CHAPTER IX. 173

Constitutional diseases -- Their nature -- Chronic constitutional

diseases -- Consumption -- Scrofula -- Rickets -- Acute

constitutional diseases -- Rheumatic fever -- Ague -- Mumps --

Typhoid fever -- Small-pox -- Inoculation and vaccination --

Chicken-pox -- Measles

APPENDIX. 213

Mental and moral faculties in childhood, and the disorders to which

they are liable

INDEX 231

THE MOTHER'S MANUAL

OF

CHILDREN'S DISEASES.

PART I.

_INTRODUCTORY._

CHAPTER I.

ON THE MORTALITY OF CHILDREN, AND ITS CAUSES.

The purpose of this little book will probably be best attained, and

needless repetition best avoided, if we begin by inquiring very briefly

why so many children die, what general signs indicate that they are ill,

and what general rules can be laid down for their management in

sickness.

The first of these inquiries would be as useless as it would be sad, if

the rate of infant mortality were fixed by determinate laws, such as

those which limit the stature of man or the age to which he can attain.

But this is not so; the mortality in early life varies widely in

different countries, in different parts of the same country, and in the

same country at different times. Thus, while in some parts of Germany

the mortality under one year was recently as high as 25 to 30 per cent.

of the total births, and in England as 15, it was only a little above 10

per cent. in Norway. Infantile mortality is higher in manufacturing

districts, lower in those which are agricultural, and varies from 16 per

cent. in Lancashire to 9 in Dorsetshire. It is then evident that

mortality in infancy is in part dependent on remediable causes; and of

this there is no better proof than the fact that the mortality in

England under one year has been reduced from 15 per cent. in 1872 to 13

per cent. in 1882.

It would lead us far from any practical purpose if we were to examine

into all the causes which govern the liability to disease and death

during infancy and childhood, in the different ranks of society. We must

therefore limit our inquiry to those conditions which are met with in

the class to which my readers may fairly be assumed to belong.

_First_ among the causes of sickly infancy and premature death may be

mentioned the intermarriage of near relatives. The experience of the

breeders of animals, who, by what is termed breeding in and in,

undoubtedly obtain certain qualities of speed, or strength, or beauty,

does not apply here. They select for their experiments animals whose

qualities in these respects are pre-eminent, and eliminate from them all

who do not occupy the first rank. In family intermarriages, however, it

is rare that any consideration is regarded, save that of wealth; and the

fact remains, explain it as we may, that the intermarriage of near

relatives during several successive generations is followed by a marked

deterioration of the children, physical, mental, and moral; and by the

intensifying of any hereditary predisposition to consumption, scrofula,

and other constitutional ailments which form the _second_ great cause of

early sickness and mortality.

These are facts known to all, which yet it is not easy to represent by

figures. All the world is aware that consumption is hereditary, that

consumptive parents are more likely than others to have consumptive

children; and a fourth of all the patients admitted into the Hospital

for Consumption at Brompton stated that the disease had existed in one

or other of their parents.[1] Scrofula, which is another disease closely

allied to consumption, is hereditary also; and hip disease, disease of

the spine, abscesses, and enlarged glands in any members of a family,

point to risks for the offspring which should not be forgotten, how much

soever mental endowments, personal beauty, or the charms of disposition

may be considered, and sometimes reasonably enough, to outweigh them.

The same liability exists with reference to epilepsy, insanity, and the

whole class of affections of the nervous system. Parents inquire, with

no misplaced solicitude, what is her fortune, or what are the pecuniary

resources of him to whom they are asked to entrust their son's or

daughter's future. Believe me, the question--what is the health of his

family, or of hers? is consumption hereditary, or scrofula, or epilepsy,

or insanity?--is of far greater moment, and touches much more nearly the

future happiness of those we love.

These two points regard the future parents themselves; but there are

other conditions on which the health of children to a great degree

depends; and of these the two most important are the _dwelling_ they

inhabit, and the _food_ they eat.

I do not refer here to the dwellings of the poor, situated in unhealthy

localities, where fresh air does not enter, where the rays of the sun do

not penetrate, with defective drainage and imperfect water-supply; but I

speak of the nurseries of well-to-do people. 'This will do for our

bedroom, and that will make a nice spare room, and that will do for the

children,' is what one often hears. Had you rare plants which cost much

money to obtain, which needed sunlight, warmth, and air, would you not

consider anxiously the position of your conservatory, and take much

pains to insure that nothing should be wanting that could help their

development, so that you might feast your eyes upon their beauty, or

delight yourselves with their fragrance? And yet a room at the top of

the house, one of the attics perhaps, is too often destined for the

little one and its nurse; or if there are two or three children, one

small room is set apart for the day nursery, and a second, probably with

a different aspect, for a sleeping room, and so small that it does not

furnish the needed five hundred cubic feet of air for each. And as a

consequence, the children are ailing, any predisposition in them to

hereditary disease is fostered, they have no strength to battle against

any acute illness that may befall them, and yet surprise is felt that

the doctor is never out of the house.[2]

It is needless to dwell on the hand-feeding of infants as one of the

great causes of mortality in infancy, and of sickliness in later life.

The statistics of Foundling Hospitals bear sad testimony to the fact of

its dangers, and the researches of physicians show that a peculiar form

of disease is produced by it, attended by symptoms, and giving rise to

appearances after death, peculiar to the form of slow starvation from

which the infant has perished. I will add, because it is not generally

known, one fresh illustration of the influence of artificial feeding in

aggravating the mortality of infants. In Berlin the certificates of

death of all infants under the age of one year, are required to state

whether the little one had been brought up at the breast, or on some

kind or other of artificial food. Of ten thousand children dying under

the age of one year, one-fourth had been brought up at the breast,

three-fourths by hand.[3]

It is, as I said in the preface, no part of my plan to enter on any

details with reference to the management of children in health. It may,

therefore, suffice to have pointed out the four great causes of

preventible disease among the wealthier classes of society; namely, the

intermarriage of near relatives, the transmission of constitutional

taint, the insanitary condition of the dwelling, and the injudicious

selection of the food of the infant.

FOOTNOTES:

[1] This is the proportion stated in Quain's _Dictionary of Medicine_,

to which the writer, Dr. Theodore Williams, adds that of 1,000 cases in

the upper classes 12 per cent. showed direct hereditary predisposition,

and 48 per cent. family predisposition.

[2] Many useful suggestions will be found in Mrs. Gladstone's little

tract, _Healthy Nurseries and Bedrooms_, published as one of the Health

Exhibition Handbooks.

[3] The actual numbers are 2,628 and 7,646. See _Generalbericht ueber

das Medizinal-und Sanitaetswesen der Stadt Berlin im Jahre 1881_. 8vo.

Berlin 1883, p. 19.

CHAPTER II.

THE GENERAL SIGNS OF DISEASE IN INFANCY AND CHILDHOOD.

The signs of disease at all ages may be referred to one or other of

three great classes: disorder of function, alteration of temperature,

complaint of pain.

In the infant it is the last of these which very often calls attention

to the illness from which it is suffering. Cries are the only language

which a young baby has to express its distress; as smiles and laughter

and merry antics tell without a word its gladness. The baby must be ill,

is all that its cries tell one person; another, who has seen much of

sick children, will gather from them more, and will be able to judge

whether its suffering is in the head, or chest, or stomach. The cries of

a baby with stomach-ache are long and loud and passionate; it sheds a

profusion of tears; now stops for a moment, and then begins again,

drawing up its legs to its stomach; and as the pain passes off,

stretches them out again, and with many little sobs passes off into a

quiet sleep. If it has inflammation of the chest it does not cry aloud,

it sheds no tears, but every few minutes, especially after drawing a

deeper breath than before, or after each short hacking cough, it gives a

little cry, which it checks apparently before it is half finished; and

this, either because it has no breath to waste in cries, or because the

effort makes its breathing more painful. If disease is going on in the

head, the child utters sharp piercing shrieks, and then between whiles a

low moan or wail, or perhaps no sound at all, but lies quiet, apparently

dozing, till pain wakes it up again.

It is not, however, by the cry alone, or by any one sign of disease,

that it is possible to judge either of its nature or of its degree, but

the mention of this serves merely as an illustration, which anyone can

understand, of the different meanings that even a baby's cry will convey

to different persons.

When a child is taken ill, be the disease from which it is about to

suffer what it may, there is at once a change from its condition when in

health, such as soon attracts the attention even of the least observant.

The child loses its appetite, is fretful and soon tired, and either very

sleepy or very restless, while most likely it is thirsty, and its skin

hotter than natural. In many instances, too, it feels sick or actually

vomits, while its bowels are either much purged or very bound. If old

enough to talk, it generally complains of feeling ill, or says that it

has pain in some part or other, though it is by no means certain that a

little child has described rightly the seat of its pain; for it very

often says that its head aches or that its stomach aches, just because

it has heard people when ill complain of pain in the head or in the

stomach. Some of these signs of illness are, of course, absent in the

infant, who can describe its feelings even by signs imperfectly; but the

baby loses its merry laugh and its cheerful look; it ceases to watch its

mother's or its nurse's eye as it was used to do, though it clings to

her more closely than ever, and will not be out of her arms even for a

moment; and if at length rocked to sleep in her lap, will yet wake up

and cry immediately on being placed in its cot again.

Symptoms such as these are sure to awaken the mother's attention to her

child, and the child's welfare and the parent's happiness alike depend,

in many instances, on the way in which she sets about to answer the

question, 'What is the matter?'

