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diff --git a/29701.txt b/29701.txt new file mode 100644 index 0000000..6f636af --- /dev/null +++ b/29701.txt @@ -0,0 +1,9010 @@ +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. 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