Abscess at back of the Throat.—I should pass unnoticed, on account of its rarity, the occasional formation of an abscess at the back of the throat, behind the gullet, interfering both with breathing and with swallowing, but that the description of it in my Lectures once enabled a lady in the wilds of Russia to detect it, to point out the nature of the case to her puzzled doctor, to urge him to open the abscess, and thus to save her child's life.

This abscess may form at any age, sometimes after fever, sometimes without any obvious cause. It shows itself by difficulty in swallowing and breathing, unattended by cough, but accompanied by a sound similar to that of croup, but not so harsh or ringing. The neck is stiff, the head thrown back, and often there is a distinct swelling on one or other side of the neck. The finger introduced into the mouth, and carried over the tongue to the back of the throat, feels there a swelling which projects over the top of the windpipe, and causes the difficulty both in swallowing and breathing. This swelling is the abscess; a prick with the surgeon's lancet lets out the matter, and saves the child.

Diseases of the Kidneys.—The kidneys perform very important duties in carrying off from the system a large amount of useless material, and thus supplement in many respects the action of the skin, and the purifying influence which is exercised by the air on the blood, as it passes through the lungs.

It is evident, therefore, that their disorder in any way must be a matter of serious moment, though at the same time the knowledge of the skilled doctor is needed to determine the nature and degree of the ailment from which they are suffering, since that requires an examination of the urine, both chemically and by means of the microscope. My remarks on these diseases must consequently be few and fragmentary.

In the grown person, what is known as Bright's disease is of frequent occurrence, assumes different forms, and depends on various causes. In the child it is comparatively rare, and is scarcely ever met with except as a consequence of a chill, or as a result of scarlatina. In these conditions the kidneys become overfilled with blood or congested, and the congestion may pass into inflammation, by which their structure may be irreparably damaged. Dropsy is the great outward sign of the affection—either slight swelling of the face, eyelids, and ankles, or very great swelling of all the limbs, and even the abundant pouring out of fluid into the belly. The degree of dropsy is, however, by no means an absolute measure of the amount of kidney mischief. It therefore behoves every parent to follow out all directions most scrupulously even in cases of very slight dropsy, in order to guard against the risk of permanent injury to the kidneys being left behind; and especially to remember the liability to the occurrence of dropsy and disease of the kidneys after scarlatina. Any check to the action of the skin while it is peeling or desquamating, as it is termed, is especially liable to be followed by these accidents. To avoid all risks as far as possible, I have been accustomed for many years to insist on a child remaining in bed for one-and-twenty days after the first appearance of the rash in even the mildest case of scarlatina, and I am absolutely sure that it is the height of imprudence ever to neglect this precaution.

It will suffice to mention the fact that diabetes, though very rare, may yet occur in childhood, and that as a rule it is more dangerous in childhood than in the grown person. Whenever a child loses flesh without obvious cause, suffers much from thirst, and at the same time passes urine in greater abundance than in health, the possibility that it may suffer from diabetes must be borne in mind.

Of far greater frequency than any other affection of the kidney is that in which the child passes gravel with the urine, either in the form of a reddish-white sediment, which collects at the bottom of the vessel as the urine cools, or of minute glistening red particles, which resemble grains of cayenne pepper.

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

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

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

In spite of the suffering which for the time attends it, there is no cause for anxiety with reference to the issue of each attack. The warm bath, a castor oil aperient, and soothing medicine soon relieve the pain, and the children return to their former state of health. It is the frequent return of the attack, even in a comparatively mild form, the persistent disposition to the formation of gravel, the remote risk in the case of male children of stone in the bladder, and the habitually imperfect performance of the digestive functions which call for special care. The avoidance of sugar, sweets, and whatever tends to impart acidity to the urine, the maintaining the due action of the skin by wearing flannel, and the judicious use of alkaline remedies, sometimes combined with iron, are the measures on which the doctor is sure to insist.

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

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

Incontinence of Urine.—The irritation which this mechanical inconvenience produces sometimes has to do with that troublesome infirmity of some children, who wet the bed at night. This may also be induced by a very acid, and consequently irritating, state of urine, either with or without the appearance in it of gravel. Often, however, it is a result of want of care on the part of the nurse, who neglects to cultivate regular habits in a child; and does not pay attention to the quantity of liquid taken at its last meal. Something, too, is due to the fact that the sleep of a child is deeper than that of the grown person, so that the sensation of want, which would arouse the latter to full consciousness, does not have the same effect on the former. It sometimes happens undoubtedly from mere indolence; and this may always be suspected when a child, otherwise healthy, wets itself not at night only, but also in the daytime. Lastly, it does sometimes occur from muscular feebleness in weakly children, the bladder being unable to bear more than a limited degree of distension.

