It can scarcely be necessary to say that in every, even the mildest,

attack of typhoid fever the attendance of the doctor is needed from

first to last. He may come every day, and may daily do nothing but

merely watch. The disease will run its course, the greatest skill cannot

cut it short, though now and then instead of lasting for three or even

four weeks it comes to an end spontaneously in fourteen days. Skilled

watching is what the competent doctor gives. You would not despise or

underestimate the pilot's skill, who steered your barque through a

dangerous sea in smoothest water, because he knew each hidden rock or

unseen quicksand on which but for his guidance you might have made

shipwreck.

=Small-pox.=--At the present day, thanks to vaccination, and to

re-vaccination, _small-pox_ is rarely met with in the well-to-do classes

of society, though it is not yet a century ago since it found its

victims not only among the poor, but among the highest in the land. It

does, however, occur sometimes after vaccination, and sometimes, though

very rarely, an attack of small-pox fails to furnish an absolute

guarantee against the occurrence of a second.

Small-pox, unmodified by previous vaccination, sets in in the child with

violent sickness; vomiting, sometimes recurring frequently for

forty-eight hours, with much depression, or even stupor; in some

instances even actual convulsions, and fever; but neither with the

sore-throat of scarlatina, nor with the sneezing, cough, and running at

the nose of measles. At the end of from forty-eight to sixty hours, an

eruption of pimples appears on the face, forehead, forearms and wrists,

whence it extends to the body and the lower limbs. They are reddish in

colour, rather pointed in form, and at first scarcely raised above the

surface; so that the eruption looks at first like the very early

eruption of measles; though the tiny pimples felt as if beneath the skin

serve even then to distinguish the one disease from the other. In

another forty-eight hours the character of the pimples has changed into

that of little vesicles or pocks, depressed instead of pointed at their

centre, and containing a little watery milky fluid. They next enlarge,

and become once more prominent at their centre as they fill more and

more with fluid, which becomes thicker, yellowish-white--looks like, and

indeed is, matter. Four or five days are occupied with this process;

the matter in the pocks then begins to dry, and scabs to form, which

gradually by the end of another week drop off, and leave the skin

spotted with red or even scarred if the pocks went deep enough to

destroy the skin, and to leave the indelible marks, the so-called

pitting of small-pox.

The danger of the disease is in childhood the nervous disorder at the

outset, and then the exhaustion produced by the so-called maturation of

the pocks when the thin watery fluid changes to the thicker matter, and

depresses the patient in the same way as he would be depressed by an

enormous abscess.

The first outbreak of the eruption is followed always by a most

remarkable abatement in the disturbance of the constitution, and for

three or four days, even though the eruption is abundant, the patient

may seem so well that it is almost impossible to realise the imminent

peril to which he will be exposed in a few days' time.

=Inoculation and Vaccination.=--The danger of small-pox is in direct

proportion to the abundance of the eruption; and the great advantage of

inoculation for the small-pox consisted in the much scantier eruption

which followed it, as compared with that which commonly took place in

the natural small-pox.

The same advantage in a greater degree is obtained by vaccination, even

in the exceptional instances in which it fails to render the person

altogether insusceptible to the disease.

The great advantage which inoculation secured was counterbalanced in

great measure by the fact that it always maintained small-pox rife

throughout the whole country, and that consequently all who either had

neglected inoculation, or young children on whom, on account of their

tender age, it had not yet been practised, were more than ever exposed

to constant risk of infection.

This very real danger led to the almost unanimous welcome which the

practice of vaccination received towards the end of the last century,

since it was hoped that by it not only would the risk attending

small-pox be lessened, and the disease when it did occur be even milder

in character than inoculated small-pox, but that small-pox itself would

eventually be extirpated.

These anticipations have not hitherto been fully realised; but the good

effected by vaccination has been such as to render it, in the opinion of

nearly everyone qualified to form an opinion on the subject, one of the

greatest boons ever conferred on the human race.

Small-pox, like other eruptive fevers, has the peculiarity of occurring

for the most part only once in a person's life. We do not know in the

least on what this protecting influence depends. We know the fact, but

are the less able to offer an explanation, since there are other

constitutional diseases, such as gout and rheumatism, in which the local

symptoms are equally the outcome of previous constitutional disorder,

where exactly the opposite rule obtains, and in which their occurrence

does but increase the liability to their return.

The protective power is apparently possessed by the mild form of the

disease communicated by inoculation as much as by the severer form of

small-pox which is contracted by direct contagion or infection. This

knowledge has been applied in the treatment of some of the diseases of

animals, and it has been found in the case of the so-called small-pox in

sheep (a disease which, however, is quite distinct from human small-pox)

that while one in two of the animals who contracted it in the ordinary

way died, death took place in only three per cent, or not one in thirty,

of those in whom it was produced by inoculation; and the inoculated

sheep were thereby safeguarded from subsequent attacks as completely as

the others.

This knowledge was more recently applied by the distinguished Frenchman

whom I have already mentioned, M. Pasteur, in the case of a fatal

pestilence among sheep in many parts of France, known by the name of

_charbon_. The inoculated sheep died, however, in such large numbers,

though in a somewhat smaller proportion than those who had been directly

infected, that he found it necessary to weaken the matter which he

employed by admixture with other innocuous materials. This experiment,

however, again yielded unsatisfactory results; slight symptoms of the

disease were produced, but the protection thus afforded was inadequate

and uncertain. Some few resisted the disease, but others contracted it

and died. With that clear insight which constitutes genius, M. Pasteur

next tried the experiment of inoculating the sheep first with a weak

matter which produced but slight symptoms, but at the same time enabled

the animal to support a second inoculation with a stronger matter; and

this second inoculation enabled them to bear, unharmed, subsequent

exposure to the disease. A grateful country has given a pension, and

conferred well-merited honours on the man who has preserved their flocks

from pestilence, but whom the silly sentimentality of the

anti-vivisectionists in England would have mulcted in a fine, and, if

possible, have sent to prison.

That weakening of the poisonous element which Pasteur strove to attain

by art, is already provided by nature in the cow-pox. The cow-pox is

nothing else than small-pox modified in character, diminished in

severity by passing through the system of the animal; but giving, when

introduced into the system, a safeguard against natural small-pox at

least as complete as that furnished by the inoculated disease.

More than 70,000 children have come under my observation, either in

hospital or in private practice; and I need not say that a physician

having much consulting practice sees far more than the average of

unusual and severe cases. Twice, and only twice, I have seen infants die

from vaccination, and in both instances death took place from erysipelas

beginning at the puncture. The one case I saw twice in consultation with

the family practitioner. The other which I watched throughout was that

of a little boy, the fifth child of a nobleman of high rank, both his

parents being perfectly healthy. He was vaccinated by the family doctor

in the country, direct from the arm of another perfectly healthy infant,

from whom ten other infants were vaccinated immediately afterwards. The

little boy was seized with convulsions within twenty-four hours, and

almost at the same time erysipelas appeared on the punctured arm. The

erysipelas extended rapidly, convulsions returned more than once, and on

the fourth day from the vaccination the child died. One of the other

children vaccinated at the same time died in the country in the same

manner; all the others passed through vaccination regularly, and without

a single bad symptom. I have no explanation to offer; this case stands

by itself just as do those of death from the sting of a bee or death

from cutting a corn.

That some people die of other diseases since the introduction of

vaccination, is undoubtedly true, for many of those who would have died

in early infancy of small-pox are cut off later by measles or

bronchitis, or die during teething; since it is obvious that vaccination

does not protect against any other disease than small-pox.

That protection, indeed, is not absolute, nor was the protection

afforded by inoculation absolute; but small-pox after vaccination, even

when it does occur, is very rarely severe, and still more seldom fatal.

There seems good reason for believing that the protecting power of

vaccination tends to diminish with the lapse of time; though apparently

this is not always the case, nor can any direct statement be made as to

the conditions which favour this in one case, or prevent it in another.

As a matter of fact, however, we do know that such a tendency does

exist, and that this tendency calls for the repetition of vaccination

from time to time; such re-vaccination carefully performed being as

nearly as possible an absolute guarantee against small-pox. All persons

engaged as nurses or attendants at the Small-Pox Hospital during the

past thirty-two years, have been vaccinated or re-vaccinated before

entering on their duties, and during this period not a single case of

the disease has occurred among the whole staff. The experience of other

small-pox hospitals for a shorter period is identical. As far as we

know, every seventh year is a reasonable interval at which

re-vaccination should be performed.

