All cases, indeed, are not equally severe, but all require careful and

gentle treatment, the cool and darkened room, the quiet, the cold to the

head, the tepid bath, and on the part of everyone the care not to allow

the apparently serious condition of the child to urge them to those

active measures which will here be out of place, and destroy the hopes

which would revive after a few hours of patience and gentle means.

Really acute inflammation of the brain is of so rare occurrence except

as the result of accident or injury, and its symptoms are of so serious

a character, even from the first, that medical advice is obviously

needed at once. I shall, therefore, pass it over here, and endeavour to

describe two forms of inflammation of the brain which are much more

frequent, and at their commencement more likely to be overlooked.

=Water on the Brain.=--One of these is the form of inflammation commonly

known as _water on the brain_, a term which, though incorrect medically,

has the advantage of being well understood. This, now, is not a simple

disease, occurring in a previously healthy child, but it is a disease

dependent on the same state of constitution as gives rise in other

children to consumption, or scrofula, or disease of the mesenteric

glands.

It is this circumstance which renders the disease so serious, and

recovery from it so extremely rare. This it is also which makes it so

desirable to become acquainted with its symptoms, both that you may be

alive to the approach of danger, and also not indulge in needless alarm

when brain symptoms occur from other causes which have no relation

whatever to those which give rise to water on the brain.

The disease comparatively seldom comes on in a child who had previously

seemed in perfect health; a state of vague ailing usually precedes its

outbreak. The child loses flesh and strength, and the look of health,

and the lustre of the eye, and the silky softness of the hair. The

appetite becomes uncertain, the bowels irregular, with a tendency to

constipation; there are little feverish attacks for a few hours,

subsiding of their own accord. The sleep is not sound, the temper

uncertain, the child tires even of its favourite toys; the brightness of

the little face is changed for a strange, weird, wistful look--an

unnatural earnestness; the child sits for moments gazing upward on

vacancy, as though it saw, or sought something beyond.

By degrees these vague premonitions, which may continue for weeks,

become more and more marked till they pass into what may be called the

first stage of the affection, in which there are signs of congestion of

the brain, such as I have already described, coupled with general

irregular attacks of feverishness. The child becomes more gloomy, more

pettish, and slower in its movements, and is little pleased by its usual

amusements. Or, at other times, its spirits are very variable; it will

sometimes cease suddenly in the midst of its play, and run to hide its

head in its mother's lap, putting its hands to its head, and complaining

of headache, or saying merely that it is tired and sleepy, and wants to

go to bed. Sometimes, too, it will turn dizzy, as you will know, not so

much from its complaint of dizziness as from its suddenly standing

still, gazing around for a moment as if lost, and then either beginning

to cry at the strange sensation, or seeming to awake from a reverie, and

at once returning to its play. The infant in its nurse's arms betrays

the same sensation by a sudden look of alarm, a momentary cry, and a

hasty clinging to its nurse. If the child can walk it may be observed to

drag one leg, halting in its gait, though but slightly, and seldom as

much at one time as at another, so that both the parents and the medical

attendant may be disposed to attribute it to an ungainly habit which the

child has contracted. The appetite is usually bad, though sometimes very

variable; and the child, when apparently busy at play, may all at once

throw down its toys and beg for food, then refuse what is offered; or

taking a hasty bite may seem to nauseate the half-tasted morsel, may

open its mouth, stretch out its tongue, and heave as if about to vomit.

The thirst is seldom considerable, and sometimes there is an actual

aversion to drink as well as to food, apparently from its exciting or

increasing the sickness. The stomach, however, seldom rejects

everything; but the same food as occasions sickness at one time is

retained at another. Sometimes the child vomits only after taking food,

at other times, even when the stomach is empty, it brings up some

greenish phlegm without much effort, and with no relief. These attacks

of vomiting seldom occur oftener than two or three times a day, but they

may return for several days together, the child's head probably growing

heavier, and its headache more severe. The bowels during this time are

disordered, generally constipated from the very first, though their

condition in this respect sometimes varies at the commencement of the

disease. The evacuations are usually scanty, sometimes pale, often of

different colours, almost always deficient in bile, frequently

mud-coloured and very offensive. The tongue is not dry, generally rather

red at the tip and edges, coated with white fur in the centre and

yellowish towards the root, but occasionally very moist, and uniformly

coated with white fur. The skin is harsh, but not very hot, the

temperature seldom above 100 deg. Fahr., varying causelessly, but usually

higher towards evening than in the daytime. The nostrils are dry, the

eyes lustreless, and _the child sheds no tears_. It is drowsy, and will

sometimes want to be put to bed two or three times in a day; but it is

restless, sleeps ill, grinds its teeth in sleep, lies with its eyes

partially open, awakes with the slightest noise, or even starts up in

alarm without any apparent cause. At night, too, the existence of

intolerance of light is often first noticed in consequence of the

child's complaints about the presence of the candle in the room.

I have purposely dwelt long on this preliminary stage because it is only

in it that treatment is likely to be of any service, while the very

indefiniteness of the symptoms constantly leads to their being

overlooked, or referred to teething, or thought at any rate to be a mere

temporary ailment for which it is not worth while to call in the doctor.

After four or five days, however, the illness of the child becomes too

marked to escape notice. All cheerfulness has fled, the eyes are closed

to shut out the light, the child lies apparently dozing, but answers

questions rationally, in a short quick manner in as few words as

possible, and from time to time complains of its head, or utters a

short, sharp lamentable cry. The night brings with it no other change

than an increase of restlessness, attended sometimes with noisy cries,

or with the wandering talk of delirium. Sickness often diminishes, but

the bowels continue constipated, and it is to be noted that whereas in

fevers the bowels are distended with wind, here all wind has disappeared

and the belly is sunken to a striking degree.

Next comes the last stage. Each stage is distinguished by peculiarities

of the pulse which tell the expert what is passing; quick and regular in

the first stage; irregular and slower in the second; quick, variable,

irregular from time to time in the third; growing more rapid and more

feeble as the end arrives. Squinting, stupor, dilated pupil, difficulty

of swallowing, tremulous limbs, convulsions, profound insensibility,

such are the series of occurrences which bring on death usually within a

fortnight, always within three weeks from the appearance of the first

decided symptoms.

What are you to do in these cases? Above all save yourselves the

heartbreak of feeling that you have overlooked the premonitory symptoms

of the disease. Guard with special care the health of any child in whose

family a disposition to consumptive disease has ever shown itself, and

keep it at any cost from the risk of catching the hooping cough or

measles. Since, too, it is not in early infancy, but after the age of

one year, and in the majority of instances between the ages of three and

six years that this disease occurs, that is to say, at the time when the

brain begins to be most actively exercised, when the new world on which

the child is just entering brings with it new wonders every day; be very

careful not to over-stimulate its intelligence, over-excite its

imagination, or over-strain its mental powers. After the age of ten the

great danger is over; up to that time it is the health of the body which

requires care; not fuss, not rearing like a hothouse plant, but the

healthy training that may fortify the system.

When any signs such as I have described indicate the threatening of

disease, do not look on them as within the scope of domestic management,

but place the child at once under the watchful care of a skilful doctor.

I have seen but one recovery in all my life, after the disease had fully

set in, and that was a recovery almost worse than death.

=Earache.=--There is another form of inflammation of the brain which is

likewise oftenest met with in children who are of weakly constitution,

or of scrofulous habit, or in whom scarlet fever has left behind that

very troublesome ailment, discharge from the ear. This is so tedious, so

difficult to cure, so apt to return under the influence of very slight

causes, that people are too ready to put up with it as an inconvenience

which it is useless to try to remedy.

In addition, however, to the risk of the child's hearing being impaired

by the extension of the mischief to the internal ear, there is another

still greater danger, namely, that of the _disease passing from the ear

to the brain_, and producing inflammation of its membranes, or even

abscess of its substance.

It is therefore of the greatest moment that every case of chronic

discharge from the ear should be looked on as important, and that no

pains be spared to bring about its cure; and further, that during its

continuance the slightest sign of disturbance of the brain--headache,

sickness, feverishness, and dulness--should at once be noticed, and the

advice of a competent doctor be immediately sought for.

These dangers, however, follow almost entirely on long-continued

discharges from the ear, but do not attend that acute inflammation of

the passage to the ear which is often met with in childhood, and the

symptoms of which sometimes cause needless fear, from being taken for

those of inflammation of the brain. Attacks of _earache_ are most

frequent before the first set of teeth have been cut, and are by no

means rare in young children, who are perfectly unable to point out the

seat of their sufferings. The attack sometimes comes on quite suddenly,

but usually the child is languid and fretful for a period varying from a

few hours to one or two days before acute pain is experienced. In this

premonitory stage, however, it will often cry if tossed or moved

briskly; noise seems unpleasant to it, and it does not care to be played

with; while children who are still at the breast show a disinclination

to suck, though they will take food from a spoon. The infant seeks to

rest its head on its mother's shoulder, or, if lying in its cot, moves

its head uneasily from side to side, and then buries its face in the

pillow. If you watch closely, you will see that it is always the same

side of the head which it seeks to bury in the pillow, or to rest on its

nurse's arm, and that no other position seems to give any ease, except

this one, which, after much restlessness, the child will take up, and to

which, if disturbed, it will always return. The gentle support to the

ear seems to soothe the little patient: it cries itself to sleep, but

after a short doze, some fresh twinge of pain arouses it, or some

accidental movement disturbs it, and it awakes crying aloud, and

refusing to be pacified, and may continue so for hours together.

Sometimes the ear is red, and the hand is often put to the affected side

of the head, but neither of these symptoms is constant. The intensity of

the pain seldom lasts for more than a few hours, when, in many instances

a copious discharge of matter takes place from the ear, and the child is

well. In some instances, indeed, the subsidence of the disease on one

side is followed by a similar attack on the opposite side, and the same

acute suffering is once more gone through, and terminates in the same

manner. Sometimes, too, this complete cure does not take place, but the

earache abates, or altogether ceases, for a day or two, and then

returns; no discharge, or but a very scanty discharge, taking place,

while, for weeks together, the child has but few intervals of perfect

ease. In infants, earache seldom follows this chronic course, but it

does sometimes in older children, and is then of the more importance,

since it shows that the disease is no longer confined to the external

passage, but has extended to the internal ear.

