redness is an indication of inflammation, or warns us to look for one of the eruptive fevers: a pale, doughy, or puffy condition, with emaciation, bids us take defensive measures against scrofula and tuberculosis: intense blueness may arise from any cause interfering with the oxygenation of the blood, or from cyanosis: yellowness from some affection of the liver: a dirty, sallow hue may be produced by diarrhoea, or any protracted disease of the abdominal viscera: and a tawny, muddy coloured skin is indicative of syphilitic taint.

The "tache meningitique, ou tache cerebrale," has been pointed out by M. Trousseau as a red mark or stain, easily produced by pressure upon the skin of children suffering from tubercular meningitis. This mark is most readily made upon the face, neck, or chest; and though most common in cases of this kind, it has also been observed in congestion of the brain, in pneumonia, &c. Dr. Baines suggests that it is due to some altered relation between the supply of nervous power to the capillaries and the circulation, allowing of a ready dilatation of the superficial vessels when any irritation is applied to the skin.

7. The Temperature of the body is a valuable aid in the diagnosis of disease, but to be of any avail the rough-andready method of estimating it by the hand alone will not suffice. For this purpose properly constructed thermometers are necessary, and they are fortunately now available in a very cheap and portable form. The information they afford is often of the utmost value and importance, and no careful observer will be content to treat severe cases of acute disease without using this means of investigation. For all purposes the axilla is probably the best position in which to place the instrument, and it should be allowed to remain there for at least ten or twelve minutes. It appears, however, from Dr. Baumler's investigations, that the length of time necessary for an observation varies according to the locality tested: thus if the thermometer be placed in the rectum, from three to six minutes will be required; if in the mouth, from nine to ten or twelve minutes; and if in the axilla, from eleven to twenty-four minutes. The registering form of thermometer is the best to use.

In children, the average temperature in health is about 99.5, and according to recent observations it appears that a temperature of 102° in the upward direction, or of 97-5 in the downward, is a sure sign of mischief, and any excess in either direction may cæteris paribus be taken as a fair test and standard of the morbid action: probably the indications it affords are more really trustworthy than those derived from the pulse.

According to our experience, an increase to 102° or 103° signifies only a moderate degree of febrile disturbance; a constant rise to 105° implies severe disorder; 106° to 107° denotes danger, and 109° or 110° is indicative of extreme danger.

The observation of the temperature is of the greatest value in cases of continued fever, in the eruptive fevers, in pneumonia, rheumatic fever, tuberculosis, &c. And in regard to prognosis we may observe, that a persistent fall in the temperature is at all times most favourable, but especially so if it be towards evening; always supposing that other symptoms are not more grave, but the reverse. If the temperature falls while the pulse rises, and other symptoms are aggravated, the patient is losing ground, probably from exhaustion, and stimulants are required. Death is always preceded by a fall in the temperature. It is supposed that an increase of one degree in the temperature above 100° is equal to the rise of ten beats of the pulse per minute. According to M. Roger, pneumonia and typhus fever are the diseases attended with the greatest rise of temperature. Thus, if the pulse and respiration be quickened, and the temperature raised to 104°, inflammation of the lungs may be diagnosed; while the same degree of heat, with a moderate pulse, is peculiar to typhus. According to Wunderlich, in favourable cases of typhoid fever the rise in temperature during the first and second weeks, is very gradual, and is always highest in the evening, if the rise be rapid and high in the first week, or if the temperature varies much, it is a bad sign. In peritonitis or enteritis the temperature is said seldom to reach 104°.

Rigors do not occur in young children, even when suffering from intermittent fevers. M. Bouchut states that he has observed the commencement of an attack of intermittent fever in several children under two years of age, and not one experienced shivering; the cold stage being only outwardly betrayed by a considerable paleness of the face, by decoloration of the lips, and by a manifest bluish tint beneath the nails.

The Respiration.-The new-born infant breathes instinctively, without method or regularity: when about two years of age the respirations become more regular. The younger the child, the less the chest dilates during inspiration, and the more freely do the muscles of the abdominal wall and the diaphragm act; hence the respiration is said to be abdominal. The respiration is most tranquil during sleep, is repeated about thirty times a minute, and the movements of inspiration and expiration succeed each other without effort. On awaking the breathing is

altered; for a time being calm and easy, then intermittent and hurried, and again free and tranquil.

The average frequency of the respiration in early infancy is about 39, but it may rise from merely transient excitement to 80; as age advances the frequency diminishes somewhat, but seldom falls below 30 during childhood.

The chests of children at the breast are but slightly resonant on percussion; and on auscultation, the respiratory bruit is heard, faint and feeble, owing probably to the incomplete dilatation of the air-cells. After this period, as the rarefaction of the pulmonary tissue becomes greater, the resonance increases; while the respiratory murmur becomes sonorous and roaring— puerile respiration.

All diseases of the glottis, larynx, and trachea are attended with difficult and noisy respiration; they are also accompanied with cough, which is hoarse and spasmodic in inflammation of the glottis, ringing in laryngitis, and crowing in croup.

