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lids are half closed; the pupil contracted; the eyeball sunk in the socket, and rolled upwards, so as to conceal entirely the pupil beneath the upper eyelid; the conjunctiva is injected with darkcolored blood; the cornea covered with a thin film of mucus; and the orbitar circle is of a livid or dark brown color.

In the acute affections of the head, the face is usually flushed, somewhat turgid, and hot.

In affections of the respiratory organs, the face is generally of a dusky red, and swollen; and in extensive hyperæmia of the lungs, the lips and cheeks are often of a deep livid hue.

In hydrocephalus, the skin of the face, and especially of the forehead, is tense and shining. The smooth and shining appearance of the skin upon the forehead is also very generally observed in protracted cases of cholera infantum.

Deep blueness of the countenance, in young children, is indicative of morbus cæruleanus, arising from an impediment to the free circulation of the venous blood. It usually exists from birth, and is increased in intensity by any exertion of the body.

A sudden contraction of the countenance, especially if accompanied by a sudden motion of the body, and a sharp scream, is generally the indication of some sudden attack of pain, usually of a spasmodic character. If, at the same time, retraction of the abdominal muscles, drawing up of the knees, or a sudden extension of the body takes place, the pain is seated in some part of the alimentary canal. In this case there is also a whitish circle often observed about the mouth.

When the painful sensation comes on more gradually, and is more prolonged in its duration, the brows are corrugated, the upper lip is stretched and elevated, and the nostrils become sharp and contracted. The contraction of the brows is usually most marked in pain of the head; sharpness of the nostrils, in painful affections of the chest; and drawing up of the upper lip, in abdominal pain.

Upon the approach of convulsions, the upper lip is often stretched firmly over the gums, and of a whitish or livid hue; there occurs a slight divergence in the axis of the eyes; there is an unusual upturning of the eyeballs, or a singular rotation of the latter upon their own axes, or a fixed staring condition of the eye, with a rapid contraction and dilatation of the pupils; there are often slight twitchings of the muscles, on one or other side of the face, and a quick alternation of flushing and pallor of the countenance. All these appearances are not observed to precede every convulsive attack. The occurrence, however, of one or more of them is sufficient to call attention to the gums, alimentary canal, or nervous system, in order to detect the source of irritation, that, by its removal, the threatened attack may be prevented.

Whenever there exists any great impediment to the freedom of respiration, the nostrils are widely dilated during inspiration, and strongly contracted during expiration, the mouth is held open, and the lips are often puckered, and always of a livid hue.

In the more severe forms of gastro-intestinal inflammation, the

mouth is extended, the lips-often pale, dry, and cracked-are applied closely to the teeth, and the chin has the appearance of unusual projection.

In chronic irritations of the bowels, the nose and upper lip are often tumefied. A peculiar puckering of the corners of the lips is frequently observed to precede the occurrence of gangrene of the mouth in children.

The countenance of infants that have been subjected to an almost habitual use of opiates, has a peculiar and striking appearance. The skin is of a sallow or dirty brown hue, and thrown into wrinkles, from the emaciation of all the soft parts beneath it; the eyelids are red and tumid; the eyes dull and watery; the lips dry and pallid, and drawn, so as to leave the mouth partially open, and the chin projecting. The whole countenance presents, indeed, a faithful miniature likeness of a sickly aged person.

The eyes are usually prominent and suffused, their superficial blood vessels being often minutely injected with blood, in violent paroxysms of crying, and of cough, and in all affections of the respiratory organs attended with much difficulty of respiration, as in croup, the more violent forms of bronchitis, hooping-cough, &c.

The pupil of the eye, in infancy, is usually dilated, during health, and it is often closely contracted during sleep, and rapidly dilates upon the child's awaking. The state of the pupil, however, varies frequently, and it is only from its fixed or permanent dilatation or contraction, that the indications of disease are to be derived.

In the course of most diseases, the occurrence of a fixed dilatation or contraction of the pupil, indicates the extension of irritation to the brain.

In the early stage of encephalic inflammation, the pupil is, in general, contracted, and, in the last stage, dilated, and insensible to light.