In children who are too young to express their sufferings by words, the

violence of their cries, coupled with the absence of any sign of disease

in the chest or the bowels, naturally leads to the suspicion of

something being wrong in the head. There are several facts, however,

which may satisfy you that the case is not one of water on the

brain--the child does not vomit, its bowels are not constipated, there

is but little fever, the cries are loud and passionate, and are attended

with shedding tears. If you watch closely, you will notice the dread of

movement and the evident relief afforded by resting one side of the

head, and always the same side, while often the movement of the hand to

the head, and the redness of the ear, with the swelling at its entrance,

will all serve to point to that organ as the source of the trouble.

Sometimes, when in doubt, you will be able to satisfy yourselves that

the cause of the suffering is in the ear by pressing the gristle of the

organ slightly inwards, which will produce very evident pain on the

affected side, while on the other side it will not occasion any

suffering.

The treatment of this painful affection is very simple. In many

instances the suffering is greatly relieved by warm fomentations, or by

applying to the ear a poultice of hot bran or camomile flowers, while at

the same time a little warm oil and laudanum are dropped into the ear.

When these means do not bring relief, a leech applied on the bone

directly behind the ear seldom fails to give ease; while the disposition

to the frequent return of the attack is often controlled by a series of

small blisters, not larger than a sixpence, behind the ear. As soon as

the tendency has sufficiently abated to admit of it, the ear should be

syringed out twice a day with warm water, or with equal parts of warm

water and Goulard lotion; but if pain or discharge still continues,

medical advice must in all cases be sought for.

=Chronic Water on the Brain.=--There is still another form of

inflammation of the brain, concerning which a few words will suffice. It

constitutes what is termed _chronic water on the brain_, and in this

instance the term is a correct one, for the disease usually depends on a

slow form of inflammation of the lining membrane of the cavities of the

brain, often beginning before, still oftener very soon after, birth,

which ends in the pouring out of a quantity of fluid into them

sufficient to enlarge the head to three or four times its natural

dimensions.

Such cases are very sad and very hopeless, and the great resource, which

is sometimes adopted by medical men, of puncturing the head and letting

out the fluid, is very seldom successful.

But there are more hopeful cases sometimes met with, those namely of

children in whom, either from simple weakness, or from that

constitutional disorder called rickets, bone formation has been

backward, and the head has consequently long remained unclosed. If such

children, either from the irritation of teething, or from the straining

during paroxysms of hooping cough, suffer from congestion of the brain,

fluid may be poured out, which, not being compressed by the too yielding

skull, may in consequence enlarge it. These cases, however, may be

distinguished from the other more serious ones by the date of their

commencement, which is always much later than that of the other form, by

the symptoms which attend them being less severe, and by the enlargement

of the skull being far slighter.

Still they require watching, for while with improved health the

enlargement ceases, the fluid is in a measure absorbed, and the head

diminishes in size, though always remaining larger than the average;

brain mischief is yet more readily set up in children with such

antecedents than in others.

The anxiety of parents about the size or shape of their child's head

after infancy has passed, is perfectly needless. When the head has once

closed it always remains so. An odd shape, with an unusual protuberance

of the forehead and the hind head, sometimes remain as the evidence of

that condition in infancy to which I have just referred. It is, however,

an evidence of mischief passed, not of mischief going on. In children

too who have suffered from rickets, an affection rarely met with except

among the poor in crowded cities, distortion of the limbs is often

associated with a peculiar form of the skull, but in this too there is

nothing to call for anxiety, still less to excite alarm. It is only a

preternaturally small head and shelving forehead, which are found

associated with mental deficiency; otherwise the greatest varieties of

size and shape, of symmetry, or of want of it, may be associated with an

equal variety of intellectual endowment, which is just as likely to be

above as below the average.

=Brain Disorder from Exhaustion.=--It may at first sight appear strange

that before leaving the subject of congestion and inflammation of the

brain, I should find it necessary to give a caution against being misled

by symptoms which though in some respects similar to those of congestion

or inflammation, are in reality due to an exactly opposite condition.

This mistake, however, is very possible; doctors themselves sometimes

fall into it, and some distinguished physicians have thought it worth

their while to lay down very minute rules for distinguishing between the

two opposite states. Headache we all know attends an overfull condition

of the vessels of the brain, and grown persons usually suffer from it

severely before an attack of apoplexy; but we also know that bad

headache accompanies states of great weakness, and that it is one of the

most distressing consequences from which a woman suffers who has lost

much blood in her confinement. In just the same way, the infant who has

been exhausted by diarrh[oe]a or by some trying illness, or who after

weaning has been kept on a diet not sufficiently nutritious, may show

symptoms of disorder of the brain.

It may become irritable, restless, very startlish, with occasional

flushings of the face, moaning in its sleep, and sleeping with

half-closed eyes. But the head is not hotter than the rest of the body;

if the head is not closed, the open part or fontanelle is not tense and

pulsating, but flat or even depressed, the hands and feet are cool, and

very readily become cold; there may be occasional vomiting, but nothing

like the constant sickness of real brain-disease, the bowels are not

shrunken but distended, constipation is not present, but on the contrary

there is a disposition to diarrh[oe]a. If the symptoms are

misinterpreted and wrongly treated, unmistakable signs of exhaustion at

last come on, and the child may die from its not being borne in mind

that results at first sight much the same may flow from causes

diametrically opposite.

The moral of this is too obvious for me to need insist upon it. Cold to

the head, low diet, aperients, possibly leeches, are needed in the one

case; increased nourishment, perhaps stimulants, in the other. In every

instance where symptoms of brain disorder occur in the child, remember

the grievous consequences of a mistake as to their nature, and seek for

further help and guidance to preserve you from the possibility of error.

=Spasmodic Croup.=--I have already tried to explain how, in early life,

the brain is often unequal to control the sensitiveness of the nervous

system to various sources of irritation from without, and how, in

consequence this irritation manifests itself by those involuntary

movements which we call convulsions. But in addition to, or in the place

of those violent contortions or convulsions, the same condition shows

itself sometimes in disordered action of the muscles which subserve

parts not directly subject to the will, as those for instance which open

and close the entrance to the windpipe, or glottis as it is called in

medical phraseology.

Cases in which this occurs are known in popular language as

child-crowing, or _spasmodic croup_, from the peculiar catch or crow

which accompanies the entrance of air through the spasmodically

contracted opening of the windpipe; a spasm which if severe and

sufficiently continued closes the opening altogether, so that after

fruitless efforts to get its breath the child dies suffocated. This

affection occurs chiefly during teething, just as the fits of a

hysterical girl oftenest occur during the transition from girlhood to

womanhood; but many other causes besides the local irritation of the

teeth may produce it, such as constipation, indigestible food, or

disorder of the bowels.

It does not often occur in perfectly healthy children; but an infant

who is attacked by it is usually observed to have been drooping for some

time previously, to have lost its appetite, to have become fretful by

day and restless at night, and to present many of those ill-defined

ailments which are popularly ascribed to teething. At length, after

these symptoms have lasted for a few days or weeks, a slight crowing

sound is occasionally heard with the child's respiration, shorter, more

high-pitched, but less loud than the hoop of hooping cough. Usually it

is first noticed on the child awaking out of sleep, but sometimes it is

perceived during a fit of crying, or comes on while the infant is

sucking. The spasm may have been excited by some temporary cause, and

the sound which is its token may not be heard again; but generally it

returns after the lapse of a few hours, or of a day or two, and its

loudness usually increases in proportion as its return becomes more

frequent. It will soon be found that certain conditions favour its

occurrence; that the child wakes suddenly with an attack of it, that

excitement induces it, or the act of swallowing, or the effort at

sucking, so that the child will drop the nipple, make a peculiar croupy

sound with its breathing, and then return to the breast again.

Throughout the whole course of the affection, its attacks will be found

to be more frequent by night than by day; and to occur mostly soon after

the child has lain down to sleep, or towards midnight, when the first

sound sleep is drawing to a close.

At first, the child seems, during the intervals of the attack, much as

before; except, perhaps, that it is rather more pettish and wilful; but

it is not long before graver symptoms than the occasional occurrence of

an unusual sound when the child draws a deep breath excite attention,

and give rise to alarm. Fits of difficult breathing occasionally come

on, in which the child throws its head back, while its face and lips

become livid, or an ashy paleness surrounds the mouth, slight convulsive

movements pass over the muscles of the face; the chest is motionless,

and suffocation seems impending. But in a few seconds the spasm yields,

expiration is effected, and a long loud crowing inspiration succeeds, or

the child begins to cry. Breathing now goes on naturally: the crowing is

not repeated, or the crying ceases; a look of apprehension dwells for a

moment on the infant's features, but then passes away; it turns once

more to its playthings, or begins sucking again as if nothing were the

matter. A few hours, or even a few days, may pass before this alarming

occurrence is again observed, but it does recur, and another symptom of

the disturbance of the nervous system is soon superadded, if it has not,

as is often the case, existed from the very beginning. This consists in

a peculiar contraction of the hands and feet; a state which may likewise

not infrequently be noticed during infancy, unattended by any

peculiarity in breathing. It differs much in degree; sometimes the thumb

is simply drawn into the palm while the fingers are unaffected; at other

times the fingers are closed more or less firmly, and the thumb is shut

into the palm; or, coupled with this, the hand itself is forcibly flexed

on the wrist. In the slightest degree of affection of the foot, the

great toe is drawn a little away from the other toes; in severer degrees

the toe is drawn away still further, and the whole foot is forcibly bent

upon the ankle, and its sole directed a little inwards. Affection of the

hands generally precedes the affection of the feet, and may even exist

without it, but the spasmodic contraction of the feet never exists

without the hands being involved likewise. At first this state is

temporary, but it does not come on and cease simultaneously with the

attacks of crowing breathing, though generally much aggravated during

its paroxysms. Sometimes a child in whom the crowing breathing has been

heard, will awake in the morning with the hands and feet firmly bent,

though he may not have had any attack of difficult breathing during the

night. When the contraction is but slight, children still use their

hands; but when considerable they cannot employ them, and they sometimes

cry, as if the contraction of the muscles were attended with pain.

