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.