Occasionally the form of the pupil is irregular; this has been observed by M. Jadelot in cases of intestinal irritation from worms.

The sudden appearance of strabismus, in the course of disease, is usually an indication of the occurrence of some cerebral affection, and is then always an unfavorable symptom. Slight irritation of the bowels, as from worms, indigestible food, &c., often gives rise, however, to temporary strabismus.

2. Of the Gestures.

In infants old enough to be attracted by surrounding objects or to be played with and amused, the approach of disease is often marked by a total disregard of everything that had previously pleased them, and an indisposition to motion of any kind. Instead of being active and playful when awake, they lie still and listless upon the nurse's lap, and no efforts to attract their attention or to excite a smile upon their countenance are successful. The cooing, chirruping sound, with which they expressed their feeling of satisfaction or delight, gives place to perfect silence, or to a short querulous plaint when moved or teased by the importunities of those around them.

If the infant had already commenced to hold up its head, to sit alone, or to stand, on the approach of disease, there often occurs a degree of muscular debility which prevents these attitudes from being continued, and the position assumed by the body and limbs is expressive of extreme languor.

When in suffering, particularly in cases of intense abdominal pain, the infant will often draw up its knees, and bend forward its body, or throw about its limbs in a wildly agitated manner; or, as we have often observed, forcibly extend its whole body, and then suddenly relax it. When one limb is kept motionless, or moved with sudden jerks, particularly if its motion excites or augments the cries of the child, that limb is generally the seat of pain.

If, after an infant has commenced to walk, it is found to apply only the toes of one of the feet to the ground, and to exhibit a gradually increasing limp in his gait, particularly if it complain of pain in one of the knees, and exhibit uneasiness when that limb is handled, we should suspect the presence of articular inflammation of the hip.

When a child is observed frequently to trip and stumble, in walking, or when, as he moves hastily or unguardedly, his legs cross each other; when he stands upright, his knees to totter and bend under him, and when seated, his legs to be crossed and drawn up under the seat; particularly if he exhibit, at the same time, great languor and listlessness, and complain of frequent pain and twitchings in his thighs, we may suspect some disease of the lower portion of the spine, probably caries of the vertebra.

A frequent application of the hands to the head is, generally, an indication of suffering in this part of the body, the seat of which is to be detected by other symptoms. A pulling at one of the ears, and violent, often frequently repeated scratching of the parts in its immediate vicinity, with frequent moans, or short acute cries is, generally, indicative of otitis. Rolling the head constantly from side to side, as it lies on the pillow, or bending it forcibly backwards upon the spine, is usually an indication of cerebral disease.

Picking at, or frequently rubbing the nose, is, usually, a symptom of irritation of the alimentary canal; it is a very common indication of the presence of worms.

Convulsive movements of one or other of the limbs, of the muscles of the face, of one side of the body, or of the voluntary muscles generally, may result from irritation or inflammation of the brain, or spinal marrow; or these movements may be produced by an irritation seated in other organs, and transmitted to the nervous centres. Convulsions are often the precursors of eruptive diseases.

Contraction of the fingers and toes, in consequence of which the first are forcibly flexed upon the palms of the hands, and the latter towards the soles of the feet, whilst the back part of the hands, and the upper surface of the feet, present a soft, puffy swelling, is an indication of convulsions. An opposite condition, or when the fingers and toes are forcibly extended, whilst the first are semiflexed upon the metacarpus, and this, at times, upon the carpus, and in the

same manner the toes upon the metatarsus, is a common attendant upon laryngismus stridulus.

As early as the fifth or sixth day subsequent to birth, infants are occasionally attacked by spasms of the muscles of the face, lower jaw, or neck, and, in severe cases, there is often a complete fixation of the jaw. This condition has been attributed to retention of the meconium, or to inflammation of the vessels of the cord. It is more generally, we suspect, produced by confined and impure air, or certain conditions of the atmosphere, endemic to particular localities.

During dentition, and from trifling irritations of the digestive canal, infants are frequently affected with slight convulsive movements of the muscles of the face, which give to the countenance an appearance of smiling. This symptom is frequently the precursor of severe general convulsions.

