-whether the child breathes as deeply as it should, or whether it makes frequent short inspirations which cannot fill the smaller bronchi. The time for ascertaining these points must vary in each case; but the earlier they are observed the better, since otherwise you run the risk of drawing your inferences not from the child's ordinary condition, but from its condition when excited and alarmed. Some of these points may be noticed though the child be so fretful that you cannot auscultate even the back of its chest satisfactorily. An imperfect auscultation, however, is better than none; for at the very worst, during the deep inspirations that are made at intervals in a fit of crying, you may ascertain how far the lungs are permeable to air, and whether the bronchi are much loaded. with mucus. Independently of auscultation, too, much may be learned from the cry. If its two periods be clearly marked-the long loud cry of expiration, and the shorter, less loud, but perfectly distinct sound that attends inspiration-you may feel convinced that there exists no important ailment of the respiratory organs.

It will still remain for you to examine the tongue, and to ascertain the condition of the gums; and it is wise to defer this to the last, since it is usually the most grievous part of your visit to the child. If during any part of your previous examination it had cried, you might seize that opportunity to look at its tongue, and, if necessary, to pass your finger over the gums, thus sparing it any further distress about the matter. If you had not this opportunity, you will generally get a good view of the mouth and throat in young infants by gently touching the lips with your finger; the child opens its mouth instinctively, and then you can run your finger quickly over its tongue, and down towards the pharynx, and thus secure a perfect view of the mouth and throat. With older children a good deal of coaxing is sometimes necessary to persuade them to open their mouth: but, if once you get your finger on the gum, you can usually keep them quiet by rubbing it, and by a little address will then seldom fail in opening the mouth wide enough to get a view of the tongue.

If little children be very ill, all this minute care in the order of your examination is not so much needed, because they will not notice so quickly; but gentleness of tone and manner will be even more necessary to soothe the pettishness and quiet the alarm of the little sufferer.

Many of the directions that I have just given you refer to the examination of infants, and become less applicable in proportion to the greater age of the patient. Minute rules for your examination of children from three years old and upwards are not needed; but patience the most untiring, and good temper the most unruffled, are indispensable.

The previous history of a patient, the circumstances under which his present illness came on, and the symptoms that at first attended it, often help to remove our doubts with reference to the nature of a disease, and sometimes greatly modify our diagnosis and influence our plan of treatment. Really trustworthy information on these points, however, is often difficult to be obtained, and the attempt to elicit it is almost sure to be unsuccessful, if the questions put to the patient are proposed at random, and without some previously well-digested plan on the part of the physician. One great object of clinical instruction is to teach the

cure.

student so to conduct this as well as other parts of his examination of the sick, as to throw from every source the greatest possible amount of light upon the nature of the disease, and thus to fit himself to decide with some approach to certainty on the means most likely to effect its Such instruction has been amply afforded you in the wards of this hospital; but you must allow me to detain you while I point out the subjects towards which your inquiries must be especially directed in the case of children, since they differ in many respects from the questions that you would propose if your patient were an adult.

We will suppose, if you please, that a child is brought to you of whose case you wish to preserve a record. Its name, age, sex, and residence will form of course the first entry in your note-book; but your next inquiries should be as to the number of living children that the parents have had, whether any of those children have died, and, if so, at what age, and of what diseases, and as to the health of both parents, and of their immediate relatives. The object of these questions is to ascertain whether there exists any hereditary tendency to disease in the family, since that plays a most important part in many of the affections of childhood, and symptoms that in the child of healthy parents would cause you but little uneasiness, would at once excite serious alarm if you knew that some members of the family had died of hydrocephalus, or consumption, or had been the subjects of scrofula.

Many of the most serious affections of childhood occur within the period of a few years, and after a certain age are comparatively rare in their occurrence, and generally mild in their character. It is therefore very desirable, when any ailment is coming on the nature of which is not yet quite apparent, to know which of the diseases incidental to childhood have already affected your patient. With this view you would ask whether the child has been vaccinated, or has had the small-pox, and whether it has passed through any other of those affections such as chicken-pox, hooping-cough, measles, or scarlatina, which generally come on in early life. If the child had suffered from any other disease, you should learn its nature, the age at which it occurred, and any other point of importance connected with it.