Some mothers send at once to the doctor whenever they see or fancy that

anything ails their child. But this way of getting rid of responsibility

is not always possible, nor, indeed, on moral grounds, is it always

desirable, for the mother who delegates each unpleasant duty to another,

whether nurse, governess, or doctor, in order to save herself trouble or

anxiety, performs but half a mother's part, and can expect but half a

mother's recompense of love.

Whenever a child is unwell, a mother may do much to ascertain what is

the matter, and may by the exercise of a little patience and common

sense save herself much needless heart-ache, and her child much

suffering.

The first point to ascertain is the presence or absence of fever; that

is to say, whether, and how much, the temperature of the body is higher

than natural. If the temperature is not higher than natural, it may be

taken as almost certain that the child neither has any inflammatory

affection of the chest, nor is about to suffer from any of the eruptive

fevers. The temperature, however, cannot be judged of merely by the

sensation conveyed to the hand, but must be ascertained by means of the

thermometer.[4] In the case of the grown person the thermometer is

placed either under the tongue, the lips being closed over it, or in the

armpit, and is kept there five or six minutes. In young children,

however, neither of these is practicable, and I prefer to place the

instrument in the groin, and crossing one leg over the other, to

maintain the thermometer there for the requisite five minutes. The

temperature of the body in health is about 98.5 deg. Fahr. in the grown

person, and very slightly higher in childhood; but any heat above 99.5 deg.

may be regarded as evidence that something is wrong, and the persistence

for more than twenty-four hours of a temperature of 101 deg. and upwards,

may be taken as almost conclusive proof of the existence of some serious

inflammation, or of the onset of one of the eruptive fevers.

At the same time it is well to bear in mind that temporary causes, such

as especially the disorders produced by over-fatigue, or by an

over-hearty or indigestible meal, may suddenly raise the temperature as

high as 102 deg., or higher, but the needed repose or the action of a

purgative may be followed in a few hours by an almost equally sudden

decline of the heat to the natural standard.

It is well to learn to count the pulse and the frequency of the

breathing; but to do the former accurately, requires practice such as is

hardly gained except by hospital training; and indeed, with few

exceptions, the value of the information furnished by the pulse is less

in the child than in the adult. The reasons for this are obvious, since

the rapidity of the circulation varies under the slightest causes, and

the very constraint of holding the sick child's hand makes it struggle,

and its efforts raise the frequency of the heart-beats by ten or twenty

in the minute. The place at which to seek the beat of the pulse is at

the wrist, just inside and below the protuberance of the wrist-bone; but

if the child is very fat it is often difficult to detect it. When

detected it is not easy to count it in early infancy, for during the

first year of life the heart beats between 120 and 130 in the minute,

diminishing between that age and five years to 100, and gradually

sinking to 90 at twelve years old. In proportion, moreover, to the

tender age of the child, is the rapidity of its circulation apt to vary

under the influence of slight causes, while both its frequency and that

of the breathing are about a third less during sleep than in the waking

state.

The frequency of the breathing is less difficult to ascertain, while at

the same time it furnishes more reliable information than the pulse.

This is best tested when the child is asleep, remembering always that

the breathing is then slower than in the waking state. The open hand,

well warmed, should be laid flat and gently over the child's night-dress

on the lower part of the chest and the pit of the stomach. Each heaving

of the chest, which marks a fresh breath being taken, may be counted,

and the information thus obtained is very valuable. Up to the age of two

years the child breathes from 30 to 40 times in a minute, and this

frequency gradually declines to from 25 to 30 till the age of twelve,

and then settles down to from 20 to 25 as in the grown person. You would

thus know that a sleeping infant who was breathing more than 30 times,

or a child of five who breathes more than 25 times, has some ailment in

its chest, and that the doctor should be sent for in order to ascertain

its exact nature.

It would answer no good purpose to give a description of the information

to be obtained by listening to the chest. To learn from this, needs the

well-trained ear; and harm, not good, comes from the half-knowledge

which serves but to lead astray.

A child may be very suffering, seem very ill, and its suffering and

illness may depend on pain in the stomach owing to indigestion,

constipation, or even to an accidental chill. After early infancy it is

not difficult to make out the seat of the child's suffering: the warm

hand placed gently on its stomach will soon ascertain whether it is

tense or tender, whether the tenderness is confined to one particular

spot, or whether it is more acute at one spot than at another; and,

lastly, whether, as is the case when pain is produced by wind in the

intestines, the pain and tenderness are both relieved by gentle rubbing.

In the young infant the character of the cry will, as I have already

said, give some clue to the seat of its pain, while, if you lay it down

in its cot or in its nurse's arms in order to examine its stomach, it

will often resist and begin to cry. Its stomach then becomes perfectly

tense, and you cannot tell whether pressure on it causes pain or whether

the cries are not altogether the consequence of fretfulness and fear. It

is therefore the best plan to pass your hand beneath the child's clothes

and to examine its stomach without altering its posture, while at the

same time the nurse in whose arms it is talks to it to distract its

attention, or holds it opposite the window, or opposite a bright light,

which seldom fails to amuse an infant. If there is no tenderness of the

stomach the child will not cry on pressure; or if during your

examination the presence of wind in the intestines should occasion pain,

gentle friction, instead of increasing suffering, will give relief.

The one thing which still remains to do, especially in the case of

children in whom teething is not over, is to examine the mouth and

ascertain the state of the gums, since some ailments are caused and

others are aggravated by teething. A wise mother or an intelligent nurse

will teach the child when well the little trick of putting out its

tongue and opening its mouth to show its teeth when told to do so; and

though it may sometimes indulge rather out of place in these

performances when wished to behave especially prettily before strangers,

yet when older it will quickly learn the proprieties of behaviour, and

in the meanwhile you profit much by the lesson when illness really

comes.

Sometimes, however, infants who when well will open their mouth and

allow their gums to be felt without difficulty, refuse to do so when

ill; and it is always desirable that the mother or nurse whose duty it

is to tend the sick child constantly, should not frighten it, or lose

its confidence, by doing forcibly that which the doctor who comes

occasionally may yet be quite right in doing. You will, however,

generally get a good view of the mouth and throat in young infants by

gently touching the lips with your finger: the child opens its mouth

instinctively, and then you can run your finger quickly over its tongue,

and drawing it slightly forward perfectly see the condition of the

throat, feel the gums as you withdraw your finger, and notice the

appearance of the tongue. Sometimes it is important to ascertain whether

a tooth which was near coming through has actually pierced the gum, and

yet the child's fretfulness renders it almost impossible to induce it to

open its mouth. If now, while the nurse holds the child in her arms, you

go behind her, you can, unseen and unawares, introduce your finger into

its mouth and ascertain all you wish to know before the little one has

recovered from its surprise.

I have but little to say here about the general signs of brain disease

in infancy and childhood, because they will need minute notice

afterwards. All that I would at present observe is, that you must not at

once conclude that a child's head is seriously affected, because it is

heavy and fretful and passionate, and refuses to be amused. The head, as

we know by our own experience, suffers by sympathy in the course of

almost every ailment, certainly of every acute ailment, at all ages. If

the babe is not sick; if its bowels can be acted on by ordinary means;

if, though drowsy, it can be roused without difficulty; if, though it

may prefer a darkened room, it does not shrink from the light when

admitted gradually; if it has no slight twitchings of its fingers or of

its wrists; if the head, though hot, is not hotter than the rest of the

body; if the large vessels of the neck, or the open part of the head, or

fontanelle as it is termed, in an infant in whom the head is not yet

closed, are not beating violently; and, above all, _if when it cries it

sheds tears_, you may quiet your mind on the score of the child's brain,

at any rate until the doctor's visit, and may turn a deaf ear to the

nurse or the friend who assures you that the child is about to have

convulsions or to be attacked by inflammation of the brain.

FOOTNOTES:

[4] The thermometer used for this purpose, called a _clinical_

thermometer, may be bought for about twelve shillings, of any chemist or

instrument-maker, and its mode of employment can be learned in five

minutes. No mother should be without it.

CHAPTER III.

THE GENERAL MANAGEMENT OF DISEASE IN INFANCY AND CHILDHOOD.

The management of the child when ill is difficult or easy in exact

proportion to whether it has been ill or well managed when in health.

The mother who lives but little with her children, who contents herself

with a daily visit to the nursery, and who then scarcely sees her little

ones until they are brought into the drawing-room in the evening in full

dress, to be petted and admired and fondled by the visitors, cannot

expect to take her place by the child's bed in its sickness, to soothe

its pain, and to expend upon it all the pent-up tenderness which, in

spite of the calls of business or of pleasure, still dwells within her

heart. She must be content to see the infant turn from her to the nurse

with whose face it has all its life been familiar; or to hear the little

one tell her to go away, for her presence is associated with none of

those 'familiar acts, made beautiful by love,' which win the young

heart: the mother is but a stranger who brings no help, who relieves no

distress. Happy such a mother if she has found a conscientious and

intelligent nurse to whom she can delegate her office; but she must

remember that with the child, love follows in the steps of daily, hourly

kindnesses, that a mother's part must be played in health if it is to be

undertaken in sickness, that it cannot be laid down and taken up again

at pleasure.

There is another mother who cannot nurse her child to any good purpose,

she who when it was well spoilt it from excess of love, who has yielded

to each wayward wish, and has allowed it to become the petty tyrant of

the household. The child is ill, it is languid, feverish, and in pain;

no position is quite easy to it, no food pleasant to it, bed is irksome,

medicine is nasty. It knows only that it suffers, it has been accustomed

to have its will obeyed in everything, and cannot understand that its

suffering is not at once taken away. It insists on getting up and on

being dressed, or on lying in its mother's or nurse's lap, where the

warmth of another person's body does but aggravate its fever; it screams

with passion at the approach of the doctor, it will not allow itself to

be examined, it will take no medicine; the doctor is powerless, the

mother heart-broken. Sickness is not the time to exercise authority

which has not been put in force before; and, not once but many times, I

have watched, a sad spectator, the death of children from an illness not

necessarily fatal, but rendered so because it was impossible to learn

the progress of disease, impossible to administer the necessary

remedies.

