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But after the third month and until the tonis. And so we observe that nervous end of the second year all of the nerve phenomena which would be of grave imcentres are most irritable, so that convulsive port in later life, loses much of its gravity seizures are common. The clinical import because it occurs in the immature. of this is, that convulsions in the very For instance, the onset of most of the young infant are of serious import and acute diseases of infancy gives rise to one that not infrequently after their subsidence or more convulsions, an event which is practhere is some weakness of the affected mus- tically unheard of in adult life. Such conculature. That convulsions occurring at the vulsions are almost always mild in their onset of some disease in an infant between effect

upon

the infant and cause little or no the ages of three months and two years, alarm to the one who is experienced are of but little import and may be due to enough to determine their significance. the most trivial cause, while in adult life And again, the digestive system bears any such event at any time would be suf- considerable of the brunt of the invasion of ficient cause for great alarm.

any disease in infancy, so that it is our comThe necessity of recognizing these dif- mon experience to observe the symptoms ferences must be apparent, because it is by of vomiting, diarrhoea or constipation at a correct analysis of them that we are en- the onset of most of the diseases of infancy. abled to determine the import of symptoms. Even making allowance for the ease with Not infrequently apparently mild symptoms which disease of the digestive apparatus is are interpreted as indicative of mild dis- produced in infants, the fact remains that a ease, while seemingly more grave ones considerable proportion of disturbance arouse unnecessary alarm and foster the which is laid to digestive disease is due drawing of wrong conclusions.

only to the onset of some acute infection. Take, for example, the symptomatology The inarticulate expression of disease in of an acute illness in the infant; we find infants has several qualities which adults that there is not the limitation of symp- do not possess. And first among these is toms referable to the particular organ or absolute honesty of such expressions. region which is primarily involved as in An infant's philosophy is contained in adult life, but the infant becomes the sub- this statement: “All that is painful is evil; ject of more general or constitutional symp- all that is pleasurable is good.” toms. Thus the expression of the disease

To the infant the mere act of living in is more constitutional than focal and the contentment is sufficient and this sufficiency younger the child the more striking the con- takes no recognition whatever of the future trast.

but is limited to the comfort of the moment. This is largely due to the fact that there Neither is there any living in the past, and is an inability in infancy to focalization of this is aptly illustrated by the experiences nervous function because immaturity leads of an infant in the pain of an intestinal colic. to an interference with the complete

complete With the quick subsidence of the pain there mechanism of inhibitory control.

is an immediate return to the usual playThen again, the reflexes are not re- fulness and no recollection of the past. strained but become generalized leading to Health and Disease are terms that have the appreciation of constitutional symp- for the infant no content.

This fact of living for the moment is one I have more than once heard it stated of the chief factors in the discomfort at- that even infants would exaggerate their tendant upon enforced restraint. The in- ailments and that the quality of introspecfant dislikes illness and by nature their re- tion in them was not entirely wanting. But bellion against the restraint which an ill- this has always been based upon the deness enforces is absolutely honest.

mands which some infants make upon their This should lead one to appreciate the attendants during an illness. Much of this fact that if an infant shows any tendency

is the result of habit which has been formed to lose interest, to lag in its play, to be- during periods of health and is not a part come fretful or act as if in discomfort, the

of the illness. cause should be sought in the bodily health.

There is no doubt but that infants need Therefore, muscular activity which is an and demand more sympathy than any other important factor in the growth and develop class of patients but the demand for it never ment of infants is responsible for some of exceeds the need. The infant crying in his the peculiarities which are noted in illness. apprehension may be labeled by the inex

In fact, the disinclination to continue the perienced as a disturber of the peace, but usual muscular activity should be inter- not so to the mother who understands the preted as an early sign of ill health and this meaning of the cry and who is moved by is often expressed by the infant in the de- its eloquence. To the infant, her arms are sire to be left undisturbed.

as a narcotic and when the mental need is The common accompaniment of dimin- fully supplied there is no further demand. ished muscular activity is a diminution of Therefore the mental attitude of the infant mental activity and the infant loses interest may be taken as a safe guide and index to in its surroundings because the exertion de- his bodily state. manded by the attentive attitude is

From these general facts which are not pleasant.

always appreciated and may

be And so when illness has marked one of unknown, we can readily see that the more these little ones as its victim, this same an- definite expression of disease in infancy tagonism to illness, this rebellion against is misinterpreted or unrecognized. There the consequent restraint keeps the infant are, of course, innumerable objective sympfrom the magnification or multiplication of toms which will give the examiner a wealth its symptoms.

