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.