_What a child has been made when well, such it will be when sick._

One more point I must insist on before going into details, and that is

as to the necessity of perfect truthfulness in dealing with sick

children. The foolish device of telling a child when ill, that the

doctor who has been sent for is its uncle or its cousin, is the outcome

of the still more foolish falsehood of threatening the child with the

doctor's visit if it does not do this or that. No endeavour should be

spared by nurse or parent, or by the doctor himself, to render his visit

popular in the nursery. Three-fourths of the difficulties which attend

the administration of medicine are commonly the result of previous bad

management of the child, of foolish over-indulgence, or of still more

foolish want of truthfulness. It may answer once to tell a child that

medicine is nice when really it is nasty, but the trick will scarcely

succeed a second time, and the one success will increase your

difficulties ever after. If medicine is absolutely necessary, and the

child is too young to understand reason, it must be given by force, very

firmly but very kindly, and the grief it occasions will be forgotten in

an hour or two. If he is old enough, tell him that the medicine is

ordered to do him good, and firmness combined with gentleness will

usually succeed in inducing him to take it. The advantage of perfect

truthfulness extends to every incident in the illness of children, even

to the not saying, 'Oh, you will soon be well,' if it is not likely so

to be. If children find you never deceive them, how implicitly they will

_trust_ you, what an infinity of trouble is saved, and how much rest of

mind is secured to the poor little sufferer!

A little boy three years old was ordered to be cupped. The cupper, a

kind old man, said to encourage him, 'Oh, dear little boy, it's

nothing.' The child turned to his mother, saying, 'Mummy, is that true?'

His mother said it was not, but that for her sake she hoped he would try

to bear it well. And the operation was performed without a cry or a

sound.

I have spoken of the moral conditions implied in the successful

management of sick children. There are certain physical conditions no

less important. The sick child should not be left in the common nursery,

of which he would taint the air, while he would be disturbed by its

other little inmates. He must (and of course I am speaking not of some

slight ailment, but of a more serious indisposition) be in a room by

himself, which should be kept quiet and shaded, and at a temperature

which should not be allowed to fall below 60 deg. if the chest is in any way

affected, nor to exceed 55 deg. in other cases, and this temperature should

always be measured, not by guess, but by the thermometer hung close to

the child's bed. The room is to be shaded, not by curtains round the

bed--for, save in special circumstances, curtains should be banished

from the nursery--nor by closed shutters which exclude both light and

air, but by letting down the blinds, so as to have a sort of twilight in

the room, and by shading any light which at night may be burned in the

apartment; while whether by day or night the child should be so placed

that his face shall be turned from the light, not directed towards it.

The room should be kept quiet, and this requires not only general quiet

in the house, but quiet in the movements of all persons in the room;

speaking, not in a whisper, but in a low and gentle voice; walking

carefully, not in a silk dress nor in creaky shoes, but not on tiptoe,

for there is a fussy sham quietness which disturbs the sick far more

than the loudest noise.

Little precautions, so trifling that few think of noticing them, have

much to do with the quiet of the sick-room, and consequently with the

patient's comfort. A rattling window will keep a child awake for hours,

or the creaking handle of the door rouse it up again each time anyone

enters the room; and to put a wedge in the window, or to tie back the

handle, and so quietly open and close the door, may do more than

medicine towards promoting the child's recovery. There can, however, be

no abiding quiet without a well-ordered room, and the old proverb

carried out, 'A place for everything, and everything in its place.' A

table covered with a cloth so that things may be taken up and put down

noiselessly, and set apart for the medicine, the drink, the nourishment,

cups, glasses, spoons, or whatever else the patient is in frequent need

of; with a _wooden_ bowl and water for rinsing cups and glasses in, and

a cloth or two for wiping them, will save much trouble and noise, and

the loud whispers of the attendants to each other, 'Where is the sugar?

where is the arrowroot? where did you put down the medicine?' of which

we hear so much in the sick-room, so much especially in the sick-room of

the child, who is unable to tell how extremely all this disturbs him.

One more caution still remains for me to give. Do not talk to the

doctor in the child's room, do not relate bad symptoms, do not express

your fears, nor ask the doctor his opinion in the child's hearing. The

child often understands much more than you would imagine, misunderstands

still more; and over and over again I have known the thoughtless

utterance of the mother, nurse, or doctor depress a child's spirits and

seriously retard his recovery.

It is consoling to bear in mind that how grave soever a child's illness

may be, the power of repair is greater in early life than in adult age,

that with few exceptions the probability of recovery is greater in the

child than it would be from the same disease in the grown person. This

too is due not simply to the activity of the reparative powers in early

life, but also in great measure to the mental and moral characteristics

of childhood.

To make the sick child happy, in order that he may get well, is the

unwritten lesson which they who have best learnt, know best how to nurse

sick children. It may seem strange, that from so high a purpose I should

at once come down to so commonplace a detail as to insist on the

importance, even on this account, of keeping the sick child in bed.

At the onset of every illness of which the nature is not obvious, during

the course of any illness in which the chest is affected, or in which

the temperature is higher than natural, bed is the best and happiest

place for the child. In it repose is most complete, far more complete

than after early babyhood it can be in the nurse's or mother's lap, and

free from the great objection of the increased heat from being in

contact with another person's body. Nothing is more painful than to

witness the little child, sick and feverish, with heavy eyes, and aching

head, up and dressed, trying to amuse itself with its customary toys;

then, with 'Please nurse me,' begging to be taken in the lap, then

getting down again; fretful, and sad, and passionate by turns; dragging

about its misery, wearing out its little strength, in deference to the

prejudice that bed is so weakening.

_The bed does not weaken, but the disease does which renders bed

necessary._

A child frets sometimes at the commencement of an illness if kept in

its own little cot. But put it in its nurse's or mother's big bed, set a

tea tray with some new toys upon it before the child, and a pillow

behind it, so that when tired with play it may lie back and go to sleep,

and you will have husbanded its strength and saved your own, have halved

your anxiety and doubled the child's happiness.

Young infants, indeed, when ill often refuse to be put out of the arms,

but over and over again I have found the experiment succeed of laying

the baby on a bed, the nurse or mother lying down by its side, and

soothing it to sleep. Were there no other drawback, it is a waste of

power to have two persons employed in nursing a sick child; one to keep

it in her lap, and the other to wait upon her.

It is important in all serious illnesses of children, as well as of a

grown person, that the bed should be so placed that the attendant can

pass on either side, and can from either side reach the patient to do

whatever is necessary. Most cots for young children have a rail round

them to prevent the child falling out of bed when asleep or at play; but

nothing can be more inconvenient than the fixed rail over which the

attendant has to bend in order to give the child food or medicine, or

for any other purpose. When I founded the Children's Hospital in Ormond

Street, I introduced children's cots (the idea of which I took from

those in the Children's Hospital at Frankfort) the sides of which let

down when needed, while on the top of the rail, or dependent from it, a

board is placed surrounded by a raised beading on which the toys, the

food, or drink may be put with great convenience. These bedsteads, with

probably some improved arrangement for letting down the sides, may be

seen now in most children's hospitals, but I have been surprised to

observe how seldom they are employed in private nurseries, and how

comparatively few bedstead-makers are acquainted with them. The result

would probably have been very different had a patent been taken out for

them, and had they been largely advertised as 'Dr. West's improved

children's bedsteads'! The uninclosed spring mattress, and the

wedge-shaped horsehair cushion, both of which I introduced in Ormond

Street, are also very valuable. The latter slightly raises the head and

shoulders, and renders any other than a thin horsehair pillow for the

head to rest on unnecessary.

A few more hints about the bed may not be out of place. First of all,

after early infancy is over, at latest after nine months, except for

some very special reason the napkin should be done away with. It heats

the child, chafes it, and makes it sore; it conceals the inattention of

the nurse, and at the same time renders it less easy to keep the little

one absolutely clean than if a folded napkin is placed under the hips,

whence it can be at once removed when soiled. In all serious illness a

piece of macintosh should be placed under the sheet, as is done in the

lying-in room, and a draw-sheet, as it is termed, over it. The

draw-sheet is, as its name implies, a folded sheet, laid under the hips,

and withdrawn in part when needed so as to prevent the child ever lying

on linen that is wet or soiled. It can be drawn away from under the

child, and a portion still clean and dry brought under it, while the

soiled part is rolled together and wrapped up in macintosh at one side

of the bed until a new draw sheet is substituted, which is easily done

by tacking a fresh sheet to that which is about to be withdrawn, when

the fresh one is brought under the child's body as that which is soiled

is removed. The greatest care should always be taken that the under

sheet is perfectly free from ruck or wrinkle; in long illnesses the skin

becomes chafed and bed-sores may be produced by neglect of this simple

precaution. The complaint that a child throws off the bed-clothes is

easily remedied by a couple of bits of tape tied on either side loosely

from the sheet or blanket to the sides of the cot.

When children are compelled to remain long in bed, great care is needed

to prevent the skin from being chafed, which is the first step that

leads to the occurrence of bed-sores. Careful washing with soap and

water daily of the whole body, not only of those parts which may be

soiled by the urine or the evacuations; the washing afterwards with pure

tepid water; careful drying, and abundant powdering with starch powder,

will do much to prevent the accident. If, in spite of this care, the

skin seems anywhere to be red or chafed, it should be sponged over with

brandy or with sweet spirits of nitre before powdering. Real bed-sores

must be seen and treated by the doctor.