One great cause of the failure of the protective power of vaccination

is the unintelligent and careless manner in which it is too often

performed, especially among the poor. To this same cause it is also due

that in some cases of almost infinite rarity one special constitutional

disease has been known to be communicated. I have never seen such a

case, but I know there are such. They are, however, no more a reason

against vaccination than the occasional death from an overdose of opium

is a reason against the use of that drug.

To avoid any risk of this kind, and also with the idea that the power of

the vaccine matter may have become weakened by transmission through many

thousands of persons, vaccination direct from the calf has been

introduced of late years, especially in America and on the Continent.

The time, however, that has as yet elapsed is scarcely sufficient to

test the comparative preservative power of this as compared with

vaccination from the human subject. Its immediate local effects are

somewhat more severe; I do not know any reason why its influence should

not be equally abiding.

There is absolutely no foundation for the idea that scrofula,

consumption, or any similar disease can be transmitted by vaccination.

In some infants, whose skin is very delicate, and especially in those,

some members of whose family have been liable to eruptions on the skin,

vaccination has seemed to act as an irritant, and to give occasion to an

eruption, or aggravate an eruption already existing. Such cases,

however, are not frequent, and the eruption is not more troublesome than

those which often appear in teething children. The occurrence of actual

erysipelas around the puncture, while very dangerous, is, as I have

already stated, of excessive rarity.

A thoroughly dispassionate review of the whole subject appears to me to

warrant the following conclusions:--

1st. That vaccination, though not a perfect guarantee against small-pox,

diminishes immensely the risk of its occurrence; and that by periodical

revaccination, this guarantee is rendered all but absolute.

2nd. That a very large proportion of the failures of vaccination are due

to its careless and imperfect performance.

3rd. That to such careless performance and to the introduction of the

blood and not of the vaccine matter alone, from one child to another are

due the extremely rare instances in which one special disease has been

transmitted by vaccination.

4th. That there is absolutely no evidence of the transmission of

scrofula, consumption, or any similar disease by vaccination.

5th. That vaccination direct from the calf appears to present some

decided advantages; but it has not yet been practised for a sufficient

time to admit of a comparison between its preservative power and that of

vaccination from one child to another.

6th. That in either case it is expedient that vaccination be performed

within the first three months after birth, so as to avoid the irritation

of teething which is unfavourable to successful vaccination, and also

because the disposition to those skin diseases which vaccination tends

to aggravate is never so considerable before the age of three months as

it becomes subsequently.

Even when vaccination fails to protect against small-pox it tends to

produce a modified and so much milder form of the disease, that while

one patient died out of every two in the Homerton Small Pox Hospital who

had the disease naturally, the deaths were only one in four of those who

had been imperfectly vaccinated, and one in forty-three of those whose

arms bore evidence of perfectly good and successful vaccination.

The influence of previous vaccination often scarcely shows itself in the

stage which precedes the appearance of the eruption of small-pox, the

fever being often just as intense, and the general symptoms just as

severe as in the unmodified disease. The difference, however, becomes at

once obvious with the appearance of the rash. The pocks are always much

fewer than even in mild small-pox, sometimes even not more than twenty.

They never attain above half the size of the ordinary small-pox

pustules; they run their course and dry off in half the time, and

consequently the dangerous fever which accompanies their development in

the natural disease is almost or altogether absent in the vast majority

of instances.

If vaccination did no more than this it would be hard to overestimate

its value, or to praise as it deserves the merit of its discoverer.

=Chicken-Pox= is an ailment of such slight importance that it would

scarcely call for notice if it were not that the resemblance of the

eruption to that of small-pox sometimes leads to its being mistaken for

that disease.

It is highly contagious, and for this reason perhaps it is usually met

with in infancy and early childhood. Sometimes, though by no means

constantly, the eruption is preceded for twenty-four or thirty-six hours

by slight feverishness; but oftener the appearance of the rash is the

first indication of anything being the matter. It shows itself in the

form of small pimples, which in a few hours change into small circular

pocks containing a little slightly turbid fluid. They appear on the

forehead, face, and body, but very rarely on the limbs; they enlarge for

some two or at most three days, then shrivel and dry up; and at the end

of a week the crusts or scabs fall off, scarcely ever causing any

permanent pitting of the skin. They are usually not above twenty or

thirty in number, though every now and then they are much more numerous

without any obvious reason. Their distinction from the small-pox

eruption consists not only in the smaller size of the pocks, and in the

entirely different course which they run, but also in the fact that two

or three successive crops of the eruption appear in the course of five

or six days, so that new ones, those at maturity, and those on which the

crusts have already formed, or from which they have already fallen, may

be seen on the child at the same time. This is sufficient of itself to

establish the difference between the two diseases, and also to

distinguish between chicken-pox and the milder variety of small-pox

which is sometimes observed in children who have been already

vaccinated.

=Measles= is a disease with which almost everyone is familiar, and one

which with proper care is not generally attended with danger. Its great

risks are twofold; first, that of its being complicated with bronchitis,

or inflammation of the lungs during its progress, and next of its being

followed by an imperfect recovery, and by the awakening into activity

any tendency to scrofulous or consumptive disease. On these two accounts

the disease is not to be made light of, and special watchfulness is to

be exercised during the whole time of convalescence. It is also unwise

when one child in a family is attacked by measles to expose the others,

as is often done, to its contagion, in order, as people say, 'to get it

over;' for its mildness in one case furnishes no guarantee of its

mildness in another, and the danger of the disease is almost in exact

proportion to the tender age of those who are attacked by it.

The early symptoms of measles are those of a bad feverish cold; the eyes

grow red, weak, and watery, and are unable to bear the light, the child

sneezes very frequently, sometimes almost every five minutes, and is

troubled by a constant short dry cough. About the fourth day, a rash

makes its appearance on the face, forehead, and behind the ears, and in

the course of the next forty-eight hours travels downwards over the body

and limbs, and then in another forty-eight hours it fades in the same

way, being at its height on the body when it has already begun to

disappear from the face. It first shows itself in the form of small red

circular spots, not unlike fleabites, but very slightly raised above the

somewhat reddened skin, and looking for a few hours not unlike the very

early stages of small-pox, before the eruption has lost the character of

minute pimples. On the face the spots sometimes run together, and then

form irregular blotches about a third of an inch long by half that

breadth; while elsewhere they present an irregular crescentic

arrangement. As the rash fades it puts on a dirty yellowish red

appearance; the surface of the skin often becomes slightly scurfy, and

it continues somewhat stained of a reddish hue for some days after the

eruption has disappeared.

The only other point on which it is necessary to dwell is this, that the

symptoms do not, as in small-pox, become less severe immediately on the

appearance of the eruption, but continue just as troublesome as before

for twenty-four hours or more, the voice being hoarse, the cough even

more incessant, and the throat often slightly sore and red. Soon,

however, improvement becomes apparent, the fever lessens, the cough

grows looser; and in less than a fortnight the patient is usually

convalescent.

The above is pretty nearly the ordinary course of measles, for we do not

meet with that extreme variation in its severity which is observed in

scarlatina, where one child will seem scarcely to ail at all, while its

brother or sister may be in a state of extreme peril. It is not wise,

however, to trust a case even of apparently mild measles to domestic

management, for while the cough is troublesome in almost every case, the

ear of the experienced doctor is needed to ascertain whether it is

merely the cough of irritation which attends the measles, or the graver

cough due to bronchitis.

One other caution will not be out of place. The danger of exposure to

cold is very real, but that does not necessitate the loading the child

with excessive covering, or the abstaining from washing its hands and

face. The child should be kept moderately cool; and sponging its hands

and face frequently with tepid water soothes it and relieves the painful

irritation and itching.

=German Measles.=--There is a disorder which seems to hold a middle

place between measles and scarlatina, akin to both, identical with

neither, and furnishing no sort of protection from their occurrence.

It is known in this country by the name of _German measles_, or

sometimes by its German name of _Roetheln_; the first clear description

of its character having been given by German writers.

It is unfortunate that a very slight resemblance of some of its symptoms

to those of scarlet fever has led to its being sometimes mistaken for

it, and as the ailment is almost always very trivial, doctors anxious to

avoid alarming their patients' friends, too often allow the error to go

unrectified, and the disease to pass as one of mild scarlet fever.

