are frequently conjoined nausea, restlessness and tossing of the limbs, transient delirium; a breathing which is irregular, sighing, and, at last, gasping; and convulsions before the scene closes.

FIG. 7.-Face after Hæmorrhage. (Modified from Corfe.)

The expression of the countenance is typically marked in certain of the inflammatory diseases of the eye.* In strumous ophthalmia, the child's brow is knit and contracted, while the ala nasi and the upper lip are drawn upward. Those muscles which tend to exclude the light from the inflamed organ, without shutting out the perception of external objects, are called into action; thus producing a peculiar and distinctive grin. In severe cases, the child will sulk all day in dark corners, or, if compelled to stay in bed, will bury the face in the pillow, since the exclusion of all light tends greatly to diminish the suffering. If brought to the window, the eyes are shaded with the hands or the arms;

LIBRARY

GENERAL LI

University

MICHIGAN

1881.]

RANNEY, The Human Face.

99

and, if the eye be opened, a profusion of hot, scalding tears will enter the nose and give rise to sneezing, or flow over the face and cause excoriation of the adjoining parts. This special intol erance of light seems to be a chief characteristic of this type of trouble, since it is often greatly out of proportion to the redness which indicates the extent of the inflammation present. In catarrhal ophthalmia, the inflammation seems to be confined to the conjunctiva and the Meibomian follicles. The eyelids are glued together by the lashes, which are bathed in the excessive secretion of the conjunctiva or of the inflamed follicles; and a redness of the surface of the eye, with some pain and uneasiness, is the only other symptom of special diagnostic value.

The deformity of iritis is characterized by a redness of the sclerotic; a change in the color of the iris, and in its general appearance, as compared with the healthy eye; an irregularity in the pupil, produced by adhesion of the iris to the adjacent structures; possibly immobility of the pupil, as the result of such adhesions; and a visible deposit of coagulable lymph. The pupil, in acute iritis, seldom dilates in the dark, on account of the intense congestion which exists;* and it is usually smaller than that of the unaffected eye. Some pain and excessive photophobia are usually also present in attacks of acute iritis. There is something very peculiar in the expression of the countenance of a person suffering from amaurosis, by which alone the physician may almost recognize the disease. Such a patient enters a room with an air of great uncertainty as to movement; the eyes are not directed toward surrounding objects; the eyelids are wide open; and the patient seems gazing into vacancy. This unmeaning stare of the face is due, in great measure, to an absence of that harmony of movement and expression which results largely from the information obtained by the exercise of vision. This seeming stare at nothing is not observed in patients who are blind in consequence of opacity of the crystalline lens or of its capsule, i. e., in consequence of cataract. They, on the contrary, while they cannot see, still seem to look

* See the experiments of Mosso, quoted by Michael Foster. Watson, op. cit.

about them, as if they were conscious that the power of sight remained in the retina, although the perception of objects was shut out from it. Patients, afflicted with cataract, who cannot detect the existence of a gas jet or a candle in a dark room, are not fit subjects for operation, as the existence of trouble behind the lens may safely be surmised; since the periphery of the lens seldom becomes opaque to such an extent as to prevent the perception of light by the retina, even if the outline of objects cannot be perceived.

The countenance of chronic hydrocephalus is perhaps the most typical of any of the conditions to which the attention of the physician or surgeon is directed. In it, the frontal bone is tilted. forward, so that the forehead, instead of slanting a little backward, rises perpendicularly, or even juts out at its upper part, and overhangs the brow. The parietal bones bulge, above, toward the sides; the occiput is pushed backward; and the head becomes long, broad and deep, but flattened on the top. This, at least, is the most ordinary result. In some instances, however, the skull rises up in a conical form, like a sugar-loaf. Not unfrequently the whole head is irregularly deformed, the two sides being unsymmetrical. Some of these rarer varieties of form are fixed and connate; others are owing, probably, to the kind of external pressure to which the head has been subjected. While the skull may be rapidly enlarging, the bones of the face grow no faster than usual, perhaps not even so fast; and the disproportion that results gives an odd and peculiar physiognomy to the unhappy subjects of this calamity. They have not the usual round or oval face of childhood. The forehead is broad, and the outline of the features tapers toward the chin. The visage is triangular. The great disproportion in size between the head and the face is diagnostic of the disease, and would serve to distinguish the skull of the hydrocephalic child from that of a giant. In acute cerebral diseases, the countenance is either wild and excited, or lethargic and expressionless.*

Thoracic affections are all accompanied by more or less change in the color of the face; whereas the alteration in the natural

Sir Charles Bell, op. cit.

hue of the features is so slight in abdominal diseases, that both the intellect and the complexion remain unaltered, up to the final struggle, though the pinched and dragged features express the acute sufferings of the patient. In pneumonia, the countenance is inanimate; the cheek, of a dusky hue, with a tinge of red; the eyelid droops over the globe; the brow is overhanging; the lips are dry, herpetic, and of a faint claret color; the chest is comparatively motionless, but the abdomen exhibits evidences of activity; the skin is hot; and the respiratory acts are usually about double the normal number, while the pulse is markedly accelerated. In cases where the dyspnoea is extreme, the patient, entirely regardless of what is going on about him, seems wholly occupied in respiring; is unable to lie down, and can scarcely speak; and the face becomes expressive of the greatest anxiety, while the expanded nostrils and their incessant movement indicate pulmonary distress.

In emphysema, the face is not only dusky but anæmic; the eyes are wide open, as the patient gazes at you; the dusky redness of the lips bespeaks the lack of proper oxygenation of the blood; the neck is thrown backward, and the mouth is slightly open, while the cheek is puffed out during the expiratory act; the distended nostril and the elevated brow stamp the case as one of dyspnoea; while the coldness of the skin shows that no acute inflammatory condition is present. If we see, in addition to these facial evidences of disease, the deformity of the chest which has been termed the "barrel-shaped" thorax, the shrugged shoulders, and the absence of that expansive movement so well marked in normal respiration, auscultation and percussion can hardly make the diagnosis more positive.

There are certain facial conditions, which so clearly tell, to the student of physiognomy, of the existence of that most prominent sign of many pulmonary and cardiac diseases, dyspnoea, that it may be well to enumerate the alterations from the normal countenance which chiefly indicate this condition. In all cases where dyspnoea is present, the brows will usually be found to be raised; the eyes will be full, staring, and clear; the nostril will be dilated, and often it may be seen to move with each respiratory

act; the mouth will commonly stand partly open, while its angles will be drawn outward and upward; the upper lip will be elevated, so as to show the margins of the teeth; and the utterance of the patient will be monosyllabic, as the rapidity of breathing renders the utterance of long sentences a matter of extreme

FIG. 8.-Countenance of Emphysema. (Modified from Corfe.)

difficulty. When we add to these symptoms those of imperfect oxygenation of blood, as is met with in all conditions where the free entrance of air is in any way interfered with, we can better understand how the clear eye becomes stupid, as coma approaches, from the carbonic-acid poisoning, and the face cyanotic from the venous tinge of the blood. It thus becomes possible for the stu