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

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

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



CHAPTER IX.

CONSTITUTIONAL DISEASES.

There remains for consideration a large class of what may be termed constitutional diseases, in which the local ailment is the outcome of a previous disorder of the whole system. These diseases are either acute or chronic. The acute constitutional diseases belong to the class of fevers. These are marked by certain local characteristics, as the swelling of the joints in acute rheumatism, the sore-throat in scarlatina, or the eruption on the skin in smallpox, and their course is more or less strictly limited by distinct periods of increase, acme, and decline. No such rule obtains in the case of consumption, scrofula, and rickets, which are instances of chronic constitutional diseases. In them too the local manifestations of the general disease vary also: the lungs being affected in one case of consumption, the bowels in another; while scrofula may show itself by affection of the glands in one case, by the formation of abscesses in a second, or by disease of the bones in a third.

Chronic Constitutional Diseases.—It may perhaps be convenient to study first the chronic constitutional diseases; and afterwards to make a few, and they will be but few, remarks on fevers.

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

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

A fractured limb may be completely mended; a fluid is poured out around and between the edges of the broken bone; by degrees this hardens, it undergoes changes which convert it into solid bone, and the limb is once more as serviceable as before, though some indications of the fracture may still be perceptible in the texture of the bone itself. Or, a person receives a severe blow on his arm or leg; in course of time the blood which had flowed from the ruptured vessels, and had formed a big bruise, is absorbed, and all is as before the injury was inflicted. If more serious damage has been done, the fibres of some muscles may have been torn, even though the skin remains unbroken. Inflammation is set up, the injured parts die, and are melted down into the matter of an abscess. The abscess discharges itself, its walls contract, the opposite surfaces come into contact, and are welded together again, so that there is no loss of substance, nor anything save a scar on the surface to indicate what has happened.

In the case of the deposits of consumption or scrofula these changes cannot take place. In technical language the matter is said to be incapable of organisation; that is to say, it cannot be transformed by nature's alchemy into anything good or useful. It is rubbish to be got rid of; and the patient's recovery depends on the possibility of getting rid of it. If there is much of it, so as to be removed from the vivifying influence which adjacent living structures still maintain about it, the deposit softens at its centre. This softening gradually extends to the circumference; the mass irritates more and more the parts around it, and where the irritation is greatest the structures yield, and are removed to make a way for its escape, and the patient spits up the contents of the abscess.

But the abscess of the lungs is not like an abscess which follows an injury. It has not formed in the midst of previously healthy parts which are capable of reproducing the original structure; its walls are themselves involved in the disease, and, in accordance with the rule I have already mentioned, 'much will have more,' and the patient goes on spitting up the perpetually renewed contents of the abscess for months or years; until by its gradually increasing size, and the more and more abundant discharge of matter, and further and further destruction of lung-substance, death takes place.

This fatal issue, however, is not invariable. In favourable circumstances, and especially in childhood, the radical constitutional defect may be amended, and with a healthier condition of the blood the unhealthy deposit may cease to take place. The lung-substance, however, with all its curious structure of air-cells and their network of minute vessels where, as in nature's laboratory, the blood receives its due supply of oxygen, is not reproduced. The lung shrinks, the sides of the abscess come together, and by slow degrees a dense material cuts it off from the adjacent healthy structure, but the most complete recovery leaves the patient with his breathing power lessened, and with his vigour consequently more or less impaired.

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

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

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

Three important conclusions follow from what has been said.

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

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

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

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

In the grown person, consumption almost always attacks the lungs, and this often to the exclusion of other organs. In the child, however, this is not so, and though the lungs are indeed oftener affected than other parts, yet in nearly half of the cases some one or other of the digestive organs is likewise involved, and in about one in seven instances the lungs are free and the digestive organs alone are attacked.

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

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

There is a form of cough which is oftenest observed in children between the ages of two and five years, which comes in fits closely resembling those of hooping-cough, and each fit ends in a sort of imperfect 'hoop.' This may depend on a particular form of consumption in which the glands connected with the lungs (the bronchial glands as they are called) are diseased, and not the lung-substance itself. The enlarged glands press on some of the nerves connected with the upper part of the windpipe, and thus occasion the spasmodic cough. Always suspect this when a cough persists for weeks together, not getting rapidly worse as hooping-cough would do, but at the same time not growing better, as would be the case with mild hooping-cough. The doctor on listening to the chest will solve your doubts; the thermometer will help you to decide whether his visit is necessary. I may add that this form of consumptive disease is less serious than that in which the lung-substance is involved.

