Lectures on diseases of children: a handbook for physicians and students

Front matter

a

TRANSFERRED TO YALE MEDICAL LIBRARY

LECTURES

Part I. Diseases Of The New-born

Icterus neonatorum 11

Trismus or tetanus neonatorum 13

Cephalhematoma 17

Hematoma of the sterno-mastoid 19

Enlargement of the breasts 20

Erysipelas neonatorum 21

Sclerema neonatorum 25

Pemphigus neonatorum 28

Aphthse of the palate 30

Melsena neonatorum 31

Part II. Diseases Of Infancy

I. — The atrophic conditions of childhood 33

II.— Sprue 37

III. — Hereditary syphilis 40

Syphilis of later childhood 49

IV. — The dyspeptic conditions of infancy 51

V. — Coryza of infancy 57

VI. — Retropharyugeal abscess 59

VII. — Dentition and its symptoms . . 63

PiGE . 65

. 69 vi CONTENTS.

Part III. Diseases Op The Nervous System

I. — Convulsions of childhood

Epilepsy

II.— Spasm of the glottis 70

III. — Idiopathic contractures '"

Tremor ; *

IV. — Nodding spasm, spasmus nutans '■*

V. — St. Vitus' Dance, chorea minor ?6

Chorea electrica °1

VI. — Hysterical affections of childhood 82

Chorea magna 84

VII. — Nocturnal terrors, pavor nocturnus 80

VIII Peripheral paralysis 91

Paralysis of the facial nerve 91

Paralysis of the brachial plexus 93

IX — Infantile spinal paralysis 94

Other diseases of the spinal cord 98

X. — Pseudo-hypertrophy of the muscles 99

XI. — Hemorrhagic paralysis 100

XII. — Tuberculosis of the brain 103

XIII.— Tumors of the brain 107

XIV. — Atrophic cerebral paralysis 108

XV. — Chronic hydrocephalus Ill

XVI. — Congestion of the brain, thrombosis of the sinuses 116

XVII. — Tubercular meningitis 119

XVIIL— Simple meningitis 126

XIX — Neuralgic affections 131

Migraine 131

Part IV. Diseases Op The Respiratory Organs

I.— Inflammation of the nasal mucous membrane, rhinitiB 1 33

IL — Pseudo -croup 134

III. — Pulmonary atelectasis 135

IV. — Inflammatory affections of the larynx and trachea 137

V. — Bronchitis and catarrhal or broncho-pneumonia 143

VI. — Croupous pneumonia 151

VII. — Chronic pneumonia 157

VIII.— Pleurisy 159

CONTENTS. Vll

PlOE

IX. — Pulmonary tuberculosis 163

X — Pulmonary gangrene 169

XI. — Whooping-cough 169

PART V DISEASES OF THE CIRCULATORY ORGANS. I. — Congenital diseases of the heart .' 177

II. — Inflammatory affections of the heart 180

Part VI. Diseases Of The Digesttve Organs

I. — Inflammatory affections of the buccal mucous membrane 186

II. — Gangrene of the mouth, noma 189

III. — Inflammatory affections of the pharynx 192

Hypertrophy of the tonsils 193

IV Contagious parotitis 194

V. — Diseases of the oesophagus 195

VI. — Diseases of the stomach 197

Gastric dyspepsia 197

Cardialgia 199

VII.— Cholera infantum 200

VIII.— Catarrhal diarrhoea 203

IX.— Dysentery 207

X— Constipation 209

Intestinal intussusception 211

XL— Rectal polypi 214

XII. — Prolapse of the rectum 215

XIII. — Entozoa of the intestinal canal 217

XIV. — Acute and chronic peritonitis 222

XV.- — Tuberculosis of the abdominal organs 225

XVI.— Diseases of the liver 232

XVII. — Diseases of the spleen 236

XVIII. — Abdominal tumors 238

PART X DISEASES OF THE SKIN. I. — Erythema and intertrigo 337

II. — Lichen-strophulus and prurigo 339

III. — Eczema and impetigo 340

IT.— Ecthyma 344

V. — Abscesses of the subcutaneous tissue 345

INDEX. 353

LECTURES ON

DISEASES OF CHILDREN.

INTRODUCTION AND METHODS OF EXAMINATION.

