the result of a slight attack of hepatitis caused by inflammation of the umbilical vein. After the eighth day the skin assumes a whitish tint, becomes transparent and rosy, with decided colour on the cheeks. It thus continues during the calm of the children, but it changes with their agitation. The face reddens, becomes more or less decidedly congested, according to circumstances, in the little fits of passion of this age, in the more or less distressing efforts of cough, &c. Thus in hoopingcough, the face sometimes becomes quite blue, and blood escapes by the eyes* or by the nostrils. This disease is not the only one in which the colour of the face may furnish valuable information. Thus, nearly abolished in the diseases of the chest, this colouration acquires an immense importance in the affections of the nervous system. The sudden, fugitive, and intermittent red colour of the face, is a certain sign of acute cerebral disease. The cyanosis of the mucous membranes and of the skin always reveals the existence of an organic affection of the heart. In diseases of the larynx, sufficiently intense to impede hematosis, the degree of the asphyxia is often only estimated by the colour of the integuments, and from this colour that the employment of an extreme means now become necessary is decided on. Thus, in croup, the usual white rosy tint of the face, is very sensibly altered; the base is no longer the same, from rose colour it passes to blue, similar to the tint of the lips, the brilliant colour of which has disappeared. The duskiness rapidly increases in intensity with the disease; when the cyanosis becomes very evident, and when we at the same time observe that peculiar condition of the pupil and of the eyes, to which we shall again refer, there can be no possible hesitation; from these symptoms of danger, energetic treatment must be at once adopted; tracheotomy is indispensable. The colour of the face is singularly altered in the diseases of the alimentary canal. I need scarcely mention the red, coppery, blackish tint, and the black tint, which become successively manifested on the outside of the mouth in spacelus of this part; but I shall allude to the leaden tint which replaces the clearness of the skin in children attacked by thrush and entero-colitis. The eyes are then excavated, the face sallow, the lips pale, colourless, without presenting the blue tint of asphyxia. Diseases of the liver are rare amongst children at the breast; in the colour of the face and body an important indication of their existence is met with. The skin, conjunctiva, and mucous membrane beneath the *This circumstance is excessively rare, but I have observed it at the Necker Hospital, in the practice of M. Trousseau. Chap. I.] PHYSIOGNOMY OF SICK CHILDREN. Laterns in Shildhood 93 alway. tongue, assume a very decided yellow colour. The value of this symptom is the more important, as there is not, I suppose, in these young children, originates an idiopathic icterus the result of an acute moral impression. All the cases of icterus I have seen, originated in an affection of the liver. In following up these researches, we may allude to the reddish roughened colour of the face and eyes in children threatened with an eruptive fever, the bluish pearl-like colour of the conjunctiva in tuberculous children, the coppery tint of certain blotches of the face of a syphilitic origin, &c.; but this would be probably exceeding the bounds of the field of positive observation. We here terminate that which refers to the colour of the integuments. ON THE FEATURES AND EXPRESSION OF THE FACE. If the face of a sleeping child is examined, we are delighted at observing there so much calm and serenity. Not a fold, not a wrinkle disturb the surface. The respiration is slow and quiet, the pulse feeble and regular. Grief and joy are the transient passions which disturb this picture. The features become sharpened and contracted in suffering; they expand, on the contrary, when agreeable sensations are present. 4 pain, Aiki ateer. ind by Every one can recognize these signs, which betray the impressions of the mind; it is useless, therefore, to insist upon this further. What concerns us is, to discover on the face, in the manifestation of the features which indicate its origin: now this is possible in a great number of circumstances. Thus, children who suffer in the head, in consequence of an acute affection of the meninges or of the brain, add ́ to their cry a very evident alteration of the features. Sometimes it is an eyelid that cannot be raised, and leaves the eye half open; at Vizule others it is the nose, one of the nostrils of which is drawn down; us sometimes it is the mouth, the commisure of which presents a considerable deviation; at others, again, it is strabismius, convulsions of the face, &c. More need not be required. Is it not, moreover, in one of the chronic diseases of the brain, in hydrocephalus, that we meet with that peculiar appearance of the countenance, occasioned by the disproportion of the cranium and of the face? Is not this deformation the most certain index that we can have of this disease? Has one ever been deceived in the case of a young child, whose head is enormous relatively to the face, whose e- Amongst the affections of the chest, let us take pneumonia, as one of the diseases which it is the most easy to recognize by the external symptoms. The examination of the nostrils is often sufficient to indicate its existence, and the alteration of the features which accompanies it is one of its best characteristics. At each inspiration the nostrils dilate with a considerable effort, the eyebrows are knitted, and sometimes, but this is at a very advanced stage, the lips are widely open, in order to facilitate respiration. These signs, such as I have just described, would be insufficient, did we not observe at the same time the gestures and cry of the little patients. Thus, placed beside a cradle containing huume a patient who utters a plaintive and jerking groan, followed by an inspiration and moment of repose, whose nostrils forcibly dilate, whose ribs are depressed laterally with violence simultaneously with a considerable projection of the abdomen, the physician may suppose that it is a case of pneumonia, and forthwith proceed to the verification of the diagnosis by the ordinary