The resemblance of German measles to scarlet fever is, however,

extremely slight, and is almost entirely limited to the existence of a

slight sore-throat, unaccompanied with glandular swelling. The rash in

no respect resembles the uniform redness of the scarlatinal eruption,

and there is no peeling of the skin, nor even any roughness of the

surface left behind.

Slight feverishness sometimes precedes the appearance of the rash for

twenty-four hours; but the cough, and sneezing, and running at the eyes

and nose, which usher in measles are entirely absent. The rash usually

appears in the course of twenty-four hours, is never postponed beyond

the second day; it begins, like that of measles, on the face, and, like

it, travels downwards, but always disappears on the third day, while

that of measles is not entirely gone before the eighth or ninth. The

rash itself also has a different character. It consists of small,

slightly elevated, round red spots which now and then coalesce into

small patches, but never have the somewhat crescentic arrangement

observed in the rash of measles. The colour of the spots is somewhat

darker than that of the eruption of measles, while the _skin between

them remains pale_, and does not assume the flush of measles. As it

disappears it simply fades, and does not at all change its tint as that

of measles does, and it leaves the skin unroughened.

Now and then German measles are severe, and are attended with a good

deal of fever for a day or two, and even with symptoms of bronchitis.

These cases are, however, very unusual, are seen only at times when the

disease prevails epidemically; and even then the symptoms of the

affection are sufficiently marked to preserve from error all but those

who wish to be deceived, and to flatter themselves that their child is

henceforth protected from scarlatina.

=Scarlatina=, or =Scarlet Fever=, for the two names mean the same thing,

the former being only the Latin term, and not implying any greater

mildness of the disease, is one of the most formidable ailments of

childhood, and especially of early childhood, since the highest

mortality from it takes place during the third year of life.

It is more dreaded in a household, and justly so, than any other

disease of childhood, though, indeed, it is not limited in its

occurrence to early life, and instances are familiar to us all in which

the mother, devoting herself to the care of her little ones, has herself

fallen a victim to the poison.

I do not think it so directly contagious, from person to person, as

small-pox, chicken-pox, or measles, but its infection appears to be

specially abiding in its character, and to cling longer to the clothes,

the bedding, and even the room of a scarlet fever patient, than that of

the other eruptive fevers, except perhaps small-pox.

It is an object of special dread also for two other reasons. One of

these reasons is the extreme and causeless variations in its severity;

so that I have known more than one or two children in the same family to

have it so slightly as scarcely to be ill, two to have their lives

placed in jeopardy, and two to die. The other reason for special dread

is that the mildness of the disease at its outset affords but a slight

guarantee against the occurrence of serious complications in its course,

and still slighter against secondary diseases which may follow in its

train, and either destroy life directly, or leave behind some

irremediable mischief.

Scarlatina has been divided by medical men into three classes, according

to its different degrees of severity; the mild--that accompanied with

bad sore-throat--and the malignant variety.

We have specially to do with the first of the three; for it is in it

only that there is danger of the disease being overlooked, or mistaken.

The symptoms of scarlatina usually appear within three days after

exposure to its contagion, and there is very good authority for

believing that the interval never exceeds six days. I should not,

however, feel quite secure until after the lapse of ten days, and during

this time the child ought to be isolated from his brothers and sisters.

In the mildest form of the disease the appearance of the rash upon the

surface, usually with, but sometimes even without slight sore-throat and

feverishness, may be the first indication of an affection which is

sometimes so deadly. In the majority of cases, however, it is ushered

in by vomiting once or oftener, accompanied by headache, heaviness, of

head, great heat of skin, and some measure of sore-throat. The brain is

easily disturbed in children, as has already been said, and delirium at

night during the first twenty-four hours of an attack of scarlet fever

need not excite anxiety, for it then often passes away, and the disease

runs a perfectly favourable course. The continuance of delirium later is

an attendant only on the graver forms of scarlet fever.

The rash often makes its appearance within twenty-four hours after the

commencement of the illness, at latest in the course of the second day.

It usually shows itself first on the neck, breast, and face, whence it

extends in twenty-four hours to the body and limbs, and is then not

seldom specially vivid on the inside of the thighs. Its colour is a very

bright red, due in part to a general flush of the skin, in part to the

presence of innumerable red dots or spots, which do not communicate any

sense of roughness to the hand, though now and then extremely minute red

pimples are interspersed. For three days the rash usually continues to

become of a deeper colour, and more generally diffused over the whole

surface; it then slowly declines, but does not wholly disappear until

the seventh or eighth day of the disease. As the rash subsides the skin

is left rough, and by degrees scales off, often in large flakes from the

hands and feet, but elsewhere in a sort of branny scales. Sometimes this

process is over in five or six days, while in other cases the skin peels

and is reproduced several times in succession, so that it is protracted

for three or four weeks or even longer. The degree of this peeling also

varies as well as its duration. It is usually most considerable where

the rash has been most abundant, while where the rash has been scanty,

it is sometimes scarcely apparent except at the tips of the fingers and

toes and just around the insertion of the nails.

Besides the rash there are commonly other symptoms not less

characteristic of scarlatina, and among them the sore-throat is one of

the most invariable. Even in mild cases, it is very rarely absent, and

if not present at the beginning, it comes on on the second or third day.

The palate and tonsils, in these circumstances are red, and the latter

are usually more or less swollen, while swallowing is attended with

pain, or at any rate with discomfort. The redness of the palate, which

extends also to the back of the throat, is a finely spotted redness

closely resembling the rash on the surface. The tongue is coated with a

thick white or yellowish coating, through which project numerous bright

red points, papillae as they are called, and this appearance of the

tongue is as distinctive of scarlatina as the rash itself. Later, as the

rash begins to fade, the coating separates from the tongue, which is

left of a bright red colour, looking raw and shining, with the little

raised red points projecting beyond its surface, and constituting what

has been called in medical language, the strawberry tongue.

When all these symptoms are present, no one can doubt but that the case

is one of scarlatina. But the decision is far less easy in mild cases,

for in them the rash is sometimes extremely evanescent, the general

disturbance of health very slight, and the fever and accompanying rise

of temperature small. The risk in such circumstances of the disease

being altogether overlooked is even greater than that of its being

confounded with some other eruptive fever. The rash of measles cannot be

confounded with that of scarlatina, and the distinctly spotty character

of the rash of German measles ought, apart even from other differences,

to render mistake impossible.

Perhaps the best rule that can be laid down is that every diffused red

rash, not obviously formed by distinct spots, even though it be not

uniform but appears in patches on the neck, breast, back, or inside of

the thighs, and persists for more than twelve hours, is scarlatinal.

Further, that in any instance in which even very slight feverishness, or

very slight sore-throat, have preceded or accompanied the rash, the

nature of the ailment is stamped beyond the possibility of doubt.

Mistakes are made from want of careful observation, much more than from

any insuperable difficulty in distinguishing one disease from the other.

When the least hesitation is felt as to the nature of any rash which

may appear on a child, with, or without previous illness, the question

should be at once referred to a medical man. People are too apt in these

circumstances to wait for a few days, and then to appeal to the doctor

when all traces of rash have disappeared, and when the grounds no longer

exist on which he could base a positive opinion.

I need not describe the symptoms of severe and dangerous scarlatina, for

long before symptoms become really formidable, the patients will have

been placed under medical care. It may suffice to say that the danger is

almost always in proportion to the severity of the throat-affection and

swelling of the glands, and not at all in proportion to the abundance of

the rash. Though severe cases usually set in with severe symptoms, yet

this is not invariably the case, and medical watching is all the more

necessary from the very commencement, since until the end of the first

week it is impossible to calculate on the subsequent course of the

disease. In malignant scarlatina happily of infrequent occurrence, the

child is struck down, as though its blood were poisoned, from the very

first; and death takes place often within forty-eight hours, the rash

appearing just sufficiently to stamp the nature of the pestilence which

has proved so deadly.

It may form a useful conclusion to all that has been said in this little

book about the diseases of children, if I endeavour to point out in what

consist the duties of parents in cases of scarlatina, or of any disease

which resembles it.