Gentlemen: Diseases of children are usually regarded as a specialty, but I consider this a mistake, as almost all diseases of childhood are found in adult life. These diseases have been converted into a specialty for the following reasons:

First. — A large proportion of the affections under consideration are observed much more frequently and more strikingly in childhood than in later life (acute exanthemata, pertussis, meningitis tuberculosa, etc.).

Second. — The medical examination of a sick child requires skill, which can only be obtained by frequent practice upon children.

In addition, the young physician, whose sphere of action is at first confined almost entirely to the lower, prolific classes of society, must, in great part, treat sick children upon entering into practice. This circumstance, which was formerly not sufficiently considered, is now more and more recognized, as I am led to judge from the continually increasing number of my hearers. It is so much more remarkable that the Faculties themselves obstinately oppose this view, and deny the right of paediatrics to a separate chair.

But I cannot deny that even the most persistent study and ripe experience will not save you from disappointment in reference to therapeutic results. The conditions of life in early childhood are of such a nature that even the most rational and faithful treatment of its diseases is useless in an extremely large number of cases.

Statistics prove unmistakably that the mortality of children is greatest in the first months of life, while that of the first year more than twice exceeds that of later years ; it gradually diminishes after the second year, and assumes ordinary proportions after the fifth year.

This is best shown by the following table : In my service in the Charite, 3,804 children were received from 1874-78, of whom 3,227 were under and 1,577 over tw» years of age. Of the former, 1,526— i.e., about 70 per cent. — died, and only 277, or about 19 per cent., of the latter. Of the 1,384 children who had not passed the sixth month, 1,117 died, or about 80 per cent. 1

This enormous mortality, especially in the first six months, is explained by two sets of causes, the first of which is found in the natural development of the child, the second in extrinsic circumstances. After the birth of the child the development of the body does not cease, but very important changes occur in the organism. 1 will merely recall to you the closure of certain fcetal channels of the circulation, the differentiation of white and gray nervous tissue, the development of the intestinal glandular system, dentition, the growth of bones — processes which are calculated to cause pathological changes in the corresponding organs. But while children of the upper classes, who are carefully nourished, more readily pass through these developmental changes, the latter are apt to become pathological under the adverse influences to which the lower classes are subject. The foul air of narrow, crowded rooms, the more or less improper food, the influence of cold, hunger, the lack of maternal care — all these influences combine to impede the normal course of development, and to produce the harrowing pictures of disease with which we come in contact. Many of these unfortunate beings carry with them the seeds of death, and die of exhaustion within the first few days after birth ; others succumb to hereditary syphilis ; the majority become puny in consequence of persistent diarrhoea, or repeated attacks of bronchitis with enlargement of the bronchial glands, which finally lead to cheesy degeneration and general tuberculosis. A large proportion of these children are illegitimate, and many mothers send their offspring to the hospital in the hope that they will thus be relieved from them. Of the cases of this category which entered my wards, a large proportion died on the day of admission.

We will now concern ourselves with the medical examination, which, at least during the first few years of childhood, differs essentially from that of adults. One source of difficulty is the absence of speech, or the inability on the part of the children to furnish the physician with a history. In private practice this may be done by the mother, while in hospital practice we are usually restricted to a purely objective examination. The difficulty is increased by the fright and opposition of the child to the strange physician. While it is best in adults to examine one system of organs after another, and then conclude with the previous history, this principle must not infrequently be sacrificed in childhood, as the struggles of the little patient may force you to utilize every favorable moment for the inspection or auscultation of those parts which can alone be examined during quiet intervals — as, for instance, the throat or heart. In this manner the examination may become disjointed and irregular. On the other hand, a resume of the symptoms is more readily obtained on account of the briefer and simpler clinical history. No definite rules can be laid down with regard to the conduct of the physician toward the patient. However sympathetic the physician may be, he will often be disturbed in his examination by the struggles of the patient, and the resistance must be overcome by kindness or force, according to the disposition of the child. Many children can be kept tolerably quiet during the examination by attracting their attention, as by showing them a watch, a toy, a lighted candle, etc.; and in especially important cases we can resort to chloroform, as in examination of the abdomen, bladder, or rectum.

