This condition has a name in medical writings, from a Greek word

expressive of the blue tint which characterises it, and is called

_cyanosis_. It depends on the blood not having undergone completely

those changes in the lungs which take place in the healthy state. The

blood, as it returns through the veins to the right side of the heart,

is of a deep purple hue. The right side of the heart contracting sends

it to the lungs, where, in the minute vessels of the air-cells, it is

purified, and returns vivified by the oxygen a bright scarlet stream, to

be distributed by the arteries over the whole body; and thence to return

once more for fresh purification to the right side of the heart. Before

birth, the blood does not run the same course, but is purified within

the mother's body, the blood running through channels which close with

the first breath the infant draws. The previously existing communication

between the two sides of the heart ceases at the same time as the new

channels are opened, by the shutting of a thin valve which had hitherto

allowed the blood to pass from one side to the other.

Sometimes this closure fails to take place, or takes place but

imperfectly; sometimes, in addition, the channels which should be

disused after birth remain open still; and sometimes also the heart is

otherwise imperfectly formed, and a large communication exists between

the two sides of the heart, which long before birth ought to have been

firmly partitioned off from each other.

According to the freedom of communication between the two sides of the

heart, there is more or less ready intermingling of the impure blood

with that which is already purified; and this is betokened by the

greater or less severity of the symptoms which I have described. When

the heart is very malformed, and the blood consequently is very impure,

life is but a short agony which ends in a few weeks; some slight

movement, some little accidental cold deranging altogether the imperfect

machinery, and bringing it to a sudden standstill. Between this and the

slightest cases there are all shades of difference, till, in the latter,

a smaller power to maintain warmth, a less rapid growth, a smaller

muscular development, a feebler power, a hurry of breathing on exertion,

or in ascending a hill, or in going up a staircase, are all, except the

sounds which the educated ear detects of the blood passing through its

devious course, that tell of nature having, in this instance, ill done

her handiwork.

The one most natural question to which, in every instance, the doctor

has to reply is this: 'Will he or she outgrow it?' To this the answer

is, '_Yes_,' and '_No_.' In the worst cases the answer is obviously

_no_; and in none does _yes_ imply a recovery so complete as to leave no

trace behind, and to make the child heartwhole. But short of this, in

many instances much may be hoped for. There is, as I shall have occasion

again to repeat, a power in the growing heart to adapt itself in large

measure to conditions other than those of perfect health. The channels,

through which the blood ought not to flow, may shrink though they may

not entirely close; the valve may shut more completely than at first the

opening between the two sides of the heart; all inconveniences may

lessen, and the child may at last become scarcely aware of the

difference between himself and others. But for any such result, or for

anything approaching it to be attained, certain conditions are

absolutely essential which it is seldom easy to induce parents to

observe. Whatever can hurry the circulation is most carefully to be

avoided. The child must be kept strictly out of the way of

hooping-cough, measles, or any other fever; must be shielded from every

risk of catching cold, and having smaller power of maintaining its

warmth than others have, must be specially warmly clad, and must live in

rooms at a temperature of 60 deg. Fahr., all the year round. Great

attention must be paid to the state of the bowels, so that constipation

may not necessitate violent efforts to relieve them.

Moreover, for years the child must be carried upstairs; when old enough

to take part in games, it must not be allowed to join in any which call

for violent exertion, such as cricket, or lawn tennis, nor ride any

other than a quiet pony at a gentle pace.

It depends entirely on the parents whether, for the sake of a very great

but far-off good, they will strictly observe these rules. The difficulty

will not arise on the child's part, for it is not hard for those who

have had charge of it from babyhood to bring it up to quiet pursuits and

quiet amusements, till it seeks no others, and, like the little

cage-bred bird, does not care to emulate the flight of others stronger

on the wing.

=Inflammation of the Heart.=--The above remarks do not comprise all

that is to be said about heart-affection in early life. _Inflammation_

may attack the investing or the lining membrane of the heart at all

ages, may produce in the child the same suffering as in the grown

person, and may tend to destroy life in a similar manner. The causes,

indeed, which produce heart disease, are far more frequent in the grown

person than in the child, and advancing age brings with it changes

which, wholly apart from active inflammation, produce grave forms of

disease unknown in early life. There is, however, one cause of heart

disease which is far more frequent in childhood and early youth than in

later life, namely, rheumatism. Eight out of ten of all cases of heart

disease under the age of fifteen are of rheumatic origin, and in

eighteen out of twenty cases of acute rheumatism under that age, whether

slight or severe, the heart becomes more or less involved. Now and then,

though rarely, the heart becomes affected in the course of scarlatina,

and still more seldom in the course of the other fevers, and every now

and then affection of the heart is associated with some other form of

inflammation of the chest.

Pain is by no means a constant attendant on it, but fever, more or less

considerable, a quickened pulse, and hurried breathing are all but

invariable, and one great reason for seeking the immediate help of the

doctor is, that his skilled ear may at once detect by the altered sounds

the heart-affection at its very outset, and employ the measures

calculated to arrest its progress.

Death in the acute stage of a first attack of inflammation of the heart

is of extreme rarity, but the damaged heart is liable to returns of

acute mischief, any one of which may prove fatal. Independently of this,

life with diseased heart is one of suffering, attended as it is by

symptoms similar in kind, though not identical with those which I have

already mentioned as attendant on malformation of the organ.

The hopeful element, however, to which I have already referred as

present in cases of malformed heart, exists here in even a greater

degree; since repair of injury is possible, while the reconstitution of

an organ faulty from birth is obviously beyond nature's power.

I can but repeat the directions already given as to the importance of

allowing the heart as much rest, and giving it as little work, as is

possible with a never-resting organ; and this with the added motive for

perseverance furnished by the happy issue which may be hoped for as its

reward.

One word I must add about the occasional occurrence of _irregular

action of the heart_ during the years of growth, especially from the age

of ten to fourteen. This is often quite independent of any disease, and

ceases when with added strength the nervous system becomes less

impressionable.

CHAPTER VIII.

DISEASES OF THE ORGANS OF DIGESTION.

=Manner of Performance of Digestion.=--The organs situated in what is

called in medical language the abdomen, have in the child no other duty

to perform than such as subserve the processes of digestion and

nutrition. The saliva secreted by the appropriate glands in the mouth,

mixing with the food, facilitates the further changes which take place

in the stomach. In the stomach the food is acted on and dissolved by the

gastric juice or pepsin, which is poured out by an almost infinity of

minute tubes, or follicles as they are termed. When the stomach has done

its work, its contents in a semi-fluid state pass into the small

intestine, and mix there with the bile, the secretions from the

intestines themselves, and with those of the large gland, the pancreas

(in culinary language known as the sweetbread), which seems to have the

special power of dissolving fatty matters. As the food, thus acted on,

travels along the intestines, whose constant movement facilitates the

passage of their contents from above downwards, its elements are taken

up, partly by the blood-vessels, partly by innumerable small vessels,

called absorbents from their power of imbibing fluids, and lacteals,

from the milky hue of the fluid within them when first absorbed. The

fluid taken up by the blood-vessels is conveyed to the liver; that taken

up by the absorbents to the mesenteric glands, and in these organs

further changes take place in it, which fit it to be received into the

mass of the circulating fluid. With this it is carried to the right side

of the heart, and thence to the lungs and, lastly, from them to the left

side of the heart, whence it is distributed, the great life and health

giver, to the rest of the body. The useless inconvertible material,

leaving every available element behind, is got rid of, either in a solid

form by the bowels, or in a fluid form by the kidneys; and thus as long

as life lasts there goes on more or less perfectly the wonderful process

of constant change, of constant renewal, and during childhood and youth,

of constant increase of size and stature.

Incomplete as this sketch is, it may yet suggest how readily one part

of this complex machinery may be thrown out of gear, and further how not

one part can suffer without all being disordered. Solid food given to

the child before it has cut its teeth, enters the stomach unreduced to

pulp by the grinders, and unmixed with the saliva, which should help its

solution, and which the undeveloped salivary glands do not yet furnish.

Too large a quantity of food, or food of an unsuitable character, on

which the gastric juice cannot act readily, may pass into a state of

fermentation; vomiting, flatulence, sour and offensive breath will be

the result, and the food will pass into the intestine unprepared to be

acted on by the bile. Exposure to cold, or the opposite condition of

excessive heat, may disturb the action of the liver, and interfere with

the secretion of bile; and the food will then pass along the intestine

in a state unsuitable for absorption. Or, again, the mesenteric glands

may be irritated by long-continued imperfect performance of the earlier

stages of digestion, or their structure may be altered, and mesenteric

disease, or consumption of the bowels, as it has been termed, may

result. From want of muscular power, or from want of care on their part

who have charge of the child, the bowels may become habitually

constipated. Health will then suffer, if the child carries about with it

for days together matters which can serve no useful purpose, but which

are to the body what an ill-kept dustbin is to the rest of the house.

Lastly, if the kidneys perform their duties imperfectly in consequence

of exposure to cold, or of the changes which some diseases, such as

scarlatina, sometimes bring about in their structure, the blood will be

imperfectly purified; dropsy and various forms of inflammation may

result; or the brain and nervous system may be disordered, and death in

convulsions may attest the dangerous nature of this blood-poisoning.

It would take too long to go in detail through all the phases of

disordered digestion in early life. Much has been already anticipated in

a former part of this book, especially with reference to the troubles of

digestion in infancy and early childhood. There is, indeed, but one form

of indigestion whose characters are so special as to require that I

should enter into any detail with reference to it.

=Dyspepsia of Weakly Children.=--Children from the age of about three to

ten years, whose health has been impaired by an attack of typhoid, or,

as it is commonly called, infantile remittent fever, or who belong to a

weakly family, or to one, some of whose members have shown a disposition

to consumptive disease, are sometimes martyrs to indigestion. It does

not need with them any special error of diet, or any casual exposure to

cold to disorder their digestion; but every two or three weeks, even

under the most scrupulous care, they lose their appetite, their tongue

becomes thickly coated with yellow fur, their breath offensive, their

bowels constipated, the evacuations being either very white or very

dark, and frequently lumpy, and coated with a thin layer of mucus from

the bowel, which also appears in shreds at the bottom of the utensil.