The warm bath is a great source of comfort to the sick child, and in all

cases of feverishness, of influenza, or threatening bronchitis, it

should not be omitted before the child is put to bed, or must be given

towards evening if the child has not been up during the day. The bath

may be either warm or hot, the temperature of the former being 90 deg. to

92 deg., that of the latter 95 deg. to 96 deg.. The temperature should always be

ascertained by the thermometer, and the _warm_ bath only should be

employed, except when the _hot_ bath is ordered by the doctor. The warm

bath relieves feverishness and quiets the system, and promotes gentle

perspiration; the hot bath is given when the eruption of scarlet fever

or of measles fails to come out properly, or in some cases of

convulsions at the same time that cold is applied to the head, or, in

some forms of dropsy when it is of importance to excite the action of

the skin as much as possible. It is not desirable that a child should

remain less than five or more than ten minutes in the bath, and

attention must be paid by the addition of warm water to maintain the

bath at the same temperature during the whole time of the child's

immersion.

Now and then infants and very young children when ill seem frightened

at the bath, and then instead of being soothed and relieved by it they

are only excited and distressed. If the bath is brought into the room,

prepared in the child's sight, and he is then taken out of bed,

undressed, and put into the water which he sees steaming before him, he

very often becomes greatly alarmed, struggles violently, cries

passionately, and does not become quiet again till he has sobbed himself

to sleep. All this time, however, he has been exerting his inflamed

lungs to the utmost, and will probably have thereby done himself ten

times more harm than the bath has done good. Very different would it

have been if the bath had been got ready out of the child's sight; if

when brought to the bedside it had been covered with a blanket so as to

hide the steam; if the child had been laid upon the blanket, and gently

let down into the water, and this even without undressing him if he were

very fearful; and then if you wish to make a baby quite happy in the

water, put in a couple of bungs or corks with feathers stuck in them,

for the baby to play with. Managed thus, I have often seen the

much-dreaded bath become a real delight to the little one, and have

found that if tears were shed at all, it was at being taken out of the

water, not at being placed in it.

In a great variety of conditions, poultices are of use. They are needed

in the case of abscesses which it is wished to bring to a head; they are

sometimes applied over wounds which are in an unhealthy condition, or

from which it is desired to keep up a discharge. They soothe the pain of

stomach-ache from any cause, and are of most essential service when

constantly applied in many forms of chest inflammation. And yet not one

mother or nurse in ten knows how to make a poultice.[5] When applied

over a wound they should not be covered with oiled silk or any

impermeable material, since the edges of the wound and the adjacent skin

are apt thereby to be rendered irritable and to become covered with

little itching pimples. When used to relieve pain in the stomach, or as

a warm application in cases of inflammation of the chest, they should be

covered with some impermeable material, and will then not require to be

changed oftener than every six hours. After poultices have been applied

over the chest or stomach for two or three days the skin is apt to

become tender, and then it is well to substitute for them what may be

termed a dry poultice, which is nothing else than a layer of dry cotton

wool an inch or an inch and a half thick, tacked inside a piece of oiled

silk.

A handy substitute for a poultice may be made of bran stitched in a

flannel bag, heated by pouring boiling water on it, then squeezed as dry

as possible and laid over the painful part. This is especially useful to

relieve the stomach-ache of infants and young children.

Spongio-piline is a useful substitute for a poultice, especially when it

is desirable to employ a soothing or stimulating liniment to the

surface. It retains heat very well when wrung out of hot water, and any

liniment sprinkled on it is brought into contact with the skin much

better than if diffused through a poultice. I may just add that its

edges should be sloped inwards, in order to prevent the moisture from it

oozing out and wetting the child's night-dress.

When I was young, leeches and bleeding were frequently, no doubt too

frequently, employed. We have now, however, gone too much to the other

extreme, for cases are met with from time to time of congestion of the

brain, or of inflammation of the chest or of the bowels, in which

leeches bring greater and more speedy relief than any other remedy. In

applying leeches it is always desirable that they should be put on where

they will be out of the child's sight if possible, and where it will be

comparatively easy to stop the bleeding. Hence, in many instances of

inflammation of the bowels, it is better to apply the leeches at the

edge of the lower bowel, the anus as it is technically termed, than on

the front of the stomach, though, of course, this will not always answer

the purpose. Leeches to the chest may usually be put on just under the

shoulder-blade; and leeches to the head on one or other side behind the

ear, where they will be out of the way of any large vein, and where the

pressure of the finger will easily stop the bleeding. Steady pressure

with the finger will, even where there is no bone to press against,

usually effect this; and then a little pad of lint put over the bite,

and one or two layers over that, and all fastened on with strips of

adhesive plaster, will prevent any renewal of the bleeding. In the few

cases where it is not arrested by these means, the application of a

little of the solution of muriate of iron will hardly fail of effect.

There is one more point to which I will refer before passing lastly to

the question of how to manage in the administration of medicine; and

this is the best way of applying cold to the head. This is often

ordered, but very seldom efficiently done. Cold is best applied by means

of a couple of bladders half-filled with pounded ice, and wrapped in two

large napkins; one of them should be placed under the child's head, the

corners of the napkin being pinned to the pillow-case to prevent its

being disturbed, while the other is allowed to rest upon the head, but

with the corners of the napkin again pinned to the pillow so as to take

off the greater part of its weight. Thus arranged, the cold application

will neither get displaced by the child's movements, nor will the child

itself be wetted, as it too commonly is when wet cloths are employed for

this purpose, nor irritated by their perpetual removal and renewal.

In London and in large towns there are various contrivances of

vulcanised rubber, which are, of course, far preferable to the bladders,

but it is not everyone who lives in London, or who can command the

resources furnished by a large city.

The difficulties in the administration of medicine to children are in

great part the fault, either of the doctor in giving needlessly

unpleasant medicine, or of the parents or nurse who either have failed

to teach the child obedience, or who are deficient in that tact by which

hundreds of small troubles are evaded.

As far as the doctor is concerned, all medicines should be prescribed by

him in small quantities, and as free from taste and smell as possible:

or where that cannot be, the unpleasant flavour should be covered by

syrup, or liquorice, or treacle.

Bulky powders should be avoided, and the child who has learned to take

rhubarb and magnesia, or Gregory's powder without resistance, certainly

does credit to his training.

Aperients are the medicines most frequently needed in the minor ailments

of children, and a wise mother will not undertake herself the management

of serious diseases. Of all aperients castor oil is perhaps the safest,

the least irritating, the most generally applicable; it acts on the

bowels and does nothing more. The idea that it tends specially to

produce constipation afterwards is unfounded; it does not do so more

than other aperients. All aperients quicken for a time what is termed

the peristaltic action of the bowels; that is to say, their constant

movement in a direction from the stomach to the lower bowel, which, as

well as a contraction on themselves, is constantly going on in every

living animal, and continues even for some time after death. The bowels

stimulated to greater activity of movement by the aperient, become for a

time more sluggish afterwards; they rest for a while, just as after a

long walk the muscles of the leg are weary and need repose.

There are indeed aperients which do more than this, as grey powder and

calomel act upon the liver, and so by promoting an increased flow of

bile cause a more permanent excitement of the bowels, and consequently

their more prolonged activity; or as Epsom salts or citrate of magnesia,

which by their action on the blood cause a greater secretion or pouring

out of fluid from the coats of the intestines, and in this way have in

addition to their purgative property a special influence in abating

various feverish conditions.

Castor oil, senna, jalap, jalapine, and scammony are simple aperients.

They empty the bowels and nothing more, and in cases of simple

constipation, or where a child is ill either from eating too much or

from taking indigestible food, are the best purgatives that can be

given. A dose of castor oil, often one of the great griefs of the

nursery, may generally be given without the least difficulty if

previously shaken up in a bottle with a wine-glassful of hot milk

sweetened and flavoured with a piece of cinnamon boiled in it, by which

all taste of the oil is effectually concealed.

The domestic remedy, senna tea with prunes which render it palatable,

confection of senna, syrup of senna, and the sweet essence of senna are

generally very readily taken by children, but all have the disadvantage

of being liable to gripe. The German liquorice powder, as it is called,

which is composed of powdered senna, liquorice powder, fennel, and a

little sulphur with white sugar, is freer from this drawback than any

other preparation, and when mixed with a little water is not generally

objected to. It is important, as senna is often adulterated and loses

its properties by exposure to the air, that this powder should always be

obtained from a very good chemist, purchased in small quantities, and

always kept in a glass-stoppered bottle.

Jalap, in the form in which it is usually sold--as compound jalap

powder--is in general readily taken; it acts speedily, but often with

pain, and is not a desirable domestic remedy. Jalapine, which is a sort

of extract of jalap, is much less apt to gripe, and owing to its small

bulk is much handier. It may be given in doses of from two to five

grains to children from two years old and upwards.

Scammony is another powerful simple aperient, apt to be violent in its

action, and therefore not to be given except when the bowels have long

been confined, or when it is given to expel worms. The compound scammony

powder is the form in which it is usually given, and of that five grains

would be a dose for a child two years old.

Scammony, however, is a costly drug, and therefore the caution given

with reference to German liquorice powder applies here also.

There is a preparation of scammony, the so-called scammony mixture,

which consists of the resin or extract of scammony dissolved in milk,

which is extremely useful when the stomach is irritable, or there is

much difficulty in inducing the child to take medicine. It is almost

tasteless, and a tablespoonful, which would be a proper dose for a child

of five years old, can be given without being detected.

