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, 1910

, Vol. V.,

But after the third month and until the end of the second year all of the nerve centres are most irritable, so that convulsive seizures are common. The clinical import of this is, that convulsions in the very young infant are of serious import and that not infrequently after their subsidence there is some weakness of the affected musculature. That convulsions occurring at the onset of some disease in an infant between the ages of three months and two years, are of but little import and may be due to the most trivial cause, while in adult life any such event at any time would be sufficient cause for great alarm.

The necessity of recognizing these differences must be apparent, because it is by a correct analysis of them that we are enabled to determine the import of symptoms. Not infrequently apparently mild symptoms are interpreted as indicative of mild disease, while seemingly more grave ones arouse unnecessary alarm and foster the drawing of wrong conclusions.

Take, for example, the symptomatology of an acute illness in the infant; we find that there is not the limitation of symptoms referable to the particular organ or region which is primarily involved as in adult life, but the infant becomes the subject of more general or constitutional symptoms. Thus the expression of the disease is more constitutional than focal and the younger the child the more striking the con

trast.

This is largely due to the fact that there is an inability in infancy to focalization of nervous function because immaturity leads

an interference with the complete mechanism of inhibitory control.

Then again, the reflexes are not restrained but become generalized leading to the appreciation of constitutional symp

toms. And so we observe that nervous phenomena which would be of grave import in later life, loses much of its gravity because it occurs in the immature.

For instance, the onset of most of the acute diseases of infancy gives rise to one or more convulsions, an event which is practically unheard of in adult life. Such convulsions are almost always mild in their effect upon the infant and cause little or no alarm to the one who is experienced enough to determine their significance.

And again, the digestive system bears. considerable of the brunt of the invasion of any disease in infancy, so that it is our common experience to observe the symptoms of vomiting, diarrhoea or constipation at the onset of most of the diseases of infancy. Even making allowance for the ease with which disease of the digestive apparatus is produced in infants, the fact remains that a considerable proportion of of disturbance which is laid to digestive disease is due only to the onset of some acute infection.

The inarticulate expression of disease in infants has several qualities which adults do not possess. And first among these is absolute honesty of such expressions.

An infant's philosophy is contained in this statement: "All that is painful is evil; all that is pleasurable is good."

To the infant the mere act of living in contentment is sufficient and this sufficiency takes no recognition whatever of the future but is limited to the comfort of the moment. Neither is there any living in the past, and this is aptly illustrated by the experiences of an infant in the pain of an intestinal colic. With the quick subsidence of the pain there is an immediate return to the usual playfulness and no recollection of the past.

Health and Disease are terms that have for the infant no content.

This fact of living for the moment is one of the chief factors in the discomfort attendant upon enforced restraint. The infant dislikes illness and by nature their rebellion against the restraint which an illness enforces is absolutely honest.

This should lead one to appreciate the fact that if an infant shows any tendency to lose interest, to lag in its play, to become fretful or act as if in discomfort, the cause should be sought in the bodily health.

Therefore, muscular activity which is an important factor in the growth and develop ment of infants is responsible for some of the peculiarities which are noted in illness. In fact, the disinclination to continue the usual muscular activity should be interpreted as an early sign of ill health and this is often expressed by the infant in the desire to be left undisturbed.

The common accompaniment of diminished muscular activity is a diminution of mental activity and the infant loses interest in its surroundings because the exertion demanded by the attentive attitude is unpleasant.

And so when illness has marked one of these little ones as its victim, this same antagonism to illness, this rebellion against the consequent restraint keeps the infant from the magnification or multiplication of its symptoms.

Further than this the infant is entirely uninfluenced by the habit of morbid introspection and is therefore incapable of exaggerating its ills for the sake of attracting attention to itself. Whatever exaggeration takes place is due to the parent who gives the history and through innocence or design distorts the facts, or to the physician who allows the given history to influence his judgment more effectively than what he finds by observation and examination.

I have more than once heard it stated that even infants would exaggerate their ailments and that the quality of introspection in them was not entirely wanting. But this has always been based upon the demands which some infants make upon their attendants during an illness. Much of this is the result of habit which has been formed during periods of health and is not a part of the illness.

There is no doubt but that infants need and demand more sympathy than any other class of patients but the demand for it never exceeds the need. The infant crying in his apprehension may be labeled by the inexperienced as a disturber of the peace, but not so to the mother who understands the meaning of the cry and who is moved by its eloquence. To the infant, her arms are as a narcotic and when the mental need is fully supplied there is no further demand. Therefore the mental attitude of the infant may be taken as a safe guide and index to his bodily state.

