease is not to be made light of, and special watchfulness is to
+be exercised during the whole time of convalescence. It is also unwise
+when 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 it
+over;' for its mildness in one case furnishes no guarantee of its
+mildness in another, and the danger of the disease is almost in exact
+proportion to the tender age of those who are attacked by it.
+
+The early symptoms of measles are those of a bad feverish cold; the eyes
+grow red, weak, and watery, and are unable to bear the light, the child
+sneezes very frequently, sometimes almost every five minutes, and is
+troubled by a constant short dry cough. About the fourth day, a rash
+makes its appearance on the face, forehead, and behind the ears, and in
+the course of the next forty-eight hours travels downwards over the body
+and limbs, and then in another forty-eight hours it fades in the same
+way, being at its height on the body when it has already begun to
+disappear from the face. It first shows itself in the form of small red
+circular spots, not unlike fleabites, but very slightly raised above the
+somewhat reddened skin, and looking for a few hours not unlike the very
+early stages of small-pox, before the eruption has lost the character of
+minute pimples. On the face the spots sometimes run together, and then
+form irregular blotches about a third of an inch long by half that
+breadth; while elsewhere they present an irregular crescentic
+arrangement. As the rash fades it puts on a dirty yellowish red
+appearance; the surface of the skin often becomes slightly scurfy, and
+it continues somewhat stained of a reddish hue for some days after the
+eruption has disappeared.
+
+The only other point on which it is necessary to dwell is this, that the
+symptoms do not, as in small-pox, become less severe immediately on the
+appearance of the eruption, but continue just as troublesome as before
+for twenty-four hours or more, the voice being hoarse, the cough even
+more incessant, and the throat often slightly sore and red. Soon,
+however, improvement becomes apparent, the fever lessens, the cough
+grows looser; and in less than a fortnight the patient is usually
+convalescent.
+
+The above is pretty nearly the ordinary course of measles, for we do not
+meet with that extreme variation in its severity which is observed in
+scarlatina, where one child will seem scarcely to ail at all, while its
+brother 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 domestic
+management, for while the cough is troublesome in almost every case, the
+ear of the experienced doctor is needed to ascertain whether it is
+merely the cough of irritation which attends the measles, or the graver
+cough due to bronchitis.
+
+One other caution will not be out of place. The danger of exposure to
+cold is very real, but that does not necessitate the loading the child
+with excessive covering, or the abstaining from washing its hands and
+face. The child should be kept moderately cool; and sponging its hands
+and face frequently with tepid water soothes it and relieves the painful
+irritation and itching.
+
+=German Measles.=--There is a disorder which seems to hold a middle
+place between measles and scarlatina, akin to both, identical with
+neither, and furnishing no sort of protection from their occurrence.
+
+It is known in this country by the name of _German measles_, or
+sometimes by its German name of _Rötheln_; the first clear description
+of its character having been given by German writers.
+
+It is unfortunate that a very slight resemblance of some of its symptoms
+to those of scarlet fever has led to its being sometimes mistaken for
+it, and as the ailment is almost always very trivial, doctors anxious to
+avoid alarming their patients' friends, too often allow the error to go
+unrectified, 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 a
+slight sore-throat, unaccompanied with glandular swelling. The rash in
+no respect resembles the uniform redness of the scarlatinal eruption,
+and there is no peeling of the skin, nor even any roughness of the
+surface left behind.
+
+Slight feverishness sometimes precedes the appearance of the rash for
+twenty-four hours; but the cough, and sneezing, and running at the eyes
+and nose, which usher in measles are entirely absent. The rash usually
+appears in the course of twenty-four hours, is never postponed beyond
+the second day; it begins, like that of measles, on the face, and, like
+it, travels downwards, but always disappears on the third day, while
+that of measles is not entirely gone before the eighth or ninth. The
+rash itself also has a different character. It consists of small,
+slightly elevated, round red spots which now and then coalesce into
+small patches, but never have the somewhat crescentic arrangement
+observed in the rash of measles. The colour of the spots is somewhat
+darker than that of the eruption of measles, while the _skin between
+them remains pale_, and does not assume the flush of measles. As it
+disappears it simply fades, and does not at all change its tint as that
+of measles does, and it leaves the skin unroughened.
+
+Now and then German measles are severe, and are attended with a good
+deal 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 the
+disease prevails epidemically; and even then the symptoms of the
+affection are sufficiently marked to preserve from error all but those
+who wish to be deceived, and to flatter themselves that their child is
+henceforth 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 greater
+mildness of the disease, is one of the most formidable ailments of
+childhood, and especially of early childhood, since the highest
+mortality from it takes place during the third year of life.
+
+It is more dreaded in a household, and justly so, than any other
+disease of childhood, though, indeed, it is not limited in its
+occurrence to early life, and instances are familiar to us all in which
+the mother, devoting herself to the care of her little ones, has herself
+fallen a victim to the poison.
+
+I do not think it so directly contagious, from person to person, as
+small-pox, chicken-pox, or measles, but its infection appears to be
+specially abiding in its character, and to cling longer to the clothes,
+the bedding, and even the room of a scarlet fever patient, than that of
+the other eruptive fevers, except perhaps small-pox.
+
+It is an object of special dread also for two other reasons. One of
+these 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 to
+have it so slightly as scarcely to be ill, two to have their lives
+placed in jeopardy, and two to die. The other reason for special dread
+is that the mildness of the disease at its outset affords but a slight
+guarantee against the occurrence of serious complications in its course,
+and still slighter against secondary diseases which may follow in its
+train, and either destroy life directly, or leave behind some
+irremediable mischief.
+
+Scarlatina has been divided by medical men into three classes, according
+to its different degrees of severity; the mild--that accompanied with
+bad sore-throat--and the malignant variety.
+
+We have specially to do with the first of the three; for it is in it
+only that there is danger of the disease being overlooked, or mistaken.
+
+The symptoms of scarlatina usually appear within three days after
+exposure to its contagion, and there is very good authority for
+believing that the interval never exceeds six days. I should not,
+however, feel quite secure until after the lapse of ten days, and during
+this 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 the
+surface, usually with, but sometimes even without slight sore-throat and
+feverishness, may be the first indication of an affection which is
+sometimes so deadly. In the majority of cases, however, it is ushered
+in by vomiting once or oftener, accompanied by headache, heaviness, of
+head, great heat of skin, and some measure of sore-throat. The brain is
+easily disturbed in children, as has already been said, and delirium at
+night during the first twenty-four hours of an attack of scarlet fever
+need not excite anxiety, for it then often passes away, and the disease
+runs a perfectly favourable course. The continuance of delirium later is
+an attendant only on the graver forms of scarlet fever.
+
+The rash often makes its appearance within twenty-four hours after the
+commencement of the illness, at latest in the course of the second day.
+It usually shows itself first on the neck, breast, and face, whence it
+extends in twenty-four hours to the body and limbs, and is then not
+seldom specially vivid on the inside of the thighs. Its colour is a very
+bright red, due in part to a general flush of the skin, in part to the
+presence of innumerable red dots or spots, which do not communicate any
+sense of roughness to the hand, though now and then extremely minute red
+pimples are interspersed. For three days the rash usually continues to
+become of a deeper colour, and more generally diffused over the whole
+surface; it then slowly declines, but does not wholly disappear until
+the seventh or eighth day of the disease. As the rash subsides the skin
+is left rough, and by degrees scales off, often in large flakes from the
+hands and feet, but elsewhere in a sort of branny scales. Sometimes this
+process is over in five or six days, while in other cases the skin peels
+and is reproduced several times in succession, so that it is protracted
+for three or four weeks or even longer. The degree of this peeling also
+varies as well as its duration. It is usually most considerable where
+the rash has been most abundant, while where the rash has been scanty,
+it is sometimes scarcely apparent except at the tips of the fingers and
+toes and just around the insertion of the nails.
+
+Besides the rash there are commonly other symptoms not less
+characteristic of scarlatina, and among them the sore-throat is one of
+the most invariable. Even in mild cases, it is very rarely absent, and
+if not present at the beginning, it comes on on the second or third day.
+The palate and tonsils, in these circumstances are red, and the latter
+are usually more or less swollen, while swallowing is attended with
+pain, or at any rate with discomfort. The redness of the palate, which
+extends also to the back of the throat, is a finely spotted redness
+closely resembling the rash on the surface. The tongue is coated with a
+thick white or yellowish coating, through which project numerous bright
+red points, papillæ as they are called, and this appearance of the
+tongue is as distinctive of scarlatina as the rash itself. Later, as the
+rash begins to fade, the coating separates from the tongue, which is
+left of a bright red colour, looking raw and shining, with the little
+raised red points projecting beyond its surface, and constituting what
+has been called in medical language, the strawberry tongue.
+
+When all these symptoms are present, no one can doubt but that the case
+is one of scarlatina. But the decision is far less easy in mild cases,
+for in them the rash is sometimes extremely evanescent, the general
+disturbance of health very slight, and the fever and accompanying rise
+of temperature small. The risk in such circumstances of the disease
+being altogether overlooked is even greater than that of its being
+confounded with some other eruptive fever. The rash of measles cannot be
+confounded with that of scarlatina, and the distinctly spotty character
+of the rash of German measles ought, apart even from other differences,
+to render mistake impossible.
+
+Perhaps the best rule that can be laid down is that every diffused red
+rash, not obviously formed by distinct spots, even though it be not
+uniform but appears in patches on the neck, breast, back, or inside of
+the thighs, and persists for more than twelve hours, is scarlatinal.
+Further, that in any instance in which even very slight feverishness, or
+very slight sore-throat, have preceded or accompanied the rash, the
+nature of the ailment is stamped beyond the possibility of doubt.
+Mistakes are made from want of careful observation, much more than from
+any insuperable difficulty in distinguishing one disease from the other.
+When the least hesitation is felt as to the nature of any rash which
+may appear on a child, with, or without previous illness, the question
+should be at once referred to a medical man. People are too apt in these
+circumstances to wait for a few days, and then to appeal to the doctor
+when all traces of rash have disappeared, and when the grounds no longer
+exist on which he could base a positive opinion.
+
+I need not describe the symptoms of severe and dangerous scarlatina, for
+long before symptoms become really formidable, the patients will have
+been placed under medical care. It may suffice to say that the danger is
+almost always in proportion to the severity of the throat-affection and
+swelling of the glands, and not at all in proportion to the abundance of
+the rash. Though severe cases usually set in with severe symptoms, yet
+this is not invariably the case, and medical watching is all the more
+necessary from the very commencement, since until the end of the first
+week it is impossible to calculate on the subsequent course of the
+disease. In malignant scarlatina happily of infrequent occurrence, the
+child is struck down, as though its blood were poisoned, from the very
+first; and death takes place often within forty-eight hours, the rash
+appearing just sufficiently to stamp the nature of the pestilence which
+has proved so deadly.
+
+It may form a useful conclusion to all that has been said in this little
+book about the diseases of children, if I endeavour to point out in what
+consist the duties of parents in cases of scarlatina, or of any disease
+which resembles it.
+
+1. To watch carefully the commencement of every slight feverish attack
+in which a diffused red rash appears, even though this should be only in
+patches, and to bear in mind the possibility of its being due to
+scarlatina.
+
+2. To remove the child immediately from the others, so long as there is
+any doubt concerning the nature of the case, and to remove with him his
+bed, bedding, and all clothes worn by him at the time when the illness
+began, or the rash appeared.
+
+3. To place the child if possible in a room at the top of the house, so
+that the other children may not pass by his door.
+
+4. Inasmuch as scarlatina often proves fatal to grown persons who have
+not already had the disease, to obtain at once the attendance of a
+skilled nurse, in order to avoid the risk of the disease spreading
+through the household.
+
+The wife belongs to her husband, the husband to his wife; their mutual
+duties are paramount over even those of the parent; and neither has the
+right to jeopardise that life which belongs to the other. To say, 'I
+shall not catch the disease, because I have no fear,' is as idle as it
+would be for the soldier to say, 'Because I am brave, therefore I am
+invulnerable.'
+
+I have been accustomed to insist on the absence from the room of father
+or mother, supposing either of them not to have had scarlatina, so long
+as I could give the assurance that every thing was going on well; but on
+the slightest anxiety I have referred to both parents for their mutual
+decision as to the course which they would choose to adopt.
+
+From a refusal to be guided by this counsel, it has more than once
+happened to me, to see the child recover from mild scarlatina without a
+bad symptom, and the mother who had insisted on nursing the little one
+die of the disease to which she had needlessly exposed herself.
+
+5. So soon as the disease has declared itself as scarlatina, to take up
+the carpets and remove the curtains from the sick child's room, to empty
+the drawers of any clothes which may be in them, and to hang up outside
+the door a sheet moistened with a solution of carbolic acid.
+
+6. To arrange for all food and necessaries to be placed in an adjoining
+room, or at the head of the stairs, so that there may be no direct
+communication between the attendants on the sick and the other inmates
+of the house.
+
+7. To insist on the attendants not wearing either silk or stuff dresses,
+but dresses of some washable material; and on their changing their
+garments as well as scrupulously washing themselves before mixing with
+other inmates of the house, and especially with the children.
+
+8. While in all respects obeying the directions of the doctor, to grease
+the child all over twice in twenty-four hours with suet or lard, to
+which a small quantity of carbolic acid has been added. This proceeding
+both lessens the amount of peeling of the skin in a later stage of the
+disease; lessens the contagiousness of the scales which are detached;
+and, by promoting the healthy action of the skin, diminishes the risk of
+subsequent disorder of the kidneys and consequent dropsy.
+
+9. Even when the case has been of the slightest possible kind, to keep
+the child always in bed for one-and-twenty days. This was a standing
+rule at the Children's Hospital, and I am certain that its
+non-observance will be followed three times out of four by dropsy and
+kidney-disease.
+
+10. When the disease is over, to destroy, if the parents' means at all
+permit it, the clothes and bedding of the child. When this is not
+practicable, to have everything exposed to the heat of superheated steam
+in a Washington Lyons or other similar disinfector, and to have all
+linen boiled as well as washed. Lastly, to have the ceiling whitewashed,
+the paint cleaned, the paper stripped, and the room repapered, as well
+as the floor washed and rewashed with strong carbolic soap.
+
+These precautions are troublesome and costly, but disease is costlier
+still; and who shall estimate the cost of death!
+
+
+
+
+APPENDIX
+
+_ON THE MENTAL AND MORAL FACULTIES IN CHILDHOOD, AND ON THE DISORDERS TO
+WHICH THEY ARE LIABLE._
+
+
+Any remarks on the ailments of children would be incomplete if no notice
+were taken of the mental and moral peculiarities of early life.
+
+For want of giving heed to them, not only are grave mistakes made in the
+education of children, but in the management of their ailments, both by
+doctors and by parents: much needless trouble is given to the doctors,
+much needless distress to the child, much needless anxiety to the
+parents.
+
+The common mistake committed by those parents who do not make their
+child an idol to fall down and worship, and thus turn him, to his own
+misery and theirs, into the most arbitrary of domestic tyrants, is to
+treat him as though he were in mind, as well as in body, a miniature
+man; feebler in intellect as he is inferior in strength, but differing
+in degree only, not in kind.
+
+Now the child differs essentially from the adult in the three respects;
+that
+
+1. He lives in the present, not in the future.
+
+2. His perceptions are more vivid, and his sensibilities more acute;
+while the world, on which he has just entered, surrounds him with daily
+novelties.
+
+3. He has less self-consciousness, less self-dependence, lives as a
+part of the world by which he is surrounded--a real practical pantheist.
+
+The child lives in the present, not in the future, nor much even in the
+past, till the world has been some time with him, and he by degrees
+shares the common heritage of retrospect and anticipation. This is the
+great secret of the quiet happiness which strikes almost all visitors to
+a children's hospital.
+
+No one can have watched the sick bed of the child without remarking the
+almost unvarying patience with which its illness is borne, and the
+extremity of peril from which apparently, in consequence of that
+patience, a complete recovery takes place. Much, indeed, is no doubt due
+to the activity of the reparative powers in early life, but much also to
+the unruffled quiet of the mind. No sorrow for the past, no gloomy
+foreboding of the future, no remorse, disappointment, nor anxiety
+depresses the spirits and enfeebles the vital powers. The prospect of
+death, even when its approach is realised--and this is not so rare as
+some may imagine--brings in general but small alarm. This may be from
+the vagueness of the child's ideas; it may be, as the poet says, that in
+his short life's journey, 'the heaven that lies about us in our infancy'
+has been so much with him, that he recognises more clearly than we can
+do
+
+          'The glories he hath known,
+    And that imperial palace whence he came.'
+
+I dwell on this truth, because it is of great practical moment that we
+should bear in mind to how very large an extent the child lives only in
+the present; because it follows from it that to keep the sick child
+happy; to remove from it all avoidable causes of alarm, of suffering, of
+discomfort; to avoid, as far as may be, any direct struggle with its
+waywardness; and even if death seems likely to occur, to look at it from
+a child's point of view--not from that which our larger understanding of
+good and evil suggests to our minds--are duties of the gravest kind
+which weigh on the parent and the nurse, no less than on the physician.
+
+But not only does the child live in the present far more than it is
+possible for the adult, but there are, besides, other important mental
+differences between the two. Not only is the mind of the child feebler
+in all respects than that of the adult, but, in proportion to the
+feebleness of his reasoning power, there is an exaggerated activity of
+his perceptive faculties, a vividness of his imagination. The child
+lives at first in the external world, as if it were a part of himself,
+or he a part of it, and the gladheartedness which it rejoices us to see
+is as much a result of the vividness with which he realises the things
+around him, as of that absence of care to which it is often attributed.
+This peculiarity shows itself in the dreams of childhood, which exceed
+in the distinctness of their images those which come in later life. It
+shows itself, too, in the frequency with which, even when awake, the
+active organs perceive unreal sounds, or in the dark, at night, conjure
+up ocular spectra; and then not merely colours, but distinct shapes,
+which pass in long procession before the eyes. This power fades away
+with advancing life; except under some conditions of disease, the
+occasional appearance of luminous objects in the dark is the only relic
+with most of us of the gift of seeing visions with which, at least in
+some degree, we were endowed in our early years. The child who dreads to
+be alone, and asserts that he hears sounds, or perceives objects, is not
+expressing merely a vague apprehension of some unknown danger, but often
+asserts a literal truth. The sounds have been heard; in the stillness of
+its nursery the little one has listened to what seemed a voice calling
+it; or, in the dark, phantasms have risen before its eyes, and the agony
+of terror with which it calls for a light, or begs for its mother's
+presence, betrays an impression far too real to be explained away, or to
+be met by hard words or by unkind treatment.
+
+Impressions such as these are not uncommon in childhood, even during
+health. Disorder, direct or indirect, of the functions of the brain,
+more commonly the latter, greatly exaggerates them, and I have known
+them to outlast for many weeks all other signs of failing health after
+convalescence from fevers. The unreal sights are far more common than
+the sounds. The sounds are usually of the simplest kind--as the tinkling
+of a bell, of which we all remember the exquisite use made by Hans
+Andersen in one of his nursery tales; or the child's own name, at
+intervals repeated, just as the little watchful boy heard it in far off
+Judæa, when it was the prelude to a wondrous communication from the
+unseen world. It came to him as he woke from sleep, before the morning
+dawned, while the lamp, lighted overnight, was burning still; and still
+it is so far the same that these occurrences which suggest to us
+problems that we cannot attempt to solve, mostly take place at times of
+transition from the sleeping to the waking state.
+
+The ocular spectra are usually far more vivid and detailed. Those which
+occur in the waking state are by no means always painful, though their
+strangeness not infrequently alarms the child, and his horror at the
+dark arises, not from his seeing nothing, but from his seeing too much.
+
+Some imaginative children amuse themselves with these phantasms, and
+then, if encouraged to relate them, will constantly transgress the
+boundary line between truth and falsehood, and weave their little
+romance. When they happen on waking they are usually preceded by
+frightful dreams, but the image which the child sees then is not the
+mere recollection of the dream, but a new, distinct, though painful
+impression; generally of some animal to which the child points, as now
+here, now there. These night terrors from the very circumstantial
+character of the impressions which attend them, often, as I have already
+said, occasion needless anxiety as to the importance of the cause on
+which they depend.
+
+Sleep-walking in its smaller degrees of getting out of bed at night, is
+by no means unusual in childhood; but the greater degrees of
+somnambulism are certainly rare; and I have always found them dependent
+on undue mental work; not always, indeed, on the tasks being excessive,
+but sometimes on the over-anxiety of the child to make progress. I have
+not yet known a poor person's child a somnambulist.
+
+But not only are the perceptions more acute in childhood than in adult
+life, the sensibilities are more intense. The child's emotions, indeed,
+are often transitory--generally very transitory; but while they last
+they produce results far greater than in the grown person. In the case
+of the latter, recollection of the past, anticipation of the future, or
+even the duties of the present, control the overwhelming sorrow, or call
+forth the energies needed to bear it. The child lives in the present,
+and this present is but the reflection of the world around, its
+impressions uncontrolled by experience, ungoverned by reason.
+
+The broken-heartedness of a child on leaving home is not the expression
+only of intense affection for its friends or relations, it is the shock
+of separation from the familiar objects which have surrounded it; and I
+have not infrequently seen children inconsolable when removed from homes
+that were most wretched, or from relations who were most unkind. Every
+now and then, indeed, I have been compelled to send children home from
+the hospital because no love nor care could reconcile them to the change
+from home; and they have refused to eat, and spent their nights in
+weeping. The feeling is an unreasoning one, like the home-sickness of
+the mountaineer.
+
+But, moreover, sudden shocks may sometimes overthrow the whole moral
+equilibrium, and disarrange the balance of the nervous system so
+seriously as to cause the death of a child previously free from any
+important ailment. Thus, I remember a little boy five years of age who
+died sixteen days after his father's funeral. The strange sad scene
+overcame him, though there had been no special tie between him and his
+father. He shivered violently, became very sick, complained by signs of
+pain in the head, for he had lost his speech, which he regained by slow
+degrees in the course of four or five days. Improvement in other
+respects did not take place, he lay in a drowsy state save when he
+called for his mother, and at length the drowsiness deepened into
+stupor, and so he died. I suppose his mother was right; she said his
+heart was broken.
+
+It behoves us to bear in mind that the heart may break, or the reason
+fail, under causes that seem to us quite insufficient; that the griefs
+of childhood may be, in proportion to the child's powers of bearing
+them, as overwhelming as those which break the strong man down. Every
+now and then we are shocked by the tale that some young child has
+committed suicide, and for reasons which to our judgment seem most
+trivial--from fear of punishment, or even from mere dread of reproof.
+These facts deserve special attention, they show how much more the
+susceptibility and sensitiveness of children need to be taken into
+consideration than is commonly done.
+
+This keenness of the emotions in children displays itself in other ways,
+and has constantly to be borne in mind in our management of them. The
+child loves intensely, or dislikes strongly; craves most earnestly for
+sympathy, clings most tenaciously to the stronger, better, higher around
+it, or to what it fancies so; or shrinks, in often causeless but
+unconquerable dread, from things or persons that have made on it an
+unpleasant impression. Reason as yet does not govern its caprices, nor
+the more intelligent selfishness of later years hinder their
+manifestation. The waywardness of the most wilful child is determined by
+some cause near at hand; and those who love children, and can read their
+thoughts, will not in general be long in discovering their motives and
+seeing through their conduct.
+
+One word more must be said with reference to that intense craving for
+sympathy so characteristic of the child. It is this which often
+underlies the disposition to exaggerate its ailments, or even to feign
+such as do not exist, and in such attempts at deception it often
+perseveres with almost incredible resolution. Over and over again I have
+met with instances where the motives to such deception were neither the
+increase of comfort nor the gratification of mere indolence; but the
+monopolising the love and sympathy which during some bygone illness had
+been extended to it, and which it could not bear to share again with its
+brothers and sisters. This feeling, too, sometimes becomes quite
+uncontrollable, and the child then needs as much care and as judicious
+management, both bodily and mental, to bring it back to health, as
+would be called for in the case of some adult hypochondriac or
+monomaniac.
+
+A caution may not be out of place as to the importance of not
+ministering to this tendency to exaggerated self-consciousness by
+talking of children's ailments in their hearing, or by seeming to notice
+the complaints they make as though they were something out of the common
+way.
+
+It will be observed that throughout I have dwelt more on disorders of
+the moral faculties than of the intellectual powers in childhood, and I
+have done so because I believe them to be the more common and the more
+important. In the feeble-minded the moral sense almost invariably
+participates in the weakness of the intellect; but it is by no means
+unusual for the former to be grievously perverted, while the
+intelligence is in no respect deficient. The moral element in the child
+seems to me to assert its superiority in this, that it is the most
+keenly sensitive, the soonest disordered--
+
+    'Like sweet bells jangled, out of tune, and harsh,'
+
+and the discord is first perceived in the finest notes.
+
+To a very great extent, a mixture of vanity and of a morbid craving for
+sympathy lie at the root of many of those perversions of character
+which excite a parent's anxiety. One of these consists in an
+over-scrupulousness with reference to the right or wrong of actions in
+themselves quite indifferent; in doubts as to whether the morning or
+evening prayer has been properly said, whether something was or was not
+absolutely true, whether this or that peccadillo was a grievous offence
+against God, and so on; and all these little cases of conscience are
+brought by the child several times a day to his mother or to his nurse
+for solution. If listened to readily the child's truthfulness becomes
+inevitably destroyed, and he grows up with a morbid frame of mind, which
+after-life will aggravate almost infinitely.
+
+One knows indeed the history of child saints; but it must be remembered
+that one great characteristic of pre-eminent sanctity at all ages of
+life is reticence, while these little people are perpetually seeking to
+interest others in themselves, their doubts, and feelings. If wisely
+dealt with, not by direct ridicule, but by a wholesome neglect of the
+child's revelations, treating them as of no special interest or
+importance, and discouraging that minute introspection which, of
+doubtful good at any age, is absolutely destructive of the simplicity of
+childhood, this unnatural condition will soon pass away. It will help
+this object very much, if the child is sent on a visit to judicious
+friends, and change of scene, of pursuits, of playmates, and amusements
+will be of all the more service since these morbid states of mind seldom
+come on in children whose bodily health is robust.
+
+Another mode in which the same perverted feelings display themselves is
+in the disposition occasionally noticed to exaggerate some real ailment,
+or to complain of some ailment which is altogether imaginary. So far is
+this from being rare that my experience coincides entirely with that of
+the French physician M. Roger, who has had larger opportunities than
+anyone else in France for observing the diseases of children, and who
+says, 'It must be borne in mind that simulated ailments are much more
+common in the children's hospital than in a hospital for adults.'
+
+It is difficult to assign any sufficient reason for this conduct. Mere
+indolence seems sometimes to be the chief reason for it, oftener vanity;
+the sense of importance in finding everything in the household arranged
+with exclusive reference to itself appears to be the motive for it; and
+this may sometimes be observed to be very powerful even at an
+exceedingly early age. In many instances a morbid craving for sympathy
+is mingled with the love of importance, and both these sentiments are
+not infrequently exaggerated by the conduct of a foolishly fond mother.
+Real illness, however, in almost all these cases exists at the
+commencement, though the child persists in complaining of its old
+symptoms long after their cause has disappeared.
+
+The great difficulty which the doctor meets with in the management of
+these cases arises from the incredulity with which his opinion is
+received. Candour is looked upon as so eminently characteristic of
+childhood, that deceit seems impossible; the case is thought by the
+parents to be an obscure one which the doctor does not understand; and
+therefore it is said, he, with want of straightforwardness and of
+kindness, throws doubts on the existence of disease, and on the
+truthfulness of a most loving, most suffering child. The vagaries of a
+hysterical girl, the fits, the palsy, the half-unconsciousness have all
+been assumed within my own observation by children from ten to fifteen
+years old, and I have more than once had to give place to the ignorant
+and impudent pretender who traded successfully on the feelings of the
+parents. Sometimes, one knows not why, except that the child has got
+tired of the part he was playing, the symptoms that had caused so much
+anxiety suddenly disappear, but even then the habit of mind left behind
+is anything but healthy. Indeed in all cases of this kind it is much
+less the state of the body than that of the mind which excites my
+apprehension. The constant watching its own sensations, the habit of
+constantly gratifying every wayward wish and temper under the plea of
+illness, and the constant indulgence which it too often meets with in
+this from the over-kindness of its parents, exert a most injurious
+influence on its character, and it grows up a juvenile hypochondriac.
+
+A doctor is very unlikely to throw doubt recklessly on the reality of a
+child's illness. His hesitation should certainly not be attributed to
+unworthy motives; the parents should co-operate with him heartily in any
+course of observation which he desires to follow, and if necessary
+another medical man of experience should be associated with the first,
+and allowed to visit the child two or three times. One does not
+associate the idea of moral delinquency with hysteria; the child who
+shams belongs to the same class with the hysterical patient. It is only
+the 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 greatly
+exaggerating or altogether feigning illness, it does not by any means
+always follow that he should at once be charged with it, since it is
+often 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 real
+ailment underlying all the half-unconscious exaggeration, and that if
+spoiling and over-indulgence do much to foster it, sternness and
+punishment interfere with recovery. To turn the thoughts away from self,
+to occupy the mind with new scenes, new amusements, new pursuits, to
+call forth by degrees self-control, and to let the child perceive rather
+by your manner than by what is actually said that the parents have not
+been duped by all his past vagaries; such are the simple means by which
+the little one will be brought round again to health of mind and health
+of body. Unhappily, in the minds of too many people the idea of the
+doctor is associated with the administration of drugs and with nothing
+else; the treatment of disease is of much wider scope; and many of our
+best remedies are those which do not admit of being weighed or measured,
+and whose names are not inscribed on the drawers or bottles in
+Apothecaries' Hall.
+
+Another phase of mental disorder in childhood sometimes presents itself
+as the result of overtasking the intellectual powers. This over-work too
+is by no means due in all cases to the parents' unwisely urging the
+child forward, but it is often quite voluntary on his part. The
+precaution too of limiting the hours of work is often inadequate from
+the want of some provision for turning the thoughts and energies during
+play hours into some perfectly different channel.
+
+In many of these cases Nature happily takes matters into her own
+management. For a year or two, or more, the mind has grown apparently at
+the expense of the body; the parents take a fearful joy in their
+darling's acquirements; and if it should live, think they, of what
+remarkable talents will it not be the possessor! By degrees, the extreme
+quickness of intellect becomes less remarkable; but the body begins to
+increase in robustness; and a year will sometimes suffice to transmute
+the little fairy, so quick, so clever, but so fragile, into a very
+commonplace, merry, rosy, romping child. I may add that it is well to
+bear in mind the converse of this; to remember that body and mind
+rarely grow in equal proportion at one time; that the incorrigible
+little 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 as
+his playmates. A dull mind, and a sickly or ill-developed frame may make
+us anxious: but if the physical development is good, the mind will not
+be likely to remain long below the average standard.
+
+But sometimes, the over-tasked mind leads to mischief which Nature
+cannot rectify; an attack of water on the brain destroys the child, or
+if not it sinks under almost any accidental disease. In other instances
+neither of these results takes place, but the whole nervous system seems
+profoundly shaken, and the moral character of the child seriously, and
+even permanently injured. I remember a quick and clever little girl aged
+five and a half years who was urged on by her governess to work which
+she delighted in, till at length the signs of over-taxed brain showed
+themselves in frequent extreme irritability, and occasional attacks of
+causeless fury amounting almost to madness. It was fully a year during
+which almost all mental work was suspended, while the child was sent to
+have complete change under most judicious management in the country,
+before her mind quite recovered its balance and she became able to
+resume her studies in a very moderate degree.
+
+Cases such as this are instances of the slightest degree of a condition
+which if not remedied may pass into confirmed insanity. I believe the
+gradations to be almost imperceptible by which the one state passes into
+the other; and I have known instances in which the ungovernable temper
+and occasional fury of the child have passed in youth into abiding
+insanity which rendered the patient the inmate, and I fear the permanent
+inmate, of a lunatic asylum.
+
+In whatever circumstances insanity comes on in childhood, and it does
+sometimes, though very seldom, come on independently of any obvious
+exciting cause, it always assumes the character of what has been termed
+moral insanity, or of that condition in which the moral system rather
+than 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 been
+speaking hitherto. The term idiocy, however, is a very wide one,
+including conditions differing remarkably from each other both in kind
+and degree, while not seldom it is misapplied to cases in which there is
+mere backwardness of intellectual power.
+
+=Backward Children.=--_Enfants arriérés_--as the French call
+them--constitute a class by no means seldom met with. They generally
+attain their bodily development slowly, and the development of their
+mind is equally tardy. They cut their teeth late, walk late, talk late,
+are slow in learning to wash and dress themselves, are generally dull in
+their perceptions, and do not lay aside the habits of infancy till far
+advanced in childhood. When the time comes for positive instruction,
+their slowness almost wears out everyone's patience; and among the poor
+indeed the attempt at teaching such children is at length given up in
+despair, and growing up in absolute ignorance, it is no wonder that they
+should be regarded as idiots. Still, dull as such children are, there is
+between 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 the
+whole course of their progress, and his delay increasing every day,
+places at length an enormous distance between him and them--a distance
+which in fact becomes insurmountable.
+
+In some of its minor degrees even, this backwardness not infrequently
+excites the solicitude of parents. It is sometimes observed in children
+who had been ill-nourished in infancy or who had been weakened by some
+serious or protracted illness, even though unattended by any special
+affection of the brain; but it is also met with independent of any
+special cause. The distinction, however, between such a case and one of
+idiocy is this, that though at four years old the child may not seem to
+be intellectually superior to most children at two, yet in manners,
+habits, and intelligence it does agree with what might be expected from
+the child at two; less bright perhaps, less joyous, but still
+presenting nothing which if it were but younger would awaken
+apprehension.
+
+It is well in all cases of unusual backwardness to ascertain the
+condition of the sense of hearing, and of the power of speech, for I
+have known the existence of deafness long overlooked, and the child's
+dulness and inability to speak referred to intellectual deficiency; and
+have also observed mere difficulty of articulation, dependent partly on
+malformation of the mouth, lead to a similar misapprehension. In both
+instances I have seen this inability to keep up ready intercourse with
+other children cast a shadow over the mind, and the little ones in
+consequence be dull, suspicious, unchild-like. I have already referred
+to a similar result as sometimes following serious illnesses. The child
+will for months cease to walk, or forget to talk, if these had been but
+comparatively recent acquirements; or will continue dull and unequal to
+any mental effort for weeks or months together, and then the mind will
+begin to develop itself once more, though slowly, possibly so slowly as
+never altogether to make up for lost ground.
+
+=Idiocy.=--In _idiocy_, however, there is much more than the mere arrest
+of the intellect at any period. The idiot of eight years old does not
+correspond in his mental development to the child at six, or four, or
+two; his mind is not only dwarfed but deformed; while feebleness of will
+is often as remarkable as mere deficiency of power of apprehension. Even
+in earliest infancy there is usually a something in the child idiotic
+from birth which marks him as different from babies of his own age. He
+is 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 perceived
+that the child, though he can see, does not notice; that his eye does
+not meet his mother's with the fond look of recognition, accompanied
+with the dimpling smile, with which the infant, even of three months
+old, greets his mother. Then it is found to have no notion of grasping
+anything, though that is usually almost the first accomplishment of
+babyhood; if tossed in its nurse's arms there seems to be no spring in
+its limbs; and though a strange vacant smile sometimes passes over its
+face, yet the merry ringing laugh of infancy or joyous chuckle of
+irrepressible glee is not heard. As time passes on, the child shows no
+pleasure at being put down 'to feel its feet,' as nurses term it; if
+laid 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 or
+walk till late, and then stands awkwardly, walks with difficulty,
+crossing its legs immediately on assuming the erect posture, an
+infirmity which it often takes years to overcome. Just, too, as the
+idiot is slow to notice, slow in learning to grasp anything, or to stand
+or walk, so he is late in learning to talk, he often acquires but few
+words, for his ideas are few. He learns even these few with difficulty,
+and employs the same to express many different things; he generally
+articulates them indistinctly, often indeed so imperfectly as to be
+almost unintelligible.
+
+In other instances the evidences of idiocy are not present at birth, or
+at any rate are not then noticed, but succeed to some attack of
+convulsions or to some illness attended with serious affection of the
+brain. Sometimes too there is no point in the child's history which can
+be laid hold on as marking the commencement of the weakening of his
+intellect, but as the body grows the mind remains stationary, or its
+powers retrocede, until by degrees the painful conviction that the child
+has become idiotic forces itself upon the unwilling parents. Here we
+have sometimes the sad spectacle of the body perfectly developed, hale
+and 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 a
+weird smile upon its face, looking at its spread-out fingers, or
+stroking a piece of cloth for a quarter of an hour together as though
+the sensation yielded it a kind of pleasure. It would be almost endless
+to describe the various degrees of mental weakness; from the slight
+silliness down to the condition in which the child is, and remains all
+life long, below the level of the brute.
+
+Parents as a rule are anxious to persuade themselves, and to persuade
+the doctor that their idiot child was once as bright and intelligent as
+others; and that the mind was darkened by some grave illness. We have,
+however, the highest authority, that of Dr. Down, for saying that as a
+rule which has but few exceptions idiocy from birth is more amenable to
+training than that which comes on afterwards, that in fact it is more
+hopeful 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 do
+for best and wisest whom the affliction has befallen of having an idiot
+child.
+
+First. To moderate their expectations as to the results of any, even the
+best devised and most successful treatment. The child who has been born
+of weak intellect, or who has become so as the result of illness, will
+always remain at a lower level than others, and this, even though some
+one faculty, as the musical faculty, or the power of calculation, should
+be above the average.
+
+Secondly. From the child's earliest infancy to occupy themselves in
+perfecting as far as possible the physical powers and aptitudes, and the
+habits of cleanliness and order. Development of mind waits on
+development of body: to stand, to sit, to walk, to grasp an object put
+into the hand, are essential to bringing the idiot child into relation
+with the world around it; are its elementary education, to be given
+patiently, cheerfully, lovingly, even for years together. To attend to
+its natural wants, and by fixed routine to accustom it at stated hours
+to empty its bowels and its bladder is a lesson hard to teach; and not
+less difficult is it to make the child learn to masticate its food, to
+drink without slobbering, and then to use the spoon and fork, and to
+feed itself; and afterwards to dress itself, to wash itself, to tie its
+shoestrings; for idiots almost without exception are awkward as well as
+lazy.
+
+The common class of nurses, even the very kindest, find it so much
+easier to feed the child, to wash it, and to dress it, than to teach it
+to do any of these things for itself, that it too often grows up, till
+too old to remain in the nursery, without having made the slightest
+advance above the condition of completest babyhood. It is absolutely
+essential either that the mother should devote herself solely to the
+care and teaching of the idiot, or that she should engage a nurse who
+will have no other duty. Such a person must be above the average in
+education and intelligence, and of course will command more than the
+ordinary wages. The mother, too, must resign herself to the little one's
+affection being transferred in a great degree from herself to the person
+who has constant charge of it--a hard trial this, but one to which, for
+her child's good, she must bring herself to submit.
+
+Thirdly. So soon as the child has been taught at home to exercise these
+lower powers, and the question of what is termed its education arises,
+it is a matter of absolute necessity that he be sent to an institution
+specially set apart for the feeble-minded. It is absolutely impossible
+with the most devoted love and the most lavish expenditure of money, to
+do at home what can be, and is constantly, accomplished even in a pauper
+idiot asylum. The imitative faculty, which is usually very strongly
+marked in the idiot, furnishes one great means of his improvement; while
+besides there are many of the moral powers which cannot be brought out
+except in the society of other children of his own age and not differing
+too widely from him in mental power.
+
+I have warned, and I repeat the warning, against exaggerated
+expectations as to the results of even the wisest treatment. To teach
+cleanliness, order, and neatness; to impart knowledge enough to enable
+the idiot to take care of himself; to develop his affections; to enable
+him to read and write; to practise some easy handicraft; to partake of
+some simple pleasures, and so at length to return to the shelter of his
+own home, and to be there, not an object to be hidden away, too painful
+to look upon, but an object rather of special tenderness, repaying with
+his guileless love the sad self-sacrifice of his parents for many a
+year; these are endeavours almost sure of accomplishment in a
+well-conducted institution, sure never to be realised in a home.
+
+I have often sent afflicted parents, who shrank from parting with their
+children, to one institution near London; and I doubt not there are
+others in England, where pains, and care, and skill, and untiring love
+awake the slumbering intellect, arouse the dormant affections, and work
+miracles 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 BY
+SPOTTISWOODE AND CO., NEW-STREET SQUARE
+LONDON
+
+
+[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.
+
+                            DISCLAIMER
+
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+End of the Project Gutenberg EBook of The Mother's Manual of Children's
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+<pre>
+
+The Project Gutenberg EBook of The Mother's Manual of Children's Diseases, by 
+Charles West, M.D.
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: The Mother's Manual of Children's Diseases
+
+Author: Charles West, M.D.
+
+Release Date: August 15, 2009 [EBook #29701]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK CHILDREN'S DISEASES ***
+
+
+
+
+Produced by Juliet Sutherland, Erica Pfister-Altschul and
+the Online Distributed Proofreading Team at
+http://www.pgdp.net
+
+
+
+
+
+
+</pre>
+
+
+
+
+
+<h1>THE<br />
+MOTHER'S MANUAL<br />
+OF<br />
+CHILDREN'S DISEASES.</h1>
+
+
+<h2>BY<br />
+CHARLES WEST, M.D.</h2>
+
+
+<h4>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.</h4>
+
+<h4>AUTHOR OF 'LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD.'</h4>
+
+
+<h5>NEW YORK:<br />
+D. APPLETON AND COMPANY.<br />
+1885.</h5>
+
+
+
+
+<hr style="width: 65%;" />
+<p><span class='pagenum'><a name="Page_v" id="Page_v"> </a></span></p>
+<h2><a name="ADVERTISEMENT" id="ADVERTISEMENT"></a>ADVERTISEMENT.</h2>
+
+
+<p>I have often asked myself whether it would not be possible to
+give in a small compass, and avoiding all technical detail, such
+an account of the diseases of infancy and childhood, as might
+be of use and comfort to the intelligent mother.</p>
+
+<p>Returning now, with health perfectly restored, to practise my
+profession for the rest of my life exclusively in my own country,
+I have brought with me this little book, in which the comparative
+leisure of my enforced sojourn at Nice has enabled me
+to realise my purpose.</p>
+
+<p>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 idle pretence of telling people
+how to treat their children's illnesses, without the help of a
+doctor. Its object is to give a description of the diseases of
+early life, such as may help a mother to understand something
+of their nature and symptoms, to save her from needless anxiety
+as to their issue, and to enable her wisely to second the doctor
+in his endeavours for their cure.</p>
+
+<p><span style="position: absolute; right: 10%;">CHARLES WEST.</span>
+<br />
+<span class="smcap">55 Harley Street, Cavendish Square.</span><br />
+<i>August 1, 1885.</i><br />
+</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="CONTENTS" id="CONTENTS"></a>CONTENTS.</h2>
+
+<ul class="TOC" style="list-style-type:none;">
+<li><p>&nbsp;<span class="ralign">PAGE</span></p></li>
+
+<li><a href="#ADVERTISEMENT">ADVERTISEMENT</a>        <span class="ralign"><a href="#Page_v">v</a></span><br /></li>
+
+<li><a href="#PART_I"><i>PART I.</i></a>
+    <p><span class="smcap">Introductory</span>        <span class="ralign"><a href="#Page_1">1</a></span></p></li>
+
+<li><a href="#CHAPTER_I">CHAPTER I.</a>        <span class="ralign"><a href="#Page_1">1</a></span>
+    <p>Mortality of children and its causes&mdash;Causes fourfold:
+    Intermarriage&mdash;Hereditary taint&mdash;Unhealthy dwellings&mdash;Unwholesome
+    food</p></li>
+
+<li><a href="#CHAPTER_II">CHAPTER II.</a>        <span class="ralign"><a href="#Page_5">5</a></span>
+    <p>General signs of disease&mdash;Shown by the cry, the temperature, the
+    pulse and breathing&mdash;Rules for examination as to these points&mdash;Signs
+    of absence of disease of the brain</p></li>
+
+<li><a href="#CHAPTER_III">CHAPTER III.</a>        <span class="ralign"><a href="#Page_12">12</a></span>
+    <p>General management of disease&mdash;Mothers who cannot nurse their
+    children when ill&mdash;Importance of truth and keeping child
+    happy&mdash;Rules for management of bed-room and bed&mdash;The
+    bath&mdash;Poultices&mdash;Leeches&mdash;Cold applications&mdash;Medicines&mdash;Note-taking
+    and relation to the doctor</p></li>
+
+<li><a href="#PART_II"><i>PART II.</i></a>
+    <p><span class="smcap">Plan proposed to be followed</span>        <span class="ralign"><a href="#Page_31">31</a></span></p></li>
+
+<li><a href="#CHAPTER_IV">CHAPTER IV.</a>        <span class="ralign"><a href="#Page_32">32</a></span>
+    <p>On the disorders and diseases of children during the first month
+    after birth&mdash;Still-birth&mdash;Premature birth&mdash;Imperfect expansion of
+    lungs&mdash;Jaundice&mdash;Ophthalmia&mdash;Scalp-swellings&mdash;Ruptured navel</p></li>
+
+<li><a href="#CHAPTER_V">CHAPTER V.</a>        <span class="ralign"><a href="#Page_45">45</a></span>
+    <p>Disorders and diseases of children after the first month, and until
+    teething is finished&mdash;Infantile atrophy&mdash;Rules for artificial
+    feeding&mdash;Management of indigestion&mdash;Thrush&mdash;Teething&mdash;Affections of
+    the skin&mdash;Eczema</p></li>
+
+
+<li><a href="#PART_III"><i>PART III.</i></a>
+    <p><span class="smcap">Disorders and Diseases incident to all Periods of Childhood</span>        <span class="ralign"><a href="#Page_85">85</a></span></p>
+    <p><span class="smcap">General Characteristics of Second Period of Childhood</span>        <span class="ralign"><a href="#Page_85">85</a></span></p></li>
+
+<li><a href="#CHAPTER_VI">CHAPTER VI.</a>        <span class="ralign"><a href="#Page_88">88</a></span>
+    <p>Disorders and diseases of the brain and nervous system&mdash;Their
+    mortality and its causes&mdash;Convulsions&mdash;Congestion of the
+    brain&mdash;Sunstroke&mdash;Water on the brain&mdash;Inflammation from disease of
+    the ear&mdash;Chronic water on brain&mdash;Brain disorder from
+    exhaustion&mdash;Spasmodic croup&mdash;Epilepsy&mdash;St. Vitus's
+    Dance&mdash;Palsy&mdash;Neuralgia and headache&mdash;Night terrors</p></li>
+
+<li><a href="#CHAPTER_VII">CHAPTER VII.</a>        <span class="ralign"><a href="#Page_128">128</a></span>
+    <p>Disorders and diseases of the chest&mdash;Catarrh and
+    snuffles&mdash;Bronchitis and
+    pneumonia&mdash;Influenza&mdash;Pleurisy&mdash;Croup&mdash;Diphtheria&mdash;Hooping-cough&mdash;Asthma&mdash;Diseases
+    of the heart</p></li>
+
+<li><a href="#CHAPTER_VIII">CHAPTER VIII.</a>        <span class="ralign"><a href="#Page_151">151</a></span>
+    <p>Diseases of organs of digestion&mdash;Description of process of
+    digestion&mdash;Dyspepsia of weakly
+    children&mdash;Jaundice&mdash;Diarrh&oelig;a&mdash;Peritonitis&mdash;Large
+    abdomen&mdash;Worms&mdash;Ulcerated mouth&mdash;Quinsy&mdash;Enlarged tonsils&mdash;Abscess
+    at back of throat&mdash;Diseases of kidneys&mdash;Incontinence of urine</p></li>
+
+<li><a href="#CHAPTER_IX">CHAPTER IX.</a>        <span class="ralign"><a href="#Page_173">173</a></span>
+    <p>Constitutional diseases&mdash;Their nature&mdash;Chronic constitutional
+    diseases&mdash;Consumption&mdash;Scrofula&mdash;Rickets&mdash;Acute constitutional
+    diseases&mdash;Rheumatic fever&mdash;Ague&mdash;Mumps&mdash;Typhoid
+    fever&mdash;Small-pox&mdash;Inoculation and vaccination&mdash;Chicken-pox&mdash;Measles</p></li>
+
+
+<li><a href="#APPENDIX">APPENDIX.</a>        <span class="ralign"><a href="#Page_213">213</a></span>
+    <p>Mental and moral faculties in childhood, and the disorders to which
+    they are liable</p></li>
+
+<li><a href="#INDEX">INDEX</a>        <span class="ralign"><a href="#Page_231">231</a></span>
+</li>
+</ul>
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_1" id="Page_1">[Pg 1]</a></span></p>
+<h2><a name="THE_MOTHERS_MANUAL" id="THE_MOTHERS_MANUAL"></a>THE MOTHER'S MANUAL<br />
+OF<br />
+CHILDREN'S DISEASES.</h2>
+
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="PART_I" id="PART_I"></a>PART I.</h2>
+
+<h3><i>INTRODUCTORY.</i></h3>
+
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="CHAPTER_I" id="CHAPTER_I"></a>CHAPTER I.</h2>
+
+<h3>ON THE MORTALITY OF CHILDREN, AND ITS CAUSES.</h3>
+
+
+<p>The purpose of this little book will probably be best attained,
+and needless repetition best avoided, if we begin by inquiring
+very briefly why so many children die, what general signs
+indicate that they are ill, and what general rules can be laid
+down for their management in sickness.</p>
+
+<p>The first of these inquiries would be as useless as it would
+be sad, if the rate of infant mortality were fixed by determinate
+laws, such as those which limit the stature of man or the age
+to which he can attain.</p>
+
+<p>But this is not so; the mortality in early life varies widely
+in different countries, in different parts of the same country,
+and in the same country at different times. Thus, while in
+some parts of Germany the 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 10 per cent. in
+Norway. Infantile mortality is higher in manufacturing districts,
+lower in those which are agricultural, and varies from
+16 per cent. in Lancashire to 9 in Dorsetshire. It is then
+<span class='pagenum'><a name="Page_2" id="Page_2">[Pg 2]</a></span>evident that mortality in infancy is in part dependent on
+remediable causes; and of this there is no better proof than
+the fact that the mortality in England under one year has been
+reduced from 15 per cent. in 1872 to 13 per cent. in 1882.</p>
+
+<p>It would lead us far from any practical purpose if we were
+to examine into all the causes which govern the liability to
+disease and death during infancy and childhood, in the different
+ranks of society. We must therefore limit our inquiry to those
+conditions which are met with in the class to which my readers
+may fairly be assumed to belong.</p>
+
+<p><i>First</i> among the causes of sickly infancy and premature
+death may be mentioned the intermarriage of near relatives.
+The experience of the breeders 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 whose qualities in these
+respects are pre-eminent, and eliminate from them all who do
+not occupy the first rank. In family intermarriages, however,
+it is rare that any consideration is regarded, save that of wealth;
+and the fact remains, explain it as we may, that the intermarriage
+of near relatives during several successive generations
+is followed by a marked deterioration of the children, physical,
+mental, and moral; and by the intensifying of any hereditary
+predisposition to consumption, scrofula, and other constitutional
+ailments which form the <i>second</i> great cause of early sickness
+and mortality.</p>
+
+<p>These are facts known to all, which yet it is not easy to
+represent by figures. All the world is aware that consumption
+is hereditary, that consumptive parents are more likely than
+others to have consumptive children; and a fourth of all the
+patients admitted into the Hospital for Consumption at
+Brompton stated that the disease had existed in one or other
+of their parents.<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a> Scrofula, which is another disease closely
+<span class='pagenum'><a name="Page_3" id="Page_3">[Pg 3]</a></span>allied to consumption, is hereditary also; and hip disease,
+disease of the spine, abscesses, and enlarged glands in any
+members of a family, point to risks for the offspring which
+should not be forgotten, how much soever mental endowments,
+personal beauty, or the charms of disposition may be
+considered, and sometimes reasonably enough, to outweigh
+them. The same liability exists with reference to epilepsy, insanity,
+and the whole class of affections of the nervous system.
+Parents inquire, with no misplaced solicitude, what is her
+fortune, or what are the pecuniary resources of him to whom
+they are asked to entrust their son's or daughter's future.
+Believe me, the question&mdash;what is the health of his family, or
+of hers? is consumption hereditary, or scrofula, or epilepsy, or
+insanity?&mdash;is of far greater moment, and touches much more
+nearly the future happiness of those we love.</p>
+
+<p>These two points regard the future parents themselves;
+but there are other conditions on which the health of children
+to a great degree depends; and of these the two most important
+are the <i>dwelling</i> they inhabit, and the <i>food</i> they eat.</p>
+
+<p>I do not refer here to the dwellings of the poor, situated in
+unhealthy localities, where fresh air does not enter, where the
+rays of the sun do not penetrate, with defective drainage and
+imperfect water-supply; but I speak of the nurseries of well-to-do
+people. 'This will do for our bedroom, and that will
+make a nice spare room, and that will do for the children,' is
+what one often hears. Had you rare plants which cost much
+money to obtain, which needed sunlight, warmth, and air,
+would you not consider anxiously the position of your conservatory,
+and take much pains to insure that nothing should
+be wanting that could help their development, so that you
+might feast your eyes upon their beauty, or delight yourselves
+with their fragrance? And yet a room at the top of the
+house, one of the attics perhaps, is too often destined for the
+little one and its nurse; or if there are two or three children,
+one small room is set apart for the day nursery, and a second,
+probably with a different aspect, for a sleeping room, and so
+small that it does not furnish the needed five hundred cubic
+<span class='pagenum'><a name="Page_4" id="Page_4">[Pg 4]</a></span>feet of air for each. And as a consequence, the children are
+ailing, any predisposition in them to hereditary disease is
+fostered, they have no strength to battle against any acute
+illness that may befall them, and yet surprise is felt that the
+doctor is never out of the house.<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a></p>
+
+<p>It is needless to dwell on the hand-feeding of infants as one
+of the great causes of mortality in infancy, and of sickliness
+in later life. The statistics of Foundling Hospitals bear sad
+testimony to the fact of its dangers, and the researches of
+physicians show that a peculiar form of disease is produced by
+it, attended by symptoms, and giving rise to appearances after
+death, peculiar to the form of slow starvation from which the
+infant has perished. I will add, because it is not generally
+known, one fresh illustration of the influence of artificial feeding
+in aggravating the mortality of infants. In Berlin the certificates
+of death of all infants under the age of one year, are required
+to state whether the little one had been brought up at
+the breast, or on some kind or other of artificial food. Of ten
+thousand children dying under the age of one year, one-fourth
+had been brought up at the breast, three-fourths by hand.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a></p>
+
+<p>It is, as I said in the preface, no part of my plan to enter
+on any details with reference to the management of children
+in health. It may, therefore, suffice to have pointed out the
+four great causes of preventible disease among the wealthier
+classes of society; namely, the intermarriage of near relatives,
+the transmission of constitutional taint, the insanitary condition
+of the dwelling, and the injudicious selection of the food of the
+infant.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1" href="#FNanchor_1_1"><span class="label">[1]</span></a> This is the proportion stated in Quain's <i>Dictionary of Medicine</i>, to
+which the writer, Dr. Theodore Williams, adds that of 1,000 cases in the
+upper classes 12 per cent. showed direct hereditary predisposition, and 48
+per cent. family predisposition.</p></div>
+
+<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2" href="#FNanchor_2_2"><span class="label">[2]</span></a> Many useful suggestions will be found in Mrs. Gladstone's little tract,
+<i>Healthy Nurseries and Bedrooms</i>, published as one of the Health Exhibition
+Handbooks.</p></div>
+
+<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3" href="#FNanchor_3_3"><span class="label">[3]</span></a> The actual numbers are 2,628 and 7,646. See <i>Generalbericht ueber
+das Medizinal-und Sanit&auml;tswesen der Stadt Berlin im Jahre 1881</i>.
+8vo. Berlin 1883, p. 19.</p></div>
+</div>
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_5" id="Page_5">[Pg 5]</a></span></p>
+<h2><a name="CHAPTER_II" id="CHAPTER_II"></a>CHAPTER II.</h2>
+
+<h3>THE GENERAL SIGNS OF DISEASE IN INFANCY AND
+CHILDHOOD.</h3>
+
+
+<p>The signs of disease at all ages may be referred to one or
+other of three great classes: disorder of function, alteration of
+temperature, complaint of pain.</p>
+
+<p>In the infant it is the last of these which very often calls
+attention to the illness from which it is suffering. Cries are the
+only language which a young baby has to express its distress;
+as smiles and laughter and 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 of sick children, will
+gather from them more, and will be able to judge whether its
+suffering is in the head, or chest, or stomach. The cries of a
+baby with stomach-ache are long and loud and passionate; it
+sheds a profusion 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 a quiet sleep. If it has inflammation
+of the chest it does not cry aloud, it sheds no tears, but every
+few minutes, especially after drawing a deeper breath than
+before, or after each short hacking cough, it gives a little cry,
+which it checks apparently before it is half finished; and this,
+either because it has no breath to waste in cries, or because the
+effort makes its breathing more painful. If disease is going
+on in the head, the child utters sharp piercing shrieks, and
+then between whiles a low moan or wail, or perhaps no sound
+at all, but lies quiet, apparently dozing, till pain wakes it up
+again.</p>
+
+<p><span class='pagenum'><a name="Page_6" id="Page_6">[Pg 6]</a></span>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, but the mention of this serves merely as an illustration,
+which anyone can understand, of the different meanings that
+even a baby's cry will convey to different persons.</p>
+
+<p>When a child is taken ill, be the disease from which it is
+about to suffer what it may, there is at once a change from its
+condition when in health, such as soon attracts the attention
+even of the least observant. The child loses its appetite, is
+fretful and soon tired, and either very sleepy or very restless,
+while most likely it is thirsty, and its skin hotter than natural.
+In many instances, too, it feels sick or actually vomits, while its
+bowels are either much purged or very bound. If old enough to
+talk, it generally complains of feeling ill, or says that it has pain
+in some part or other, though it is by no means certain that a
+little child has described rightly the seat of its pain; for it very
+often says that its head aches or that its stomach aches, just
+because it has heard people when ill complain of pain in the head
+or in the stomach. Some of these signs of illness are, of course,
+absent in the infant, who can describe its feelings even by signs
+imperfectly; but the baby loses its merry laugh and its cheerful
+look; it ceases to watch its mother's or its nurse's eye as it
+was used to do, though it clings to her more closely than ever,
+and will not be out of her arms even for a moment; and if at
+length rocked to sleep in her lap, will yet wake up and cry
+immediately on being placed in its cot again.</p>
+
+<p>Symptoms such as these are sure to awaken the mother's
+attention to her child, 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 the question, 'What is the matter?'</p>
+
+<p>Some mothers send at once to the doctor whenever they
+see or fancy that anything ails their child. But this way of
+getting rid of responsibility is not always possible, nor, indeed,
+on moral grounds, is it always desirable, for the mother who
+delegates each unpleasant duty to another, whether nurse,
+governess, or doctor, in order to save herself trouble or anxiety,
+<span class='pagenum'><a name="Page_7" id="Page_7">[Pg 7]</a></span>performs but half a mother's part, and can expect but half a
+mother's recompense of love.</p>
+
+<p>Whenever a child is unwell, a mother may do much to
+ascertain what is the matter, and may by the exercise of a little
+patience and common sense save herself much needless heart-ache,
+and her child much suffering.</p>
+
+<p>The first point to ascertain is the presence or absence of
+fever; that is to say, whether, and how much, the temperature
+of the body is higher than natural. If the temperature is not
+higher than natural, it may be taken as almost certain that the
+child neither has any inflammatory affection of the chest, nor is
+about to suffer from any of the eruptive fevers. The temperature,
+however, cannot be judged of merely by the sensation
+conveyed to the hand, but must be ascertained by means of the
+thermometer.<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> In the case of the grown person the thermometer
+is placed either under the tongue, the lips being closed
+over it, or in the armpit, and is kept there five or six minutes.
+In young children, however, neither of these is practicable, and
+I prefer to place the instrument in the groin, and crossing one
+leg over the other, to maintain the thermometer there for the
+requisite five minutes. The temperature of the body in health
+is about 98.5&deg; Fahr. in the grown person, and very slightly
+higher in childhood; but any heat above 99.5&deg; may be regarded
+as evidence that something is wrong, and the persistence
+for more than twenty-four hours of a temperature of 101&deg; and
+upwards, may be taken as almost conclusive proof of the
+existence of some serious inflammation, or of the onset of one
+of the eruptive fevers.</p>
+
+<p>At the same time it is well to bear in mind that temporary
+causes, such as especially the disorders produced by over-fatigue,
+or by an over-hearty or indigestible meal, may suddenly
+raise the temperature as high as 102&deg;, or higher, but the
+needed repose or the action of a purgative may be followed
+<span class='pagenum'><a name="Page_8" id="Page_8">[Pg 8]</a></span>in a few hours by an almost equally sudden decline of the heat
+to the natural standard.</p>
+
+<p>It is well to learn to count the pulse and the frequency of
+the breathing; but to do the former accurately, requires
+practice such as is hardly gained except by hospital training;
+and indeed, with few exceptions, the value of the information
+furnished by the pulse is less in the child than in the adult.
+The reasons for this are obvious, since the rapidity of the
+circulation varies under the slightest causes, and the 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
+twenty in the minute. The place at which to seek the beat
+of the pulse is at the wrist, just inside and below the protuberance
+of the wrist-bone; but if the child is very fat it is
+often difficult to detect it. When detected it is not easy to
+count it in early infancy, for during the first year of life the
+heart beats between 120 and 130 in the minute, diminishing
+between that age and five years to 100, and gradually sinking
+to 90 at twelve years old. In proportion, moreover, to the
+tender age of the child, is the rapidity of its circulation apt to
+vary under the influence of slight causes, while both its frequency
+and that of the breathing are about a third less during
+sleep than in the waking state.</p>
+
+<p>The frequency of the breathing is less difficult to ascertain,
+while at the same time it furnishes more reliable information
+than the pulse. This is best tested when the child is asleep,
+remembering always that the 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-dress on the lower
+part of the chest and the pit of the stomach. Each heaving of
+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 two years the child breathes from 30 to 40
+times in a minute, and this frequency 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 would thus know that
+a sleeping infant who was breathing more than 30 times, or a
+<span class='pagenum'><a name="Page_9" id="Page_9">[Pg 9]</a></span>child of five who breathes more than 25 times, has some ailment
+in its chest, and that the doctor should be sent for in
+order to ascertain its exact nature.</p>
+
+<p>It would answer no good purpose to give a description of
+the information to be obtained by listening to the chest. To
+learn from this, needs the well-trained ear; and harm, not
+good, comes from the half-knowledge which serves but to lead
+astray.</p>
+
+<p>A child may be very suffering, seem very ill, and its suffering
+and illness may depend on pain in the stomach owing to
+indigestion, constipation, or even to an accidental chill. After
+early infancy it is not difficult to make out the seat of the
+child's suffering: the warm hand placed gently on its stomach
+will soon ascertain whether it is tense or tender, whether the
+tenderness is confined to one particular spot, 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 the
+intestines, the pain and tenderness are both relieved by gentle
+rubbing.</p>
+
+<p>In the young infant the character of the cry will, as I have
+already said, give some clue to the seat of its pain, while, if
+you lay it down in its cot or in its nurse's arms in order to
+examine its stomach, it will often resist and begin to cry. Its
+stomach then becomes perfectly tense, and you cannot tell
+whether pressure on it causes pain or whether the cries are
+not altogether the consequence of fretfulness and fear. It is
+therefore the best plan to pass your hand beneath the child's
+clothes and to examine its stomach without altering its posture,
+while at the same time the nurse in whose arms it is talks to it
+to distract its attention, or holds it opposite the window, or
+opposite a bright light, which seldom fails to amuse an infant.
+If there is no tenderness of the stomach the child will not cry
+on pressure; or if during your examination the presence of
+wind in the intestines should occasion pain, gentle friction,
+instead of increasing suffering, will give relief.</p>
+
+<p>The one thing which still remains to do, especially in the
+case of children in whom teething is not over, is to examine
+<span class='pagenum'><a name="Page_10" id="Page_10">[Pg 10]</a></span>the mouth and ascertain the state of the gums, since some
+ailments are caused and others are aggravated by teething.
+A wise mother or an intelligent nurse will teach the child when
+well the little trick of putting out its tongue and opening its
+mouth to show its teeth when told to do so; and though it
+may sometimes indulge rather out of place in these performances
+when wished to behave especially prettily before
+strangers, yet when older it will quickly learn the proprieties
+of behaviour, and in the meanwhile you profit much by the
+lesson when illness really comes.</p>
+
+<p>Sometimes, however, infants who when well will open their
+mouth and allow their gums to be felt without difficulty, refuse
+to do so when ill; and it is always desirable that the mother
+or nurse whose duty it is to tend the sick child constantly,
+should not frighten it, or lose its confidence, by doing forcibly
+that which the doctor who comes occasionally may yet be
+quite right in doing. You will, however, generally get a good
+view of the mouth and throat in young infants by gently
+touching the lips with your finger: the child opens its mouth
+instinctively, and then you can run your finger quickly over its
+tongue, and drawing it slightly forward perfectly see the condition
+of the throat, feel the gums as you withdraw your finger,
+and notice the appearance of the tongue. Sometimes it is
+important to ascertain whether a tooth which was near coming
+through has actually pierced the gum, and yet the child's
+fretfulness renders it almost impossible to induce it to open
+its mouth. If now, while the nurse holds the child in her
+arms, you go behind her, you can, unseen and unawares,
+introduce your finger into its mouth and ascertain all you wish
+to know before the little one has recovered from its surprise.</p>
+
+<p>I have but little to say here about the general signs of
+brain disease in infancy and childhood, because they will need
+minute notice afterwards. All that I would at present observe
+is, that you must not at once conclude that a child's head is
+seriously affected, because it is heavy and fretful and passionate,
+and refuses to be amused. The head, as we know by our own
+experience, suffers by sympathy in the course of almost every
+<span class='pagenum'><a name="Page_11" id="Page_11">[Pg 11]</a></span>ailment, certainly of every acute ailment, at all ages. If the
+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 it may prefer a darkened room, it does not shrink
+from the light when admitted gradually; if it has no slight
+twitchings of its fingers or of its wrists; if the head, though hot,
+is not hotter than the rest of the body; if the large vessels of
+the neck, or the open part of the head, or fontanelle as it is
+termed, in an infant in whom the head is not yet closed, are
+not beating violently; and, above all, <i>if when it cries it sheds
+tears</i>, 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 the nurse or the friend who assures you that the child
+is about to have convulsions or to be attacked by inflammation
+of the brain.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4" href="#FNanchor_4_4"><span class="label">[4]</span></a> The thermometer used for this purpose, called a <i>clinical</i> thermometer,
+may be bought for about twelve shillings, of any chemist or instrument-maker,
+and its mode of employment can be learned in five minutes. No
+mother should be without it.</p></div>
+</div>
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_12" id="Page_12">[Pg 12]</a></span></p>
+<h2><a name="CHAPTER_III" id="CHAPTER_III"></a>CHAPTER III.</h2>
+
+<h3>THE GENERAL MANAGEMENT OF DISEASE IN INFANCY
+AND CHILDHOOD.</h3>
+
+
+<p>The management of the child when ill is difficult or easy in
+exact proportion to whether it has been ill or well managed
+when in health. The mother who lives but little with her
+children, who contents herself with a daily visit to the nursery,
+and who then scarcely sees her little ones until they are brought
+into the drawing-room in the evening in full dress, to be petted
+and admired and fondled by the visitors, cannot expect to take
+her place by the child's bed in its sickness, to soothe its pain,
+and to expend upon it all the pent-up tenderness which, in
+spite of the calls of business or of pleasure, still dwells within
+her heart. She must be content to see the infant turn from
+her to the nurse with whose face it has all its life been
+familiar; or to hear the little one tell her to go away, for her
+presence is associated with none of those 'familiar acts, made
+beautiful by love,' which win the young heart: the mother is
+but a stranger who brings no help, who relieves no distress.
+Happy such a mother if she has found a conscientious and intelligent
+nurse to whom she can delegate her office; but she
+must remember that with the child, love follows in the steps of
+daily, hourly kindnesses, that a mother's part must be played
+in health if it is to be undertaken in sickness, that it cannot
+be laid down and taken up again at pleasure.</p>
+
+<p>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 yielded to each wayward wish, and has
+<span class='pagenum'><a name="Page_13" id="Page_13">[Pg 13]</a></span>allowed it to become the petty tyrant of the 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 accustomed
+to have its will obeyed in everything, and cannot understand
+that its suffering is not at once taken away. It insists on
+getting up and on being dressed, or on lying in its mother's or
+nurse's lap, where the warmth of another person's body does
+but aggravate its fever; it screams with passion at the approach
+of the doctor, it will not allow itself to be examined, it will
+take no medicine; the doctor is powerless, the mother heart-broken.
+Sickness is not the time to exercise authority which
+has not been put in force before; and, not once but many
+times, I have watched, a sad spectator, the death of children
+from an illness not necessarily fatal, but rendered so because it
+was impossible to learn the progress of disease, impossible to
+administer the necessary remedies.</p>
+
+
+<p class="center"><i>What a child has been made when well, such it will be
+when sick.</i></p>
+
+<p>One more point I must insist on before going into details,
+and that is as to the necessity of perfect truthfulness in dealing
+with sick children. The foolish device of telling a child when
+ill, that the doctor who has been sent for is its uncle or its
+cousin, is the outcome of the still more foolish falsehood of
+threatening the child with the doctor's visit if it does not do
+this or that. No endeavour should be spared by nurse or
+parent, or by the doctor himself, to render his visit popular in
+the nursery. Three-fourths of the difficulties which attend the
+administration of medicine are commonly the result of previous
+bad management of the child, of foolish over-indulgence, or of
+still more foolish want of truthfulness. It may answer once to
+tell a child that medicine is nice when really it is nasty, but
+the trick will scarcely succeed a second time, and the one
+success will increase your difficulties ever after. If medicine is
+<span class='pagenum'><a name="Page_14" id="Page_14">[Pg 14]</a></span>absolutely necessary, and the child is too young to understand
+reason, it must be given by force, very firmly but very kindly,
+and the grief it occasions will be forgotten in an hour or two.
+If he is old enough, tell him that the medicine is ordered to do
+him good, and firmness combined with gentleness will usually
+succeed in inducing him to take it. The advantage of perfect
+truthfulness extends to every incident in the illness of children,
+even to the not saying, 'Oh, you will soon be well,' if it is not
+likely so to be. If children find you never deceive them, how
+implicitly they will <i>trust</i> you, what an infinity of trouble is
+saved, and how much rest of mind is secured to the poor little
+sufferer!</p>
+
+<p>A little boy three years old was ordered to be cupped. The
+cupper, a kind old man, said to encourage him, 'Oh, dear little
+boy, it's nothing.' 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 try to bear it well. And the
+operation was performed without a cry or a sound.</p>
+
+<p>I have spoken of the moral conditions implied in the
+successful management of sick children. There are certain
+physical conditions no less 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 its other little inmates.
+He must (and of course I am speaking not of some slight
+ailment, but of a more serious indisposition) be in a room
+by himself, which should be kept quiet and shaded, and
+at a temperature which should not be allowed to fall below
+60&deg; if the chest is in any way affected, nor to exceed 55&deg; in
+other cases, and this temperature should always be measured,
+not by guess, but by the thermometer hung close to the
+child's bed. The room is to be shaded, not by curtains
+round the bed&mdash;for, save in special circumstances, curtains
+should be banished from the nursery&mdash;nor by closed shutters
+which exclude both light and air, but by letting down the
+blinds, so as to have a sort of twilight in the room, and by
+shading any light which at night may be burned in the apartment;
+while whether by day or night the child should be so
+<span class='pagenum'><a name="Page_15" id="Page_15">[Pg 15]</a></span>placed that his face shall be turned from the light, not directed
+towards it. The room should be kept quiet, and this requires
+not only general quiet in 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; walking carefully, 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 more than the loudest
+noise.</p>
+
+<p>Little precautions, so trifling that few think of noticing
+them, have much to do with the quiet of the sick-room, and
+consequently with the patient'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 anyone enters the room; and
+to put a wedge in the window, or to tie back the handle, and
+so quietly open and close the door, may do more than medicine
+towards promoting the child's recovery. There can, however,
+be no abiding quiet without a well-ordered room, and the old
+proverb carried out, 'A place for everything, and everything in
+its place.' A table covered with a cloth so that things may
+be taken up and put down noiselessly, and set apart for the
+medicine, the drink, the nourishment, cups, glasses, spoons, or
+whatever else the patient is in frequent need of; with a <i>wooden</i>
+bowl and water for rinsing cups and glasses in, and a cloth or
+two for wiping them, will save much trouble and noise, and the
+loud whispers of the attendants to each other, 'Where is the
+sugar? where is the arrowroot? where did you put down the
+medicine?' of which we hear so much in the sick-room, so
+much especially in the sick-room of the child, who is unable to
+tell how extremely all this disturbs him.</p>
+
+<p>One more caution still remains for me to give. Do not
+talk to the doctor in the child's room, do not relate bad
+symptoms, do not express your fears, nor ask the doctor his
+opinion in the child's hearing. The child often understands
+much more than you would imagine, misunderstands still more;
+and over and over again I have known the thoughtless utterance
+of the mother, nurse, or doctor depress a child's spirits
+and seriously retard his recovery.</p>
+
+<p><span class='pagenum'><a name="Page_16" id="Page_16">[Pg 16]</a></span>It is consoling to bear in mind that how grave soever a
+child's illness may 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 the child than it would be from the
+same disease in the grown person. This too is due not simply
+to the activity of the reparative powers in early life, but also in
+great measure to the mental and moral characteristics of childhood.</p>
+
+<p>To make the sick child happy, in order that he may get
+well, is the unwritten lesson which they who have best learnt,
+know best how to nurse sick children. It may seem strange,
+that from so high a purpose I should at once come down to
+so commonplace a detail as to insist on the importance, even
+on this account, of keeping the sick child in bed.</p>
+
+<p>At the onset of every illness of which the nature is not
+obvious, during the course of any illness in which the chest
+is affected, or in which the temperature is higher than natural,
+bed is the best and happiest place for the child. In it repose
+is most complete, far more complete than after early babyhood
+it can be in the nurse's or mother's lap, and free from the great
+objection of the increased heat from being in contact with
+another person's body. Nothing is more painful than to
+witness the little child, sick and feverish, with heavy eyes, and
+aching head, up and dressed, trying to amuse itself with its
+customary toys; then, with 'Please nurse me,' begging to be
+taken in the lap, then getting down again; fretful, and sad,
+and passionate by turns; dragging about its misery, wearing
+out its little strength, in deference to the prejudice that bed is
+so weakening.</p>
+
+
+<p class="center"><i>The bed does not weaken, but the disease does which renders
+bed necessary.</i></p>
+
+<p>A child frets sometimes at the commencement of an illness
+if kept in its own little cot. But put it in its nurse's or
+mother's big bed, set a tea tray with some new toys upon it
+before the child, and a pillow behind it, so that when tired with
+<span class='pagenum'><a name="Page_17" id="Page_17">[Pg 17]</a></span>play it may lie back and go to sleep, and you will have husbanded
+its strength and saved your own, have halved your
+anxiety and doubled the child's happiness.</p>
+
+<p>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 laying the baby on a bed, the nurse or mother
+lying down by its side, and soothing it to sleep. Were there
+no other drawback, it is a waste of power to have two persons
+employed in nursing a sick child; one to keep it in her lap,
+and the other to wait upon her.</p>
+
+<p>It is important in all serious illnesses of children, as well as
+of a grown person, that the bed should be so placed that the
+attendant can pass on either side, and can from either side
+reach the patient to do whatever is necessary. Most cots for
+young children have a rail round them to prevent the child
+falling out of bed when asleep or at play; but nothing can be
+more inconvenient than the fixed rail over which the attendant
+has to bend in order to give the child food or medicine, or for
+any other purpose. When I founded the Children's Hospital
+in Ormond Street, I introduced children's cots (the idea of
+which I took from those in the Children's Hospital at Frankfort)
+the sides of which let down when needed, while on the
+top of the rail, or dependent from it, a board is placed surrounded
+by a raised beading on which the toys, the food, or
+drink may be put with great convenience. These bedsteads,
+with probably some improved arrangement for letting down the
+sides, may be seen now in most children's hospitals, but I have
+been surprised to observe how seldom they are employed in
+private nurseries, and how comparatively few bedstead-makers
+are acquainted with them. The result would probably have
+been very different had a patent been taken out for them, and
+had they been largely advertised as 'Dr. West's improved
+children's bedsteads'! The uninclosed spring mattress, and
+the wedge-shaped horsehair cushion, both of which I introduced
+in Ormond Street, are also very valuable. The latter slightly
+raises the head and shoulders, and renders any other than a
+thin horsehair pillow for the head to rest on unnecessary.</p>
+
+<p><span class='pagenum'><a name="Page_18" id="Page_18">[Pg 18]</a></span>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 for some very special reason the napkin should
+be done away with. It heats the child, chafes it, and makes it
+sore; it conceals the inattention of the nurse, and at the same
+time renders it less easy to keep the little one 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 a
+piece of macintosh should be placed under the sheet, as is
+done in the lying-in room, and a draw-sheet, as it is termed,
+over it. The draw-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 lying on linen that is wet or soiled.
+It can be drawn away from under the child, and a portion still
+clean and dry brought under it, while the soiled part is rolled
+together and wrapped up in macintosh at one side of the bed
+until a new draw sheet is substituted, which is easily done by
+tacking a fresh sheet to that which is about to be withdrawn,
+when the fresh one is brought under the child's body as that
+which is soiled is removed. The greatest care should always
+be taken that the under sheet is perfectly free from ruck or
+wrinkle; in long illnesses the skin becomes chafed and bed-sores
+may be produced by neglect of this simple precaution.
+The complaint that a child throws off the bed-clothes is easily
+remedied by a couple of bits of tape tied on either side loosely
+from the sheet or blanket to the sides of the cot.</p>
+
+<p>When children are compelled to remain long in bed, great
+care is needed to prevent the skin from being chafed, which is
+the first step that leads to the occurrence of bed-sores. Careful
+washing with soap and water daily of the whole body, not only
+of those parts which may be soiled by the urine or the evacuations;
+the washing afterwards with pure tepid water; careful
+drying, and abundant powdering with starch powder, will do
+much to prevent the accident. If, in spite of this care, the
+skin seems anywhere to be red or chafed, it should be sponged
+over with brandy or with sweet spirits of nitre before powdering.
+Real bed-sores must be seen and treated by the doctor.</p>
+
+<p><span class='pagenum'><a name="Page_19" id="Page_19">[Pg 19]</a></span>The warm bath is a great source of comfort to the sick
+child, and in all cases of feverishness, of influenza, or threatening
+bronchitis, it should not be omitted before the child is put
+to bed, or must be given towards evening if the child has not
+been up during the day. The bath may be either warm or hot,
+the temperature of the former being 90&deg; to 92&deg;, that of the latter
+95&deg; to 96&deg;. The temperature should always be ascertained by
+the thermometer, and the <i>warm</i> bath only should be employed,
+except when the <i>hot</i> bath is ordered by the doctor. The warm
+bath relieves feverishness and quiets the system, and promotes
+gentle perspiration; the hot bath is given when the eruption
+of scarlet fever or of measles fails to come out properly, or in
+some cases of convulsions at the same time that cold is applied
+to the head, or, in some forms of dropsy when it is of importance
+to excite the action of the skin as much as possible. It
+is not desirable that a child should remain less than five or
+more than ten minutes in the bath, and attention must be paid
+by the addition of warm water to maintain the bath at the same
+temperature during the whole time of the child's immersion.</p>
+
+<p>Now and then infants and very young children when ill
+seem frightened at the bath, and then instead of being soothed
+and relieved by it they are 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, he very often becomes
+greatly alarmed, struggles violently, cries passionately, and
+does not become quiet again till he has sobbed himself to
+sleep. All this time, however, he has been exerting his inflamed
+lungs to the utmost, and will probably have thereby
+done himself ten times more harm than the bath has done
+good. Very different would it have been if the bath had been
+got ready out of the child's sight; if when brought to the bedside
+it had been covered with a blanket so as to hide the steam;
+if the child had been laid upon the blanket, and gently let
+down into the water, and this even without undressing him if
+he were very fearful; and then if you wish to make a baby quite
+happy in the water, put in a couple of bungs or corks with
+<span class='pagenum'><a name="Page_20" id="Page_20">[Pg 20]</a></span>feathers stuck in them, for the baby to play with. Managed
+thus, I have often seen the much-dreaded bath become a real
+delight to the little one, and have found that if tears were shed
+at all, it was at being taken out of the water, not at being placed
+in it.</p>
+
+<p>In a great variety of conditions, poultices are of use. They
+are needed in the case of abscesses which it is wished to bring
+to a head; they are sometimes applied over wounds which are
+in an unhealthy condition, or from which it is desired to keep
+up a discharge. They soothe the pain of stomach-ache from
+any cause, and are of most essential service when constantly
+applied in many forms of chest inflammation. And yet not
+one mother or nurse in ten knows how to make a poultice.<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a>
+<span class='pagenum'><a name="Page_21" id="Page_21">[Pg 21]</a></span>When applied over a wound they should not be covered with
+oiled silk or any impermeable material, since the edges of the
+wound and the adjacent skin are apt thereby to be rendered irritable
+and to become covered with little itching pimples. When
+used to relieve pain in the stomach, or as a warm application
+in cases of inflammation of the chest, they should be covered
+with some impermeable material, and will then not require to
+be changed oftener than every six hours. After poultices have
+been applied over the chest or stomach for two or three days
+the skin is apt to become tender, and then it is well to substitute
+for them what may be termed a dry poultice, which is
+nothing else than a layer of dry cotton wool an inch or an
+inch and a half thick, tacked inside a piece of oiled silk.</p>
+
+<p>A handy substitute for a poultice may be made of bran
+stitched in a flannel bag, heated by pouring boiling water on
+it, then squeezed as dry as possible and laid over the painful
+part. This is especially useful to relieve the stomach-ache of
+infants and young children.</p>
+
+<p>Spongio-piline is a useful substitute for a poultice, especially
+when it is desirable to employ a soothing or stimulating liniment
+to the surface. It retains heat very well when wrung out of
+hot water, and any liniment sprinkled on it is brought into
+contact with the skin much better than if diffused through a
+poultice. I may just add that its edges should be sloped inwards,
+in order to prevent the moisture from it oozing out and
+wetting the child's night-dress.</p>
+
+<p>When I was young, leeches and bleeding were frequently,
+no doubt too frequently, employed. We have now, however,
+gone too much to the other extreme, for cases are met with
+from time to time of congestion of the brain, or of inflammation
+of the chest or of the bowels, in which leeches bring greater
+and more speedy relief than any other remedy. In applying
+leeches it is always desirable that they should be put on where
+they will be out of the child's sight if possible, and where it will
+be comparatively easy to stop the bleeding. Hence, in many
+instances of inflammation of the bowels, it is better to apply
+the leeches at the edge of the lower bowel, the anus as it is
+<span class='pagenum'><a name="Page_22" id="Page_22">[Pg 22]</a></span>technically termed, than on the front of the stomach, though,
+of course, this will not always answer the purpose. Leeches
+to the chest may usually be put on just under the shoulder-blade;
+and leeches to the head on one or other side behind
+the ear, where they will be out of the way of any large vein, and
+where the pressure of the finger will easily stop the bleeding.
+Steady pressure with 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 of adhesive plaster, will prevent any
+renewal of the bleeding. In the few cases where it is not
+arrested by these means, the application of a little of the solution
+of muriate of iron will hardly fail of effect.</p>
+
+<p>There is one more point to which I will refer before passing
+lastly to the question of how to manage in the administration
+of medicine; and this is the best way of applying cold to the
+head. This is often ordered, but very seldom efficiently done.
+Cold is best applied by means of a couple of bladders half-filled
+with pounded ice, and wrapped in two large napkins;
+one of them should be placed under the child's head, the
+corners of the napkin being pinned to the pillow-case to prevent
+its being disturbed, while the other is allowed to rest upon
+the head, but with the corners of the napkin again pinned
+to the pillow so as to take off the greater part of its weight.
+Thus arranged, the cold application will neither get displaced
+by the child's movements, nor will the child itself be wetted,
+as it too commonly is when wet cloths are employed for
+this purpose, nor irritated by their perpetual removal and
+renewal.</p>
+
+<p>In London and in large towns there are various contrivances
+of vulcanised rubber, which are, of course, far preferable to the
+bladders, but it is not everyone who lives in London, or who
+can command the resources furnished by a large city.</p>
+
+<p>The difficulties in the administration of medicine to
+children are in great part the fault, either of the doctor in
+giving needlessly unpleasant medicine, or of the parents or
+nurse who either have failed to teach the child obedience, or
+<span class='pagenum'><a name="Page_23" id="Page_23">[Pg 23]</a></span>who are deficient in that tact by which hundreds of small
+troubles are evaded.</p>
+
+<p>As far as the doctor is concerned, all medicines should be
+prescribed by him in small quantities, and as free from taste
+and smell as possible: or where that cannot be, the unpleasant
+flavour should be covered by syrup, or liquorice, or treacle.</p>
+
+<p>Bulky powders should be avoided, and the child who has
+learned to take rhubarb and magnesia, or Gregory's powder
+without resistance, certainly does credit to his training.</p>
+
+<p>Aperients are the medicines most frequently needed in the
+minor ailments of children, and a wise mother will not undertake
+herself the management of serious diseases. Of all
+aperients castor oil is perhaps the safest, the least irritating, the
+most generally applicable; it acts on the bowels and does nothing
+more. The idea that it tends specially to produce constipation
+afterwards is unfounded; it does not do so more than other
+aperients. All aperients quicken for a time what is termed the
+peristaltic action of the bowels; that is to say, their constant
+movement in a direction from the stomach to the lower bowel,
+which, as well as a contraction on themselves, is constantly
+going on in every living animal, and continues even for some
+time after death. The bowels stimulated to greater activity
+of movement by the aperient, become for a time more sluggish
+afterwards; they rest for a while, just as after a long walk the
+muscles of the leg are weary and need repose.</p>
+
+<p>There are indeed aperients which do more than this, as grey
+powder and calomel act upon the liver, and so by promoting
+an increased flow of bile cause a more permanent excitement
+of the bowels, and consequently their more prolonged activity;
+or as Epsom salts or citrate of magnesia, which by their action
+on the blood cause a greater secretion or pouring out of
+fluid from the coats of the intestines, and in this way have in
+addition to their purgative property a special influence in
+abating various feverish conditions.</p>
+
+<p>Castor oil, senna, jalap, jalapine, and scammony are simple
+aperients. They empty the bowels and nothing more, and in
+cases of simple constipation, or where a child is ill either from
+<span class='pagenum'><a name="Page_24" id="Page_24">[Pg 24]</a></span>eating too much or from taking indigestible food, are the best
+purgatives that can be given. A dose of castor oil, often one
+of the great griefs of the nursery, may generally be given without
+the least difficulty if previously shaken up in a bottle with
+a wine-glassful of hot milk sweetened and flavoured with a piece
+of cinnamon boiled in it, by which all taste of the oil is effectually
+concealed.</p>
+
+<p>The domestic remedy, senna tea with prunes which render
+it palatable, confection of senna, syrup of senna, and the sweet
+essence of senna are generally very readily taken by children,
+but all have the disadvantage of being liable to gripe. The
+German liquorice powder, as it is called, which is composed of
+powdered senna, liquorice powder, fennel, and a little sulphur
+with white sugar, is freer from this drawback than any other
+preparation, and when mixed with a little water is not generally
+objected to. It is important, as senna is often adulterated and
+loses its properties by exposure to the air, that this powder
+should always be obtained from a very good chemist, purchased
+in small quantities, and always kept in a glass-stoppered bottle.</p>
+
+<p>Jalap, in the form in which it is usually sold&mdash;as compound
+jalap powder&mdash;is in general readily taken; it acts speedily,
+but often with pain, and is not a desirable domestic remedy.
+Jalapine, which is a sort of extract of jalap, is much less apt to
+gripe, and owing to its small bulk is much handier. It may be
+given in doses of from two to five grains to children from two
+years old and upwards.</p>
+
+<p>Scammony is another powerful simple aperient, apt to be
+violent in its action, and therefore not to be given except
+when the bowels have long been confined, or when it is given
+to expel worms. The compound scammony powder is the
+form in which it is usually given, and of that five grains would
+be a dose for a child two years old.</p>
+
+<p>Scammony, however, is a costly drug, and therefore the
+caution given with reference to German liquorice powder applies
+here also.</p>
+
+<p>There is a preparation of scammony, the so-called scammony
+mixture, which consists of the resin or extract of
+<span class='pagenum'><a name="Page_25" id="Page_25">[Pg 25]</a></span>scammony dissolved in milk, which is extremely useful when
+the stomach is irritable, or there is much difficulty in inducing
+the child to take medicine. It is almost tasteless, and a tablespoonful,
+which would be a proper dose for a child of five
+years old, can be given without being detected.</p>
+
+<p>Much of the difficulty experienced in giving powders arises
+from their being mixed with the arrowroot or jam in which
+they are administered. A very small quantity of arrowroot,
+bread and milk, or jam, should be put in a tea-spoon; the
+powder then laid upon it, and covered over with the arrowroot
+or jelly, so, in short, as to make a kind of sandwich, with the
+powder, which would thus be untasted, in the middle.</p>
+
+<p>Aloes is a purgative which acts chiefly on the large bowel
+and to some degree also on the liver, and is of most use in the
+habitual constipation of weakly children. In spite of its bitter
+taste the powder is seldom objected to if given between two
+layers of coarse brown sugar, while with most children the
+addition of a teaspoonful of treacle will induce them to take
+very readily that useful medicine, the compound decoction of
+aloes.</p>
+
+<p>Both rhubarb, aloes, and indeed other remedies which are
+nauseous if given as a liquid and are bulky in the form of powder,
+may very readily be given in extract in the form of very tiny
+pills. Thus I have constantly ordered the extract of rhubarb,
+which is nearly twice as strong as the powder, made up into
+pills scarcely bigger than what children call 'hundreds and
+thousands' and silver-coated. Ten or a dozen of these go
+down in a teaspoonful of jelly unknown, and with no expenditure
+of temper or tears.</p>
+
+<p>The citrate of magnesia, or Dinneford's Magnesia, taken
+effervescing with lemon juice, or when the effervescence has
+passed off, or the French Limonade Purgative, are almost
+always very readily taken, and are often very useful in the
+little febrile attacks, or in the slight feverish rashes to which
+children are liable in the spring and autumn.</p>
+
+<p>Mercurials should have no place among domestic remedies.
+I do not mean that the doctor need be called in to prescribe
+<span class='pagenum'><a name="Page_26" id="Page_26">[Pg 26]</a></span>each time that they are given, but that the mother should
+learn from him distinctly with reference to each individual
+child the circumstances which justify their employment.
+They stimulate the liver, as well as produce thereby action of
+the bowels, but they have, especially if often employed, a far-reaching
+influence on the constitution, and that undoubtedly
+of a depressing kind: an influence more than made up for
+when really needed by their other qualities, and especially by
+their power in doing away with the results of many forms of
+chronic inflammation. They are 'edged tools,' however, and
+we know the proverb about those who play with them.<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a></p>
+
+<p>Grey powder, blue pill, and calomel are the three forms in
+one or other of which mercurials are commonly given. Of the
+three, grey powder is the mildest; but it has the inconvenience
+of not infrequently causing nausea, or actual sickness. This
+objection does not apply to blue pill, which can be given either
+in the tiny pills of which I have already spoken, or else
+broken down, and given in a little jam, or in a teaspoonful of
+syrup or treacle. On the whole I prefer calomel in small
+doses. It has the great advantage of tastelessness, small bulk,
+and of never causing sickness. Half a grain of calomel may
+be regarded as equivalent to two grains of grey powder or blue
+pill.</p>
+
+<p>I shall speak afterwards of other medicines, which may in
+various circumstances be given, to act upon the bowels; but
+the above include all that are at all fit for common use in the
+nursery.</p>
+
+<p>Before leaving this subject I will add a word or two about
+the use of suppositories and lavements in infancy and childhood.
+A piece of paper rolled up into a conical form and
+greased, or a bit of soap, is not infrequently introduced by
+nurses just within the bowel, as a means of overcoming constipation
+in infants. The irritation of the muscle at its orifice
+<span class='pagenum'><a name="Page_27" id="Page_27">[Pg 27]</a></span>(the sphincter, as it is termed) excites the bowels to action,
+and does away with the necessity for giving an aperient. The
+drawback from this, as well as from the use of the lavement, is
+that if frequently employed they become habitually necessary,
+and the bowels will then never act without their customary
+stimulus. The lavement, too, has the additional disadvantage
+that while the lower part of the bowel is in proportion more
+capacious in infancy and childhood than in the adult, this
+peculiarity becomes exaggerated by the constant distension of
+the intestine, and a larger and still larger quantity of fluid
+needs to be thrown up in order to produce the requisite action
+of the bowels.</p>
+
+<p>Opiates and other soothing medicines should never be
+given except when prescribed by the doctor. Thirty-two
+deaths in England under five years of age in 1882 represent
+but a very small part of the evil wrought by the overdose
+or injudicious use of these remedies. Above all, soothing
+medicines of varying strength, as syrup of poppies, or of
+unknown composition, as Dalby's Carminative or Winslow's
+Soothing Syrup, should never be employed. The only safe
+preparation, and this to be given only by the doctor's orders
+or with his approval, is the compound tincture of camphor, or
+paregoric elixir, as it is called, of which sixty measured drops
+contain a quarter of a grain of opium. Ten to fifteen measured
+drops of this are a sufficient dose for a child one year
+old, and this ought not to be repeated within twelve hours.
+The repetition every few hours of small doses of opiates is
+quite as hazardous as the giving of a single overdose; and if
+it does not work serious mischief by stupefying the child, it
+renders it impossible to judge of its real condition.</p>
+
+<p>Thus much may suffice with reference to the more important
+remedies. Others will necessarily call for notice when
+the diseases come to be considered in which they may be of
+service.</p>
+
+<p>There are two points which still remain to be noticed before
+I leave the introductory part of this little book.</p>
+
+<p>The first of these concerns the importance of keeping
+<span class='pagenum'><a name="Page_28" id="Page_28">[Pg 28]</a></span>written notes in the course of every case of serious illness.
+For want of doing this the most imperfect and conflicting
+accounts of what has happened are given to the doctor. No
+person can watch to any good purpose for four-and-twenty
+hours together; and no one's memory, least of all in the midst
+of fatigue and anxiety, can correctly retain all details concerning
+medicine, food, and sleep, which yet it may be of paramount
+importance that the doctor should be made acquainted with.
+I am accustomed to desire a record to be kept on a sheet of
+paper divided into six columns, one for food, a second for
+medicine, a third for sleep, a fourth for the evacuations, and a
+fifth for any special point which the nature of the illness renders
+it of special moment to observe, while the date is entered
+on the first column of all, indicating when food or medicine
+was given, or when and for how long the child slept. It is
+best to enter the variations of temperature on a separate paper,
+in order that the doctor may at a glance perceive the daily
+changes in this important respect. No one who has not
+made the experiment can tell the relief which the keeping this
+simple record gives to the anxiety of nursing the sick, especially
+when the sick one is loved most tenderly.</p>
+
+<p>The other point concerns the relations of the mother or of
+the parents to the doctor. I have often heard it said, 'Dr. Green
+always attends my husband and myself, but we have Dr. White
+for the servants and children,' implying a lower degree of
+medical knowledge as required in their case, and to be acknowledged
+by a lower rate of remuneration.</p>
+
+<p>Need I say that the assumption is a mistaken one&mdash;that as
+much knowledge, as large experience, are needed in the one
+case as in the other; while over and above, to treat children
+successfully, a special tact and a special fondness for children
+are needed? A man may be a very good doctor without those
+special gifts; but their possession, apart from real medical
+knowledge, may make a good children's nurse, but never a
+good children's doctor.</p>
+
+<p>Another matter not to be forgotten is the confidence to be
+reposed in the doctor&mdash;the readiness to acquiesce in his sometimes
+<span class='pagenum'><a name="Page_29" id="Page_29">[Pg 29]</a></span>visiting the child more frequently in the course of an
+illness than the symptoms may seem to you to require. Were
+you involved in some civil action, in which your succession to
+large property was involved, you would scarcely expect your
+solicitor to give you his opinion on all the questions at a single
+interview. In the same way, the doctor, even the most
+experienced, may need to visit his little patient several times
+before he can feel quite certain as to the nature of the disease
+that is impending, while he may not wish to alarm you by
+suggesting all the possibilities that are present to his mind.
+The child after a restless night may be asleep, and it may be
+most undesirable to wake him; or he may be excessively cross
+and unmanageable, so that it is impossible to listen to his chest;
+or it may be very important to ascertain whether the high
+temperature present in the morning has risen still higher towards
+night, or whether, after free action of the bowels, it has fallen
+a degree or two, showing that no fever is impending, but that
+the undue heat of the body was occasioned by the constipation.
+Or, again, some remedy may have been ordered, of the effect
+of which the doctor does not feel quite sure: he wishes to see
+for himself whether it is right to continue or wiser to suspend
+it. The wise physician, like the able general, leaves as little as
+may be to chance.</p>
+
+<p>Nearly forty years ago, in addressing a class of medical
+students, I said to them:</p>
+
+<p>'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 lavish of your time; you must be content to turn
+aside from the direct course of investigation, which you would
+pursue uninterruptedly in the adult, in order to soothe the waywardness
+of the child, to quiet its fears, or even to cheat it into
+good humour by joining in its play; and you must be ready to
+do this, not the first time only, but every time that you visit the
+child, and must try to win its affections in order to cure its
+disease. If you fail in the former, you will often be foiled in
+your attempts at the latter. Nor is this all; you must visit
+your patient very often if the disease is serious in its nature
+<span class='pagenum'><a name="Page_30" id="Page_30">[Pg 30]</a></span>and rapid in its course. New symptoms succeed each other in
+infancy and childhood with great rapidity; complications occur
+that call for some change in your treatment, or the vital powers
+falter suddenly when you least expect it. The issues of life
+and death often hang on the immediate adoption of a certain
+plan of treatment, or on its timely discontinuance. Do not
+wait, therefore, for symptoms of great urgency before you visit
+a child three or four times a day; but if the disease is one in
+which changes are likely to take place rapidly, be frequent in
+your visits as well as watchful in your observation.'</p>
+
+<p>Each year has added to my conviction of the perfect truth
+of each word which I have quoted. If you believe your doctor
+to be a man of integrity and intelligence, be thankful for his
+frequent visits, which will cease as 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 your
+doctor; but do not say to him in a tone and with an emphasis
+which there is no mistaking, 'Well, if you think it <i>really</i>
+necessary to come'!</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5" href="#FNanchor_5_5"><span class="label">[5]</span></a> 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 to enter
+into all the details, important though they are, of a sick nurse's duties.</p>
+
+<p>For a linseed meal poultice, see that the water is <i>boiling</i>, not merely
+hot; warm the basin, put the water in <i>first</i>; sprinkle the meal on it,
+stirring the whole time, till it becomes of the uniform consistency of
+porridge, then spread it about half an inch thick over the linen, or whatever
+it is spread on, and turn up the edges for an inch all round to prevent
+the poultice crumbling and soiling the night-dress; and then having smeared
+the surface with a little oil, test its warmth by applying it to your cheek
+before putting it on the patient. A broad bandage of some sort or a soft
+towel must then be put round the body to keep the poultice in its place,
+and secured with safety pins.</p>
+
+<p>Pure mustard poultices are never used in children, on account of the
+pain they occasion, and the too great irritation which they would cause
+of the delicate skin of children. A mixture of one part of mustard to
+two of linseed meal is, however, often of much use in the chest affections
+of children.</p>
+
+<p>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, and
+are chiefly used in cuts, wounds, or small abscesses; and also because they
+are so easily made. A slice of stale bread without the crust is put on a
+plate, boiling water is poured over it, and drained off; it is then placed on a
+piece of muslin, pressed between two plates to squeeze out the remaining
+water, and its surface is greased before it is applied with a little oil or lard.
+I would refer for details about how to make poultices, and for many other
+things well worth the knowing, to Miss Wood's <i>Handbook of Nursing</i>,
+London, 12mo, 1883.</p></div>
+
+<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6" href="#FNanchor_6_6"><span class="label">[6]</span></a> I am not ignorant of the doubts which have been raised with reference
+to the special influence of mercurial remedies on the liver, but prefer in a
+book written for non-medical readers to leave the popular opinion unquestioned.</p></div>
+</div>
+
+
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_31" id="Page_31">[Pg 31]</a></span></p>
+<h2><a name="PART_II" id="PART_II"></a>PART II.</h2>
+
+
+<p>All that has been said hitherto is only introductory to the
+great purpose of this book, which is to give an account of the
+nature, symptoms, and course of the more important diseases of
+infancy and childhood.</p>
+
+<p>Any attempt at scientific arrangement of a popular book
+is useless. I prefer, therefore, to consult simply the general
+convenience of my readers. I think I do so best by considering
+first the disorders which beset the child in the first month of
+its existence, during what may be termed its transition from
+the condition of existence in the womb, to its living, breathing
+state as an inhabitant of this world; and next the more
+important ailments to which it is liable during that important
+time of development which ends with the completion of
+teething. Afterwards may be studied the diseases of the head,
+the chest, and the bowels; next constitutional diseases, such as
+consumption and scrofula; and lastly, the various fevers, as
+typhoid, or, as it is popularly called, remittent fever, measles,
+scarlatina, and small-pox; and last of all I will add a few
+remarks on the mental and moral characteristics of childhood,
+and their disorders.</p>
+
+
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_32" id="Page_32">[Pg 32]</a></span></p>
+<h2><a name="CHAPTER_IV" id="CHAPTER_IV"></a>CHAPTER IV.</h2>
+
+<h3>ON THE DISORDERS AND DISEASES OF CHILDREN DURING
+THE FIRST MONTH AFTER BIRTH.</h3>
+
+
+<p><b>Still-birth.</b>&mdash;The infant cries almost as soon as it comes
+into the world. The cry is the evidence that air has entered
+its lungs, that the blood has now begun to take a different
+course from that which it followed before birth, and that the
+child has entered on a new existence. The child who does not
+cry, does not breathe; it is said to be <i>still-born</i>; its quietude
+means death.</p>
+
+<p>After a long or a difficult labour, or after the use of instruments,
+the child is sometimes still-born in consequence of
+blood being poured out on its brain, and it is thus killed before
+birth by apoplexy. This, however, is not usually the case, but
+the child is generally still-born because some cause or other,
+generally the protraction of labour, interfered with the due
+changes of its blood within the womb, and it is born suffocated
+before its birth, and consequently unable to make the necessary
+efforts to breathe afterwards.</p>
+
+<p>Drowned people are often resuscitated; the child's case is
+analogous to theirs; and in both the same measures have to be
+pursued, namely to try to 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 its surface, the presence or
+absence of perceptible beating of its heart, measure the chances
+of success. Sometimes mere exposure to the cold air produces
+the necessary effect; at other times breathing is excited by
+dashing cold water in the child's face, by slapping it, by tickling its
+nostrils, or by dipping it for a few seconds in a hot bath at 100&deg;
+<span class='pagenum'><a name="Page_33" id="Page_33">[Pg 33]</a></span>or 102&deg;; and then swinging it a few times backwards and forwards
+in the air.</p>
+
+<p>Much time, however, must not be lost over these proceedings,
+but the child must be laid on its back, the lower part of
+its body well wrapped up, the chest slightly raised by a folded
+napkin placed under it. The two arms must then be taken
+firmly, raised and slowly extended on either side of the head,
+then brought down again and gently pressed on either side of
+the chest; and this movement of alternate raising and extending
+the arms and bringing them back again beside the chest
+must be repeated regularly some thirty times in the minute,
+thus imitating the movements of the chest in breathing. These
+efforts, too, must not be discontinued so long as the surface
+retains its warmth, and as an occasional heart-beat shows that
+life is not absolutely extinct; and I believe that in many
+instances failure is due to want of perseverance rather than to
+the absolute uselessness of the measure.</p>
+
+<p><b>Premature Birth.</b>&mdash;In spite of very extraordinary exceptions,
+it may be laid down as a rule that children born before
+the completion of six and a half months of pregnancy do not
+survive. After that date, each additional week adds greatly to
+the chances of the child living. There is a mistaken idea,
+founded on a superstition connected with the number seven,
+that a seven-months child is more likely to survive than one
+born at the eighth month. But this notion is as destitute of
+support in fact as it is opposed to common sense, and the
+nearer any woman has approached the full term of forty weeks
+of pregnancy, the greater are the chances of her child being
+born alive and healthy.</p>
+
+<p>The premature child is by no means necessarily still-born.
+It breathes, but does so imperfectly, so that air does not enter
+all the smaller air-cells; and its voice is a whimper rather than
+a cry. Those changes in the heart and large vessels, which
+prepare, as pregnancy draws to a close, for the altered course of
+the blood when the child has to breathe through the lungs, are
+too little advanced for it to bear well the sudden alteration
+in its mode of being. The feebly beating heart and the not
+<span class='pagenum'><a name="Page_34" id="Page_34">[Pg 34]</a></span>completely developed lungs seem but imperfectly to maintain
+the bodily heat. The glands of the stomach and intestines
+are not yet fit to perform digestion properly, while the muscular
+power is too feeble for the effort at sucking. Everything is
+sketched out, but to nothing has the finishing touch been put,
+and hence the frail machinery too often breaks down, in the
+endeavour to discharge its functions.</p>
+
+<p>It is surprising, however, with what rapidity Nature in some
+instances perfects the work which she has been called on prematurely
+to perform.</p>
+
+<p>It is our business to second Nature's endeavours. First of
+all, and of most importance, is the duty of providing from without
+the warmth which the child is unable to generate. When
+very feeble, it must, even without any previous washing or
+dressing, be at once wrapped in cotton wool, and then in a hot
+blanket, and surrounded with hot-water bottles. A tin stomach-warmer
+filled with hot water is very convenient to place under
+the blanket on which the child lies. Being too feeble to suck,
+it must be fed, a few drops at a time, from a small spoon; or
+still better, if it is able to make any effort at sucking, it may
+draw its nourishment through a quill. The mother after a
+premature confinement is almost sure to have no milk with
+which to nourish her child, at any rate for two or three days.