1. To watch carefully the commencement of every slight feverish attack

in which a diffused red rash appears, even though this should be only in

patches, and to bear in mind the possibility of its being due to

scarlatina.

2. To remove the child immediately from the others, so long as there is

any doubt concerning the nature of the case, and to remove with him his

bed, bedding, and all clothes worn by him at the time when the illness

began, or the rash appeared.

3. To place the child if possible in a room at the top of the house, so

that the other children may not pass by his door.

4. Inasmuch as scarlatina often proves fatal to grown persons who have

not already had the disease, to obtain at once the attendance of a

skilled nurse, in order to avoid the risk of the disease spreading

through the household.

The wife belongs to her husband, the husband to his wife; their mutual

duties are paramount over even those of the parent; and neither has the

right to jeopardise that life which belongs to the other. To say, 'I

shall not catch the disease, because I have no fear,' is as idle as it

would be for the soldier to say, 'Because I am brave, therefore I am

invulnerable.'

I have been accustomed to insist on the absence from the room of father

or mother, supposing either of them not to have had scarlatina, so long

as I could give the assurance that every thing was going on well; but on

the slightest anxiety I have referred to both parents for their mutual

decision as to the course which they would choose to adopt.

From a refusal to be guided by this counsel, it has more than once

happened to me, to see the child recover from mild scarlatina without a

bad symptom, and the mother who had insisted on nursing the little one

die of the disease to which she had needlessly exposed herself.

5. So soon as the disease has declared itself as scarlatina, to take up

the carpets and remove the curtains from the sick child's room, to empty

the drawers of any clothes which may be in them, and to hang up outside

the door a sheet moistened with a solution of carbolic acid.

6. To arrange for all food and necessaries to be placed in an adjoining

room, or at the head of the stairs, so that there may be no direct

communication between the attendants on the sick and the other inmates

of the house.

7. To insist on the attendants not wearing either silk or stuff dresses,

but dresses of some washable material; and on their changing their

garments as well as scrupulously washing themselves before mixing with

other inmates of the house, and especially with the children.

8. While in all respects obeying the directions of the doctor, to grease

the child all over twice in twenty-four hours with suet or lard, to

which a small quantity of carbolic acid has been added. This proceeding

both lessens the amount of peeling of the skin in a later stage of the

disease; lessens the contagiousness of the scales which are detached;

and, by promoting the healthy action of the skin, diminishes the risk of

subsequent disorder of the kidneys and consequent dropsy.

9. Even when the case has been of the slightest possible kind, to keep

the child always in bed for one-and-twenty days. This was a standing

rule at the Children's Hospital, and I am certain that its

non-observance will be followed three times out of four by dropsy and

kidney-disease.

10. When the disease is over, to destroy, if the parents' means at all

permit it, the clothes and bedding of the child. When this is not

practicable, to have everything exposed to the heat of superheated steam

in a Washington Lyons or other similar disinfector, and to have all

linen boiled as well as washed. Lastly, to have the ceiling whitewashed,

the paint cleaned, the paper stripped, and the room repapered, as well

as the floor washed and rewashed with strong carbolic soap.

These precautions are troublesome and costly, but disease is costlier

still; and who shall estimate the cost of death!

APPENDIX

_ON THE MENTAL AND MORAL FACULTIES IN CHILDHOOD, AND ON THE DISORDERS TO

WHICH THEY ARE LIABLE._

Any remarks on the ailments of children would be incomplete if no notice

were taken of the mental and moral peculiarities of early life.

For want of giving heed to them, not only are grave mistakes made in the

education of children, but in the management of their ailments, both by

doctors and by parents: much needless trouble is given to the doctors,

much needless distress to the child, much needless anxiety to the

parents.

The common mistake committed by those parents who do not make their

child an idol to fall down and worship, and thus turn him, to his own

misery and theirs, into the most arbitrary of domestic tyrants, is to

treat him as though he were in mind, as well as in body, a miniature

man; feebler in intellect as he is inferior in strength, but differing

in degree only, not in kind.

Now the child differs essentially from the adult in the three respects;

that

1. He lives in the present, not in the future.

2. His perceptions are more vivid, and his sensibilities more acute;

while the world, on which he has just entered, surrounds him with daily

novelties.

3. He has less self-consciousness, less self-dependence, lives as a

part of the world by which he is surrounded--a real practical pantheist.

The child lives in the present, not in the future, nor much even in the

past, till the world has been some time with him, and he by degrees

shares the common heritage of retrospect and anticipation. This is the

great secret of the quiet happiness which strikes almost all visitors to

a children's hospital.

No one can have watched the sick bed of the child without remarking the

almost unvarying patience with which its illness is borne, and the

extremity of peril from which apparently, in consequence of that

patience, a complete recovery takes place. Much, indeed, is no doubt due

to the activity of the reparative powers in early life, but much also to

the unruffled quiet of the mind. No sorrow for the past, no gloomy

foreboding of the future, no remorse, disappointment, nor anxiety

depresses the spirits and enfeebles the vital powers. The prospect of

death, even when its approach is realised--and this is not so rare as

some may imagine--brings in general but small alarm. This may be from

the vagueness of the child's ideas; it may be, as the poet says, that in

his short life's journey, 'the heaven that lies about us in our infancy'

has been so much with him, that he recognises more clearly than we can

do

'The glories he hath known,

And that imperial palace whence he came.'

I dwell on this truth, because it is of great practical moment that we

should bear in mind to how very large an extent the child lives only in

the present; because it follows from it that to keep the sick child

happy; to remove from it all avoidable causes of alarm, of suffering, of

discomfort; to avoid, as far as may be, any direct struggle with its

waywardness; and even if death seems likely to occur, to look at it from

a child's point of view--not from that which our larger understanding of

good and evil suggests to our minds--are duties of the gravest kind

which weigh on the parent and the nurse, no less than on the physician.

But not only does the child live in the present far more than it is

possible for the adult, but there are, besides, other important mental

differences between the two. Not only is the mind of the child feebler

in all respects than that of the adult, but, in proportion to the

feebleness of his reasoning power, there is an exaggerated activity of

his perceptive faculties, a vividness of his imagination. The child

lives at first in the external world, as if it were a part of himself,

or he a part of it, and the gladheartedness which it rejoices us to see

is as much a result of the vividness with which he realises the things

around him, as of that absence of care to which it is often attributed.

This peculiarity shows itself in the dreams of childhood, which exceed

in the distinctness of their images those which come in later life. It

shows itself, too, in the frequency with which, even when awake, the

active organs perceive unreal sounds, or in the dark, at night, conjure

up ocular spectra; and then not merely colours, but distinct shapes,

which pass in long procession before the eyes. This power fades away

with advancing life; except under some conditions of disease, the

occasional appearance of luminous objects in the dark is the only relic

with most of us of the gift of seeing visions with which, at least in

some degree, we were endowed in our early years. The child who dreads to

be alone, and asserts that he hears sounds, or perceives objects, is not

expressing merely a vague apprehension of some unknown danger, but often

asserts a literal truth. The sounds have been heard; in the stillness of

its nursery the little one has listened to what seemed a voice calling

it; or, in the dark, phantasms have risen before its eyes, and the agony

of terror with which it calls for a light, or begs for its mother's

presence, betrays an impression far too real to be explained away, or to

be met by hard words or by unkind treatment.

Impressions such as these are not uncommon in childhood, even during

health. Disorder, direct or indirect, of the functions of the brain,

more commonly the latter, greatly exaggerates them, and I have known

them to outlast for many weeks all other signs of failing health after

convalescence from fevers. The unreal sights are far more common than

the sounds. The sounds are usually of the simplest kind--as the tinkling

of a bell, of which we all remember the exquisite use made by Hans

Andersen in one of his nursery tales; or the child's own name, at

intervals repeated, just as the little watchful boy heard it in far off

Judaea, when it was the prelude to a wondrous communication from the

unseen world. It came to him as he woke from sleep, before the morning

dawned, while the lamp, lighted overnight, was burning still; and still

it is so far the same that these occurrences which suggest to us

problems that we cannot attempt to solve, mostly take place at times of

transition from the sleeping to the waking state.

The ocular spectra are usually far more vivid and detailed. Those which

occur in the waking state are by no means always painful, though their

strangeness not infrequently alarms the child, and his horror at the

dark arises, not from his seeing nothing, but from his seeing too much.