Sometimes, too, there is a degree of puffiness both of hands and feet, a

sort of dropsical condition, which, whenever it is present, adds much to

the anxiety with reference to the child.

As the condition becomes more serious, a slight crowing sound is heard

each time the child draws its breath, the fits of difficult breathing

are much more severe; they last longer, and sometimes end in general

convulsions. The breathing now does not return at once to its natural

frequency, but continues hurried for a few minutes after the occurrence

of each fit of difficult breathing, and is sometimes attended with a

little wheezing. The slightest cause is now sufficient to bring on an

attack; it may be produced by a current of air, by a sudden change of

temperature, by slight pressure on the windpipe, by the act of

swallowing, or by momentary excitement. The state of sleep seems

particularly favourable to its occurrence, and the short fitful dozes

are interrupted by the return of impending suffocation, in one paroxysm

of which longer and severer than the others the infant may fall back

dead.

It scarcely need be said that the great majority of cases have no such

sad ending as I have described, but still, whenever this spasm exists,

even in a slight degree, there is always the possibility, never to be

forgotten, of a sudden catastrophe. Usually, after some tooth has been

cut which caused special irritation, or as disorder of the bowels has

been set right, the symptoms abate by degrees, and then cease

altogether, though liable to be reproduced by the same causes as those

to which they were originally due.

The seeking out and removing the exciting causes must be the care of the

medical man, but there are some special precautions which come within

the mother's own province to observe.

First of all, as sudden excitement, and especially a fit of crying, are

likely to bring on the attack, and since there is a possibility that any

attack may prove fatal, the greatest care must be taken in the

management of the child to avoid all unnecessary occasion of annoyance

or of distress.

Although the benefit that accrues from fresh air, or from a change of

air, is often very great, yet it is very important that the child should

not be exposed to the cold or wind, for I have seen such exposure

followed by a severe attack of difficult breathing, or by the occurrence

of general convulsions. Another reason for caution in this respect is

that the occurrence of catarrh is almost sure to be followed by an

aggravation of the spasmodic affection, which, though previously slight,

may thereby be rendered serious or even dangerous.

I have nothing to add to what I have already said with reference to the

treatment of the attack, when actual convulsions come on. Since,

however, in this affection convulsions may occur quite unexpectedly at

any moment, it is well always to have a basin of cold water and a bunch

of feathers handy, in order to be able at once to dash the water on the

child's face, and induce that deep inspiration which saves it from the

threatening danger. If this should not suffice, the finger must be put

into the mouth, and run over the back of the tongue in the way that I

have already explained when speaking of convulsions. Now and then it

happens, though but very rarely, that violent _general convulsions_ come

on in infancy quite independent of spasmodic croup, not preceded nor

attended by any sign of disease of the brain, and which end in the

course of some hours or of a few days in death, the child being partly

worn out by the violence of the muscular movements, partly by the

disturbance of breathing which each fit occasions. Happily, however, in

most of these instances the convulsions by degrees lessen both in

violence and frequency, and the child recovers.

=Epilepsy.=--There is one other point of view from which convulsions in

infancy and early childhood must be looked on with apprehension, and

that is from their being frequently followed in after years by

_epilepsy_. In nearly a fifth of all cases of epilepsy in childhood that

have come under my notice the first occurrence of fits dated back to

early infancy, and this, even though an interval of years had passed

between the last fit in infancy and the first in childhood. It seems,

indeed, as though there were in these cases a peculiar abiding

sensitiveness of the nervous system, which, dating back from very early

life, dependent often on hereditary predisposition, was kindled into

activity by any special cause, such as the cutting of the second set of

teeth, or the transition from boyhood or girlhood to manhood or

womanhood.

In the child, just as in the grown person, epilepsy manifests itself in

two different ways; either by momentary unconsciousness, or by violent

convulsions, in which latter there is little distinction from the

occasional fit which may be observed at any period of infancy.

The attacks of momentary unconsciousness often pass long unnoticed.

They occur, perhaps, when the child is at play or at meals; it stops as

if dazed, its eye fixed on vacancy; if standing, it does not fall, nor

does it drop the toy or the spoon which it was holding from its hand. If

speaking, it just breaks off in the midst of the half-uttered sentence.

Then, in less time than it takes to tell, it suddenly looks up again,

finishes what it was saying, or goes on with its play, or with its meal

as though nothing had happened; or it suffices to call the child and the

cloud passes from its face, and it is itself again; and the nurse or

perhaps even the mother, thinks that it is some odd trick which the

child has got. By degrees the attacks become more frequent, and may

continue to recur several times a day without any obvious cause, even

for months; and this without any change in their character. By degrees,

however, under their influence, an alteration takes place slowly in the

child's disposition. It loses its cheerfulness and brightness, its face

assumes a heavy look, it becomes fretful, and its intelligence grows

duller.

Almost invariably after the attacks of this, which has been called the

_petit mal_, have continued for some months, a change begins to take

place, which does not fail to excite attention and to cause alarm. If

seated, the child's head drops forward for a moment, and strikes against

the table; if standing, it becomes for an instant dizzy, and staggers,

or even falls, and then there is twitching of one limb, or of the

muscles of the face, and then the complete fit of epilepsy, ushered in

sometimes, but not always, by a momentary cry, and then the convulsive

twitching of one limb, followed in a minute or in less time by

convulsions of the whole body as well as of the limbs. The upturned

eyes, which do not see, are horribly distorted, the child foams at the

mouth, it is insensible, and the insensibility deepens into stupor, or

is followed by heavy sleep, for a quarter of an hour, or an hour or

more, from which the patient arouses feeling tired and bruised, and

often with an aching head, but with no remembrance of what has passed

during the seizure so distressing to bystanders.

It has throughout been my endeavour not to lose sight of those for whom

this little book has been written, and with reference to epilepsy, as

with reference to many other things, I pass over much that would be

important to the practitioner of medicine, to dwell on those points

which mainly interest the parents, and which they are perfectly able to

appreciate.

The question is often put as to the probability of fits terminating in

epilepsy; or, on the other hand, as to the ground for hope in any case

that epileptic attacks, which have already often recurred, will

eventually cease. In the first place, no conclusion can safely be drawn

from the severity of a convulsion, nor from its general character, as to

the probability of its frequent recurrence, or of its passing into

permanent epilepsy. The severity of a fit certainly affords no reason

for this apprehension, nor does its recurrence, so long as a distinct

exciting cause can be discovered for each return. The fits, which cease

in the teething child when the gum is lanced, and which, on each

succeeding return are equally relieved by the same proceeding, do not

imply that there is any great tendency on their part to become habitual.

In the same way, the attacks which follow on constipation, or on

indigestion, or on some other definite exciting cause, may probably with

care be guarded against, and their return prevented. It is not the

violence of a single fit, nor even the frequent return of fits for a

limited time, which warrants the gravest apprehension; but it is their

recurrence when all observable causes of irritation have passed away; it

is their return when the child is otherwise apparently in perfect

health.

If, on the one hand, the violence of a convulsion does not by any means

imply the greater proportionate risk of its recurrence, so neither can

any hopeful conclusion be drawn from the slightness of an attack, or

from its momentary duration. In childhood, such attacks are at least as

common preludes to confirmed epilepsy as in the adult, and are the more

deserving of attention from their very liability to be overlooked. I

believe, too, that an imperfect suspension of consciousness, the child

knowing what passes, though unable to speak, is not very uncommon, and

further, that it is far from unusual to have the early stage of epilepsy

in childhood announced by sudden incoherent talking for a few seconds,

or by a wild look; a cry of surprise, or a short fit of sobbing,

announcing as in a hysterical girl, the close of the paroxysm. The early

symptoms of epilepsy in childhood are also the more likely to be

misinterpreted from the circumstance that they are frequently

accompanied by a moral perversion much more striking than any loss of

mental power. It is true that in early life there are alternations of

intellectual activity and mental indolence, of quickness and comparative

dulness, which all who have had much to do with education are well aware

of, and which are perfectly compatible with health of body and health of

mind. But changes in the moral character of a child who is still under

the same influences, have a far deeper meaning than is often attached to

them; a child does not suddenly become wayward, fretful, passionate, or

mischievous, except under the pressure of some grave cause.

One other point there is also to be borne in mind; namely, that the

child is compelled by the vague sensation of hitherto unknown dread, not

to conceal the early symptoms of epilepsy as the grown person would do;

longing as the child does for love and sympathy, and weakened in its

moral force, it craves for more love, more sympathy, it exaggerates its

symptoms, it assumes some which do not exist at all. The conclusion is a

natural one, but none the less mistaken, that the child who is

discovered to be shamming has nothing the matter with it--is simply a

naughty child. This is a fact of much importance, on which I shall have

occasion to insist further on.

In the child, as in the adult, epilepsy blunts the intellect as well as

weakens the moral powers; and does both more speedily and more

effectually in proportion as the child is younger, and its mind and will

are less developed. And yet this has its compensation; for as the powers

fade quickly, so, if the attacks cease, they recover with surprising

rapidity, and as the moral powers are the first to suffer, so they are

the first to regain--I will not say full vigour, but at least a degree

which raises the children to be objects of specially tender affection,

rather than of pity and compassion.

The conditions which justify the most hopeful view of any case of

epilepsy are then, first, the absence of any history of frequently

recurring convulsions in early infancy; secondly, the existence of a

distinct exciting cause for the attacks; thirdly, the rarity of their

return far more than their slight severity; and lastly, the more the

attacks approach in character to what one knows as hysteria, the less

profound the insensibility in the fit, the shorter its duration

afterwards, the greater are the grounds for hope that the seizures will

eventually cease.

Cases of this last class are to some degree, at any rate, under the

child's control. I have several times seen a fit warded off by the

threat of the shower bath, or even by calling to the child, and sending

it to fetch something in another room. Such cases may indeed pass into

ordinary epilepsy, but often, under judicious management, moral rather

than medical, they cease, so that one can venture on taking a more

hopeful view of them than of others.

