The Mother's Manual of Children's Diseases Part 6

THE DISORDERS AND DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

It is stated on good authority[11] that more than half of the deaths at all ages from these causes take place in children under five years, a fact which at first sight seems as inexplicable as it is startling.

There is, however, a twofold explanation of it: the circulation through the much softer tissue of the brain, unenclosed within a _firm bony case_ as in after-life, varies with far greater rapidity in the infant than in the grown person, and hence the organ is far more easily overfilled with or emptied of its blood. Besides, any organ in which growth is going on with great rapidity is proportionately liable to become disordered or diseased. Now the brain doubles its weight in the first two years of life, and attains nearly its full size by the end of the seventh year.

These two facts suggest a bright as well as a dark view of disorders of the brain and nervous system in early life. If disorder is more frequent, it is excited by slighter causes, is more likely to be temporary, and even its gravest symptoms, such as convulsions and paralysis, have a less serious import in the one case than in the others. If the grown man has a fit, and still more, if that fit is followed by paralysis, we fear and with reason that some vessel in the brain-substance has given way, or that some grave, probably irreparable damage has been inflicted on it. In the child, and especially in the young infant, these accidents may mean nothing more than that the brain has suddenly become over-filled with blood, or that it has been disturbed by irritation--I know of no better term--in some distant organ.

CONVULSIONS.--There are in the body two great nerve ma.s.ses, the brain and the spinal cord, through which all parts are brought into relation with each other. The spinal cord or spinal marrow receives impressions from all parts, imparts movement to the limbs, as well as gives activity to the functions of the various internal organs. The brain is the controlling power, and governs more or less consciously the movements which the spinal cord originates, and hence in proportion as the development of the brain advances, and its controlling power increases, those involuntary movements, fits or convulsions, which originate in irritation of the spinal cord, become rarer. The brain, at the age of three years, is more than twice as large as in the first year of life, and deaths from convulsions have then sunk to a third of their former frequency; while from the age of ten to fifteen years, when the brain may be said to be perfected, only four per cent., instead of nearly eighty per cent. as in the first years of life, of all deaths from disorders of the nervous system are due to convulsions.[12]

I dwell on this subject the more because there is in a fit of _convulsions_ something so intensely painful to behold that it is easy to exaggerate its danger, and to lose all presence of mind in panic.

First, then, it is well to bear in mind that real disease of the brain rarely, very rarely, I do not say never, begins with convulsions; and next, that their real danger is in general in exactly opposite relation to the frequency of their occurrence. Convulsions now and then return thirty, forty, or more times in twenty-four hours, and continue to do so sometimes for three or four days together. They are, indeed, not without peril, for the perpetually returning disturbance of the circulation may give rise to an overfilling of the vessels of the brain, or to a stagnation of the blood within them, or the spasm may affect the muscles which open and close the entrance to the windpipe, and the child may die choked as in a paroxysm of whooping cough, or in a fit of spasmodic croup, or lastly the violent and frequently repeated muscular movements may at length exhaust its feeble frame. But still, such frequently recurring convulsions are in themselves no evidence that the brain is diseased; they do but show that the irritability of the spinal cord is increased to a degree which the brain is no longer able to control, and which therefore manifests itself in violent convulsive movements.

It is thus that the poison of scarlet fever or of small-pox sometimes displays its influence over the whole system by producing violent convulsions at the outset of those diseases; thus that they follow on some indigestible article of food, or that the mother, over-heated by violent exertion, or overwhelmed by the news of some unexpected calamity, sees her babe, to whom she is in the act of giving the breast, suddenly seized by a violent convulsion.

In every instance, therefore, the first business is to ascertain the cause of the convulsion, to determine the seat of the irritation which has excited the nervous system to such tumultuous reaction. The convulsion which ushers in any one of the eruptive fevers in the infant or in the child, is only an exaggeration of the s.h.i.+vering which precedes the onset of fever in the adult. Has the child been exposed to the contagion of measles, small-pox, or scarlatina? is it teething, and if so, when did its last tooth appear? of what did its last meal consist?

when were its bowels last open? has it been exposed to the sun with its head uncovered? or has it, though in the shade, been sitting or playing out of doors in the intense heat of a summer's day? has it had a fall, or been frightened? or is it suffering from whooping-cough which has of late been very severe? or has its breathing been accompanied with a peculiar catch or crow, the sign of spasmodic croup, and have at the same time its hands been usually half clenched, and the thumb shut into the palm, the sign of that disturbance which at length has culminated in an attack of convulsions? Such are the questions, which in less time than it takes me to write, or others to read, the intelligent mother will put to herself, and will answer, instead of, in unreasoning alarm, giving all up as lost, or hastening without reflection to do something or other that were better left undone.

