A practical treatise on the diseases of children

Front matter

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TRANSFERRED TO YALE MEDICAL LIBRARY its

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Preface

TO THE SIXTH EDITION.

In preparing the present edition for the press, attention has been devoted rather to the careful revision of the text than to the addition of new articles. A few have, however, been added, as upon Night Terrors, and on Epidemic Cerebro-spinal Meningitis; while others have been rewritten, as in the case of the article on Cerebral Congestion. Wherever our own views have undergone modification since the publication of the last edition, it has been carefully noted ; and the attempt has been made to incorporate whatever is most important and trustworthy among the recent additions to our knowledge of children's diseases. It is hoped that the thorough revision which has thus been given may entitle the present edition to as favorable a reception as has been accorded to its predecessors.

Philadelphia, January, 1877.

PREFACE

.TO THE FIFTH EDITION.

Owing to the comparatively short time which has elapsed since the apjDearauce of the last edition of this work, it has not been thought necessary to introduce any extensive changes in many parts of the text. All of it has, however, been subjected to careful revision, and such modifications made as were called for by changes in our own views, or by the results of the recent researches of others. In addition to this, several important articles have been almost entirely rewritten ; among which may be mentioned that on the Diseases of the Heart ; on Progressive Muscular Sclerosis ; on the treatment of Scarlet Fever, and of Measles ; on Variola, and on the Vaccine Disease. •

Some of the articles which seem appropriate in a systematic work on the diseases of children, but which were unavoidably omitted in the last edition, have been supplied. Among these will be found articles on Pulmonary Emphysema, Pneumothorax, Affections of the Tonsils, Retropharyngeal Abscess, Malarial Fevers, and Scrofula. To obviate the increase in the size of the work necessitated by these additions, most of the illustrative cases, fhe number of which has been considerably increased, have been placed in smaller type, and in many places the former text has been condensed. Despite these changes, however, an increase of ninety pages has resulted from the large amount of new matter added. On the whole, it is felt that the hope may reasonably be entertained that the work in its present form will prove of more practical utility than heretofore, and will continue to serve the purpose, which has actuated its authors, of facilitating the study and treatment of this interesting and important class of diseases.

Philadelphia, January, 1874.

diseases of the larynx.

General Kemarks, 59

Article I. Simple laryngitis without spasm, 61

" II. Spasmodic simple laryngitis, (37

" III. Pseudo-membranous laryngitis, 8.3

Chapter II. Diseases Of The Lungs And Pleura

Article I. Atelectasis pulmonum, " II. Pneumonia, " III. Bronchitis, " IV. Emphysema, " V. Pleurisy, " VI. Pneumothorax, " VII. Hooping-cough,

TABLE OF CONTENTS.

CLASS II.

DISEASES OF THE CIRCULATORY ORGANS.

Article I. Cyanosis, .

" II. Diseases of the heart,

276 284

CLASS III.

DISEASES OF THE DIGESTIVE ORGANS.

CHAPTER I.

DISEASES OF THE MOUTH AND THROAT.

Article I. Simple or erythematous stomatitis, .

III. Ulcerative or ulcero-membranous stomatitis,

IV. Gangrene of the mouth, V. Thrush,

VI. Affections of the tonsils, ....

VII. Simple or erythematous pharyngitis, VIII. Retropharyngeal abscess, ....

CHAPTER II.

diseases of the stomach and intestines.

General Remarks

SECTION I.

FUNCTIONAL DISEASES OR MILD CATARRH OF THE STOMACH AND

INTESTINES.

Article I. Indigestion,

" II. Simple diarrhoea,

353 364

SECTION II.

DISEASES OF THE STOMACH AND INTESTINES, ATTENDED WITH APPRE- CIABLE ANATOMICAL ALTERATIONS.

Article I. Gastritis, ....

II. Entero-colitis, or inflammatory diarrhoea,

374 380

TABLE OF CONTENTS. Xlll

PAGK

Article III. Cholera infantum, 416

" IV. Dysentery, 436

" V. Diseases of the caecum and appendix creci, . . . 441

VI. Intussusception, 456

CLASS IV.

DISEASES OF THE NERVOUS SYSTEM.

Article I. Tubercular meningitis, ' 473

" II. Simple meningitis, 503

" III. Cerebral congestion, 510

" IV. Cerebral hemorrhage, ....... 513

" V. Chronic hydrocephalus, ..... . . 522

" VI. General convulsions or eclampsia, 532

" VII. Laryngismus stridulus, ....... 550

" VIII. Contraction with rigidity, 567

" IX. Tetanus, 576

" X. Chorea, ■ 584

'• XI. Atrophic infantile paralysis, 609

" XII. Facial paralysis, 626

" XIII. Progressive muscular sclerosis, or pseudo-hypertrophic

muscular paralysis, 628

" XIV. Night terrors, 639

CLASS V.

general diseases— constitutional and zymotic.