of information about the condition of the Further than this the infant is entirely infant, but many of these are not under the uninfluenced by the habit of morbid intro- control of the infant and, therefore, do not spection and is therefore incapable of ex- come with the province of this paper. But aggerating its ills for the sake of attracting on the other hand, there are many things attention to itself. Whatever exaggeration which are directly subject to the volition of takes place is due to the parent who gives the infant and a brief resume of these may the history and through innocence or de- prove suggestive. sign distorts the facts, or to the physician And first, the posture which the infant who allows the given history to influence assumes may be significant. The attitude of his judgment more effectively than what he the infant on the one hand, may be reassurfinds by observation and examination. ing, as we note that he rests easily and turns

un

even

to greet the physician. It assures one that sequent upon much light in severe photothe ailment is slight, or that convalescence phobia. is established. On the other hand, the re- Under forced positions it is only necesfusal to be attracted indicates that the ill- sary to make mention of opisthotonos and ness is of a severer type. Thus in an infant emprosthotonos, which occur in some cases with a suspected meningeal condition, if he of tetany, strychnine poisoning, and menturns promptly to locate a noise or upon ingitis. the approach of a stranger, he is improbably The upright or sitting position may be the subject of meningitis.

assumed as the result of abdominal accumThe side position is characteristically as- ulations of fluid; from large effusions in sumed in two diseases-acute pleurisy and the pleural cavity; and it attends some cases pneumonia. In both instances, the infant of laryngeal diphtheria. lies upon the affected side, so as to limit Also the face of the average infant exas much as possible the motion of the dis- presses more clearly than does the adult the eased side, and to allow free expansion of feelings and character of the individual. the unaffected. In pneumonia it is not dif- Except as the child more closely approxificult to get the infant to temporarily change mates the adult type, there is no attempt at this posture but in pleurisy there is decided deception by the facial expression. Sick objection to such a procedure, which in or well, there is a candid frankness which most instances amounts to absolute refusal. allows of no exaggeration or dishonesty.

If this side position has been persistently The value of facial expression as indiassumed and as the illness advances, the cating diseased conditions will exist only infant gradually but persistently changes as one appreciates what is normal; then, to the dorsal posture, it indicates that ef- with the capability of comparison which fusion is taking place.

comes by many observations, one can inThe dorsal position (a) with slightly terpret the expression of the infant. bent legs, is the position of election in cases The normal expression of an infant while of acute peritonitis and tubercular periton- asleep is one of perfect unbroken calm and itis. Motion is carefully avoided, and in peace. The eyelids are closed, the lips very acute peritonitis there is generally evidence slightly parted, and the nostrils immobile. of fear as the infant is approached.

Normal expression plus twitching of the (b) With a curve of the trunk slightly

facial muscles is indicative of irritation of toward the right side, and with the right some portion of the nervous system. It knee more or less flexed, or in some in

may be the forerunner which indicates an stances held up by the infant, which gives impending attack of general convulsions ; relief to some extent, the dorsal position but if so, there is very apt to be restlessness is often assumed in appendicitis.

also. On the abdomen is the position taken in

Normal expression with eyelids parted (a) some cases of Pott's disease, but it is may be observed in many of the milder disby no means characteristic; (b) in phleg- orders of the nervous system and during mons of the back (to relieve the pressure); digestive disturbances. If the muscles of (c) and to eliminate the pain which is con- the face are drawn from time to time, it strongly indicates that the disorder is a features, with the angles of the mouth digestive one.

drawn and considerable pallor of the face Listlessness (that is, marked by a relaxed noticeable, in cholera infantum. (c) If the attention) may be due to several causes: upper lip is retracted, exposing the teeth, (a) After some days' illness with typhoid and along with this there is visible prostrafever a listless expression is an almost con- tion, it is indicative of acute peritonitis. stant feature. (b) If associated with (d) Associated with shallow respirations motionless or seldom moving eyelids, or

and increased frequency of breathing, and with wide-open eyes staring steadily into the cramped position on the side, it is prethe distance, it is quite indicative of menin- sumptive evidence of acute pleurisy. gitis, and this condition of the eyes and the An old expression (a) with a pale, expression may help in some cases to dif- pinched and weazened face, and associated ferentiate it from typhoid.