And this brings me to the question of what can be done, or rather what

can parents do to promote recovery from epilepsy. First of all, do not

listen to what you may hear about this medicine or the other being a

specific for it. There is no specific whatever for epilepsy, but there

are certain remedies which in skilful hands do have a real though

limited power to control the frequency and lessen the severity of the

attacks. Next, there are cases in which the attacks depend on some

definite cause; it may be indigestion, or constipation, or the cutting

of the second set of teeth, and on the irritation produced by those

teeth being too crowded. Thus, I remember a boy twelve years old, in

whom two severe epileptic fits occurred apparently without cause. He was

cutting his back grinding teeth, and in the lower jaw the teeth seemed

overcrowded. I had a tooth extracted on either side, the fits ceased,

and when I last heard of him many years afterwards they had not

returned.

Epilepsy often lasts for many years, and no one's memory is retentive

enough to be trusted with all the details between the different attacks,

the causes which seemed to produce them, the measures which appeared at

different times to be of service. I am therefore accustomed to advise

people, any of whose children have the misfortune to be epileptic, to

write as brief an account as possible of the child's previous history,

and to supplement it by a daily record kept in parallel columns of date,

food, state of bowels, sleep, medicine, attacks, specifying their

character and duration; and general remarks, which would bear on the

child's temper and general condition, and in which column any probable

exciting cause of an attack would be recorded. It is surprising how much

important information is gathered in a few months from such a record

kept faithfully.

The diet should be mild, nutritious, but as a general rule

unstimulating; and should include meat comparatively seldom, and in

small quantities. Some fifty years ago, a very distinguished American

physician, Dr. Jackson of Boston, in the United States, insisted very

strongly on the importance of a diet exclusively of milk and vegetables

in greatly lessening the frequency and severity of epileptic attacks. I

believe in the great majority of cases of epilepsy in childhood Dr.

Jackson's advice is worth following. And I may add that, while I have

little faith in the influence of mere drugs, I have a yearly increasing

confidence in that of judicious management, mental and moral, as well as

physical.

The first requisite in all cases is a firm and gentle rule of love on

the part of those who have charge of the child. As violent and sudden

excitement of any kind will often bring on an epileptic seizure, so the

influence of the opposite condition in warding off its attacks is very

remarkable; and on several occasions I have received patients into the

Children's Hospital who were reported to have epileptic seizures several

times in a day, and who nevertheless remained a fortnight or more in the

institution without any attack coming on. The disorder, however, was not

cured, but only kept in check by the gentle rule to which the little

ones were subjected. The order goes for much in these cases; the novelty

goes for something too, for almost invariably I have found that after a

time the apparent improvement becomes less marked, and though they

continued better than when they first came to the hospital, the children

were still epileptic; the advance of the disease had been retarded, but

its progress had not been arrested. The quiet then which suits the

epileptic, is not the quiet of listless, apathetic idleness, but the

judicious alternation of tranquil occupation and amusement. The mind

must not be left to slumber from the apprehension of work bringing on a

fit, but the work must, as far as possible, be such as to interest the

child. In the occupations of epileptics therefore, pursuits which not

merely employ the mental faculties, but also give work to the hands,

such as gardening, carpentering, or the tending of animals, are

specially to be recommended; and if by these the mind can be kept awake,

the grand object of teaching is answered, and backwardness in reading,

writing, or those kinds of knowledge which other children at the same

age have acquired, is of very little moment. Many epileptics have an

indistinct articulation, and almost all have a slouching gait, and an

awkward manner. The former can often be corrected to a considerable

degree by teaching the child simple chants, which are almost always

easily acquired, and practised with pleasure. The latter may be

rectified by drilling, not carried out into tedious minutiae, but limited

to simple movements; and the irksomeness of drill is almost completely

done away with by music, while I believe that the accustoming a child to

the strict control and regulation of all its voluntary movements is of

very great importance indeed as a curative agent.

It is difficult to carry out these minute precautions on which so much

depends in the home with other children of the same family. It is

therefore, I believe, better for the child, painful though it is to the

parents, that he should be placed under the care of some competent

person who will devote the whole of his time to the care of the patient.

=St. Vitus's Dance.=--A state of unconsciousness, accompanied with more

or less violent involuntary movements, is characteristic of epilepsy.

Involuntary movements without loss of consciousness constitute the

disorder commonly known as _St. Vitus's Dance_. It is rare in early

childhood, becomes more common after the age of five, and attains its

greatest frequency between the ages of ten and fifteen, girls, owing to

their more impressionable nervous system, being affected by it more than

twice as often as boys.

It seldom comes on in a child previously in perfect health, and

strangely enough it occurs with special frequency in children who have

before suffered from rheumatism. Sudden shock or fright is often said to

have been its exciting cause; but even then the symptoms seldom come at

once, but are gradually developed in the course of two or three days. At

first, it is noticed that the child has certain odd fidgety movements,

usually of one arm, next of the leg of the same side, so that it

stumbles in walking, and then the muscles of the face become affected,

the child grimacing strangely, and next the limbs of the opposite side

become involved, and as things go on from bad to worse, the child

becomes unable to hold anything in its hand, to walk, or even to stand,

and even if on the ground still writhes about with the strangest

contortions of its body. If matters grow still worse, the child becomes

unable to put out its tongue, it swallows with difficulty, it loses not

only the power of distinct articulation but even the faculty of speech,

while the mind itself becomes weakened, the child seems half idiotic,

and even though the movements lessen in violence, power over the limbs

is lost for the time, and they seem almost paralysed. Happily cases so

severe are very rare, and it is rarer still for them to have a fatal

termination. Almost invariably recovery takes place by degrees, the

movements lessen, swallowing is performed with less difficulty, the

power of speech, returns, and the intellect regains its brightness: but

the child is left with a special liability to return of the affection,

though the first attack is usually the most severe.

Even at the best, however, the disorder is always tedious, as is shown

by the fact that its average duration is seventy days. It is very

natural, therefore, that parents should be anxious when they see that

their child has some awkward or ungainly habit, some odd trick or

gesture never noticed before, lest it should be the beginning of this

tedious ailment. Now it is well to remember that St. Vitus's dance does

not begin with twitching of the muscles of the face, but that its

earliest symptoms are involuntary movements of the arms and twitching of

the fingers, and that contortions of the face do not come on till

afterwards. Movements of this sort too, even when not limited to the

face, vary in the course of a few days in the parts which they affect,

and show themselves, now in winking the eyes, then in grimacing, in

twitching of the muscles of the face or neck, or in some awkward gait or

manner. These are all best left unnoticed, for they are almost

invariably made worse if the child's attention is called to them. They

are, or at least before the days of Board Schools they were, scarcely

ever met with among the children of the poor, for they almost invariably

depend on mental strain; not of necessity on undue length of the hours

of study, or on the difficulty of the tasks imposed, but often on a

child's anxiety to make progress and to keep up with his schoolfellows.

In corroboration of this being their cause I may say that, contrary to

the rule which obtains with St. Vitus's dance, these movements are more

frequent in boys than in girls, for the over-mental strain of boys comes

earlier; that of girls seldom occurs before the time of transition to

womanhood, and its results are then different, though much graver. In

cases of this kind, lessening the mental strain is almost always

followed by a cessation of the movements; change of air, country

amusements, and a generally tonic treatment perfect the cure, and

dancing and gymnastics overcome the remains of any awkward habit.

The movements in real St. Vitus's dance do not shift about as these do

from one part to another, but tend to involve various parts in

succession, without previously ceasing where they had begun.

The relative share which the parents and the doctor take in the

treatment of these cases depends to a great extent on their severity.

While attention to the state of the bowels, and a generally tonic

treatment are almost always needed, gymnastics and drill are often of

very great service in the slighter cases; and a very distinguished Paris

physician was accustomed to send children thus affected to march round

the Place Vendome, keeping step while the band was playing. The utility

of gymnastics turns very much on the degree in which the child is able

by attention to control his movements, and when either as in young

children fixed attention cannot be roused, or as in severe cases the

effort only adds to the child's nervousness, and in consequence

increases the movements, they must be given up. All drill and gymnastics

are best carried out in class with other children, and regulated not

simply by word of mouth, but by a tune or chant. When recovery is in

progress gymnastics will then in almost all instances find their place.

Even when drill and gymnastics cannot be practised, regulated movements

of the limbs carried out twice a day for ten minutes at a time are of

very real service. Another's will here takes the place of that of the

patient, and the limbs are thus taught, though far more imperfectly, to

act in concert.

Two or three more cautions may still be of service. Do not keep a child

out of bed, and force it to try to exert itself when the movements are

very severe; continued movement, voluntary or involuntary, fatigues. Let

the child lie in bed; it rests there, and the movements, which always

cease during sleep, become at once greatly lessened. So important indeed

is it to avoid the exhaustion caused by incessant violent movement, that

in bad cases it is sometimes necessary to swathe the limbs in flannel

bandages, and so to confine them to splints in order to restrain them.

Next, do not become over-anxious because the child grows stupid and

ceases to talk; intelligence and the power of speech will certainly come

back again. And, lastly, do not be impatient and think your medical

adviser incompetent because the disorder lasts so long. An average

duration of seventy days implies that while sometimes it ceases sooner,

in others it lasts much longer than the two weary months of watching and

waiting with which in any case you must lay your account.

=Paralysis, or Palsy.=--When speaking of St. Vitus's dance I said that

there was a partial loss of power in the limbs as well as an inability

to control their movements. After a fit of convulsions, or an epileptic

seizure, power over some limb is often lost for a time which may vary

from a few minutes to some hours. In the course of some serious diseases

of the brain, one of the manifestations of the mischief is the

impairment or the loss of power over one arm or leg, rarely over both;

and lastly, that terrible disease diphtheria is often followed by a

paralysis so general that the patient is sometimes for days unable to

move even a finger, although the condition may eventually pass away.

There is, however, a very _real paralysis_ which occurs sometimes in

infants and young children. It comes on for the most part quite

suddenly, often unaccompanied by any sign of brain disorder, but tending

nevertheless to issue in great permanent impairment of the power over

the affected limb or limbs, and eventually to interfere with their

growth and thus to produce serious deformity.

It is in general impossible to assign any distinct exciting cause for

the affection, though the fact that in two-thirds of the cases it occurs

between the ages of six months and three years, proves it to be in some

way intimately associated with teething. The oldest child in whom I have

ever seen it was aged between seven and eight years, and the youngest a

little under six months. It is of excessive rarity for the arm alone to

be affected, but it is by no means unusual for the legs alone to be

paralysed; though in the majority of instances power is lost on one side

only, the leg and arm being both involved.