The first thing to do in every case of convulsions, be their cause what it may, is to loosen the dress, so that no string nor band may interfere with respiration, and for this purpose strings must be cut and dresses torn. The next thing is to dash cold water on the face to induce a deep inspiration, for sudden death in a fit almost always takes place from interruption to breathing. With the same purpose the forefinger should be put into the mouth, and run rapidly to the root of the tongue, which should be drawn forward. The object of doing this is twofold; first, to prevent the tongue falling back, as in these circ.u.mstances it is apt to do, over the entrance of the windpipe and so producing suffocation, and in the next place the act very frequently puts an end to the spasmodic closure of the windpipe, and is followed by a deep-drawn breath which announces the infant's safety. If the child has cut any teeth, the handle of a spoon, round which a bit of rag has been wrapped, or a bit of wood, or a thin strip of india-rubber, should be put between the teeth as far back as possible to prevent the tongue being bitten; and often this is all that can be done.

There are two circ.u.mstances, and two only, in which the warm bath is likely to be of use. At the onset of one of the eruptive fevers, a hot bath is sometimes of great service by stimulating the skin and thus bringing out the rash. In these cases the fit scarcely ever comes on in a child previously in perfect health, but for some hours at least it has appeared very ill, tossing about with great restlessness, with a dry, hot skin, and twitching of the tendons of the wrists; or, perhaps, with a pale face and cold hands and feet, but with the temperature of the body as high as 103 or 105. Here the hot bath at 96 to 98, even rendered more stimulating by the addition of mustard, and continued for not more than five minutes, is sometimes of great service, and is speedily followed by the cessation of the convulsions and the outbreak of the eruption.

These, too, are the cases in which the use of the wet sheet, as practised in hydropathic inst.i.tutions, is sometimes of great benefit, but I do not advise its employment except under medical advice.

The second condition in which the bath, and here it is the tepid and not the hot bath--that is to say, the bath at from 87 to 90--is of service, is where the child is feverish and restless from over-fatigue or over-excitement, or from exposure to the sun or to an excessively hot atmosphere, and convulsions have come on in the course of this ailing.

Here the tepid bath for ten or fifteen minutes, coupled with the application of cold to the head, will soothe the excitement and prevent the return of the convulsions.

In neither this case, nor in that in which the hot bath is employed, is the result of the agent as magical as people sometimes seem to expect.

It is rarely that convulsions cease while a child is actually in the bath. For the most part the influence of the bath is limited to abating their severity, shortening their duration, and indisposing to their return.

The bath, then, is to be used when either a stimulating or a soothing influence on the surface is likely to be of service, and only then. In cases where the fits are produced by constipation, by improper food, or by the irritation of a tooth pressing against the gum, it is idle to use it, and equally so in instances where many fits have been recurring in the course of the same day. Where that is the case it must be self-evident that, be the cause what it may, it must be one over which either a hot or a tepid bath can have no influence, and that, painful as it must be to wait a pa.s.sive spectator, that position is far wiser than that of a mischievous meddler. It is some consolation, also, to know that unconsciousness to suffering attends convulsions.

There is one agent, chloroform, which often has a very remarkable influence in controlling frequently repeated convulsions. It is an agent, however, too hazardous to be trusted out of medical hands, and even when the doctor administers it himself, the parents must fully recognise the fact that, inasmuch as the child may die during a fit quite independently of breathing chloroform, so the occurrence of that catastrophe during its employment is not to be made a subject of self-reproach to them, or of blame to the doctor.