Much of the difficulty experienced in giving powders arises from their

being mixed with the arrowroot or jam in which they are administered. A

very small quantity of arrowroot, bread and milk, or jam, should be put

in a tea-spoon; the powder then laid upon it, and covered over with the

arrowroot or jelly, so, in short, as to make a kind of sandwich, with

the powder, which would thus be untasted, in the middle.

Aloes is a purgative which acts chiefly on the large bowel and to some

degree also on the liver, and is of most use in the habitual

constipation of weakly children. In spite of its bitter taste the powder

is seldom objected to if given between two layers of coarse brown sugar,

while with most children the addition of a teaspoonful of treacle will

induce them to take very readily that useful medicine, the compound

decoction of aloes.

Both rhubarb, aloes, and indeed other remedies which are nauseous if

given as a liquid and are bulky in the form of powder, may very readily

be given in extract in the form of very tiny pills. Thus I have

constantly ordered the extract of rhubarb, which is nearly twice as

strong as the powder, made up into pills scarcely bigger than what

children call 'hundreds and thousands' and silver-coated. Ten or a dozen

of these go down in a teaspoonful of jelly unknown, and with no

expenditure of temper or tears.

The citrate of magnesia, or Dinneford's Magnesia, taken effervescing

with lemon juice, or when the effervescence has passed off, or the

French Limonade Purgative, are almost always very readily taken, and are

often very useful in the little febrile attacks, or in the slight

feverish rashes to which children are liable in the spring and autumn.

Mercurials should have no place among domestic remedies. I do not mean

that the doctor need be called in to prescribe each time that they are

given, but that the mother should learn from him distinctly with

reference to each individual child the circumstances which justify their

employment. They stimulate the liver, as well as produce thereby action

of the bowels, but they have, especially if often employed, a

far-reaching influence on the constitution, and that undoubtedly of a

depressing kind: an influence more than made up for when really needed

by their other qualities, and especially by their power in doing away

with the results of many forms of chronic inflammation. They are 'edged

tools,' however, and we know the proverb about those who play with

them.[6]

Grey powder, blue pill, and calomel are the three forms in one or other

of which mercurials are commonly given. Of the three, grey powder is the

mildest; but it has the inconvenience of not infrequently causing

nausea, or actual sickness. This objection does not apply to blue pill,

which can be given either in the tiny pills of which I have already

spoken, or else broken down, and given in a little jam, or in a

teaspoonful of syrup or treacle. On the whole I prefer calomel in small

doses. It has the great advantage of tastelessness, small bulk, and of

never causing sickness. Half a grain of calomel may be regarded as

equivalent to two grains of grey powder or blue pill.

I shall speak afterwards of other medicines, which may in various

circumstances be given, to act upon the bowels; but the above include

all that are at all fit for common use in the nursery.

Before leaving this subject I will add a word or two about the use of

suppositories and lavements in infancy and childhood. A piece of paper

rolled up into a conical form and greased, or a bit of soap, is not

infrequently introduced by nurses just within the bowel, as a means of

overcoming constipation in infants. The irritation of the muscle at its

orifice (the sphincter, as it is termed) excites the bowels to action,

and does away with the necessity for giving an aperient. The drawback

from this, as well as from the use of the lavement, is that if

frequently employed they become habitually necessary, and the bowels

will then never act without their customary stimulus. The lavement, too,

has the additional disadvantage that while the lower part of the bowel

is in proportion more capacious in infancy and childhood than in the

adult, this peculiarity becomes exaggerated by the constant distension

of the intestine, and a larger and still larger quantity of fluid needs

to be thrown up in order to produce the requisite action of the bowels.

Opiates and other soothing medicines should never be given except when

prescribed by the doctor. Thirty-two deaths in England under five years

of age in 1882 represent but a very small part of the evil wrought by

the overdose or injudicious use of these remedies. Above all, soothing

medicines of varying strength, as syrup of poppies, or of unknown

composition, as Dalby's Carminative or Winslow's Soothing Syrup, should

never be employed. The only safe preparation, and this to be given only

by the doctor's orders or with his approval, is the compound tincture of

camphor, or paregoric elixir, as it is called, of which sixty measured

drops contain a quarter of a grain of opium. Ten to fifteen measured

drops of this are a sufficient dose for a child one year old, and this

ought not to be repeated within twelve hours. The repetition every few

hours of small doses of opiates is quite as hazardous as the giving of a

single overdose; and if it does not work serious mischief by stupefying

the child, it renders it impossible to judge of its real condition.

Thus much may suffice with reference to the more important remedies.

Others will necessarily call for notice when the diseases come to be

considered in which they may be of service.

There are two points which still remain to be noticed before I leave the

introductory part of this little book.

The first of these concerns the importance of keeping written notes in

the course of every case of serious illness. For want of doing this the

most imperfect and conflicting accounts of what has happened are given

to the doctor. No person can watch to any good purpose for

four-and-twenty hours together; and no one's memory, least of all in the

midst of fatigue and anxiety, can correctly retain all details

concerning medicine, food, and sleep, which yet it may be of paramount

importance that the doctor should be made acquainted with. I am

accustomed to desire a record to be kept on a sheet of paper divided

into six columns, one for food, a second for medicine, a third for

sleep, a fourth for the evacuations, and a fifth for any special point

which the nature of the illness renders it of special moment to observe,

while the date is entered on the first column of all, indicating when

food or medicine was given, or when and for how long the child slept. It

is best to enter the variations of temperature on a separate paper, in

order that the doctor may at a glance perceive the daily changes in this

important respect. No one who has not made the experiment can tell the

relief which the keeping this simple record gives to the anxiety of

nursing the sick, especially when the sick one is loved most tenderly.

The other point concerns the relations of the mother or of the parents

to the doctor. I have often heard it said, 'Dr. Green always attends my

husband and myself, but we have Dr. White for the servants and

children,' implying a lower degree of medical knowledge as required in

their case, and to be acknowledged by a lower rate of remuneration.

Need I say that the assumption is a mistaken one--that as much

knowledge, as large experience, are needed in the one case as in the

other; while over and above, to treat children successfully, a special

tact and a special fondness for children are needed? A man may be a very

good doctor without those special gifts; but their possession, apart

from real medical knowledge, may make a good children's nurse, but never

a good children's doctor.

Another matter not to be forgotten is the confidence to be reposed in

the doctor--the readiness to acquiesce in his sometimes visiting the

child more frequently in the course of an illness than the symptoms may

seem to you to require. Were you involved in some civil action, in which

your succession to large property was involved, you would scarcely

expect your solicitor to give you his opinion on all the questions at a

single interview. In the same way, the doctor, even the most

experienced, may need to visit his little patient several times before

he can feel quite certain as to the nature of the disease that is

impending, while he may not wish to alarm you by suggesting all the

possibilities that are present to his mind. The child after a restless

night may be asleep, and it may be most undesirable to wake him; or he

may be excessively cross and unmanageable, so that it is impossible to

listen to his chest; or it may be very important to ascertain whether

the high temperature present in the morning has risen still higher

towards night, or whether, after free action of the bowels, it has

fallen a degree or two, showing that no fever is impending, but that the

undue heat of the body was occasioned by the constipation. Or, again,

some remedy may have been ordered, of the effect of which the doctor

does not feel quite sure: he wishes to see for himself whether it is

right to continue or wiser to suspend it. The wise physician, like the

able general, leaves as little as may be to chance.

Nearly forty years ago, in addressing a class of medical students, I

said to them:

'If you are carefully to observe all the points which I have mentioned,

and to make yourselves thoroughly masters of a case, you must be lavish

of your time; you must be content to turn aside from the direct course

of investigation, which you would pursue uninterruptedly in the adult,

in order to soothe the waywardness of the child, to quiet its fears, or

even to cheat it into good humour by joining in its play; and you must

be ready to do this, not the first time only, but every time that you

visit the child, and must try to win its affections in order to cure its

disease. If you fail in the former, you will often be foiled in your

attempts at the latter. Nor is this all; you must visit your patient

very often if the disease is serious in its nature and rapid in its

course. New symptoms succeed each other in infancy and childhood with

great rapidity; complications occur that call for some change in your

treatment, or the vital powers falter suddenly when you least expect it.

The issues of life and death often hang on the immediate adoption of a

certain plan of treatment, or on its timely discontinuance. Do not wait,

therefore, for symptoms of great urgency before you visit a child three

or four times a day; but if the disease is one in which changes are

likely to take place rapidly, be frequent in your visits as well as

watchful in your observation.'

Each year has added to my conviction of the perfect truth of each word

which I have quoted. If you believe your doctor to be a man of integrity

and intelligence, be thankful for his frequent visits, which will cease

as his anxiety abates. Be convinced that in the mean time they are made,

not for his sake, but for yours. If you doubt his integrity, change your

doctor; but do not say to him in a tone and with an emphasis which there

is no mistaking, 'Well, if you think it _really_ necessary to come'!

FOOTNOTES:

[5] I add in this note a few simple directions for making poultices,

though, as I have stated in my preface, it is no part of my purpose to

enter into all the details, important though they are, of a sick nurse's

duties.

For a linseed meal poultice, see that the water is _boiling_, not merely

hot; warm the basin, put the water in _first_; sprinkle the meal on it,

stirring the whole time, till it becomes of the uniform consistency of

porridge, then spread it about half an inch thick over the linen, or

whatever it is spread on, and turn up the edges for an inch all round to

prevent the poultice crumbling and soiling the night-dress; and then

having smeared the surface with a little oil, test its warmth by

applying it to your cheek before putting it on the patient. A broad

bandage of some sort or a soft towel must then be put round the body to

keep the poultice in its place, and secured with safety pins.

Pure mustard poultices are never used in children, on account of the

pain they occasion, and the too great irritation which they would cause

of the delicate skin of children. A mixture of one part of mustard to

two of linseed meal is, however, often of much use in the chest

affections of children.