During the first few years of childhood the patients are best examined by having them seated, opposite to the physician, on the lap of the mother or nurse, the face being turned toward the window. If at all justifiable, I even have patients who are suffering from fever, taken out of bed and placed in this position. Not infrequently, however, the child resists the hands which endeavor to hold it, thus producing the greatest obstacles to percussion and auscultation. When the children are very restless, we can alone perform auscultation with the unaided ear, as the movements of the patient can thus be readily followed, if the physician, grasping the thorax of the child, keeps his head constantly in contact with it. I must insist that the examination not only of the posterior, but also of the anterior and lateral surfaces of the chest, should not be neglected in any case. I have not infrequently found signs of pneumonia below the clavicle, although everything was normal posteriorly, and the tongue-shaped prolongation of the left lung has often presented signs of pneumonia, which I heard much more indistinctly or not at all in other parts of the thorax. The anterior surface of the thorax may be examined in the sitting or recumbent position, the latter method being used especially in very young children ; the posterior surface should be examined only in the sitting or lateral position, but never while the child is on its belly, as the compression of the abdomen will press the diaphragm upward and diminish the thoracic dimensions, and may thus not alone increase the dyspnoea due to thoracic disease, but has also been known to cause sudden death during physical exploration.

Percussion causes much more annoyance to many children than auscultation, and crying interferes very markedly with the clearness of the results. In addition, every unsymmetrical position of the body, every muscular action during the movements of the thorax, causes a slight difference in the percussion-note, and you can therefore understand how careful we must be in the percussion of restless children. In an extremely large number of cases, I have thought, after a first examination, that there was a difference in the percussion-note over both halves of the thorax, although further repeated examinations proved my mistake. In doubtful cases auscultation affords the best control. Moreover, you should never fail to perform percussion both during inspiration and expiration, especially in crying children, as the percussed parts become more or less emptied of air during the cry, and therefore give a dull sound, which disappears during inspiration. This is especially so, as Vogel remarks, over the lower part of the right side posteriorly, where the liver, which has been forced upward during the crying and struggling, may give rise to dulness. Our patience may be sorely tried when we must wait for the rare inspirations for purposes of percussion. But auscultation is not interfered with, by any means, to so marked an extent. On the contrary, I find that, in the deep inspirations which occur during the intervals of crying, the pulmonary sounds are heard much more distinctly than during repose. I do not, therefore, try very long to quiet a crying child prior to auscultation, but insist upon absolute quiet on the part of those in the vicinity. With regard to percussion, I would also advise the lightest possible strokes of the pleximeter. The conditions of the child's thorax with regard to resonance are so favorable on account of the elasticity of its walls, that strong percussion will cause a sonorous sound from vibration of surrounding parts, though the parts percussed may be empty of air, and therefore dull on gentle percussion. I make use of a small ivory pleximeter and an ordinary hammer. In great emaciation and in percussion of the supraclavicular region, the pleximeter must be superseded by a finger of the left hand.

In order to determine the frequency of the respirations, the child should be examined when quiet, and, when possible, during sleep. If the

4 DISEASES OF CHILDKEK.

hand is carefully placed upon the thorax or abdomen, the number of the respiratory movements can be readily determined. "When the child is awake, even if it is not crying, this examination is often disturbed by the fact that the patient holds his breath. It is, therefore, not easy to give the normal frequency of respirations for any given age in childhood. It is greater in children under seven or eight years than in adults, and the frequency is greater, the younger the child, corresponding to the rapidity of the pulse. The heart's action is in itself more rapid than that of adults, very irritable under psychical impressions, and dread of the physician often increases its frequency to such an extent as to render it valueless for diagnosis. This is best shown in children suffering from icterus. The retardation of the pulse, so characteristic of this disease in the adult, I have never observed before the seventh year, and can only account for this fact by the above-mentioned irritability of the cardiac nerves. The pulse, especially in small children, can, therefore, alone be properly counted during sleep. But it must be remembered that, even in perfectly healthy children, the pulse is sometimes somewhat irregular during sleep.