But you may ask whether there are no _signs_ of that disturbance of the nervous system, by which you can judge beforehand that the occurrence of convulsions is probable. In proportion to the tender age of a babe, the greater is the probability, as I have already stated, that convulsions will be induced by slight causes, especially by such as digestive troubles. Unless you are aware of the phraseology that used at any rate to be common among nurses, you may be much alarmed at being told that the child who had seemed scarcely unwell has been very much convulsed, when all that is meant is that the child has shown some of the signs that threaten convulsions--has had, in short, what in the time of our grandmothers used to be called _inward fits_. A child thus affected lies as though it were asleep, winks its imperfectly closed eyes, and gently twitches the muscles of its face--a movement especially observable about the lips, which are drawn as though into a smile. Sometimes, too, this movement of the mouth is seen during sleep, and poets have told us that it is the angels' whisper which makes the babe to smile--I am sorry that its meaning in plain prose should be so different. If this condition increases, the child breathes with difficulty, its respiration sometimes seems for a moment almost stopped, and a livid ring surrounds the mouth.

At every little noise the child wakes up; it makes a gentle moaning, brings up the milk while sleeping, or often pa.s.ses a great quant.i.ty of wind, especially if the stomach is gently rubbed. When the disorder of the digestion, on whatever cause it depended, is removed, these symptoms speedily subside, nor is there much reason to fear general convulsions so long as no more serious symptoms show themselves. There is more cause for apprehension, however, when the thumbs are drawn into the palm, either habitually or during sleep; when the eyes are never more than half-closed during sleep; when the twitching of the muscles is no longer confined to the angles of the mouth, but affects the face and extremities; when the child awakes with a sudden start, its face growing flushed or livid, its eyes turning up under the upper eyelid, or the pupils suddenly dilating, while the countenance wears an expression of great anxiety or alarm, and the child either utters a shriek, or sometimes begins to cry.

When a fit comes on, the muscles of the face twitch, the body is stiff, immovable, and then in a short time, in a state of twitching motion, the head and neck are drawn backwards and the limbs violently bent and stretched. Sometimes these movements are confined to certain muscles or are limited to one side, and I may add that such cases are of more importance as far as the state of the brain is concerned than those in which the convulsions are general. The eye is fixed and does not see; the fingers may be pa.s.sed over it without its winking, the pupil is immovably contracted or dilated; the ear is insensible even to loud sounds, the pulse is small, very frequent, often too small, and too frequent even for the skilled doctor to count it; the breathing hurried, laboured and irregular; the skin bathed in abundant perspiration.

After this condition has lasted for a minute, or ten minutes, or an hour or more, the convulsions cease; and the child either falls asleep, or lies for a short time as if it were bewildered, or bursts out crying, and then returns to its senses, or sinks into a state of stupor, in which it may either be perfectly motionless, or twitching of some muscles may still continue; or, lastly, it may, though this seldom happens, die in the fit.

It seems then, from all that has been said, that convulsions, though one of the most striking, are by no means one of the most conclusive signs of brain disease; that they are even more commonly the result of disorders of the nervous system from causes seated elsewhere, than of actual disease of what may be termed the great nervous centre.

We may now therefore pa.s.s to the examination of these diseases, which for the purposes of this book may be considered under the two heads of congestion and inflammation.

I am forced to use these terms in somewhat of a popular sense, for to attempt in a little book like this to define everything with strict scientific accuracy would simply confuse and mislead.

CONGESTION OF THE BRAIN.--By _congestion of the brain_ is meant a condition in which its vessels are overcharged with blood; a condition which if it exists in an aggravated degree, ends either in the pouring out of blood on, or into the brain, on the one hand, or in inflammation on the other. Either of these terminations, however, is so rare in the previous healthy child, that I shall confine my remarks entirely to congestion of the brain, an affection specially liable to occur in children during teething. A certain degree of feverishness almost always accompanies teething. It is, therefore, not difficult to understand how, when the circulation is in a state of permanent excitement, a very slight cause may suffice to overturn its equilibrium, and occasion a greater flow of blood to the brain than the organ is able to bear.

Congestion of the brain, however, is not by any means limited to this season, but may occur at other times without any obvious exciting cause, and with no other explanation than is furnished by the well-known fact that all periods of development such as childhood, are periods during which the growing organs are most apt to become disordered.

