or that anything had occurred to diminish its chances of surviving its early difficulties.

Something of the same kind is occasionally observed, when, in the course of an attack of bronchitis or pneumonia, a large extent of lung becomes suddenly collapsed, and the amount of breathing surface thus considerably lessened. This is liable to happen in proportion to the tender age of the infant.

Another class of cases in which disorder of respiration may be followed by sudden death, is where serous effusion takes place suddenly into the cavity of the pleuræ.

In other cases the sudden death is to be referred to asthenia, or to a want of nervous power to keep the vital functions in activity. This is apt to be the case in severe attacks of diarrhoea; or when, in early infancy, a too active treatment has been pursued for the cure of bronchitis or pneumonia; or when due care, in such cases, has not been taken to provide for the sufficient nourishment of the patient. The danger is the greater in proportion to the tender age of the patient, and when frequent relapses of the diarrhoea occur.

It is very rare that after sudden death in early life any important lesion of the brain is to be discovered. This, Dr. West believes, may be accounted for, from the fact, 1st, That in early life the vessels of the brain have not undergone those changes by which, in after life, their coats are rendered brittle, and thus disposed to give way. 2d. That the unossified skull, while it allows, during infancy and early childhood, of greater fluctuation in the quantity of blood circulating through the brain than is possible when ossification is complete, yet, at the same time, renders such changes far less serious; the yielding fontanelles and unclosed sutures, allowing of the ready adaptation of the organ to its varying contents. Even the actual effusion of blood into the cavity of the arachnoid seldom causes immediate death. It is oftener the first step in the production of hydrocephalus, which may last for months or years. Dr. West's general conclusions are

"1st. That in the great majority of instances, when death suddenly befalls the infant or young child, it is an accident, and not a neccessary inevitable result of any disease from which it is suffering.

"2d. That the danger of this accident happening, may often be foreseen, and that such foresight is not hard to attain by any who will cultivate the habit of minute observation."

Dr. West concludes, that as small things portend the danger, so small things go far towards warding it off. Food, warmth, posture, quiet-little matters such as these often turn the scale upwards or downwards. Many an infant's life has been saved or lost by observing or neglecting things which are too apt to be lost sight of as utterly beneath the dignity of science.

CHAPTER IV

SEMEIOLOGY OF THE DISEASES OF INFANCY AND CHILDHOOD.

THE detection and diagnosis of disease in the infant is based, the same as in the adult, upon a careful examination and analysis of its various phenomena. In the infant, the occurrence and extent of these phenomena must be derived, altogether, from an attentive observation on the part of the physician, compared with that of the parents or nurse. From the little patient he can derive no other information than such as is expressed by the countenance, the posi tions of the body, the motions of the head, trunk, and limbs, the nature of the cries emitted, and the condition of the respective organs, as indicated by the regularity of their functions, or the extent and manner in which these are disturbed.

In the infant, the condition of the skin, the state of the various secretions and excretions, the appearance of the eye, the manner in which respiration is performed, have the same amount of value, as indications of the seat, nature, and extent of morbid action, and are as readily detected as in the adult. But, in the infant, the physician can derive no assistance in forming his diagnosis, from the character and location of any pain or other uneasy sensation the patient may experience consituting, in many cases of disease, an important pathological feature-excepting from the external physiognomy peculiar to the various grades of suffering that occur in the different

organs.

It is this physiognomy of suffering, as derived from the expression of the face, the cries, and the movements, which constitutes, in a great measure, the special semeiology of infantile diseases. M. Jadelot has attempted to present a correct exposition of the indications of disease, as founded upon the expressions of the countenance, from the period of the first dentition until puberty: his remarks, as furnished us by M. De Salle, in his edition of Underwood, are certainly interesting, but, in many respects, they are purely hypothetical.

The general phenomena of disease in infancy, notwithstanding they experience certain modifications, dependent upon the peculiar state of the organization, differ, nevertheless, but little from those observed in the adult. There are, however, a few morbid phenomena that are peculiar to the infant; and others, which, in the correct diagnosis of disease, have an importance far beyond what they possess in after life.

As a preliminary to the study of the semeiology of the diseases of infancy, it is essential that the physician should make himself fully acquainted with the external appearance usually presented by an infant during health: the expression of his countenance, the atti

tudes of his body, as well as with the physiological condition generally, at the different stages of development of his several organs, and of their respective functions. It is only from the nature and extent of the deviations from the normal standard, that, in many cases, he will be enabled to appreciate the value of the morbid phenomena that exist, either individually or collectively.

It is but within a very short period that the physiology of infancy, and the manner in which its organism is developed, have been accurately investigated; and it is curious that not a few of the phenomena which writers on the diseases of the early stage of existence, of no very remote date, described as important indications, or as results of morbid action, are found to be invariably present in the infant during health.

We have already presented a brief sketch of the condition of the different organs, during infancy, and the manner in which their respective functions are successively brought into action. We need here only remark that, in the healthy infant, the limbs are uniformly covered with flesh, rounded and plump, and, to the touch, present a certain feeling of firmness and elasticity. The skin is soft, flexible, and of a rosy hue. The complexion lively and fresh. The eye, when attracted by any object, has a peculiar quickness and suddenness in its movements. The pupil is usually large when the infant is awake, but often minutely contracted during sleep; and always more or less turned upwards, beneath the upper eyelid. The countenance, when in repose, exhibits, in the earlier stages of infancy, but little or no expression, except that of perfect calmness. At a later age, it becomes quickly lighted up, smiling, and animated, upon the approach of its parents or nurse, or when attracted by any pleasing object. The surface of the infant is cool; the abdomen full and soft -gentle pressure upon it seeming rather to please, than to cause the slightest uneasiness. The tongue is generally slightly covered with a whitish mucus; the mouth is always moist, and the lips freshcolored, and often protruding.