From these general facts which are not always appreciated and may even be unknown, we can readily see that the more definite expression of disease in infancy is misinterpreted or unrecognized. There are, of course, innumerable objective symptoms which will give the examiner a wealth of information about the condition of the infant, but many of these are not under the control of the infant and, therefore, do not come with the province of this paper. But on the other hand, there are many things which are directly subject to the volition of the infant and a brief resumé of these may prove suggestive.

And first, the posture which the infant assumes may be significant. The attitude of the infant on the one hand, may be reassuring, as we note that he rests easily and turns

to greet the physician. It assures one that the ailment is slight, or that convalescence is established. On the other hand, the refusal to be attracted indicates that the illness is of a severer type. Thus in an infant with a suspected meningeal condition, if he turns promptly to locate a noise or upon the approach of a stranger, he is improbably the subject of meningitis.

The side position is characteristically assumed in two diseases-acute pleurisy and pneumonia. In both instances, the infant lies upon the affected side, so as to limit. as much as possible the motion of the diseased side, and to allow free expansion of the unaffected. In pneumonia it is not difficult to get the infant to temporarily change this posture but in pleurisy there is decided objection to such a procedure, which in most instances amounts to absolute refusal.

If this side position has been persistently assumed and as the illness advances, the infant gradually but persistently changes to the dorsal posture, it indicates that effusion is taking place.

The dorsal position (a) with slightly bent legs, is the position of election in cases of acute peritonitis and tubercular peritonitis. Motion is carefully avoided, and in acute peritonitis there is generally evidence of fear as the infant is approached.

(b) With a curve of the trunk slightly toward the right side, and with the right knee more or less flexed, or in some instances held up by the infant, which gives relief to some extent, the dorsal position. is often assumed in appendicitis.

On the abdomen is the position taken in (a) some cases of Pott's disease, but it is by no means characteristic; (b) in phlegmons of the back (to relieve the pressure); (c) and to eliminate the pain which is con

sequent upon much light in severe photophobia.

Under forced positions it is only necessary to make mention of opisthotonos and emprosthotonos, which occur in some cases of tetany, strychnine poisoning, and meningitis.

The upright or sitting position may be assumed as the result of abdominal accumulations of fluid; from large effusions in the pleural cavity; and it attends some cases of laryngeal diphtheria.

Also the face of the average infant expresses more clearly than does the adult the feelings and character of the individual. Except as the child more closely approximates the adult type, there is no attempt at deception by the facial expression. or well, there is a candid frankness which allows of no exaggeration or dishonesty.

Sick

The value of facial expression as indicating diseased conditions will exist only as one appreciates what is normal; then, with the capability of comparison which comes by many observations, one can interpret the expression of the infant.

The normal expression of an infant while asleep is one of perfect unbroken calm and peace. The eyelids are closed, the lips very slightly parted, and the nostrils immobile.

Normal expression plus twitching of the facial muscles is indicative of irritation of some portion of the nervous system. It may be the forerunner which indicates an impending attack of general convulsions; but if so, there is very apt to be restlessness also.

Normal expression with eyelids parted may be observed in many of the milder disorders of the nervous system and during digestive disturbances. If the muscles of the face are drawn from time to time, it

strongly indicates that the disorder is a digestive one.

Listlessness (that is, marked by a relaxed attention) may be due to several causes: (a) After some days' illness with typhoid fever a listless expression is an almost constant feature. (b) If associated with motionless or seldom moving eyelids, or with wide-open eyes staring steadily into the distance, it is quite indicative of meningitis, and this condition of the eyes and the expression may help in some cases to differentiate it from typhoid. (c) With sunken eyes, and occurring at any time during any disease, it is a symptom of ill import, for it is then a sign of suddenly increasing prostration or impending death.

Vacant expression (a) associated with enlarged head, but the bones of the face remaining small, and the eyeballs perhaps slightly protruding, is seen in hydrocephalus; (b) with thickened lips, more or less gaping mouth, small nasal orifices, and a broadened root of the nose, is quite common in hypertrophied tonsils and adenoids which are almost invariably associated with them.

When the expression is idiotic and the lips thickened, the tongue protruding so that saliva is almost constantly dribbling from the mouth, the nose flattened and the skin of a pallid, waxy hue, cretinism is probably the cause. (b) If the same picture is presented, but in a very much lessened degree, we may be dealing with an exaggerated form of mental deficiency.

