A text-book on hygiene and pediatrics from a chiropractic standpoint

ANALYZING INFANTS

One of the most baffling situations the chiropractor meets is in caring for sick babies. There are several reasons for this: The baby can give no assistance in the way of subjective symptoms. It is difficult to nerve trace with any degree of satisfaction and assurance of accuracy; it is even very difficult to keep the child still for palpation. Therefore, it becomes necessary to rely largely upon the objective symptoms and the palpation, with what verification may be obtained from nerve tracing and the spinograph. However, there is no class of patients in which the results are so gratifying as with the babies and small children, for they respond to adjustments more readily than does the adult.

There is no time in the practice of the chiropractor when he needs to have better self-control than when he is taking care of infants. There is great need of every faculty that is employed in the analyzing and adjusting, especially if the child is seriously ill. Usually the parents are more or less excited and worried and are likely to keep urging the chiropractor to do something and thus unduly influence him unless he is accustomed to such cases. If the child is in pain and crying it is likely to get on the nerve of every one present and this will tend to make the chiropractor nervous. He must be careful that these things do not influence him to act too hastily before he has had time to make a careful analysis.

History of the Case

Great care must of necessity be exercised in taking the analysis of the baby and of the small child. A very careful history should be taken. This, of course, must be obtained from the parents or nurse. This history should include such points as whether birth was instrumental or natural, whether it was premature or full term, whether there were any peculiarities of respiration at birth, whether there have been any convulsions and what sickness, if any, the child has suffered with. Inquiry should be made relative to the condition of the bowels and kidneys, how the child sleeps, and if there is a tendency to cry out during sleep. If the child refuses to nurse or nurses with difficulty it may indicate an incoördination of the mouth or the throat.

Objective Symptoms

In view of the fact that the child can give no aid in the way of subjective symptoms, it is necessary for the chiropractor to make most careful observations and substitute, as far as possible, the objective symptoms for the subjective ones. About the first thing we see when we begin the analysis is the baby’s face. It may reveal valuable information. A very careful study should be made of the facial expression and the condition of the eyes. In the face we take into consideration the color. We should look for pallor, cyanosis and jaundice; we notice whether there is perspiration, whether the face is cold and clammy or warm and moist; also we observe the expression as to the muscular condition, since there may be muscular spasms which will produce grimace. This is either the result of pain some place in the body or an abnormal action of the facial muscles. There may be a pinched expression or a look of fear or anxiety. In some severe cases the face will be expressionless, while in others it may be that of an adult.

The condition of the eyes is important. They may have a dull expressionless look. The lids may droop and the eyeballs be sunken. In cerebral incoördinations there may be strabismus, or the eyeballs may be rolled upward and inward. These symptoms are significant and should all be very carefully noted, for, as has been stated, there will be no chance to profit by subjective symptoms.

After a careful observation of the face and facial expression has been made, the child should be undressed and placed in a convenient position for further observation. Before the clothing is removed the room must be heated to a proper temperature so the infant will not take cold or be exposed to an atmosphere that will be distressing. A temperature suitable for the bath will be satisfactory. The child should be placed on his back and every movement of the body observed. Such movements as the flexing of the thighs on the abdomen, as in abdominal pain, may lead the chiropractor to a conclusion on the zone involved.

The general appearance of the child must be carefully considered, whether the child is properly developed and whether or not there are any deformities. The chiropractor should look for dyspnea and other objective symptoms. A very careful inspection should be made of the spine to determine any malformations or marked curvatures. The character of the cry is sometimes important, as for instance in pneumonia or bronchitis there is a short, catchy cry; the cry of laryngitis and croup will be hoarse. In extreme prostration, as in many cases of malnutrition, the cry will be very feeble.

Respiration

Since the chiropractor must depend almost entirely upon objective symptoms and upon the palpation of the infant in determining the character of the incoördination he should be thoroughly familiar with the characteristics of the normal child. The rate of respiration of the infant, especially during sleep, is of some importance. The following table is given by Holt and Howland and indicates the normal rate of respiration at different ages:

Respiration is very much faster than this when the child is awake. If the child is at all active it may be twice as fast. It is advisable to observe the respiration to determine whether it is normal or labored, shallow or deep, regular or irregular.

Irregularity of respiration in infants is characteristic and must not be mistaken for indications of incoördination. The least excitement will disturb the rhythm; as a matter of fact, the only time there will be perfect rhythm is during sleep. In observing infants it will be found that the lungs sometimes do not expand equally. This is due to the delicate muscular walls of the thorax and does not necessarily indicate incoördination. It is well to take this into consideration when observing the infant. This must be very carefully considered when incoördinations of the lungs are suspected. Placed in certain positions one lung may expand very much more than the other in normal respiration; or in some positions, and sometimes for unknown reasons, there may be practically no expansion in one lung for a short time. This peculiarity is due to the inability of Innate to maintain adaptation through the delicate structures of the thorax to the atmospheric pressure. This might be very misleading and result in the conclusion that one lung was badly affected when there would be nothing at all wrong. However, if there are symptoms which indicate an incoördination in the lungs there should be a very careful palpation made of the upper dorsal region to locate the subluxation and the hot box.