+It is, therefore, wise to obtain the help of a woman with a
+healthy baby. She must be allowed to bring her baby with
+her, since otherwise her supply of milk would fail, especially if
+she had no other means of getting rid of it than by the breast-pump
+or by drawing her breast. Even though she may have
+her own baby, there are few women who can submit, for more
+than a very few days, to the artificial emptying their breast
+without the secretion being either greatly lessened or altogether
+arrested. This, therefore, must be regarded as a resource
+available only for a few days, and as the child gains strength
+every effort must be made to get it to take its mother's breast,
+if she has any supply, or that of the wet-nurse. If this is found
+impossible, it will be wisest to give up, at any rate for the
+present, the attempt to nourish the child from the breast, and
+<span class='pagenum'><a name="Page_35" id="Page_35">[Pg 35]</a></span>to obtain for it asses' milk, which is the best substitute. By no
+means whatever can more than from a sixth to a fourth part
+of a pint of milk be obtained either by the breast-pump or by
+drawing the breast; and since a healthy infant of a few weeks
+old sucks about two pints of milk in twenty-four hours, it is
+evident that the supply artificially obtained must after the first
+few days be utterly inadequate.</p>
+
+<p>I have in cases of extreme weakness in premature children
+succeeded in preserving them by giving them every two hours
+for two or three days ten measured drops of raw beef juice,
+five of brandy, and two teaspoonfuls of breast milk. Medicine
+has no place in the management of these cases; the question
+is one entirely of warmth, food, and for a time the judicious
+use of stimulants.</p>
+
+<p><b>Imperfect Expansion of the Lungs.</b>&mdash;Children not
+premature and perfectly well nourished are yet sometimes
+feeble, breathe imperfectly, cry weakly, suck difficultly or not
+at all, and die at the end of a few days. Their lamp of life
+flickered and went out. Such cases are met with for the most
+part in conditions similar to those in which children are
+actually still-born; or now and then they take place when
+labour has been of unusually short duration, the child hurried
+into the world too rapidly; while in other instances it is not
+possible to account for their occurrence.</p>
+
+<p>For a long time the nature of these cases was not understood;
+but rather more than sixty years ago a German
+physician discovered that air had entered the lungs but imperfectly;
+that perhaps a third, perhaps even as much as half,
+of the lungs had never been dilated, but had remained solid
+and useless; that in consequence the blood was but half-purified,
+and vitality therefore but half-sustained. The lungs,
+however, were found to have undergone no real change; they
+were not diseased, but if air was blown into them the dark
+solid patches sunk below the level of the surrounding substance,
+expanded, grew bright in colour and like a sponge from which
+the water has been squeezed, and crackled, or crepitated as
+the technical term is, from the air contained within them.</p>
+
+<p><span class='pagenum'><a name="Page_36" id="Page_36">[Pg 36]</a></span>We breathe in health so without conscious effort that we
+never realise the fact that, according to the calculation of
+most competent observers, the mere elasticity of the lungs,
+independent even of the elasticity of the chest walls, opposes
+a resistance to each inspiration equal to 150 pounds avoirdupois
+in the grown man and 120 in the grown woman. The
+want of breath puts the respiratory muscles into play: the
+man takes a deep inspiration, and by this unconscious effort,
+he overcomes the resistance of the chest and the elasticity
+of the lungs. The new-born infant feels the same want and
+makes the same effort; but its muscular power is small,
+and its inspirations are often so feeble as to draw the air
+in some parts only into the larger tubes, while many of the
+smaller remain undilated, and much of the lung continues in
+the state in which it was before birth. The blood being thus
+but imperfectly purified, all the processes of nutrition go on
+imperfectly, the vital powers languish, the inspiratory efforts
+become more and more feeble, while the elasticity of the
+lung is constantly tending to empty the small cells of air and
+to oppose its entrance, and next the temperature sinks and the
+infant dies.</p>
+
+<p>Cases in which this condition of the lungs exists usually
+present the history of the child from the very first having
+failed to utter a strong and loud cry like that of other children.
+Even after breathing has gone on for some time, such children
+usually appear feeble, and they suck with difficulty, although
+they often make the effort. An infant thus affected sleeps
+even more than new-born infants usually do; its voice is very
+feeble, and rather a whimper than a cry. In the cry of the
+healthy infant you at once detect two parts&mdash;the loud cry,
+suffering or passionate as the case may be, and the less loud
+back draught of inspiration. The French have two words for
+these two sounds&mdash;the <i>cri</i> and the <i>reprise</i>. The <i>cri</i> is feeble,
+the <i>reprise</i> is altogether wanting wherever expansion of the
+lung has to any considerable extent failed to take place, and
+you would hail this second sound as the best proof of an
+improvement in the child's condition.</p>
+
+<p><span class='pagenum'><a name="Page_37" id="Page_37">[Pg 37]</a></span>If you watch the child with a little attention you will see
+that while the chest moves up and down, it is very little, if at
+all, dilated by the respiratory movements. The temperature
+falls, the skin becomes pale, and the lips grow livid, and often
+slight twitching is observed about the muscles of the face.
+The difficulty in sucking increases, the cry grows weaker and
+more whimpering, or even altogether inaudible, while breathing
+is attended with a slight rattle or a feeble cough, and the
+convulsive movements return more frequently, and are no
+longer confined to the face, but affect also the muscles of the
+extremities. Any sudden movement suffices to bring on these
+convulsive seizures, but even while perfectly still the child's
+condition is not uniform, but it will suddenly become convulsed,
+and during this seizure the respiration will be extremely
+difficult, and death will seem momentarily impending. In a
+few minutes, however, all this disturbance ceases, and the
+extreme weakness of the child, its inability to suck, its feeble
+cry, and its frequent and imperfect inspirations, are the only
+abiding indications of the serious disorder from which it
+suffers. But the other symptoms return again and again,
+until after the lapse of a few days or a few weeks the infant
+dies.</p>
+
+<p>I have dwelt at some length on this condition because it is
+important to know that during the first few weeks of life real
+inflammation of the lungs or air-tubes is of extremely rare
+occurrence, and that the symptoms which are not infrequently
+supposed to depend on it are really due to a portion of the
+lung more or less extensive never having been called into
+proper activity. I may add that we shall hereafter have to
+notice a similar condition of the lung&mdash;its collapse after having
+once been inflated&mdash;as occurring sometimes in the course of
+real inflammation of the organs of respiration in early life, and
+forming a very serious complication of the original disease.</p>
+
+<p>If the collapse of the lung is not so considerable as to
+destroy life within the first few hours or days after birth, the
+babe wastes as well as grows weaker and weaker, and this wasting
+coupled with the difficult breathing not seldom causes the fear
+<span class='pagenum'><a name="Page_38" id="Page_38">[Pg 38]</a></span>that the child has been born consumptive and that its death is
+inevitable.</p>
+
+<p>No such gloomy view need be taken. Collapse, or at least
+non-expansion of the lung to some extent, is by no means
+unusual: consumptive disease to such an extent in the new-born
+infant as to interfere with the establishment of breathing
+is extremely rare. The consumptive babe can suck, it is not
+so weak as the one whose lungs are imperfectly expanded; it
+has no convulsive twitchings, nor any of the strange head-symptoms
+which we notice in the former. It wastes less
+rapidly, it is feverish instead 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.</p>
+
+<p>The treatment of these cases is abundantly simple. The
+child who breathes imperfectly but ill maintains its heat. It
+must be kept warm at a temperature never less than 70&deg;; it
+may, like the premature child, need stimulants, and all the precautions
+already mentioned as to feeding. Twice in the day it
+should be put for five minutes in a hot bath at 100&deg;, rendered
+even more stimulating by the addition of a little mustard. The
+back and chest may be rubbed from time to time with a stimulating
+liniment, and an emetic of ipecacuanha wine may be
+given twice a day. The act of vomiting not only removes any
+of the mucus which is apt to accumulate in the larger air tubes,
+but the powerful inspirations which follow the effort tend to introduce
+air into the smallest vesicles of the lungs, and to do away
+with their collapse.</p>
+
+<p>Let these directions be carried out sensibly, patiently, perseveringly,
+and three times out of four, or oftener still, the
+mother's ear will before many days be greeted by the loud cry,
+with its <i>cri</i> and <i>reprise</i> of which I have already spoken, and
+which assures her that her little one will live.</p>
+
+<p>There are no other affections of the lungs so peculiar to the
+first month of life as to call for notice here. I shall have a few
+<span class='pagenum'><a name="Page_39" id="Page_39">[Pg 39]</a></span>observations to make about malformations of the heart, and
+the precautions for which they call in the after-life of children;
+but they will find their fittest place in the chapter on Affections
+of the Chest.</p>
+
+<p><b>Jaundice of New-born Children.</b>&mdash;A certain yellow
+tinge of the skin, unattended by any other sign of jaundice,
+such as the yellowness of the eye and the dark colour of the
+urine, is by no means to be confounded with real jaundice. It
+is no real jaundice, but is merely the result of the changes
+which the blood with which the small vessels of the skin are
+overcharged at birth is undergoing; the redness fading as
+bruises fade, through shades of yellow into the genuine flesh
+colour.</p>
+
+<p>This is no disease, to be treated with the grey powder and the
+castor oil wherewith the over-busy monthly nurse is always ready.
+It is a natural process, which the intelligent may watch with
+interest, with which none but the ignorant will try to interfere.</p>
+
+<p>There is, however, beside this a real jaundice, in which
+the skin is more deeply stained, the whites of the eyes are
+yellow, the urine high-coloured, and in which the dark evacuations
+that carry away the contents of the bowels before birth
+are succeeded by white motions, from which the bile is absent.
+This condition is not very usual, save where children have been
+exposed to cold, or where the air they breathe is unwholesome.
+Of this no better proof can be given than is afforded by the
+fact that in the Dublin Lying-in Hospital, where the children
+are defended with the greatest care both from cold and from a
+vitiated atmosphere, infantile jaundice is extremely rare, while it
+attacks three-fourths of the children received into the Foundling
+Hospital of Paris. Still it does sometimes occur when yet
+no cause can be assigned for it, and it is noteworthy that it is
+sometimes met with in successive infants in the same family.</p>
+
+<p>As the respiratory function and that of the skin increase
+in activity, the jaundice will disappear of its own accord. Great
+attention must be paid during its continuance to avoid exposure
+of the child to cold, while no other food than the mother's
+milk should be given. If the bowels are at all constipated, half
+<span class='pagenum'><a name="Page_40" id="Page_40">[Pg 40]</a></span>a grain of grey powder or a quarter of a grain of calomel may be
+given, followed by a small dose of castor oil, and the aperient
+will often seem to hasten the disappearance of the jaundice;
+but in a large number of cases even this amount of medical
+interference is not needed.</p>
+
+<p>There is, indeed, a very grave form of jaundice, happily of
+excessive rarity, due to malformation of the liver, to absence
+or obstruction of the bile-ducts, and often accompanied with
+bleeding from the navel. I do but mention it; the intensity
+and daily deepening of the jaundice, the fruitlessness of all
+treatment, and the grave illness of the child, even though no
+bleeding should occur, render it impossible to confound this
+hopeless condition with the trivial ailment of which I have been
+speaking.</p>
+
+<p>The next chapter will furnish a fitter place than the present
+for speaking fully of the Disorders of the Digestive Organs.</p>
+
+<p>I will say now but this: that whatever a mother may do
+eventually, she avoids grave perils for herself by suckling her
+infant for the first month; while the health of her child, just
+launched upon the world, is terribly endangered if fed upon
+those substitutes for its proper nutriment on which after the
+lapse of a few weeks it may subsist, may even manage to
+thrive.</p>
+
+<p>There are some local affections incident to the new-born
+child concerning which a few words may not be out of place;
+and first of the</p>
+
+<p><b>Ophthalmia of New-born Children.</b>&mdash;It is the cause
+of the loss of sight of nine-tenths of all persons who, among
+the poor, are said to have been born blind. In the wealthier
+classes of society it is comparatively rare, and seldom fails to
+meet with timely treatment, yet many people scarcely realise its
+dangerous character, or the extreme rapidity of its course.</p>
+
+<p>It generally begins about the third day after birth with
+swelling of the lid of one or other eye, though both are
+soon involved. The eyelids swell rapidly, and if the affection
+is let alone, they soon put on the appearance of two semi-transparent
+cushions over the eyes. On separating the lids,
+<span class='pagenum'><a name="Page_41" id="Page_41">[Pg 41]</a></span>which it is often very difficult to do owing to the spasmodic
+contraction of the muscles, their inner surface is seen to be
+enormously swollen, bright red, like scarlet velvet, bathed in
+an abundant yellowish thin secretion, which often squirts out
+in a jet as the lids are forcibly separated. Great care must be
+taken not to allow any of this fluid to enter the eye of a bystander,
+nor to touch his own eye until the fingers have been
+most carefully washed, since the discharge is highly contagious,
+and may produce most dangerous inflammation of the eyes
+of any grown person. The discharge being wiped or washed
+away, the eye itself may be seen at the bottom of the swelling
+very red, and its small vessels very blood-shot. By degrees the
+surface of the eye assumes a deeper red, it loses its brightness
+and its polish, while the swelling of the lids lessens, and they
+can be opened with less difficulty; their inner surface at the
+same time becomes softer, but thick and granular, and next the
+eyes themselves put on likewise a granular condition which obscures
+vision. The discharge by this time has become thicker
+and white, and looks like matter from an abscess. By slow
+degrees the inflammation may subside, the discharge lessen,
+the swelling diminish, and the eye in the course of weeks may
+regain its natural condition. But the danger is&mdash;and when
+proper treatment is not adopted early the danger is very great&mdash;lest
+the mischief should extend beyond the surface of the eye,
+lest ulceration of the eye should take place, the ulceration
+reach so deep as to perforate it, and not merely interfere with
+the sight, but destroy the organ of vision altogether.</p>
+
+<p>In every instance, then, in which the eyelids of a new-born
+infant swell, or the slightest discharge appears from them, the
+attention of the doctor must at once be called to the condition.
+In the meantime, and during whatever treatment he may think
+it right to follow, the eye must be 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 squeezed into it
+abundantly from a sponge held above, but not touching it, so
+as to completely wash away all the discharge. A weak solution
+of alum and zinc, as one grain of the latter to three of the
+<span class='pagenum'><a name="Page_42" id="Page_42">[Pg 42]</a></span>former to an ounce of water, may in like manner be dropped
+from a large camel's-hair brush four times a day into the eye
+after careful washing. Simple as these measures are they yet
+suffice, if adopted at the very beginning, and carried on perseveringly,
+to entirely cure in a few days an ailment which if let
+alone leads almost always to most lamentable results.</p>
+
+<p>I do not pursue the subject further, for bad cases require all
+the care of the most skilful oculist for their treatment.</p>
+
+<p><b>Scalp Swellings.</b>&mdash;Almost every new-born child has on
+one or other side of its head a puffy swelling, owing to the
+pressure to which the head has been subjected in birth, and
+this swelling disappears at the end of twenty-four or forty-eight
+hours.</p>
+
+<p>Now and then, however, though indeed very seldom, the
+swelling does not disappear, but it goes on gradually increasing
+and becoming more definite in its outlines until at the end of
+three or four days it may be as big as half a small orange, or
+sometimes even larger, soft, elastic, painless, under the unchanged
+scalp, but presenting the peculiarity of having a hard
+raised margin with a distinct edge, which gives to the finger
+passed over it the sensation of a bony ridge, beyond which the
+bone seems deficient. This tumour is due usually to the same
+cause as that which produces the other temporary puffy swelling
+of the scalp, only the pressure having been more severe, blood
+has actually been forced out from the small vessels under the
+membrane which covers the skull, and hence its gradual increase,
+its definite outline; and hence, too, the bony ridge
+which surrounds it, and which is due to nature's effort at cure,
+in the course of which the raised edge of the membrane
+covering the skull (the <i>pericranium</i>) becomes converted into
+bone.</p>
+
+<p>When the nature of these swellings was not understood,
+they used to be poulticed, and to be opened with a lancet to
+let out their contents. We know now, however, that we have
+nothing to do but to let them alone; that by degrees the
+blood will be absorbed and the tumour will disappear, and as
+it does so we may trace the gradual transformation of the membrane
+<span class='pagenum'><a name="Page_43" id="Page_43">[Pg 43]</a></span>which covered it into bone, as we feel it crackling like tinsel
+under the finger. Two, three, or four weeks may be needed
+for the entire removal of one of these blood-swellings. The
+doctor will at once recognise its character, and you will then
+have nothing to do but to wait&mdash;often, unhappily, so much
+harder for the anxious mother than to meddle.</p>
+
+<p><b>Ruptured Navel.</b>&mdash;There is a period some time before
+the birth of a child when the two halves of its body are not
+united in front, as they become afterwards; and hare-lip or
+cleft-palate sometimes remains as the result of the arrest of
+that development which should have closed the fissured lip or
+united the two halves of the palate.</p>
+
+<p>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 the bowels are not supported by the
+muscles, but protected only by the skin.</p>
+
+<p>More frequently than this, especially in the case of children
+who are born before the time, the opening through which the
+navel string passes is large at birth, and fails to close as speedily
+and completely as it should do afterwards. When everything
+goes on as it ought, the gradual contraction of the opening
+helps to bring about the separation of the navel string and its
+detachment, and the perfect closure of the opening takes place
+at the same time, between the fifth and the eighth day after
+birth.</p>
+
+<p>If this does not occur, the bowels are very apt to protrude
+through the opening, and if allowed to do so for weeks
+or months, the opening becomes so dilated that its closure
+is impossible, and the child grows up afflicted permanently
+with rupture through the navel. This is always an inconvenience,
+sometimes even a source of serious danger; but if means
+are taken to prevent the condition becoming worse, nature
+seldom fails eventually to bring about a cure, and to effect the
+complete closure of the opening.</p>
+
+<p>If the muscles on either side do not come into apposition,
+but leave a cleft between them, the infant should constantly
+<span class='pagenum'><a name="Page_44" id="Page_44">[Pg 44]</a></span>wear a broad bandage of fine flannel round the stomach, not
+applied too tightly, in order to give support. The circular
+bandages of vulcanised india-rubber with a pad in the centre
+are nowise to be recommended. The pad is apt to become
+displaced, and to press anywhere but over the navel, while its
+edges irritate the infant's delicate skin, and the pressure which
+it exerts if it is sufficiently tight to retain its place interferes
+with respiration.</p>
+
+<p>A pad composed of pieces of plaster spread on wash-leather,
+and of graduated sizes and kept in place by adhesive
+strapping,<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a> answers the purpose of preventing the protrusion at
+the navel, and of thus facilitating the closure of the ring better
+than any other device with which I am acquainted. They
+need, however, to be continued even for two or three years,
+and though they should have been left off it is wise to resume
+their use if the child should be attacked by whooping-cough,
+diarrh&oelig;a, or any other ailment likely to occasion violent
+straining.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7" href="#FNanchor_7_7"><span class="label">[7]</span></a> These plasters for ruptured navel in sets of a dozen are to be had of
+Ewen, 106 Jermyn Street, St. James's, London, and I dare say at many
+other places besides.</p></div>
+</div>
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_45" id="Page_45">[Pg 45]</a></span></p>
+<h2><a name="CHAPTER_V" id="CHAPTER_V"></a>CHAPTER V.</h2>
+
+<h3>ON THE DISORDERS AND DISEASES OF CHILDREN AFTER THE
+FIRST MONTH, AND UNTIL TEETHING IS FINISHED.</h3>
+
+
+<p><b>Infantile Atrophy.</b>&mdash;In by far the greater number of
+instances, the wasting of young children is due to their being
+fed upon food which they cannot digest, or which when digested
+fails to yield them proper nourishment. I quoted some figures
+in my introductory remarks, to show from the evidence obtained
+at Berlin how much larger was the proportion of deaths under
+the age of one year among hand-fed infants than among those
+brought up at the breast. Foundling hospitals on the Continent,
+in which the children are all drawn from the same class, and
+subjected in all respects to a similar treatment, except that in
+some they are fed at the breast, in others brought up by hand,
+show a mortality in the latter case exactly double of that in the
+former.</p>
+
+<p>It is as idle to ignore these facts, and to adduce in their
+disproof the case of some child brought up most successfully
+by hand, as it would be to deny that a battle-field was a place
+of danger because some people had been present there and
+had come away unwounded.</p>
+
+<p>But it is always well not merely to accept a fact, but also
+to know the reason why a thing is so. The reason is twofold:
+partly because the different substitutes for the mother's milk,
+taken for the most part from the vegetable kingdom, are less
+easy of digestion than the milk, and partly because, even were
+they digested with the same facility, they do not furnish the
+elements necessary to support life in due proportion.</p>
+
+<p><span class='pagenum'><a name="Page_46" id="Page_46">[Pg 46]</a></span>All food has to answer two distinct purposes: the one to
+furnish materials for the growth of the body, the other to afford
+matter for the maintenance of its temperature; and life cannot
+be supported except on a diet in which the elements of
+nutrition and those of respiration bear a certain proportion to
+each other. Now, in milk, the proper food of infants, the
+elements of the former are to those of the latter about in the
+proportion of 1 to 2, while in arrowroot, sago, and tapioca they
+are only as 1 to 26, and in wheaten flour only as 1 to 7. If to
+this we add the absence in these substances of the oleaginous
+matters which the milk contributes to supply the body with
+fat, and the smaller quantity, and to 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 of the
+infant must almost inevitably be sacrificed.</p>
+
+<p>But these substances are not only less nutritious, they
+are also less easy of digestion than the infant's natural food.
+We all know how complex is the digestive apparatus of the
+herbivorous animal, of which the four stomachs of the ruminants
+are an instance, and how large is the bulk of food in proportion
+to his size which the elephant requires, compared with that
+which suffices for the lion or the tiger.</p>
+
+<p>The stomach of the infant is the simple stomach of the
+carnivorous animal, intended for food which shall not need to
+stay long in that receptacle, but shall be speedily digested; and
+it is only as the child grows older, and takes more varied food,
+that the stomach alters somewhat in form, that it assumes a
+more rounded shape, resembling somewhat that of the herbivorous
+animal, and suited to retain the food longer. The
+young of all creatures live upon their mother for a certain time
+after birth; but in all the preparation for a different kind of
+food, and with it for an independent existence, begins much
+sooner and goes on more rapidly than in man. Young rabbits
+are always provided with two teeth when born, and the others
+make their appearance within ten days. In the different
+ruminants the teeth have either begun to appear before birth,
+or they show themselves a few days afterwards; and in either
+<span class='pagenum'><a name="Page_47" id="Page_47">[Pg 47]</a></span>case dentition is completed within the first month, and in dogs
+and cats within the first ten weeks of existence.</p>
+
+<p>In the human subject the process of teething begins late,
+between the seventh and the ninth month, and goes on slowly:
+the first grinding teeth are seldom cut before the beginning of
+the second year, and teething is not finished until after its end.
+Until teething has begun the child ought to live exclusively on
+the food which nature provides; for until that time the internal
+organs have not become fitted to digest other sustenance,
+and the infant deprived of this too often languishes and dies.
+To get from other food the necessary amount of nourishment,
+that food has to be taken in larger quantities, and, from the
+difficulty in digesting it, needs to remain longer in the stomach
+than the mother's milk. One of the results of the indigestibility
+of the food is that the child is often sick, the stomach getting
+rid of a part of that food which it is unable to turn to any
+useful purpose; and so far well. But the innutritious substances
+do not relieve the sense of hunger. The child cries in
+discomfort, and more is given to it, and by degrees the over-distended
+stomach becomes permanently dilated, and holds a
+larger quantity than it was originally meant to contain. The
+undigested mass passes into a state of fermentation, and the
+infant's breath becomes sour and offensive, it suffers from wind
+and acid eructations, and nurses sometimes express surprise
+that the child does not thrive since it is always hungry. While
+some of the food is got rid of by vomiting, some passes into
+the intestines, and there becomes putrid, as the horribly offensive
+evacuations prove. They come away, large and solid and
+white, for the secretion of the bile is inadequate to complete
+that second digestion which should take place in the intestines;
+or else the irritation which they excite occasions diarrh&oelig;a&mdash;a
+green putty-like matter comes away mixed with a profuse
+watery discharge.</p>
+
+<p>What wonder is it that in such circumstances the body
+should waste most rapidly; for it is forced from its own tissues
+to supply those elements essential to the maintenance of life,
+which its food contains in far too scanty a proportion. Every
+<span class='pagenum'><a name="Page_48" id="Page_48">[Pg 48]</a></span>organ of the body contributes to the general support, and
+life is thus prolonged, if no kind disease curtail it, until each
+member has furnished all that it can spare, and then death
+takes place from starvation, its approach having been slower,
+but the suffering which preceded it not therefore less, than if
+all food had been withheld.</p>
+
+<p>Do not suppose that in this description I have been
+painting too dark a picture, or that children who die thus have
+been exceptionally weak, and so under the acknowledged
+difficulties of hand-feeding at length became consumptive.
+They do not die of consumption, and in a large number of
+instances their bodies show no trace of consumptive disease,
+but present appearances characteristic of this condition of
+starvation, and of this only.</p>
+
+<p>Along the whole track of the stomach and intestines are
+the signs of irritation and inflammation. The glands of the
+bowels are enlarged, actual ulceration of the stomach is often
+met with; while so far-reaching is the influence of this slow
+starvation, that even the substance of the kidneys and of the
+brain are often found softened and otherwise altered, though
+it might not unreasonably have been supposed that these organs
+lay quite beyond the reach of any disorder of digestion.</p>
+
+<p>No doubt all these grievous results do not always follow;
+and sometimes children exceptionally strong manage to take
+and digest enough even of unsuitable food to maintain their
+health, and may as they grow up, and the changes take place in
+the system which fit it for a varied diet, even become robust.
+In the majority of instances, however, hand-fed infants, and
+those especially who have been brought up chiefly on farinaceous
+food, are less strong than others, and are more apt to develop
+any latent tendency to hereditary disease, such as scrofula or
+consumption, than members of the same family who have been
+brought up at the breast.</p>
+
+<p>Enough has already been said to satisfy all but those who
+do not wish to be convinced, how incumbent it is on every
+mother to try to suckle her child. But though it is most desirable
+that for the first six months of their existence children
+<span class='pagenum'><a name="Page_49" id="Page_49">[Pg 49]</a></span>should derive their support entirely from their mother, and
+that until they are a year or at least nine months old their
+mother's milk should form the chief part of their food, yet
+many circumstances may occur to render the full adoption of
+this plan impracticable. In some women the supply of milk,
+although at first abundant, yet in the course of a few weeks
+undergoes so considerable a diminution as to become altogether
+insufficient for the child's support; while in other cases,
+although its quantity continues undiminished, yet from some
+defect in its quality it does not furnish the infant with proper
+nutriment. Cases of the former kind are not unusual in young,
+tolerably healthy, but not robust women; while instances of the
+latter are met with chiefly among those who have given birth
+to several children, whose health is bad, or among the poor,
+who have been enfeebled by hard living or hard work. The
+children in the former case thrive 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 their rapid growth, they
+pine and fret, they lose both flesh and strength, and, unless the
+food given to supply their wants be judiciously selected, their
+stomach and bowels become disordered, and nutrition, instead
+of being aided, is more seriously impaired. In the case of the
+mother whose milk disagrees with the child from some defect
+in its quality, the signs are in general more pronounced.
+Either the infant vomits more than that small quantity which a
+babe who has sucked greedily or overmuch often rejects immediately
+on leaving the breast, or it is purged, or it seems
+never satisfied, does not gain flesh, does not thrive, cries much
+and is not happy. In these cases, too, the mother's supply of
+milk, though abundant at first, diminishes in a few weeks; she
+feels exhausted, and suffers from back-ache, or from pain in
+the breasts each time after the child's sucking; while, further,
+her general weakness leaves her no alternative but to wean the
+child.</p>
+
+<p>Knowing the attempt to rear her child entirely at the breast
+to be vain, the mother may in such cases be tempted to bring
+it up by hand from the very first. But how short soever the
+<span class='pagenum'><a name="Page_50" id="Page_50">[Pg 50]</a></span>period may be during which the mother may be able to suckle
+her child, it is very desirable that she should nurse it during
+that period, and also that her milk should then constitute its
+only food. For the first four or five days after the infant's
+birth the milk possesses peculiar qualities, and not merely
+abounds in fatty and saccharine matter, but presents its casein
+or curd in a form in which it is specially easy of digestion.
+These peculiarities indeed become less marked within a week
+or two; but not only is it of moment that the infant should at
+any rate make its start in life with every advantage, but the
+mother who nurses her little one even for a month avoids thereby
+almost half the risks which follow her confinement. For the
+indolent, among the wealthy, a numerous class who have but
+to form a wish in order to have it gratified, a wet-nurse for the
+baby suggests itself at once to the mother as a ready means of
+saving herself trouble, and of shirking responsibility. This
+course, to which love of pleasure and personal vanity tend alike
+to prompt her, often finds, in spite of all opposing reasons,
+the approval of the nurse, to whom it saves trouble, and the
+too ready acquiescence of the doctor in a course which pleases
+his patient. But many circumstances besides those moral
+considerations, which ought never to be forgotten before the
+determination is formed to employ a wet-nurse, may put this
+expedient out of the question, and it becomes therefore of importance
+to learn what is the best course for a mother to adopt
+who is either wholly unable to suckle her child, or who can do
+so only for a very short time.</p>
+
+<p>It is obvious that the more nearly the substitute approaches
+to the character of the mother's milk, the greater will be the
+prospect of the attempt to rear the child upon it proving
+successful. There is no argument needed to prove that the milk
+of some animal more closely resembles the mother's milk, and
+is more likely to prove a useful substitute for it than any kind
+of farinaceous substance. The milk of all animals, however,
+differs in many important respects from human milk, and
+differs too very widely in different animals. Thus, the milk of
+the cow and that of the ewe contain nearly double the quantity
+<span class='pagenum'><a name="Page_51" id="Page_51">[Pg 51]</a></span>of curd, and that of the goat more than twice the quantity
+of butter, and it is only in the milk of the ass that the solid
+constituents are arranged in the same order as in man. On
+this account, therefore, asses' milk is regarded, and with propriety,
+as the best substitute for the child's natural food. Unfortunately,
+however, expense is very frequently a bar to its
+employment, and compels the use of the less easily digested
+cows' milk. But though the cost may be a valid objection to
+the permanent employment of asses' milk, it is yet very desirable
+when a young infant cannot have the breast, that it
+should be supplied with asses' milk for the first four or five
+weeks, until the first dangers of the experiment of bringing it up
+by hand have been surmounted. The deficiency of asses' milk
+in butter may be corrected by the addition of about a twentieth
+part of cream, and its disposition to act on the bowels may be
+lessened by heating it to boiling point, not over the fire but in
+a vessel of hot water; and still more effectually by the addition
+to it of a fourth part of lime-water or of a teaspoonful of the
+solution of saccharated carbonate of lime to two ounces or
+four tablespoonfuls of the milk.</p>
+
+<p>When cows' milk is given, it must be borne in mind that it
+contains nearly twice as much curd, and about an eighth less
+sugar, than human milk. It is therefore necessary that it should
+be given in a diluted state and slightly sweetened. The dilution
+must vary according to the infant's age; at first the milk
+may be mixed with an equal quantity of water, but as the child
+grows older the proportion of water may be reduced to one-third.
+Mere dilution with water, however, leaves the proportion
+of curd unaltered, and it is precisely the curd which the
+infant is unable to digest. Instead, therefore, of diluting the
+milk simply with water, it is often better to add one part of
+whey to about two parts of milk, which, according to the
+child's age, may or may not be previously diluted.<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a></p>
+
+<p><span class='pagenum'><a name="Page_52" id="Page_52">[Pg 52]</a></span>Attention must be paid to the temperature of the food
+when given to the infant, which ought to be as nearly as possible
+the same as that of the mother's milk, namely from 90&deg; to
+95&deg; Fahrenheit, and in all cases in which care is needed a
+thermometer should be employed in order to insure the food
+being given at the same temperature. Human milk is alkaline,
+and even if kept for a considerable time it shows little tendency
+to become sour. The milk of animals when in perfect health
+likewise presents an alkaline reaction, and that of cows when at
+grass forms no exception to this rule. Milk even very slightly
+acid is certain to disagree with an infant; it is therefore always
+worth while the moment that a hand-fed infant seems ailing to
+ascertain this point. If alkaline, the milk will deepen the blue
+colour of litmus paper, which is to be had of any chemist; if
+acid, it will discharge the colour and turn it red. It is, perhaps,
+as well to add that, as the oxygen in the atmosphere tends to
+redden litmus paper, it should not be left exposed to the air,
+but should always be kept in a glass-stoppered bottle.</p>
+
+<p>The milk of the cow is very liable to alteration from comparatively
+slight causes, and particularly from changes in the
+animal's diet; while even in the most favourable circumstances
+if the animal is shut up in a city and stall-fed, all the solid constituents
+of its milk suffer a remarkable diminution; while the
+<span class='pagenum'><a name="Page_53" id="Page_53">[Pg 53]</a></span>secretion further has a great tendency to become acid, or to
+undergo even more serious deterioration. Mere acidity of the
+milk can be counteracted for the moment by the addition of lime-water,
+or by stirring up with it a small quantity of prepared
+chalk, which may be allowed to subside to the bottom of the
+vessel; or if it should happen, though indeed that is rarely
+the case in these circumstances, that the child is constipated,
+carbonate of magnesia may be substituted for the chalk or
+lime-water. If these simple proceedings are not sufficient to
+restore the infant's health, it will be wise to seek at once for
+another source of milk supply, and to place the suspected milk
+in the hands of the medical officer of health or of the public
+analyst, in order that it may be submitted to a thorough
+chemical and microscopical examination.</p>
+
+<p>The difficulty sometimes found in obtaining an unvaryingly
+good milk supply, as well as practical convenience in many
+respects, has led to the extensive employment of various forms
+of condensed milk. They form undoubtedly the best substitute
+for fresh cows' milk which we possess, and are a great boon
+especially to the poor in large towns where the milk supply is
+often scanty, not always fresh, and sometimes of bad quality.
+I should certainly prefer condensed milk for an infant to milk
+from cows living in close dirty stables, such as my experience
+thirty years ago made me familiar with in some parts of London.</p>
+
+<p>Still all the varieties of condensed milk are far inferior in
+quality to good fresh milk. They contain less butter, less
+albumen, that is to say less of the main constituents of all animal
+solids and fluids, and a greater proportion of what are termed
+the hydro-carbonates, such for instance as sugar; or, to state the
+same thing differently, the elements which serve for nutrition are
+in smaller proportion than in fresh milk to those which minister
+to respiration. They are not only less nutritious, but the large
+quantity of sugar which they contain not infrequently disagrees
+with the child, and causes bowel complaint. I do not know
+how far the so-called unsweetened condensed milk which has of
+late come into the market is free from this objection; but I have
+always preferred the Aylesbury condensed milk, which is manufactured
+<span class='pagenum'><a name="Page_54" id="Page_54">[Pg 54]</a></span>with sugar, to the Swiss condensed milk, into which, as
+I have been given to understand, honey largely enters.</p>
+
+<p>How much food does an infant of a month old require?
+what intervals should be allowed between each time of feeding?
+and how should the food be given? are three questions which
+call for a moment's notice. The attempt has been made to
+determine the first point by two very distinguished French
+physicians, who weighed the infants before and after each time
+of sucking. Their observations, however, were not sufficiently
+numerous to be decisive, and their results were very conflicting;
+the one estimating the quantity at two pounds and a quarter
+avoirdupois, which would be equivalent to nearly a quart, the
+other at not quite half as much; but the observations of the latter
+were made on exceptionally weak and sickly infants. Infants
+no doubt vary, as do grown people, as to the quantity of food
+they require. I should estimate from my own experience and
+observation, apart from accurate data, a pint as 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 months
+seems to me very reasonable, I should doubt its sufficing for
+a child of nine months unless it were supplemented by other
+food.</p>
+
+<p>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 three hours; and this frequent need of food continues
+until the age of two, sometimes even until three, months.
+Afterwards, and until six months old, the child does not need to
+be fed oftener than every three hours during the twelve waking
+hours, and every four hours during the sleeping time. Later
+on, five times in the twenty-four hours, namely thrice by day,
+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.</p>
+
+<p>How is an infant not at the breast to be fed? Certainly
+not with the cup or spoon; a child so fed has no choice in the
+matter, but must either swallow or choke, and is fed as they
+fatten turkeys for the market. The infant, on the other hand,
+<span class='pagenum'><a name="Page_55" id="Page_55">[Pg 55]</a></span>sucks the bottle as it would suck its mother's breast; it rests
+when fatigued, it stops to play, it leaves off when it has had
+enough, and many a useful inference may be drawn by the
+observant nurse or mother who watches the infant sucking, and
+notices if the child sucks feebly, or leaves off panting from want
+of breath, or stops in the midst, and cries because its mouth is
+sore or its gums are tender.</p>
+
+<p>But it is not every bottle which an infant should be fed
+from, and least 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 hour together with the end in its
+mouth, sucking, or making as though it sucked, even when the
+bottle is empty. These bottles, as well as the tubes connected
+with them, are most difficult to keep clean; and so serious is
+this evil, that many French physicians not only denounce their
+use, in which they are perfectly justified, but prefer, to the use
+of any bottle at all, the feeding the infant with a spoon; and
+here I think they are mistaken. The old-fashioned flat bottle,
+with an opening in the middle, and a short end to which the
+nipple is attached without any tube, the only one known in
+the time of our grandmothers, continues still the best, and very
+good. My friend, Mr. Edmund Owen, in a lecture at which I
+presided at the Health Exhibition in August last year, pointed
+out very humorously the differences between the old bottle
+and the new. An infant to be kept in health must not be
+always sucking, but must be fed at regular intervals. The
+careful nurse takes the infant on her knee, feeds it from the old-fashioned
+feeding-bottle, regulating the flow of the milk
+according as the infant sucks heartily or slowly, withdraws it
+for a minute or two, and raises the child into a sitting posture
+if it seems troubled with flatulence, and then after a pause
+lets it recommence its meal. This occupies her a quarter of an
+hour or twenty minutes of well-spent time, while the lazy nurse,
+or the mother who has never given the matter a thought, just
+puts the tube in the infant's mouth, and either takes no further
+trouble or occupies herself with something else. And yet,
+obvious though this is, how constantly one sees infants taken
+<span class='pagenum'><a name="Page_56" id="Page_56">[Pg 56]</a></span>about in the perambulator with the feeding-bottle wrapped up
+and laid by its side, because it is said the child always cries
+when it is not sucking, and the intelligence and the common
+sense are wanting, as well as the patient love, that would strive
+to make out which it is of many possible causes that makes the
+infant cry. One more observation with reference to bottle-feeding
+may not be out of place. It is this: that no food be
+left in the bottle after the child has had its meal, but that it
+should be emptied, washed out with a little warm water and
+soda, and it and the india-rubber end should be kept in water
+till again needed. To insure the most perfect cleanliness it is
+always well to have two bottles in use, and to employ them
+alternately.</p>
+
+<p>How strictly soever an infant may be kept at the breast, or
+however exactly the precautions on which I have insisted are
+observed, sickness, constipation, or diarrh&oelig;a may occur, causing
+much anxiety to the parents, and giving much trouble to the
+doctor.</p>
+
+<p>It sometimes happens, without its being possible to assign
+for it any sufficient reason, that the mother's milk disagrees
+with her infant, or entirely fails to nourish it, so that, much
+against her will, she is compelled to give up suckling it. In
+some instances this is due to errors in diet, to the neglect of
+those rules the observance of which is essential to health, as
+proper exercise for instance; and then the secretion is usually
+deficient in quantity as well as defective in its composition. In
+such cases the child often vomits soon after sucking, it suffers
+from stomach-ache, its motions are very sour, of the consistence
+of putty, and either green, or become so soon after being
+passed, instead of presenting the bright yellow colour and
+semi-fluid consistence of the evacuations of the healthy infant,
+and sometimes they are also lumpy from the presence of masses
+of undigested curd. In addition, also, the child is troubled
+with griping, which makes it cry; its breath is sour, or actually
+offensive, and the tongue is much whiter than it should be,
+though it must be remembered that the tongue of the sucking
+child always has a very slight coating of whitish mucus, and is
+<span class='pagenum'><a name="Page_57" id="Page_57">[Pg 57]</a></span>neither as red nor as perfectly free from all coating as it becomes
+in the perfectly healthy child of three or four years
+old.</p>
+
+<p>In these circumstances, the diminution of stimulants, such
+as the stout of which young women are sometimes mistakenly
+urged to take a quantity to which they were previously quite
+unaccustomed, is often followed by an increase of the quantity
+as well as an improvement in the quality of the milk. It is
+true that a nursing mother may often find her strength maintained,
+and her supply of milk increased, by taking a glass of
+stout at lunch and another at dinner, instead of, but not in
+addition to, any other stimulant; but mere stimulants will no
+more enable a woman to suckle her infant better than she otherwise
+would do, than they would fit a man to undergo great
+fatigue for days together, or to go through a walking tour in
+Switzerland. A tumbler of one-third milk and two-thirds good
+grit gruel taken three times a day will have greater influence in
+increasing the quantity of milk than any conceivable amount of
+stimulant.</p>
+
+<p>There is an entirely opposite condition in which the infant
+does not thrive at the breast, and this for the most part is met
+with when the mother has already given birth to and suckled
+several children. In these instances the secretion is sometimes,
+though not always, abundant, but the infant does not thrive
+upon it. The babe does not get on, is always hungry after
+leaving the breast, and cries as though it wanted more; in
+addition to which it is often purged, either while sucking or
+within a few minutes afterwards, though the motions, except
+in being more frequent and more watery than in health, do not
+by any means constantly show any other change. The mother's
+history explains the rest. She is constantly languid, suffers
+from back-ache, feels exhausted each time after the babe has
+sucked, probably has neuralgia in her face, or abiding headache.
+In many instances, too, her monthly periods return,
+though as a rule they do not appear in healthy women while
+suckling. All these symptoms show that her system is not
+equal to the duty she has undertaken, and that therefore, for
+<span class='pagenum'><a name="Page_58" id="Page_58">[Pg 58]</a></span>her sake as well as for that of the infant, she must give up the
+attempt.</p>
+
+<p>One more case there is in which suckling has to be given
+up, at any rate in part, and that is when the milk is good in
+kind, but insufficient in quantity for the child as it grows older.
+This insufficiency of quantity shows itself at different periods
+after the infant's birth&mdash;at two months, three, or four. The
+child is not otherwise ill than that it is no longer bright, as it
+was wont to be, it ceases to gain flesh, it sleeps more than it
+used to do, though when it wakes it is always eager for the
+breast, and cries when leaving it, and if the experiment is made
+of giving it some milk and water immediately on leaving it, it
+takes that greedily. Mothers are loth to believe this failure of
+their resources, and in the case of some who have firm and well-formed
+breasts, there is but little change in their appearance
+to show that what remains may serve for beauty, not for use.
+But if while the child is sucking, the nipple is taken suddenly
+from its mouth, instead of innumerable little jets of milk,
+spirting out from the openings of the milk-ducts, the nipple
+will be seen to be barely moistened by its languid flow.</p>
+
+<p>In conditions such as these the question of weaning partially
+or completely inevitably occurs, and where the mother's weakness
+is the occasion of the failure to nourish the child, half-measures
+are of no avail, for so long as she does not entirely
+give up the attempt to do that to which her health is unequal, her
+own state will grow worse, that of the child will not improve.
+When errors of diet or inattention to general rules of health
+incapacitate the mother from the performance of her duty,
+there may be hope from the adoption of a wiser course; while
+when the supply simply fails from its inadequacy, much may
+be hoped for from a wise combination of hand-feeding with
+nursing at the breast; the mother perhaps suckling the infant
+by day, but being undisturbed by demands upon her at night.</p>
+
+<p>Last of all, I must refer to cases in which love has been
+stronger than reason, as indeed it often is, and in which young
+people with some pronounced hereditary taint of scrofula or
+consumption marry and have children. In such cases, if the
+<span class='pagenum'><a name="Page_59" id="Page_59">[Pg 59]</a></span>consumptive taint is on the mother's side, it is, I believe, much
+wiser, in the inability to obtain a good wet-nurse, to bring up
+the child by hand rather than at the mother's breast. One
+word, however, applicable in such circumstances, age and long
+experience entitle me to add, and it is this. It is essential that,
+in the absence of that guarantee against the too rapid succession
+of pregnancies which suckling for a reasonable time presents,
+there should be self-restraint on both sides, lest the inscription
+on the young wife's grave should be, as I have too often known
+it, the same as, in despite of poetry and romance, her biographer
+assigns as the cause of the death of Petrarch's Laura, that she
+died worn out <i>crebris partubus</i>, by too many babies.</p>
+
+<p>In all of these cases the rules which I have already given
+with reference to hand-feeding have to be borne in mind: the
+preference for asses' milk at first, the careful regulation of the
+amount of curd in the cows' milk afterwards, increased or
+diminished by the greater or less proportion of whey mixed
+with it. Sometimes, however much the quantity of curd or
+casein may be reduced, the child is yet unable to digest it,
+for it is firm and not easily acted on by the juices of the
+stomach. It is then best to omit it altogether, and to supply
+the necessary albumen by white of egg. A very good food in
+these circumstances is made of&mdash;</p>
+
+<p>
+<span style="margin-left: 2em;">White of one raw egg,</span><br />
+<span style="margin-left: 2em;">Quarter of an ounce of sugar of milk,</span><br />
+<span style="margin-left: 2em;">Three teaspoonfuls of cream,</span><br />
+<span style="margin-left: 2em;">Half a pint of whey.</span><br />
+</p>
+
+<p>In the course of a few weeks, or when the child seems to need
+stronger nourishment, one part of veal-tea, made with a pound of
+veal to a pint of water, may be added to one part of whey, with
+the white of egg and sugar of milk as before, and one part of
+white decoction, as it was called some two centuries ago in
+England. It is composed of&mdash;</p>
+
+<p>
+<span style="margin-left: 2em;">Half an ounce of hartshorn shavings,</span><br />
+<span style="margin-left: 2em;">Inside of one French roll,</span><br />
+<span style="margin-left: 2em;">Three pints of water&mdash;boiled to two, strained and sweetened.</span><br />
+</p>
+
+<p><span class='pagenum'><a name="Page_60" id="Page_60">[Pg 60]</a></span>This forms an extremely useful way of introducing farinaceous
+food into the infant's diet, and preparing the way for
+a larger amount of it which by degrees becomes necessary. Of
+these, one of the most generally useful is Liebig's or Savory and
+Moore's food for infants, which has the advantage of not constipating
+as so many other farinaceous foods do. Chapman's
+Entire Wheat Flour is an extremely good food; and wheat, as you
+will remember, excels other farinaceous substances in its nutritive
+properties, but it is not so easy of digestion as Liebig. There is,
+however, scarcely any kind of farinaceous food, among which
+Nestl&eacute;'s must not be forgotten, which may not answer for an
+infant; provided always that at first it is not given oftener than
+twice a day, that it is not made too thick, nor given in larger
+proportion than one-third of the farinaceous food to two-thirds
+of the whey, milk, or whatever it is mixed with; and besides,
+whatever the food may be, it should be prepared each time
+afresh.</p>
+
+<p>This is not the place for going into all details on the subject
+of feeding infants, or to explain how if wisely managed the
+child weans itself by degrees from the bottle or the breast&mdash;the
+best way, be it said, of weaning&mdash;or how by degrees it
+comes to its daily midday meal of beef-tea and bread, and
+then, when the first grinding teeth have been cut, to a small
+meat meal daily, finely minced or scraped, and so little by
+little adopts the modes of living of its elders.</p>
+
+<p>But, last of all, there are instances, though not so many as
+the public imagine, in which the infant, in spite of most judicious
+management, fails to thrive, and suffers from various disorders
+of its digestion.</p>
+
+<p>The most unmanageable and the least hopeful of these
+cases are those in which the infant is the subject of consumptive
+disease. It is very rare for its symptoms, even in
+cases of the most marked tendency to consumption on the part
+of the parents, to show themselves before the age of three
+months, and I think I may add, that apart from such tendency
+consumption never appears in infancy or early childhood, except
+when it follows on some acute illness, such as inflammation
+<span class='pagenum'><a name="Page_61" id="Page_61">[Pg 61]</a></span>of the lungs, or on typhoid, or, as it is commonly called,
+remittent fever.</p>
+
+<p>Consumption of the bowels, as it is popularly termed, may
+be said never to occur in early infancy apart from consumptive
+disease of the lungs, and is then always accompanied by an increase
+towards evening of the temperature from its natural
+standard of 98.5&deg; to 100&deg;. Hence the absence of cough and
+the persistence of a natural temperature may be taken as
+almost conclusive evidence that there is no consumptive disease
+of the bowels. Consumptive disease in infancy is invariably
+attended with glandular enlargement. The glands of the
+bowels when irritated always communicate their irritation to
+the glands in the groin and the bend 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 of the bowels,
+other tiny enlarged glands will be felt, like shot, under the skin
+of the belly, from which in the general progress of emaciation
+the layer of fat always present in the healthy baby will already
+have been removed. Besides this, too, the veins running
+beneath the skin there, invisible in the healthy infant, will be
+seen meandering like blue lines, and telling the story that more
+blood than usual flows through them, because the diseased
+glands inside interfere with its ready passage through its proper
+channels.</p>
+
+<p>Two cautions, however, have to be borne in mind with
+reference to both of these indications of disease. The first
+is, that the glands in the groin may be enlarged from mere
+irritation, independent of actual disease communicated to them
+from the glands inside. If, however, you find the glands at the
+corner of the lower jaw and those on either side of the neck
+enlarged too, you are then driven to the conclusion that the
+glands in the groin are enlarged not from mere local irritation,
+but from general disease, and that consumption is its cause.</p>
+
+<p>Again, the superficial veins of the belly may be enlarged
+from any cause which interferes with the proper circulation
+through the vessels inside. Hence they are often enlarged in
+grown people in dropsy, and hence too in infants and young
+<span class='pagenum'><a name="Page_62" id="Page_62">[Pg 62]</a></span>children from flatulent distension of the bowels. But in this
+case the other signs of consumption are wanting; the emaciation,
+the cough, the increase of evening temperature, and the
+enlargement of the glands, are all absent.</p>
+
+<p>Sometimes we meet with instances where the child does
+not digest its food, does not thrive, does not gain flesh, never
+passes healthy evacuations, at length wastes, loses strength,
+and dies, without having had any of the signs which I have
+pointed out as indicative of consumptive disease, and in fact
+without having suffered from it. Now, these cases are connected
+with imperfect performance of the function of the liver,
+and sometimes with an imperfection of its structure. Before
+birth the functions of the liver are not called into action in
+the same way nor to the same degree as afterwards, and its
+structure differs in this respect that it contains a larger amount
+of fat and a smaller proportion of bile-secreting cells than
+afterwards. It sometimes happens from causes which we do
+not understand that the liver structure not only does not
+undergo that higher development which should take place,
+but that the fat cells increase at the expense of the bile cells.
+In these circumstances 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 of consumption, only there are no cough,
+no glandular enlargement, no big superficial veins, no increased
+temperature, while on a careful examination the doctor will
+seldom fail to find the rounded edge of the enlarged liver
+coming lower down than natural. In these cases too there is
+a disposition to convulsive affections, and to that peculiar form
+of convulsion called spasmodic croup, concerning which I shall
+have something to say later on.</p>
+
+<p>In its less serious form this is both a more frequent and a
+less grave condition than consumption, and its existence explains
+to a great degree those cases in which young children
+have failed to be nourished by the milk food which commonly
+suits their tender age, but have improved on beef-tea, raw meat
+or its juice, and food entirely destitute of saccharine matter.</p>
+
+<p>In cases where there is reason to apprehend consumptive
+<span class='pagenum'><a name="Page_63" id="Page_63">[Pg 63]</a></span>disease, the skill and resources of the doctor will often be
+heavily taxed to meet each 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 which the asses' milk is deficient,
+a couple of teaspoonfuls of raw meat juice in the course of
+every twenty-four hours, much care in the introduction of
+farinaceous substances into the diet, and cod-liver oil twice a
+day, beginning with ten drops and gradually increasing the
+dose to a teaspoonful, are all that the mother herself can do.
+When the cod-liver oil is not borne by the stomach, or when&mdash;which,
+however, is not often the case&mdash;the child refuses to take
+it, glycerine may be substituted for it, though it must be owned
+that it is a very poor and inefficient substitute. The inunction
+of cod-liver oil is in any case not to be had recourse
+to; it makes the child unpleasant to itself and loathsome to
+others, while the power of the skin to absorb oily matters is
+far too limited to be worth taking into account.</p>
+
+<p>Vomiting, though by no means a prominent symptom of
+either of the two very grave conditions of which I have
+been speaking just now, is yet a very common attendant on
+all disorders of digestion in early life. It is indeed much
+more frequent in the infant than in the adult, and the greater
+irritability of the stomach continues even after the first few
+months of existence are past, and does not completely cease
+during the early years of childhood. In every case of vomiting
+in childhood, therefore, the first question to set at rest is
+whether it depends on disorder of the digestive system, or
+whether it heralds the onset of one of the eruptive fevers, or
+of inflammation of the chest, or of affection of the brain; and
+in determining this all the directions given when I was speaking
+of the general symptoms of disease are to be carefully studied.
+Vomiting often accompanies infantile diarrh&oelig;a, even when the
+food taken cannot be regarded as its occasion; and now and
+then the stomach, with no obvious exciting cause, suddenly
+becomes too irritable to retain any food, and this indeed may
+be the case even though attended by few or no other indications
+of intestinal disorder. The child in such cases seems still
+<span class='pagenum'><a name="Page_64" id="Page_64">[Pg 64]</a></span>anxious for the breast; but so great is the irritability of the
+stomach that the milk is either thrown up unchanged immediately
+after it has been swallowed, or it is retained only for a
+few minutes, and is then rejected in a curdled state; while
+each application of the child to the breast is followed by the
+same result. It will generally be found, when this accident
+takes place in the previously healthy child of a healthy mother,
+that it has been occasioned by some act of indiscretion on the
+part of its mother or nurse. 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; or the
+infant has been roused from sleep before its customary hour,
+or it has been over-excited or over-wearied at play, or in hot
+weather has been carried about in the sun without proper protection
+from its rays.</p>
+
+<p>The infant in whom from any of these causes vomiting
+has come on, must at once be taken from the breast, and for
+a couple of hours neither food nor medicine should be given
+to it. It may then be offered a teaspoonful of cold water;
+and should the stomach retain this, one or two spoonfuls may
+be given in the course of the next half-hour. If this is not
+rejected, a little isinglass may be dissolved in the water,
+which must still be given by a teaspoonful at a time, frequently
+repeated; or cold barley-water may be given in the same manner.
+In eight or ten hours, if no return of vomiting takes
+place, the experiment may be tried of giving the child its
+mother's milk, or cows' milk diluted with water, in small quantities
+from a teaspoon. If the food thus given does not occasion
+sickness, the infant may in from twelve to twenty-four
+hours be restored to the breast: with the precaution, however,
+of allowing it to suck only very small quantities at a time, lest,
+the stomach being overloaded, the vomiting should again be
+produced.</p>
+
+<p>In many instances when the sickness has arisen from some
+accidental cause, such as those above referred to, the adoption
+of these precautions will suffice to restore the child's health.
+<span class='pagenum'><a name="Page_65" id="Page_65">[Pg 65]</a></span>If, however, other signs of disorder of the stomach or bowels
+have preceded the sickness, or are associated with it, medicine
+cannot be wholly dispensed with, and the advice of the doctor
+must be sought for. Very likely in addition to directing
+the rules above laid down to be attended to, he may lay
+a tiny dose of calomel, as a quarter, half or a whole grain
+on the tongue, which often has a wonderful influence in
+arresting sickness; while he may further put a small poultice
+not much bigger than a crown piece, made half of mustard,
+half of flour, on the pit of the stomach for a few minutes, and
+may give the child a little saline, with a grain or 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 be prescribed, and their effect watched by the medical
+attendant.</p>
+
+<p>Sickness, indeed, is not always a solitary symptom unattended
+by other evidences of disordered digestion, but is
+sometimes associated with signs of its general impairment, and
+this may be so serious as to lead to great loss of flesh, and even
+to end in endangering life. In many instances, however, the
+child does not lose much flesh though it digests ill, and its
+symptoms would be troublesome rather than alarming, if it
+were not that they are often the signs of an unhealthy constitution,
+out of which in the course of a few months consumption
+is not infrequently developed. Long-continued
+indigestion in the infant always warrants anxiety on the part of
+the parent.</p>
+
+<p>In some of these cases there is complete loss of appetite,
+the infant caring neither for the breast nor for any other food.
+It loses the look of health and grows pale and languid, though
+it may not have any special disorder either of the stomach or
+of the bowels. It sucks but seldom and is soon satisfied, and
+even of the small quantity taken, a portion is often regurgitated
+almost immediately. This state of things is sometimes brought
+on by a mother's over-anxious care, who, fearful of her infant
+taking cold, keeps it in a room too hot or too imperfectly
+ventilated. It follows, also, in delicate infants on attacks of
+<span class='pagenum'><a name="Page_66" id="Page_66">[Pg 66]</a></span>catarrh or of diarrh&oelig;a, but it is then for the most part a passing
+evil which time will cure. In the majority of cases, however,
+the loss of appetite is associated with evidence of the stomach's
+inability to digest even the small quantity of food taken, and
+the bowels are irregular in their action, as well as unhealthy in
+their secretion. Loss of appetite, too, though a frequent is by
+no means a constant attendant on infantile indigestion, but
+is replaced sometimes by an unnatural craving, in which the
+child never seems so comfortable as when sucking. It sucks
+much, but the milk evidently does not sit well upon the
+stomach; for soon after sucking, the child begins to cry and
+appears to be in much pain until it has 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 often can be
+pacified only by allowing it to suck again. In other cases
+vomiting is of much less frequent occurrence, and there is
+neither craving desire for food, nor much pain after sucking;
+but the infant is distressed by frequent acid or offensive
+eructations; its breath has a sour or nauseous smell, and its
+evacuations have a most f&oelig;tid odour. The condition of the
+bowels that exists in connection with these different forms of
+indigestion is variable. In cases of simple loss of appetite,
+the debility of the stomach is participated in by the intestines,
+and constipation is of frequent occurrence, though the evacuations
+do not always appear unhealthy. In other instances in
+which the desire for food still continues, the bowels may act
+with due regularity, but the motions may have a very unnatural
+appearance. If the child is brought up entirely at the breast,
+the motions are usually liquid, of a very pale yellow colour,
+often extremely offensive, and contain shreds of curdled milk,
+which not having been digested within the stomach, pass unchanged
+through the whole track of the bowels. In many
+instances, however, the infant having been observed not to
+thrive at the breast, arrowroot or other farinaceous food is given
+to it, which the stomach is wholly unable to digest, and which
+gives to the motions the appearance of putty or pipe-clay,
+besmeared more or less abundantly with slime or mucus. The
+<span class='pagenum'><a name="Page_67" id="Page_67">[Pg 67]</a></span>evacuations are often parti-coloured, and sometimes one or two
+unhealthy motions are followed by others which appear perfectly
+natural; while attacks of diarrh&oelig;a often come on, and
+the matters discharged are then watery, of a dark dirty green
+colour, and exceedingly offensive.</p>
+
+<p>Children, like grown persons suffering from indigestion,
+often continue, as I have already said, to keep up their flesh
+much better than could be expected, and in many cases grow
+up to be strong and healthy. Still the condition is one that
+not merely entails much suffering on the infant, but by its continuance
+seriously impairs the health, and tends to develop the
+seeds of any constitutional predisposition to consumptive
+disease.</p>
+
+<p>In these cases there are many respects in which the mother
+can most efficiently second the doctor. All causes unfavourable
+to health must be examined into, and as far as possible removed.
+It must be seen that the nursery is well ventilated, and that its
+temperature is not too high; while it will often be found that
+no remedy is half so efficacious as change of air. Next, it
+must not be forgotten that the regurgitation of the food is due
+in great measure to the weakness and consequent irritability of
+the stomach, and care must therefore be taken not to overload
+it. If these two points are attended to, benefit may then be
+looked for from the employment of tonics, and as the general
+health improves the constipated condition of the bowels, so
+usual in these cases, will by degrees disappear; while if
+aperients are needed those simple remedies only should be
+employed of which I spoke in the first part of this book, and
+the use of mercurials is not to be resorted to without distinct
+medical order.</p>
+
+<p>The above mode of treatment is appropriate to cases of
+what may be termed the indigestion of debility, but a different
+plan must be adopted in 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 no less applicable
+here, for the rejection of some of the milk may be the result of
+nothing more than of an effort which nature makes to reduce
+<span class='pagenum'><a name="Page_68" id="Page_68">[Pg 68]</a></span>the work that the stomach has to do within the powers of that
+organ. But when, notwithstanding that due attention is paid
+to this important point, uneasiness is always produced by
+taking food, and is not relieved till after the lapse of some
+twenty minutes, when vomiting takes place, or when the infant
+suffers much from flatulence and from frequent acid or nauseous
+eructations, it is clear that the symptoms are due to something
+more than the mere feebleness of the system.</p>
+
+<p>It is not, however, the mere fact that the child vomits its
+food, or of the milk so vomited being rejected in a coagulated
+state, which proves that the stomach is disordered, but it is the
+fact of firmly coagulated milk being rejected with much pain,
+and after the lapse of a considerable interval from the time of
+its being taken, which warrants this conclusion. The coagulation
+of the curd is the first change which the milk of any
+animal undergoes when introduced into the stomach. The
+coagulum of human milk is soft and flocculent, and not so
+thoroughly separated from the other elements of the fluid, as
+the firm hard coagulum or curd of cow's milk becomes from
+the whey in which it floats. In a state of health the abundantly
+secreted gastric juice speedily redissolves the chief part of the
+curd in the stomach, while when it has passed into the intestine
+the alkaline bile which there becomes mixed with it, completes
+its solution, and converts the whole into a fluid which
+closely resembles one of the chief elements of the blood, is
+consequently very easily taken up by the minute vessels whose
+office it is to do so, and thus supplies with nourishment the
+whole body.</p>
+
+<p>Milk tends, however, to undergo changes spontaneously,
+which produce its coagulation, and the occurrence of these
+changes is greatly favoured by a moderately high temperature,
+such as that which exists in the stomach. But the alterations
+of the fluid that accompany this spontaneous coagulation are
+very different from those which are brought about by the vital
+processes of digestion. An acid becomes formed within it,
+and the acid thus produced has none of the solvent power of
+gastric juice, but by its presence impedes rather than favours
+<span class='pagenum'><a name="Page_69" id="Page_69">[Pg 69]</a></span>digestion. Every nurse is aware that a very slight acidity of the
+milk will suffice to give an infant vomiting, stomach ache, and
+diarrh&oelig;a, and the result must be much the same whether
+fermentation had begun in the milk before it was swallowed, or
+whether it commences afterwards, in consequence of the disordered
+condition of the stomach, and the absence of a healthy
+secretion of gastric juice.</p>
+
+<p>The nature of the food is the first point that requires attention
+in the management of these cases of infantile dyspepsia.
+If the child had been fed on cow's milk the symptoms may be
+due to the gastric juice not having been able to dissolve the
+curd, which you will remember is much firmer than that of
+human milk as well as twice as abundant. In this case the
+substitution of asses' milk, the employing whey either entirely
+or in part instead of milk, and the adding white of egg in order
+to present the elements of the curd in a more easily digestible
+form, may all be tried with advantage. Sometimes children
+refuse whey; and then a mixture of cream and veal broth, more
+or less diluted either with water or 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 of service, since it
+not only prevents the occurrence of fermentation, but also
+renders the curd of cow's milk more easily soluble.</p>
+
+<p>The indiscriminate and over-free employment of these
+alkalies, however, as nursery remedies is by all means to be
+avoided, for the symptoms of indigestion for which a grown
+person if suffering would seek the advice of a skilful doctor
+require his help no less when the patient is a child. When
+acids will be of service in promoting the secretion of the gastric
+juice, when pepsine will be likely to be of use, when stimulants
+such as a little brandy, when aromatics to get rid of flatulence,
+opiates to relieve pain or check diarrh&oelig;a, or when an occasional
+mercurial, or some other remedy may be of use by
+stimulating the liver to increased action, are questions which I
+would not advise any mother to try to answer for herself.
+Much care and pains and knowledge and experience are often
+required by the doctor to enable him to answer them correctly.</p>
+
+<p><span class='pagenum'><a name="Page_70" id="Page_70">[Pg 70]</a></span>I must not leave the consideration of the ailments of the
+digestive organs in early infancy without some notice of that
+affection of the mouth popularly known as <i>thrush</i> to which an
+exaggerated importance was once attached as the supposed
+cause of those symptoms of disordered health, of which it is
+in reality only the accompaniment. Still it is a sign of such
+grave disorder that it needs a careful study.</p>
+
+<p><span class="smcap">Thrush.</span>&mdash;If you examine the mouth of a young infant, in
+whom the attempt at hand-feeding is not turning out well, you
+will often observe its lining to be beset with numerous small
+white spots, that look like little bits of curd lying upon its surface,
+but which on a more attentive examination are found to
+be so firmly adherent to it as not to be removed without some
+difficulty, when they leave the surface beneath it a deep red
+colour, and now and then bleeding slightly. These specks
+appear upon the inner surface of the lips, especially near the
+angles of the mouth, on the inside of the cheeks, and upon
+the tongue, where they are more numerous at the tip and edges
+than towards the centre. They are likewise seen upon the gums,
+though less frequently and in smaller numbers. When they
+first appear they are usually of a circular form, scarcely larger
+than a small pin's head; but after having existed for a day or two,
+some of the spots become three or four times as large, while at
+the same time they in general lose something of their circular
+form. By degrees the small white crusts fall off of their own
+accord, leaving the surface where they were seated redder than
+before; a colour which gradually subsides, as with the infant's
+improved health the mouth returns to its natural condition. If
+the improvement is tardy the white specks may be reproduced
+and again detached several times before the mouth resumes its
+healthy aspect. In the worst cases the specks coalesce, and
+coat the mouth as though lined with a membrane which is
+usually of a yellowish-white tint instead of having the dead
+white colour of the separate spots. Even here, however,
+though the surface is very red, it scarcely bleeds if the deposit
+is removed from it gently and with care.</p>
+
+<p>The popular notion that when the deposit of thrush appears
+<span class='pagenum'><a name="Page_71" id="Page_71">[Pg 71]</a></span>not only in the mouth, but also at the edge of the bowel, it has
+passed through the child is altogether erroneous. The lining
+membrane of the bowel indeed is red, inflamed, and presents
+those conditions to which I have already referred when speaking
+of the atrophy of hand-fed children, but the actual deposit of
+thrush can take place only where there exists an appropriate
+structure for its formation, and that is to be found, not in the
+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 by the acrid motions, and this irritation sometimes
+extends to the skin over the lower part of the baby's person,
+which becomes rough, and covered with a blush of redness.</p>
+
+<p>Thrush in the child is of far less serious import than in the
+grown person. In the latter it indicates the existence of some
+very serious, almost hopeless disease, and hence it is that we
+meet with it in the last stages of dysentery, cancer, and consumption.
+In the child a slight attack 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 already described
+when speaking of the troubles of digestion in early infancy.</p>
+
+<p>While in any case it must rest with the doctor to regulate
+as he best knows how the constitutional treatment of the condition
+on which the thrush depends, it must be for the mother
+to see that appropriate local measures are adopted. One point
+of considerable moment, and to which less care than it deserves
+is usually paid, is the removing from the mouth, each time after
+the infant has been fed, of all remains of the milk or other
+food. For this purpose whenever the least sign of thrush appears,
+the mouth should be carefully wiped out with a piece of soft
+rag dipped in a little warm water every time after food has
+been given. Supposing the attack to be but slight this precaution
+will of itself suffice in many instances to remove all
+traces of the affection in two or three days. If, however, there
+is much redness of the mouth, or if the specks of thrush are
+numerous, some medicated application is desirable.</p>
+
+<p>The once popular honey and borax is not the best application,
+<span class='pagenum'><a name="Page_72" id="Page_72">[Pg 72]</a></span>and this for a reason which I will at once explain. The
+secretion of the mouth in infants is acid, disease increases this
+acidity; and it has been found that 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 of membrane
+formed by a peculiar microscopic growth, of whose
+existence, just as of that of the phylloxera which destroys the
+vine, or the muscardine which kills the silkworm, we were
+ignorant till brought to light by recent scientific research.</p>
+
+<p>You will therefore at once see why saccharine substances,
+apt as they are to pass into a state of fermentation, are not
+suitable, and why it is better to employ a solution of&mdash;</p>
+
+<p>
+<span style="margin-left: 2em;">Borax, twenty grains</span><br />
+<span style="margin-left: 2em;">Glycerine, one teaspoonful</span><br />
+<span style="margin-left: 2em;">Water, an ounce.</span><br />
+</p>
+
+<p>Now and then the use once or twice a day in addition of a
+very weak solution of caustic, as two grains of lunar caustic to
+an ounce of water, in bad cases is necessary; but of this it
+must be left to the doctor to decide.</p>
+
+<p><span class="smcap">Teething.</span>&mdash;The transition is a very natural one by which
+we pass from the study of the dangers and difficulties which
+attend the feeding and rearing of young infants, to those which
+accompany <i>teething</i>.</p>
+
+<p>The time of teething is looked forward to by most mothers
+with undisguised apprehension, nurses attribute to it the most
+varied forms of constitutional disturbance, and doctors constantly
+hold forth to anxious parents the expectation that their
+child will have better health when it has cut all its teeth. The
+time of teething, too, is in reality one of more than ordinary
+peril,<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a> though why it should be so is not always rightly understood.
+It is a time of most active development, a time of
+transition from one mode of being to another, in respect of all
+<span class='pagenum'><a name="Page_73" id="Page_73">[Pg 73]</a></span>those important functions by whose due performance the body
+is nourished and built up.</p>
+
+<p>The error which has been committed with reference to this
+matter, consists not in overrating the hazard of the time, when
+changes so important are being accomplished, but in regarding
+only one of the manifestations&mdash;though that indeed is the most
+striking one of the many important ends which nature is then
+labouring to bring about. A child in perfect health usually
+cuts its teeth at a certain time and in a certain order, just as a
+girl at a certain age begins to show signs of approaching womanhood;
+and at length attains it with but slight inconvenience
+or discomfort. The two processes, however, have this in
+common, that during both, constitutional disturbance is more
+common, and serious diseases are more frequent than at other
+times, and the cause in both lies far deeper than the outward
+manifestation.</p>
+
+<p>The great changes which nature is constantly bringing
+about around us and 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 which often disappoints human endeavours,
+or of the dangers which often attend on their accomplishment.
+Thus when her object is to render the child no
+longer dependent on the mother for its food, she begins to
+prepare for this long beforehand. The first indication of it is
+furnished by the greatly increased activity of the salivary
+glands, which during the first few months of existence have
+scarcely begun to perform their function, a fact which accounts
+for the tendency to dryness of the tongue of the young infant
+under the influence of very trivial ailments. About the fourth or
+fifth month, this condition undergoes a marked alteration; the
+mouth is now found continually full of saliva, and the child is
+constantly drivelling; but no other indication appears of the
+approach of the teeth to the surface, except that the ridge of
+the gums sometimes becomes broader than it was before. No
+further change may take place for many weeks; and it is
+generally near the end of the seventh month before the first
+teeth make their appearance. The middle cutting teeth of the
+<span class='pagenum'><a name="Page_74" id="Page_74">[Pg 74]</a></span>lower jaw are in most instances the first to pierce the gum; next
+the middle cutting teeth of the upper jaw; then usually the
+side cutting teeth of the lower jaw, and lastly, the corresponding
+ones of the upper. This, however, is not quite invariable,
+for sometimes all the cutting teeth in one jaw precede in their
+appearance any of those in the other. The first four grinding
+teeth next succeed, and often without any very definite order
+as to whether those of the upper or of the lower jaw are first
+visible, though in the majority of instances the lower are the
+first to appear. The four eye teeth follow, and lastly, the remaining
+four grinding teeth, which complete the set of first, or
+as they are often called, milk teeth.</p>
+
+<p>We must not, however, picture to ourselves this process as
+going on uninterruptedly until completed&mdash;a mistake into which
+parents often fall, whose anxiety respecting their children is excited
+by observing that after several teeth have appeared in rapid
+succession, the process appears to come to a standstill. Nature
+has so ordered it that teething which begins at the seventh or
+eighth month, shall not be completed until the twenty-fourth
+or thirtieth; and has doubtless done so in some measure with
+the view of diminishing the risk of constitutional disturbance
+that might be incurred if the evolution of the teeth went on
+without a pause. As a rule the two lower central incisors or
+cutting teeth make their appearance in the course of a week;
+six weeks or two months often intervene before the central
+upper incisors pierce the gum, but they are in general quickly
+followed by the lateral incisors. A pause of three or four
+months most frequently occurs before we see the first grinding
+teeth, another of equal length previous to the appearance of
+the eye teeth, and then another still longer before the last
+grinding teeth are cut.</p>
+
+<p>Though a perfectly natural process, teething is almost
+always attended with some degree of suffering. This, however,
+is not always the case, for sometimes we discover that an infant
+has cut a tooth, who yet had shown no signs of discomfort,
+nor any indication that teething was commencing, with the exception
+of an increased flow of saliva. More frequently indeed,
+<span class='pagenum'><a name="Page_75" id="Page_75">[Pg 75]</a></span>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;
+or the eruption of the teeth is preceded by much redness, and
+great heat of the mouth with profuse flow of saliva, and even with
+little painful ulcers of the edge of the tongue, or of the inner
+surface of either lip. With either of these conditions the child
+is feverish, fretful, and cries from time to time with pain, while
+at the same time the bowels often are relaxed, or the child
+coughs and wheezes as if it had caught cold.</p>
+
+<p>Symptoms such as these make up what nurses mean when
+they say that the child is suffering from its teeth, and this
+opinion is constantly followed by a request to the doctor to
+lance the baby's gums. Now this little operation when really
+called for often gives great relief, both to the local discomfort,
+and also to the general ailment from which the infant
+suffers, but it is often done when there is no occasion for it,
+and when consequently it causes needless pain, and does no
+good.</p>
+
+<p>There are four different conditions in which it may be right
+to have the child's gums lanced:</p>
+
+<p>First. When a tooth is very near the surface, and by cutting
+through the thin gum the child may be spared some
+needless suffering.</p>
+
+<p>Second. When the gums are very red and hot and swollen;
+only in this case the gum is scratched or cut, to bleed it, not
+with the idea of letting out the imprisoned tooth.</p>
+
+<p>Third. When the child has for some week or two been
+feverish and suffering; while, though the gum is tense and
+swollen, the tooth does not seem to advance.</p>
+
+<p>Fourth. As an experiment, when during the progress of
+teething a child is suddenly seized with convulsions for which
+there is no obvious cause. The irritation of the teeth may
+have to do with their occurrence; and the chance of relieving
+it by so simple a means is not to be thrown away.</p>
+
+<p>If the process of teething is going on quite naturally, no
+interference, medical or other, is either necessary or proper.
+<span class='pagenum'><a name="Page_76" id="Page_76">[Pg 76]</a></span>The special liability of children to illness at this time must
+indeed be borne in mind, and care must be taken not to make
+any alteration in the infant's food while it is actually cutting its
+teeth, but rather to choose the opportunity of some one of
+those pauses to which reference has been made, as occurring
+between the dates of appearance of the successive teeth, for
+making any such change. If the child is feverish, a little soda
+or seltzer water sweetened and given after the effervescence has
+subsided will be taken eagerly, and avoid the risk of putting
+the child too often to the breast, or giving it food too frequently.
+It seeks the one or the other because it is thirsty, and craves
+for moisture to relieve its hot mouth; not because it is hungry
+and needs nourishment. If the child has been weaned, still
+greater care will be required, for it will often be found that it is
+no longer able to digest its ordinary food, which either is at
+once rejected by the stomach, or else passes through the intestines
+undigested. Very thin arrowroot made with water, with
+the addition of one third of milk, will suit in many cases, or
+equal parts of milk and water with isinglass, or equal parts of
+milk and the white decoction. The bowels of course must be
+kept open with very simple and mild aperients, but the bowels
+are in general more inclined to diarrh&oelig;a than to constipation,
+and the diarrh&oelig;a of teething children is often troublesome and
+requires good medical advice.</p>
+
+<p>The ulcerated state of the mouth is usually connected with
+special disorder of the digestive organs, and that condition of
+acidity for which I have already recommended soda, magnesia,
+and similar remedies, while locally the mouth needs just that
+local care which is applicable in cases of thrush. Now and
+then, severe inflammation of the gums occurs, in which they
+become extremely swollen; and ulceration takes place of the
+gum just above where the tooth should come through, and
+even around some of those which have already appeared. These
+are cases in which lancing the gums would do nothing but
+mischief. They require the local care already insisted on, a
+mild plan of diet, and treatment to reduce any feverishness;
+and above all one medicine, the chlorate of potass, which in
+<span class='pagenum'><a name="Page_77" id="Page_77">[Pg 77]</a></span>doses of four grains every four hours for a child a year old, is
+almost a specific.</p>
+
+<p><span class="smcap">Affections of the Skin</span>.&mdash;There are a few affections of
+the skin to which children in early infancy are especially liable,
+concerning which a few words must be said.</p>
+
+<p>The Latin word <i>intertrigo</i> is used for that <i>chafing</i> of the
+skin of the 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 of care. Either wetted napkins are
+dried, and put on again without previous rinsing in water, or
+they have been washed in water containing soda, and not
+passed through pure water afterwards, or attention is not paid
+to change the infant's napkin immediately that it requires; or
+a fresh napkin is put on without previous careful ablution of
+the child; or lastly it occurs almost unavoidably in cases of
+diarrh&oelig;a from the extension of irritation beginning at the
+edge of the bowel.</p>
+
+<p>Care is usually all that is needed to remove, as it is to prevent
+this condition. The precautions which I have referred to
+with regard to cleanliness must be carefully observed, and
+moreover, each time even after passing water, the child should
+be carefully washed with thin gruel, or barley water, then dusted
+abundantly with starch powder, while the napkin must be
+thickly greased with zinc ointment. After the first six or seven
+months of life the napkin can be almost always dispensed with,
+if the child has been brought up in good habits, and in all
+cases of chafing, it is much the better way to put no napkin on
+the child when in bed, but to lay under it a folded towel,
+which can be removed, and a clean one substituted for it as
+soon as it becomes soiled.</p>
+
+<p>There is a very obstinate form of chafing, with great redness
+of the skin, and disposition to crack about the edge of the
+bowel which depends on constitutional causes, and calls at
+once for the interference of the doctor.</p>
+
+<p>Besides this purely local ailment, there is another skin
+affection which is seen over the body generally, and is known
+popularly by the name of <i>red gum</i>, or in Latin <i>strophulus</i>. I
+<span class='pagenum'><a name="Page_78" id="Page_78">[Pg 78]</a></span>mention the Latin name because I have known persons sometimes,
+misled by the similarity of sound, fancy that it had
+some connection with scrofula. It is met with less commonly
+now than formerly, when people were accustomed to keep
+infants unduly wrapped up, and to be less careful than most
+are now-a-days about washing and bathing. It depends on
+over-irritation of the sweat glands of the delicate skin of the
+infant, the result of which shows itself in the eruption on the
+body and face of a number of small dry pimples sometimes
+surrounded by a little redness, itching considerably, and when
+their top has been rubbed off by scratching having a little
+speck of dried blood at their summit.</p>
+
+<p>A rash like this, a sort of <i>nettle rash</i>, more blotchy and
+causing little lumps on the skin, which in a day or two come
+and go, sometimes appears in the intervals between the pimples,
+sometimes takes their place, and causes, as they do, much irritation.
+This nettle rash is usually dependent on some error of diet, on
+some acidity of the stomach, and, on their being corrected soon
+passes away, leaving the pimples as they were before, but
+sometimes being reproduced if the pimples cause excessive
+irritation of the tender skin.</p>
+
+<p>The matter of chief importance for a mother to know, is
+that these rashes have no serious signification. Their treatment
+is very simple. It consists in dressing the child very lightly,
+in bathing it very frequently with tepid water, avoiding as far
+as may be the use of soap, and in sponging it often to relieve
+the irritation with some simple alkaline lotion; such for instance
+as one recommended by the late Dr. Tilbury Fox, and which
+is composed of twenty grains of carbonate of soda, two teaspoonfuls
+of glycerine, and six ounces of rose water. Of course
+if the stomach is out of order that must be attended to, but a
+little fluid magnesia, once or twice a day, is all that is usually
+needed in the way of medicine.</p>
+
+<p>One other affection of the skin, very common, very distressing,
+very tedious, of which there are many varieties, generally known
+by the technical name of <i>eczema</i>, from a compound
+Greek word which signifies to flow, needs that I should
+<span class='pagenum'><a name="Page_79" id="Page_79">[Pg 79]</a></span>say something about it. It is not limited in its occurrence to
+infancy, nor does it of necessity cease when childhood is over,
+but continues to recur even in grown persons, and shows itself
+still from time to time even in the aged.</p>
+
+<p>For the most part, however, it makes its appearance between
+the fifth and twelfth month; sometimes seeming to be induced
+by the change of food when the child is weaned, and that even
+though the weaning may have been wisely managed; at other
+times showing itself when the irritation of teething begins, and
+in every instance being aggravated by the approach of each
+tooth to the surface, and abating in the intervals.</p>
+
+<p>It does not occur in all children with equal frequency or
+severity, and though there is no doubt but that it is often
+hereditary, and this especially 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 the same parents to be
+affected by it severely, while no trace of it appears in the
+others.</p>
+
+<p>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 looking very closely&mdash;more closely indeed than
+most persons are wont to do&mdash;this appearance will be seen to
+be produced by innumerable small pimples, smaller than pins'
+heads, and which itch violently. Now and then, even in the
+course of a few hours, these pimples disappear, leaving the skin
+rough, and peeling off in branny scales, while the surface beneath
+is red and irritable, a condition which also in a few days may
+subside. This, however, is less frequent than the opposite
+course of the affection, in which a drop of fluid forms at the
+top of each tiny pimple, and escaping forms a yellowish, thin,
+transparent, watery, irritating discharge, which reddens still
+more the raw and weeping surface of the skin. The fluid when
+abundant dries at length into yellowish flakes or crusts, which
+sometimes assume a brownish colour if the surface is made to
+bleed by irritating or scratching. If the crusts are not removed,
+the fluid which still continues to be poured out beneath them
+soon changes into matter or <i>pus</i> as it is called, and this, shut up
+<span class='pagenum'><a name="Page_80" id="Page_80">[Pg 80]</a></span>beneath the hard crust above, increases the irritation, and
+thickens the deposit. After a time the inflammation lessens of
+its own accord, the secretion diminishes, the crusts dry up, and
+at length fall off, leaving the skin red, slightly swollen, and its
+surface scaling off in flakes, which gradually cease to form, and
+the skin by degrees becomes quite sound again, and so remains,
+until perhaps the irritation caused by the approach of a new
+tooth to the surface, rekindles the old trouble, to go once
+again through the same stages as before.</p>
+
+<p>It is on the cheeks, the sides of the face, and the top of the
+head that these changes may be best studied, but there are other
+situations in which the same kind of process often goes on. It
+may be seen in the creases of the neck, or the folds of the thigh
+in fat children, only as two surfaces of skin are there in contact
+the fluid never dries to a crust, but the skin, red and sore and
+swollen, pours out an abundant secretion which, just as when
+it occurs behind the ears, gives out a strong 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 on the front of
+the chest, the back, and sometimes even over the whole body,
+and especially at any part where the pressure of the dress
+irritates the skin. When thus general, it seldom fails to pass
+into a chronic state such as to call for constant, skilled medical
+treatment.</p>
+
+<p>The attack often comes on with general feverishness, a hot
+skin, fretfulness, and restlessness, which subside when the skin
+begins to discharge, though the discomfort produced by the
+local irritation still continues. At other times, and this perhaps
+more often when the eruption first appears on the head, its onset
+is more gradual, and slight scurfiness and redness at the top
+of the head are first noticed, and then a little crust forms there
+which is firmly adherent, and is, therefore, often not entirely
+removed as it should be, and thus bit by bit the mischief extends
+until its cure becomes tedious and troublesome. When
+either from neglect, or from the ailment having set in acutely,
+the affection of the scalp is severe, the child's state is one of
+much suffering. The whole of the scalp becomes hot and
+<span class='pagenum'><a name="Page_81" id="Page_81">[Pg 81]</a></span>swollen, and covered over a large surface by a thick dirty crust,
+through cracks in which a thick ill-smelling greenish-yellow
+matter exudes on pressure. At different points around,
+pimples form with mattery heads,&mdash;pustules they are called&mdash;while
+the glands on each side of the neck become swollen and
+tender. When thus severe on the head it will be found also
+not merely on the face, but also on the body, and the poor
+suffering child is not only a miserable object to look upon, but,
+worn by constant restlessness, it loses flesh, and seems almost
+as though it could not long survive. Happily, however, the
+condition scarcely ever terminates fatally, though feeble health
+and stunted growth are not seldom the results of the early
+suffering. But besides, severe eczema in infancy always returns
+again and again in childhood and in after-life, and there is
+also a distinct connection between liability to eczema and to
+asthma; and this not simply nor mainly that the disappearance
+of an attack of eczema may be succeeded by an attack of asthma,
+but that the child who in infancy has had severe general eczema
+is more prone than another to develop a disposition to asthma
+as he attains the age of five or six, and this even though he should
+not have had any return of the skin affection in a severe form.</p>
+
+<p>It is evident then, that one cannot take too much pains to
+guard against the occurrence of eczema if possible, and at any
+rate to prevent its becoming severe. The disposition to it is
+often controlled by very simple precautions, such as bathing
+the face, the moment the skin shows any redness or roughness,
+with thin gruel or barley water, then powdering it with starch
+powder, and when the infant goes out, smearing the spot very
+lightly with benzoated zinc ointment, and making the child wear
+a veil. It will be observed that the exclusion of the air is in
+all these cases the object of the application far more than any
+specific virtue which it is supposed to possess, and many of the
+worst cases of eczema in grown persons are treated, in the great
+hospital for skin diseases in Paris, by an india-rubber mask, or
+by india-rubber covering of the affected part, and benefit
+thereby without any medicated application whatever. The
+thin layer of scurf which often forms on an infant's head should
+<span class='pagenum'><a name="Page_82" id="Page_82">[Pg 82]</a></span>not be allowed to remain there, since its presence is a source
+of irritation. If it is very adherent, the surface may be well
+greased overnight with a little clarified lard which will soften it,
+so that it can be readily washed off with weak soap and water
+in the morning. 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 instead of a sponge, which would be
+too harsh, it is better to employ a very large camel's hair brush
+or a soft shaving brush, which is more handy, and the surface
+after careful drying may be lightly smeared with zinc ointment.
+All ointments used must be washed off most scrupulously every
+day, otherwise they become rancid, irritate, and make matters
+worse.</p>
+
+<p>When eczema sets in acutely, with general feverish disturbance,
+cooling medicines are required, and the help of the
+doctor becomes necessary. These are the cases in which the
+eruption is not confined to the head or the face, but extends
+over the body generally. The child must be dressed as loosely
+as possible; and when in its cot, should lie there with no other
+covering than its little shirt; and nothing gives so much relief
+to the irritation as the abundant use of powder, either simple
+starch powder, or ten parts of starch powder to one of oxide of
+zinc, or carbonate 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 be used to apply
+the powder; but between the creases of the skin&mdash;which it is
+important to keep apart&mdash;fine linen, lint, or charpie must be
+employed, covered freely with powder, so as to prevent the
+surfaces from coming into contact. If the irritation is very
+distressing, a weak spirit lotion with a little carbolic acid
+may sometimes be sponged over the surface, and the powder
+renewed immediately; or other forms of soothing lotions may
+be used to abate the irritation.</p>
+
+<p>When the scalp is affected in the acute form of eczema
+crusts form very quickly; or in other cases they collect because
+people fear to disturb them when they see the raw surface
+<span class='pagenum'><a name="Page_83" id="Page_83">[Pg 83]</a></span>beneath. It is, however, a grievous mistake to allow them to
+collect; they are in themselves a source of irritation, and they
+entirely prevent any application reaching the skin beneath.
+They must always be removed, and never be allowed to form
+again. They can be removed either by the employment of a
+poultice, half of bread, half of linseed meal, or by the application
+over-night of a handkerchief soaked in sweet oil, and
+covered over with a piece of oiled silk, which softens the
+crusts effectually, and allows of their easy removal by abundant
+washing with weak soap and water.</p>
+
+<p>The best applications afterwards vary so much that it is
+impossible to lay down any positive rule. Sometimes the
+Carron oil, as it is termed: a liniment compound of equal parts
+of linseed oil and lime-water&mdash;a popular and most useful application
+in burns&mdash;gives most ease to the irritated skin; sometimes
+the mere exclusion of the air by means of the india-rubber
+cap; sometimes the abundant use of powder. In every
+case, at least once in every twenty-four hours the whole surface
+must be washed quite clean with barley water or thin gruel;
+and when the discharge lessens or ceases, as it will do in the
+course of time, then, but not till then, various ointments may
+be of service.</p>
+
+<p>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, and for arsenic; of which latter remedy, however,
+the results are uncertain; while in the acute stage, its
+influence is simply mischievous. Nothing is more difficult,
+nor calls for more skill, or larger medical experience, than the
+proper management of the various forms of chronic eczema.</p>
+
+<p>The question is sometimes asked whether it is safe to cure,
+or, as people call it, to dry up these eruptions in teething
+children. There can be no doubt but that it is very desirable
+to prevent their occurrence as far as may be by the use of the
+precautionary measures which I have explained. But when
+they have existed for some time, either attended with profuse
+discharge, or causing great irritation by their extent, there is no
+doubt but that care must be exercised in attempts at their cure,
+<span class='pagenum'><a name="Page_84" id="Page_84">[Pg 84]</a></span>that soothing measures such as I have advocated should be
+chiefly employed, and that the sudden drying up of the discharge
+by a too abundant use of dusting powders must be
+avoided. If, too, the diminution of the rash were followed by
+a worsening of the child's condition, by feverishness, by heaviness
+of the head, or any sign of disturbance of the brain, the
+attempt to cure the rash must at once be abandoned. At the
+same time I must add that such occurrences are very rare, and
+that for one case where I have had to regret my success in
+curing the rash, I have seen fifty in which I have been mortified
+by the failure of my endeavour.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8" href="#FNanchor_8_8"><span class="label">[8]</span></a> The directions given by the distinguished chemist, Dr. Frankland,
+to whom I am indebted for the suggestion, are as follows: 'One-third of
+a pint of new milk is allowed to stand until the cream has settled; the
+latter is removed, and to the blue milk thus obtained about a square inch
+of rennet is to be added, and the milk vessel placed in warm water.' (I
+may add that the artificial rennet sold by most chemists may be substituted
+for the other.) 'In about five minutes the rennet, which may again be
+repeatedly used, being removed, the whey is carefully poured off, and immediately
+heated to boiling to prevent its becoming sour. A further quantity of
+curd separates, and must be removed by straining through calico. In one
+quarter of a pint of this hot whey is to be dissolved three-eighths of an
+ounce of milk sugar, and this solution, along with the cream removed from
+the one-third of a pint of milk, must be added to half a pint of new milk.
+This will constitute the food for an infant of from five to eight months old
+for twelve hours; or, more correctly speaking, it will be one-half of the
+quantity required for twenty-four hours. It is absolutely necessary that a
+fresh quantity should be prepared every twelve hours; and it is scarcely
+necessary to add that the strictest cleanliness in all the vessels used is
+indispensable.'</p></div>
+
+<div class="footnote"><p><a name="Footnote_9_9" id="Footnote_9_9" href="#FNanchor_9_9"><span class="label">[9]</span></a> In our tables of mortality we find teething registered as having occasioned
+the death of nearly 5 (4.8) per cent. of all children who died in
+London under one year old; and of 7.3 per cent. of those who died between
+the age of twelve months and three years.</p></div>
+</div>
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_85" id="Page_85">[Pg 85]</a></span></p>
+<h2><a name="PART_III" id="PART_III"></a>PART III.</h2>
+
+<h3><i>ON THE DISORDERS AND DISEASES INCIDENT
+TO ALL PERIODS OF CHILDHOOD.</i></h3>
+
+
+<p>The ailments hitherto noticed are by no means all that may
+occur during infancy and early childhood, but those only which
+either happen then exclusively, or at least with far greater
+frequency than at other times.</p>
+
+<p>It will be most convenient to consider the others under the
+different systems to which they belong, as diseases of the head,
+of the chest, and of the bowels.</p>
+
+<p>Before entering on these new subjects, however, a few words
+may not be out of place with reference to what may be termed
+the second period of childhood. It is above all a time of
+wonderfully lessened sickness and mortality. We have not the
+means of stating exactly the rate at which mortality is lessened
+between the cessation of the first and the commencement of
+the second dentition; but we do know that it is ten times less
+between the age of one and five, and nearly twenty times less
+between five and ten than it was in the first year of existence.<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a>
+A mother's anxiety then may safely be quieted after the first
+year of her infant's life, and still more after the first set of teeth
+have been cut, for if her child is strong and healthy then, there
+will be comparatively little to fear for its future.</p>
+
+<p>Four years or thereabouts now follow, before any important
+<span class='pagenum'><a name="Page_86" id="Page_86">[Pg 86]</a></span>change takes place in the child's condition, for it is not until
+between six and seven years old that the first set of teeth begin
+to be shed, and the second to take their place. This change
+of teeth too is of far less moment as far as the health is concerned,
+than was the cutting of the first set. The first dentition
+was the preparation for an entirely new mode of life for the child,
+and was intended to fit it for a life independent of its mother.
+The second has no such signification; it is a mere local
+alteration rendered necessary by the growth of the jaws, and
+takes place quietly, by the gradual absorption of the roots of
+the first set of teeth, brought about by the pressure of the others
+as they approach the surface. Four teeth in each jaw are new,
+and replace no others, but usually they are cut without much
+discomfort, and the wisdom teeth do not concern us here, for
+they do not appear until childhood has long passed.</p>
+
+<p>But, though between the age of two years and of ten there
+is no important change, nor even preparation for a change in
+the constitution, the time is yet one of most active growth of
+the body, and consolidation of 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 the long bones
+previously connected with the shafts by means of cartilage or
+gristle, become firmly united by the conversion of that cartilage
+into bone, and a similar process goes on, though not
+completed till later, in the ribs and the breast bone.</p>
+
+<p>Rapid increase of height and weight; conversion of the
+elements of bone into bone itself, formation of muscle out of
+the fat, which in the young child was stored up as so much
+building material for an edifice in course of construction, require
+for their accomplishment perfect health, and the power of converting
+to its highest purposes all the nourishment received.
+What wonder then, if from time to time, the machinery thus
+hardly taxed, fails to be quite equal to the demands upon
+it, if pains in the limbs&mdash;growing pains, as they are commonly
+called, or head-ache, tell of the inadequate nerve supply. Or
+if from the same cause, a vague feverish condition comes on,
+in which the temperature is slightly raised, and the child
+<span class='pagenum'><a name="Page_87" id="Page_87">[Pg 87]</a></span>listless, and yet fretful, loses its cheerfulness, is dull at its easy
+tasks, and yet indifferent to play. This too is the time when
+any unsuspected defects, physical, or mental, or moral, begin
+to show themselves distinctly; when short sight becomes
+apparent so soon as the child has to learn its letters, when the
+dull hearing is perceived which makes it seem inattentive, and
+gives to its manner an unchildlike nervousness; and the weak
+intellect is displayed in causeless laughter, causeless mischief,
+causeless passion, imperfect power of articulation, or want of
+words, and by a restless busyness in doing nothing.</p>
+
+<p>Of all these things I shall have to speak later on more fully.
+They are the things however, which only those mothers notice
+who live much with their children, who do not banish them all
+day long to the nursery or the school-room, and learn from
+another whether they fare well or ill. They and only they
+will notice these things in whom there dwells that which the
+poet tells us of:</p>
+
+<div class="poem"><div class="stanza">
+<span class="i8">The mother's love that grows<br /></span>
+<span class="i0">From the soft child, to the strong man; now soft,<br /></span>
+<span class="i0">Now strong as either, and still one sole same love.<br /></span>
+</div></div>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_10_10" id="Footnote_10_10" href="#FNanchor_10_10"><span class="label">[10]</span></a> The exact numbers as given at p. xiv of the forty-fifth Report of the
+Registrar-General for all England in 1881 are to 1,000 living under one
+year 58 deaths; from one to five 6.1; from five to ten 3.3.</p></div>
+</div>
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_88" id="Page_88">[Pg 88]</a></span></p>
+<h2><a name="CHAPTER_VI" id="CHAPTER_VI"></a>CHAPTER VI.</h2>
+
+<h3>THE DISORDERS AND DISEASES OF THE BRAIN AND
+NERVOUS SYSTEM.</h3>
+
+
+<p>It is stated on good authority<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a> that more than half of the
+deaths at all ages from these causes take place in children
+under five years, a fact which at first sight seems as inexplicable
+as it is startling. There is, however, a twofold explanation of
+it: the circulation through the much softer tissue of the brain,
+unenclosed within a <i>firm bony case</i> as in after-life, varies with
+far greater rapidity in the infant than in the grown person, and
+hence the organ is far more easily overfilled with or emptied
+of its blood. Besides, any organ in which growth is going on
+with great rapidity is proportionately liable to become disordered
+or diseased. Now the brain doubles its weight in the
+first two years of life, and attains nearly its full size by the end
+of the seventh year.</p>
+
+<p>These two facts suggest a bright as well as a dark view of
+disorders of the brain and nervous system in early life. If
+disorder is more frequent, it is excited by slighter causes, is
+more likely to be temporary, and even its gravest symptoms,
+such as convulsions and paralysis, have a less serious import
+in the one case than in the others. If the grown man has a
+fit, and still more, if that fit is followed by paralysis, we fear
+and with reason that some vessel in the brain-substance has
+given way, or that some grave, probably irreparable damage
+<span class='pagenum'><a name="Page_89" id="Page_89">[Pg 89]</a></span>has been inflicted on it. In the child, and especially in the
+young infant, these accidents may mean nothing more than
+that the brain has suddenly become over-filled with blood, or
+that it has been disturbed by irritation&mdash;I know of no better
+term&mdash;in some distant organ.</p>
+
+<p><span class="smcap">Convulsions.</span>&mdash;There are in the body two great nerve
+masses, the brain and the spinal cord, through which all parts are
+brought into relation with each other. The spinal cord or spinal
+marrow receives impressions from all parts, imparts movement
+to the limbs, as well as gives activity to the functions of the various
+internal organs. The brain is the controlling power, and
+governs more or less consciously the movements which the
+spinal cord originates, and hence in proportion as the development
+of the brain advances, and its controlling power increases,
+those involuntary movements, fits or convulsions, which originate
+in irritation of the spinal cord, become rarer. The brain,
+at the age of three 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 former frequency; while from the age of ten
+to fifteen years, when the brain may be said to be perfected,
+only four per cent., instead of nearly eighty per cent. as in the
+first years of life, of all deaths from disorders of the nervous
+system are due to convulsions.<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a></p>
+
+<p>I dwell on this subject the more because there is in a fit of
+<i>convulsions</i> something so intensely painful to behold that it is
+easy to 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 brain rarely, very rarely, I do not say never, begins with
+convulsions; and next, that their real danger is in general in
+exactly opposite relation to the frequency of their occurrence.
+Convulsions now and then return thirty, forty, or more times
+in twenty-four hours, and continue to do so sometimes for
+three or four days together. They are, indeed, not without
+peril, for the perpetually returning disturbance of the circulation
+may give rise to an overfilling of the vessels of the brain, or to
+a stagnation of the blood within them, or the spasm may affect
+<span class='pagenum'><a name="Page_90" id="Page_90">[Pg 90]</a></span>the muscles which open and close the entrance to the windpipe,
+and the child may die choked as in a paroxysm of whooping
+cough, or in a fit of spasmodic croup, or lastly the violent and
+frequently repeated muscular movements may at length exhaust
+its feeble frame. But still, such frequently recurring
+convulsions are in themselves no evidence that the brain is
+diseased; they do but show that the irritability of the spinal
+cord is increased to a degree which the brain is no longer able
+to control, and which therefore manifests itself in violent convulsive
+movements.</p>
+
+<p>It is thus that the poison of scarlet fever or of small-pox
+sometimes displays its influence over the whole system by producing
+violent convulsions at the outset of those diseases; thus
+that they follow on some indigestible article of food, or that
+the mother, over-heated by violent exertion, or overwhelmed
+by the news of some unexpected calamity, sees her babe, to
+whom she is in the act of giving the breast, suddenly seized by
+a violent convulsion.</p>
+
+<p>In every instance, therefore, the first business is to ascertain
+the cause of the convulsion, to determine the seat of the irritation
+which has excited the nervous system to such tumultuous
+reaction. The convulsion which ushers in any one of the
+eruptive fevers in the infant or in the child, is only an exaggeration
+of the shivering which precedes the onset of fever
+in the adult. Has the child been exposed to the contagion of
+measles, small-pox, or scarlatina? is it teething, and if so, 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 its head uncovered? or has it, though in the shade,
+been sitting or playing out 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 of late been very
+severe? or has its breathing been accompanied with a peculiar
+catch or crow, the sign of spasmodic croup, and have at the
+same time its hands been usually half clenched, and the thumb
+shut into the palm, the sign of that disturbance which at length
+has culminated in an attack of convulsions? Such are the
+<span class='pagenum'><a name="Page_91" id="Page_91">[Pg 91]</a></span>questions, which in less time than it takes me to write, or others
+to read, the intelligent mother will put to herself, and will
+answer, instead of, in unreasoning alarm, giving all up as lost, or
+hastening without reflection to do something or other that
+were better left undone.</p>
+
+<p>The first thing to do in every case of convulsions, be their
+cause what it may, is to loosen the dress, so that no string nor
+band may interfere with respiration, and for this purpose strings
+must be cut and dresses torn. The next thing is to dash cold
+water on the face to induce a deep inspiration, for sudden death
+in a fit almost always takes place from interruption to breathing.
+With the same purpose the forefinger should be put into the
+mouth, and run rapidly to the root of the tongue, which should
+be drawn forward. The object of doing this is twofold; first,
+to prevent the tongue falling back, as in these circumstances it
+is apt to do, over the entrance of the windpipe and so producing
+suffocation, and in the next place the act very frequently puts
+an end to the spasmodic closure of the windpipe, and is followed
+by a deep-drawn breath which announces the infant's
+safety. If the child has cut any teeth, the handle of a spoon,
+round which a bit of rag has been wrapped, or a bit of wood,
+or a thin strip of india-rubber, should be put between the teeth
+as far back as possible to prevent the tongue being bitten; and
+often this is all that can be done.</p>
+
+<p>There are two circumstances, and two only, in which the
+warm bath is likely to be of use. At the onset of one of the
+eruptive fevers, a hot bath is sometimes of great service by
+stimulating the skin and thus bringing out the rash. In these
+cases the fit scarcely ever comes on in a child previously in
+perfect health, but for some hours at least it has appeared very
+ill, tossing about with great restlessness, with a dry, hot skin,
+and twitching of the tendons of the wrists; or, perhaps, with
+a pale face and cold hands and feet, but with the temperature
+of the body as high as 103&deg; or 105&deg;. Here the hot bath at
+96&deg; to 98&deg;, even rendered more stimulating by the addition
+of mustard, and continued for not more than five minutes,
+is sometimes of great service, and is speedily followed by
+<span class='pagenum'><a name="Page_92" id="Page_92">[Pg 92]</a></span>the cessation of the convulsions and the outbreak of the
+eruption.</p>
+
+<p>These, too, are the cases in which the use of the wet sheet,
+as practised in hydropathic institutions, is sometimes of great
+benefit, but I do not advise its employment except under
+medical advice.</p>
+
+<p>The second condition in which the bath, and here it is the
+tepid and not the hot bath&mdash;that is to say, the bath at from 87&deg; to
+90&deg;&mdash;is of service, is where the child is feverish and restless from
+over-fatigue or over-excitement, or from exposure to the sun or
+to an excessively hot atmosphere, and convulsions have come
+on in the course of this ailing. Here the tepid bath for ten
+or fifteen minutes, coupled with the application of cold to the
+head, will soothe the excitement and prevent the return of the
+convulsions.</p>
+
+<p>In neither this case, nor in that in which the hot bath is
+employed, is the result of the agent as magical as people sometimes
+seem to expect. It is rarely that convulsions cease while
+a child is actually in the bath. For the most part the influence
+of the bath is limited to abating their severity, shortening their
+duration, and indisposing to their return.</p>
+
+<p>The bath, then, is to be used when either a stimulating or
+a soothing influence on the surface is likely to be of service,
+and only then. In cases where the fits are produced by constipation,
+by improper food, or by the irritation of a tooth
+pressing against the gum, it is idle to use it, and equally so in
+instances where many fits have been recurring in the course of
+the same day. Where that is the case it must be self-evident
+that, be the cause what it may, it must be one over which either
+a hot or a tepid bath can have no influence, and that, painful
+as it must be to wait a passive spectator, that position is far
+wiser than that of a mischievous meddler. It is some consolation,
+also, to know that unconsciousness to suffering attends
+convulsions.</p>
+
+<p>There is one agent, chloroform, which often has a very
+remarkable influence in controlling frequently repeated convulsions.