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

Now and then infants are born with consumptive disease. In that case the lungs are always affected; and the symptoms of fever, cough, and wasting usually show themselves within the first three or four months, and the infants almost invariably die within the year. Now and then, however, an infant thus affected may continue apparently in good health for a few months, and then be suddenly attacked by symptoms of acute inflammation or of severe bronchitis which prove rapidly fatal; and it may be found after death that the acute attack destroyed life because the lungs were already the seat of extensive consumptive disease.

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

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

I have already noticed the connection between water on the brain and consumption. It is indeed nothing else than inflammation excited by the presence of the deposit of consumptive matter in the brain or its membranes.

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

Consumptive Disease of the Bowels.—Consumptive disease sometimes invades the whole system from the very first, while in other instances it attacks from the outset the organs of digestion, and continues throughout to affect them chiefly, and loss of flesh is then one of its earliest symptoms. In instances where there is a strong family predisposition to the disease, consumption of the bowels or mesenteric disease, or disease of the glands of the bowels, all three popular names for the affection, sometimes shows itself at the time of weaning. In the majority of cases, however, it comes on later, after the completion of teething, and between the age of three and ten years. Indigestion such as I have already spoken of sometimes precedes it, with the irregular condition of bowels, and the patchy state of the tongue. But this is by no means constant, scarcely I think general; and not infrequently momentary, causeless, colicky pains precede for a short time any other symptom. In a few weeks after their occurrence, sometimes indeed independently of them, the appetite fails, or becomes capricious; the bowels begin to act irregularly, being alternately constipated and relaxed; and the motions are unnatural in character, being, for the most part, dark, loose, and slimy. Sometimes indeed, they are solid, and then often white, as if from complete inactivity of the liver, and sometimes half-liquid, frothy, and like yeast. One peculiarity which they always present, be their other characters what they may, is their extreme abundance, quite out of proportion to the quantity of food taken, and due to their admixture with the unhealthy secretions from the bowels. The child next becomes restless and feverish at night, its thirst is considerable, and the colicky pains become both more severe and more frequent. Sometimes the stomach grows very irritable, and the food taken is occasionally vomited, while the tongue, in the early stages of the affection, continues for the most part clean and moist, and except that it is often unnaturally red deviates but little from its appearance in health. Next comes a change in the condition of the belly, the date of which varies considerably. It becomes larger than natural, owing to the filling of the bowels with wind, but at the same time it is tense and tender on pressure—two points of great importance to be noticed, and the glands in the groin, which in a healthy child cannot be felt, become enlarged, and are felt and perhaps even seen like tiny beans under the skin.

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

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

Even then, however, there is no ground for despair; for, while consumptive disease in any form is less seldom recovered from in childhood than in after-life, such recovery oftener takes place in cases of affection of the digestive organs than when the disease is seated elsewhere.

Scrofula.—With this word of comfort I leave the subject of consumption, and pass to that of the allied disease scrofula. Briefly stated, two of the great differences between it and consumption are that scrofula is almost entirely limited to childhood and youth, while consumption may occur at any age; and next, that while scrofula attacks the bones and the glands, the skin and the membranes adjacent to it, consumption has its seat in the lungs, the brain, and the internal organs.

Scrofulous diseases of the bones come so exclusively under the observation of the surgeon, that I do not feel myself competent to say anything about them. I would however warn all parents to be very much alive to the importance of noticing the early symptoms of any such diseases, as shown by slight lameness, complaint of pain in the back, or difficulty in moving the hand or arm, or in turning the head or bending the neck. They may be but temporary accidents, due to cold, or to slight muscular rheumatism, or to some sprain not noticed at the time; but they may also be signs of the commencement of scrofulous disease of some bone; and in no disease whatever is early judicious treatment of greater value, or the result of neglect less remediable.

Besides these graver ailments which seldom appear until after the time of infancy has passed, there are others of a less serious nature which often show themselves within the first year of life. One of these consists in the formation beneath the skin of numerous small lumps of a rounded form, and of the size of a kidney-bean, slightly movable, and not tender. By degrees such lumps become adherent to the skin, the surface of which above them grows red, they project slightly above it, and at last open by a small circular aperture, discharge a little matter, and then subside. They collapse and disappear; a slight depression and a degree of lividity of the skin mark for a considerable time the situation they had occupied. I refer to them, because while they are a sign of a scrofulous constitution, which may require special care in diet and preparations of iron and cod-liver oil, they are best left absolutely alone—neither poulticed nor lanced. The same principle of non-intervention applies equally to the swellings which sometimes form on two or three of the fingers in infancy, not involving the joints but producing great thickening and a hard swelling around the bone. These swellings disappear by degrees as the constitutional vigour improves, and this is especially promoted by a long stay at the seaside; but they tend, if the health fails, to affect the bones themselves, and thus to occasion deformities of the hand.

