DIMINISHED NERVOUS SENSIBILITY. danger that the defective nutrition, at first merely temporary, may become confirmed; in other words, that chronic disease may be established. One consequence of the weakly condition to which badly nourished children are reduced is their liability to secondary acute diseases. In a child suffering from the results of chronic interference with nutrition, from whatever cause, the power of resisting new injurious influences is very much impaired. In such a state he is constantly found to be affected by causes so slight as to pass almost unnoticed, and which in a healthy child would be completely powerless to do harm. If the emaciation and debility of the child are very great, these secondary diseases may give very little evidence of their presence; for an infant reduced by malnutrition to a cachectic state loses many of the vital characteristics of early childhood, especially the intense excitability of the nervous system which is so striking a peculiarity of healthy infancy. In a robust child we constantly find the whole system suffering violently from sympathetic derangement set up by some trifling disturbance. A lump of indigestible food, or a slight impression of cold, will not unfrequently produce burning fever, and alarming nervous symptoms, as delirium, convulsions, or even a state approaching to coma. On the other hand, in an infant much reduced by long-continued impairment of nutrition, the most serious diseases may give no signs of their presence. Pneumonia may exist with little fever and no cough, and a serious intestinal lesion without pain and with only trifling diarrhoea.* A good example of the insensibility of the nervous system to local impressions is seen by attempting the well-known experiment of gently stimulating the genito-crural nerve, described by Sir William Jenner in his Lectures on Rickets.† In a healthy child the finger-nail drawn lightly along the * Rilliet et Barthez. Maladies des Enfants. Vol. i. p. 19. upper two-thirds of the inner aspect of the thigh produces an instantaneous rise of the testicle of that side, by the action of the cremaster muscle which draws it up close to the external abdominal ring. In a cachectic child the same experiment is followed by no result whatever; the cremaster does not contract, and the testicle remains motionless. In such cases, therefore, there is absence of the normal excitability of the nervous system so characteristic of healthy infancy. This insensibility of the parts of the nervous system concerned in the production of reflex movements is further indicated by the infrequency of reflex convulsions in such children. In well-nourished children these are exceedingly common, and the natural nervous sensibility appears to be heightened by anything which causes a sudden weakening of the system, as severe acute diarrhea, or great loss of blood. When, however, the debility is produced more slowly the same result does not follow, and the excitability of the nervous system, instead of being exalted, is more or less completely destroyed. For this reason, acute diseases, attacking a child whose nutrition is thus seriously impaired, have a character all their own. They are distinguished by an absence of those peculiarities which we are accustomed to consider inseparable from the disorders of childhood, and resemble more the same diseases as they occur in advanced age. They begin more insidiously; run their course more slowly; give rise to fewer symptoms; and often end suddenly and unexpectedly in death. Although thus undemonstrative, they are not, however, on that account the less dangerous; indeed, the prognosis may be said to be serious in proportion to the fewness of the symptoms by which their existence is announced. By offering an additional obstacle to nutrition they still further weaken the already enfeebled constitution, and the disease, if it does not prove immediately fatal, is apt to hang on, gradually reducing the child more and more, until he sinks under its effects. JADELOT'S "TRAITS." 5 It is difficult to over-estimate the importance of an early diagnosis of these secondary disorders. On account of their insidious commencement they are frequently overlooked, and it is often only by the more rapid debility they induce that suspicions of their existence are at last excited. As the infant is unable to communicate his ideas by speech, the eye should be practised to gather from the expression and gestures of the child the information which he can communicate in no other way. A careful perusal of the face is therefore of the utmost importance. By it we can ascertain the existence of pain, and can often distinguish the part of the body which is the seat of serious disease. Thus, pain in the head is indicated by contraction of the brows; in the chest, by a sharpness of the nostrils; and in the belly, by a drawing of the upper lip. M. Jadelot,* formerly physician to the Hôpital des Enfants Trouvés at Paris, was the first to draw attention to certain "traits," or