In the great majority of cases the symptoms of congestion of the brain come on slowly; and for the most part, general uneasiness, or disordered state of the bowels, which are usually, though not invariably constipated, and feverishness precede for a few days the more serious attack. The head by degrees becomes hot, the child grows restless and fretful, and seems distressed by light, or noise, or sudden motion, and children who are old enough sometimes complain of their head. Usually too, vomiting occurs repeatedly; a symptom of the greatest importance, since it may exist before there is any well-marked sign of head affection. Causeless frequently repeated vomiting in a child not ill but ailing, is nine times out of ten a sign of mischief in the head. The degree of fever which attends this condition varies much, and its returns are irregular; but any one who knows how to feel the pulse will find it permanently quickened, and if the head is unclosed the pulsations of the brain may be seen and felt distinctly. The sleep is disturbed, the child often waking with a start, while there is occasional twitching of the muscles of its face, or of the tendons of its wrist.

The child may continue in this condition for many days and then recover its health without any medical interference. This is especially likely to be the case with children while teething, the fever subsiding, the head growing cool, and the little one appearing quite well so soon as the tooth has cut through the gum, but the approach of each tooth to the surface being attended by the recurrence of the same symptoms.

The fortunate issue of these cases though frequent, is by no means invariable, for sometimes they are but the precursors of that formidable, I might indeed say, all but hopeless disease, water on the brain. But even of itself congestion of the brain is by no means a trivial ailment, for it may pa.s.s into a stage in which the smaller discomforts of the child lead to the sad mistake that the condition of the child is improving, instead of which it is really the dulling of sensibility from approaching death. The head, indeed, becomes less hot, the flush of the face grows slighter and less constant; but the countenance is heavy and anxious, the indifference to surrounding objects increases, and the child lies in a state of torpor or drowsiness, from which indeed it can at first be roused to complete consciousness The manner on being roused is always fretful, but, if old enough to talk, the child's answers are natural, though generally very short; and murmuring, 'I am so sleepy, so sleepy,' it subsides into its former drowsiness. The bowels generally continue constipated, and the vomiting seldom ceases, though it is sometimes less frequent than before. In this state, without any apparent cause, the child sometimes has an attack of convulsions, which subsiding, leaves the torpor deeper than before. The fits return, and death may take place in one of them, or the torpor growing more profound after each convulsive seizure, the child at length dies insensible.

Now and then, especially in infants of only five or six months old, recovery takes place even where there seemed almost no ground for hope.

The overfull vessels have at length relieved themselves, fluid has been poured out into the cavities of the brain, the yielding skull has given way under the pressure from within, and should the child after all survive, its large head, due to chronic water on the brain, tells to all who know how to interpret the signs, the tale of its past illness, and the manner of its imperfect recovery.

Cases such as these are obviously beyond the reach of domestic management, and call for all the resources of medical skill. The mistake commonly made is that of calling in the doctor too late, because it is not realised how grave may be the import of symptoms which at first appear so little alarming; and the so-called experienced nurse having said, 'Oh! it's nothing but the baby's teeth,' time is lost and danger not antic.i.p.ated till too late for remedy.

The application of two, three, or four leeches at the very outset of these cases is often of great service, and sometimes cuts short symptoms which had seemed very threatening. The doctor, of course, must be the judge of its expediency, but I refer to it because I have known parents raise objections to it, and beg to have milder means tried first. It must be borne in mind then, that whenever leeches are of use it is at the beginning of an attack, and that the opportunity once let slip does not return. Purgatives, cold to the head, saline medicines, and perhaps some carefully selected sedative, are the measures which will probably be employed in most cases, but success will in great measure depend on the minute care with which all the details which I dwelt on in the introduction, are carried out.

It is not always, indeed, that active treatment is desirable, and gentle measures then suffice; but nothing except close and frequent watching can enable the doctor to steer safely between the two opposite dangers of too little and too much.

When I come to speak of the eruptive fevers, I shall have to mention the convulsions and other signs of most serious brain disturbance, which sometimes occur at their outset, and which are due to the condition of the blood charged with the fever poison.

A somewhat similar set of symptoms, attributed with reason to the overheated state of the blood, occurs in cases of _sunstroke_. It is true that sunstroke, with the formidable characters that it presents in hot countries, is not seen in England, but even here the mere exposure of an infant or young child to an overheated atmosphere, is by no means unattended with risk, and I refer to it here, because mothers are by no means aware of the danger, and believe that it suffices to guard the child from the direct rays of the sun.