With this condition, too, there is some, though not considerable,

feverishness, and the urine becomes turbid on cooling, and throws down a

reddish-white deposit, which disappears if heated. At the end of two or

three days of rest in bed, of a diet of beef-tea and milk, with no solid

food, with simple saline medicines, mild aperients, and perhaps a single

small dose of calomel, the symptoms pass off; but return again and again

at uncertain intervals, and without any obvious cause.

In these cases, the children almost always, when in their ordinary

health, have a peculiar patchy condition of the tongue, one part of it

being covered with a thin white coating, through which little red points

project, while another part is of a vivid red, and looks raw and

shining, as though it had been scalded, while the red points, or the

papillae, as they are termed, project above its surface like so many

pins' heads. Children in whom this condition exists, require much

watching and much care. I have dwelt upon it in order to impress on

parents the conviction that it is not a state to be cured, once for all,

even by the most skilful doctor, but that years are needed to eradicate

a bad habit of the body, as much as to cure a bad habit of the mind.

=Jaundice.=--I have already spoken of the jaundice of new-born infants;

but a sluggish condition of the liver, accompanied by very white or pale

evacuations, constipation, and loss of appetite, with a sallow tint of

the skin, and sometimes even with actual _jaundice_, are by no means

uncommon during the first ten years of childhood. Neither condition is

serious; that of actual jaundice occurs mostly in the summer, and is

then connected with the sudden onset of hot weather. When severe, it may

be associated with some degree of feverishness, with dizziness, and

complaint of headache, and occasionally with vomiting, while the child

rests ill at night, or awakes in a state of alarm, and these symptoms

sometimes give rise to the fear that the child is about to be attacked

by water on the brain. But the following consideration may serve to calm

anxiety on that score. The attack is not preceded, as water on the brain

is almost invariably, by several days or even weeks of failing health.

It is not attended by heat of head, nor by intolerance of light, nor by

constant nausea; and the belly is full rather than shrunken. When to

these symptoms are added tenderness on the right side, high-coloured

urine and white evacuations, you may set your mind at rest, even before

the yellow colour of the skin, which appears in a day or two, stamps the

case unmistakably as one of jaundice.

My business is, as I have said more than once, the endeavour to describe

the symptoms of disease, to explain their nature, to indicate the

principles to be observed in attempting their cure, and not to lay down

definite rules for their treatment, with the idle expectation that I

could thus enable every mother to be her children's doctor.

=Diarrh[oe]a.=--I have, therefore, comparatively little to say about

_diarrh[oe]a_ in children, important though it is, for its symptoms

force themselves on the notice even of the least observant. There are,

however, a few points concerning it worth bearing in mind. Before the

commencement of teething, diarrh[oe]a is almost always the result of

premature weaning, or of a diet in some respect or other unsuitable. As

soon as teething begins, the liability to diarrh[oe]a increases greatly,

and cases of it are more than twice as frequent, and twice as fatal,

between the ages of six and eighteen months as they were in the first

six months of life; while, as soon as teething is over, their number

immediately declines again to the half of what it was during the

continuance of that process. The practical conclusions to be drawn from

these facts are that looseness of the bowels during teething is not a

desirable occurrence to be promoted, as some mistakenly imagine, but a

risk to be by all means avoided, and I may add, when it does take place,

far less easy to control than constipation is to remedy. And next, that

in order to prevent its occurrence, care should be taken to make changes

in the diet of a child, not during the time when a fresh eruption of

teeth is taking place, but during one of the pauses in that process.

There are certain seasons of the year when diarrh[oe]a is specially

prevalent, independent of any change in diet, or alteration, in any

respect, of the circumstances in which the child is placed. Thus, in

May, June, and July, diarrh[oe]a is twice as prevalent among children at

all ages as in November, December, and January; and in August,

September, and October, its prevalence is three times as great as during

the winter months. The high mortality of children in the summer months

is due almost entirely to diarrh[oe]a, and even the bitter Northern

winter of a city like Berlin is a third less fatal to infants and young

children than the heat of its short summer.

The next point to remember is that mere looseness of the bowels is

never to be regarded during the first three years of life as of no

importance; for I have seen infants die exhausted from its continuance,

even though the examination of the body after death showed almost no

sign of disease. Doctors distinguish two forms of diarrh[oe]a: the

simple, or, as it is technically called, catarrhal diarrh[oe]a; and

inflammatory diarrh[oe]a, or dysentery. The one may pass into the other,

just as a common cold, or catarrh, may pass, if unattended to, into a

dangerous bronchitis.

_Simple diarrh[oe]a_ usually comes on gradually, and is some days

before it grows severe, or passes into the more dangerous dysentery.

Simple precautions will often arrest its progress, and, among them, rest

in bed is one of the most important. Over and over again I have known a

diarrh[oe]a which had continued in spite of all sorts of medicines so

long as the child was running about, cease at once when the child was

kept for a couple of days in bed. The reason of this is obvious;

constant movement of the intestines themselves, which serves so

important a part in maintaining due action of the bowels, is increased

by the upright position and by movement, and is reduced to a minimum by

the horizontal position. A second precaution concerns the diet; solid

food and animal broths should for a time be discontinued, and arrowroot,

milk and water, and rice substituted for it, for a day or two, with

isinglass jelly, and the white decoction of which I have already spoken.

It is not always that astringents are suitable at the beginning of an

attack, and the sending to the neighbouring chemist for diarrh[oe]a

medicine, which often contains an unknown quantity of opium, is always

risky, frequently mischievous. In a first attack of diarrh[oe]a, the

doctor should always be consulted, for when it is associated with

disorder of the liver a mercurial may in the first instance be needed,

or possibly very small doses of a saline medicine, such as Epsom salts,

with the addition of a few drops of the tincture of rhubarb; or, again,

if the diarrh[oe]a sets in with profuse watery discharges, sulphuric

acid for the first few hours is often of extreme service. It is at a

later time that direct astringents commonly have their use; and the

mother, who in her child's first attack of diarrh[oe]a has had the

advice of a judicious doctor, will often be helped by him to manage for

herself slight returns of the ailment.

_Inflammatory diarrh[oe]a_, or dysentery, not only follows the

continuance of the simpler forms of the disease, but sometimes in the

hot months of summer or autumn sets in suddenly with violence. It then

frequently commences with vomiting, and the stomach may continue so

irritable for twenty-four hours as not to retain even a teaspoonful of

cold water. At the same time the over-action of the bowels sets in, and

twenty or thirty evacuations may be passed in twenty-four hours. The

motions soon lose their natural character, and become watery, slimy, and

mixed with blood. They are at first expelled with violence, afterwards

with much pain, effort, and often fruitless straining. With these local

symptoms, the child, as might be expected, is very ill, feverish, and

stupid, though without sound sleep, much exhausted, and its nervous

system so disturbed as to occasion frequent twitchings of the fingers

and of the corners of the mouth, while sometimes actual convulsions take

place. The thirst is intense, the child calling constantly for cold

water, and crying out for more the moment the cup is taken away from its

lips; while the loss of flesh and the exhaustion are more rapid than in

any other disease with which I am acquainted. The fat happy babe of four

and twenty hours before is scarcely to be recognised in the miserable

little being, with sunken lustreless eyes, and wizened features, and

miserable countenance, lying in a state of half-stupor, sensible only to

pain, which yet rouses it but to utter a moan, and then sinks again into

silent suffering. I can well believe what we are told, that in some

countries this, the so-called Summer Complaint of many of the American

cities, sometimes carries off children in a few hours.

If a fatal termination does not take place speedily, the disease passes

into the chronic stage, the diarrh[oe]a diminishing in frequency, but

the pain and straining, and the unhealthy character of the evacuations

persisting. Ulceration of the bowels has taken place, emaciation becomes

extreme, and the child often sinks at the end of several weeks, worn out

by suffering; while recovery, doubtful at the best, is always very slow.

But I need not pursue this subject further: enough has already been said

to show how little infantile diarrh[oe]a is a disorder for domestic

management.

=Peritonitis=, or inflammation of the membrane covering the bowels and

lining the cavity of the belly, is of excessive rarity in its acute

form; and is attended by such general illness and such severe local

suffering, that it is impossible to overlook it or to misapprehend its

gravity. Severe pain in the belly is sometimes complained of by

children, and is due to what is termed colic, a spasm of the bowels

which is generally associated with constipation. The great test of the

cause of the pain is furnished by the presence or absence of tenderness

on pressure. The pain of colic is relieved by gentle pressure and gentle

rubbing. The pain of inflammation in any degree and of any kind is

aggravated by them. This applies also to cases, not indeed very common,

in which inflammation is set up by some small body, such as a

cherry-stone getting fixed in a little offshoot or appendage of about

the size and length of the little finger, connected with the

commencement of the large bowel, and producing ulceration. In these

circumstances the bowels are confined, there are nausea and sickness,

together with pain and tenderness of the belly, especially on the right

side. The disease is a very dangerous one, and often proves fatal in the

course of a few days. I refer to it because I have often seen it

overlooked both by parents and doctors at its outset, since the pain

then is often not severe nor the tenderness intense, and because I have

seen the patient's condition rendered hopeless by strong aperients being

given to overcome the constipation which was supposed to be all that

ailed the child. I repeat then the caution, never to overlook the

existence of tenderness, never to attempt to treat a case in which it is

present; but always to call in medical advice, and above all always to

abstain, unless ordered by a medical man, in every such case from the

use of aperients.

=Large Abdomen.=--I must not leave the subject of disorder of the

digestive organs without some reference to a condition which often

excites much needless anxiety among mothers, namely, the large size of a

child's belly. This is sometimes supposed to be a certain evidence of

the presence of worms, at other times to be a positive proof of the

existence of grave disease, especially of disease of the mesenteric

glands, or glands of the bowels as they are popularly termed. It is

evidence of neither the one nor the other.

If you go into a gallery of the old masters, and look at any of the

pictures of angels which are generally to be seen there in such

abundance, you will probably be struck in the case of all the child

angels by what will seem to you the undue size of their abdomen. You

will notice this even in the works of painters who, like Raphael, most

idealise their subjects, while in those of others who, like Rubens,

interpret nature more literally, the apparent disproportion becomes

grotesque; or, in the coarser hands of Jordaens, even repulsive.