Glandular swelling, discharges from the ear, offensive secretion from the nose, and in female children, even of very tender age, a discharge of whites, are all common signs of a scrofulous constitution, and all tedious and troublesome. They all, however, are very much under the influence of judicious medical treatment. It must at the same time be borne in mind that none of these ailments admit of what may be called active treatment. There are no royal means of dispersing scrofulous glands, or of curing discharges from the ear, or of doing away with the offensive smell which in some cases proceeds from the nostrils. Fresh air, suitable diet, preparations of iron, residence at the seaside, and sea-bathing, measures directed to improve the general health, are of chief value, and without them local treatment is of small avail.

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

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

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

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

Offensive discharge from the nostrils does not depend, in by far the majority of cases, on disease of the bones, but on an unhealthy condition of their lining membrane. It is exceedingly obstinate and difficult of cure, is four times more frequent in girls than in boys, and unfortunately often lasts into womanhood, and continues even when the general health is perfect.

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

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

It must not be forgotten that all these ailments have a special tendency to recur; and that when people say 'Dr. A. or Dr. B. did the child good for the time, but this or that symptom returned as soon as the treatment was discontinued,' as though this were the doctor's fault, they are unjust; for the tendency to return of every form of scrofulous disease is one of the great characteristics of the malady. Patience and perseverance on the parents' part, even for months and years, are often as much needed as skill on the part of the doctor.

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

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

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

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

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

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

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

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

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

Acute Constitutional Diseases.—It still remains for us to glance rapidly at the characters of the acute constitutional diseases, all of which belong, as has already been stated, to the class of fevers. Of them all but two are contagious—that is to say, are capable of being communicated directly from person to person. They are likewise infectious, or, in other words, articles of bedding or clothes which have been worn by the sick, retain a something—an exhalation from the breath, an emanation from the skin, or a secretion from the bowels—which may reproduce the same disease in a person previously healthy.

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

Rheumatic Fever.—The main features of rheumatic fever are the same at all ages. Fever, pain in the limbs, swelling of the joints, sweats unattended by that relief which usually accompanies abundant action of the skin in fevers, are its characteristics. In the child all these symptoms are usually less even than in the adult. The swelling of the joints in particular is less considerable, and both the pain and the swelling are apt to wander from one to another joint, or to a different limb, instead of remaining fixed as they do in the grown person for several days in the same joint, even though fresh joints may be implicated in the course of the disease.

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

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

Ague.—Intermittent fever or ague is very rare in childhood in London; or at any rate it is very rare among children of the wealthier classes. I believe it is everywhere rarer among children than among grown persons, probably because they are as a rule less exposed to those malarious influences which produce it. In the child it generally takes the form of tertian ague, that is to say the attack recurs every second day; one day of freedom intervening between two attacks.

The three stages of shivering, heat, and sweating are less marked in the child than in the grown person, and this indistinctness of its symptoms is greater in proportion to the tenderer age of the child. Shivering is scarcely ever well-marked, a condition of unaccountable depression usually taking its place, while once or twice I have known convulsions occur which gave rise to the apprehension that disease of the brain existed. The hot stage is long, and passes off gradually without the profuse perspiration that occurs in the grown person, and the child even between the attacks is almost always more or less ailing.

A first and even a second attack may puzzle not the parents only, but also the doctor; but after the symptoms have returned a few times, the child being neither better nor worse in the intervals, it becomes evident that no serious disease is impending. The risk of an overhasty conclusion is that the depression and disturbance of the nervous system may be supposed to imply the existence of brain disease; and lead to unsuitable treatment, instead of the administration of quinine, which nine times out of ten proves a specific for ague. The rapid increase of temperature in the attack, and its equally rapid subsidence afterwards, will, if carefully noted, preserve from error.

There is much that is obscure with reference to the nature both of rheumatic and intermittent fever. They differ from other fevers not only by being neither contagious nor infectious but also by their readiness to return, while a single attack of any of the others furnishes a guarantee, and often a complete guarantee, against its recurrence. In addition to these peculiarities, the fevers of which I have now to speak are characterised by running a certain definite course, being accompanied by certain peculiar appearances on the surface (generally rashes on the skin, whence their name of eruptive fevers); being attended each with its own peculiar dangers, and all having a tendency to what is termed epidemic prevalence; that is to say to occur one year, and without obvious cause with vastly greater frequency than in other years.

Mumps.—It has been questioned whether that painful but not dangerous ailment the mumps, ought or ought not to be classed with these fevers. I think it should, for it is contagious, infectious, runs a fairly definite course, is attended with invariable external appearances, often prevails epidemically, and one attack preserves in most instances from a second.

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

The treatment suitable for a severe common cold, together with the constant application of a warm poultice to the swollen gland, is all that is usually required, though the doctor's help is often needed to relieve the suffering which for the first day or two in many instances attends the ailment.