Bread poultices are less generally useful than those of linseed meal.

They do not retain the heat nearly so well as those of linseed meal, and

are chiefly used in cuts, wounds, or small abscesses; and also because

they are so easily made. A slice of stale bread without the crust is put

on a plate, boiling water is poured over it, and drained off; it is then

placed on a piece of muslin, pressed between two plates to squeeze out

the remaining water, and its surface is greased before it is applied

with a little oil or lard. I would refer for details about how to make

poultices, and for many other things well worth the knowing, to Miss

Wood's _Handbook of Nursing_, London, 12mo, 1883.

[6] I am not ignorant of the doubts which have been raised with

reference to the special influence of mercurial remedies on the liver,

but prefer in a book written for non-medical readers to leave the

popular opinion unquestioned.

PART II.

All that has been said hitherto is only introductory to the great

purpose of this book, which is to give an account of the nature,

symptoms, and course of the more important diseases of infancy and

childhood.

Any attempt at scientific arrangement of a popular book is useless. I

prefer, therefore, to consult simply the general convenience of my

readers. I think I do so best by considering first the disorders which

beset the child in the first month of its existence, during what may be

termed its transition from the condition of existence in the womb, to

its living, breathing state as an inhabitant of this world; and next the

more important ailments to which it is liable during that important time

of development which ends with the completion of teething. Afterwards

may be studied the diseases of the head, the chest, and the bowels; next

constitutional diseases, such as consumption and scrofula; and lastly,

the various fevers, as typhoid, or, as it is popularly called, remittent

fever, measles, scarlatina, and small-pox; and last of all I will add a

few remarks on the mental and moral characteristics of childhood, and

their disorders.

CHAPTER IV.

ON THE DISORDERS AND DISEASES OF CHILDREN DURING THE FIRST MONTH AFTER

BIRTH.

=Still-birth.=--The infant cries almost as soon as it comes into the

world. The cry is the evidence that air has entered its lungs, that the

blood has now begun to take a different course from that which it

followed before birth, and that the child has entered on a new

existence. The child who does not cry, does not breathe; it is said to

be _still-born_; its quietude means death.

After a long or a difficult labour, or after the use of instruments, the

child is sometimes still-born in consequence of blood being poured out

on its brain, and it is thus killed before birth by apoplexy. This,

however, is not usually the case, but the child is generally still-born

because some cause or other, generally the protraction of labour,

interfered with the due changes of its blood within the womb, and it is

born suffocated before its birth, and consequently unable to make the

necessary efforts to breathe afterwards.

Drowned people are often resuscitated; the child's case is analogous to

theirs; and in both the same measures have to be pursued, namely to try

to establish respiration. The degree of the warmth of the child's body,

the resistance of its muscles, the red tint or the white colour of its

surface, the presence or absence of perceptible beating of its heart,

measure the chances of success. Sometimes mere exposure to the cold air

produces the necessary effect; at other times breathing is excited by

dashing cold water in the child's face, by slapping it, by tickling its

nostrils, or by dipping it for a few seconds in a hot bath at 100 deg. or

102 deg.; and then swinging it a few times backwards and forwards in the

air.

Much time, however, must not be lost over these proceedings, but the

child must be laid on its back, the lower part of its body well wrapped

up, the chest slightly raised by a folded napkin placed under it. The

two arms must then be taken firmly, raised and slowly extended on either

side of the head, then brought down again and gently pressed on either

side of the chest; and this movement of alternate raising and extending

the arms and bringing them back again beside the chest must be repeated

regularly some thirty times in the minute, thus imitating the movements

of the chest in breathing. These efforts, too, must not be discontinued

so long as the surface retains its warmth, and as an occasional

heart-beat shows that life is not absolutely extinct; and I believe that

in many instances failure is due to want of perseverance rather than to

the absolute uselessness of the measure.

=Premature Birth.=--In spite of very extraordinary exceptions, it may be

laid down as a rule that children born before the completion of six and

a half months of pregnancy do not survive. After that date, each

additional week adds greatly to the chances of the child living. There

is a mistaken idea, founded on a superstition connected with the number

seven, that a seven-months child is more likely to survive than one born

at the eighth month. But this notion is as destitute of support in fact

as it is opposed to common sense, and the nearer any woman has

approached the full term of forty weeks of pregnancy, the greater are

the chances of her child being born alive and healthy.

The premature child is by no means necessarily still-born. It breathes,

but does so imperfectly, so that air does not enter all the smaller

air-cells; and its voice is a whimper rather than a cry. Those changes

in the heart and large vessels, which prepare, as pregnancy draws to a

close, for the altered course of the blood when the child has to breathe

through the lungs, are too little advanced for it to bear well the

sudden alteration in its mode of being. The feebly beating heart and the

not completely developed lungs seem but imperfectly to maintain the

bodily heat. The glands of the stomach and intestines are not yet fit to

perform digestion properly, while the muscular power is too feeble for

the effort at sucking. Everything is sketched out, but to nothing has

the finishing touch been put, and hence the frail machinery too often

breaks down, in the endeavour to discharge its functions.

It is surprising, however, with what rapidity Nature in some instances

perfects the work which she has been called on prematurely to perform.

It is our business to second Nature's endeavours. First of all, and of

most importance, is the duty of providing from without the warmth which

the child is unable to generate. When very feeble, it must, even without

any previous washing or dressing, be at once wrapped in cotton wool, and

then in a hot blanket, and surrounded with hot-water bottles. A tin

stomach-warmer filled with hot water is very convenient to place under

the blanket on which the child lies. Being too feeble to suck, it must

be fed, a few drops at a time, from a small spoon; or still better, if

it is able to make any effort at sucking, it may draw its nourishment

through a quill. The mother after a premature confinement is almost sure

to have no milk with which to nourish her child, at any rate for two or

three days. It is, therefore, wise to obtain the help of a woman with a

healthy baby. She must be allowed to bring her baby with her, since

otherwise her supply of milk would fail, especially if she had no other

means of getting rid of it than by the breast-pump or by drawing her

breast. Even though she may have her own baby, there are few women who

can submit, for more than a very few days, to the artificial emptying

their breast without the secretion being either greatly lessened or

altogether arrested. This, therefore, must be regarded as a resource

available only for a few days, and as the child gains strength every

effort must be made to get it to take its mother's breast, if she has

any supply, or that of the wet-nurse. If this is found impossible, it

will be wisest to give up, at any rate for the present, the attempt to

nourish the child from the breast, and to obtain for it asses' milk,

which is the best substitute. By no means whatever can more than from a

sixth to a fourth part of a pint of milk be obtained either by the

breast-pump or by drawing the breast; and since a healthy infant of a

few weeks old sucks about two pints of milk in twenty-four hours, it is

evident that the supply artificially obtained must after the first few

days be utterly inadequate.

I have in cases of extreme weakness in premature children succeeded in

preserving them by giving them every two hours for two or three days ten

measured drops of raw beef juice, five of brandy, and two teaspoonfuls

of breast milk. Medicine has no place in the management of these cases;

the question is one entirely of warmth, food, and for a time the

judicious use of stimulants.

=Imperfect Expansion of the Lungs.=--Children not premature and

perfectly well nourished are yet sometimes feeble, breathe imperfectly,

cry weakly, suck difficultly or not at all, and die at the end of a few

days. Their lamp of life flickered and went out. Such cases are met with

for the most part in conditions similar to those in which children are

actually still-born; or now and then they take place when labour has

been of unusually short duration, the child hurried into the world too

rapidly; while in other instances it is not possible to account for

their occurrence.

For a long time the nature of these cases was not understood; but

rather more than sixty years ago a German physician discovered that air

had entered the lungs but imperfectly; that perhaps a third, perhaps

even as much as half, of the lungs had never been dilated, but had

remained solid and useless; that in consequence the blood was but

half-purified, and vitality therefore but half-sustained. The lungs,

however, were found to have undergone no real change; they were not

diseased, but if air was blown into them the dark solid patches sunk

below the level of the surrounding substance, expanded, grew bright in

colour and like a sponge from which the water has been squeezed, and

crackled, or crepitated as the technical term is, from the air contained

within them.

We breathe in health so without conscious effort that we never realise

the fact that, according to the calculation of most competent observers,

the mere elasticity of the lungs, independent even of the elasticity of

the chest walls, opposes a resistance to each inspiration equal to 150

pounds avoirdupois in the grown man and 120 in the grown woman. The want

of breath puts the respiratory muscles into play: the man takes a deep

inspiration, and by this unconscious effort, he overcomes the resistance

of the chest and the elasticity of the lungs. The new-born infant feels

the same want and makes the same effort; but its muscular power is

small, and its inspirations are often so feeble as to draw the air in

some parts only into the larger tubes, while many of the smaller remain

undilated, and much of the lung continues in the state in which it was

before birth. The blood being thus but imperfectly purified, all the

processes of nutrition go on imperfectly, the vital powers languish, the

inspiratory efforts become more and more feeble, while the elasticity of

the lung is constantly tending to empty the small cells of air and to

oppose its entrance, and next the temperature sinks and the infant dies.

Cases in which this condition of the lungs exists usually present the

history of the child from the very first having failed to utter a strong

and loud cry like that of other children. Even after breathing has gone

on for some time, such children usually appear feeble, and they suck

with difficulty, although they often make the effort. An infant thus

affected sleeps even more than new-born infants usually do; its voice is

very feeble, and rather a whimper than a cry. In the cry of the healthy

infant you at once detect two parts--the loud cry, suffering or

passionate as the case may be, and the less loud back draught of

inspiration. The French have two words for these two sounds--the _cri_

and the _reprise_. The _cri_ is feeble, the _reprise_ is altogether

wanting wherever expansion of the lung has to any considerable extent

failed to take place, and you would hail this second sound as the best

proof of an improvement in the child's condition.