These painters were, after all, true interpreters of nature. In infancy

and early childhood the abdomen is much larger comparatively than in the

grown person. For this there is a twofold cause; the larger size of the

liver on the one hand, and the smaller development of the hips on the

other. In a weakly child this appearance is exaggerated by its want of

muscular power, which allows the intestines to become much distended

with air. If the child is not merely weakly but also ricketty, the

contracted chest will leave less room than natural for the lungs, while

at the same time the ordinary development of the hips being arrested by

the rickets, the disproportion is further increased both by that and by

the flatulence due to the imperfect digestion with which the condition

is almost always associated.

In no case need the mere size of the abdomen occasion grave anxiety, so

long as when the child lies upon its back the abdomen is uniformly soft,

nor so long as even if tense it is not tender, and as it everywhere

gives out a hollow sound like a drum when tapped with the finger.

It is not for a moment meant that no notice is to be taken, nor opinion

asked, as to the cause of excessive size of the abdomen, for its

distension may be due to real disease; but it is yet worth while to

remember that its mere size is not of itself evidence of disease, nor

cause of grave anxiety.

=Worms.=--There is no mistaking or overlooking the existence of _worms_

when they are really present. Their presence, however, is often

suspected without any sufficient reason. Ravenous or uncertain appetite,

indigestion, flatulence, undue size of the abdomen, a dark circle round

the eyes, itching of the nose and of the entrance of the bowel, a coated

tongue, and offensive breath are no real proof of the presence of worms,

and do not justify the frequent repetition of violent purgatives or of

so-called worm medicines. The only real proof of the presence of worms

is their being seen in the evacuations.

The worms commonly found in children are either the round-worm, which

resembles the earth-worm, the thread-worm, or the tape-worm; the

appearance of each of which is clearly indicated by its name. None of

them are spontaneously generated in the body, but they are all

introduced from without; their eggs, or, as they are technically called,

their ova, being swallowed unperceived in some article of food, or

drink. A proof of this is afforded by the fact that an infant, so long

as it is nourished exclusively at the breast, never has worms.

The _round-worm_ occasions the fewest symptoms, and is rather an object

of disgust than of grave importance, at least in this country, where it

seldom happens that more than two or three are present. In other

countries, as some parts of Italy, for instance, where the drinking

water is bad and stagnant, they are sometimes found in great numbers, as

thirty or forty, and it is then not easy to determine whether the

symptoms which accompany them are produced by the worms, or by the

unwholesome character of the water in other respects.

They appear to live on the contents of the intestines, and do not adhere

to them, as the tape-worm does, and hence their comparative

harmlessness, and they have no power, as has sometimes been mistakenly

imagined, of perforating the bowels, and of thus producing grave

mischief.

The _thread-worm_ is the commonest variety of these creatures, and has

the peculiarity of inhabiting the lowest twelve inches of the bowel,

where it produces much irritation and causes very distressing itching.

It is often present in great numbers, and is so rapidly reproduced, that

in a week or two after it has been apparently got rid of, it may again

be found as numerous as before. Certain articles of food seem to favour

its development, such as pastry, sugar, sweets, beer, fruit, and

anything which is apt to undergo fermentation, and thereby to impart to

the evacuations a specially acid character. These worms are often

accompanied with more or less marked symptoms of indigestion, but

otherwise the local irritation is usually the only indication of their

presence. They produce, indeed, such disturbance of the nervous system

as may attend indigestion in any of its forms, but I have never but once

known convulsions occur apparently due to their presence in great

numbers, and ceasing on their expulsion; and this was in a child between

eighteen months and two years old.

The _tape-worm_ is developed in the human body from a minute germ or

ovum; one form of which exists in the flesh of the bullock, the other in

that of the pig; and which seems to require for its growth the favouring

conditions of warmth and moisture which are found in the intestines. It

fixes itself to the lining of the bowels by means of its mouth, which is

furnished with minute tentacles, and it thus derives its support from

the juices which it imbibes. The head is so small as not to be seen

distinctly without a magnifying glass; and immediately beyond it the

jointed body begins; at first, scarcely bigger than a thread of worsted,

but gradually enlarging, till at the distance of three inches it is an

eighth of an inch wide, and thence rapidly widens till each joint is

half an inch wide, and from a third to half an inch apart. It does not

exceed these dimensions, even though it may grow to the length of four

or six yards. Portions of it, sometimes a yard or two in length, are

thrown off from its lower end occasionally, and this occurrence often

gives the first indication of its presence, the worm continuing to grow

as before, and fresh portions being detached from time to time. It does

not appear that the worm has the power of reproducing itself; hence its

French name of _ver solitaire_, and the occasional presence of two or

three would seem to be due to the development of two or three distinct

ova within the intestine.

Deriving as it does its support from the system of the child, and not as

the other worms do from the contents of the bowel, the tape-worm often

produces graver inconveniences. It sometimes causes uncomfortable

colicky sensations, which may even be very distressing, and the

disorders of digestion which accompany it are often very considerable;

certainly more so than in the case of the other varieties of worms; but

I have seen no instance of convulsions which could be attributed to

them, notwithstanding the generally received opinion to the contrary.

When the existence of worms is suspected, one or two doses of a simple

aperient, such as castor oil, repeated two days successively, seldom

fail to produce evidence of their presence; which in the case of

tape-worm is also furnished by the spontaneous detachment of some of the

joints. It must be remembered, however, that until the head has been

detached from its connection with the bowel, nothing has been gained,

and the tape-worm will in a short time grow again. To obtain the

detachment of the head it is necessary that any worm medicine should be

given when the intestines are empty. I am, therefore, always accustomed

to give a dose of castor oil about two hours after the child's mid-day

meal; and to send the child to bed as soon as the aperient begins to

act, and to give it no more food except a biscuit and a little milk and

water during the rest of the day. In the early morning, the special worm

medicine is given, and over and over again I have known the worm to be

brought away completely after many previous failures. When the smallness

of the joints shows that the greater part of the worm has been thrown

off, and that little more than the head remains, it is necessary to have

recourse to the unpleasant proceeding of mixing the evacuations with

water, and then straining them through muslin, in order that the doctor

may by means of the microscope make out whether or no the head has been

really detached. This is no question of mere curiosity, but a matter of

the gravest moment, since nothing has been really gained so long as the

head of the worm remains adherent to the bowel.

Precautions such as these are not needed in the case of the other kinds

of worms. Thread-worms, however, are best attacked in their habitation;

that is to say, in the lower bowel, by means of lavements. It is,

therefore, desirable before they are administered that the bowels should

be emptied by a dose of castor oil.

The only other caution which remains for me to give refers to the

peculiar effect which salicine, a very valuable medicine, especially in

the case of thread-worms, has upon the urine. It sometimes turns the

urine of a greenish-yellow, often of a red colour, as though it were

mixed with blood. The appearance, however, has no grave meaning, but is

due simply to a chemical action of the medicine on the colouring matter

and salts of the urine.

There still remain some local ailments of parts connected with the

process of digestion, concerning which a few words must be said.

=Ulcerated Mouth.=--First, with reference to the _sore-mouth_ of

children. I have already noticed a form of inflammation and ulceration

of the gums sometimes met with during teething, but the sore-mouth of

which I am now about to speak is often quite independent of that

process; though it may sometimes be found associated with it, and is

indeed rarely met with after five years of age. In almost all instances

it is preceded and attended with symptoms of indigestion, during the

course of which the mouth becomes inflamed, hot and red, and small very

painful shallow ulcers with sharp-cut edges, and a little yellowish

deposit on their surface, appear at the edge of the tongue, on the

inside of the mouth, and especially on the inside of the lower lip, and

the adjacent surface of the gum. Successive crops of these little

ulcerations not unfrequently appear, so that for many weeks the child

may be kept by them in a state of extreme discomfort; swallowing, and

even speaking being the occasions of considerable suffering.

It is seldom that nursery remedies, and the so-called cooling

medicines, though often of some service, suffice to get rid of the

ailment, which for the most part needs judicious medical treatment, and

local as well as constitutional measures. Now and then this condition

comes on in the course of measles, and is then sometimes of serious

importance.

In the other form, the disease is usually limited to the gums, and

affects especially those of the front of the lower jaw, which become

swollen, ulcerated at their edges, where a very ill-smelling deposit

takes place of a dirty white or greyish colour, the surface beneath

being spongy, swollen, raw, and bleeding. The ulceration sometimes

extends so as to lay bare a large part of the sockets of the teeth; but

though loosened they seldom drop out. Coupled with this, the glands at

the angle of the jaw are swollen, and the child dribbles constantly a

large quantity of horribly offensive saliva. In the children of the

well-to-do classes the condition is seldom seen except in a slight

degree; but even when severe it is rarely accompanied by any grave

disorder of the general health. It seems to tend, whether treated or

left to itself, slowly to get well; but its progress to a natural cure

is extremely tedious, and the gums are left by it for a long time

spongy, bleeding easily, and only very imperfectly covering the teeth.

Anxiety is sometimes excited by this condition; it being supposed that

the white deposit on the edge of the gum implies some relation between

it and diphtheria. This is not so, for though this peculiar ulceration

of the gums has now and then been found associated with diphtheria, the

nature of the two diseases is essentially different. It is, however,

always wise to call in medical advice in order to settle this important

question, and the more so, since there is one remedy, the chlorate of

potass, which, in appropriate doses, acts upon the condition almost as a

charm.

I say nothing about a dreadful form of inflammation of the mouth which

ends in mortification, because it is of infinite rarity except among the

destitute poor, and even among them it is very seldom seen except as a

consequence of measles, or of some kind of fever. It is only among the

very poor that I have seen it, and even among them it has come under my

notice only ten times in the whole course of my life.

There is a very common but inaccurate opinion that sore-mouth in

childhood is often produced by the employment of mercury. I never yet

saw a sore mouth due to the administration of mercury in any child

before the first set of teeth were entirely cut; and never but once out

of 70,000 cases which have come under my notice in hospital or

dispensary practice, have I seen in children of any age under twelve any

affection of the mouth from mercury sufficiently severe to cause me a

moment's anxiety.