A child goes to bed quite well, or at the worst having seemed slightly

ailing and feverish for a day or two, and on waking in the morning it is

suddenly discovered that power is lost over one leg or both, or over

both arm and leg of one side. The loss of power is at first seldom

complete, though neither arm nor leg can be used to any good purpose,

and during the ensuing twenty-four hours the palsy often grows worse,

and sometimes affects one or both limbs of the opposite side. After that

time recovery in general begins. It is now and then speedy, so that in

three or four days all trace of the paralysis may have disappeared.

This, however, is a fortunate exception to the general rule, which is

that amendment is very tardy, showing itself first in the arm,

afterwards in the leg, and, if both sides have been affected, more on

one side than on the other. Unless the improvement is very rapid, it is

almost always only partial, and the palsied limb, though it does not

lose sensation, regains but little power; it grows much more slowly than

the other, is always colder and wastes considerably, while, some muscles

still retaining more power than others, it becomes twisted out of shape,

and requires all the skill of the orthopaedic surgeon to remedy or at

least to lessen the consequent deformity.

It has been ascertained that this form of palsy depends on a state of

congestion, or overfilling of the minute blood-vessels of the spinal

marrow. When the child gets well the congestion has passed away; but it

does this speedily, and recovery is then rapid as well as complete. If

it does not soon pass away, other changes take place in the spinal

marrow, and recovery is then slow, incomplete, or even does not take

place at all.

Remedies are unfortunately of little avail here, but it is evident that

when the palsy is quite recent all movement of the limb must be

mischievous, and that the congestion of the spinal marrow to which it is

due will be most likely to abate under the influence of perfect quiet,

rest in bed, and soothing or fever medicines, or of such as are

calculated to overcome constipation, or to correct any fault of

digestion, while the importance of teething, and the possible expediency

of lancing the gums must not be forgotten.

Afterwards comes the time for exercise of the paralysed limb, for

friction, for shampooing, for galvanism; all continued perhaps for

months or years with unwearied patience, and I must add with reasonable

expectations as to the result. The only additional remark which I have

to make is this, that to gain any real good from galvanism, a battery

must be procured under the direction of some medical man specially

skilled in the use of electricity, and the mode of employing it must be

learned thoroughly from him. It is merely idle to purchase a toy

machine, and, giving it to the nurse to turn the handle for ten minutes

twice a day, to fancy that you are making a serious trial of the effects

of galvanism. As a mere money question, a costly machine, and several

fees paid in order to be thoroughly instructed in the way to use it, is

much cheaper than a cripple child.

A few words may not be out of place with reference to cases in which

paralysis is mistakenly supposed to exist. Much anxiety is sometimes

expressed by parents concerning children who have long passed the usual

age without making any attempt to walk; or who having once walked seem

to have lost that power. Now it often happens that after any weakening

illness a child ceases for some weeks to walk, just as it ceases to

talk. The power in both cases was newly acquired, it called for effort

which, when strength is regained, will be put forth once more. The same

applies to other instances in which children are late in learning to

walk; or who, having once walked, leave off walking when a back tooth,

or when one of the eye teeth is coming near the surface of the gum, and

regaining the power lose it again, or lose at least the desire to exert

it more than once during the active progress of teething. But, holding

the child under its arms, you have but to put its feet to the ground,

and at once it will draw up its legs though it will make no other

movement; or take it on your lap and tickle the soles of its feet, and

laughing or crying, as the mood takes it, it will move its legs about as

freely as you could wish and show that the power is still there, though

for the present the child will not take the trouble to exert it.

Gradual loss of power over one or other leg, especially if attended with

pain either in the back or in the knee or hip, should always call for

attention, and induce you to seek at once for medical advice. Such cases

generally occur later in childhood than the conditions of which I spoke

in the former paragraph, and may depend on disease of the spine or of

the hip-joint, two serious conditions which it needs the medical expert

to discover and to treat.

=Neuralgia and Headache.=--In the grown person neuralgia, as many of us

know to our cost, is by no means infrequent; in the child it is very

rare, and when a child complains of severe pain in the head, or of

severe pain to the knee or hip apart from rheumatism, it is almost

invariably the sign of disease of the brain in the one case, of the

hip-joint in the other. To this rule there are indeed exceptions, but it

will always be well to leave it to the doctor to determine--no easy

matter by the bye--whether any given case is one of the rare exceptions

or not.

There is, however, one form of real _neuralgic headache_ which is by no

means rare in children after the commencement of the second dentition,

and which sometimes goes on into early manhood or womanhood, when it

becomes what is commonly known as sick headache. It is essentially an

ailment of development, incidental to the time when the brain is first

called on for the performance of its higher functions.

It does not by any means always depend on over-study, though I do not

remember meeting with it in children who had not yet gone into the

school-room; and I have frequently found it dependent on too continuous

application, though the number of hours devoted to study in the course

of the day may not have been by any means excessive.

The child's brain soon tires, and the arrangement, so convenient to

parents of morning lessons and afternoon play, works far less well for

it than if the time were more equally divided between the two.

The attacks not infrequently come on on waking in the morning, and

rapidly become worse, the pain, which is almost always referred to the

forehead, being attended with much intolerance of light and sound, with

nausea, and often with actual vomiting. Like the vomiting of

sea-sickness, however, previous stomach disorder has no necessary share

in its production, and I may add, indeed, that it is often difficult to

assign any special exciting cause for the attack. The suffering is more

often relieved by warm or tepid than by cold applications, and not

infrequently pressure or a tight bandage greatly mitigates it. In no

case does the attack last more than twelve hours--usually not more than

half that time; it passes off with sleep, and leaves the patient weak

and with a degree of tenderness of the head to the touch.

Such attacks may occur every fortnight, ten days, or even oftener, but

their very frequent return, instead of increasing apprehension, should

diminish anxiety. A first attack, indeed, may seem as though it

threatened mischief, till it is seen how speedily and completely it

passes off, and when afterwards a second or a third attack comes on with

the same severity of onset, the same rapid worsening, and the same quick

passing away, you will feel convinced that the symptoms have no grave

meaning.

There is a headache of quite a different kind to which I must for a

moment refer, that, namely, which depends entirely on imperfect vision,

and for which spectacles are the remedy, not physic. The infirmity is

not noticed during the first few years of life, but in later childhood,

when a tolerably close attention to study has become necessary. Some of

the minor degrees of short-sightedness, and want of power of adaptation

of the eyes, such as exists in the aged, soon begin to interfere

sensibly with the child's comfort, and the strain to which the eyes are

subject produces a constant pain over the brow, the cause of which is

often unsuspected.[13]

In all cases, therefore, in which a child complains of constant pain

over the brow for which there is no obvious cause, it is well to take

the opinion of an oculist, who can best ascertain the power of _reading

at different distances_ and with each eye separately, and the real cause

of symptoms which had occasioned much anxiety is thus often brought to

light.

=Night Terrors.=--Before taking leave of the disorders of the nervous

system, I must briefly mention the Nightmare, or Night Terrors of

children, which often cause a degree of alarm quite out of proportion to

their real importance.

It happens sometimes that a child who has gone to bed apparently well,

and who has slept soundly for a short time, awakes suddenly with a sharp

and piercing cry. The child will be found sitting up in bed, crying out

as if in an agony of fear, 'Oh dear! Oh dear! take it away! father!

mother!' while terror is depicted on its countenance, and it does not

recognise its parents, who, alarmed by the shrieks, have come into its

room, but seems wholly occupied by the fearful impression that has

roused it from sleep. By degrees consciousness returns; the child now

clings to its mother or its nurse, sometimes wants to be taken up and

carried about the room, and by degrees, sometimes in ten minutes,

sometimes in half-an-hour, it grows quiet and falls asleep; and then

usually the rest of the night is passed undisturbed, though sometimes a

second or even a third attack may occur before daybreak.

Seizures of this kind may come on in a great variety of circumstances,

and may either happen only two or three times, or may continue to recur

at intervals for several weeks. The great point, however, to bear in

mind is that they depend invariably on some disorder of the stomach or

bowels, and are never an evidence of the commencement of real disease of

the brain.

FOOTNOTES:

[11] Reports of the Registrar-General, as quoted at p. 30 of my

_Lectures on Diseases of Children_. The actual numbers are 9,350 under

five years old, out of a total of 16,258.

[12] Figures deduced from the 44th Report of the Registrar-General.

[13] Before I called attention to this form of headache in the last

edition of my lectures, it had already been noticed without my

knowledge, by a friend of mine, Dr. Blache, of Paris, in a very valuable

essay on the headaches which occur during the period of growth.

CHAPTER VII.

THE DISORDERS AND DISEASES OF THE CHEST.

In speaking of the ailments which occur during the first month after

birth, I have already noticed the peculiarities of breathing in early

infancy, and the difficulties that sometimes attend the complete filling

of the air-cells of the lungs, and the readiness with which when once

filled they become emptied of air and collapse.

On this ground it is therefore needless for me again to enter, and I may

pass at once to consider those ailments which rise in increasing

importance from a simple cold or catarrh to inflammation of the

air-tubes or bronchitis, inflammation of the lung substance, as

pneumonia, and inflammation of the membrane which lines the chest and

covers the lungs, or pleurisy.

=Catarrh.=--A common cold or _catarrh_ is not one of the ailments of

very early infancy. The watery eyes, the sneezing, the cough, the slight

feverishness and the heavy head are scarcely met with until after the

age of three months; nor, indeed, are they often seen till the child is

old enough to run about, to go out for a walk, and to encounter in

consequence all the variations of temperature and of damp or dryness

inseparable from the English climate.

This, however, is not entirely due to the greater exposure of the child

to these influences as it grows older, but in part also to the fact that

the lining of the air-tubes is less sensitive in early infancy than it

afterwards becomes. The young babe if it catches cold gets _snuffles_,

or stoppage of the nostrils, which first become dry, and then pour out

an abundant discharge, which sometimes dries and forms crusts, and

causes the child to suck with difficulty, and to breathe uncomfortably

and with open mouth. In a few days, however, at the worst this

discomfort passes away; and the only additional remark I have to make

is, that since obstinate snuffles are sometimes a constitutional

disease, the doctor's advice should always be sought if they last longer

than a week.