+It is an agent, however, too hazardous to be trusted
+<span class='pagenum'><a name="Page_93" id="Page_93">[Pg 93]</a></span>out of medical hands, and even when the doctor administers it
+himself, the parents must fully recognise the fact that, inasmuch
+as the child may die during a fit quite independently of breathing
+chloroform, so the occurrence of that catastrophe during its
+employment is not to be made a subject of self-reproach to
+them, or of blame to the doctor.</p>
+
+<p>But you may ask whether there are no <i>signs</i> of that disturbance
+of the nervous system, by which you can judge beforehand
+that the occurrence of convulsions is probable. In proportion
+to the tender age of a babe, the greater is the probability,
+as I have already stated, that convulsions will be induced by
+slight causes, especially by such as digestive troubles. Unless
+you are aware of the phraseology that used at any rate to be
+common among nurses, you may be much alarmed at being
+told that the 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 signs that threaten convulsions&mdash;has
+had, in short, what in the time of our grandmothers used to be
+called <i>inward fits</i>. A child thus affected lies as though it were
+asleep, winks its imperfectly closed eyes, and gently twitches
+the muscles of its face&mdash;a movement especially observable
+about the lips, which are drawn as though into a smile. Sometimes,
+too, this movement of the mouth is seen during sleep,
+and poets have told us that it is the angels' whisper which
+makes the babe to smile&mdash;I am sorry that its meaning in plain
+prose should be so different. If this condition increases, the
+child breathes with difficulty, its respiration sometimes seems
+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 of wind, especially if the stomach is
+gently rubbed. When the disorder of the digestion, on whatever
+cause it depended, is removed, these symptoms speedily
+subside, nor is there much reason to fear general convulsions
+so long as no more serious symptoms show themselves. There
+is more cause for apprehension, however, when the thumbs are
+drawn into the palm, either habitually or during sleep; when
+<span class='pagenum'><a name="Page_94" id="Page_94">[Pg 94]</a></span>the eyes are never more than half-closed during sleep; when
+the twitching of the muscles is no longer confined to the angles
+of the mouth, but affects the face and extremities; when the
+child awakes with a sudden start, its face growing flushed or
+livid, its eyes turning up under the upper eyelid, or the pupils
+suddenly dilating, while the countenance wears an expression
+of great anxiety or alarm, and the child either utters a shriek,
+or sometimes begins to cry.</p>
+
+<p>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, the head and neck are drawn backwards
+and the limbs violently bent and stretched. Sometimes these
+movements are confined to certain muscles or are limited to
+one side, and I may add that such cases are of more importance
+as far as the state of the brain is concerned than those in
+which the convulsions are general. The eye is fixed and does
+not see; the fingers may be passed over it without its winking,
+the pupil is immovably contracted or dilated; the ear is insensible
+even to loud sounds, the pulse is small, very frequent,
+often too small, and too frequent even for the skilled doctor
+to count it; the breathing hurried, laboured and irregular;
+the skin bathed in abundant perspiration.</p>
+
+<p>After this condition has lasted for a minute, or ten minutes,
+or an hour or more, the convulsions cease; and the child
+either falls asleep, or lies 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, in which it may either be perfectly
+motionless, or twitching of some muscles may still continue;
+or, lastly, it may, though this seldom happens, die in
+the fit.</p>
+
+<p>It seems then, from all that has been said, that convulsions,
+though one of the most striking, are by no means one of the
+most conclusive signs of brain disease; that they are even more
+commonly the result of disorders of the nervous system from
+causes seated elsewhere, than of actual disease of what may be
+termed the great nervous centre.</p>
+
+<p>We may now therefore pass to the examination of these
+<span class='pagenum'><a name="Page_95" id="Page_95">[Pg 95]</a></span>diseases, which for the purposes of this book may be considered
+under the two heads of congestion and inflammation.</p>
+
+<p>I am forced to use these terms in somewhat of a popular
+sense, for to attempt in a little book like this to define everything
+with strict scientific accuracy would simply confuse and
+mislead.</p>
+
+<p><span class="smcap">Congestion of the Brain.</span>&mdash;By <i>congestion of the brain</i>
+is meant a condition in which its vessels are overcharged with
+blood; a condition which if it exists in an aggravated degree,
+ends either in the pouring out of blood on, or into the brain,
+on the one hand, or in inflammation on the other. Either of
+these terminations, however, is so rare in the previous healthy
+child, that I shall confine my remarks entirely to congestion
+of the brain, an affection specially liable to occur in children
+during teething. A certain degree of feverishness almost
+always accompanies teething. It is, therefore, not difficult to
+understand how, when the circulation is in a state of permanent
+excitement, a very slight cause may suffice to overturn
+its equilibrium, and occasion a greater 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 this season, but may
+occur at other times without any obvious exciting cause,
+and with no other explanation than is furnished by the well-known
+fact that all periods of development such as childhood,
+are periods during which the growing organs are most
+apt to become disordered.</p>
+
+<p>In the great majority of cases the symptoms of congestion
+of the brain come on slowly; and for the most part, general
+uneasiness, or disordered state of the bowels, which are usually,
+though not invariably constipated, and feverishness precede for
+a few days the more serious attack. The head by degrees becomes
+hot, the child grows restless and fretful, and seems distressed
+by light, or noise, or sudden motion, and children who
+are old enough sometimes complain of their head. Usually
+too, vomiting occurs repeatedly; a symptom of the greatest importance,
+since it may exist before there is any well-marked
+sign of head affection. Causeless frequently repeated vomiting
+<span class='pagenum'><a name="Page_96" id="Page_96">[Pg 96]</a></span>in a child not ill but ailing, is nine times out of ten a sign of
+mischief in the head. The degree of fever which attends
+this condition varies much, and its returns are irregular; but any
+one who knows how to feel the pulse will find it permanently
+quickened, and if the head is unclosed the pulsations of the
+brain may be seen and felt distinctly. The sleep is disturbed,
+the child often waking with a start, while there is occasional
+twitching of the muscles of its face, or of the tendons of its
+wrist.</p>
+
+<p>The child may continue in this condition for many days
+and then recover its health without any medical interference.
+This is especially likely to be the case with children while
+teething, the fever subsiding, the head growing cool, and the
+little one appearing quite well so soon as the tooth has cut
+through the gum, but the approach of each tooth to the
+surface being attended by the recurrence of the same
+symptoms.</p>
+
+<p>The fortunate issue of these cases though frequent, is by no
+means invariable, for sometimes they are but the precursors of
+that formidable, I might indeed say, all but hopeless disease,
+water on the brain. But even of itself congestion of the brain
+is by no means a trivial ailment, for it may pass into a stage in
+which the smaller discomforts of the child lead to the sad
+mistake that the condition of the child is improving, instead of
+which it is really the dulling of sensibility from approaching
+death. The head, indeed, becomes less hot, the flush of the face
+grows slighter and less constant; but the countenance is heavy
+and anxious, the indifference to surrounding objects increases,
+and the child lies in a state of torpor or drowsiness, from which
+indeed it can at first be roused to complete consciousness
+The manner on being roused is always fretful, but, if old
+enough to talk, the child's answers are natural, though generally
+very short; and murmuring, 'I am so sleepy, so sleepy,'
+it subsides into its former drowsiness. The bowels generally
+continue constipated, and the vomiting seldom ceases, though
+it is sometimes less frequent than before. In this state, without
+any apparent cause, the child sometimes has an attack of convulsions,
+<span class='pagenum'><a name="Page_97" id="Page_97">[Pg 97]</a></span>which subsiding, leaves the torpor deeper than before.
+The fits return, and death may take place in one of them, or
+the torpor growing more profound after each convulsive seizure,
+the child at length dies insensible.</p>
+
+<p>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 been poured out into the cavities of
+the brain, the yielding skull has given way under the pressure
+from within, and should the child after all survive, its large head,
+due to chronic water on the brain, tells to all who know how to
+interpret the signs, the tale of its past illness, and the manner
+of its imperfect recovery.</p>
+
+<p>Cases such as these are obviously beyond the reach of
+domestic management, and call for all the resources of medical
+skill. The mistake commonly made is that of calling in the
+doctor too late, because it is not realised how grave may be the
+import of symptoms which at first appear so little alarming;
+and the so-called experienced nurse having said, 'Oh! it's
+nothing but the baby's teeth,' time is lost and danger not anticipated
+till too late for remedy.</p>
+
+<p>The application of two, three, or four leeches at the very
+outset of these cases is often of great service, and sometimes
+cuts short symptoms which had seemed very threatening.
+The doctor, of course, must be the judge of its expediency, but
+I refer to it because I have known parents raise objections to it,
+and beg to have milder means tried first. It must be borne in
+mind then, that whenever leeches are of use it is at the beginning
+of an attack, and that the opportunity once let slip does
+not return. Purgatives, cold to the head, saline medicines,
+and perhaps some carefully selected sedative, are the measures
+which will probably be employed in most cases, but success will
+in great measure depend on the minute care with which all
+the details which I dwelt on in the introduction, are carried
+out.</p>
+
+<p>It is not always, indeed, that active treatment is desirable,
+and gentle measures then suffice; but nothing except close and
+<span class='pagenum'><a name="Page_98" id="Page_98">[Pg 98]</a></span>frequent watching can enable the doctor to steer safely between
+the two opposite dangers of too little and too much.</p>
+
+<p>When I come to speak of the eruptive fevers, I shall have to
+mention the convulsions and other signs of most serious brain disturbance,
+which sometimes occur at their outset, and which are
+due to the condition of the blood charged with the fever poison.</p>
+
+<p>A somewhat similar set of symptoms, attributed with reason
+to the overheated state of the blood, occurs in cases of <i>sunstroke</i>.
+It is true that sunstroke, with the formidable characters that it
+presents in hot countries, is not seen in England, but even here
+the mere exposure of an infant or young child to an overheated
+atmosphere, is by no means unattended with risk, and I refer to
+it here, because mothers are by no means aware of the danger,
+and believe that it suffices to guard the child from the direct
+rays of the sun.</p>
+
+<p>Alarm, restlessness, and fretfulness, alternating with drowsiness,
+hurried, irregular breathing, intense heat of skin, violent
+beating of the open part of the head, twitching of the limbs, and
+starting of the tendons of the wrists, with a pulse too rapid to
+be counted, are the symptoms when the attack is severe. Convulsions
+are rare, though they sometimes occur. Sickness is
+almost invariable, the stomach rejecting everything, and the
+bowels are almost invariably relaxed, severe diarrh&oelig;a or dysentery
+sometimes coming on, as the brain disturbance abates.
+The first shock may kill the child in a few hours, or it may sink
+under the subsequent diarrh&oelig;a, but as a rule recovery eventually
+takes place.</p>
+
+<p>All cases, indeed, are not equally severe, but all require
+careful and gentle treatment, the cool and darkened room, the
+quiet, the cold to the head, the tepid bath, and on the part of
+everyone the care not to allow the apparently serious condition
+of the child to urge them to those active measures which will
+here be out of place, and destroy the hopes which would revive
+after a few hours of patience and gentle means.</p>
+
+<p>Really acute inflammation of the brain is of so rare occurrence
+except as the result of accident or injury, and its symptoms
+are of so serious a character, even from the first, that medical
+<span class='pagenum'><a name="Page_99" id="Page_99">[Pg 99]</a></span>advice is obviously needed at once. I shall, therefore, pass it
+over here, and endeavour to describe two forms of inflammation
+of the brain which are much more frequent, and at their commencement
+more likely to be overlooked.</p>
+
+<p><b>Water on the Brain.</b>&mdash;One of these is the form of inflammation
+commonly known as <i>water on the brain</i>, a term which,
+though incorrect medically, has the advantage of being well
+understood. This, now, is not a simple disease, occurring in a
+previously healthy child, but it is a disease dependent on the
+same state of constitution as gives rise in other children to
+consumption, or scrofula, or disease of the mesenteric glands.</p>
+
+<p>It is this circumstance which renders the disease so serious,
+and recovery from it so extremely rare. This it is also which
+makes it so desirable to become acquainted with its symptoms,
+both that you may be alive to the approach of danger, and also
+not indulge in needless alarm when brain symptoms occur from
+other causes which have no relation whatever to those which
+give rise to water on the brain.</p>
+
+<p>The disease comparatively seldom comes on in a child who
+had previously seemed in perfect health; a state of vague ailing
+usually precedes its outbreak. The child loses flesh and
+strength, and the look of health, and the lustre of the eye, and
+the silky softness of the hair. The appetite becomes uncertain,
+the bowels irregular, with a tendency to constipation; there
+are little feverish attacks for a few hours, subsiding of their
+own accord. The sleep is not sound, the temper uncertain,
+the child tires even of its favourite toys; the brightness of the
+little face is changed for a strange, weird, wistful look&mdash;an
+unnatural earnestness; the child sits for moments gazing
+upward on vacancy, as though it saw, or sought something
+beyond.</p>
+
+<p>By degrees these vague premonitions, which may continue
+for weeks, become more and more marked till they pass into
+what may be called the first stage of the affection, in which
+there are signs of congestion of the brain, such as I have
+already described, coupled with general irregular attacks of
+feverishness. The child becomes more gloomy, more pettish,
+<span class='pagenum'><a name="Page_100" id="Page_100">[Pg 100]</a></span>and slower in its movements, and is little pleased by its usual
+amusements. Or, at other times, its spirits are very variable;
+it will sometimes cease suddenly in the midst of its play, and
+run to hide its head in its mother's lap, putting its hands to its
+head, and complaining of headache, or saying merely that it is
+tired and sleepy, and wants to go to bed. Sometimes, too, it
+will turn dizzy, as you will know, not so much from its complaint
+of dizziness as from its suddenly standing still, gazing
+around for a moment as if lost, and then either beginning to
+cry at the strange sensation, or seeming to awake from a reverie,
+and at once returning to its play. The infant in its nurse's
+arms betrays the same sensation by a sudden look of alarm, a
+momentary cry, and a hasty clinging to its nurse. If the child
+can walk it may be observed to drag one leg, halting in its gait,
+though but slightly, and seldom as much at one time as at
+another, so that both the parents and the medical attendant
+may be disposed to attribute it to an ungainly habit which the
+child has contracted. The appetite is usually bad, though
+sometimes very variable; and the child, when apparently busy
+at play, may all at once throw down its toys and beg for food,
+then refuse what is offered; or taking a hasty bite may seem to
+nauseate the half-tasted morsel, may open its mouth, stretch
+out its tongue, and heave as if about to vomit. The thirst
+is seldom considerable, and sometimes there is an actual aversion
+to drink as well as to food, apparently from its exciting
+or increasing the sickness. The stomach, however, seldom
+rejects everything; but the same food as occasions sickness at
+one time is retained at another. Sometimes the child vomits
+only after taking food, at other times, even when the stomach
+is empty, it brings up some greenish phlegm without much
+effort, and with no relief. These attacks of vomiting seldom
+occur oftener than two or three times a day, but they may
+return for several days together, the child's head probably growing
+heavier, and its headache more severe. The bowels during
+this time are disordered, generally constipated from the very
+first, though their condition in this respect sometimes varies
+at the commencement of the disease. The evacuations are
+<span class='pagenum'><a name="Page_101" id="Page_101">[Pg 101]</a></span>usually scanty, sometimes pale, often of different colours, almost
+always deficient in bile, frequently mud-coloured and very
+offensive. The tongue is not dry, generally rather red at the
+tip and edges, coated with white fur in the centre and yellowish
+towards the root, but occasionally very moist, and uniformly
+coated with white fur. The skin is harsh, but not very hot, the
+temperature seldom above 100&deg; Fahr., varying causelessly, but
+usually higher towards evening than in the daytime. The
+nostrils are dry, the eyes lustreless, and <i>the child sheds no tears</i>.
+It is drowsy, and will sometimes want to be put to bed two or
+three times in a day; but it is restless, sleeps ill, grinds its
+teeth in sleep, lies with its eyes partially open, awakes with the
+slightest noise, or even starts up in alarm without any apparent
+cause. At night, too, the existence of intolerance of light is
+often first noticed in consequence of the child's complaints
+about the presence of the candle in the room.</p>
+
+<p>I have purposely dwelt long on this preliminary stage because
+it is only in it that treatment is likely to be of any service,
+while the very indefiniteness of the symptoms constantly leads
+to their being overlooked, or referred to teething, or thought at
+any rate to be a mere temporary ailment for which it is not
+worth while to call in the doctor.</p>
+
+<p>After four or five days, however, the illness of the child
+becomes too marked to escape notice. All cheerfulness has
+fled, the eyes are closed to shut out the light, the child lies
+apparently dozing, but answers questions rationally, in a short
+quick manner in as few words as possible, and from time to
+time complains of its head, or utters a short, sharp lamentable
+cry. The night brings with it no other change than an increase
+of restlessness, attended sometimes with noisy cries, or with
+the wandering talk of delirium. Sickness often diminishes,
+but the bowels continue constipated, and it is to be noted that
+whereas in fevers the bowels are distended with wind, here all
+wind has disappeared and the belly is sunken to a striking
+degree.</p>
+
+<p>Next comes the last stage. Each stage is distinguished by
+peculiarities of the pulse which tell the expert what is passing;
+<span class='pagenum'><a name="Page_102" id="Page_102">[Pg 102]</a></span>quick and regular in the first stage; irregular and slower in the
+second; quick, variable, irregular from time to time in the
+third; growing more rapid and more feeble as the end arrives.
+Squinting, stupor, dilated pupil, difficulty of swallowing,
+tremulous limbs, convulsions, profound insensibility, such are
+the series of occurrences which bring on death usually within
+a fortnight, always within three weeks from the appearance of
+the first decided symptoms.</p>
+
+<p>What are you to do in these cases? Above all save yourselves
+the heartbreak of feeling that you have overlooked the
+premonitory symptoms of the disease. Guard with special care
+the health of any child in whose family a disposition to consumptive
+disease has ever shown itself, and keep it at any cost
+from the risk of catching the hooping cough or measles. Since,
+too, it is not in early infancy, but after the age of one year, and
+in the majority of instances between the ages of three and six
+years that this disease occurs, that is to say, at the time when
+the brain begins to be most actively exercised, when the new
+world on which the child is just entering brings with it new
+wonders every day; be very careful not to over-stimulate its
+intelligence, over-excite its imagination, or over-strain its mental
+powers. After the age of ten the great danger is over; up to
+that time it is the health of the body which requires care; not
+fuss, not rearing like a hothouse plant, but the healthy training
+that may fortify the system.</p>
+
+<p>When any signs such as I have described indicate the
+threatening of disease, 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 fully set in, and that
+was a recovery almost worse than death.</p>
+
+<p><b>Earache.</b>&mdash;There is another form of inflammation of the
+brain which is likewise oftenest met with in children who are of
+weakly constitution, or of scrofulous habit, or in whom scarlet
+fever has left behind that very troublesome ailment, discharge
+from the ear. This is so tedious, so difficult to cure, so apt to
+return under the influence of very slight causes, that people are
+<span class='pagenum'><a name="Page_103" id="Page_103">[Pg 103]</a></span>too ready to put up with it as an inconvenience which it is useless
+to try to remedy.</p>
+
+<p>In addition, however, to the risk of the child's hearing
+being impaired by the extension of the mischief to the internal
+ear, there is another still greater danger, namely, that of the
+<i>disease passing from the ear to the brain</i>, and producing inflammation
+of its membranes, or even abscess of its substance.</p>
+
+<p>It is therefore of the greatest moment that every case of
+chronic discharge from the ear should be looked on as important,
+and that no pains be spared to bring about its cure; and
+further, that during its continuance the slightest sign of disturbance
+of the brain&mdash;headache, sickness, feverishness, and dulness&mdash;should
+at once be noticed, and the advice of a competent
+doctor be immediately sought for.</p>
+
+<p>These dangers, however, follow almost entirely on long-continued
+discharges from the ear, but do not attend that
+acute inflammation of the passage to the ear which is often
+met with in childhood, and the symptoms of which sometimes
+cause needless fear, from being taken for those of inflammation
+of the brain. Attacks of <i>earache</i> are most frequent before the
+first set of teeth have been cut, and are by no means rare in
+young children, who are perfectly unable to point out the seat
+of their sufferings. The attack sometimes comes on quite
+suddenly, but usually the child is languid and fretful for a
+period varying from a few hours to one or two days before
+acute pain is experienced. In this premonitory stage, however,
+it will often cry if tossed or moved briskly; noise seems
+unpleasant to it, and it does not care to be played with; while
+children who are still at the breast show a disinclination to
+suck, though they will take food from a spoon. The infant
+seeks to rest its head on its mother's shoulder, or, if lying in
+its cot, moves its head uneasily from side to side, and then
+buries its face in the pillow. If you watch closely, you will see
+that it is always the same side of the head which it seeks to
+bury in the pillow, or to rest on its nurse's arm, and that no
+other position seems to give any ease, except this one, which,
+after much restlessness, the child will take up, and to which, if
+<span class='pagenum'><a name="Page_104" id="Page_104">[Pg 104]</a></span>disturbed, it will always return. The gentle support to the ear
+seems to soothe the little patient: it cries itself to sleep, but
+after a short doze, some fresh twinge of pain arouses it, or
+some accidental movement disturbs it, and it awakes crying
+aloud, and refusing to be pacified, and may continue so for
+hours together. Sometimes the ear is red, and the hand is
+often put to the affected side of the head, but neither of these
+symptoms is constant. The intensity of the pain seldom lasts
+for more than a few hours, when, in many instances a copious
+discharge of matter takes place from the ear, and the child is
+well. In some instances, indeed, the subsidence of the disease
+on one side is followed by a similar attack on the opposite
+side, and the same acute suffering is once more gone through,
+and terminates in the same manner. Sometimes, too, this
+complete cure does not take place, but the earache abates, or
+altogether ceases, for a day or two, and then returns; no
+discharge, or but a very scanty discharge, taking place, while,
+for weeks together, the child has but few intervals of perfect
+ease. In infants, earache seldom follows this chronic course,
+but it does sometimes in older children, and is then of the
+more importance, since it shows that the disease is no longer
+confined to the external passage, but has extended to the
+internal ear.</p>
+
+<p>In children who are too young to express their sufferings
+by words, the violence of their cries, coupled with the absence
+of any sign of disease in the chest or the bowels, naturally leads
+to the suspicion of something being wrong in the head. There
+are several facts, however, which may satisfy you that the case
+is not one of water on the brain&mdash;the child does not vomit, its
+bowels are not constipated, there is but little fever, the cries
+are loud and passionate, and are attended with shedding tears.
+If you watch closely, you will notice the dread of movement
+and the evident relief afforded by resting one side of the head,
+and always the same side, while often the movement of the
+hand to the 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
+<span class='pagenum'><a name="Page_105" id="Page_105">[Pg 105]</a></span>to satisfy yourselves that the cause of the suffering is in the ear
+by pressing the gristle of the organ slightly inwards, which will
+produce very evident pain on the affected side, while on the
+other side it will not occasion any suffering.</p>
+
+<p>The treatment of this painful affection is very simple. In
+many instances the suffering is greatly relieved by warm fomentations,
+or by applying to the ear a poultice of hot bran or
+camomile flowers, while at the 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 bone directly behind
+the ear seldom fails to give ease; while the disposition to the
+frequent return of the attack is often controlled by a series of
+small blisters, not larger than a sixpence, behind the ear. As
+soon as the tendency has sufficiently abated to admit of it, the
+ear should be syringed out twice a day with warm water, or
+with equal parts of warm water and Goulard lotion; but if
+pain or discharge still continues, medical advice must in all
+cases be sought for.</p>
+
+<p><b>Chronic Water on the Brain.</b>&mdash;There is still another
+form of inflammation of the brain, concerning which a few words
+will suffice. It constitutes what is termed <i>chronic water on the
+brain</i>, and in this instance the term is a correct one, for the
+disease usually depends on a slow form of inflammation of the
+lining membrane of the cavities of the brain, often beginning before,
+still oftener very soon after, birth, which ends in the pouring
+out of a quantity of fluid into them sufficient to enlarge
+the head to three or four times its natural dimensions.</p>
+
+<p>Such cases are very sad and very hopeless, and the great
+resource, which is sometimes adopted by medical men, of
+puncturing the head and letting out the fluid, is very seldom
+successful.</p>
+
+<p>But there are more hopeful cases sometimes met with, those
+namely of children in whom, either from simple weakness, or
+from that constitutional disorder called rickets, bone formation
+has been backward, and the head has consequently long remained
+unclosed. If such children, either from the irritation
+of teething, or from the straining during paroxysms of
+<span class='pagenum'><a name="Page_106" id="Page_106">[Pg 106]</a></span>hooping cough, suffer from congestion of the brain, fluid may
+be poured out, which, not being compressed by the too yielding
+skull, may in consequence enlarge it. These cases, however,
+may be distinguished from the other more serious ones by the
+date of their commencement, which is always much later than
+that of the other form, by the symptoms which attend them
+being less severe, and by the enlargement of the skull being
+far slighter.</p>
+
+<p>Still they require watching, for while with improved health
+the enlargement ceases, the fluid is in a measure absorbed, and
+the head diminishes in size, though always remaining larger
+than the average; brain mischief is yet more readily set up in
+children with such antecedents than in others.</p>
+
+<p>The anxiety of parents about the size or shape of their
+child's head after infancy has passed, is perfectly needless.
+When the head has once closed it always remains so. An odd
+shape, with an unusual protuberance of the forehead and the
+hind head, sometimes remain as the evidence of that condition
+in infancy to which I have just referred. It is, however, an
+evidence of mischief passed, not of mischief going on. In
+children too who have suffered from rickets, an affection rarely
+met with except among the poor in crowded cities, distortion
+of the limbs is often associated with a peculiar form of the
+skull, but in this too there is nothing to call for anxiety, still
+less to excite alarm. It is only a preternaturally small head
+and shelving forehead, which are found associated with mental
+deficiency; otherwise the greatest varieties of size and shape,
+of symmetry, or of want of it, may be associated with an equal
+variety of intellectual endowment, which is just as likely to be
+above as below the average.</p>
+
+<p><b>Brain Disorder from Exhaustion.</b>&mdash;It may at first
+sight appear strange that before leaving the subject of congestion
+and inflammation of the brain, I should find it necessary to give
+a caution against being misled by symptoms which though in
+some respects similar to those of congestion or inflammation,
+are in reality due to an exactly opposite condition.</p>
+
+<p>This mistake, however, is very possible; doctors themselves
+<span class='pagenum'><a name="Page_107" id="Page_107">[Pg 107]</a></span>sometimes fall into it,
+and some distinguished physicians have
+thought it worth their while to lay down very minute rules for
+distinguishing between the two opposite states. Headache we
+all know attends an overfull condition of the vessels of the
+brain, and grown persons usually suffer from it severely before
+an attack of apoplexy; but we also know that bad headache
+accompanies states of great weakness, and that it is one of the
+most distressing consequences from which a woman suffers who
+has lost much blood in her confinement. In just the same
+way, the infant who has been exhausted by diarrh&oelig;a or by some
+trying illness, or who after weaning has been kept on a diet not
+sufficiently nutritious, may show symptoms of disorder of the
+brain.</p>
+
+<p>It may become irritable, restless, very startlish, with occasional
+flushings of the face, moaning in its sleep, and sleeping
+with half-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 and pulsating, but flat or even depressed,
+the hands and feet are cool, and very readily become cold;
+there may be occasional vomiting, but nothing like the constant
+sickness of real brain-disease, the bowels are not shrunken but
+distended, constipation is not present, but on the contrary there
+is a disposition to diarrh&oelig;a. If the symptoms are misinterpreted
+and wrongly treated, unmistakable signs of exhaustion
+at last come on, and the child may die from its not being borne
+in mind that results at first sight much the same may flow
+from causes diametrically opposite.</p>
+
+<p>The moral of this is too obvious for me to need insist
+upon it. Cold to the head, low diet, aperients, possibly
+leeches, are needed in the one case; increased nourishment,
+perhaps stimulants, in the other. In every instance where
+symptoms of brain disorder occur in the child, remember the
+grievous consequences of a mistake as to their nature, and seek
+for further help and guidance to preserve you from the possibility
+of error.</p>
+
+<p><b>Spasmodic Croup.</b>&mdash;I have already tried to explain how,
+in early life, the brain is often unequal to control the sensitiveness
+<span class='pagenum'><a name="Page_108" id="Page_108">[Pg 108]</a></span>of the nervous system to various sources of irritation from
+without, and how, in consequence this irritation manifests itself
+by those involuntary movements which we call convulsions.
+But in addition to, or in the place of those violent contortions
+or convulsions, the same condition shows itself sometimes in
+disordered action of the muscles which subserve parts not
+directly subject to the will, as those for instance which open and
+close the entrance to the windpipe, or glottis as it is called in
+medical phraseology.</p>
+
+<p>Cases in which this occurs are known in popular language
+as child-crowing, or <i>spasmodic croup</i>, from the peculiar catch or
+crow which accompanies the entrance of air through the spasmodically
+contracted opening of the windpipe; a spasm which
+if severe and sufficiently continued closes the opening altogether,
+so that after fruitless efforts to get its breath the child
+dies suffocated. This affection occurs chiefly during teething,
+just as the fits of a hysterical girl oftenest occur during the
+transition from girlhood to womanhood; but many other causes
+besides the local irritation of the teeth may produce it, such as
+constipation, indigestible food, or disorder of the bowels.</p>
+
+<p>It does not often occur in perfectly healthy children; but
+an infant who is attacked by it is usually observed to have been
+drooping for some time previously, to have lost its appetite,
+to have become fretful by day and restless at night, and to
+present many of those ill-defined ailments which are popularly
+ascribed to teething. At length, after these symptoms have
+lasted for a few days or weeks, a slight crowing sound is occasionally
+heard with the child's respiration, shorter, more high-pitched,
+but less loud than the hoop of hooping cough.
+Usually it is first noticed on the child awaking out of sleep,
+but sometimes it is perceived during a fit of crying, or comes
+on while the infant is sucking. The spasm may have been
+excited by some temporary cause, and the sound which is its
+token may not be heard again; but generally it returns after
+the lapse of a few hours, or of a day or two, and its loudness
+usually increases in proportion as its return becomes more
+frequent. It will soon be found that certain conditions favour
+<span class='pagenum'><a name="Page_109" id="Page_109">[Pg 109]</a></span>its occurrence; that the child wakes suddenly with an attack of
+it, that excitement induces it, or the act of swallowing, or the
+effort at sucking, so that the child will drop the nipple, make a
+peculiar croupy sound with its breathing, and then return to
+the breast again. Throughout the whole course of the affection,
+its attacks will be found to be more frequent by night than by
+day; and to occur mostly soon after the child has lain down to
+sleep, or towards midnight, when the first sound sleep is drawing
+to a close.</p>
+
+<p>At first, the child seems, during the intervals of the attack,
+much as before; except, perhaps, that it is rather more pettish
+and wilful; but it is not long before graver symptoms than the
+occasional occurrence of an unusual sound when the child
+draws a deep breath excite attention, and give rise to alarm.
+Fits of difficult breathing occasionally come on, in which the
+child throws its head back, while its face and lips become livid,
+or an ashy paleness surrounds the mouth, slight convulsive
+movements 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, or the child begins to cry.
+Breathing now goes on naturally: the crowing is not repeated,
+or the crying ceases; a look of apprehension dwells for a
+moment on the infant's features, but then passes away; it turns
+once more to its playthings, or begins sucking again as if
+nothing were the matter. A few hours, or even a few days,
+may pass before this alarming occurrence is again observed, but
+it does recur, and another symptom of the disturbance of the
+nervous system is soon superadded, if it has not, as is often
+the case, existed from the very beginning. This consists in a
+peculiar contraction of the hands and feet; a state which may
+likewise not infrequently be noticed during infancy, unattended
+by any peculiarity in breathing. It differs much in degree;
+sometimes the thumb is simply drawn into the palm while the
+fingers are unaffected; at other times the fingers are closed
+more or less firmly, and the thumb is shut into the palm; or,
+coupled with this, the hand itself is forcibly flexed on the
+<span class='pagenum'><a name="Page_110" id="Page_110">[Pg 110]</a></span>wrist. In the slightest degree of affection of the foot, the
+great toe is drawn a little away from the other toes; in severer
+degrees the toe is drawn away still further, and the whole foot
+is forcibly bent upon the ankle, and its sole directed a little
+inwards. Affection of the hands generally precedes the affection
+of the feet, and may even exist without it, but the spasmodic
+contraction of the feet never exists without the hands being
+involved likewise. At first this state is temporary, but it does
+not come on and cease simultaneously with the attacks of crowing
+breathing, though generally much aggravated during its
+paroxysms. Sometimes a child in whom the crowing breathing
+has been heard, will awake in the morning with the hands and
+feet firmly bent, though he may not have had any attack of
+difficult breathing during the night. When the contraction is
+but slight, children still use their hands; but when considerable
+they cannot employ them, and they sometimes cry, as if
+the contraction of the muscles were attended with pain.
+Sometimes, too, there is a degree of puffiness both of hands
+and feet, a sort of dropsical condition, which, whenever it is
+present, adds much to the anxiety with reference to the child.</p>
+
+<p>As the condition becomes more serious, a slight crowing
+sound is heard each time the child draws its breath, the fits of
+difficult breathing are much more severe; they last longer, and
+sometimes end in general convulsions. The breathing now
+does not return at once to its natural frequency, but continues
+hurried for a few minutes after the occurrence of each fit of
+difficult breathing, and is sometimes attended with a little
+wheezing. The slightest cause is now sufficient to bring on an
+attack; it may be produced by a current of air, by a sudden
+change of temperature, by slight pressure on the windpipe, by
+the act of swallowing, or by momentary excitement. The state
+of sleep seems particularly favourable to its occurrence, and
+the short fitful dozes are interrupted by the return of impending
+suffocation, in one paroxysm of which longer and severer
+than the others the infant may fall back dead.</p>
+
+<p>It scarcely need be said that the great majority of cases
+have no such sad ending as I have described, but still, whenever
+<span class='pagenum'><a name="Page_111" id="Page_111">[Pg 111]</a></span>this spasm exists, even in a slight degree, there is always
+the possibility, never to be forgotten, of a sudden catastrophe.
+Usually, after some tooth has been cut which caused special
+irritation, or as disorder of the bowels has been set right, the
+symptoms abate by degrees, and then cease altogether, though
+liable to be reproduced by the same causes as those to which
+they were originally due.</p>
+
+<p>The seeking out and removing the exciting causes must
+be the care of the medical man, but there are some special
+precautions which come within the mother's own province to
+observe.</p>
+
+<p>First of all, as sudden excitement, and especially a fit of
+crying, are likely to bring on the attack, and since there is a
+possibility that any attack may prove fatal, the greatest care
+must be taken in the management of the child to avoid all unnecessary
+occasion of annoyance or of distress.</p>
+
+<p>Although the benefit that accrues from fresh air, or from a
+change of air, is often very great, yet it is very important that
+the child should not be exposed to the cold or wind, for I have
+seen such exposure followed by a severe attack of difficult breathing,
+or by the occurrence of general convulsions. Another reason
+for caution in this respect is that the occurrence of catarrh is
+almost sure to be followed by an aggravation of the spasmodic
+affection, which, though previously slight, may thereby be rendered
+serious or even dangerous.</p>
+
+<p>I have nothing to add to what I have already said with
+reference to the treatment of the attack, when actual convulsions
+come on. Since, however, in this affection convulsions
+may occur quite unexpectedly at any moment, it is well always
+to have a basin of cold water and a bunch of feathers handy,
+in order to be able at once to dash the water on the child's
+face, and induce that deep inspiration which saves it from
+the threatening danger. If this should not suffice, the finger
+must be put into the mouth, and run over the back of the
+tongue in the way that I have already explained when speaking
+of convulsions. Now and then it happens, though but very
+rarely, that violent <i>general convulsions</i> come on in infancy
+<span class='pagenum'><a name="Page_112" id="Page_112">[Pg 112]</a></span>quite independent of spasmodic croup, not preceded nor
+attended by any sign of disease of the brain, and which end in
+the course of some hours or of a few days in death, the child
+being partly worn out by the violence of the muscular movements,
+partly by the disturbance of breathing which each fit
+occasions. Happily, however, in most of these instances the
+convulsions by degrees lessen both in violence and frequency,
+and the child recovers.</p>
+
+<p><b>Epilepsy.</b>&mdash;There is one other point of view from which
+convulsions in infancy and early childhood must be looked
+on with apprehension, and that is from their being frequently
+followed in after years by <i>epilepsy</i>. In nearly a fifth of all
+cases of epilepsy in childhood that have come under my notice
+the first occurrence of fits dated back to early infancy, and
+this, even though an interval of years had passed between the
+last fit in infancy and the first in childhood. It seems, indeed,
+as though there were in these cases a peculiar abiding sensitiveness
+of the nervous system, which, dating back from very
+early life, dependent often on hereditary predisposition, was
+kindled into activity by any special cause, such as the cutting
+of the second set of teeth, or the transition from boyhood or
+girlhood to manhood or womanhood.</p>
+
+<p>In the child, just as in the grown person, epilepsy manifests
+itself in two different ways; either by momentary unconsciousness,
+or by violent convulsions, in which latter there is little
+distinction from the occasional fit which may be observed at
+any period of infancy.</p>
+
+<p>The attacks of momentary unconsciousness often pass long
+unnoticed. They occur, perhaps, when the child is at play or at
+meals; it stops as if dazed, its eye fixed on vacancy; if standing,
+it does not fall, nor does it drop the toy or the spoon which it
+was holding from its hand. If speaking, 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 meal as though
+nothing had happened; or it suffices to call the child and the
+cloud passes from its face, and it is itself again; and the nurse
+<span class='pagenum'><a name="Page_113" id="Page_113">[Pg 113]</a></span>or perhaps even the mother, thinks that it is some odd trick
+which the child has got. By degrees the attacks become more
+frequent, and may continue to recur several times a day without
+any obvious cause, even for months; and this without any
+change in their character. By degrees, however, under their
+influence, an alteration takes place slowly in the child's disposition.
+It loses its cheerfulness and brightness, its face
+assumes a heavy look, it becomes fretful, and its intelligence
+grows duller.</p>
+
+<p>Almost invariably after the attacks of this, which has been
+called the <i>petit mal</i>, have continued for some months, a change
+begins to take place, which does not fail to excite attention and
+to cause alarm. If seated, the child's head drops forward for
+a moment, and strikes against the table; if standing, it becomes
+for an instant dizzy, and staggers, or even falls, and then there
+is twitching of one limb, or of the muscles of the face, and then
+the complete fit of epilepsy, ushered in sometimes, but not always,
+by a momentary cry, and then the convulsive twitching of one
+limb, followed in a minute or in less time by convulsions of the
+whole body as well as of the limbs. The upturned eyes, which
+do not see, are horribly distorted, the child foams at the mouth,
+it is insensible, and the insensibility deepens into stupor, or is
+followed by heavy sleep, for a quarter of an hour, or an hour or
+more, from which the patient arouses feeling tired and bruised,
+and often with an aching head, but with no remembrance of
+what has passed during the seizure so distressing to bystanders.</p>
+
+<p>It has throughout been my endeavour not to lose sight of
+those for whom this little book has been written, and with reference
+to epilepsy, as with reference to many other things, I pass
+over much that would be important to the practitioner of medicine,
+to dwell on those points which mainly interest the parents,
+and which they are perfectly able to appreciate.</p>
+
+<p>The question is often put as to the probability of fits terminating
+in epilepsy; or, on the other hand, as to the ground for
+hope in any case that epileptic attacks, which have already often
+recurred, will eventually cease. In the first place, no conclusion
+<span class='pagenum'><a name="Page_114" id="Page_114">[Pg 114]</a></span>can safely be drawn from the severity of a convulsion, nor from
+its general character, as to the probability of its frequent recurrence,
+or of its passing into permanent epilepsy. The severity
+of a fit certainly affords no reason for this apprehension, nor
+does its recurrence, so long as a distinct exciting cause can be
+discovered for each return. The fits, which cease in the teething
+child when the gum is lanced, and which, on each succeeding
+return are equally relieved by the same proceeding, do not
+imply that there is any great tendency on their part to become
+habitual. In the same way, the attacks which follow on constipation,
+or on indigestion, or on some other definite exciting
+cause, may probably with care be guarded against, and their
+return prevented. It is not the violence of a single fit, nor even
+the frequent return of fits for a limited time, which warrants the
+gravest apprehension; but it is their recurrence when all observable
+causes of irritation have passed away; it is their return
+when the child is otherwise apparently in perfect health.</p>
+
+<p>If, on the one hand, the violence of a convulsion does not
+by any means imply the greater proportionate risk of its recurrence,
+so neither can any hopeful conclusion be drawn from the
+slightness of an attack, or from its momentary duration. In
+childhood, such attacks are at least as common preludes to confirmed
+epilepsy as in the adult, and are the more deserving of
+attention from their very liability to be overlooked. I believe,
+too, that an imperfect suspension of consciousness, the child
+knowing what passes, though unable to speak, is not very uncommon,
+and further, that it is far from unusual to have the
+early stage of epilepsy in 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 early symptoms of
+epilepsy in childhood are also the more likely to be misinterpreted
+from the circumstance that they are frequently accompanied
+by a moral perversion much more striking than any loss
+of mental power. It is true that in early life there are alternations
+of intellectual activity and mental indolence, of quickness
+and comparative dulness, which all who have had much to do
+<span class='pagenum'><a name="Page_115" id="Page_115">[Pg 115]</a></span>with education are well aware of, and which are perfectly compatible
+with health of body and health of mind. But changes
+in the moral character of a child who is still under the same
+influences, have a far deeper meaning than is often attached
+to them; a child does not suddenly become wayward, fretful,
+passionate, or mischievous, except under the pressure of some
+grave cause.</p>
+
+<p>One other point there is also to be borne in mind; namely,
+that the child is compelled by the vague sensation of hitherto
+unknown dread, not to conceal the early symptoms of epilepsy
+as the grown person would do; longing as the child does for
+love and sympathy, and weakened in its moral force, it craves
+for more love, more sympathy, it exaggerates its symptoms, it
+assumes some which do not exist at all. The conclusion is a
+natural one, but none the less mistaken, that the child who is
+discovered to be shamming has nothing the matter with it&mdash;is
+simply a naughty child. This is a fact of much importance, on
+which I shall have occasion to insist further on.</p>
+
+<p>In the child, as in the adult, epilepsy blunts the intellect as
+well as weakens the moral powers; and does both more speedily
+and more effectually in proportion as the child is younger, and
+its mind and will are less developed. And yet this has its
+compensation; for as the powers fade quickly, so, if the attacks
+cease, they recover with surprising rapidity, and as the moral
+powers are the first to suffer, so they are the first to regain&mdash;I
+will not say full vigour, but at least a degree which raises the
+children to be objects of specially tender affection, rather than
+of pity and compassion.</p>
+
+<p>The conditions which justify the most hopeful view of any
+case of epilepsy are then, first, the absence of any history of
+frequently recurring convulsions in early infancy; secondly, the
+existence of a distinct exciting cause for the attacks; thirdly,
+the rarity of their return far more than their slight severity; and
+lastly, the more the attacks approach in character to what one
+knows as hysteria, the less profound the insensibility in the fit,
+the shorter its duration afterwards, the greater are the grounds
+for hope that the seizures will eventually cease.</p>
+
+<p><span class='pagenum'><a name="Page_116" id="Page_116">[Pg 116]</a></span>Cases of this last class are to some degree, at any rate,
+under the child's control. I have several times seen a fit
+warded off by the threat of the shower bath, or even by calling
+to the child, and sending it to fetch something in another
+room. Such cases may indeed pass into ordinary epilepsy, but
+often, under judicious management, moral rather than medical,
+they cease, so that one can venture on taking a more hopeful
+view of them than of others.</p>
+
+<p>And this brings me to the question of what can be done,
+or rather what can parents do to promote recovery from epilepsy.
+First of all, do not listen to what you may hear about this medicine
+or the other being a specific for it. There is no specific whatever
+for epilepsy, but there are certain remedies which in skilful
+hands do have a real though limited power to control the
+frequency and lessen the severity of the attacks. Next, there
+are cases in which the attacks depend on some definite cause;
+it may be indigestion, or constipation, or the cutting of the
+second set of teeth, and on the irritation produced by those
+teeth being too crowded. Thus, I remember a boy twelve
+years old, in whom two severe epileptic fits occurred apparently
+without cause. He was cutting his back grinding teeth, and
+in the lower jaw the teeth seemed overcrowded. I had a
+tooth extracted on either side, the fits ceased, and when I last
+heard of him many years afterwards they had not returned.</p>
+
+<p>Epilepsy often lasts for many years, and no one's memory
+is retentive enough to be trusted with all the details between
+the different attacks, the causes which seemed to produce
+them, the measures which appeared at different times to be of
+service. I am therefore accustomed to advise people, any of
+whose children have the misfortune to be epileptic, to write 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
+their character and duration; and general remarks, which
+would bear on the child's temper and general condition, and
+in which column any probable exciting cause of an attack
+would be recorded. It is surprising how much important information
+<span class='pagenum'><a name="Page_117" id="Page_117">[Pg 117]</a></span>is gathered in a few months from such a record kept
+faithfully.</p>
+
+<p>The diet should be mild, nutritious, but as a general rule
+unstimulating; and should include meat comparatively seldom,
+and in small quantities. Some fifty years ago, a very distinguished
+American physician, Dr. Jackson of Boston, in the
+United States, insisted very strongly on the importance of a
+diet exclusively of milk and vegetables in greatly lessening the
+frequency and severity of epileptic attacks. I believe in the
+great majority of cases of epilepsy in childhood Dr. Jackson's
+advice is worth following. And I may add that, while I have
+little faith in the influence of mere drugs, I have a yearly increasing
+confidence in that of judicious management, mental
+and moral, as well as physical.</p>
+
+<p>The first requisite in all cases is a firm and gentle rule of
+love on the part of those who have charge of the child. As
+violent and sudden excitement of any kind will often bring on
+an epileptic seizure, so the influence of the opposite condition
+in warding off its attacks is very remarkable; and on several
+occasions I have received patients into the Children's Hospital
+who were reported to have epileptic seizures several times in a
+day, and who nevertheless remained a fortnight or more in the
+institution without any attack coming on. The disorder, however,
+was not cured, but only kept in check by the gentle rule
+to which the little ones were subjected. The order goes for
+much in these cases; the novelty goes for something too, for
+almost invariably I have found that after a time the apparent
+improvement becomes less marked, and though they continued
+better than when they first came to the hospital, the children
+were still epileptic; the advance of the disease had been retarded,
+but its progress had not been arrested. The quiet
+then which suits the epileptic, is not the quiet of listless,
+apathetic idleness, but the judicious alternation of tranquil
+occupation and amusement. The mind must not be left to
+slumber from the apprehension of work bringing on a fit, but
+the work must, as far as possible, be such as to interest the
+child. In the occupations of epileptics therefore, pursuits
+<span class='pagenum'><a name="Page_118" id="Page_118">[Pg 118]</a></span>which not merely employ the mental faculties, but also give work
+to the hands, such as gardening, carpentering, or the tending
+of animals, are specially 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 same age have
+acquired, is of very little moment. Many epileptics have an
+indistinct articulation, and almost all have a slouching gait, and
+an awkward manner. The former can often be corrected to a
+considerable degree by teaching the child simple chants, which
+are almost always easily acquired, and practised with pleasure.
+The latter may be rectified by drilling, not carried out into
+tedious minuti&aelig;, but limited to simple movements; and the
+irksomeness of drill is almost completely done away with by
+music, while I believe that the accustoming a child to the
+strict control and regulation of all its voluntary movements is
+of very great importance indeed as a curative agent.</p>
+
+<p>It is difficult to carry out these minute precautions on
+which so much depends in the home with other children of the
+same family. It is therefore, I believe, better for the child,
+painful though it is to the parents, that he should be placed
+under the care of some competent person who will devote the
+whole of his time to the care of the patient.</p>
+
+<p><b>St. Vitus's Dance.</b>&mdash;A state of unconsciousness, accompanied
+with more or less violent involuntary movements, is
+characteristic of epilepsy. Involuntary movements without
+loss of consciousness constitute the disorder commonly known
+as <i>St. Vitus's Dance</i>. It is rare in early childhood, becomes
+more common after the age of five, and attains its greatest frequency
+between the ages of ten and fifteen, girls, owing to
+their more impressionable nervous system, being affected by it
+more than twice as often as boys.</p>
+
+<p>It seldom comes on in a child previously in perfect
+health, and strangely enough it occurs with special frequency
+in children who have before suffered from rheumatism. Sudden
+shock or fright is often said to have been its exciting cause;
+but even then the symptoms seldom come at once, but are
+<span class='pagenum'><a name="Page_119" id="Page_119">[Pg 119]</a></span>gradually developed in the course of two or three days. At
+first, 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 it stumbles in walking, and then the muscles of the face
+become affected, the child grimacing strangely, and next the
+limbs of the opposite side become involved, and as things go on
+from bad to worse, the child becomes unable to hold anything
+in its hand, to walk, or even to stand, and even if on the ground
+still writhes about with the strangest contortions of its body.
+If matters grow still worse, the child becomes unable to put
+out its tongue, it swallows with difficulty, it loses not only 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 limbs is lost for the time, and they seem almost
+paralysed. Happily cases so severe are very rare, and it is
+rarer still for them to have a fatal termination. Almost invariably
+recovery takes place by degrees, the movements lessen,
+swallowing is performed with less difficulty, the power of speech,
+returns, and the intellect regains its brightness: but the child
+is left with a special liability to return of the affection, though
+the first attack is usually the most severe.</p>
+
+<p>Even at the best, however, the disorder is always tedious,
+as is shown by the fact that its average duration is seventy
+days. It is very natural, therefore, that parents should be
+anxious when they see that their child has some awkward or
+ungainly habit, some odd trick or gesture never noticed before,
+lest it should be the beginning of this tedious ailment. Now
+it is well to remember that St. Vitus's dance does not begin
+with twitching of the muscles of the face, but that its earliest
+symptoms are involuntary movements of the arms and twitching
+of the fingers, and that contortions of the face do not come on
+till afterwards. Movements of this sort too, even when not
+limited to the face, 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, in twitching of the muscles of the
+face or neck, or in some awkward gait or manner. These are
+<span class='pagenum'><a name="Page_120" id="Page_120">[Pg 120]</a></span>all best left unnoticed, for they are almost invariably made
+worse if the child's attention is called to them. They are, or
+at least before the days of Board Schools they were, scarcely
+ever met with among the children of the poor, for they almost
+invariably depend on mental strain; not of necessity on undue
+length of the hours of study, or on the difficulty of the tasks
+imposed, but often on a child's anxiety to make progress and
+to keep up with his schoolfellows. In corroboration of this
+being their cause I may say that, contrary to the rule which
+obtains with St. Vitus's dance, these movements are more
+frequent in boys than in girls, for the over-mental strain of
+boys comes earlier; that of girls seldom occurs before the time
+of transition to womanhood, and its results are then different,
+though much graver. In cases of this kind, lessening the
+mental strain is almost always followed by a cessation of the
+movements; change of air, country amusements, and a generally
+tonic treatment perfect the cure, and dancing and gymnastics
+overcome the remains of any awkward habit.</p>
+
+<p>The movements in real St. Vitus's dance do not shift
+about as these do from one part to another, but tend to involve
+various parts in succession, without previously ceasing where
+they had begun.</p>
+
+<p>The relative share which the parents and the doctor take
+in the treatment of these cases depends to a great extent on
+their severity. While attention to the state of the bowels, and
+a generally tonic treatment are almost always needed, gymnastics
+and drill are often of very great service in the slighter cases;
+and a very distinguished Paris physician was accustomed to
+send children thus affected to march round the Place Vend&ocirc;me,
+keeping step while the band was playing. The utility of gymnastics
+turns very much on the degree in which the child is
+able by attention to control his movements, and when either
+as in young children fixed attention cannot be roused, or as in
+severe cases the effort only adds to the child's nervousness,
+and in consequence increases the movements, they must be
+given up. All drill and gymnastics are best carried out in
+class with other children, and regulated not simply by word of
+<span class='pagenum'><a name="Page_121" id="Page_121">[Pg 121]</a></span>mouth, but by a tune or chant. When recovery is in progress
+gymnastics will then in almost all instances find their place.</p>
+
+<p>Even when drill and gymnastics cannot be practised, regulated
+movements of the limbs carried out twice a day for ten
+minutes at a time are of very real service. Another's will here
+takes the place of that of the patient, and the limbs are thus
+taught, though far more imperfectly, to act in concert.</p>
+
+<p>Two or three more cautions may still be of service. Do
+not keep a child out of bed, and force it to try to exert itself
+when the movements are very severe; continued movement,
+voluntary or involuntary, fatigues. Let the child lie in bed;
+it rests there, and the movements, which always cease during
+sleep, become at once greatly lessened. So important indeed
+is it to avoid the exhaustion caused by incessant violent movement,
+that in bad cases it is sometimes necessary to swathe
+the limbs in flannel bandages, and so to confine them to splints
+in order to restrain them. Next, do not become over-anxious
+because the child grows stupid and ceases to talk; intelligence
+and the power of speech will certainly come back again. And,
+lastly, do not be impatient and think your medical adviser
+incompetent because the disorder lasts so long. An average
+duration of seventy days implies that while sometimes it ceases
+sooner, in others it lasts much longer than the two weary months
+of watching and waiting with which in any case you must lay
+your account.</p>
+
+<p><b>Paralysis, or Palsy.</b>&mdash;When speaking of St. Vitus's
+dance I said that there was a partial loss of power in the
+limbs as well as an inability to control their movements. After
+a fit of convulsions, or an epileptic seizure, power over some
+limb is often lost for a time which may vary from a few minutes
+to some hours. In the course of some serious diseases of the
+brain, one of the manifestations of the mischief is the impairment
+or the loss of power over one arm or leg, rarely over
+both; and lastly, that terrible disease diphtheria is often followed
+by a paralysis so general that the patient is sometimes
+for days unable to move even a finger, although the condition
+may eventually pass away.</p>
+
+<p><span class='pagenum'><a name="Page_122" id="Page_122">[Pg 122]</a></span>There is, however, a very <i>real paralysis</i> which occurs sometimes
+in infants and young children. It comes on for the most
+part quite suddenly, often unaccompanied by any sign of brain
+disorder, but tending nevertheless to issue in great permanent
+impairment of the power over the affected limb or limbs, and
+eventually to interfere with their growth and thus to produce
+serious deformity.</p>
+
+<p>It is in general impossible to assign any distinct exciting
+cause for the affection, though the fact that in two-thirds of
+the cases it occurs between the ages of six months and three
+years, proves it to be in some way intimately associated with
+teething. The oldest child in whom I have ever seen it was
+aged between seven and eight years, and the youngest a little
+under six months. It is of excessive rarity for the arm alone
+to be affected, but it is by no means unusual for the legs alone
+to be paralysed; though in the majority of instances power is
+lost on one side only, the leg and arm being both involved.</p>
+
+<p>A child goes to bed quite well, or at the worst having
+seemed slightly ailing and feverish for a day or two, and on
+waking in the morning it is suddenly discovered that power is
+lost over one leg or both, or over both arm and leg of one
+side. The loss of power is at first seldom complete, 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 that time recovery in general begins. It is now and
+then speedy, so that in three or four days all trace of the paralysis
+may have disappeared. This, however, is a fortunate exception
+to the general rule, which is that amendment is very tardy,
+showing itself first in the arm, afterwards in the leg, and, if
+both sides have been affected, more on one side than on the
+other. Unless the improvement is very rapid, it is almost
+always only partial, and the palsied limb, though it does not
+lose sensation, regains but little power; it grows much more
+slowly than the other, is always colder and wastes considerably,
+while, some muscles still retaining more power than others,
+it becomes twisted out of shape, and requires all the skill of
+<span class='pagenum'><a name="Page_123" id="Page_123">[Pg 123]</a></span>the orthop&aelig;dic surgeon to remedy or at least to lessen the
+consequent deformity.</p>
+
+<p>It has been ascertained that this form of palsy depends on
+a state of congestion, or overfilling of the minute blood-vessels
+of the spinal marrow. When the child gets well the congestion
+has passed away; but it does this speedily, and recovery is
+then rapid as well as complete. If it does not soon pass away,
+other changes take place in the spinal marrow, and recovery
+is then slow, incomplete, or even does not take place at all.</p>
+
+<p>Remedies are unfortunately of little avail here, but it is
+evident that when the palsy is quite recent all movement of
+the limb must be mischievous, and that the congestion of the
+spinal marrow to which it is due will be most likely to abate
+under the influence of perfect quiet, rest in bed, and soothing
+or fever medicines, or of such as are calculated to overcome
+constipation, or to correct any fault of digestion, while the
+importance of teething, and the possible expediency of lancing
+the gums must not be forgotten.</p>
+
+<p>Afterwards comes the time for exercise of the paralysed
+limb, for friction, for shampooing, for galvanism; all continued
+perhaps for months or years with unwearied patience, and I
+must add with reasonable expectations as to the result. The
+only additional remark which I have to make is this, that to
+gain any real good from galvanism, a battery must be procured
+under the direction of some medical man specially skilled in
+the use of electricity, and the mode of employing it must be
+learned thoroughly from him. It is merely idle to purchase a
+toy machine, and, giving it to the nurse to turn the handle for
+ten minutes twice a day, to fancy that you are making a serious
+trial of the effects of galvanism. As a mere money question,
+a costly machine, and several fees paid in order to be thoroughly
+instructed in the way to use it, is much cheaper than a
+cripple child.</p>
+
+<p>A few words may not be out of place with reference to
+cases in which paralysis is mistakenly supposed to exist. Much
+anxiety is sometimes expressed by parents concerning children
+who have long passed the usual age without making any
+<span class='pagenum'><a name="Page_124" id="Page_124">[Pg 124]</a></span>attempt to walk; or who having once walked seem to have
+lost that power. Now it often happens that after any weakening
+illness a child ceases for some weeks to walk, just as it
+ceases to talk. The power in both cases was newly acquired,
+it called for effort which, when strength is regained, will be put
+forth once more. The same applies to other instances in
+which children are late in learning to walk; 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,
+and regaining the power lose it again, or lose at least the
+desire to exert it more than once during the active progress of
+teething. But, holding the 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 other movement; or take it on your
+lap and tickle the soles of its feet, and laughing or crying, as
+the mood takes it, it will move its legs about as freely as you
+could wish and show that the power is still there, though for
+the present the child will not take the trouble to exert it.</p>
+
+<p>Gradual loss of power over one or other leg, especially if
+attended with pain either in the back or in the knee or hip,
+should always call for attention, and induce you to seek at
+once for medical advice. Such cases generally occur later in
+childhood than the conditions of which I spoke in the former
+paragraph, and may depend on disease of the spine or of the
+hip-joint, two serious conditions which it needs the medical
+expert to discover and to treat.</p>
+
+<p><b>Neuralgia and Headache.</b>&mdash;In the grown person neuralgia,
+as many of us know to our cost, is by no means infrequent;
+in the child it is very rare, and when a child
+complains of severe pain in the head, or of severe pain to the
+knee or hip apart from rheumatism, it is almost invariably the
+sign of disease of the brain in the one case, of the hip-joint in
+the other. To this rule there are indeed exceptions, but it will
+always be well to leave it to the doctor to determine&mdash;no easy
+matter by the bye&mdash;whether any given case is one of the rare
+exceptions or not.</p>
+
+<p>There is, however, one form of real <i>neuralgic headache</i>
+<span class='pagenum'><a name="Page_125" id="Page_125">[Pg 125]</a></span>which is by no means rare in children after the commencement
+of the second dentition, and which sometimes goes on into
+early manhood or womanhood, when it becomes what is commonly
+known as sick headache. It is essentially an ailment of
+development, incidental to the time when the brain is first
+called on for the performance of its higher functions.</p>
+
+<p>It does not by any means always depend on over-study,
+though I do not remember meeting with it in children who had
+not yet gone into the school-room; and I have frequently
+found it dependent on too continuous application, though the
+number of hours devoted to study in the course of the day
+may not have been by any means excessive.</p>
+
+<p>The child's brain soon tires, and the arrangement, so convenient
+to parents of morning lessons and afternoon play,
+works far less well for it than if the time were more equally
+divided between the two.</p>
+
+<p>The attacks not infrequently come on on waking in the
+morning, and rapidly become worse, the pain, which is almost
+always referred to the forehead, being attended with much
+intolerance of light and sound, with nausea, and often with
+actual vomiting. Like the vomiting of sea-sickness, however,
+previous stomach disorder has no necessary share in its production,
+and I may add, indeed, that it is often difficult to
+assign any special exciting cause for the attack. The suffering
+is more often relieved by warm or tepid than by cold applications,
+and not infrequently pressure or a tight bandage greatly
+mitigates it. In no case does the attack last more than twelve
+hours&mdash;usually not more than half that time; it passes off with
+sleep, and leaves the patient weak and with a degree of tenderness
+of the head to the touch.</p>
+
+<p>Such attacks may occur every fortnight, ten days, or even
+oftener, but their very frequent return, instead of increasing
+apprehension, should diminish anxiety. A first attack, indeed,
+may seem as though it threatened mischief, till it is seen how
+speedily and completely it passes off, and when afterwards a
+second or a third attack comes on with the same severity of
+onset, the same rapid worsening, and the same quick passing
+<span class='pagenum'><a name="Page_126" id="Page_126">[Pg 126]</a></span>away, you will feel convinced that the symptoms have no grave
+meaning.</p>
+
+<p>There is a headache of quite a different kind to which
+I must for a moment refer, that, namely, which depends entirely
+on imperfect vision, and for which spectacles are the remedy,
+not physic. The infirmity is not noticed during the first few
+years of life, but in later childhood, when a tolerably close attention
+to study has become necessary. Some of the minor degrees
+of short-sightedness, and want of power of adaptation of the
+eyes, such as exists in the aged, soon begin to interfere sensibly
+with the child's comfort, and the strain to which the eyes are
+subject produces a constant pain over the brow, the cause of
+which is often unsuspected.<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a></p>
+
+<p>In all cases, therefore, in which a child complains of constant
+pain over the brow for which there is no obvious cause, it
+is well to take the opinion of an oculist, who can best ascertain
+the power of <i>reading at different distances</i> and with each eye
+separately, and the real cause of symptoms which had occasioned
+much anxiety is thus often brought to light.</p>
+
+<p><b>Night Terrors.</b>&mdash;Before taking leave of the disorders of
+the nervous system, I must briefly mention the Nightmare, or
+Night Terrors of children, which often cause a degree of alarm
+quite out of proportion to their real importance.</p>
+
+<p>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 sharp and piercing cry. The child
+will be found sitting up in bed, crying out as 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 not
+recognise its parents, who, alarmed by the shrieks, have come
+into its room, but seems wholly occupied by the fearful impression
+that has roused it from sleep. By degrees consciousness
+returns; the child now clings to its mother or its nurse,
+<span class='pagenum'><a name="Page_127" id="Page_127">[Pg 127]</a></span>sometimes wants to be taken up and carried about the room,
+and by degrees, sometimes in ten minutes, sometimes in half-an-hour,
+it grows quiet and falls asleep; and then usually the
+rest of the night is passed undisturbed, though sometimes a
+second or even a third attack may occur before daybreak.</p>
+
+<p>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 recur at intervals for several weeks.
+The great point, however, to bear in mind is that they depend
+invariably on some disorder of the stomach or bowels, and are
+never an evidence of the commencement of real disease of the
+brain.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_11_11" id="Footnote_11_11" href="#FNanchor_11_11"><span class="label">[11]</span></a> Reports of the Registrar-General, as quoted at p. 30 of my <i>Lectures
+on Diseases of Children</i>. The actual numbers are 9,350 under five years
+old, out of a total of 16,258.</p></div>
+
+<div class="footnote"><p><a name="Footnote_12_12" id="Footnote_12_12" href="#FNanchor_12_12"><span class="label">[12]</span></a> Figures deduced from the 44th Report of the Registrar-General.</p></div>
+
+<div class="footnote"><p><a name="Footnote_13_13" id="Footnote_13_13" href="#FNanchor_13_13"><span class="label">[13]</span></a> Before I called attention to this form of headache in the last edition
+of my lectures, it had already been noticed without my knowledge, by a
+friend of mine, Dr. Blache, of Paris, in a very valuable essay on the headaches
+which occur during the period of growth.</p></div>
+</div>
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_128" id="Page_128">[Pg 128]</a></span></p>
+<h2><a name="CHAPTER_VII" id="CHAPTER_VII"></a>CHAPTER VII.</h2>
+
+<h3>THE DISORDERS AND DISEASES OF THE CHEST.</h3>
+
+
+<p>In speaking of the ailments which occur during the first month
+after birth, I have already noticed the peculiarities of breathing
+in early infancy, and the difficulties that sometimes attend the
+complete filling of the air-cells of the lungs, and the readiness
+with which when once filled they become emptied of air and
+collapse.</p>
+
+<p>On this ground it is therefore needless for me again to
+enter, and I may pass at once to consider those ailments which
+rise in increasing importance from a simple cold or catarrh to
+inflammation of the air-tubes or bronchitis, inflammation of the
+lung substance, as pneumonia, and inflammation of the membrane
+which lines the chest and covers the lungs, or pleurisy.</p>
+
+<p><b>Catarrh.</b>&mdash;A common cold or <i>catarrh</i> is not one of the
+ailments of very early infancy. The watery eyes, the sneezing,
+the cough, the slight feverishness and the heavy head are
+scarcely met with until after the age of three months; nor,
+indeed, are they often seen till the child is old enough to run
+about, to go out for a walk, and to encounter in consequence
+all the variations of temperature and of damp or dryness inseparable
+from the English climate.</p>
+
+<p>This, however, is not entirely due to the greater exposure
+of the child to these influences as it grows older, but in part
+also to the fact that the lining of the air-tubes is less sensitive
+in early infancy than it afterwards becomes. The young babe
+if it catches cold gets <i>snuffles</i>, or stoppage of the nostrils, which
+first become dry, and then pour out an abundant discharge,
+which sometimes dries and forms crusts, and causes the child to
+<span class='pagenum'><a name="Page_129" id="Page_129">[Pg 129]</a></span>suck with difficulty, and to breathe uncomfortably and with
+open mouth. In a few days, however, at the worst this discomfort
+passes away; and the only additional remark I have
+to make is, that since obstinate snuffles are sometimes a
+constitutional disease, the doctor's advice should always be sought
+if they last longer than a week.</p>
+
+<p>It is needless to describe a cold, but it is much more to
+the purpose to say how its occurrence is to be prevented, and
+nine times out of ten the observance of two simple rules will
+suffice for this. First, take care that there is no great difference
+between the temperature of the day and of the night
+nursery. The one should never be above 60&deg;, nor the other
+below 50&deg;, and the undressing and the bath should always take
+place in the warmer room. Second, never let the child wear
+the same shoes or boots in the house as it does out of doors.
+The change should be as much a matter of routine as the
+taking off its hat or its bonnet.</p>
+
+<p>The domestic management of a cold is simple enough.
+The usual error is the overdoing precautions, the keeping the
+room too hot, or overloading the child with extra garments,
+or its bed with extra covering, by which it is kept in a state of
+feverishness, or of needlessly profuse perspiration.</p>
+
+<p>If, for the first two days of a bad cold, the child is kept in
+bed, the room being at a temperature of 60&deg;, with no extra
+covering on the bed, but a flannel jacket for the child to wear
+when it sits up in bed to play, 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 a light diet of rice,
+and arrowroot, and milk, and a roasted apple, and some orange
+juice; nine times out of ten, or nineteen out of twenty, the
+cold will pass away with small discomfort to the child and no
+anxiety to the parents.</p>
+
+<p>Often a child objects to stop all day in its little cot, but
+move it to its mother's or nurse's big bed; and with a large
+tray of toys before it, and a little of the tact which love
+teaches, the day will pass in unclouded content and cheerfulness.</p>
+
+<p><span class='pagenum'><a name="Page_130" id="Page_130">[Pg 130]</a></span>It must of course be borne in mind that measles set in with
+all the symptoms of a bad cold, followed on the fourth day by
+the appearance of the eruption; and, moreover, watchfulness
+must always be alive to detect increase of fever, hurry of
+breathing, hardness or extreme frequency of cough, the sign of
+the irritation of the larger air-tubes having extended and
+become more severe, the evidence that the case from simple
+catarrh has become one of bronchitis.</p>
+
+<p><b>Bronchitis and Pneumonia.</b>&mdash;It is impossible to enable
+persons who have not received a medical education to distinguish
+between a case of bronchitis and one of pneumonia.
+Neither, indeed, is it of much importance that they should do
+so, for in both the dangers are of a similar kind, and both call
+equally for the advice of a skilful doctor.</p>
+
+<p>In <i>bronchitis</i> inflammation affects the lining of the air-tubes,
+travelling from the larger towards the smaller, and in
+bad cases extending even to their termination in the minute
+air-cells. The inflammation leads to the pouring out of a
+secretion, which by degrees becomes thick like matter, or
+even very tenacious, almost as tough as though it were a thin
+layer of skin. If this is very extensive, and reaches to the
+small air-cells, it is evident that air cannot enter, while that
+elasticity of the lung which I have already spoken of tends to
+drive out from the cells the small quantity of air they contained,
+and the child dies suffocated, partly from the difficulty in the
+entrance of air, partly from the collapse of air-cells from which
+the air has been slowly expelled.</p>
+
+<p>In <i>pneumonia</i> or inflammation of the lung-substance the
+process is different. A portion of one or other lung, sometimes
+of both, becomes overfilled with blood, or congested, and though
+the air-tubes themselves are not the special seat of the congestion,
+yet the air-cells are pressed on by the surrounding
+swollen substance, and the entrance of air into them is impeded.
+If the mischief goes further the substance becomes solid and
+impervious to air, and lastly it becomes softened, its structure
+destroyed, and infiltrated with matter; the affected part
+becomes really an abscess, though not bounded by the distinct
+<span class='pagenum'><a name="Page_131" id="Page_131">[Pg 131]</a></span>limits which would shut in an abscess of the hand or the foot.
+Inflammation, and the formation of an abscess anywhere is, as
+we know, attended by fever and much general illness, and inflammation
+of the lung is of course attended by fever and
+general illness in proportion to the importance of the organ
+affected. To these, too, must be added all the disturbance
+inseparable from any ailment which gravely interferes with
+breathing.</p>
+
+<p>In the great majority of instances inflammation of the lung-substance
+does not go on to the last stage, and recovery is not
+only possible, but probable, from congestion and solidification of
+the organ. Pneumonia, too, usually attacks only a portion of
+one lung, while in bronchitis the air-tubes of both are always
+involved. Hence of the two, serious bronchitis is more to be
+dreaded than serious pneumonia.</p>
+
+<p>Bronchitis is always developed out of previous catarrh,
+though there is a wide difference between the duration of the
+preliminary stage and the occurrence of serious symptoms in
+different cases; while it may be laid down as a general rule
+that the severity and danger of an attack are in proportion to
+the rapidity of its onset. An attack of pneumonia, or inflammation
+of the lung-substance sets in, as a rule, more suddenly,
+with fever, a temperature of 103&deg; to 105&deg;, general distress, headache,
+not unfrequently delirium; the urgency of which symptoms,
+the hurried breathing and the short, dry, hacking cough, and
+the tearless eyes are too often misinterpreted, and the state of
+the chest not examined.</p>
+
+<p>The doctor, of course, skilled in auscultation, will listen to
+the chest and give to all these symptoms their true signification.
+The lesson for the parent to bear in mind is never to
+neglect in a child the symptoms of what may seem to be but a
+common cold, but to seek for advice the moment the cough
+shows any disposition to become hard, or the breathing hurried.
+Next, when any sudden illness sets in with very high temperature
+and much general ailing, not to let the disorder of the
+head, or the delirium, make you shut your eyes to the import
+of the short cough, the dry eyes, the hurried breathing; and
+<span class='pagenum'><a name="Page_132" id="Page_132">[Pg 132]</a></span>lastly, to remember that, grave though the symptoms may be,
+the tendency in pneumonia is to eventual recovery, and that in
+early life bronchitis is the graver of the two diseases.</p>
+
+<p>A caution may not be out of place with reference to cases
+which may occur during the epidemic prevalence of <i>influenza</i>.
+A child is sometimes struck down by it, just as grown persons
+are sometimes, with great depression, extreme rapidity of
+breathing, and very high fever, which, passing off in a couple
+of days, leave a state of great exhaustion behind. It is well to
+bear in mind that such symptoms have no such grave meaning
+when influenza is prevalent as they would have at another time;
+and the knowledge of this fact may serve in some degree to
+control your anxiety.</p>
+
+<p><b>Pleurisy.</b>&mdash;It is not possible for anyone, without medical
+experience, to discriminate between pneumonia, or inflammation
+of the substance of the lung, and pleurisy, or inflammation
+of its covering. Some degree of the latter, indeed, very often
+accompanies the former, and this accounts for the pain which
+interferes with every attempt of the child to draw a deep breath.
+When pleurisy comes on independent of affection of the lung-substance,
+it generally sets in suddenly with severe pain in the
+chest, and a short hacking cough which causes so much pain
+that the child tries as much as possible to suppress it. After a
+few hours the severity of the pain usually subsides, but fever,
+hurried breathing, and cough continue, and the child, though
+usually it looks heavy and seems drowsy, yet becomes extremely
+restless at intervals&mdash;cries and struggles as if in pain, and
+violently resists any attempt to alter its position, since every
+movement brings on an increase of its sufferings. The posture
+which it selects varies much; sometimes its breathing seems
+disturbed in any other position than sitting straight up in bed;
+at other times it lies on its back, or one side; but whatever be
+the posture, any alteration of it causes much distress, and is
+sure to be resisted by the child.</p>
+
+<p>The variations of posture depend on the seat of the inflammation;
+the pain depends on the two inflamed surfaces
+of the membrane rubbing against each other, and accordingly
+<span class='pagenum'><a name="Page_133" id="Page_133">[Pg 133]</a></span>is relieved not merely by the abatement of the inflammation,
+but also when either the two surfaces become, as they often do,
+adherent to each other, or when fluid is poured out into the
+cavity of the chest, and thus keeps them asunder.</p>
+
+<p>I dwell on this, because when fluid is poured out, the most
+distressing symptoms greatly abate, or even disappear, and
+parents sometimes put off in consequence sending for the
+doctor, while yet, if unattended to, the fluid may increase to
+so large a quantity as to press upon the lung, and so interfere
+with the entrance of air, or it may, if the mischief is not
+checked, change into matter, and then have to be let out by
+tapping the chest, for just the same reason as it may be necessary
+to open an abscess in any other situation.</p>
+
+<p>Whenever, then, symptoms, such as I have described, come
+on, send at once for medical advice, and do not let some
+diminution of suffering, or slight general improvement, lead
+you to delay.</p>
+
+<p><b>Croup.</b>&mdash;I endeavoured to explain, a few pages back, the
+cause of that peculiar sound which is heard in spasmodic
+croup. The contraction of the opening of the windpipe
+changes the sound which passes through it, just as the opening
+or closing the keys of a wind instrument modifies the sound
+which it gives forth. But the windpipe is not simply a wind
+instrument, it is a stringed instrument too, and the strings or
+vocal cords, as they are termed, give forth, as they vibrate,
+tones now deeper, now more shrill. The action of this delicate
+apparatus is readily disturbed, if the nerve-supply to it is disordered
+by irritation in some distant organ, and then the
+breathing is accompanied by the peculiar sound of spasmodic
+croup, or in older children this may show itself in a different
+way, as in the loud, barking cough heard in some cases of constipation,
+or of disordered digestion; or another illustration of
+it is furnished by the loud, long breath&mdash;the 'hoop,' which gives
+its name to hooping-cough. But there is one sound that sometimes
+attends the breathing of children, which more than any
+other causes, and justly causes, the greatest anxiety to a mother;
+and that is the sound which is characteristic of croup.</p>
+
+<p><span class='pagenum'><a name="Page_134" id="Page_134">[Pg 134]</a></span>The word croup, which comes from the Lowland Scotch,
+signifies merely hoarseness in breathing or coughing, and is
+therefore, strictly speaking, the name of a sign of disease,
+rather than that of the disease itself. The peculiar sound is
+heard in two different conditions&mdash;the one in which a child
+having caught cold, instead of the air-tubes alone being
+affected, the windpipe, and especially its upper part, becomes
+congested, and the lining membrane swollen. Partly owing to
+this, partly owing to its nerve-supply being disturbed, the child
+breathes noisily and hoarsely, and the cough has a peculiar
+metallic clangor. In the other case there is not merely the
+congestion of the windpipe, the disturbed nerve-supply, and
+the swollen state of the membrane; but in connection with
+the influence of the special poison of diphtheria, a deposit
+takes place at the back of the throat, whence it extends to the
+windpipe, and in many instances even far beyond it, blocking
+up its canal, and mechanically excluding the entrance of air.</p>
+
+<p>To determine at once to which class a case of croup belongs
+is so far from easy, that I should advise that on the first
+sound of voice, or cough, or breathing resembling that of croup,
+medical advice should at once be sought. I dwell on the
+difference between the two: the first which has been called
+false croup, or better catarrhal croup, and the second called
+true croup, or diphtheritic croup, in order to save much needless
+apprehension to parents, in whose mind the croupy sound
+is invariably associated with nothing short of that most
+dangerous disease&mdash;diphtheria.</p>
+
+<p>As a general rule catarrhal croup is rarely met with after the
+age of six. Children in whom it occurs have either seemed
+quite well, or at most 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 a long-drawn sound, half-hissing,
+half-ringing, and the child soon wakes alarmed, and
+fighting for breath, the skin bathed in perspiration, the face
+flushed and anxious. The cough, the difficult breathing, and
+<span class='pagenum'><a name="Page_135" id="Page_135">[Pg 135]</a></span>the struggle for air last for an hour or two, or sometimes all
+night long, though they gradually subside, at any rate towards
+the approach of morning, when the child falls asleep, and, but
+for a somewhat hoarse sounding cough, and a look of fatigue,
+there are but few signs of all that it has endured.</p>
+
+<p>The attack may not return, or it may recur for two or three
+successive nights, though in general with lessened severity, the
+child during the daytime seeming to suffer only from a slight
+cold, or now and then, and so rarely that I have not known it
+to occur above once or twice in all my experience, it may end
+in real inflammation of the windpipe; but not in diphtheria.</p>
+
+<p>Attacks of this kind may recur three, four, or more times
+even in childhood, while diphtheria has no tendency to recur,
+but like measles or scarlatina seldom appears more than once,
+though the rule is subject to more numerous exceptions than
+are found in the case of the eruptive fevers. Still the fact of
+an attack of this sort returning should of itself lessen apprehension
+and make the parents look forward to its issue with less
+anxiety than that with which they regarded its first occurrence.</p>
+
+<p>A fact which shows how large a part is played by disturbance
+of the nervous system in these cases is the liability of children
+who have suffered from it to attacks of asthma, often of great
+severity as they grow older, while very often after the transition
+from childhood to youth has passed these attacks too lessen in
+frequency and severity, and often altogether cease.</p>
+
+<p>There are two measures which, while waiting for the doctor's
+arrival, may at once be taken, and which sometimes remove
+the symptoms almost as if by magic, while even were the case
+one of diphtheria they would still be of some service, and
+could not possibly do any harm. They are the hot bath, and
+a full dose of ipecacuanha wine. The former should be as hot
+as it can be borne, 93&deg; or 94&deg;, and the child should be kept in
+it for five minutes, and the latter should be given in a full dose,
+as a teaspoonful in warm water every quarter of an hour till
+free vomiting takes place. How much better soever the child
+may seem after the use of these remedies, it should still be kept
+for two or three days under careful medical observation.</p>
+
+<p><span class='pagenum'><a name="Page_136" id="Page_136">[Pg 136]</a></span></p><p><b>Diphtheria.</b>&mdash;In <i>diphtheria</i> croup is only one, though the
+most frequent, and one of the most serious, of the many
+dangerous symptoms which attend it. The croupal symptoms
+hardly ever come on quite suddenly, but are almost always preceded
+for some days by slight feverishness, languor, and restlessness,
+in spite of which the child still amuses itself; and if
+too young to express its sensations, the slight degree of sore-throat
+it experiences is manifested rather by a disinclination to
+take food than by any obvious difficulty in swallowing. There
+is no cough, nor any change of voice when the child is awake,
+but when asleep&mdash;and the sleep is generally uneasy&mdash;it often
+breathes with its mouth open, it snores slightly, or there is a
+little hoarse sound accompanying the breathing owing to a
+trivial swelling of the throat; while, if sought for, there will
+generally be found a very little enlargement, and a very little
+tenderness of the glands at the corner of the lower jaw. The
+eyes are sometimes tearful, there may be slight running at the
+nose, and the child is said to have a bad cold with slight sore-throat&mdash;the
+most remarkable feature of the case being generally
+that the depression of the patient is out of proportion to the
+severity of the local ailment. If now the throat is examined&mdash;and
+examination of the throat should never be omitted in any
+case where there is the slightest difficulty of swallowing&mdash;nothing
+may at first be seen but a very little swelling, and some redness
+of one or other tonsil. In a few hours more, white specks like
+little bits of curd will be seen first on one tonsil, then on the
+other, and next these specks will have united to form one continuous
+layer of a sort of yellowish-white membrane over the
+palate and tonsils. The examination of the throat, often so
+difficult when children are ill, is attended with almost none, if
+while they are well they have been taught the little trick of
+opening their mouths to show their throat, and of allowing the
+introduction of a spoon to keep down the tongue, a proceeding
+which though 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 be reproduced, and this even though
+<span class='pagenum'><a name="Page_137" id="Page_137">[Pg 137]</a></span>no treatment has been adopted, and in two or three days the
+child may be pretty well again, though strength is in general
+regained less rapidly than might have been expected from
+the comparative mildness of the attack.</p>
+
+<p>In cases so slight it is no easy matter to recognise the
+features of a highly dangerous disease; still, out of forerunners
+so trivial as these, croupal symptoms may be developed, and
+their advances may be most insidious, and unless both parents
+and doctor have been closely on the watch they may be surprised
+all at once by the breathing suddenly becoming very
+laboured, by that and the cough becoming attended by the
+sounds characteristic of croup, and by the child's life being
+in extreme jeopardy, or in danger even beyond the hope of
+recovery.</p>
+
+<p>It is not that here, as in cases of catarrhal croup, the ailment
+has really come on suddenly, but that the disease has been silently
+making unsuspected progress. Whenever then a child, after a
+few days of slight causeless ailing, accompanied with some little
+discomfort in swallowing, is seen to have white patches at the
+back of its throat, do not allow yourselves to be lulled even by
+their disappearance into a feeling of absolute security. Watch
+the child, and beg the doctor to watch it carefully, until it is
+perfectly well again, for though the deposit may have disappeared
+from the back of the throat it may continue to be
+formed in the windpipe, and in the somewhat depressed state of
+the nervous system which attends diphtheria it may not excite
+that irritation which any such cause would produce in a child
+in perfect health, and consequently not announce its presence
+until its amount has become so considerable as to offer an
+almost insurmountable obstacle to the entrance of air. Any,
+even the slightest, hurry of breathing, a hissing sound when the
+child draws its breath, hoarseness of voice, or a ringing cough,
+should quicken your apprehension of danger, and make you
+seek for immediate help.</p>
+
+<p>It may be as well, however, to mention here, that not every
+white speck seen at the back of the throat is of necessity due
+to diphtheria, but that in some cases of ordinary sore-throat
+<span class='pagenum'><a name="Page_138" id="Page_138">[Pg 138]</a></span>white spots may form on the surface of the tonsils. These
+white spots are due to the collection at their openings of the
+secretion formed in the minute glands which beset the surface
+of the tonsils, and which at these seasons is poured out in
+greater abundance than usual. They are distinct from each
+other, and do not coalesce into a membrane; the surface
+beneath is not the uniform red shining surface on which the
+membrane in diphtheria has formed, but the separate tiny
+openings from which the white matter has exuded may be distinctly
+seen if the surface is wiped with a camel's-hair brush.
+It is, of course, wise in every case to leave to the doctor the
+decision as to the nature of the deposit, but it may sometimes
+relieve needless anxiety to know beforehand that there is another
+cause besides diphtheria to which white spots at the back of
+the throat may be due.</p>
+
+<p>There are other dangers, indeed, besides those arising from
+croup, which accompany diphtheria, though those just mentioned
+are of all the most frequent. There are cases in which death
+takes place not from the severity of any local ailment, but from
+the intense depression of the nervous system. There are other
+instances too, in which the case assumes what is termed a
+malignant character; profuse discharge taking place from the
+nostrils, swallowing being from the first exceedingly difficult,
+membrane being deposited on the lips, behind the ears, or at
+the edge of the bowel; death taking place in twenty-four or
+thirty-six hours from the outset of the first serious symptoms,
+either in convulsions, or from utter exhaustion.</p>
+
+<p>But the very urgency of such cases must of necessity call
+for the immediate assistance of the doctor; and my business
+throughout this book is rather with those points which it is
+important for a mother to notice, and those things which it
+behoves her to do.</p>
+
+<p>What does diphtheria depend on? is a question more easily
+asked than answered. The disease is contagious, as scarlatina
+is contagious, though not 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, be too much to say that it
+<span class='pagenum'><a name="Page_139" id="Page_139">[Pg 139]</a></span>is dependent on an unsanitary condition of a town, a village, or
+a house, but there is no doubt but that, as is the case with
+cholera, scarlet-fever, or typhus, unsanitary conditions favour
+its spread, and increase its severity.</p>
+
+<p>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 child during a fit of coughing,
+that none of the membrane which it spits up enters the mouth;
+and, that if the child's breath is caught, the attendant gargle
+immediately with a teaspoonful of Condy's fluid in a tumbler of
+water.</p>
+
+<p>In the next place, as the depression of the nervous system
+in some cases of diphtheria is quite out of proportion to the
+local disease, and as children who have not seemed very suffering,
+have yet been known to die suddenly in an unexpected
+faint, it is of moment that the child remain constantly in bed
+from the commencement of the attack till complete convalescence.
+Nor, indeed, in serious cases is even this precaution
+sufficient; but in such circumstances not only must the child
+not be taken out of bed for any purpose, but it must even not
+be suddenly raised in bed, from a recumbent to a sitting posture.
+I have, on several occasions, known the neglect of these
+precautions followed immediately by what cannot but be regarded
+as the needless death of the patient.</p>
+
+<p>During the illness, there is little for the mother to do, except
+to try to carry out the doctor's directions, and to give the child
+constantly little bits of ice to suck, which lessen the swelling of
+the throat, and relieve the pain and inflammation. If the child
+knows how to gargle, it should be induced to do so constantly,
+and finding the relief which this affords, will do so very readily.
+This is not the time, however, when the lesson 'how to gargle'
+can be learnt. A thoughtful mother teaches it while the child
+is well, and if the gargle is composed of raspberry vinegar and
+water, the lesson is learnt without tears. There comes a time,
+however, if the disease is at all severe, when gargling is no
+<span class='pagenum'><a name="Page_140" id="Page_140">[Pg 140]</a></span>longer possible, for the muscles of the back of the throat lose
+their power; but now some medicated solution, employed by
+means of the spray-producer, may most efficiently take its
+place.</p>
+
+<p>When croupal symptoms have gone on growing worse and
+worse, and the child is in the agonies of suffocation, the doctor
+may propose to open the windpipe, in the hope of giving the
+child another chance of recovery, and even though the operation
+fail, of at least lessening its sufferings.</p>
+
+<p>The operation is sometimes objected to by the parents, on
+the ground of the uncertainty of the result, and the torture of
+the operation to the child. Now the anguish of a child dying
+of croup is due to two causes; first, the actual mechanical
+impediment to the entrance of air produced by the deposit in
+the windpipe, and secondly, to the spasm of the muscles in the
+upper part of the windpipe which that deposit produces. How
+large an amount of distress the latter may produce, anyone can
+judge for himself, to whom it has ever happened to swallow the
+wrong way, as it is called. The opening made below the seat
+of the muscles which close the windpipe, leaves them in perfect
+rest, and does away with all the suffering produced by
+spasm, while there is always a fair prospect if the operation
+is not put off too long, of the deposit being limited to the
+part above the artificial opening, and of the good being permanent.</p>
+
+<p>It is true that we have no certain means of knowing the
+extent of the deposit beforehand; it is true also that the operation
+is not in itself a cure of the disease, but at any rate, it is a
+reprieve which gives time for remedies to take effect, and at the
+worst, it substitutes a comparatively painless death for one of
+intolerable anguish. It can, too, be performed under the influence
+of chloroform, so that the idea that it adds in any way
+to the child's distress is unfounded. Who that has seen the
+calm, happy face, and watched the tranquil sleep of the child
+after the operation, who before was struggling, with distorted
+features and agonised countenance, to get a breath of air, but
+would feel as I do, that I would have it done in a child of
+<span class='pagenum'><a name="Page_141" id="Page_141">[Pg 141]</a></span>mine for the sake of a painless death, even though I knew for
+certain that it would not prolong life even for an hour?</p>
+
+<p>One additional remark I have to make with reference to the
+loss of power, or palsy of various muscles, which frequently follows
+diphtheria. Almost always there is some impairment of
+power in the muscles of the throat on which the deposit had
+taken place, and there is, in consequence, a little difficulty in
+swallowing for a few days. If this should get worse, food and
+especially drink sometimes return by the nose, and next there
+may be a slight squint, and the sight may become weakened,
+and an uncertain tottering gait; and sometimes for a week or
+two the child may be unable even to stand. In bad cases
+there is with these symptoms a general loss of nervous as well
+as of muscular power, though the child may still be fairly cheerful,
+and ready to amuse itself as well as it can. This condition
+may last for many weeks before it passes quite away, and if
+under the mistaken impression that the limbs will gain strength
+by exercise, the child is allowed to sit up and encouraged to
+exert itself, recovery will be delayed much longer; and dangerous
+weakness or fatal exhaustion may suddenly come on.</p>
+
+<p>The inference is too obvious for me to need dwell on it,
+that repose is the great resource, and quiet waiting the true
+wisdom.</p>
+
+<p><b>Hooping-Cough.</b>&mdash;I need not say much about <i>hooping-cough</i>,
+for there is scarcely a nursery in which, to everyone's great
+discomfort, it is not known as a familiar and most unwelcome
+visitant. It varies remarkably in its importance, being sometimes
+so slight as scarcely to amount to an illness, but in other
+instances one of the most deadly of diseases. It causes the
+death of a fourth of all children who die under the age of five,
+and three out of four of these deaths take place in infants of
+less than two years old.</p>
+
+<p>It occurs, however, comparatively seldom during the first
+three or four months of life, probably because very young children
+are kept more at home than others, and are thus less exposed
+to catch it. Though hooping-cough is undoubtedly very
+contagious, it seems to be communicated only by the breath,
+<span class='pagenum'><a name="Page_142" id="Page_142">[Pg 142]</a></span>and there is absolutely no evidence to show that the clothes of
+a child suffering from hooping-cough can carry the infection as
+they might were the child suffering from measles, or smallpox,
+or scarlet-fever; still less that a person who has visited a room
+where children are suffering from hooping-cough can convey
+the disease to another house, or to other children.</p>
+
+<p>The disease derives its name, as everyone knows, from the
+peculiar sound which attends the cough, and which is due, as is
+the sound of croup, to spasm of the upper part of the windpipe.
+It is equally characterised by the cough returning in fits or
+paroxysms, which end in a long-drawn breath, attended by the
+hoop. An occasional sound like a hoop, in a young child who
+has a cold, is not so conclusive of a case being one of hooping-cough
+as is the recurrence of the cough in fits; for until teething
+is completed, slight and temporary irritation will suffice to
+produce a passing spasm of the upper part of the windpipe.</p>
+
+<p>An ordinary attack of hooping-cough begins like a common
+cold, but as the little ailment passes off, the cough still
+continues, the fits of coughing become more frequent, last
+longer, grow severer and more suffocative, and end with the
+loud long breath, the hoop; while sometimes no sooner is one
+fit over than another follows it almost immediately, and quiet
+breathing does not return until the child is tired out by its
+efforts. Nevertheless, the child's health continues fairly good,
+and little or nothing ails it during the intervals of the cough.
+For about a fortnight the cough usually goes on to increase; and
+during this time the night attacks especially become more frequent.
+It then for a week or ten days continues stationary,
+and then declines, a diminution in the frequency and severity
+of the night attacks being in general the first sign of amendment,
+and at the end of six weeks from the beginning of the
+attack the child is in general quite convalescent. Even then,
+however, a trifling cause will reproduce the characteristic cough
+for a few days, and not seldom for many months afterwards any
+cold which the child may catch will be attended by a paroxysmal
+cough undistinguishable save by its milder character and
+<span class='pagenum'><a name="Page_143" id="Page_143">[Pg 143]</a></span>shorter duration from the previous hooping-cough, though I
+believe incapable of communicating that disease.</p>
+
+<p>In mild hooping-cough there is little or nothing to be
+done, save to follow the dictates of common sense, and not
+to neglect them in quest of some imaginary specific&mdash;some
+vaunted medicine which is said to be a certain cure; or such
+as shutting up the child in a room the atmosphere of which
+is charged with the vapour of tar, or of carbolic acid, or of
+sulphur.</p>
+
+<p>It cannot be too strongly impressed on the minds of parents
+that there is no specific whatever for hooping-cough; no
+remedy which will cut it short, as quinine cuts short a fit of
+ague. The domestic treatment of mild hooping-cough is
+the domestic treatment of a common cold, implying the same
+precautions as to the equal temperature of the day and night
+nursery, the little doses of ipecacuanha at night, but as seldom
+as possible during the day, in order not to interfere with the
+appetite and digestion, together with special care to insure the
+regular action of the bowels. It sometimes happens that after
+a week or two the severer fits of coughing are followed by
+vomiting; and the child may lose flesh and strength from inability
+to retain its food. In these circumstances food must be
+given, little in quantity, at short intervals, and of a kind 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
+ordinary meals, and be given twice as often.</p>
+
+<p>The different liniments, and the favourite Roche's Embrocation,
+are of use when the disease is on the decline, and may
+also be of service if bronchitis should occur to complicate the
+hooping-cough, but not otherwise.</p>
+
+<p>Change of air when hooping-cough is on the decline is
+often of great service, and change even from good air to one
+less good appears to be sometimes of use; but change in the
+early stages, or when hooping-cough has become really severe,
+is but adding another to the already existing dangers.</p>
+
+<p>The danger in hooping-cough arises through the medium
+<span class='pagenum'><a name="Page_144" id="Page_144">[Pg 144]</a></span>either of the head or of the lungs, and through each of them
+with about equal frequency. The head becomes affected in
+consequence of the often recurring congestion of the brain,
+produced, as in spasmodic croup, by the constantly returning
+interruption to the breathing. In these cases the cough is
+frequent, and so violent that the child becomes livid during
+each paroxysm, and that instead of ending in a loud hoop
+it finishes by a fit of convulsions or by the child sinking into
+a state of semi-insensibility. Increased violence of the cough,
+with suppression of the hoop, is always a bad omen in
+hooping-cough.</p>
+
+<p>On the other hand, when the cough becomes complicated
+with bronchitis, it ceases to recur in distinct fits which leave
+behind them intervals of comparative, or of absolute ease.
+The hurried breathing which precedes and follows a fit of
+coughing never entirely subsides, while each returning cough
+aggravates the irritation and inflammation of the air-tubes, and
+the child's condition becomes the very dangerous one of hooping-cough
+complicated with bronchitis.</p>
+
+<p>So long as a child seems pretty well in the intervals between
+the fits of coughing, as the hurried breathing subsides after
+each to a natural frequency, as a long loud hoop follows each
+cough, as vomiting takes place only after a fit of coughing and
+never in the intervals, as the child becomes flushed only and
+not livid during a cough, and recovers itself perfectly afterwards,
+as it does not complain of constant headache, nor spits
+blood, nor has nose-bleeding, nor is feverish, nor depressed,
+nor drowsy, you may feel happy about it. When any of the
+symptoms just enumerated show themselves you have reason
+for grave solicitude, and the child requires daily medical
+watching.</p>
+
+<p>One word in conclusion. A child who has recently had
+hooping-cough is more liable than another to be attacked by
+chicken-pox or measles; and, moreover, imperfect recovery
+from hooping-cough is apt, especially if there is any tendency
+to consumption in the family, to be followed by consumptive
+disease.</p>
+
+<p><span class='pagenum'><a name="Page_145" id="Page_145">[Pg 145]</a></span><b>Asthma.</b>&mdash;<i>Asthma</i>, attended by distress of breathing quite
+as considerable as in the grown person, is by no means unusual
+in the child. 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 or lungs, which in the former occasion or
+aggravate it. It belongs to the class of what has been termed
+nervous asthma and is observed with special frequency in
+children who, when younger, had been liable to catarrhal
+croup; spasm of the air-tubes having taken the place of the
+previous spasm of the windpipe. Independently of that
+antecedent it comes on sometimes about the time of the second
+teething in nervous and impressionable children, in whom an
+attack may be produced by indigestion, constipation, or over-fatigue.
+It is also by no means rare in children in whom that
+skin affection, eczema, of which I have already spoken, outlasts
+the time of infancy, and becomes general and severe.
+The improper performance of the functions of the skin seems
+to cause a peculiar sensitiveness of the air-tubes, and to render
+them liable to the occasional occurrence of that spasm which
+produces asthma. These cases are less hopeful than others,
+and the liability to the attacks ceases only when the skin-affection
+has been completely cured; a reason this 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 severe
+hooping-cough, and in these two conditions the prospects of
+recovery are less hopeful than in the others.</p>
+
+<p>When asthma occurs in childhood, the first point is to
+ascertain the cause on which the attack depends; and it is
+worth any amount of care to discover and remove it; for if
+what may be called the asthmatic habit is not formed, the
+attacks will, in the majority of instances, cease between 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
+the boy who grows up an asthmatic youth is very unlikely to
+get rid of the disorder in later life.</p>
+
+<p>It is in that form of asthma which succeeds to frequent
+<span class='pagenum'><a name="Page_146" id="Page_146">[Pg 146]</a></span>attacks of catching cold, and in which bronchitis precedes or
+accompanies each seizure, that change of climate is most
+useful. In the majority of instances a moderately sheltered
+seaside place, with a sandy soil such as Bournemouth, is the
+best, and a few years' residence there not infrequently overcomes
+every disposition to asthma through the whole remainder
+of the patient's life. To this, however, there are exceptions,
+and I have seen instances in which residence at Bournemouth
+and in the Riviera have failed, but where a perfect cure has
+been wrought by the cold, still air of Davos.</p>
+
+<p><b>Diseases of the Heart.</b>&mdash;<b>Malformed Heart.</b>&mdash;Every
+now and then one sees a little babe, carefully wrapped up in
+its nurse's arms to shield it, even on a warm day, from the air;
+and, on removing the shawl which covered 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 of lips and fingertips,
+as though perished with cold. The babe wakes on being
+disturbed, and gives a faint short cry of distress; the livid hue
+of its surface deepens, it struggles feebly, its mouth twitches
+as though convulsions might be coming on. Soon, however,
+these symptoms subside, the babe smiles again, is cheerful, and
+save for the tints of its face and lips, it looks like other infants,
+but frailer.</p>
+
+<p>This condition has a name in medical writings, from a
+Greek word expressive of the blue tint which characterises it,
+and is called <i>cyanosis</i>. It depends on the blood not having
+undergone completely those changes in the lungs which take
+place in the healthy state. The blood, 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 sends it to the lungs,
+where, in the minute vessels of the air-cells, it is purified, and
+returns vivified by the oxygen a bright scarlet stream, to be
+distributed by the arteries over the whole body; and thence to
+return once more for fresh purification to the right side of the
+heart. Before birth, the blood does not run the same course,
+but is purified within the mother's body, the blood running
+through channels which close with the first breath the infant
+<span class='pagenum'><a name="Page_147" id="Page_147">[Pg 147]</a></span>draws. The previously existing communication between the
+two sides of the heart ceases at the same time as the new
+channels are opened, by the shutting of a thin valve which
+had hitherto allowed the blood to pass from one side to the
+other.</p>
+
+<p>Sometimes this closure fails to take place, or takes place but
+imperfectly; sometimes, in addition, the channels which should
+be disused after birth remain open still; and sometimes also
+the heart is otherwise imperfectly formed, and a large communication
+exists between the two sides of the heart, which long
+before birth ought to have been firmly partitioned off from each
+other.</p>
+
+<p>According to the freedom of communication between the
+two sides of the heart, there is more or less ready intermingling
+of the impure blood with that which is already purified; and
+this is betokened by the greater or less severity of the symptoms
+which I have described. When the heart is very malformed,
+and the blood consequently is very impure, life is but
+a short agony which ends in a few weeks; some slight movement,
+some little accidental cold deranging altogether the
+imperfect machinery, and bringing it to a sudden standstill.
+Between this and the slightest cases there are all shades of
+difference, till, in the latter, a smaller power to maintain
+warmth, a less rapid growth, a smaller muscular development,
+a feebler power, a hurry of breathing on exertion, or in ascending
+a hill, or in going up a staircase, are all, except the sounds
+which the educated ear detects of the blood passing through
+its devious course, that tell of nature having, in this instance,
+ill done her handiwork.</p>
+
+<p>The one most natural question to which, in every instance,
+the doctor has to reply is this: 'Will he or she outgrow it?'
+To this the answer is, '<i>Yes</i>,' and '<i>No</i>.' In the worst cases the
+answer is obviously <i>no</i>; and in none does <i>yes</i> imply a recovery
+so complete as to leave no trace behind, and to make the child
+heartwhole. But short of this, in many instances much may
+be hoped for. There is, as I shall have occasion again to
+repeat, a power in the growing heart to adapt itself in large
+<span class='pagenum'><a name="Page_148" id="Page_148">[Pg 148]</a></span>measure to conditions other than those of perfect health. The
+channels, through which the blood ought not to flow, may shrink
+though they may not entirely close; the valve may shut more
+completely than at first the opening between the two sides of
+the heart; all inconveniences may lessen, and the child may at
+last become scarcely aware of the difference between himself
+and others. But for any such result, or for anything approaching
+it to be attained, certain conditions are absolutely essential
+which it is seldom easy to induce parents to observe. Whatever
+can hurry the circulation is most carefully to be avoided. The
+child must be kept strictly out of the way of hooping-cough,
+measles, or any other fever; must be shielded from every risk
+of catching cold, and having smaller power of maintaining its
+warmth than others have, must be specially warmly clad, and
+must live in rooms at a temperature of 60 deg. Fahr., all the
+year round. Great attention must be paid to the state of the
+bowels, so that constipation may not necessitate violent efforts
+to relieve them.</p>
+
+<p>Moreover, for years the child must be carried upstairs; when
+old enough to take part in games, it must not be allowed to join
+in any which call for violent exertion, such as cricket, or lawn
+tennis, nor ride any other than a quiet pony at a gentle
+pace.</p>
+
+<p>It depends entirely on the parents whether, for the sake of
+a very great but far-off good, they will strictly observe these
+rules. The difficulty will not arise on the child's part, for it is
+not hard for those who have had charge of it from babyhood
+to bring it up to quiet pursuits and quiet amusements, till it
+seeks no others, and, like the little cage-bred bird, does not care
+to emulate the flight of others stronger on the wing.</p>
+
+<p><b>Inflammation of the Heart.</b>&mdash;The above remarks do
+not comprise all that is to be said about heart-affection in early
+life. <i>Inflammation</i> may attack the investing or the lining membrane
+of the heart at all ages, may produce in the child the same
+suffering as in the grown person, and may tend to destroy life
+in a similar manner. The causes, indeed, which produce heart
+disease, are far more frequent in the grown person than in the
+<span class='pagenum'><a name="Page_149" id="Page_149">[Pg 149]</a></span>child, and advancing age brings with it changes which, wholly
+apart from active inflammation, produce grave forms of disease
+unknown in early life. There is, however, one cause of heart
+disease which is far more frequent in childhood and early youth
+than in later life, namely, rheumatism. Eight out of ten of all
+cases of heart disease under the age of fifteen are of rheumatic
+origin, and in eighteen out of twenty cases of acute rheumatism
+under that age, whether slight 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 now and
+then affection of the heart is associated with some other form
+of inflammation of the chest.</p>
+
+<p>Pain is by no means a constant attendant on it, but fever,
+more or less considerable, a quickened pulse, and hurried
+breathing are all but invariable, and one great reason for seeking
+the immediate help of the doctor is, that his skilled ear may
+at once detect by the altered sounds the heart-affection at its
+very outset, and employ the measures calculated to arrest its
+progress.</p>
+
+<p>Death in the acute stage of a first attack of inflammation of
+the heart is of extreme rarity, but the damaged heart is liable to
+returns of acute mischief, any one of which may prove fatal.
+Independently of this, life with diseased heart is one of suffering,
+attended as it is by symptoms similar in kind, though not
+identical with those which I have already mentioned as attendant
+on malformation of the organ.</p>
+
+<p>The hopeful element, however, to which I have already
+referred as present in cases of malformed heart, exists here in
+even a greater degree; since repair of injury is possible, while
+the reconstitution of an organ faulty from birth is obviously
+beyond nature's power.</p>
+
+<p>I can but repeat the directions already given as to the importance
+of allowing the heart as much rest, and giving it as
+little work, as is possible with a never-resting organ; and this
+with the added motive for perseverance furnished by the happy
+issue which may be hoped for as its reward.</p>
+
+<p><span class='pagenum'><a name="Page_150" id="Page_150">[Pg 150]</a></span>One word I must add about the occasional occurrence
+of <i>irregular action of the heart</i> during the years of growth,
+especially from the age of ten to fourteen. This is often quite
+independent of any disease, and ceases when with added
+strength the nervous system becomes less impressionable.</p>
+
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_151" id="Page_151">[Pg 151]</a></span></p>
+<h2><a name="CHAPTER_VIII" id="CHAPTER_VIII"></a>CHAPTER VIII.</h2>
+
+<h3>DISEASES OF THE ORGANS OF DIGESTION.</h3>
+
+
+<p><b>Manner of Performance of Digestion.</b>&mdash;The organs
+situated in what is called in medical language the abdomen,
+have in the child no other duty to perform than such as subserve
+the processes of digestion and nutrition. The saliva
+secreted by the appropriate glands in the mouth, mixing with
+the food, facilitates the further changes which take place in the
+stomach. In the stomach the food is acted on and dissolved
+by the gastric juice or pepsin, which is poured out by an almost
+infinity of minute tubes, or follicles as they are termed. When
+the stomach has done its work, its contents in a semi-fluid state
+pass into the small intestine, and mix there with the bile, the
+secretions from the intestines themselves, and with those of the
+large gland, the pancreas (in culinary language known as the
+sweetbread), which seems to have the special power of dissolving
+fatty matters. As the food, thus acted on, travels along the
+intestines, whose constant movement facilitates the passage of
+their contents from above downwards, its elements are taken up,
+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. The fluid taken up by the blood-vessels is conveyed
+to the liver; that taken up by the absorbents to the mesenteric
+glands, and in these organs further changes take place in it, which
+fit it to be received into the mass of the circulating fluid. With
+this it is carried to the right side of the heart, and thence to
+the lungs and, lastly, from them to the left side of the heart,
+whence it is distributed, the great life and health giver, to the
+<span class='pagenum'><a name="Page_152" id="Page_152">[Pg 152]</a></span>rest of the body. The useless inconvertible material, leaving
+every available element behind, is got rid of, either in a solid
+form by the bowels, or in a fluid form by the kidneys; and
+thus as long as life lasts there goes on more or less perfectly the
+wonderful process of constant change, of constant renewal, and
+during childhood and youth, of constant increase of size and
+stature.</p>
+
+<p>Incomplete as this sketch is, it may yet suggest how readily
+one part of this complex machinery may be thrown out of gear,
+and further how not one part can suffer without all being disordered.
