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of children are of no account. It might as well be said that the physiognomy has no expression in people who, as a matter of custom, veil their countenance.
We must not reason thus. The expression of the face is studied when it is placed in the most advantageous position for the examination of the features, that is to say, when the face is uncovered. Let the children be free, and the gestures and attitude which betray the suffering of such and such an organ may be appreciated.
Thus when we observe a young child attacked with cerebral fever, at the commencement, during the stage of germination, he is suddenly heard to utter piercing cries; the hand is either raised, striking the air, or pulling at a portion of his clothing or of the materials which cover him, as if to remove an object which frightens him. This gesture is characteristic, and in children of more advanced age, speech comes to their aid, they call their mother to their assistance to deliver them from the beast which they perceive before them.
Sometimes, at this moment, the body assumes a strange attitude; the bed face expresses fright; the children sit upright, and are much concerned to get rid of the object of their terror.
At a more advanced period of the disease, in the convulsive stage, the nowhun gestures and attitudes are different. The movements are automatic; are au thus the hand wandering over the counterpane labours to pluck off the nap; moreover, the limbs are agitated by general convulsive movements, or are contracted. Lastly, in some patients, the body is in the most profound state of prostration; one of the sides is affected with paralysis, and is observed in the most complete resolution; the other 12
Lol alone remains capable of motion. Are these gestures then of no value, and is this attitude insignificant ? No; there is no physician who is not already cognizant of its complete importance.
In the diseases of the mouth, at the period of dentition, when the buccal mucous membrane is intensely inflamed, perhaps ulcerated, o particular gestures indicate the seat of the suffering which the ai evolution of the teeth occasions. In a little girl, twenty months old, in whom the process of dentition was tedious, the lips were forcibly separated, the mouth half open, and the four fingers of both hands were incessantly pressed between the dental arches. In the diseases of the larynx, in croup, the children cannot remain
19 completely recumbent; they become suffocated, and utter cries until they are placed in a sitting posture, supported by pillows which keepude a them in this position. They wish to be incessantly carried on the arm, because in this vertical attitude they find a point of support which facilitates their respiration.
they trah When they are observed at the periods of the crisis of suffocation, and of the attack of dyspnæawhich determine the asphyxia in the last
Su mere adorned stages of
Tue' Serram-stage of down they makeed to them, they seize their bed, throw
antroduction onilar movement
var you are not cohe obstruction offitude of chi
the stage of the disease, they are heard to utter screams; and when they
are laid down they make violent efforts to raise themselves. Thus,
when the hand is presented to them, they seize it with a convulsive h 201 Dumy grasp, and, pulling it rapidly, raise themselves on their bed, throwing
back the head so as to seize the air which seems to escape them.
In some children it is not the attitude alone which must be considered ; hob the gestures are also at this time very significant. How many times,
in these cases, has one not seen them carry their hands to the neck, and compress the larynx laterally, as if to remove the obstacle to the
introduction of air in the chest. There is no tracheotomised child WHO in whom similar movements are not observed.) They are not the wins result of the pain caused by the presence of the canula, for they
are not continual. They only exist in the moments of deep distress, in which the obstruction of the canula is about to determine asphyxia.
In pneumonia, the attitude of children presents nothing which deserves to be indicated in a special manner. The gestures and movements of the body, on the contrary, are more significant. They have been pointed out in speaking of the alterations of the physiognomy; they will, moreover, occupy our attention further on, when the external phenomena of respiration are treated of; it is, therefore, useless to refer to them in this place.
It is, further, by particular movements, without the aid of speech,
that the child expresses to us the suffering which it experiences in lit? Like the interior of the abdomen. These movements are fugitive; they
are correctly referred to the pain produced by colic. ***** In fact, in the course of a slight irritation of the bowels, the face,
usually calm, becomes suddenly contracted; the child cries out; flexes the thighs on the abdomen, which it forcibly makes tense; twists about for a moment, and all these symptoms disappear at the end of some seconds, when, at the same time, the habitual serenity of the face reappears.
The observation of the attitude and gestures presents, then, whatever may have been said to the contrary, characteristics sufficiently interesting to fix the attention of the pathologist; but we have not yet enumerated all of them. There are diseases of childhood in which these characters form the indispensable basis of the diagnosis. Thus, the involuntary and tumultuous gestures of the limbs most surely betray the affection known as St. Vitus's dance. However, it must be admitted, that this disease is scarcely ever observed in children at the breast.
The feeble attitude, so to speak, of certain children arrived at the i Pad, age of fifteen or twenty months, the impossibility which they experience
of holding themselves upright, even when the hand is given them Co l te as a support ; the incurvation of the vertebral column, the legs, and
is the thighs; the deformity of the chest ; are the only characteristics
of a disease of rather common occurrence in the early stages of childhood; they indicate rachitis : it is important, then, to recognize them.
Lastly, we may mention the different attitudes of the body consequent on muscular retractions; the nature of which is, at present, little known. Thus, the deviation of the head, of the stature, &c., in consequence of the retraction of the sterno-mastoid and spinal muscles, are diseases which inspection alone will detect; it would be puerile to dwell upon them further.
* CHAPTER III.
The size of children, their degree of plumpness, can only furnish general notions, very imperfect ones it is true, but which, however, must be taken into consideration. They may be insufficient when it is required to give a precise diagnosis, but they may be of assistance, to the physician. Thus, it is remarked, such a child does not make a progress, because it is feeble, of small size, and that at its age other children are much more developed than it. The fault of this is often Out in the nurse, who is too indifferent; who saves herself by giving it y too little suck; or who affords a poor and insufficient supply of milk. In these cases, change the nurse, and the child will recover its strength, and will become developed with an increased vigour.
