The Mother's Manual of Children's Diseases Part 9

Whenever, then, symptoms, such as I have described, come on, send at once for medical advice, and do not let some diminution of suffering, or slight general improvement, lead you to delay.

=Croup.=--I endeavoured to explain, a few pages back, the cause of that peculiar sound which is heard in spasmodic croup. The contraction of the opening of the windpipe changes the sound which pa.s.ses through it, just as the opening or closing the keys of a wind instrument modifies the sound which it gives forth. But the windpipe is not simply a wind instrument, it is a stringed instrument too, and the strings or vocal cords, as they are termed, give forth, as they vibrate, tones now deeper, now more shrill. The action of this delicate apparatus is readily disturbed, if the nerve-supply to it is disordered by irritation in some distant organ, and then the breathing is accompanied by the peculiar sound of spasmodic croup, or in older children this may show itself in a different way, as in the loud, barking cough heard in some cases of constipation, or of disordered digestion; or another ill.u.s.tration of it is furnished by the loud, long breath--the 'hoop,'

which gives its name to hooping-cough. But there is one sound that sometimes attends the breathing of children, which more than any other causes, and justly causes, the greatest anxiety to a mother; and that is the sound which is characteristic of croup.

The word croup, which comes from the Lowland Scotch, signifies merely hoa.r.s.eness in breathing or coughing, and is therefore, strictly speaking, the name of a sign of disease, rather than that of the disease itself. The peculiar sound is heard in two different conditions--the one in which a child having caught cold, instead of the air-tubes alone being affected, the windpipe, and especially its upper part, becomes congested, and the lining membrane swollen. Partly owing to this, partly owing to its nerve-supply being disturbed, the child breathes noisily and hoa.r.s.ely, and the cough has a peculiar metallic clangor. In the other case there is not merely the congestion of the windpipe, the disturbed nerve-supply, and the swollen state of the membrane; but in connection with the influence of the special poison of diphtheria, a deposit takes place at the back of the throat, whence it extends to the windpipe, and in many instances even far beyond it, blocking up its ca.n.a.l, and mechanically excluding the entrance of air.

To determine at once to which cla.s.s a case of croup belongs is so far from easy, that I should advise that on the first sound of voice, or cough, or breathing resembling that of croup, medical advice should at once be sought. I dwell on the difference between the two: the first which has been called false croup, or better catarrhal croup, and the second called true croup, or diphtheritic croup, in order to save much needless apprehension to parents, in whose mind the croupy sound is invariably a.s.sociated with nothing short of that most dangerous disease--diphtheria.

As a general rule catarrhal croup is rarely met with after the age of six. Children in whom it occurs have either seemed quite well, or at most have been a little ailing for a day or two with cold, and cough, and perhaps slight hoa.r.s.eness. They go to bed and fall asleep as usual, but the cough, which does not wake them, becomes suddenly noisy, ringing, croupy, and the breathing is speedily attended with a long-drawn sound, half-hissing, half-ringing, and the child soon wakes alarmed, and fighting for breath, the skin bathed in perspiration, the face flushed and anxious. The cough, the difficult breathing, and the struggle for air last for an hour or two, or sometimes all night long, though they gradually subside, at any rate towards the approach of morning, when the child falls asleep, and, but for a somewhat hoa.r.s.e sounding cough, and a look of fatigue, there are but few signs of all that it has endured.

The attack may not return, or it may recur for two or three successive nights, though in general with lessened severity, the child during the daytime seeming to suffer only from a slight cold, or now and then, and so rarely that I have not known it to occur above once or twice in all my experience, it may end in real inflammation of the windpipe; but not in diphtheria.

Attacks of this kind may recur three, four, or more times even in childhood, while diphtheria has no tendency to recur, but like measles or scarlatina seldom appears more than once, though the rule is subject to more numerous exceptions than are found in the case of the eruptive fevers. Still the fact of an attack of this sort returning should of itself lessen apprehension and make the parents look forward to its issue with less anxiety than that with which they regarded its first occurrence.

A fact which shows how large a part is played by disturbance of the nervous system in these cases is the liability of children who have suffered from it to attacks of asthma, often of great severity as they grow older, while very often after the transition from childhood to youth has pa.s.sed these attacks too lessen in frequency and severity, and often altogether cease.