In infants the respiration is altogether diaphragmatic; it is irregular at times; it may be superficial for a time and then deep. This irregularity continues in the child more or less until the seventh year. After this such an irregularity indicates some disturbance and should receive consideration.

The muscular walls of the thorax are very feebly developed and are therefore very soft and yielding; a slight obstruction in respiration will result in a marked sinking of the thorax from the normal atmospheric air pressure.

Pulse Rate

It is not necessary to take the pulse of the infant, but it might be well to know what the normal pulse rate is at different ages. The following table will give the desired information:

Very slight disturbances will often increase the pulse rate out of all proportion to the severity of the condition. The heart will beat very much faster just from the handling of the child in making the analysis, or as a result of any excitement or crying. It may be very difficult to count the pulse because of its rapidity.

Often a very moderate incoördination will result in a marked increase in the pulse rate and especially is this true in cases in which there is slight fever.

An increase of the heart action does not, necessarily, mean that heart place should be adjusted. This increased action may be due to the natural adaptation because of handling or to nervousness at the presence of strangers. Especially is this likely to be true of the child that is old enough to notice things. It is not uncommon to have the pulse beat increased as much as 25 beats per minute in this way.

During sleep the pulse may be slightly irregular, even when the child is normal. In cerebral disturbances it will be slow and irregular. In cerebral tumor it may be as slow as 40 or 50 beats per minute. In acute incoördinations the pulse rate may be very greatly increased. With incoördinations in such families as the poison, fever, degeneration, and some incoördinations in the spasms family, the pulse rate may be very high, even when the condition is not at all alarming. It is well to take this into consideration when observing a case so that the chiropractor will not be misled in making the analysis and that the objective symptoms may be of greatest value to him.

Zones Involved

In analyzing an infant it is well to keep in mind the zones in which incoördination is most commonly found. In the majority of cases these zones will include the gastro-intestinal tract, the respiratory tract, the kidney zones and the brain. Very frequently there will be incoördinations of the pharynx, tonsils and mouth.

The incoördinations found in the digestive tract will include all forms of indigestion and dysentery. Such incoördinations as pneumonia and bronchitis will involve the respiratory tract. From the kidneys there are the various conditions involving the poison family due to improper elimination. Meningitis and all forms of cerebral incoördinations as well as conditions of the eyes and ears are common to infancy and childhood.

It must be remembered that with an infant grave symptoms may develop in a very short time, likewise recovery may take place very quickly following even the most alarming symptoms. However, no chances should be taken for it is not uncommon for an infant previously in good health to become sick very suddenly and die within a few hours. Therefore, in handling children most careful attention should be given and conditions should always be regarded more or less serious until developments prove otherwise. The chiropractor must realize that his success in handling infants does not depend entirely upon his observations of the case, for with every patient there must be a thorough and complete analysis of the spine. The only value to be received from the observations is that they may lead him to specific regions of the spine.

The Child’s Cry

It is not uncommon for an infant to cry with no apparent localized cause. This crying may continue for hours with no other symptoms. There will be no indication of colic or other symptoms to denote the seat of the pain. The crying is constant and, while in some cases may be quite violent, yet there are no paroxysmal attacks; this indicates that the pain is constant. It is easily distinguished from a hunger cry in that the child usually refuses to nurse. If the crying persists for hours there will be more or less exhaustion. Such cases are very pitiful and draw heavily upon the sympathies of the chiropractor as well as upon other attendants. In such cases the first thing to do is to strip the infant of all clothing and look for open safety pins, rough places in the clothing, such as folds or wrinkles; foreign objects, as small buttons, for example. Usually, however, this will be done before the chiropractor is called. It may be an advantage for the chiropractor to observe the infant very carefully for a few minutes after the clothing has been removed, in an effort to locate the seat of the pain. However, this is not so very important because first, in most of these cases it is practically impossible to determine the location of pain, and second, because a very careful palpation of the child will always reveal the causative subluxation. In making the analysis the chiropractor should give himself plenty of time to make a thorough palpation. He should not be in too great a hurry to adjust the child merely because of his anxiety to relieve the crying. He must not allow the incessant crying of the child to work upon his nerve and destroy his efficiency in caring for the patient. In these cases the subluxation may be located in any part of the spine, although it is less often found in the cervical region. If there is a subluxation in the cervical region, great enough to produce this constant crying, there is very likely to be cerebral symptoms. In these cases the subluxations are usually quite exaggerated and very often the hot box becomes the determining factor.