The sleep of the healthy infant is quiet and profound: it awakes from it cheerful and smiling, and soon demands food. During its waking hours, after, at least, the first month or two, it is inclined to as much activity as its limbs will permit, and exhibits a surprising springiness and rapidity in all its movements. It delights to be played with and carried about, and, when old enough, to roll and crawl about upon the carpet.

In health, infants seldom cry, excepting to express their wants, or in consequence of experiencing some accidental uneasiness or pain, and are immediately quieted upon their wants being gratified, the cause of their uneasiness removed, or their pain appeased. Crying is not, however, always the indication of either ungratified wants, pain, or disease. Some infants cry repeatedly, being with difficulty appeased, without our being able to detect any apparent cause of suffering, and without any interruption to the full nutrition, and regular development of their bodies.

Every deviation from what we have just given, as the picture of a

healthy child, is not, however, to be considered, of itself, an indication of disease. The limbs of an infant may exhibit a certain degree of meagreness-its complexion may be somewhat pallid-its sleep short, or occasionally restless-or many of its waking hours may be passed in crying, without the existence of any positive disease. All changes, however, occurring in an infant, either suddenly or gradually, whether in the ordinary expression of its countenance-in the condition of its body-its habits or disposition-should be looked upon with a suspicious eye, and be the signal for a careful examination into the condition of its several organs; in one or other of which some commencing disturbance will, in general, be detected.

Whenever there is observed in an infant any marked alteration in the countenance, or in the external appearance of the body—an unwonted dulness of the eye-an indisposition to playfulness-a loss of its accustomed gayety-unusual listlessness-disturbed sleepuncommon wakefulness-sudden starting in slumber, or awaking with apparent affright-an unusual degree of somnolency-the occurrence of sudden paleness of the face, or paleness alternating with a suffusion of red, more or less deep-increased heat of the hands and feet, or of the entire surface-unusual coldness of the extremitiesunaccustomed fretfulness-frequently repeated or prolonged fits of crying, or a marked change in the character of the cry-frequent or constant corrugation of the brow-twitching of the muscles of the face-rejection of the breast or of food-unusual movements of the head and limbs-and crying or moaning when the body is moved or handled, are invariably to be considered as the indications of nascent or confirmed disease.

No disturbance or irregularity of function occurring in an infant, however slight, should be considered as unimportant. The suddenness with which some of the most violent affections of this period of life are developed, and the rapid occurrence of effusion or of disorganization in the tissues and organs in which morbid action is seated, give to every indication by which the inception of disease can be detected, even a greater degree of importance than in after life. In their commencement many of the maladies of infancy may be promptly arrested by simple remedies, that, if allowed to become fully developed, are scarcely within the control of the most judicious and active plan of treatment.

A slight irritation of the gastro-intestinal mucous membrane of the infant will often, by being suddenly reflected upon the brain, give rise to a violent convulsive attack, or produce some other and equally serious train of symptoms, which might have been prevented by the early detection and removal of the primary irritation. Not a few, also, of the maladies that occur during infancy, give rise, during their first stages, to so few prominent symptoms, that their existence is often unsuspected, until disorganization of some important organ has taken place, or a sympathetic affection of the brain occurs, and their character and extent are thus revealed, at a period when their cure is impossible. Even in these insidious forms of disease, by a close attention to the countenance, manners, and

gestures of the little patient, the physician will seldom fail to detect the presence of morbid action, and make out, with sufficient accuracy, its diagnosis, at a period when it is still within the control of appropriate remedial agents.

The principal sources of diagnosis in the diseases of infancy, are the expressions of the countenance-the gestures-the phenomena of sleep-the mode in which respiration is effected-the cry-the condition of the tongue and mouth-the condition of the surfacethe state of the breath-the evacuations.

1. Of the Countenance.

The infant's countenance offers to us the most interesting and the most intelligible page in Nature's book. In its calm, we read the health and ease of all the organs-of all the functions. In its smiles, we read the happiness of body and of mind. In its expressions of uneasiness or pain, we first discover the invasion of disorder or disease. Our attention will probably be first attracted by some undefined change, which it will require a stricter observation to decipher, and associate with its peculiar cause. (Hall.)

Although we cannot go as far as does M. Jadelot, and assert that. from the movements of the infant's face, we may determine the location of its diseases, in one or other of the great splanchnic cavities the disturbed expression of the upper part of the face, the forehead, eyes, and brows, indicating disease of the brain, or of the nervous system; the altered features of the middle portion of the face, particularly of the nose, being indicative of affections of the thoracic organs; while the expression of the lower part of the face, the mouth and lips, point to the abdominal region as the seat of morbid action; yet we are convinced that, from the condition of the countenance alone-often from some indescribable expression of suffering the observing physician will be able to detect, at once, the existence of disease, and not unfrequently to determine its location.

In most of the diseases of the alimentary canal, the face of the infant is pallid, and exhibits a very peculiar expression of fretfulness or peevishness-excepting when these diseases give rise to febrile reaction, during the exacerbations of which, the face is more or less flushed. In many of the chronic affections of the digestive organs, especially when attended with disease or functional derangement of the liver, the face and surface generally acquire a dirty brown, or a deep yellow hue.

Great paleness of the face, if accompanied with diminished temperature, or alternating suddenly with flushing and heat, is often the indication of exhaustion, as from profuse diarrhoea. It is likewise frequently observed previously to the occurrence of convulsive. attacks, or of acute meningitis.

In extreme cases of exhaustion, particularly from profuse evacuations from the bowels, as in protracted cases of cholera infantum, the cheeks are cold and pallid, and of a waxy appearance; the eye