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

The belief in the special character of each of these diseases has received strong confirmation from the researches of the eminent Frenchman, M. Pasteur, and others who have followed in his track. They have discovered in the blood and other secretions, and in some of the tissues both of men and animals, minute microscopic organisms which differ in their characters in different diseases. Experiment has further shown that in some mysterious way these organisms are the cause of these diseases, for on inoculating animals with them the peculiar disease of which each was the accompaniment, and no other, was reproduced in the inoculated animal.

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

We have already seen how, in the course of various diseases, the pulse is quickened, and the temperature raised, constituting that state which we commonly call fever, but as the local ailment subsides the fever disappears. There is, apart from smallpox, measles, and the other so-called eruptive fevers, only one real essential fever commonly met with in childhood, and that is what the doctors call typhoid fever. The name, from the similarity of sound to typhus, from which, however, it is essentially different, has long been a name of terror in the nursery, and all sorts of epithets have been substituted for it, as gastric fever, and infantile remittent fever, and so on. Name it as you may, the fever is one and the same with the typhoid fever, which one hears of as prevailing constantly in many continental cities, and proving dangerous and fatal in any district almost in direct relation to the neglect of drainage and of proper sanitary precautions.

It is extremely rare in infancy, though I saw it once in a babe eight months old, and is comparatively seldom met with before the age of five years. From five to ten years old it is more frequent than from ten to fifteen, but it is consolatory to know that it is less fatal in early childhood than at any subsequent time of life, and that cases of such exceedingly mild character that the child's condition can be more properly described as ailing rather than ill, are then far from uncommon. The symptoms, however, are in all instances similar in kind, though widely varying in degree, and the duration of the fever is, as nearly as may be, three weeks. By this it is not meant that at three weeks' end the child who has had typhoid fever is well again, but only that the temperature, which had hitherto been high, and always higher at night than in the morning, has subsided, that the skin has become less dry, the tongue slightly moist, the intelligence more clear, that the fever has run its course. For the first week or ten days, the symptoms have probably become every day more grave; and for the next ten the doctor could find no better consolation than the assurance—happy if he could give it—that the condition was not worse, but that you must have patience, for the time for improvement had not yet arrived. If the attack has been severe, the child will be left greatly exhausted, sadly emaciated, and suffering from the effects of that ulceration of the bowels which accompanies the fever, and from which life may still be in imminent danger. But the fire is quenched; the question is no longer how to put out the conflagration, but how to repair the mischief it has caused.

When mild, the disease usually comes on very gradually, the child loses its cheerfulness, the appearance of health leaves it, the appetite fails, and the thirst becomes troublesome; in the daytime it is listless and fretful, and drowsy towards evening, but the nights are often restless, and the slumber broken and unrefreshing. The skin is hotter, and almost always drier than natural, or if there is any perspiration, it comes on at irregular times, lasts but an hour or two and brings no refreshing. The thermometer will quite, in the early days, solve all doubt as to the nature of the case. In the morning the thermometer will be natural, or nearly so, but at seven o'clock in the evening it will have risen to 101 deg. or 102 deg., and will continue so during the early part of the unquiet night. After midnight it will begin to fall, and by six o'clock in the morning, or even earlier, will have regained its natural standard. There is no other disease but typhoid fever, and now and then some forms of galloping consumption, in which these oscillations of temperature take place regularly. Other symptoms attend typhoid fever besides these, and serve to stamp upon it its distinctive character. The bowels are usually loose, or if not, a moderate aperient acts on them excessively, the evacuations being loose, often watery, of a light yellow-ochrey colour. The abdomen is full, the bowels being more or less distended with wind, sometimes tender, especially at the right side, and both tender and painful in all cases where the disease is severe. Towards the end of the first, or at the latest by the middle of the second week, small rose-red spots or pimples appear on the abdomen, sometimes also on the chest and back. They disappear for the moment if pressure is made on them, but reappear the moment the pressure is withdrawn. Now and then they are numerous, and sometimes two or three successive crops appear, the old ones fading as the others show themselves; but in childhood they are often scanty, though whether few or many, they are the external characteristic of the disease just as the rash is in scarlatina or measles.

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

When the disease comes on gradually, it seldom becomes dangerous, though until the end of the first week there is always considerable uncertainty on this point. The amount of diarrh[oe]a and the degree of disorder of the brain, as shown by restlessness, delirium, and stupor are the measure of the gravity of any case. There is, however, scarcely any disease from which even when most severe recovery so often takes place in childhood, and this not as persons so often imagine from some critical occurrence but by a process of gradual amendment. The first signs of amendment, too, may be taken as giving almost certain promise of complete recovery; but it is well to bear in mind that there is no disease of early life in which the mental faculties, though time brings them back at length uninjured, remain so long in a state of feebleness and torpor as in typhoid fever. Though the first signs of improvement, too, are very seldom deceptive, yet the patient's convalescence is almost always slow, and interrupted by many fluctuations.

