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 diarrhœa, 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 diarrhœa 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.
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.