+Solid food given to the child before it has cut its
+teeth, enters the stomach unreduced to pulp by the grinders,
+and unmixed with the saliva, which should help its solution,
+and which the undeveloped salivary glands do not yet furnish.
+Too large a quantity of food, or food of an unsuitable character,
+on which the gastric juice cannot act readily, may pass into a
+state of fermentation; vomiting, flatulence, sour and offensive
+breath will be the result, and the food will pass into the intestine
+unprepared to be acted on by the bile. Exposure to cold,
+or the opposite condition of excessive heat, may disturb the
+action of the liver, and interfere with the secretion of bile;
+and the food will then pass along the intestine in a state
+unsuitable for absorption. Or, again, the mesenteric glands
+may be irritated by long-continued imperfect performance of
+the earlier stages of digestion, or their structure may be altered,
+and mesenteric disease, or consumption of the bowels, as it has
+been termed, may result. From want of muscular power, or
+from want of care on their part who have charge of the child,
+the bowels may become habitually constipated. Health will
+then suffer, if the child carries about with it for days together
+matters which can serve no useful purpose, but which are to
+the body what an ill-kept dustbin is to the rest of the house.
+Lastly, if the kidneys perform their duties imperfectly in consequence
+of exposure to cold, or of the changes which some
+diseases, such as scarlatina, sometimes bring about in their
+structure, the blood will be imperfectly purified; dropsy and
+various forms of inflammation may result; or the brain and
+<span class='pagenum'><a name="Page_153" id="Page_153">[Pg 153]</a></span>nervous system may be disordered, and death in convulsions
+may attest the dangerous nature of this blood-poisoning.</p>
+
+<p>It would take too long to go in detail through all the phases
+of disordered digestion in early life. Much has been already
+anticipated in a former part of this book, especially with reference
+to the troubles of digestion in infancy and early childhood.
+There is, indeed, but one form of indigestion whose characters
+are so special as to require that I should enter into any detail
+with reference to it.</p>
+
+<p><b>Dyspepsia of Weakly Children.</b>&mdash;Children from the
+age of about three to ten years, whose health has been impaired
+by an attack of typhoid, or, as it is commonly called, infantile
+remittent fever, or who belong to a weakly family, or to one,
+some of whose members have shown a disposition to consumptive
+disease, are sometimes martyrs to indigestion. It does not
+need with them any special error of diet, or any casual exposure
+to cold to disorder their digestion; but every two or three
+weeks, even under the most scrupulous care, they lose their
+appetite, their tongue becomes thickly coated with yellow fur,
+their breath offensive, their bowels constipated, the evacuations
+being either very white or very dark, and frequently lumpy,
+and coated with a thin layer of mucus from the 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 a reddish-white deposit, which disappears if heated. At
+the end of two or three days of rest in bed, of a diet of beef-tea
+and milk, with no solid food, with simple saline medicines,
+mild aperients, and perhaps a single small dose of calomel, the
+symptoms pass off; but return again and again at uncertain
+intervals, and without any obvious cause.</p>
+
+<p>In these cases, the children almost always, when in their
+ordinary health, have a peculiar patchy condition of the tongue,
+one part of it being covered with a thin white coating, through
+which little red points project, while another part is of a vivid
+red, and looks raw and shining, as though it had been scalded,
+while the red points, or the papill&aelig;, as they are termed, project
+<span class='pagenum'><a name="Page_154" id="Page_154">[Pg 154]</a></span>above its surface like so many pins' heads. Children in whom
+this condition exists, require much watching and much care. I
+have dwelt upon it in order to impress on parents 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 eradicate a bad
+habit of the body, as much as to cure a bad habit of the mind.</p>
+
+<p><b>Jaundice.</b>&mdash;I have already spoken of the jaundice of new-born
+infants; but a sluggish condition of the liver, accompanied
+by very white or pale evacuations, constipation, and loss of appetite,
+with a sallow tint of the skin, and sometimes even with
+actual <i>jaundice</i>, are by no means uncommon during the first ten
+years of childhood. Neither condition is serious; that of actual
+jaundice occurs mostly in the summer, and is then connected
+with the sudden onset of hot weather. When severe, it may
+be associated with some degree of feverishness, with dizziness,
+and complaint of headache, and occasionally with vomiting,
+while the child rests ill at night, or awakes in a state of alarm,
+and these symptoms sometimes give rise to the fear that the
+child is about to be attacked by water on the brain. But the
+following consideration may serve to calm anxiety on that score.
+The attack is not preceded, as water on the brain is 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 by constant nausea; and the belly is full rather than
+shrunken. When to these symptoms are added tenderness on
+the right side, high-coloured urine and white evacuations, you
+may set your mind at rest, even before the yellow colour of the
+skin, which appears in a day or two, stamps the case unmistakably
+as one of jaundice.</p>
+
+<p>My business is, as I have said more than once, the endeavour
+to describe the symptoms of disease, to explain their
+nature, to indicate the principles to be observed in attempting
+their cure, and not to lay down definite rules for their treatment,
+with the idle expectation that I could thus enable every
+mother to be her children's doctor.</p>
+
+<p><b>Diarrh&oelig;a.</b>&mdash;I have, therefore, comparatively little to say
+about <i>diarrh&oelig;a</i> in children, important though it is, for its
+<span class='pagenum'><a name="Page_155" id="Page_155">[Pg 155]</a></span>symptoms force themselves on the notice even of the least
+observant. There are, however, a few points concerning it
+worth bearing in mind. Before the commencement of teething,
+diarrh&oelig;a is almost always the result of premature weaning,
+or of a diet in some respect or other unsuitable. As soon as
+teething begins, the liability to diarrh&oelig;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 first six months of life; while, as soon as teething is over,
+their number immediately declines again to the half of what
+it was during the continuance of that process. The practical
+conclusions to be drawn from these facts are that looseness of
+the bowels during teething is not a desirable occurrence to be
+promoted, as some mistakenly imagine, but a risk 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,
+that in order to prevent its occurrence, care should be taken
+to make changes in the diet of a child, not during the time
+when a fresh eruption of teeth is taking place, but during one
+of the pauses in that process. There are certain seasons of the
+year when diarrh&oelig;a is specially prevalent, independent of any
+change in diet, or alteration, in any respect, of the circumstances
+in which the child is placed. Thus, in May, June, and
+July, diarrh&oelig;a is twice as prevalent among children at all ages
+as in November, December, and January; and in August,
+September, and October, its prevalence is three times as great
+as during the winter months. The high mortality of children
+in the summer months is due almost entirely to diarrh&oelig;a, and
+even the bitter Northern winter of a city like Berlin is a third
+less fatal to infants and young children than the heat of its
+short summer.</p>
+
+<p>The next point to remember is that mere looseness of the
+bowels is never to be regarded during the first three years of
+life as of no importance; for I have seen infants die exhausted
+from its continuance, even though the examination of the body
+after death showed almost no sign of disease. Doctors distinguish
+two forms of diarrh&oelig;a: the simple, or, as it is technically
+<span class='pagenum'><a name="Page_156" id="Page_156">[Pg 156]</a></span>called, catarrhal diarrh&oelig;a; and inflammatory diarrh&oelig;a, or
+dysentery. The one may pass into the other, just as a common
+cold, or catarrh, may pass, if unattended to, into a dangerous
+bronchitis.</p>
+
+<p><i>Simple diarrh&oelig;a</i> usually comes on gradually, and is some
+days before it grows severe, or passes into the more dangerous
+dysentery. Simple precautions will often arrest its progress,
+and, among them, rest in bed is one of the most important.
+Over and over again I have known a diarrh&oelig;a which had continued
+in spite of all sorts of medicines so long as the child
+was running about, cease at once when the child was kept for
+a couple of days in bed. The reason of this is obvious; constant
+movement of the intestines themselves, which serves so
+important a part in maintaining due action of the bowels, is
+increased by the upright position and by movement, and is
+reduced to a minimum by the horizontal position. A second
+precaution concerns the diet; solid food and animal broths
+should for a time be discontinued, and arrowroot, milk and
+water, and rice substituted for it, for a day or two, with isinglass
+jelly, and the white decoction of which I have already
+spoken. It is not always that astringents are suitable at the
+beginning of an attack, and the sending to the neighbouring
+chemist for diarrh&oelig;a medicine, which often contains an unknown
+quantity of opium, is always risky, frequently mischievous.
+In a first attack of diarrh&oelig;a, the doctor should always be consulted,
+for when it is associated with disorder 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&oelig;a sets in with profuse watery discharges, sulphuric
+acid for the first few hours is often of extreme service.
+It is at a later time that direct astringents commonly have
+their use; and the mother, who in her child's first attack of
+diarrh&oelig;a has had the advice of a judicious doctor, will often
+be helped by him to manage for herself slight returns of the
+ailment.</p>
+
+<p><span class='pagenum'><a name="Page_157" id="Page_157">[Pg 157]</a></span><i>Inflammatory diarrh&oelig;a</i>, or dysentery, not only follows the
+continuance of the simpler forms of the disease, but sometimes
+in the hot months of summer or autumn sets in suddenly
+with violence. It then frequently commences with vomiting,
+and the stomach may continue so irritable for twenty-four
+hours as not to retain even a teaspoonful of cold water. At
+the same time the over-action of the bowels sets in, and twenty
+or thirty evacuations may be passed in twenty-four hours. The
+motions soon lose their natural character, and become watery,
+slimy, and mixed with blood. They are at first expelled with
+violence, afterwards with much pain, effort, and often fruitless
+straining. With these local symptoms, the child, as might be
+expected, is very ill, feverish, and stupid, though without sound
+sleep, much exhausted, and its nervous system so disturbed as
+to occasion frequent twitchings of the fingers and of the corners
+of the mouth, while sometimes actual convulsions take place.
+The thirst is intense, the child calling constantly for cold water,
+and crying out for more the moment the cup is taken away
+from its lips; while the loss of flesh and the exhaustion are
+more rapid than in any other disease with which I am acquainted.
+The fat happy babe of four and twenty hours before
+is scarcely to be recognised in the miserable little being, with
+sunken lustreless eyes, and wizened features, and miserable
+countenance, lying in a state of half-stupor, sensible only to
+pain, which yet rouses it but to utter a moan, and then sinks
+again into silent suffering. I can well believe what we are told,
+that in some countries this, the so-called Summer Complaint
+of many of the American cities, sometimes carries off children
+in a few hours.</p>
+
+<p>If a fatal termination does not take place speedily, the
+disease passes into the chronic stage, the diarrh&oelig;a diminishing
+in frequency, but the pain and straining, and the unhealthy
+character of the evacuations persisting. Ulceration of the
+bowels has taken place, emaciation becomes extreme, and the
+child often sinks at the end of several weeks, worn out by
+suffering; while recovery, doubtful at the best, is always very
+<span class='pagenum'><a name="Page_158" id="Page_158">[Pg 158]</a></span>slow. But I need not pursue this subject further: enough has
+already been said to show how little infantile diarrh&oelig;a is a disorder
+for domestic management.</p>
+
+<p><b>Peritonitis</b>, or inflammation of the membrane covering
+the bowels and lining the cavity of the belly, is of excessive
+rarity in its acute form; and is attended by such general illness
+and such severe local suffering, that it is impossible to overlook
+it or to misapprehend its gravity. Severe pain in the belly is
+sometimes complained of by children, and is due to what is
+termed colic, a spasm of the bowels which is generally associated
+with constipation. The great test of the cause of the
+pain is furnished by the presence or absence of tenderness on
+pressure. The pain of colic is relieved by gentle pressure and
+gentle rubbing. The pain of inflammation in any degree and
+of any kind is aggravated by them. This applies also to cases,
+not indeed very common, in which inflammation is set up by
+some small body, such as a cherry-stone getting fixed in a little
+offshoot or appendage of about the size and length of the little
+finger, connected with the commencement of the large bowel,
+and producing ulceration. In these circumstances the bowels
+are confined, there are nausea and sickness, together with pain
+and tenderness of the belly, especially on the right side. The
+disease is a very dangerous one, and often proves fatal in the
+course of a few days. I refer to it because I have often seen
+it overlooked both by parents and doctors at its outset, since
+the pain then is often not severe nor the tenderness intense,
+and because I have seen the patient's condition rendered
+hopeless by strong aperients being given to overcome the constipation
+which was supposed to be all that ailed the child.
+I repeat then the caution, never to overlook the existence
+of tenderness, never to attempt to treat a case in which it is
+present; but always to call in medical advice, and above all
+always to abstain, unless ordered by a medical man, in every
+such case from the use of aperients.</p>
+
+<p><b>Large Abdomen.</b>&mdash;I must not leave the subject of disorder
+of the digestive organs without some reference to a
+condition which often excites much needless anxiety among
+<span class='pagenum'><a name="Page_159" id="Page_159">[Pg 159]</a></span>mothers, namely, the large size of a child's belly. This is
+sometimes supposed to be a certain evidence of the presence
+of worms, at other times to be a positive proof of the existence
+of grave disease, especially of disease of the mesenteric glands,
+or glands of the bowels as they are popularly termed. It is
+evidence of neither the one nor the other.</p>
+
+<p>If you go into a gallery of the old masters, and look at any
+of the pictures of angels which are generally to be seen there
+in such abundance, you will probably be struck in the case of
+all the child angels by what will seem to you the undue size of
+their abdomen. You will notice this even in the works of
+painters who, like Raphael, most idealise their subjects, while
+in those of others who, like Rubens, interpret nature more
+literally, the apparent disproportion becomes grotesque; or, in
+the coarser hands of Jordaens, even repulsive.</p>
+
+<p>These painters were, after all, true interpreters of nature.
+In infancy and early childhood the abdomen is much larger
+comparatively than in the grown person. For this there is a
+twofold cause; the larger size of the liver on the one hand,
+and the smaller development of the hips on the other. In a
+weakly child this appearance is exaggerated by its want of
+muscular power, which allows the intestines to become much
+distended with air. If the child is not merely weakly but also
+ricketty, the contracted chest will leave less room than natural
+for the lungs, while at the same time the ordinary development
+of the hips being arrested by the rickets, the disproportion is
+further increased both by that and by the flatulence due to the
+imperfect digestion with which the condition is almost always
+associated.</p>
+
+<p>In no case need the mere size of the abdomen occasion
+grave anxiety, so long 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 everywhere gives out a hollow sound like a
+drum when tapped with the finger.</p>
+
+<p>It is not for a moment meant that no notice is to be taken,
+nor opinion asked, as to the cause of excessive size of the abdomen,
+for its distension may be due to real disease; but it is yet
+<span class='pagenum'><a name="Page_160" id="Page_160">[Pg 160]</a></span>worth while to remember that its mere size is not of itself
+evidence of disease, nor cause of grave anxiety.</p>
+
+<p><b>Worms.</b>&mdash;There is no mistaking or overlooking the existence
+of <i>worms</i> when they are really present. Their presence,
+however, is often suspected without any sufficient reason.
+Ravenous or uncertain appetite, indigestion, flatulence, undue
+size of the abdomen, a dark circle round the eyes, itching of
+the nose and of the entrance of the bowel, a coated tongue,
+and offensive breath are no real proof of the presence of
+worms, and do not justify the frequent repetition of violent
+purgatives or of so-called worm medicines. The only real
+proof of the presence of worms is their being seen in the
+evacuations.</p>
+
+<p>The worms commonly found in children are either the round-worm,
+which resembles the earth-worm, the thread-worm, or
+the tape-worm; the appearance of each of which is clearly
+indicated by its name. None of them are spontaneously generated
+in the body, but they are all introduced from without;
+their eggs, or, as they are technically called, their ova, being
+swallowed unperceived in some article of food, or drink. A
+proof of this is afforded by the fact that an infant, so long as it
+is nourished exclusively at the breast, never has worms.</p>
+
+<p>The <i>round-worm</i> occasions the fewest symptoms, and is
+rather an object of disgust than of grave importance, at least
+in this country, where it seldom happens that more than two or
+three are present. In other countries, as some parts of Italy,
+for instance, where the drinking water is bad and stagnant, they
+are sometimes found in great numbers, as thirty or forty, and
+it is then not easy to determine whether the symptoms which
+accompany them are produced by the worms, or by the unwholesome
+character of the water in other respects.</p>
+
+<p>They appear to live on the contents of the intestines, and
+do not adhere to them, as the tape-worm does, and hence their
+comparative harmlessness, and they have no power, as has sometimes
+been mistakenly imagined, of perforating the bowels, and
+of thus producing grave mischief.</p>
+
+<p>The <i>thread-worm</i> is the commonest variety of these creatures,
+<span class='pagenum'><a name="Page_161" id="Page_161">[Pg 161]</a></span>and has the 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, that in a week or two after it has
+been apparently got rid of, it may again be found as numerous
+as before. Certain articles of food seem to favour its development,
+such as pastry, sugar, sweets, beer, fruit, and anything
+which is apt to undergo fermentation, and thereby to impart
+to the evacuations a specially acid character. These worms
+are often accompanied with more or less marked symptoms of
+indigestion, but otherwise the local irritation is usually the only
+indication of their presence. They produce, indeed, such disturbance
+of the nervous system as may attend indigestion in
+any of its forms, but I have never but once known convulsions
+occur apparently due to their presence in great numbers, and
+ceasing on their expulsion; and this was in a child between
+eighteen months and two years old.</p>
+
+<p>The <i>tape-worm</i> is developed in the human body from a
+minute germ or ovum; one form of which exists in the flesh of
+the bullock, the other in that of the pig; and which seems to
+require for its growth the favouring conditions of warmth and
+moisture which are found in the intestines. It fixes itself to the
+lining of the bowels by means of its mouth, which is furnished
+with minute tentacles, and it thus derives its support from the
+juices which it imbibes. The head is so small as not to be seen
+distinctly without a magnifying glass; and immediately beyond
+it the jointed body begins; at first, scarcely bigger than a thread
+of worsted, but gradually enlarging, till at the distance of three
+inches it is an eighth of an inch wide, and thence rapidly
+widens till each joint is half an inch wide, and from a third
+to half an inch apart. It does not exceed these dimensions,
+even though it may grow to the length of four or six yards.
+Portions of it, sometimes a yard or two in length, are thrown off
+from its lower end occasionally, and this occurrence often gives
+the first indication of its presence, the worm continuing to grow
+as before, and fresh portions being detached from time to time.
+It does not appear that the worm has the power of reproducing
+<span class='pagenum'><a name="Page_162" id="Page_162">[Pg 162]</a></span>itself; hence its French name of <i>ver solitaire</i>, and the occasional
+presence of two or three would seem to be due to the development
+of two or three distinct ova within the intestine.</p>
+
+<p>Deriving as it does its support from the system of the child,
+and not as the other worms do from the contents of the bowel,
+the tape-worm often produces graver inconveniences. It sometimes
+causes uncomfortable colicky sensations, which may even
+be very distressing, and the disorders of digestion which accompany
+it are often very considerable; certainly more so than in
+the case of the other varieties of worms; but I have seen no
+instance of convulsions which could be attributed to them, notwithstanding
+the generally received opinion to the contrary.</p>
+
+<p>When the existence of worms is suspected, one or two doses
+of a simple aperient, such as castor oil, repeated two days
+successively, seldom fail to produce evidence of their presence;
+which in the case of tape-worm is also furnished by the spontaneous
+detachment of some of the joints. It must be remembered,
+however, that until the head has been detached from its
+connection with the bowel, nothing has been gained, and the
+tape-worm will in a short time grow again. To obtain the detachment
+of the head it is necessary that any worm medicine should
+be given when the intestines are empty. I am, therefore,
+always accustomed to give a dose of castor oil about two hours
+after the child's mid-day meal; and to send the child to bed as
+soon as the aperient begins to act, and to give it no more food
+except a biscuit and a little milk and water during the rest of
+the day. In the early morning, the special worm medicine is
+given, and over and over again I have known the worm to be
+brought away completely after many previous failures. When
+the smallness of the joints shows that the greater part of the
+worm has been thrown off, and that little more than the head
+remains, it is necessary to have recourse to the unpleasant proceeding
+of mixing the evacuations with water, and then straining
+them through muslin, in order that the doctor may by
+means of the microscope make out whether or no the head has
+been really detached. This is no question of mere curiosity,
+but a matter of the gravest moment, since nothing has been
+<span class='pagenum'><a name="Page_163" id="Page_163">[Pg 163]</a></span>really gained so long as the head of the worm remains adherent
+to the bowel.</p>
+
+<p>Precautions such as these are not needed in the case of the
+other kinds of 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 should be emptied by a dose
+of castor oil.</p>
+
+<p>The only other caution which remains for me to give refers
+to the peculiar effect which salicine, a very valuable medicine,
+especially in the case of thread-worms, has upon the urine. It
+sometimes turns the urine of a greenish-yellow, often of a red
+colour, as though it were mixed with blood. The appearance,
+however, has no grave meaning, but is due simply to a chemical
+action of the medicine on the colouring matter and salts of the
+urine.</p>
+
+<p>There still remain some local ailments of parts connected
+with the process of digestion, concerning which a few words
+must be said.</p>
+
+<p><b>Ulcerated Mouth.</b>&mdash;First, with reference to the <i>sore-mouth</i>
+of children. I have already noticed a form of inflammation
+and ulceration of the gums sometimes met with during
+teething, but the sore-mouth of which I am now about to speak
+is often quite independent of that process; though it may sometimes
+be found associated with it, and is indeed rarely met with
+after five years of age. In almost all instances it is preceded
+and attended with symptoms of indigestion, during the course
+of which the mouth becomes inflamed, hot and red, and small
+very painful shallow ulcers with sharp-cut edges, and a little
+yellowish deposit on their surface, appear at the edge of the
+tongue, on the inside of the mouth, and especially on the inside
+of the lower lip, and the adjacent surface of the gum.
+Successive crops of these little ulcerations not unfrequently
+appear, so that for many weeks the child may be kept by them
+in a state of extreme discomfort; swallowing, and even speaking
+being the occasions of considerable suffering.</p>
+
+<p>It is seldom that nursery remedies, and the so-called cooling
+<span class='pagenum'><a name="Page_164" id="Page_164">[Pg 164]</a></span>medicines, though often of some service, suffice to get rid
+of the ailment, which for the most part needs judicious medical
+treatment, and local as well as constitutional measures. Now
+and then this condition comes on in the course of measles, and
+is then sometimes of serious importance.</p>
+
+<p>In the other form, the disease is usually limited to the
+gums, and affects especially those of the front of the lower jaw,
+which become swollen, ulcerated at their edges, where a very
+ill-smelling deposit takes place of a dirty white or greyish
+colour, the surface beneath being spongy, swollen, raw, and
+bleeding. The ulceration sometimes extends so as to lay bare
+a large part of the sockets of the teeth; but though loosened
+they seldom drop out. Coupled with this, the glands at the
+angle of the jaw are swollen, and the child dribbles constantly
+a large quantity of horribly offensive saliva. In the children of
+the well-to-do classes the condition is seldom seen except in a
+slight degree; but even when severe it is rarely accompanied
+by any grave disorder of the general health. It seems to tend,
+whether treated or left to itself, slowly to get well; but its
+progress to a natural cure is extremely tedious, and the gums
+are left by it for a long time spongy, bleeding easily, and only
+very imperfectly covering the teeth.</p>
+
+<p>Anxiety is sometimes excited by this condition; it being
+supposed that the white deposit on the edge of the gum implies
+some relation between it and diphtheria. This is not so, for
+though this peculiar ulceration of the gums has now and then
+been found associated with diphtheria, the nature of the two
+diseases is essentially different. It is, however, always wise to
+call in medical advice in order to settle this important question,
+and the more so, since there is one remedy, the chlorate of
+potass, which, in appropriate doses, acts upon the condition
+almost as a charm.</p>
+
+<p>I say nothing about a dreadful form of inflammation of
+the mouth which ends in mortification, because it is of infinite
+rarity except among the destitute poor, and even among them
+it is very seldom seen except as a consequence of measles, or
+of some kind of fever. It is only among the very poor that I
+<span class='pagenum'><a name="Page_165" id="Page_165">[Pg 165]</a></span>have seen it, and even among them it has come under my
+notice only ten times in the whole course of my life.</p>
+
+<p>There is a very common but inaccurate opinion that sore-mouth
+in childhood is often produced by the employment of
+mercury. I never yet saw a sore mouth due to the administration
+of mercury in any child before the first set of teeth were
+entirely cut; and never but once out of 70,000 cases which
+have come under my notice in hospital or dispensary practice,
+have I seen in children of any age under twelve any affection
+of the mouth from mercury sufficiently severe to cause me a
+moment's anxiety.</p>
+
+<p><b>Quinsey</b>, or inflammatory sore-throat, has in it nothing
+specially peculiar to the child, but occurs at all ages with the
+same symptoms. It is, however, comparatively rare under
+twelve years of age, and is almost always less severe in childhood
+than at or after puberty, while I scarcely remember to have
+met with it under five years of age. This circumstance attaches
+special importance to sore-throat in young children, since it
+will usually be found to betoken the approach of scarlet fever,
+or of diphtheria, rather than the existence of simple inflammation,
+or quinsey.</p>
+
+<p>While this fact affords a reason for most scrupulous attention
+to every case of sore-throat in children, and this in proportion
+to the tender age of the child, needless alarm is sometimes
+caused by the appearance on the inflamed tonsils of numerous
+white specks, which are at once supposed to be diphtheritic. I
+have already pointed out the distinction between the two conditions
+when speaking of diphtheria, but the matter is so
+important that I will repeat what I then said. These spots are
+not in the form of a uniform white patch or membrane, which,
+on being removed, leaves the surface beneath red, raw, and often
+slightly bleeding; but they are rather distinct circular spots,
+firmly adherent to the tonsil, wiped off with difficulty, and evidently
+exuding from the openings of little pits, blind pouches,
+or glands, with which the surface of the tonsil is beset. I do
+not advise any parent to rest satisfied with his or her judgment
+on this matter the first time that they notice this appearance;
+<span class='pagenum'><a name="Page_166" id="Page_166">[Pg 166]</a></span>but there are children with whom slight sore-throat is always
+attended by this condition, and others in whom the tonsils are
+habitually enlarged, and seldom free from these white spots
+flecking their surface.</p>
+
+<p><b>Enlarged Tonsils.</b>&mdash;I have said that quinsey or acute
+inflammation of the tonsils is unusual in early childhood; but
+a sort of chronic inflammation of those glands which leads to
+their very considerable enlargement is far from uncommon; and
+is sometimes the cause of very serious discomfort. It is seldom
+traceable to any acute attack of sore-throat, but usually comes
+on imperceptibly in children who are feeble or out of health, or
+takes place slowly during the cutting of the first set of grinding
+teeth; the irritation which that produces being in some cases
+its only apparent exciting cause. Not seldom the enlargement
+has become considerable before it attracts attention; one of the
+first symptoms that indicate it being the loud snoring of the
+child during sleep, who is compelled by the obstruction at the
+back of the nostrils to breathe with its mouth open. The voice
+at the same time becomes thick, and this and the snoring breathing
+are both greatly aggravated when the child catches cold.</p>
+
+<p>A greater degree of enlargement of the tonsils occasions
+deafness from pressure on the passage leading to the internal
+ear, and is also apt to give rise to a troublesome hacking cough
+which sometimes excites apprehension lest the child's lungs
+should be diseased. When still more considerable the enlarged
+tonsils block up the passage through the nostrils, and air consequently
+enters the lungs but very imperfectly. The nostrils thus
+disused become extremely small, narrow, and compressed, the
+upper jaw does not undergo its proper development, the teeth
+are crowded and overlap each other, the palate remains narrow
+and unusually high-arched, and the face assumes something of
+a bird-like character. Besides this the child grows pigeon-breasted,
+owing to the lungs not being filled sufficiently at each
+inspiration to overcome the pressure of the external air on the
+yielding sides of the chest.</p>
+
+<p>When any considerable enlargement of the tonsils exists, each
+cold that the child may catch aggravates it, and if diphtheria,
+<span class='pagenum'><a name="Page_167" id="Page_167">[Pg 167]</a></span>scarlatina, or severe sore-throat should occur, the temporary
+increase of the swelling may become the occasion of serious
+danger. The question arises, what are the chances that a child
+whose tonsils are enlarged will outgrow the condition, or when
+is it necessary to have the enlarged tonsils removed?</p>
+
+<p>It scarcely ever happens that any such enlargement of the
+tonsils exists in children under six years of age as to call for
+their removal. There is almost always ground for the hope
+that after the irritation caused by cutting the first four permanent
+grinding teeth has completely ceased, the tonsils may return by
+degrees to their former size. A similar shrinking of the enlarged
+tonsil sometimes takes place, especially in the boy, at the time
+of approach to manhood, when the vocal organs undergo full
+development. This can be counted on, however, only in cases
+where the tonsils are not of extreme size, and have not undergone
+frequent attacks of inflammation. Whenever the hearing
+is habitually dull, and the voice always thick, when cough is
+frequent, the nostrils narrow, the chest pigeon-breasted, and the
+child feeble and ill-thriven, removal of the tonsils is absolutely
+necessary. In cases where the question is doubtful, its decision
+must turn on whether the tonsils have often been inflamed. So
+long as their surface is smooth, and their substance soft and
+elastic, delay is permissible. When their substance is hard, like
+gristle, and their surface uneven and corrugated, they have
+undergone such changes that absorption is impossible, and their
+removal absolutely necessary.</p>
+
+<p>I dwell thus particularly on the question of removal of the
+tonsils, because there is among many persons an unreasoning
+dread of the operation, which is entirely devoid of danger,
+requiring only a few seconds for its performance, and which
+may even be done under chloroform. The painting tincture
+of iodine behind the angle of the jaw, or the touching the
+tonsils with caustic, iodine, alum, tannin, or sweet spirits of
+nitre are utterly futile proceedings. They diminish the unhealthy
+and often offensive secretion from the glands which beset the
+tonsils, and restore the surface to a more healthy condition, but
+they are absolutely without influence in lessening their size.</p>
+
+<p><span class='pagenum'><a name="Page_168" id="Page_168">[Pg 168]</a></span>Now and then all the symptoms of enlarged tonsils are
+present, but yet most careful examination fails to discover any
+increase of their size. When this is the case the symptoms are
+due to a thickening of the membrane at the back part of the
+nostrils, often attended with spongy outgrowths from their
+surface, which obstruct just as completely as enlarged tonsils
+would do the free entrance of air. It will, in any case where
+this condition is suspected, be absolutely necessary to seek
+the advice of some of those gentlemen who make a specialty
+of diseases of the throat, and who will have the necessary
+technical dexterity to discover the condition, and to treat it
+skilfully.</p>
+
+<p><b>Abscess at back of the Throat.</b>&mdash;I should pass unnoticed,
+on account of its rarity, the occasional formation of
+an abscess at the back of the throat, behind the gullet, interfering
+both with breathing and with swallowing, but that the
+description of it in my Lectures once enabled a lady in the
+wilds of Russia to detect it, to point out the nature of the case
+to her puzzled doctor, to urge him to open the abscess, and
+thus to save her child's life.</p>
+
+<p>This abscess may form at any age, sometimes after fever,
+sometimes without any obvious cause. It shows itself by
+difficulty in swallowing and breathing, unattended by cough,
+but accompanied by a sound similar to that of croup, but not
+so harsh or ringing. The neck is stiff, the head thrown back,
+and often there is a distinct swelling on one or other side of
+the neck. The finger introduced into the mouth, and carried
+over the tongue to the back of the throat, feels there a swelling
+which projects over the top of the windpipe, and causes the
+difficulty both in swallowing and breathing. This swelling is
+the abscess; a prick with the surgeon's lancet lets out the
+matter, and saves the child.</p>
+
+<p><b>Diseases of the Kidneys.</b>&mdash;The <i>kidneys</i> perform very
+important duties in carrying off from the system a large amount
+of useless material, and thus supplement in many respects the
+action of the skin, and the purifying influence which is exercised
+by the air on the blood, as it passes through the lungs.</p>
+
+<p><span class='pagenum'><a name="Page_169" id="Page_169">[Pg 169]</a></span>It is evident, therefore, that their disorder in any way must
+be a matter of serious moment, though at the same time the
+knowledge of the skilled doctor is needed to determine the
+nature and degree of the ailment from which they are suffering,
+since that requires an examination of the urine, both chemically
+and by means of the microscope. My remarks on these
+diseases must consequently be few and fragmentary.</p>
+
+<p>In the grown person, what is known as <i>Bright's disease</i> is
+of frequent occurrence, assumes different forms, and depends
+on various causes. In the child it is comparatively rare, and is
+scarcely ever met with except as a consequence of a chill, or as
+a result of scarlatina. In these conditions the kidneys become
+overfilled with blood or congested, and the congestion may pass
+into inflammation, by which their structure may be irreparably
+damaged. Dropsy is the great outward sign of the affection&mdash;either
+slight swelling of the face, eyelids, and ankles, or very
+great swelling of all the limbs, and even the abundant pouring
+out of fluid into the belly. The degree of dropsy is, however,
+by no means an absolute measure of the amount of kidney
+mischief. It therefore behoves every parent to follow out all
+directions most scrupulously even in cases of very slight dropsy,
+in order to guard against the risk of permanent injury to the
+kidneys being left behind; and especially to remember the
+liability to the occurrence of dropsy and disease of the kidneys
+after scarlatina. Any check to the action of the skin while it
+is peeling or desquamating, as it is termed, is especially liable
+to be followed by these accidents. To avoid all risks as far
+as possible, I have been accustomed for many years to insist
+on a child remaining in bed for one-and-twenty days after the
+first appearance of the rash in even the mildest case of scarlatina,
+and I am absolutely sure that it is the height of imprudence
+ever to neglect this precaution.</p>
+
+<p>It will suffice to mention the fact that <i>diabetes</i>, though very
+rare, may yet occur in childhood, and that as a rule it is more
+dangerous in childhood than in the grown person. Whenever
+a child loses flesh without obvious cause, suffers much from
+thirst, and at the same time passes urine in greater abundance
+<span class='pagenum'><a name="Page_170" id="Page_170">[Pg 170]</a></span>than in health, the possibility that it may suffer from diabetes
+must be borne in mind.</p>
+
+<p>Of far greater frequency than any other affection of the
+kidney is that in which the child passes <i>gravel</i> with the urine,
+either in the form of a reddish-white sediment, which collects
+at the bottom of the vessel as the urine cools, or of minute
+glistening red particles, which resemble grains of cayenne
+pepper.</p>
+
+<p>These deposits, when abundant in the male child, have a
+tendency to collect 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, that more than a third&mdash;indeed, nearly
+half&mdash;of all the operations for stone performed in English
+hospitals are done on boys under ten years old.</p>
+
+<p>Even when this grave consequence does not follow the
+presence of gravel in the kidneys, and its passage into the
+bladder, it is often accompanied with much suffering. The
+pain is like that of stomach-ache or colic, the child crying
+and drawing up its legs on every attempt to pass water, which
+sometimes is voided only in a few drops at a time, and now
+and then is completely suppressed for some hours. The very
+acute form of the ailment seldom occurs, except in infants who
+inherit from their parents a disposition to gouty or rheumatic
+affections. In them, however, a trifling cold, slight disorder of
+the digestion, a state of constipation, or the feverishness and
+general irritation which sometimes attend on teething, not infrequently
+produce these deposits and give rise to all these painful
+symptoms, the deposit disappearing and the pain ceasing so
+soon as the brief constitutional disturbance subsides.</p>
+
+<p>The very acute attacks seldom occur after the first two
+years of life, but similar symptoms, though less severe, are by
+no means unusual in older children, and continue to recur
+from very trifling causes, especially from errors in diet and disorders
+of digestion.</p>
+
+<p>In spite of the suffering which for the time attends it, there
+is no cause for anxiety with reference to the issue of each
+attack. The warm bath, a castor oil aperient, and soothing
+<span class='pagenum'><a name="Page_171" id="Page_171">[Pg 171]</a></span>medicine soon relieve the pain, and the children return to their
+former state of health. It is the frequent return of the attack,
+even in a comparatively mild form, the persistent disposition
+to the formation of gravel, the remote risk in the case of male
+children of stone in the bladder, and the habitually imperfect
+performance of the digestive functions which call for special
+care. The avoidance of sugar, sweets, and whatever tends to
+impart acidity to the urine, the maintaining the due action of
+the skin by wearing flannel, and the judicious use of alkaline
+remedies, sometimes combined with iron, are the measures on
+which the doctor is sure to insist.</p>
+
+<p>The difficulty usually encountered in the treatment of these
+cases arises from the reluctance of the parents to continue for
+months and years the observance of the necessary rules. It
+seems so hard to deny their little one the small gratifications in
+which other children may indulge with impunity; and they fail
+to realise the heavy penalty, in the shape of gout, rheumatism,
+gravel, and stone, which in after-life their darling may have to
+pay for their over-indulgence in his early years.</p>
+
+<p>I will just mention that symptoms similar to those above
+described, less severe, though more abiding, yet unattended
+by gravel in the urine, are sometimes produced in little boys
+by an unnatural narrowness of the end of the passage for the
+urine. It is well to bear in mind this possible cause of the
+child's sufferings, and to consult a doctor with reference to it,
+since he will be able to relieve it by a trivial operation.</p>
+
+<p><b>Incontinence of Urine.</b>&mdash;The irritation which this mechanical
+inconvenience produces sometimes has to do with
+that troublesome infirmity of some children, who wet the bed
+at night. This may also be induced 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 to cultivate
+regular habits in a child; and does not pay attention to the
+quantity of liquid taken at its last meal. Something, too, is
+due to the fact that the sleep of a child is deeper than that of
+the grown person, so that the sensation of want, which would
+<span class='pagenum'><a name="Page_172" id="Page_172">[Pg 172]</a></span>arouse the latter to full consciousness, does not have the same
+effect on the former. It sometimes happens undoubtedly from
+mere indolence; and this may always be suspected when a
+child, otherwise healthy, wets itself not at night only, but also
+in the daytime. Lastly, it does sometimes occur from muscular
+feebleness in weakly children, the bladder being unable to bear
+more than a limited degree of distension.</p>
+
+<p>The accident usually happens either soon after going to
+bed, when the warmth stimulates the action of the bladder, or
+towards morning, when the bladder has become full. The
+posture on the back favours its occurrence very much, and it
+is therefore of importance that the child should lie on its side
+when in bed. The good effect of a blister on the lower part
+of the back as a means of cure was largely due to its forcing
+the child to lie on its side. This object can be attained, however,
+in a much kindlier way, by tying half a dozen cotton reels
+together, and fastening them at the child's back. The habit
+may also often be broken through by arousing the child in the
+night, and compelling it to empty its bladder, the hour being
+first ascertained at which the accident usually happens. For
+this, however, to be of any real use, the child must be awakened
+thoroughly; since otherwise it will mechanically, and quite
+unconsciously, empty its bladder while still asleep. The habit
+in this case is not in the least overcome; only for the time the
+bed escapes the wetting. The utensil must therefore be placed
+on different nights at different parts of the room, so that the
+child, in order to find it, must have been roused to thorough
+consciousness.</p>
+
+<p>Lastly, I will add that the cases in which the accident is
+the result of mere indolence are very rare, and though in such
+cases strictness may be necessary, yet actual punishment is out
+of place. As a rule, reward answers much better. A penny,
+or a threepenny-piece every night that the accident does not
+happen, and a forfeit of a halfpenny or two pence for every
+night of misfortune, is a very efficacious help to a cure.</p>
+
+<p>When all these domestic means, persevered in for months,
+fail to produce any result, medical aid must be called in.</p>
+
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_173" id="Page_173">[Pg 173]</a></span></p>
+<h2><a name="CHAPTER_IX" id="CHAPTER_IX"></a>CHAPTER IX.</h2>
+
+<h3>CONSTITUTIONAL DISEASES.</h3>
+
+
+<p>There remains for consideration a large class of what may
+be termed <i>constitutional diseases</i>, in which the local ailment is
+the outcome of a previous disorder of the whole system. These
+diseases are either acute or chronic. The acute constitutional
+diseases belong to the class of fevers. These are marked by
+certain local characteristics, as the swelling of the joints in
+acute rheumatism, the sore-throat in scarlatina, or the eruption
+on the skin in smallpox, and their course is more or less strictly
+limited by distinct periods of increase, acme, and decline. No
+such rule obtains in the case of consumption, scrofula, and
+rickets, which are instances of chronic constitutional diseases.
+In them too the local manifestations of the general disease
+vary also: the lungs being affected in one case of consumption,
+the bowels in another; while scrofula may show itself by
+affection of the glands in one case, by the formation of abscesses
+in a second, or by disease of the bones in a third.</p>
+
+<p><b>Chronic Constitutional Diseases.</b>&mdash;It may perhaps be
+convenient to study first the chronic constitutional diseases;
+and afterwards to make a few, and they will be but few, remarks
+on fevers.</p>
+
+<p><b>Consumption</b> and Scrofula, though similar, are not the
+same disease. Both, however, depend on some defect in the
+blood, as the result of which certain materials, incapable of
+being converted into the natural constituents of the body, are
+deposited in the substance of different external parts or internal
+organs. If deposited in small quantities, these materials may
+<span class='pagenum'><a name="Page_174" id="Page_174">[Pg 174]</a></span>be absorbed, as it is termed, that is to say, got rid of, by natural
+processes, which even now we understand but imperfectly.</p>
+
+<p>If deposited more abundantly, they press upon and gradually
+spoil the healthy parts in which they are seated, and
+thereby interfere with the proper performance of their duties.
+Thus, the deposit of consumption encroaches on the proper
+substance of the lungs, and so lessens the area in which the
+blood is exposed to the air and purified: the deposit of scrofula
+around and in a joint interferes with its powers of movement.
+Nor is this all; but wherever any deposit has once taken place,
+it tends especially to increase in that very spot, guided as it
+were by a certain affinity; and the substance of the previously
+healthy part is removed as fresh deposit comes to occupy its
+place. Further, the matter deposited has no power of being
+changed into healthy substance of lung, or of bone, or of any
+other part.</p>
+
+<p>A fractured limb may be completely mended; a fluid is
+poured out around and between the edges of the broken bone;
+by degrees this hardens, it undergoes changes which convert it
+into solid bone, and the limb is once more as serviceable as
+before, though some indications of the fracture may still be
+perceptible in the texture of the bone itself. Or, a person
+receives a severe blow on his arm or leg; in course of time the
+blood which had flowed from the ruptured vessels, and had
+formed a big bruise, is absorbed, and all is as before the injury
+was inflicted. If more serious damage has been done, the
+fibres of some muscles may have been torn, even though the
+skin remains unbroken. Inflammation is set up, the injured
+parts die, and are melted down into the matter of an abscess.
+The abscess discharges itself, its walls contract, the opposite
+surfaces come into contact, and are welded together again, so
+that there is no loss of substance, nor anything save a scar on
+the surface to indicate what has happened.</p>
+
+<p>In the case of the deposits of consumption or scrofula
+these changes cannot take place. In technical language the
+matter is said to be incapable of organisation; that is to say,
+it cannot be transformed by nature's alchemy into anything
+<span class='pagenum'><a name="Page_175" id="Page_175">[Pg 175]</a></span>good or useful. It is rubbish to be got rid of; and the patient's
+recovery depends on the possibility of getting rid of it.
+If there is much of it, so as to be removed from the vivifying
+influence which adjacent living structures still maintain about
+it, the deposit softens at its centre. This softening gradually
+extends to the circumference; the mass irritates more and
+more the parts around it, and where the irritation is greatest
+the structures yield, and are removed to make a way for its
+escape, and the patient spits up the contents of the abscess.</p>
+
+<p>But the abscess of the lungs is not like an abscess which
+follows an injury. It has not formed in the midst of previously
+healthy parts which are capable of reproducing the original
+structure; its walls are themselves involved in the disease, and,
+in accordance with the rule I have already mentioned, 'much
+will have more,' and the patient goes on spitting up the perpetually
+renewed contents of the abscess for months or years;
+until by its gradually increasing size, and the more and more
+abundant discharge of matter, and further and further destruction
+of lung-substance, death takes place.</p>
+
+<p>This fatal issue, however, is not invariable. In favourable
+circumstances, and especially in childhood, the radical constitutional
+defect may be amended, and with a healthier condition
+of the blood the unhealthy deposit may cease to take place.
+The lung-substance, however, with all its curious structure of
+air-cells and their network of minute vessels where, as in
+nature's laboratory, the blood receives its due supply of oxygen,
+is not reproduced. The lung shrinks, the sides of the abscess
+come together, and by slow degrees a dense material cuts it off
+from the adjacent healthy structure, but the most complete recovery
+leaves the patient with his breathing power lessened,
+and with his vigour consequently more or less impaired.</p>
+
+<p>When the deposit is less considerable, a different change
+takes place. The material dries by degrees, and is at last converted
+by a purely chemical change into a hard chalky substance,
+which in the course of time becomes of more than stony
+hardness.</p>
+
+<p>Last of all; when the deposit is smallest in quantity, it may
+<span class='pagenum'><a name="Page_176" id="Page_176">[Pg 176]</a></span>be completely got rid of; and a lung in which consumptive
+disease once existed, may eventually regain perfect soundness.</p>
+
+<p>I have dwelt on these processes as they take place in the
+lungs; but, allowing for differences of locality, they resemble
+such as take place elsewhere.</p>
+
+<p>Three important conclusions follow from what has been said.</p>
+
+<p>First. It is only in quite the early stage of consumptive
+disease that absolutely perfect recovery can be hoped for.
+There is a euphemism, more amiable than honest, which
+doctors not seldom make use of, saying that a child's lungs are
+not diseased, but only tender. They mean by this, that on
+listening to the chest, they detect such changes in the sounds
+of breathing as their experience tells them are usually produced
+in the early stage of consumptive disease of the lungs. If the
+opinion is confirmed by a second competent medical man,
+<i>then, and not later</i>, is the time for precautions, for removing the
+child from school, and for selecting, as far as may be, a suitable
+winter climate. When the signs of disease are well marked, a
+reprieve, perhaps a long one, is all that can be confidently
+reckoned on.</p>
+
+<p>Second. When softening of the consumptive deposit has
+taken place, of which certain sounds attending breathing are all
+but conclusive, recovery, even the most complete, always implies
+loss of a certain amount of lung-substance, and consequently
+loss of a certain amount of breathing power.</p>
+
+<p>Third, and this is most important, as well as most cheering;
+consumption, which is at no age the absolutely hopeless disease
+that it was once supposed to be, admits of far more cheerful
+anticipations in children than in grown persons, or, for that
+matter, than in the youth or maiden.</p>
+
+<p>The principal <i>causes</i> of consumptive disease are, hereditary
+predisposition, and improper feeding in infancy. There are
+besides two diseases incidental to childhood, and one of them
+almost peculiar to it, namely typhoid fever and measles, which
+are more apt than any others to develop a tendency to consumption.
+During convalescence from either of them, therefore,
+special care is needed.</p>
+
+<p><span class='pagenum'><a name="Page_177" id="Page_177">[Pg 177]</a></span>In the grown person, consumption almost always attacks
+the lungs, and this often to the exclusion of other organs. In
+the child, however, this is not so, and though the lungs are
+indeed oftener affected than other parts, yet in nearly half of
+the cases some one or other of the digestive organs is likewise
+involved, and in about one in seven instances the lungs are free
+and the digestive organs alone are attacked.</p>
+
+<p>Fever, cough, and wasting are the three sets of symptoms
+which in some degree 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&deg;, there is no cause for
+anxiety. On the other hand, if the evening temperature for a
+week or ten days together always amounts to 100&deg;, there is
+grave presumption that consumptive disease is present. In
+advanced consumption the evening temperature is constantly
+103&deg; to 105&deg;, while in the morning it may fall to 101&deg; or 100&deg;.</p>
+
+<p>Cough is but rarely absent even in cases where the lungs
+are but slightly involved, for the irritation of the digestive
+organs often excites a sympathetic cough, and in these circumstances
+observation of the evening temperature will often furnish
+a clue to the right interpretation of the symptoms.</p>
+
+<p>There is a form of cough which is oftenest observed in
+children between the ages of two and five years, which comes
+in fits closely resembling those 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 <i>glands connected
+with the lungs</i> (the bronchial glands as they are called) <i>are
+diseased</i>, and not the lung-substance itself. The enlarged
+glands press on some of the nerves connected with the upper
+part of the windpipe, and thus occasion the spasmodic cough.
+Always suspect this when a cough persists for weeks together,
+not getting rapidly worse as hooping-cough would do, but at
+the same time not growing better, as would be the case with
+mild hooping-cough. The doctor on listening to the chest
+will solve your doubts; the thermometer will help you to
+decide whether his visit is necessary. I may add that this
+<span class='pagenum'><a name="Page_178" id="Page_178">[Pg 178]</a></span>form of consumptive disease is less serious than that in which
+the lung-substance is involved.</p>
+
+<p>Consumption sometimes follows bronchitis, especially when
+a child has been subject to frequent attacks of it. A very slow
+and imperfect recovery from an attack of bronchitis which had
+not been specially severe is always a reason for solicitude.</p>
+
+<p>Now and then infants are born with consumptive disease.
+In that case the lungs are always affected; and the symptoms
+of fever, cough, and wasting usually show themselves within the
+first three or four months, and the infants almost invariably
+die within the year. Now and then, however, an infant thus
+affected may continue apparently in good health for a few
+months, and then be suddenly attacked by symptoms of acute
+inflammation or of severe bronchitis which prove rapidly fatal;
+and it may be found after death that the acute attack destroyed
+life because the lungs were already the seat of extensive consumptive
+disease.</p>
+
+<p>No infant in whose mother's family a predisposition to consumption
+exists 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 but a small admixture of farinaceous
+food.</p>
+
+<p>There is a form of very rapid, or so-called galloping consumption,
+which is seldom observed before the age of seven
+years; generally two or three years 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 say that the doctor
+who mistakes the one for the other can scarcely be regarded
+as blameworthy; and the mistake is of the less importance
+since the treatment applicable to the one case would do no
+harm in the other.</p>
+
+<p>I have already noticed the connection between water on
+the brain and consumption. It is indeed nothing else than
+inflammation excited by the presence of the deposit of consumptive
+matter in the brain or its membranes.</p>
+
+<p>Little has been said hitherto about the wasting which was
+referred to as one of the characteristics of consumption. When
+<span class='pagenum'><a name="Page_179" id="Page_179">[Pg 179]</a></span>the disease is limited, or nearly so, to the lungs, the wasting is
+not considerable until the mischief 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 best sign 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
+grows thinner, not by real wasting but by conversion of its fat
+into bone and muscle. The child is thinner, but is taller and
+weighs heavier. The only real test therefore of the condition
+of the child is afforded by its increase in height and in weight.
+One need not be solicitous about the child who increases in
+height, and maintains his previous weight, nor about him who
+while he does not grow yet becomes heavier; but the child
+who neither gains in weight, nor in height, or who loses weight
+out of proportion to his increased height, is in a condition that
+warrants anxiety. I have long been accustomed, in the case of
+children whose parents were resident in India, to instruct those
+who have charge of them to send every three months a statement
+of the height and weight of the children, as the best
+evidence of their state of health.</p>
+
+<p><b>Consumptive Disease of the Bowels.</b>&mdash;Consumptive
+disease sometimes invades the whole system from the very
+first, while in other instances it attacks from the outset the
+organs of digestion, and continues throughout to affect them
+chiefly, and loss of flesh is then one of its earliest symptoms.
+In instances where there is a strong family predisposition to the
+disease, consumption of the bowels or mesenteric disease, or
+disease of the glands of the bowels, all three popular names for
+the affection, sometimes shows itself at the time of weaning. In
+the majority of cases, however, it comes on later, after the completion
+of teething, and between the age of three and ten years.
+Indigestion such as I have already spoken of sometimes precedes
+it, with the irregular condition of bowels, and the patchy
+state of the tongue. But this is by no means constant, scarcely
+I think general; and not infrequently momentary, causeless,
+<span class='pagenum'><a name="Page_180" id="Page_180">[Pg 180]</a></span>colicky pains precede for a short time any other symptom. In
+a few weeks after their occurrence, sometimes indeed independently
+of them, the appetite fails, or becomes capricious; the
+bowels begin to act irregularly, being alternately constipated
+and relaxed; and the motions are unnatural in character, being,
+for the most part, dark, loose, and slimy. Sometimes indeed,
+they are solid, and then often white, as if from complete inactivity
+of the liver, and sometimes half-liquid, frothy, and like
+yeast. One peculiarity which they always present, be their
+other characters what they may, is their extreme abundance,
+quite out of proportion to the quantity of food taken, and due
+to their admixture with the unhealthy secretions from the bowels.
+The child next becomes restless and feverish at night, its
+thirst is considerable, and the colicky pains become both more
+severe and more frequent. Sometimes the stomach grows very
+irritable, and the food taken is occasionally vomited, while the
+tongue, in the early stages of the affection, continues for the
+most part clean and moist, and except that it is often unnaturally
+red deviates but little from its appearance in health. Next
+comes a change in the condition of the belly, the date of which
+varies considerably. It becomes larger than natural, owing to
+the filling of the bowels with wind, but at the same time it is
+tense and tender on pressure&mdash;two points of great importance
+to be noticed, and the glands in the groin, which in a healthy
+child cannot be felt, become enlarged, and are felt and perhaps
+even seen like tiny beans under the skin.</p>
+
+<p>As in other forms of consumptive disease, so here the
+progress from bad to worse seldom goes on uninterruptedly.
+Pauses take place in its course, though each time they become
+shorter; and signs of amendment now and then appear, but
+they too promise less and less with each return. The child
+wastes rapidly; is always more or less feverish; the abdomen
+is constantly tender, but does not in general go on increasing
+in size; the pains become more frequent and more severe,
+and the bowels are almost always habitually relaxed. Life is
+sometimes cut short by the lungs becoming affected, but when
+this is not the case the patient may linger on for weeks, or
+<span class='pagenum'><a name="Page_181" id="Page_181">[Pg 181]</a></span>months, or even for two or three years, until, worn to a skeleton,
+death at last takes place from exhaustion.</p>
+
+<p>Much apprehension is often needlessly excited in the minds
+of parents, with reference to any child whose digestion is imperfect,
+who loses flesh, and has a large abdomen; and the words
+mesenteric disease, sometimes uttered thoughtlessly by the doctors,
+seem to them to seal their little one's doom. Now, first of all,
+it must be remembered that mesenteric disease, due to consumption,
+plays but a very small part in the production of the symptoms
+just described, but that the covering and the lining of the
+bowels are chiefly involved. Next, enlargement of the mesenteric
+glands and disorder of their functions take place from many
+causes other than consumption. They are always more or
+less enlarged in typhoid fever; they become enlarged when
+irritated by unwholesome food in infancy, or they may swell
+in the course of chronic indigestion. In all these cases too, the
+glands in the groin may be enlarged by sympathy, and this
+without the existence of any actual abiding disease. A big
+abdomen is, of itself, no evidence of it, nor even when associated
+with indigestion and frequent stomach-ache; but when to these
+you add abiding tenderness, and an evening temperature always
+at least one degree above that in the morning, there is every
+reason to fear that consumptive disease has attacked the organs
+of digestion.</p>
+
+<p>Even then, however, there is no ground for despair; for,
+while consumptive disease in any form is less seldom recovered
+from in childhood than in after-life, such recovery oftener takes
+place in cases of affection of the digestive organs than when
+the disease is seated elsewhere.</p>
+
+<p><b>Scrofula.</b>&mdash;With this word of comfort I leave the subject
+of consumption, and pass to that of the allied disease <i>scrofula</i>.
+Briefly stated, two of the great differences between it and
+consumption are that scrofula is almost entirely limited to
+childhood and youth, while consumption may occur at any
+age; and next, that while scrofula attacks the bones and the
+glands, the skin and the membranes adjacent to it, consumption
+has its seat in the lungs, the brain, and the internal organs.</p>
+
+<p><span class='pagenum'><a name="Page_182" id="Page_182">[Pg 182]</a></span>Scrofulous diseases of the bones come so exclusively under
+the observation of the surgeon, that I do not feel myself competent
+to say anything about them. I would however warn
+all parents to be very much alive to the importance of noticing
+the early symptoms of any such diseases, as shown by slight
+lameness, complaint of pain in the back, or difficulty in moving
+the hand or arm, or in turning the head or bending the neck.
+They may be but temporary accidents, due to cold, or to slight
+muscular rheumatism, or to some sprain not noticed at the
+time; but they may also be signs of the commencement of
+scrofulous disease of some bone; and in no disease whatever
+is early judicious treatment of greater value, or the result of
+neglect less remediable.</p>
+
+<p>Besides these graver ailments which seldom appear until
+after the time of infancy has passed, there are others of a less
+serious nature which often show themselves within the first
+year of life. One of these consists in the formation beneath the
+skin of numerous small lumps of a rounded form, and of the
+size of a kidney-bean, slightly movable, and not tender. By
+degrees such lumps become adherent to the skin, the surface
+of which above them grows red, they project slightly above it,
+and at last open by a small circular aperture, discharge a little
+matter, and then subside. They collapse and disappear; a
+slight depression and a degree of lividity of the skin mark for a
+considerable time the situation they had occupied. I refer to
+them, because while they are a sign of a scrofulous constitution,
+which may require special care in diet and preparations
+of iron and cod-liver oil, they are best left absolutely alone&mdash;neither
+poulticed nor lanced. The same principle of non-intervention
+applies equally to the swellings which sometimes
+form on two or three of the fingers in infancy, not involving
+the joints but producing great thickening and a hard swelling
+around the bone. These swellings disappear by degrees as the
+constitutional vigour improves, and this is especially promoted
+by a long stay at the seaside; but they tend, if the health fails,
+to affect the bones themselves, and thus to occasion deformities
+of the hand.</p>
+
+<p><span class='pagenum'><a name="Page_183" id="Page_183">[Pg 183]</a></span>Glandular swelling, discharges from the ear, offensive
+secretion from the nose, and in female children, even of very
+tender age, a discharge of whites, are all common signs of a
+scrofulous constitution, and all tedious and troublesome.
+They all, however, are very much under the influence of
+judicious medical treatment. It must at the same time be
+borne in mind that none of these ailments admit of what may
+be called active treatment. There are no royal means of
+dispersing scrofulous glands, or of curing discharges from the
+ear, or of doing away with the offensive smell which in some
+cases proceeds from the nostrils. Fresh air, suitable diet,
+preparations of iron, residence at the seaside, and sea-bathing,
+measures directed to improve the general health, are of chief
+value, and without them local treatment is of small avail.</p>
+
+<p>A few words, however, may with propriety be added with
+reference to the local treatment of the minor ailments to which
+I have just referred.</p>
+
+<p>No local application is of use in the <i>scrofulous swellings
+of the fingers</i>. Tincture of iodine, indeed, may be painted over
+them when quite small, while at the same time the joints are
+kept quiet by a small gutta-percha splint. When they become
+considerable, iodine is useless; and even if matter forms in the
+swelling it is much better to let it make its way out by a small
+opening spontaneously than to make a puncture with a lancet,
+since the edges of the wound would not heal, and the risk of
+the disease affecting the bone would be increased.</p>
+
+<p>The <i>glandular swellings</i> of the neck or about the lower jaw
+are likewise 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 of Goulard water and spirits of
+wine, constantly applied, will reduce the swelling and lessen the
+discomfort. When stationary, a mild iodine ointment may be
+smeared over the gland at bedtime, and covered with oiled
+silk. Applications of iodine, however, need careful watching,
+for sometimes they over-irritate the gland, and cause an
+abscess. If the gland were out of sight there would be no
+<span class='pagenum'><a name="Page_184" id="Page_184">[Pg 184]</a></span>objection to this, which would probably be a rapid mode of
+getting rid of the swelling; but the scar left behind, if the
+abscess burst or were opened, is an objection when the swelling
+is situated in the neck or at the jaw.</p>
+
+<p>If the skin over the top of the swelling becomes red, and
+its substance begins to feel soft, then, but not till then, it is
+desirable to apply a warm poultice constantly. At the same
+time the progress must be daily watched by the doctor, in
+order that he may seize the proper moment to make a small
+puncture and let out the matter. The small cut leaves a less
+puckered scar than the natural opening. The subsequent
+management of the case must be superintended by the doctor.</p>
+
+<p><i>Offensive discharge from the nostrils</i> does not depend, in by
+far the majority of cases, on disease of the bones, but on an
+unhealthy condition of their lining membrane. It is exceedingly
+obstinate and difficult of cure, is four times more frequent
+in girls than in boys, and unfortunately often lasts into
+womanhood, and continues even when the general health is
+perfect.</p>
+
+<p>Much may be done to abate the annoyance by diligent
+sniffing up the nostrils some weak disinfectant; or by regularly
+irrigating the nostrils by means of a simple apparatus, to be
+obtained from any instrument-maker. In spite of this, however,
+it is often necessary to introduce a little plug of cotton
+wool dipped in the fluid some distance up the nostrils, with a
+thread attached by which it can be withdrawn, and a fresh one
+substituted twice a day.</p>
+
+<p>The discharge of <i>whites</i> is sometimes very troublesome, and
+apt to return from the commencement of teething up even to
+womanhood. It is a mere sign of debility, usually also connected
+with a scrofulous habit, but has no further or graver
+meaning. Locally, constant cold ablution by means of a
+sponge held above the child, not touching it, is the great
+remedy, and this may have to be repeated every hour or two if
+the case is severe. Astringent lotions of different kinds may
+be used in the same manner; while care must be taken that
+the child's drawers are large and loose, so as not to irritate her
+<span class='pagenum'><a name="Page_185" id="Page_185">[Pg 185]</a></span>when sitting. General treatment, however, sea air and sea
+bathing are especially in these cases the great remedy.</p>
+
+<p>It must not be forgotten that all these ailments have a
+special tendency to recur; and that when people say 'Dr. A.
+or Dr. B. did the child good for the time, but this or that
+symptom returned as soon as the treatment was discontinued,'
+as though this were the doctor's fault, they are unjust; for the
+tendency to return of every form of scrofulous disease is one
+of the great characteristics of the malady. Patience and
+perseverance on the parents' part, even for months and years,
+are often as much needed as skill on the part of the doctor.</p>
+
+<p>One more remark may not be out of place. Some persons
+have an impression that there is something specially shameful
+in scrofulous disease, and while they will readily admit the
+existence of a consumptive tendency in their family, they
+almost resent the suggestion that their child's ailment is
+scrofulous. For this prejudice there is absolutely no foundation.
+There is no more reason for connecting scrofula in a child with
+any antecedent wrong-doing on the part of its progenitors, than
+there is for attaching that idea to the red hair or black eyes
+which a child may have in common with the rest of its family.</p>
+
+<p><b>Rickets.</b>&mdash;We sometimes see, especially in the poorer
+quarters of a great 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 a grown person on
+the body of a child, and we know that they suffered from
+<i>rickets</i> when young.</p>
+
+<p>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, they bend under the weight
+of the body, or under their own weight, and with every slight
+movement which its feeble muscular power enables it to make.
+It does more, however, than interfere with the hardening of
+the limbs: it arrests growth to a great degree, interferes with
+<span class='pagenum'><a name="Page_186" id="Page_186">[Pg 186]</a></span>development, retards teething, postpones the closure of the
+open part of the head, or fontanelle, weakens constitutional
+vigour, and impairs muscular power. To this feeble muscular
+power it is due that the child cannot make the effort to fill its
+lungs completely, and hence the pressure of the external air
+forces the soft ribs inwards, and gives to the chest the
+peculiar form of pigeon-breast. In the course of time the
+delayed bone-formation takes place, and the bones themselves
+become as hard as ivory, but the limbs do not straighten, and
+the deformity produced in infancy is but confirmed in after-life.</p>
+
+<p>The greater degrees of rickets are scarcely ever seen among
+the children of the wealthier classes, but over-crowded and
+ill-ventilated nurseries, cots from which the air is well-nigh
+shut out by closed sides and overhanging curtains; injudicious
+feeding, with undue preponderance of farinaceous food,
+often produce its slighter forms. I never yet saw rickets in a
+child while brought up exclusively at its mother's breast.</p>
+
+<p>The slighter forms of rickets show themselves in a tardy
+closure of the infant's head, which sweats profusely when the
+child is laid down to sleep; in big wrists, which contrast with
+the attenuated arms; in a general limpness of the whole body,
+and a bowing of the back under the weight of the head, which
+bends as a green stick would bend if a weight were placed
+upon it. They are further marked by backwardness in teething,
+and by the irregular order in which the teeth appear, and,
+further, by the peculiar narrowness of the chest, and by what
+has been termed the beading of the ends of the ribs: little
+round prominences due to a heaping up of gristle just where
+the ribs join on to the breastbone, marking the spots at which
+the tardy bone-making has come to a standstill.</p>
+
+<p>Children who bear these stamps of rickets are far more
+apt than others to suffer from spasmodic croup, and in them it
+is also specially likely to be severe and to be accompanied by
+convulsions. They will also be more liable than others to
+attacks of bronchitis, they will suffer more during teething,
+they will be often constipated, and will be troubled by various
+<span class='pagenum'><a name="Page_187" id="Page_187">[Pg 187]</a></span>forms of indigestion. Now and then, too, they will have causeless
+attacks of feverishness lasting for a few days, or for two or
+three weeks, attended with general tenderness of the surface,
+and a disposition to perspiration, which brings no relief but
+serves only to weaken.</p>
+
+<p>It is true that these symptoms do not often become immediately
+dangerous to life, though spasmodic croup and bronchitis
+both have their perils; but they interfere with health,
+and growth, and good looks, and cheerfulness, and quick
+intelligence.</p>
+
+<p>If mothers would but ask themselves the real signification
+of these symptoms, and change the conditions which surround
+the child, and alter their mode of feeding it, they would many
+and many a time be spared the heart-ache of seeing their little
+ones grow up weakly, ugly, ill-thriven.</p>
+
+<p>Unfortunately, it is so much easier to give cod-liver oil and
+iron than to turn the best spare room into a night nursery, and
+to uglify the cot by taking away the curtains which made it so
+pretty, and to give up some of the pleasures of society in order
+to superintend the preparation of the baby's food; that the
+doctor is called in to correct by drugs the evil which drugs
+cannot reach. Iron and cod-liver oil are very useful in the
+second place; fresh air, good ventilation, and a wise diet must
+always occupy the first.</p>
+
+<p><b>Acute Constitutional Diseases.</b>&mdash;It still remains for
+us to glance rapidly at the characters of the <i>acute constitutional
+diseases</i>, all of which belong, as has already been stated, to the
+class of fevers. Of them all but two are contagious&mdash;that is
+to say, are capable of being communicated directly from person
+to person. They are likewise infectious, or, in other words,
+articles of bedding or clothes which have been worn by the
+sick, retain a something&mdash;an exhalation from the breath, an
+emanation from the skin, or a secretion from the bowels&mdash;which
+may reproduce the same disease in a person previously healthy.</p>
+
+<p>To this contagious and infectious property there are two
+exceptions; the one is furnished by acute rheumatism, or
+rheumatic fever, the other by intermittent fever, or ague.</p>
+
+<p><span class='pagenum'><a name="Page_188" id="Page_188">[Pg 188]</a></span><b>Rheumatic Fever.</b>&mdash;The main features of <i>rheumatic
+fever</i> are the same at all ages. Fever, pain in the limbs,
+swelling of the joints, sweats unattended by that relief which
+usually accompanies abundant action of the skin in fevers, are
+its characteristics. In the child all these symptoms are usually
+less even than in the adult. The swelling of the joints in
+particular is less considerable, and both the pain and the
+swelling are apt to wander from one to another joint, or to a
+different limb, instead of remaining fixed as they do in the
+grown person for several days in the same joint, even though
+fresh joints may be implicated in the course of the disease.</p>
+
+<p>These circumstances tend to make people look on rheumatic
+fever in the child too often as a comparatively trivial
+ailment; and this not only because the suffering which attends
+the disease is slighter, but because its duration is also shorter.
+But there is one fact which forbids this low estimate of its importance,
+and that is the great tendency to affection of the
+heart even in cases of comparatively mild rheumatism in the
+child; while in the grown person there is a direct relation
+between the general severity of the rheumatic symptoms and
+the liability of the heart to be involved. I have already stated
+that nine out of ten of all cases of heart disease in early life,
+not due to original malformation, are of rheumatic origin, and
+further that heart disease comes on in the course of four out
+of five cases of rheumatic fever in the child, slight as well as
+severe. It seldom occurs before the third or fourth day of the
+illness, so that if parents take the alarm at the very outset,
+it is usually though not invariably possible for the doctor by
+judicious treatment to anticipate and to prevent its occurrence,
+or at any rate greatly to control its progress.</p>
+
+<p>Every threatening of rheumatism, therefore, is to be watched
+with the most anxious care, since so serious a complication as
+disease of the heart may accompany extremely slight general
+symptoms. It is wise too, to place any child in whom general
+feverish symptoms come on at once under medical observation,
+for though it does not usually happen, yet it does sometimes
+occur, that rheumatic inflammation attacks the heart before any
+<span class='pagenum'><a name="Page_189" id="Page_189">[Pg 189]</a></span>other local signs of the malady have manifested themselves.
+It is scarcely necessary to add that tenfold precautions are
+needed when rheumatism has once occurred, since the liability
+to its return is very great, and the heart which escaped in the
+first attack may suffer in the second; or the comparatively small
+mischief done the first time may become an incurable disorder.</p>
+
+<p><b>Ague.</b>&mdash;<i>Intermittent fever</i> or <i>ague</i> is very rare in childhood
+in London; or at any rate it is very rare among children of
+the wealthier classes. I believe it is everywhere rarer among
+children than among grown persons, probably because they are
+as a rule less exposed to those malarious influences which produce
+it. In the child it generally takes the form of tertian ague,
+that is to say the attack recurs every second day; one day of
+freedom intervening between two attacks.</p>
+
+<p>The three stages of shivering, heat, and sweating are less
+marked in the child than in the grown person, and this indistinctness
+of its symptoms is greater in proportion to the tenderer
+age of the child. Shivering is scarcely ever well-marked, a
+condition of unaccountable depression usually taking its place,
+while once or twice I have known convulsions occur which
+gave rise to the apprehension that disease of the brain existed.
+The hot stage is long, and passes off gradually without the
+profuse perspiration that occurs in the grown person, and the
+child even between the attacks is almost always more or less
+ailing.</p>
+
+<p>A first and even a second attack may puzzle not the parents
+only, but also the doctor; but after the symptoms have
+returned a few times, the child being neither better nor worse
+in the intervals, it becomes evident that no serious disease is
+impending. The risk of an overhasty conclusion is that the
+depression and disturbance of the nervous system may be
+supposed to imply the existence of brain disease; and lead to
+unsuitable treatment, instead of the administration of quinine,
+which nine times out of ten proves a specific for ague. The
+rapid increase of temperature in the attack, and its equally
+rapid subsidence afterwards, will, if carefully noted, preserve
+from error.</p>
+
+<p><span class='pagenum'><a name="Page_190" id="Page_190">[Pg 190]</a></span>There is much that is obscure with reference to the nature
+both of rheumatic and intermittent fever. They differ from
+other fevers not only by being neither contagious nor infectious
+but also by their readiness to return, while a single attack of
+any of the others furnishes a guarantee, and often a complete
+guarantee, against its recurrence. In addition to these peculiarities,
+the fevers of which I have now to speak are characterised
+by running a certain definite course, being accompanied
+by certain peculiar appearances on the surface (generally rashes
+on the skin, whence their name of eruptive fevers); being
+attended each with its own peculiar dangers, and all having a
+tendency to what is termed epidemic prevalence; that is to say
+to occur one year, and without obvious cause with vastly greater
+frequency than in other years.</p>
+
+<p><b>Mumps.</b>&mdash;It has been questioned whether that painful
+but not dangerous ailment the <i>mumps</i>, ought or ought not to
+be classed with these fevers. I think it should, for it is contagious,
+infectious, runs a fairly definite course, is attended
+with invariable external appearances, often prevails epidemically,
+and one attack preserves in most instances from a second.</p>
+
+<p>It very seldom befalls children under seven years of age,
+and is more frequent in early youth than in childhood. It sets
+in with the ordinary symptoms of a cold, which are followed
+in about twenty-four hours by stiffness of the neck, and pain
+about the lower jaw, which is increased by speaking or swallowing.
+At the same time a swelling appears, sometimes on one
+side sometimes on both of the lower jaw, and increases very
+rapidly so as to occasion great disfigurement of the face. The
+swelling goes on to increase, and to become more tense, attended
+with more head-ache, fever, and discomfort for some forty-eight
+hours, but then 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, or more; and now and then, though very
+rarely, an abscess forms, which is both tedious and troublesome.</p>
+
+<p>The treatment suitable for a severe common cold, together
+with the constant application of a warm poultice to the swollen
+<span class='pagenum'><a name="Page_191" id="Page_191">[Pg 191]</a></span>gland, is all that is usually required, though the doctor's help is
+often needed to relieve the suffering which for the first day or
+two in many instances attends the ailment.</p>
+
+<p><b>Typhoid Fever.</b>&mdash;There is no question as to the place
+which should be occupied by typhoid fever, smallpox, measles,
+and scarlatina, for all belong to the class of eruptive fevers.
+They are all specific diseases, each due to its own peculiar
+poison, and not capable of being produced by any mere unsanitary
+conditions, though such may aggravate their severity
+and facilitate their spread.</p>
+
+<p>The belief in the special character of each of these diseases
+has received strong confirmation from the researches of the
+eminent Frenchman, M. Pasteur, and others who have followed
+in his track. They have discovered in the blood and other
+secretions, and in some of the tissues both of men and animals,
+minute microscopic organisms which differ in their characters
+in different diseases. Experiment has further shown that in
+some mysterious way these organisms are the cause of these
+diseases, for on inoculating animals with them the peculiar
+disease of which each was the accompaniment, and no other,
+was reproduced in the inoculated animal.</p>
+
+<p>As far as our knowledge goes at present then, we are forced
+to regard each of these as a separate disease, measles never
+passing into scarlatina, nor that into smallpox, but each, whether
+slight or severe, retaining throughout its distinct character.</p>
+
+<p>We have already seen how, in the course of various diseases,
+the pulse is quickened, and the temperature raised, constituting
+that state which we commonly call fever, but as the local
+ailment subsides the fever disappears. There is, apart from
+smallpox, measles, and the other so-called eruptive fevers, only
+one real essential fever commonly met with in childhood, and
+that is what the doctors call <i>typhoid fever</i>. The name, from
+the similarity of sound to <i>typhus</i>, from which, however, it is
+essentially different, has long been a name of terror in the
+nursery, and all sorts of epithets have been substituted for it, as
+gastric fever, and infantile remittent fever, and so on. Name
+it as you may, the fever is one and the same with the typhoid
+<span class='pagenum'><a name="Page_192" id="Page_192">[Pg 192]</a></span>fever, which one hears of as prevailing constantly in many continental
+cities, and proving dangerous and fatal in any district
+almost in direct relation to the neglect of drainage and
+of proper sanitary precautions.</p>
+
+<p>It is extremely rare in infancy, though I saw it once in a
+babe eight months old, and is comparatively seldom met with
+before the age of five years. From five to ten years old it is
+more frequent than from ten to fifteen, but it is consolatory
+to know that it is less fatal in early childhood than at any
+subsequent time of life, and that cases of such exceedingly
+mild character that the child's condition can be more
+properly described as ailing rather than ill, are then far
+from uncommon. The symptoms, however, are in all instances
+similar in kind, though widely varying in degree,
+and the duration of the fever is, as nearly as may be, three
+weeks. By this it is not meant that at three weeks' end the
+child who has had typhoid fever is well again, but only that
+the temperature, which had hitherto been high, and always
+higher at night than in the morning, has subsided, that the
+skin has become less dry, the tongue slightly moist, the
+intelligence more clear, that the fever has run its course. For
+the first week or ten days, the symptoms have probably become
+every day more grave; and for the next ten the doctor
+could find no better consolation than the assurance&mdash;happy if
+he could give it&mdash;that the condition was not worse, but that
+you must have patience, for the time for improvement had not
+yet arrived. If the attack has been severe, the child will be
+left greatly exhausted, sadly emaciated, and suffering from the
+effects of that ulceration of the bowels which accompanies
+the fever, and from which life may still be in imminent danger.
+But the fire is quenched; the question is no longer how to
+put out the conflagration, but how to repair the mischief it has
+caused.</p>
+
+<p>When mild, the disease usually comes on very gradually,
+the child loses its cheerfulness, the appearance of health leaves
+it, the appetite fails, and the thirst becomes troublesome; in the
+daytime it is listless and fretful, and drowsy towards evening,
+<span class='pagenum'><a name="Page_193" id="Page_193">[Pg 193]</a></span>but the nights are often restless, 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 no refreshing. The
+thermometer will quite, in the early days, solve all doubt as to
+the nature of the case. In the morning the thermometer will be
+natural, or nearly so, but at seven o'clock in the evening it will
+have risen to 101&deg; or 102&deg;, and will continue so during the early
+part of the unquiet night. After midnight it will begin to fall, and
+by six o'clock in the morning, or even earlier, will have regained
+its natural standard. There is no other disease but typhoid
+fever, and now and then some forms of galloping consumption,
+in which these oscillations of temperature take place regularly.
+Other symptoms attend typhoid fever besides these, and serve
+to stamp upon it its distinctive character. The bowels are
+usually loose, or if not, a moderate aperient acts on them excessively,
+the evacuations being loose, often watery, of a light
+yellow-ochrey colour. The abdomen is full, the bowels being
+more or less distended with wind, sometimes tender, especially
+at the right side, and both 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 the second week, small rose-red
+spots or pimples appear on the abdomen, sometimes also on
+the chest and back. They disappear for the moment if pressure
+is made on them, but reappear the moment the pressure
+is withdrawn. Now and then they are numerous, and sometimes
+two or three successive crops appear, the old ones fading
+as the others show themselves; but in childhood they are often
+scanty, though whether few or many, they are the external
+characteristic of the disease just as the rash is in scarlatina or
+measles.</p>
+
+<p>Whenever a child of whatever age begins without obvious
+cause to lose appetite and health, to become feverish, with
+marked increase of temperature towards evening for several
+days together, and more or less disposition to diarrh&oelig;a, it is
+all but absolutely certain that the child has contracted typhoid
+fever.</p>
+
+<p><span class='pagenum'><a name="Page_194" id="Page_194">[Pg 194]</a></span>When the disease comes on gradually, it seldom becomes
+dangerous, though until the end of the first week there is always
+considerable uncertainty on this point. The amount of diarrh&oelig;a
+and the degree of disorder of the brain, as shown by
+restlessness, delirium, and stupor are the measure of the gravity
+of any case. There is, however, scarcely any disease from
+which even when most severe recovery so often takes place in
+childhood, and this not as persons so often imagine from some
+critical occurrence but by a process of gradual amendment.
+The first signs of amendment, too, may be taken as giving
+almost certain promise of complete recovery; but it is well to
+bear in mind that there is no disease of early life in which the
+mental faculties, though time brings them back at length uninjured,
+remain so long in a state of feebleness and torpor as
+in typhoid fever. Though the first signs of improvement, too,
+are very seldom deceptive, yet the patient's convalescence is
+almost always slow, and interrupted by many fluctuations.</p>
+
+<p>Though contagious, still typhoid fever is far less directly
+contagious than measles or scarlatina. It seems as if with this
+disease, just as with cholera, the contagious element were present
+in its most active form in the discharges from the bowels.
+These should therefore be disinfected by carbolic acid or some
+other disinfectant immediately; and should never be emptied
+in a closet used by other members of the family, and more
+particularly by children. Special precautions also should be
+taken with the bed-linen, and night-dresses of the patient; and
+it must be remembered that wise precautions have nothing in
+common with exaggerated alarm. One more hint will not be
+out of place. In typhoid fever, and still more in the highly
+contagious measles and scarlatina, the person who sleeps in
+the patient's room is much more likely to contract the disease
+than she who sits up and watches at night keeping wide awake.
+Whoever takes charge of a fever patient during the night
+should therefore sit up and watch, not lie down and doze, and
+this not for the patient's sake only, but for her own.</p>
+
+<p>It can scarcely be necessary to say that in every, even the
+mildest, attack of typhoid fever the attendance of the doctor is
+<span class='pagenum'><a name="Page_195" id="Page_195">[Pg 195]</a></span>needed from first to last. He may come every day, and may
+daily do nothing but merely watch. The disease will run its
+course, the greatest skill cannot cut it short, though now and
+then instead of lasting for three or even four weeks it comes to
+an end spontaneously in fourteen days. Skilled watching is
+what the competent doctor gives. You would not despise or
+underestimate the pilot's skill, who steered your barque through
+a dangerous sea in smoothest water, because he knew each
+hidden rock or unseen quicksand on which but for his guidance
+you might have made shipwreck.</p>
+
+<p><b>Small-pox.</b>&mdash;At the present day, thanks to vaccination,
+and to re-vaccination, <i>small-pox</i> is rarely met with in the well-to-do
+classes of society, though it is not yet a century ago since
+it found its victims not only among the poor, but among the
+highest in the land. It does, however, occur sometimes after
+vaccination, and sometimes, though very rarely, an attack of
+small-pox fails to furnish an absolute guarantee against the
+occurrence of a second.</p>
+
+<p>Small-pox, unmodified by previous vaccination, sets in in the
+child with violent sickness; vomiting, sometimes recurring frequently
+for forty-eight hours, with much depression, or even
+stupor; in some instances even actual convulsions, and fever;
+but neither with the sore-throat of scarlatina, nor with the sneezing,
+cough, and running at the nose of measles. At the end of
+from forty-eight to sixty hours, an eruption of pimples appears
+on the face, forehead, forearms and wrists, whence it extends to
+the body and the lower limbs. They are reddish in colour, rather
+pointed in form, and at first scarcely raised above the surface;
+so that the eruption looks at first like the very early eruption of
+measles; though the tiny pimples felt as if beneath the skin
+serve even then to distinguish the one disease from the other.
+In another forty-eight hours the character of the pimples has
+changed into that of little vesicles or pocks, depressed instead of
+pointed at their centre, and containing a little watery milky fluid.
+They next enlarge, and become once more prominent at their
+centre as they fill more and more with fluid, which becomes
+thicker, yellowish-white&mdash;looks like, and indeed is, matter. Four
+<span class='pagenum'><a name="Page_196" id="Page_196">[Pg 196]</a></span>or five days are occupied with this process; the matter in the
+pocks then begins to dry, and scabs to form, which gradually
+by the end of another week drop off, and leave the skin spotted
+with red or even scarred if the pocks went deep enough to
+destroy the skin, and to leave the indelible marks, the so-called
+pitting of small-pox.</p>
+
+<p>The danger of the disease is in childhood the nervous
+disorder at the outset, and then the exhaustion produced by
+the so-called maturation of the pocks when the thin watery
+fluid changes to the thicker matter, and depresses the patient
+in the same way as he would be depressed by an enormous
+abscess.</p>
+
+<p>The first outbreak of the eruption is followed always by a
+most remarkable abatement in the disturbance of the constitution,
+and for three or four days, even though the eruption is
+abundant, the patient may seem so well that it is almost impossible
+to realise the imminent peril to which he will be exposed
+in a few days' time.</p>
+
+<p><b>Inoculation and Vaccination.</b>&mdash;The danger of small-pox
+is in direct proportion to the abundance of the eruption;
+and the great advantage of inoculation for the small-pox consisted
+in the much scantier eruption which followed it, as compared
+with that which commonly took place in the natural
+small-pox.</p>
+
+<p>The same advantage in a greater degree is obtained by
+vaccination, even in the exceptional instances in which it
+fails to render the person altogether insusceptible to the
+disease.</p>
+
+<p>The great advantage which inoculation secured was counterbalanced
+in great measure by the fact that it always maintained
+small-pox rife throughout the whole country, and that
+consequently all who either had neglected inoculation, or young
+children on whom, on account of their tender age, it had not
+yet been practised, were more than ever exposed to constant
+risk of infection.</p>
+
+<p>This very real danger led to the almost unanimous welcome
+which the practice of vaccination received towards the end of
+<span class='pagenum'><a name="Page_197" id="Page_197">[Pg 197]</a></span>the last century, since it was hoped that by it not only would
+the risk attending small-pox be lessened, and the disease when
+it did occur be even milder in character than inoculated small-pox,
+but that small-pox itself would eventually be extirpated.</p>
+
+<p>These anticipations have not hitherto been fully realised;
+but the good effected by vaccination has been such as to
+render it, in the opinion of nearly everyone qualified to form an
+opinion on the subject, one of the greatest boons ever conferred
+on the human race.</p>
+
+<p>Small-pox, like other eruptive fevers, has the peculiarity of
+occurring for the most part only once in a person's life. We
+do not know in the least on what this protecting influence
+depends. We know the fact, but are the less able to offer an
+explanation, since there are other constitutional diseases, such
+as gout and rheumatism, in which the local symptoms are
+equally the outcome of previous constitutional disorder, where
+exactly the opposite rule obtains, and in which their occurrence
+does but increase the liability to their return.</p>
+
+<p>The protective power is apparently possessed by the mild
+form of the disease communicated by inoculation as much as
+by the severer form of small-pox which is contracted by direct
+contagion or infection. This knowledge has been applied in
+the treatment of some of the diseases of animals, and it has
+been found in the case of the so-called small-pox in sheep (a
+disease which, however, is quite distinct from human small-pox)
+that while one in two of the animals who contracted it in
+the ordinary way 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 inoculated sheep were thereby safeguarded
+from subsequent attacks as completely as the others.</p>
+
+<p>This knowledge was more recently applied by the distinguished
+Frenchman whom I have already mentioned,
+M. Pasteur, in the case of a fatal pestilence among sheep in
+many parts of France, known by the name of <i>charbon</i>. The
+inoculated sheep died, however, in such large numbers,
+though in a somewhat smaller proportion than those who had
+been directly infected, that he found it necessary to weaken the
+<span class='pagenum'><a name="Page_198" id="Page_198">[Pg 198]</a></span>matter which he employed by admixture with other innocuous
+materials. This experiment, however, again yielded unsatisfactory
+results; slight symptoms of the disease were produced,
+but the protection thus afforded was inadequate and uncertain.
+Some few resisted the disease, but others contracted it and
+died. With that clear insight which constitutes genius, M.
+Pasteur next tried the experiment of inoculating the sheep first
+with a weak matter which produced but slight symptoms, but
+at the same time enabled the animal to support a second inoculation
+with a stronger matter; and this second inoculation
+enabled them to bear, unharmed, subsequent exposure to the
+disease. A grateful country has given a pension, and conferred
+well-merited honours on the man who has preserved their flocks
+from pestilence, but whom the silly sentimentality of the anti-vivisectionists
+in England would have mulcted in a fine, and, if
+possible, have sent to prison.</p>
+
+<p>That weakening of the poisonous element which Pasteur
+strove to attain by art, is already provided by nature in the
+cow-pox. The cow-pox is nothing else than small-pox modified
+in character, diminished in severity by passing through the
+system of the animal; but giving, when introduced into the
+system, a safeguard against natural small-pox at least as complete
+as that furnished by the inoculated disease.</p>
+
+<p>More than 70,000 children have come under my observation,
+either in hospital or in private practice; and I need not
+say that a physician having much consulting practice sees far
+more than the average of unusual and severe cases. Twice,
+and only twice, I have seen infants die from vaccination, and
+in both instances death took place from erysipelas beginning at
+the puncture. The one case I saw twice in consultation with
+the family practitioner. The other which I watched throughout
+was that of a little boy, the fifth child of a nobleman of
+high rank, both his parents being perfectly healthy. He was
+vaccinated by the family doctor in the country, direct from the
+arm of another perfectly healthy infant, from whom ten other
+infants were vaccinated immediately afterwards. The little
+boy was seized with convulsions within twenty-four hours, and
+<span class='pagenum'><a name="Page_199" id="Page_199">[Pg 199]</a></span>almost at the same time erysipelas appeared on the punctured
+arm. The erysipelas extended rapidly, convulsions returned
+more than once, and on the fourth day from the vaccination
+the child died. One of the other children vaccinated at the
+same time died in the country in the same manner; all the
+others passed through vaccination regularly, and without a
+single bad symptom. I have no explanation to offer; this
+case stands by itself just as do those of death from the sting of
+a bee or death from cutting a corn.</p>
+
+<p>That some people die of other diseases since the introduction
+of vaccination, is undoubtedly true, for many of those who
+would have died in early infancy of small-pox are cut off later
+by measles or bronchitis, or die during teething; since it is
+obvious that vaccination does not protect against any other
+disease than small-pox.</p>
+
+<p>That protection, indeed, is not absolute, nor was the protection
+afforded by inoculation absolute; but small-pox after
+vaccination, even when it does occur, is very rarely severe, and
+still more seldom fatal.</p>
+
+<p>There seems good reason for believing that the protecting
+power of vaccination tends to diminish with the lapse of time;
+though apparently this is not always the case, nor can any
+direct statement be made as to the 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 does exist, and that
+this tendency calls for the repetition of vaccination from time
+to time; such re-vaccination carefully performed being as
+nearly as possible an absolute guarantee against small-pox. All
+persons engaged as nurses or attendants at the Small-Pox
+Hospital during the past thirty-two years, have been vaccinated
+or re-vaccinated before entering on their duties, and during
+this period not a single case of the disease has occurred among
+the whole staff. The experience of other small-pox hospitals
+for a shorter period is identical. As far as we know, every
+seventh year is a reasonable interval at which re-vaccination
+should be performed.</p>
+
+<p>One great cause of the failure of the protective power of
+<span class='pagenum'><a name="Page_200" id="Page_200">[Pg 200]</a></span>vaccination is the unintelligent and careless manner in which
+it is too often performed, especially among the poor. To this
+same cause it is also due that in some cases of almost infinite
+rarity one special constitutional disease has been known to be
+communicated. I have never seen such a case, but I know
+there are such. They are, however, no more a reason against
+vaccination than the occasional death from an overdose of
+opium is a reason against the use of that drug.</p>
+
+<p>To avoid any risk of this kind, and also with the idea that
+the power of the vaccine matter may have become weakened
+by transmission through many thousands of persons, vaccination
+direct from the calf has been introduced of late
+years, especially in America and on the Continent. The time,
+however, that has as yet elapsed is scarcely sufficient to test
+the comparative preservative power of this as compared with
+vaccination from the human subject. Its immediate local
+effects are somewhat more severe; I do not know any reason
+why its influence should not be equally abiding.</p>
+
+<p>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 an eruption, or
+aggravate an eruption already existing. Such cases, however,
+are not frequent, and the eruption is not more troublesome
+than those which often appear in teething children. The
+occurrence of actual erysipelas around the puncture, while very
+dangerous, is, as I have already stated, of excessive rarity.</p>
+
+<p>A thoroughly dispassionate review of the whole subject
+appears to me to warrant the following conclusions:&mdash;</p>
+
+<p>1st. That vaccination, though not a perfect guarantee against
+small-pox, diminishes immensely the risk of its occurrence;
+and that by periodical revaccination, this guarantee is rendered
+all but absolute.</p>
+
+<p>2nd. That a very large proportion of the failures of vaccination
+are due to its careless and imperfect performance.</p>
+
+<p><span class='pagenum'><a name="Page_201" id="Page_201">[Pg 201]</a></span>3rd. That to such careless performance and to the introduction
+of the blood and not of the vaccine matter alone, from
+one child to another are due the extremely rare instances in
+which one special disease has been transmitted by vaccination.</p>
+
+<p>4th. That there is absolutely no evidence of the transmission
+of scrofula, consumption, or any similar disease by
+vaccination.</p>
+
+<p>5th. That vaccination direct from the calf appears to present
+some decided advantages; but it has not yet been practised
+for a sufficient time to admit of a comparison between its
+preservative power and that of vaccination from one child to
+another.</p>
+
+<p>6th. That in either case it is expedient that vaccination be
+performed within the first three months after birth, so as to
+avoid the irritation of teething which is unfavourable to successful
+vaccination, and also because the disposition to those
+skin diseases which vaccination tends to aggravate is never so
+considerable before the age of three months as it becomes
+subsequently.</p>
+
+<p>Even when vaccination fails to protect against small-pox
+it tends to produce a modified and so much milder form of the
+disease, that while one patient died out of every two in the
+Homerton Small Pox Hospital who had the disease naturally, the
+deaths were only one in four of those who had been imperfectly
+vaccinated, and one in forty-three of those whose arms bore
+evidence of perfectly good and successful vaccination.</p>
+
+<p>The influence of previous vaccination often scarcely shows
+itself in the stage which precedes the appearance of the eruption
+of small-pox, the fever being often just as intense, and the
+general symptoms just as severe as in the unmodified disease.
+The difference, however, becomes at once obvious with the
+appearance of the rash. The pocks are always much fewer
+than even in mild small-pox, sometimes even not more than
+twenty. They never attain above half the size of the ordinary
+small-pox pustules; they run their course and dry off in half
+the time, and consequently the dangerous fever which accompanies
+<span class='pagenum'><a name="Page_202" id="Page_202">[Pg 202]</a></span>their development in the natural disease is almost or
+altogether absent in the vast majority of instances.</p>
+
+<p>If vaccination did no more than this it would be hard to
+overestimate its value, or to praise as it deserves the merit of
+its discoverer.</p>
+
+<p><b>Chicken-Pox</b> is an ailment of such slight importance that
+it would scarcely call for notice if it were not that the resemblance
+of the eruption to that of small-pox sometimes leads to
+its being mistaken for that disease.</p>
+
+<p>It is highly contagious, and for this reason perhaps it is
+usually met with in infancy and early childhood. Sometimes,
+though by no means constantly, the eruption is preceded for
+twenty-four or thirty-six hours by slight feverishness; but
+oftener the appearance of the rash is the first indication of anything
+being the matter. It shows itself in the form of small
+pimples, which in a few hours change into small circular pocks
+containing a little slightly turbid fluid. They appear on the
+forehead, face, and body, but very rarely on the limbs; they
+enlarge for some two or at most three days, then shrivel
+and dry up; and at the end of a week the crusts or scabs fall
+off, scarcely ever causing any permanent pitting of the skin.
+They are usually not above twenty or thirty in number, though
+every now and then they are much more numerous without
+any obvious reason. Their distinction from the small-pox
+eruption consists not only in the smaller size of the pocks, and
+in the entirely different course which they run, but also in the
+fact that two or three successive crops of the eruption appear
+in the course of five or six days, so that new ones, those at
+maturity, and those on which the crusts have already formed,
+or from which they have already fallen, may be seen on the
+child at the same time. This is sufficient of itself to establish
+the difference between the two diseases, and also to distinguish
+between chicken-pox and the milder variety of small-pox which
+is sometimes observed in children who have been already
+vaccinated.</p>
+
+<p><b>Measles</b> is a disease with which almost everyone is
+familiar, and one which with proper care is not generally
+<span class='pagenum'><a name="Page_203" id="Page_203">[Pg 203]</a></span>attended with danger. Its great risks are twofold; first, that
+of its being complicated with bronchitis, or inflammation of the
+lungs during its progress, and next of its being followed by an
+imperfect recovery, and by the awakening into activity any
+tendency to scrofulous or consumptive disease. On these two
+accounts the disease is not to be made light of, and special
+watchfulness is to be exercised during the whole time of
+convalescence. It is also unwise when 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 it over;'
+for its mildness in one case furnishes no guarantee of its mildness
+in another, and the danger of the disease is almost in exact
+proportion to the tender age of those who are attacked by it.</p>
+
+<p>The early symptoms of measles are those of a bad feverish
+cold; the eyes grow red, weak, and watery, and are unable to
+bear the light, the child sneezes very frequently, sometimes
+almost every five minutes, and is troubled by a constant short
+dry cough. About the fourth day, a rash makes its appearance
+on the face, forehead, and behind the ears, and in the course
+of the next forty-eight hours travels downwards over the body
+and limbs, and then in another forty-eight hours it fades in the
+same way, being at its height on the body when it has already
+begun to disappear from the face. It first shows itself in the
+form of small red circular spots, not unlike fleabites, but very
+slightly raised above the somewhat reddened skin, and looking
+for a few hours not unlike the very early stages of small-pox,
+before the eruption has lost the character of minute pimples.
+On the face the spots sometimes run together, and then form
+irregular blotches about a third of an inch long by half that
+breadth; while elsewhere they present an irregular crescentic
+arrangement. As the rash fades it puts on a dirty yellowish
+red appearance; the surface of the skin often becomes slightly
+scurfy, and it continues somewhat stained of a reddish hue for
+some days after the eruption has disappeared.</p>
+
+<p>The only other point on which it is necessary to dwell is
+this, that the symptoms do not, as in small-pox, become less
+severe immediately on the appearance of the eruption, but continue
+<span class='pagenum'><a name="Page_204" id="Page_204">[Pg 204]</a></span>just as troublesome as before for twenty-four hours or
+more, the voice being hoarse, the cough even more incessant,
+and the throat often slightly sore and red. Soon, however,
+improvement becomes apparent, the fever lessens, the cough
+grows looser; and in less than a fortnight the patient is usually
+convalescent.</p>
+
+<p>The above is pretty nearly the ordinary course of measles,
+for we do not meet with that extreme variation in its severity
+which is observed in scarlatina, where one child will seem
+scarcely to ail at all, while its brother 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 domestic management, for
+while the cough is troublesome in almost every case, the ear
+of the experienced doctor is needed to ascertain whether it is
+merely the cough of irritation which attends the measles, or the
+graver cough due to bronchitis.</p>
+
+<p>One other caution will not be out of place. The danger of
+exposure to cold is very real, but that does not necessitate the
+loading the child with excessive covering, or the abstaining
+from washing its hands and face. The child should be kept
+moderately cool; and sponging its hands and face frequently
+with tepid water soothes it and relieves the painful irritation
+and itching.</p>
+
+<p><b>German Measles.</b>&mdash;There is a disorder which seems to
+hold a middle place between measles and scarlatina, akin to
+both, identical with neither, and furnishing no sort of protection
+from their occurrence.</p>
+
+<p>It is known in this country by the name of <i>German measles</i>,
+or sometimes by its German name of <i>R&ouml;theln</i>; the first clear description
+of its character having been given by German writers.</p>
+
+<p>It is unfortunate that a very slight resemblance of some of
+its symptoms to those of scarlet fever has led to its being
+sometimes mistaken for it, and as the ailment is almost always
+very trivial, doctors anxious to avoid alarming their patients'
+friends, too often allow the error to go unrectified, and the
+disease to pass as one of mild scarlet fever.</p>
+
+<p>The resemblance of German measles to scarlet fever is,
+<span class='pagenum'><a name="Page_205" id="Page_205">[Pg 205]</a></span>however, extremely slight, and is almost entirely limited to the
+existence of a slight sore-throat, unaccompanied with glandular
+swelling. The rash in no respect resembles the uniform redness
+of the scarlatinal eruption, and there is no peeling of the
+skin, nor even any roughness of the surface left behind.</p>
+
+<p>Slight feverishness sometimes precedes the appearance of
+the rash for twenty-four hours; but the cough, and sneezing,
+and running at the eyes and nose, which usher in measles are
+entirely absent. The rash usually appears in the course of
+twenty-four hours, is never postponed beyond the second day;
+it begins, like that of measles, on the face, and, like it, travels
+downwards, but always disappears on the third day, while that
+of measles is not entirely gone before the eighth or ninth.
+The rash itself also has a different character. It consists of
+small, slightly elevated, round red spots which now and then
+coalesce into small patches, but never have the somewhat
+crescentic arrangement observed in the rash of measles. The
+colour of the spots is somewhat darker than that of the eruption
+of measles, while the <i>skin between them remains pale</i>, and does
+not assume the flush of measles. As it disappears it simply
+fades, and does not at all change its tint as that of measles
+does, and it leaves the skin unroughened.</p>
+
+<p>Now and then German measles are severe, and are
+attended with a good deal 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 the disease prevails
+epidemically; and even then the symptoms of the affection are
+sufficiently marked to preserve from error all but those who
+wish to be deceived, and to flatter themselves that their child
+is henceforth protected from scarlatina.</p>
+
+<p><b>Scarlatina</b>, or <b>Scarlet Fever</b>, for the two names mean
+the same thing, the former being only the Latin term, and
+not implying any greater mildness of the disease, is one of the
+most formidable ailments of childhood, and especially of early
+childhood, since the highest mortality from it takes place
+during the third year of life.</p>
+
+<p>It is more dreaded in a household, and justly so, than any
+<span class='pagenum'><a name="Page_206" id="Page_206">[Pg 206]</a></span>other disease of childhood, though, indeed, it is not limited in
+its occurrence to early life, and instances are familiar to us
+all in which the mother, devoting herself to the care of her
+little ones, has herself fallen a victim to the poison.</p>
+
+<p>I do not think it so directly contagious, from person to
+person, as small-pox, chicken-pox, or measles, but its infection
+appears to be specially abiding in its character, and to cling
+longer to the clothes, the bedding, and even the room of a
+scarlet fever patient, than that of the other eruptive fevers,
+except perhaps small-pox.</p>
+
+<p>It is an object of special dread also for two other reasons.
+One of these 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 to have it so slightly as scarcely to
+be ill, two to have their lives placed in jeopardy, and two to
+die. The other reason for special dread is that the mildness
+of the disease at its outset affords but a slight guarantee against
+the occurrence of serious complications in its course, and still
+slighter against secondary diseases which may follow in its
+train, and either destroy life directly, or leave behind some
+irremediable mischief.</p>
+
+<p>Scarlatina has been divided by medical men into three
+classes, according to its different degrees of severity; the mild&mdash;that
+accompanied with bad sore-throat&mdash;and the malignant
+variety.</p>
+
+<p>We have specially to do with the first of the three; for it is
+in it only that there is danger of the disease being overlooked,
+or mistaken.</p>
+
+<p>The symptoms of scarlatina usually appear within three
+days after exposure to its contagion, and there is very good
+authority for believing that the interval never exceeds six days.
+I should not, however, feel quite secure until after the lapse of
+ten days, and during this 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 the surface, usually with,
+but sometimes even without slight sore-throat and feverishness,
+may be the first indication of an affection which is sometimes
+<span class='pagenum'><a name="Page_207" id="Page_207">[Pg 207]</a></span>so deadly. In the majority of cases, however, it is ushered in
+by vomiting once or oftener, accompanied by headache, heaviness,
+of head, great heat of skin, and some measure of sore-throat.
+The brain is easily disturbed in children, as has
+already been said, and delirium at night during the first
+twenty-four hours of an attack of scarlet fever need not excite
+anxiety, for it then often passes away, and the disease runs
+a perfectly favourable course. The continuance of delirium
+later is an attendant only on the graver forms of scarlet fever.</p>
+
+<p>The rash often makes its appearance within twenty-four
+hours after the commencement of the illness, at latest in the
+course of the second day. It usually shows itself first on the
+neck, breast, and face, whence it extends in twenty-four hours
+to the body and limbs, and is then not seldom specially vivid
+on the inside of the thighs. Its colour is a very bright red,
+due in part to a general flush of the skin, in part to the
+presence of innumerable red dots or spots, which do not
+communicate any sense of roughness to the hand, though now
+and then extremely minute red pimples are interspersed. For
+three days the rash usually continues to become of a deeper
+colour, and more generally diffused over the whole surface;
+it then slowly declines, but does not wholly disappear until the
+seventh or eighth day of the disease. As the rash subsides the
+skin is left rough, and by degrees scales off, often in large
+flakes from the hands and feet, but elsewhere in a sort of
+branny scales. Sometimes this process is over in five or six
+days, while in other cases the skin peels and is reproduced
+several times in succession, so that it is protracted for three or
+four weeks or even longer. The degree of this peeling also
+varies as well as its duration. It is usually most considerable
+where the rash has been most abundant, while where the rash
+has been scanty, it is sometimes scarcely apparent except at
+the tips of the fingers and toes and just around the insertion of
+the nails.</p>
+
+<p>Besides the rash there are commonly other symptoms not
+less characteristic of scarlatina, and among them the sore-throat
+is one of the most invariable. Even in mild cases, it is very
+<span class='pagenum'><a name="Page_208" id="Page_208">[Pg 208]</a></span>rarely absent, and if not present at the beginning, it comes on
+on the second or third day. The palate and tonsils, in these
+circumstances are red, and the latter are usually more or less
+swollen, while swallowing is attended with pain, or at any rate
+with discomfort. The redness of the palate, which extends
+also to the back of the throat, is a finely spotted redness closely
+resembling the rash on the surface. The tongue is coated with
+a thick white or yellowish coating, through which project
+numerous bright red points, papill&aelig; as they are called, and
+this appearance of the tongue is as distinctive of scarlatina as
+the rash itself. Later, as the rash begins to fade, the coating
+separates from the tongue, which is left of a bright red colour,
+looking raw and shining, with the little raised red points
+projecting beyond its surface, and constituting what has been
+called in medical language, the strawberry tongue.</p>
+
+<p>When all these symptoms are present, no one can doubt
+but that the case is one of scarlatina. But the decision is far
+less easy in mild cases, for in them the rash is sometimes
+extremely evanescent, the general disturbance of health very
+slight, and the fever and accompanying rise of temperature
+small. The risk in such circumstances of the disease being
+altogether overlooked is even greater than that of its being
+confounded with some other eruptive fever. The rash of
+measles cannot be confounded with that of scarlatina, and the
+distinctly spotty character of the rash of German measles ought,
+apart even from other differences, to render mistake impossible.</p>
+
+<p>Perhaps the best rule that can be laid down is that every
+diffused red rash, not obviously formed by distinct spots, even
+though it be not uniform but appears in patches on the neck,
+breast, back, or inside of the thighs, and persists for more than
+twelve hours, is scarlatinal. Further, that in any instance in
+which even very slight feverishness, or very slight sore-throat,
+have preceded or accompanied the rash, the nature of the ailment
+is stamped beyond the possibility of doubt. Mistakes
+are made from want of careful observation, much more than from
+any insuperable difficulty in distinguishing one disease from the
+other. When the least hesitation is felt as to the nature of any
+<span class='pagenum'><a name="Page_209" id="Page_209">[Pg 209]</a></span>rash which may appear on a child, with, or without previous
+illness, the question should be at once referred to a medical
+man. People are too apt in these circumstances to wait for a
+few days, and then to appeal to the doctor when all traces of
+rash have disappeared, and when the grounds no longer exist
+on which he could base a positive opinion.</p>
+
+<p>I need not describe the symptoms of severe and dangerous
+scarlatina, for long before symptoms become really formidable,
+the patients will have been placed under medical care. It may
+suffice to say that the danger is almost always in proportion to
+the severity of the throat-affection and swelling of the glands,
+and not at all in proportion to the abundance of the rash.