Introductory Remarks, 645

Article I. Rheumatism, 645

" II. Diphtheria, 651

" III. Mumps, 685

" IV. Malarial fever, 689

" V Epidemic cerebro-spinal meningitis 693

VI. Scarlet fever, or scarlatina, .... . 702

" VII. Measles, or rubeola, or morbilli, 764

" VIII. Small-pox, or variola, 787

" IX. Vaccine disease, 809

X. Varicella, 824

" XI. Typhoid fever, 827 xiv TABLE OF CONTENTS.

CLASS VI.

CACHECTIC DISEASES.

PAGU

Article I. Scrofula,

" II. Tuberculosis, 848

" III. Rickets, 8^3

" IV. Congenital syphilis, 875

CLASS VII.

diseases of the skin.

Introductory Remarks, 882

CHAPTER I.

RASHES.

Article I. Erythema, 883

" II. Erysipelas, 888

" III. Roseola, 896

" IV. Urticaria, 899

CHAPTER II.

VESICLES.

Article I. Eczematous affections, 903

" II. Herpes, 918

" III. Scabies, 923

Chapter VII. Diseases Hot Classified Among The Preceding

SECTION I. parasitic diseases of the skin.

Article I. Favus,

II. Tinea,

" III. Alopecia areata, .... • ■ 958

SECTION II.

Article I. Sclerema, • 960

CLASS VIII.

WORMS IN THE ALIMENTARY CANAL.

Article I. Ascaris lumbricoides, 969

" II. Ascaris vermicularis, 981

PRACTICAL TREATISE

DISEASES OF CHILDREN.

INTRODUCTORY ESSAY.

ON THE CLINICAL EXAMINATION OE CHILDREN.

The clinical examination of children, and particularly of young infants, cannot be successfully practiced upon the same method as that habitually made use of in the case of adults. The truth of this statement will be readily assented to by all who have had much experience in the treatment of the diseases of the two ages, by those who will reflect for a moment on the great differences in the expressions of the various organs in early and adult life, and by those who are acquainted with the opinions of distinguished writers upon children's diseases. It is proper and useful, therefore, to preface a practical work on the diseases of children, with a sketch or plan of the best method to be pursued in forming a diagnosis of these diseases, and with remarks upon the physiological characters which distinguish the organization of early life from that of maturity.

The difficulties that beset the path of the practitioner in his clinical examination of children are so great that he who has not been prepared by preliminary study to surmount these obstacles, will find it a most uncertain and dubious task to unravel the history and nature of any case that may be set before him. The helpless silence of the infant, — the wilful silence, or the loose and inconsistent answers of the older child, which lead astray the mind rather than guide it to true results, — the agitation and fright produced by the examination, rendering it impossible at times to ascertain the real state of the different functions of the economy, — and, lastly, the difficulty of obtaining accurate and reliable accounts of the history of the case from the attendants, all combine to make the duty of the physician most perplexing, and, unless he be gifted with a large share of patient and philosophic calmness, most irksome and trying to the temper.

So great, indeed, are the difficulties encountered by some practitioners who enter upon this branch of the practice of medicine without proper preliminary preparation, that they never overcome them ; but, to use the words of Dr. "West, "grow satisfied with their ignorance, and will then, with the greatest gravity, assure you that the attempt to understand these affections is useless." That it is possible, however, to overcome, in great measure, these obstacles, and to arrive at a correct diagnosis in nearly all cases, is quite as true as that these obstacles really exist. But, in order to do this, the physician must first be aware that difficulties exist, and must have formed in his mind some plan or method by which to surmount or elude them.

Before proceeding to show what is the best method of examining or exploring disease in children, we must state that our remarks apply chiefly to infants and very young subjects ; for, after the age of eight and ten years, the physical and intellectual development have progressed to such a point as to render the method of diagnosis nearly the same as that employed in adults.

The chief causes which render the diagnosis of disease in young children difficult, are the absence of the faculty of speech, and the violent agitation generally caused by the examination, which prevents a proper appreciation of the state of certain organs and functions.