Some imaginative children amuse themselves with these phantasms, and

then, if encouraged to relate them, will constantly transgress the

boundary line between truth and falsehood, and weave their little

romance. When they happen on waking they are usually preceded by

frightful dreams, but the image which the child sees then is not the

mere recollection of the dream, but a new, distinct, though painful

impression; generally of some animal to which the child points, as now

here, now there. These night terrors from the very circumstantial

character of the impressions which attend them, often, as I have already

said, occasion needless anxiety as to the importance of the cause on

which they depend.

Sleep-walking in its smaller degrees of getting out of bed at night, is

by no means unusual in childhood; but the greater degrees of

somnambulism are certainly rare; and I have always found them dependent

on undue mental work; not always, indeed, on the tasks being excessive,

but sometimes on the over-anxiety of the child to make progress. I have

not yet known a poor person's child a somnambulist.

But not only are the perceptions more acute in childhood than in adult

life, the sensibilities are more intense. The child's emotions, indeed,

are often transitory--generally very transitory; but while they last

they produce results far greater than in the grown person. In the case

of the latter, recollection of the past, anticipation of the future, or

even the duties of the present, control the overwhelming sorrow, or call

forth the energies needed to bear it. The child lives in the present,

and this present is but the reflection of the world around, its

impressions uncontrolled by experience, ungoverned by reason.

The broken-heartedness of a child on leaving home is not the expression

only of intense affection for its friends or relations, it is the shock

of separation from the familiar objects which have surrounded it; and I

have not infrequently seen children inconsolable when removed from homes

that were most wretched, or from relations who were most unkind. Every

now and then, indeed, I have been compelled to send children home from

the hospital because no love nor care could reconcile them to the change

from home; and they have refused to eat, and spent their nights in

weeping. The feeling is an unreasoning one, like the home-sickness of

the mountaineer.

But, moreover, sudden shocks may sometimes overthrow the whole moral

equilibrium, and disarrange the balance of the nervous system so

seriously as to cause the death of a child previously free from any

important ailment. Thus, I remember a little boy five years of age who

died sixteen days after his father's funeral. The strange sad scene

overcame him, though there had been no special tie between him and his

father. He shivered violently, became very sick, complained by signs of

pain in the head, for he had lost his speech, which he regained by slow

degrees in the course of four or five days. Improvement in other

respects did not take place, he lay in a drowsy state save when he

called for his mother, and at length the drowsiness deepened into

stupor, and so he died. I suppose his mother was right; she said his

heart was broken.

It behoves us to bear in mind that the heart may break, or the reason

fail, under causes that seem to us quite insufficient; that the griefs

of childhood may be, in proportion to the child's powers of bearing

them, as overwhelming as those which break the strong man down. Every

now and then we are shocked by the tale that some young child has

committed suicide, and for reasons which to our judgment seem most

trivial--from fear of punishment, or even from mere dread of reproof.

These facts deserve special attention, they show how much more the

susceptibility and sensitiveness of children need to be taken into

consideration than is commonly done.

This keenness of the emotions in children displays itself in other ways,

and has constantly to be borne in mind in our management of them. The

child loves intensely, or dislikes strongly; craves most earnestly for

sympathy, clings most tenaciously to the stronger, better, higher around

it, or to what it fancies so; or shrinks, in often causeless but

unconquerable dread, from things or persons that have made on it an

unpleasant impression. Reason as yet does not govern its caprices, nor

the more intelligent selfishness of later years hinder their

manifestation. The waywardness of the most wilful child is determined by

some cause near at hand; and those who love children, and can read their

thoughts, will not in general be long in discovering their motives and

seeing through their conduct.

One word more must be said with reference to that intense craving for

sympathy so characteristic of the child. It is this which often

underlies the disposition to exaggerate its ailments, or even to feign

such as do not exist, and in such attempts at deception it often

perseveres with almost incredible resolution. Over and over again I have

met with instances where the motives to such deception were neither the

increase of comfort nor the gratification of mere indolence; but the

monopolising the love and sympathy which during some bygone illness had

been extended to it, and which it could not bear to share again with its

brothers and sisters. This feeling, too, sometimes becomes quite

uncontrollable, and the child then needs as much care and as judicious

management, both bodily and mental, to bring it back to health, as

would be called for in the case of some adult hypochondriac or

monomaniac.

A caution may not be out of place as to the importance of not

ministering to this tendency to exaggerated self-consciousness by

talking of children's ailments in their hearing, or by seeming to notice

the complaints they make as though they were something out of the common

way.

It will be observed that throughout I have dwelt more on disorders of

the moral faculties than of the intellectual powers in childhood, and I

have done so because I believe them to be the more common and the more

important. In the feeble-minded the moral sense almost invariably

participates in the weakness of the intellect; but it is by no means

unusual for the former to be grievously perverted, while the

intelligence is in no respect deficient. The moral element in the child

seems to me to assert its superiority in this, that it is the most

keenly sensitive, the soonest disordered--

'Like sweet bells jangled, out of tune, and harsh,'

and the discord is first perceived in the finest notes.

To a very great extent, a mixture of vanity and of a morbid craving for

sympathy lie at the root of many of those perversions of character

which excite a parent's anxiety. One of these consists in an

over-scrupulousness with reference to the right or wrong of actions in

themselves quite indifferent; in doubts as to whether the morning or

evening prayer has been properly said, whether something was or was not

absolutely true, whether this or that peccadillo was a grievous offence

against God, and so on; and all these little cases of conscience are

brought by the child several times a day to his mother or to his nurse

for solution. If listened to readily the child's truthfulness becomes

inevitably destroyed, and he grows up with a morbid frame of mind, which

after-life will aggravate almost infinitely.

One knows indeed the history of child saints; but it must be remembered

that one great characteristic of pre-eminent sanctity at all ages of

life is reticence, while these little people are perpetually seeking to

interest others in themselves, their doubts, and feelings. If wisely

dealt with, not by direct ridicule, but by a wholesome neglect of the

child's revelations, treating them as of no special interest or

importance, and discouraging that minute introspection which, of

doubtful good at any age, is absolutely destructive of the simplicity of

childhood, this unnatural condition will soon pass away. It will help

this object very much, if the child is sent on a visit to judicious

friends, and change of scene, of pursuits, of playmates, and amusements

will be of all the more service since these morbid states of mind seldom

come on in children whose bodily health is robust.

Another mode in which the same perverted feelings display themselves is

in the disposition occasionally noticed to exaggerate some real ailment,

or to complain of some ailment which is altogether imaginary. So far is

this from being rare that my experience coincides entirely with that of

the French physician M. Roger, who has had larger opportunities than

anyone else in France for observing the diseases of children, and who

says, 'It must be borne in mind that simulated ailments are much more

common in the children's hospital than in a hospital for adults.'

It is difficult to assign any sufficient reason for this conduct. Mere

indolence seems sometimes to be the chief reason for it, oftener vanity;

the sense of importance in finding everything in the household arranged

with exclusive reference to itself appears to be the motive for it; and

this may sometimes be observed to be very powerful even at an

exceedingly early age. In many instances a morbid craving for sympathy

is mingled with the love of importance, and both these sentiments are

not infrequently exaggerated by the conduct of a foolishly fond mother.

Real illness, however, in almost all these cases exists at the

commencement, though the child persists in complaining of its old

symptoms long after their cause has disappeared.

The great difficulty which the doctor meets with in the management of

these cases arises from the incredulity with which his opinion is

received. Candour is looked upon as so eminently characteristic of

childhood, that deceit seems impossible; the case is thought by the

parents to be an obscure one which the doctor does not understand; and

therefore it is said, he, with want of straightforwardness and of

kindness, throws doubts on the existence of disease, and on the

truthfulness of a most loving, most suffering child. The vagaries of a

hysterical girl, the fits, the palsy, the half-unconsciousness have all

been assumed within my own observation by children from ten to fifteen

years old, and I have more than once had to give place to the ignorant

and impudent pretender who traded successfully on the feelings of the

parents. Sometimes, one knows not why, except that the child has got

tired of the part he was playing, the symptoms that had caused so much

anxiety suddenly disappear, but even then the habit of mind left behind

is anything but healthy. Indeed in all cases of this kind it is much

less the state of the body than that of the mind which excites my

apprehension. The constant watching its own sensations, the habit of

constantly gratifying every wayward wish and temper under the plea of

illness, and the constant indulgence which it too often meets with in

this from the over-kindness of its parents, exert a most injurious

influence on its character, and it grows up a juvenile hypochondriac.