=Quinsey=, or inflammatory sore-throat, has in it nothing specially

peculiar to the child, but occurs at all ages with the same symptoms. It

is, however, comparatively rare under twelve years of age, and is almost

always less severe in childhood than at or after puberty, while I

scarcely remember to have met with it under five years of age. This

circumstance attaches special importance to sore-throat in young

children, since it will usually be found to betoken the approach of

scarlet fever, or of diphtheria, rather than the existence of simple

inflammation, or quinsey.

While this fact affords a reason for most scrupulous attention to every

case of sore-throat in children, and this in proportion to the tender

age of the child, needless alarm is sometimes caused by the appearance

on the inflamed tonsils of numerous white specks, which are at once

supposed to be diphtheritic. I have already pointed out the distinction

between the two conditions when speaking of diphtheria, but the matter

is so important that I will repeat what I then said. These spots are not

in the form of a uniform white patch or membrane, which, on being

removed, leaves the surface beneath red, raw, and often slightly

bleeding; but they are rather distinct circular spots, firmly adherent

to the tonsil, wiped off with difficulty, and evidently exuding from the

openings of little pits, blind pouches, or glands, with which the

surface of the tonsil is beset. I do not advise any parent to rest

satisfied with his or her judgment on this matter the first time that

they notice this appearance; but there are children with whom slight

sore-throat is always attended by this condition, and others in whom the

tonsils are habitually enlarged, and seldom free from these white spots

flecking their surface.

=Enlarged Tonsils.=--I have said that quinsey or acute inflammation of

the tonsils is unusual in early childhood; but a sort of chronic

inflammation of those glands which leads to their very considerable

enlargement is far from uncommon; and is sometimes the cause of very

serious discomfort. It is seldom traceable to any acute attack of

sore-throat, but usually comes on imperceptibly in children who are

feeble or out of health, or takes place slowly during the cutting of the

first set of grinding teeth; the irritation which that produces being in

some cases its only apparent exciting cause. Not seldom the enlargement

has become considerable before it attracts attention; one of the first

symptoms that indicate it being the loud snoring of the child during

sleep, who is compelled by the obstruction at the back of the nostrils

to breathe with its mouth open. The voice at the same time becomes

thick, and this and the snoring breathing are both greatly aggravated

when the child catches cold.

A greater degree of enlargement of the tonsils occasions deafness from

pressure on the passage leading to the internal ear, and is also apt to

give rise to a troublesome hacking cough which sometimes excites

apprehension lest the child's lungs should be diseased. When still more

considerable the enlarged tonsils block up the passage through the

nostrils, and air consequently enters the lungs but very imperfectly.

The nostrils thus disused become extremely small, narrow, and

compressed, the upper jaw does not undergo its proper development, the

teeth are crowded and overlap each other, the palate remains narrow and

unusually high-arched, and the face assumes something of a bird-like

character. Besides this the child grows pigeon-breasted, owing to the

lungs not being filled sufficiently at each inspiration to overcome the

pressure of the external air on the yielding sides of the chest.

When any considerable enlargement of the tonsils exists, each cold that

the child may catch aggravates it, and if diphtheria, scarlatina, or

severe sore-throat should occur, the temporary increase of the swelling

may become the occasion of serious danger. The question arises, what are

the chances that a child whose tonsils are enlarged will outgrow the

condition, or when is it necessary to have the enlarged tonsils removed?

It scarcely ever happens that any such enlargement of the tonsils exists

in children under six years of age as to call for their removal. There

is almost always ground for the hope that after the irritation caused by

cutting the first four permanent grinding teeth has completely ceased,

the tonsils may return by degrees to their former size. A similar

shrinking of the enlarged tonsil sometimes takes place, especially in

the boy, at the time of approach to manhood, when the vocal organs

undergo full development. This can be counted on, however, only in cases

where the tonsils are not of extreme size, and have not undergone

frequent attacks of inflammation. Whenever the hearing is habitually

dull, and the voice always thick, when cough is frequent, the nostrils

narrow, the chest pigeon-breasted, and the child feeble and ill-thriven,

removal of the tonsils is absolutely necessary. In cases where the

question is doubtful, its decision must turn on whether the tonsils have

often been inflamed. So long as their surface is smooth, and their

substance soft and elastic, delay is permissible. When their substance

is hard, like gristle, and their surface uneven and corrugated, they

have undergone such changes that absorption is impossible, and their

removal absolutely necessary.

I dwell thus particularly on the question of removal of the tonsils,

because there is among many persons an unreasoning dread of the

operation, which is entirely devoid of danger, requiring only a few

seconds for its performance, and which may even be done under

chloroform. The painting tincture of iodine behind the angle of the jaw,

or the touching the tonsils with caustic, iodine, alum, tannin, or sweet

spirits of nitre are utterly futile proceedings. They diminish the

unhealthy and often offensive secretion from the glands which beset the

tonsils, and restore the surface to a more healthy condition, but they

are absolutely without influence in lessening their size.

Now and then all the symptoms of enlarged tonsils are present, but yet

most careful examination fails to discover any increase of their size.

When this is the case the symptoms are due to a thickening of the

membrane at the back part of the nostrils, often attended with spongy

outgrowths from their surface, which obstruct just as completely as

enlarged tonsils would do the free entrance of air. It will, in any case

where this condition is suspected, be absolutely necessary to seek the

advice of some of those gentlemen who make a specialty of diseases of

the throat, and who will have the necessary technical dexterity to

discover the condition, and to treat it skilfully.

=Abscess at back of the Throat.=--I should pass unnoticed, on account of

its rarity, the occasional formation of an abscess at the back of the

throat, behind the gullet, interfering both with breathing and with

swallowing, but that the description of it in my Lectures once enabled a

lady in the wilds of Russia to detect it, to point out the nature of the

case to her puzzled doctor, to urge him to open the abscess, and thus to

save her child's life.

This abscess may form at any age, sometimes after fever, sometimes

without any obvious cause. It shows itself by difficulty in swallowing

and breathing, unattended by cough, but accompanied by a sound similar

to that of croup, but not so harsh or ringing. The neck is stiff, the

head thrown back, and often there is a distinct swelling on one or other

side of the neck. The finger introduced into the mouth, and carried over

the tongue to the back of the throat, feels there a swelling which

projects over the top of the windpipe, and causes the difficulty both in

swallowing and breathing. This swelling is the abscess; a prick with the

surgeon's lancet lets out the matter, and saves the child.

=Diseases of the Kidneys.=--The _kidneys_ perform very important duties

in carrying off from the system a large amount of useless material, and

thus supplement in many respects the action of the skin, and the

purifying influence which is exercised by the air on the blood, as it

passes through the lungs.

It is evident, therefore, that their disorder in any way must be a

matter of serious moment, though at the same time the knowledge of the

skilled doctor is needed to determine the nature and degree of the

ailment from which they are suffering, since that requires an

examination of the urine, both chemically and by means of the

microscope. My remarks on these diseases must consequently be few and

fragmentary.

In the grown person, what is known as _Bright's disease_ is of frequent

occurrence, assumes different forms, and depends on various causes. In

the child it is comparatively rare, and is scarcely ever met with except

as a consequence of a chill, or as a result of scarlatina. In these

conditions the kidneys become overfilled with blood or congested, and

the congestion may pass into inflammation, by which their structure may

be irreparably damaged. Dropsy is the great outward sign of the

affection--either slight swelling of the face, eyelids, and ankles, or

very great swelling of all the limbs, and even the abundant pouring out

of fluid into the belly. The degree of dropsy is, however, by no means

an absolute measure of the amount of kidney mischief. It therefore

behoves every parent to follow out all directions most scrupulously even

in cases of very slight dropsy, in order to guard against the risk of

permanent injury to the kidneys being left behind; and especially to

remember the liability to the occurrence of dropsy and disease of the

kidneys after scarlatina. Any check to the action of the skin while it

is peeling or desquamating, as it is termed, is especially liable to be

followed by these accidents. To avoid all risks as far as possible, I

have been accustomed for many years to insist on a child remaining in

bed for one-and-twenty days after the first appearance of the rash in

even the mildest case of scarlatina, and I am absolutely sure that it is

the height of imprudence ever to neglect this precaution.

It will suffice to mention the fact that _diabetes_, though very rare,

may yet occur in childhood, and that as a rule it is more dangerous in

childhood than in the grown person. Whenever a child loses flesh without

obvious cause, suffers much from thirst, and at the same time passes

urine in greater abundance than in health, the possibility that it may

suffer from diabetes must be borne in mind.

Of far greater frequency than any other affection of the kidney is that

in which the child passes _gravel_ with the urine, either in the form of

a reddish-white sediment, which collects at the bottom of the vessel as

the urine cools, or of minute glistening red particles, which resemble

grains of cayenne pepper.

These deposits, when abundant in the male child, have a tendency to

collect in the bladder, and there to form a stone. This painful disease,

too, is so much more frequent in childhood than at a later age, that

more than a third--indeed, nearly half--of all the operations for stone

performed in English hospitals are done on boys under ten years old.

Even when this grave consequence does not follow the presence of gravel

in the kidneys, and its passage into the bladder, it is often

accompanied with much suffering. The pain is like that of stomach-ache

or colic, the child crying and drawing up its legs on every attempt to

pass water, which sometimes is voided only in a few drops at a time, and

now and then is completely suppressed for some hours. The very acute

form of the ailment seldom occurs, except in infants who inherit from

their parents a disposition to gouty or rheumatic affections. In them,

however, a trifling cold, slight disorder of the digestion, a state of

constipation, or the feverishness and general irritation which sometimes

attend on teething, not infrequently produce these deposits and give

rise to all these painful symptoms, the deposit disappearing and the

pain ceasing so soon as the brief constitutional disturbance subsides.

The very acute attacks seldom occur after the first two years of life,

but similar symptoms, though less severe, are by no means unusual in

older children, and continue to recur from very trifling causes,

especially from errors in diet and disorders of digestion.

