sallow and sunken, the mouth retracted or drawn, and the lips colourless or brown. eye In addition to the above there are, according to M. Jadelot, and we have ourselves verified his observations in many though not in all points, certain well defined lines or "traits" in a child's face which may be taken as roughly indicative of disorders of the several viscera. For instance, a line called by him the oculozygomatic, which runs from the inner angle of the downwards and outwards to the malar bone, was regarded by him as indicative of cerebro-spinal disease, actual or sympathetic. A second, called the labial, running from the angle of the mouth downwards and backwards, he considered was indicative of pulmonary disease. A third, called the nasal, springs from the upper margin of the alæ nasi, encircles the angle of the mouth, and is there joined by another line called genal, which springs from the malar bone; this line indicates disorder of some of the abdominal viscera. In acute affections of the brain or meninges, the face is generally flushed, turgid, and hot, or the colour is intermittentthe redness being fugitive and followed by pallor; the eyes are vacant or staring, and often a good deal suffused, sometimes the upper eyelid cannot be voluntarily raised, and the eye is half open, or there may be strabismus; in the early stage the pupil is contracted, but becomes dilated as the disease advances; in the later stages, owing to the rapid emaciation, the eyes become deeply sunken in their sockets; the upper lip is drawn firmly over the gums, and is of a livid hue; and, at times, there are convulsions of all the features. The deformity produced by chronic hydrocephalus can hardly be mistaken, the disproportion between the size of the cranium and face, with the raised and bulging forehead, at once attracting attention. Similar changes to those mentioned above in regard to the eyes sometimes occur from intestinal irritation, as from worms, &c. Diseases of the organs of respiration, as laryngitis, bronchitis, or pneumonia, produce a dusky-red, swollen appearance of the features; wide dilatation of the nostrils during each inspiration, and strong contraction with each expiration; knitting of the eyebrows; and lividity of the lips, which, moreover, are widely opened to facilitate respiration if the breathing be much oppressed. Should the disease assume a chronic form, the features will become emaciated, and present an appearance of decrepitude. The expression of countenance produced by disorders of the abdomen is mostly characteristic; it being difficult to mistake the cause of the peculiar peevish or fretful look, sharp pinched features, sunken eyes, pallor, and dark colour of the lips and skin surrounding the mouth. In severe forms of gastrointestinal inflammation, the face rapidly becomes sallow and emaciated; the lips are stretched firmly over the gums, and are pale, dry, and cracked; the chin seems to project unusually; and the nose looks swollen. In chronic irritation of the bowels from worms, the nose and upper lip are often tumid, the conjunctiva is said to look pearl-like, the skin assumes a dusky, muddy appearance, and the pupils are often a good deal dilated, it is said by a kind of reflex paralysis. In weakness and exhaustion from diarrhoea, or from loss of blood, &c., the face is alternately flushed in patches and pale, hot and cold: while, in very extreme cases, the cheeks are pallid, cold, and glistening; the eyelids half closed; the corneæ covered with films of mucus; and the pupils contracted. The form of the face differs much in certain constitutional disorders thus, in tuberculous subjects it is oval, thin, with a clear complexion, bright eyes, long and fine hair and eyelashes; in scrofulous subjects the face is rather rounded, fat, complexion muddy, skin thick, lips and alæ of nose pouting; in rickets the face is small, but broad, the forehead square, the eyes dull and languid looking, complexion pasty, skin thick and sometimes hairy. It only remains to remark that the countenance is of a yellow hue in icterus or jaundice; livid, when the blood is improperly aërated; and of a deep blue or purple in morbus cæruleus, in which affection a malformation of the heart allows of an admixture of the venous with the arterial blood. The lachrymation, redness of the eyes, and swelling of the eyelids, which precede the eruption of measles, will not be forgotten by one who has witnessed these premonitory symptoms; and the same statement applies to the brilliancy of the iris and extreme contraction of the pupil in a child who has taken an over-dose of opium. 2. The Gestures and Attitude.-In children old enough to be playful and easily amused when awake, the commencement of disease is frequently signalized by their ceasing to be attracted by surrounding objects, by their listlessness and dislike of any movement, by their generally saddened expression, and their dislike apparently to take the trouble even to smile. As indisposition creeps on, the child begins to give evidence of its uneasiness by frequent startings and general restlessness, especially in its sleep: if it has begun to support itself—to hold up its head-it perhaps ceases to do so, at the same time it begins to assume the posture and movements of extreme languor; all this clearly indicates that muscular debility which so commonly precedes an attack of acute disease. If a child has arrived at the age of fifteen or eighteen months without being able to hold. itself upright, we shall probably find it suffering from rachitis, which will be indicated also by deformity of the thorax, curvature of the spine, weakness and bowing of the lower extremities, and other external characters, which will be afterwards enumerated. The pain of inflammatory affections often causes the child to avoid all movement, and, in inflammation of any part of a limb, all motion of the affected member. In severe abdominal irritation or inflammation, the child lies with the knees bent and drawn upwards, rolling about, however, and uttering loud cries on the sudden accession of pain. An acute spasmodic pain induces immediate contraction of the whole of the muscles, the infant starting in terror and surprise. In convulsions the head is drawn backwards, one or both arms. become rigid, and the legs are drawn upwards or violently extended: at the same time, the breathing may be spasmodically affected, hurried and irregular, the thumbs and fingers may be drawn into the palms of the hands, while the toes are firmly flexed. Sometimes only one set of muscles is affected, or one side of the body only is convulsed. The eyes are generally fixed, or