+Though severe cases usually set in with severe symptoms, yet
+this is not invariably the case, and medical watching is all the
+more necessary from the very commencement, since until the
+end of the first week it is impossible to calculate on the subsequent
+course of the disease. In malignant scarlatina happily
+of infrequent occurrence, the child is struck down, as though
+its blood were poisoned, from the very first; and death takes
+place often within forty-eight hours, the rash appearing just
+sufficiently to stamp the nature of the pestilence which has
+proved so deadly.</p>
+
+<p>It may form a useful conclusion to all that has been said in
+this little book about the diseases of children, if I endeavour
+to point out in what consist the duties of parents in cases of
+scarlatina, or of any disease which resembles it.</p>
+
+<p>1. To watch carefully the commencement of every slight
+feverish attack in which a diffused red rash appears, even
+though this should be only in patches, and to bear in mind the
+possibility of its being due to scarlatina.</p>
+
+<p>2. To remove the child immediately from the others, so
+long as there is any doubt concerning the nature of the case,
+and to remove with him his bed, bedding, and all clothes worn
+by him at the time when the illness began, or the rash appeared.</p>
+
+<p>3. To place the child if possible in a room at the top of
+the house, so that the other children may not pass by his door.</p>
+
+<p>4. Inasmuch as scarlatina often proves fatal to grown
+<span class='pagenum'><a name="Page_210" id="Page_210">[Pg 210]</a></span>persons who have not already had the disease, to obtain at once
+the attendance of a skilled nurse, in order to avoid the risk of
+the disease spreading through the household.</p>
+
+<p>The wife belongs to her husband, the husband to his wife;
+their mutual duties are paramount over even those of the
+parent; and neither has the right to jeopardise that life which
+belongs to the other. To say, 'I shall not catch the disease,
+because I have no fear,' is as idle as it would be for the soldier
+to say, 'Because I am brave, therefore I am invulnerable.'</p>
+
+<p>I have been accustomed to insist on the absence from the
+room of father or mother, supposing either of them not to have
+had scarlatina, so long as I could give the assurance that every
+thing was going on well; but on the slightest anxiety I have
+referred to both parents for their mutual decision as to the
+course which they would choose to adopt.</p>
+
+<p>From a refusal to be guided by this counsel, it has more
+than once happened to me, to see the child recover from mild
+scarlatina without a bad symptom, and the mother who had insisted
+on nursing the little one die of the disease to which she
+had needlessly exposed herself.</p>
+
+<p>5. So soon as the disease has declared itself as scarlatina,
+to take up the carpets and remove the curtains from the sick
+child's room, to empty the drawers of any clothes which may
+be in them, and to hang up outside the door a sheet moistened
+with a solution of carbolic acid.</p>
+
+<p>6. To arrange for all food and necessaries to be placed in
+an adjoining room, or at the head of the stairs, so that there
+may be no direct communication between the attendants on the
+sick and the other inmates of the house.</p>
+
+<p>7. To insist on the attendants not wearing either silk or
+stuff dresses, but dresses of some washable material; and on
+their changing their garments as well as scrupulously washing
+themselves before mixing with other inmates of the house, and
+especially with the children.</p>
+
+<p>8. While in all respects obeying the directions of the
+doctor, to grease the child all over twice in twenty-four hours
+with suet or lard, to which a small quantity of carbolic acid has
+<span class='pagenum'><a name="Page_211" id="Page_211">[Pg 211]</a></span>been added. This proceeding both lessens the amount of
+peeling of the skin in a later stage of the disease; lessens the
+contagiousness of the scales which are detached; and, by promoting
+the healthy action of the skin, diminishes the risk of
+subsequent disorder of the kidneys and consequent dropsy.</p>
+
+<p>9. Even when the case has been of the slightest possible
+kind, to keep the child always in bed for one-and-twenty days.
+This was a standing rule at the Children's Hospital, and I am
+certain that its non-observance will be followed three times out
+of four by dropsy and kidney-disease.</p>
+
+<p>10. When the disease is over, to destroy, if the parents'
+means at all permit it, the clothes and bedding of the child.
+When this is not practicable, to have everything exposed to
+the heat of superheated steam in a Washington Lyons or other
+similar disinfector, and to have all linen boiled as well as
+washed. Lastly, to have the ceiling whitewashed, the paint
+cleaned, the paper stripped, and the room repapered, as well
+as the floor washed and rewashed with strong carbolic soap.</p>
+
+<p>These precautions are troublesome and costly, but disease
+is costlier still; and who shall estimate the cost of death!</p>
+
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_213" id="Page_213">[Pg 213]</a></span></p>
+<h2><a name="APPENDIX" id="APPENDIX"></a>APPENDIX</h2>
+
+<h3><i>ON THE MENTAL AND MORAL FACULTIES IN
+CHILDHOOD, AND ON THE DISORDERS TO
+WHICH THEY ARE LIABLE.</i></h3>
+
+
+<p>Any remarks on the ailments of children would be incomplete
+if no notice were taken of the mental and moral peculiarities
+of early life.</p>
+
+<p>For want of giving heed to them, not only are grave mistakes
+made in the education of children, but in the management
+of their ailments, both by doctors and by parents: much
+needless trouble is given to the doctors, much needless distress
+to the child, much needless anxiety to the parents.</p>
+
+<p>The common mistake committed by those parents who do
+not make their child an idol to fall down and worship, and thus
+turn him, to his own misery and theirs, into the most arbitrary
+of domestic tyrants, is to treat him as though he were in mind,
+as well as in body, a miniature man; feebler in intellect as he
+is inferior in strength, but differing in degree only, not in kind.</p>
+
+<p>Now the child differs essentially from the adult in the three
+respects; that</p>
+
+<p>1. He lives in the present, not in the future.</p>
+
+<p>2. His perceptions are more vivid, and his sensibilities
+more acute; while the world, on which he has just entered,
+surrounds him with daily novelties.</p>
+
+<p>3. He has less self-consciousness, less self-dependence, lives
+<span class='pagenum'><a name="Page_214" id="Page_214">[Pg 214]</a></span>as a part of the world by which he is surrounded&mdash;a real
+practical pantheist.</p>
+
+<p>The child lives in the present, not in the future, nor much
+even in the past, till the world has been some time with him,
+and he by degrees shares the common heritage of retrospect
+and anticipation. This is the great secret of the quiet happiness
+which strikes almost all visitors to a children's hospital.</p>
+
+<p>No one can have watched the sick bed of the child without
+remarking the almost unvarying patience with which its
+illness is borne, and the extremity of peril from which apparently,
+in consequence of that patience, a complete recovery
+takes place. Much, indeed, is no doubt due to the activity of
+the reparative powers in early life, but much also to the unruffled
+quiet of the mind. No sorrow for the past, no gloomy
+foreboding of the future, no remorse, disappointment, nor
+anxiety depresses the spirits and enfeebles the vital powers.
+The prospect of death, even when its approach is realised&mdash;and
+this is not so rare as some may imagine&mdash;brings in general
+but small alarm. This may be from the vagueness of the
+child's ideas; it may be, as the poet says, that in his short
+life's journey, 'the heaven that lies about us in our infancy'
+has been so much with him, that he recognises more clearly
+than we can do</p>
+
+<div class="poem"><div class="stanza">
+<span class="i6">'The glories he hath known,<br /></span>
+<span class="i0">And that imperial palace whence he came.'<br /></span>
+</div></div>
+
+<p>I dwell on this truth, because it is of great practical
+moment that we should bear in mind to how very large an
+extent the child lives only in the present; because it follows
+from it that to keep the sick child happy; to remove from it
+all avoidable causes of alarm, of suffering, of discomfort; to
+avoid, as far as may be, any direct struggle with its waywardness;
+and even if death seems likely to occur, to look at it
+from a child's point of view&mdash;not from that which our larger
+understanding of good and evil suggests to our minds&mdash;are
+duties of the gravest kind which weigh on the parent and the
+nurse, no less than on the physician.</p>
+
+<p><span class='pagenum'><a name="Page_215" id="Page_215">[Pg 215]</a></span>But not only does the child live in the present far more
+than it is possible for the adult, but there are, besides, other
+important mental differences between the two. Not only is
+the mind of the child feebler in all respects than that of the
+adult, but, in proportion to the feebleness of his reasoning
+power, there is an exaggerated activity of his perceptive faculties,
+a vividness of his imagination. The child lives at first in
+the external world, as if it were a part of himself, or he a part
+of it, and the gladheartedness which it rejoices us to see is as
+much a result of the vividness with which he realises the things
+around him, as of that absence of care to which it is often
+attributed. This peculiarity shows itself in the dreams of
+childhood, which exceed in the distinctness of their images
+those which come in later life. It shows itself, too, in the frequency
+with which, even when awake, the active organs perceive
+unreal sounds, or in the dark, at night, conjure up ocular
+spectra; and then not merely colours, but distinct shapes,
+which pass in long procession before the eyes. This power
+fades away with advancing life; except under some conditions
+of disease, the occasional appearance of luminous objects in
+the dark is the only relic with most of us of the gift of seeing
+visions with which, at least in some degree, we were endowed
+in our early years. The child who dreads to be alone, and
+asserts that he hears sounds, or perceives objects, is not
+expressing merely a vague apprehension of some unknown
+danger, but often asserts a literal truth. The sounds have
+been heard; in the stillness of its nursery the little one has
+listened to what seemed a voice calling it; or, in the dark,
+phantasms have risen before its eyes, and the agony of terror
+with which it calls for a light, or begs for its mother's presence,
+betrays an impression far too real to be explained away, or to
+be met by hard words or by unkind treatment.</p>
+
+<p>Impressions such as these are not uncommon in childhood,
+even during health. Disorder, direct or indirect, of the functions
+of the brain, more commonly the latter, greatly exaggerates
+them, and I have known them to outlast for many weeks all
+other signs of failing health after convalescence from fevers.
+<span class='pagenum'><a name="Page_216" id="Page_216">[Pg 216]</a></span>The unreal sights are far more common than the sounds. The
+sounds are usually of the simplest kind&mdash;as the tinkling of a bell,
+of which we all remember the exquisite use made by Hans
+Andersen in one of his nursery tales; or the child's own name,
+at intervals repeated, just as the little watchful boy heard it in
+far off Jud&aelig;a, when it was the prelude to a wondrous communication
+from the unseen world. It came to him as he woke
+from sleep, before the morning dawned, while the lamp, lighted
+overnight, was burning still; and still it is so far the same that
+these occurrences which suggest to us problems that we cannot
+attempt to solve, mostly take place at times of transition from
+the sleeping to the waking state.</p>
+
+<p>The ocular spectra are usually far more vivid and detailed.
+Those which occur in the waking state are by no means always
+painful, though their strangeness not infrequently alarms the
+child, and his horror at the dark arises, not from his seeing
+nothing, but from his seeing too much.</p>
+
+<p>Some imaginative children amuse themselves with these
+phantasms, and then, if encouraged to relate them, will constantly
+transgress the boundary line between truth and falsehood,
+and weave their little romance. When they happen on
+waking they are usually preceded by frightful dreams, but the
+image which the child sees then is not the mere recollection
+of the dream, but a new, distinct, though painful impression;
+generally of some animal to which the child points, as now
+here, now there. These night terrors from the very circumstantial
+character of the impressions which attend them, often,
+as I have already said, occasion needless anxiety as to the
+importance of the cause on which they depend.</p>
+
+<p>Sleep-walking in its smaller degrees of getting out of bed at
+night, is by no means unusual in childhood; but the greater
+degrees of somnambulism are certainly rare; and I have
+always found them dependent on undue mental work; not
+always, indeed, on the tasks being excessive, but sometimes on
+the over-anxiety of the child to make progress. I have not
+yet known a poor person's child a somnambulist.</p>
+
+<p>But not only are the perceptions more acute in childhood
+<span class='pagenum'><a name="Page_217" id="Page_217">[Pg 217]</a></span>than in adult life, the sensibilities are more intense. The
+child's emotions, indeed, are often transitory&mdash;generally very
+transitory; but while they last they produce results far greater
+than in the grown person. In the case of the latter, recollection
+of the past, anticipation of the future, or even the
+duties of the present, control the overwhelming sorrow, or call
+forth the energies needed to bear it. The child lives in the
+present, and this present is but the reflection of the world
+around, its impressions uncontrolled by experience, ungoverned
+by reason.</p>
+
+<p>The broken-heartedness of a child on leaving home is not
+the expression only of intense affection for its friends or relations,
+it is the shock of separation from the familiar objects
+which have surrounded it; and I have not infrequently seen
+children inconsolable when removed from homes that were
+most wretched, or from relations who were most unkind.
+Every now and then, indeed, I have been compelled to send
+children home from the hospital because no love nor care could
+reconcile them to the change from home; and they have refused
+to eat, and spent their nights in weeping. The feeling
+is an unreasoning one, like the home-sickness of the mountaineer.</p>
+
+<p>But, moreover, sudden shocks may sometimes overthrow
+the whole moral equilibrium, and disarrange the balance of
+the nervous system so seriously as to cause the death of a child
+previously free from any important ailment. Thus, I remember
+a little boy five years of age who died sixteen days after his
+father's funeral. The strange sad scene overcame him, though
+there had been no special tie between him and his father. He
+shivered violently, became very sick, complained by signs of
+pain in the head, for he had lost his speech, which he regained
+by slow degrees in the course of four or five days. Improvement
+in other respects did not take place, he lay in a drowsy
+state save when he called for his mother, and at length the
+drowsiness deepened into stupor, and so he died. I suppose
+his mother was right; she said his heart was broken.</p>
+
+<p>It behoves us to bear in mind that the heart may break,
+<span class='pagenum'><a name="Page_218" id="Page_218">[Pg 218]</a></span>or the reason fail, under causes that seem to us quite insufficient;
+that the griefs of childhood may be, in proportion to the child's
+powers of bearing them, as overwhelming as those which break
+the strong man down. Every now and then we are shocked
+by the tale that some young child has committed suicide, and
+for reasons which to our judgment seem most trivial&mdash;from
+fear of punishment, or even from mere dread of reproof.
+These facts deserve special attention, they show how much
+more the susceptibility and sensitiveness of children need to be
+taken into consideration than is commonly done.</p>
+
+<p>This keenness of the emotions in children displays itself
+in other ways, and has constantly to be borne in mind in our
+management of them. The child loves intensely, or dislikes
+strongly; craves most earnestly for sympathy, clings most
+tenaciously to the stronger, better, higher around it, or to what
+it fancies so; or shrinks, in often causeless but unconquerable
+dread, from things or persons that have made on it an unpleasant
+impression. Reason as yet does not govern its
+caprices, nor the more intelligent selfishness of later years
+hinder their manifestation. The waywardness of the most
+wilful child is determined by some cause near at hand; and
+those who love children, and can read their thoughts, will not
+in general be long in discovering their motives and seeing
+through their conduct.</p>
+
+<p>One word more must be said with reference to that intense
+craving for sympathy so characteristic of the child. It is this
+which often underlies the disposition to exaggerate its ailments,
+or even to feign such as do not exist, and in such attempts at
+deception it often perseveres with almost incredible resolution.
+Over and over again I have met with instances where the
+motives to such deception were neither the increase of comfort
+nor the gratification of mere indolence; but the monopolising
+the love and sympathy which during some bygone illness had
+been extended to it, and which it could not bear to share again
+with its brothers and sisters. This feeling, too, sometimes
+becomes quite uncontrollable, and the child then needs as
+much care and as judicious management, both bodily and
+<span class='pagenum'><a name="Page_219" id="Page_219">[Pg 219]</a></span>mental, to bring it back to health, as would be called for in the
+case of some adult hypochondriac or monomaniac.</p>
+
+<p>A caution may not be out of place as to the importance of
+not ministering to this tendency to exaggerated self-consciousness
+by talking of children's ailments in their hearing, or by
+seeming to notice the complaints they make as though they
+were something out of the common way.</p>
+
+<p>It will be observed that throughout I have dwelt more on
+disorders of the moral faculties than of the intellectual powers
+in childhood, and I have done so because I believe them to be
+the more common and the more important. In the feeble-minded
+the moral sense almost invariably participates in the
+weakness of the intellect; but it is by no means unusual for
+the former to be grievously perverted, while the intelligence is
+in no respect deficient. The moral element in the child seems
+to me to assert its superiority in this, that it is the most keenly
+sensitive, the soonest disordered&mdash;</p>
+
+<div class="poem"><div class="stanza">
+<span class="i0">'Like sweet bells jangled, out of tune, and harsh,'<br /></span>
+</div></div>
+
+<p>and the discord is first perceived in the finest notes.</p>
+
+<p>To a very great extent, a mixture of vanity and of a morbid
+craving for sympathy lie at the root of many of those perversions
+of character which excite a parent's anxiety. One of
+these consists in an over-scrupulousness with reference to the
+right or wrong of actions in themselves quite indifferent; in
+doubts as to whether the morning or evening prayer has been
+properly said, whether something was or was not absolutely
+true, whether this or that peccadillo was a grievous offence
+against God, and so on; and all these little cases of conscience
+are brought by the child several times a day to his mother or
+to his nurse for solution. If listened to readily the child's
+truthfulness becomes inevitably destroyed, and he grows up
+with a morbid frame of mind, which after-life will aggravate
+almost infinitely.</p>
+
+<p>One knows indeed the history of child saints; but it must
+be remembered that one great characteristic of pre-eminent
+sanctity at all ages of life is reticence, while these little people
+<span class='pagenum'><a name="Page_220" id="Page_220">[Pg 220]</a></span>are perpetually seeking to interest others in themselves, their
+doubts, and feelings. If wisely dealt with, not by direct
+ridicule, but by a wholesome neglect of the child's revelations,
+treating them as of no special interest or importance, and discouraging
+that minute introspection which, of doubtful good at
+any age, is absolutely destructive of the simplicity of childhood,
+this unnatural condition will soon pass away. It will help this
+object very much, if the child is sent on a visit to judicious
+friends, and change of scene, of pursuits, of playmates, and
+amusements will be of all the more service since these morbid
+states of mind seldom come on in children whose bodily health
+is robust.</p>
+
+<p>Another mode in which the same perverted feelings display
+themselves is in the disposition occasionally noticed to exaggerate
+some real ailment, or to complain of some ailment
+which is altogether imaginary. So far is this from being rare
+that my experience coincides entirely with that of the French
+physician M. Roger, who has had larger opportunities than
+anyone else in France for observing the diseases of children,
+and who says, 'It must be borne in mind that simulated ailments
+are much more common in the children's hospital than
+in a hospital for adults.'</p>
+
+<p>It is difficult to assign any sufficient reason for this conduct.
+Mere indolence seems sometimes to be the chief reason for
+it, oftener vanity; the sense of importance in finding everything
+in the household arranged with exclusive reference to
+itself appears to be the motive for it; and this may sometimes
+be observed to be very powerful even at an exceedingly early
+age. In many instances a morbid craving for sympathy is
+mingled with the love of importance, and both these sentiments
+are not infrequently exaggerated by the conduct of a foolishly
+fond mother. Real illness, however, in almost all these cases
+exists at the commencement, though the child persists in complaining
+of its old symptoms long after their cause has disappeared.</p>
+
+<p>The great difficulty which the doctor meets with in the
+management of these cases arises from the incredulity with
+<span class='pagenum'><a name="Page_221" id="Page_221">[Pg 221]</a></span>which his opinion is received. Candour is looked upon as so
+eminently characteristic of childhood, that deceit seems impossible;
+the case is thought by the parents to be an obscure
+one which the doctor does not understand; and therefore it is
+said, he, with want of straightforwardness and of kindness, throws
+doubts on the existence of disease, and on the truthfulness of a
+most loving, most suffering child. The vagaries of a hysterical
+girl, the fits, the palsy, the half-unconsciousness have all been
+assumed within my own observation by children from ten to
+fifteen years old, and I have more than once had to give place
+to the ignorant and impudent pretender who traded successfully
+on the feelings of the parents. Sometimes, one knows
+not why, except that the child has got tired of the part he was
+playing, the symptoms that had caused so much anxiety suddenly
+disappear, but even then the habit of mind left behind is
+anything but healthy. Indeed in all cases of this kind it is
+much less the state of the body than that of the mind which
+excites my apprehension. The constant watching its own
+sensations, the habit of constantly gratifying every wayward
+wish and temper under the plea of illness, and the constant
+indulgence which it too often meets with in this from the over-kindness
+of its parents, exert a most injurious influence on its
+character, and it grows up a juvenile hypochondriac.</p>
+
+<p>A doctor is very unlikely to throw doubt recklessly on the
+reality of a child's illness. His hesitation should certainly
+not be attributed to unworthy motives; the parents should
+co-operate with him heartily in any course of observation which
+he desires to follow, and if necessary another medical man
+of experience should be associated with the first, and allowed
+to visit the child two or three times. One does not associate
+the idea of moral delinquency with hysteria; the child who
+shams belongs to the same class with the hysterical patient. It
+is only the strangeness of the occurrence in the eyes of non-medical
+people, that makes them fancy it something worse.</p>
+
+<p>If now the suspicion is justified that the child is either
+greatly exaggerating or altogether feigning illness, it does not
+by any means always follow that he should at once be charged
+<span class='pagenum'><a name="Page_222" id="Page_222">[Pg 222]</a></span>with it, since it is often 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 real ailment underlying all the
+half-unconscious exaggeration, and that if spoiling and over-indulgence
+do much to foster it, sternness and punishment
+interfere with recovery. To turn the thoughts away from self,
+to occupy the mind with new scenes, new amusements, new
+pursuits, to call forth by degrees self-control, and to let the
+child perceive rather by your manner than by what is actually
+said that the parents have not been duped by all his past
+vagaries; such are the simple means by which the little one will
+be brought round again to health of mind and health of body.
+Unhappily, in the minds of too many people the idea of the
+doctor is associated with the administration of drugs and with
+nothing else; the treatment of disease is of much wider scope;
+and many of our best remedies are those which do not admit
+of being weighed or measured, and whose names are not inscribed
+on the drawers or bottles in Apothecaries' Hall.</p>
+
+<p>Another phase of mental disorder in childhood sometimes
+presents itself as the result of overtasking the intellectual
+powers. This over-work too is by no means due in all cases
+to the parents' unwisely urging the child forward, but it is often
+quite voluntary on his part. The precaution too of limiting the
+hours of work is often inadequate from the want of some provision
+for turning the thoughts and energies during play hours
+into some perfectly different channel.</p>
+
+<p>In many of these cases Nature happily takes matters into
+her own management. For a year or two, or more, the mind
+has grown apparently at the expense of the body; the parents
+take a fearful joy in their darling's acquirements; and if it
+should live, think they, of what remarkable talents will it not
+be the possessor! By degrees, the extreme quickness of
+intellect becomes less remarkable; but the body begins to
+increase in robustness; and a year will sometimes suffice to
+transmute the little fairy, so quick, so clever, but so fragile, into
+a very commonplace, merry, rosy, romping child. I may add
+that it is well to bear in mind the converse of this; to remember
+<span class='pagenum'><a name="Page_223" id="Page_223">[Pg 223]</a></span>that body and mind rarely grow in equal proportion at
+one time; that the incorrigible little 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 as his playmates.
+A dull mind, and a sickly or ill-developed frame may make us
+anxious: but if the physical development is good, the mind
+will not be likely to remain long below the average standard.</p>
+
+<p>But sometimes, the over-tasked mind leads to mischief
+which Nature cannot rectify; an attack of water on the brain
+destroys the child, or if not it sinks under almost any accidental
+disease. In other instances neither of these results takes place,
+but the whole nervous system seems profoundly shaken, and
+the moral character of the child seriously, and even permanently
+injured. I remember a quick and clever little girl aged five and a
+half years who was urged on by her governess to work which she
+delighted in, till at length the signs of over-taxed brain showed
+themselves in frequent extreme irritability, and occasional
+attacks of causeless fury amounting almost to madness. It
+was fully a year during which almost all mental work was suspended,
+while the child was sent to have complete change
+under most judicious management in the country, before her
+mind quite recovered its balance and she became able to
+resume her studies in a very moderate degree.</p>
+
+<p>Cases such as this are instances of the slightest degree of
+a condition which if not remedied may pass into confirmed
+insanity. I believe the gradations to be almost imperceptible
+by which the one state passes into the other; and I have
+known instances in which the ungovernable temper and
+occasional fury of the child have passed in youth into abiding
+insanity which rendered the patient the inmate, and I fear the
+permanent inmate, of a lunatic asylum.</p>
+
+<p>In whatever circumstances insanity comes on in childhood,
+and it does sometimes, though very seldom, come on independently
+of any obvious exciting cause, it always assumes the
+character of what has been termed moral insanity, or of that
+condition in which the moral system rather than the mental
+power is chiefly disordered.</p>
+
+<p><span class='pagenum'><a name="Page_224" id="Page_224">[Pg 224]</a></span>Idiocy is unquestionably of much more frequent occurrence
+in childhood, than any of those forms of mental or moral
+disorder of which I have been speaking hitherto. The term
+idiocy, however, is a very wide one, including conditions differing
+remarkably from each other both in kind and degree,
+while not seldom it is misapplied to cases in which there is
+mere backwardness of intellectual power.</p>
+
+<p><b>Backward Children.</b>&mdash;<i>Enfants arri&eacute;r&eacute;s</i>&mdash;as the French
+call them&mdash;constitute a class by no means seldom met with.
+They generally attain their bodily development slowly, and the
+development of their mind is equally tardy. They cut their
+teeth late, walk late, talk late, are slow in learning to wash and
+dress themselves, are generally dull in their perceptions, and do
+not lay aside the habits of infancy till far advanced in childhood.
+When the time comes for positive instruction, their slowness
+almost wears out everyone's patience; and among the poor
+indeed the attempt at teaching such children is at length given
+up in despair, and growing up in absolute ignorance, it is
+no wonder that they should be regarded as idiots. Still, dull
+as such children are, there is between 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 the
+whole course of their progress, and his delay increasing every
+day, places at length an enormous distance between him and
+them&mdash;a distance which in fact becomes insurmountable.</p>
+
+<p>In some of its minor degrees even, this backwardness
+not infrequently excites the solicitude of parents. It is sometimes
+observed in children who had been ill-nourished in infancy or
+who had been weakened by some serious or protracted illness,
+even though unattended by any special affection of the brain;
+but it is also met with independent of any special cause. The
+distinction, however, between such a case and one of idiocy is
+this, that though at four years old the child may not seem to
+be intellectually superior to most children at two, yet in manners,
+habits, and intelligence it does agree with what might be
+expected from the child at two; less bright perhaps, less joyous,
+<span class='pagenum'><a name="Page_225" id="Page_225">[Pg 225]</a></span>but still presenting nothing which if it were but younger would
+awaken apprehension.</p>
+
+<p>It is well in all cases of unusual backwardness to ascertain
+the condition of the sense of hearing, and of the power of
+speech, for I have known the existence of deafness long overlooked,
+and the child's dulness and inability to speak referred
+to intellectual deficiency; and have also observed mere difficulty
+of articulation, dependent partly on malformation of the
+mouth, lead to a similar misapprehension. In both instances
+I have seen this inability to keep up ready intercourse with
+other children cast a shadow over the mind, and the little
+ones in consequence be dull, suspicious, unchild-like. I have
+already referred to a similar result as sometimes following
+serious illnesses. The child will for months cease to walk, or
+forget to talk, if these had been but comparatively recent
+acquirements; or will continue dull and unequal to any mental
+effort for weeks or months together, and then the mind will
+begin to develop itself once more, though slowly, possibly so
+slowly as never altogether to make up for lost ground.</p>
+
+<p><b>Idiocy.</b>&mdash;In <i>idiocy</i>, however, there is much more than the
+mere arrest of the intellect at any period. The idiot of eight
+years old does not correspond in his mental development to the
+child at six, or four, or two; his mind is not only dwarfed but
+deformed; while feebleness of will is often as remarkable as
+mere deficiency of power of apprehension. Even in earliest
+infancy there is usually a something in the child idiotic from
+birth which marks him as different from babies of his own age.
+He is 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 perceived that the child, though he can see, does not
+notice; that his eye does not meet his mother's with the fond
+look of recognition, accompanied with the dimpling smile, with
+which the infant, even of three months old, greets his mother.
+Then it is found to have no notion of grasping anything, though
+that is usually almost the first accomplishment of babyhood;
+if tossed in its nurse's arms there seems to be no spring in its
+<span class='pagenum'><a name="Page_226" id="Page_226">[Pg 226]</a></span>limbs; and though a strange vacant smile sometimes passes
+over its face, yet the merry ringing laugh of infancy or joyous
+chuckle of irrepressible glee is not heard. As time passes
+on, the child shows no pleasure at being put down 'to feel its
+feet,' as nurses term it; if laid 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 or walk till late,
+and then stands awkwardly, walks with difficulty, crossing
+its legs immediately on assuming the erect posture, an infirmity
+which it often takes years to overcome. Just, too, as the idiot
+is slow to notice, slow in learning to grasp anything, or to
+stand or walk, so he is late in learning to talk, he often acquires
+but few words, for his ideas are few. He learns even these few
+with difficulty, and employs the same to express many different
+things; he generally articulates them indistinctly, often indeed
+so imperfectly as to be almost unintelligible.</p>
+
+<p>In other instances the evidences of idiocy are not present at
+birth, or at any rate are not then noticed, but succeed to some
+attack of convulsions or to some illness attended with serious
+affection of the brain. Sometimes too there is no point in the
+child's history which can be laid hold on as marking the commencement
+of the weakening of his intellect, but as the body
+grows the mind remains stationary, or its powers retrocede,
+until by degrees the painful conviction that the child has
+become idiotic forces itself upon the unwilling parents. Here
+we have sometimes the sad spectacle of the body perfectly
+developed, hale and 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 a weird smile upon its face,
+looking at its spread-out fingers, or stroking a piece of cloth
+for a quarter of an hour together as though the sensation
+yielded it a kind of pleasure. It would be almost endless to
+describe the various degrees of mental weakness; from the
+slight silliness down to the condition in which the child is, and
+remains all life long, below the level of the brute.</p>
+
+<p>Parents as a rule are anxious to persuade themselves, and
+<span class='pagenum'><a name="Page_227" id="Page_227">[Pg 227]</a></span>to persuade the doctor that their idiot child was once as
+bright and intelligent as others; and that the mind was darkened
+by some grave illness. We have, however, the highest
+authority, that of Dr. Down, for saying that as a rule which
+has but few exceptions idiocy from birth is more amenable to
+training than that which comes on afterwards, that in fact it is
+more hopeful to have to do with an ill-developed than with a
+damaged brain.</p>
+
+<p>The one great question which still remains is what can the
+parents do for best and wisest whom the affliction has befallen
+of having an idiot child.</p>
+
+<p>First. To moderate their expectations as to the results of
+any, even the best devised and most successful treatment. The
+child who has been born of weak intellect, or who has become
+so as the result of illness, will always remain at a lower level
+than others, and this, even though some one faculty, as the
+musical faculty, or the power of calculation, should be above
+the average.</p>
+
+<p>Secondly. From the child's earliest infancy to occupy themselves
+in perfecting as far as possible the physical powers and
+aptitudes, and the habits of cleanliness and order. Development
+of mind waits on development of body: to stand, to sit,
+to walk, to grasp an object put into the hand, are essential to
+bringing the idiot child into relation with the world around it;
+are its elementary education, to be given patiently, cheerfully,
+lovingly, even for years together. To attend to its natural
+wants, and by fixed routine to accustom it at stated hours to
+empty its bowels and its bladder is a lesson hard to teach; and
+not less difficult is it to make the child learn to masticate its
+food, to drink without slobbering, and then to use the spoon
+and fork, and to feed itself; and afterwards to dress itself, to
+wash itself, to tie its shoestrings; for idiots almost without
+exception are awkward as well as lazy.</p>
+
+<p>The common class of nurses, even the very kindest, find it
+so much easier to feed the child, to wash it, and to dress it,
+than to teach it to do any of these things for itself, that it too
+often grows up, till too old to remain in the nursery, without
+<span class='pagenum'><a name="Page_228" id="Page_228">[Pg 228]</a></span>having made the slightest advance above the condition of completest
+babyhood. It is absolutely essential either that the
+mother should devote herself solely to the care and teaching of
+the idiot, or that she should engage a nurse who will have no
+other duty. Such a person must be above the average in education
+and intelligence, and of course will command more than
+the ordinary wages. The mother, too, must resign herself to
+the little one's affection being transferred in a great degree from
+herself to the person who has constant charge of it&mdash;a hard
+trial this, but one to which, for her child's good, she must bring
+herself to submit.</p>
+
+<p>Thirdly. So soon as the child has been taught at home to
+exercise these lower powers, and the question of what is termed
+its education arises, it is a matter of absolute necessity that he
+be sent to an institution specially set apart for the feeble-minded.
+It is absolutely impossible with the most devoted
+love and the most lavish expenditure of money, to do at home
+what can be, and is constantly, accomplished even in a pauper
+idiot asylum. The imitative faculty, which is usually very
+strongly marked in the idiot, furnishes one great means of his
+improvement; while besides there are many of the moral
+powers which cannot be brought out except in the society of
+other children of his own age and not differing too widely from
+him in mental power.</p>
+
+<p>I have warned, and I repeat the warning, against exaggerated
+expectations as to the results of even the wisest treatment. To
+teach cleanliness, order, and neatness; to impart knowledge
+enough to enable the idiot to take care of himself; to develop
+his affections; to enable him to read and write; to practise
+some easy handicraft; to partake of some simple pleasures,
+and so at length to return to the shelter of his own home, and
+to be there, not an object to be hidden away, too painful to
+look upon, but an object rather of special tenderness, repaying
+with his guileless love the sad self-sacrifice of his parents for
+many a year; these are endeavours almost sure of accomplishment
+in a well-conducted institution, sure never to be realised
+in a home.</p>
+
+<p><span class='pagenum'><a name="Page_229" id="Page_229">[Pg 229]</a></span>I have often sent afflicted parents, who shrank from parting
+with their children, to one institution near London; and I
+doubt not there are others in England, where pains, and care,
+and skill, and untiring love awake the slumbering intellect,
+arouse the dormant affections, and work miracles of healing
+on these helpless little ones.</p>
+<p><span class='pagenum'><a name="Page_230" id="Page_230">[Pg 230]</a></span></p>
+
+
+<hr style="width: 65%;" /><p><span class='pagenum'><a name="Page_231" id="Page_231">[Pg 231]</a></span></p>
+<h2><a name="INDEX" id="INDEX"></a>INDEX.</h2>
+
+
+<ul class="IX">
+<li>Abdomen, large, its importance exaggerated, <a href="#Page_158">158</a></li>
+  <li><span class="invisible">Abdomen, </span>tenderness of, very important, <a href="#Page_158">158</a></li>
+
+<li>Acute constitutional diseases, <a href="#Page_187">187</a></li>
+
+<li>Aperients, <a href="#Page_23">23</a></li>
+
+<li>Artificial feeding, its dangers, <a href="#Page_45">45</a></li>
+  <li><span class="invisible">Artificial feeding, </span> rules for, <a href="#Page_50">50</a></li>
+  <li><span class="invisible">Artificial feeding, </span> sometimes necessary, <a href="#Page_49">49</a>, <a href="#Page_58">58</a></li>
+  <li><span class="invisible">Artificial feeding, </span> substitutes for milk, <a href="#Page_59">59</a></li>
+
+<li>Asses' milk best substitute for human, <a href="#Page_51">51</a></li>
+
+<li>Asthma, <a href="#Page_145">145</a></li>
+
+<li>Atrophy, infantile, <a href="#Page_45">45</a></li>
+  <li><span class="invisible">Atrophy, </span>its causes and symptoms, <a href="#Page_47">47</a></li>
+  <li><span class="invisible">Atrophy, </span>symptoms essentially different from consumption, <a href="#Page_48">48</a>, <a href="#Page_62">62</a></li>
+  <li><span class="invisible">Atrophy, </span>may depend on consumption, <a href="#Page_61">61</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Backwardness, <a href="#Page_224">224</a></li>
+
+<li>Bath, warm, management of, <a href="#Page_19">19</a></li>
+  <li><span class="invisible">Bath, warm, </span>when to be used in convulsions, <a href="#Page_91">91</a></li>
+
+<li>Bed, importance of, in illness, <a href="#Page_16">16</a></li>
+
+<li>Bedsores, how to prevent, and treat, <a href="#Page_18">18</a></li>
+
+<li>Bedstead, best form of, for children, <a href="#Page_17">17</a></li>
+
+<li>Brain, disease of, cry in, <a href="#Page_5">5</a></li>
+  <li><span class="invisible">Brain, disease of, </span>proofs of absence of, <a href="#Page_10">10</a></li>
+  <li><span class="invisible">Brain </span>and nervous system, mortality from diseases of, <a href="#Page_88">88</a></li>
+  <li><span class="invisible">Brain, disease of, </span>convulsions as a sign of, <a href="#Page_89">89</a></li>
+  <li><span class="invisible">Brain, </span>congestion of, <a href="#Page_95">95</a></li>
+  <li><span class="invisible">Brain, </span>disorder of, from exhaustion, <a href="#Page_106">106</a></li>
+  <li><span class="invisible">Brain, </span>inflammation of, <a href="#Page_99">99</a>. <i>See</i> Water on the Brain.</li>
+  <li><span class="invisible">Brain, </span>disease from disease of the ear, <a href="#Page_102">102</a></li>
+  <li><span class="invisible">Brain, disease of, </span>symptoms of, <a href="#Page_103">103</a></li>
+  <li><span class="invisible">Brain, disease of, </span>treatment of, <a href="#Page_105">105</a></li>
+
+<li>Breathing, frequency of, in health and disease, <a href="#Page_8">8</a></li>
+
+<li>Bright's disease of the kidneys, <a href="#Page_169">169</a></li>
+
+<li>Bronchitis, <a href="#Page_130">130</a></li>
+  <li><span class="invisible">Bronchitis, </span>more serious than pneumonia, <a href="#Page_131">131</a></li>
+  <li><span class="invisible">Bronchitis, </span>its symptoms, <a href="#Page_131">131</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Catarrh, <a href="#Page_128">128</a></li>
+  <li><span class="invisible">Catarrh, </span>its prevention and treatment, <a href="#Page_129">129</a></li>
+
+<li>Chafing, <a href="#Page_77">77</a></li>
+
+<li>Chest, cry in disease of, <a href="#Page_5">5</a></li>
+
+<li>Chicken-pox, <a href="#Page_202">202</a></li>
+
+<li>Childhood, characters of second period of, <a href="#Page_85">85</a></li>
+  <li><span class="invisible">Childhood, </span>mental and moral faculties, peculiarities in, <a href="#Page_213">213</a></li>
+  <li><span class="invisible">Childhood, </span>difference between child and adult, <a href="#Page_213">213</a></li>
+  <li><span class="invisible">Childhood, </span>patience of child, <a href="#Page_214">214</a></li>
+  <li><span class="invisible">Childhood, </span>vividness of imagination, <a href="#Page_215">215</a></li>
+  <li><span class="invisible">Childhood, </span>phantasms and sounds, <a href="#Page_216">216</a></li>
+  <li><span class='pagenum'><a name="Page_232" id="Page_232">[Pg 232]</a></span><span class="invisible">Childhood, </span>sensibility intense, <a href="#Page_217">217</a></li>
+  <li><span class="invisible">Childhood, </span>craving for sympathy in, <a href="#Page_218">218</a></li>
+
+<li>Children and infants, mortality of, <a href="#Page_1">1</a>; <i>see</i> Mortality.</li>
+  <li><span class="invisible">Children, </span>diseases of, their signs, <a href="#Page_5">5</a>; <i>see</i> Diseases of Children.</li>
+  <li><span class="invisible">Children, </span>management, <a href="#Page_12">12</a></li>
+  <li><span class="invisible">Children, </span>spoiled, <a href="#Page_13">13</a></li>
+  <li><span class="invisible">Children, </span>sick, importance of truth with them, <a href="#Page_13">13</a></li>
+  <li><span class="invisible">Children, </span>keeping happy, <a href="#Page_16">16</a></li>
+
+<li>Chloroform in convulsions, <a href="#Page_92">92</a></li>
+
+<li>Chronic constitutional diseases, <a href="#Page_173">173</a></li>
+
+<li>Cold to the head, how to apply, <a href="#Page_22">22</a></li>
+
+<li>Colic, characters of, <a href="#Page_158">158</a></li>
+
+<li>Congestion of the brain, <a href="#Page_95">95</a></li>
+  <li><span class="invisible">Congestion of the brain, </span>fatal termination of, <a href="#Page_96">96</a></li>
+  <li><span class="invisible">Congestion of the brain, </span>chronic water on brain from, <a href="#Page_97">97</a></li>
+  <li><span class="invisible">Congestion of the brain, </span>treatment of, <a href="#Page_97">97</a></li>
+
+<li>Constitutional diseases, <a href="#Page_173">173</a></li>
+
+<li>Consumption, how distinguished from non-expansion of lungs, <a href="#Page_38">38</a></li>
+  <li><span class="invisible">Consumption, </span>its symptoms when cause of infantile atrophy, <a href="#Page_61">61</a></li>
+  <li><span class="invisible">Consumption, </span>its nature, <a href="#Page_174">174</a></li>
+  <li><span class="invisible">Consumption, </span>recovery from, <a href="#Page_176">176</a></li>
+  <li><span class="invisible">Consumption, </span>causes of, <a href="#Page_176">176</a></li>
+  <li><span class="invisible">Consumption, </span>symptoms, <a href="#Page_177">177</a></li>
+  <li><span class="invisible">Consumption, </span>dependent on disease of glands of lungs, <a href="#Page_177">177</a></li>
+  <li><span class="invisible">Consumption, </span>in infancy, <a href="#Page_178">178</a></li>
+  <li><span class="invisible">Consumption, </span>galloping, <a href="#Page_178">178</a></li>
+  <li><span class="invisible">Consumption, </span>of the bowels, <a href="#Page_179">179</a></li>
+
+<li>Convulsions, as sign of brain disorder, <a href="#Page_88">88</a></li>
+  <li><span class="invisible">Convulsions, </span>less serious than in grown person, <a href="#Page_89">89</a></li>
+  <li><span class="invisible">Convulsions, </span>signs of their approach, <a href="#Page_93">93</a></li>
+  <li><span class="invisible">Convulsions, </span>causes of, various, <a href="#Page_90">90</a></li>
+  <li><span class="invisible">Convulsions, </span>description of a fit of, <a href="#Page_94">94</a></li>
+  <li><span class="invisible">Convulsions, </span>treatment of, <a href="#Page_91">91</a></li>
+  <li><span class="invisible">Convulsions, </span>now and then without apparent cause, <a href="#Page_111">111</a></li>
+
+<li>Cough, from disease of glands of lungs, <a href="#Page_177">177</a></li>
+
+<li>Cow's milk, excess of curd in, <a href="#Page_51">51</a></li>
+  <li><span class="invisible">Cow's milk, </span>easily deteriorated, <a href="#Page_52">52</a></li>
+
+<li>Cow-pox, its nature, <a href="#Page_198">198</a></li>
+
+<li>Croup, its nature, <a href="#Page_133">133</a></li>
+  <li><span class="invisible">Croup, </span>its two kinds, <a href="#Page_134">134</a></li>
+  <li><span class="invisible">Croup, </span>catarrhal, <a href="#Page_134">134</a></li>
+  <li><span class="invisible">Croup, </span>distinction from diphtheria, <a href="#Page_135">135</a></li>
+  <li><span class="invisible">Croup, </span>treatment of, <a href="#Page_135">135</a></li>
+  <li><span class="invisible">Croup, </span>spasmodic, <a href="#Page_107">107</a>. <i>See</i> Spasmodic Croup.</li>
+
+<li>Cry in illness, various meanings of, <a href="#Page_5">5</a></li>
+  <li><span class="invisible">Cry </span>when lungs are imperfectly expanded, <a href="#Page_36">36</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Diabetes, <a href="#Page_169">169</a></li>
+
+<li>Diarrh&oelig;a in childhood, <a href="#Page_154">154</a></li>
+  <li><span class="invisible">Diarrh&oelig;a, </span>simple, <a href="#Page_156">156</a></li>
+  <li><span class="invisible">Diarrh&oelig;a, </span>inflammatory, <a href="#Page_157">157</a></li>
+
+<li>Digestion, how performed, <a href="#Page_151">151</a></li>
+
+<li>Digestive organs, peculiarities of, in infancy, <a href="#Page_46">46</a></li>
+
+<li>Diphtheria, <a href="#Page_136">136</a></li>
+  <li><span class="invisible">Diphtheria, </span>its gradual progress, <a href="#Page_136">136</a></li>
+  <li><span class="invisible">Diphtheria, </span>caution not to overlook it, <a href="#Page_137">137</a></li>
+  <li><span class="invisible">Diphtheria, </span>various dangers of, <a href="#Page_138">138</a></li>
+  <li><span class="invisible">Diphtheria, </span>management of, <a href="#Page_139">139</a></li>
+  <li><span class="invisible">Diphtheria, </span>opening windpipe in, <a href="#Page_140">140</a></li>
+  <li><span class="invisible">Diphtheria, </span>paralysis after, <a href="#Page_141">141</a></li>
+
+<li>Diseases of infants and children, their signs, <a href="#Page_5">5</a></li>
+  <li><span class="invisible">Diseases of infants and children, </span>management, <a href="#Page_12">12</a></li>
+
+<li>Doctor, proper relation of parents to, <a href="#Page_28">28</a></li>
+
+<li>Dream images vivid in childhood, <a href="#Page_215">215</a></li>
+
+<li>Dyspepsia of weakly children, <a href="#Page_153">153</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Earache, symptoms of, <a href="#Page_103">103</a></li>
+  <li><span class="invisible">Earache, </span>treatment of, <a href="#Page_105">105</a></li>
+  <li><span class="invisible">Earache, </span>inflammation of brain from disease of ear, <a href="#Page_102">102</a></li>
+
+<li>Eczema, <a href="#Page_79">79</a></li>
+  <li><span class="invisible">Eczema, </span>its symptoms and course, <a href="#Page_79">79</a></li>
+  <li><span class="invisible">Eczema, </span>treatment, <a href="#Page_81">81</a></li>
+  <li><span class="invisible">Eczema, </span>alleged dangers of curing, <a href="#Page_84">84</a></li>
+
+<li><span class='pagenum'><a name="Page_233" id="Page_233">[Pg 233]</a></span>Epilepsy, its two forms, <a href="#Page_112">112</a></li>
+  <li><span class="invisible">Epilepsy, </span>prospects of recovery from, <a href="#Page_113">113</a></li>
+  <li><span class="invisible">Epilepsy, </span>moral perversion, from, <a href="#Page_114">114</a></li>
+  <li><span class="invisible">Epilepsy, </span>treatment of, <a href="#Page_116">116</a></li>
+  <li><span class="invisible">Epilepsy, </span>moral management of, <a href="#Page_117">117</a></li>
+
+<li>Exhaustion a cause of brain disorder, <a href="#Page_106">106</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Farinaceous food, why unsuitable, <a href="#Page_46">46</a></li>
+  <li><span class="invisible">Farinaceous food, </span>results of its excess, <a href="#Page_47">47</a></li>
+  <li><span class="invisible">Farinaceous food, </span>best forms of, <a href="#Page_60">60</a></li>
+
+<li>Feeding-bottle, best form of, <a href="#Page_55">55</a></li>
+
+<li>Feigned illness, <a href="#Page_221">221</a></li>
+
+<li>Fingers, scrofulous disease of bones of, <a href="#Page_183">183</a></li>
+
+<li>Food, quantity required by an infant, <a href="#Page_54">54</a></li>
+  <li><span class="invisible">Food, </span>best mode of giving, <a href="#Page_54">54</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Galvanism, in cases of paralysis, <a href="#Page_123">123</a></li>
+
+<li>German measles, <a href="#Page_204">204</a></li>
+
+<li>Glandular enlargement in infantile consumption, <a href="#Page_61">61</a></li>
+  <li><span class="invisible">Glandular </span>swellings from scrofula, <a href="#Page_183">183</a></li>
+
+<li>Gravel, <a href="#Page_170">170</a></li>
+
+<li>Grimacing, distinct from St. Vitus's dance, <a href="#Page_119">119</a></li>
+
+<li>Gums in teething, when to be lanced, <a href="#Page_75">75</a></li>
+  <li><span class="invisible">Gums, </span>management when ulcerated, <a href="#Page_76">76</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Head, varieties in shape of, unimportant, <a href="#Page_106">106</a></li>
+
+<li>Headache, neuralgic, <a href="#Page_124">124</a></li>
+  <li><span class="invisible">Headache </span>from defective sight, <a href="#Page_126">126</a></li>
+
+<li>Heart, malformation of, <a href="#Page_146">146</a></li>
+  <li><span class="invisible">Heart, malformation of, </span>management of, <a href="#Page_148">148</a></li>
+  <li><span class="invisible">Heart, </span>frequency of disease of, from rheumatic fever, <a href="#Page_149">149</a>, <a href="#Page_188">188</a></li>
+  <li><span class="invisible">Heart, </span>inflammation of, <a href="#Page_148">148</a></li>
+
+<li>Hooping-cough, <a href="#Page_141">141</a></li>
+  <li><span class="invisible">Hooping-cough, </span>management of, <a href="#Page_143">143</a></li>
+  <li><span class="invisible">Hooping-cough, </span>its dangers, <a href="#Page_144">144</a></li>
+
+<li>Hysteria, relation of, to epilepsy, <a href="#Page_115">115</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Idiocy, <a href="#Page_224">224</a>, <a href="#Page_225">225</a></li>
+  <li><span class="invisible">Idiocy, </span>its management, <a href="#Page_227">227</a></li>
+
+<li>Incontinence of urine, <a href="#Page_171">171</a></li>
+
+<li>Indigestion in infancy, <a href="#Page_47">47</a>, <a href="#Page_56">56</a></li>
+  <li><span class="invisible">Indigestion, </span>its management, <a href="#Page_65">65</a></li>
+
+<li>Infants and children, mortality of. <i>See</i> Mortality</li>
+  <li><span class="invisible">Infants, </span>rules for artificial feeding of, <a href="#Page_50">50</a></li>
+  <li><span class="invisible">Infants, </span>substitutes for mother's milk, <a href="#Page_51">51</a></li>
+  <li><span class="invisible">Infants, </span>quantity of food required, <a href="#Page_54">54</a></li>
+  <li><span class="invisible">Infants, </span>feeding-bottles, <a href="#Page_55">55</a></li>
+
+<li>Influenza, <a href="#Page_132">132</a></li>
+
+<li>Inoculation and vaccination, <a href="#Page_196">196</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Jaundice of new-born children, <a href="#Page_39">39</a></li>
+  <li><span class="invisible">Jaundice </span>in childhood, <a href="#Page_154">154</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Kidneys, disease of, <a href="#Page_168">168</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Lavements, their use and abuse, <a href="#Page_26">26</a></li>
+
+<li>Leeches very useful in some cases, <a href="#Page_21">21</a></li>
+  <li><span class="invisible">Leeches, </span>how to apply, <a href="#Page_21">21</a></li>
+
+<li>Liver, disease of, a cause of infantile atrophy, <a href="#Page_62">62</a></li>
+
+<li>Lungs, imperfect expansion of, <a href="#Page_35">35</a></li>
+  <li><span class="invisible">Lungs, imperfect expansion of, </span>its symptoms, <a href="#Page_36">36</a></li>
+  <li><span class="invisible">Lungs, imperfect expansion of, its </span>treatment, <a href="#Page_38">38</a></li>
+  <li><span class="invisible">Lungs, </span>inflammation of, rare in early infancy, <a href="#Page_37">37</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Measles, <a href="#Page_202">202</a></li>
+  <li><span class="invisible">Measles, </span>its symptoms and dangers, <a href="#Page_203">203</a></li>
+  <li><span class="invisible">Measles, its </span>management, <a href="#Page_204">204</a></li>
+
+<li><span class='pagenum'><a name="Page_234" id="Page_234">[Pg 234]</a></span>Medicine, choice and administration of, <a href="#Page_23">23</a></li>
+
+<li>Mercury, not cause of sore-mouth in children, <a href="#Page_165">165</a></li>
+
+<li>Mesenteric disease, <a href="#Page_179">179</a></li>
+  <li><span class="invisible">Mesenteric disease, </span>its importance exaggerated, <a href="#Page_181">181</a></li>
+
+<li>Milk, why proper food of infants, <a href="#Page_46">46</a></li>
+  <li><span class="invisible">Milk, </span>mother's, peculiarities of, soon after birth of child, <a href="#Page_50">50</a></li>
+  <li><span class="invisible">Milk, mother's, </span>best substitutes for, <a href="#Page_50">50</a></li>
+  <li><span class="invisible">Milk, mother's, </span>and that of animals compared, <a href="#Page_50">50</a></li>
+  <li><span class="invisible">Milk, </span>substitutes for, <a href="#Page_59">59</a></li>
+  <li><span class="invisible">Milk, </span>condensed, inferior to fresh milk, <a href="#Page_53">53</a></li>
+
+<li>Moral insanity in childhood, <a href="#Page_219">219</a>-<a href="#Page_223">223</a></li>
+  <li><span class="invisible">Moral </span>perversion from epilepsy, <a href="#Page_114">114</a></li>
+
+<li>Mortality of infants and children, <a href="#Page_1">1</a></li>
+  <li><span class="invisible">Mortality, </span>varies in different places and times, <a href="#Page_1">1</a></li>
+  <li><span class="invisible">Mortality, </span>causes of, <a href="#Page_2">2</a></li>
+  <li><span class="invisible">Mortality, causes of, </span>intermarriage and hereditary taint, <a href="#Page_2">2</a></li>
+  <li><span class="invisible">Mortality, causes of, </span>unhealthy dwellings, <a href="#Page_3">3</a></li>
+  <li><span class="invisible">Mortality, causes of, </span>unwholesome food, <a href="#Page_4">4</a></li>
+  <li><span class="invisible">Mortality, </span>increased during teething, <a href="#Footnote_9_9">72 note</a></li>
+
+<li>Mother not always good nurse, <a href="#Page_12">12</a></li>
+
+<li>Mouth, how to examine, <a href="#Page_10">10</a></li>
+  <li><span class="invisible">Mouth, </span>sore, <a href="#Page_163">163</a></li>
+
+<li>Mumps, <a href="#Page_190">190</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Napkins, inconvenience of, <a href="#Page_18">18</a></li>
+
+<li>Navel, rupture of, <a href="#Page_43">43</a></li>
+
+<li>Nettle-rash, <a href="#Page_78">78</a></li>
+
+<li>Neuralgia and headache, <a href="#Page_124">124</a></li>
+
+<li>Night terrors, <a href="#Page_126">126</a></li>
+
+<li>Nose, offensive discharge from, <a href="#Page_184">184</a></li>
+
+<li>Notes, importance of keeping in illness, <a href="#Page_28">28</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Ophthalmia of new-born children, <a href="#Page_40">40</a></li>
+
+<li>Opiates, <a href="#Page_27">27</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Palsy, <a href="#Page_121">121</a></li>
+  <li><span class="invisible">Palsy, </span>form of, peculiar to childhood, <a href="#Page_122">122</a></li>
+  <li><span class="invisible">Palsy, </span>its cause, <a href="#Page_123">123</a></li>
+  <li><span class="invisible">Palsy, its </span>treatment, <a href="#Page_123">123</a></li>
+  <li><span class="invisible">Palsy, </span>cases mistaken for it, <a href="#Page_124">124</a></li>
+
+<li>Peritonitis, <a href="#Page_158">158</a></li>
+  <li><span class="invisible">Peritonitis, </span>local, often overlooked, <a href="#Page_158">158</a></li>
+
+<li>Phantasms in childhood, <a href="#Page_215">215</a></li>
+
+<li>Pleurisy, <a href="#Page_132">132</a></li>
+
+<li>Pneumonia, <a href="#Page_130">130</a></li>
+  <li><span class="invisible">Pneumonia, </span>its symptoms, <a href="#Page_131">131</a></li>
+
+<li>Poultices, uses of, <a href="#Page_20">20</a></li>
+  <li><span class="invisible">Poultices, </span>how made, <a href="#Footnote_5_5">20 note</a></li>
+
+<li>Premature birth, <a href="#Page_33">33</a></li>
+  <li><span class="invisible">Premature birth, </span>its management, <a href="#Page_34">34</a></li>
+
+<li>Pulse, frequency of, in health and disease, <a href="#Page_8">8</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Quinsy, <a href="#Page_165">165</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Red-gum, <a href="#Page_77">77</a></li>
+
+<li>Respiration, frequency of, in health and disease, <a href="#Page_8">8</a></li>
+  <li><span class="invisible">Respiration, </span>artificial, <a href="#Page_33">33</a></li>
+
+<li>Rheumatic fever, <a href="#Page_188">188</a></li>
+
+<li>Rheumatism, connection of, with St. Vitus's dance, <a href="#Page_118">118</a></li>
+  <li><span class="invisible">Rheumatism, </span>chief cause of heart inflammation, <a href="#Page_149">149</a></li>
+
+<li>Rickets, <a href="#Page_185">185</a></li>
+
+<li>Round-worm, <a href="#Page_160">160</a></li>
+
+<li>Rupture of navel, <a href="#Page_43">43</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Scalp-swellings, <a href="#Page_42">42</a></li>
+
+<li>Scarlatina, <a href="#Page_205">205</a></li>
+  <li><span class="invisible">Scarlatina, </span>its dangers and symptoms, <a href="#Page_206">206</a></li>
+  <li><span class="invisible">Scarlatina, </span>characters of rash, <a href="#Page_207">207</a></li>
+  <li><span class="invisible">Scarlatina, </span>sore-throat of, <a href="#Page_208">208</a></li>
+  <li><span class="invisible">Scarlatina, </span>how recognised, <a href="#Page_208">208</a></li>
+  <li><span class="invisible">Scarlatina, </span>management of; duties of parents, <a href="#Page_209">209</a></li>
+
+<li>Scrofula, <a href="#Page_181">181</a></li>
+  <li><span class="invisible">Scrofula, </span>abscesses under skin, <a href="#Page_182">182</a></li>
+  <li><span class='pagenum'><a name="Page_235" id="Page_235">[Pg 235]</a></span><span class="invisible">Scrofula, </span>disease of bones of fingers, <a href="#Page_183">183</a></li>
+  <li><span class="invisible">Scrofula, </span>glandular swellings, <a href="#Page_183">183</a></li>
+  <li><span class="invisible">Scrofula, </span>offensive discharge from nostrils, <a href="#Page_184">184</a></li>
+
+<li>Shamming does not disprove illness, <a href="#Page_115">115</a></li>
+
+<li>Sick-room, management of, <a href="#Page_14">14</a></li>
+
+<li>Sleep-walking, <a href="#Page_216">216</a></li>
+
+<li>Small-pox, <a href="#Page_195">195</a></li>
+  <li><span class="invisible">Small-pox, </span>after vaccination, <a href="#Page_201">201</a></li>
+
+<li>Snuffles, <a href="#Page_128">128</a></li>
+
+<li>Sore-mouth, <a href="#Page_163">163</a></li>
+  <li><span class="invisible">Sore-mouth, </span>not diphtheritic, <a href="#Page_164">164</a></li>
+  <li><span class="invisible">Sore-mouth, </span>not due to mercury, <a href="#Page_165">165</a></li>
+  <li><span class="invisible">Sore </span>throat of scarlatina, <a href="#Page_208">208</a></li>
+
+<li>Spasmodic croup, <a href="#Page_107">107</a></li>
+  <li><span class="invisible">Spasmodic croup, </span>its nature and symptoms, <a href="#Page_108">108</a></li>
+  <li><span class="invisible">Spasmodic croup, its </span>treatment, <a href="#Page_111">111</a></li>
+
+<li>Still-birth, <a href="#Page_32">32</a></li>
+
+<li>Stomach, how to examine, <a href="#Page_9">9</a></li>
+  <li><span class="invisible">Stomach, </span>ache, cry in, characteristic, <a href="#Page_5">5</a></li>
+
+<li>St. Vitus's dance, <a href="#Page_118">118</a></li>
+  <li><span class="invisible">St. Vitus's dance, </span>its connection with rheumatism, <a href="#Page_118">118</a></li>
+  <li><span class="invisible">St. Vitus's dance, </span>its symptoms, <a href="#Page_118">118</a></li>
+  <li><span class="invisible">St. Vitus's dance, </span>distinct from mere grimacing, <a href="#Page_119">119</a></li>
+  <li><span class="invisible">St. Vitus's dance, </span>its treatment, <a href="#Page_120">120</a></li>
+
+<li>Suckling, importance of, to mother and child, <a href="#Page_40">40</a>, <a href="#Page_50">50</a></li>
+  <li><span class="invisible">Suckling, </span>unfitness of some mothers for it, <a href="#Page_49">49</a></li>
+  <li><span class="invisible">Suckling, </span>sometimes has to be abandoned, <a href="#Page_57">57</a></li>
+
+<li>Sunstroke, <a href="#Page_98">98</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Tape-worm, <a href="#Page_161">161</a></li>
+
+<li>Tears, their value as a sign of disease, <a href="#Page_11">11</a>, <a href="#Page_101">101</a></li>
+
+<li>Teething, takes place later in man than in other animals, <a href="#Page_47">47</a></li>
+  <li><span class="invisible">Teething, </span>order in which teeth appear, <a href="#Page_73">73</a></li>
+  <li><span class="invisible">Teething, </span>when the gums should be lanced, <a href="#Page_75">75</a></li>
+  <li><span class="invisible">Teething, </span>rules for management of, <a href="#Page_76">76</a></li>
+
+<li>Temperature, in health and disease, <a href="#Page_7">7</a></li>
+  <li><span class="invisible">Temperature, </span>of sick-room, <a href="#Page_14">14</a></li>
+  <li><span class="invisible">Temperature, </span>increase of, in infantile consumption, <a href="#Page_61">61</a></li>
+
+<li>Thermometer, importance of use of, <a href="#Page_7">7</a>, <a href="#Page_28">28</a></li>
+
+<li>Thread-worms, <a href="#Page_160">160</a></li>
+
+<li>Throat, white spots on, not always diphtheritic, <a href="#Page_137">137</a></li>
+  <li><span class="invisible">Throat, </span>sore, inflammatory, or quinsey, <a href="#Page_165">165</a></li>
+  <li><span class="invisible">Throat, </span>abscess at back of, <a href="#Page_168">168</a></li>
+
+<li>Thrush, <a href="#Page_70">70</a></li>
+
+<li>Tonsils, enlarged, <a href="#Page_166">166</a></li>
+  <li><span class="invisible">Tonsils, </span>inflamed, <a href="#Page_165">165</a></li>
+  <li><span class="invisible">Tonsils, </span>when to be removed, <a href="#Page_167">167</a></li>
+
+<li>Typhoid fever, <a href="#Page_191">191</a></li>
+  <li><span class="invisible">Typhoid fever, </span>its symptoms, <a href="#Page_192">192</a></li>
+  <li><span class="invisible">Typhoid fever, its symptoms, </span>management, <a href="#Page_194">194</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Urine, incontinence of, <a href="#Page_171">171</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Vaccination, <a href="#Page_196">196</a></li>
+  <li><span class="invisible">Vaccination, </span>M. Pasteur's experiments, <a href="#Page_197">197</a></li>
+  <li><span class="invisible">Vaccination, </span>death from, <a href="#Page_198">198</a></li>
+  <li><span class="invisible">Vaccination, </span>re-vaccination, <a href="#Page_199">199</a></li>
+  <li><span class="invisible">Vaccination, </span>animal, <a href="#Page_200">200</a></li>
+  <li><span class="invisible">Vaccination, </span>alleged transmission of disease by, <a href="#Page_200">200</a></li>
+  <li><span class="invisible">Vaccination, </span>conclusions with reference to it, <a href="#Page_200">200</a></li>
+  <li><span class="invisible">Vaccination, </span>small-pox after, <a href="#Page_201">201</a></li>
+
+<li>Vomiting in infancy, <a href="#Page_63">63</a></li>
+  <li><span class="invisible">Vomiting in infancy, </span>its treatment, <a href="#Page_64">64</a></li>
+  <li><span class="invisible">Vomiting in infancy, </span>as sign of congestion of brain, <a href="#Page_95">95</a></li>
+</ul>
+
+
+<ul class="IX">
+<li>Water on the brain, acute, its early symptoms, <a href="#Page_99">99</a></li>
+  <li><span class='pagenum'><a name="Page_236" id="Page_236">[Pg 236]</a></span><span class="invisible">Water on the brain, acute, </span>symptoms of its progress, <a href="#Page_101">101</a></li>
+  <li><span class="invisible">Water on the brain, acute, </span>chronic, two kinds of, <a href="#Page_97">97</a>, <a href="#Page_105">105</a></li>
+
+<li>Whey, Dr. Frankland's rules for preparing, <a href="#Footnote_8_8">51 note</a></li>
+  <li><span class="invisible">Whey, </span>its uses, <a href="#Page_51">51</a></li>
+
+<li>White decoction, <a href="#Page_59">59</a></li>
+
+<li>Whites in children, <a href="#Page_184">184</a></li>
+
+<li>Worms, <a href="#Page_160">160</a></li>
+  <li><span class="invisible">Worms, </span>the round, and the thread-worm, <a href="#Page_160">160</a></li>
+  <li><span class="invisible">Worms, </span>tape-worm, <a href="#Page_161">161</a></li>
+  <li><span class="invisible">Worms, </span>treatment of, <a href="#Page_162">162</a></li>
+</ul>
+
+
+<h5>PRINTED BY<br />
+SPOTTISWOODE AND CO., NEW-STREET SQUARE<br />
+LONDON</h5>
+
+
+
+<div id="tnote"><h4>Transcriber's Notes</h4>
+Printer's errors have been corrected as follows:
+  <ul><li>Page 2--thoes corrected to those (to those conditions)</li>
+  <li>Page 2--do corrected to does (The experience ... does not apply)</li>
+  <li>Page 99--added comma (more gloomy, more pettish)</li>
+  <li>Page 107--removed space (distinguished)</li>
+  <li>Page 119--fidgetty corrected to fidgety (odd fidgety movements)</li>
+  <li>Page 160--added hyphen to round worm (round-worm)</li>
+  <li>Page 220--added quotation mark (a hospital for adults.')</li>
+  <li>Page 231--203 corrected to 202 (Chicken-pox, 202)</li></ul>
+All other spelling, hyphenation, and punctuation has been left as written.<br /><br />
+
+Footnotes have been moved to end of the chapters.  The page numbers in the Index which
+reference these footnotes are the original ones, but the links point to the new locations.<br />
+
+<h4>DISCLAIMER</h4>
+The medical knowledge represented in this book is over a century old.
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+
+
+
+
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+
+
+
+<pre>
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+
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+
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+The Project Gutenberg EBook of The Mother's Manual of Children's Diseases, by
+Charles West, M.D.
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: The Mother's Manual of Children's Diseases
+
+Author: Charles West, M.D.
+
+Release Date: August 15, 2009 [EBook #29701]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK CHILDREN'S DISEASES ***
+
+
+
+
+Produced by Juliet Sutherland, Erica Pfister-Altschul and
+the Online Distributed Proofreading Team at
+http://www.pgdp.net
+
+
+
+
+
+
+
+
+
+                                  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 a
+small compass, and avoiding all technical detail, such an account of the
+diseases of infancy and childhood, as might be of use and comfort to the
+intelligent mother.
+
+Returning now, with health perfectly restored, to practise my profession
+for the rest of my life exclusively in my own country, I have brought
+with me this little book, in which the comparative leisure of my
+enforced 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 idle
+pretence of telling people how to treat their children's illnesses,
+without the help of a doctor. Its object is to give a description of the
+diseases of early life, such as may help a mother to understand
+something of their nature and symptoms, to save her from needless
+anxiety as to their issue, and to enable her wisely to second the doctor
+in 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, and
+needless repetition best avoided, if we begin by inquiring very briefly
+why so many children die, what general signs indicate that they are ill,
+and what general rules can be laid down for their management in
+sickness.
+
+The first of these inquiries would be as useless as it would be sad, if
+the rate of infant mortality were fixed by determinate laws, such as
+those 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 in
+different countries, in different parts of the same country, and in the
+same country at different times. Thus, while in some parts of Germany
+the 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 10
+per cent. in Norway. Infantile mortality is higher in manufacturing
+districts, lower in those which are agricultural, and varies from 16 per
+cent. in Lancashire to 9 in Dorsetshire. It is then evident that
+mortality in infancy is in part dependent on remediable causes; and of
+this there is no better proof than the fact that the mortality in
+England under one year has been reduced from 15 per cent. in 1872 to 13
+per cent. in 1882.
+
+It would lead us far from any practical purpose if we were to examine
+into all the causes which govern the liability to disease and death
+during infancy and childhood, in the different ranks of society. We must
+therefore limit our inquiry to those conditions which are met with in
+the class to which my readers may fairly be assumed to belong.
+
+_First_ among the causes of sickly infancy and premature death may be
+mentioned the intermarriage of near relatives. The experience of the
+breeders 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 whose
+qualities in these respects are pre-eminent, and eliminate from them all
+who do not occupy the first rank. In family intermarriages, however, it
+is rare that any consideration is regarded, save that of wealth; and the
+fact remains, explain it as we may, that the intermarriage of near
+relatives during several successive generations is followed by a marked
+deterioration of the children, physical, mental, and moral; and by the
+intensifying of any hereditary predisposition to consumption, scrofula,
+and other constitutional ailments which form the _second_ great cause of
+early sickness and mortality.
+
+These are facts known to all, which yet it is not easy to represent by
+figures. All the world is aware that consumption is hereditary, that
+consumptive parents are more likely than others to have consumptive
+children; and a fourth of all the patients admitted into the Hospital
+for Consumption at Brompton stated that the disease had existed in one
+or other of their parents.[1] Scrofula, which is another disease closely
+allied to consumption, is hereditary also; and hip disease, disease of
+the spine, abscesses, and enlarged glands in any members of a family,
+point to risks for the offspring which should not be forgotten, how much
+soever mental endowments, personal beauty, or the charms of disposition
+may be considered, and sometimes reasonably enough, to outweigh them.
+The same liability exists with reference to epilepsy, insanity, and the
+whole class of affections of the nervous system. Parents inquire, with
+no misplaced solicitude, what is her fortune, or what are the pecuniary
+resources of him to whom they are asked to entrust their son's or
+daughter's future. Believe me, the question--what is the health of his
+family, or of hers? is consumption hereditary, or scrofula, or epilepsy,
+or insanity?--is of far greater moment, and touches much more nearly the
+future happiness of those we love.
+
+These two points regard the future parents themselves; but there are
+other conditions on which the health of children to a great degree
+depends; and of these the two most important are the _dwelling_ they
+inhabit, and the _food_ they eat.
+
+I do not refer here to the dwellings of the poor, situated in unhealthy
+localities, where fresh air does not enter, where the rays of the sun do
+not penetrate, with defective drainage and imperfect water-supply; but I
+speak of the nurseries of well-to-do people. 'This will do for our
+bedroom, and that will make a nice spare room, and that will do for the
+children,' is what one often hears. Had you rare plants which cost much
+money to obtain, which needed sunlight, warmth, and air, would you not
+consider anxiously the position of your conservatory, and take much
+pains to insure that nothing should be wanting that could help their
+development, so that you might feast your eyes upon their beauty, or
+delight yourselves with their fragrance? And yet a room at the top of
+the house, one of the attics perhaps, is too often destined for the
+little one and its nurse; or if there are two or three children, one
+small room is set apart for the day nursery, and a second, probably with
+a different aspect, for a sleeping room, and so small that it does not
+furnish the needed five hundred cubic feet of air for each. And as a
+consequence, the children are ailing, any predisposition in them to
+hereditary disease is fostered, they have no strength to battle against
+any acute illness that may befall them, and yet surprise is felt that
+the doctor is never out of the house.[2]
+
+It is needless to dwell on the hand-feeding of infants as one of the
+great causes of mortality in infancy, and of sickliness in later life.
+The statistics of Foundling Hospitals bear sad testimony to the fact of
+its dangers, and the researches of physicians show that a peculiar form
+of disease is produced by it, attended by symptoms, and giving rise to
+appearances after death, peculiar to the form of slow starvation from
+which the infant has perished. I will add, because it is not generally
+known, one fresh illustration of the influence of artificial feeding in
+aggravating the mortality of infants. In Berlin the certificates of
+death of all infants under the age of one year, are required to state
+whether the little one had been brought up at the breast, or on some
+kind or other of artificial food. Of ten thousand children dying under
+the 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 any
+details with reference to the management of children in health. It may,
+therefore, suffice to have pointed out the four great causes of
+preventible disease among the wealthier classes of society; namely, the
+intermarriage of near relatives, the transmission of constitutional
+taint, the insanitary condition of the dwelling, and the injudicious
+selection 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 in
+the 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 little
+tract, _Healthy Nurseries and Bedrooms_, published as one of the Health
+Exhibition Handbooks.
+
+[3] The actual numbers are 2,628 and 7,646. See _Generalbericht ueber
+das Medizinal-und Sanitaetswesen 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 of
+three great classes: disorder of function, alteration of temperature,
+complaint of pain.
+
+In the infant it is the last of these which very often calls attention
+to the illness from which it is suffering. Cries are the only language
+which a young baby has to express its distress; as smiles and laughter
+and 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 of
+sick children, will gather from them more, and will be able to judge
+whether its suffering is in the head, or chest, or stomach. The cries of
+a baby with stomach-ache are long and loud and passionate; it sheds a
+profusion 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 a
+quiet sleep. If it has inflammation of the chest it does not cry aloud,
+it sheds no tears, but every few minutes, especially after drawing a
+deeper breath than before, or after each short hacking cough, it gives a
+little cry, which it checks apparently before it is half finished; and
+this, either because it has no breath to waste in cries, or because the
+effort makes its breathing more painful. If disease is going on in the
+head, the child utters sharp piercing shrieks, and then between whiles a
+low moan or wail, or perhaps no sound at all, but lies quiet, apparently
+dozing, 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, but
+the mention of this serves merely as an illustration, which anyone can
+understand, of the different meanings that even a baby's cry will convey
+to different persons.
+
+When a child is taken ill, be the disease from which it is about to
+suffer what it may, there is at once a change from its condition when in
+health, such as soon attracts the attention even of the least observant.
+The child loses its appetite, is fretful and soon tired, and either very
+sleepy or very restless, while most likely it is thirsty, and its skin
+hotter than natural. In many instances, too, it feels sick or actually
+vomits, while its bowels are either much purged or very bound. If old
+enough to talk, it generally complains of feeling ill, or says that it
+has pain in some part or other, though it is by no means certain that a
+little child has described rightly the seat of its pain; for it very
+often says that its head aches or that its stomach aches, just because
+it has heard people when ill complain of pain in the head or in the
+stomach. Some of these signs of illness are, of course, absent in the
+infant, who can describe its feelings even by signs imperfectly; but the
+baby loses its merry laugh and its cheerful look; it ceases to watch its
+mother's or its nurse's eye as it was used to do, though it clings to
+her more closely than ever, and will not be out of her arms even for a
+moment; and if at length rocked to sleep in her lap, will yet wake up
+and cry immediately on being placed in its cot again.
+
+Symptoms such as these are sure to awaken the mother's attention to her
+child, 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 the
+question, 'What is the matter?'
+
+Some mothers send at once to the doctor whenever they see or fancy that
+anything ails their child. But this way of getting rid of responsibility
+is not always possible, nor, indeed, on moral grounds, is it always
+desirable, for the mother who delegates each unpleasant duty to another,
+whether nurse, governess, or doctor, in order to save herself trouble or
+anxiety, performs but half a mother's part, and can expect but half a
+mother's recompense of love.
+
+Whenever a child is unwell, a mother may do much to ascertain what is
+the matter, and may by the exercise of a little patience and common
+sense save herself much needless heart-ache, and her child much
+suffering.
+
+The first point to ascertain is the presence or absence of fever; that
+is to say, whether, and how much, the temperature of the body is higher
+than natural. If the temperature is not higher than natural, it may be
+taken as almost certain that the child neither has any inflammatory
+affection of the chest, nor is about to suffer from any of the eruptive
+fevers. The temperature, however, cannot be judged of merely by the
+sensation conveyed to the hand, but must be ascertained by means of the
+thermometer.[4] In the case of the grown person the thermometer is
+placed either under the tongue, the lips being closed over it, or in the
+armpit, and is kept there five or six minutes. In young children,
+however, neither of these is practicable, and I prefer to place the
+instrument in the groin, and crossing one leg over the other, to
+maintain the thermometer there for the requisite five minutes. The
+temperature of the body in health is about 98.5 deg. Fahr. in the grown
+person, and very slightly higher in childhood; but any heat above 99.5 deg.
+may be regarded as evidence that something is wrong, and the persistence
+for more than twenty-four hours of a temperature of 101 deg. and upwards,
+may be taken as almost conclusive proof of the existence of some serious
+inflammation, or of the onset of one of the eruptive fevers.
+
+At the same time it is well to bear in mind that temporary causes, such
+as especially the disorders produced by over-fatigue, or by an
+over-hearty or indigestible meal, may suddenly raise the temperature as
+high as 102 deg., or higher, but the needed repose or the action of a
+purgative may be followed in a few hours by an almost equally sudden
+decline of the heat to the natural standard.
+
+It is well to learn to count the pulse and the frequency of the
+breathing; but to do the former accurately, requires practice such as is
+hardly gained except by hospital training; and indeed, with few
+exceptions, the value of the information furnished by the pulse is less
+in the child than in the adult. The reasons for this are obvious, since
+the rapidity of the circulation varies under the slightest causes, and
+the 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 twenty
+in the minute. The place at which to seek the beat of the pulse is at
+the wrist, just inside and below the protuberance of the wrist-bone; but
+if the child is very fat it is often difficult to detect it. When
+detected it is not easy to count it in early infancy, for during the
+first year of life the heart beats between 120 and 130 in the minute,
+diminishing between that age and five years to 100, and gradually
+sinking to 90 at twelve years old. In proportion, moreover, to the
+tender age of the child, is the rapidity of its circulation apt to vary
+under the influence of slight causes, while both its frequency and that
+of the breathing are about a third less during sleep than in the waking
+state.
+
+The frequency of the breathing is less difficult to ascertain, while at
+the same time it furnishes more reliable information than the pulse.
+This is best tested when the child is asleep, remembering always that
+the 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-dress
+on the lower part of the chest and the pit of the stomach. Each heaving
+of 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 two
+years the child breathes from 30 to 40 times in a minute, and this
+frequency 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 would
+thus 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 in
+its chest, and that the doctor should be sent for in order to ascertain
+its exact nature.
+
+It would answer no good purpose to give a description of the information
+to be obtained by listening to the chest. To learn from this, needs the
+well-trained ear; and harm, not good, comes from the half-knowledge
+which serves but to lead astray.
+
+A child may be very suffering, seem very ill, and its suffering and
+illness may depend on pain in the stomach owing to indigestion,
+constipation, or even to an accidental chill. After early infancy it is
+not difficult to make out the seat of the child's suffering: the warm
+hand placed gently on its stomach will soon ascertain whether it is
+tense or tender, whether the tenderness is confined to one particular
+spot, 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 the
+intestines, the pain and tenderness are both relieved by gentle rubbing.
+
+In the young infant the character of the cry will, as I have already
+said, give some clue to the seat of its pain, while, if you lay it down
+in its cot or in its nurse's arms in order to examine its stomach, it
+will often resist and begin to cry. Its stomach then becomes perfectly
+tense, and you cannot tell whether pressure on it causes pain or whether
+the cries are not altogether the consequence of fretfulness and fear. It
+is therefore the best plan to pass your hand beneath the child's clothes
+and to examine its stomach without altering its posture, while at the
+same time the nurse in whose arms it is talks to it to distract its
+attention, or holds it opposite the window, or opposite a bright light,
+which seldom fails to amuse an infant. If there is no tenderness of the
+stomach the child will not cry on pressure; or if during your
+examination 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 of
+children in whom teething is not over, is to examine the mouth and
+ascertain the state of the gums, since some ailments are caused and
+others are aggravated by teething. A wise mother or an intelligent nurse
+will teach the child when well the little trick of putting out its
+tongue and opening its mouth to show its teeth when told to do so; and
+though it may sometimes indulge rather out of place in these
+performances when wished to behave especially prettily before strangers,
+yet when older it will quickly learn the proprieties of behaviour, and
+in the meanwhile you profit much by the lesson when illness really
+comes.
+
+Sometimes, however, infants who when well will open their mouth and
+allow their gums to be felt without difficulty, refuse to do so when
+ill; and it is always desirable that the mother or nurse whose duty it
+is to tend the sick child constantly, should not frighten it, or lose
+its confidence, by doing forcibly that which the doctor who comes
+occasionally may yet be quite right in doing. You will, however,
+generally get a good view of the mouth and throat in young infants by
+gently touching the lips with your finger: the child opens its mouth
+instinctively, and then you can run your finger quickly over its tongue,
+and drawing it slightly forward perfectly see the condition of the
+throat, feel the gums as you withdraw your finger, and notice the
+appearance of the tongue. Sometimes it is important to ascertain whether
+a tooth which was near coming through has actually pierced the gum, and
+yet the child's fretfulness renders it almost impossible to induce it to
+open its mouth. If now, while the nurse holds the child in her arms, you
+go behind her, you can, unseen and unawares, introduce your finger into
+its mouth and ascertain all you wish to know before the little one has
+recovered from its surprise.
+
+I have but little to say here about the general signs of brain disease
+in infancy and childhood, because they will need minute notice
+afterwards. All that I would at present observe is, that you must not at
+once conclude that a child's head is seriously affected, because it is
+heavy and fretful and passionate, and refuses to be amused. The head, as
+we know by our own experience, suffers by sympathy in the course of
+almost every ailment, certainly of every acute ailment, at all ages. If
+the 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 it
+may prefer a darkened room, it does not shrink from the light when
+admitted gradually; if it has no slight twitchings of its fingers or of
+its wrists; if the head, though hot, is not hotter than the rest of the
+body; if the large vessels of the neck, or the open part of the head, or
+fontanelle as it is termed, in an infant in whom the head is not yet
+closed, are not beating violently; and, above all, _if when it cries it
+sheds 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 the
+nurse or the friend who assures you that the child is about to have
+convulsions 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 or
+instrument-maker, and its mode of employment can be learned in five
+minutes. 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 exact
+proportion to whether it has been ill or well managed when in health.
+The mother who lives but little with her children, who contents herself
+with a daily visit to the nursery, and who then scarcely sees her little
+ones until they are brought into the drawing-room in the evening in full
+dress, to be petted and admired and fondled by the visitors, cannot
+expect to take her place by the child's bed in its sickness, to soothe
+its pain, and to expend upon it all the pent-up tenderness which, in
+spite of the calls of business or of pleasure, still dwells within her
+heart. She must be content to see the infant turn from her to the nurse
+with whose face it has all its life been familiar; or to hear the little
+one tell her to go away, for her presence is associated with none of
+those 'familiar acts, made beautiful by love,' which win the young
+heart: the mother is but a stranger who brings no help, who relieves no
+distress. Happy such a mother if she has found a conscientious and
+intelligent nurse to whom she can delegate her office; but she must
+remember that with the child, love follows in the steps of daily, hourly
+kindnesses, that a mother's part must be played in health if it is to be
+undertaken in sickness, that it cannot be laid down and taken up again
+at 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 yielded
+to each wayward wish, and has allowed it to become the petty tyrant of
+the 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 accustomed
+to have its will obeyed in everything, and cannot understand that its
+suffering is not at once taken away. It insists on getting up and on
+being dressed, or on lying in its mother's or nurse's lap, where the
+warmth of another person's body does but aggravate its fever; it screams
+with passion at the approach of the doctor, it will not allow itself to
+be examined, it will take no medicine; the doctor is powerless, the
+mother heart-broken. Sickness is not the time to exercise authority
+which has not been put in force before; and, not once but many times, I
+have watched, a sad spectator, the death of children from an illness not
+necessarily fatal, but rendered so because it was impossible to learn
+the progress of disease, impossible to administer the necessary
+remedies.
+
+
+_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 is
+as to the necessity of perfect truthfulness in dealing with sick
+children. The foolish device of telling a child when ill, that the
+doctor who has been sent for is its uncle or its cousin, is the outcome
+of the still more foolish falsehood of threatening the child with the
+doctor's visit if it does not do this or that. No endeavour should be
+spared by nurse or parent, or by the doctor himself, to render his visit
+popular in the nursery. Three-fourths of the difficulties which attend
+the administration of medicine are commonly the result of previous bad
+management of the child, of foolish over-indulgence, or of still more
+foolish want of truthfulness. It may answer once to tell a child that
+medicine is nice when really it is nasty, but the trick will scarcely
+succeed a second time, and the one success will increase your
+difficulties ever after. If medicine is absolutely necessary, and the
+child is too young to understand reason, it must be given by force, very
+firmly but very kindly, and the grief it occasions will be forgotten in
+an hour or two. If he is old enough, tell him that the medicine is
+ordered to do him good, and firmness combined with gentleness will
+usually succeed in inducing him to take it. The advantage of perfect
+truthfulness extends to every incident in the illness of children, even
+to the not saying, 'Oh, you will soon be well,' if it is not likely so
+to 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 of
+mind is secured to the poor little sufferer!
+
+A little boy three years old was ordered to be cupped. The cupper, a
+kind old man, said to encourage him, 'Oh, dear little boy, it's
+nothing.' 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 try
+to bear it well. And the operation was performed without a cry or a
+sound.
+
+I have spoken of the moral conditions implied in the successful
+management of sick children. There are certain physical conditions no
+less 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 its
+other little inmates. He must (and of course I am speaking not of some
+slight ailment, but of a more serious indisposition) be in a room by
+himself, which should be kept quiet and shaded, and at a temperature
+which should not be allowed to fall below 60 deg. if the chest is in any way
+affected, nor to exceed 55 deg. in other cases, and this temperature should
+always be measured, not by guess, but by the thermometer hung close to
+the child's bed. The room is to be shaded, not by curtains round the
+bed--for, save in special circumstances, curtains should be banished
+from the nursery--nor by closed shutters which exclude both light and
+air, but by letting down the blinds, so as to have a sort of twilight in
+the room, and by shading any light which at night may be burned in the
+apartment; while whether by day or night the child should be so placed
+that his face shall be turned from the light, not directed towards it.
+The room should be kept quiet, and this requires not only general quiet
+in 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; walking
+carefully, 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 more
+than the loudest noise.
+
+Little precautions, so trifling that few think of noticing them, have
+much to do with the quiet of the sick-room, and consequently with the
+patient'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 anyone
+enters the room; and to put a wedge in the window, or to tie back the
+handle, and so quietly open and close the door, may do more than
+medicine towards promoting the child's recovery. There can, however, be
+no abiding quiet without a well-ordered room, and the old proverb
+carried out, 'A place for everything, and everything in its place.' A
+table covered with a cloth so that things may be taken up and put down
+noiselessly, and set apart for the medicine, the drink, the nourishment,
+cups, glasses, spoons, or whatever else the patient is in frequent need
+of; with a _wooden_ bowl and water for rinsing cups and glasses in, and
+a cloth or two for wiping them, will save much trouble and noise, and
+the loud whispers of the attendants to each other, 'Where is the sugar?
+where is the arrowroot? where did you put down the medicine?' of which
+we hear so much in the sick-room, so much especially in the sick-room of
+the 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 the
+doctor in the child's room, do not relate bad symptoms, do not express
+your fears, nor ask the doctor his opinion in the child's hearing. The
+child often understands much more than you would imagine, misunderstands
+still more; and over and over again I have known the thoughtless
+utterance of the mother, nurse, or doctor depress a child's spirits and
+seriously retard his recovery.
+
+It is consoling to bear in mind that how grave soever a child's illness
+may 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 the
+child than it would be from the same disease in the grown person. This
+too is due not simply to the activity of the reparative powers in early
+life, but also in great measure to the mental and moral characteristics
+of childhood.
+
+To make the sick child happy, in order that he may get well, is the
+unwritten lesson which they who have best learnt, know best how to nurse
+sick children. It may seem strange, that from so high a purpose I should
+at once come down to so commonplace a detail as to insist on the
+importance, even on this account, of keeping the sick child in bed.
+
+At the onset of every illness of which the nature is not obvious, during
+the course of any illness in which the chest is affected, or in which
+the temperature is higher than natural, bed is the best and happiest
+place for the child. In it repose is most complete, far more complete
+than after early babyhood it can be in the nurse's or mother's lap, and
+free from the great objection of the increased heat from being in
+contact with another person's body. Nothing is more painful than to
+witness the little child, sick and feverish, with heavy eyes, and aching
+head, up and dressed, trying to amuse itself with its customary toys;
+then, with 'Please nurse me,' begging to be taken in the lap, then
+getting down again; fretful, and sad, and passionate by turns; dragging
+about its misery, wearing out its little strength, in deference to the
+prejudice that bed is so weakening.
+
+
+_The bed does not weaken, but the disease does which renders bed
+necessary._
+
+A child frets sometimes at the commencement of an illness if kept in
+its own little cot. But put it in its nurse's or mother's big bed, set a
+tea tray with some new toys upon it before the child, and a pillow
+behind 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 halved
+your 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 laying
+the baby on a bed, the nurse or mother lying down by its side, and
+soothing it to sleep. Were there no other drawback, it is a waste of
+power to have two persons employed in nursing a sick child; one to keep
+it in her lap, and the other to wait upon her.
+
+It is important in all serious illnesses of children, as well as of a
+grown person, that the bed should be so placed that the attendant can
+pass on either side, and can from either side reach the patient to do
+whatever is necessary. Most cots for young children have a rail round
+them to prevent the child falling out of bed when asleep or at play; but
+nothing can be more inconvenient than the fixed rail over which the
+attendant has to bend in order to give the child food or medicine, or
+for any other purpose. When I founded the Children's Hospital in Ormond
+Street, I introduced children's cots (the idea of which I took from
+those in the Children's Hospital at Frankfort) the sides of which let
+down when needed, while on the top of the rail, or dependent from it, a
+board is placed surrounded by a raised beading on which the toys, the
+food, or drink may be put with great convenience. These bedsteads, with
+probably some improved arrangement for letting down the sides, may be
+seen now in most children's hospitals, but I have been surprised to
+observe how seldom they are employed in private nurseries, and how
+comparatively few bedstead-makers are acquainted with them. The result
+would probably have been very different had a patent been taken out for
+them, and had they been largely advertised as 'Dr. West's improved
+children's bedsteads'! The uninclosed spring mattress, and the
+wedge-shaped horsehair cushion, both of which I introduced in Ormond
+Street, are also very valuable. The latter slightly raises the head and
+shoulders, and renders any other than a thin horsehair pillow for the
+head 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 for
+some very special reason the napkin should be done away with. It heats
+the child, chafes it, and makes it sore; it conceals the inattention of
+the nurse, and at the same time renders it less easy to keep the little
+one 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 a
+piece of macintosh should be placed under the sheet, as is done in the
+lying-in room, and a draw-sheet, as it is termed, over it. The
+draw-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 lying
+on linen that is wet or soiled. It can be drawn away from under the
+child, and a portion still clean and dry brought under it, while the
+soiled part is rolled together and wrapped up in macintosh at one side
+of the bed until a new draw sheet is substituted, which is easily done
+by tacking a fresh sheet to that which is about to be withdrawn, when
+the fresh one is brought under the child's body as that which is soiled
+is removed. The greatest care should always be taken that the under
+sheet is perfectly free from ruck or wrinkle; in long illnesses the skin
+becomes chafed and bed-sores may be produced by neglect of this simple
+precaution. The complaint that a child throws off the bed-clothes is
+easily remedied by a couple of bits of tape tied on either side loosely
+from the sheet or blanket to the sides of the cot.
+
+When children are compelled to remain long in bed, great care is needed
+to prevent the skin from being chafed, which is the first step that
+leads to the occurrence of bed-sores. Careful washing with soap and
+water daily of the whole body, not only of those parts which may be
+soiled by the urine or the evacuations; the washing afterwards with pure
+tepid water; careful drying, and abundant powdering with starch powder,
+will do much to prevent the accident. If, in spite of this care, the
+skin seems anywhere to be red or chafed, it should be sponged over with
+brandy or with sweet spirits of nitre before powdering. Real bed-sores
+must be seen and treated by the doctor.
+
+The warm bath is a great source of comfort to the sick child, and in all
+cases of feverishness, of influenza, or threatening bronchitis, it
+should not be omitted before the child is put to bed, or must be given
+towards evening if the child has not been up during the day. The bath
+may be either warm or hot, the temperature of the former being 90 deg. to
+92 deg., that of the latter 95 deg. to 96 deg.. The temperature should always be
+ascertained by the thermometer, and the _warm_ bath only should be
+employed, except when the _hot_ bath is ordered by the doctor. The warm
+bath relieves feverishness and quiets the system, and promotes gentle
+perspiration; the hot bath is given when the eruption of scarlet fever
+or of measles fails to come out properly, or in some cases of
+convulsions at the same time that cold is applied to the head, or, in
+some forms of dropsy when it is of importance to excite the action of
+the skin as much as possible. It is not desirable that a child should
+remain less than five or more than ten minutes in the bath, and
+attention must be paid by the addition of warm water to maintain the
+bath at the same temperature during the whole time of the child's
+immersion.
+
+Now and then infants and very young children when ill seem frightened
+at the bath, and then instead of being soothed and relieved by it they
+are 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, he
+very often becomes greatly alarmed, struggles violently, cries
+passionately, and does not become quiet again till he has sobbed himself
+to sleep. All this time, however, he has been exerting his inflamed
+lungs to the utmost, and will probably have thereby done himself ten
+times more harm than the bath has done good. Very different would it
+have been if the bath had been got ready out of the child's sight; if
+when brought to the bedside it had been covered with a blanket so as to
+hide the steam; if the child had been laid upon the blanket, and gently
+let down into the water, and this even without undressing him if he were
+very fearful; and then if you wish to make a baby quite happy in the
+water, 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 the
+much-dreaded bath become a real delight to the little one, and have
+found that if tears were shed at all, it was at being taken out of the
+water, not at being placed in it.
+
+In a great variety of conditions, poultices are of use. They are needed
+in the case of abscesses which it is wished to bring to a head; they are
+sometimes applied over wounds which are in an unhealthy condition, or
+from which it is desired to keep up a discharge. They soothe the pain of
+stomach-ache from any cause, and are of most essential service when
+constantly applied in many forms of chest inflammation. And yet not one
+mother or nurse in ten knows how to make a poultice.[5] When applied
+over a wound they should not be covered with oiled silk or any
+impermeable material, since the edges of the wound and the adjacent skin
+are apt thereby to be rendered irritable and to become covered with
+little itching pimples. When used to relieve pain in the stomach, or as
+a warm application in cases of inflammation of the chest, they should be
+covered with some impermeable material, and will then not require to be
+changed oftener than every six hours. After poultices have been applied
+over the chest or stomach for two or three days the skin is apt to
+become tender, and then it is well to substitute for them what may be
+termed a dry poultice, which is nothing else than a layer of dry cotton
+wool an inch or an inch and a half thick, tacked inside a piece of oiled
+silk.
+
+A handy substitute for a poultice may be made of bran stitched in a
+flannel bag, heated by pouring boiling water on it, then squeezed as dry
+as possible and laid over the painful part. This is especially useful to
+relieve the stomach-ache of infants and young children.
+
+Spongio-piline is a useful substitute for a poultice, especially when it
+is desirable to employ a soothing or stimulating liniment to the
+surface. It retains heat very well when wrung out of hot water, and any
+liniment sprinkled on it is brought into contact with the skin much
+better than if diffused through a poultice. I may just add that its
+edges should be sloped inwards, in order to prevent the moisture from it
+oozing out and wetting the child's night-dress.
+
+When I was young, leeches and bleeding were frequently, no doubt too
+frequently, employed. We have now, however, gone too much to the other
+extreme, for cases are met with from time to time of congestion of the
+brain, or of inflammation of the chest or of the bowels, in which
+leeches bring greater and more speedy relief than any other remedy. In
+applying leeches it is always desirable that they should be put on where
+they will be out of the child's sight if possible, and where it will be
+comparatively easy to stop the bleeding. Hence, in many instances of
+inflammation of the bowels, it is better to apply the leeches at the
+edge of the lower bowel, the anus as it is technically termed, than on
+the front of the stomach, though, of course, this will not always answer
+the purpose. Leeches to the chest may usually be put on just under the
+shoulder-blade; and leeches to the head on one or other side behind the
+ear, where they will be out of the way of any large vein, and where the
+pressure of the finger will easily stop the bleeding. Steady pressure
+with 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 of
+adhesive plaster, will prevent any renewal of the bleeding. In the few
+cases where it is not arrested by these means, the application of a
+little 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 to
+the question of how to manage in the administration of medicine; and
+this is the best way of applying cold to the head. This is often
+ordered, but very seldom efficiently done. Cold is best applied by means
+of a couple of bladders half-filled with pounded ice, and wrapped in two
+large napkins; one of them should be placed under the child's head, the
+corners of the napkin being pinned to the pillow-case to prevent its
+being disturbed, while the other is allowed to rest upon the head, but
+with the corners of the napkin again pinned to the pillow so as to take
+off the greater part of its weight. Thus arranged, the cold application
+will neither get displaced by the child's movements, nor will the child
+itself be wetted, as it too commonly is when wet cloths are employed for
+this purpose, nor irritated by their perpetual removal and renewal.
+
+In London and in large towns there are various contrivances of
+vulcanised rubber, which are, of course, far preferable to the bladders,
+but it is not everyone who lives in London, or who can command the
+resources furnished by a large city.
+
+The difficulties in the administration of medicine to children are in
+great part the fault, either of the doctor in giving needlessly
+unpleasant medicine, or of the parents or nurse who either have failed
+to teach the child obedience, or who are deficient in that tact by which
+hundreds of small troubles are evaded.
+
+As far as the doctor is concerned, all medicines should be prescribed by
+him in small quantities, and as free from taste and smell as possible:
+or where that cannot be, the unpleasant flavour should be covered by
+syrup, or liquorice, or treacle.
+
+Bulky powders should be avoided, and the child who has learned to take
+rhubarb and magnesia, or Gregory's powder without resistance, certainly
+does credit to his training.
+
+Aperients are the medicines most frequently needed in the minor ailments
+of children, and a wise mother will not undertake herself the management
+of serious diseases. Of all aperients castor oil is perhaps the safest,
+the least irritating, the most generally applicable; it acts on the
+bowels and does nothing more. The idea that it tends specially to
+produce constipation afterwards is unfounded; it does not do so more
+than other aperients. All aperients quicken for a time what is termed
+the peristaltic action of the bowels; that is to say, their constant
+movement in a direction from the stomach to the lower bowel, which, as
+well as a contraction on themselves, is constantly going on in every
+living animal, and continues even for some time after death. The bowels
+stimulated to greater activity of movement by the aperient, become for a
+time more sluggish afterwards; they rest for a while, just as after a
+long walk the muscles of the leg are weary and need repose.
+
+There are indeed aperients which do more than this, as grey powder and
+calomel act upon the liver, and so by promoting an increased flow of
+bile cause a more permanent excitement of the bowels, and consequently
+their more prolonged activity; or as Epsom salts or citrate of magnesia,
+which by their action on the blood cause a greater secretion or pouring
+out of fluid from the coats of the intestines, and in this way have in
+addition to their purgative property a special influence in abating
+various feverish conditions.
+
+Castor oil, senna, jalap, jalapine, and scammony are simple aperients.
+They empty the bowels and nothing more, and in cases of simple
+constipation, or where a child is ill either from eating too much or
+from taking indigestible food, are the best purgatives that can be
+given. A dose of castor oil, often one of the great griefs of the
+nursery, may generally be given without the least difficulty if
+previously shaken up in a bottle with a wine-glassful of hot milk
+sweetened and flavoured with a piece of cinnamon boiled in it, by which
+all 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 are
+generally very readily taken by children, but all have the disadvantage
+of being liable to gripe. The German liquorice powder, as it is called,
+which is composed of powdered senna, liquorice powder, fennel, and a
+little sulphur with white sugar, is freer from this drawback than any
+other preparation, and when mixed with a little water is not generally
+objected to. It is important, as senna is often adulterated and loses
+its properties by exposure to the air, that this powder should always be
+obtained from a very good chemist, purchased in small quantities, and
+always kept in a glass-stoppered bottle.
+
+Jalap, in the form in which it is usually sold--as compound jalap
+powder--is in general readily taken; it acts speedily, but often with
+pain, and is not a desirable domestic remedy. Jalapine, which is a sort
+of extract of jalap, is much less apt to gripe, and owing to its small
+bulk is much handier. It may be given in doses of from two to five
+grains to children from two years old and upwards.
+
+Scammony is another powerful simple aperient, apt to be violent in its
+action, and therefore not to be given except when the bowels have long
+been confined, or when it is given to expel worms. The compound scammony
+powder is the form in which it is usually given, and of that five grains
+would be a dose for a child two years old.
+
+Scammony, however, is a costly drug, and therefore the caution given
+with 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 is
+much difficulty in inducing the child to take medicine. It is almost
+tasteless, and a tablespoonful, which would be a proper dose for a child
+of five years old, can be given without being detected.
+
+Much of the difficulty experienced in giving powders arises from their
+being mixed with the arrowroot or jam in which they are administered. A
+very small quantity of arrowroot, bread and milk, or jam, should be put
+in a tea-spoon; the powder then laid upon it, and covered over with the
+arrowroot or jelly, so, in short, as to make a kind of sandwich, with
+the powder, which would thus be untasted, in the middle.
+
+Aloes is a purgative which acts chiefly on the large bowel and to some
+degree also on the liver, and is of most use in the habitual
+constipation of weakly children. In spite of its bitter taste the powder
+is seldom objected to if given between two layers of coarse brown sugar,
+while with most children the addition of a teaspoonful of treacle will
+induce them to take very readily that useful medicine, the compound
+decoction of aloes.
+
+Both rhubarb, aloes, and indeed other remedies which are nauseous if
+given as a liquid and are bulky in the form of powder, may very readily
+be given in extract in the form of very tiny pills. Thus I have
+constantly ordered the extract of rhubarb, which is nearly twice as
+strong as the powder, made up into pills scarcely bigger than what
+children call 'hundreds and thousands' and silver-coated. Ten or a dozen
+of these go down in a teaspoonful of jelly unknown, and with no
+expenditure of temper or tears.
+
+The citrate of magnesia, or Dinneford's Magnesia, taken effervescing
+with lemon juice, or when the effervescence has passed off, or the
+French Limonade Purgative, are almost always very readily taken, and are
+often very useful in the little febrile attacks, or in the slight
+feverish rashes to which children are liable in the spring and autumn.
+
+Mercurials should have no place among domestic remedies. I do not mean
+that the doctor need be called in to prescribe each time that they are
+given, but that the mother should learn from him distinctly with
+reference to each individual child the circumstances which justify their
+employment. They stimulate the liver, as well as produce thereby action
+of the bowels, but they have, especially if often employed, a
+far-reaching influence on the constitution, and that undoubtedly of a
+depressing kind: an influence more than made up for when really needed
+by their other qualities, and especially by their power in doing away
+with the results of many forms of chronic inflammation. They are 'edged
+tools,' however, and we know the proverb about those who play with
+them.[6]
+
+Grey powder, blue pill, and calomel are the three forms in one or other
+of which mercurials are commonly given. Of the three, grey powder is the
+mildest; but it has the inconvenience of not infrequently causing
+nausea, or actual sickness. This objection does not apply to blue pill,
+which can be given either in the tiny pills of which I have already
+spoken, or else broken down, and given in a little jam, or in a
+teaspoonful of syrup or treacle. On the whole I prefer calomel in small
+doses. It has the great advantage of tastelessness, small bulk, and of
+never causing sickness. Half a grain of calomel may be regarded as
+equivalent to two grains of grey powder or blue pill.
+
+I shall speak afterwards of other medicines, which may in various
+circumstances be given, to act upon the bowels; but the above include
+all 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 of
+suppositories and lavements in infancy and childhood. A piece of paper
+rolled up into a conical form and greased, or a bit of soap, is not
+infrequently introduced by nurses just within the bowel, as a means of
+overcoming constipation in infants. The irritation of the muscle at its
+orifice (the sphincter, as it is termed) excites the bowels to action,
+and does away with the necessity for giving an aperient. The drawback
+from this, as well as from the use of the lavement, is that if
+frequently employed they become habitually necessary, and the bowels
+will then never act without their customary stimulus. The lavement, too,
+has the additional disadvantage that while the lower part of the bowel
+is in proportion more capacious in infancy and childhood than in the
+adult, this peculiarity becomes exaggerated by the constant distension
+of the intestine, and a larger and still larger quantity of fluid needs
+to be thrown up in order to produce the requisite action of the bowels.
+
+Opiates and other soothing medicines should never be given except when
+prescribed by the doctor. Thirty-two deaths in England under five years
+of age in 1882 represent but a very small part of the evil wrought by
+the overdose or injudicious use of these remedies. Above all, soothing
+medicines of varying strength, as syrup of poppies, or of unknown
+composition, as Dalby's Carminative or Winslow's Soothing Syrup, should
+never be employed. The only safe preparation, and this to be given only
+by the doctor's orders or with his approval, is the compound tincture of
+camphor, or paregoric elixir, as it is called, of which sixty measured
+drops contain a quarter of a grain of opium. Ten to fifteen measured
+drops of this are a sufficient dose for a child one year old, and this
+ought not to be repeated within twelve hours. The repetition every few
+hours of small doses of opiates is quite as hazardous as the giving of a
+single overdose; and if it does not work serious mischief by stupefying
+the 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 be
+considered in which they may be of service.
+
+There are two points which still remain to be noticed before I leave the
+introductory part of this little book.
+
+The first of these concerns the importance of keeping written notes in
+the course of every case of serious illness. For want of doing this the
+most imperfect and conflicting accounts of what has happened are given
+to the doctor. No person can watch to any good purpose for
+four-and-twenty hours together; and no one's memory, least of all in the
+midst of fatigue and anxiety, can correctly retain all details
+concerning medicine, food, and sleep, which yet it may be of paramount
+importance that the doctor should be made acquainted with. I am
+accustomed to desire a record to be kept on a sheet of paper divided
+into six columns, one for food, a second for medicine, a third for
+sleep, a fourth for the evacuations, and a fifth for any special point
+which the nature of the illness renders it of special moment to observe,
+while the date is entered on the first column of all, indicating when
+food or medicine was given, or when and for how long the child slept. It
+is best to enter the variations of temperature on a separate paper, in
+order that the doctor may at a glance perceive the daily changes in this
+important respect. No one who has not made the experiment can tell the
+relief which the keeping this simple record gives to the anxiety of
+nursing the sick, especially when the sick one is loved most tenderly.