On the average, I believe that a frequency, during the first few months, of 120-140, and, during the second year, of 100-120, should be regarded as normal. After this period a gradual reduction occurs. In children of three to six years the pulse is always above 90, and it is only after the second dentition that it approaches the conditions of adult life. The frequency of the respirations changes in a corresponding manner, its relation to that of the pulse being as one to three and one-half or four. But I repeat that very little is gained in practice by these averages. It is only under very definite circumstances that the rapidity of the pulse assumes a diagnostic or prognostic importance, as, for instance, its retardation in the beginning of tubercular meningitis and its remarkable acceleration at the close, and its extreme rapidity in scarlatina. On the whole, the rhythm and quality of the pulse have always appeared to me to possess greater importance to the physician. This is also true of the relation of the pulse to the respirations, which is, under normal conditions, as three and one-half or four to one. If this is permanently disturbed — if there are 40 to 60 respirations, with a pulse of 120 to 140 — you may almost certainly assume that there is some disease of the respiratory organs. Only in exceptional instances is this due to nervous influences. The certainty of the diagnosis is increased if the respirations are not alone more rapid and superficial, but, at the same time, more labored, when certain accessory muscles are brought into play and expiration is stertorous. Bronchitis, pneumonia, or pleurisy is almost always present under these circumstances.

The examination of the heart in early childhood is attended with, perhaps, even greater difficulties. The rapid succession of the beats and the frequently accompanying cries not infrequently render it impossible, at the first examination, to form a decisive opinion concerning the clearness of the sounds and the conditions of percussion. The laryngoscopical examination of the larynx is, however, the most difficult. While there is scarcely any question of such an examination in very young children, even in older ones the physician, as a rule, meets with opposition which can with difficulty be overcome. Even if the laryno-oscopic mirror is properly introduced, its surface is soon obscured by moisture, so that a distinct image cannot be obtained. In the large majority of cases therefore, no results, or very uncertain ones, are obtained by this method. Still more unsatisfactory are the conclusions drawn by the older writers from the character of the cry. I only attribute any practical significance to hoarseness or the substitution of painful moaning for the voice. You are probably aware that the new-born never shed tears in crying. The secretion of the lachrymal glands must, therefore, be as defective at this time as that of the salivary glands. After some practice the examination of the mouth and pharynx rarely presents any difficulties. If the child, when asked, does not voluntarily open the mouth, it is best to push the lower lip, with the forefinger, over the border of the lower jaw, and exert pressure upon it. The opposition which is made can usually, after a little persistency, be rapidly overcome, especially if the child is forced, by closure of the nostrils, to breathe through the mouth. As soon as the finger is pushed beyond the lower row of teeth, the child usually opens the mouth sufficiently to permit examination of the mouth and pharynx. In the contrary event, resort may be had to a spatula. Above all, good illumination must be secured, either by the bright daylight, or, if this is not possible, by means of a candle, the flame of which is placed in front of a silver spoon held by the same hand. With this simple mirror, which can be everywhere readily obtained, we can secure excellent illumination, to which I very frequently resort. But occasionally we meet with children who resist all our efforts, so that we must finally desist or resort to forcible means to separate the jaws.

In order to derive any benefit from the results of the examination, you must make yourselves acquainted with those factors by which certain appearances in childhood, which are found under normal conditions, are differentiated from those present in the adult, so that you do not consider normal conditions as pathological. I will first draw your attention to the differences in the character of normal vesicular breathing in various periods of life. During the first few weeks and months after birth, the breathing is still very feeble, as the short, superficial respirations are insufficient to force the air vigorously into the alveoli, and, for the same reason, the resonance on percussion is less sonorous. But from the middle of the first year the respiratory murmur begins to assume those characteristics which are also found in the adult under certain conditions, and are known as puerile breathing. It has a markedly sharp, almost blowing character, inspiration is almost alone audible, and expiration very slightly or not at all during repose, while it is more distinctly audible during excitement. 1 The rough, puerile breathing is also increased in those cases in which the thorax is abnormally narrowed by rachitic deformity, and we can therefore imagine that in healthy children also the relative narrowness of the thorax produces the rough blowing character by slight compression of the lungs which are being dilated by inspiration. 2

1 I will also mention that, even in healthy children, fright may temporarily lead to that rhythm which is significant of the respiratory diseases of childhood, viz., ihe predominance of a prolonged, stertorous expiration over the short inspiration which follows the former like an echo.

s The explanation of Sabatier (Etude sur 1'Auscultation du Poumon chez les Enfants, Paris, 1803 1 is ingenious, but not by any means conclusive. According to the measurements of this author, the capacity of the bronchial tree in man and the mammalia increases from the centre to the periphery, but diminishes in children, i.e.. the lumen of the two branches of a bronchus combined is narrower than that of the primary bronchus. For this reason the velocity of the current of air in the bronchi diminishes toward the periphery, but increase < in children, and the respiratory murmur in the latter therefore appears rougher ; this is aided by the greater sharpness of the cartilage, situated between two separating bronchial tubes, and which increases the vibrations of the passing column of air.