roll about, and are insensible to light and even to touch. In great prostration from any cause the child lies motionless, or one side of its body may be paralyzed. There are some few gestures which point at once to the seat of the disease: "as the tongue speaketh to the ear, so the gesture speaketh to the eye." Thus, in inflammation of the brain or its membranes, the hand is frequently raised to the head, attempts are made to tear off the cap, and a quick movement, as of striking the air, is performed, while the head is rolled from side to side as it lies on the pillow. In disorders of the tongue or fauces, and during dentition, the child presses its fingers into the mouth, or seizes the mother's nipple roughly and greedily, or rubs the gums with anything it can get hold of. In croup and other diseases producing difficulty of breathing, it pulls at its larynx, tries to compress it laterally, and by its urgent cries indicates the seat of suffering and pain. Sometimes all this is relieved when the child is placed in an erect position. Lastly, there are the convulsive movements of the muscles of the face so common during dentition, or when any irritation of the digestive canal exists; and the involuntary and tumultuous movements which betray chorea in the more advanced child. These latter, however, need no description. 3. The Sleep of a healthy child is tranquil, deep, and pro longed, its countenance at the time being calm and quiet, a smile sometimes passing over it; its breathing is slow and occasionally interrupted by deep inspirations or sighs, and its limbs are relaxed; on waking it is lively, and seeks the breast. In disease, on the contrary, the rest is disturbed and broken, the respiration may be loud and laboured, the brow contracted or the mouth drawn, there is grinding of the teeth or gums, sudden startings occur, and the child wakes either fretful and peevish, or-if frightened-to cry and scream. For the first few weeks after birth infants pass much of their time in sleep, during which the skin is moist and the digestion. energetic. As the system is slightly enfeebled during sleep, and the power of maintaining the animal heat lessened, care should be taken to shield them from draughts, cold, &c. Any irritation in the bowels or brain, or any slight degree of uneasiness or pain, will prevent sleep or make the child fretful and disturbed; during convalescence from acute disorders there is also very frequently troublesome sleeplessness. On the other hand, somnolency is often produced by overloading the stomach, by serious cerebral disease, and sometimes by dentition. A strong indication of a tendency to convulsive disorders is evidenced by a rigid extension of the limbs, with a turning inwards of the great toes and thumbs during sleep. 4. The Cry.-Often the first indication which an infant gives of life is to cry, and the more loudly and freely it does so the better; since it proves that the most important of the vital organs are well formed, and that the child is not deficient in health and vigour. After the first few hours of existence, however, the properly-nursed healthy infant cries but little; the act of crying, being, as it were, reserved to express pain, distress, or hunger. Violent paroxysms of crying are generally produced by great pain; and when prolonged become injurious, causing conjestion of the brain, and sometimes convulsions. In affections of the lungs-especially pneumonia-the cry is said to be laborious, or smothered-i. e., it is rather a groan than a cry; in croup it is hoarse and muffled, and attended by a peculiar ringing sound, or crowding inspiration: in œdematous angina-according to Billard-it is tremulous. In acute cerebral diseases there is sometimes a single sharp, powerful cry, occurring at rather distant intervals, which has been termed by the French the cri hydrencéphalic. Lastly, in most diseases of the stomach and intestinal tube the cry is prolonged and acute, or low and moaning if they have produced much exhaustion. In young children the cries are often accompanied by an abundant secretion of tears, but this it not the case with infants until about the third or fourth month; since the functions of the lachrymal gland are not brought into play until this time. Hence, when no tears are shed, we must consider whether this be due to the age of the little patient or to the functions of the lachrymal gland having been suspended by acute disease. M. Trousseau believed that in acute disease in children, no matter how severe the symptoms were, if tears were shed the prognosis would be favourable, while on the other hand, if no tears are shed, and especially if the eyes are sunken, then the prognosis is unfavourable. The younger the children the more certainly is this rule observed. 5. The Mouth and Breath.-In health, the mouth is moist and pale, the tongue smooth and partially covered with a layer of whitish mucus, the gums red, and the breath free from smell or having only the odour of the mother's milk. These conditions are altered by slight causes: the mouth may become hot, red, and dry; the tongue loaded with a white, curdy matter; and the breath hot, sour, or acid. This is especially the case in fevers, in acute affections of any of the important viscera, in diseases of the alimentary canal, and in painful dentition. In severe cases of small-pox, scarlatina, measles, laryngitis, and croup, the tongue often swells, and becomes covered with a dark brown fur. In scarlatina, the tongue is loaded with a thick white fur, through which enlarged and prominent papillæ project; but, as the fur clears away, it becomes clean and preternally red, and of a strawberry appearance. Aphthæ of the mouth, throat, and tongue, are common in infants; they may be due to improper food, to impure air, to the irritation of dentition, or to more serious causes. The breath may be rendered fœtid by attacks of fever and by indigestion; it becomes positively foul in gangrene of the cheek or lungs, or in severe ulcerations about the nose or throat. 6. The Skin in the healthy infant should be firm, elastic, and smooth, of a rosy flesh colour-neither too red nor too pale-moist and warm, and uniformly distended by soft subcutaneous areolar tissue and fat. Whenever it becomes hot and dry, or pale and flabby, or yellow or intensely red, we may be sure all is not right: moreover, the slightest eruption should attract attention, and, if it be contagious, the parents should be warned. A hot, harsh, dry skin is common to all febrile and acute diseases; a cold, moist one to constitutional feebleness, or to sclerema, or to disorders producing great prostration: increased |