In writing out our history of the case, these preliminary matters would naturally be mentioned at the beginning, and though you would not follow any very strict order in proposing your questions, yet it is always desirable to obtain information on these points at an early stage of your examination, since it may guide you in some of the questions that you afterwards propose, or may lead you to pay particular attention to symptoms which otherwise would not seem to be of much moment. Besides, if you postpone these inquiries till you have nearly completed your examination of the patient, the parents will probably apprehend that they are suggested by some doubt and apprehension in your mind as to the nature of the case, and will distress themselves by causeless fears, or perhaps disconcert you by questions to which you are not prepared to return a positive answer.

There are two other points which bear on the general condition of the child, to one or both of which your inquiries must in many instances be directed. If your patient be an infant at the breast, you must learn

whether it lives entirely on its mother's milk, or has other food besides.
If it has been weaned, you must ask its age at weaning-whether it was
taken from the breast on account of any failure in its own health, or its
mother's, and on what diet it has since been fed. The process of den-
tition is the other subject for inquiry; and in reference to it, you must
ascertain how many teeth the child has, and which they are-whether
they were cut easily or with difficulty, the age at which teething com-
menced, and the time that has elapsed since any fresh teeth appeared.
You may now endeavour to obtain a clear and connected history of
the present illness; and for this purpose it is well to begin with asking
when did the child last seem quite well? since you thus get a fixed
starting point from which you can make the mother or nurse set out in
her detail of symptoms. The date thus assigned, indeed, will often be
a wrong one, the disease having begun before with some symptom that
was not noticed, or its real origin having been considerably subsequent
to its supposed commencement. But notwithstanding this possible
error, you derive much advantage from thus making sure of the symp-
toms being told you in something like their chronological order, since
otherwise it is very likely that those only would be mentioned which
had chanced to strike the mind of the mother or nurse, while the others
would be passed over in silence. Your object in the examination must
not be to curtail the garrulity of the nurse, or to suppress the mother's
expression of her sometimes imaginary fears, but to get as clear an
account as possible of everything that has been observed. You must
'be careful not to underrate the value of the information they communi-
cate, or even of the opinions they express. Both are much more likely
to be correct when your patients are children, than when they are
adults. A mother hanging over her sick infant, or a nurse watching
the child she has helped to rear from babyhood, may sometimes see
dangers that have no existence, but will generally be the first to per-
ceive the approach of such as are real. You see the child but for a
few minutes, and at distant intervals, and the excitement or alarm
which your presence is so likely to occasion may greatly modify its
condition during your visit. They tend the little one by day and
night, notice each movement, and seize the most transient variations
in its expression.

I need not say much concerning the necessity of inquiring about the appetite and thirst, the state of the bowels, and the appearance of the evacuations; for these are points which you would investigate in patients of every age. I will just mention, however, that the degree of appetite and thirst cannot be so readily determined in the infant as they may be in the adult, or even in the weaned child; for an infant may suck, not because it is hungry, but in order to quench its thirst. That extreme craving for the breast, which is appeased only so long as the child is sucking, while the milk swallowed is speedily vomited, may be taken as a sign of thirst; but it is always better to record the fact than the inference, It is likewise often desirable to let the infant be put to the breast in your presence, not only for the sake of observing the above-mentioned facts, but also in order to notice the vigour with which it sucks, the ease or difficulty with which it swallows, and other

CASE-TAKING-PLAN OF THE COURSE.

25

25

similar points from which very important conclusions may often be drawn.

Before you venture on drawing any inferences from the state of the child at the time of your visit, you should ascertain whether it has just before been taking food, or has been recently excited or fatigued by being washed or dressed; since comparatively trivial causes are sufficient to accelerate the pulse and respiration, and to give rise to changes which might, if unexplained, lead you to very erroneous conclusions. Any such circumstances ought of course to be mentioned in your notes, as should also the fact of the child being asleep at the time of your visit, since that would explain even a very considerable diminution in the frequency of the pulse and respiration.