There are two measures which, while waiting for the doctor's arrival, may at once be taken, and which sometimes remove the symptoms almost as if by magic, while even were the case one of diphtheria they would still be of some service, and could not possibly do any harm. They are the hot bath, and a full dose of ipecacuanha wine. The former should be as hot as it can be borne, 93 or 94, and the child should be kept in it for five minutes, and the latter should be given in a full dose, as a teaspoonful in warm water every quarter of an hour till free vomiting takes place. How much better soever the child may seem after the use of these remedies, it should still be kept for two or three days under careful medical observation.

=Diphtheria.=--In _diphtheria_ croup is only one, though the most frequent, and one of the most serious, of the many dangerous symptoms which attend it. The croupal symptoms hardly ever come on quite suddenly, but are almost always preceded for some days by slight feverishness, languor, and restlessness, in spite of which the child still amuses itself; and if too young to express its sensations, the slight degree of sore-throat it experiences is manifested rather by a disinclination to take food than by any obvious difficulty in swallowing. There is no cough, nor any change of voice when the child is awake, but when asleep--and the sleep is generally uneasy--it often breathes with its mouth open, it snores slightly, or there is a little hoa.r.s.e sound accompanying the breathing owing to a trivial swelling of the throat; while, if sought for, there will generally be found a very little enlargement, and a very little tenderness of the glands at the corner of the lower jaw. The eyes are sometimes tearful, there may be slight running at the nose, and the child is said to have a bad cold with slight sore-throat--the most remarkable feature of the case being generally that the depression of the patient is out of proportion to the severity of the local ailment. If now the throat is examined--and examination of the throat should never be omitted in any case where there is the slightest difficulty of swallowing--nothing may at first be seen but a very little swelling, and some redness of one or other tonsil. In a few hours more, white specks like little bits of curd will be seen first on one tonsil, then on the other, and next these specks will have united to form one continuous layer of a sort of yellowish-white membrane over the palate and tonsils. The examination of the throat, often so difficult when children are ill, is attended with almost none, if while they are well they have been taught the little trick of opening their mouths to show their throat, and of allowing the introduction of a spoon to keep down the tongue, a proceeding which though certainly unpleasant they will almost always readily agree to, like Martha Trapbois, in the 'Fortunes of Nigel,' 'for a consideration.'

The deposit on the throat may disappear of its own accord, and not be reproduced, and this even though no treatment has been adopted, and in two or three days the child may be pretty well again, though strength is in general regained less rapidly than might have been expected from the comparative mildness of the attack.

In cases so slight it is no easy matter to recognise the features of a highly dangerous disease; still, out of forerunners so trivial as these, croupal symptoms may be developed, and their advances may be most insidious, and unless both parents and doctor have been closely on the watch they may be surprised all at once by the breathing suddenly becoming very laboured, by that and the cough becoming attended by the sounds characteristic of croup, and by the child's life being in extreme jeopardy, or in danger even beyond the hope of recovery.

It is not that here, as in cases of catarrhal croup, the ailment has really come on suddenly, but that the disease has been silently making unsuspected progress. Whenever then a child, after a few days of slight causeless ailing, accompanied with some little discomfort in swallowing, is seen to have white patches at the back of its throat, do not allow yourselves to be lulled even by their disappearance into a feeling of absolute security. Watch the child, and beg the doctor to watch it carefully, until it is perfectly well again, for though the deposit may have disappeared from the back of the throat it may continue to be formed in the windpipe, and in the somewhat depressed state of the nervous system which attends diphtheria it may not excite that irritation which any such cause would produce in a child in perfect health, and consequently not announce its presence until its amount has become so considerable as to offer an almost insurmountable obstacle to the entrance of air. Any, even the slightest, hurry of breathing, a hissing sound when the child draws its breath, hoa.r.s.eness of voice, or a ringing cough, should quicken your apprehension of danger, and make you seek for immediate help.

It may be as well, however, to mention here, that not every white speck seen at the back of the throat is of necessity due to diphtheria, but that in some cases of ordinary sore-throat white spots may form on the surface of the tonsils. These white spots are due to the collection at their openings of the secretion formed in the minute glands which beset the surface of the tonsils, and which at these seasons is poured out in greater abundance than usual. They are distinct from each other, and do not coalesce into a membrane; the surface beneath is not the uniform red shining surface on which the membrane in diphtheria has formed, but the separate tiny openings from which the white matter has exuded may be distinctly seen if the surface is wiped with a camel's-hair brush. It is, of course, wise in every case to leave to the doctor the decision as to the nature of the deposit, but it may sometimes relieve needless anxiety to know beforehand that there is another cause besides diphtheria to which white spots at the back of the throat may be due.