(c) With with “snuffies” in an infant, is indicative of sunken eyes, and occurring at any time hereditary syphilis. These infants look preduring any disease, it is a symptom of ill maturely old and may also show a depresimport, for it is then a sign of suddenly in- sion at the bridge of the nose and a promicreasing prostration or impending death. nent forehead. Such an expression is most

Vacant expression (a) associated with apt to be noticed during the first two months enlarged head, but the bones of the face of life. (b) When the skin has a leaden remaining small, and the eyeballs perhaps hue and is loose and wrinkled, one would slightly protruding, is seen

seen in hydro- naturally suspect marasmus. (c) An old cephalus; (b) with thickened lips, more or expresion is common to infants of all ages, less gaping mouth, small nasal orifices, and who are suffering or who have recently a broadened root of the nose, is quite com- suffered from chronic starvation, and such mon in hypertrophied tonsils and adenoids an expression is quite in proportion to the which are almost invariably associated with chronicity of the condition,

. them.

In edema and erysipelas all the lines of When the expression is idiotic and the expression may be lost. lips thickened, the tongue protruding so Painful disfiguration of the face while that saliva is almost constantly dribbling pressure is being made over some distant from the mouth, the nose flattened and the portion of the body aids in definitely loskin of a pallid, waxy hue, cretinism is cating the site of tenderness, and sometimes probably the cause. (b) If the same pic(b) If the same pic- of pain, for pain may be referred.

, ture is presented, but in a very much les- Crying is not expressive of the emosened degree, we may be dealing with an tions until near the end of the third month exaggerated form of mental deficiency. of life, and about this time tears are obAnxious expression (a) with nostrils served to accompany

the
cry.

It is a matter more or less dilated and labored breathing, of interest to observe that the tears, per

, is indicative of some disturbance to the cir- spiration, and a free flow of saliva all apculation, and especially so if any cyanosis pear about the same time of life. is detectable. (b) This expression is A lusty cry directly after birth is a most present, with sunken eyes, depressed fon- welcome sound, not alone as a sign that tanelles, a general sharpening of all of the the most difficult stage of labor is termi

the cry.

nated, but it indicates the undoubted Continued, suppressed cry should attract respiratory vigor of the infant.

attention to conditions in the head, the abWeak, feeble at birth, or absence of any domen, or the chest. If pain is caused by crying at this time, is at once indicative the use of the abdominal muscles or those of-(a) the general feebleness of the in- of the chest, the infant will try to suppress fant, (b) pulmonary atelectasis, (c) con- all motion. If venous stasis increases pain genital heart lesions. The first is self-evi- in the head, the infant will refuse to move dent, the second being indicated by lividity that member freely, and tries to suppress and infrequent or absent respirations, and the last by the general pallidity and weak Continued but low cry may indicate sevfluttering heart.

eral conditions: Loud cry, occurring several times during (a) With loss of weight, but no apthe day or night, arising suddenly and preciable rise in the temperature, the voidstopping just as suddenly especially after ing of a much lessened amount of urine, the expulsion of gas from the stomach or and, as a rule, with constipation, it indibowel, is strongly indicative of colic from cates that the infant is hungry. This may indigestion. During the act of crying the be corroborated by an examination of the infant is very apt to throw its legs about milk, or testing what effect upon the conor to rub them violently together, but this dition a feeding or two with a modified is not any more characteristic of this cry milk will have. When the cry has been than it is of any violent crying spell. If due to a chronic state of hunger, one such due to colic, it is at once relieved by an feeding will make the child restful. Someenema, and the evacuations may give evi- times the infant may vigorously suck the dence of feeble digestion. If the same fingers, but this is not a constant feature. character of a cry is present with a rise (b) When more forcible an hour or of temperature to 101° F. or over, it is two after nursing and associated with ocproof that we are not dealing with a simple casional attacks of colic, it indicates that dyspeptic colic, but that there is some the cause is chronic intestinal indigestion. associated condition.

(c) With progressive

prostration Continued loud cry, with a stiffening of (which is more marked in young infants) the body and the head thrown backward, and with a tone to the cry which is a sort may be due to one of two things—temper of thin, crowing, quacky sound, it points or acute pain. The first is very rarely seen to the existence of retro-pharyngeal lymphbefore the fourth month of life, and is aptadenitis. to occur under similar circumstances. To (d) With progressive emaciation and properly diagnose the latter cause, it is the cry being quite hoarse in character it necessary to examine the infant and its

would suggest hereditary syphilis, if there surroundings for the cause of the distress. was a persistent rhinitis of a more or less Loosened pins and the bites of insects are severe type and an old look on the face a prolific cause. If the pain is relieved by of the infant. the ingestion of food, but after a time re- (e) After the subsidence of the acute turns again, it is evidence of some diges- symptoms of several diseases, as cholera tive condition causing the pain.

infantum and chronic ileocolitis, there may

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