When we make an observation on a sick child, its condition of . thinness or of plumpness produces a certain impression on the physician, which, alone, is often sufficient to indicate the nature of the disease, its acute or chronic form, and even its approximative duration. It is thus that an acute or chronic diarrhea, or a case of rachitis, may sometimes be recognized.
In the acute state, the emaciation is rapid; the flesh, naturally smooth, is soft and flabby, but the skin is still rather firm : its surface
се пише is not yet thrown into folds. In the chronic state, on the contrary, besides the flaccidity and the softness of the tissues, the skin appears í to have lost its elasticity; it preserves the fold which the pressure of the finger causes; it is covered with wrinkles which become still more decided at the period of muscular contraction. LThe persistence of the fold of the skin consequent on the pressure of the fingers is especially observed in the diseases of the abdomen.) It is sufficiently Olarikas constant in entero-colitis to be ranked amongst the symptoms of this Hero disease. In rachitis, the disproportion between the head and the limbs, which are relatively smaller; the latteral flattening of the chest;, the size of the belly ; and the enlargement of the larger articulations, are sufficient to establish the diagnosis.
Thusu in ulei
In the study of diseases of the first stage of childhood, we must, then, take into consideration the development and the plumpness of the subjects. We may here discover signs which do not possess great importance, it is true, but the value of which cannot be completely put aside.
ON THE CRY.
The cry, the most natural manifestation of suffering, is at the same time the most energetic of the child's means of expression, to whom speech is wanting. In a special manner it indicates pain, the origin and the source of which it occasionally specifies by the various modifications which it experiences.
Like the articulate voice, the cry presents particular characteristics easily appreciated but impossible to describe, characteristics peculiar to certain passions, certain moral pains, and certain physical sufferings.
Voice betrays the man, and reveals the sweetness as well as the asperity of his character, his sincerity as well as his probity, the good as well as the evil sentiments which animate his soul, courage as well as cowardice, love as well as anger, &c.
Young children also know how to manifest their joy, their impatience, and their anger, by cries which every one can recognize; but these are not the ones we are about to consider. In the state of disease, the cries are caused both by moral griefs and by physical pains, which result from the affection of such or such an organ; all these cries are modified by the age and constitution of the children, and sometimes even by the nature of the sufferings which provoke them. We have, then, to investigate what are the characteristics of the cry in the diseases of young children.
These modifications are easily appreciated, and any one may detect them. It is always very embarrassing to translate them into common language. In fact, the sound which strikes the air and arrives at our ear penetrates and impresses us, without our being able to give a description of the sensations to which it gives rise. Although fugitive and varied, these sensations are real, and sometimes very profound. We may be convinced of this by the remarkable and well authenticated examples of several mothers, who, in calamitous circumstances, separated from their child, have been able to recognize it, amongst a thousand others, simply by its cries.
Notwithstanding these difficulties, which render the interpretation embarrassing and obscure, we propose examining the characters of the
cry in the affections of young children; and we shall endeavour to determine whether the modifications which it undergoes are really under the influence of their different states of suffering.
The cry is always produced at the moment of expiration, it lasts as long as it can, ceases during the inspiration which follows, and reappears with a fresh expiration. In some children the inspiration is itself noisy; this is what Billard has qualified by the name of reprise. Thus in the cry two distinct periods exist: the cry, properly so called, which takes place during expiration; and the reprise, which makes itself heard, on the contrary, during inspiration. The cry is usually stronger than the reprise. They both undergo the modifications to which we shall allude further on.
At the time of the cries a general phenomenon, characterized by .turgescence of the face, colouring of this part and of the whole surface of the body, by a general congestion, seems to indicate the presence of an obstacle to the return of blood in the heart. The veins of the neck and hands are swollen, and in sick children, who have erythema or inflammation of a portion of the skin, the areola of vaccination for instance, these parts assume at the time a much more decided colour. The cerebral congestion is so intense in some children, at the time of their cries, that they fall back, faint, and swoon for some seconds. This condition is not far removed from asphyxia.
The cries are often accompanied by an abundant secretion of tears; Law ! this phenomenon is not observed in very young children: the lachrymal Mus gland has not yet assumed its functions. It only commences to secrete towards the third or fourth month. It is then right to take into consideration the presence or the suppression of tears; for, as M. Jo Trousseau has remarked, the functions of the lachrymal gland are suspended under the influence of very severe acute diseases. The suppression of tears might then be considered as an important general, symptom in the prognosis of diseases.
The cries may be changed in their form, in their tone, and in their duration.
· [The tears of children may certainly furnish something towards the prognosis, for 9 M. Trousseau states that it may be laid down as an aphorism as seldom liable to exceptions as those of Hippocrates, that when a child sheds tears a favourable, prognosis may be delivered, however menacing the symptoms; while when this is not the case in painful diseases, and especially if the eyes are dry and sunken in the orbits, great danger to life exists. The observation applies almost invariably to children less than two years of age, and particularly to those less than one, but w e may frequently be verified even until seven. In no one of his operations for croup has he ever seen a child shed tears, and he has always felt much pleased if they did h ilo so some days after, as when they did not the unfavourable prognosis given was almost always verified.-P.H.B.) en