A rigid extension of the limbs with a turning inwards of the thumbs and great toes, is often the precursor of a convulsive attack. When, upon the child being put to the breast, it sucks eagerly for a moment or two, and then suddenly ceases, throwing back the head with an expression of anxiety in its countenance, it will, in general, be found that it is laboring under some disease of the respiratory organs, as severe bronchitis or pneumonia. The same phenomena, with a rolling of the head from side to side, are often the precursors of an attack of convulsions.

Sudden rejection of the breast after sucking for a few moments, the infant at the same time exhibiting pain or uneasiness by its cries and the movements of its body, is common in cases of coryza and of inflammation of the throat-it is often observed, also, in severe cases of stomatitis.

Weakness or contraction of certain muscles, or partial paralysis often marks the formation of tubercles in the brain.

Partial paralysis, as of one leg, is not, however, an uncommon symptom, during dentition and in cases of gastric irritation. Although this, in some cases, is a serious symptom, yet, very generally, the paralyzed limb, sooner or later, regains its power.

An uplifted step, or staggering gait, and rocking of the legs, or a total inability to stand erect, are indicative of serious disease of the brain or spinal marrow. These symptoms are often the precursors of sudden serous effusions upon the brain.

A sudden increase of muscular activity in young children, with unwonted exhilaration of spirits, and liveliness of manner, denotes increased excitement of the brain, and often precedes acute attacks of meningeal inflammation.

Great restlessness, and frequent involuntary movements of the limbs, are, in general, when they occur in the course of protracted maladies, unfavorable symptoms, and depend upon disease of some portion of the brain.

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In a healthy infant, sleep is calm and profound. The position is, generally, upon the side, with the limbs perfectly relaxed; the res

piration being full, slow, regular, and quiet. The eyelids are never forcibly closed, and not unfrequently, are slightly separated. The cornea is partially concealed beneath the upper lid, the ball of the eye being turned upwards; the pupil is often greatly contracted. The skin is soft and cool.

It is not uncommon in the sleep of infants for imperfect respiration to occur for a time, followed by a deeper inspiration or sigh, to supply the previous deficiency in the function. This has sometimes been mistaken for an indication of disease; it is, however, a perfectly healthy phenomenon, and results from the reduction of innervation that occurs during sleep. Cutaneous transpiration is always increased during the period of sleep: if the room in which the infant reposes is warm, or he is too warmly clad, or covered with too many bedclothes, profuse perspiration is liable to occur, particularly about the head and neck.

On awaking from sleep, the healthy infant is lively and cheerful, and quickly seeks the breast or calls for food.

The younger the infant, the greater is the time passed in sleep. After the first month or two, the intervals of waking and repose become more regular, and the infant will, very generally, fall asleep and awake, very nearly at stated hours.

During sleep, the countenance of the infant will, by its expression, often give intimation of the existence of uneasiness or pain, of which no indication is presented during the period of wakefulness -the infant's attention being then diverted from slight degrees of bodily suffering, by the various objects and sounds that occupy its external senses.

The commencement of irritation in the bowels, or brain, may often be detected by slight twitchings of the mouth and eyelids, or by the grinding of the teeth, that occur during sleep, when no symptom is manifested while the child is awake.

In the same manner, the approach of disease will be indicated by frequent movements of the body and limbs, and by sudden starts that take place during sleep.

Sleeplessness, when not the result of suffering, is usually caused by a morbid excitability of the brain; it is often present during convalescence from acute affections.

Sudden starting from sleep, with a wild alarmed expression of countenance, or without the child appearing, for some time, to recollect himself, or to recognize surrounding objects, is often caused by irritation of the alimentary canal, and may, in many cases, be the precursor of convulsions, or of acute meningeal inflammation.

Children often awake from sleep in affright, and quickly burst into tears. At other times, their sleep appears troubled, and, without awaking, the child sobs, or utters words or indistinct sentences; this is, generally, produced by the occurrence of dreams, excited by intestinal irritation, or by the presence of too much or improper food in the stomach.

An unusual degree of somnolency in general indicates hyperæmia

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