It is needless to describe a cold, but it is much more to the purpose to

say how its occurrence is to be prevented, and nine times out of ten the

observance of two simple rules will suffice for this. First, take care

that there is no great difference between the temperature of the day and

of the night nursery. The one should never be above 60 deg., nor the other

below 50 deg., and the undressing and the bath should always take place in

the warmer room. Second, never let the child wear the same shoes or

boots in the house as it does out of doors. The change should be as much

a matter of routine as the taking off its hat or its bonnet.

The domestic management of a cold is simple enough. The usual error is

the overdoing precautions, the keeping the room too hot, or overloading

the child with extra garments, or its bed with extra covering, by which

it is kept in a state of feverishness, or of needlessly profuse

perspiration.

If, for the first two days of a bad cold, the child is kept in bed, the

room being at a temperature of 60 deg., with no extra covering on the bed,

but a flannel jacket for the child to wear when it sits up in bed to

play, a few drops of ipecacuanha wine several times a day, a warm bath,

a linseed poultice to the chest, and a little paregoric at night, with a

light diet of rice, and arrowroot, and milk, and a roasted apple, and

some orange juice; nine times out of ten, or nineteen out of twenty, the

cold will pass away with small discomfort to the child and no anxiety to

the parents.

Often a child objects to stop all day in its little cot, but move it to

its mother's or nurse's big bed; and with a large tray of toys before

it, and a little of the tact which love teaches, the day will pass in

unclouded content and cheerfulness.

It must of course be borne in mind that measles set in with all the

symptoms of a bad cold, followed on the fourth day by the appearance of

the eruption; and, moreover, watchfulness must always be alive to detect

increase of fever, hurry of breathing, hardness or extreme frequency of

cough, the sign of the irritation of the larger air-tubes having

extended and become more severe, the evidence that the case from simple

catarrh has become one of bronchitis.

=Bronchitis and Pneumonia.=--It is impossible to enable persons who have

not received a medical education to distinguish between a case of

bronchitis and one of pneumonia. Neither, indeed, is it of much

importance that they should do so, for in both the dangers are of a

similar kind, and both call equally for the advice of a skilful doctor.

In _bronchitis_ inflammation affects the lining of the air-tubes,

travelling from the larger towards the smaller, and in bad cases

extending even to their termination in the minute air-cells. The

inflammation leads to the pouring out of a secretion, which by degrees

becomes thick like matter, or even very tenacious, almost as tough as

though it were a thin layer of skin. If this is very extensive, and

reaches to the small air-cells, it is evident that air cannot enter,

while that elasticity of the lung which I have already spoken of tends

to drive out from the cells the small quantity of air they contained,

and the child dies suffocated, partly from the difficulty in the

entrance of air, partly from the collapse of air-cells from which the

air has been slowly expelled.

In _pneumonia_ or inflammation of the lung-substance the process is

different. A portion of one or other lung, sometimes of both, becomes

overfilled with blood, or congested, and though the air-tubes themselves

are not the special seat of the congestion, yet the air-cells are

pressed on by the surrounding swollen substance, and the entrance of air

into them is impeded. If the mischief goes further the substance becomes

solid and impervious to air, and lastly it becomes softened, its

structure destroyed, and infiltrated with matter; the affected part

becomes really an abscess, though not bounded by the distinct limits

which would shut in an abscess of the hand or the foot. Inflammation,

and the formation of an abscess anywhere is, as we know, attended by

fever and much general illness, and inflammation of the lung is of

course attended by fever and general illness in proportion to the

importance of the organ affected. To these, too, must be added all the

disturbance inseparable from any ailment which gravely interferes with

breathing.

In the great majority of instances inflammation of the lung-substance

does not go on to the last stage, and recovery is not only possible, but

probable, from congestion and solidification of the organ. Pneumonia,

too, usually attacks only a portion of one lung, while in bronchitis the

air-tubes of both are always involved. Hence of the two, serious

bronchitis is more to be dreaded than serious pneumonia.

Bronchitis is always developed out of previous catarrh, though there is

a wide difference between the duration of the preliminary stage and the

occurrence of serious symptoms in different cases; while it may be laid

down as a general rule that the severity and danger of an attack are in

proportion to the rapidity of its onset. An attack of pneumonia, or

inflammation of the lung-substance sets in, as a rule, more suddenly,

with fever, a temperature of 103 deg. to 105 deg., general distress, headache,

not unfrequently delirium; the urgency of which symptoms, the hurried

breathing and the short, dry, hacking cough, and the tearless eyes are

too often misinterpreted, and the state of the chest not examined.

The doctor, of course, skilled in auscultation, will listen to the

chest and give to all these symptoms their true signification. The

lesson for the parent to bear in mind is never to neglect in a child the

symptoms of what may seem to be but a common cold, but to seek for

advice the moment the cough shows any disposition to become hard, or the

breathing hurried. Next, when any sudden illness sets in with very high

temperature and much general ailing, not to let the disorder of the

head, or the delirium, make you shut your eyes to the import of the

short cough, the dry eyes, the hurried breathing; and lastly, to

remember that, grave though the symptoms may be, the tendency in

pneumonia is to eventual recovery, and that in early life bronchitis is

the graver of the two diseases.

A caution may not be out of place with reference to cases which may

occur during the epidemic prevalence of _influenza_. A child is

sometimes struck down by it, just as grown persons are sometimes, with

great depression, extreme rapidity of breathing, and very high fever,

which, passing off in a couple of days, leave a state of great

exhaustion behind. It is well to bear in mind that such symptoms have no

such grave meaning when influenza is prevalent as they would have at

another time; and the knowledge of this fact may serve in some degree to

control your anxiety.

=Pleurisy.=--It is not possible for anyone, without medical experience,

to discriminate between pneumonia, or inflammation of the substance of

the lung, and pleurisy, or inflammation of its covering. Some degree of

the latter, indeed, very often accompanies the former, and this accounts

for the pain which interferes with every attempt of the child to draw a

deep breath. When pleurisy comes on independent of affection of the

lung-substance, it generally sets in suddenly with severe pain in the

chest, and a short hacking cough which causes so much pain that the

child tries as much as possible to suppress it. After a few hours the

severity of the pain usually subsides, but fever, hurried breathing, and

cough continue, and the child, though usually it looks heavy and seems

drowsy, yet becomes extremely restless at intervals--cries and struggles

as if in pain, and violently resists any attempt to alter its position,

since every movement brings on an increase of its sufferings. The

posture which it selects varies much; sometimes its breathing seems

disturbed in any other position than sitting straight up in bed; at

other times it lies on its back, or one side; but whatever be the

posture, any alteration of it causes much distress, and is sure to be

resisted by the child.

The variations of posture depend on the seat of the inflammation; the

pain depends on the two inflamed surfaces of the membrane rubbing

against each other, and accordingly is relieved not merely by the

abatement of the inflammation, but also when either the two surfaces

become, as they often do, adherent to each other, or when fluid is

poured out into the cavity of the chest, and thus keeps them asunder.

I dwell on this, because when fluid is poured out, the most distressing

symptoms greatly abate, or even disappear, and parents sometimes put off

in consequence sending for the doctor, while yet, if unattended to, the

fluid may increase to so large a quantity as to press upon the lung, and

so interfere with the entrance of air, or it may, if the mischief is not

checked, change into matter, and then have to be let out by tapping the

chest, for just the same reason as it may be necessary to open an

abscess in any other situation.

Whenever, then, symptoms, such as I have described, come on, send at

once for medical advice, and do not let some diminution of suffering, or

slight general improvement, lead you to delay.

=Croup.=--I endeavoured to explain, a few pages back, the cause of that

peculiar sound which is heard in spasmodic croup. The contraction of the

opening of the windpipe changes the sound which passes through it, just

as the opening or closing the keys of a wind instrument modifies the

sound which it gives forth. But the windpipe is not simply a wind

instrument, it is a stringed instrument too, and the strings or vocal

cords, as they are termed, give forth, as they vibrate, tones now

deeper, now more shrill. The action of this delicate apparatus is

readily disturbed, if the nerve-supply to it is disordered by irritation

in some distant organ, and then the breathing is accompanied by the

peculiar sound of spasmodic croup, or in older children this may show

itself in a different way, as in the loud, barking cough heard in some

cases of constipation, or of disordered digestion; or another

illustration of it is furnished by the loud, long breath--the 'hoop,'

which gives its name to hooping-cough. But there is one sound that

sometimes attends the breathing of children, which more than any other

causes, and justly causes, the greatest anxiety to a mother; and that is

the sound which is characteristic of croup.

The word croup, which comes from the Lowland Scotch, signifies merely

hoarseness in breathing or coughing, and is therefore, strictly

speaking, the name of a sign of disease, rather than that of the disease

itself. The peculiar sound is heard in two different conditions--the one

in which a child having caught cold, instead of the air-tubes alone

being affected, the windpipe, and especially its upper part, becomes

congested, and the lining membrane swollen. Partly owing to this, partly

owing to its nerve-supply being disturbed, the child breathes noisily

and hoarsely, and the cough has a peculiar metallic clangor. In the

other case there is not merely the congestion of the windpipe, the

disturbed nerve-supply, and the swollen state of the membrane; but in

connection with the influence of the special poison of diphtheria, a

deposit takes place at the back of the throat, whence it extends to the

windpipe, and in many instances even far beyond it, blocking up its

canal, and mechanically excluding the entrance of air.

To determine at once to which class a case of croup belongs is so far

from easy, that I should advise that on the first sound of voice, or

cough, or breathing resembling that of croup, medical advice should at

once be sought. I dwell on the difference between the two: the first

which has been called false croup, or better catarrhal croup, and the

second called true croup, or diphtheritic croup, in order to save much

needless apprehension to parents, in whose mind the croupy sound is

invariably associated with nothing short of that most dangerous

disease--diphtheria.