A doctor is very unlikely to throw doubt recklessly on the reality of a

child's illness. His hesitation should certainly not be attributed to

unworthy motives; the parents should co-operate with him heartily in any

course of observation which he desires to follow, and if necessary

another medical man of experience should be associated with the first,

and allowed to visit the child two or three times. One does not

associate the idea of moral delinquency with hysteria; the child who

shams belongs to the same class with the hysterical patient. It is only

the strangeness of the occurrence in the eyes of non-medical people,

that makes them fancy it something worse.

If now the suspicion is justified that the child is either greatly

exaggerating or altogether feigning illness, it does not by any means

always follow that he should at once be charged with it, since it is

often of much importance that his self-respect should not be destroyed.

It must be remembered that there is in all these cases a measure of real

ailment underlying all the half-unconscious exaggeration, and that if

spoiling and over-indulgence do much to foster it, sternness and

punishment interfere with recovery. To turn the thoughts away from self,

to occupy the mind with new scenes, new amusements, new pursuits, to

call forth by degrees self-control, and to let the child perceive rather

by your manner than by what is actually said that the parents have not

been duped by all his past vagaries; such are the simple means by which

the little one will be brought round again to health of mind and health

of body. Unhappily, in the minds of too many people the idea of the

doctor is associated with the administration of drugs and with nothing

else; the treatment of disease is of much wider scope; and many of our

best remedies are those which do not admit of being weighed or measured,

and whose names are not inscribed on the drawers or bottles in

Apothecaries' Hall.

Another phase of mental disorder in childhood sometimes presents itself

as the result of overtasking the intellectual powers. This over-work too

is by no means due in all cases to the parents' unwisely urging the

child forward, but it is often quite voluntary on his part. The

precaution too of limiting the hours of work is often inadequate from

the want of some provision for turning the thoughts and energies during

play hours into some perfectly different channel.

In many of these cases Nature happily takes matters into her own

management. For a year or two, or more, the mind has grown apparently at

the expense of the body; the parents take a fearful joy in their

darling's acquirements; and if it should live, think they, of what

remarkable talents will it not be the possessor! By degrees, the extreme

quickness of intellect becomes less remarkable; but the body begins to

increase in robustness; and a year will sometimes suffice to transmute

the little fairy, so quick, so clever, but so fragile, into a very

commonplace, merry, rosy, romping child. I may add that it is well to

bear in mind the converse of this; to remember that body and mind

rarely grow in equal proportion at one time; that the incorrigible

little dunce, though not likely to prove a genius as he grows older,

will yet very probably be found at twelve or fourteen to know as much as

his playmates. A dull mind, and a sickly or ill-developed frame may make

us anxious: but if the physical development is good, the mind will not

be likely to remain long below the average standard.

But sometimes, the over-tasked mind leads to mischief which Nature

cannot rectify; an attack of water on the brain destroys the child, or

if not it sinks under almost any accidental disease. In other instances

neither of these results takes place, but the whole nervous system seems

profoundly shaken, and the moral character of the child seriously, and

even permanently injured. I remember a quick and clever little girl aged

five and a half years who was urged on by her governess to work which

she delighted in, till at length the signs of over-taxed brain showed

themselves in frequent extreme irritability, and occasional attacks of

causeless fury amounting almost to madness. It was fully a year during

which almost all mental work was suspended, while the child was sent to

have complete change under most judicious management in the country,

before her mind quite recovered its balance and she became able to

resume her studies in a very moderate degree.

Cases such as this are instances of the slightest degree of a condition

which if not remedied may pass into confirmed insanity. I believe the

gradations to be almost imperceptible by which the one state passes into

the other; and I have known instances in which the ungovernable temper

and occasional fury of the child have passed in youth into abiding

insanity which rendered the patient the inmate, and I fear the permanent

inmate, of a lunatic asylum.

In whatever circumstances insanity comes on in childhood, and it does

sometimes, though very seldom, come on independently of any obvious

exciting cause, it always assumes the character of what has been termed

moral insanity, or of that condition in which the moral system rather

than the mental power is chiefly disordered.

Idiocy is unquestionably of much more frequent occurrence in childhood,

than any of those forms of mental or moral disorder of which I have been

speaking hitherto. The term idiocy, however, is a very wide one,

including conditions differing remarkably from each other both in kind

and degree, while not seldom it is misapplied to cases in which there is

mere backwardness of intellectual power.

=Backward Children.=--_Enfants arrieres_--as the French call

them--constitute a class by no means seldom met with. They generally

attain their bodily development slowly, and the development of their

mind is equally tardy. They cut their teeth late, walk late, talk late,

are slow in learning to wash and dress themselves, are generally dull in

their perceptions, and do not lay aside the habits of infancy till far

advanced in childhood. When the time comes for positive instruction,

their slowness almost wears out everyone's patience; and among the poor

indeed the attempt at teaching such children is at length given up in

despair, and growing up in absolute ignorance, it is no wonder that they

should be regarded as idiots. Still, dull as such children are, there is

between them and the idiot an essential difference. The backward child,

unlike the idiot, does not remain stationary; his development goes on,

but more slowly than that of other children, he is behind them in the

whole course of their progress, and his delay increasing every day,

places at length an enormous distance between him and them--a distance

which in fact becomes insurmountable.

In some of its minor degrees even, this backwardness not infrequently

excites the solicitude of parents. It is sometimes observed in children

who had been ill-nourished in infancy or who had been weakened by some

serious or protracted illness, even though unattended by any special

affection of the brain; but it is also met with independent of any

special cause. The distinction, however, between such a case and one of

idiocy is this, that though at four years old the child may not seem to

be intellectually superior to most children at two, yet in manners,

habits, and intelligence it does agree with what might be expected from

the child at two; less bright perhaps, less joyous, but still

presenting nothing which if it were but younger would awaken

apprehension.

It is well in all cases of unusual backwardness to ascertain the

condition of the sense of hearing, and of the power of speech, for I

have known the existence of deafness long overlooked, and the child's

dulness and inability to speak referred to intellectual deficiency; and

have also observed mere difficulty of articulation, dependent partly on

malformation of the mouth, lead to a similar misapprehension. In both

instances I have seen this inability to keep up ready intercourse with

other children cast a shadow over the mind, and the little ones in

consequence be dull, suspicious, unchild-like. I have already referred

to a similar result as sometimes following serious illnesses. The child

will for months cease to walk, or forget to talk, if these had been but

comparatively recent acquirements; or will continue dull and unequal to

any mental effort for weeks or months together, and then the mind will

begin to develop itself once more, though slowly, possibly so slowly as

never altogether to make up for lost ground.

=Idiocy.=--In _idiocy_, however, there is much more than the mere arrest

of the intellect at any period. The idiot of eight years old does not

correspond in his mental development to the child at six, or four, or

two; his mind is not only dwarfed but deformed; while feebleness of will

is often as remarkable as mere deficiency of power of apprehension. Even

in earliest infancy there is usually a something in the child idiotic

from birth which marks him as different from babies of his own age. He

is unable to support his head, which rolls about from side to side,

almost without an effort on his part to prevent it. Next it is perceived

that the child, though he can see, does not notice; that his eye does

not meet his mother's with the fond look of recognition, accompanied

with the dimpling smile, with which the infant, even of three months

old, greets his mother. Then it is found to have no notion of grasping

anything, though that is usually almost the first accomplishment of

babyhood; if tossed in its nurse's arms there seems to be no spring in

its limbs; and though a strange vacant smile sometimes passes over its

face, yet the merry ringing laugh of infancy or joyous chuckle of

irrepressible glee is not heard. As time passes on, the child shows no

pleasure at being put down 'to feel its feet,' as nurses term it; if

laid on the floor it probably cries, but does not attempt to turn round,

nor try to crawl about as other babies do. It does not learn to stand or

walk till late, and then stands awkwardly, walks with difficulty,

crossing its legs immediately on assuming the erect posture, an

infirmity which it often takes years to overcome. Just, too, as the

idiot is slow to notice, slow in learning to grasp anything, or to stand

or walk, so he is late in learning to talk, he often acquires but few

words, for his ideas are few. He learns even these few with difficulty,

and employs the same to express many different things; he generally

articulates them indistinctly, often indeed so imperfectly as to be

almost unintelligible.