It is easy to understand how much our means of diagnosis are restricted by the absence of the faculty of speech. How many symptoms are there in the case of adults with which we become acquainted only through the patient's own account of his sensations ; and, consequently of how many must we be deprived in children by the absence of this account. It might, indeed, at first view, seem impossible to detect the nature of the sickness without the assistance of this means, so greatly do we depend upon it in our examination of adults. Nevertheless, we shall find ourselves enabled, by an attentive consideration of other resources in the child, by a close study of its physiognomical expression, its decubitus, the nature of its cry, and by the most rigidly careful physical examination, to form our conclusions with almost as great a degree of precision as in older patients.

The other causes of difficulty, — the violent disturbance, both physical and moral, of the child, its fright, agitation, and cries, — constitute, when they are present in a high degree, much greater embarrassments than the want of speech. To overcome these, the physician must use all his skill, tact, and patience ; for, unless they can be avoided by art, or overcome by soothing and gentle persuasion, he can learn but little that will be of essential service to him in making up his opinion. He can neither read the countenance of the little patient, nor judge by its attitudes or decubitus of the state of the various organs, whether internal or external ; he will be unable to ascertain the rate, force, or regularity of the circulatory or respiratory functions; he cannot, to any useful purpose, examine the abdomen, to learn whether it be tender on pressure, or whether its contained organs be in their natural condition as to size and position ; and, lastly, he will find that the physical exploration of the lungs and heart, by auscultation and percussion, yield him at best only imperfect results.

METHOD OF DIAGNOSIS. 19

To avoid the difficulties just detailed, it is always useful, if not absolutely necessary, to conduct certain portions of the examination whilst the child is calm and quiet, and certain others whilst it is disturbed and agitated. This distinction of the examination into two periods, or stages, is one of the utmost importance in a practical point of view, and should never be forgotten by the physician during his clinical observation of the various symptoms the patient may present.

By the period of calm is meant a condition of total quiescence, in which the child is undisturbed either by internal or external causes of irritation. This condition is best found in the state of sleep. If this cannot be obtained, the one most nearly approaching to it is that which exists during the act of nursing, or which follows that act. Suckling is usually followed, even in the sick child, by a condition of drowsiness or by a gentle and languid slumber, during which it will allow a careful examination upon many points without agitation. If possible, therefore, the physician should always see the child when asleep, and if the mother or nurse propose, on the occasion of his visit, to hurry upstairs to prepare the child, or to bring it down into the parlor or lower room, he should ask, as a favor, that he may see it asleep.

If, in spite of having just been nursed, the child be awake and fretting, and when, also, it is more advanced in age, we should endeavor, by the attraction of toys, by gentle and soothing words and manners, by fondling, or by having it carried about the room, to get it quiet.

Before proceeding to a consideration of the particular means by which we are to judge of the state of health or sickness of young subjects, it is proper to call attention to the great importance of a careful examination of the attendants, in regard to the history of the case, previous to and between the medical visits. In the instance of children, their inability to describe their own symptoms compels us to depend entirely upon the mother or nurse for all detail of the case previous to our first visit, and for all accounts of what may have happened between two subsequent ones. It is, therefore, extremely important that this part of the examination should be conducted with every care and caution. Very much that is useful may be learned from it, if it be well managed. A great deal of skill and art are required in putting the questions, and in sifting the evidence thus collected. We should always bear in mind the character of the persons questioned. Much depends upon their education, and much more on their natural powers of observation, and manner of relating what they may have seen. The degree of credence to be attached to their answers must rest upon their probable intelligence. Nurses and mothers will often give accounts of their charges which must be received with large allowance, and even in some few instances with disbelief. We would, however, in this place, most earnestly caution the young practitioner of medicine to be very careful not to misbelieve, or even mistrust, without well-poised reasons, the account of a sick child given by a mother ; for though a foolish, weak woman will often give a false or exaggerated statement of the symptoms of her child, an observant and intelligent, and sometimes a foolish and weak one, when guided by maternal instinct, will detect variations from the healthful condition of the child, which may entirely escape the search of the most acute and rigorous medical observer.

A mother may perceive a change in the expression of the face, in the manner of the muscular movements, in the temper or conduct of her child, which shall fail to attract the attention of the practitioner ; or it may be that the symptom which has caused the parent to take alarm occurs only during the absence of the physician. The medical attendant ought, for these reasons, to listen patiently and kindly to whatever the mother or nurse may have to say, and if unable to detect immediately what they assert they have seen, let him not determine at once that there has been a mistake, that their anxiety has deceived them ; but let him examine the patient yet again, and more carefully, or let him pay another visit to learn whether the symptom or symptoms continue, or have occurred again. Our own rule, in a doubtful case, is to listen with religious attention to the mother, and unless she be far beneath the average of human intelligence, our opinion as to the fact of some deviation from the ordinary health of the child is considerably influenced by what she tells us.