There are other dangers, indeed, besides those arising from croup, which accompany diphtheria, though those just mentioned are of all the most frequent. There are cases in which death takes place not from the severity of any local ailment, but from the intense depression of the nervous system. There are other instances too, in which the case a.s.sumes what is termed a malignant character; profuse discharge taking place from the nostrils, swallowing being from the first exceedingly difficult, membrane being deposited on the lips, behind the ears, or at the edge of the bowel; death taking place in twenty-four or thirty-six hours from the outset of the first serious symptoms, either in convulsions, or from utter exhaustion.

But the very urgency of such cases must of necessity call for the immediate a.s.sistance of the doctor; and my business throughout this book is rather with those points which it is important for a mother to notice, and those things which it behoves her to do.

What does diphtheria depend on? is a question more easily asked than answered. The disease is contagious, as scarlatina is contagious, though not to the same degree. I may add, it is not identical with scarlatina, nor does the one disease protect from the other. It would, perhaps, be too much to say that it is dependent on an unsanitary condition of a town, a village, or a house, but there is no doubt but that, as is the case with cholera, scarlet-fever, or typhus, unsanitary conditions favour its spread, and increase its severity.

Being contagious, it is most important to keep cups, gla.s.ses, spoons, towels, and bed-linen separate from those of other inmates of the house, and to remove the patient from any room occupied by other children.

Great care too is to be observed, if anyone is standing over the child during a fit of coughing, that none of the membrane which it spits up enters the mouth; and, that if the child's breath is caught, the attendant gargle immediately with a teaspoonful of Condy's fluid in a tumbler of water.

In the next place, as the depression of the nervous system in some cases of diphtheria is quite out of proportion to the local disease, and as children who have not seemed very suffering, have yet been known to die suddenly in an unexpected faint, it is of moment that the child remain constantly in bed from the commencement of the attack till complete convalescence. Nor, indeed, in serious cases is even this precaution sufficient; but in such circ.u.mstances not only must the child not be taken out of bed for any purpose, but it must even not be suddenly raised in bed, from a rec.u.mbent to a sitting posture. I have, on several occasions, known the neglect of these precautions followed immediately by what cannot but be regarded as the needless death of the patient.

During the illness, there is little for the mother to do, except to try to carry out the doctor's directions, and to give the child constantly little bits of ice to suck, which lessen the swelling of the throat, and relieve the pain and inflammation. If the child knows how to gargle, it should be induced to do so constantly, and finding the relief which this affords, will do so very readily. This is not the time, however, when the lesson 'how to gargle' can be learnt. A thoughtful mother teaches it while the child is well, and if the gargle is composed of raspberry vinegar and water, the lesson is learnt without tears. There comes a time, however, if the disease is at all severe, when gargling is no longer possible, for the muscles of the back of the throat lose their power; but now some medicated solution, employed by means of the spray-producer, may most efficiently take its place.

When croupal symptoms have gone on growing worse and worse, and the child is in the agonies of suffocation, the doctor may propose to open the windpipe, in the hope of giving the child another chance of recovery, and even though the operation fail, of at least lessening its sufferings.

The operation is sometimes objected to by the parents, on the ground of the uncertainty of the result, and the torture of the operation to the child. Now the anguish of a child dying of croup is due to two causes; first, the actual mechanical impediment to the entrance of air produced by the deposit in the windpipe, and secondly, to the spasm of the muscles in the upper part of the windpipe which that deposit produces.

How large an amount of distress the latter may produce, anyone can judge for himself, to whom it has ever happened to swallow the wrong way, as it is called. The opening made below the seat of the muscles which close the windpipe, leaves them in perfect rest, and does away with all the suffering produced by spasm, while there is always a fair prospect if the operation is not put off too long, of the deposit being limited to the part above the artificial opening, and of the good being permanent.

It is true that we have no certain means of knowing the extent of the deposit beforehand; it is true also that the operation is not in itself a cure of the disease, but at any rate, it is a reprieve which gives time for remedies to take effect, and at the worst, it subst.i.tutes a comparatively painless death for one of intolerable anguish. It can, too, be performed under the influence of chloroform, so that the idea that it adds in any way to the child's distress is unfounded. Who that has seen the calm, happy face, and watched the tranquil sleep of the child after the operation, who before was struggling, with distorted features and agonised countenance, to get a breath of air, but would feel as I do, that I would have it done in a child of mine for the sake of a painless death, even though I knew for certain that it would not prolong life even for an hour?