As a general rule catarrhal croup is rarely met with after the age of

six. Children in whom it occurs have either seemed quite well, or at

most have been a little ailing for a day or two with cold, and cough,

and perhaps slight hoarseness. They go to bed and fall asleep as usual,

but the cough, which does not wake them, becomes suddenly noisy,

ringing, croupy, and the breathing is speedily attended with a

long-drawn sound, half-hissing, half-ringing, and the child soon wakes

alarmed, and fighting for breath, the skin bathed in perspiration, the

face flushed and anxious. The cough, the difficult breathing, and the

struggle for air last for an hour or two, or sometimes all night long,

though they gradually subside, at any rate towards the approach of

morning, when the child falls asleep, and, but for a somewhat hoarse

sounding cough, and a look of fatigue, there are but few signs of all

that it has endured.

The attack may not return, or it may recur for two or three successive

nights, though in general with lessened severity, the child during the

daytime seeming to suffer only from a slight cold, or now and then, and

so rarely that I have not known it to occur above once or twice in all

my experience, it may end in real inflammation of the windpipe; but not

in diphtheria.

Attacks of this kind may recur three, four, or more times even in

childhood, while diphtheria has no tendency to recur, but like measles

or scarlatina seldom appears more than once, though the rule is subject

to more numerous exceptions than are found in the case of the eruptive

fevers. Still the fact of an attack of this sort returning should of

itself lessen apprehension and make the parents look forward to its

issue with less anxiety than that with which they regarded its first

occurrence.

A fact which shows how large a part is played by disturbance of the

nervous system in these cases is the liability of children who have

suffered from it to attacks of asthma, often of great severity as they

grow older, while very often after the transition from childhood to

youth has passed these attacks too lessen in frequency and severity, and

often altogether cease.

There are two measures which, while waiting for the doctor's arrival,

may at once be taken, and which sometimes remove the symptoms almost as

if by magic, while even were the case one of diphtheria they would still

be of some service, and could not possibly do any harm. They are the hot

bath, and a full dose of ipecacuanha wine. The former should be as hot

as it can be borne, 93 deg. or 94 deg., and the child should be kept in it for

five minutes, and the latter should be given in a full dose, as a

teaspoonful in warm water every quarter of an hour till free vomiting

takes place. How much better soever the child may seem after the use of

these remedies, it should still be kept for two or three days under

careful medical observation.

=Diphtheria.=--In _diphtheria_ croup is only one, though the most

frequent, and one of the most serious, of the many dangerous symptoms

which attend it. The croupal symptoms hardly ever come on quite

suddenly, but are almost always preceded for some days by slight

feverishness, languor, and restlessness, in spite of which the child

still amuses itself; and if too young to express its sensations, the

slight degree of sore-throat it experiences is manifested rather by a

disinclination to take food than by any obvious difficulty in

swallowing. There is no cough, nor any change of voice when the child is

awake, but when asleep--and the sleep is generally uneasy--it often

breathes with its mouth open, it snores slightly, or there is a little

hoarse sound accompanying the breathing owing to a trivial swelling of

the throat; while, if sought for, there will generally be found a very

little enlargement, and a very little tenderness of the glands at the

corner of the lower jaw. The eyes are sometimes tearful, there may be

slight running at the nose, and the child is said to have a bad cold

with slight sore-throat--the most remarkable feature of the case being

generally that the depression of the patient is out of proportion to the

severity of the local ailment. If now the throat is examined--and

examination of the throat should never be omitted in any case where

there is the slightest difficulty of swallowing--nothing may at first be

seen but a very little swelling, and some redness of one or other

tonsil. In a few hours more, white specks like little bits of curd will

be seen first on one tonsil, then on the other, and next these specks

will have united to form one continuous layer of a sort of

yellowish-white membrane over the palate and tonsils. The examination of

the throat, often so difficult when children are ill, is attended with

almost none, if while they are well they have been taught the little

trick of opening their mouths to show their throat, and of allowing the

introduction of a spoon to keep down the tongue, a proceeding which

though certainly unpleasant they will almost always readily agree to,

like Martha Trapbois, in the 'Fortunes of Nigel,' 'for a consideration.'

The deposit on the throat may disappear of its own accord, and not be

reproduced, and this even though no treatment has been adopted, and in

two or three days the child may be pretty well again, though strength is

in general regained less rapidly than might have been expected from the

comparative mildness of the attack.

In cases so slight it is no easy matter to recognise the features of a

highly dangerous disease; still, out of forerunners so trivial as these,

croupal symptoms may be developed, and their advances may be most

insidious, and unless both parents and doctor have been closely on the

watch they may be surprised all at once by the breathing suddenly

becoming very laboured, by that and the cough becoming attended by the

sounds characteristic of croup, and by the child's life being in extreme

jeopardy, or in danger even beyond the hope of recovery.

It is not that here, as in cases of catarrhal croup, the ailment has

really come on suddenly, but that the disease has been silently making

unsuspected progress. Whenever then a child, after a few days of slight

causeless ailing, accompanied with some little discomfort in swallowing,

is seen to have white patches at the back of its throat, do not allow

yourselves to be lulled even by their disappearance into a feeling of

absolute security. Watch the child, and beg the doctor to watch it

carefully, until it is perfectly well again, for though the deposit may

have disappeared from the back of the throat it may continue to be

formed in the windpipe, and in the somewhat depressed state of the

nervous system which attends diphtheria it may not excite that

irritation which any such cause would produce in a child in perfect

health, and consequently not announce its presence until its amount has

become so considerable as to offer an almost insurmountable obstacle to

the entrance of air. Any, even the slightest, hurry of breathing, a

hissing sound when the child draws its breath, hoarseness of voice, or a

ringing cough, should quicken your apprehension of danger, and make you

seek for immediate help.

It may be as well, however, to mention here, that not every white speck

seen at the back of the throat is of necessity due to diphtheria, but

that in some cases of ordinary sore-throat white spots may form on the

surface of the tonsils. These white spots are due to the collection at

their openings of the secretion formed in the minute glands which beset

the surface of the tonsils, and which at these seasons is poured out in

greater abundance than usual. They are distinct from each other, and do

not coalesce into a membrane; the surface beneath is not the uniform red

shining surface on which the membrane in diphtheria has formed, but the

separate tiny openings from which the white matter has exuded may be

distinctly seen if the surface is wiped with a camel's-hair brush. It

is, of course, wise in every case to leave to the doctor the decision as

to the nature of the deposit, but it may sometimes relieve needless

anxiety to know beforehand that there is another cause besides

diphtheria to which white spots at the back of the throat may be due.

There are other dangers, indeed, besides those arising from croup, which

accompany diphtheria, though those just mentioned are of all the most

frequent. There are cases in which death takes place not from the

severity of any local ailment, but from the intense depression of the

nervous system. There are other instances too, in which the case assumes

what is termed a malignant character; profuse discharge taking place

from the nostrils, swallowing being from the first exceedingly

difficult, membrane being deposited on the lips, behind the ears, or at

the edge of the bowel; death taking place in twenty-four or thirty-six

hours from the outset of the first serious symptoms, either in

convulsions, or from utter exhaustion.

But the very urgency of such cases must of necessity call for the

immediate assistance of the doctor; and my business throughout this book

is rather with those points which it is important for a mother to

notice, and those things which it behoves her to do.

What does diphtheria depend on? is a question more easily asked than

answered. The disease is contagious, as scarlatina is contagious, though

not to the same degree. I may add, it is not identical with scarlatina,

nor does the one disease protect from the other. It would, perhaps, be

too much to say that it is dependent on an unsanitary condition of a

town, a village, or a house, but there is no doubt but that, as is the

case with cholera, scarlet-fever, or typhus, unsanitary conditions

favour its spread, and increase its severity.

Being contagious, it is most important to keep cups, glasses, spoons,

towels, and bed-linen separate from those of other inmates of the house,

and to remove the patient from any room occupied by other children.

Great care too is to be observed, if anyone is standing over the child

during a fit of coughing, that none of the membrane which it spits up

enters the mouth; and, that if the child's breath is caught, the

attendant gargle immediately with a teaspoonful of Condy's fluid in a

tumbler of water.

In the next place, as the depression of the nervous system in some cases

of diphtheria is quite out of proportion to the local disease, and as

children who have not seemed very suffering, have yet been known to die

suddenly in an unexpected faint, it is of moment that the child remain

constantly in bed from the commencement of the attack till complete

convalescence. Nor, indeed, in serious cases is even this precaution

sufficient; but in such circumstances not only must the child not be

taken out of bed for any purpose, but it must even not be suddenly

raised in bed, from a recumbent to a sitting posture. I have, on several

occasions, known the neglect of these precautions followed immediately

by what cannot but be regarded as the needless death of the patient.

During the illness, there is little for the mother to do, except to try

to carry out the doctor's directions, and to give the child constantly

little bits of ice to suck, which lessen the swelling of the throat, and

relieve the pain and inflammation. If the child knows how to gargle, it

should be induced to do so constantly, and finding the relief which this

affords, will do so very readily. This is not the time, however, when

the lesson 'how to gargle' can be learnt. A thoughtful mother teaches it

while the child is well, and if the gargle is composed of raspberry

vinegar and water, the lesson is learnt without tears. There comes a

time, however, if the disease is at all severe, when gargling is no

longer possible, for the muscles of the back of the throat lose their

power; but now some medicated solution, employed by means of the

spray-producer, may most efficiently take its place.

When croupal symptoms have gone on growing worse and worse, and the

child is in the agonies of suffocation, the doctor may propose to open

the windpipe, in the hope of giving the child another chance of

recovery, and even though the operation fail, of at least lessening its

sufferings.

The operation is sometimes objected to by the parents, on the ground of

the uncertainty of the result, and the torture of the operation to the

child. Now the anguish of a child dying of croup is due to two causes;

first, the actual mechanical impediment to the entrance of air produced

by the deposit in the windpipe, and secondly, to the spasm of the

muscles in the upper part of the windpipe which that deposit produces.

How large an amount of distress the latter may produce, anyone can judge

for himself, to whom it has ever happened to swallow the wrong way, as

it is called. The opening made below the seat of the muscles which close

the windpipe, leaves them in perfect rest, and does away with all the

suffering produced by spasm, while there is always a fair prospect if

the operation is not put off too long, of the deposit being limited to

the part above the artificial opening, and of the good being permanent.