In other instances the evidences of idiocy are not present at birth, or

at any rate are not then noticed, but succeed to some attack of

convulsions or to some illness attended with serious affection of the

brain. Sometimes too there is no point in the child's history which can

be laid hold on as marking the commencement of the weakening of his

intellect, but as the body grows the mind remains stationary, or its

powers retrocede, until by degrees the painful conviction that the child

has become idiotic forces itself upon the unwilling parents. Here we

have sometimes the sad spectacle of the body perfectly developed, hale

and strong, but the mind obscured; the child in constant unrest,

perpetually chattering, laughing without cause, destroying its clothes,

or the furniture of its room, for no purpose; or sitting silent, with a

weird smile upon its face, looking at its spread-out fingers, or

stroking a piece of cloth for a quarter of an hour together as though

the sensation yielded it a kind of pleasure. It would be almost endless

to describe the various degrees of mental weakness; from the slight

silliness down to the condition in which the child is, and remains all

life long, below the level of the brute.

Parents as a rule are anxious to persuade themselves, and to persuade

the doctor that their idiot child was once as bright and intelligent as

others; and that the mind was darkened by some grave illness. We have,

however, the highest authority, that of Dr. Down, for saying that as a

rule which has but few exceptions idiocy from birth is more amenable to

training than that which comes on afterwards, that in fact it is more

hopeful to have to do with an ill-developed than with a damaged brain.

The one great question which still remains is what can the parents do

for best and wisest whom the affliction has befallen of having an idiot

child.

First. To moderate their expectations as to the results of any, even the

best devised and most successful treatment. The child who has been born

of weak intellect, or who has become so as the result of illness, will

always remain at a lower level than others, and this, even though some

one faculty, as the musical faculty, or the power of calculation, should

be above the average.

Secondly. From the child's earliest infancy to occupy themselves in

perfecting as far as possible the physical powers and aptitudes, and the

habits of cleanliness and order. Development of mind waits on

development of body: to stand, to sit, to walk, to grasp an object put

into the hand, are essential to bringing the idiot child into relation

with the world around it; are its elementary education, to be given

patiently, cheerfully, lovingly, even for years together. To attend to

its natural wants, and by fixed routine to accustom it at stated hours

to empty its bowels and its bladder is a lesson hard to teach; and not

less difficult is it to make the child learn to masticate its food, to

drink without slobbering, and then to use the spoon and fork, and to

feed itself; and afterwards to dress itself, to wash itself, to tie its

shoestrings; for idiots almost without exception are awkward as well as

lazy.

The common class of nurses, even the very kindest, find it so much

easier to feed the child, to wash it, and to dress it, than to teach it

to do any of these things for itself, that it too often grows up, till

too old to remain in the nursery, without having made the slightest

advance above the condition of completest babyhood. It is absolutely

essential either that the mother should devote herself solely to the

care and teaching of the idiot, or that she should engage a nurse who

will have no other duty. Such a person must be above the average in

education and intelligence, and of course will command more than the

ordinary wages. The mother, too, must resign herself to the little one's

affection being transferred in a great degree from herself to the person

who has constant charge of it--a hard trial this, but one to which, for

her child's good, she must bring herself to submit.

Thirdly. So soon as the child has been taught at home to exercise these

lower powers, and the question of what is termed its education arises,

it is a matter of absolute necessity that he be sent to an institution

specially set apart for the feeble-minded. It is absolutely impossible

with the most devoted love and the most lavish expenditure of money, to

do at home what can be, and is constantly, accomplished even in a pauper

idiot asylum. The imitative faculty, which is usually very strongly

marked in the idiot, furnishes one great means of his improvement; while

besides there are many of the moral powers which cannot be brought out

except in the society of other children of his own age and not differing

too widely from him in mental power.

I have warned, and I repeat the warning, against exaggerated

expectations as to the results of even the wisest treatment. To teach

cleanliness, order, and neatness; to impart knowledge enough to enable

the idiot to take care of himself; to develop his affections; to enable

him to read and write; to practise some easy handicraft; to partake of

some simple pleasures, and so at length to return to the shelter of his

own home, and to be there, not an object to be hidden away, too painful

to look upon, but an object rather of special tenderness, repaying with

his guileless love the sad self-sacrifice of his parents for many a

year; these are endeavours almost sure of accomplishment in a

well-conducted institution, sure never to be realised in a home.

I have often sent afflicted parents, who shrank from parting with their

children, to one institution near London; and I doubt not there are

others in England, where pains, and care, and skill, and untiring love

awake the slumbering intellect, arouse the dormant affections, and work

miracles of healing on these helpless little ones.

INDEX.

Abdomen, large, its importance exaggerated, 158

---- tenderness of, very important, 158

Acute constitutional diseases, 187

Aperients, 23

Artificial feeding, its dangers, 45

---- ---- rules for, 50

---- ---- sometimes necessary, 49, 58

---- ---- substitutes for milk, 59

Asses' milk best substitute for human, 51

Asthma, 145

Atrophy, infantile, 45

---- its causes and symptoms, 47

---- symptoms essentially different from consumption, 48, 62

---- may depend on consumption, 61

Backwardness, 224

Bath, warm, management of, 19

---- ---- when to be used in convulsions, 91

Bed, importance of, in illness, 16

Bedsores, how to prevent, and treat, 18

Bedstead, best form of, for children, 17

Brain, disease of, cry in, 5

---- ---- proofs of absence of, 10

---- and nervous system, mortality from diseases of, 88

---- ---- convulsions as a sign of, 89

---- congestion of, 95

---- disorder of, from exhaustion, 106

---- inflammation of, 99. _See_ Water on the Brain.

---- disease from disease of the ear, 102

---- ---- symptoms of, 103

---- ---- treatment of, 105

Breathing, frequency of, in health and disease, 8

Bright's disease of the kidneys, 169

Bronchitis, 130

---- more serious than pneumonia, 131

---- its symptoms, 131

Catarrh, 128

---- its prevention and treatment, 129

Chafing, 77

Chest, cry in disease of, 5

Chicken-pox, 202

Childhood, characters of second period of, 85

---- mental and moral faculties, peculiarities in, 213

---- difference between child and adult, 213

---- patience of child, 214

---- vividness of imagination, 215

---- phantasms and sounds, 216

---- sensibility intense, 217

---- craving for sympathy in, 218

Children and infants, mortality of, 1; _see_ Mortality.

---- diseases of, their signs, 5; _see_ Diseases of Children.

---- management, 12

---- spoiled, 13

---- sick, importance of truth with them, 13

---- keeping happy, 16

Chloroform in convulsions, 92

Chronic constitutional diseases, 173

Cold to the head, how to apply, 22

Colic, characters of, 158

Congestion of the brain, 95

---- fatal termination of, 96

---- chronic water on brain from, 97

---- treatment of, 97

Constitutional diseases, 173

Consumption, how distinguished from non-expansion of lungs, 38

---- its symptoms when cause of infantile atrophy, 61

---- its nature, 174

---- recovery from, 176

---- causes of, 176

---- symptoms, 177

---- dependent on disease of glands of lungs, 177

---- in infancy, 178

---- galloping, 178

---- of the bowels, 179

Convulsions, as sign of brain disorder, 88

---- less serious than in grown person, 89

---- signs of their approach, 93

---- causes of, various, 90

---- description of a fit of, 94

---- treatment of, 91

---- now and then without apparent cause, 111

Cough, from disease of glands of lungs, 177

Cow's milk, excess of curd in, 51

---- ---- easily deteriorated, 52

Cow-pox, its nature, 198

Croup, its nature, 133

---- its two kinds, 134

---- catarrhal, 134

---- distinction from diphtheria, 135

---- treatment of, 135

---- spasmodic, 107. _See_ Spasmodic Croup.

Cry in illness, various meanings of, 5

---- when lungs are imperfectly expanded, 36

Diabetes, 169

Diarrh[oe]a in childhood, 154

---- simple, 156

---- inflammatory, 157

Digestion, how performed, 151

Digestive organs, peculiarities of, in infancy, 46

Diphtheria, 136

---- its gradual progress, 136

---- caution not to overlook it, 137.

