Chapter IX: Constitutional Diseases (1)

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°, 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°, there is grave presumption that consumptive disease is present. In advanced consumption the evening temperature is constantly 103° to 105°, while in the morning it may fall to 101° or 100°.

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° or 102°, and will continue so during the early part of the unquiet night. After midnight it will begin to fall, and by six o'clock in the morning, or even earlier, will have regained its natural standard. There is no other disease but typhoid fever, and now and then some forms of galloping consumption, in which these oscillations of temperature take place regularly. Other symptoms attend typhoid fever besides these, and serve to stamp upon it its distinctive character. The bowels are usually loose, or if not, a moderate aperient acts on them excessively, the evacuations being loose, often watery, of a light yellow-ochrey colour. The abdomen is full, the bowels being more or less distended with wind, sometimes tender, especially at the right side, and both tender and painful in all cases where the disease is severe. Towards the end of the first, or at the latest by the middle of the second week, small rose-red spots or pimples appear on the abdomen, sometimes also on the chest and back. They disappear for the moment if pressure is made on them, but reappear the moment the pressure is withdrawn. Now and then they are numerous, and sometimes two or three successive crops appear, the old ones fading as the others show themselves; but in childhood they are often scanty, though whether few or many, they are the external characteristic of the disease just as the rash is in scarlatina or measles.

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

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

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

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

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

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

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

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

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

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

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

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

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

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