In spite of the suffering which for the time attends it, there is no

cause for anxiety with reference to the issue of each attack. The warm

bath, a castor oil aperient, and soothing medicine soon relieve the

pain, and the children return to their former state of health. It is the

frequent return of the attack, even in a comparatively mild form, the

persistent disposition to the formation of gravel, the remote risk in

the case of male children of stone in the bladder, and the habitually

imperfect performance of the digestive functions which call for special

care. The avoidance of sugar, sweets, and whatever tends to impart

acidity to the urine, the maintaining the due action of the skin by

wearing flannel, and the judicious use of alkaline remedies, sometimes

combined with iron, are the measures on which the doctor is sure to

insist.

The difficulty usually encountered in the treatment of these cases

arises from the reluctance of the parents to continue for months and

years the observance of the necessary rules. It seems so hard to deny

their little one the small gratifications in which other children may

indulge with impunity; and they fail to realise the heavy penalty, in

the shape of gout, rheumatism, gravel, and stone, which in after-life

their darling may have to pay for their over-indulgence in his early

years.

I will just mention that symptoms similar to those above described, less

severe, though more abiding, yet unattended by gravel in the urine, are

sometimes produced in little boys by an unnatural narrowness of the end

of the passage for the urine. It is well to bear in mind this possible

cause of the child's sufferings, and to consult a doctor with reference

to it, since he will be able to relieve it by a trivial operation.

=Incontinence of Urine.=--The irritation which this mechanical

inconvenience produces sometimes has to do with that troublesome

infirmity of some children, who wet the bed at night. This may also be

induced by a very acid, and consequently irritating, state of urine,

either with or without the appearance in it of gravel. Often, however,

it is a result of want of care on the part of the nurse, who neglects to

cultivate regular habits in a child; and does not pay attention to the

quantity of liquid taken at its last meal. Something, too, is due to the

fact that the sleep of a child is deeper than that of the grown person,

so that the sensation of want, which would arouse the latter to full

consciousness, does not have the same effect on the former. It sometimes

happens undoubtedly from mere indolence; and this may always be

suspected when a child, otherwise healthy, wets itself not at night

only, but also in the daytime. Lastly, it does sometimes occur from

muscular feebleness in weakly children, the bladder being unable to bear

more than a limited degree of distension.

The accident usually happens either soon after going to bed, when the

warmth stimulates the action of the bladder, or towards morning, when

the bladder has become full. The posture on the back favours its

occurrence very much, and it is therefore of importance that the child

should lie on its side when in bed. The good effect of a blister on the

lower part of the back as a means of cure was largely due to its forcing

the child to lie on its side. This object can be attained, however, in a

much kindlier way, by tying half a dozen cotton reels together, and

fastening them at the child's back. The habit may also often be broken

through by arousing the child in the night, and compelling it to empty

its bladder, the hour being first ascertained at which the accident

usually happens. For this, however, to be of any real use, the child

must be awakened thoroughly; since otherwise it will mechanically, and

quite unconsciously, empty its bladder while still asleep. The habit in

this case is not in the least overcome; only for the time the bed

escapes the wetting. The utensil must therefore be placed on different

nights at different parts of the room, so that the child, in order to

find it, must have been roused to thorough consciousness.

Lastly, I will add that the cases in which the accident is the result of

mere indolence are very rare, and though in such cases strictness may be

necessary, yet actual punishment is out of place. As a rule, reward

answers much better. A penny, or a threepenny-piece every night that the

accident does not happen, and a forfeit of a halfpenny or two pence for

every night of misfortune, is a very efficacious help to a cure.

When all these domestic means, persevered in for months, fail to

produce any result, medical aid must be called in.

CHAPTER IX.

CONSTITUTIONAL DISEASES.

There remains for consideration a large class of what may be termed

_constitutional diseases_, in which the local ailment is the outcome of

a previous disorder of the whole system. These diseases are either acute

or chronic. The acute constitutional diseases belong to the class of

fevers. These are marked by certain local characteristics, as the

swelling of the joints in acute rheumatism, the sore-throat in

scarlatina, or the eruption on the skin in smallpox, and their course is

more or less strictly limited by distinct periods of increase, acme, and

decline. No such rule obtains in the case of consumption, scrofula, and

rickets, which are instances of chronic constitutional diseases. In them

too the local manifestations of the general disease vary also: the lungs

being affected in one case of consumption, the bowels in another; while

scrofula may show itself by affection of the glands in one case, by the

formation of abscesses in a second, or by disease of the bones in a

third.

=Chronic Constitutional Diseases.=--It may perhaps be convenient to

study first the chronic constitutional diseases; and afterwards to make

a few, and they will be but few, remarks on fevers.

=Consumption= and Scrofula, though similar, are not the same disease.

Both, however, depend on some defect in the blood, as the result of

which certain materials, incapable of being converted into the natural

constituents of the body, are deposited in the substance of different

external parts or internal organs. If deposited in small quantities,

these materials may be absorbed, as it is termed, that is to say, got

rid of, by natural processes, which even now we understand but

imperfectly.

If deposited more abundantly, they press upon and gradually spoil the

healthy parts in which they are seated, and thereby interfere with the

proper performance of their duties. Thus, the deposit of consumption

encroaches on the proper substance of the lungs, and so lessens the area

in which the blood is exposed to the air and purified: the deposit of

scrofula around and in a joint interferes with its powers of movement.

Nor is this all; but wherever any deposit has once taken place, it tends

especially to increase in that very spot, guided as it were by a certain

affinity; and the substance of the previously healthy part is removed as

fresh deposit comes to occupy its place. Further, the matter deposited

has no power of being changed into healthy substance of lung, or of

bone, or of any other part.

A fractured limb may be completely mended; a fluid is poured out around

and between the edges of the broken bone; by degrees this hardens, it

undergoes changes which convert it into solid bone, and the limb is once

more as serviceable as before, though some indications of the fracture

may still be perceptible in the texture of the bone itself. Or, a person

receives a severe blow on his arm or leg; in course of time the blood

which had flowed from the ruptured vessels, and had formed a big bruise,

is absorbed, and all is as before the injury was inflicted. If more

serious damage has been done, the fibres of some muscles may have been

torn, even though the skin remains unbroken. Inflammation is set up, the

injured parts die, and are melted down into the matter of an abscess.

The abscess discharges itself, its walls contract, the opposite surfaces

come into contact, and are welded together again, so that there is no

loss of substance, nor anything save a scar on the surface to indicate

what has happened.

In the case of the deposits of consumption or scrofula these changes

cannot take place. In technical language the matter is said to be

incapable of organisation; that is to say, it cannot be transformed by

nature's alchemy into anything good or useful. It is rubbish to be got

rid of; and the patient's recovery depends on the possibility of getting

rid of it. If there is much of it, so as to be removed from the

vivifying influence which adjacent living structures still maintain

about it, the deposit softens at its centre. This softening gradually

extends to the circumference; the mass irritates more and more the parts

around it, and where the irritation is greatest the structures yield,

and are removed to make a way for its escape, and the patient spits up

the contents of the abscess.

But the abscess of the lungs is not like an abscess which follows an

injury. It has not formed in the midst of previously healthy parts which

are capable of reproducing the original structure; its walls are

themselves involved in the disease, and, in accordance with the rule I

have already mentioned, 'much will have more,' and the patient goes on

spitting up the perpetually renewed contents of the abscess for months

or years; until by its gradually increasing size, and the more and more

abundant discharge of matter, and further and further destruction of

lung-substance, death takes place.

This fatal issue, however, is not invariable. In favourable

circumstances, and especially in childhood, the radical constitutional

defect may be amended, and with a healthier condition of the blood the

unhealthy deposit may cease to take place. The lung-substance, however,

with all its curious structure of air-cells and their network of minute

vessels where, as in nature's laboratory, the blood receives its due

supply of oxygen, is not reproduced. The lung shrinks, the sides of the

abscess come together, and by slow degrees a dense material cuts it off

from the adjacent healthy structure, but the most complete recovery

leaves the patient with his breathing power lessened, and with his

vigour consequently more or less impaired.

When the deposit is less considerable, a different change takes place.

The material dries by degrees, and is at last converted by a purely

chemical change into a hard chalky substance, which in the course of

time becomes of more than stony hardness.

Last of all; when the deposit is smallest in quantity, it may be

completely got rid of; and a lung in which consumptive disease once

existed, may eventually regain perfect soundness.

I have dwelt on these processes as they take place in the lungs; but,

allowing for differences of locality, they resemble such as take place

elsewhere.

Three important conclusions follow from what has been said.

First. It is only in quite the early stage of consumptive disease that

absolutely perfect recovery can be hoped for. There is a euphemism, more

amiable than honest, which doctors not seldom make use of, saying that a

child's lungs are not diseased, but only tender. They mean by this, that

on listening to the chest, they detect such changes in the sounds of

breathing as their experience tells them are usually produced in the

early stage of consumptive disease of the lungs. If the opinion is

confirmed by a second competent medical man, _then, and not later_, is

the time for precautions, for removing the child from school, and for

selecting, as far as may be, a suitable winter climate. When the signs

of disease are well marked, a reprieve, perhaps a long one, is all that

can be confidently reckoned on.

Second. When softening of the consumptive deposit has taken place, of

which certain sounds attending breathing are all but conclusive,

recovery, even the most complete, always implies loss of a certain

amount of lung-substance, and consequently loss of a certain amount of

breathing power.

Third, and this is most important, as well as most cheering;

consumption, which is at no age the absolutely hopeless disease that it

was once supposed to be, admits of far more cheerful anticipations in

children than in grown persons, or, for that matter, than in the youth

or maiden.

The principal _causes_ of consumptive disease are, hereditary

predisposition, and improper feeding in infancy. There are besides two

diseases incidental to childhood, and one of them almost peculiar to it,

namely typhoid fever and measles, which are more apt than any others to

develop a tendency to consumption. During convalescence from either of

them, therefore, special care is needed.

In the grown person, consumption almost always attacks the lungs, and

this often to the exclusion of other organs. In the child, however, this

is not so, and though the lungs are indeed oftener affected than other

parts, yet in nearly half of the cases some one or other of the

digestive organs is likewise involved, and in about one in seven

instances the lungs are free and the digestive organs alone are

attacked.

Fever, cough, and wasting are the three sets of symptoms which in some

degree or other are always present in consumptive disease of the lungs.