---- various dangers of, 138

---- management of, 139

---- opening windpipe in, 140

---- paralysis after, 141

Diseases of infants and children, their signs, 5

---- management, 12

Doctor, proper relation of parents to, 28

Dream images vivid in childhood, 215

Dyspepsia of weakly children, 153

Earache, symptoms of, 103

---- treatment of, 105

---- inflammation of brain from disease of ear, 102

Eczema, 79

---- its symptoms and course, 79

---- treatment, 81

---- alleged dangers of curing, 84

Epilepsy, its two forms, 112

---- prospects of recovery from, 113

---- moral perversion, from, 114

---- treatment of, 116

---- moral management of, 117

Exhaustion a cause of brain disorder, 106

Farinaceous food, why unsuitable, 46

---- ---- results of its excess, 47

---- ---- best forms of, 60

Feeding-bottle, best form of, 55

Feigned illness, 221

Fingers, scrofulous disease of bones of, 183

Food, quantity required by an infant, 54

---- best mode of giving, 54

Galvanism, in cases of paralysis, 123

German measles, 204

Glandular enlargement in infantile consumption, 61

---- swellings from scrofula, 183

Gravel, 170

Grimacing, distinct from St. Vitus's dance, 119

Gums in teething, when to be lanced, 75

---- management when ulcerated, 76

Head, varieties in shape of, unimportant, 106

Headache, neuralgic, 124

---- from defective sight, 126

Heart, malformation of, 146

---- ---- management of, 148

---- frequency of disease of, from rheumatic fever, 149, 188

---- inflammation of, 148

Hooping-cough, 141

---- management of, 143

---- its dangers, 144

Hysteria, relation of, to epilepsy, 115

Idiocy, 224, 225

---- its management, 227

Incontinence of urine, 171

Indigestion in infancy, 47, 56

---- its management, 65

Infants and children, mortality of. _See_ Mortality

---- rules for artificial feeding of, 50

---- substitutes for mother's milk, 51

---- quantity of food required, 54

---- feeding-bottles, 55

Influenza, 132

Inoculation and vaccination, 196

Jaundice of new-born children, 39

---- in childhood, 154

Kidneys, disease of, 168

Lavements, their use and abuse, 26

Leeches very useful in some cases, 21

---- how to apply, 21

Liver, disease of, a cause of infantile atrophy, 62

Lungs, imperfect expansion of, 35

---- ---- ---- ---- its symptoms, 36

---- ---- ---- ---- ---- treatment, 38

---- inflammation of, rare in early infancy, 37

Measles, 202

---- its symptoms and dangers, 203

---- ---- management, 204

Medicine, choice and administration of, 23

Mercury, not cause of sore-mouth in children, 165

Mesenteric disease, 179

---- ---- its importance exaggerated, 181

Milk, why proper food of infants, 46

---- mother's, peculiarities of, soon after birth of child, 50

---- ---- best substitutes for, 50

---- ---- and that of animals compared, 50

---- substitutes for, 59

---- condensed, inferior to fresh milk, 53

Moral insanity in childhood, 219-223

---- perversion from epilepsy, 114

Mortality of infants and children, 1

---- varies in different places and times, 1

---- causes of, 2

---- ---- intermarriage and hereditary taint, 2

---- ---- unhealthy dwellings, 3

---- ---- unwholesome food, 4

---- increased during teething, 72 note

Mother not always good nurse, 12

Mouth, how to examine, 10

---- sore, 163

Mumps, 190

Napkins, inconvenience of, 18

Navel, rupture of, 43

Nettle-rash, 78

Neuralgia and headache, 124

Night terrors, 126

Nose, offensive discharge from, 184

Notes, importance of keeping in illness, 28

Ophthalmia of new-born children, 40

Opiates, 27

Palsy, 121

---- form of, peculiar to childhood, 122

---- its cause, 123

---- ---- treatment, 123

---- cases mistaken for it, 124

Peritonitis, 158

---- local, often overlooked, 158

Phantasms in childhood, 215

Pleurisy, 132

Pneumonia, 130

---- its symptoms, 131

Poultices, uses of, 20

---- how made, 20 note

Premature birth, 33

---- ---- its management, 34

Pulse, frequency of, in health and disease, 8

Quinsy, 165

Red-gum, 77

Respiration, frequency of, in health and disease, 8

---- artificial, 33

Rheumatic fever, 188

Rheumatism, connection of, with St. Vitus's dance, 118

---- chief cause of heart inflammation, 149

Rickets, 185

Round-worm, 160

Rupture of navel, 43

Scalp-swellings, 42

Scarlatina, 205

---- its dangers and symptoms, 206

---- characters of rash, 207

---- sore-throat of, 208

---- how recognised, 208

---- management of; duties of parents, 209

Scrofula, 181

---- abscesses under skin, 182

---- disease of bones of fingers, 183

---- glandular swellings, 183

---- offensive discharge from nostrils, 184

Shamming does not disprove illness, 115

Sick-room, management of, 14

Sleep-walking, 216

Small-pox, 195

---- after vaccination, 201

Snuffles, 128

Sore-mouth, 163

---- ---- not diphtheritic, 164

---- ---- not due to mercury, 165

---- throat of scarlatina, 208

Spasmodic croup, 107

---- ---- its nature and symptoms, 108

---- ---- ---- treatment, 111

Still-birth, 32

Stomach, how to examine, 9

---- ache, cry in, characteristic, 5

St. Vitus's dance, 118

---- ---- ---- its connection with rheumatism, 118

---- ---- ---- its symptoms, 118

---- ---- ---- distinct from mere grimacing, 119

---- ---- ---- its treatment, 120

Suckling, importance of, to mother and child, 40, 50

---- unfitness of some mothers for it, 49

---- sometimes has to be abandoned, 57

Sunstroke, 98

Tape-worm, 161

Tears, their value as a sign of disease, 11, 101

Teething, takes place later in man than in other animals, 47

---- order in which teeth appear, 73

---- when the gums should be lanced, 75

---- rules for management of, 76

Temperature, in health and disease, 7

---- of sick-room, 14

---- increase of, in infantile consumption, 61

Thermometer, importance of use of, 7, 28

Thread-worms, 160

Throat, white spots on, not always diphtheritic, 137

---- sore, inflammatory, or quinsey, 165

---- abscess at back of, 168

Thrush, 70

Tonsils, enlarged, 166

---- inflamed, 165

---- when to be removed, 167

Typhoid fever, 191

---- ---- its symptoms, 192

---- ---- ---- management, 194

Urine, incontinence of, 171

Vaccination, 196

---- M. Pasteur's experiments, 197

---- death from, 198

---- re-vaccination, 199

---- animal, 200

---- alleged transmission of disease by, 200

---- conclusions with reference to it, 200

---- small-pox after, 201

Vomiting in infancy, 63

---- its treatment, 64

---- as sign of congestion of brain, 95

Water on the brain, acute, its early symptoms, 99

---- ---- ---- ---- symptoms of its progress, 101

---- ---- ----- ---- chronic, two kinds of, 97, 105

Whey, Dr. Frankland's rules for preparing, 51 note

---- its uses, 51

White decoction, 59

Whites in children, 184

Worms, 160

---- the round, and the thread-worm, 160

---- tape-worm, 161

---- treatment of, 162

PRINTED BY

SPOTTISWOODE AND CO., NEW-STREET SQUARE

LONDON

[Transcriber's Notes: Printer's errors have been corrected as follows:

Page 2--thoes corrected to those (to those conditions)

Page 2--do corrected to does (The experience ... does not apply)

Page 99--added comma (more gloomy, more pettish)

Page 107--removed space (distinguished)

Page 119--fidgetty corrected to fidgety (odd fidgety movements)

Page 160--added hyphen to round worm (round-worm)

Page 220--added quotation mark (a hospital for adults.')

Page 231--203 corrected to 202 (Chicken-pox, 202)

All other spelling, hyphenation, and punctuation has been left as written.

DISCLAIMER

The medical knowledge represented in this book is over a century old.

The publication of this book is for historical interest only, and is not

to be construed as a medical advice by Project Gutenberg, its board of

directors, or its volunteers. Prescriptions should not be applied

without consulting trained medical professionals. Medical science has

made considerable progress since this book was written. Recommendations

or prescriptions may have been superseded by better alternatives, or

invalidated altogether. ]