One additional remark I have to make with reference to the loss of power, or palsy of various muscles, which frequently follows diphtheria.

Almost always there is some impairment of power in the muscles of the throat on which the deposit had taken place, and there is, in consequence, a little difficulty in swallowing for a few days. If this should get worse, food and especially drink sometimes return by the nose, and next there may be a slight squint, and the sight may become weakened, and an uncertain tottering gait; and sometimes for a week or two the child may be unable even to stand. In bad cases there is with these symptoms a general loss of nervous as well as of muscular power, though the child may still be fairly cheerful, and ready to amuse itself as well as it can. This condition may last for many weeks before it pa.s.ses quite away, and if under the mistaken impression that the limbs will gain strength by exercise, the child is allowed to sit up and encouraged to exert itself, recovery will be delayed much longer; and dangerous weakness or fatal exhaustion may suddenly come on.

The inference is too obvious for me to need dwell on it, that repose is the great resource, and quiet waiting the true wisdom.

=Hooping-Cough.=--I need not say much about _hooping-cough_, for there is scarcely a nursery in which, to everyone's great discomfort, it is not known as a familiar and most unwelcome visitant. It varies remarkably in its importance, being sometimes so slight as scarcely to amount to an illness, but in other instances one of the most deadly of diseases. It causes the death of a fourth of all children who die under the age of five, and three out of four of these deaths take place in infants of less than two years old.

It occurs, however, comparatively seldom during the first three or four months of life, probably because very young children are kept more at home than others, and are thus less exposed to catch it. Though hooping-cough is undoubtedly very contagious, it seems to be communicated only by the breath, and there is absolutely no evidence to show that the clothes of a child suffering from hooping-cough can carry the infection as they might were the child suffering from measles, or smallpox, or scarlet-fever; still less that a person who has visited a room where children are suffering from hooping-cough can convey the disease to another house, or to other children.

The disease derives its name, as everyone knows, from the peculiar sound which attends the cough, and which is due, as is the sound of croup, to spasm of the upper part of the windpipe. It is equally characterised by the cough returning in fits or paroxysms, which end in a long-drawn breath, attended by the hoop. An occasional sound like a hoop, in a young child who has a cold, is not so conclusive of a case being one of hooping-cough as is the recurrence of the cough in fits; for until teething is completed, slight and temporary irritation will suffice to produce a pa.s.sing spasm of the upper part of the windpipe.

An ordinary attack of hooping-cough begins like a common cold, but as the little ailment pa.s.ses off, the cough still continues, the fits of coughing become more frequent, last longer, grow severer and more suffocative, and end with the loud long breath, the hoop; while sometimes no sooner is one fit over than another follows it almost immediately, and quiet breathing does not return until the child is tired out by its efforts. Nevertheless, the child's health continues fairly good, and little or nothing ails it during the intervals of the cough. For about a fortnight the cough usually goes on to increase; and during this time the night attacks especially become more frequent. It then for a week or ten days continues stationary, and then declines, a diminution in the frequency and severity of the night attacks being in general the first sign of amendment, and at the end of six weeks from the beginning of the attack the child is in general quite convalescent.

Even then, however, a trifling cause will reproduce the characteristic cough for a few days, and not seldom for many months afterwards any cold which the child may catch will be attended by a paroxysmal cough undistinguishable save by its milder character and shorter duration from the previous hooping-cough, though I believe incapable of communicating that disease.

In mild hooping-cough there is little or nothing to be done, save to follow the dictates of common sense, and not to neglect them in quest of some imaginary specific--some vaunted medicine which is said to be a certain cure; or such as shutting up the child in a room the atmosphere of which is charged with the vapour of tar, or of carbolic acid, or of sulphur.

It cannot be too strongly impressed on the minds of parents that there is no specific whatever for hooping-cough; no remedy which will cut it short, as quinine cuts short a fit of ague. The domestic treatment of mild hooping-cough is the domestic treatment of a common cold, implying the same precautions as to the equal temperature of the day and night nursery, the little doses of ipecacuanha at night, but as seldom as possible during the day, in order not to interfere with the appet.i.te and digestion, together with special care to insure the regular action of the bowels. It sometimes happens that after a week or two the severer fits of coughing are followed by vomiting; and the child may lose flesh and strength from inability to retain its food. In these circ.u.mstances food must be given, little in quant.i.ty, at short intervals, and of a kind that need not remain long in the stomach in order to be digested.