The fever in the early stages of consumption is not in general severe;

but so long as the evening temperature of a child never exceeds 99 deg.,

there is no cause for anxiety. On the other hand, if the evening

temperature for a week or ten days together always amounts to 100 deg.,

there is grave presumption that consumptive disease is present. In

advanced consumption the evening temperature is constantly 103 deg. to 105 deg.,

while in the morning it may fall to 101 deg. or 100 deg..

Cough is but rarely absent even in cases where the lungs are but

slightly involved, for the irritation of the digestive organs often

excites a sympathetic cough, and in these circumstances observation of

the evening temperature will often furnish a clue to the right

interpretation of the symptoms.

There is a form of cough which is oftenest observed in children between

the ages of two and five years, which comes in fits closely resembling

those of hooping-cough, and each fit ends in a sort of imperfect 'hoop.'

This may depend on a particular form of consumption in which the _glands

connected with the lungs_ (the bronchial glands as they are called) _are

diseased_, and not the lung-substance itself. The enlarged glands press

on some of the nerves connected with the upper part of the windpipe, and

thus occasion the spasmodic cough. Always suspect this when a cough

persists for weeks together, not getting rapidly worse as hooping-cough

would do, but at the same time not growing better, as would be the case

with mild hooping-cough. The doctor on listening to the chest will solve

your doubts; the thermometer will help you to decide whether his visit

is necessary. I may add that this form of consumptive disease is less

serious than that in which the lung-substance is involved.

Consumption sometimes follows bronchitis, especially when a child has

been subject to frequent attacks of it. A very slow and imperfect

recovery from an attack of bronchitis which had not been specially

severe is always a reason for solicitude.

Now and then infants are born with consumptive disease. In that case the

lungs are always affected; and the symptoms of fever, cough, and wasting

usually show themselves within the first three or four months, and the

infants almost invariably die within the year. Now and then, however, an

infant thus affected may continue apparently in good health for a few

months, and then be suddenly attacked by symptoms of acute inflammation

or of severe bronchitis which prove rapidly fatal; and it may be found

after death that the acute attack destroyed life because the lungs were

already the seat of extensive consumptive disease.

No infant in whose mother's family a predisposition to consumption

exists ought to be nursed by its mother, but by a healthy wet nurse; or,

if that is impossible, it should be brought up on a milk diet, with but

a small admixture of farinaceous food.

There is a form of very rapid, or so-called galloping consumption, which

is seldom observed before the age of seven years; generally two or three

years later. Its symptoms so closely resemble those of typhoid fever,

that it may readily be mistaken for it. I refer to it in order to say

that the doctor who mistakes the one for the other can scarcely be

regarded as blameworthy; and the mistake is of the less importance since

the treatment applicable to the one case would do no harm in the other.

I have already noticed the connection between water on the brain and

consumption. It is indeed nothing else than inflammation excited by the

presence of the deposit of consumptive matter in the brain or its

membranes.

Little has been said hitherto about the wasting which was referred to as

one of the characteristics of consumption. When the disease is limited,

or nearly so, to the lungs, the wasting is not considerable until the

mischief in the chest is far advanced. It must be remembered, however,

in order to judge of this, that while in the full-grown man the best

sign of health is the persistence for years together of the same weight,

the case of the child is different. The child ought to grow in height,

and increase in weight, and during these changes the plump infant grows

thinner, not by real wasting but by conversion of its fat into bone and

muscle. The child is thinner, but is taller and weighs heavier. The only

real test therefore of the condition of the child is afforded by its

increase in height and in weight. One need not be solicitous about the

child who increases in height, and maintains his previous weight, nor

about him who while he does not grow yet becomes heavier; but the child

who neither gains in weight, nor in height, or who loses weight out of

proportion to his increased height, is in a condition that warrants

anxiety. I have long been accustomed, in the case of children whose

parents were resident in India, to instruct those who have charge of

them to send every three months a statement of the height and weight of

the children, as the best evidence of their state of health.

=Consumptive Disease of the Bowels.=--Consumptive disease sometimes

invades the whole system from the very first, while in other instances

it attacks from the outset the organs of digestion, and continues

throughout to affect them chiefly, and loss of flesh is then one of its

earliest symptoms. In instances where there is a strong family

predisposition to the disease, consumption of the bowels or mesenteric

disease, or disease of the glands of the bowels, all three popular names

for the affection, sometimes shows itself at the time of weaning. In the

majority of cases, however, it comes on later, after the completion of

teething, and between the age of three and ten years. Indigestion such

as I have already spoken of sometimes precedes it, with the irregular

condition of bowels, and the patchy state of the tongue. But this is by

no means constant, scarcely I think general; and not infrequently

momentary, causeless, colicky pains precede for a short time any other

symptom. In a few weeks after their occurrence, sometimes indeed

independently of them, the appetite fails, or becomes capricious; the

bowels begin to act irregularly, being alternately constipated and

relaxed; and the motions are unnatural in character, being, for the most

part, dark, loose, and slimy. Sometimes indeed, they are solid, and then

often white, as if from complete inactivity of the liver, and sometimes

half-liquid, frothy, and like yeast. One peculiarity which they always

present, be their other characters what they may, is their extreme

abundance, quite out of proportion to the quantity of food taken, and

due to their admixture with the unhealthy secretions from the bowels.

The child next becomes restless and feverish at night, its thirst is

considerable, and the colicky pains become both more severe and more

frequent. Sometimes the stomach grows very irritable, and the food taken

is occasionally vomited, while the tongue, in the early stages of the

affection, continues for the most part clean and moist, and except that

it is often unnaturally red deviates but little from its appearance in

health. Next comes a change in the condition of the belly, the date of

which varies considerably. It becomes larger than natural, owing to the

filling of the bowels with wind, but at the same time it is tense and

tender on pressure--two points of great importance to be noticed, and

the glands in the groin, which in a healthy child cannot be felt, become

enlarged, and are felt and perhaps even seen like tiny beans under the

skin.

As in other forms of consumptive disease, so here the progress from bad

to worse seldom goes on uninterruptedly. Pauses take place in its

course, though each time they become shorter; and signs of amendment now

and then appear, but they too promise less and less with each return.

The child wastes rapidly; is always more or less feverish; the abdomen

is constantly tender, but does not in general go on increasing in size;

the pains become more frequent and more severe, and the bowels are

almost always habitually relaxed. Life is sometimes cut short by the

lungs becoming affected, but when this is not the case the patient may

linger on for weeks, or months, or even for two or three years, until,

worn to a skeleton, death at last takes place from exhaustion.

Much apprehension is often needlessly excited in the minds of parents,

with reference to any child whose digestion is imperfect, who loses

flesh, and has a large abdomen; and the words mesenteric disease,

sometimes uttered thoughtlessly by the doctors, seem to them to seal

their little one's doom. Now, first of all, it must be remembered that

mesenteric disease, due to consumption, plays but a very small part in

the production of the symptoms just described, but that the covering and

the lining of the bowels are chiefly involved. Next, enlargement of the

mesenteric glands and disorder of their functions take place from many

causes other than consumption. They are always more or less enlarged in

typhoid fever; they become enlarged when irritated by unwholesome food

in infancy, or they may swell in the course of chronic indigestion. In

all these cases too, the glands in the groin may be enlarged by

sympathy, and this without the existence of any actual abiding disease.

A big abdomen is, of itself, no evidence of it, nor even when associated

with indigestion and frequent stomach-ache; but when to these you add

abiding tenderness, and an evening temperature always at least one

degree above that in the morning, there is every reason to fear that

consumptive disease has attacked the organs of digestion.

Even then, however, there is no ground for despair; for, while

consumptive disease in any form is less seldom recovered from in

childhood than in after-life, such recovery oftener takes place in cases

of affection of the digestive organs than when the disease is seated

elsewhere.

=Scrofula.=--With this word of comfort I leave the subject of

consumption, and pass to that of the allied disease _scrofula_. Briefly

stated, two of the great differences between it and consumption are that

scrofula is almost entirely limited to childhood and youth, while

consumption may occur at any age; and next, that while scrofula attacks

the bones and the glands, the skin and the membranes adjacent to it,

consumption has its seat in the lungs, the brain, and the internal

organs.

Scrofulous diseases of the bones come so exclusively under the

observation of the surgeon, that I do not feel myself competent to say

anything about them. I would however warn all parents to be very much

alive to the importance of noticing the early symptoms of any such

diseases, as shown by slight lameness, complaint of pain in the back, or

difficulty in moving the hand or arm, or in turning the head or bending

the neck. They may be but temporary accidents, due to cold, or to slight

muscular rheumatism, or to some sprain not noticed at the time; but they

may also be signs of the commencement of scrofulous disease of some

bone; and in no disease whatever is early judicious treatment of greater

value, or the result of neglect less remediable.

Besides these graver ailments which seldom appear until after the time

of infancy has passed, there are others of a less serious nature which

often show themselves within the first year of life. One of these

consists in the formation beneath the skin of numerous small lumps of a

rounded form, and of the size of a kidney-bean, slightly movable, and

not tender. By degrees such lumps become adherent to the skin, the

surface of which above them grows red, they project slightly above it,

and at last open by a small circular aperture, discharge a little

matter, and then subside. They collapse and disappear; a slight

depression and a degree of lividity of the skin mark for a considerable

time the situation they had occupied. I refer to them, because while

they are a sign of a scrofulous constitution, which may require special

care in diet and preparations of iron and cod-liver oil, they are best

left absolutely alone--neither poulticed nor lanced. The same principle

of non-intervention applies equally to the swellings which sometimes

form on two or three of the fingers in infancy, not involving the joints

but producing great thickening and a hard swelling around the bone.

These swellings disappear by degrees as the constitutional vigour

improves, and this is especially promoted by a long stay at the seaside;

but they tend, if the health fails, to affect the bones themselves, and

thus to occasion deformities of the hand.