Alarm, restlessness, and fretfulness, alternating with drowsiness, hurried, irregular breathing, intense heat of skin, violent beating of the open part of the head, twitching of the limbs, and starting of the tendons of the wrists, with a pulse too rapid to be counted, are the symptoms when the attack is severe. Convulsions are rare, though they sometimes occur. Sickness is almost invariable, the stomach rejecting everything, and the bowels are almost invariably relaxed, severe diarrh[oe]a or dysentery sometimes coming on, as the brain disturbance abates. The first shock may kill the child in a few hours, or it may sink under the subsequent diarrh[oe]a, but as a rule recovery eventually takes place.

All cases, indeed, are not equally severe, but all require careful and gentle treatment, the cool and darkened room, the quiet, the cold to the head, the tepid bath, and on the part of everyone the care not to allow the apparently serious condition of the child to urge them to those active measures which will here be out of place, and destroy the hopes which would revive after a few hours of patience and gentle means.

Really acute inflammation of the brain is of so rare occurrence except as the result of accident or injury, and its symptoms are of so serious a character, even from the first, that medical advice is obviously needed at once. I shall, therefore, pa.s.s it over here, and endeavour to describe two forms of inflammation of the brain which are much more frequent, and at their commencement more likely to be overlooked.

=Water on the Brain.=--One of these is the form of inflammation commonly known as _water on the brain_, a term which, though incorrect medically, has the advantage of being well understood. This, now, is not a simple disease, occurring in a previously healthy child, but it is a disease dependent on the same state of const.i.tution as gives rise in other children to consumption, or scrofula, or disease of the mesenteric glands.

It is this circ.u.mstance which renders the disease so serious, and recovery from it so extremely rare. This it is also which makes it so desirable to become acquainted with its symptoms, both that you may be alive to the approach of danger, and also not indulge in needless alarm when brain symptoms occur from other causes which have no relation whatever to those which give rise to water on the brain.

The disease comparatively seldom comes on in a child who had previously seemed in perfect health; a state of vague ailing usually precedes its outbreak. The child loses flesh and strength, and the look of health, and the l.u.s.tre of the eye, and the silky softness of the hair. The appet.i.te becomes uncertain, the bowels irregular, with a tendency to constipation; there are little feverish attacks for a few hours, subsiding of their own accord. The sleep is not sound, the temper uncertain, the child tires even of its favourite toys; the brightness of the little face is changed for a strange, weird, wistful look--an unnatural earnestness; the child sits for moments gazing upward on vacancy, as though it saw, or sought something beyond.

By degrees these vague premonitions, which may continue for weeks, become more and more marked till they pa.s.s into what may be called the first stage of the affection, in which there are signs of congestion of the brain, such as I have already described, coupled with general irregular attacks of feverishness. The child becomes more gloomy, more pettish, and slower in its movements, and is little pleased by its usual amus.e.m.e.nts. Or, at other times, its spirits are very variable; it will sometimes cease suddenly in the midst of its play, and run to hide its head in its mother's lap, putting its hands to its head, and complaining of headache, or saying merely that it is tired and sleepy, and wants to go to bed. Sometimes, too, it will turn dizzy, as you will know, not so much from its complaint of dizziness as from its suddenly standing still, gazing around for a moment as if lost, and then either beginning to cry at the strange sensation, or seeming to awake from a reverie, and at once returning to its play. The infant in its nurse's arms betrays the same sensation by a sudden look of alarm, a momentary cry, and a hasty clinging to its nurse. If the child can walk it may be observed to drag one leg, halting in its gait, though but slightly, and seldom as much at one time as at another, so that both the parents and the medical attendant may be disposed to attribute it to an ungainly habit which the child has contracted. The appet.i.te is usually bad, though sometimes very variable; and the child, when apparently busy at play, may all at once throw down its toys and beg for food, then refuse what is offered; or taking a hasty bite may seem to nauseate the half-tasted morsel, may open its mouth, stretch out its tongue, and heave as if about to vomit.