+
+The other point concerns the relations of the mother or of the parents
+to the doctor. I have often heard it said, 'Dr. Green always attends my
+husband and myself, but we have Dr. White for the servants and
+children,' implying a lower degree of medical knowledge as required in
+their case, and to be acknowledged by a lower rate of remuneration.
+
+Need I say that the assumption is a mistaken one--that as much
+knowledge, as large experience, are needed in the one case as in the
+other; while over and above, to treat children successfully, a special
+tact and a special fondness for children are needed? A man may be a very
+good doctor without those special gifts; but their possession, apart
+from real medical knowledge, may make a good children's nurse, but never
+a good children's doctor.
+
+Another matter not to be forgotten is the confidence to be reposed in
+the doctor--the readiness to acquiesce in his sometimes visiting the
+child more frequently in the course of an illness than the symptoms may
+seem to you to require. Were you involved in some civil action, in which
+your succession to large property was involved, you would scarcely
+expect your solicitor to give you his opinion on all the questions at a
+single interview. In the same way, the doctor, even the most
+experienced, may need to visit his little patient several times before
+he can feel quite certain as to the nature of the disease that is
+impending, while he may not wish to alarm you by suggesting all the
+possibilities that are present to his mind. The child after a restless
+night may be asleep, and it may be most undesirable to wake him; or he
+may be excessively cross and unmanageable, so that it is impossible to
+listen to his chest; or it may be very important to ascertain whether
+the high temperature present in the morning has risen still higher
+towards night, or whether, after free action of the bowels, it has
+fallen a degree or two, showing that no fever is impending, but that the
+undue heat of the body was occasioned by the constipation. Or, again,
+some remedy may have been ordered, of the effect of which the doctor
+does not feel quite sure: he wishes to see for himself whether it is
+right to continue or wiser to suspend it. The wise physician, like the
+able general, leaves as little as may be to chance.
+
+Nearly forty years ago, in addressing a class of medical students, I
+said 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 lavish
+of your time; you must be content to turn aside from the direct course
+of investigation, which you would pursue uninterruptedly in the adult,
+in order to soothe the waywardness of the child, to quiet its fears, or
+even to cheat it into good humour by joining in its play; and you must
+be ready to do this, not the first time only, but every time that you
+visit the child, and must try to win its affections in order to cure its
+disease. If you fail in the former, you will often be foiled in your
+attempts at the latter. Nor is this all; you must visit your patient
+very often if the disease is serious in its nature and rapid in its
+course. New symptoms succeed each other in infancy and childhood with
+great rapidity; complications occur that call for some change in your
+treatment, or the vital powers falter suddenly when you least expect it.
+The issues of life and death often hang on the immediate adoption of a
+certain plan of treatment, or on its timely discontinuance. Do not wait,
+therefore, for symptoms of great urgency before you visit a child three
+or four times a day; but if the disease is one in which changes are
+likely to take place rapidly, be frequent in your visits as well as
+watchful in your observation.'
+
+Each year has added to my conviction of the perfect truth of each word
+which I have quoted. If you believe your doctor to be a man of integrity
+and intelligence, be thankful for his frequent visits, which will cease
+as 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 your
+doctor; but do not say to him in a tone and with an emphasis which there
+is 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 to
+enter into all the details, important though they are, of a sick nurse's
+duties.
+
+For a linseed meal poultice, see that the water is _boiling_, not merely
+hot; warm the basin, put the water in _first_; sprinkle the meal on it,
+stirring the whole time, till it becomes of the uniform consistency of
+porridge, then spread it about half an inch thick over the linen, or
+whatever it is spread on, and turn up the edges for an inch all round to
+prevent the poultice crumbling and soiling the night-dress; and then
+having smeared the surface with a little oil, test its warmth by
+applying it to your cheek before putting it on the patient. A broad
+bandage of some sort or a soft towel must then be put round the body to
+keep the poultice in its place, and secured with safety pins.
+
+Pure mustard poultices are never used in children, on account of the
+pain they occasion, and the too great irritation which they would cause
+of the delicate skin of children. A mixture of one part of mustard to
+two of linseed meal is, however, often of much use in the chest
+affections 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, and
+are chiefly used in cuts, wounds, or small abscesses; and also because
+they are so easily made. A slice of stale bread without the crust is put
+on a plate, boiling water is poured over it, and drained off; it is then
+placed on a piece of muslin, pressed between two plates to squeeze out
+the remaining water, and its surface is greased before it is applied
+with a little oil or lard. I would refer for details about how to make
+poultices, and for many other things well worth the knowing, to Miss
+Wood's _Handbook of Nursing_, London, 12mo, 1883.
+
+[6] I am not ignorant of the doubts which have been raised with
+reference to the special influence of mercurial remedies on the liver,
+but prefer in a book written for non-medical readers to leave the
+popular opinion unquestioned.
+
+
+
+
+PART II.
+
+
+All that has been said hitherto is only introductory to the great
+purpose of this book, which is to give an account of the nature,
+symptoms, and course of the more important diseases of infancy and
+childhood.
+
+Any attempt at scientific arrangement of a popular book is useless. I
+prefer, therefore, to consult simply the general convenience of my
+readers. I think I do so best by considering first the disorders which
+beset the child in the first month of its existence, during what may be
+termed its transition from the condition of existence in the womb, to
+its living, breathing state as an inhabitant of this world; and next the
+more important ailments to which it is liable during that important time
+of development which ends with the completion of teething. Afterwards
+may be studied the diseases of the head, the chest, and the bowels; next
+constitutional diseases, such as consumption and scrofula; and lastly,
+the various fevers, as typhoid, or, as it is popularly called, remittent
+fever, measles, scarlatina, and small-pox; and last of all I will add a
+few remarks on the mental and moral characteristics of childhood, and
+their disorders.
+
+
+
+
+CHAPTER IV.
+
+ON THE DISORDERS AND DISEASES OF CHILDREN DURING THE FIRST MONTH AFTER
+BIRTH.
+
+
+=Still-birth.=--The infant cries almost as soon as it comes into the
+world. The cry is the evidence that air has entered its lungs, that the
+blood has now begun to take a different course from that which it
+followed before birth, and that the child has entered on a new
+existence. The child who does not cry, does not breathe; it is said to
+be _still-born_; its quietude means death.
+
+After a long or a difficult labour, or after the use of instruments, the
+child is sometimes still-born in consequence of blood being poured out
+on its brain, and it is thus killed before birth by apoplexy. This,
+however, is not usually the case, but the child is generally still-born
+because some cause or other, generally the protraction of labour,
+interfered with the due changes of its blood within the womb, and it is
+born suffocated before its birth, and consequently unable to make the
+necessary efforts to breathe afterwards.
+
+Drowned people are often resuscitated; the child's case is analogous to
+theirs; and in both the same measures have to be pursued, namely to try
+to 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 its
+surface, the presence or absence of perceptible beating of its heart,
+measure the chances of success. Sometimes mere exposure to the cold air
+produces the necessary effect; at other times breathing is excited by
+dashing cold water in the child's face, by slapping it, by tickling its
+nostrils, or by dipping it for a few seconds in a hot bath at 100 deg. or
+102 deg.; and then swinging it a few times backwards and forwards in the
+air.
+
+Much time, however, must not be lost over these proceedings, but the
+child must be laid on its back, the lower part of its body well wrapped
+up, the chest slightly raised by a folded napkin placed under it. The
+two arms must then be taken firmly, raised and slowly extended on either
+side of the head, then brought down again and gently pressed on either
+side of the chest; and this movement of alternate raising and extending
+the arms and bringing them back again beside the chest must be repeated
+regularly some thirty times in the minute, thus imitating the movements
+of the chest in breathing. These efforts, too, must not be discontinued
+so long as the surface retains its warmth, and as an occasional
+heart-beat shows that life is not absolutely extinct; and I believe that
+in many instances failure is due to want of perseverance rather than to
+the absolute uselessness of the measure.
+
+=Premature Birth.=--In spite of very extraordinary exceptions, it may be
+laid down as a rule that children born before the completion of six and
+a half months of pregnancy do not survive. After that date, each
+additional week adds greatly to the chances of the child living. There
+is a mistaken idea, founded on a superstition connected with the number
+seven, that a seven-months child is more likely to survive than one born
+at the eighth month. But this notion is as destitute of support in fact
+as it is opposed to common sense, and the nearer any woman has
+approached the full term of forty weeks of pregnancy, the greater are
+the 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 smaller
+air-cells; and its voice is a whimper rather than a cry. Those changes
+in the heart and large vessels, which prepare, as pregnancy draws to a
+close, for the altered course of the blood when the child has to breathe
+through the lungs, are too little advanced for it to bear well the
+sudden alteration in its mode of being. The feebly beating heart and the
+not completely developed lungs seem but imperfectly to maintain the
+bodily heat. The glands of the stomach and intestines are not yet fit to
+perform digestion properly, while the muscular power is too feeble for
+the effort at sucking. Everything is sketched out, but to nothing has
+the finishing touch been put, and hence the frail machinery too often
+breaks down, in the endeavour to discharge its functions.
+
+It is surprising, however, with what rapidity Nature in some instances
+perfects the work which she has been called on prematurely to perform.
+
+It is our business to second Nature's endeavours. First of all, and of
+most importance, is the duty of providing from without the warmth which
+the child is unable to generate. When very feeble, it must, even without
+any previous washing or dressing, be at once wrapped in cotton wool, and
+then in a hot blanket, and surrounded with hot-water bottles. A tin
+stomach-warmer filled with hot water is very convenient to place under
+the blanket on which the child lies. Being too feeble to suck, it must
+be fed, a few drops at a time, from a small spoon; or still better, if
+it is able to make any effort at sucking, it may draw its nourishment
+through a quill. The mother after a premature confinement is almost sure
+to have no milk with which to nourish her child, at any rate for two or
+three days. It is, therefore, wise to obtain the help of a woman with a
+healthy baby. She must be allowed to bring her baby with her, since
+otherwise her supply of milk would fail, especially if she had no other
+means of getting rid of it than by the breast-pump or by drawing her
+breast. Even though she may have her own baby, there are few women who
+can submit, for more than a very few days, to the artificial emptying
+their breast without the secretion being either greatly lessened or
+altogether arrested. This, therefore, must be regarded as a resource
+available only for a few days, and as the child gains strength every
+effort must be made to get it to take its mother's breast, if she has
+any supply, or that of the wet-nurse. If this is found impossible, it
+will be wisest to give up, at any rate for the present, the attempt to
+nourish 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 a
+sixth to a fourth part of a pint of milk be obtained either by the
+breast-pump or by drawing the breast; and since a healthy infant of a
+few weeks old sucks about two pints of milk in twenty-four hours, it is
+evident that the supply artificially obtained must after the first few
+days be utterly inadequate.
+
+I have in cases of extreme weakness in premature children succeeded in
+preserving them by giving them every two hours for two or three days ten
+measured drops of raw beef juice, five of brandy, and two teaspoonfuls
+of breast milk. Medicine has no place in the management of these cases;
+the question is one entirely of warmth, food, and for a time the
+judicious use of stimulants.
+
+=Imperfect Expansion of the Lungs.=--Children not premature and
+perfectly well nourished are yet sometimes feeble, breathe imperfectly,
+cry weakly, suck difficultly or not at all, and die at the end of a few
+days. Their lamp of life flickered and went out. Such cases are met with
+for the most part in conditions similar to those in which children are
+actually still-born; or now and then they take place when labour has
+been of unusually short duration, the child hurried into the world too
+rapidly; while in other instances it is not possible to account for
+their occurrence.
+
+For a long time the nature of these cases was not understood; but
+rather more than sixty years ago a German physician discovered that air
+had entered the lungs but imperfectly; that perhaps a third, perhaps
+even as much as half, of the lungs had never been dilated, but had
+remained solid and useless; that in consequence the blood was but
+half-purified, and vitality therefore but half-sustained. The lungs,
+however, were found to have undergone no real change; they were not
+diseased, but if air was blown into them the dark solid patches sunk
+below the level of the surrounding substance, expanded, grew bright in
+colour and like a sponge from which the water has been squeezed, and
+crackled, or crepitated as the technical term is, from the air contained
+within them.
+
+We breathe in health so without conscious effort that we never realise
+the fact that, according to the calculation of most competent observers,
+the mere elasticity of the lungs, independent even of the elasticity of
+the chest walls, opposes a resistance to each inspiration equal to 150
+pounds avoirdupois in the grown man and 120 in the grown woman. The want
+of breath puts the respiratory muscles into play: the man takes a deep
+inspiration, and by this unconscious effort, he overcomes the resistance
+of the chest and the elasticity of the lungs. The new-born infant feels
+the same want and makes the same effort; but its muscular power is
+small, and its inspirations are often so feeble as to draw the air in
+some parts only into the larger tubes, while many of the smaller remain
+undilated, and much of the lung continues in the state in which it was
+before birth. The blood being thus but imperfectly purified, all the
+processes of nutrition go on imperfectly, the vital powers languish, the
+inspiratory efforts become more and more feeble, while the elasticity of
+the lung is constantly tending to empty the small cells of air and to
+oppose its entrance, and next the temperature sinks and the infant dies.
+
+Cases in which this condition of the lungs exists usually present the
+history of the child from the very first having failed to utter a strong
+and loud cry like that of other children. Even after breathing has gone
+on for some time, such children usually appear feeble, and they suck
+with difficulty, although they often make the effort. An infant thus
+affected sleeps even more than new-born infants usually do; its voice is
+very feeble, and rather a whimper than a cry. In the cry of the healthy
+infant you at once detect two parts--the loud cry, suffering or
+passionate as the case may be, and the less loud back draught of
+inspiration. The French have two words for these two sounds--the _cri_
+and the _reprise_. The _cri_ is feeble, the _reprise_ is altogether
+wanting wherever expansion of the lung has to any considerable extent
+failed to take place, and you would hail this second sound as the best
+proof of an improvement in the child's condition.
+
+If you watch the child with a little attention you will see that while
+the chest moves up and down, it is very little, if at all, dilated by
+the respiratory movements. The temperature falls, the skin becomes pale,
+and the lips grow livid, and often slight twitching is observed about
+the muscles of the face. The difficulty in sucking increases, the cry
+grows weaker and more whimpering, or even altogether inaudible, while
+breathing is attended with a slight rattle or a feeble cough, and the
+convulsive movements return more frequently, and are no longer confined
+to the face, but affect also the muscles of the extremities. Any sudden
+movement suffices to bring on these convulsive seizures, but even while
+perfectly still the child's condition is not uniform, but it will
+suddenly become convulsed, and during this seizure the respiration will
+be extremely difficult, and death will seem momentarily impending. In a
+few minutes, however, all this disturbance ceases, and the extreme
+weakness of the child, its inability to suck, its feeble cry, and its
+frequent and imperfect inspirations, are the only abiding indications of
+the serious disorder from which it suffers. But the other symptoms
+return again and again, until after the lapse of a few days or a few
+weeks the infant dies.
+
+I have dwelt at some length on this condition because it is important to
+know that during the first few weeks of life real inflammation of the
+lungs or air-tubes is of extremely rare occurrence, and that the
+symptoms which are not infrequently supposed to depend on it are really
+due to a portion of the lung more or less extensive never having been
+called into proper activity. I may add that we shall hereafter have to
+notice a similar condition of the lung--its collapse after having once
+been inflated--as occurring sometimes in the course of real inflammation
+of the organs of respiration in early life, and forming a very serious
+complication of the original disease.
+
+If the collapse of the lung is not so considerable as to destroy life
+within the first few hours or days after birth, the babe wastes as well
+as grows weaker and weaker, and this wasting coupled with the difficult
+breathing not seldom causes the fear that the child has been born
+consumptive and that its death is inevitable.
+
+No such gloomy view need be taken. Collapse, or at least non-expansion
+of the lung to some extent, is by no means unusual: consumptive disease
+to such an extent in the new-born infant as to interfere with the
+establishment of breathing is extremely rare. The consumptive babe can
+suck, it is not so weak as the one whose lungs are imperfectly expanded;
+it has no convulsive twitchings, nor any of the strange head-symptoms
+which we notice in the former. It wastes less rapidly, it is feverish
+instead 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 who
+breathes imperfectly but ill maintains its heat. It must be kept warm at
+a temperature never less than 70 deg.; it may, like the premature child,
+need stimulants, and all the precautions already mentioned as to
+feeding. Twice in the day it should be put for five minutes in a hot
+bath at 100 deg., rendered even more stimulating by the addition of a little
+mustard. The back and chest may be rubbed from time to time with a
+stimulating liniment, and an emetic of ipecacuanha wine may be given
+twice a day. The act of vomiting not only removes any of the mucus which
+is apt to accumulate in the larger air tubes, but the powerful
+inspirations which follow the effort tend to introduce air into the
+smallest 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 will
+before many days be greeted by the loud cry, with its _cri_ and
+_reprise_ of which I have already spoken, and which assures her that her
+little one will live.
+
+There are no other affections of the lungs so peculiar to the first
+month of life as to call for notice here. I shall have a few
+observations to make about malformations of the heart, and the
+precautions for which they call in the after-life of children; but they
+will 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 the
+eye and the dark colour of the urine, is by no means to be confounded
+with real jaundice. It is no real jaundice, but is merely the result of
+the changes which the blood with which the small vessels of the skin are
+overcharged 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 castor
+oil wherewith the over-busy monthly nurse is always ready. It is a
+natural process, which the intelligent may watch with interest, with
+which none but the ignorant will try to interfere.
+
+There is, however, beside this a real jaundice, in which the skin is
+more deeply stained, the whites of the eyes are yellow, the urine
+high-coloured, and in which the dark evacuations that carry away the
+contents of the bowels before birth are succeeded by white motions, from
+which the bile is absent. This condition is not very usual, save where
+children have been exposed to cold, or where the air they breathe is
+unwholesome. Of this no better proof can be given than is afforded by
+the fact that in the Dublin Lying-in Hospital, where the children are
+defended with the greatest care both from cold and from a vitiated
+atmosphere, infantile jaundice is extremely rare, while it attacks
+three-fourths of the children received into the Foundling Hospital of
+Paris. Still it does sometimes occur when yet no cause can be assigned
+for it, and it is noteworthy that it is sometimes met with in successive
+infants 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 be
+paid during its continuance to avoid exposure of the child to cold,
+while no other food than the mother's milk should be given. If the
+bowels are at all constipated, half a grain of grey powder or a quarter
+of a grain of calomel may be given, followed by a small dose of castor
+oil, and the aperient will often seem to hasten the disappearance of the
+jaundice; but in a large number of cases even this amount of medical
+interference is not needed.
+
+There is, indeed, a very grave form of jaundice, happily of excessive
+rarity, due to malformation of the liver, to absence or obstruction of
+the bile-ducts, and often accompanied with bleeding from the navel. I do
+but mention it; the intensity and daily deepening of the jaundice, the
+fruitlessness of all treatment, and the grave illness of the child, even
+though no bleeding should occur, render it impossible to confound this
+hopeless condition with the trivial ailment of which I have been
+speaking.
+
+The next chapter will furnish a fitter place than the present for
+speaking fully of the Disorders of the Digestive Organs.
+
+I will say now but this: that whatever a mother may do eventually, she
+avoids grave perils for herself by suckling her infant for the first
+month; while the health of her child, just launched upon the world, is
+terribly endangered if fed upon those substitutes for its proper
+nutriment on which after the lapse of a few weeks it may subsist, may
+even manage to thrive.
+
+There are some local affections incident to the new-born child
+concerning 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 sight
+of nine-tenths of all persons who, among the poor, are said to have been
+born blind. In the wealthier classes of society it is comparatively
+rare, and seldom fails to meet with timely treatment, yet many people
+scarcely realise its dangerous character, or the extreme rapidity of its
+course.
+
+It generally begins about the third day after birth with swelling of
+the lid of one or other eye, though both are soon involved. The eyelids
+swell rapidly, and if the affection is let alone, they soon put on the
+appearance of two semi-transparent cushions over the eyes. On separating
+the lids, which it is often very difficult to do owing to the spasmodic
+contraction of the muscles, their inner surface is seen to be enormously
+swollen, bright red, like scarlet velvet, bathed in an abundant
+yellowish thin secretion, which often squirts out in a jet as the lids
+are forcibly separated. Great care must be taken not to allow any of
+this fluid to enter the eye of a bystander, nor to touch his own eye
+until the fingers have been most carefully washed, since the discharge
+is highly contagious, and may produce most dangerous inflammation of the
+eyes of any grown person. The discharge being wiped or washed away, the
+eye itself may be seen at the bottom of the swelling very red, and its
+small vessels very blood-shot. By degrees the surface of the eye assumes
+a deeper red, it loses its brightness and its polish, while the swelling
+of the lids lessens, and they can be opened with less difficulty; their
+inner surface at the same time becomes softer, but thick and granular,
+and next the eyes themselves put on likewise a granular condition which
+obscures vision. The discharge by this time has become thicker and
+white, and looks like matter from an abscess. By slow degrees the
+inflammation may subside, the discharge lessen, the swelling diminish,
+and the eye in the course of weeks may regain its natural condition. But
+the danger is--and when proper treatment is not adopted early the danger
+is very great--lest the mischief should extend beyond the surface of the
+eye, lest ulceration of the eye should take place, the ulceration reach
+so deep as to perforate it, and not merely interfere with the sight, but
+destroy the organ of vision altogether.
+
+In every instance, then, in which the eyelids of a new-born infant
+swell, or the slightest discharge appears from them, the attention of
+the doctor must at once be called to the condition. In the meantime, and
+during whatever treatment he may think it right to follow, the eye must
+be 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 squeezed
+into it abundantly from a sponge held above, but not touching it, so as
+to completely wash away all the discharge. A weak solution of alum and
+zinc, as one grain of the latter to three of the former to an ounce of
+water, may in like manner be dropped from a large camel's-hair brush
+four times a day into the eye after careful washing. Simple as these
+measures are they yet suffice, if adopted at the very beginning, and
+carried on perseveringly, to entirely cure in a few days an ailment
+which if let alone leads almost always to most lamentable results.
+
+I do not pursue the subject further, for bad cases require all the care
+of the most skilful oculist for their treatment.
+
+=Scalp Swellings.=--Almost every new-born child has on one or other side
+of its head a puffy swelling, owing to the pressure to which the head
+has been subjected in birth, and this swelling disappears at the end of
+twenty-four or forty-eight hours.
+
+Now and then, however, though indeed very seldom, the swelling does not
+disappear, but it goes on gradually increasing and becoming more
+definite in its outlines until at the end of three or four days it may
+be as big as half a small orange, or sometimes even larger, soft,
+elastic, painless, under the unchanged scalp, but presenting the
+peculiarity of having a hard raised margin with a distinct edge, which
+gives to the finger passed over it the sensation of a bony ridge, beyond
+which the bone seems deficient. This tumour is due usually to the same
+cause as that which produces the other temporary puffy swelling of the
+scalp, only the pressure having been more severe, blood has actually
+been forced out from the small vessels under the membrane which covers
+the skull, and hence its gradual increase, its definite outline; and
+hence, too, the bony ridge which surrounds it, and which is due to
+nature's effort at cure, in the course of which the raised edge of the
+membrane covering the skull (the _pericranium_) becomes converted into
+bone.
+
+When the nature of these swellings was not understood, they used to be
+poulticed, and to be opened with a lancet to let out their contents. We
+know now, however, that we have nothing to do but to let them alone;
+that by degrees the blood will be absorbed and the tumour will
+disappear, and as it does so we may trace the gradual transformation of
+the membrane which covered it into bone, as we feel it crackling like
+tinsel under the finger. Two, three, or four weeks may be needed for the
+entire removal of one of these blood-swellings. The doctor will at once
+recognise its character, and you will then have nothing to do but to
+wait--often, unhappily, so much harder for the anxious mother than to
+meddle.
+
+=Ruptured Navel.=--There is a period some time before the birth of a
+child when the two halves of its body are not united in front, as they
+become afterwards; and hare-lip or cleft-palate sometimes remains as the
+result of the arrest of that development which should have closed the
+fissured 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 the
+bowels are not supported by the muscles, but protected only by the skin.
+
+More frequently than this, especially in the case of children who are
+born before the time, the opening through which the navel string passes
+is large at birth, and fails to close as speedily and completely as it
+should do afterwards. When everything goes on as it ought, the gradual
+contraction of the opening helps to bring about the separation of the
+navel string and its detachment, and the perfect closure of the opening
+takes place at the same time, between the fifth and the eighth day after
+birth.
+
+If this does not occur, the bowels are very apt to protrude through the
+opening, and if allowed to do so for weeks or months, the opening
+becomes so dilated that its closure is impossible, and the child grows
+up afflicted permanently with rupture through the navel. This is always
+an inconvenience, sometimes even a source of serious danger; but if
+means are taken to prevent the condition becoming worse, nature seldom
+fails eventually to bring about a cure, and to effect the complete
+closure of the opening.
+
+If the muscles on either side do not come into apposition, but leave a
+cleft between them, the infant should constantly wear a broad bandage of
+fine flannel round the stomach, not applied too tightly, in order to
+give support. The circular bandages of vulcanised india-rubber with a
+pad in the centre are nowise to be recommended. The pad is apt to become
+displaced, and to press anywhere but over the navel, while its edges
+irritate the infant's delicate skin, and the pressure which it exerts if
+it is sufficiently tight to retain its place interferes with
+respiration.
+
+A pad composed of pieces of plaster spread on wash-leather, and of
+graduated sizes and kept in place by adhesive strapping,[7] answers the
+purpose of preventing the protrusion at the navel, and of thus
+facilitating the closure of the ring better than any other device with
+which I am acquainted. They need, however, to be continued even for two
+or three years, and though they should have been left off it is wise to
+resume 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 had
+of Ewen, 106 Jermyn Street, St. James's, London, and I dare say at many
+other places besides.
+
+
+
+
+CHAPTER V.
+
+ON THE DISORDERS AND DISEASES OF CHILDREN AFTER THE FIRST MONTH, AND
+UNTIL TEETHING IS FINISHED.
+
+
+=Infantile Atrophy.=--In by far the greater number of instances, the
+wasting of young children is due to their being fed upon food which they
+cannot digest, or which when digested fails to yield them proper
+nourishment. I quoted some figures in my introductory remarks, to show
+from the evidence obtained at Berlin how much larger was the proportion
+of deaths under the age of one year among hand-fed infants than among
+those brought up at the breast. Foundling hospitals on the Continent, in
+which the children are all drawn from the same class, and subjected in
+all respects to a similar treatment, except that in some they are fed at
+the breast, in others brought up by hand, show a mortality in the latter
+case exactly double of that in the former.
+
+It is as idle to ignore these facts, and to adduce in their disproof the
+case of some child brought up most successfully by hand, as it would be
+to deny that a battle-field was a place of danger because some people
+had been present there and had come away unwounded.
+
+But it is always well not merely to accept a fact, but also to know the
+reason why a thing is so. The reason is twofold: partly because the
+different substitutes for the mother's milk, taken for the most part
+from the vegetable kingdom, are less easy of digestion than the milk,
+and partly because, even were they digested with the same facility, they
+do not furnish the elements necessary to support life in due proportion.
+
+All food has to answer two distinct purposes: the one to furnish
+materials for the growth of the body, the other to afford matter for the
+maintenance of its temperature; and life cannot be supported except on a
+diet in which the elements of nutrition and those of respiration bear a
+certain proportion to each other. Now, in milk, the proper food of
+infants, the elements of the former are to those of the latter about in
+the proportion of 1 to 2, while in arrowroot, sago, and tapioca they are
+only as 1 to 26, and in wheaten flour only as 1 to 7. If to this we add
+the absence in these substances of the oleaginous matters which the milk
+contributes to supply the body with fat, and the smaller quantity, and
+to 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 of
+the infant must almost inevitably be sacrificed.
+
+But these substances are not only less nutritious, they are also less
+easy of digestion than the infant's natural food. We all know how
+complex is the digestive apparatus of the herbivorous animal, of which
+the four stomachs of the ruminants are an instance, and how large is the
+bulk 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 carnivorous
+animal, intended for food which shall not need to stay long in that
+receptacle, but shall be speedily digested; and it is only as the child
+grows older, and takes more varied food, that the stomach alters
+somewhat in form, that it assumes a more rounded shape, resembling
+somewhat that of the herbivorous animal, and suited to retain the food
+longer. The young of all creatures live upon their mother for a certain
+time after birth; but in all the preparation for a different kind of
+food, and with it for an independent existence, begins much sooner and
+goes on more rapidly than in man. Young rabbits are always provided with
+two teeth when born, and the others make their appearance within ten
+days. In the different ruminants the teeth have either begun to appear
+before birth, or they show themselves a few days afterwards; and in
+either case dentition is completed within the first month, and in dogs
+and cats within the first ten weeks of existence.
+
+In the human subject the process of teething begins late, between the
+seventh and the ninth month, and goes on slowly: the first grinding
+teeth are seldom cut before the beginning of the second year, and
+teething is not finished until after its end. Until teething has begun
+the child ought to live exclusively on the food which nature provides;
+for until that time the internal organs have not become fitted to digest
+other sustenance, and the infant deprived of this too often languishes
+and dies. To get from other food the necessary amount of nourishment,
+that food has to be taken in larger quantities, and, from the difficulty
+in digesting it, needs to remain longer in the stomach than the mother's
+milk. One of the results of the indigestibility of the food is that the
+child is often sick, the stomach getting rid of a part of that food
+which it is unable to turn to any useful purpose; and so far well. But
+the innutritious substances do not relieve the sense of hunger. The
+child cries in discomfort, and more is given to it, and by degrees the
+over-distended stomach becomes permanently dilated, and holds a larger
+quantity than it was originally meant to contain. The undigested mass
+passes into a state of fermentation, and the infant's breath becomes
+sour and offensive, it suffers from wind and acid eructations, and
+nurses sometimes express surprise that the child does not thrive since
+it is always hungry. While some of the food is got rid of by vomiting,
+some passes into the intestines, and there becomes putrid, as the
+horribly offensive evacuations prove. They come away, large and solid
+and white, for the secretion of the bile is inadequate to complete that
+second digestion which should take place in the intestines; or else the
+irritation which they excite occasions diarrh[oe]a--a green putty-like
+matter comes away mixed with a profuse watery discharge.
+
+What wonder is it that in such circumstances the body should waste most
+rapidly; for it is forced from its own tissues to supply those elements
+essential to the maintenance of life, which its food contains in far too
+scanty a proportion. Every organ of the body contributes to the general
+support, and life is thus prolonged, if no kind disease curtail it,
+until each member has furnished all that it can spare, and then death
+takes place from starvation, its approach having been slower, but the
+suffering which preceded it not therefore less, than if all food had
+been withheld.
+
+Do not suppose that in this description I have been painting too dark a
+picture, or that children who die thus have been exceptionally weak, and
+so under the acknowledged difficulties of hand-feeding at length became
+consumptive. They do not die of consumption, and in a large number of
+instances their bodies show no trace of consumptive disease, but present
+appearances characteristic of this condition of starvation, and of this
+only.
+
+Along the whole track of the stomach and intestines are the signs of
+irritation and inflammation. The glands of the bowels are enlarged,
+actual ulceration of the stomach is often met with; while so
+far-reaching is the influence of this slow starvation, that even the
+substance of the kidneys and of the brain are often found softened and
+otherwise altered, though it might not unreasonably have been supposed
+that these organs lay quite beyond the reach of any disorder of
+digestion.
+
+No doubt all these grievous results do not always follow; and sometimes
+children exceptionally strong manage to take and digest enough even of
+unsuitable food to maintain their health, and may as they grow up, and
+the changes take place in the system which fit it for a varied diet,
+even become robust. In the majority of instances, however, hand-fed
+infants, and those especially who have been brought up chiefly on
+farinaceous food, are less strong than others, and are more apt to
+develop any latent tendency to hereditary disease, such as scrofula or
+consumption, than members of the same family who have been brought up at
+the breast.
+
+Enough has already been said to satisfy all but those who do not wish
+to be convinced, how incumbent it is on every mother to try to suckle
+her child. But though it is most desirable that for the first six months
+of their existence children should derive their support entirely from
+their mother, and that until they are a year or at least nine months old
+their mother's milk should form the chief part of their food, yet many
+circumstances may occur to render the full adoption of this plan
+impracticable. In some women the supply of milk, although at first
+abundant, yet in the course of a few weeks undergoes so considerable a
+diminution as to become altogether insufficient for the child's support;
+while in other cases, although its quantity continues undiminished, yet
+from some defect in its quality it does not furnish the infant with
+proper nutriment. Cases of the former kind are not unusual in young,
+tolerably healthy, but not robust women; while instances of the latter
+are met with chiefly among those who have given birth to several
+children, whose health is bad, or among the poor, who have been
+enfeebled by hard living or hard work. The children in the former case
+thrive 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 their
+rapid growth, they pine and fret, they lose both flesh and strength,
+and, unless the food given to supply their wants be judiciously
+selected, their stomach and bowels become disordered, and nutrition,
+instead of being aided, is more seriously impaired. In the case of the
+mother whose milk disagrees with the child from some defect in its
+quality, the signs are in general more pronounced. Either the infant
+vomits more than that small quantity which a babe who has sucked
+greedily or overmuch often rejects immediately on leaving the breast, or
+it is purged, or it seems never satisfied, does not gain flesh, does not
+thrive, cries much and is not happy. In these cases, too, the mother's
+supply of milk, though abundant at first, diminishes in a few weeks; she
+feels exhausted, and suffers from back-ache, or from pain in the breasts
+each time after the child's sucking; while, further, her general
+weakness leaves her no alternative but to wean the child.
+
+Knowing the attempt to rear her child entirely at the breast to be
+vain, the mother may in such cases be tempted to bring it up by hand
+from the very first. But how short soever the period may be during which
+the mother may be able to suckle her child, it is very desirable that
+she should nurse it during that period, and also that her milk should
+then constitute its only food. For the first four or five days after the
+infant's birth the milk possesses peculiar qualities, and not merely
+abounds in fatty and saccharine matter, but presents its casein or curd
+in a form in which it is specially easy of digestion. These
+peculiarities indeed become less marked within a week or two; but not
+only is it of moment that the infant should at any rate make its start
+in life with every advantage, but the mother who nurses her little one
+even for a month avoids thereby almost half the risks which follow her
+confinement. For the indolent, among the wealthy, a numerous class who
+have but to form a wish in order to have it gratified, a wet-nurse for
+the baby suggests itself at once to the mother as a ready means of
+saving herself trouble, and of shirking responsibility. This course, to
+which love of pleasure and personal vanity tend alike to prompt her,
+often finds, in spite of all opposing reasons, the approval of the
+nurse, to whom it saves trouble, and the too ready acquiescence of the
+doctor in a course which pleases his patient. But many circumstances
+besides those moral considerations, which ought never to be forgotten
+before the determination is formed to employ a wet-nurse, may put this
+expedient out of the question, and it becomes therefore of importance to
+learn what is the best course for a mother to adopt who is either wholly
+unable 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 the
+character of the mother's milk, the greater will be the prospect of the
+attempt to rear the child upon it proving successful. There is no
+argument needed to prove that the milk of some animal more closely
+resembles the mother's milk, and is more likely to prove a useful
+substitute for it than any kind of farinaceous substance. The milk of
+all animals, however, differs in many important respects from human
+milk, and differs too very widely in different animals. Thus, the milk
+of the cow and that of the ewe contain nearly double the quantity of
+curd, and that of the goat more than twice the quantity of butter, and
+it is only in the milk of the ass that the solid constituents are
+arranged in the same order as in man. On this account, therefore, asses'
+milk is regarded, and with propriety, as the best substitute for the
+child's natural food. Unfortunately, however, expense is very frequently
+a bar to its employment, and compels the use of the less easily digested
+cows' milk. But though the cost may be a valid objection to the
+permanent employment of asses' milk, it is yet very desirable when a
+young infant cannot have the breast, that it should be supplied with
+asses' milk for the first four or five weeks, until the first dangers of
+the experiment of bringing it up by hand have been surmounted. The
+deficiency of asses' milk in butter may be corrected by the addition of
+about a twentieth part of cream, and its disposition to act on the
+bowels may be lessened by heating it to boiling point, not over the fire
+but in a vessel of hot water; and still more effectually by the addition
+to it of a fourth part of lime-water or of a teaspoonful of the solution
+of saccharated carbonate of lime to two ounces or four tablespoonfuls of
+the milk.
+
+When cows' milk is given, it must be borne in mind that it contains
+nearly twice as much curd, and about an eighth less sugar, than human
+milk. It is therefore necessary that it should be given in a diluted
+state and slightly sweetened. The dilution must vary according to the
+infant's age; at first the milk may be mixed with an equal quantity of
+water, but as the child grows older the proportion of water may be
+reduced to one-third. Mere dilution with water, however, leaves the
+proportion of curd unaltered, and it is precisely the curd which the
+infant is unable to digest. Instead, therefore, of diluting the milk
+simply with water, it is often better to add one part of whey to about
+two parts of milk, which, according to the child's age, may or may not
+be previously diluted.[8]
+
+Attention must be paid to the temperature of the food when given to the
+infant, which ought to be as nearly as possible the same as that of the
+mother's milk, namely from 90 deg. to 95 deg. Fahrenheit, and in all cases in
+which care is needed a thermometer should be employed in order to insure
+the food being given at the same temperature. Human milk is alkaline,
+and even if kept for a considerable time it shows little tendency to
+become sour. The milk of animals when in perfect health likewise
+presents an alkaline reaction, and that of cows when at grass forms no
+exception to this rule. Milk even very slightly acid is certain to
+disagree with an infant; it is therefore always worth while the moment
+that a hand-fed infant seems ailing to ascertain this point. If
+alkaline, the milk will deepen the blue colour of litmus paper, which is
+to be had of any chemist; if acid, it will discharge the colour and turn
+it red. It is, perhaps, as well to add that, as the oxygen in the
+atmosphere tends to redden litmus paper, it should not be left exposed
+to the air, but should always be kept in a glass-stoppered bottle.
+
+The milk of the cow is very liable to alteration from comparatively
+slight causes, and particularly from changes in the animal's diet; while
+even in the most favourable circumstances if the animal is shut up in a
+city and stall-fed, all the solid constituents of its milk suffer a
+remarkable diminution; while the secretion further has a great tendency
+to become acid, or to undergo even more serious deterioration. Mere
+acidity of the milk can be counteracted for the moment by the addition
+of lime-water, or by stirring up with it a small quantity of prepared
+chalk, which may be allowed to subside to the bottom of the vessel; or
+if it should happen, though indeed that is rarely the case in these
+circumstances, that the child is constipated, carbonate of magnesia may
+be substituted for the chalk or lime-water. If these simple proceedings
+are not sufficient to restore the infant's health, it will be wise to
+seek at once for another source of milk supply, and to place the
+suspected milk in the hands of the medical officer of health or of the
+public analyst, in order that it may be submitted to a thorough chemical
+and microscopical examination.
+
+The difficulty sometimes found in obtaining an unvaryingly good milk
+supply, as well as practical convenience in many respects, has led to
+the extensive employment of various forms of condensed milk. They form
+undoubtedly the best substitute for fresh cows' milk which we possess,
+and are a great boon especially to the poor in large towns where the
+milk supply is often scanty, not always fresh, and sometimes of bad
+quality. I should certainly prefer condensed milk for an infant to milk
+from cows living in close dirty stables, such as my experience thirty
+years ago made me familiar with in some parts of London.
+
+Still all the varieties of condensed milk are far inferior in quality
+to good fresh milk. They contain less butter, less albumen, that is to
+say less of the main constituents of all animal solids and fluids, and a
+greater proportion of what are termed the hydro-carbonates, such for
+instance as sugar; or, to state the same thing differently, the elements
+which serve for nutrition are in smaller proportion than in fresh milk
+to those which minister to respiration. They are not only less
+nutritious, but the large quantity of sugar which they contain not
+infrequently disagrees with the child, and causes bowel complaint. I do
+not know how far the so-called unsweetened condensed milk which has of
+late come into the market is free from this objection; but I have always
+preferred the Aylesbury condensed milk, which is manufactured with
+sugar, to the Swiss condensed milk, into which, as I have been given to
+understand, honey largely enters.
+
+How much food does an infant of a month old require? what intervals
+should be allowed between each time of feeding? and how should the food
+be given? are three questions which call for a moment's notice. The
+attempt has been made to determine the first point by two very
+distinguished French physicians, who weighed the infants before and
+after each time of sucking. Their observations, however, were not
+sufficiently numerous to be decisive, and their results were very
+conflicting; the one estimating the quantity at two pounds and a quarter
+avoirdupois, which would be equivalent to nearly a quart, the other at
+not quite half as much; but the observations of the latter were made on
+exceptionally weak and sickly infants. Infants no doubt vary, as do
+grown people, as to the quantity of food they require. I should estimate
+from my own experience and observation, apart from accurate data, a pint
+as 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 months
+seems to me very reasonable, I should doubt its sufficing for a child of
+nine 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 three
+hours; and this frequent need of food continues until the age of two,
+sometimes even until three, months. Afterwards, and until six months
+old, the child does not need to be fed oftener than every three hours
+during the twelve waking hours, and every four hours during the sleeping
+time. Later on, five times in the twenty-four hours, namely thrice by
+day, 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 the
+cup or spoon; a child so fed has no choice in the matter, but must
+either swallow or choke, and is fed as they fatten turkeys for the
+market. The infant, on the other hand, sucks the bottle as it would suck
+its mother's breast; it rests when fatigued, it stops to play, it leaves
+off when it has had enough, and many a useful inference may be drawn by
+the observant nurse or mother who watches the infant sucking, and
+notices if the child sucks feebly, or leaves off panting from want of
+breath, or stops in the midst, and cries because its mouth is sore or
+its gums are tender.
+
+But it is not every bottle which an infant should be fed from, and
+least 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 hour
+together with the end in its mouth, sucking, or making as though it
+sucked, even when the bottle is empty. These bottles, as well as the
+tubes connected with them, are most difficult to keep clean; and so
+serious is this evil, that many French physicians not only denounce
+their use, in which they are perfectly justified, but prefer, to the use
+of any bottle at all, the feeding the infant with a spoon; and here I
+think they are mistaken. The old-fashioned flat bottle, with an opening
+in the middle, and a short end to which the nipple is attached without
+any tube, the only one known in the time of our grandmothers, continues
+still the best, and very good. My friend, Mr. Edmund Owen, in a lecture
+at which I presided at the Health Exhibition in August last year,
+pointed out very humorously the differences between the old bottle and
+the new. An infant to be kept in health must not be always sucking, but
+must be fed at regular intervals. The careful nurse takes the infant on
+her knee, feeds it from the old-fashioned feeding-bottle, regulating the
+flow of the milk according as the infant sucks heartily or slowly,
+withdraws it for a minute or two, and raises the child into a sitting
+posture if it seems troubled with flatulence, and then after a pause
+lets it recommence its meal. This occupies her a quarter of an hour or
+twenty minutes of well-spent time, while the lazy nurse, or the mother
+who has never given the matter a thought, just puts the tube in the
+infant's mouth, and either takes no further trouble or occupies herself
+with something else. And yet, obvious though this is, how constantly one
+sees infants taken about in the perambulator with the feeding-bottle
+wrapped up and laid by its side, because it is said the child always
+cries when it is not sucking, and the intelligence and the common sense
+are wanting, as well as the patient love, that would strive to make out
+which it is of many possible causes that makes the infant cry. One more
+observation with reference to bottle-feeding may not be out of place. It
+is this: that no food be left in the bottle after the child has had its
+meal, but that it should be emptied, washed out with a little warm water
+and soda, and it and the india-rubber end should be kept in water till
+again needed. To insure the most perfect cleanliness it is always well
+to have two bottles in use, and to employ them alternately.
+
+How strictly soever an infant may be kept at the breast, or however
+exactly the precautions on which I have insisted are observed, sickness,
+constipation, or diarrh[oe]a may occur, causing much anxiety to the
+parents, and giving much trouble to the doctor.
+
+It sometimes happens, without its being possible to assign for it any
+sufficient reason, that the mother's milk disagrees with her infant, or
+entirely fails to nourish it, so that, much against her will, she is
+compelled to give up suckling it. In some instances this is due to
+errors in diet, to the neglect of those rules the observance of which is
+essential to health, as proper exercise for instance; and then the
+secretion is usually deficient in quantity as well as defective in its
+composition. In such cases the child often vomits soon after sucking, it
+suffers from stomach-ache, its motions are very sour, of the consistence
+of putty, and either green, or become so soon after being passed,
+instead of presenting the bright yellow colour and semi-fluid
+consistence of the evacuations of the healthy infant, and sometimes they
+are also lumpy from the presence of masses of undigested curd. In
+addition, also, the child is troubled with griping, which makes it cry;
+its breath is sour, or actually offensive, and the tongue is much whiter
+than it should be, though it must be remembered that the tongue of the
+sucking child always has a very slight coating of whitish mucus, and is
+neither as red nor as perfectly free from all coating as it becomes in
+the perfectly healthy child of three or four years old.
+
+In these circumstances, the diminution of stimulants, such as the stout
+of which young women are sometimes mistakenly urged to take a quantity
+to which they were previously quite unaccustomed, is often followed by
+an increase of the quantity as well as an improvement in the quality of
+the milk. It is true that a nursing mother may often find her strength
+maintained, and her supply of milk increased, by taking a glass of stout
+at lunch and another at dinner, instead of, but not in addition to, any
+other stimulant; but mere stimulants will no more enable a woman to
+suckle her infant better than she otherwise would do, than they would
+fit a man to undergo great fatigue for days together, or to go through a
+walking tour in Switzerland. A tumbler of one-third milk and two-thirds
+good grit gruel taken three times a day will have greater influence in
+increasing the quantity of milk than any conceivable amount of
+stimulant.
+
+There is an entirely opposite condition in which the infant does not
+thrive at the breast, and this for the most part is met with when the
+mother has already given birth to and suckled several children. In these
+instances the secretion is sometimes, though not always, abundant, but
+the infant does not thrive upon it. The babe does not get on, is always
+hungry after leaving the breast, and cries as though it wanted more; in
+addition to which it is often purged, either while sucking or within a
+few minutes afterwards, though the motions, except in being more
+frequent and more watery than in health, do not by any means constantly
+show any other change. The mother's history explains the rest. She is
+constantly languid, suffers from back-ache, feels exhausted each time
+after the babe has sucked, probably has neuralgia in her face, or
+abiding headache. In many instances, too, her monthly periods return,
+though as a rule they do not appear in healthy women while suckling. All
+these symptoms show that her system is not equal to the duty she has
+undertaken, and that therefore, for her sake as well as for that of the
+infant, she must give up the attempt.
+
+One more case there is in which suckling has to be given up, at any rate
+in part, and that is when the milk is good in kind, but insufficient in
+quantity for the child as it grows older. This insufficiency of quantity
+shows itself at different periods after the infant's birth--at two
+months, three, or four. The child is not otherwise ill than that it is
+no longer bright, as it was wont to be, it ceases to gain flesh, it
+sleeps more than it used to do, though when it wakes it is always eager
+for the breast, and cries when leaving it, and if the experiment is made
+of giving it some milk and water immediately on leaving it, it takes
+that greedily. Mothers are loth to believe this failure of their
+resources, and in the case of some who have firm and well-formed
+breasts, there is but little change in their appearance to show that
+what remains may serve for beauty, not for use. But if while the child
+is sucking, the nipple is taken suddenly from its mouth, instead of
+innumerable little jets of milk, spirting out from the openings of the
+milk-ducts, the nipple will be seen to be barely moistened by its
+languid flow.
+
+In conditions such as these the question of weaning partially or
+completely inevitably occurs, and where the mother's weakness is the
+occasion of the failure to nourish the child, half-measures are of no
+avail, for so long as she does not entirely give up the attempt to do
+that to which her health is unequal, her own state will grow worse, that
+of the child will not improve. When errors of diet or inattention to
+general rules of health incapacitate the mother from the performance of
+her duty, there may be hope from the adoption of a wiser course; while
+when the supply simply fails from its inadequacy, much may be hoped for
+from a wise combination of hand-feeding with nursing at the breast; the
+mother perhaps suckling the infant by day, but being undisturbed by
+demands upon her at night.
+
+Last of all, I must refer to cases in which love has been stronger than
+reason, as indeed it often is, and in which young people with some
+pronounced hereditary taint of scrofula or consumption marry and have
+children. In such cases, if the consumptive taint is on the mother's
+side, it is, I believe, much wiser, in the inability to obtain a good
+wet-nurse, to bring up the child by hand rather than at the mother's
+breast. One word, however, applicable in such circumstances, age and
+long experience entitle me to add, and it is this. It is essential that,
+in the absence of that guarantee against the too rapid succession of
+pregnancies which suckling for a reasonable time presents, there should
+be self-restraint on both sides, lest the inscription on the young
+wife's grave should be, as I have too often known it, the same as, in
+despite of poetry and romance, her biographer assigns as the cause of
+the death of Petrarch's Laura, that she died worn out _crebris
+partubus_, by too many babies.
+
+In all of these cases the rules which I have already given with
+reference to hand-feeding have to be borne in mind: the preference for
+asses' milk at first, the careful regulation of the amount of curd in
+the cows' milk afterwards, increased or diminished by the greater or
+less proportion of whey mixed with it. Sometimes, however much the
+quantity of curd or casein may be reduced, the child is yet unable to
+digest it, for it is firm and not easily acted on by the juices of the
+stomach. It is then best to omit it altogether, and to supply the
+necessary albumen by white of egg. A very good food in these
+circumstances 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 stronger
+nourishment, one part of veal-tea, made with a pound of veal to a pint
+of water, may be added to one part of whey, with the white of egg and
+sugar of milk as before, and one part of white decoction, as it was
+called 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 into
+the infant's diet, and preparing the way for a larger amount of it which
+by degrees becomes necessary. Of these, one of the most generally useful
+is Liebig's or Savory and Moore's food for infants, which has the
+advantage of not constipating as so many other farinaceous foods do.
+Chapman's Entire Wheat Flour is an extremely good food; and wheat, as
+you will remember, excels other farinaceous substances in its nutritive
+properties, but it is not so easy of digestion as Liebig. There is,
+however, scarcely any kind of farinaceous food, among which Nestle's
+must not be forgotten, which may not answer for an infant; provided
+always that at first it is not given oftener than twice a day, that it
+is not made too thick, nor given in larger proportion than one-third of
+the farinaceous food to two-thirds of the whey, milk, or whatever it is
+mixed with; and besides, whatever the food may be, it should be prepared
+each time afresh.
+
+This is not the place for going into all details on the subject of
+feeding infants, or to explain how if wisely managed the child weans
+itself by degrees from the bottle or the breast--the best way, be it
+said, of weaning--or how by degrees it comes to its daily midday meal of
+beef-tea and bread, and then, when the first grinding teeth have been
+cut, to a small meat meal daily, finely minced or scraped, and so little
+by little adopts the modes of living of its elders.
+
+But, last of all, there are instances, though not so many as the public
+imagine, 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 in
+which the infant is the subject of consumptive disease. It is very rare
+for its symptoms, even in cases of the most marked tendency to
+consumption on the part of the parents, to show themselves before the
+age of three months, and I think I may add, that apart from such
+tendency consumption never appears in infancy or early childhood, except
+when it follows on some acute illness, such as inflammation of the
+lungs, or on typhoid, or, as it is commonly called, remittent fever.
+
+Consumption of the bowels, as it is popularly termed, may be said never
+to occur in early infancy apart from consumptive disease of the lungs,
+and is then always accompanied by an increase towards evening of the
+temperature from its natural standard of 98.5 deg. to 100 deg.. Hence the
+absence of cough and the persistence of a natural temperature may be
+taken as almost conclusive evidence that there is no consumptive disease
+of the bowels. Consumptive disease in infancy is invariably attended
+with glandular enlargement. The glands of the bowels when irritated
+always communicate their irritation to the glands in the groin and the
+bend 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 of
+the bowels, other tiny enlarged glands will be felt, like shot, under
+the skin of the belly, from which in the general progress of emaciation
+the layer of fat always present in the healthy baby will already have
+been removed. Besides this, too, the veins running beneath the skin
+there, invisible in the healthy infant, will be seen meandering like
+blue lines, and telling the story that more blood than usual flows
+through them, because the diseased glands inside interfere with its
+ready passage through its proper channels.
+
+Two cautions, however, have to be borne in mind with reference to both
+of these indications of disease. The first is, that the glands in the
+groin may be enlarged from mere irritation, independent of actual
+disease communicated to them from the glands inside. If, however, you
+find the glands at the corner of the lower jaw and those on either side
+of the neck enlarged too, you are then driven to the conclusion that the
+glands in the groin are enlarged not from mere local irritation, but
+from general disease, and that consumption is its cause.
+
+Again, the superficial veins of the belly may be enlarged from any
+cause which interferes with the proper circulation through the vessels
+inside. Hence they are often enlarged in grown people in dropsy, and
+hence too in infants and young children from flatulent distension of the
+bowels. But in this case the other signs of consumption are wanting; the
+emaciation, the cough, the increase of evening temperature, and the
+enlargement of the glands, are all absent.
+
+Sometimes we meet with instances where the child does not digest its
+food, does not thrive, does not gain flesh, never passes healthy
+evacuations, at length wastes, loses strength, and dies, without having
+had any of the signs which I have pointed out as indicative of
+consumptive disease, and in fact without having suffered from it. Now,
+these cases are connected with imperfect performance of the function of
+the liver, and sometimes with an imperfection of its structure. Before
+birth the functions of the liver are not called into action in the same
+way nor to the same degree as afterwards, and its structure differs in
+this respect that it contains a larger amount of fat and a smaller
+proportion of bile-secreting cells than afterwards. It sometimes happens
+from causes which we do not understand that the liver structure not only
+does not undergo that higher development which should take place, but
+that the fat cells increase at the expense of the bile cells. In these
+circumstances 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 of
+consumption, only there are no cough, no glandular enlargement, no big
+superficial veins, no increased temperature, while on a careful
+examination the doctor will seldom fail to find the rounded edge of the
+enlarged liver coming lower down than natural. In these cases too there
+is a disposition to convulsive affections, and to that peculiar form of
+convulsion called spasmodic croup, concerning which I shall have
+something to say later on.
+
+In its less serious form this is both a more frequent and a less grave
+condition than consumption, and its existence explains to a great degree
+those cases in which young children have failed to be nourished by the
+milk food which commonly suits their tender age, but have improved on
+beef-tea, raw meat or its juice, and food entirely destitute of
+saccharine matter.
+
+In cases where there is reason to apprehend consumptive disease, the
+skill and resources of the doctor will often be heavily taxed to meet
+each 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 which
+the asses' milk is deficient, a couple of teaspoonfuls of raw meat juice
+in the course of every twenty-four hours, much care in the introduction
+of farinaceous substances into the diet, and cod-liver oil twice a day,
+beginning with ten drops and gradually increasing the dose to a
+teaspoonful, are all that the mother herself can do. When the cod-liver
+oil is not borne by the stomach, or when--which, however, is not often
+the case--the child refuses to take it, glycerine may be substituted for
+it, though it must be owned that it is a very poor and inefficient
+substitute. The inunction of cod-liver oil is in any case not to be had
+recourse to; it makes the child unpleasant to itself and loathsome to
+others, while the power of the skin to absorb oily matters is far too
+limited to be worth taking into account.
+
+Vomiting, though by no means a prominent symptom of either of the two
+very grave conditions of which I have been speaking just now, is yet a
+very common attendant on all disorders of digestion in early life. It is
+indeed much more frequent in the infant than in the adult, and the
+greater irritability of the stomach continues even after the first few
+months of existence are past, and does not completely cease during the
+early years of childhood. In every case of vomiting in childhood,
+therefore, the first question to set at rest is whether it depends on
+disorder of the digestive system, or whether it heralds the onset of one
+of the eruptive fevers, or of inflammation of the chest, or of affection
+of the brain; and in determining this all the directions given when I
+was speaking of the general symptoms of disease are to be carefully
+studied. Vomiting often accompanies infantile diarrh[oe]a, even when the
+food taken cannot be regarded as its occasion; and now and then the
+stomach, with no obvious exciting cause, suddenly becomes too irritable
+to retain any food, and this indeed may be the case even though attended
+by few or no other indications of intestinal disorder. The child in such
+cases seems still anxious for the breast; but so great is the
+irritability of the stomach that the milk is either thrown up unchanged
+immediately after it has been swallowed, or it is retained only for a
+few minutes, and is then rejected in a curdled state; while each
+application of the child to the breast is followed by the same result.
+It will generally be found, when this accident takes place in the
+previously healthy child of a healthy mother, that it has been
+occasioned by some act of indiscretion on the part of its mother or
+nurse. 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; or
+the infant has been roused from sleep before its customary hour, or it
+has been over-excited or over-wearied at play, or in hot weather has
+been carried about in the sun without proper protection from its rays.
+
+The infant in whom from any of these causes vomiting has come on, must
+at once be taken from the breast, and for a couple of hours neither food
+nor medicine should be given to it. It may then be offered a teaspoonful
+of cold water; and should the stomach retain this, one or two spoonfuls
+may be given in the course of the next half-hour. If this is not
+rejected, a little isinglass may be dissolved in the water, which must
+still be given by a teaspoonful at a time, frequently repeated; or cold
+barley-water may be given in the same manner. In eight or ten hours, if
+no return of vomiting takes place, the experiment may be tried of giving
+the child its mother's milk, or cows' milk diluted with water, in small
+quantities from a teaspoon. If the food thus given does not occasion
+sickness, the infant may in from twelve to twenty-four hours be restored
+to the breast: with the precaution, however, of allowing it to suck only
+very small quantities at a time, lest, the stomach being overloaded, the
+vomiting should again be produced.
+
+In many instances when the sickness has arisen from some accidental
+cause, such as those above referred to, the adoption of these
+precautions will suffice to restore the child's health. If, however,
+other signs of disorder of the stomach or bowels have preceded the
+sickness, or are associated with it, medicine cannot be wholly dispensed
+with, and the advice of the doctor must be sought for. Very likely in
+addition to directing the rules above laid down to be attended to, he
+may lay a tiny dose of calomel, as a quarter, half or a whole grain on
+the tongue, which often has a wonderful influence in arresting sickness;
+while he may further put a small poultice not much bigger than a crown
+piece, made half of mustard, half of flour, on the pit of the stomach
+for a few minutes, and may give the child a little saline, with a grain
+or 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 be
+prescribed, and their effect watched by the medical attendant.
+
+Sickness, indeed, is not always a solitary symptom unattended by other
+evidences of disordered digestion, but is sometimes associated with
+signs of its general impairment, and this may be so serious as to lead
+to great loss of flesh, and even to end in endangering life. In many
+instances, however, the child does not lose much flesh though it digests
+ill, and its symptoms would be troublesome rather than alarming, if it
+were not that they are often the signs of an unhealthy constitution, out
+of which in the course of a few months consumption is not infrequently
+developed. Long-continued indigestion in the infant always warrants
+anxiety on the part of the parent.
+
+In some of these cases there is complete loss of appetite, the infant
+caring neither for the breast nor for any other food. It loses the look
+of health and grows pale and languid, though it may not have any special
+disorder either of the stomach or of the bowels. It sucks but seldom and
+is soon satisfied, and even of the small quantity taken, a portion is
+often regurgitated almost immediately. This state of things is sometimes
+brought on by a mother's over-anxious care, who, fearful of her infant
+taking cold, keeps it in a room too hot or too imperfectly ventilated.
+It follows, also, in delicate infants on attacks of catarrh or of
+diarrh[oe]a, but it is then for the most part a passing evil which time
+will cure. In the majority of cases, however, the loss of appetite is
+associated with evidence of the stomach's inability to digest even the
+small quantity of food taken, and the bowels are irregular in their
+action, as well as unhealthy in their secretion. Loss of appetite, too,
+though a frequent is by no means a constant attendant on infantile
+indigestion, but is replaced sometimes by an unnatural craving, in which
+the child never seems so comfortable as when sucking. It sucks much, but
+the milk evidently does not sit well upon the stomach; for soon after
+sucking, the child begins to cry and appears to be in much pain until it
+has 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 often
+can be pacified only by allowing it to suck again. In other cases
+vomiting is of much less frequent occurrence, and there is neither
+craving desire for food, nor much pain after sucking; but the infant is
+distressed by frequent acid or offensive eructations; its breath has a
+sour or nauseous smell, and its evacuations have a most f[oe]tid odour.
+The condition of the bowels that exists in connection with these
+different forms of indigestion is variable. In cases of simple loss of
+appetite, the debility of the stomach is participated in by the
+intestines, and constipation is of frequent occurrence, though the
+evacuations do not always appear unhealthy. In other instances in which
+the desire for food still continues, the bowels may act with due
+regularity, but the motions may have a very unnatural appearance. If the
+child is brought up entirely at the breast, the motions are usually
+liquid, of a very pale yellow colour, often extremely offensive, and
+contain shreds of curdled milk, which not having been digested within
+the stomach, pass unchanged through the whole track of the bowels. In
+many instances, however, the infant having been observed not to thrive
+at the breast, arrowroot or other farinaceous food is given to it, which
+the stomach is wholly unable to digest, and which gives to the motions
+the appearance of putty or pipe-clay, besmeared more or less abundantly
+with slime or mucus. The evacuations are often parti-coloured, and
+sometimes one or two unhealthy motions are followed by others which
+appear perfectly natural; while attacks of diarrh[oe]a often come on,
+and the matters discharged are then watery, of a dark dirty green
+colour, 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 be
+expected, and in many cases grow up to be strong and healthy. Still the
+condition is one that not merely entails much suffering on the infant,
+but by its continuance seriously impairs the health, and tends to
+develop the seeds of any constitutional predisposition to consumptive
+disease.
+
+In these cases there are many respects in which the mother can most
+efficiently second the doctor. All causes unfavourable to health must be
+examined into, and as far as possible removed. It must be seen that the
+nursery is well ventilated, and that its temperature is not too high;
+while it will often be found that no remedy is half so efficacious as
+change of air. Next, it must not be forgotten that the regurgitation of
+the food is due in great measure to the weakness and consequent
+irritability of the stomach, and care must therefore be taken not to
+overload it. If these two points are attended to, benefit may then be
+looked for from the employment of tonics, and as the general health
+improves the constipated condition of the bowels, so usual in these
+cases, will by degrees disappear; while if aperients are needed those
+simple remedies only should be employed of which I spoke in the first
+part of this book, and the use of mercurials is not to be resorted to
+without distinct medical order.
+
+The above mode of treatment is appropriate to cases of what may be
+termed the indigestion of debility, but a different plan must be adopted
+in 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 no
+less applicable here, for the rejection of some of the milk may be the
+result of nothing more than of an effort which nature makes to reduce
+the work that the stomach has to do within the powers of that organ. But
+when, notwithstanding that due attention is paid to this important
+point, uneasiness is always produced by taking food, and is not relieved
+till after the lapse of some twenty minutes, when vomiting takes place,
+or when the infant suffers much from flatulence and from frequent acid
+or nauseous eructations, it is clear that the symptoms are due to
+something more than the mere feebleness of the system.
+
+It is not, however, the mere fact that the child vomits its food, or of
+the milk so vomited being rejected in a coagulated state, which proves
+that the stomach is disordered, but it is the fact of firmly coagulated
+milk being rejected with much pain, and after the lapse of a
+considerable interval from the time of its being taken, which warrants
+this conclusion. The coagulation of the curd is the first change which
+the milk of any animal undergoes when introduced into the stomach. The
+coagulum of human milk is soft and flocculent, and not so thoroughly
+separated from the other elements of the fluid, as the firm hard
+coagulum or curd of cow's milk becomes from the whey in which it floats.
+In a state of health the abundantly secreted gastric juice speedily
+redissolves the chief part of the curd in the stomach, while when it has
+passed into the intestine the alkaline bile which there becomes mixed
+with it, completes its solution, and converts the whole into a fluid
+which closely resembles one of the chief elements of the blood, is
+consequently very easily taken up by the minute vessels whose office it
+is to do so, and thus supplies with nourishment the whole body.
+
+Milk tends, however, to undergo changes spontaneously, which produce
+its coagulation, and the occurrence of these changes is greatly favoured
+by a moderately high temperature, such as that which exists in the
+stomach. But the alterations of the fluid that accompany this
+spontaneous coagulation are very different from those which are brought
+about by the vital processes of digestion. An acid becomes formed within
+it, and the acid thus produced has none of the solvent power of gastric
+juice, but by its presence impedes rather than favours digestion. Every
+nurse is aware that a very slight acidity of the milk will suffice to
+give an infant vomiting, stomach ache, and diarrh[oe]a, and the result
+must be much the same whether fermentation had begun in the milk before
+it was swallowed, or whether it commences afterwards, in consequence of
+the disordered condition of the stomach, and the absence of a healthy
+secretion of gastric juice.
+
+The nature of the food is the first point that requires attention in the
+management of these cases of infantile dyspepsia. If the child had been
+fed on cow's milk the symptoms may be due to the gastric juice not
+having been able to dissolve the curd, which you will remember is much
+firmer than that of human milk as well as twice as abundant. In this
+case the substitution of asses' milk, the employing whey either entirely
+or in part instead of milk, and the adding white of egg in order to
+present the elements of the curd in a more easily digestible form, may
+all be tried with advantage. Sometimes children refuse whey; and then a
+mixture of cream and veal broth, more or less diluted either with water
+or 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 of
+service, since it not only prevents the occurrence of fermentation, but
+also 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 of
+indigestion for which a grown person if suffering would seek the advice
+of a skilful doctor require his help no less when the patient is a
+child. When acids will be of service in promoting the secretion of the
+gastric juice, when pepsine will be likely to be of use, when stimulants
+such as a little brandy, when aromatics to get rid of flatulence,
+opiates to relieve pain or check diarrh[oe]a, or when an occasional
+mercurial, or some other remedy may be of use by stimulating the liver
+to increased action, are questions which I would not advise any mother
+to try to answer for herself. Much care and pains and knowledge and
+experience are often required by the doctor to enable him to answer them
+correctly.
+
+I must not leave the consideration of the ailments of the digestive
+organs in early infancy without some notice of that affection of the
+mouth popularly known as _thrush_ to which an exaggerated importance was
+once attached as the supposed cause of those symptoms of disordered
+health, of which it is in reality only the accompaniment. Still it is a
+sign of such grave disorder that it needs a careful study.
+
+THRUSH.--If you examine the mouth of a young infant, in whom the attempt
+at hand-feeding is not turning out well, you will often observe its
+lining to be beset with numerous small white spots, that look like
+little bits of curd lying upon its surface, but which on a more
+attentive examination are found to be so firmly adherent to it as not to
+be removed without some difficulty, when they leave the surface beneath
+it a deep red colour, and now and then bleeding slightly. These specks
+appear upon the inner surface of the lips, especially near the angles of
+the mouth, on the inside of the cheeks, and upon the tongue, where they
+are more numerous at the tip and edges than towards the centre. They are
+likewise seen upon the gums, though less frequently and in smaller
+numbers. When they first appear they are usually of a circular form,
+scarcely larger than a small pin's head; but after having existed for a
+day or two, some of the spots become three or four times as large, while
+at the same time they in general lose something of their circular form.
+By degrees the small white crusts fall off of their own accord, leaving
+the surface where they were seated redder than before; a colour which
+gradually subsides, as with the infant's improved health the mouth
+returns to its natural condition. If the improvement is tardy the white
+specks may be reproduced and again detached several times before the
+mouth resumes its healthy aspect. In the worst cases the specks
+coalesce, and coat the mouth as though lined with a membrane which is
+usually of a yellowish-white tint instead of having the dead white
+colour of the separate spots. Even here, however, though the surface is
+very red, it scarcely bleeds if the deposit is removed from it gently
+and with care.
+
+The popular notion that when the deposit of thrush appears not only in
+the mouth, but also at the edge of the bowel, it has passed through the
+child is altogether erroneous. The lining membrane of the bowel indeed
+is red, inflamed, and presents those conditions to which I have already
+referred when speaking of the atrophy of hand-fed children, but the
+actual deposit of thrush can take place only where there exists an
+appropriate structure for its formation, and that is to be found, not in
+the 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 by
+the acrid motions, and this irritation sometimes extends to the skin
+over the lower part of the baby's person, which becomes rough, and
+covered with a blush of redness.
+
+Thrush in the child is of far less serious import than in the grown
+person. In the latter it indicates the existence of some very serious,
+almost hopeless disease, and hence it is that we meet with it in the
+last stages of dysentery, cancer, and consumption. In the child a slight
+attack 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 already
+described when speaking of the troubles of digestion in early infancy.
+
+While in any case it must rest with the doctor to regulate as he best
+knows how the constitutional treatment of the condition on which the
+thrush depends, it must be for the mother to see that appropriate local
+measures are adopted. One point of considerable moment, and to which
+less care than it deserves is usually paid, is the removing from the
+mouth, each time after the infant has been fed, of all remains of the
+milk or other food. For this purpose whenever the least sign of thrush
+appears, the mouth should be carefully wiped out with a piece of soft
+rag dipped in a little warm water every time after food has been given.
+Supposing the attack to be but slight this precaution will of itself
+suffice in many instances to remove all traces of the affection in two
+or three days. If, however, there is much redness of the mouth, or if
+the specks of thrush are numerous, some medicated application is
+desirable.
+
+The once popular honey and borax is not the best application, and this
+for a reason which I will at once explain. The secretion of the mouth in
+infants is acid, disease increases this acidity; and it has been found
+that 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 of
+membrane formed by a peculiar microscopic growth, of whose existence,
+just as of that of the phylloxera which destroys the vine, or the
+muscardine which kills the silkworm, we were ignorant till brought to
+light by recent scientific research.
+
+You will therefore at once see why saccharine substances, apt as they
+are to pass into a state of fermentation, are not suitable, and why it
+is better to employ a solution of--
+
+Borax, twenty grains
+Glycerine, one teaspoonful
+Water, an ounce.
+
+Now and then the use once or twice a day in addition of a very weak
+solution of caustic, as two grains of lunar caustic to an ounce of
+water, in bad cases is necessary; but of this it must be left to the
+doctor to decide.
+
+TEETHING.--The transition is a very natural one by which we pass from
+the study of the dangers and difficulties which attend the feeding and
+rearing of young infants, to those which accompany _teething_.
+
+The time of teething is looked forward to by most mothers with
+undisguised apprehension, nurses attribute to it the most varied forms
+of constitutional disturbance, and doctors constantly hold forth to
+anxious parents the expectation that their child will have better health
+when it has cut all its teeth. The time of teething, too, is in reality
+one of more than ordinary peril,[9] though why it should be so is not
+always rightly understood. It is a time of most active development, a
+time of transition from one mode of being to another, in respect of all
+those important functions by whose due performance the body is nourished
+and built up.
+
+The error which has been committed with reference to this matter,
+consists not in overrating the hazard of the time, when changes so
+important are being accomplished, but in regarding only one of the
+manifestations--though that indeed is the most striking one of the many
+important ends which nature is then labouring to bring about. A child in
+perfect health usually cuts its teeth at a certain time and in a certain
+order, just as a girl at a certain age begins to show signs of
+approaching womanhood; and at length attains it with but slight
+inconvenience or discomfort. The two processes, however, have this in
+common, that during both, constitutional disturbance is more common, and
+serious diseases are more frequent than at other times, and the cause in
+both lies far deeper than the outward manifestation.
+
+The great changes which nature is constantly bringing about around us
+and 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 which
+often disappoints human endeavours, or of the dangers which often attend
+on their accomplishment. Thus when her object is to render the child no
+longer dependent on the mother for its food, she begins to prepare for
+this long beforehand. The first indication of it is furnished by the
+greatly increased activity of the salivary glands, which during the
+first few months of existence have scarcely begun to perform their
+function, a fact which accounts for the tendency to dryness of the
+tongue of the young infant under the influence of very trivial ailments.
+About the fourth or fifth month, this condition undergoes a marked
+alteration; the mouth is now found continually full of saliva, and the
+child is constantly drivelling; but no other indication appears of the
+approach of the teeth to the surface, except that the ridge of the gums
+sometimes becomes broader than it was before. No further change may take
+place for many weeks; and it is generally near the end of the seventh
+month before the first teeth make their appearance. The middle cutting
+teeth of the lower jaw are in most instances the first to pierce the
+gum; next the middle cutting teeth of the upper jaw; then usually the
+side cutting teeth of the lower jaw, and lastly, the corresponding ones
+of the upper. This, however, is not quite invariable, for sometimes all
+the cutting teeth in one jaw precede in their appearance any of those in
+the other. The first four grinding teeth next succeed, and often without
+any very definite order as to whether those of the upper or of the lower
+jaw are first visible, though in the majority of instances the lower are
+the first to appear. The four eye teeth follow, and lastly, the
+remaining four grinding teeth, which complete the set of first, or as
+they are often called, milk teeth.
+
+We must not, however, picture to ourselves this process as going on
+uninterruptedly until completed--a mistake into which parents often
+fall, whose anxiety respecting their children is excited by observing
+that after several teeth have appeared in rapid succession, the process
+appears to come to a standstill. Nature has so ordered it that teething
+which begins at the seventh or eighth month, shall not be completed
+until the twenty-fourth or thirtieth; and has doubtless done so in some
+measure with the view of diminishing the risk of constitutional
+disturbance that might be incurred if the evolution of the teeth went on
+without a pause. As a rule the two lower central incisors or cutting
+teeth make their appearance in the course of a week; six weeks or two
+months often intervene before the central upper incisors pierce the gum,
+but they are in general quickly followed by the lateral incisors. A
+pause of three or four months most frequently occurs before we see the
+first grinding teeth, another of equal length previous to the appearance
+of the eye teeth, and then another still longer before the last grinding
+teeth are cut.
+
+Though a perfectly natural process, teething is almost always attended
+with some degree of suffering. This, however, is not always the case,
+for sometimes we discover that an infant has cut a tooth, who yet had
+shown no signs of discomfort, nor any indication that teething was
+commencing, with the exception of an increased flow of saliva. More
+frequently 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; or
+the eruption of the teeth is preceded by much redness, and great heat of
+the mouth with profuse flow of saliva, and even with little painful
+ulcers of the edge of the tongue, or of the inner surface of either lip.
+With either of these conditions the child is feverish, fretful, and
+cries from time to time with pain, while at the same time the bowels
+often are relaxed, or the child coughs and wheezes as if it had caught
+cold.
+
+Symptoms such as these make up what nurses mean when they say that the
+child is suffering from its teeth, and this opinion is constantly
+followed by a request to the doctor to lance the baby's gums. Now this
+little operation when really called for often gives great relief, both
+to the local discomfort, and also to the general ailment from which the
+infant 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 the
+child's gums lanced:
+
+First. When a tooth is very near the surface, and by cutting through the
+thin gum the child may be spared some needless suffering.
+
+Second. When the gums are very red and hot and swollen; only in this
+case the gum is scratched or cut, to bleed it, not with the idea of
+letting out the imprisoned tooth.
+
+Third. When the child has for some week or two been feverish and
+suffering; while, though the gum is tense and swollen, the tooth does
+not seem to advance.
+
+Fourth. As an experiment, when during the progress of teething a child
+is suddenly seized with convulsions for which there is no obvious cause.
+The irritation of the teeth may have to do with their occurrence; and
+the chance of relieving it by so simple a means is not to be thrown
+away.
+
+If the process of teething is going on quite naturally, no
+interference, medical or other, is either necessary or proper. The
+special liability of children to illness at this time must indeed be
+borne in mind, and care must be taken not to make any alteration in the
+infant's food while it is actually cutting its teeth, but rather to
+choose the opportunity of some one of those pauses to which reference
+has been made, as occurring between the dates of appearance of the
+successive teeth, for making any such change. If the child is feverish,
+a little soda or seltzer water sweetened and given after the
+effervescence has subsided will be taken eagerly, and avoid the risk of
+putting the child too often to the breast, or giving it food too
+frequently. It seeks the one or the other because it is thirsty, and
+craves for moisture to relieve its hot mouth; not because it is hungry
+and needs nourishment. If the child has been weaned, still greater care
+will be required, for it will often be found that it is no longer able
+to digest its ordinary food, which either is at once rejected by the
+stomach, or else passes through the intestines undigested. Very thin
+arrowroot made with water, with the addition of one third of milk, will
+suit in many cases, or equal parts of milk and water with isinglass, or
+equal parts of milk and the white decoction. The bowels of course must
+be kept open with very simple and mild aperients, but the bowels are in
+general more inclined to diarrh[oe]a than to constipation, and the
+diarrh[oe]a of teething children is often troublesome and requires good
+medical advice.
+
+The ulcerated state of the mouth is usually connected with special
+disorder of the digestive organs, and that condition of acidity for
+which I have already recommended soda, magnesia, and similar remedies,
+while locally the mouth needs just that local care which is applicable
+in cases of thrush. Now and then, severe inflammation of the gums
+occurs, in which they become extremely swollen; and ulceration takes
+place of the gum just above where the tooth should come through, and
+even around some of those which have already appeared. These are cases
+in which lancing the gums would do nothing but mischief. They require
+the local care already insisted on, a mild plan of diet, and treatment
+to reduce any feverishness; and above all one medicine, the chlorate of
+potass, which in doses of four grains every four hours for a child a
+year old, is almost a specific.
+
+AFFECTIONS OF THE SKIN.--There are a few affections of the skin to which
+children in early infancy are especially liable, concerning which a few
+words must be said.
+
+The Latin word _intertrigo_ is used for that _chafing_ of the skin of
+the 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 of
+care. Either wetted napkins are dried, and put on again without previous
+rinsing in water, or they have been washed in water containing soda, and
+not passed through pure water afterwards, or attention is not paid to
+change the infant's napkin immediately that it requires; or a fresh
+napkin is put on without previous careful ablution of the child; or
+lastly it occurs almost unavoidably in cases of diarrh[oe]a from the
+extension of irritation beginning at the edge of the bowel.
+
+Care is usually all that is needed to remove, as it is to prevent this
+condition. The precautions which I have referred to with regard to
+cleanliness must be carefully observed, and moreover, each time even
+after passing water, the child should be carefully washed with thin
+gruel, or barley water, then dusted abundantly with starch powder, while
+the napkin must be thickly greased with zinc ointment. After the first
+six or seven months of life the napkin can be almost always dispensed
+with, if the child has been brought up in good habits, and in all cases
+of chafing, it is much the better way to put no napkin on the child when
+in bed, but to lay under it a folded towel, which can be removed, and a
+clean one substituted for it as soon as it becomes soiled.
+
+There is a very obstinate form of chafing, with great redness of the
+skin, and disposition to crack about the edge of the bowel which depends
+on constitutional causes, and calls at once for the interference of the
+doctor.
+
+Besides this purely local ailment, there is another skin affection
+which is seen over the body generally, and is known popularly by the
+name of _red gum_, or in Latin _strophulus_. I mention the Latin name
+because I have known persons sometimes, misled by the similarity of
+sound, fancy that it had some connection with scrofula. It is met with
+less commonly now than formerly, when people were accustomed to keep
+infants unduly wrapped up, and to be less careful than most are
+now-a-days about washing and bathing. It depends on over-irritation of
+the sweat glands of the delicate skin of the infant, the result of which
+shows itself in the eruption on the body and face of a number of small
+dry pimples sometimes surrounded by a little redness, itching
+considerably, and when their top has been rubbed off by scratching
+having a little speck of dried blood at their summit.
+
+A rash like this, a sort of _nettle rash_, more blotchy and causing
+little lumps on the skin, which in a day or two come and go, sometimes
+appears in the intervals between the pimples, sometimes takes their
+place, and causes, as they do, much irritation. This nettle rash is
+usually dependent on some error of diet, on some acidity of the stomach,
+and, on their being corrected soon passes away, leaving the pimples as
+they were before, but sometimes being reproduced if the pimples cause
+excessive irritation of the tender skin.
+
+The matter of chief importance for a mother to know, is that these
+rashes have no serious signification. Their treatment is very simple. It
+consists in dressing the child very lightly, in bathing it very
+frequently with tepid water, avoiding as far as may be the use of soap,
+and in sponging it often to relieve the irritation with some simple
+alkaline lotion; such for instance as one recommended by the late Dr.
+Tilbury Fox, and which is composed of twenty grains of carbonate of
+soda, two teaspoonfuls of glycerine, and six ounces of rose water. Of
+course if the stomach is out of order that must be attended to, but a
+little fluid magnesia, once or twice a day, is all that is usually
+needed in the way of medicine.
+
+One other affection of the skin, very common, very distressing, very
+tedious, of which there are many varieties, generally known by the
+technical name of _eczema_, from a compound Greek word which signifies
+to flow, needs that I should say something about it. It is not limited
+in its occurrence to infancy, nor does it of necessity cease when
+childhood is over, but continues to recur even in grown persons, and
+shows itself still from time to time even in the aged.
+
+For the most part, however, it makes its appearance between the fifth
+and twelfth month; sometimes seeming to be induced by the change of food
+when the child is weaned, and that even though the weaning may have been
+wisely managed; at other times showing itself when the irritation of
+teething begins, and in every instance being aggravated by the approach
+of each tooth to the surface, and abating in the intervals.
+
+It does not occur in all children with equal frequency or severity, and
+though there is no doubt but that it is often hereditary, and this
+especially 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 the
+same parents to be affected by it severely, while no trace of it appears
+in 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 looking
+very closely--more closely indeed than most persons are wont to do--this
+appearance will be seen to be produced by innumerable small pimples,
+smaller than pins' heads, and which itch violently. Now and then, even
+in the course of a few hours, these pimples disappear, leaving the skin
+rough, and peeling off in branny scales, while the surface beneath is
+red and irritable, a condition which also in a few days may subside.
+This, however, is less frequent than the opposite course of the
+affection, in which a drop of fluid forms at the top of each tiny
+pimple, and escaping forms a yellowish, thin, transparent, watery,
+irritating discharge, which reddens still more the raw and weeping
+surface of the skin. The fluid when abundant dries at length into
+yellowish flakes or crusts, which sometimes assume a brownish colour if
+the surface is made to bleed by irritating or scratching. If the crusts
+are not removed, the fluid which still continues to be poured out
+beneath them soon changes into matter or _pus_ as it is called, and
+this, shut up beneath the hard crust above, increases the irritation,
+and thickens the deposit. After a time the inflammation lessens of its
+own accord, the secretion diminishes, the crusts dry up, and at length
+fall off, leaving the skin red, slightly swollen, and its surface
+scaling off in flakes, which gradually cease to form, and the skin by
+degrees becomes quite sound again, and so remains, until perhaps the
+irritation caused by the approach of a new tooth to the surface,
+rekindles the old trouble, to go once again through the same stages as
+before.
+
+It is on the cheeks, the sides of the face, and the top of the head that
+these changes may be best studied, but there are other situations in
+which the same kind of process often goes on. It may be seen in the
+creases of the neck, or the folds of the thigh in fat children, only as
+two surfaces of skin are there in contact the fluid never dries to a
+crust, but the skin, red and sore and swollen, pours out an abundant
+secretion which, just as when it occurs behind the ears, gives out a
+strong 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 on
+the front of the chest, the back, and sometimes even over the whole
+body, and especially at any part where the pressure of the dress
+irritates the skin. When thus general, it seldom fails to pass into a
+chronic 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 to
+discharge, though the discomfort produced by the local irritation still
+continues. At other times, and this perhaps more often when the eruption
+first appears on the head, its onset is more gradual, and slight
+scurfiness and redness at the top of the head are first noticed, and
+then a little crust forms there which is firmly adherent, and is,
+therefore, often not entirely removed as it should be, and thus bit by
+bit the mischief extends until its cure becomes tedious and troublesome.
+When either from neglect, or from the ailment having set in acutely, the
+affection of the scalp is severe, the child's state is one of much
+suffering. The whole of the scalp becomes hot and swollen, and covered
+over a large surface by a thick dirty crust, through cracks in which a
+thick ill-smelling greenish-yellow matter exudes on pressure. At
+different points around, pimples form with mattery heads,--pustules they
+are called--while the glands on each side of the neck become swollen and
+tender. When thus severe on the head it will be found also not merely on
+the face, but also on the body, and the poor suffering child is not only
+a miserable object to look upon, but, worn by constant restlessness, it
+loses flesh, and seems almost as though it could not long survive.
+Happily, however, the condition scarcely ever terminates fatally, though
+feeble health and stunted growth are not seldom the results of the early
+suffering. But besides, severe eczema in infancy always returns again
+and again in childhood and in after-life, and there is also a distinct
+connection between liability to eczema and to asthma; and this not
+simply nor mainly that the disappearance of an attack of eczema may be
+succeeded by an attack of asthma, but that the child who in infancy has
+had severe general eczema is more prone than another to develop a
+disposition to asthma as he attains the age of five or six, and this
+even though he should not have had any return of the skin affection in a
+severe form.
+
+It is evident then, that one cannot take too much pains to guard
+against the occurrence of eczema if possible, and at any rate to prevent
+its becoming severe. The disposition to it is often controlled by very
+simple precautions, such as bathing the face, the moment the skin shows
+any redness or roughness, with thin gruel or barley water, then
+powdering it with starch powder, and when the infant goes out, smearing
+the spot very lightly with benzoated zinc ointment, and making the child
+wear a veil. It will be observed that the exclusion of the air is in all
+these cases the object of the application far more than any specific
+virtue which it is supposed to possess, and many of the worst cases of
+eczema in grown persons are treated, in the great hospital for skin
+diseases in Paris, by an india-rubber mask, or by india-rubber covering
+of the affected part, and benefit thereby without any medicated
+application whatever. The thin layer of scurf which often forms on an
+infant's head should not be allowed to remain there, since its presence
+is a source of irritation. If it is very adherent, the surface may be
+well greased overnight with a little clarified lard which will soften
+it, so that it can be readily washed off with weak soap and water in the
+morning. 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 instead
+of a sponge, which would be too harsh, it is better to employ a very
+large camel's hair brush or a soft shaving brush, which is more handy,
+and the surface after careful drying may be lightly smeared with zinc
+ointment. All ointments used must be washed off most scrupulously every
+day, otherwise they become rancid, irritate, and make matters worse.
+
+When eczema sets in acutely, with general feverish disturbance, cooling
+medicines are required, and the help of the doctor becomes necessary.
+These are the cases in which the eruption is not confined to the head or
+the face, but extends over the body generally. The child must be dressed
+as loosely as possible; and when in its cot, should lie there with no
+other covering than its little shirt; and nothing gives so much relief
+to the irritation as the abundant use of powder, either simple starch
+powder, or ten parts of starch powder to one of oxide of zinc, or
+carbonate 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 be
+used to apply the powder; but between the creases of the skin--which it
+is important to keep apart--fine linen, lint, or charpie must be
+employed, covered freely with powder, so as to prevent the surfaces from
+coming into contact. If the irritation is very distressing, a weak
+spirit lotion with a little carbolic acid may sometimes be sponged over
+the surface, and the powder renewed immediately; or other forms of
+soothing lotions may be used to abate the irritation.
+
+When the scalp is affected in the acute form of eczema crusts form very
+quickly; or in other cases they collect because people fear to disturb
+them when they see the raw surface beneath. It is, however, a grievous
+mistake to allow them to collect; they are in themselves a source of
+irritation, and they entirely prevent any application reaching the skin
+beneath. They must always be removed, and never be allowed to form
+again. They can be removed either by the employment of a poultice, half
+of bread, half of linseed meal, or by the application over-night of a
+handkerchief soaked in sweet oil, and covered over with a piece of oiled
+silk, which softens the crusts effectually, and allows of their easy
+removal by abundant washing with weak soap and water.
+
+The best applications afterwards vary so much that it is impossible to
+lay down any positive rule. Sometimes the Carron oil, as it is termed: a
+liniment compound of equal parts of linseed oil and lime-water--a
+popular and most useful application in burns--gives most ease to the
+irritated skin; sometimes the mere exclusion of the air by means of the
+india-rubber cap; sometimes the abundant use of powder. In every case,
+at least once in every twenty-four hours the whole surface must be
+washed quite clean with barley water or thin gruel; and when the
+discharge 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, and
+for arsenic; of which latter remedy, however, the results are uncertain;
+while in the acute stage, its influence is simply mischievous. Nothing
+is more difficult, nor calls for more skill, or larger medical
+experience, than the proper management of the various forms of chronic
+eczema.
+
+The question is sometimes asked whether it is safe to cure, or, as
+people call it, to dry up these eruptions in teething children. There
+can be no doubt but that it is very desirable to prevent their
+occurrence as far as may be by the use of the precautionary measures
+which I have explained. But when they have existed for some time, either
+attended with profuse discharge, or causing great irritation by their
+extent, there is no doubt but that care must be exercised in attempts at
+their cure, that soothing measures such as I have advocated should be
+chiefly employed, and that the sudden drying up of the discharge by a
+too abundant use of dusting powders must be avoided. If, too, the
+diminution of the rash were followed by a worsening of the child's
+condition, by feverishness, by heaviness of the head, or any sign of
+disturbance of the brain, the attempt to cure the rash must at once be
+abandoned. At the same time I must add that such occurrences are very
+rare, and that for one case where I have had to regret my success in
+curing the rash, I have seen fifty in which I have been mortified by the
+failure of my endeavour.
+
+FOOTNOTES:
+
+[8] The directions given by the distinguished chemist, Dr. Frankland, to
+whom I am indebted for the suggestion, are as follows: 'One-third of a
+pint of new milk is allowed to stand until the cream has settled; the
+latter is removed, and to the blue milk thus obtained about a square
+inch of rennet is to be added, and the milk vessel placed in warm
+water.' (I may add that the artificial rennet sold by most chemists may
+be substituted for the other.) 'In about five minutes the rennet, which
+may again be repeatedly used, being removed, the whey is carefully
+poured off, and immediately heated to boiling to prevent its becoming
+sour. A further quantity of curd separates, and must be removed by
+straining through calico. In one quarter of a pint of this hot whey is
+to be dissolved three-eighths of an ounce of milk sugar, and this
+solution, along with the cream removed from the one-third of a pint of
+milk, must be added to half a pint of new milk. This will constitute the
+food for an infant of from five to eight months old for twelve hours;
+or, more correctly speaking, it will be one-half of the quantity
+required for twenty-four hours. It is absolutely necessary that a fresh
+quantity should be prepared every twelve hours; and it is scarcely
+necessary to add that the strictest cleanliness in all the vessels used
+is indispensable.'
+
+[9] In our tables of mortality we find teething registered as having
+occasioned the death of nearly 5 (4.8) per cent. of all children who
+died in London under one year old; and of 7.3 per cent. of those who
+died 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 during
+infancy and early childhood, but those only which either happen then
+exclusively, or at least with far greater frequency than at other times.
+
+It will be most convenient to consider the others under the different
+systems to which they belong, as diseases of the head, of the chest, and
+of the bowels.
+
+Before entering on these new subjects, however, a few words may not be
+out of place with reference to what may be termed the second period of
+childhood. It is above all a time of wonderfully lessened sickness and
+mortality. We have not the means of stating exactly the rate at which
+mortality is lessened between the cessation of the first and the
+commencement of the second dentition; but we do know that it is ten
+times less between the age of one and five, and nearly twenty times less
+between five and ten than it was in the first year of existence.[10] A
+mother's anxiety then may safely be quieted after the first year of her
+infant's life, and still more after the first set of teeth have been
+cut, for if her child is strong and healthy then, there will be
+comparatively little to fear for its future.
+
+Four years or thereabouts now follow, before any important change takes
+place in the child's condition, for it is not until between six and
+seven years old that the first set of teeth begin to be shed, and the
+second to take their place. This change of teeth too is of far less
+moment as far as the health is concerned, than was the cutting of the
+first set. The first dentition was the preparation for an entirely new
+mode of life for the child, and was intended to fit it for a life
+independent of its mother. The second has no such signification; it is a
+mere local alteration rendered necessary by the growth of the jaws, and
+takes place quietly, by the gradual absorption of the roots of the first
+set of teeth, brought about by the pressure of the others as they
+approach the surface. Four teeth in each jaw are new, and replace no
+others, but usually they are cut without much discomfort, and the wisdom
+teeth do not concern us here, for they do not appear until childhood has
+long passed.
+
+But, though between the age of two years and of ten there is no
+important change, nor even preparation for a change in the constitution,
+the time is yet one of most active growth of the body, and consolidation
+of 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 the
+long bones previously connected with the shafts by means of cartilage or
+gristle, become firmly united by the conversion of that cartilage into
+bone, and a similar process goes on, though not completed till later, in
+the ribs and the breast bone.
+
+Rapid increase of height and weight; conversion of the elements of bone
+into bone itself, formation of muscle out of the fat, which in the young
+child was stored up as so much building material for an edifice in
+course of construction, require for their accomplishment perfect health,
+and the power of converting to its highest purposes all the nourishment
+received. What wonder then, if from time to time, the machinery thus
+hardly taxed, fails to be quite equal to the demands upon it, if pains
+in 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 vague
+feverish condition comes on, in which the temperature is slightly
+raised, and the child listless, and yet fretful, loses its cheerfulness,
+is dull at its easy tasks, and yet indifferent to play. This too is the
+time when any unsuspected defects, physical, or mental, or moral, begin
+to show themselves distinctly; when short sight becomes apparent so soon
+as the child has to learn its letters, when the dull hearing is
+perceived which makes it seem inattentive, and gives to its manner an
+unchildlike nervousness; and the weak intellect is displayed in
+causeless laughter, causeless mischief, causeless passion, imperfect
+power of articulation, or want of words, and by a restless busyness in
+doing nothing.
+
+Of all these things I shall have to speak later on more fully. They are
+the things however, which only those mothers notice who live much with
+their children, who do not banish them all day long to the nursery or
+the school-room, and learn from another whether they fare well or ill.
+They and only they will notice these things in whom there dwells that
+which 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 of
+the Registrar-General for all England in 1881 are to 1,000 living under
+one 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 at
+all ages from these causes take place in children under five years, a
+fact which at first sight seems as inexplicable as it is startling.
+There is, however, a twofold explanation of it: the circulation through
+the much softer tissue of the brain, unenclosed within a _firm bony
+case_ as in after-life, varies with far greater rapidity in the infant
+than in the grown person, and hence the organ is far more easily
+overfilled with or emptied of its blood. Besides, any organ in which
+growth is going on with great rapidity is proportionately liable to
+become disordered or diseased. Now the brain doubles its weight in the
+first two years of life, and attains nearly its full size by the end of
+the seventh year.
+
+These two facts suggest a bright as well as a dark view of disorders of
+the brain and nervous system in early life. If disorder is more
+frequent, it is excited by slighter causes, is more likely to be
+temporary, and even its gravest symptoms, such as convulsions and
+paralysis, have a less serious import in the one case than in the
+others. If the grown man has a fit, and still more, if that fit is
+followed by paralysis, we fear and with reason that some vessel in the
+brain-substance has given way, or that some grave, probably irreparable
+damage has been inflicted on it. In the child, and especially in the
+young infant, these accidents may mean nothing more than that the brain
+has suddenly become over-filled with blood, or that it has been
+disturbed by irritation--I know of no better term--in some distant
+organ.
+
+CONVULSIONS.--There are in the body two great nerve masses, the brain
+and the spinal cord, through which all parts are brought into relation
+with each other. The spinal cord or spinal marrow receives impressions
+from all parts, imparts movement to the limbs, as well as gives activity
+to the functions of the various internal organs. The brain is the
+controlling power, and governs more or less consciously the movements
+which the spinal cord originates, and hence in proportion as the
+development of the brain advances, and its controlling power increases,
+those involuntary movements, fits or convulsions, which originate in
+irritation of the spinal cord, become rarer. The brain, at the age of
+three 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 former
+frequency; while from the age of ten to fifteen years, when the brain
+may be said to be perfected, only four per cent., instead of nearly
+eighty per cent. as in the first years of life, of all deaths from
+disorders 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 easy
+to 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 brain
+rarely, very rarely, I do not say never, begins with convulsions; and
+next, that their real danger is in general in exactly opposite relation
+to the frequency of their occurrence. Convulsions now and then return
+thirty, forty, or more times in twenty-four hours, and continue to do so
+sometimes for three or four days together. They are, indeed, not without
+peril, for the perpetually returning disturbance of the circulation may
+give rise to an overfilling of the vessels of the brain, or to a
+stagnation of the blood within them, or the spasm may affect the muscles
+which open and close the entrance to the windpipe, and the child may die
+choked as in a paroxysm of whooping cough, or in a fit of spasmodic
+croup, or lastly the violent and frequently repeated muscular movements
+may at length exhaust its feeble frame. But still, such frequently
+recurring convulsions are in themselves no evidence that the brain is
+diseased; they do but show that the irritability of the spinal cord is
+increased to a degree which the brain is no longer able to control, and
+which therefore manifests itself in violent convulsive movements.
+
+It is thus that the poison of scarlet fever or of small-pox sometimes
+displays its influence over the whole system by producing violent
+convulsions at the outset of those diseases; thus that they follow on
+some indigestible article of food, or that the mother, over-heated by
+violent exertion, or overwhelmed by the news of some unexpected
+calamity, 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 the
+cause of the convulsion, to determine the seat of the irritation which
+has excited the nervous system to such tumultuous reaction. The
+convulsion which ushers in any one of the eruptive fevers in the infant
+or in the child, is only an exaggeration of the shivering which precedes
+the onset of fever in the adult. Has the child been exposed to the
+contagion of measles, small-pox, or scarlatina? is it teething, and if
+so, 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 its
+head uncovered? or has it, though in the shade, been sitting or playing
+out 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 of
+late been very severe? or has its breathing been accompanied with a
+peculiar catch or crow, the sign of spasmodic croup, and have at the
+same time its hands been usually half clenched, and the thumb shut into
+the palm, the sign of that disturbance which at length has culminated in
+an attack of convulsions? Such are the questions, which in less time
+than it takes me to write, or others to read, the intelligent mother
+will put to herself, and will answer, instead of, in unreasoning alarm,
+giving all up as lost, or hastening without reflection to do something
+or other that were better left undone.
+
+The first thing to do in every case of convulsions, be their cause what
+it may, is to loosen the dress, so that no string nor band may interfere
+with respiration, and for this purpose strings must be cut and dresses
+torn. The next thing is to dash cold water on the face to induce a deep
+inspiration, for sudden death in a fit almost always takes place from
+interruption to breathing. With the same purpose the forefinger should
+be put into the mouth, and run rapidly to the root of the tongue, which
+should be drawn forward. The object of doing this is twofold; first, to
+prevent the tongue falling back, as in these circumstances it is apt to
+do, over the entrance of the windpipe and so producing suffocation, and
+in the next place the act very frequently puts an end to the spasmodic
+closure of the windpipe, and is followed by a deep-drawn breath which
+announces the infant's safety. If the child has cut any teeth, the
+handle of a spoon, round which a bit of rag has been wrapped, or a bit
+of wood, or a thin strip of india-rubber, should be put between the
+teeth as far back as possible to prevent the tongue being bitten; and
+often this is all that can be done.
+
+There are two circumstances, and two only, in which the warm bath is
+likely to be of use. At the onset of one of the eruptive fevers, a hot
+bath is sometimes of great service by stimulating the skin and thus
+bringing out the rash. In these cases the fit scarcely ever comes on in
+a child previously in perfect health, but for some hours at least it has
+appeared very ill, tossing about with great restlessness, with a dry,
+hot skin, and twitching of the tendons of the wrists; or, perhaps, with
+a pale face and cold hands and feet, but with the temperature of the
+body as high as 103 deg. or 105 deg.. Here the hot bath at 96 deg. to 98 deg., even
+rendered more stimulating by the addition of mustard, and continued for
+not more than five minutes, is sometimes of great service, and is
+speedily followed by the cessation of the convulsions and the outbreak
+of the eruption.
+
+These, too, are the cases in which the use of the wet sheet, as
+practised 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 not
+the hot bath--that is to say, the bath at from 87 deg. to 90 deg.--is of
+service, is where the child is feverish and restless from over-fatigue
+or over-excitement, or from exposure to the sun or to an excessively hot
+atmosphere, and convulsions have come on in the course of this ailing.
+Here the tepid bath for ten or fifteen minutes, coupled with the
+application of cold to the head, will soothe the excitement and prevent
+the return of the convulsions.
+
+In neither this case, nor in that in which the hot bath is employed, is
+the result of the agent as magical as people sometimes seem to expect.
+It is rarely that convulsions cease while a child is actually in the
+bath. For the most part the influence of the bath is limited to abating
+their severity, shortening their duration, and indisposing to their
+return.
+
+The bath, then, is to be used when either a stimulating or a soothing
+influence on the surface is likely to be of service, and only then. In
+cases where the fits are produced by constipation, by improper food, or
+by the irritation of a tooth pressing against the gum, it is idle to use
+it, and equally so in instances where many fits have been recurring in
+the course of the same day. Where that is the case it must be
+self-evident that, be the cause what it may, it must be one over which
+either a hot or a tepid bath can have no influence, and that, painful as
+it must be to wait a passive spectator, that position is far wiser than
+that of a mischievous meddler. It is some consolation, also, to know
+that unconsciousness to suffering attends convulsions.
+
+There is one agent, chloroform, which often has a very remarkable
+influence in controlling frequently repeated convulsions. It is an
+agent, however, too hazardous to be trusted out of medical hands, and
+even when the doctor administers it himself, the parents must fully
+recognise the fact that, inasmuch as the child may die during a fit
+quite independently of breathing chloroform, so the occurrence of that
+catastrophe during its employment is not to be made a subject of
+self-reproach to them, or of blame to the doctor.
+
+But you may ask whether there are no _signs_ of that disturbance of the
+nervous system, by which you can judge beforehand that the occurrence of
+convulsions is probable. In proportion to the tender age of a babe, the
+greater is the probability, as I have already stated, that convulsions
+will be induced by slight causes, especially by such as digestive
+troubles. Unless you are aware of the phraseology that used at any rate
+to be common among nurses, you may be much alarmed at being told that
+the 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 signs
+that threaten convulsions--has had, in short, what in the time of our
+grandmothers used to be called _inward fits_. A child thus affected lies
+as though it were asleep, winks its imperfectly closed eyes, and gently
+twitches the muscles of its face--a movement especially observable about
+the lips, which are drawn as though into a smile. Sometimes, too, this
+movement of the mouth is seen during sleep, and poets have told us that
+it is the angels' whisper which makes the babe to smile--I am sorry that
+its meaning in plain prose should be so different. If this condition
+increases, the child breathes with difficulty, its respiration sometimes
+seems 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 of
+wind, especially if the stomach is gently rubbed. When the disorder of
+the digestion, on whatever cause it depended, is removed, these symptoms
+speedily subside, nor is there much reason to fear general convulsions
+so long as no more serious symptoms show themselves. There is more cause
+for apprehension, however, when the thumbs are drawn into the palm,
+either habitually or during sleep; when the eyes are never more than
+half-closed during sleep; when the twitching of the muscles is no longer
+confined to the angles of the mouth, but affects the face and
+extremities; when the child awakes with a sudden start, its face growing
+flushed or livid, its eyes turning up under the upper eyelid, or the
+pupils suddenly dilating, while the countenance wears an expression of
+great anxiety or alarm, and the child either utters a shriek, or
+sometimes 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, the
+head and neck are drawn backwards and the limbs violently bent and
+stretched. Sometimes these movements are confined to certain muscles or
+are limited to one side, and I may add that such cases are of more
+importance as far as the state of the brain is concerned than those in
+which the convulsions are general. The eye is fixed and does not see;
+the fingers may be passed over it without its winking, the pupil is
+immovably contracted or dilated; the ear is insensible even to loud
+sounds, the pulse is small, very frequent, often too small, and too
+frequent 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 hour
+or more, the convulsions cease; and the child either falls asleep, or
+lies 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, in
+which it may either be perfectly motionless, or twitching of some
+muscles may still continue; or, lastly, it may, though this seldom
+happens, die in the fit.
+
+It seems then, from all that has been said, that convulsions, though one
+of the most striking, are by no means one of the most conclusive signs
+of brain disease; that they are even more commonly the result of
+disorders of the nervous system from causes seated elsewhere, than of
+actual disease of what may be termed the great nervous centre.
+
+We may now therefore pass to the examination of these diseases, which
+for the purposes of this book may be considered under the two heads of
+congestion and inflammation.
+
+I am forced to use these terms in somewhat of a popular sense, for to
+attempt in a little book like this to define everything with strict
+scientific accuracy would simply confuse and mislead.
+
+CONGESTION OF THE BRAIN.--By _congestion of the brain_ is meant a
+condition in which its vessels are overcharged with blood; a condition
+which if it exists in an aggravated degree, ends either in the pouring
+out of blood on, or into the brain, on the one hand, or in inflammation
+on the other. Either of these terminations, however, is so rare in the
+previous healthy child, that I shall confine my remarks entirely to
+congestion of the brain, an affection specially liable to occur in
+children during teething. A certain degree of feverishness almost always
+accompanies teething. It is, therefore, not difficult to understand how,
+when the circulation is in a state of permanent excitement, a very
+slight cause may suffice to overturn its equilibrium, and occasion a
+greater 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 this
+season, but may occur at other times without any obvious exciting cause,
+and with no other explanation than is furnished by the well-known fact
+that all periods of development such as childhood, are periods during
+which the growing organs are most apt to become disordered.
+
+In the great majority of cases the symptoms of congestion of the brain
+come on slowly; and for the most part, general uneasiness, or disordered
+state of the bowels, which are usually, though not invariably
+constipated, and feverishness precede for a few days the more serious
+attack. The head by degrees becomes hot, the child grows restless and
+fretful, and seems distressed by light, or noise, or sudden motion, and
+children who are old enough sometimes complain of their head. Usually
+too, vomiting occurs repeatedly; a symptom of the greatest importance,
+since it may exist before there is any well-marked sign of head
+affection. Causeless frequently repeated vomiting in a child not ill but
+ailing, is nine times out of ten a sign of mischief in the head. The
+degree of fever which attends this condition varies much, and its
+returns are irregular; but any one who knows how to feel the pulse will
+find it permanently quickened, and if the head is unclosed the
+pulsations of the brain may be seen and felt distinctly. The sleep is
+disturbed, the child often waking with a start, while there is
+occasional twitching of the muscles of its face, or of the tendons of
+its wrist.
+
+The child may continue in this condition for many days and then recover
+its health without any medical interference. This is especially likely
+to be the case with children while teething, the fever subsiding, the
+head growing cool, and the little one appearing quite well so soon as
+the tooth has cut through the gum, but the approach of each tooth to the
+surface being attended by the recurrence of the same symptoms.