Glandular swelling, discharges from the ear, offensive secretion from

the nose, and in female children, even of very tender age, a discharge

of whites, are all common signs of a scrofulous constitution, and all

tedious and troublesome. They all, however, are very much under the

influence of judicious medical treatment. It must at the same time be

borne in mind that none of these ailments admit of what may be called

active treatment. There are no royal means of dispersing scrofulous

glands, or of curing discharges from the ear, or of doing away with the

offensive smell which in some cases proceeds from the nostrils. Fresh

air, suitable diet, preparations of iron, residence at the seaside, and

sea-bathing, measures directed to improve the general health, are of

chief value, and without them local treatment is of small avail.

A few words, however, may with propriety be added with reference to the

local treatment of the minor ailments to which I have just referred.

No local application is of use in the _scrofulous swellings of the

fingers_. Tincture of iodine, indeed, may be painted over them when

quite small, while at the same time the joints are kept quiet by a small

gutta-percha splint. When they become considerable, iodine is useless;

and even if matter forms in the swelling it is much better to let it

make its way out by a small opening spontaneously than to make a

puncture with a lancet, since the edges of the wound would not heal, and

the risk of the disease affecting the bone would be increased.

The _glandular swellings_ of the neck or about the lower jaw are

likewise best let alone, or merely covered with a layer of cotton wool,

stitched inside a piece of oiled silk to maintain a uniform temperature.

If they become suddenly painful and more swollen, a cooling lotion of

Goulard water and spirits of wine, constantly applied, will reduce the

swelling and lessen the discomfort. When stationary, a mild iodine

ointment may be smeared over the gland at bedtime, and covered with

oiled silk. Applications of iodine, however, need careful watching, for

sometimes they over-irritate the gland, and cause an abscess. If the

gland were out of sight there would be no objection to this, which

would probably be a rapid mode of getting rid of the swelling; but the

scar left behind, if the abscess burst or were opened, is an objection

when the swelling is situated in the neck or at the jaw.

If the skin over the top of the swelling becomes red, and its substance

begins to feel soft, then, but not till then, it is desirable to apply a

warm poultice constantly. At the same time the progress must be daily

watched by the doctor, in order that he may seize the proper moment to

make a small puncture and let out the matter. The small cut leaves a

less puckered scar than the natural opening. The subsequent management

of the case must be superintended by the doctor.

_Offensive discharge from the nostrils_ does not depend, in by far the

majority of cases, on disease of the bones, but on an unhealthy

condition of their lining membrane. It is exceedingly obstinate and

difficult of cure, is four times more frequent in girls than in boys,

and unfortunately often lasts into womanhood, and continues even when

the general health is perfect.

Much may be done to abate the annoyance by diligent sniffing up the

nostrils some weak disinfectant; or by regularly irrigating the nostrils

by means of a simple apparatus, to be obtained from any

instrument-maker. In spite of this, however, it is often necessary to

introduce a little plug of cotton wool dipped in the fluid some distance

up the nostrils, with a thread attached by which it can be withdrawn,

and a fresh one substituted twice a day.

The discharge of _whites_ is sometimes very troublesome, and apt to

return from the commencement of teething up even to womanhood. It is a

mere sign of debility, usually also connected with a scrofulous habit,

but has no further or graver meaning. Locally, constant cold ablution by

means of a sponge held above the child, not touching it, is the great

remedy, and this may have to be repeated every hour or two if the case

is severe. Astringent lotions of different kinds may be used in the same

manner; while care must be taken that the child's drawers are large and

loose, so as not to irritate her when sitting. General treatment,

however, sea air and sea bathing are especially in these cases the great

remedy.

It must not be forgotten that all these ailments have a special tendency

to recur; and that when people say 'Dr. A. or Dr. B. did the child good

for the time, but this or that symptom returned as soon as the treatment

was discontinued,' as though this were the doctor's fault, they are

unjust; for the tendency to return of every form of scrofulous disease

is one of the great characteristics of the malady. Patience and

perseverance on the parents' part, even for months and years, are often

as much needed as skill on the part of the doctor.

One more remark may not be out of place. Some persons have an impression

that there is something specially shameful in scrofulous disease, and

while they will readily admit the existence of a consumptive tendency in

their family, they almost resent the suggestion that their child's

ailment is scrofulous. For this prejudice there is absolutely no

foundation. There is no more reason for connecting scrofula in a child

with any antecedent wrong-doing on the part of its progenitors, than

there is for attaching that idea to the red hair or black eyes which a

child may have in common with the rest of its family.

=Rickets.=--We sometimes see, especially in the poorer quarters of a

great city, persons dwarfed in stature, with large hands, bowed legs,

bent arms, swollen wrists and ankles, walking with an awkward gait,

though usually holding themselves remarkably upright, with the face of a

grown person on the body of a child, and we know that they suffered from

_rickets_ when young.

Rickets is essentially a disease of childhood, and of early childhood,

in which proper bone-formation does not take place, the soft material,

or gristle, which should turn to bone, remaining long in the soft state.

When, therefore, the child begins to walk, or to use its limbs, they

bend under the weight of the body, or under their own weight, and with

every slight movement which its feeble muscular power enables it to

make. It does more, however, than interfere with the hardening of the

limbs: it arrests growth to a great degree, interferes with

development, retards teething, postpones the closure of the open part of

the head, or fontanelle, weakens constitutional vigour, and impairs

muscular power. To this feeble muscular power it is due that the child

cannot make the effort to fill its lungs completely, and hence the

pressure of the external air forces the soft ribs inwards, and gives to

the chest the peculiar form of pigeon-breast. In the course of time the

delayed bone-formation takes place, and the bones themselves become as

hard as ivory, but the limbs do not straighten, and the deformity

produced in infancy is but confirmed in after-life.

The greater degrees of rickets are scarcely ever seen among the children

of the wealthier classes, but over-crowded and ill-ventilated nurseries,

cots from which the air is well-nigh shut out by closed sides and

overhanging curtains; injudicious feeding, with undue preponderance of

farinaceous food, often produce its slighter forms. I never yet saw

rickets in a child while brought up exclusively at its mother's breast.

The slighter forms of rickets show themselves in a tardy closure of the

infant's head, which sweats profusely when the child is laid down to

sleep; in big wrists, which contrast with the attenuated arms; in a

general limpness of the whole body, and a bowing of the back under the

weight of the head, which bends as a green stick would bend if a weight

were placed upon it. They are further marked by backwardness in

teething, and by the irregular order in which the teeth appear, and,

further, by the peculiar narrowness of the chest, and by what has been

termed the beading of the ends of the ribs: little round prominences due

to a heaping up of gristle just where the ribs join on to the

breastbone, marking the spots at which the tardy bone-making has come to

a standstill.

Children who bear these stamps of rickets are far more apt than others

to suffer from spasmodic croup, and in them it is also specially likely

to be severe and to be accompanied by convulsions. They will also be

more liable than others to attacks of bronchitis, they will suffer more

during teething, they will be often constipated, and will be troubled by

various forms of indigestion. Now and then, too, they will have

causeless attacks of feverishness lasting for a few days, or for two or

three weeks, attended with general tenderness of the surface, and a

disposition to perspiration, which brings no relief but serves only to

weaken.

It is true that these symptoms do not often become immediately dangerous

to life, though spasmodic croup and bronchitis both have their perils;

but they interfere with health, and growth, and good looks, and

cheerfulness, and quick intelligence.

If mothers would but ask themselves the real signification of these

symptoms, and change the conditions which surround the child, and alter

their mode of feeding it, they would many and many a time be spared the

heart-ache of seeing their little ones grow up weakly, ugly,

ill-thriven.

Unfortunately, it is so much easier to give cod-liver oil and iron than

to turn the best spare room into a night nursery, and to uglify the cot

by taking away the curtains which made it so pretty, and to give up some

of the pleasures of society in order to superintend the preparation of

the baby's food; that the doctor is called in to correct by drugs the

evil which drugs cannot reach. Iron and cod-liver oil are very useful in

the second place; fresh air, good ventilation, and a wise diet must

always occupy the first.

=Acute Constitutional Diseases.=--It still remains for us to glance

rapidly at the characters of the _acute constitutional diseases_, all of

which belong, as has already been stated, to the class of fevers. Of

them all but two are contagious--that is to say, are capable of being

communicated directly from person to person. They are likewise

infectious, or, in other words, articles of bedding or clothes which

have been worn by the sick, retain a something--an exhalation from the

breath, an emanation from the skin, or a secretion from the

bowels--which may reproduce the same disease in a person previously

healthy.

To this contagious and infectious property there are two exceptions; the

one is furnished by acute rheumatism, or rheumatic fever, the other by

intermittent fever, or ague.

=Rheumatic Fever.=--The main features of _rheumatic fever_ are the same

at all ages. Fever, pain in the limbs, swelling of the joints, sweats

unattended by that relief which usually accompanies abundant action of

the skin in fevers, are its characteristics. In the child all these

symptoms are usually less even than in the adult. The swelling of the

joints in particular is less considerable, and both the pain and the

swelling are apt to wander from one to another joint, or to a different

limb, instead of remaining fixed as they do in the grown person for

several days in the same joint, even though fresh joints may be

implicated in the course of the disease.

These circumstances tend to make people look on rheumatic fever in the

child too often as a comparatively trivial ailment; and this not only

because the suffering which attends the disease is slighter, but because

its duration is also shorter. But there is one fact which forbids this

low estimate of its importance, and that is the great tendency to

affection of the heart even in cases of comparatively mild rheumatism in

the child; while in the grown person there is a direct relation between

the general severity of the rheumatic symptoms and the liability of the

heart to be involved. I have already stated that nine out of ten of all

cases of heart disease in early life, not due to original malformation,

are of rheumatic origin, and further that heart disease comes on in the

course of four out of five cases of rheumatic fever in the child, slight

as well as severe. It seldom occurs before the third or fourth day of

the illness, so that if parents take the alarm at the very outset, it is

usually though not invariably possible for the doctor by judicious

treatment to anticipate and to prevent its occurrence, or at any rate

greatly to control its progress.

Every threatening of rheumatism, therefore, is to be watched with the

most anxious care, since so serious a complication as disease of the

heart may accompany extremely slight general symptoms. It is wise too,

to place any child in whom general feverish symptoms come on at once

under medical observation, for though it does not usually happen, yet it

does sometimes occur, that rheumatic inflammation attacks the heart

before any other local signs of the malady have manifested themselves.