Good soup, beef-tea, milk, rice milk, or a raw egg beaten up in milk, and biscuit rather than bread, must take the place of the ordinary meals, and be given twice as often.

The different liniments, and the favourite Roche's Embrocation, are of use when the disease is on the decline, and may also be of service if bronchitis should occur to complicate the hooping-cough, but not otherwise.

Change of air when hooping-cough is on the decline is often of great service, and change even from good air to one less good appears to be sometimes of use; but change in the early stages, or when hooping-cough has become really severe, is but adding another to the already existing dangers.

The danger in hooping-cough arises through the medium either of the head or of the lungs, and through each of them with about equal frequency. The head becomes affected in consequence of the often recurring congestion of the brain, produced, as in spasmodic croup, by the constantly returning interruption to the breathing. In these cases the cough is frequent, and so violent that the child becomes livid during each paroxysm, and that instead of ending in a loud hoop it finishes by a fit of convulsions or by the child sinking into a state of semi-insensibility. Increased violence of the cough, with suppression of the hoop, is always a bad omen in hooping-cough.

On the other hand, when the cough becomes complicated with bronchitis, it ceases to recur in distinct fits which leave behind them intervals of comparative, or of absolute ease. The hurried breathing which precedes and follows a fit of coughing never entirely subsides, while each returning cough aggravates the irritation and inflammation of the air-tubes, and the child's condition becomes the very dangerous one of hooping-cough complicated with bronchitis.

So long as a child seems pretty well in the intervals between the fits of coughing, as the hurried breathing subsides after each to a natural frequency, as a long loud hoop follows each cough, as vomiting takes place only after a fit of coughing and never in the intervals, as the child becomes flushed only and not livid during a cough, and recovers itself perfectly afterwards, as it does not complain of constant headache, nor spits blood, nor has nose-bleeding, nor is feverish, nor depressed, nor drowsy, you may feel happy about it. When any of the symptoms just enumerated show themselves you have reason for grave solicitude, and the child requires daily medical watching.

One word in conclusion. A child who has recently had hooping-cough is more liable than another to be attacked by chicken-pox or measles; and, moreover, imperfect recovery from hooping-cough is apt, especially if there is any tendency to consumption in the family, to be followed by consumptive disease.

=Asthma.=--_Asthma_, attended by distress of breathing quite as considerable as in the grown person, is by no means unusual in the child. Recovery from it is far more likely to take place in the latter, since it is almost always independent of those diseases of the heart or lungs, which in the former occasion or aggravate it. It belongs to the cla.s.s of what has been termed nervous asthma and is observed with special frequency in children who, when younger, had been liable to catarrhal croup; spasm of the air-tubes having taken the place of the previous spasm of the windpipe. Independently of that antecedent it comes on sometimes about the time of the second teething in nervous and impressionable children, in whom an attack may be produced by indigestion, constipation, or over-fatigue. It is also by no means rare in children in whom that skin affection, eczema, of which I have already spoken, outlasts the time of infancy, and becomes general and severe.

The improper performance of the functions of the skin seems to cause a peculiar sensitiveness of the air-tubes, and to render them liable to the occasional occurrence of that spasm which produces asthma. These cases are less hopeful than others, and the liability to the attacks ceases only when the skin-affection has been completely cured; a reason this for not neglecting eczema in infancy and early childhood.

Sometimes, too, it follows frequently-recurring attacks of bronchitis, and, though less often than might be expected, it succeeds severe hooping-cough, and in these two conditions the prospects of recovery are less hopeful than in the others.

When asthma occurs in childhood, the first point is to ascertain the cause on which the attack depends; and it is worth any amount of care to discover and remove it; for if what may be called the asthmatic habit is not formed, the attacks will, in the majority of instances, cease between the ages of twelve and fifteen. Bad habits of the body are, however, as difficult to get rid of as bad habits of the mind, and the boy who grows up an asthmatic youth is very unlikely to get rid of the disorder in later life.

It is in that form of asthma which succeeds to frequent attacks of catching cold, and in which bronchitis precedes or accompanies each seizure, that change of climate is most useful. In the majority of instances a moderately sheltered seaside place, with a sandy soil such as Bournemouth, is the best, and a few years' residence there not infrequently overcomes every disposition to asthma through the whole remainder of the patient's life. To this, however, there are exceptions, and I have seen instances in which residence at Bournemouth and in the Riviera have failed, but where a perfect cure has been wrought by the cold, still air of Davos.