Abnormal pulmonary and pleural murmurs are, on the whole, not different from those in the adult, but moderate and fine rhonehi are much more frequent, not infrequently with the peculiarity that they predominate in expiration, while inspiration may be almost entirely free. The abdominal type of respiration predominates until the third year. The diaphragm and abdominal muscles contract with exceptional force, so that, even in the healthy condition, the slight retraction of the epigastrium and the lower ribs foreshadows the pathological change, which is so marked in severe respiratory diseases. Irregularity of breathing in the waking state, and even slight intermissions, should not cause any anxiety, as this occurs not infrequently in small children. The relatively narrow chest contrasts with the large abdomen, which mothers so often consider abnormal, though it is merely produced by the depression of the diaphragm and a tendency to the formation of gas in the intestines.

Among the appearances found in examination of the head, an auscultatory phenomenon deserves mention. In quiet children whose large fontanelle is still open (until the age of two years), the ear or stethoscope, when applied to this part, recognizes, although not constantly, a more or less loud blowing murmur, which is synchronous with the systole of the heart. As the respiratory murmur is also heard at the fontanelle on account of the vibration of the column of air passing through the pharynx, as is also every sound caused by moaning, chewing, and swallowing, the hand should be placed on the pulse during auscultation, in order to prevent mistakes. With some practice, however, we are soon able to differentiate the murmur even without this precaution. In only one case I heard the murmur over the closed fontanelle and other parts of the skull, and others have observed it over the lateral and posterior fontanelles, in the situation of the middle meningeal artery, and even on the spinous processes of the cervical vertebrae. While Fisher (1833) and Whitney (1843), the discoverers of this murmur, attributed a pathological significance to it, and I was also inclined to connect it with rachitis, Hennig and Wirthgen emphasized its normal occurrence from the twenty-second or twentythird week to the period of osseous closure of the fontanelles. I now agree with the views of these writers, and believe that the murmur is heard so much more frequently in rachitic subjects because in them the fontanelles remain open so much longer. The causes of this murmur are still undetermined. Jurascz' ' view that it was due to relative narrowness of the sulcus caroticus in the carotids, was opposed by Epstein, who attempted to connect it with a murmur heard in the carotids in the neck. However, the cerebral blowing murmur possesses no clinical interest and is of no diagnostic value.

The relations of the fontanelles and sutures are much more important. In the new-born child the latter are found closed by a cartilaginous ridge, but the former are still membranous, so that the cerebral pulsations can be felt over the anterior fontanelle, and most distinctly when the brain is congested and presses the fontanelle above the level of the surrounding bones. The tense, elastic, pulsating condition of the anterior fontanelle is, therefore, a valuable sign of cerebral congestion, while its depression indicates an anaemic condition of the brain, which is so frequently found in marasmic children or at the termination of exhausting diseases (diarrhoea, cholera infantum). While the lateral and posterior fontanelles are ossified during the first few months afterbirth, the anterior one