+
+The fortunate issue of these cases though frequent, is by no means
+invariable, for sometimes they are but the precursors of that
+formidable, I might indeed say, all but hopeless disease, water on the
+brain. But even of itself congestion of the brain is by no means a
+trivial ailment, for it may pass into a stage in which the smaller
+discomforts of the child lead to the sad mistake that the condition of
+the child is improving, instead of which it is really the dulling of
+sensibility from approaching death. The head, indeed, becomes less hot,
+the flush of the face grows slighter and less constant; but the
+countenance is heavy and anxious, the indifference to surrounding
+objects increases, and the child lies in a state of torpor or
+drowsiness, from which indeed it can at first be roused to complete
+consciousness The manner on being roused is always fretful, but, if old
+enough to talk, the child's answers are natural, though generally very
+short; and murmuring, 'I am so sleepy, so sleepy,' it subsides into its
+former drowsiness. The bowels generally continue constipated, and the
+vomiting seldom ceases, though it is sometimes less frequent than
+before. In this state, without any apparent cause, the child sometimes
+has an attack of convulsions, which subsiding, leaves the torpor deeper
+than before. The fits return, and death may take place in one of them,
+or the torpor growing more profound after each convulsive seizure, the
+child 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 been
+poured out into the cavities of the brain, the yielding skull has given
+way under the pressure from within, and should the child after all
+survive, its large head, due to chronic water on the brain, tells to all
+who know how to interpret the signs, the tale of its past illness, and
+the manner of its imperfect recovery.
+
+Cases such as these are obviously beyond the reach of domestic
+management, and call for all the resources of medical skill. The mistake
+commonly made is that of calling in the doctor too late, because it is
+not realised how grave may be the import of symptoms which at first
+appear so little alarming; and the so-called experienced nurse having
+said, 'Oh! it's nothing but the baby's teeth,' time is lost and danger
+not anticipated till too late for remedy.
+
+The application of two, three, or four leeches at the very outset of
+these cases is often of great service, and sometimes cuts short symptoms
+which had seemed very threatening. The doctor, of course, must be the
+judge of its expediency, but I refer to it because I have known parents
+raise objections to it, and beg to have milder means tried first. It
+must be borne in mind then, that whenever leeches are of use it is at
+the beginning of an attack, and that the opportunity once let slip does
+not return. Purgatives, cold to the head, saline medicines, and perhaps
+some carefully selected sedative, are the measures which will probably
+be employed in most cases, but success will in great measure depend on
+the minute care with which all the details which I dwelt on in the
+introduction, are carried out.
+
+It is not always, indeed, that active treatment is desirable, and
+gentle measures then suffice; but nothing except close and frequent
+watching can enable the doctor to steer safely between the two opposite
+dangers of too little and too much.
+
+When I come to speak of the eruptive fevers, I shall have to mention the
+convulsions and other signs of most serious brain disturbance, which
+sometimes occur at their outset, and which are due to the condition of
+the blood charged with the fever poison.
+
+A somewhat similar set of symptoms, attributed with reason to the
+overheated state of the blood, occurs in cases of _sunstroke_. It is
+true that sunstroke, with the formidable characters that it presents in
+hot countries, is not seen in England, but even here the mere exposure
+of an infant or young child to an overheated atmosphere, is by no means
+unattended with risk, and I refer to it here, because mothers are by no
+means aware of the danger, and believe that it suffices to guard the
+child from the direct rays of the sun.
+
+Alarm, restlessness, and fretfulness, alternating with drowsiness,
+hurried, irregular breathing, intense heat of skin, violent beating of
+the open part of the head, twitching of the limbs, and starting of the
+tendons of the wrists, with a pulse too rapid to be counted, are the
+symptoms when the attack is severe. Convulsions are rare, though they
+sometimes occur. Sickness is almost invariable, the stomach rejecting
+everything, and the bowels are almost invariably relaxed, severe
+diarrh[oe]a or dysentery sometimes coming on, as the brain disturbance
+abates. The first shock may kill the child in a few hours, or it may
+sink under the subsequent diarrh[oe]a, but as a rule recovery eventually
+takes place.
+
+All cases, indeed, are not equally severe, but all require careful and
+gentle treatment, the cool and darkened room, the quiet, the cold to the
+head, the tepid bath, and on the part of everyone the care not to allow
+the apparently serious condition of the child to urge them to those
+active measures which will here be out of place, and destroy the hopes
+which would revive after a few hours of patience and gentle means.
+
+Really acute inflammation of the brain is of so rare occurrence except
+as the result of accident or injury, and its symptoms are of so serious
+a character, even from the first, that medical advice is obviously
+needed at once. I shall, therefore, pass it over here, and endeavour to
+describe two forms of inflammation of the brain which are much more
+frequent, and at their commencement more likely to be overlooked.
+
+=Water on the Brain.=--One of these is the form of inflammation commonly
+known as _water on the brain_, a term which, though incorrect medically,
+has the advantage of being well understood. This, now, is not a simple
+disease, occurring in a previously healthy child, but it is a disease
+dependent on the same state of constitution as gives rise in other
+children to consumption, or scrofula, or disease of the mesenteric
+glands.
+
+It is this circumstance which renders the disease so serious, and
+recovery from it so extremely rare. This it is also which makes it so
+desirable to become acquainted with its symptoms, both that you may be
+alive to the approach of danger, and also not indulge in needless alarm
+when brain symptoms occur from other causes which have no relation
+whatever to those which give rise to water on the brain.
+
+The disease comparatively seldom comes on in a child who had previously
+seemed in perfect health; a state of vague ailing usually precedes its
+outbreak. The child loses flesh and strength, and the look of health,
+and the lustre of the eye, and the silky softness of the hair. The
+appetite becomes uncertain, the bowels irregular, with a tendency to
+constipation; there are little feverish attacks for a few hours,
+subsiding of their own accord. The sleep is not sound, the temper
+uncertain, the child tires even of its favourite toys; the brightness of
+the little face is changed for a strange, weird, wistful look--an
+unnatural earnestness; the child sits for moments gazing upward on
+vacancy, 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 the
+first stage of the affection, in which there are signs of congestion of
+the brain, such as I have already described, coupled with general
+irregular attacks of feverishness. The child becomes more gloomy, more
+pettish, and slower in its movements, and is little pleased by its usual
+amusements. Or, at other times, its spirits are very variable; it will
+sometimes cease suddenly in the midst of its play, and run to hide its
+head in its mother's lap, putting its hands to its head, and complaining
+of headache, or saying merely that it is tired and sleepy, and wants to
+go to bed. Sometimes, too, it will turn dizzy, as you will know, not so
+much from its complaint of dizziness as from its suddenly standing
+still, gazing around for a moment as if lost, and then either beginning
+to cry at the strange sensation, or seeming to awake from a reverie, and
+at once returning to its play. The infant in its nurse's arms betrays
+the same sensation by a sudden look of alarm, a momentary cry, and a
+hasty clinging to its nurse. If the child can walk it may be observed to
+drag one leg, halting in its gait, though but slightly, and seldom as
+much at one time as at another, so that both the parents and the medical
+attendant may be disposed to attribute it to an ungainly habit which the
+child has contracted. The appetite is usually bad, though sometimes very
+variable; and the child, when apparently busy at play, may all at once
+throw down its toys and beg for food, then refuse what is offered; or
+taking a hasty bite may seem to nauseate the half-tasted morsel, may
+open its mouth, stretch out its tongue, and heave as if about to vomit.
+The thirst is seldom considerable, and sometimes there is an actual
+aversion to drink as well as to food, apparently from its exciting or
+increasing the sickness. The stomach, however, seldom rejects
+everything; but the same food as occasions sickness at one time is
+retained at another. Sometimes the child vomits only after taking food,
+at other times, even when the stomach is empty, it brings up some
+greenish phlegm without much effort, and with no relief. These attacks
+of vomiting seldom occur oftener than two or three times a day, but they
+may return for several days together, the child's head probably growing
+heavier, and its headache more severe. The bowels during this time are
+disordered, generally constipated from the very first, though their
+condition in this respect sometimes varies at the commencement of the
+disease. The evacuations are usually scanty, sometimes pale, often of
+different colours, almost always deficient in bile, frequently
+mud-coloured and very offensive. The tongue is not dry, generally rather
+red at the tip and edges, coated with white fur in the centre and
+yellowish towards the root, but occasionally very moist, and uniformly
+coated with white fur. The skin is harsh, but not very hot, the
+temperature seldom above 100 deg. Fahr., varying causelessly, but usually
+higher towards evening than in the daytime. The nostrils are dry, the
+eyes lustreless, and _the child sheds no tears_. It is drowsy, and will
+sometimes want to be put to bed two or three times in a day; but it is
+restless, sleeps ill, grinds its teeth in sleep, lies with its eyes
+partially open, awakes with the slightest noise, or even starts up in
+alarm without any apparent cause. At night, too, the existence of
+intolerance of light is often first noticed in consequence of the
+child's complaints about the presence of the candle in the room.
+
+I have purposely dwelt long on this preliminary stage because it is only
+in it that treatment is likely to be of any service, while the very
+indefiniteness of the symptoms constantly leads to their being
+overlooked, or referred to teething, or thought at any rate to be a mere
+temporary 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 too
+marked to escape notice. All cheerfulness has fled, the eyes are closed
+to shut out the light, the child lies apparently dozing, but answers
+questions rationally, in a short quick manner in as few words as
+possible, and from time to time complains of its head, or utters a
+short, sharp lamentable cry. The night brings with it no other change
+than an increase of restlessness, attended sometimes with noisy cries,
+or with the wandering talk of delirium. Sickness often diminishes, but
+the bowels continue constipated, and it is to be noted that whereas in
+fevers the bowels are distended with wind, here all wind has disappeared
+and the belly is sunken to a striking degree.
+
+Next comes the last stage. Each stage is distinguished by peculiarities
+of the pulse which tell the expert what is passing; quick and regular in
+the first stage; irregular and slower in the second; quick, variable,
+irregular from time to time in the third; growing more rapid and more
+feeble as the end arrives. Squinting, stupor, dilated pupil, difficulty
+of swallowing, tremulous limbs, convulsions, profound insensibility,
+such are the series of occurrences which bring on death usually within a
+fortnight, always within three weeks from the appearance of the first
+decided symptoms.
+
+What are you to do in these cases? Above all save yourselves the
+heartbreak of feeling that you have overlooked the premonitory symptoms
+of the disease. Guard with special care the health of any child in whose
+family a disposition to consumptive disease has ever shown itself, and
+keep it at any cost from the risk of catching the hooping cough or
+measles. Since, too, it is not in early infancy, but after the age of
+one year, and in the majority of instances between the ages of three and
+six years that this disease occurs, that is to say, at the time when the
+brain begins to be most actively exercised, when the new world on which
+the child is just entering brings with it new wonders every day; be very
+careful not to over-stimulate its intelligence, over-excite its
+imagination, or over-strain its mental powers. After the age of ten the
+great danger is over; up to that time it is the health of the body which
+requires care; not fuss, not rearing like a hothouse plant, but the
+healthy training that may fortify the system.
+
+When any signs such as I have described indicate the threatening of
+disease, 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 fully
+set in, and that was a recovery almost worse than death.
+
+=Earache.=--There is another form of inflammation of the brain which is
+likewise oftenest met with in children who are of weakly constitution,
+or of scrofulous habit, or in whom scarlet fever has left behind that
+very troublesome ailment, discharge from the ear. This is so tedious, so
+difficult to cure, so apt to return under the influence of very slight
+causes, that people are too ready to put up with it as an inconvenience
+which it is useless to try to remedy.
+
+In addition, however, to the risk of the child's hearing being impaired
+by the extension of the mischief to the internal ear, there is another
+still greater danger, namely, that of the _disease passing from the ear
+to the brain_, and producing inflammation of its membranes, or even
+abscess of its substance.
+
+It is therefore of the greatest moment that every case of chronic
+discharge from the ear should be looked on as important, and that no
+pains be spared to bring about its cure; and further, that during its
+continuance the slightest sign of disturbance of the brain--headache,
+sickness, feverishness, and dulness--should at once be noticed, and the
+advice of a competent doctor be immediately sought for.
+
+These dangers, however, follow almost entirely on long-continued
+discharges from the ear, but do not attend that acute inflammation of
+the passage to the ear which is often met with in childhood, and the
+symptoms of which sometimes cause needless fear, from being taken for
+those of inflammation of the brain. Attacks of _earache_ are most
+frequent before the first set of teeth have been cut, and are by no
+means rare in young children, who are perfectly unable to point out the
+seat of their sufferings. The attack sometimes comes on quite suddenly,
+but usually the child is languid and fretful for a period varying from a
+few hours to one or two days before acute pain is experienced. In this
+premonitory stage, however, it will often cry if tossed or moved
+briskly; noise seems unpleasant to it, and it does not care to be played
+with; while children who are still at the breast show a disinclination
+to suck, though they will take food from a spoon. The infant seeks to
+rest its head on its mother's shoulder, or, if lying in its cot, moves
+its head uneasily from side to side, and then buries its face in the
+pillow. If you watch closely, you will see that it is always the same
+side of the head which it seeks to bury in the pillow, or to rest on its
+nurse's arm, and that no other position seems to give any ease, except
+this one, which, after much restlessness, the child will take up, and to
+which, if disturbed, it will always return. The gentle support to the
+ear seems to soothe the little patient: it cries itself to sleep, but
+after a short doze, some fresh twinge of pain arouses it, or some
+accidental movement disturbs it, and it awakes crying aloud, and
+refusing to be pacified, and may continue so for hours together.
+Sometimes the ear is red, and the hand is often put to the affected side
+of the head, but neither of these symptoms is constant. The intensity of
+the pain seldom lasts for more than a few hours, when, in many instances
+a copious discharge of matter takes place from the ear, and the child is
+well. In some instances, indeed, the subsidence of the disease on one
+side is followed by a similar attack on the opposite side, and the same
+acute suffering is once more gone through, and terminates in the same
+manner. Sometimes, too, this complete cure does not take place, but the
+earache abates, or altogether ceases, for a day or two, and then
+returns; no discharge, or but a very scanty discharge, taking place,
+while, for weeks together, the child has but few intervals of perfect
+ease. In infants, earache seldom follows this chronic course, but it
+does sometimes in older children, and is then of the more importance,
+since it shows that the disease is no longer confined to the external
+passage, but has extended to the internal ear.
+
+In children who are too young to express their sufferings by words, the
+violence of their cries, coupled with the absence of any sign of disease
+in the chest or the bowels, naturally leads to the suspicion of
+something being wrong in the head. There are several facts, however,
+which may satisfy you that the case is not one of water on the
+brain--the child does not vomit, its bowels are not constipated, there
+is but little fever, the cries are loud and passionate, and are attended
+with shedding tears. If you watch closely, you will notice the dread of
+movement and the evident relief afforded by resting one side of the
+head, and always the same side, while often the movement of the hand to
+the 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 that
+the cause of the suffering is in the ear by pressing the gristle of the
+organ slightly inwards, which will produce very evident pain on the
+affected side, while on the other side it will not occasion any
+suffering.
+
+The treatment of this painful affection is very simple. In many
+instances the suffering is greatly relieved by warm fomentations, or by
+applying to the ear a poultice of hot bran or camomile flowers, while at
+the 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 bone
+directly behind the ear seldom fails to give ease; while the disposition
+to the frequent return of the attack is often controlled by a series of
+small blisters, not larger than a sixpence, behind the ear. As soon as
+the tendency has sufficiently abated to admit of it, the ear should be
+syringed out twice a day with warm water, or with equal parts of warm
+water 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 of
+inflammation of the brain, concerning which a few words will suffice. It
+constitutes what is termed _chronic water on the brain_, and in this
+instance the term is a correct one, for the disease usually depends on a
+slow form of inflammation of the lining membrane of the cavities of the
+brain, often beginning before, still oftener very soon after, birth,
+which ends in the pouring out of a quantity of fluid into them
+sufficient to enlarge the head to three or four times its natural
+dimensions.
+
+Such cases are very sad and very hopeless, and the great resource, which
+is sometimes adopted by medical men, of puncturing the head and letting
+out the fluid, is very seldom successful.
+
+But there are more hopeful cases sometimes met with, those namely of
+children in whom, either from simple weakness, or from that
+constitutional disorder called rickets, bone formation has been
+backward, and the head has consequently long remained unclosed. If such
+children, either from the irritation of teething, or from the straining
+during paroxysms of hooping cough, suffer from congestion of the brain,
+fluid may be poured out, which, not being compressed by the too yielding
+skull, may in consequence enlarge it. These cases, however, may be
+distinguished from the other more serious ones by the date of their
+commencement, which is always much later than that of the other form, by
+the symptoms which attend them being less severe, and by the enlargement
+of the skull being far slighter.
+
+Still they require watching, for while with improved health the
+enlargement ceases, the fluid is in a measure absorbed, and the head
+diminishes in size, though always remaining larger than the average;
+brain mischief is yet more readily set up in children with such
+antecedents than in others.
+
+The anxiety of parents about the size or shape of their child's head
+after infancy has passed, is perfectly needless. When the head has once
+closed it always remains so. An odd shape, with an unusual protuberance
+of the forehead and the hind head, sometimes remain as the evidence of
+that condition in infancy to which I have just referred. It is, however,
+an evidence of mischief passed, not of mischief going on. In children
+too who have suffered from rickets, an affection rarely met with except
+among the poor in crowded cities, distortion of the limbs is often
+associated with a peculiar form of the skull, but in this too there is
+nothing to call for anxiety, still less to excite alarm. It is only a
+preternaturally small head and shelving forehead, which are found
+associated with mental deficiency; otherwise the greatest varieties of
+size and shape, of symmetry, or of want of it, may be associated with an
+equal variety of intellectual endowment, which is just as likely to be
+above as below the average.
+
+=Brain Disorder from Exhaustion.=--It may at first sight appear strange
+that before leaving the subject of congestion and inflammation of the
+brain, I should find it necessary to give a caution against being misled
+by symptoms which though in some respects similar to those of congestion
+or inflammation, are in reality due to an exactly opposite condition.
+
+This mistake, however, is very possible; doctors themselves sometimes
+fall into it, and some distinguished physicians have thought it worth
+their while to lay down very minute rules for distinguishing between the
+two opposite states. Headache we all know attends an overfull condition
+of the vessels of the brain, and grown persons usually suffer from it
+severely before an attack of apoplexy; but we also know that bad
+headache accompanies states of great weakness, and that it is one of the
+most distressing consequences from which a woman suffers who has lost
+much blood in her confinement. In just the same way, the infant who has
+been exhausted by diarrh[oe]a or by some trying illness, or who after
+weaning has been kept on a diet not sufficiently nutritious, may show
+symptoms of disorder of the brain.
+
+It may become irritable, restless, very startlish, with occasional
+flushings of the face, moaning in its sleep, and sleeping with
+half-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 and
+pulsating, but flat or even depressed, the hands and feet are cool, and
+very readily become cold; there may be occasional vomiting, but nothing
+like the constant sickness of real brain-disease, the bowels are not
+shrunken but distended, constipation is not present, but on the contrary
+there is a disposition to diarrh[oe]a. If the symptoms are
+misinterpreted and wrongly treated, unmistakable signs of exhaustion at
+last come on, and the child may die from its not being borne in mind
+that results at first sight much the same may flow from causes
+diametrically opposite.
+
+The moral of this is too obvious for me to need insist upon it. Cold to
+the head, low diet, aperients, possibly leeches, are needed in the one
+case; increased nourishment, perhaps stimulants, in the other. In every
+instance where symptoms of brain disorder occur in the child, remember
+the grievous consequences of a mistake as to their nature, and seek for
+further 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 nervous
+system to various sources of irritation from without, and how, in
+consequence this irritation manifests itself by those involuntary
+movements which we call convulsions. But in addition to, or in the place
+of those violent contortions or convulsions, the same condition shows
+itself sometimes in disordered action of the muscles which subserve
+parts not directly subject to the will, as those for instance which open
+and close the entrance to the windpipe, or glottis as it is called in
+medical phraseology.
+
+Cases in which this occurs are known in popular language as
+child-crowing, or _spasmodic croup_, from the peculiar catch or crow
+which accompanies the entrance of air through the spasmodically
+contracted opening of the windpipe; a spasm which if severe and
+sufficiently continued closes the opening altogether, so that after
+fruitless efforts to get its breath the child dies suffocated. This
+affection occurs chiefly during teething, just as the fits of a
+hysterical girl oftenest occur during the transition from girlhood to
+womanhood; but many other causes besides the local irritation of the
+teeth may produce it, such as constipation, indigestible food, or
+disorder of the bowels.
+
+It does not often occur in perfectly healthy children; but an infant
+who is attacked by it is usually observed to have been drooping for some
+time previously, to have lost its appetite, to have become fretful by
+day and restless at night, and to present many of those ill-defined
+ailments which are popularly ascribed to teething. At length, after
+these symptoms have lasted for a few days or weeks, a slight crowing
+sound is occasionally heard with the child's respiration, shorter, more
+high-pitched, but less loud than the hoop of hooping cough. Usually it
+is first noticed on the child awaking out of sleep, but sometimes it is
+perceived during a fit of crying, or comes on while the infant is
+sucking. The spasm may have been excited by some temporary cause, and
+the sound which is its token may not be heard again; but generally it
+returns after the lapse of a few hours, or of a day or two, and its
+loudness usually increases in proportion as its return becomes more
+frequent. It will soon be found that certain conditions favour its
+occurrence; that the child wakes suddenly with an attack of it, that
+excitement induces it, or the act of swallowing, or the effort at
+sucking, so that the child will drop the nipple, make a peculiar croupy
+sound with its breathing, and then return to the breast again.
+Throughout the whole course of the affection, its attacks will be found
+to be more frequent by night than by day; and to occur mostly soon after
+the child has lain down to sleep, or towards midnight, when the first
+sound sleep is drawing to a close.
+
+At first, the child seems, during the intervals of the attack, much as
+before; except, perhaps, that it is rather more pettish and wilful; but
+it is not long before graver symptoms than the occasional occurrence of
+an unusual sound when the child draws a deep breath excite attention,
+and give rise to alarm. Fits of difficult breathing occasionally come
+on, in which the child throws its head back, while its face and lips
+become livid, or an ashy paleness surrounds the mouth, slight convulsive
+movements 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, or
+the child begins to cry. Breathing now goes on naturally: the crowing is
+not repeated, or the crying ceases; a look of apprehension dwells for a
+moment on the infant's features, but then passes away; it turns once
+more to its playthings, or begins sucking again as if nothing were the
+matter. A few hours, or even a few days, may pass before this alarming
+occurrence is again observed, but it does recur, and another symptom of
+the disturbance of the nervous system is soon superadded, if it has not,
+as is often the case, existed from the very beginning. This consists in
+a peculiar contraction of the hands and feet; a state which may likewise
+not infrequently be noticed during infancy, unattended by any
+peculiarity in breathing. It differs much in degree; sometimes the thumb
+is simply drawn into the palm while the fingers are unaffected; at other
+times the fingers are closed more or less firmly, and the thumb is shut
+into the palm; or, coupled with this, the hand itself is forcibly flexed
+on the wrist. In the slightest degree of affection of the foot, the
+great toe is drawn a little away from the other toes; in severer degrees
+the toe is drawn away still further, and the whole foot is forcibly bent
+upon the ankle, and its sole directed a little inwards. Affection of the
+hands generally precedes the affection of the feet, and may even exist
+without it, but the spasmodic contraction of the feet never exists
+without the hands being involved likewise. At first this state is
+temporary, but it does not come on and cease simultaneously with the
+attacks of crowing breathing, though generally much aggravated during
+its paroxysms. Sometimes a child in whom the crowing breathing has been
+heard, will awake in the morning with the hands and feet firmly bent,
+though he may not have had any attack of difficult breathing during the
+night. When the contraction is but slight, children still use their
+hands; but when considerable they cannot employ them, and they sometimes
+cry, as if the contraction of the muscles were attended with pain.
+Sometimes, too, there is a degree of puffiness both of hands and feet, a
+sort of dropsical condition, which, whenever it is present, adds much to
+the anxiety with reference to the child.
+
+As the condition becomes more serious, a slight crowing sound is heard
+each time the child draws its breath, the fits of difficult breathing
+are much more severe; they last longer, and sometimes end in general
+convulsions. The breathing now does not return at once to its natural
+frequency, but continues hurried for a few minutes after the occurrence
+of each fit of difficult breathing, and is sometimes attended with a
+little wheezing. The slightest cause is now sufficient to bring on an
+attack; it may be produced by a current of air, by a sudden change of
+temperature, by slight pressure on the windpipe, by the act of
+swallowing, or by momentary excitement. The state of sleep seems
+particularly favourable to its occurrence, and the short fitful dozes
+are interrupted by the return of impending suffocation, in one paroxysm
+of which longer and severer than the others the infant may fall back
+dead.
+
+It scarcely need be said that the great majority of cases have no such
+sad ending as I have described, but still, whenever this spasm exists,
+even in a slight degree, there is always the possibility, never to be
+forgotten, of a sudden catastrophe. Usually, after some tooth has been
+cut which caused special irritation, or as disorder of the bowels has
+been set right, the symptoms abate by degrees, and then cease
+altogether, though liable to be reproduced by the same causes as those
+to which they were originally due.
+
+The seeking out and removing the exciting causes must be the care of the
+medical man, but there are some special precautions which come within
+the mother's own province to observe.
+
+First of all, as sudden excitement, and especially a fit of crying, are
+likely to bring on the attack, and since there is a possibility that any
+attack may prove fatal, the greatest care must be taken in the
+management of the child to avoid all unnecessary occasion of annoyance
+or of distress.
+
+Although the benefit that accrues from fresh air, or from a change of
+air, is often very great, yet it is very important that the child should
+not be exposed to the cold or wind, for I have seen such exposure
+followed by a severe attack of difficult breathing, or by the occurrence
+of general convulsions. Another reason for caution in this respect is
+that the occurrence of catarrh is almost sure to be followed by an
+aggravation 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 the
+treatment of the attack, when actual convulsions come on. Since,
+however, in this affection convulsions may occur quite unexpectedly at
+any moment, it is well always to have a basin of cold water and a bunch
+of feathers handy, in order to be able at once to dash the water on the
+child's face, and induce that deep inspiration which saves it from the
+threatening danger. If this should not suffice, the finger must be put
+into the mouth, and run over the back of the tongue in the way that I
+have already explained when speaking of convulsions. Now and then it
+happens, though but very rarely, that violent _general convulsions_ come
+on in infancy quite independent of spasmodic croup, not preceded nor
+attended by any sign of disease of the brain, and which end in the
+course of some hours or of a few days in death, the child being partly
+worn out by the violence of the muscular movements, partly by the
+disturbance of breathing which each fit occasions. Happily, however, in
+most of these instances the convulsions by degrees lessen both in
+violence and frequency, and the child recovers.
+
+=Epilepsy.=--There is one other point of view from which convulsions in
+infancy and early childhood must be looked on with apprehension, and
+that is from their being frequently followed in after years by
+_epilepsy_. In nearly a fifth of all cases of epilepsy in childhood that
+have come under my notice the first occurrence of fits dated back to
+early infancy, and this, even though an interval of years had passed
+between the last fit in infancy and the first in childhood. It seems,
+indeed, as though there were in these cases a peculiar abiding
+sensitiveness of the nervous system, which, dating back from very early
+life, dependent often on hereditary predisposition, was kindled into
+activity by any special cause, such as the cutting of the second set of
+teeth, or the transition from boyhood or girlhood to manhood or
+womanhood.
+
+In the child, just as in the grown person, epilepsy manifests itself in
+two different ways; either by momentary unconsciousness, or by violent
+convulsions, in which latter there is little distinction from the
+occasional 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 as
+if dazed, its eye fixed on vacancy; if standing, it does not fall, nor
+does it drop the toy or the spoon which it was holding from its hand. If
+speaking, 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 meal
+as though nothing had happened; or it suffices to call the child and the
+cloud passes from its face, and it is itself again; and the nurse or
+perhaps even the mother, thinks that it is some odd trick which the
+child has got. By degrees the attacks become more frequent, and may
+continue to recur several times a day without any obvious cause, even
+for months; and this without any change in their character. By degrees,
+however, under their influence, an alteration takes place slowly in the
+child's disposition. It loses its cheerfulness and brightness, its face
+assumes a heavy look, it becomes fretful, and its intelligence grows
+duller.
+
+Almost invariably after the attacks of this, which has been called the
+_petit mal_, have continued for some months, a change begins to take
+place, which does not fail to excite attention and to cause alarm. If
+seated, the child's head drops forward for a moment, and strikes against
+the table; if standing, it becomes for an instant dizzy, and staggers,
+or even falls, and then there is twitching of one limb, or of the
+muscles of the face, and then the complete fit of epilepsy, ushered in
+sometimes, but not always, by a momentary cry, and then the convulsive
+twitching of one limb, followed in a minute or in less time by
+convulsions of the whole body as well as of the limbs. The upturned
+eyes, which do not see, are horribly distorted, the child foams at the
+mouth, it is insensible, and the insensibility deepens into stupor, or
+is followed by heavy sleep, for a quarter of an hour, or an hour or
+more, from which the patient arouses feeling tired and bruised, and
+often with an aching head, but with no remembrance of what has passed
+during the seizure so distressing to bystanders.
+
+It has throughout been my endeavour not to lose sight of those for whom
+this little book has been written, and with reference to epilepsy, as
+with reference to many other things, I pass over much that would be
+important to the practitioner of medicine, to dwell on those points
+which mainly interest the parents, and which they are perfectly able to
+appreciate.
+
+The question is often put as to the probability of fits terminating in
+epilepsy; or, on the other hand, as to the ground for hope in any case
+that epileptic attacks, which have already often recurred, will
+eventually cease. In the first place, no conclusion can safely be drawn
+from the severity of a convulsion, nor from its general character, as to
+the probability of its frequent recurrence, or of its passing into
+permanent epilepsy. The severity of a fit certainly affords no reason
+for this apprehension, nor does its recurrence, so long as a distinct
+exciting cause can be discovered for each return. The fits, which cease
+in the teething child when the gum is lanced, and which, on each
+succeeding return are equally relieved by the same proceeding, do not
+imply that there is any great tendency on their part to become habitual.
+In the same way, the attacks which follow on constipation, or on
+indigestion, or on some other definite exciting cause, may probably with
+care be guarded against, and their return prevented. It is not the
+violence of a single fit, nor even the frequent return of fits for a
+limited time, which warrants the gravest apprehension; but it is their
+recurrence when all observable causes of irritation have passed away; it
+is their return when the child is otherwise apparently in perfect
+health.
+
+If, on the one hand, the violence of a convulsion does not by any means
+imply the greater proportionate risk of its recurrence, so neither can
+any hopeful conclusion be drawn from the slightness of an attack, or
+from its momentary duration. In childhood, such attacks are at least as
+common preludes to confirmed epilepsy as in the adult, and are the more
+deserving of attention from their very liability to be overlooked. I
+believe, too, that an imperfect suspension of consciousness, the child
+knowing what passes, though unable to speak, is not very uncommon, and
+further, that it is far from unusual to have the early stage of epilepsy
+in 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 early
+symptoms of epilepsy in childhood are also the more likely to be
+misinterpreted from the circumstance that they are frequently
+accompanied by a moral perversion much more striking than any loss of
+mental power. It is true that in early life there are alternations of
+intellectual activity and mental indolence, of quickness and comparative
+dulness, which all who have had much to do with education are well aware
+of, and which are perfectly compatible with health of body and health of
+mind. But changes in the moral character of a child who is still under
+the same influences, have a far deeper meaning than is often attached to
+them; a child does not suddenly become wayward, fretful, passionate, or
+mischievous, except under the pressure of some grave cause.
+
+One other point there is also to be borne in mind; namely, that the
+child is compelled by the vague sensation of hitherto unknown dread, not
+to conceal the early symptoms of epilepsy as the grown person would do;
+longing as the child does for love and sympathy, and weakened in its
+moral force, it craves for more love, more sympathy, it exaggerates its
+symptoms, it assumes some which do not exist at all. The conclusion is a
+natural one, but none the less mistaken, that the child who is
+discovered to be shamming has nothing the matter with it--is simply a
+naughty child. This is a fact of much importance, on which I shall have
+occasion to insist further on.
+
+In the child, as in the adult, epilepsy blunts the intellect as well as
+weakens the moral powers; and does both more speedily and more
+effectually in proportion as the child is younger, and its mind and will
+are less developed. And yet this has its compensation; for as the powers
+fade quickly, so, if the attacks cease, they recover with surprising
+rapidity, and as the moral powers are the first to suffer, so they are
+the first to regain--I will not say full vigour, but at least a degree
+which 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 of
+epilepsy are then, first, the absence of any history of frequently
+recurring convulsions in early infancy; secondly, the existence of a
+distinct exciting cause for the attacks; thirdly, the rarity of their
+return far more than their slight severity; and lastly, the more the
+attacks approach in character to what one knows as hysteria, the less
+profound the insensibility in the fit, the shorter its duration
+afterwards, the greater are the grounds for hope that the seizures will
+eventually cease.
+
+Cases of this last class are to some degree, at any rate, under the
+child's control. I have several times seen a fit warded off by the
+threat of the shower bath, or even by calling to the child, and sending
+it to fetch something in another room. Such cases may indeed pass into
+ordinary epilepsy, but often, under judicious management, moral rather
+than medical, they cease, so that one can venture on taking a more
+hopeful view of them than of others.
+
+And this brings me to the question of what can be done, or rather what
+can parents do to promote recovery from epilepsy. First of all, do not
+listen to what you may hear about this medicine or the other being a
+specific for it. There is no specific whatever for epilepsy, but there
+are certain remedies which in skilful hands do have a real though
+limited power to control the frequency and lessen the severity of the
+attacks. Next, there are cases in which the attacks depend on some
+definite cause; it may be indigestion, or constipation, or the cutting
+of the second set of teeth, and on the irritation produced by those
+teeth being too crowded. Thus, I remember a boy twelve years old, in
+whom two severe epileptic fits occurred apparently without cause. He was
+cutting his back grinding teeth, and in the lower jaw the teeth seemed
+overcrowded. I had a tooth extracted on either side, the fits ceased,
+and when I last heard of him many years afterwards they had not
+returned.
+
+Epilepsy often lasts for many years, and no one's memory is retentive
+enough to be trusted with all the details between the different attacks,
+the causes which seemed to produce them, the measures which appeared at
+different times to be of service. I am therefore accustomed to advise
+people, any of whose children have the misfortune to be epileptic, to
+write 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 their
+character and duration; and general remarks, which would bear on the
+child's temper and general condition, and in which column any probable
+exciting cause of an attack would be recorded. It is surprising how much
+important information is gathered in a few months from such a record
+kept faithfully.
+
+The diet should be mild, nutritious, but as a general rule
+unstimulating; and should include meat comparatively seldom, and in
+small quantities. Some fifty years ago, a very distinguished American
+physician, Dr. Jackson of Boston, in the United States, insisted very
+strongly on the importance of a diet exclusively of milk and vegetables
+in greatly lessening the frequency and severity of epileptic attacks. I
+believe in the great majority of cases of epilepsy in childhood Dr.
+Jackson's advice is worth following. And I may add that, while I have
+little faith in the influence of mere drugs, I have a yearly increasing
+confidence in that of judicious management, mental and moral, as well as
+physical.
+
+The first requisite in all cases is a firm and gentle rule of love on
+the part of those who have charge of the child. As violent and sudden
+excitement of any kind will often bring on an epileptic seizure, so the
+influence of the opposite condition in warding off its attacks is very
+remarkable; and on several occasions I have received patients into the
+Children's Hospital who were reported to have epileptic seizures several
+times in a day, and who nevertheless remained a fortnight or more in the
+institution without any attack coming on. The disorder, however, was not
+cured, but only kept in check by the gentle rule to which the little
+ones were subjected. The order goes for much in these cases; the novelty
+goes for something too, for almost invariably I have found that after a
+time the apparent improvement becomes less marked, and though they
+continued better than when they first came to the hospital, the children
+were still epileptic; the advance of the disease had been retarded, but
+its progress had not been arrested. The quiet then which suits the
+epileptic, is not the quiet of listless, apathetic idleness, but the
+judicious alternation of tranquil occupation and amusement. The mind
+must not be left to slumber from the apprehension of work bringing on a
+fit, but the work must, as far as possible, be such as to interest the
+child. In the occupations of epileptics therefore, pursuits which not
+merely employ the mental faculties, but also give work to the hands,
+such as gardening, carpentering, or the tending of animals, are
+specially 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 same
+age have acquired, is of very little moment. Many epileptics have an
+indistinct articulation, and almost all have a slouching gait, and an
+awkward manner. The former can often be corrected to a considerable
+degree by teaching the child simple chants, which are almost always
+easily acquired, and practised with pleasure. The latter may be
+rectified by drilling, not carried out into tedious minutiae, but limited
+to simple movements; and the irksomeness of drill is almost completely
+done away with by music, while I believe that the accustoming a child to
+the strict control and regulation of all its voluntary movements is of
+very great importance indeed as a curative agent.
+
+It is difficult to carry out these minute precautions on which so much
+depends in the home with other children of the same family. It is
+therefore, I believe, better for the child, painful though it is to the
+parents, that he should be placed under the care of some competent
+person who will devote the whole of his time to the care of the patient.
+
+=St. Vitus's Dance.=--A state of unconsciousness, accompanied with more
+or less violent involuntary movements, is characteristic of epilepsy.
+Involuntary movements without loss of consciousness constitute the
+disorder commonly known as _St. Vitus's Dance_. It is rare in early
+childhood, becomes more common after the age of five, and attains its
+greatest frequency between the ages of ten and fifteen, girls, owing to
+their more impressionable nervous system, being affected by it more than
+twice as often as boys.
+
+It seldom comes on in a child previously in perfect health, and
+strangely enough it occurs with special frequency in children who have
+before suffered from rheumatism. Sudden shock or fright is often said to
+have been its exciting cause; but even then the symptoms seldom come at
+once, but are gradually developed in the course of two or three days. At
+first, 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 it
+stumbles in walking, and then the muscles of the face become affected,
+the child grimacing strangely, and next the limbs of the opposite side
+become involved, and as things go on from bad to worse, the child
+becomes unable to hold anything in its hand, to walk, or even to stand,
+and even if on the ground still writhes about with the strangest
+contortions of its body. If matters grow still worse, the child becomes
+unable to put out its tongue, it swallows with difficulty, it loses not
+only 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 limbs
+is lost for the time, and they seem almost paralysed. Happily cases so
+severe are very rare, and it is rarer still for them to have a fatal
+termination. Almost invariably recovery takes place by degrees, the
+movements lessen, swallowing is performed with less difficulty, the
+power of speech, returns, and the intellect regains its brightness: but
+the 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 shown
+by the fact that its average duration is seventy days. It is very
+natural, therefore, that parents should be anxious when they see that
+their child has some awkward or ungainly habit, some odd trick or
+gesture never noticed before, lest it should be the beginning of this
+tedious ailment. Now it is well to remember that St. Vitus's dance does
+not begin with twitching of the muscles of the face, but that its
+earliest symptoms are involuntary movements of the arms and twitching of
+the fingers, and that contortions of the face do not come on till
+afterwards. Movements of this sort too, even when not limited to the
+face, 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, in
+twitching of the muscles of the face or neck, or in some awkward gait or
+manner. These are all best left unnoticed, for they are almost
+invariably made worse if the child's attention is called to them. They
+are, or at least before the days of Board Schools they were, scarcely
+ever met with among the children of the poor, for they almost invariably
+depend on mental strain; not of necessity on undue length of the hours
+of study, or on the difficulty of the tasks imposed, but often on a
+child's anxiety to make progress and to keep up with his schoolfellows.
+In corroboration of this being their cause I may say that, contrary to
+the rule which obtains with St. Vitus's dance, these movements are more
+frequent in boys than in girls, for the over-mental strain of boys comes
+earlier; that of girls seldom occurs before the time of transition to
+womanhood, and its results are then different, though much graver. In
+cases of this kind, lessening the mental strain is almost always
+followed by a cessation of the movements; change of air, country
+amusements, and a generally tonic treatment perfect the cure, and
+dancing and gymnastics overcome the remains of any awkward habit.
+
+The movements in real St. Vitus's dance do not shift about as these do
+from one part to another, but tend to involve various parts in
+succession, without previously ceasing where they had begun.
+
+The relative share which the parents and the doctor take in the
+treatment of these cases depends to a great extent on their severity.
+While attention to the state of the bowels, and a generally tonic
+treatment are almost always needed, gymnastics and drill are often of
+very great service in the slighter cases; and a very distinguished Paris
+physician was accustomed to send children thus affected to march round
+the Place Vendome, keeping step while the band was playing. The utility
+of gymnastics turns very much on the degree in which the child is able
+by attention to control his movements, and when either as in young
+children fixed attention cannot be roused, or as in severe cases the
+effort only adds to the child's nervousness, and in consequence
+increases the movements, they must be given up. All drill and gymnastics
+are best carried out in class with other children, and regulated not
+simply by word of mouth, but by a tune or chant. When recovery is in
+progress gymnastics will then in almost all instances find their place.
+
+Even when drill and gymnastics cannot be practised, regulated movements
+of the limbs carried out twice a day for ten minutes at a time are of
+very real service. Another's will here takes the place of that of the
+patient, and the limbs are thus taught, though far more imperfectly, to
+act in concert.
+
+Two or three more cautions may still be of service. Do not keep a child
+out of bed, and force it to try to exert itself when the movements are
+very severe; continued movement, voluntary or involuntary, fatigues. Let
+the child lie in bed; it rests there, and the movements, which always
+cease during sleep, become at once greatly lessened. So important indeed
+is it to avoid the exhaustion caused by incessant violent movement, that
+in bad cases it is sometimes necessary to swathe the limbs in flannel
+bandages, and so to confine them to splints in order to restrain them.
+Next, do not become over-anxious because the child grows stupid and
+ceases to talk; intelligence and the power of speech will certainly come
+back again. And, lastly, do not be impatient and think your medical
+adviser incompetent because the disorder lasts so long. An average
+duration of seventy days implies that while sometimes it ceases sooner,
+in others it lasts much longer than the two weary months of watching and
+waiting with which in any case you must lay your account.
+
+=Paralysis, or Palsy.=--When speaking of St. Vitus's dance I said that
+there was a partial loss of power in the limbs as well as an inability
+to control their movements. After a fit of convulsions, or an epileptic
+seizure, power over some limb is often lost for a time which may vary
+from a few minutes to some hours. In the course of some serious diseases
+of the brain, one of the manifestations of the mischief is the
+impairment or the loss of power over one arm or leg, rarely over both;
+and lastly, that terrible disease diphtheria is often followed by a
+paralysis so general that the patient is sometimes for days unable to
+move even a finger, although the condition may eventually pass away.
+
+There is, however, a very _real paralysis_ which occurs sometimes in
+infants and young children. It comes on for the most part quite
+suddenly, often unaccompanied by any sign of brain disorder, but tending
+nevertheless to issue in great permanent impairment of the power over
+the affected limb or limbs, and eventually to interfere with their
+growth and thus to produce serious deformity.
+
+It is in general impossible to assign any distinct exciting cause for
+the affection, though the fact that in two-thirds of the cases it occurs
+between the ages of six months and three years, proves it to be in some
+way intimately associated with teething. The oldest child in whom I have
+ever seen it was aged between seven and eight years, and the youngest a
+little under six months. It is of excessive rarity for the arm alone to
+be affected, but it is by no means unusual for the legs alone to be
+paralysed; though in the majority of instances power is lost on one side
+only, the leg and arm being both involved.
+
+A child goes to bed quite well, or at the worst having seemed slightly
+ailing and feverish for a day or two, and on waking in the morning it is
+suddenly discovered that power is lost over one leg or both, or over
+both arm and leg of one side. The loss of power is at first seldom
+complete, 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 that
+time recovery in general begins. It is now and then speedy, so that in
+three or four days all trace of the paralysis may have disappeared.
+This, however, is a fortunate exception to the general rule, which is
+that amendment is very tardy, showing itself first in the arm,
+afterwards in the leg, and, if both sides have been affected, more on
+one side than on the other. Unless the improvement is very rapid, it is
+almost always only partial, and the palsied limb, though it does not
+lose sensation, regains but little power; it grows much more slowly than
+the other, is always colder and wastes considerably, while, some muscles
+still retaining more power than others, it becomes twisted out of shape,
+and requires all the skill of the orthopaedic surgeon to remedy or at
+least to lessen the consequent deformity.
+
+It has been ascertained that this form of palsy depends on a state of
+congestion, or overfilling of the minute blood-vessels of the spinal
+marrow. When the child gets well the congestion has passed away; but it
+does this speedily, and recovery is then rapid as well as complete. If
+it does not soon pass away, other changes take place in the spinal
+marrow, and recovery is then slow, incomplete, or even does not take
+place at all.
+
+Remedies are unfortunately of little avail here, but it is evident that
+when the palsy is quite recent all movement of the limb must be
+mischievous, and that the congestion of the spinal marrow to which it is
+due will be most likely to abate under the influence of perfect quiet,
+rest in bed, and soothing or fever medicines, or of such as are
+calculated to overcome constipation, or to correct any fault of
+digestion, while the importance of teething, and the possible expediency
+of lancing the gums must not be forgotten.
+
+Afterwards comes the time for exercise of the paralysed limb, for
+friction, for shampooing, for galvanism; all continued perhaps for
+months or years with unwearied patience, and I must add with reasonable
+expectations as to the result. The only additional remark which I have
+to make is this, that to gain any real good from galvanism, a battery
+must be procured under the direction of some medical man specially
+skilled in the use of electricity, and the mode of employing it must be
+learned thoroughly from him. It is merely idle to purchase a toy
+machine, and, giving it to the nurse to turn the handle for ten minutes
+twice a day, to fancy that you are making a serious trial of the effects
+of galvanism. As a mere money question, a costly machine, and several
+fees paid in order to be thoroughly instructed in the way to use it, is
+much cheaper than a cripple child.
+
+A few words may not be out of place with reference to cases in which
+paralysis is mistakenly supposed to exist. Much anxiety is sometimes
+expressed by parents concerning children who have long passed the usual
+age without making any attempt to walk; or who having once walked seem
+to have lost that power. Now it often happens that after any weakening
+illness a child ceases for some weeks to walk, just as it ceases to
+talk. The power in both cases was newly acquired, it called for effort
+which, when strength is regained, will be put forth once more. The same
+applies to other instances in which children are late in learning to
+walk; 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, and
+regaining the power lose it again, or lose at least the desire to exert
+it more than once during the active progress of teething. But, holding
+the 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 other
+movement; or take it on your lap and tickle the soles of its feet, and
+laughing or crying, as the mood takes it, it will move its legs about as
+freely as you could wish and show that the power is still there, though
+for the present the child will not take the trouble to exert it.
+
+Gradual loss of power over one or other leg, especially if attended with
+pain either in the back or in the knee or hip, should always call for
+attention, and induce you to seek at once for medical advice. Such cases
+generally occur later in childhood than the conditions of which I spoke
+in the former paragraph, and may depend on disease of the spine or of
+the hip-joint, two serious conditions which it needs the medical expert
+to discover and to treat.
+
+=Neuralgia and Headache.=--In the grown person neuralgia, as many of us
+know to our cost, is by no means infrequent; in the child it is very
+rare, and when a child complains of severe pain in the head, or of
+severe pain to the knee or hip apart from rheumatism, it is almost
+invariably the sign of disease of the brain in the one case, of the
+hip-joint in the other. To this rule there are indeed exceptions, but it
+will always be well to leave it to the doctor to determine--no easy
+matter by the bye--whether any given case is one of the rare exceptions
+or not.
+
+There is, however, one form of real _neuralgic headache_ which is by no
+means rare in children after the commencement of the second dentition,
+and which sometimes goes on into early manhood or womanhood, when it
+becomes what is commonly known as sick headache. It is essentially an
+ailment of development, incidental to the time when the brain is first
+called on for the performance of its higher functions.
+
+It does not by any means always depend on over-study, though I do not
+remember meeting with it in children who had not yet gone into the
+school-room; and I have frequently found it dependent on too continuous
+application, though the number of hours devoted to study in the course
+of the day may not have been by any means excessive.
+
+The child's brain soon tires, and the arrangement, so convenient to
+parents of morning lessons and afternoon play, works far less well for
+it than if the time were more equally divided between the two.
+
+The attacks not infrequently come on on waking in the morning, and
+rapidly become worse, the pain, which is almost always referred to the
+forehead, being attended with much intolerance of light and sound, with
+nausea, and often with actual vomiting. Like the vomiting of
+sea-sickness, however, previous stomach disorder has no necessary share
+in its production, and I may add, indeed, that it is often difficult to
+assign any special exciting cause for the attack. The suffering is more
+often relieved by warm or tepid than by cold applications, and not
+infrequently pressure or a tight bandage greatly mitigates it. In no
+case does the attack last more than twelve hours--usually not more than
+half that time; it passes off with sleep, and leaves the patient weak
+and with a degree of tenderness of the head to the touch.
+
+Such attacks may occur every fortnight, ten days, or even oftener, but
+their very frequent return, instead of increasing apprehension, should
+diminish anxiety. A first attack, indeed, may seem as though it
+threatened mischief, till it is seen how speedily and completely it
+passes off, and when afterwards a second or a third attack comes on with
+the same severity of onset, the same rapid worsening, and the same quick
+passing away, you will feel convinced that the symptoms have no grave
+meaning.
+
+There is a headache of quite a different kind to which I must for a
+moment refer, that, namely, which depends entirely on imperfect vision,
+and for which spectacles are the remedy, not physic. The infirmity is
+not noticed during the first few years of life, but in later childhood,
+when a tolerably close attention to study has become necessary. Some of
+the minor degrees of short-sightedness, and want of power of adaptation
+of the eyes, such as exists in the aged, soon begin to interfere
+sensibly with the child's comfort, and the strain to which the eyes are
+subject produces a constant pain over the brow, the cause of which is
+often unsuspected.[13]
+
+In all cases, therefore, in which a child complains of constant pain
+over the brow for which there is no obvious cause, it is well to take
+the opinion of an oculist, who can best ascertain the power of _reading
+at different distances_ and with each eye separately, and the real cause
+of symptoms which had occasioned much anxiety is thus often brought to
+light.
+
+=Night Terrors.=--Before taking leave of the disorders of the nervous
+system, I must briefly mention the Nightmare, or Night Terrors of
+children, which often cause a degree of alarm quite out of proportion to
+their 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 sharp
+and piercing cry. The child will be found sitting up in bed, crying out
+as 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 not
+recognise its parents, who, alarmed by the shrieks, have come into its
+room, but seems wholly occupied by the fearful impression that has
+roused it from sleep. By degrees consciousness returns; the child now
+clings to its mother or its nurse, sometimes wants to be taken up and
+carried about the room, and by degrees, sometimes in ten minutes,
+sometimes in half-an-hour, it grows quiet and falls asleep; and then
+usually the rest of the night is passed undisturbed, though sometimes a
+second 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 recur
+at intervals for several weeks. The great point, however, to bear in
+mind is that they depend invariably on some disorder of the stomach or
+bowels, and are never an evidence of the commencement of real disease of
+the 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 under
+five 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 last
+edition of my lectures, it had already been noticed without my
+knowledge, by a friend of mine, Dr. Blache, of Paris, in a very valuable
+essay 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 after
+birth, I have already noticed the peculiarities of breathing in early
+infancy, and the difficulties that sometimes attend the complete filling
+of the air-cells of the lungs, and the readiness with which when once
+filled they become emptied of air and collapse.
+
+On this ground it is therefore needless for me again to enter, and I may
+pass at once to consider those ailments which rise in increasing
+importance from a simple cold or catarrh to inflammation of the
+air-tubes or bronchitis, inflammation of the lung substance, as
+pneumonia, and inflammation of the membrane which lines the chest and
+covers the lungs, or pleurisy.
+
+=Catarrh.=--A common cold or _catarrh_ is not one of the ailments of
+very early infancy. The watery eyes, the sneezing, the cough, the slight
+feverishness and the heavy head are scarcely met with until after the
+age of three months; nor, indeed, are they often seen till the child is
+old enough to run about, to go out for a walk, and to encounter in
+consequence all the variations of temperature and of damp or dryness
+inseparable from the English climate.
+
+This, however, is not entirely due to the greater exposure of the child
+to these influences as it grows older, but in part also to the fact that
+the lining of the air-tubes is less sensitive in early infancy than it
+afterwards becomes. The young babe if it catches cold gets _snuffles_,
+or stoppage of the nostrils, which first become dry, and then pour out
+an abundant discharge, which sometimes dries and forms crusts, and
+causes the child to suck with difficulty, and to breathe uncomfortably
+and with open mouth. In a few days, however, at the worst this
+discomfort passes away; and the only additional remark I have to make
+is, that since obstinate snuffles are sometimes a constitutional
+disease, the doctor's advice should always be sought if they last longer
+than a week.
+
+It is needless to describe a cold, but it is much more to the purpose to
+say how its occurrence is to be prevented, and nine times out of ten the
+observance of two simple rules will suffice for this. First, take care
+that there is no great difference between the temperature of the day and
+of the night nursery. The one should never be above 60 deg., nor the other
+below 50 deg., and the undressing and the bath should always take place in
+the warmer room. Second, never let the child wear the same shoes or
+boots in the house as it does out of doors. The change should be as much
+a matter of routine as the taking off its hat or its bonnet.
+
+The domestic management of a cold is simple enough. The usual error is
+the overdoing precautions, the keeping the room too hot, or overloading
+the child with extra garments, or its bed with extra covering, by which
+it is kept in a state of feverishness, or of needlessly profuse
+perspiration.
+
+If, for the first two days of a bad cold, the child is kept in bed, the
+room being at a temperature of 60 deg., with no extra covering on the bed,
+but a flannel jacket for the child to wear when it sits up in bed to
+play, 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 a
+light diet of rice, and arrowroot, and milk, and a roasted apple, and
+some orange juice; nine times out of ten, or nineteen out of twenty, the
+cold will pass away with small discomfort to the child and no anxiety to
+the parents.
+
+Often a child objects to stop all day in its little cot, but move it to
+its mother's or nurse's big bed; and with a large tray of toys before
+it, and a little of the tact which love teaches, the day will pass in
+unclouded content and cheerfulness.
+
+It must of course be borne in mind that measles set in with all the
+symptoms of a bad cold, followed on the fourth day by the appearance of
+the eruption; and, moreover, watchfulness must always be alive to detect
+increase of fever, hurry of breathing, hardness or extreme frequency of
+cough, the sign of the irritation of the larger air-tubes having
+extended and become more severe, the evidence that the case from simple
+catarrh has become one of bronchitis.
+
+=Bronchitis and Pneumonia.=--It is impossible to enable persons who have
+not received a medical education to distinguish between a case of
+bronchitis and one of pneumonia. Neither, indeed, is it of much
+importance that they should do so, for in both the dangers are of a
+similar 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 cases
+extending even to their termination in the minute air-cells. The
+inflammation leads to the pouring out of a secretion, which by degrees
+becomes thick like matter, or even very tenacious, almost as tough as
+though it were a thin layer of skin. If this is very extensive, and
+reaches to the small air-cells, it is evident that air cannot enter,
+while that elasticity of the lung which I have already spoken of tends
+to drive out from the cells the small quantity of air they contained,
+and the child dies suffocated, partly from the difficulty in the
+entrance of air, partly from the collapse of air-cells from which the
+air has been slowly expelled.
+
+In _pneumonia_ or inflammation of the lung-substance the process is
+different. A portion of one or other lung, sometimes of both, becomes
+overfilled with blood, or congested, and though the air-tubes themselves
+are not the special seat of the congestion, yet the air-cells are
+pressed on by the surrounding swollen substance, and the entrance of air
+into them is impeded. If the mischief goes further the substance becomes
+solid and impervious to air, and lastly it becomes softened, its
+structure destroyed, and infiltrated with matter; the affected part
+becomes really an abscess, though not bounded by the distinct limits
+which would shut in an abscess of the hand or the foot. Inflammation,
+and the formation of an abscess anywhere is, as we know, attended by
+fever and much general illness, and inflammation of the lung is of
+course attended by fever and general illness in proportion to the
+importance of the organ affected. To these, too, must be added all the
+disturbance inseparable from any ailment which gravely interferes with
+breathing.
+
+In the great majority of instances inflammation of the lung-substance
+does not go on to the last stage, and recovery is not only possible, but
+probable, from congestion and solidification of the organ. Pneumonia,
+too, usually attacks only a portion of one lung, while in bronchitis the
+air-tubes of both are always involved. Hence of the two, serious
+bronchitis is more to be dreaded than serious pneumonia.
+
+Bronchitis is always developed out of previous catarrh, though there is
+a wide difference between the duration of the preliminary stage and the
+occurrence of serious symptoms in different cases; while it may be laid
+down as a general rule that the severity and danger of an attack are in
+proportion to the rapidity of its onset. An attack of pneumonia, or
+inflammation of the lung-substance sets in, as a rule, more suddenly,
+with fever, a temperature of 103 deg. to 105 deg., general distress, headache,
+not unfrequently delirium; the urgency of which symptoms, the hurried
+breathing and the short, dry, hacking cough, and the tearless eyes are
+too often misinterpreted, and the state of the chest not examined.
+
+The doctor, of course, skilled in auscultation, will listen to the
+chest and give to all these symptoms their true signification. The
+lesson for the parent to bear in mind is never to neglect in a child the
+symptoms of what may seem to be but a common cold, but to seek for
+advice the moment the cough shows any disposition to become hard, or the
+breathing hurried. Next, when any sudden illness sets in with very high
+temperature and much general ailing, not to let the disorder of the
+head, or the delirium, make you shut your eyes to the import of the
+short cough, the dry eyes, the hurried breathing; and lastly, to
+remember that, grave though the symptoms may be, the tendency in
+pneumonia is to eventual recovery, and that in early life bronchitis is
+the graver of the two diseases.
+
+A caution may not be out of place with reference to cases which may
+occur during the epidemic prevalence of _influenza_. A child is
+sometimes struck down by it, just as grown persons are sometimes, with
+great depression, extreme rapidity of breathing, and very high fever,
+which, passing off in a couple of days, leave a state of great
+exhaustion behind. It is well to bear in mind that such symptoms have no
+such grave meaning when influenza is prevalent as they would have at
+another time; and the knowledge of this fact may serve in some degree to
+control your anxiety.
+
+=Pleurisy.=--It is not possible for anyone, without medical experience,
+to discriminate between pneumonia, or inflammation of the substance of
+the lung, and pleurisy, or inflammation of its covering. Some degree of
+the latter, indeed, very often accompanies the former, and this accounts
+for the pain which interferes with every attempt of the child to draw a
+deep breath. When pleurisy comes on independent of affection of the
+lung-substance, it generally sets in suddenly with severe pain in the
+chest, and a short hacking cough which causes so much pain that the
+child tries as much as possible to suppress it. After a few hours the
+severity of the pain usually subsides, but fever, hurried breathing, and
+cough continue, and the child, though usually it looks heavy and seems
+drowsy, yet becomes extremely restless at intervals--cries and struggles
+as if in pain, and violently resists any attempt to alter its position,
+since every movement brings on an increase of its sufferings. The
+posture which it selects varies much; sometimes its breathing seems
+disturbed in any other position than sitting straight up in bed; at
+other times it lies on its back, or one side; but whatever be the
+posture, any alteration of it causes much distress, and is sure to be
+resisted by the child.
+
+The variations of posture depend on the seat of the inflammation; the
+pain depends on the two inflamed surfaces of the membrane rubbing
+against each other, and accordingly is relieved not merely by the
+abatement of the inflammation, but also when either the two surfaces
+become, as they often do, adherent to each other, or when fluid is
+poured out into the cavity of the chest, and thus keeps them asunder.
+
+I dwell on this, because when fluid is poured out, the most distressing
+symptoms greatly abate, or even disappear, and parents sometimes put off
+in consequence sending for the doctor, while yet, if unattended to, the
+fluid may increase to so large a quantity as to press upon the lung, and
+so interfere with the entrance of air, or it may, if the mischief is not
+checked, change into matter, and then have to be let out by tapping the
+chest, for just the same reason as it may be necessary to open an
+abscess in any other situation.
+
+Whenever, then, symptoms, such as I have described, come on, send at
+once for medical advice, and do not let some diminution of suffering, or
+slight general improvement, lead you to delay.
+
+=Croup.=--I endeavoured to explain, a few pages back, the cause of that
+peculiar sound which is heard in spasmodic croup. The contraction of the
+opening of the windpipe changes the sound which passes through it, just
+as the opening or closing the keys of a wind instrument modifies the
+sound which it gives forth. But the windpipe is not simply a wind
+instrument, it is a stringed instrument too, and the strings or vocal
+cords, as they are termed, give forth, as they vibrate, tones now
+deeper, now more shrill. The action of this delicate apparatus is
+readily disturbed, if the nerve-supply to it is disordered by irritation
+in some distant organ, and then the breathing is accompanied by the
+peculiar sound of spasmodic croup, or in older children this may show
+itself in a different way, as in the loud, barking cough heard in some
+cases of constipation, or of disordered digestion; or another
+illustration of it is furnished by the loud, long breath--the 'hoop,'
+which gives its name to hooping-cough. But there is one sound that
+sometimes attends the breathing of children, which more than any other
+causes, and justly causes, the greatest anxiety to a mother; and that is
+the sound which is characteristic of croup.
+
+The word croup, which comes from the Lowland Scotch, signifies merely
+hoarseness in breathing or coughing, and is therefore, strictly
+speaking, the name of a sign of disease, rather than that of the disease
+itself. The peculiar sound is heard in two different conditions--the one
+in which a child having caught cold, instead of the air-tubes alone
+being affected, the windpipe, and especially its upper part, becomes
+congested, and the lining membrane swollen. Partly owing to this, partly
+owing to its nerve-supply being disturbed, the child breathes noisily
+and hoarsely, and the cough has a peculiar metallic clangor. In the
+other case there is not merely the congestion of the windpipe, the
+disturbed nerve-supply, and the swollen state of the membrane; but in
+connection with the influence of the special poison of diphtheria, a
+deposit takes place at the back of the throat, whence it extends to the
+windpipe, and in many instances even far beyond it, blocking up its
+canal, and mechanically excluding the entrance of air.
+
+To determine at once to which class a case of croup belongs is so far
+from easy, that I should advise that on the first sound of voice, or
+cough, or breathing resembling that of croup, medical advice should at
+once be sought. I dwell on the difference between the two: the first
+which has been called false croup, or better catarrhal croup, and the
+second called true croup, or diphtheritic croup, in order to save much
+needless apprehension to parents, in whose mind the croupy sound is
+invariably associated with nothing short of that most dangerous
+disease--diphtheria.
+
+As a general rule catarrhal croup is rarely met with after the age of
+six. Children in whom it occurs have either seemed quite well, or at
+most 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 a
+long-drawn sound, half-hissing, half-ringing, and the child soon wakes
+alarmed, and fighting for breath, the skin bathed in perspiration, the
+face flushed and anxious. The cough, the difficult breathing, and the
+struggle for air last for an hour or two, or sometimes all night long,
+though they gradually subside, at any rate towards the approach of
+morning, when the child falls asleep, and, but for a somewhat hoarse
+sounding cough, and a look of fatigue, there are but few signs of all
+that it has endured.
+
+The attack may not return, or it may recur for two or three successive
+nights, though in general with lessened severity, the child during the
+daytime seeming to suffer only from a slight cold, or now and then, and
+so rarely that I have not known it to occur above once or twice in all
+my experience, it may end in real inflammation of the windpipe; but not
+in diphtheria.
+
+Attacks of this kind may recur three, four, or more times even in
+childhood, while diphtheria has no tendency to recur, but like measles
+or scarlatina seldom appears more than once, though the rule is subject
+to more numerous exceptions than are found in the case of the eruptive
+fevers. Still the fact of an attack of this sort returning should of
+itself lessen apprehension and make the parents look forward to its
+issue with less anxiety than that with which they regarded its first
+occurrence.
+
+A fact which shows how large a part is played by disturbance of the
+nervous system in these cases is the liability of children who have
+suffered from it to attacks of asthma, often of great severity as they
+grow older, while very often after the transition from childhood to
+youth has passed these attacks too lessen in frequency and severity, and
+often 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 as
+if by magic, while even were the case one of diphtheria they would still
+be of some service, and could not possibly do any harm. They are the hot
+bath, and a full dose of ipecacuanha wine. The former should be as hot
+as it can be borne, 93 deg. or 94 deg., and the child should be kept in it for
+five minutes, and the latter should be given in a full dose, as a
+teaspoonful in warm water every quarter of an hour till free vomiting
+takes place. How much better soever the child may seem after the use of
+these remedies, it should still be kept for two or three days under
+careful medical observation.
+
+=Diphtheria.=--In _diphtheria_ croup is only one, though the most
+frequent, and one of the most serious, of the many dangerous symptoms
+which attend it. The croupal symptoms hardly ever come on quite
+suddenly, but are almost always preceded for some days by slight
+feverishness, languor, and restlessness, in spite of which the child
+still amuses itself; and if too young to express its sensations, the
+slight degree of sore-throat it experiences is manifested rather by a
+disinclination to take food than by any obvious difficulty in
+swallowing. There is no cough, nor any change of voice when the child is
+awake, but when asleep--and the sleep is generally uneasy--it often
+breathes with its mouth open, it snores slightly, or there is a little
+hoarse sound accompanying the breathing owing to a trivial swelling of
+the throat; while, if sought for, there will generally be found a very
+little enlargement, and a very little tenderness of the glands at the
+corner of the lower jaw. The eyes are sometimes tearful, there may be
+slight running at the nose, and the child is said to have a bad cold
+with slight sore-throat--the most remarkable feature of the case being
+generally that the depression of the patient is out of proportion to the
+severity of the local ailment. If now the throat is examined--and
+examination of the throat should never be omitted in any case where
+there is the slightest difficulty of swallowing--nothing may at first be
+seen but a very little swelling, and some redness of one or other
+tonsil. In a few hours more, white specks like little bits of curd will
+be seen first on one tonsil, then on the other, and next these specks
+will have united to form one continuous layer of a sort of
+yellowish-white membrane over the palate and tonsils. The examination of
+the throat, often so difficult when children are ill, is attended with
+almost none, if while they are well they have been taught the little
+trick of opening their mouths to show their throat, and of allowing the
+introduction of a spoon to keep down the tongue, a proceeding which
+though 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 be
+reproduced, and this even though no treatment has been adopted, and in
+two or three days the child may be pretty well again, though strength is
+in general regained less rapidly than might have been expected from the
+comparative mildness of the attack.
+
+In cases so slight it is no easy matter to recognise the features of a
+highly dangerous disease; still, out of forerunners so trivial as these,
+croupal symptoms may be developed, and their advances may be most
+insidious, and unless both parents and doctor have been closely on the
+watch they may be surprised all at once by the breathing suddenly
+becoming very laboured, by that and the cough becoming attended by the
+sounds characteristic of croup, and by the child's life being in extreme
+jeopardy, or in danger even beyond the hope of recovery.
+
+It is not that here, as in cases of catarrhal croup, the ailment has
+really come on suddenly, but that the disease has been silently making
+unsuspected progress. Whenever then a child, after a few days of slight
+causeless ailing, accompanied with some little discomfort in swallowing,
+is seen to have white patches at the back of its throat, do not allow
+yourselves to be lulled even by their disappearance into a feeling of
+absolute security. Watch the child, and beg the doctor to watch it
+carefully, until it is perfectly well again, for though the deposit may
+have disappeared from the back of the throat it may continue to be
+formed in the windpipe, and in the somewhat depressed state of the
+nervous system which attends diphtheria it may not excite that
+irritation which any such cause would produce in a child in perfect
+health, and consequently not announce its presence until its amount has
+become so considerable as to offer an almost insurmountable obstacle to
+the entrance of air. Any, even the slightest, hurry of breathing, a
+hissing sound when the child draws its breath, hoarseness of voice, or a
+ringing cough, should quicken your apprehension of danger, and make you
+seek for immediate help.
+
+It may be as well, however, to mention here, that not every white speck
+seen at the back of the throat is of necessity due to diphtheria, but
+that in some cases of ordinary sore-throat white spots may form on the
+surface of the tonsils. These white spots are due to the collection at
+their openings of the secretion formed in the minute glands which beset
+the surface of the tonsils, and which at these seasons is poured out in
+greater abundance than usual. They are distinct from each other, and do
+not coalesce into a membrane; the surface beneath is not the uniform red
+shining surface on which the membrane in diphtheria has formed, but the
+separate tiny openings from which the white matter has exuded may be
+distinctly seen if the surface is wiped with a camel's-hair brush. It
+is, of course, wise in every case to leave to the doctor the decision as
+to the nature of the deposit, but it may sometimes relieve needless
+anxiety to know beforehand that there is another cause besides
+diphtheria to which white spots at the back of the throat may be due.
+
+There are other dangers, indeed, besides those arising from croup, which
+accompany diphtheria, though those just mentioned are of all the most
+frequent. There are cases in which death takes place not from the
+severity of any local ailment, but from the intense depression of the
+nervous system. There are other instances too, in which the case assumes
+what is termed a malignant character; profuse discharge taking place
+from the nostrils, swallowing being from the first exceedingly
+difficult, membrane being deposited on the lips, behind the ears, or at
+the edge of the bowel; death taking place in twenty-four or thirty-six
+hours from the outset of the first serious symptoms, either in
+convulsions, or from utter exhaustion.
+
+But the very urgency of such cases must of necessity call for the
+immediate assistance of the doctor; and my business throughout this book
+is rather with those points which it is important for a mother to
+notice, and those things which it behoves her to do.
+
+What does diphtheria depend on? is a question more easily asked than
+answered. The disease is contagious, as scarlatina is contagious, though
+not 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, be
+too much to say that it is dependent on an unsanitary condition of a
+town, a village, or a house, but there is no doubt but that, as is the
+case with cholera, scarlet-fever, or typhus, unsanitary conditions
+favour 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 child
+during a fit of coughing, that none of the membrane which it spits up
+enters the mouth; and, that if the child's breath is caught, the
+attendant gargle immediately with a teaspoonful of Condy's fluid in a
+tumbler of water.
+
+In the next place, as the depression of the nervous system in some cases
+of diphtheria is quite out of proportion to the local disease, and as
+children who have not seemed very suffering, have yet been known to die
+suddenly in an unexpected faint, it is of moment that the child remain
+constantly in bed from the commencement of the attack till complete
+convalescence. Nor, indeed, in serious cases is even this precaution
+sufficient; but in such circumstances not only must the child not be
+taken out of bed for any purpose, but it must even not be suddenly
+raised in bed, from a recumbent to a sitting posture. I have, on several
+occasions, known the neglect of these precautions followed immediately
+by 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 try
+to carry out the doctor's directions, and to give the child constantly
+little bits of ice to suck, which lessen the swelling of the throat, and
+relieve the pain and inflammation. If the child knows how to gargle, it
+should be induced to do so constantly, and finding the relief which this
+affords, will do so very readily. This is not the time, however, when
+the lesson 'how to gargle' can be learnt. A thoughtful mother teaches it
+while the child is well, and if the gargle is composed of raspberry
+vinegar and water, the lesson is learnt without tears. There comes a
+time, however, if the disease is at all severe, when gargling is no
+longer possible, for the muscles of the back of the throat lose their
+power; but now some medicated solution, employed by means of the
+spray-producer, may most efficiently take its place.
+
+When croupal symptoms have gone on growing worse and worse, and the
+child is in the agonies of suffocation, the doctor may propose to open
+the windpipe, in the hope of giving the child another chance of
+recovery, and even though the operation fail, of at least lessening its
+sufferings.
+
+The operation is sometimes objected to by the parents, on the ground of
+the uncertainty of the result, and the torture of the operation to the
+child. Now the anguish of a child dying of croup is due to two causes;
+first, the actual mechanical impediment to the entrance of air produced
+by the deposit in the windpipe, and secondly, to the spasm of the
+muscles in the upper part of the windpipe which that deposit produces.
+How large an amount of distress the latter may produce, anyone can judge
+for himself, to whom it has ever happened to swallow the wrong way, as
+it is called. The opening made below the seat of the muscles which close
+the windpipe, leaves them in perfect rest, and does away with all the
+suffering produced by spasm, while there is always a fair prospect if
+the operation is not put off too long, of the deposit being limited to
+the 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 the
+deposit beforehand; it is true also that the operation is not in itself
+a cure of the disease, but at any rate, it is a reprieve which gives
+time for remedies to take effect, and at the worst, it substitutes a
+comparatively painless death for one of intolerable anguish. It can,
+too, be performed under the influence of chloroform, so that the idea
+that it adds in any way to the child's distress is unfounded. Who that
+has seen the calm, happy face, and watched the tranquil sleep of the
+child after the operation, who before was struggling, with distorted
+features and agonised countenance, to get a breath of air, but would
+feel as I do, that I would have it done in a child of mine for the sake
+of a painless death, even though I knew for certain that it would not
+prolong life even for an hour?
+
+One additional remark I have to make with reference to the loss of
+power, or palsy of various muscles, which frequently follows diphtheria.
+Almost always there is some impairment of power in the muscles of the
+throat on which the deposit had taken place, and there is, in
+consequence, a little difficulty in swallowing for a few days. If this
+should get worse, food and especially drink sometimes return by the
+nose, and next there may be a slight squint, and the sight may become
+weakened, and an uncertain tottering gait; and sometimes for a week or
+two the child may be unable even to stand. In bad cases there is with
+these symptoms a general loss of nervous as well as of muscular power,
+though the child may still be fairly cheerful, and ready to amuse itself
+as well as it can. This condition may last for many weeks before it
+passes quite away, and if under the mistaken impression that the limbs
+will gain strength by exercise, the child is allowed to sit up and
+encouraged to exert itself, recovery will be delayed much longer; and
+dangerous weakness or fatal exhaustion may suddenly come on.
+
+The inference is too obvious for me to need dwell on it, that repose is
+the great resource, and quiet waiting the true wisdom.
+
+=Hooping-Cough.=--I need not say much about _hooping-cough_, for there
+is scarcely a nursery in which, to everyone's great discomfort, it is
+not known as a familiar and most unwelcome visitant. It varies
+remarkably in its importance, being sometimes so slight as scarcely to
+amount to an illness, but in other instances one of the most deadly of
+diseases. It causes the death of a fourth of all children who die under
+the age of five, and three out of four of these deaths take place in
+infants of less than two years old.
+
+It occurs, however, comparatively seldom during the first three or four
+months of life, probably because very young children are kept more at
+home than others, and are thus less exposed to catch it. Though
+hooping-cough is undoubtedly very contagious, it seems to be
+communicated only by the breath, and there is absolutely no evidence to
+show that the clothes of a child suffering from hooping-cough can carry
+the infection as they might were the child suffering from measles, or
+smallpox, or scarlet-fever; still less that a person who has visited a
+room where children are suffering from hooping-cough can convey the
+disease to another house, or to other children.
+
+The disease derives its name, as everyone knows, from the peculiar sound
+which attends the cough, and which is due, as is the sound of croup, to
+spasm of the upper part of the windpipe. It is equally characterised by
+the cough returning in fits or paroxysms, which end in a long-drawn
+breath, attended by the hoop. An occasional sound like a hoop, in a
+young child who has a cold, is not so conclusive of a case being one of
+hooping-cough as is the recurrence of the cough in fits; for until
+teething is completed, slight and temporary irritation will suffice to
+produce a passing spasm of the upper part of the windpipe.
+
+An ordinary attack of hooping-cough begins like a common cold, but as
+the little ailment passes off, the cough still continues, the fits of
+coughing become more frequent, last longer, grow severer and more
+suffocative, and end with the loud long breath, the hoop; while
+sometimes no sooner is one fit over than another follows it almost
+immediately, and quiet breathing does not return until the child is
+tired out by its efforts. Nevertheless, the child's health continues
+fairly good, and little or nothing ails it during the intervals of the
+cough. For about a fortnight the cough usually goes on to increase; and
+during this time the night attacks especially become more frequent. It
+then for a week or ten days continues stationary, and then declines, a
+diminution in the frequency and severity of the night attacks being in
+general the first sign of amendment, and at the end of six weeks from
+the beginning of the attack the child is in general quite convalescent.
+Even then, however, a trifling cause will reproduce the characteristic
+cough for a few days, and not seldom for many months afterwards any cold
+which the child may catch will be attended by a paroxysmal cough
+undistinguishable save by its milder character and shorter duration from
+the previous hooping-cough, though I believe incapable of communicating
+that disease.
+
+In mild hooping-cough there is little or nothing to be done, save to
+follow the dictates of common sense, and not to neglect them in quest of
+some imaginary specific--some vaunted medicine which is said to be a
+certain cure; or such as shutting up the child in a room the atmosphere
+of which is charged with the vapour of tar, or of carbolic acid, or of
+sulphur.
+
+It cannot be too strongly impressed on the minds of parents that there
+is no specific whatever for hooping-cough; no remedy which will cut it
+short, as quinine cuts short a fit of ague. The domestic treatment of
+mild hooping-cough is the domestic treatment of a common cold, implying
+the same precautions as to the equal temperature of the day and night
+nursery, the little doses of ipecacuanha at night, but as seldom as
+possible during the day, in order not to interfere with the appetite and
+digestion, together with special care to insure the regular action of
+the bowels. It sometimes happens that after a week or two the severer
+fits of coughing are followed by vomiting; and the child may lose flesh
+and strength from inability to retain its food. In these circumstances
+food must be given, little in quantity, at short intervals, and of a
+kind 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 ordinary
+meals, and be given twice as often.
+
+The different liniments, and the favourite Roche's Embrocation, are of
+use when the disease is on the decline, and may also be of service if
+bronchitis should occur to complicate the hooping-cough, but not
+otherwise.
+
+Change of air when hooping-cough is on the decline is often of great
+service, and change even from good air to one less good appears to be
+sometimes of use; but change in the early stages, or when hooping-cough
+has become really severe, is but adding another to the already existing
+dangers.
+
+The danger in hooping-cough arises through the medium either of the
+head or of the lungs, and through each of them with about equal
+frequency. The head becomes affected in consequence of the often
+recurring congestion of the brain, produced, as in spasmodic croup, by
+the constantly returning interruption to the breathing. In these cases
+the cough is frequent, and so violent that the child becomes livid
+during each paroxysm, and that instead of ending in a loud hoop it
+finishes by a fit of convulsions or by the child sinking into a state of
+semi-insensibility. Increased violence of the cough, with suppression of
+the 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 of
+comparative, or of absolute ease. The hurried breathing which precedes
+and follows a fit of coughing never entirely subsides, while each
+returning cough aggravates the irritation and inflammation of the
+air-tubes, and the child's condition becomes the very dangerous one of
+hooping-cough complicated with bronchitis.
+
+So long as a child seems pretty well in the intervals between the fits
+of coughing, as the hurried breathing subsides after each to a natural
+frequency, as a long loud hoop follows each cough, as vomiting takes
+place only after a fit of coughing and never in the intervals, as the
+child becomes flushed only and not livid during a cough, and recovers
+itself perfectly afterwards, as it does not complain of constant
+headache, nor spits blood, nor has nose-bleeding, nor is feverish, nor
+depressed, nor drowsy, you may feel happy about it. When any of the
+symptoms just enumerated show themselves you have reason for grave
+solicitude, and the child requires daily medical watching.
+
+One word in conclusion. A child who has recently had hooping-cough is
+more liable than another to be attacked by chicken-pox or measles; and,
+moreover, imperfect recovery from hooping-cough is apt, especially if
+there is any tendency to consumption in the family, to be followed by
+consumptive disease.
+
+=Asthma.=--_Asthma_, attended by distress of breathing quite as
+considerable as in the grown person, is by no means unusual in the
+child. 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 or
+lungs, which in the former occasion or aggravate it. It belongs to the
+class of what has been termed nervous asthma and is observed with
+special frequency in children who, when younger, had been liable to
+catarrhal croup; spasm of the air-tubes having taken the place of the
+previous spasm of the windpipe. Independently of that antecedent it
+comes on sometimes about the time of the second teething in nervous and
+impressionable children, in whom an attack may be produced by
+indigestion, constipation, or over-fatigue. It is also by no means rare
+in children in whom that skin affection, eczema, of which I have already
+spoken, outlasts the time of infancy, and becomes general and severe.
+The improper performance of the functions of the skin seems to cause a
+peculiar sensitiveness of the air-tubes, and to render them liable to
+the occasional occurrence of that spasm which produces asthma. These
+cases are less hopeful than others, and the liability to the attacks
+ceases only when the skin-affection has been completely cured; a reason
+this 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 severe
+hooping-cough, and in these two conditions the prospects of recovery are
+less hopeful than in the others.
+
+When asthma occurs in childhood, the first point is to ascertain the
+cause on which the attack depends; and it is worth any amount of care to
+discover and remove it; for if what may be called the asthmatic habit is
+not formed, the attacks will, in the majority of instances, cease
+between 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 the
+boy who grows up an asthmatic youth is very unlikely to get rid of the
+disorder in later life.
+
+It is in that form of asthma which succeeds to frequent attacks of
+catching cold, and in which bronchitis precedes or accompanies each
+seizure, that change of climate is most useful. In the majority of
+instances a moderately sheltered seaside place, with a sandy soil such
+as Bournemouth, is the best, and a few years' residence there not
+infrequently overcomes every disposition to asthma through the whole
+remainder of the patient's life. To this, however, there are exceptions,
+and I have seen instances in which residence at Bournemouth and in the
+Riviera have failed, but where a perfect cure has been wrought by the
+cold, still air of Davos.
+
+=Diseases of the Heart.=--=Malformed Heart.=--Every now and then one
+sees a little babe, carefully wrapped up in its nurse's arms to shield
+it, even on a warm day, from the air; and, on removing the shawl which
+covered 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 of
+lips and fingertips, as though perished with cold. The babe wakes on
+being disturbed, and gives a faint short cry of distress; the livid hue
+of its surface deepens, it struggles feebly, its mouth twitches as
+though convulsions might be coming on. Soon, however, these symptoms
+subside, the babe smiles again, is cheerful, and save for the tints of
+its face and lips, it looks like other infants, but frailer.
+
+This condition has a name in medical writings, from a Greek word
+expressive of the blue tint which characterises it, and is called
+_cyanosis_. It depends on the blood not having undergone completely
+those changes in the lungs which take place in the healthy state. The
+blood, 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 sends
+it to the lungs, where, in the minute vessels of the air-cells, it is
+purified, and returns vivified by the oxygen a bright scarlet stream, to
+be distributed by the arteries over the whole body; and thence to return
+once more for fresh purification to the right side of the heart. Before
+birth, the blood does not run the same course, but is purified within
+the mother's body, the blood running through channels which close with
+the first breath the infant draws. The previously existing communication
+between the two sides of the heart ceases at the same time as the new
+channels are opened, by the shutting of a thin valve which had hitherto
+allowed the blood to pass from one side to the other.
+
+Sometimes this closure fails to take place, or takes place but
+imperfectly; sometimes, in addition, the channels which should be
+disused after birth remain open still; and sometimes also the heart is
+otherwise imperfectly formed, and a large communication exists between
+the two sides of the heart, which long before birth ought to have been
+firmly partitioned off from each other.
+
+According to the freedom of communication between the two sides of the
+heart, there is more or less ready intermingling of the impure blood
+with that which is already purified; and this is betokened by the
+greater or less severity of the symptoms which I have described. When
+the heart is very malformed, and the blood consequently is very impure,
+life is but a short agony which ends in a few weeks; some slight
+movement, some little accidental cold deranging altogether the imperfect
+machinery, and bringing it to a sudden standstill. Between this and the
+slightest cases there are all shades of difference, till, in the latter,
+a smaller power to maintain warmth, a less rapid growth, a smaller
+muscular development, a feebler power, a hurry of breathing on exertion,
+or in ascending a hill, or in going up a staircase, are all, except the
+sounds which the educated ear detects of the blood passing through its
+devious course, that tell of nature having, in this instance, ill done
+her handiwork.
+
+The one most natural question to which, in every instance, the doctor
+has to reply is this: 'Will he or she outgrow it?' To this the answer
+is, '_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 no
+trace behind, and to make the child heartwhole. But short of this, in
+many instances much may be hoped for. There is, as I shall have occasion
+again to repeat, a power in the growing heart to adapt itself in large
+measure to conditions other than those of perfect health. The channels,
+through which the blood ought not to flow, may shrink though they may
+not entirely close; the valve may shut more completely than at first the
+opening between the two sides of the heart; all inconveniences may
+lessen, and the child may at last become scarcely aware of the
+difference between himself and others. But for any such result, or for
+anything approaching it to be attained, certain conditions are
+absolutely essential which it is seldom easy to induce parents to
+observe. Whatever can hurry the circulation is most carefully to be
+avoided. The child must be kept strictly out of the way of
+hooping-cough, measles, or any other fever; must be shielded from every
+risk of catching cold, and having smaller power of maintaining its
+warmth than others have, must be specially warmly clad, and must live in
+rooms at a temperature of 60 deg. Fahr., all the year round. Great
+attention must be paid to the state of the bowels, so that constipation
+may not necessitate violent efforts to relieve them.
+
+Moreover, for years the child must be carried upstairs; when old enough
+to take part in games, it must not be allowed to join in any which call
+for violent exertion, such as cricket, or lawn tennis, nor ride any
+other than a quiet pony at a gentle pace.
+
+It depends entirely on the parents whether, for the sake of a very great
+but far-off good, they will strictly observe these rules. The difficulty
+will not arise on the child's part, for it is not hard for those who
+have had charge of it from babyhood to bring it up to quiet pursuits and
+quiet amusements, till it seeks no others, and, like the little
+cage-bred bird, does not care to emulate the flight of others stronger
+on the wing.
+
+=Inflammation of the Heart.=--The above remarks do not comprise all
+that is to be said about heart-affection in early life. _Inflammation_
+may attack the investing or the lining membrane of the heart at all
+ages, may produce in the child the same suffering as in the grown
+person, and may tend to destroy life in a similar manner. The causes,
+indeed, which produce heart disease, are far more frequent in the grown
+person than in the child, and advancing age brings with it changes
+which, wholly apart from active inflammation, produce grave forms of
+disease unknown in early life. There is, however, one cause of heart
+disease which is far more frequent in childhood and early youth than in
+later life, namely, rheumatism. Eight out of ten of all cases of heart
+disease under the age of fifteen are of rheumatic origin, and in
+eighteen out of twenty cases of acute rheumatism under that age, whether
+slight 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 now
+and then affection of the heart is associated with some other form of
+inflammation of the chest.
+
+Pain is by no means a constant attendant on it, but fever, more or less
+considerable, a quickened pulse, and hurried breathing are all but
+invariable, and one great reason for seeking the immediate help of the
+doctor is, that his skilled ear may at once detect by the altered sounds
+the heart-affection at its very outset, and employ the measures
+calculated to arrest its progress.
+
+Death in the acute stage of a first attack of inflammation of the heart
+is of extreme rarity, but the damaged heart is liable to returns of
+acute mischief, any one of which may prove fatal. Independently of this,
+life with diseased heart is one of suffering, attended as it is by
+symptoms similar in kind, though not identical with those which I have
+already mentioned as attendant on malformation of the organ.
+
+The hopeful element, however, to which I have already referred as
+present in cases of malformed heart, exists here in even a greater
+degree; since repair of injury is possible, while the reconstitution of
+an organ faulty from birth is obviously beyond nature's power.
+
+I can but repeat the directions already given as to the importance of
+allowing the heart as much rest, and giving it as little work, as is
+possible with a never-resting organ; and this with the added motive for
+perseverance furnished by the happy issue which may be hoped for as its
+reward.
+
+One word I must add about the occasional occurrence of _irregular
+action of the heart_ during the years of growth, especially from the age
+of ten to fourteen. This is often quite independent of any disease, and
+ceases when with added strength the nervous system becomes less
+impressionable.
+
+
+
+
+CHAPTER VIII.
+
+DISEASES OF THE ORGANS OF DIGESTION.
+
+
+=Manner of Performance of Digestion.=--The organs situated in what is
+called in medical language the abdomen, have in the child no other duty
+to perform than such as subserve the processes of digestion and
+nutrition. The saliva secreted by the appropriate glands in the mouth,
+mixing with the food, facilitates the further changes which take place
+in the stomach. In the stomach the food is acted on and dissolved by the
+gastric juice or pepsin, which is poured out by an almost infinity of
+minute tubes, or follicles as they are termed. When the stomach has done
+its work, its contents in a semi-fluid state pass into the small
+intestine, and mix there with the bile, the secretions from the
+intestines themselves, and with those of the large gland, the pancreas
+(in culinary language known as the sweetbread), which seems to have the
+special power of dissolving fatty matters. As the food, thus acted on,
+travels along the intestines, whose constant movement facilitates the
+passage of their contents from above downwards, its elements are taken
+up, 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. The
+fluid taken up by the blood-vessels is conveyed to the liver; that taken
+up by the absorbents to the mesenteric glands, and in these organs
+further changes take place in it, which fit it to be received into the
+mass of the circulating fluid. With this it is carried to the right side
+of the heart, and thence to the lungs and, lastly, from them to the left
+side of the heart, whence it is distributed, the great life and health
+giver, to the rest of the body. The useless inconvertible material,
+leaving every available element behind, is got rid of, either in a solid
+form by the bowels, or in a fluid form by the kidneys; and thus as long
+as life lasts there goes on more or less perfectly the wonderful process
+of 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 part
+of this complex machinery may be thrown out of gear, and further how not
+one part can suffer without all being disordered. Solid food given to
+the child before it has cut its teeth, enters the stomach unreduced to
+pulp by the grinders, and unmixed with the saliva, which should help its
+solution, and which the undeveloped salivary glands do not yet furnish.
+Too large a quantity of food, or food of an unsuitable character, on
+which the gastric juice cannot act readily, may pass into a state of
+fermentation; vomiting, flatulence, sour and offensive breath will be
+the result, and the food will pass into the intestine unprepared to be
+acted on by the bile. Exposure to cold, or the opposite condition of
+excessive heat, may disturb the action of the liver, and interfere with
+the secretion of bile; and the food will then pass along the intestine
+in a state unsuitable for absorption. Or, again, the mesenteric glands
+may be irritated by long-continued imperfect performance of the earlier
+stages of digestion, or their structure may be altered, and mesenteric
+disease, or consumption of the bowels, as it has been termed, may
+result. From want of muscular power, or from want of care on their part
+who have charge of the child, the bowels may become habitually
+constipated. Health will then suffer, if the child carries about with it
+for days together matters which can serve no useful purpose, but which
+are to the body what an ill-kept dustbin is to the rest of the house.
+Lastly, if the kidneys perform their duties imperfectly in consequence
+of exposure to cold, or of the changes which some diseases, such as
+scarlatina, sometimes bring about in their structure, the blood will be
+imperfectly purified; dropsy and various forms of inflammation may
+result; or the brain and nervous system may be disordered, and death in
+convulsions may attest the dangerous nature of this blood-poisoning.
+
+It would take too long to go in detail through all the phases of
+disordered digestion in early life. Much has been already anticipated in
+a former part of this book, especially with reference to the troubles of
+digestion in infancy and early childhood. There is, indeed, but one form
+of indigestion whose characters are so special as to require that I
+should enter into any detail with reference to it.
+
+=Dyspepsia of Weakly Children.=--Children from the age of about three to
+ten years, whose health has been impaired by an attack of typhoid, or,
+as it is commonly called, infantile remittent fever, or who belong to a
+weakly family, or to one, some of whose members have shown a disposition
+to consumptive disease, are sometimes martyrs to indigestion. It does
+not need with them any special error of diet, or any casual exposure to
+cold to disorder their digestion; but every two or three weeks, even
+under the most scrupulous care, they lose their appetite, their tongue
+becomes thickly coated with yellow fur, their breath offensive, their
+bowels constipated, the evacuations being either very white or very
+dark, and frequently lumpy, and coated with a thin layer of mucus from
+the 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 a
+reddish-white deposit, which disappears if heated. At the end of two or
+three days of rest in bed, of a diet of beef-tea and milk, with no solid
+food, with simple saline medicines, mild aperients, and perhaps a single
+small dose of calomel, the symptoms pass off; but return again and again
+at uncertain intervals, and without any obvious cause.
+
+In these cases, the children almost always, when in their ordinary
+health, have a peculiar patchy condition of the tongue, one part of it
+being covered with a thin white coating, through which little red points
+project, while another part is of a vivid red, and looks raw and
+shining, as though it had been scalded, while the red points, or the
+papillae, as they are termed, project above its surface like so many
+pins' heads. Children in whom this condition exists, require much
+watching and much care. I have dwelt upon it in order to impress on
+parents 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 eradicate
+a 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 pale
+evacuations, constipation, and loss of appetite, with a sallow tint of
+the skin, and sometimes even with actual _jaundice_, are by no means
+uncommon during the first ten years of childhood. Neither condition is
+serious; that of actual jaundice occurs mostly in the summer, and is
+then connected with the sudden onset of hot weather. When severe, it may
+be associated with some degree of feverishness, with dizziness, and
+complaint of headache, and occasionally with vomiting, while the child
+rests ill at night, or awakes in a state of alarm, and these symptoms
+sometimes give rise to the fear that the child is about to be attacked
+by water on the brain. But the following consideration may serve to calm
+anxiety on that score. The attack is not preceded, as water on the brain
+is 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 by
+constant nausea; and the belly is full rather than shrunken. When to
+these symptoms are added tenderness on the right side, high-coloured
+urine and white evacuations, you may set your mind at rest, even before
+the yellow colour of the skin, which appears in a day or two, stamps the
+case unmistakably as one of jaundice.
+
+My business is, as I have said more than once, the endeavour to describe
+the symptoms of disease, to explain their nature, to indicate the
+principles to be observed in attempting their cure, and not to lay down
+definite rules for their treatment, with the idle expectation that I
+could 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 symptoms
+force themselves on the notice even of the least observant. There are,
+however, a few points concerning it worth bearing in mind. Before the
+commencement of teething, diarrh[oe]a is almost always the result of
+premature weaning, or of a diet in some respect or other unsuitable. As
+soon 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 first
+six months of life; while, as soon as teething is over, their number
+immediately declines again to the half of what it was during the
+continuance of that process. The practical conclusions to be drawn from
+these facts are that looseness of the bowels during teething is not a
+desirable occurrence to be promoted, as some mistakenly imagine, but a
+risk 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, that
+in order to prevent its occurrence, care should be taken to make changes
+in the diet of a child, not during the time when a fresh eruption of
+teeth is taking place, but during one of the pauses in that process.
+There are certain seasons of the year when diarrh[oe]a is specially
+prevalent, independent of any change in diet, or alteration, in any
+respect, of the circumstances in which the child is placed. Thus, in
+May, June, and July, diarrh[oe]a is twice as prevalent among children at
+all ages as in November, December, and January; and in August,
+September, and October, its prevalence is three times as great as during
+the winter months. The high mortality of children in the summer months
+is due almost entirely to diarrh[oe]a, and even the bitter Northern
+winter of a city like Berlin is a third less fatal to infants and young
+children than the heat of its short summer.
+
+The next point to remember is that mere looseness of the bowels is
+never to be regarded during the first three years of life as of no
+importance; for I have seen infants die exhausted from its continuance,
+even though the examination of the body after death showed almost no
+sign of disease. Doctors distinguish two forms of diarrh[oe]a: the
+simple, or, as it is technically called, catarrhal diarrh[oe]a; and
+inflammatory 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 a
+dangerous bronchitis.
+
+_Simple diarrh[oe]a_ usually comes on gradually, and is some days
+before it grows severe, or passes into the more dangerous dysentery.
+Simple precautions will often arrest its progress, and, among them, rest
+in bed is one of the most important. Over and over again I have known a
+diarrh[oe]a which had continued in spite of all sorts of medicines so
+long as the child was running about, cease at once when the child was
+kept for a couple of days in bed. The reason of this is obvious;
+constant movement of the intestines themselves, which serves so
+important a part in maintaining due action of the bowels, is increased
+by the upright position and by movement, and is reduced to a minimum by
+the horizontal position. A second precaution concerns the diet; solid
+food and animal broths should for a time be discontinued, and arrowroot,
+milk and water, and rice substituted for it, for a day or two, with
+isinglass jelly, and the white decoction of which I have already spoken.
+It is not always that astringents are suitable at the beginning of an
+attack, and the sending to the neighbouring chemist for diarrh[oe]a
+medicine, which often contains an unknown quantity of opium, is always
+risky, frequently mischievous. In a first attack of diarrh[oe]a, the
+doctor should always be consulted, for when it is associated with
+disorder 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, sulphuric
+acid for the first few hours is often of extreme service. It is at a
+later time that direct astringents commonly have their use; and the
+mother, who in her child's first attack of diarrh[oe]a has had the
+advice of a judicious doctor, will often be helped by him to manage for
+herself slight returns of the ailment.
+
+_Inflammatory diarrh[oe]a_, or dysentery, not only follows the
+continuance of the simpler forms of the disease, but sometimes in the
+hot months of summer or autumn sets in suddenly with violence. It then
+frequently commences with vomiting, and the stomach may continue so
+irritable for twenty-four hours as not to retain even a teaspoonful of
+cold water. At the same time the over-action of the bowels sets in, and
+twenty or thirty evacuations may be passed in twenty-four hours. The
+motions soon lose their natural character, and become watery, slimy, and
+mixed with blood. They are at first expelled with violence, afterwards
+with much pain, effort, and often fruitless straining. With these local
+symptoms, the child, as might be expected, is very ill, feverish, and
+stupid, though without sound sleep, much exhausted, and its nervous
+system so disturbed as to occasion frequent twitchings of the fingers
+and of the corners of the mouth, while sometimes actual convulsions take
+place. The thirst is intense, the child calling constantly for cold
+water, and crying out for more the moment the cup is taken away from its
+lips; while the loss of flesh and the exhaustion are more rapid than in
+any other disease with which I am acquainted. The fat happy babe of four
+and twenty hours before is scarcely to be recognised in the miserable
+little being, with sunken lustreless eyes, and wizened features, and
+miserable countenance, lying in a state of half-stupor, sensible only to
+pain, which yet rouses it but to utter a moan, and then sinks again into
+silent suffering. I can well believe what we are told, that in some
+countries this, the so-called Summer Complaint of many of the American
+cities, sometimes carries off children in a few hours.
+
+If a fatal termination does not take place speedily, the disease passes
+into the chronic stage, the diarrh[oe]a diminishing in frequency, but
+the pain and straining, and the unhealthy character of the evacuations
+persisting. Ulceration of the bowels has taken place, emaciation becomes
+extreme, and the child often sinks at the end of several weeks, worn out
+by suffering; while recovery, doubtful at the best, is always very slow.
+But I need not pursue this subject further: enough has already been said
+to show how little infantile diarrh[oe]a is a disorder for domestic
+management.
+
+=Peritonitis=, or inflammation of the membrane covering the bowels and
+lining the cavity of the belly, is of excessive rarity in its acute
+form; and is attended by such general illness and such severe local
+suffering, that it is impossible to overlook it or to misapprehend its
+gravity. Severe pain in the belly is sometimes complained of by
+children, and is due to what is termed colic, a spasm of the bowels
+which is generally associated with constipation. The great test of the
+cause of the pain is furnished by the presence or absence of tenderness
+on pressure. The pain of colic is relieved by gentle pressure and gentle
+rubbing. The pain of inflammation in any degree and of any kind is
+aggravated by them. This applies also to cases, not indeed very common,
+in which inflammation is set up by some small body, such as a
+cherry-stone getting fixed in a little offshoot or appendage of about
+the size and length of the little finger, connected with the
+commencement of the large bowel, and producing ulceration. In these
+circumstances the bowels are confined, there are nausea and sickness,
+together with pain and tenderness of the belly, especially on the right
+side. The disease is a very dangerous one, and often proves fatal in the
+course of a few days. I refer to it because I have often seen it
+overlooked both by parents and doctors at its outset, since the pain
+then is often not severe nor the tenderness intense, and because I have
+seen the patient's condition rendered hopeless by strong aperients being
+given to overcome the constipation which was supposed to be all that
+ailed the child. I repeat then the caution, never to overlook the
+existence of tenderness, never to attempt to treat a case in which it is
+present; but always to call in medical advice, and above all always to
+abstain, unless ordered by a medical man, in every such case from the
+use of aperients.
+
+=Large Abdomen.=--I must not leave the subject of disorder of the
+digestive organs without some reference to a condition which often
+excites much needless anxiety among mothers, namely, the large size of a
+child's belly. This is sometimes supposed to be a certain evidence of
+the presence of worms, at other times to be a positive proof of the
+existence of grave disease, especially of disease of the mesenteric
+glands, or glands of the bowels as they are popularly termed. It is
+evidence of neither the one nor the other.
+
+If you go into a gallery of the old masters, and look at any of the
+pictures of angels which are generally to be seen there in such
+abundance, you will probably be struck in the case of all the child
+angels by what will seem to you the undue size of their abdomen. You
+will notice this even in the works of painters who, like Raphael, most
+idealise their subjects, while in those of others who, like Rubens,
+interpret nature more literally, the apparent disproportion becomes
+grotesque; or, in the coarser hands of Jordaens, even repulsive.
+
+These painters were, after all, true interpreters of nature. In infancy
+and early childhood the abdomen is much larger comparatively than in the
+grown person. For this there is a twofold cause; the larger size of the
+liver on the one hand, and the smaller development of the hips on the
+other. In a weakly child this appearance is exaggerated by its want of
+muscular power, which allows the intestines to become much distended
+with air. If the child is not merely weakly but also ricketty, the
+contracted chest will leave less room than natural for the lungs, while
+at the same time the ordinary development of the hips being arrested by
+the rickets, the disproportion is further increased both by that and by
+the flatulence due to the imperfect digestion with which the condition
+is almost always associated.
+
+In no case need the mere size of the abdomen occasion grave anxiety, so
+long 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 everywhere
+gives 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 opinion
+asked, as to the cause of excessive size of the abdomen, for its
+distension may be due to real disease; but it is yet worth while to
+remember that its mere size is not of itself evidence of disease, nor
+cause of grave anxiety.
+
+=Worms.=--There is no mistaking or overlooking the existence of _worms_
+when they are really present. Their presence, however, is often
+suspected without any sufficient reason. Ravenous or uncertain appetite,
+indigestion, flatulence, undue size of the abdomen, a dark circle round
+the eyes, itching of the nose and of the entrance of the bowel, a coated
+tongue, and offensive breath are no real proof of the presence of worms,
+and do not justify the frequent repetition of violent purgatives or of
+so-called worm medicines. The only real proof of the presence of worms
+is their being seen in the evacuations.
+
+The worms commonly found in children are either the round-worm, which
+resembles the earth-worm, the thread-worm, or the tape-worm; the
+appearance of each of which is clearly indicated by its name. None of
+them are spontaneously generated in the body, but they are all
+introduced from without; their eggs, or, as they are technically called,
+their ova, being swallowed unperceived in some article of food, or
+drink. A proof of this is afforded by the fact that an infant, so long
+as it is nourished exclusively at the breast, never has worms.
+
+The _round-worm_ occasions the fewest symptoms, and is rather an object
+of disgust than of grave importance, at least in this country, where it
+seldom happens that more than two or three are present. In other
+countries, as some parts of Italy, for instance, where the drinking
+water is bad and stagnant, they are sometimes found in great numbers, as
+thirty or forty, and it is then not easy to determine whether the
+symptoms which accompany them are produced by the worms, or by the
+unwholesome character of the water in other respects.
+
+They appear to live on the contents of the intestines, and do not adhere
+to them, as the tape-worm does, and hence their comparative
+harmlessness, and they have no power, as has sometimes been mistakenly
+imagined, of perforating the bowels, and of thus producing grave
+mischief.
+
+The _thread-worm_ is the commonest variety of these creatures, and has
+the 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, that
+in a week or two after it has been apparently got rid of, it may again
+be found as numerous as before. Certain articles of food seem to favour
+its development, such as pastry, sugar, sweets, beer, fruit, and
+anything which is apt to undergo fermentation, and thereby to impart to
+the evacuations a specially acid character. These worms are often
+accompanied with more or less marked symptoms of indigestion, but
+otherwise the local irritation is usually the only indication of their
+presence. They produce, indeed, such disturbance of the nervous system
+as may attend indigestion in any of its forms, but I have never but once
+known convulsions occur apparently due to their presence in great
+numbers, and ceasing on their expulsion; and this was in a child between
+eighteen months and two years old.
+
+The _tape-worm_ is developed in the human body from a minute germ or
+ovum; one form of which exists in the flesh of the bullock, the other in
+that of the pig; and which seems to require for its growth the favouring
+conditions of warmth and moisture which are found in the intestines. It
+fixes itself to the lining of the bowels by means of its mouth, which is
+furnished with minute tentacles, and it thus derives its support from
+the juices which it imbibes. The head is so small as not to be seen
+distinctly without a magnifying glass; and immediately beyond it the
+jointed body begins; at first, scarcely bigger than a thread of worsted,
+but gradually enlarging, till at the distance of three inches it is an
+eighth of an inch wide, and thence rapidly widens till each joint is
+half an inch wide, and from a third to half an inch apart. It does not
+exceed these dimensions, even though it may grow to the length of four
+or six yards. Portions of it, sometimes a yard or two in length, are
+thrown off from its lower end occasionally, and this occurrence often
+gives the first indication of its presence, the worm continuing to grow
+as before, and fresh portions being detached from time to time. It does
+not appear that the worm has the power of reproducing itself; hence its
+French name of _ver solitaire_, and the occasional presence of two or
+three would seem to be due to the development of two or three distinct
+ova within the intestine.
+
+Deriving as it does its support from the system of the child, and not as
+the other worms do from the contents of the bowel, the tape-worm often
+produces graver inconveniences. It sometimes causes uncomfortable
+colicky sensations, which may even be very distressing, and the
+disorders of digestion which accompany it are often very considerable;
+certainly more so than in the case of the other varieties of worms; but
+I have seen no instance of convulsions which could be attributed to
+them, notwithstanding the generally received opinion to the contrary.
+
+When the existence of worms is suspected, one or two doses of a simple
+aperient, such as castor oil, repeated two days successively, seldom
+fail to produce evidence of their presence; which in the case of
+tape-worm is also furnished by the spontaneous detachment of some of the
+joints. It must be remembered, however, that until the head has been
+detached from its connection with the bowel, nothing has been gained,
+and the tape-worm will in a short time grow again. To obtain the
+detachment of the head it is necessary that any worm medicine should be
+given when the intestines are empty. I am, therefore, always accustomed
+to give a dose of castor oil about two hours after the child's mid-day
+meal; and to send the child to bed as soon as the aperient begins to
+act, and to give it no more food except a biscuit and a little milk and
+water during the rest of the day. In the early morning, the special worm
+medicine is given, and over and over again I have known the worm to be
+brought away completely after many previous failures. When the smallness
+of the joints shows that the greater part of the worm has been thrown
+off, and that little more than the head remains, it is necessary to have
+recourse to the unpleasant proceeding of mixing the evacuations with
+water, and then straining them through muslin, in order that the doctor
+may by means of the microscope make out whether or no the head has been
+really detached. This is no question of mere curiosity, but a matter of
+the gravest moment, since nothing has been really gained so long as the
+head of the worm remains adherent to the bowel.