The inquiry in regard to the history of the case, previous to the first visit of the physician, should bear particularly upon the causes of the sickness, its precise moment and mode of attack, and its course and symptoms up to the present time. The most important points to be considered in connection wTith these objects, are the health of the parents, including their ordinary health, or their habitual diseases, the causes and periods of their death, if they are not living, and the state of health of the child at the moment of birth and since. The hygienic conditions in which the patient has been placed ought always to be investigated ; the place of habitation ; the kind of house, and whether a large well-ventilated room, or a small, narrow, and close one ; the clothing ; the food ; and lastly, whether the infant has been suckled, or brought up on artificial diet. The state of the health just anterior to the attack ought always to be examined into. Has it been good and strong, or feeble and delicate? If delicate, what diseases? If the approach of any of the eruptive fevers be suspected from the character of the symptoms, the question as to whether the child has previously had measles or scarlet fever, or has been vaccinated or had variola, should always be asked.

It is next necessary to fix as accurately as possible, the precise period of the onset of the sickness. If the question, " When was the child taken sick?" be asked, as it usually is, the answer will be, "Oh, several days ago," or, " I don't recollect exactly— I think yesterday, or the day before," or some such loose answer. The best way to learn the exact period in a recent case, is to go back, day by day, or else to inquire as to some particular day. We may ask, was the child quite well day before yesterday ; was it well last Sunday ? did it play and amuse itself? was it as gay and good-tempered as usual yesterday, or the day before, or the day before that? Did it sleep well night before last, or the night before that? A sick child never scarcely sleeps well at night, and very often we may learn by close inquiry into this particular, the exact time at which the attack began. In this way, by forcing the attendant to tax her memory, and to

DIAGNOSIS OF ANTECEDENTS. 21

go minutely over the events of the several days previous, we shall nearly always succeed in fixing very precisely the moment of onset.

Having determined these points, we should proceed to inquire in regard to the course of the disease prior to the first visit. This is to be done only by patient and repeated questioning. The questions must be so framed as to elicit free and unbiassed answers. They should be general, and not leading. Lastly, we are to inquire into the treatment of the case up to the present time.

It is best that all these interrogatories should be made previous to seeing the child, in some other room than the nursery, iu order to avoid the risk of alarming the child by the presence, during an unnecessary length of time, of a stranger. If, however, the child be well acquainted with the physician, it matters not where the inquiries are made.

Having now obtained from the attendants all the information they can give in regard to the history and nature of the case, the physician must proceed to the personal examination of the patient, in order to determine, by his own observation, the exact nature of the sickness, and the treatment it may require.

The most important points to be attended to during the clinical examination, are the countenauce or facies, noting its expression, coloration, the presence or absence of furrows and wrinkles from pain, from emaciation, or from disordered muscular action, the appearances presented by the nasal orifices, and especially by the al» nasi, and the characters exhibited by the mouth ; the sleep ; the cry ; the state of embonpoint or emaciation ; the condition of the skin as to coloration, temperature, moisture or dryness, the presence of swellings of any kind, such as those produced by dropsy or by affections of the joints, and the existence of eruptions ; the pulse ; impulse of the heart ; the respiration ; the signs furnished by the state of the mouth and throat, and by the disposition towards and power of sucking, or by the manner in which drinks are taken ; and lastly, the state of the abdomen.

The Countenance. — The countenance of a young and healthy infant, who is sleeping or perfectly quiet, wears no expression except that of comfort and content. It is composed and still ; no movement disturbs its innocent tranquillity, unless, perhaps, some gentle smile light it up from time to time, when we might well believe the happy superstition of the fond mother, who will tell us that angels are whispering it. In sickness, even when slight, the countenance soon loses this expressionless character. In all acute disorders the alteration is very great, such indeed as to strike the most careless and inexperienced observer. The features become contracted, furrows and wrinkles appear about the forehead, the nostrils are dilated, or pinched and thin, and the mouth becomes drawn and rigid. The extent of the change is generally in proportion to the severity of the attack. The part of the face most altered will depend very much upon the particular system of organs implicated in the disease.