If you watch the child with a little attention you will see that while

the chest moves up and down, it is very little, if at all, dilated by

the respiratory movements. The temperature falls, the skin becomes pale,

and the lips grow livid, and often slight twitching is observed about

the muscles of the face. The difficulty in sucking increases, the cry

grows weaker and more whimpering, or even altogether inaudible, while

breathing is attended with a slight rattle or a feeble cough, and the

convulsive movements return more frequently, and are no longer confined

to the face, but affect also the muscles of the extremities. Any sudden

movement suffices to bring on these convulsive seizures, but even while

perfectly still the child's condition is not uniform, but it will

suddenly become convulsed, and during this seizure the respiration will

be extremely difficult, and death will seem momentarily impending. In a

few minutes, however, all this disturbance ceases, and the extreme

weakness of the child, its inability to suck, its feeble cry, and its

frequent and imperfect inspirations, are the only abiding indications of

the serious disorder from which it suffers. But the other symptoms

return again and again, until after the lapse of a few days or a few

weeks the infant dies.

I have dwelt at some length on this condition because it is important to

know that during the first few weeks of life real inflammation of the

lungs or air-tubes is of extremely rare occurrence, and that the

symptoms which are not infrequently supposed to depend on it are really

due to a portion of the lung more or less extensive never having been

called into proper activity. I may add that we shall hereafter have to

notice a similar condition of the lung--its collapse after having once

been inflated--as occurring sometimes in the course of real inflammation

of the organs of respiration in early life, and forming a very serious

complication of the original disease.

If the collapse of the lung is not so considerable as to destroy life

within the first few hours or days after birth, the babe wastes as well

as grows weaker and weaker, and this wasting coupled with the difficult

breathing not seldom causes the fear that the child has been born

consumptive and that its death is inevitable.

No such gloomy view need be taken. Collapse, or at least non-expansion

of the lung to some extent, is by no means unusual: consumptive disease

to such an extent in the new-born infant as to interfere with the

establishment of breathing is extremely rare. The consumptive babe can

suck, it is not so weak as the one whose lungs are imperfectly expanded;

it has no convulsive twitchings, nor any of the strange head-symptoms

which we notice in the former. It wastes less rapidly, it is feverish

instead of having a lower temperature than natural, it seems less ill,

and yet its death within a few weeks or months is absolutely certain;

while the child whose lungs are not diseased but simply unexpanded may,

if that accidental condition is removed, grow up to vigorous manhood.

The treatment of these cases is abundantly simple. The child who

breathes imperfectly but ill maintains its heat. It must be kept warm at

a temperature never less than 70 deg.; it may, like the premature child,

need stimulants, and all the precautions already mentioned as to

feeding. Twice in the day it should be put for five minutes in a hot

bath at 100 deg., rendered even more stimulating by the addition of a little

mustard. The back and chest may be rubbed from time to time with a

stimulating liniment, and an emetic of ipecacuanha wine may be given

twice a day. The act of vomiting not only removes any of the mucus which

is apt to accumulate in the larger air tubes, but the powerful

inspirations which follow the effort tend to introduce air into the

smallest vesicles of the lungs, and to do away with their collapse.

Let these directions be carried out sensibly, patiently, perseveringly,

and three times out of four, or oftener still, the mother's ear will

before many days be greeted by the loud cry, with its _cri_ and

_reprise_ of which I have already spoken, and which assures her that her

little one will live.

There are no other affections of the lungs so peculiar to the first

month of life as to call for notice here. I shall have a few

observations to make about malformations of the heart, and the

precautions for which they call in the after-life of children; but they

will find their fittest place in the chapter on Affections of the Chest.

=Jaundice of New-born Children.=--A certain yellow tinge of the skin,

unattended by any other sign of jaundice, such as the yellowness of the

eye and the dark colour of the urine, is by no means to be confounded

with real jaundice. It is no real jaundice, but is merely the result of

the changes which the blood with which the small vessels of the skin are

overcharged at birth is undergoing; the redness fading as bruises fade,

through shades of yellow into the genuine flesh colour.

This is no disease, to be treated with the grey powder and the castor

oil wherewith the over-busy monthly nurse is always ready. It is a

natural process, which the intelligent may watch with interest, with

which none but the ignorant will try to interfere.

There is, however, beside this a real jaundice, in which the skin is

more deeply stained, the whites of the eyes are yellow, the urine

high-coloured, and in which the dark evacuations that carry away the

contents of the bowels before birth are succeeded by white motions, from

which the bile is absent. This condition is not very usual, save where

children have been exposed to cold, or where the air they breathe is

unwholesome. Of this no better proof can be given than is afforded by

the fact that in the Dublin Lying-in Hospital, where the children are

defended with the greatest care both from cold and from a vitiated

atmosphere, infantile jaundice is extremely rare, while it attacks

three-fourths of the children received into the Foundling Hospital of

Paris. Still it does sometimes occur when yet no cause can be assigned

for it, and it is noteworthy that it is sometimes met with in successive

infants in the same family.

As the respiratory function and that of the skin increase in activity,

the jaundice will disappear of its own accord. Great attention must be

paid during its continuance to avoid exposure of the child to cold,

while no other food than the mother's milk should be given. If the

bowels are at all constipated, half a grain of grey powder or a quarter

of a grain of calomel may be given, followed by a small dose of castor

oil, and the aperient will often seem to hasten the disappearance of the

jaundice; but in a large number of cases even this amount of medical

interference is not needed.

There is, indeed, a very grave form of jaundice, happily of excessive

rarity, due to malformation of the liver, to absence or obstruction of

the bile-ducts, and often accompanied with bleeding from the navel. I do

but mention it; the intensity and daily deepening of the jaundice, the

fruitlessness of all treatment, and the grave illness of the child, even

though no bleeding should occur, render it impossible to confound this

hopeless condition with the trivial ailment of which I have been

speaking.

The next chapter will furnish a fitter place than the present for

speaking fully of the Disorders of the Digestive Organs.

I will say now but this: that whatever a mother may do eventually, she

avoids grave perils for herself by suckling her infant for the first

month; while the health of her child, just launched upon the world, is

terribly endangered if fed upon those substitutes for its proper

nutriment on which after the lapse of a few weeks it may subsist, may

even manage to thrive.

There are some local affections incident to the new-born child

concerning which a few words may not be out of place; and first of the

=Ophthalmia of New-born Children.=--It is the cause of the loss of sight

of nine-tenths of all persons who, among the poor, are said to have been

born blind. In the wealthier classes of society it is comparatively

rare, and seldom fails to meet with timely treatment, yet many people

scarcely realise its dangerous character, or the extreme rapidity of its

course.

It generally begins about the third day after birth with swelling of

the lid of one or other eye, though both are soon involved. The eyelids

swell rapidly, and if the affection is let alone, they soon put on the

appearance of two semi-transparent cushions over the eyes. On separating

the lids, which it is often very difficult to do owing to the spasmodic

contraction of the muscles, their inner surface is seen to be enormously

swollen, bright red, like scarlet velvet, bathed in an abundant

yellowish thin secretion, which often squirts out in a jet as the lids

are forcibly separated. Great care must be taken not to allow any of

this fluid to enter the eye of a bystander, nor to touch his own eye

until the fingers have been most carefully washed, since the discharge

is highly contagious, and may produce most dangerous inflammation of the

eyes of any grown person. The discharge being wiped or washed away, the

eye itself may be seen at the bottom of the swelling very red, and its

small vessels very blood-shot. By degrees the surface of the eye assumes

a deeper red, it loses its brightness and its polish, while the swelling

of the lids lessens, and they can be opened with less difficulty; their

inner surface at the same time becomes softer, but thick and granular,

and next the eyes themselves put on likewise a granular condition which

obscures vision. The discharge by this time has become thicker and

white, and looks like matter from an abscess. By slow degrees the

inflammation may subside, the discharge lessen, the swelling diminish,

and the eye in the course of weeks may regain its natural condition. But

the danger is--and when proper treatment is not adopted early the danger

is very great--lest the mischief should extend beyond the surface of the

eye, lest ulceration of the eye should take place, the ulceration reach

so deep as to perforate it, and not merely interfere with the sight, but

destroy the organ of vision altogether.

In every instance, then, in which the eyelids of a new-born infant

swell, or the slightest discharge appears from them, the attention of

the doctor must at once be called to the condition. In the meantime, and

during whatever treatment he may think it right to follow, the eye must

be constantly covered with a piece of folded lint dipped in cold water;

and every hour at least the eye must be opened and tepid water squeezed

into it abundantly from a sponge held above, but not touching it, so as

to completely wash away all the discharge. A weak solution of alum and

zinc, as one grain of the latter to three of the former to an ounce of

water, may in like manner be dropped from a large camel's-hair brush

four times a day into the eye after careful washing. Simple as these

measures are they yet suffice, if adopted at the very beginning, and

carried on perseveringly, to entirely cure in a few days an ailment

which if let alone leads almost always to most lamentable results.

I do not pursue the subject further, for bad cases require all the care

of the most skilful oculist for their treatment.

=Scalp Swellings.=--Almost every new-born child has on one or other side

of its head a puffy swelling, owing to the pressure to which the head

has been subjected in birth, and this swelling disappears at the end of

twenty-four or forty-eight hours.