The thirst is seldom considerable, and sometimes there is an actual aversion to drink as well as to food, apparently from its exciting or increasing the sickness. The stomach, however, seldom rejects everything; but the same food as occasions sickness at one time is retained at another. Sometimes the child vomits only after taking food, at other times, even when the stomach is empty, it brings up some greenish phlegm without much effort, and with no relief. These attacks of vomiting seldom occur oftener than two or three times a day, but they may return for several days together, the child's head probably growing heavier, and its headache more severe. The bowels during this time are disordered, generally constipated from the very first, though their condition in this respect sometimes varies at the commencement of the disease. The evacuations are usually scanty, sometimes pale, often of different colours, almost always deficient in bile, frequently mud-coloured and very offensive. The tongue is not dry, generally rather red at the tip and edges, coated with white fur in the centre and yellowish towards the root, but occasionally very moist, and uniformly coated with white fur. The skin is harsh, but not very hot, the temperature seldom above 100 Fahr., varying causelessly, but usually higher towards evening than in the daytime. The nostrils are dry, the eyes l.u.s.treless, and _the child sheds no tears_. It is drowsy, and will sometimes want to be put to bed two or three times in a day; but it is restless, sleeps ill, grinds its teeth in sleep, lies with its eyes partially open, awakes with the slightest noise, or even starts up in alarm without any apparent cause. At night, too, the existence of intolerance of light is often first noticed in consequence of the child's complaints about the presence of the candle in the room.

I have purposely dwelt long on this preliminary stage because it is only in it that treatment is likely to be of any service, while the very indefiniteness of the symptoms constantly leads to their being overlooked, or referred to teething, or thought at any rate to be a mere temporary ailment for which it is not worth while to call in the doctor.

After four or five days, however, the illness of the child becomes too marked to escape notice. All cheerfulness has fled, the eyes are closed to shut out the light, the child lies apparently dozing, but answers questions rationally, in a short quick manner in as few words as possible, and from time to time complains of its head, or utters a short, sharp lamentable cry. The night brings with it no other change than an increase of restlessness, attended sometimes with noisy cries, or with the wandering talk of delirium. Sickness often diminishes, but the bowels continue constipated, and it is to be noted that whereas in fevers the bowels are distended with wind, here all wind has disappeared and the belly is sunken to a striking degree.

Next comes the last stage. Each stage is distinguished by peculiarities of the pulse which tell the expert what is pa.s.sing; quick and regular in the first stage; irregular and slower in the second; quick, variable, irregular from time to time in the third; growing more rapid and more feeble as the end arrives. Squinting, stupor, dilated pupil, difficulty of swallowing, tremulous limbs, convulsions, profound insensibility, such are the series of occurrences which bring on death usually within a fortnight, always within three weeks from the appearance of the first decided symptoms.

What are you to do in these cases? Above all save yourselves the heartbreak of feeling that you have overlooked the premonitory symptoms of the disease. Guard with special care the health of any child in whose family a disposition to consumptive disease has ever shown itself, and keep it at any cost from the risk of catching the hooping cough or measles. Since, too, it is not in early infancy, but after the age of one year, and in the majority of instances between the ages of three and six years that this disease occurs, that is to say, at the time when the brain begins to be most actively exercised, when the new world on which the child is just entering brings with it new wonders every day; be very careful not to over-stimulate its intelligence, over-excite its imagination, or over-strain its mental powers. After the age of ten the great danger is over; up to that time it is the health of the body which requires care; not fuss, not rearing like a hothouse plant, but the healthy training that may fortify the system.

When any signs such as I have described indicate the threatening of disease, do not look on them as within the scope of domestic management, but place the child at once under the watchful care of a skilful doctor.

I have seen but one recovery in all my life, after the disease had fully set in, and that was a recovery almost worse than death.

=Earache.=--There is another form of inflammation of the brain which is likewise oftenest met with in children who are of weakly const.i.tution, or of scrofulous habit, or in whom scarlet fever has left behind that very troublesome ailment, discharge from the ear. This is so tedious, so difficult to cure, so apt to return under the influence of very slight causes, that people are too ready to put up with it as an inconvenience which it is useless to try to remedy.

In addition, however, to the risk of the child's hearing being impaired by the extension of the mischief to the internal ear, there is another still greater danger, namely, that of the _disease pa.s.sing from the ear to the brain_, and producing inflammation of its membranes, or even abscess of its substance.

It is therefore of the greatest moment that every case of chronic discharge from the ear should be looked on as important, and that no pains be spared to bring about its cure; and further, that during its continuance the slightest sign of disturbance of the brain--headache, sickness, feverishness, and dulness--should at once be noticed, and the advice of a competent doctor be immediately sought for.