It is scarcely necessary to add that tenfold precautions are needed when

rheumatism has once occurred, since the liability to its return is very

great, and the heart which escaped in the first attack may suffer in the

second; or the comparatively small mischief done the first time may

become an incurable disorder.

=Ague.=--_Intermittent fever_ or _ague_ is very rare in childhood in

London; or at any rate it is very rare among children of the wealthier

classes. I believe it is everywhere rarer among children than among

grown persons, probably because they are as a rule less exposed to those

malarious influences which produce it. In the child it generally takes

the form of tertian ague, that is to say the attack recurs every second

day; one day of freedom intervening between two attacks.

The three stages of shivering, heat, and sweating are less marked in the

child than in the grown person, and this indistinctness of its symptoms

is greater in proportion to the tenderer age of the child. Shivering is

scarcely ever well-marked, a condition of unaccountable depression

usually taking its place, while once or twice I have known convulsions

occur which gave rise to the apprehension that disease of the brain

existed. The hot stage is long, and passes off gradually without the

profuse perspiration that occurs in the grown person, and the child even

between the attacks is almost always more or less ailing.

A first and even a second attack may puzzle not the parents only, but

also the doctor; but after the symptoms have returned a few times, the

child being neither better nor worse in the intervals, it becomes

evident that no serious disease is impending. The risk of an overhasty

conclusion is that the depression and disturbance of the nervous system

may be supposed to imply the existence of brain disease; and lead to

unsuitable treatment, instead of the administration of quinine, which

nine times out of ten proves a specific for ague. The rapid increase of

temperature in the attack, and its equally rapid subsidence afterwards,

will, if carefully noted, preserve from error.

There is much that is obscure with reference to the nature both of

rheumatic and intermittent fever. They differ from other fevers not only

by being neither contagious nor infectious but also by their readiness

to return, while a single attack of any of the others furnishes a

guarantee, and often a complete guarantee, against its recurrence. In

addition to these peculiarities, the fevers of which I have now to speak

are characterised by running a certain definite course, being

accompanied by certain peculiar appearances on the surface (generally

rashes on the skin, whence their name of eruptive fevers); being

attended each with its own peculiar dangers, and all having a tendency

to what is termed epidemic prevalence; that is to say to occur one year,

and without obvious cause with vastly greater frequency than in other

years.

=Mumps.=--It has been questioned whether that painful but not dangerous

ailment the _mumps_, ought or ought not to be classed with these fevers.

I think it should, for it is contagious, infectious, runs a fairly

definite course, is attended with invariable external appearances, often

prevails epidemically, and one attack preserves in most instances from a

second.

It very seldom befalls children under seven years of age, and is more

frequent in early youth than in childhood. It sets in with the ordinary

symptoms of a cold, which are followed in about twenty-four hours by

stiffness of the neck, and pain about the lower jaw, which is increased

by speaking or swallowing. At the same time a swelling appears,

sometimes on one side sometimes on both of the lower jaw, and increases

very rapidly so as to occasion great disfigurement of the face. The

swelling goes on to increase, and to become more tense, attended with

more head-ache, fever, and discomfort for some forty-eight hours, but

then it begins to lessen, and the general illness subsides rapidly,

though the enlarged gland, for that is the cause of the swelling,

sometimes does not return to its natural size for a week, ten days, or

more; and now and then, though very rarely, an abscess forms, which is

both tedious and troublesome.

The treatment suitable for a severe common cold, together with the

constant application of a warm poultice to the swollen gland, is all

that is usually required, though the doctor's help is often needed to

relieve the suffering which for the first day or two in many instances

attends the ailment.

=Typhoid Fever.=--There is no question as to the place which should be

occupied by typhoid fever, smallpox, measles, and scarlatina, for all

belong to the class of eruptive fevers. They are all specific diseases,

each due to its own peculiar poison, and not capable of being produced

by any mere unsanitary conditions, though such may aggravate their

severity and facilitate their spread.

The belief in the special character of each of these diseases has

received strong confirmation from the researches of the eminent

Frenchman, M. Pasteur, and others who have followed in his track. They

have discovered in the blood and other secretions, and in some of the

tissues both of men and animals, minute microscopic organisms which

differ in their characters in different diseases. Experiment has further

shown that in some mysterious way these organisms are the cause of these

diseases, for on inoculating animals with them the peculiar disease of

which each was the accompaniment, and no other, was reproduced in the

inoculated animal.

As far as our knowledge goes at present then, we are forced to regard

each of these as a separate disease, measles never passing into

scarlatina, nor that into smallpox, but each, whether slight or severe,

retaining throughout its distinct character.

We have already seen how, in the course of various diseases, the pulse

is quickened, and the temperature raised, constituting that state which

we commonly call fever, but as the local ailment subsides the fever

disappears. There is, apart from smallpox, measles, and the other

so-called eruptive fevers, only one real essential fever commonly met

with in childhood, and that is what the doctors call _typhoid fever_.

The name, from the similarity of sound to _typhus_, from which, however,

it is essentially different, has long been a name of terror in the

nursery, and all sorts of epithets have been substituted for it, as

gastric fever, and infantile remittent fever, and so on. Name it as you

may, the fever is one and the same with the typhoid fever, which one

hears of as prevailing constantly in many continental cities, and

proving dangerous and fatal in any district almost in direct relation to

the neglect of drainage and of proper sanitary precautions.

It is extremely rare in infancy, though I saw it once in a babe eight

months old, and is comparatively seldom met with before the age of five

years. From five to ten years old it is more frequent than from ten to

fifteen, but it is consolatory to know that it is less fatal in early

childhood than at any subsequent time of life, and that cases of such

exceedingly mild character that the child's condition can be more

properly described as ailing rather than ill, are then far from

uncommon. The symptoms, however, are in all instances similar in kind,

though widely varying in degree, and the duration of the fever is, as

nearly as may be, three weeks. By this it is not meant that at three

weeks' end the child who has had typhoid fever is well again, but only

that the temperature, which had hitherto been high, and always higher at

night than in the morning, has subsided, that the skin has become less

dry, the tongue slightly moist, the intelligence more clear, that the

fever has run its course. For the first week or ten days, the symptoms

have probably become every day more grave; and for the next ten the

doctor could find no better consolation than the assurance--happy if he

could give it--that the condition was not worse, but that you must have

patience, for the time for improvement had not yet arrived. If the

attack has been severe, the child will be left greatly exhausted, sadly

emaciated, and suffering from the effects of that ulceration of the

bowels which accompanies the fever, and from which life may still be in

imminent danger. But the fire is quenched; the question is no longer how

to put out the conflagration, but how to repair the mischief it has

caused.

When mild, the disease usually comes on very gradually, the child loses

its cheerfulness, the appearance of health leaves it, the appetite

fails, and the thirst becomes troublesome; in the daytime it is listless

and fretful, and drowsy towards evening, but the nights are often

restless, and the slumber broken and unrefreshing. The skin is hotter,

and almost always drier than natural, or if there is any perspiration,

it comes on at irregular times, lasts but an hour or two and brings no

refreshing. The thermometer will quite, in the early days, solve all

doubt as to the nature of the case. In the morning the thermometer will

be natural, or nearly so, but at seven o'clock in the evening it will

have risen to 101 deg. or 102 deg., and will continue so during the early part

of the unquiet night. After midnight it will begin to fall, and by six

o'clock in the morning, or even earlier, will have regained its natural

standard. There is no other disease but typhoid fever, and now and then

some forms of galloping consumption, in which these oscillations of

temperature take place regularly. Other symptoms attend typhoid fever

besides these, and serve to stamp upon it its distinctive character. The

bowels are usually loose, or if not, a moderate aperient acts on them

excessively, the evacuations being loose, often watery, of a light

yellow-ochrey colour. The abdomen is full, the bowels being more or less

distended with wind, sometimes tender, especially at the right side, and

both tender and painful in all cases where the disease is severe.

Towards the end of the first, or at the latest by the middle of the

second week, small rose-red spots or pimples appear on the abdomen,

sometimes also on the chest and back. They disappear for the moment if

pressure is made on them, but reappear the moment the pressure is

withdrawn. Now and then they are numerous, and sometimes two or three

successive crops appear, the old ones fading as the others show

themselves; but in childhood they are often scanty, though whether few

or many, they are the external characteristic of the disease just as the

rash is in scarlatina or measles.

Whenever a child of whatever age begins without obvious cause to lose

appetite and health, to become feverish, with marked increase of

temperature towards evening for several days together, and more or less

disposition to diarrh[oe]a, it is all but absolutely certain that the

child has contracted typhoid fever.

When the disease comes on gradually, it seldom becomes dangerous, though

until the end of the first week there is always considerable uncertainty

on this point. The amount of diarrh[oe]a and the degree of disorder of

the brain, as shown by restlessness, delirium, and stupor are the

measure of the gravity of any case. There is, however, scarcely any

disease from which even when most severe recovery so often takes place

in childhood, and this not as persons so often imagine from some

critical occurrence but by a process of gradual amendment. The first

signs of amendment, too, may be taken as giving almost certain promise

of complete recovery; but it is well to bear in mind that there is no

disease of early life in which the mental faculties, though time brings

them back at length uninjured, remain so long in a state of feebleness

and torpor as in typhoid fever. Though the first signs of improvement,

too, are very seldom deceptive, yet the patient's convalescence is

almost always slow, and interrupted by many fluctuations.

Though contagious, still typhoid fever is far less directly contagious

than measles or scarlatina. It seems as if with this disease, just as

with cholera, the contagious element were present in its most active

form in the discharges from the bowels. These should therefore be

disinfected by carbolic acid or some other disinfectant immediately; and

should never be emptied in a closet used by other members of the family,

and more particularly by children. Special precautions also should be

taken with the bed-linen, and night-dresses of the patient; and it must

be remembered that wise precautions have nothing in common with

exaggerated alarm. One more hint will not be out of place. In typhoid

fever, and still more in the highly contagious measles and scarlatina,

the person who sleeps in the patient's room is much more likely to

contract the disease than she who sits up and watches at night keeping

wide awake. Whoever takes charge of a fever patient during the night

should therefore sit up and watch, not lie down and doze, and this not

for the patient's sake only, but for her own.