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

It can scarcely be necessary to say that in every, even the mildest, attack of typhoid fever the attendance of the doctor is needed from first to last. He may come every day, and may daily do nothing but merely watch. The disease will run its course, the greatest skill cannot cut it short, though now and then instead of lasting for three or even four weeks it comes to an end spontaneously in fourteen days. Skilled watching is what the competent doctor gives. You would not despise or underestimate the pilot's skill, who steered your barque through a dangerous sea in smoothest water, because he knew each hidden rock or unseen quicksand on which but for his guidance you might have made shipwreck.

Small-pox.—At the present day, thanks to vaccination, and to re-vaccination, small-pox is rarely met with in the well-to-do classes of society, though it is not yet a century ago since it found its victims not only among the poor, but among the highest in the land. It does, however, occur sometimes after vaccination, and sometimes, though very rarely, an attack of small-pox fails to furnish an absolute guarantee against the occurrence of a second.

Small-pox, unmodified by previous vaccination, sets in in the child with violent sickness; vomiting, sometimes recurring frequently for forty-eight hours, with much depression, or even stupor; in some instances even actual convulsions, and fever; but neither with the sore-throat of scarlatina, nor with the sneezing, cough, and running at the nose of measles. At the end of from forty-eight to sixty hours, an eruption of pimples appears on the face, forehead, forearms and wrists, whence it extends to the body and the lower limbs. They are reddish in colour, rather pointed in form, and at first scarcely raised above the surface; so that the eruption looks at first like the very early eruption of measles; though the tiny pimples felt as if beneath the skin serve even then to distinguish the one disease from the other. In another forty-eight hours the character of the pimples has changed into that of little vesicles or pocks, depressed instead of pointed at their centre, and containing a little watery milky fluid. They next enlarge, and become once more prominent at their centre as they fill more and more with fluid, which becomes thicker, yellowish-white—looks like, and indeed is, matter. Four or five days are occupied with this process; the matter in the pocks then begins to dry, and scabs to form, which gradually by the end of another week drop off, and leave the skin spotted with red or even scarred if the pocks went deep enough to destroy the skin, and to leave the indelible marks, the so-called pitting of small-pox.

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

The first outbreak of the eruption is followed always by a most remarkable abatement in the disturbance of the constitution, and for three or four days, even though the eruption is abundant, the patient may seem so well that it is almost impossible to realise the imminent peril to which he will be exposed in a few days' time.

Inoculation and Vaccination.—The danger of small-pox is in direct proportion to the abundance of the eruption; and the great advantage of inoculation for the small-pox consisted in the much scantier eruption which followed it, as compared with that which commonly took place in the natural small-pox.

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

The great advantage which inoculation secured was counterbalanced in great measure by the fact that it always maintained small-pox rife throughout the whole country, and that consequently all who either had neglected inoculation, or young children on whom, on account of their tender age, it had not yet been practised, were more than ever exposed to constant risk of infection.

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

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

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

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

This knowledge was more recently applied by the distinguished Frenchman whom I have already mentioned, M. Pasteur, in the case of a fatal pestilence among sheep in many parts of France, known by the name of charbon. The inoculated sheep died, however, in such large numbers, though in a somewhat smaller proportion than those who had been directly infected, that he found it necessary to weaken the matter which he employed by admixture with other innocuous materials. This experiment, however, again yielded unsatisfactory results; slight symptoms of the disease were produced, but the protection thus afforded was inadequate and uncertain. Some few resisted the disease, but others contracted it and died. With that clear insight which constitutes genius, M. Pasteur next tried the experiment of inoculating the sheep first with a weak matter which produced but slight symptoms, but at the same time enabled the animal to support a second inoculation with a stronger matter; and this second inoculation enabled them to bear, unharmed, subsequent exposure to the disease. A grateful country has given a pension, and conferred well-merited honours on the man who has preserved their flocks from pestilence, but whom the silly sentimentality of the anti-vivisectionists in England would have mulcted in a fine, and, if possible, have sent to prison.

That weakening of the poisonous element which Pasteur strove to attain by art, is already provided by nature in the cow-pox. The cow-pox is nothing else than small-pox modified in character, diminished in severity by passing through the system of the animal; but giving, when introduced into the system, a safeguard against natural small-pox at least as complete as that furnished by the inoculated disease.