In a case recently an infant three weeks old had been crying constantly for several hours. The clothing had been removed and the child very carefully bathed and powdered; then instead of the clothing being replaced the child was wrapped in a blanket. Still the crying persisted. A very careful observation of the patient gave no information whatsoever as to the possible location of the cause for the crying. There was nothing that would quiet the child. He finally grew so exhausted that the cry became little more than a whimper, beads of perspiration standing out over the entire body. There were no signs of colic or tympanites. A careful palpation revealed the sixth dorsal very badly subluxated and a slight subluxation of the first lumbar. These were adjusted and the child stopped crying almost instantly and in less than ten minutes was sleeping normally. There was no return of the abnormal crying and the child had no further adjustments.

We have many such cases on record, but the citation of this one is sufficient to illustrate the results that are obtained in such cases.

Palpating the Infant

In palpating an infant the first thing to look for is the hot box. It may be possible to locate it very easily and if this is so it then becomes necessary only to list the direction in which the vertebra is subluxated. In looking for the hot box it is necessary to use care so as not to be misled by the difference in the temperature of the back due to some article of clothing being in contact with the back and raising the temperature in that region. Notice that there has not been some woolen garment, such as the band, pressing against the spine. To eliminate the possibility of thus being misled the entire back should be exposed to the atmosphere a sufficient length of time to allow the back to become influenced alike to the temperature of the air. The majority of incoördinations of infancy are acute, therefore the hot box is present. After the hot box is located then a very careful palpation should be made to determine the direction in which the vertebra is subluxated. It is not sufficient to consider that because the patient is an infant all that is necessary is to list the vertebra straight posterior and adjust it accordingly. Laterality, superiority and inferiority are quite as essential, and the chiropractor should not be satisfied until he has convinced himself on the question of these directions. If there is no laterality, superiority or inferiority then the adjustment should be given straight toward the anterior.

In palpating an infant it is usually best to place the child on the knees of an adult in the position for an adjustment. The child will be almost constantly on the move. It will therefore be necessary for the chiropractor to adapt himself to this constant moving. The child should be placed in as many different positions as possible to make the palpation. He may be held up over the shoulder of the mother or nurse; first on one side, then on the other, this giving opportunity to palpate with both hands and make comparisons.

No effort should be made to force the child to be still. It is a good policy to hold the palpating fingers on the spine and let the child wiggle and squirm all he wants to, moving the spine beneath the palpating fingers of the chiropractor. In this way a comparison may be made of what is felt under the fingers while the child is moving.

It is quite difficult to nerve trace an infant in any measure of accuracy because the infant can not coöperate to any degree of satisfaction. In some, however, nerve tracing may be used to a certain extent by producing slight pressure and noticing whether or not the child flinches.

It is very much more difficult to palpate the cervical vertebrae of an infant than it is those of the dorsal and lumbar regions. The same technique and tactics are used, however. It is sometimes an advantage to place the child on the mother’s lap in such a way that the head will be unsupported by the lap. One hand should support the child’s forehead, while the other hand palpates or it may be necessary to place the infant in some other position. The chiropractor should be sufficiently resourceful to find a way to get an accurate palpation of the cervical region. Here, again, he will meet with the difficulty of keeping the child still. This makes it necessary that he be very alert and at the instant it is possible to feel the vertebra to be ready to make his comparisons quickly and decide the direction in which it is subluxated.

The cervical vertebrae of an infant are very hard to feel, but if one of the segments is subluxated sufficiently to cause pressure on a nerve that segment will be easier to feel because it is out of the median line; especially will it be easier to feel if it is subluxated posteriorly. Every possible means must be used to make an accurate palpation. If there is a subluxation in the cervical region there will very likely be symptoms which will indicate it. Subluxations are not as commonly found in the cervical region as in the other regions of the spine.

In making an analysis of the infant the importance of the sacrum must not be overlooked. It will be remembered that the segments of the child’s sacrum are separated with cartilage and are subject to being subluxated. These segments coalesce later in adolescence and form the sacrum into one solid bone. Therefore it is highly important that the subluxations that may exist between the segments be adjusted before this process takes place.

The tubercular ridge formed by the rudimentary spinous process in the median line of the posterior surface of the sacrum is of very little value in palpating the segments of the sacrum. It is best to palpate the articular crest on each side of the tubercular ridge. In this way it is possible to determine if one segment is more prominent on one side than on the other. This should be done very carefully and if a subluxation is found it should be adjusted on the side that is most prominent. The contact is on the articular ridge and the thumb may be used for nail point the same as in the dorsal region; or if the child is large enough nail point one may be used.

Whenever possible a spinograph should be made of the child. This may not always be possible with the small child and with the very young infant it may be very difficult. In many acute incoördinations it is impracticable to try to get a spinograph, not because the spinograph would not be of value, but because it is difficult to get to the office to take it. In the chronic cases a spinograph should by all means be taken. Every possible means should be used to verify the palpation.