=Diseases of the Heart.=--=Malformed Heart.=--Every now and then one sees a little babe, carefully wrapped up in its nurse's arms to shield it, even on a warm day, from the air; and, on removing the shawl which covered it, one is struck by the sight of a little pale pinched face, with a livid ring around the mouth, and a blue instead of a rosy tint of lips and fingertips, as though perished with cold. The babe wakes on being disturbed, and gives a faint short cry of distress; the livid hue of its surface deepens, it struggles feebly, its mouth twitches as though convulsions might be coming on. Soon, however, these symptoms subside, the babe smiles again, is cheerful, and save for the tints of its face and lips, it looks like other infants, but frailer.

This condition has a name in medical writings, from a Greek word expressive of the blue tint which characterises it, and is called _cyanosis_. It depends on the blood not having undergone completely those changes in the lungs which take place in the healthy state. The blood, as it returns through the veins to the right side of the heart, is of a deep purple hue. The right side of the heart contracting sends it to the lungs, where, in the minute vessels of the air-cells, it is purified, and returns vivified by the oxygen a bright scarlet stream, to be distributed by the arteries over the whole body; and thence to return once more for fresh purification to the right side of the heart. Before birth, the blood does not run the same course, but is purified within the mother's body, the blood running through channels which close with the first breath the infant draws. The previously existing communication between the two sides of the heart ceases at the same time as the new channels are opened, by the shutting of a thin valve which had hitherto allowed the blood to pa.s.s from one side to the other.

Sometimes this closure fails to take place, or takes place but imperfectly; sometimes, in addition, the channels which should be disused after birth remain open still; and sometimes also the heart is otherwise imperfectly formed, and a large communication exists between the two sides of the heart, which long before birth ought to have been firmly part.i.tioned off from each other.

According to the freedom of communication between the two sides of the heart, there is more or less ready intermingling of the impure blood with that which is already purified; and this is betokened by the greater or less severity of the symptoms which I have described. When the heart is very malformed, and the blood consequently is very impure, life is but a short agony which ends in a few weeks; some slight movement, some little accidental cold deranging altogether the imperfect machinery, and bringing it to a sudden standstill. Between this and the slightest cases there are all shades of difference, till, in the latter, a smaller power to maintain warmth, a less rapid growth, a smaller muscular development, a feebler power, a hurry of breathing on exertion, or in ascending a hill, or in going up a staircase, are all, except the sounds which the educated ear detects of the blood pa.s.sing through its devious course, that tell of nature having, in this instance, ill done her handiwork.

The one most natural question to which, in every instance, the doctor has to reply is this: 'Will he or she outgrow it?' To this the answer is, '_Yes_,' and '_No_.' In the worst cases the answer is obviously _no_; and in none does _yes_ imply a recovery so complete as to leave no trace behind, and to make the child heartwhole. But short of this, in many instances much may be hoped for. There is, as I shall have occasion again to repeat, a power in the growing heart to adapt itself in large measure to conditions other than those of perfect health. The channels, through which the blood ought not to flow, may shrink though they may not entirely close; the valve may shut more completely than at first the opening between the two sides of the heart; all inconveniences may lessen, and the child may at last become scarcely aware of the difference between himself and others. But for any such result, or for anything approaching it to be attained, certain conditions are absolutely essential which it is seldom easy to induce parents to observe. Whatever can hurry the circulation is most carefully to be avoided. The child must be kept strictly out of the way of hooping-cough, measles, or any other fever; must be shielded from every risk of catching cold, and having smaller power of maintaining its warmth than others have, must be specially warmly clad, and must live in rooms at a temperature of 60 deg. Fahr., all the year round. Great attention must be paid to the state of the bowels, so that constipation may not necessitate violent efforts to relieve them.

Moreover, for years the child must be carried upstairs; when old enough to take part in games, it must not be allowed to join in any which call for violent exertion, such as cricket, or lawn tennis, nor ride any other than a quiet pony at a gentle pace.

It depends entirely on the parents whether, for the sake of a very great but far-off good, they will strictly observe these rules. The difficulty will not arise on the child's part, for it is not hard for those who have had charge of it from babyhood to bring it up to quiet pursuits and quiet amus.e.m.e.nts, till it seeks no others, and, like the little cage-bred bird, does not care to emulate the flight of others stronger on the wing.