It is true that we have no certain means of knowing the extent of the

deposit beforehand; it is true also that the operation is not in itself

a cure of the disease, but at any rate, it is a reprieve which gives

time for remedies to take effect, and at the worst, it substitutes a

comparatively painless death for one of intolerable anguish. It can,

too, be performed under the influence of chloroform, so that the idea

that it adds in any way to the child's distress is unfounded. Who that

has seen the calm, happy face, and watched the tranquil sleep of the

child after the operation, who before was struggling, with distorted

features and agonised countenance, to get a breath of air, but would

feel as I do, that I would have it done in a child of mine for the sake

of a painless death, even though I knew for certain that it would not

prolong life even for an hour?

One additional remark I have to make with reference to the loss of

power, or palsy of various muscles, which frequently follows diphtheria.

Almost always there is some impairment of power in the muscles of the

throat on which the deposit had taken place, and there is, in

consequence, a little difficulty in swallowing for a few days. If this

should get worse, food and especially drink sometimes return by the

nose, and next there may be a slight squint, and the sight may become

weakened, and an uncertain tottering gait; and sometimes for a week or

two the child may be unable even to stand. In bad cases there is with

these symptoms a general loss of nervous as well as of muscular power,

though the child may still be fairly cheerful, and ready to amuse itself

as well as it can. This condition may last for many weeks before it

passes quite away, and if under the mistaken impression that the limbs

will gain strength by exercise, the child is allowed to sit up and

encouraged to exert itself, recovery will be delayed much longer; and

dangerous weakness or fatal exhaustion may suddenly come on.

The inference is too obvious for me to need dwell on it, that repose is

the great resource, and quiet waiting the true wisdom.

=Hooping-Cough.=--I need not say much about _hooping-cough_, for there

is scarcely a nursery in which, to everyone's great discomfort, it is

not known as a familiar and most unwelcome visitant. It varies

remarkably in its importance, being sometimes so slight as scarcely to

amount to an illness, but in other instances one of the most deadly of

diseases. It causes the death of a fourth of all children who die under

the age of five, and three out of four of these deaths take place in

infants of less than two years old.

It occurs, however, comparatively seldom during the first three or four

months of life, probably because very young children are kept more at

home than others, and are thus less exposed to catch it. Though

hooping-cough is undoubtedly very contagious, it seems to be

communicated only by the breath, and there is absolutely no evidence to

show that the clothes of a child suffering from hooping-cough can carry

the infection as they might were the child suffering from measles, or

smallpox, or scarlet-fever; still less that a person who has visited a

room where children are suffering from hooping-cough can convey the

disease to another house, or to other children.

The disease derives its name, as everyone knows, from the peculiar sound

which attends the cough, and which is due, as is the sound of croup, to

spasm of the upper part of the windpipe. It is equally characterised by

the cough returning in fits or paroxysms, which end in a long-drawn

breath, attended by the hoop. An occasional sound like a hoop, in a

young child who has a cold, is not so conclusive of a case being one of

hooping-cough as is the recurrence of the cough in fits; for until

teething is completed, slight and temporary irritation will suffice to

produce a passing spasm of the upper part of the windpipe.

An ordinary attack of hooping-cough begins like a common cold, but as

the little ailment passes off, the cough still continues, the fits of

coughing become more frequent, last longer, grow severer and more

suffocative, and end with the loud long breath, the hoop; while

sometimes no sooner is one fit over than another follows it almost

immediately, and quiet breathing does not return until the child is

tired out by its efforts. Nevertheless, the child's health continues

fairly good, and little or nothing ails it during the intervals of the

cough. For about a fortnight the cough usually goes on to increase; and

during this time the night attacks especially become more frequent. It

then for a week or ten days continues stationary, and then declines, a

diminution in the frequency and severity of the night attacks being in

general the first sign of amendment, and at the end of six weeks from

the beginning of the attack the child is in general quite convalescent.

Even then, however, a trifling cause will reproduce the characteristic

cough for a few days, and not seldom for many months afterwards any cold

which the child may catch will be attended by a paroxysmal cough

undistinguishable save by its milder character and shorter duration from

the previous hooping-cough, though I believe incapable of communicating

that disease.

In mild hooping-cough there is little or nothing to be done, save to

follow the dictates of common sense, and not to neglect them in quest of

some imaginary specific--some vaunted medicine which is said to be a

certain cure; or such as shutting up the child in a room the atmosphere

of which is charged with the vapour of tar, or of carbolic acid, or of

sulphur.

It cannot be too strongly impressed on the minds of parents that there

is no specific whatever for hooping-cough; no remedy which will cut it

short, as quinine cuts short a fit of ague. The domestic treatment of

mild hooping-cough is the domestic treatment of a common cold, implying

the same precautions as to the equal temperature of the day and night

nursery, the little doses of ipecacuanha at night, but as seldom as

possible during the day, in order not to interfere with the appetite and

digestion, together with special care to insure the regular action of

the bowels. It sometimes happens that after a week or two the severer

fits of coughing are followed by vomiting; and the child may lose flesh

and strength from inability to retain its food. In these circumstances

food must be given, little in quantity, at short intervals, and of a

kind that need not remain long in the stomach in order to be digested.

Good soup, beef-tea, milk, rice milk, or a raw egg beaten up in milk,

and biscuit rather than bread, must take the place of the ordinary

meals, and be given twice as often.

The different liniments, and the favourite Roche's Embrocation, are of

use when the disease is on the decline, and may also be of service if

bronchitis should occur to complicate the hooping-cough, but not

otherwise.

Change of air when hooping-cough is on the decline is often of great

service, and change even from good air to one less good appears to be

sometimes of use; but change in the early stages, or when hooping-cough

has become really severe, is but adding another to the already existing

dangers.

The danger in hooping-cough arises through the medium either of the

head or of the lungs, and through each of them with about equal

frequency. The head becomes affected in consequence of the often

recurring congestion of the brain, produced, as in spasmodic croup, by

the constantly returning interruption to the breathing. In these cases

the cough is frequent, and so violent that the child becomes livid

during each paroxysm, and that instead of ending in a loud hoop it

finishes by a fit of convulsions or by the child sinking into a state of

semi-insensibility. Increased violence of the cough, with suppression of

the hoop, is always a bad omen in hooping-cough.

On the other hand, when the cough becomes complicated with bronchitis,

it ceases to recur in distinct fits which leave behind them intervals of

comparative, or of absolute ease. The hurried breathing which precedes

and follows a fit of coughing never entirely subsides, while each

returning cough aggravates the irritation and inflammation of the

air-tubes, and the child's condition becomes the very dangerous one of

hooping-cough complicated with bronchitis.

So long as a child seems pretty well in the intervals between the fits

of coughing, as the hurried breathing subsides after each to a natural

frequency, as a long loud hoop follows each cough, as vomiting takes

place only after a fit of coughing and never in the intervals, as the

child becomes flushed only and not livid during a cough, and recovers

itself perfectly afterwards, as it does not complain of constant

headache, nor spits blood, nor has nose-bleeding, nor is feverish, nor

depressed, nor drowsy, you may feel happy about it. When any of the

symptoms just enumerated show themselves you have reason for grave

solicitude, and the child requires daily medical watching.

One word in conclusion. A child who has recently had hooping-cough is

more liable than another to be attacked by chicken-pox or measles; and,

moreover, imperfect recovery from hooping-cough is apt, especially if

there is any tendency to consumption in the family, to be followed by

consumptive disease.

=Asthma.=--_Asthma_, attended by distress of breathing quite as

considerable as in the grown person, is by no means unusual in the

child. Recovery from it is far more likely to take place in the latter,

since it is almost always independent of those diseases of the heart or

lungs, which in the former occasion or aggravate it. It belongs to the

class of what has been termed nervous asthma and is observed with

special frequency in children who, when younger, had been liable to

catarrhal croup; spasm of the air-tubes having taken the place of the

previous spasm of the windpipe. Independently of that antecedent it

comes on sometimes about the time of the second teething in nervous and

impressionable children, in whom an attack may be produced by

indigestion, constipation, or over-fatigue. It is also by no means rare

in children in whom that skin affection, eczema, of which I have already

spoken, outlasts the time of infancy, and becomes general and severe.

The improper performance of the functions of the skin seems to cause a

peculiar sensitiveness of the air-tubes, and to render them liable to

the occasional occurrence of that spasm which produces asthma. These

cases are less hopeful than others, and the liability to the attacks

ceases only when the skin-affection has been completely cured; a reason

this for not neglecting eczema in infancy and early childhood.

Sometimes, too, it follows frequently-recurring attacks of bronchitis,

and, though less often than might be expected, it succeeds severe

hooping-cough, and in these two conditions the prospects of recovery are

less hopeful than in the others.

When asthma occurs in childhood, the first point is to ascertain the

cause on which the attack depends; and it is worth any amount of care to

discover and remove it; for if what may be called the asthmatic habit is

not formed, the attacks will, in the majority of instances, cease

between the ages of twelve and fifteen. Bad habits of the body are,

however, as difficult to get rid of as bad habits of the mind, and the

boy who grows up an asthmatic youth is very unlikely to get rid of the

disorder in later life.

It is in that form of asthma which succeeds to frequent attacks of

catching cold, and in which bronchitis precedes or accompanies each

seizure, that change of climate is most useful. In the majority of

instances a moderately sheltered seaside place, with a sandy soil such

as Bournemouth, is the best, and a few years' residence there not

infrequently overcomes every disposition to asthma through the whole

remainder of the patient's life. To this, however, there are exceptions,

and I have seen instances in which residence at Bournemouth and in the

Riviera have failed, but where a perfect cure has been wrought by the

cold, still air of Davos.

=Diseases of the Heart.=--=Malformed Heart.=--Every now and then one

sees a little babe, carefully wrapped up in its nurse's arms to shield

it, even on a warm day, from the air; and, on removing the shawl which

covered it, one is struck by the sight of a little pale pinched face,

with a livid ring around the mouth, and a blue instead of a rosy tint of

lips and fingertips, as though perished with cold. The babe wakes on

being disturbed, and gives a faint short cry of distress; the livid hue

of its surface deepens, it struggles feebly, its mouth twitches as

though convulsions might be coming on. Soon, however, these symptoms

subside, the babe smiles again, is cheerful, and save for the tints of

its face and lips, it looks like other infants, but frailer.