But if you are carefully to observe all the points which I have mentioned, and to make yourselves thoroughly masters of a case, you must be most lavish of your time; you must be content to turn aside from the direct course of investigation, which you would pursue uninterruptedly in the adult, in order to soothe the waywardness of the child, to quiet its fear, or even to cheat it into good humour by joining in its play; and you must be ready to do this, not the first time only, but every time that you visit the child, and must try to win its affections in order to cure its disease. If you fail in the former, you will often be foiled in your attempts at the latter. Nor is this all: you must visit your patient very often, if the disease be serious in its nature and rapid in its course. New symptoms succeed each other in infancy and childhood with great rapidity; complications occur that call for some change in your treatment, or the vital powers falter suddenly, when you least expect it. The issues of life and death often hang on the immediate adoption of a certain plan of treatment, or its timely discontinuance. Do not wait, therefore, for symptoms of great urgency before you visit a child three or four times a day, but if the disease be one in which changes are likely to take place rapidly, be frequent in your visits as well as watchful in your observation.

You will naturally think, that before I finish this lecture I should. tell you something definite about the subjects that I mean to bring before your notice, and the manner in which I propose to treat them. The title of these lectures can, I should think, scarcely need any explanation, for by the diseases of infancy and childhood you will naturally understand all those affections which are either limited in the time of their occurrence to early life, or which, though incidental to all ages, yet in the child present many peculiarities in their symptoms, and require many important modifications in their treatment. Some of these diseases, indeed, are usually allotted to the care of the surgeon, and on their examination I will not enter, since I could tell you nothing more than has already been better said by others. They, however, are but few in number, and most of them are purely local affections, so that these omissions will not be many, and most of them not important.

In the description of the diseases of children, no practically useful end would be attained by following any elaborate nosological system. I shall therefore adopt the most simple classification possible, and shall

26.

FREQUENCY OF DISEASES OF THE NERVOUS SYSTEM.

treat in succession of the diseases of the nervous system, of the respiratory and circulatory, and of the digestive systems and their appendages. There will still remain one very important class of affections, namely, fevers; and these I propose to consider last of all, because much of their danger arises from their complications, and to treat them judiciously you must be familiar with the diseases of the brain, the lungs, and the bowels. In this plan it will be easy to detect a want, perhaps too great a want, of scientific arrangement, but the one object of my endeavours will be to communicate to you, as clearly as I can, such information as may be most useful to you in the discharge of your daily duties.

With this view, I have, while composing these lectures, tried to think over the doubts I felt, the difficulties I met with, and the errors I fell into, when, some years ago, I entered on the office of physician to a large institution for the cure of children's diseases. I have presumed that where I had encountered difficulties there you might meet them too, that where I had made mistakes there you would need a guide, and remembering the many anxious hours I passed when I hesitatingly adopted some course of treatment which I feared might after all be a mistaken one, it has been my endeavour to lay down, not only the rules for the diagnosis, but also the indications for the treatment of each disease as minutely as possible.

To the task before me I now apply myself, with a deep conviction of the narrow limits of my own knowledge, but still feeling that I'have contracted an obligation to impart to others what I trust experience has taught me. My end will be answered, if you learn it at an easier rate than I did; and if I can be the means of saving you from some of those errors in diagnosis, and same of those mistakes in treatment, which, for want of some one to guide me aright, I committed.

LECTURE II.

DISEASES OF THE BRAIN AND NERVOUS SYSTEM.-Their extreme frequency in early life favoured by the rapid development of the brain, and the wide variations in the cerebral circulation during childhood.-Peculiar difficulties of their study.-Symptoms of cerebral disease in the child.-Convulsions, their frequency in great measure due to the predominance of the spinal system in childhood--may be excited by many causeshence attention should always be paid to the precursors of an attack. Description of a fit of convulsions.

Ir can scarcely be necessary to assign many reasons for beginning this course of lectures with the study of the diseases of the nervous system. The subject, although beset with many difficulties, has always engaged much attention; partly, no doubt, from the natural tendency of the human mind to inquire most curiously into those truths that seem most hidden; but still more from the alarming nature of many of the symptoms that betoken disturbance of the nervous system, and from the frequently fatal issue of its diseases. But besides the general