means. His falling into error would be a matter of difficulty. Sigu The pleurisy of children at the breast does not present any of these signs. They are sometimes met with in very intense capillary bronchitis, but it must be allowed that it is very difficult to distinguish it from lobular pneumonia, even by the aid of auscultation. The diseases of the abdomen are of a nature to exercise the sagacity of the medical physiognomist. Some of them manifest themselves on the face by characters which it is impossible to mistake; others, on the contrary, leave no impression on its surface. Acute entero-colitis is accompanied by speedy and evident deformation of the features. This deformation has already been pointed out by some physicians as peculiar to softening of the mucous membrane of the stomach. But the existence of this disease is far from being proved; it is probable that it has been confounded with that to which we allude (see entero-colitis); the discovery of the similarity of the features between them, which I am about to enumerate, is not then to be wondered at. In these diseases, and in the short space of one night, the face becomes sallow and rapidly emaciated. The lips lose their colour, the nose becomes sharpened, the cheeks are sunken, the eyes hollow, Hose their lustre, and are surrounded by a deeply excavated sub-orbital ring. What can be at the same time more characteristic and peculiar? There is no other disease which presents such symptoms. Should colic come on, as it frequently does in this disease, the child cannot direct our attention to it: it is, however, possible to detect it. Over this countenance thus changed, to which we have just alluded, passes a cloud of pain; the face becomes sombre, the features contracted, the eyebrows drawn together, the eyes half closed, 1: The the nostrils elevated, forming a wrinkle on the cheek; the lips, In chronic entero-colitis, other characteristics, of not less value, are Same The rapid emaciation of the countenance, observed in acute entero- changem colitis, does not fail to progress. It has not continued to advance Chrome in the same proportions; this would be a matter of impossibility. The skin, deprived of its cellular tissue, remains soft, flaccid, and blows, wrinkled on the muscles which draw it in every direction. The children then present emaciated figures; they are fleshless; all the bones project; numerous wrinkles furrow the forehead and around the eyes, on the cheeks, around the lips, on the chin and neck. They resemble little old men about to die, and as a witty physician, one of my teachers, observed, they possess the Voltairian au han au Old Wotarian, countenance. To him who is conversant with the sketches made of an end to existence. Chronic pneumonia is the only disease in which life is sufficiently but prolonged to communicate to the physiognomy the well characterized Coule appearance of decrepitude. And then it may be asked if alvine evacuations, sufficiently numerous to constitute consecutive entero-colitis, Puume. Рише have not presented themselves as complications of this pneumonia, kid. so as to constitute the greater part of the influence of both these diseases. [Dr. Schreber remarks (Die Eigenthümlichkeiten des Kindlichen, p. 55): "In all diseases associated with diminished nutrition, the child emaciates far more quickly than the adult, but, on the other hand, the former regains its condition much sooner then it than the latter. Such emaciation, if the disease is not very dangerous, is of no great T 10411 " import so long as the countenance does not exhibit marked change; but if it does, if it assumes an unnatural, more aged, thin, wrinkled appearance, we may always reckon upon a deep and danger-threatening diminution of reproduction, and of the whole vital power."-P.H.B.] There is yet another disease of the alimentary canal, which was formerly attempted to be diagnosed from the inspection of the face: it is perhaps the only one which it is impossible to recognize in this manner-I refer to the presence of worms in the intestines. If we are to believe authors, children attacked with this disease present a grey leaden tint, bluish conjunctiva, very dilated pupils ; and they are continually contracting their nostrils, in consequence of a rather intense itching of this part of the face. Thomas Fieni, Signa a naso, thus expressess himself: "Itching of the nose, in acute diseases, indicates delirium; if it has no evident and manifest cause, as a hair which irritates it, it announces the presence of worms in the intestines, especially in children." I am not aware whether it is thus in the districts where the verminous affection is common; but at Paris, where it is rather rare, nothing of the sort is observed. Children who have worms, do not often present the pearl-like condition of the conjunctiva and the dilatation of the pupils; they do not complain of itchings of the nose, and they do not carry their hand to this part of the countenance in order to testify their sensations when their speech is insufficient to express them. On the other hand, the dilatation of the pupils, the blue tint of the conjunctiva, and the itchings of the nose, exists in children who have not worms, or who, at least, have not passed any in their stools. Certain general affections leave an impression on the physiognomy which cannot always be recognized, for the change in the features is not considerable. Thus the scrofulous affection is ill characterized externally in children at the breast; its manifestation is more tardy. The face very rarely presents the aspect which, at a more advanced period, is caused by the enlargement of the glands of the neck, the redness and tumefaction on the edges of the eyelids, &c. ON THE EXPRESSION OF THE EYES. The eyes of the infant are open at the time of birth, but they appear to be insensible to the action of light. They are dull, without expression les and without a fixed look; life does not yet animate them, they move ར in all directions but without any determinate aim. At the end of a fortnight they follow the light, insensibly accustom themselves to exterior objects which they finally recognize at the age of six weeks or two months. The first, and one of the most interesting characteristics of pathological physiognomy, furnished by the examination of the eyes, relates |