More than 70,000 children have come under my observation, either in hospital or in private practice; and I need not say that a physician having much consulting practice sees far more than the average of unusual and severe cases. Twice, and only twice, I have seen infants die from vaccination, and in both instances death took place from erysipelas beginning at the puncture. The one case I saw twice in consultation with the family practitioner. The other which I watched throughout was that of a little boy, the fifth child of a nobleman of high rank, both his parents being perfectly healthy. He was vaccinated by the family doctor in the country, direct from the arm of another perfectly healthy infant, from whom ten other infants were vaccinated immediately afterwards. The little boy was seized with convulsions within twenty-four hours, and almost at the same time erysipelas appeared on the punctured arm. The erysipelas extended rapidly, convulsions returned more than once, and on the fourth day from the vaccination the child died. One of the other children vaccinated at the same time died in the country in the same manner; all the others passed through vaccination regularly, and without a single bad symptom. I have no explanation to offer; this case stands by itself just as do those of death from the sting of a bee or death from cutting a corn.

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

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

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

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

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

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

A thoroughly dispassionate review of the whole subject appears to me to warrant the following conclusions:—

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

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

3rd. That to such careless performance and to the introduction of the blood and not of the vaccine matter alone, from one child to another are due the extremely rare instances in which one special disease has been transmitted by vaccination.

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

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

6th. That in either case it is expedient that vaccination be performed within the first three months after birth, so as to avoid the irritation of teething which is unfavourable to successful vaccination, and also because the disposition to those skin diseases which vaccination tends to aggravate is never so considerable before the age of three months as it becomes subsequently.

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

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

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

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

It is highly contagious, and for this reason perhaps it is usually met with in infancy and early childhood. Sometimes, though by no means constantly, the eruption is preceded for twenty-four or thirty-six hours by slight feverishness; but oftener the appearance of the rash is the first indication of anything being the matter. It shows itself in the form of small pimples, which in a few hours change into small circular pocks containing a little slightly turbid fluid. They appear on the forehead, face, and body, but very rarely on the limbs; they enlarge for some two or at most three days, then shrivel and dry up; and at the end of a week the crusts or scabs fall off, scarcely ever causing any permanent pitting of the skin. They are usually not above twenty or thirty in number, though every now and then they are much more numerous without any obvious reason. Their distinction from the small-pox eruption consists not only in the smaller size of the pocks, and in the entirely different course which they run, but also in the fact that two or three successive crops of the eruption appear in the course of five or six days, so that new ones, those at maturity, and those on which the crusts have already formed, or from which they have already fallen, may be seen on the child at the same time. This is sufficient of itself to establish the difference between the two diseases, and also to distinguish between chicken-pox and the milder variety of small-pox which is sometimes observed in children who have been already vaccinated.

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

The early symptoms of measles are those of a bad feverish cold; the eyes grow red, weak, and watery, and are unable to bear the light, the child sneezes very frequently, sometimes almost every five minutes, and is troubled by a constant short dry cough. About the fourth day, a rash makes its appearance on the face, forehead, and behind the ears, and in the course of the next forty-eight hours travels downwards over the body and limbs, and then in another forty-eight hours it fades in the same way, being at its height on the body when it has already begun to disappear from the face. It first shows itself in the form of small red circular spots, not unlike fleabites, but very slightly raised above the somewhat reddened skin, and looking for a few hours not unlike the very early stages of small-pox, before the eruption has lost the character of minute pimples. On the face the spots sometimes run together, and then form irregular blotches about a third of an inch long by half that breadth; while elsewhere they present an irregular crescentic arrangement. As the rash fades it puts on a dirty yellowish red appearance; the surface of the skin often becomes slightly scurfy, and it continues somewhat stained of a reddish hue for some days after the eruption has disappeared.

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

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

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

German Measles.—There is a disorder which seems to hold a middle place between measles and scarlatina, akin to both, identical with neither, and furnishing no sort of protection from their occurrence.

It is known in this country by the name of German measles, or sometimes by its German name of Roetheln; the first clear description of its character having been given by German writers.

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

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

Slight feverishness sometimes precedes the appearance of the rash for twenty-four hours; but the cough, and sneezing, and running at the eyes and nose, which usher in measles are entirely absent. The rash usually appears in the course of twenty-four hours, is never postponed beyond the second day; it begins, like that of measles, on the face, and, like it, travels downwards, but always disappears on the third day, while that of measles is not entirely gone before the eighth or ninth. The rash itself also has a different character. It consists of small, slightly elevated, round red spots which now and then coalesce into small patches, but never have the somewhat crescentic arrangement observed in the rash of measles. The colour of the spots is somewhat darker than that of the eruption of measles, while the skin between them remains pale, and does not assume the flush of measles. As it disappears it simply fades, and does not at all change its tint as that of measles does, and it leaves the skin unroughened.