Now and then, however, though indeed very seldom, the swelling does not

disappear, but it goes on gradually increasing and becoming more

definite in its outlines until at the end of three or four days it may

be as big as half a small orange, or sometimes even larger, soft,

elastic, painless, under the unchanged scalp, but presenting the

peculiarity of having a hard raised margin with a distinct edge, which

gives to the finger passed over it the sensation of a bony ridge, beyond

which the bone seems deficient. This tumour is due usually to the same

cause as that which produces the other temporary puffy swelling of the

scalp, only the pressure having been more severe, blood has actually

been forced out from the small vessels under the membrane which covers

the skull, and hence its gradual increase, its definite outline; and

hence, too, the bony ridge which surrounds it, and which is due to

nature's effort at cure, in the course of which the raised edge of the

membrane covering the skull (the _pericranium_) becomes converted into

bone.

When the nature of these swellings was not understood, they used to be

poulticed, and to be opened with a lancet to let out their contents. We

know now, however, that we have nothing to do but to let them alone;

that by degrees the blood will be absorbed and the tumour will

disappear, and as it does so we may trace the gradual transformation of

the membrane which covered it into bone, as we feel it crackling like

tinsel under the finger. Two, three, or four weeks may be needed for the

entire removal of one of these blood-swellings. The doctor will at once

recognise its character, and you will then have nothing to do but to

wait--often, unhappily, so much harder for the anxious mother than to

meddle.

=Ruptured Navel.=--There is a period some time before the birth of a

child when the two halves of its body are not united in front, as they

become afterwards; and hare-lip or cleft-palate sometimes remains as the

result of the arrest of that development which should have closed the

fissured lip or united the two halves of the palate.

In a similar way it happens sometimes that though the skin is closed,

the muscles of the stomach (or, more properly speaking, of the belly)

are not in the close apposition in which they should be, so that the

bowels are not supported by the muscles, but protected only by the skin.

More frequently than this, especially in the case of children who are

born before the time, the opening through which the navel string passes

is large at birth, and fails to close as speedily and completely as it

should do afterwards. When everything goes on as it ought, the gradual

contraction of the opening helps to bring about the separation of the

navel string and its detachment, and the perfect closure of the opening

takes place at the same time, between the fifth and the eighth day after

birth.

If this does not occur, the bowels are very apt to protrude through the

opening, and if allowed to do so for weeks or months, the opening

becomes so dilated that its closure is impossible, and the child grows

up afflicted permanently with rupture through the navel. This is always

an inconvenience, sometimes even a source of serious danger; but if

means are taken to prevent the condition becoming worse, nature seldom

fails eventually to bring about a cure, and to effect the complete

closure of the opening.

If the muscles on either side do not come into apposition, but leave a

cleft between them, the infant should constantly wear a broad bandage of

fine flannel round the stomach, not applied too tightly, in order to

give support. The circular bandages of vulcanised india-rubber with a

pad in the centre are nowise to be recommended. The pad is apt to become

displaced, and to press anywhere but over the navel, while its edges

irritate the infant's delicate skin, and the pressure which it exerts if

it is sufficiently tight to retain its place interferes with

respiration.

A pad composed of pieces of plaster spread on wash-leather, and of

graduated sizes and kept in place by adhesive strapping,[7] answers the

purpose of preventing the protrusion at the navel, and of thus

facilitating the closure of the ring better than any other device with

which I am acquainted. They need, however, to be continued even for two

or three years, and though they should have been left off it is wise to

resume their use if the child should be attacked by whooping-cough,

diarrh[oe]a, or any other ailment likely to occasion violent straining.

FOOTNOTES:

[7] These plasters for ruptured navel in sets of a dozen are to be had

of Ewen, 106 Jermyn Street, St. James's, London, and I dare say at many

other places besides.

CHAPTER V.

ON THE DISORDERS AND DISEASES OF CHILDREN AFTER THE FIRST MONTH, AND

UNTIL TEETHING IS FINISHED.

=Infantile Atrophy.=--In by far the greater number of instances, the

wasting of young children is due to their being fed upon food which they

cannot digest, or which when digested fails to yield them proper

nourishment. I quoted some figures in my introductory remarks, to show

from the evidence obtained at Berlin how much larger was the proportion

of deaths under the age of one year among hand-fed infants than among

those brought up at the breast. Foundling hospitals on the Continent, in

which the children are all drawn from the same class, and subjected in

all respects to a similar treatment, except that in some they are fed at

the breast, in others brought up by hand, show a mortality in the latter

case exactly double of that in the former.

It is as idle to ignore these facts, and to adduce in their disproof the

case of some child brought up most successfully by hand, as it would be

to deny that a battle-field was a place of danger because some people

had been present there and had come away unwounded.

But it is always well not merely to accept a fact, but also to know the

reason why a thing is so. The reason is twofold: partly because the

different substitutes for the mother's milk, taken for the most part

from the vegetable kingdom, are less easy of digestion than the milk,

and partly because, even were they digested with the same facility, they

do not furnish the elements necessary to support life in due proportion.

All food has to answer two distinct purposes: the one to furnish

materials for the growth of the body, the other to afford matter for the

maintenance of its temperature; and life cannot be supported except on a

diet in which the elements of nutrition and those of respiration bear a

certain proportion to each other. Now, in milk, the proper food of

infants, the elements of the former are to those of the latter about in

the proportion of 1 to 2, while in arrowroot, sago, and tapioca they are

only as 1 to 26, and in wheaten flour only as 1 to 7. If to this we add

the absence in these substances of the oleaginous matters which the milk

contributes to supply the body with fat, and the smaller quantity, and

to a certain extent the different kind, of the salts which they contain,

it becomes apparent that by such a diet the health if not the life of

the infant must almost inevitably be sacrificed.

But these substances are not only less nutritious, they are also less

easy of digestion than the infant's natural food. We all know how

complex is the digestive apparatus of the herbivorous animal, of which

the four stomachs of the ruminants are an instance, and how large is the

bulk of food in proportion to his size which the elephant requires,

compared with that which suffices for the lion or the tiger.

The stomach of the infant is the simple stomach of the carnivorous

animal, intended for food which shall not need to stay long in that

receptacle, but shall be speedily digested; and it is only as the child

grows older, and takes more varied food, that the stomach alters

somewhat in form, that it assumes a more rounded shape, resembling

somewhat that of the herbivorous animal, and suited to retain the food

longer. The young of all creatures live upon their mother for a certain

time after birth; but in all the preparation for a different kind of

food, and with it for an independent existence, begins much sooner and

goes on more rapidly than in man. Young rabbits are always provided with

two teeth when born, and the others make their appearance within ten

days. In the different ruminants the teeth have either begun to appear

before birth, or they show themselves a few days afterwards; and in

either case dentition is completed within the first month, and in dogs

and cats within the first ten weeks of existence.

In the human subject the process of teething begins late, between the

seventh and the ninth month, and goes on slowly: the first grinding

teeth are seldom cut before the beginning of the second year, and

teething is not finished until after its end. Until teething has begun

the child ought to live exclusively on the food which nature provides;

for until that time the internal organs have not become fitted to digest

other sustenance, and the infant deprived of this too often languishes

and dies. To get from other food the necessary amount of nourishment,

that food has to be taken in larger quantities, and, from the difficulty

in digesting it, needs to remain longer in the stomach than the mother's

milk. One of the results of the indigestibility of the food is that the

child is often sick, the stomach getting rid of a part of that food

which it is unable to turn to any useful purpose; and so far well. But

the innutritious substances do not relieve the sense of hunger. The

child cries in discomfort, and more is given to it, and by degrees the

over-distended stomach becomes permanently dilated, and holds a larger

quantity than it was originally meant to contain. The undigested mass

passes into a state of fermentation, and the infant's breath becomes

sour and offensive, it suffers from wind and acid eructations, and

nurses sometimes express surprise that the child does not thrive since

it is always hungry. While some of the food is got rid of by vomiting,

some passes into the intestines, and there becomes putrid, as the

horribly offensive evacuations prove. They come away, large and solid

and white, for the secretion of the bile is inadequate to complete that

second digestion which should take place in the intestines; or else the

irritation which they excite occasions diarrh[oe]a--a green putty-like

matter comes away mixed with a profuse watery discharge.

What wonder is it that in such circumstances the body should waste most

rapidly; for it is forced from its own tissues to supply those elements

essential to the maintenance of life, which its food contains in far too

scanty a proportion. Every organ of the body contributes to the general

support, and life is thus prolonged, if no kind disease curtail it,

until each member has furnished all that it can spare, and then death

takes place from starvation, its approach having been slower, but the

suffering which preceded it not therefore less, than if all food had

been withheld.

Do not suppose that in this description I have been painting too dark a

picture, or that children who die thus have been exceptionally weak, and

so under the acknowledged difficulties of hand-feeding at length became

consumptive. They do not die of consumption, and in a large number of

instances their bodies show no trace of consumptive disease, but present

appearances characteristic of this condition of starvation, and of this

only.

Along the whole track of the stomach and intestines are the signs of

irritation and inflammation. The glands of the bowels are enlarged,

actual ulceration of the stomach is often met with; while so

far-reaching is the influence of this slow starvation, that even the

substance of the kidneys and of the brain are often found softened and

otherwise altered, though it might not unreasonably have been supposed

that these organs lay quite beyond the reach of any disorder of

digestion.

No doubt all these grievous results do not always follow; and sometimes

children exceptionally strong manage to take and digest enough even of

unsuitable food to maintain their health, and may as they grow up, and

the changes take place in the system which fit it for a varied diet,

even become robust. In the majority of instances, however, hand-fed

infants, and those especially who have been brought up chiefly on

farinaceous food, are less strong than others, and are more apt to

develop any latent tendency to hereditary disease, such as scrofula or

consumption, than members of the same family who have been brought up at

the breast.