1 Beitriige zur Kinderheilk., p. 170. Berlin, 1861.

even increases in size during the first six months, becomes gradually smaller during the second half of the first year, and is completely closed about the fifteenth month. But not infrequently the fontanelle shows a slight membranous structure far into the second year, though this cannot always be regarded as a pathological appearance. But other deviations, especially if the great and small fontanelle remain open to a greater extent and for a much longer period, if the sutures are separated and the edges of the bones are unusually movable, must be regarded as pathological. This is also true of some anomalies in the shape of the head, connected with certain diseases (rachitis, hydrocephalus), while individual differences, due to anomalies in the growth of the bones (asymmetry, dolichocephalus, etc.), barely possess any clinical interest. As a main distinction from the adult, you must remember that in children, until the age of two years, the size of the skull is much greater than that of the face, so that their relation is as 6 to 1 (even 8 to 1 in the new-born), and in the adult as 2£ to 1. Many timid mothers consider their children hydrocephalus, especially when there is rachitic thickening of the bones of the skull. Under these circumstances many children only become able to hold the head erect without aid at a very late period, although this is often possible, in the healthy condition, between the third and fifth months. But there are many exceptions to this, chiefly induced by the greater or less amount of muscular strength, especially of the muscles of the neck. Even if the child does not hold the head erect in the fifth or six month, we are not justified in diagnosing a cerebral disease, unless other symptoms are present, such as deficient intellectual development, fixed gaze, nystagmus, awkward movements of the hands, or complete apathy.

In the examination of the buccal cavity of the new-born, you will be at once struck by the dark red color of the mucous membrane, which slowly disappears after a few weeks, and must be regarded as normal. This hypersemia is combined with a certain degree of dryness, as the secretion of saliva is still deficient. Recent investigations (Ritter, Korowin, Schiffer, and Zweifel) have shown that saliva is present from birth, but in such small quantities that it possesses very little or no glycogenic power. Toward the end of the second month the salivary secretion increases perceptibly ; according to Zweifel, it only begins at this time in the submaxillary glands and pancreas, while the parotid contains ptyalin at birth. On account of the deficient secretion, also, the buccal mucous membrane, during the first few months of life, is almost always somewhat acid in its reaction, and only after being carefully washed does it become neutral, or, very rarely, alkaline.

In very many new-born infants the raphe of the hard palate presents whitish yellow nodules, projecting slightly above the mucous membrane, from the size of a millet-seed to that of a pin's head; they are either sep- .arate, or there are several behind one another, which are sometimes surrounded by a narrow red zone. These nodules, which are sometimes somewhat elongated, are frequently found during the first four to six weeks of life, arid possess no pathological significance. Bohn regarded them as obstructed mucous follicles, Guyon and Thierry as epidermoid cysts, and Moldenhauer ' as solid proliferations of the epithelium, and as newly forming glandular coils. But the researches of Epstein 3 have re-

1 Archiv fur Gynakol. Bd. VII. , Heft 2.

2 Ueber die Epithelperlen in der Mundhdble u. s. w. Zeitachr. fur Heilkunde. 1 Bd. Prag. 1880.

eently shown that they are spaces filled with epithelium, which have been left over after the union of both halves of the palate.

With regard to the tongue, you should bear in mind that it is usually covered, in nursing infants, with a thin, whitish coating, especially after nursing, and that it presents, in many older children, a peculiar appearance, like a chart, i.e., the dorsum shows numerous, curved or straight, whitish gray figures. This appearance, which is perhaps due to irregular desquamation of the epithelium, is often found in perfectly healthy children.

Examination of the heart furnishes results which are almost identical with those found in the adult. For practical purposes, it is sufficient to know that the movements of the normal heart are often perceptible in two or three intercostal spaces, and that the ribs are raised more than in later life ; the apex-beat can often be felt a little outside of the line of the nipple, although there*s no hypertrophy of the organ.

The employment of the thermometer cannot be praised too highly, but it can alone be thoroughly carried out in hospital and private practice, while it is not feasible in dispensary practice. Under such circumstances we must be satisfied, except in important cases, with estimating the temperature by means of the hand, and relying for information as to the further course of the fever upon the statements of the mother. I always take the thermometric measurements in the axilla. Although this usually lasts from ten to fifteen minutes (twice as long as in the rectum), I cannot persuade myself to choose the latter site for examination, since, despite all precautions, a sudden movement may break the thermometer in the rectum, as I have witnessed. The conditions of temperature are similar in children and adults, except that there is a decided tendency to coolness during the first three or four months. The production of heat appears to be less active at this age, and in many cases of defective nutrition, exhausting discharges, or insufficient action of the lungs, the temperature gradually falls, and may even sink to 30° C. or less. This peculiarity is also shown in the fact that acute febrile diseases often run their course at this age with normal or even subnormal temperatures. But it is unnecessary to create a new disease under the title " Algor progressiva," as was done by Hervieux, since this condition may develop under the most different circumstances, provided they finally terminate in exhaustion.