+
+Precautions such as these are not needed in the case of the other kinds
+of 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 should
+be emptied by a dose of castor oil.
+
+The only other caution which remains for me to give refers to the
+peculiar effect which salicine, a very valuable medicine, especially in
+the case of thread-worms, has upon the urine. It sometimes turns the
+urine of a greenish-yellow, often of a red colour, as though it were
+mixed with blood. The appearance, however, has no grave meaning, but is
+due simply to a chemical action of the medicine on the colouring matter
+and salts of the urine.
+
+There still remain some local ailments of parts connected with the
+process of digestion, concerning which a few words must be said.
+
+=Ulcerated Mouth.=--First, with reference to the _sore-mouth_ of
+children. I have already noticed a form of inflammation and ulceration
+of the gums sometimes met with during teething, but the sore-mouth of
+which I am now about to speak is often quite independent of that
+process; though it may sometimes be found associated with it, and is
+indeed rarely met with after five years of age. In almost all instances
+it is preceded and attended with symptoms of indigestion, during the
+course of which the mouth becomes inflamed, hot and red, and small very
+painful shallow ulcers with sharp-cut edges, and a little yellowish
+deposit on their surface, appear at the edge of the tongue, on the
+inside of the mouth, and especially on the inside of the lower lip, and
+the adjacent surface of the gum. Successive crops of these little
+ulcerations not unfrequently appear, so that for many weeks the child
+may be kept by them in a state of extreme discomfort; swallowing, and
+even speaking being the occasions of considerable suffering.
+
+It is seldom that nursery remedies, and the so-called cooling
+medicines, though often of some service, suffice to get rid of the
+ailment, which for the most part needs judicious medical treatment, and
+local as well as constitutional measures. Now and then this condition
+comes on in the course of measles, and is then sometimes of serious
+importance.
+
+In the other form, the disease is usually limited to the gums, and
+affects especially those of the front of the lower jaw, which become
+swollen, ulcerated at their edges, where a very ill-smelling deposit
+takes place of a dirty white or greyish colour, the surface beneath
+being spongy, swollen, raw, and bleeding. The ulceration sometimes
+extends so as to lay bare a large part of the sockets of the teeth; but
+though loosened they seldom drop out. Coupled with this, the glands at
+the angle of the jaw are swollen, and the child dribbles constantly a
+large quantity of horribly offensive saliva. In the children of the
+well-to-do classes the condition is seldom seen except in a slight
+degree; but even when severe it is rarely accompanied by any grave
+disorder of the general health. It seems to tend, whether treated or
+left to itself, slowly to get well; but its progress to a natural cure
+is extremely tedious, and the gums are left by it for a long time
+spongy, bleeding easily, and only very imperfectly covering the teeth.
+
+Anxiety is sometimes excited by this condition; it being supposed that
+the white deposit on the edge of the gum implies some relation between
+it and diphtheria. This is not so, for though this peculiar ulceration
+of the gums has now and then been found associated with diphtheria, the
+nature of the two diseases is essentially different. It is, however,
+always wise to call in medical advice in order to settle this important
+question, and the more so, since there is one remedy, the chlorate of
+potass, which, in appropriate doses, acts upon the condition almost as a
+charm.
+
+I say nothing about a dreadful form of inflammation of the mouth which
+ends in mortification, because it is of infinite rarity except among the
+destitute poor, and even among them it is very seldom seen except as a
+consequence of measles, or of some kind of fever. It is only among the
+very poor that I have seen it, and even among them it has come under my
+notice only ten times in the whole course of my life.
+
+There is a very common but inaccurate opinion that sore-mouth in
+childhood is often produced by the employment of mercury. I never yet
+saw a sore mouth due to the administration of mercury in any child
+before the first set of teeth were entirely cut; and never but once out
+of 70,000 cases which have come under my notice in hospital or
+dispensary practice, have I seen in children of any age under twelve any
+affection of the mouth from mercury sufficiently severe to cause me a
+moment's anxiety.
+
+=Quinsey=, or inflammatory sore-throat, has in it nothing specially
+peculiar to the child, but occurs at all ages with the same symptoms. It
+is, however, comparatively rare under twelve years of age, and is almost
+always less severe in childhood than at or after puberty, while I
+scarcely remember to have met with it under five years of age. This
+circumstance attaches special importance to sore-throat in young
+children, since it will usually be found to betoken the approach of
+scarlet fever, or of diphtheria, rather than the existence of simple
+inflammation, or quinsey.
+
+While this fact affords a reason for most scrupulous attention to every
+case of sore-throat in children, and this in proportion to the tender
+age of the child, needless alarm is sometimes caused by the appearance
+on the inflamed tonsils of numerous white specks, which are at once
+supposed to be diphtheritic. I have already pointed out the distinction
+between the two conditions when speaking of diphtheria, but the matter
+is so important that I will repeat what I then said. These spots are not
+in the form of a uniform white patch or membrane, which, on being
+removed, leaves the surface beneath red, raw, and often slightly
+bleeding; but they are rather distinct circular spots, firmly adherent
+to the tonsil, wiped off with difficulty, and evidently exuding from the
+openings of little pits, blind pouches, or glands, with which the
+surface of the tonsil is beset. I do not advise any parent to rest
+satisfied with his or her judgment on this matter the first time that
+they notice this appearance; but there are children with whom slight
+sore-throat is always attended by this condition, and others in whom the
+tonsils are habitually enlarged, and seldom free from these white spots
+flecking their surface.
+
+=Enlarged Tonsils.=--I have said that quinsey or acute inflammation of
+the tonsils is unusual in early childhood; but a sort of chronic
+inflammation of those glands which leads to their very considerable
+enlargement is far from uncommon; and is sometimes the cause of very
+serious discomfort. It is seldom traceable to any acute attack of
+sore-throat, but usually comes on imperceptibly in children who are
+feeble or out of health, or takes place slowly during the cutting of the
+first set of grinding teeth; the irritation which that produces being in
+some cases its only apparent exciting cause. Not seldom the enlargement
+has become considerable before it attracts attention; one of the first
+symptoms that indicate it being the loud snoring of the child during
+sleep, who is compelled by the obstruction at the back of the nostrils
+to breathe with its mouth open. The voice at the same time becomes
+thick, and this and the snoring breathing are both greatly aggravated
+when the child catches cold.
+
+A greater degree of enlargement of the tonsils occasions deafness from
+pressure on the passage leading to the internal ear, and is also apt to
+give rise to a troublesome hacking cough which sometimes excites
+apprehension lest the child's lungs should be diseased. When still more
+considerable the enlarged tonsils block up the passage through the
+nostrils, and air consequently enters the lungs but very imperfectly.
+The nostrils thus disused become extremely small, narrow, and
+compressed, the upper jaw does not undergo its proper development, the
+teeth are crowded and overlap each other, the palate remains narrow and
+unusually high-arched, and the face assumes something of a bird-like
+character. Besides this the child grows pigeon-breasted, owing to the
+lungs not being filled sufficiently at each inspiration to overcome the
+pressure of the external air on the yielding sides of the chest.
+
+When any considerable enlargement of the tonsils exists, each cold that
+the child may catch aggravates it, and if diphtheria, scarlatina, or
+severe sore-throat should occur, the temporary increase of the swelling
+may become the occasion of serious danger. The question arises, what are
+the chances that a child whose tonsils are enlarged will outgrow the
+condition, or when is it necessary to have the enlarged tonsils removed?
+
+It scarcely ever happens that any such enlargement of the tonsils exists
+in children under six years of age as to call for their removal. There
+is almost always ground for the hope that after the irritation caused by
+cutting the first four permanent grinding teeth has completely ceased,
+the tonsils may return by degrees to their former size. A similar
+shrinking of the enlarged tonsil sometimes takes place, especially in
+the boy, at the time of approach to manhood, when the vocal organs
+undergo full development. This can be counted on, however, only in cases
+where the tonsils are not of extreme size, and have not undergone
+frequent attacks of inflammation. Whenever the hearing is habitually
+dull, and the voice always thick, when cough is frequent, the nostrils
+narrow, the chest pigeon-breasted, and the child feeble and ill-thriven,
+removal of the tonsils is absolutely necessary. In cases where the
+question is doubtful, its decision must turn on whether the tonsils have
+often been inflamed. So long as their surface is smooth, and their
+substance soft and elastic, delay is permissible. When their substance
+is hard, like gristle, and their surface uneven and corrugated, they
+have undergone such changes that absorption is impossible, and their
+removal absolutely necessary.
+
+I dwell thus particularly on the question of removal of the tonsils,
+because there is among many persons an unreasoning dread of the
+operation, which is entirely devoid of danger, requiring only a few
+seconds for its performance, and which may even be done under
+chloroform. The painting tincture of iodine behind the angle of the jaw,
+or the touching the tonsils with caustic, iodine, alum, tannin, or sweet
+spirits of nitre are utterly futile proceedings. They diminish the
+unhealthy and often offensive secretion from the glands which beset the
+tonsils, and restore the surface to a more healthy condition, but they
+are absolutely without influence in lessening their size.
+
+Now and then all the symptoms of enlarged tonsils are present, but yet
+most careful examination fails to discover any increase of their size.
+When this is the case the symptoms are due to a thickening of the
+membrane at the back part of the nostrils, often attended with spongy
+outgrowths from their surface, which obstruct just as completely as
+enlarged tonsils would do the free entrance of air. It will, in any case
+where this condition is suspected, be absolutely necessary to seek the
+advice of some of those gentlemen who make a specialty of diseases of
+the throat, and who will have the necessary technical dexterity to
+discover the condition, and to treat it skilfully.
+
+=Abscess at back of the Throat.=--I should pass unnoticed, on account of
+its rarity, the occasional formation of an abscess at the back of the
+throat, behind the gullet, interfering both with breathing and with
+swallowing, but that the description of it in my Lectures once enabled a
+lady in the wilds of Russia to detect it, to point out the nature of the
+case to her puzzled doctor, to urge him to open the abscess, and thus to
+save her child's life.
+
+This abscess may form at any age, sometimes after fever, sometimes
+without any obvious cause. It shows itself by difficulty in swallowing
+and breathing, unattended by cough, but accompanied by a sound similar
+to that of croup, but not so harsh or ringing. The neck is stiff, the
+head thrown back, and often there is a distinct swelling on one or other
+side of the neck. The finger introduced into the mouth, and carried over
+the tongue to the back of the throat, feels there a swelling which
+projects over the top of the windpipe, and causes the difficulty both in
+swallowing and breathing. This swelling is the abscess; a prick with the
+surgeon's lancet lets out the matter, and saves the child.
+
+=Diseases of the Kidneys.=--The _kidneys_ perform very important duties
+in carrying off from the system a large amount of useless material, and
+thus supplement in many respects the action of the skin, and the
+purifying influence which is exercised by the air on the blood, as it
+passes through the lungs.
+
+It is evident, therefore, that their disorder in any way must be a
+matter of serious moment, though at the same time the knowledge of the
+skilled doctor is needed to determine the nature and degree of the
+ailment from which they are suffering, since that requires an
+examination of the urine, both chemically and by means of the
+microscope. My remarks on these diseases must consequently be few and
+fragmentary.
+
+In the grown person, what is known as _Bright's disease_ is of frequent
+occurrence, assumes different forms, and depends on various causes. In
+the child it is comparatively rare, and is scarcely ever met with except
+as a consequence of a chill, or as a result of scarlatina. In these
+conditions the kidneys become overfilled with blood or congested, and
+the congestion may pass into inflammation, by which their structure may
+be irreparably damaged. Dropsy is the great outward sign of the
+affection--either slight swelling of the face, eyelids, and ankles, or
+very great swelling of all the limbs, and even the abundant pouring out
+of fluid into the belly. The degree of dropsy is, however, by no means
+an absolute measure of the amount of kidney mischief. It therefore
+behoves every parent to follow out all directions most scrupulously even
+in cases of very slight dropsy, in order to guard against the risk of
+permanent injury to the kidneys being left behind; and especially to
+remember the liability to the occurrence of dropsy and disease of the
+kidneys after scarlatina. Any check to the action of the skin while it
+is peeling or desquamating, as it is termed, is especially liable to be
+followed by these accidents. To avoid all risks as far as possible, I
+have been accustomed for many years to insist on a child remaining in
+bed for one-and-twenty days after the first appearance of the rash in
+even the mildest case of scarlatina, and I am absolutely sure that it is
+the 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 in
+childhood than in the grown person. Whenever a child loses flesh without
+obvious cause, suffers much from thirst, and at the same time passes
+urine in greater abundance than in health, the possibility that it may
+suffer from diabetes must be borne in mind.
+
+Of far greater frequency than any other affection of the kidney is that
+in which the child passes _gravel_ with the urine, either in the form of
+a reddish-white sediment, which collects at the bottom of the vessel as
+the urine cools, or of minute glistening red particles, which resemble
+grains of cayenne pepper.
+
+These deposits, when abundant in the male child, have a tendency to
+collect 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, that
+more than a third--indeed, nearly half--of all the operations for stone
+performed in English hospitals are done on boys under ten years old.
+
+Even when this grave consequence does not follow the presence of gravel
+in the kidneys, and its passage into the bladder, it is often
+accompanied with much suffering. The pain is like that of stomach-ache
+or colic, the child crying and drawing up its legs on every attempt to
+pass water, which sometimes is voided only in a few drops at a time, and
+now and then is completely suppressed for some hours. The very acute
+form of the ailment seldom occurs, except in infants who inherit from
+their parents a disposition to gouty or rheumatic affections. In them,
+however, a trifling cold, slight disorder of the digestion, a state of
+constipation, or the feverishness and general irritation which sometimes
+attend on teething, not infrequently produce these deposits and give
+rise to all these painful symptoms, the deposit disappearing and the
+pain 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 in
+older 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 no
+cause for anxiety with reference to the issue of each attack. The warm
+bath, a castor oil aperient, and soothing medicine soon relieve the
+pain, and the children return to their former state of health. It is the
+frequent return of the attack, even in a comparatively mild form, the
+persistent disposition to the formation of gravel, the remote risk in
+the case of male children of stone in the bladder, and the habitually
+imperfect performance of the digestive functions which call for special
+care. The avoidance of sugar, sweets, and whatever tends to impart
+acidity to the urine, the maintaining the due action of the skin by
+wearing flannel, and the judicious use of alkaline remedies, sometimes
+combined with iron, are the measures on which the doctor is sure to
+insist.
+
+The difficulty usually encountered in the treatment of these cases
+arises from the reluctance of the parents to continue for months and
+years the observance of the necessary rules. It seems so hard to deny
+their little one the small gratifications in which other children may
+indulge with impunity; and they fail to realise the heavy penalty, in
+the shape of gout, rheumatism, gravel, and stone, which in after-life
+their darling may have to pay for their over-indulgence in his early
+years.
+
+I will just mention that symptoms similar to those above described, less
+severe, though more abiding, yet unattended by gravel in the urine, are
+sometimes produced in little boys by an unnatural narrowness of the end
+of the passage for the urine. It is well to bear in mind this possible
+cause of the child's sufferings, and to consult a doctor with reference
+to it, since he will be able to relieve it by a trivial operation.
+
+=Incontinence of Urine.=--The irritation which this mechanical
+inconvenience produces sometimes has to do with that troublesome
+infirmity of some children, who wet the bed at night. This may also be
+induced 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 to
+cultivate regular habits in a child; and does not pay attention to the
+quantity of liquid taken at its last meal. Something, too, is due to the
+fact 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 full
+consciousness, does not have the same effect on the former. It sometimes
+happens undoubtedly from mere indolence; and this may always be
+suspected when a child, otherwise healthy, wets itself not at night
+only, but also in the daytime. Lastly, it does sometimes occur from
+muscular feebleness in weakly children, the bladder being unable to bear
+more than a limited degree of distension.
+
+The accident usually happens either soon after going to bed, when the
+warmth stimulates the action of the bladder, or towards morning, when
+the bladder has become full. The posture on the back favours its
+occurrence very much, and it is therefore of importance that the child
+should lie on its side when in bed. The good effect of a blister on the
+lower part of the back as a means of cure was largely due to its forcing
+the child to lie on its side. This object can be attained, however, in a
+much kindlier way, by tying half a dozen cotton reels together, and
+fastening them at the child's back. The habit may also often be broken
+through by arousing the child in the night, and compelling it to empty
+its bladder, the hour being first ascertained at which the accident
+usually happens. For this, however, to be of any real use, the child
+must be awakened thoroughly; since otherwise it will mechanically, and
+quite unconsciously, empty its bladder while still asleep. The habit in
+this case is not in the least overcome; only for the time the bed
+escapes the wetting. The utensil must therefore be placed on different
+nights at different parts of the room, so that the child, in order to
+find it, must have been roused to thorough consciousness.
+
+Lastly, I will add that the cases in which the accident is the result of
+mere indolence are very rare, and though in such cases strictness may be
+necessary, yet actual punishment is out of place. As a rule, reward
+answers much better. A penny, or a threepenny-piece every night that the
+accident does not happen, and a forfeit of a halfpenny or two pence for
+every night of misfortune, is a very efficacious help to a cure.
+
+When all these domestic means, persevered in for months, fail to
+produce 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 of
+a previous disorder of the whole system. These diseases are either acute
+or chronic. The acute constitutional diseases belong to the class of
+fevers. These are marked by certain local characteristics, as the
+swelling of the joints in acute rheumatism, the sore-throat in
+scarlatina, or the eruption on the skin in smallpox, and their course is
+more or less strictly limited by distinct periods of increase, acme, and
+decline. No such rule obtains in the case of consumption, scrofula, and
+rickets, which are instances of chronic constitutional diseases. In them
+too the local manifestations of the general disease vary also: the lungs
+being affected in one case of consumption, the bowels in another; while
+scrofula may show itself by affection of the glands in one case, by the
+formation of abscesses in a second, or by disease of the bones in a
+third.
+
+=Chronic Constitutional Diseases.=--It may perhaps be convenient to
+study first the chronic constitutional diseases; and afterwards to make
+a 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 of
+which certain materials, incapable of being converted into the natural
+constituents of the body, are deposited in the substance of different
+external parts or internal organs. If deposited in small quantities,
+these materials may be absorbed, as it is termed, that is to say, got
+rid of, by natural processes, which even now we understand but
+imperfectly.
+
+If deposited more abundantly, they press upon and gradually spoil the
+healthy parts in which they are seated, and thereby interfere with the
+proper performance of their duties. Thus, the deposit of consumption
+encroaches on the proper substance of the lungs, and so lessens the area
+in which the blood is exposed to the air and purified: the deposit of
+scrofula around and in a joint interferes with its powers of movement.
+Nor is this all; but wherever any deposit has once taken place, it tends
+especially to increase in that very spot, guided as it were by a certain
+affinity; and the substance of the previously healthy part is removed as
+fresh deposit comes to occupy its place. Further, the matter deposited
+has no power of being changed into healthy substance of lung, or of
+bone, or of any other part.
+
+A fractured limb may be completely mended; a fluid is poured out around
+and between the edges of the broken bone; by degrees this hardens, it
+undergoes changes which convert it into solid bone, and the limb is once
+more as serviceable as before, though some indications of the fracture
+may still be perceptible in the texture of the bone itself. Or, a person
+receives a severe blow on his arm or leg; in course of time the blood
+which had flowed from the ruptured vessels, and had formed a big bruise,
+is absorbed, and all is as before the injury was inflicted. If more
+serious damage has been done, the fibres of some muscles may have been
+torn, even though the skin remains unbroken. Inflammation is set up, the
+injured parts die, and are melted down into the matter of an abscess.
+The abscess discharges itself, its walls contract, the opposite surfaces
+come into contact, and are welded together again, so that there is no
+loss of substance, nor anything save a scar on the surface to indicate
+what has happened.
+
+In the case of the deposits of consumption or scrofula these changes
+cannot take place. In technical language the matter is said to be
+incapable of organisation; that is to say, it cannot be transformed by
+nature's alchemy into anything good or useful. It is rubbish to be got
+rid of; and the patient's recovery depends on the possibility of getting
+rid of it. If there is much of it, so as to be removed from the
+vivifying influence which adjacent living structures still maintain
+about it, the deposit softens at its centre. This softening gradually
+extends to the circumference; the mass irritates more and more the parts
+around it, and where the irritation is greatest the structures yield,
+and are removed to make a way for its escape, and the patient spits up
+the contents of the abscess.
+
+But the abscess of the lungs is not like an abscess which follows an
+injury. It has not formed in the midst of previously healthy parts which
+are capable of reproducing the original structure; its walls are
+themselves involved in the disease, and, in accordance with the rule I
+have already mentioned, 'much will have more,' and the patient goes on
+spitting up the perpetually renewed contents of the abscess for months
+or years; until by its gradually increasing size, and the more and more
+abundant discharge of matter, and further and further destruction of
+lung-substance, death takes place.
+
+This fatal issue, however, is not invariable. In favourable
+circumstances, and especially in childhood, the radical constitutional
+defect may be amended, and with a healthier condition of the blood the
+unhealthy deposit may cease to take place. The lung-substance, however,
+with all its curious structure of air-cells and their network of minute
+vessels where, as in nature's laboratory, the blood receives its due
+supply of oxygen, is not reproduced. The lung shrinks, the sides of the
+abscess come together, and by slow degrees a dense material cuts it off
+from the adjacent healthy structure, but the most complete recovery
+leaves the patient with his breathing power lessened, and with his
+vigour 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 purely
+chemical change into a hard chalky substance, which in the course of
+time becomes of more than stony hardness.
+
+Last of all; when the deposit is smallest in quantity, it may be
+completely got rid of; and a lung in which consumptive disease once
+existed, 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 place
+elsewhere.
+
+Three important conclusions follow from what has been said.
+
+First. It is only in quite the early stage of consumptive disease that
+absolutely perfect recovery can be hoped for. There is a euphemism, more
+amiable than honest, which doctors not seldom make use of, saying that a
+child's lungs are not diseased, but only tender. They mean by this, that
+on listening to the chest, they detect such changes in the sounds of
+breathing as their experience tells them are usually produced in the
+early stage of consumptive disease of the lungs. If the opinion is
+confirmed by a second competent medical man, _then, and not later_, is
+the time for precautions, for removing the child from school, and for
+selecting, as far as may be, a suitable winter climate. When the signs
+of disease are well marked, a reprieve, perhaps a long one, is all that
+can be confidently reckoned on.
+
+Second. When softening of the consumptive deposit has taken place, of
+which certain sounds attending breathing are all but conclusive,
+recovery, even the most complete, always implies loss of a certain
+amount of lung-substance, and consequently loss of a certain amount of
+breathing power.
+
+Third, and this is most important, as well as most cheering;
+consumption, which is at no age the absolutely hopeless disease that it
+was once supposed to be, admits of far more cheerful anticipations in
+children than in grown persons, or, for that matter, than in the youth
+or maiden.
+
+The principal _causes_ of consumptive disease are, hereditary
+predisposition, and improper feeding in infancy. There are besides two
+diseases incidental to childhood, and one of them almost peculiar to it,
+namely typhoid fever and measles, which are more apt than any others to
+develop a tendency to consumption. During convalescence from either of
+them, therefore, special care is needed.
+
+In the grown person, consumption almost always attacks the lungs, and
+this often to the exclusion of other organs. In the child, however, this
+is not so, and though the lungs are indeed oftener affected than other
+parts, yet in nearly half of the cases some one or other of the
+digestive organs is likewise involved, and in about one in seven
+instances the lungs are free and the digestive organs alone are
+attacked.
+
+Fever, cough, and wasting are the three sets of symptoms which in some
+degree 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 deg.,
+there is no cause for anxiety. On the other hand, if the evening
+temperature for a week or ten days together always amounts to 100 deg.,
+there is grave presumption that consumptive disease is present. In
+advanced consumption the evening temperature is constantly 103 deg. to 105 deg.,
+while in the morning it may fall to 101 deg. or 100 deg..
+
+Cough is but rarely absent even in cases where the lungs are but
+slightly involved, for the irritation of the digestive organs often
+excites a sympathetic cough, and in these circumstances observation of
+the evening temperature will often furnish a clue to the right
+interpretation of the symptoms.
+
+There is a form of cough which is oftenest observed in children between
+the ages of two and five years, which comes in fits closely resembling
+those 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 _glands
+connected with the lungs_ (the bronchial glands as they are called) _are
+diseased_, and not the lung-substance itself. The enlarged glands press
+on some of the nerves connected with the upper part of the windpipe, and
+thus occasion the spasmodic cough. Always suspect this when a cough
+persists for weeks together, not getting rapidly worse as hooping-cough
+would do, but at the same time not growing better, as would be the case
+with mild hooping-cough. The doctor on listening to the chest will solve
+your doubts; the thermometer will help you to decide whether his visit
+is necessary. I may add that this form of consumptive disease is less
+serious than that in which the lung-substance is involved.
+
+Consumption sometimes follows bronchitis, especially when a child has
+been subject to frequent attacks of it. A very slow and imperfect
+recovery from an attack of bronchitis which had not been specially
+severe is always a reason for solicitude.
+
+Now and then infants are born with consumptive disease. In that case the
+lungs are always affected; and the symptoms of fever, cough, and wasting
+usually show themselves within the first three or four months, and the
+infants almost invariably die within the year. Now and then, however, an
+infant thus affected may continue apparently in good health for a few
+months, and then be suddenly attacked by symptoms of acute inflammation
+or of severe bronchitis which prove rapidly fatal; and it may be found
+after death that the acute attack destroyed life because the lungs were
+already the seat of extensive consumptive disease.
+
+No infant in whose mother's family a predisposition to consumption
+exists 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 but
+a small admixture of farinaceous food.
+
+There is a form of very rapid, or so-called galloping consumption, which
+is seldom observed before the age of seven years; generally two or three
+years 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 say
+that the doctor who mistakes the one for the other can scarcely be
+regarded as blameworthy; and the mistake is of the less importance since
+the treatment applicable to the one case would do no harm in the other.
+
+I have already noticed the connection between water on the brain and
+consumption. It is indeed nothing else than inflammation excited by the
+presence of the deposit of consumptive matter in the brain or its
+membranes.
+
+Little has been said hitherto about the wasting which was referred to as
+one of the characteristics of consumption. When the disease is limited,
+or nearly so, to the lungs, the wasting is not considerable until the
+mischief 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 best
+sign 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 grows
+thinner, not by real wasting but by conversion of its fat into bone and
+muscle. The child is thinner, but is taller and weighs heavier. The only
+real test therefore of the condition of the child is afforded by its
+increase in height and in weight. One need not be solicitous about the
+child who increases in height, and maintains his previous weight, nor
+about him who while he does not grow yet becomes heavier; but the child
+who neither gains in weight, nor in height, or who loses weight out of
+proportion to his increased height, is in a condition that warrants
+anxiety. I have long been accustomed, in the case of children whose
+parents were resident in India, to instruct those who have charge of
+them to send every three months a statement of the height and weight of
+the children, as the best evidence of their state of health.
+
+=Consumptive Disease of the Bowels.=--Consumptive disease sometimes
+invades the whole system from the very first, while in other instances
+it attacks from the outset the organs of digestion, and continues
+throughout to affect them chiefly, and loss of flesh is then one of its
+earliest symptoms. In instances where there is a strong family
+predisposition to the disease, consumption of the bowels or mesenteric
+disease, or disease of the glands of the bowels, all three popular names
+for the affection, sometimes shows itself at the time of weaning. In the
+majority of cases, however, it comes on later, after the completion of
+teething, and between the age of three and ten years. Indigestion such
+as I have already spoken of sometimes precedes it, with the irregular
+condition of bowels, and the patchy state of the tongue. But this is by
+no means constant, scarcely I think general; and not infrequently
+momentary, causeless, colicky pains precede for a short time any other
+symptom. In a few weeks after their occurrence, sometimes indeed
+independently of them, the appetite fails, or becomes capricious; the
+bowels begin to act irregularly, being alternately constipated and
+relaxed; and the motions are unnatural in character, being, for the most
+part, dark, loose, and slimy. Sometimes indeed, they are solid, and then
+often white, as if from complete inactivity of the liver, and sometimes
+half-liquid, frothy, and like yeast. One peculiarity which they always
+present, be their other characters what they may, is their extreme
+abundance, quite out of proportion to the quantity of food taken, and
+due to their admixture with the unhealthy secretions from the bowels.
+The child next becomes restless and feverish at night, its thirst is
+considerable, and the colicky pains become both more severe and more
+frequent. Sometimes the stomach grows very irritable, and the food taken
+is occasionally vomited, while the tongue, in the early stages of the
+affection, continues for the most part clean and moist, and except that
+it is often unnaturally red deviates but little from its appearance in
+health. Next comes a change in the condition of the belly, the date of
+which varies considerably. It becomes larger than natural, owing to the
+filling of the bowels with wind, but at the same time it is tense and
+tender on pressure--two points of great importance to be noticed, and
+the glands in the groin, which in a healthy child cannot be felt, become
+enlarged, and are felt and perhaps even seen like tiny beans under the
+skin.
+
+As in other forms of consumptive disease, so here the progress from bad
+to worse seldom goes on uninterruptedly. Pauses take place in its
+course, though each time they become shorter; and signs of amendment now
+and then appear, but they too promise less and less with each return.
+The child wastes rapidly; is always more or less feverish; the abdomen
+is constantly tender, but does not in general go on increasing in size;
+the pains become more frequent and more severe, and the bowels are
+almost always habitually relaxed. Life is sometimes cut short by the
+lungs becoming affected, but when this is not the case the patient may
+linger 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 loses
+flesh, and has a large abdomen; and the words mesenteric disease,
+sometimes uttered thoughtlessly by the doctors, seem to them to seal
+their little one's doom. Now, first of all, it must be remembered that
+mesenteric disease, due to consumption, plays but a very small part in
+the production of the symptoms just described, but that the covering and
+the lining of the bowels are chiefly involved. Next, enlargement of the
+mesenteric glands and disorder of their functions take place from many
+causes other than consumption. They are always more or less enlarged in
+typhoid fever; they become enlarged when irritated by unwholesome food
+in infancy, or they may swell in the course of chronic indigestion. In
+all these cases too, the glands in the groin may be enlarged by
+sympathy, and this without the existence of any actual abiding disease.
+A big abdomen is, of itself, no evidence of it, nor even when associated
+with indigestion and frequent stomach-ache; but when to these you add
+abiding tenderness, and an evening temperature always at least one
+degree above that in the morning, there is every reason to fear that
+consumptive disease has attacked the organs of digestion.
+
+Even then, however, there is no ground for despair; for, while
+consumptive disease in any form is less seldom recovered from in
+childhood than in after-life, such recovery oftener takes place in cases
+of affection of the digestive organs than when the disease is seated
+elsewhere.
+
+=Scrofula.=--With this word of comfort I leave the subject of
+consumption, and pass to that of the allied disease _scrofula_. Briefly
+stated, two of the great differences between it and consumption are that
+scrofula is almost entirely limited to childhood and youth, while
+consumption may occur at any age; and next, that while scrofula attacks
+the bones and the glands, the skin and the membranes adjacent to it,
+consumption has its seat in the lungs, the brain, and the internal
+organs.
+
+Scrofulous diseases of the bones come so exclusively under the
+observation of the surgeon, that I do not feel myself competent to say
+anything about them. I would however warn all parents to be very much
+alive to the importance of noticing the early symptoms of any such
+diseases, as shown by slight lameness, complaint of pain in the back, or
+difficulty in moving the hand or arm, or in turning the head or bending
+the neck. They may be but temporary accidents, due to cold, or to slight
+muscular rheumatism, or to some sprain not noticed at the time; but they
+may also be signs of the commencement of scrofulous disease of some
+bone; and in no disease whatever is early judicious treatment of greater
+value, or the result of neglect less remediable.
+
+Besides these graver ailments which seldom appear until after the time
+of infancy has passed, there are others of a less serious nature which
+often show themselves within the first year of life. One of these
+consists in the formation beneath the skin of numerous small lumps of a
+rounded form, and of the size of a kidney-bean, slightly movable, and
+not tender. By degrees such lumps become adherent to the skin, the
+surface of which above them grows red, they project slightly above it,
+and at last open by a small circular aperture, discharge a little
+matter, and then subside. They collapse and disappear; a slight
+depression and a degree of lividity of the skin mark for a considerable
+time the situation they had occupied. I refer to them, because while
+they are a sign of a scrofulous constitution, which may require special
+care in diet and preparations of iron and cod-liver oil, they are best
+left absolutely alone--neither poulticed nor lanced. The same principle
+of non-intervention applies equally to the swellings which sometimes
+form on two or three of the fingers in infancy, not involving the joints
+but producing great thickening and a hard swelling around the bone.
+These swellings disappear by degrees as the constitutional vigour
+improves, and this is especially promoted by a long stay at the seaside;
+but they tend, if the health fails, to affect the bones themselves, and
+thus to occasion deformities of the hand.
+
+Glandular swelling, discharges from the ear, offensive secretion from
+the nose, and in female children, even of very tender age, a discharge
+of whites, are all common signs of a scrofulous constitution, and all
+tedious and troublesome. They all, however, are very much under the
+influence of judicious medical treatment. It must at the same time be
+borne in mind that none of these ailments admit of what may be called
+active treatment. There are no royal means of dispersing scrofulous
+glands, or of curing discharges from the ear, or of doing away with the
+offensive smell which in some cases proceeds from the nostrils. Fresh
+air, suitable diet, preparations of iron, residence at the seaside, and
+sea-bathing, measures directed to improve the general health, are of
+chief value, and without them local treatment is of small avail.
+
+A few words, however, may with propriety be added with reference to the
+local treatment of the minor ailments to which I have just referred.
+
+No local application is of use in the _scrofulous swellings of the
+fingers_. Tincture of iodine, indeed, may be painted over them when
+quite small, while at the same time the joints are kept quiet by a small
+gutta-percha splint. When they become considerable, iodine is useless;
+and even if matter forms in the swelling it is much better to let it
+make its way out by a small opening spontaneously than to make a
+puncture with a lancet, since the edges of the wound would not heal, and
+the risk of the disease affecting the bone would be increased.
+
+The _glandular swellings_ of the neck or about the lower jaw are
+likewise 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 of
+Goulard water and spirits of wine, constantly applied, will reduce the
+swelling and lessen the discomfort. When stationary, a mild iodine
+ointment may be smeared over the gland at bedtime, and covered with
+oiled silk. Applications of iodine, however, need careful watching, for
+sometimes they over-irritate the gland, and cause an abscess. If the
+gland were out of sight there would be no objection to this, which
+would probably be a rapid mode of getting rid of the swelling; but the
+scar left behind, if the abscess burst or were opened, is an objection
+when the swelling is situated in the neck or at the jaw.
+
+If the skin over the top of the swelling becomes red, and its substance
+begins to feel soft, then, but not till then, it is desirable to apply a
+warm poultice constantly. At the same time the progress must be daily
+watched by the doctor, in order that he may seize the proper moment to
+make a small puncture and let out the matter. The small cut leaves a
+less puckered scar than the natural opening. The subsequent management
+of the case must be superintended by the doctor.
+
+_Offensive discharge from the nostrils_ does not depend, in by far the
+majority of cases, on disease of the bones, but on an unhealthy
+condition of their lining membrane. It is exceedingly obstinate and
+difficult of cure, is four times more frequent in girls than in boys,
+and unfortunately often lasts into womanhood, and continues even when
+the general health is perfect.
+
+Much may be done to abate the annoyance by diligent sniffing up the
+nostrils some weak disinfectant; or by regularly irrigating the nostrils
+by means of a simple apparatus, to be obtained from any
+instrument-maker. In spite of this, however, it is often necessary to
+introduce a little plug of cotton wool dipped in the fluid some distance
+up 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 to
+return from the commencement of teething up even to womanhood. It is a
+mere sign of debility, usually also connected with a scrofulous habit,
+but has no further or graver meaning. Locally, constant cold ablution by
+means of a sponge held above the child, not touching it, is the great
+remedy, and this may have to be repeated every hour or two if the case
+is severe. Astringent lotions of different kinds may be used in the same
+manner; while care must be taken that the child's drawers are large and
+loose, so as not to irritate her when sitting. General treatment,
+however, sea air and sea bathing are especially in these cases the great
+remedy.
+
+It must not be forgotten that all these ailments have a special tendency
+to recur; and that when people say 'Dr. A. or Dr. B. did the child good
+for the time, but this or that symptom returned as soon as the treatment
+was discontinued,' as though this were the doctor's fault, they are
+unjust; for the tendency to return of every form of scrofulous disease
+is one of the great characteristics of the malady. Patience and
+perseverance on the parents' part, even for months and years, are often
+as much needed as skill on the part of the doctor.
+
+One more remark may not be out of place. Some persons have an impression
+that there is something specially shameful in scrofulous disease, and
+while they will readily admit the existence of a consumptive tendency in
+their family, they almost resent the suggestion that their child's
+ailment is scrofulous. For this prejudice there is absolutely no
+foundation. There is no more reason for connecting scrofula in a child
+with any antecedent wrong-doing on the part of its progenitors, than
+there is for attaching that idea to the red hair or black eyes which a
+child may have in common with the rest of its family.
+
+=Rickets.=--We sometimes see, especially in the poorer quarters of a
+great 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 a
+grown 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, they
+bend under the weight of the body, or under their own weight, and with
+every slight movement which its feeble muscular power enables it to
+make. It does more, however, than interfere with the hardening of the
+limbs: it arrests growth to a great degree, interferes with
+development, retards teething, postpones the closure of the open part of
+the head, or fontanelle, weakens constitutional vigour, and impairs
+muscular power. To this feeble muscular power it is due that the child
+cannot make the effort to fill its lungs completely, and hence the
+pressure of the external air forces the soft ribs inwards, and gives to
+the chest the peculiar form of pigeon-breast. In the course of time the
+delayed bone-formation takes place, and the bones themselves become as
+hard as ivory, but the limbs do not straighten, and the deformity
+produced in infancy is but confirmed in after-life.
+
+The greater degrees of rickets are scarcely ever seen among the children
+of the wealthier classes, but over-crowded and ill-ventilated nurseries,
+cots from which the air is well-nigh shut out by closed sides and
+overhanging curtains; injudicious feeding, with undue preponderance of
+farinaceous food, often produce its slighter forms. I never yet saw
+rickets in a child while brought up exclusively at its mother's breast.
+
+The slighter forms of rickets show themselves in a tardy closure of the
+infant's head, which sweats profusely when the child is laid down to
+sleep; in big wrists, which contrast with the attenuated arms; in a
+general limpness of the whole body, and a bowing of the back under the
+weight of the head, which bends as a green stick would bend if a weight
+were placed upon it. They are further marked by backwardness in
+teething, and by the irregular order in which the teeth appear, and,
+further, by the peculiar narrowness of the chest, and by what has been
+termed the beading of the ends of the ribs: little round prominences due
+to a heaping up of gristle just where the ribs join on to the
+breastbone, marking the spots at which the tardy bone-making has come to
+a standstill.
+
+Children who bear these stamps of rickets are far more apt than others
+to suffer from spasmodic croup, and in them it is also specially likely
+to be severe and to be accompanied by convulsions. They will also be
+more liable than others to attacks of bronchitis, they will suffer more
+during teething, they will be often constipated, and will be troubled by
+various forms of indigestion. Now and then, too, they will have
+causeless attacks of feverishness lasting for a few days, or for two or
+three weeks, attended with general tenderness of the surface, and a
+disposition to perspiration, which brings no relief but serves only to
+weaken.
+
+It is true that these symptoms do not often become immediately dangerous
+to life, though spasmodic croup and bronchitis both have their perils;
+but they interfere with health, and growth, and good looks, and
+cheerfulness, and quick intelligence.
+
+If mothers would but ask themselves the real signification of these
+symptoms, and change the conditions which surround the child, and alter
+their mode of feeding it, they would many and many a time be spared the
+heart-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 than
+to turn the best spare room into a night nursery, and to uglify the cot
+by taking away the curtains which made it so pretty, and to give up some
+of the pleasures of society in order to superintend the preparation of
+the baby's food; that the doctor is called in to correct by drugs the
+evil which drugs cannot reach. Iron and cod-liver oil are very useful in
+the second place; fresh air, good ventilation, and a wise diet must
+always occupy the first.
+
+=Acute Constitutional Diseases.=--It still remains for us to glance
+rapidly at the characters of the _acute constitutional diseases_, all of
+which belong, as has already been stated, to the class of fevers. Of
+them all but two are contagious--that is to say, are capable of being
+communicated directly from person to person. They are likewise
+infectious, or, in other words, articles of bedding or clothes which
+have been worn by the sick, retain a something--an exhalation from the
+breath, an emanation from the skin, or a secretion from the
+bowels--which may reproduce the same disease in a person previously
+healthy.
+
+To this contagious and infectious property there are two exceptions; the
+one is furnished by acute rheumatism, or rheumatic fever, the other by
+intermittent fever, or ague.
+
+=Rheumatic Fever.=--The main features of _rheumatic fever_ are the same
+at all ages. Fever, pain in the limbs, swelling of the joints, sweats
+unattended by that relief which usually accompanies abundant action of
+the skin in fevers, are its characteristics. In the child all these
+symptoms are usually less even than in the adult. The swelling of the
+joints in particular is less considerable, and both the pain and the
+swelling are apt to wander from one to another joint, or to a different
+limb, instead of remaining fixed as they do in the grown person for
+several days in the same joint, even though fresh joints may be
+implicated in the course of the disease.
+
+These circumstances tend to make people look on rheumatic fever in the
+child too often as a comparatively trivial ailment; and this not only
+because the suffering which attends the disease is slighter, but because
+its duration is also shorter. But there is one fact which forbids this
+low estimate of its importance, and that is the great tendency to
+affection of the heart even in cases of comparatively mild rheumatism in
+the child; while in the grown person there is a direct relation between
+the general severity of the rheumatic symptoms and the liability of the
+heart to be involved. I have already stated that nine out of ten of all
+cases of heart disease in early life, not due to original malformation,
+are of rheumatic origin, and further that heart disease comes on in the
+course of four out of five cases of rheumatic fever in the child, slight
+as well as severe. It seldom occurs before the third or fourth day of
+the illness, so that if parents take the alarm at the very outset, it is
+usually though not invariably possible for the doctor by judicious
+treatment to anticipate and to prevent its occurrence, or at any rate
+greatly to control its progress.
+
+Every threatening of rheumatism, therefore, is to be watched with the
+most anxious care, since so serious a complication as disease of the
+heart may accompany extremely slight general symptoms. It is wise too,
+to place any child in whom general feverish symptoms come on at once
+under medical observation, for though it does not usually happen, yet it
+does sometimes occur, that rheumatic inflammation attacks the heart
+before any other local signs of the malady have manifested themselves.
+It is scarcely necessary to add that tenfold precautions are needed when
+rheumatism has once occurred, since the liability to its return is very
+great, and the heart which escaped in the first attack may suffer in the
+second; or the comparatively small mischief done the first time may
+become an incurable disorder.
+
+=Ague.=--_Intermittent fever_ or _ague_ is very rare in childhood in
+London; or at any rate it is very rare among children of the wealthier
+classes. I believe it is everywhere rarer among children than among
+grown persons, probably because they are as a rule less exposed to those
+malarious influences which produce it. In the child it generally takes
+the form of tertian ague, that is to say the attack recurs every second
+day; one day of freedom intervening between two attacks.
+
+The three stages of shivering, heat, and sweating are less marked in the
+child than in the grown person, and this indistinctness of its symptoms
+is greater in proportion to the tenderer age of the child. Shivering is
+scarcely ever well-marked, a condition of unaccountable depression
+usually taking its place, while once or twice I have known convulsions
+occur which gave rise to the apprehension that disease of the brain
+existed. The hot stage is long, and passes off gradually without the
+profuse perspiration that occurs in the grown person, and the child even
+between the attacks is almost always more or less ailing.
+
+A first and even a second attack may puzzle not the parents only, but
+also the doctor; but after the symptoms have returned a few times, the
+child being neither better nor worse in the intervals, it becomes
+evident that no serious disease is impending. The risk of an overhasty
+conclusion is that the depression and disturbance of the nervous system
+may be supposed to imply the existence of brain disease; and lead to
+unsuitable treatment, instead of the administration of quinine, which
+nine times out of ten proves a specific for ague. The rapid increase of
+temperature 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 of
+rheumatic and intermittent fever. They differ from other fevers not only
+by being neither contagious nor infectious but also by their readiness
+to return, while a single attack of any of the others furnishes a
+guarantee, and often a complete guarantee, against its recurrence. In
+addition to these peculiarities, the fevers of which I have now to speak
+are characterised by running a certain definite course, being
+accompanied by certain peculiar appearances on the surface (generally
+rashes on the skin, whence their name of eruptive fevers); being
+attended each with its own peculiar dangers, and all having a tendency
+to what is termed epidemic prevalence; that is to say to occur one year,
+and without obvious cause with vastly greater frequency than in other
+years.
+
+=Mumps.=--It has been questioned whether that painful but not dangerous
+ailment the _mumps_, ought or ought not to be classed with these fevers.
+I think it should, for it is contagious, infectious, runs a fairly
+definite course, is attended with invariable external appearances, often
+prevails epidemically, and one attack preserves in most instances from a
+second.
+
+It very seldom befalls children under seven years of age, and is more
+frequent in early youth than in childhood. It sets in with the ordinary
+symptoms of a cold, which are followed in about twenty-four hours by
+stiffness of the neck, and pain about the lower jaw, which is increased
+by speaking or swallowing. At the same time a swelling appears,
+sometimes on one side sometimes on both of the lower jaw, and increases
+very rapidly so as to occasion great disfigurement of the face. The
+swelling goes on to increase, and to become more tense, attended with
+more head-ache, fever, and discomfort for some forty-eight hours, but
+then 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, or
+more; and now and then, though very rarely, an abscess forms, which is
+both tedious and troublesome.
+
+The treatment suitable for a severe common cold, together with the
+constant application of a warm poultice to the swollen gland, is all
+that is usually required, though the doctor's help is often needed to
+relieve the suffering which for the first day or two in many instances
+attends the ailment.
+
+=Typhoid Fever.=--There is no question as to the place which should be
+occupied by typhoid fever, smallpox, measles, and scarlatina, for all
+belong to the class of eruptive fevers. They are all specific diseases,
+each due to its own peculiar poison, and not capable of being produced
+by any mere unsanitary conditions, though such may aggravate their
+severity and facilitate their spread.
+
+The belief in the special character of each of these diseases has
+received strong confirmation from the researches of the eminent
+Frenchman, M. Pasteur, and others who have followed in his track. They
+have discovered in the blood and other secretions, and in some of the
+tissues both of men and animals, minute microscopic organisms which
+differ in their characters in different diseases. Experiment has further
+shown that in some mysterious way these organisms are the cause of these
+diseases, for on inoculating animals with them the peculiar disease of
+which each was the accompaniment, and no other, was reproduced in the
+inoculated animal.
+
+As far as our knowledge goes at present then, we are forced to regard
+each of these as a separate disease, measles never passing into
+scarlatina, 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 pulse
+is quickened, and the temperature raised, constituting that state which
+we commonly call fever, but as the local ailment subsides the fever
+disappears. There is, apart from smallpox, measles, and the other
+so-called eruptive fevers, only one real essential fever commonly met
+with 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 the
+nursery, and all sorts of epithets have been substituted for it, as
+gastric fever, and infantile remittent fever, and so on. Name it as you
+may, the fever is one and the same with the typhoid fever, which one
+hears of as prevailing constantly in many continental cities, and
+proving dangerous and fatal in any district almost in direct relation to
+the neglect of drainage and of proper sanitary precautions.
+
+It is extremely rare in infancy, though I saw it once in a babe eight
+months old, and is comparatively seldom met with before the age of five
+years. From five to ten years old it is more frequent than from ten to
+fifteen, but it is consolatory to know that it is less fatal in early
+childhood than at any subsequent time of life, and that cases of such
+exceedingly mild character that the child's condition can be more
+properly described as ailing rather than ill, are then far from
+uncommon. The symptoms, however, are in all instances similar in kind,
+though widely varying in degree, and the duration of the fever is, as
+nearly as may be, three weeks. By this it is not meant that at three
+weeks' end the child who has had typhoid fever is well again, but only
+that the temperature, which had hitherto been high, and always higher at
+night than in the morning, has subsided, that the skin has become less
+dry, the tongue slightly moist, the intelligence more clear, that the
+fever has run its course. For the first week or ten days, the symptoms
+have probably become every day more grave; and for the next ten the
+doctor could find no better consolation than the assurance--happy if he
+could give it--that the condition was not worse, but that you must have
+patience, for the time for improvement had not yet arrived. If the
+attack has been severe, the child will be left greatly exhausted, sadly
+emaciated, and suffering from the effects of that ulceration of the
+bowels which accompanies the fever, and from which life may still be in
+imminent danger. But the fire is quenched; the question is no longer how
+to put out the conflagration, but how to repair the mischief it has
+caused.
+
+When mild, the disease usually comes on very gradually, the child loses
+its cheerfulness, the appearance of health leaves it, the appetite
+fails, and the thirst becomes troublesome; in the daytime it is listless
+and fretful, and drowsy towards evening, but the nights are often
+restless, 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 no
+refreshing. The thermometer will quite, in the early days, solve all
+doubt as to the nature of the case. In the morning the thermometer will
+be natural, or nearly so, but at seven o'clock in the evening it will
+have risen to 101 deg. or 102 deg., and will continue so during the early part
+of the unquiet night. After midnight it will begin to fall, and by six
+o'clock in the morning, or even earlier, will have regained its natural
+standard. There is no other disease but typhoid fever, and now and then
+some forms of galloping consumption, in which these oscillations of
+temperature take place regularly. Other symptoms attend typhoid fever
+besides these, and serve to stamp upon it its distinctive character. The
+bowels are usually loose, or if not, a moderate aperient acts on them
+excessively, the evacuations being loose, often watery, of a light
+yellow-ochrey colour. The abdomen is full, the bowels being more or less
+distended with wind, sometimes tender, especially at the right side, and
+both 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 the
+second week, small rose-red spots or pimples appear on the abdomen,
+sometimes also on the chest and back. They disappear for the moment if
+pressure is made on them, but reappear the moment the pressure is
+withdrawn. Now and then they are numerous, and sometimes two or three
+successive crops appear, the old ones fading as the others show
+themselves; but in childhood they are often scanty, though whether few
+or many, they are the external characteristic of the disease just as the
+rash is in scarlatina or measles.
+
+Whenever a child of whatever age begins without obvious cause to lose
+appetite and health, to become feverish, with marked increase of
+temperature towards evening for several days together, and more or less
+disposition to diarrh[oe]a, it is all but absolutely certain that the
+child has contracted typhoid fever.
+
+When the disease comes on gradually, it seldom becomes dangerous, though
+until the end of the first week there is always considerable uncertainty
+on this point. The amount of diarrh[oe]a and the degree of disorder of
+the brain, as shown by restlessness, delirium, and stupor are the
+measure of the gravity of any case. There is, however, scarcely any
+disease from which even when most severe recovery so often takes place
+in childhood, and this not as persons so often imagine from some
+critical occurrence but by a process of gradual amendment. The first
+signs of amendment, too, may be taken as giving almost certain promise
+of complete recovery; but it is well to bear in mind that there is no
+disease of early life in which the mental faculties, though time brings
+them back at length uninjured, remain so long in a state of feebleness
+and torpor as in typhoid fever. Though the first signs of improvement,
+too, are very seldom deceptive, yet the patient's convalescence is
+almost always slow, and interrupted by many fluctuations.
+
+Though contagious, still typhoid fever is far less directly contagious
+than measles or scarlatina. It seems as if with this disease, just as
+with cholera, the contagious element were present in its most active
+form in the discharges from the bowels. These should therefore be
+disinfected by carbolic acid or some other disinfectant immediately; and
+should never be emptied in a closet used by other members of the family,
+and more particularly by children. Special precautions also should be
+taken with the bed-linen, and night-dresses of the patient; and it must
+be remembered that wise precautions have nothing in common with
+exaggerated alarm. One more hint will not be out of place. In typhoid
+fever, and still more in the highly contagious measles and scarlatina,
+the person who sleeps in the patient's room is much more likely to
+contract the disease than she who sits up and watches at night keeping
+wide awake. Whoever takes charge of a fever patient during the night
+should therefore sit up and watch, not lie down and doze, and this not
+for 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 from
+first to last. He may come every day, and may daily do nothing but
+merely watch. The disease will run its course, the greatest skill cannot
+cut it short, though now and then instead of lasting for three or even
+four weeks it comes to an end spontaneously in fourteen days. Skilled
+watching is what the competent doctor gives. You would not despise or
+underestimate the pilot's skill, who steered your barque through a
+dangerous sea in smoothest water, because he knew each hidden rock or
+unseen quicksand on which but for his guidance you might have made
+shipwreck.
+
+=Small-pox.=--At the present day, thanks to vaccination, and to
+re-vaccination, _small-pox_ is rarely met with in the well-to-do classes
+of society, though it is not yet a century ago since it found its
+victims not only among the poor, but among the highest in the land. It
+does, however, occur sometimes after vaccination, and sometimes, though
+very rarely, an attack of small-pox fails to furnish an absolute
+guarantee against the occurrence of a second.
+
+Small-pox, unmodified by previous vaccination, sets in in the child with
+violent sickness; vomiting, sometimes recurring frequently for
+forty-eight hours, with much depression, or even stupor; in some
+instances even actual convulsions, and fever; but neither with the
+sore-throat of scarlatina, nor with the sneezing, cough, and running at
+the nose of measles. At the end of from forty-eight to sixty hours, an
+eruption of pimples appears on the face, forehead, forearms and wrists,
+whence it extends to the body and the lower limbs. They are reddish in
+colour, rather pointed in form, and at first scarcely raised above the
+surface; so that the eruption looks at first like the very early
+eruption of measles; though the tiny pimples felt as if beneath the skin
+serve even then to distinguish the one disease from the other. In
+another forty-eight hours the character of the pimples has changed into
+that of little vesicles or pocks, depressed instead of pointed at their
+centre, and containing a little watery milky fluid. They next enlarge,
+and become once more prominent at their centre as they fill more and
+more with fluid, which becomes thicker, yellowish-white--looks like, and
+indeed is, matter. Four or five days are occupied with this process;
+the matter in the pocks then begins to dry, and scabs to form, which
+gradually by the end of another week drop off, and leave the skin
+spotted with red or even scarred if the pocks went deep enough to
+destroy the skin, and to leave the indelible marks, the so-called
+pitting of small-pox.
+
+The danger of the disease is in childhood the nervous disorder at the
+outset, and then the exhaustion produced by the so-called maturation of
+the pocks when the thin watery fluid changes to the thicker matter, and
+depresses the patient in the same way as he would be depressed by an
+enormous abscess.
+
+The first outbreak of the eruption is followed always by a most
+remarkable abatement in the disturbance of the constitution, and for
+three or four days, even though the eruption is abundant, the patient
+may seem so well that it is almost impossible to realise the imminent
+peril to which he will be exposed in a few days' time.
+
+=Inoculation and Vaccination.=--The danger of small-pox is in direct
+proportion to the abundance of the eruption; and the great advantage of
+inoculation for the small-pox consisted in the much scantier eruption
+which followed it, as compared with that which commonly took place in
+the natural small-pox.
+
+The same advantage in a greater degree is obtained by vaccination, even
+in the exceptional instances in which it fails to render the person
+altogether insusceptible to the disease.
+
+The great advantage which inoculation secured was counterbalanced in
+great measure by the fact that it always maintained small-pox rife
+throughout the whole country, and that consequently all who either had
+neglected inoculation, or young children on whom, on account of their
+tender age, it had not yet been practised, were more than ever exposed
+to constant risk of infection.
+
+This very real danger led to the almost unanimous welcome which the
+practice of vaccination received towards the end of the last century,
+since it was hoped that by it not only would the risk attending
+small-pox be lessened, and the disease when it did occur be even milder
+in character than inoculated small-pox, but that small-pox itself would
+eventually be extirpated.
+
+These anticipations have not hitherto been fully realised; but the good
+effected by vaccination has been such as to render it, in the opinion of
+nearly everyone qualified to form an opinion on the subject, one of the
+greatest boons ever conferred on the human race.
+
+Small-pox, like other eruptive fevers, has the peculiarity of occurring
+for the most part only once in a person's life. We do not know in the
+least on what this protecting influence depends. We know the fact, but
+are the less able to offer an explanation, since there are other
+constitutional diseases, such as gout and rheumatism, in which the local
+symptoms are equally the outcome of previous constitutional disorder,
+where exactly the opposite rule obtains, and in which their occurrence
+does but increase the liability to their return.
+
+The protective power is apparently possessed by the mild form of the
+disease communicated by inoculation as much as by the severer form of
+small-pox which is contracted by direct contagion or infection. This
+knowledge has been applied in the treatment of some of the diseases of
+animals, and it has been found in the case of the so-called small-pox in
+sheep (a disease which, however, is quite distinct from human small-pox)
+that while one in two of the animals who contracted it in the ordinary
+way 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 inoculated
+sheep were thereby safeguarded from subsequent attacks as completely as
+the others.
+
+This knowledge was more recently applied by the distinguished Frenchman
+whom I have already mentioned, M. Pasteur, in the case of a fatal
+pestilence 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 directly
+infected, that he found it necessary to weaken the matter which he
+employed by admixture with other innocuous materials. This experiment,
+however, again yielded unsatisfactory results; slight symptoms of the
+disease were produced, but the protection thus afforded was inadequate
+and uncertain. Some few resisted the disease, but others contracted it
+and died. With that clear insight which constitutes genius, M. Pasteur
+next tried the experiment of inoculating the sheep first with a weak
+matter which produced but slight symptoms, but at the same time enabled
+the animal to support a second inoculation with a stronger matter; and
+this second inoculation enabled them to bear, unharmed, subsequent
+exposure to the disease. A grateful country has given a pension, and
+conferred well-merited honours on the man who has preserved their flocks
+from pestilence, but whom the silly sentimentality of the
+anti-vivisectionists in England would have mulcted in a fine, and, if
+possible, have sent to prison.
+
+That weakening of the poisonous element which Pasteur strove to attain
+by art, is already provided by nature in the cow-pox. The cow-pox is
+nothing else than small-pox modified in character, diminished in
+severity by passing through the system of the animal; but giving, when
+introduced into the system, a safeguard against natural small-pox at
+least as complete as that furnished by the inoculated disease.
+
+More than 70,000 children have come under my observation, either in
+hospital or in private practice; and I need not say that a physician
+having much consulting practice sees far more than the average of
+unusual and severe cases. Twice, and only twice, I have seen infants die
+from vaccination, and in both instances death took place from erysipelas
+beginning at the puncture. The one case I saw twice in consultation with
+the family practitioner. The other which I watched throughout was that
+of a little boy, the fifth child of a nobleman of high rank, both his
+parents being perfectly healthy. He was vaccinated by the family doctor
+in the country, direct from the arm of another perfectly healthy infant,
+from whom ten other infants were vaccinated immediately afterwards. The
+little boy was seized with convulsions within twenty-four hours, and
+almost at the same time erysipelas appeared on the punctured arm. The
+erysipelas extended rapidly, convulsions returned more than once, and on
+the fourth day from the vaccination the child died. One of the other
+children vaccinated at the same time died in the country in the same
+manner; all the others passed through vaccination regularly, and without
+a single bad symptom. I have no explanation to offer; this case stands
+by itself just as do those of death from the sting of a bee or death
+from cutting a corn.
+
+That some people die of other diseases since the introduction of
+vaccination, is undoubtedly true, for many of those who would have died
+in early infancy of small-pox are cut off later by measles or
+bronchitis, or die during teething; since it is obvious that vaccination
+does not protect against any other disease than small-pox.
+
+That protection, indeed, is not absolute, nor was the protection
+afforded by inoculation absolute; but small-pox after vaccination, even
+when it does occur, is very rarely severe, and still more seldom fatal.
+
+There seems good reason for believing that the protecting power of
+vaccination tends to diminish with the lapse of time; though apparently
+this is not always the case, nor can any direct statement be made as to
+the 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 does
+exist, and that this tendency calls for the repetition of vaccination
+from time to time; such re-vaccination carefully performed being as
+nearly as possible an absolute guarantee against small-pox. All persons
+engaged as nurses or attendants at the Small-Pox Hospital during the
+past thirty-two years, have been vaccinated or re-vaccinated before
+entering on their duties, and during this period not a single case of
+the disease has occurred among the whole staff. The experience of other
+small-pox hospitals for a shorter period is identical. As far as we
+know, every seventh year is a reasonable interval at which
+re-vaccination should be performed.
+
+One great cause of the failure of the protective power of vaccination
+is the unintelligent and careless manner in which it is too often
+performed, especially among the poor. To this same cause it is also due
+that in some cases of almost infinite rarity one special constitutional
+disease has been known to be communicated. I have never seen such a
+case, but I know there are such. They are, however, no more a reason
+against vaccination than the occasional death from an overdose of opium
+is a reason against the use of that drug.
+
+To avoid any risk of this kind, and also with the idea that the power of
+the vaccine matter may have become weakened by transmission through many
+thousands of persons, vaccination direct from the calf has been
+introduced of late years, especially in America and on the Continent.
+The time, however, that has as yet elapsed is scarcely sufficient to
+test the comparative preservative power of this as compared with
+vaccination from the human subject. Its immediate local effects are
+somewhat more severe; I do not know any reason why its influence should
+not 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 an
+eruption, or aggravate an eruption already existing. Such cases,
+however, are not frequent, and the eruption is not more troublesome than
+those which often appear in teething children. The occurrence of actual
+erysipelas around the puncture, while very dangerous, is, as I have
+already stated, of excessive rarity.
+
+A thoroughly dispassionate review of the whole subject appears to me to
+warrant the following conclusions:--
+
+1st. That vaccination, though not a perfect guarantee against small-pox,
+diminishes immensely the risk of its occurrence; and that by periodical
+revaccination, this guarantee is rendered all but absolute.
+
+2nd. That a very large proportion of the failures of vaccination are due
+to its careless and imperfect performance.
+
+3rd. That to such careless performance and to the introduction of the
+blood and not of the vaccine matter alone, from one child to another are
+due the extremely rare instances in which one special disease has been
+transmitted by vaccination.
+
+4th. That there is absolutely no evidence of the transmission of
+scrofula, consumption, or any similar disease by vaccination.
+
+5th. That vaccination direct from the calf appears to present some
+decided advantages; but it has not yet been practised for a sufficient
+time to admit of a comparison between its preservative power and that of
+vaccination from one child to another.
+
+6th. That in either case it is expedient that vaccination be performed
+within the first three months after birth, so as to avoid the irritation
+of teething which is unfavourable to successful vaccination, and also
+because the disposition to those skin diseases which vaccination tends
+to aggravate is never so considerable before the age of three months as
+it becomes subsequently.
+
+Even when vaccination fails to protect against small-pox it tends to
+produce a modified and so much milder form of the disease, that while
+one patient died out of every two in the Homerton Small Pox Hospital who
+had the disease naturally, the deaths were only one in four of those who
+had been imperfectly vaccinated, and one in forty-three of those whose
+arms bore evidence of perfectly good and successful vaccination.
+
+The influence of previous vaccination often scarcely shows itself in the
+stage which precedes the appearance of the eruption of small-pox, the
+fever being often just as intense, and the general symptoms just as
+severe as in the unmodified disease. The difference, however, becomes at
+once obvious with the appearance of the rash. The pocks are always much
+fewer than even in mild small-pox, sometimes even not more than twenty.
+They never attain above half the size of the ordinary small-pox
+pustules; they run their course and dry off in half the time, and
+consequently the dangerous fever which accompanies their development in
+the natural disease is almost or altogether absent in the vast majority
+of instances.
+
+If vaccination did no more than this it would be hard to overestimate
+its value, or to praise as it deserves the merit of its discoverer.
+
+=Chicken-Pox= is an ailment of such slight importance that it would
+scarcely call for notice if it were not that the resemblance of the
+eruption to that of small-pox sometimes leads to its being mistaken for
+that disease.
+
+It is highly contagious, and for this reason perhaps it is usually met
+with in infancy and early childhood. Sometimes, though by no means
+constantly, the eruption is preceded for twenty-four or thirty-six hours
+by slight feverishness; but oftener the appearance of the rash is the
+first indication of anything being the matter. It shows itself in the
+form of small pimples, which in a few hours change into small circular
+pocks containing a little slightly turbid fluid. They appear on the
+forehead, face, and body, but very rarely on the limbs; they enlarge for
+some two or at most three days, then shrivel and dry up; and at the end
+of a week the crusts or scabs fall off, scarcely ever causing any
+permanent pitting of the skin. They are usually not above twenty or
+thirty in number, though every now and then they are much more numerous
+without any obvious reason. Their distinction from the small-pox
+eruption consists not only in the smaller size of the pocks, and in the
+entirely different course which they run, but also in the fact that two
+or three successive crops of the eruption appear in the course of five
+or six days, so that new ones, those at maturity, and those on which the
+crusts have already formed, or from which they have already fallen, may
+be seen on the child at the same time. This is sufficient of itself to
+establish the difference between the two diseases, and also to
+distinguish between chicken-pox and the milder variety of small-pox
+which is sometimes observed in children who have been already
+vaccinated.
+
+=Measles= is a disease with which almost everyone is familiar, and one
+which with proper care is not generally attended with danger. Its great
+risks are twofold; first, that of its being complicated with bronchitis,
+or inflammation of the lungs during its progress, and next of its being
+followed by an imperfect recovery, and by the awakening into activity
+any tendency to scrofulous or consumptive disease. On these two accounts
+the disease is not to be made light of, and special watchfulness is to
+be exercised during the whole time of convalescence. It is also unwise
+when 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 it
+over;' for its mildness in one case furnishes no guarantee of its
+mildness in another, and the danger of the disease is almost in exact
+proportion to the tender age of those who are attacked by it.
+
+The early symptoms of measles are those of a bad feverish cold; the eyes
+grow red, weak, and watery, and are unable to bear the light, the child
+sneezes very frequently, sometimes almost every five minutes, and is
+troubled by a constant short dry cough. About the fourth day, a rash
+makes its appearance on the face, forehead, and behind the ears, and in
+the course of the next forty-eight hours travels downwards over the body
+and limbs, and then in another forty-eight hours it fades in the same
+way, being at its height on the body when it has already begun to
+disappear from the face. It first shows itself in the form of small red
+circular spots, not unlike fleabites, but very slightly raised above the
+somewhat reddened skin, and looking for a few hours not unlike the very
+early stages of small-pox, before the eruption has lost the character of
+minute pimples. On the face the spots sometimes run together, and then
+form irregular blotches about a third of an inch long by half that
+breadth; while elsewhere they present an irregular crescentic
+arrangement. As the rash fades it puts on a dirty yellowish red
+appearance; the surface of the skin often becomes slightly scurfy, and
+it continues somewhat stained of a reddish hue for some days after the
+eruption has disappeared.
+
+The only other point on which it is necessary to dwell is this, that the
+symptoms do not, as in small-pox, become less severe immediately on the
+appearance of the eruption, but continue just as troublesome as before
+for twenty-four hours or more, the voice being hoarse, the cough even
+more incessant, and the throat often slightly sore and red. Soon,
+however, improvement becomes apparent, the fever lessens, the cough
+grows looser; and in less than a fortnight the patient is usually
+convalescent.
+
+The above is pretty nearly the ordinary course of measles, for we do not
+meet with that extreme variation in its severity which is observed in
+scarlatina, where one child will seem scarcely to ail at all, while its
+brother 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 domestic
+management, for while the cough is troublesome in almost every case, the
+ear of the experienced doctor is needed to ascertain whether it is
+merely the cough of irritation which attends the measles, or the graver
+cough due to bronchitis.
+
+One other caution will not be out of place. The danger of exposure to
+cold is very real, but that does not necessitate the loading the child
+with excessive covering, or the abstaining from washing its hands and
+face. The child should be kept moderately cool; and sponging its hands
+and face frequently with tepid water soothes it and relieves the painful
+irritation and itching.
+
+=German Measles.=--There is a disorder which seems to hold a middle
+place between measles and scarlatina, akin to both, identical with
+neither, and furnishing no sort of protection from their occurrence.
+
+It is known in this country by the name of _German measles_, or
+sometimes by its German name of _Roetheln_; the first clear description
+of its character having been given by German writers.
+
+It is unfortunate that a very slight resemblance of some of its symptoms
+to those of scarlet fever has led to its being sometimes mistaken for
+it, and as the ailment is almost always very trivial, doctors anxious to
+avoid alarming their patients' friends, too often allow the error to go
+unrectified, 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 a
+slight sore-throat, unaccompanied with glandular swelling. The rash in
+no respect resembles the uniform redness of the scarlatinal eruption,
+and there is no peeling of the skin, nor even any roughness of the
+surface left behind.
+
+Slight feverishness sometimes precedes the appearance of the rash for
+twenty-four hours; but the cough, and sneezing, and running at the eyes
+and nose, which usher in measles are entirely absent. The rash usually
+appears in the course of twenty-four hours, is never postponed beyond
+the second day; it begins, like that of measles, on the face, and, like
+it, travels downwards, but always disappears on the third day, while
+that of measles is not entirely gone before the eighth or ninth. The
+rash itself also has a different character. It consists of small,
+slightly elevated, round red spots which now and then coalesce into
+small patches, but never have the somewhat crescentic arrangement
+observed in the rash of measles. The colour of the spots is somewhat
+darker than that of the eruption of measles, while the _skin between
+them remains pale_, and does not assume the flush of measles. As it
+disappears it simply fades, and does not at all change its tint as that
+of measles does, and it leaves the skin unroughened.
+
+Now and then German measles are severe, and are attended with a good
+deal 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 the
+disease prevails epidemically; and even then the symptoms of the
+affection are sufficiently marked to preserve from error all but those
+who wish to be deceived, and to flatter themselves that their child is
+henceforth 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 greater
+mildness of the disease, is one of the most formidable ailments of
+childhood, and especially of early childhood, since the highest
+mortality from it takes place during the third year of life.
+
+It is more dreaded in a household, and justly so, than any other
+disease of childhood, though, indeed, it is not limited in its
+occurrence to early life, and instances are familiar to us all in which
+the mother, devoting herself to the care of her little ones, has herself
+fallen a victim to the poison.
+
+I do not think it so directly contagious, from person to person, as
+small-pox, chicken-pox, or measles, but its infection appears to be
+specially abiding in its character, and to cling longer to the clothes,
+the bedding, and even the room of a scarlet fever patient, than that of
+the other eruptive fevers, except perhaps small-pox.
+
+It is an object of special dread also for two other reasons. One of
+these 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 to
+have it so slightly as scarcely to be ill, two to have their lives
+placed in jeopardy, and two to die. The other reason for special dread
+is that the mildness of the disease at its outset affords but a slight
+guarantee against the occurrence of serious complications in its course,
+and still slighter against secondary diseases which may follow in its
+train, and either destroy life directly, or leave behind some
+irremediable mischief.
+
+Scarlatina has been divided by medical men into three classes, according
+to its different degrees of severity; the mild--that accompanied with
+bad sore-throat--and the malignant variety.
+
+We have specially to do with the first of the three; for it is in it
+only that there is danger of the disease being overlooked, or mistaken.
+
+The symptoms of scarlatina usually appear within three days after
+exposure to its contagion, and there is very good authority for
+believing that the interval never exceeds six days. I should not,
+however, feel quite secure until after the lapse of ten days, and during
+this 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 the
+surface, usually with, but sometimes even without slight sore-throat and
+feverishness, may be the first indication of an affection which is
+sometimes so deadly. In the majority of cases, however, it is ushered
+in by vomiting once or oftener, accompanied by headache, heaviness, of
+head, great heat of skin, and some measure of sore-throat. The brain is
+easily disturbed in children, as has already been said, and delirium at
+night during the first twenty-four hours of an attack of scarlet fever
+need not excite anxiety, for it then often passes away, and the disease
+runs a perfectly favourable course. The continuance of delirium later is
+an attendant only on the graver forms of scarlet fever.
+
+The rash often makes its appearance within twenty-four hours after the
+commencement of the illness, at latest in the course of the second day.
+It usually shows itself first on the neck, breast, and face, whence it
+extends in twenty-four hours to the body and limbs, and is then not
+seldom specially vivid on the inside of the thighs. Its colour is a very
+bright red, due in part to a general flush of the skin, in part to the
+presence of innumerable red dots or spots, which do not communicate any
+sense of roughness to the hand, though now and then extremely minute red
+pimples are interspersed. For three days the rash usually continues to
+become of a deeper colour, and more generally diffused over the whole
+surface; it then slowly declines, but does not wholly disappear until
+the seventh or eighth day of the disease. As the rash subsides the skin
+is left rough, and by degrees scales off, often in large flakes from the
+hands and feet, but elsewhere in a sort of branny scales. Sometimes this
+process is over in five or six days, while in other cases the skin peels
+and is reproduced several times in succession, so that it is protracted
+for three or four weeks or even longer. The degree of this peeling also
+varies as well as its duration. It is usually most considerable where
+the rash has been most abundant, while where the rash has been scanty,
+it is sometimes scarcely apparent except at the tips of the fingers and
+toes and just around the insertion of the nails.
+
+Besides the rash there are commonly other symptoms not less
+characteristic of scarlatina, and among them the sore-throat is one of
+the most invariable. Even in mild cases, it is very rarely absent, and
+if not present at the beginning, it comes on on the second or third day.
+The palate and tonsils, in these circumstances are red, and the latter
+are usually more or less swollen, while swallowing is attended with
+pain, or at any rate with discomfort. The redness of the palate, which
+extends also to the back of the throat, is a finely spotted redness
+closely resembling the rash on the surface. The tongue is coated with a
+thick white or yellowish coating, through which project numerous bright
+red points, papillae as they are called, and this appearance of the
+tongue is as distinctive of scarlatina as the rash itself. Later, as the
+rash begins to fade, the coating separates from the tongue, which is
+left of a bright red colour, looking raw and shining, with the little
+raised red points projecting beyond its surface, and constituting what
+has been called in medical language, the strawberry tongue.
+
+When all these symptoms are present, no one can doubt but that the case
+is one of scarlatina. But the decision is far less easy in mild cases,
+for in them the rash is sometimes extremely evanescent, the general
+disturbance of health very slight, and the fever and accompanying rise
+of temperature small. The risk in such circumstances of the disease
+being altogether overlooked is even greater than that of its being
+confounded with some other eruptive fever. The rash of measles cannot be
+confounded with that of scarlatina, and the distinctly spotty character
+of the rash of German measles ought, apart even from other differences,
+to render mistake impossible.
+
+Perhaps the best rule that can be laid down is that every diffused red
+rash, not obviously formed by distinct spots, even though it be not
+uniform but appears in patches on the neck, breast, back, or inside of
+the thighs, and persists for more than twelve hours, is scarlatinal.
+Further, that in any instance in which even very slight feverishness, or
+very slight sore-throat, have preceded or accompanied the rash, the
+nature of the ailment is stamped beyond the possibility of doubt.
+Mistakes are made from want of careful observation, much more than from
+any insuperable difficulty in distinguishing one disease from the other.
+When the least hesitation is felt as to the nature of any rash which
+may appear on a child, with, or without previous illness, the question
+should be at once referred to a medical man. People are too apt in these
+circumstances to wait for a few days, and then to appeal to the doctor
+when all traces of rash have disappeared, and when the grounds no longer
+exist on which he could base a positive opinion.
+
+I need not describe the symptoms of severe and dangerous scarlatina, for
+long before symptoms become really formidable, the patients will have
+been placed under medical care. It may suffice to say that the danger is
+almost always in proportion to the severity of the throat-affection and
+swelling of the glands, and not at all in proportion to the abundance of
+the rash. Though severe cases usually set in with severe symptoms, yet
+this is not invariably the case, and medical watching is all the more
+necessary from the very commencement, since until the end of the first
+week it is impossible to calculate on the subsequent course of the
+disease. In malignant scarlatina happily of infrequent occurrence, the
+child is struck down, as though its blood were poisoned, from the very
+first; and death takes place often within forty-eight hours, the rash
+appearing just sufficiently to stamp the nature of the pestilence which
+has proved so deadly.
+
+It may form a useful conclusion to all that has been said in this little
+book about the diseases of children, if I endeavour to point out in what
+consist the duties of parents in cases of scarlatina, or of any disease
+which resembles it.
+
+1. To watch carefully the commencement of every slight feverish attack
+in which a diffused red rash appears, even though this should be only in
+patches, and to bear in mind the possibility of its being due to
+scarlatina.
+
+2. To remove the child immediately from the others, so long as there is
+any doubt concerning the nature of the case, and to remove with him his
+bed, bedding, and all clothes worn by him at the time when the illness
+began, or the rash appeared.
+
+3. To place the child if possible in a room at the top of the house, so
+that the other children may not pass by his door.
+
+4. Inasmuch as scarlatina often proves fatal to grown persons who have
+not already had the disease, to obtain at once the attendance of a
+skilled nurse, in order to avoid the risk of the disease spreading
+through the household.
+
+The wife belongs to her husband, the husband to his wife; their mutual
+duties are paramount over even those of the parent; and neither has the
+right to jeopardise that life which belongs to the other. To say, 'I
+shall not catch the disease, because I have no fear,' is as idle as it
+would be for the soldier to say, 'Because I am brave, therefore I am
+invulnerable.'
+
+I have been accustomed to insist on the absence from the room of father
+or mother, supposing either of them not to have had scarlatina, so long
+as I could give the assurance that every thing was going on well; but on
+the slightest anxiety I have referred to both parents for their mutual
+decision as to the course which they would choose to adopt.
+
+From a refusal to be guided by this counsel, it has more than once
+happened to me, to see the child recover from mild scarlatina without a
+bad symptom, and the mother who had insisted on nursing the little one
+die of the disease to which she had needlessly exposed herself.
+
+5. So soon as the disease has declared itself as scarlatina, to take up
+the carpets and remove the curtains from the sick child's room, to empty
+the drawers of any clothes which may be in them, and to hang up outside
+the door a sheet moistened with a solution of carbolic acid.
+
+6. To arrange for all food and necessaries to be placed in an adjoining
+room, or at the head of the stairs, so that there may be no direct
+communication between the attendants on the sick and the other inmates
+of the house.
+
+7. To insist on the attendants not wearing either silk or stuff dresses,
+but dresses of some washable material; and on their changing their
+garments as well as scrupulously washing themselves before mixing with
+other inmates of the house, and especially with the children.
+
+8. While in all respects obeying the directions of the doctor, to grease
+the child all over twice in twenty-four hours with suet or lard, to
+which a small quantity of carbolic acid has been added. This proceeding
+both lessens the amount of peeling of the skin in a later stage of the
+disease; lessens the contagiousness of the scales which are detached;
+and, by promoting the healthy action of the skin, diminishes the risk of
+subsequent disorder of the kidneys and consequent dropsy.
+
+9. Even when the case has been of the slightest possible kind, to keep
+the child always in bed for one-and-twenty days. This was a standing
+rule at the Children's Hospital, and I am certain that its
+non-observance will be followed three times out of four by dropsy and
+kidney-disease.
+
+10. When the disease is over, to destroy, if the parents' means at all
+permit it, the clothes and bedding of the child. When this is not
+practicable, to have everything exposed to the heat of superheated steam
+in a Washington Lyons or other similar disinfector, and to have all
+linen boiled as well as washed. Lastly, to have the ceiling whitewashed,
+the paint cleaned, the paper stripped, and the room repapered, as well
+as the floor washed and rewashed with strong carbolic soap.
+
+These precautions are troublesome and costly, but disease is costlier
+still; and who shall estimate the cost of death!
+
+
+
+
+APPENDIX
+
+_ON THE MENTAL AND MORAL FACULTIES IN CHILDHOOD, AND ON THE DISORDERS TO
+WHICH THEY ARE LIABLE._
+
+
+Any remarks on the ailments of children would be incomplete if no notice
+were taken of the mental and moral peculiarities of early life.
+
+For want of giving heed to them, not only are grave mistakes made in the
+education of children, but in the management of their ailments, both by
+doctors and by parents: much needless trouble is given to the doctors,
+much needless distress to the child, much needless anxiety to the
+parents.
+
+The common mistake committed by those parents who do not make their
+child an idol to fall down and worship, and thus turn him, to his own
+misery and theirs, into the most arbitrary of domestic tyrants, is to
+treat him as though he were in mind, as well as in body, a miniature
+man; feebler in intellect as he is inferior in strength, but differing
+in degree only, not in kind.
+
+Now the child differs essentially from the adult in the three respects;
+that
+
+1. He lives in the present, not in the future.
+
+2. His perceptions are more vivid, and his sensibilities more acute;
+while the world, on which he has just entered, surrounds him with daily
+novelties.
+
+3. He has less self-consciousness, less self-dependence, lives as a
+part of the world by which he is surrounded--a real practical pantheist.
+
+The child lives in the present, not in the future, nor much even in the
+past, till the world has been some time with him, and he by degrees
+shares the common heritage of retrospect and anticipation. This is the
+great secret of the quiet happiness which strikes almost all visitors to
+a children's hospital.
+
+No one can have watched the sick bed of the child without remarking the
+almost unvarying patience with which its illness is borne, and the
+extremity of peril from which apparently, in consequence of that
+patience, a complete recovery takes place. Much, indeed, is no doubt due
+to the activity of the reparative powers in early life, but much also to
+the unruffled quiet of the mind. No sorrow for the past, no gloomy
+foreboding of the future, no remorse, disappointment, nor anxiety
+depresses the spirits and enfeebles the vital powers. The prospect of
+death, even when its approach is realised--and this is not so rare as
+some may imagine--brings in general but small alarm. This may be from
+the vagueness of the child's ideas; it may be, as the poet says, that in
+his short life's journey, 'the heaven that lies about us in our infancy'
+has been so much with him, that he recognises more clearly than we can
+do
+
+          'The glories he hath known,
+    And that imperial palace whence he came.'
+
+I dwell on this truth, because it is of great practical moment that we
+should bear in mind to how very large an extent the child lives only in
+the present; because it follows from it that to keep the sick child
+happy; to remove from it all avoidable causes of alarm, of suffering, of
+discomfort; to avoid, as far as may be, any direct struggle with its
+waywardness; and even if death seems likely to occur, to look at it from
+a child's point of view--not from that which our larger understanding of
+good and evil suggests to our minds--are duties of the gravest kind
+which weigh on the parent and the nurse, no less than on the physician.
+
+But not only does the child live in the present far more than it is
+possible for the adult, but there are, besides, other important mental
+differences between the two. Not only is the mind of the child feebler
+in all respects than that of the adult, but, in proportion to the
+feebleness of his reasoning power, there is an exaggerated activity of
+his perceptive faculties, a vividness of his imagination. The child
+lives at first in the external world, as if it were a part of himself,
+or he a part of it, and the gladheartedness which it rejoices us to see
+is as much a result of the vividness with which he realises the things
+around him, as of that absence of care to which it is often attributed.
+This peculiarity shows itself in the dreams of childhood, which exceed
+in the distinctness of their images those which come in later life. It
+shows itself, too, in the frequency with which, even when awake, the
+active organs perceive unreal sounds, or in the dark, at night, conjure
+up ocular spectra; and then not merely colours, but distinct shapes,
+which pass in long procession before the eyes. This power fades away
+with advancing life; except under some conditions of disease, the
+occasional appearance of luminous objects in the dark is the only relic
+with most of us of the gift of seeing visions with which, at least in
+some degree, we were endowed in our early years. The child who dreads to
+be alone, and asserts that he hears sounds, or perceives objects, is not
+expressing merely a vague apprehension of some unknown danger, but often
+asserts a literal truth. The sounds have been heard; in the stillness of
+its nursery the little one has listened to what seemed a voice calling
+it; or, in the dark, phantasms have risen before its eyes, and the agony
+of terror with which it calls for a light, or begs for its mother's
+presence, betrays an impression far too real to be explained away, or to
+be met by hard words or by unkind treatment.
+
+Impressions such as these are not uncommon in childhood, even during
+health. Disorder, direct or indirect, of the functions of the brain,
+more commonly the latter, greatly exaggerates them, and I have known
+them to outlast for many weeks all other signs of failing health after
+convalescence from fevers. The unreal sights are far more common than
+the sounds. The sounds are usually of the simplest kind--as the tinkling
+of a bell, of which we all remember the exquisite use made by Hans
+Andersen in one of his nursery tales; or the child's own name, at
+intervals repeated, just as the little watchful boy heard it in far off
+Judaea, when it was the prelude to a wondrous communication from the
+unseen world. It came to him as he woke from sleep, before the morning
+dawned, while the lamp, lighted overnight, was burning still; and still
+it is so far the same that these occurrences which suggest to us
+problems that we cannot attempt to solve, mostly take place at times of
+transition from the sleeping to the waking state.
+
+The ocular spectra are usually far more vivid and detailed. Those which
+occur in the waking state are by no means always painful, though their
+strangeness not infrequently alarms the child, and his horror at the
+dark arises, not from his seeing nothing, but from his seeing too much.
+
+Some imaginative children amuse themselves with these phantasms, and
+then, if encouraged to relate them, will constantly transgress the
+boundary line between truth and falsehood, and weave their little
+romance. When they happen on waking they are usually preceded by
+frightful dreams, but the image which the child sees then is not the
+mere recollection of the dream, but a new, distinct, though painful
+impression; generally of some animal to which the child points, as now
+here, now there. These night terrors from the very circumstantial
+character of the impressions which attend them, often, as I have already
+said, occasion needless anxiety as to the importance of the cause on
+which they depend.
+
+Sleep-walking in its smaller degrees of getting out of bed at night, is
+by no means unusual in childhood; but the greater degrees of
+somnambulism are certainly rare; and I have always found them dependent
+on undue mental work; not always, indeed, on the tasks being excessive,
+but sometimes on the over-anxiety of the child to make progress. I have
+not yet known a poor person's child a somnambulist.
+
+But not only are the perceptions more acute in childhood than in adult
+life, the sensibilities are more intense. The child's emotions, indeed,
+are often transitory--generally very transitory; but while they last
+they produce results far greater than in the grown person. In the case
+of the latter, recollection of the past, anticipation of the future, or
+even the duties of the present, control the overwhelming sorrow, or call
+forth the energies needed to bear it. The child lives in the present,
+and this present is but the reflection of the world around, its
+impressions uncontrolled by experience, ungoverned by reason.
+
+The broken-heartedness of a child on leaving home is not the expression
+only of intense affection for its friends or relations, it is the shock
+of separation from the familiar objects which have surrounded it; and I
+have not infrequently seen children inconsolable when removed from homes
+that were most wretched, or from relations who were most unkind. Every
+now and then, indeed, I have been compelled to send children home from
+the hospital because no love nor care could reconcile them to the change
+from home; and they have refused to eat, and spent their nights in
+weeping. The feeling is an unreasoning one, like the home-sickness of
+the mountaineer.
+
+But, moreover, sudden shocks may sometimes overthrow the whole moral
+equilibrium, and disarrange the balance of the nervous system so
+seriously as to cause the death of a child previously free from any
+important ailment. Thus, I remember a little boy five years of age who
+died sixteen days after his father's funeral. The strange sad scene
+overcame him, though there had been no special tie between him and his
+father. He shivered violently, became very sick, complained by signs of
+pain in the head, for he had lost his speech, which he regained by slow
+degrees in the course of four or five days. Improvement in other
+respects did not take place, he lay in a drowsy state save when he
+called for his mother, and at length the drowsiness deepened into
+stupor, and so he died. I suppose his mother was right; she said his
+heart was broken.
+
+It behoves us to bear in mind that the heart may break, or the reason
+fail, under causes that seem to us quite insufficient; that the griefs
+of childhood may be, in proportion to the child's powers of bearing
+them, as overwhelming as those which break the strong man down. Every
+now and then we are shocked by the tale that some young child has
+committed suicide, and for reasons which to our judgment seem most
+trivial--from fear of punishment, or even from mere dread of reproof.
+These facts deserve special attention, they show how much more the
+susceptibility and sensitiveness of children need to be taken into
+consideration than is commonly done.
+
+This keenness of the emotions in children displays itself in other ways,
+and has constantly to be borne in mind in our management of them. The
+child loves intensely, or dislikes strongly; craves most earnestly for
+sympathy, clings most tenaciously to the stronger, better, higher around
+it, or to what it fancies so; or shrinks, in often causeless but
+unconquerable dread, from things or persons that have made on it an
+unpleasant impression. Reason as yet does not govern its caprices, nor
+the more intelligent selfishness of later years hinder their
+manifestation. The waywardness of the most wilful child is determined by
+some cause near at hand; and those who love children, and can read their
+thoughts, will not in general be long in discovering their motives and
+seeing through their conduct.
+
+One word more must be said with reference to that intense craving for
+sympathy so characteristic of the child. It is this which often
+underlies the disposition to exaggerate its ailments, or even to feign
+such as do not exist, and in such attempts at deception it often
+perseveres with almost incredible resolution. Over and over again I have
+met with instances where the motives to such deception were neither the
+increase of comfort nor the gratification of mere indolence; but the
+monopolising the love and sympathy which during some bygone illness had
+been extended to it, and which it could not bear to share again with its
+brothers and sisters. This feeling, too, sometimes becomes quite
+uncontrollable, and the child then needs as much care and as judicious
+management, both bodily and mental, to bring it back to health, as
+would be called for in the case of some adult hypochondriac or
+monomaniac.
+
+A caution may not be out of place as to the importance of not
+ministering to this tendency to exaggerated self-consciousness by
+talking of children's ailments in their hearing, or by seeming to notice
+the complaints they make as though they were something out of the common
+way.
+
+It will be observed that throughout I have dwelt more on disorders of
+the moral faculties than of the intellectual powers in childhood, and I
+have done so because I believe them to be the more common and the more
+important. In the feeble-minded the moral sense almost invariably
+participates in the weakness of the intellect; but it is by no means
+unusual for the former to be grievously perverted, while the
+intelligence is in no respect deficient. The moral element in the child
+seems to me to assert its superiority in this, that it is the most
+keenly sensitive, the soonest disordered--
+
+    'Like sweet bells jangled, out of tune, and harsh,'
+
+and the discord is first perceived in the finest notes.
+
+To a very great extent, a mixture of vanity and of a morbid craving for
+sympathy lie at the root of many of those perversions of character
+which excite a parent's anxiety. One of these consists in an
+over-scrupulousness with reference to the right or wrong of actions in
+themselves quite indifferent; in doubts as to whether the morning or
+evening prayer has been properly said, whether something was or was not
+absolutely true, whether this or that peccadillo was a grievous offence
+against God, and so on; and all these little cases of conscience are
+brought by the child several times a day to his mother or to his nurse
+for solution. If listened to readily the child's truthfulness becomes
+inevitably destroyed, and he grows up with a morbid frame of mind, which
+after-life will aggravate almost infinitely.
+
+One knows indeed the history of child saints; but it must be remembered
+that one great characteristic of pre-eminent sanctity at all ages of
+life is reticence, while these little people are perpetually seeking to
+interest others in themselves, their doubts, and feelings. If wisely
+dealt with, not by direct ridicule, but by a wholesome neglect of the
+child's revelations, treating them as of no special interest or
+importance, and discouraging that minute introspection which, of
+doubtful good at any age, is absolutely destructive of the simplicity of
+childhood, this unnatural condition will soon pass away. It will help
+this object very much, if the child is sent on a visit to judicious
+friends, and change of scene, of pursuits, of playmates, and amusements
+will be of all the more service since these morbid states of mind seldom
+come on in children whose bodily health is robust.
+
+Another mode in which the same perverted feelings display themselves is
+in the disposition occasionally noticed to exaggerate some real ailment,
+or to complain of some ailment which is altogether imaginary. So far is
+this from being rare that my experience coincides entirely with that of
+the French physician M. Roger, who has had larger opportunities than
+anyone else in France for observing the diseases of children, and who
+says, 'It must be borne in mind that simulated ailments are much more
+common in the children's hospital than in a hospital for adults.'
+
+It is difficult to assign any sufficient reason for this conduct. Mere
+indolence seems sometimes to be the chief reason for it, oftener vanity;
+the sense of importance in finding everything in the household arranged
+with exclusive reference to itself appears to be the motive for it; and
+this may sometimes be observed to be very powerful even at an
+exceedingly early age. In many instances a morbid craving for sympathy
+is mingled with the love of importance, and both these sentiments are
+not infrequently exaggerated by the conduct of a foolishly fond mother.
+Real illness, however, in almost all these cases exists at the
+commencement, though the child persists in complaining of its old
+symptoms long after their cause has disappeared.
+
+The great difficulty which the doctor meets with in the management of
+these cases arises from the incredulity with which his opinion is
+received. Candour is looked upon as so eminently characteristic of
+childhood, that deceit seems impossible; the case is thought by the
+parents to be an obscure one which the doctor does not understand; and
+therefore it is said, he, with want of straightforwardness and of
+kindness, throws doubts on the existence of disease, and on the
+truthfulness of a most loving, most suffering child. The vagaries of a
+hysterical girl, the fits, the palsy, the half-unconsciousness have all
+been assumed within my own observation by children from ten to fifteen
+years old, and I have more than once had to give place to the ignorant
+and impudent pretender who traded successfully on the feelings of the
+parents. Sometimes, one knows not why, except that the child has got
+tired of the part he was playing, the symptoms that had caused so much
+anxiety suddenly disappear, but even then the habit of mind left behind
+is anything but healthy. Indeed in all cases of this kind it is much
+less the state of the body than that of the mind which excites my
+apprehension. The constant watching its own sensations, the habit of
+constantly gratifying every wayward wish and temper under the plea of
+illness, and the constant indulgence which it too often meets with in
+this from the over-kindness of its parents, exert a most injurious
+influence on its character, and it grows up a juvenile hypochondriac.
+
+A doctor is very unlikely to throw doubt recklessly on the reality of a
+child's illness. His hesitation should certainly not be attributed to
+unworthy motives; the parents should co-operate with him heartily in any
+course of observation which he desires to follow, and if necessary
+another medical man of experience should be associated with the first,
+and allowed to visit the child two or three times. One does not
+associate the idea of moral delinquency with hysteria; the child who
+shams belongs to the same class with the hysterical patient. It is only
+the 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 greatly
+exaggerating or altogether feigning illness, it does not by any means
+always follow that he should at once be charged with it, since it is
+often 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 real
+ailment underlying all the half-unconscious exaggeration, and that if
+spoiling and over-indulgence do much to foster it, sternness and
+punishment interfere with recovery. To turn the thoughts away from self,
+to occupy the mind with new scenes, new amusements, new pursuits, to
+call forth by degrees self-control, and to let the child perceive rather
+by your manner than by what is actually said that the parents have not
+been duped by all his past vagaries; such are the simple means by which
+the little one will be brought round again to health of mind and health
+of body. Unhappily, in the minds of too many people the idea of the
+doctor is associated with the administration of drugs and with nothing
+else; the treatment of disease is of much wider scope; and many of our
+best remedies are those which do not admit of being weighed or measured,
+and whose names are not inscribed on the drawers or bottles in
+Apothecaries' Hall.
+
+Another phase of mental disorder in childhood sometimes presents itself
+as the result of overtasking the intellectual powers. This over-work too
+is by no means due in all cases to the parents' unwisely urging the
+child forward, but it is often quite voluntary on his part. The
+precaution too of limiting the hours of work is often inadequate from
+the want of some provision for turning the thoughts and energies during
+play hours into some perfectly different channel.
+
+In many of these cases Nature happily takes matters into her own
+management. For a year or two, or more, the mind has grown apparently at
+the expense of the body; the parents take a fearful joy in their
+darling's acquirements; and if it should live, think they, of what
+remarkable talents will it not be the possessor! By degrees, the extreme
+quickness of intellect becomes less remarkable; but the body begins to
+increase in robustness; and a year will sometimes suffice to transmute
+the little fairy, so quick, so clever, but so fragile, into a very
+commonplace, merry, rosy, romping child. I may add that it is well to
+bear in mind the converse of this; to remember that body and mind
+rarely grow in equal proportion at one time; that the incorrigible
+little 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 as
+his playmates. A dull mind, and a sickly or ill-developed frame may make
+us anxious: but if the physical development is good, the mind will not
+be likely to remain long below the average standard.
+
+But sometimes, the over-tasked mind leads to mischief which Nature
+cannot rectify; an attack of water on the brain destroys the child, or
+if not it sinks under almost any accidental disease. In other instances
+neither of these results takes place, but the whole nervous system seems
+profoundly shaken, and the moral character of the child seriously, and
+even permanently injured. I remember a quick and clever little girl aged
+five and a half years who was urged on by her governess to work which
+she delighted in, till at length the signs of over-taxed brain showed
+themselves in frequent extreme irritability, and occasional attacks of
+causeless fury amounting almost to madness. It was fully a year during
+which almost all mental work was suspended, while the child was sent to
+have complete change under most judicious management in the country,
+before her mind quite recovered its balance and she became able to
+resume her studies in a very moderate degree.
+
+Cases such as this are instances of the slightest degree of a condition
+which if not remedied may pass into confirmed insanity. I believe the
+gradations to be almost imperceptible by which the one state passes into
+the other; and I have known instances in which the ungovernable temper
+and occasional fury of the child have passed in youth into abiding
+insanity which rendered the patient the inmate, and I fear the permanent
+inmate, of a lunatic asylum.
+
+In whatever circumstances insanity comes on in childhood, and it does
+sometimes, though very seldom, come on independently of any obvious
+exciting cause, it always assumes the character of what has been termed
+moral insanity, or of that condition in which the moral system rather
+than 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 been
+speaking hitherto. The term idiocy, however, is a very wide one,
+including conditions differing remarkably from each other both in kind
+and degree, while not seldom it is misapplied to cases in which there is
+mere backwardness of intellectual power.
+
+=Backward Children.=--_Enfants arrieres_--as the French call
+them--constitute a class by no means seldom met with. They generally
+attain their bodily development slowly, and the development of their
+mind is equally tardy. They cut their teeth late, walk late, talk late,
+are slow in learning to wash and dress themselves, are generally dull in
+their perceptions, and do not lay aside the habits of infancy till far
+advanced in childhood. When the time comes for positive instruction,
+their slowness almost wears out everyone's patience; and among the poor
+indeed the attempt at teaching such children is at length given up in
+despair, and growing up in absolute ignorance, it is no wonder that they
+should be regarded as idiots. Still, dull as such children are, there is
+between 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 the
+whole course of their progress, and his delay increasing every day,
+places at length an enormous distance between him and them--a distance
+which in fact becomes insurmountable.
+
+In some of its minor degrees even, this backwardness not infrequently
+excites the solicitude of parents. It is sometimes observed in children
+who had been ill-nourished in infancy or who had been weakened by some
+serious or protracted illness, even though unattended by any special
+affection of the brain; but it is also met with independent of any
+special cause. The distinction, however, between such a case and one of
+idiocy is this, that though at four years old the child may not seem to
+be intellectually superior to most children at two, yet in manners,
+habits, and intelligence it does agree with what might be expected from
+the child at two; less bright perhaps, less joyous, but still
+presenting nothing which if it were but younger would awaken
+apprehension.
+
+It is well in all cases of unusual backwardness to ascertain the
+condition of the sense of hearing, and of the power of speech, for I
+have known the existence of deafness long overlooked, and the child's
+dulness and inability to speak referred to intellectual deficiency; and
+have also observed mere difficulty of articulation, dependent partly on
+malformation of the mouth, lead to a similar misapprehension. In both
+instances I have seen this inability to keep up ready intercourse with
+other children cast a shadow over the mind, and the little ones in
+consequence be dull, suspicious, unchild-like. I have already referred
+to a similar result as sometimes following serious illnesses. The child
+will for months cease to walk, or forget to talk, if these had been but
+comparatively recent acquirements; or will continue dull and unequal to
+any mental effort for weeks or months together, and then the mind will
+begin to develop itself once more, though slowly, possibly so slowly as
+never altogether to make up for lost ground.
+
+=Idiocy.=--In _idiocy_, however, there is much more than the mere arrest
+of the intellect at any period. The idiot of eight years old does not
+correspond in his mental development to the child at six, or four, or
+two; his mind is not only dwarfed but deformed; while feebleness of will
+is often as remarkable as mere deficiency of power of apprehension. Even
+in earliest infancy there is usually a something in the child idiotic
+from birth which marks him as different from babies of his own age. He
+is 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 perceived
+that the child, though he can see, does not notice; that his eye does
+not meet his mother's with the fond look of recognition, accompanied
+with the dimpling smile, with which the infant, even of three months
+old, greets his mother. Then it is found to have no notion of grasping
+anything, though that is usually almost the first accomplishment of
+babyhood; if tossed in its nurse's arms there seems to be no spring in
+its limbs; and though a strange vacant smile sometimes passes over its
+face, yet the merry ringing laugh of infancy or joyous chuckle of
+irrepressible glee is not heard. As time passes on, the child shows no
+pleasure at being put down 'to feel its feet,' as nurses term it; if
+laid 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 or
+walk till late, and then stands awkwardly, walks with difficulty,
+crossing its legs immediately on assuming the erect posture, an
+infirmity which it often takes years to overcome. Just, too, as the
+idiot is slow to notice, slow in learning to grasp anything, or to stand
+or walk, so he is late in learning to talk, he often acquires but few
+words, for his ideas are few. He learns even these few with difficulty,
+and employs the same to express many different things; he generally
+articulates them indistinctly, often indeed so imperfectly as to be
+almost unintelligible.
+
+In other instances the evidences of idiocy are not present at birth, or
+at any rate are not then noticed, but succeed to some attack of
+convulsions or to some illness attended with serious affection of the
+brain. Sometimes too there is no point in the child's history which can
+be laid hold on as marking the commencement of the weakening of his
+intellect, but as the body grows the mind remains stationary, or its
+powers retrocede, until by degrees the painful conviction that the child
+has become idiotic forces itself upon the unwilling parents. Here we
+have sometimes the sad spectacle of the body perfectly developed, hale
+and 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 a
+weird smile upon its face, looking at its spread-out fingers, or
+stroking a piece of cloth for a quarter of an hour together as though
+the sensation yielded it a kind of pleasure. It would be almost endless
+to describe the various degrees of mental weakness; from the slight
+silliness down to the condition in which the child is, and remains all
+life long, below the level of the brute.
+
+Parents as a rule are anxious to persuade themselves, and to persuade
+the doctor that their idiot child was once as bright and intelligent as
+others; and that the mind was darkened by some grave illness. We have,
+however, the highest authority, that of Dr. Down, for saying that as a
+rule which has but few exceptions idiocy from birth is more amenable to
+training than that which comes on afterwards, that in fact it is more
+hopeful 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 do
+for best and wisest whom the affliction has befallen of having an idiot
+child.
+
+First. To moderate their expectations as to the results of any, even the
+best devised and most successful treatment. The child who has been born
+of weak intellect, or who has become so as the result of illness, will
+always remain at a lower level than others, and this, even though some
+one faculty, as the musical faculty, or the power of calculation, should
+be above the average.
+
+Secondly. From the child's earliest infancy to occupy themselves in
+perfecting as far as possible the physical powers and aptitudes, and the
+habits of cleanliness and order. Development of mind waits on
+development of body: to stand, to sit, to walk, to grasp an object put
+into the hand, are essential to bringing the idiot child into relation
+with the world around it; are its elementary education, to be given
+patiently, cheerfully, lovingly, even for years together. To attend to
+its natural wants, and by fixed routine to accustom it at stated hours
+to empty its bowels and its bladder is a lesson hard to teach; and not
+less difficult is it to make the child learn to masticate its food, to
+drink without slobbering, and then to use the spoon and fork, and to
+feed itself; and afterwards to dress itself, to wash itself, to tie its
+shoestrings; for idiots almost without exception are awkward as well as
+lazy.
+
+The common class of nurses, even the very kindest, find it so much
+easier to feed the child, to wash it, and to dress it, than to teach it
+to do any of these things for itself, that it too often grows up, till
+too old to remain in the nursery, without having made the slightest
+advance above the condition of completest babyhood. It is absolutely
+essential either that the mother should devote herself solely to the
+care and teaching of the idiot, or that she should engage a nurse who
+will have no other duty. Such a person must be above the average in
+education and intelligence, and of course will command more than the
+ordinary wages. The mother, too, must resign herself to the little one's
+affection being transferred in a great degree from herself to the person
+who has constant charge of it--a hard trial this, but one to which, for
+her child's good, she must bring herself to submit.
+
+Thirdly. So soon as the child has been taught at home to exercise these
+lower powers, and the question of what is termed its education arises,
+it is a matter of absolute necessity that he be sent to an institution
+specially set apart for the feeble-minded. It is absolutely impossible
+with the most devoted love and the most lavish expenditure of money, to
+do at home what can be, and is constantly, accomplished even in a pauper
+idiot asylum. The imitative faculty, which is usually very strongly
+marked in the idiot, furnishes one great means of his improvement; while
+besides there are many of the moral powers which cannot be brought out
+except in the society of other children of his own age and not differing
+too widely from him in mental power.
+
+I have warned, and I repeat the warning, against exaggerated
+expectations as to the results of even the wisest treatment. To teach
+cleanliness, order, and neatness; to impart knowledge enough to enable
+the idiot to take care of himself; to develop his affections; to enable
+him to read and write; to practise some easy handicraft; to partake of
+some simple pleasures, and so at length to return to the shelter of his
+own home, and to be there, not an object to be hidden away, too painful
+to look upon, but an object rather of special tenderness, repaying with
+his guileless love the sad self-sacrifice of his parents for many a
+year; these are endeavours almost sure of accomplishment in a
+well-conducted institution, sure never to be realised in a home.
+
+I have often sent afflicted parents, who shrank from parting with their
+children, to one institution near London; and I doubt not there are
+others in England, where pains, and care, and skill, and untiring love
+awake the slumbering intellect, arouse the dormant affections, and work
+miracles 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 BY
+SPOTTISWOODE AND CO., NEW-STREET SQUARE
+LONDON
+
+
+[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.
+
+                            DISCLAIMER
+
+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
+to be construed as a medical advice by Project Gutenberg, its board of
+directors, or its volunteers. Prescriptions should not be applied
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+
+
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+
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+End of the Project Gutenberg EBook of The Mother's Manual of Children's
+Diseases, by Charles West, M.D.
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