lines, which become marked on the face of a child suffering from serious disease, and the situation of which furnishes indications as to the part of the body to which it is necessary to direct our examination. The oculozygomatic line, or furrow, begins at the inner angle of the eye, and passing outwards underneath the lower lid, is lost a little below the projection formed by the cheek-bone. This indicates disorder of the cerebro-nervous system, becoming strongly marked in all those diseases whose primary seat is the brain or nerves, or in cases where those organs become affected secondarily to disease commencing in other parts. The nasal line rises at the upper part of the ala of the nose, and, passing downwards, forms a rough semicircle round the corner of the mouth. Joining this at an angle about its middle is another line, called genal, which reaches from that point almost to the malar bone, and in certain * Quoted in Dr. Dunglisson's work On the Diseases of the Stomach and Bowels in Young Children. faces forms the dimple of the cheek. These indicate disease of the digestive passages and the abdominal viscera. The labial line begins at the angle of the mouth, and is directed outwards, to be lost in the lower part of the face. It is seldom so deep as the preceding. It indicates disease of the lungs and air-passages. M. Jadelot attributed immense importance to these lines, and even stated that he had been enabled to discover the exact period at which the cough of pertussis assumed its convulsive character by the appearance of the oculozygomatic line upon the child's face. Without, however, attaching to them the same significance which they assumed in the opinion of their discoverer, there is no doubt that they often furnish important indications, and are, therefore, points to which attention should always be directed in the examination of a young child. The colour of the face should be carefully noted. Lividity of the lips and of the eyelids is a sign of imperfect aeration of the blood, or may indicate digestive disturbance, or merely weak circulation. A peculiar waxy-yellow tint is seen in certain parts of the face in congenital syphilis ; and there is an earthy tinge of the face and whole body in many cases of chronic bowel complaint. Exhaustion is indicated by coolness and pallor of the face, by lividity of the eyelids and mouth, and, in extreme cases, by a half-closure of the eyes, so as to leave the lower parts of the whites exposed, while at the same time the fontanelle is deeply depressed. The state of the fontanelle should be always examined, for it forms a very important guide to treatment: if much depressed, stimulants should never be withheld. The breathing must be watched. If rapid, and accompanied by movement of the nares, there is usually bronchitis or pneumonia, and a careful examination of the chest should always be made. Unequal movement of the two sides of the chest in respiration generally indicates a serious lesion on the side at which the movement is least. If the CAUSES OF ABDOMINAL ENLARGEMENT. 7 respiratory action of the abdominal muscles is increased, attention is at once directed to the chest. If the belly is motionless, it is often the seat of an inflammatory complication. The cry of the infant varies very much in character. In cerebral affections it is sharp, short, and sudden. In lesions of the abdomen, exciting pain, it is prolonged. In congenital syphilis, it is high-pitched and hoarse. In inflammatory diseases of the larynx, it is hoarse, and may be whispering. In inflammatory diseases of the lungs, and in severe rickets, the child is unusually quiet, and unwilling to cry on account of the action interfering with the respiratory functions. The infant should always be completely stripped for examination. We can then at once observe the form and play of the chest, the state of the abdomen, the condition of the skin, whether hot or cool, dry or moist, and the conformation of his limbs. Besides, any eruption upon the skin is at once detected by this means. The large size of the belly in weakly children often attracts the attention of parents, and excites much anxiety. It is most commonly produced by accumulation of flatus, owing to the weakness of the abdominal walls. It may be also due to displacement of the liver and spleen, such as occurs so often in rickets on account of the depression of the diaphragm forcing those organs downwards from beneath the cover of the ribs. The liver and spleen may be themselves enlarged; and great masses of cancer occasionally spring from the kidney and from the other abdominal organs. Ascites may be present from tubercular or simple peritonitis, from Bright's disease, or, rarely, from disease of the liver. Tubercular peritonitis may also produce extreme tympanitis. Accumulations of fæcal matters may take place in sufficient quantities to cause distension; and, lastly, the mesenteric glands may be so enlarged as to produce a visible tumour. Flatulence is, however, as has been said, |