Anxious expression (a) with nostrils. more or less dilated and labored breathing, is indicative of some disturbance to the circulation, and especially so if any cyanosis is detectable. (b) This expression is present, with sunken eyes, depressed fontanelles, a general sharpening of all of the

, 1910

, Vol. V.

features, with the angles of the mouth drawn and considerable pallor of the face. noticeable, in cholera infantum. (c) If the upper lip is retracted, exposing the teeth, and along with this there is visible prostration, it is indicative of acute peritonitis. (d) Associated with shallow respirations and increased frequency of breathing, and the cramped position on the side, it is presumptive evidence of acute pleurisy.

An old expression (a) with a pale, pinched and weazened face, and associated. with "snuffles" in an infant, is indicative of hereditary syphilis. These infants look prematurely old and may also show a depression at the bridge of the nose and a prominent forehead. Such an expression is most apt to be noticed during the first two months of life. (b) When the skin has a leaden hue and is loose and wrinkled, one would naturally suspect marasmus. (c) An old expresion is common to infants of all ages, who are suffering or who have recently suffered from chronic starvation, and such an expression is quite in proportion to the chronicity of the condition.

In edema and erysipelas all the lines of expression may be lost.

Painful disfiguration of the face while pressure is being made over some distant portion of the body aids in definitely locating the site of tenderness, and sometimes of pain, for pain may be referred.

Crying is not expressive of the emotions until near the end of the third month of life, and about this time tears are observed to accompany the cry. It is a matter of interest to observe that the tears, perspiration, and a free flow of saliva all appear about the same time of life.

A lusty cry directly after birth is a most welcome sound, not alone as a sign that the most difficult stage of labor is termi

nated, but it indicates the undoubted respiratory vigor of the infant.

Weak, feeble at birth, or absence of any crying at this time, is at once indicative of (a), the general feebleness of the infant, (b) pulmonary atelectasis, (c) congenital heart lesions. The first is self-evident, the second being indicated by lividity and infrequent or absent respirations, and the last by the general pallidity and weak fluttering heart.

Loud cry, occurring several times during the day or night, arising suddenly and stopping just as suddenly especially after the expulsion of gas from the stomach or bowel, is strongly indicative of colic from indigestion. During the act of crying the infant is very apt to throw its legs about or to rub them violently together, but this is not any more characteristic of this cry than it is of any violent crying spell. If due to colic, it is at once relieved by an enema, and the evacuations may give evidence of feeble digestion. If the same character of a cry is present with a rise of temperature to 101° F. or over, it is proof that we are not dealing with a simple dyspeptic colic, but that there is some associated condition.

Continued loud cry, with a stiffening of the body and the head thrown backward, may be due to one of two things-temper or acute pain. The first is very rarely seen before the fourth month of life, and is apt to occur under similar circumstances. To properly diagnose the latter cause, it is necessary to examine the infant and its surroundings for the cause of the distress. Loosened pins and the bites of insects are a prolific cause. If the pain is relieved by the ingestion of food, but after a time returns again, it is evidence of some digestive condition causing the pain.

Continued, suppressed cry should attract attention to conditions in the head, the abdomen, or the chest. If pain is caused by the use of the abdominal muscles or those of the chest, the infant will try to suppress all motion. If venous stasis increases pain. in the head, the infant will refuse to move that member freely, and tries to suppress the cry.

Continued but low cry may indicate several conditions:

(a) With loss of weight, but no appreciable rise in the temperature, the voiding of a much lessened amount of urine, and, as a rule, with constipation, it indicates that the infant is hungry. This may be corroborated by an examination of the milk, or testing what effect upon the condition a feeding or two with a modified milk will have. When the cry has been due to a chronic state of hunger, one such feeding will make the child restful. Sometimes the infant may vigorously suck the fingers, but this is not a constant feature.

(b) When more forcible an hour or two after nursing and associated with occasional attacks of colic, it indicates that the cause is chronic intestinal indigestion.

(c) With progressive prostration (which is more marked in young infants) and with a tone to the cry which is a sort of thin, crowing, quacky sound, it points to the existence of retro-pharyngeal lymphadenitis.

(d) With progressive emaciation and the cry being quite hoarse in character it would suggest hereditary syphilis, if there was a persistent rhinitis of a more or less severe type and an old look on the face of the infant.

(e) After the subsidence of the acute symptoms of several diseases, as cholera infantum and chronic ileocolitis, there may

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