In bronchitis, pleurisy, and commencing pneumonia, the breathing is merely hurried, the cough hacking and dry, and unaccompanied with expectoration: as the severity of the inflammation increases, however, the rapidity of the breathing becomes augmented, so that, in confirmed pneumonia, the respiration may be termed panting, from sixty to eighty inspirations being made in the minute. At the same time there is rapid dilatation and contraction of the nostrils, violent moist cough, and copious secretion; the matter secreted is, however, generally swallowed, so that we are unable to aid the diagnosis by its examination. When the pain in pleurisy is acute the respiration has the peculiar character of being restrained—i. e., it is suddenly stopped at each effort by a kind of convulsive spasm. In peritonitis, also, the inspirations are short, jerking, and difficult, owing to the pain to which all movement of the abdominal muscles gives rise.

As regards the value of auscultation in the pulmonary affections of very young children, we need only here mention that though in many such cases it is of comparatively little value, while in all, less reliance can be placed upon the signs derived from its practice than in the diseases of the adult; yet at the same time no diagnosis can be complete without a careful chest examination in cases presumably of a pulmonic character.

In some cerebral diseases the respiration is sometimes irregular, short and jerking, at other times sighing; the effect being as though the respiratory muscles were subject to a kind of convulsive action.

The Circulation.-Authors who have paid attention to the

frequency of the pulse in children at the breast have not all arrived at the same conclusions. Thus, Haller fixes the number of beats at 140 a minute; Sommering, at 130 or 140 the first year, 120 the second, and 110 the third; Billiard observed a minimum of 80, and a maximum of 180, in thirty-nine infants from one to ten days old; while M. Trousseau found a minimum of 96, and a maximum of 152, in children of from fifteen to thirty days.

From a careful examination, however, of much that has been written upon this subject, and from our own experiences, we believe we are justified in making the following observations: 1. In young infants, no signs can be deduced from the fulness or hardness, the strength or weakness, of the pulse, since generally these distinctions cannot be even recognized. 2. The pulsations are often irregular, without any disease being present.

3. They are very frequent, the normal quickness varying from 100 to 120 a minute; the average frequency being about 104 for children under five years of age. 4. They diminish gradually as the period of weaning approaches, continuing to do so until adult age, when they are about 80.

5. Sex has no influence up to the age of seven years, after that the female pulse becomes slightly quicker than that of the male.

6. Sleep lowers the frequency by about eighteen or twenty beats per minute, and makes it also more regular.

In estimating the value of the indications derived from the pulse it must be remembered that the heart's action is more variable in infancy than at any other period of existence, and that moral impressions' quicken the pulsations as much as fever or inflammatory disease.

There are some peculiarities of the pulse which undoubtedly possess a diagnostic value in certain diseases. Thus, in acute hydrocephalus it is characterized by irregularity of rhythm, with occasional intermission; it may vary in a short time from 80 to 150. In pulmonary inflammations the pulse respiration ratio is disturbed, the breathing being quicker in proportion than the pulse, for instead of the former being as 1 to 3 of the latter, it may be as 1 to 2, or even as 1 to 1. A rapid pulse is indicative of fever only when there is also increased tempera

ture.

Discharges by Vomiting and Stool.-Infants frequently vomit from mere repletion, a greater quantity of milk having

been sucked than the stomach can digest. In such cases the milk is brought up unchanged, or partly coagulated.

Any disturbance of the process of digestion will induce sickness. Repeated vomiting, however, shows that the cause is more than temporary, and should be sought for. It may be due to improper food, to indigestion, to disease of the stomach or intestines, or to disease of the brain. The vomiting in the latter is often very peculiar and noteworthy; it is sometimes one of the earliest symptoms; is altogether irrespective of food being taken, often very persistent, and when apparently causeless should always excite suspicion in children of three or four years of age and upwards, especially when of an intractable character. Some of the eruptive fevers-particularly scarlatina-are ushered in by vomiting; so is infantile diarrhoea or cholera. Very often inflammation of the lungs or pleura begins in the same way. The paroxysms of hooping-cough are frequently terminated by a fit of vomiting. As children usually swallow matters secreted from the bronchial tubes, they are often again ejected with the contents of the stomach.

During the whole period of infancy and childhood the evacuations from the bowels are more frequent than in after-life. Diarrhoea, moreover, is readily induced by any excess in the quantity, or any fault in the quality, of the food, or by any irritation or inflammation of the alimentary canal, or by the irritation of dentition.

The first stools after birth-called the meconium-are of a dark-green or black colour, very viscid, and have an odour resembling that of the perspiration. Subsequently the evacuations become of a light-brown or yellow hue, of a curdy consistence, and free from odour. Frothy, acid motions, of a pale-green colour, indicate some disturbance of digestion; discharges of slimy mucus are common during dentition, or when worms are present in the intestines; thin, foetid, dark-brown stools signalize chronic diarrhoea: and lastly, a dark-green colour of the discharges generally indicates serious disease of the stomach or intestines.

Constipation is not common in infancy. It may arise from the quality of the mother's milk, or from the food administered, from the exhibition of soothing syrups containing opium, or from some derangement of the liver preventing the free secre

tion of bile.

The Urine.-The examination of the renal secretion affords but little information in the diagnosis of the disorders of early life, moreover it is obtained with such difficulty that nurses are seldom able to procure a specimen. Still, it is necessary to