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

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

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

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

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

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

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

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

The rash often makes its appearance within twenty-four hours after the commencement of the illness, at latest in the course of the second day. It usually shows itself first on the neck, breast, and face, whence it extends in twenty-four hours to the body and limbs, and is then not seldom specially vivid on the inside of the thighs. Its colour is a very bright red, due in part to a general flush of the skin, in part to the presence of innumerable red dots or spots, which do not communicate any sense of roughness to the hand, though now and then extremely minute red pimples are interspersed. For three days the rash usually continues to become of a deeper colour, and more generally diffused over the whole surface; it then slowly declines, but does not wholly disappear until the seventh or eighth day of the disease. As the rash subsides the skin is left rough, and by degrees scales off, often in large flakes from the hands and feet, but elsewhere in a sort of branny scales. Sometimes this process is over in five or six days, while in other cases the skin peels and is reproduced several times in succession, so that it is protracted for three or four weeks or even longer. The degree of this peeling also varies as well as its duration. It is usually most considerable where the rash has been most abundant, while where the rash has been scanty, it is sometimes scarcely apparent except at the tips of the fingers and toes and just around the insertion of the nails.

Besides the rash there are commonly other symptoms not less characteristic of scarlatina, and among them the sore-throat is one of the most invariable. Even in mild cases, it is very rarely absent, and if not present at the beginning, it comes on on the second or third day. The palate and tonsils, in these circumstances are red, and the latter are usually more or less swollen, while swallowing is attended with pain, or at any rate with discomfort. The redness of the palate, which extends also to the back of the throat, is a finely spotted redness closely resembling the rash on the surface. The tongue is coated with a thick white or yellowish coating, through which project numerous bright red points, papillae as they are called, and this appearance of the tongue is as distinctive of scarlatina as the rash itself. Later, as the rash begins to fade, the coating separates from the tongue, which is left of a bright red colour, looking raw and shining, with the little raised red points projecting beyond its surface, and constituting what has been called in medical language, the strawberry tongue.

When all these symptoms are present, no one can doubt but that the case is one of scarlatina. But the decision is far less easy in mild cases, for in them the rash is sometimes extremely evanescent, the general disturbance of health very slight, and the fever and accompanying rise of temperature small. The risk in such circumstances of the disease being altogether overlooked is even greater than that of its being confounded with some other eruptive fever. The rash of measles cannot be confounded with that of scarlatina, and the distinctly spotty character of the rash of German measles ought, apart even from other differences, to render mistake impossible.

Perhaps the best rule that can be laid down is that every diffused red rash, not obviously formed by distinct spots, even though it be not uniform but appears in patches on the neck, breast, back, or inside of the thighs, and persists for more than twelve hours, is scarlatinal. Further, that in any instance in which even very slight feverishness, or very slight sore-throat, have preceded or accompanied the rash, the nature of the ailment is stamped beyond the possibility of doubt. Mistakes are made from want of careful observation, much more than from any insuperable difficulty in distinguishing one disease from the other. When the least hesitation is felt as to the nature of any rash which may appear on a child, with, or without previous illness, the question should be at once referred to a medical man. People are too apt in these circumstances to wait for a few days, and then to appeal to the doctor when all traces of rash have disappeared, and when the grounds no longer exist on which he could base a positive opinion.

I need not describe the symptoms of severe and dangerous scarlatina, for long before symptoms become really formidable, the patients will have been placed under medical care. It may suffice to say that the danger is almost always in proportion to the severity of the throat-affection and swelling of the glands, and not at all in proportion to the abundance of the rash. Though severe cases usually set in with severe symptoms, yet this is not invariably the case, and medical watching is all the more necessary from the very commencement, since until the end of the first week it is impossible to calculate on the subsequent course of the disease. In malignant scarlatina happily of infrequent occurrence, the child is struck down, as though its blood were poisoned, from the very first; and death takes place often within forty-eight hours, the rash appearing just sufficiently to stamp the nature of the pestilence which has proved so deadly.

It may form a useful conclusion to all that has been said in this little book about the diseases of children, if I endeavour to point out in what consist the duties of parents in cases of scarlatina, or of any disease which resembles it.

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

2. To remove the child immediately from the others, so long as there is any doubt concerning the nature of the case, and to remove with him his bed, bedding, and all clothes worn by him at the time when the illness began, or the rash appeared.

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

4. Inasmuch as scarlatina often proves fatal to grown persons who have not already had the disease, to obtain at once the attendance of a skilled nurse, in order to avoid the risk of the disease spreading through the household.

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

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

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

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

6. To arrange for all food and necessaries to be placed in an adjoining room, or at the head of the stairs, so that there may be no direct communication between the attendants on the sick and the other inmates of the house.

7. To insist on the attendants not wearing either silk or stuff dresses, but dresses of some washable material; and on their changing their garments as well as scrupulously washing themselves before mixing with other inmates of the house, and especially with the children.