Some authors have endeavored to show that different diseases give to the physiognomy certain peculiar and characteristic expressions. This is true only to a certain extent. Thus, the facies is very different in abdominal from that observed in thoracic or cerebral diseases ; but though it is generally easy for a practiced physician to distinguish by the facies alone between a cerebral and thoracic disorder, it is quite impossible for him to distinguish between any two cerebral, thoracic, or abdominal affections. The particular changes impressed upon the face by different diseases cannot, however, be discussed in this place, but must be considered in the separate articles upon each disease. Here it can only be stated in general terms, that, in diseases of the brain, the upper part of the face, the forehead, and the eyes are chiefly affected ; that in diseases of the thoracic organs, the middle portion of the face, and especially the nostrils ; while in those of the digestive organs, the lower part of the face, the mouth and lips, are the parts which undergo the greatest changes in their expression.

Pain may almost always be detected by the expression of the face. It gives to the countenance various shades of expression, according to its degree of severity, and its permanency or recurrence at intervals. Pain in the head is said, by Dr. M. Hall, to produce a contracted brow, pain in the belly to occasion an elevation of the upper lip, whilst pain in the chest is chiefly denoted by sharpness of the nostrils. We doubt, however, whether pain in any particular organ imparts an expression to one part of the face rather than to another, for indeed pain in any part of the body, whether the head, chest, abdomen, or limbs, gives rise to a contraction of all the features. Not one part of the face alone, but the forehead, mouth, nose, and the whole face, become changed in expression and contracted, when there is severe pain in any part of the body, so that we deem it impossible from the expression alone, to determine where the painful sensation may be seated. The countenance merely tells us there is pain, but not where it is located. The painful expression will be permanent or occasional, as the pain itself is constant or only paroxysmal.

The coloration of the face becomes often an important means of diagnosis. In all the fevers, phlegmasia?, and diseases of general excitement, the face will be more or less suffused and red, unless the attack be so severe as to occasion a violent shock to the nervous system, in which event the countenance instead of being suffused, is paler than natural. In such cases the face becomes of a dead white, all traces of red disappear, and the skin at the same time has often a slightly shining or varnished appearance. We have not unfrequently observed this symptom in pneumonia and bronchitis, and also in the latter stages of true croup. It is a very striking phenomenon, and one which portends great danger.

In chronic cases of all kinds in which the hematosic and nutritive functions are enfeebled, the face assumes a pallid and waxen hue, which is very characteristic. In the various digestive ailments it becomes icterode or sallow, and iu affections of the liver more or less yellow. Lastly, in certain diseases and malformations of the heart or lungs, it becomes bluish or livid, constituting one of the most important sigus of what is called morbus coeruleus, blue disease, or cyanosis.

In reading the countenance of a sick child, the practitioner should always notice the play of the nostrils, since this reveals, to a certain extent, the state of the lungs. In pneumonia, bronchitis, and pleurisy, the

SIGNS FKOM THE SLEEP. 23

movements of the aire nasi become rapid and energetic, expressing, by the degree of their violence and extent, the amount of embarrassment under which the respiratory function is laboring.

The nostrils and nasal passages should always be examined also to ascertain the presence of mucous or purulent secretions, or of pseudo-membranous deposits, since these fluids or their inspissated products interfere more or less with the free passage of air through those canals.

Of the Sleep. — Much useful information as to the state of health of infants and children may be obtained from a careful consideration of the various phenomena connected with their sleep. Of this we are fully convinced from somewhat long and patient observation. We cannot ascertain, indeed, the nature of the disease under which the child may be laboring, but we can detect, with very great certainty, the existence of a deviation from health. We know of few more certain means of fixing the period at which any attack of illness may have begun, than by inquiring at what time the child began to have restless or broken sleep, or insomnia.

A perfectly healthy infant, within the month, who is suckled at an abundant and wholesome breast, will usually sleep twenty out of the twenty-four hours, waking to nurse every two or three hours during daylight, and twice or three times during the night. After the age of two or three months, the child is much more wakeful during the day, though it will still take a nap of two or three hours in the morning, and a shorter one in the afternoon, while it will sleep from early evening until the following morning, waking but once or twice to suck. Indeed, many perfectly healthy infants, of between three and six or seven months of age, sleep without waking from nine or ten o'clock in the evening until six the next morning. After the latter age the sleep is seldom so unbroken ; the child begins to undergo the first considerable trial to its health, dentition, and it is rendered thereby more or less ailing and irritable, and consequently restless and troublesome at night.

Children who have passed through the epoch of dentition, and who are perfectly well, usually go to sleep soon after being put to bed, and never wake until the following morning. Not only so, but they sleep soundly and quietly, without being disturbed by slight sounds, and without tossing or turning much in their sleep.

In healthful sleep the whole appearance of the child, its expression of countenance, its attitude, and its breathing, all declare a most perfect and beautiful ease and tranquillity. Nothing can be more suggestive of the comfort and well-being that naturally attend upon health, than the perfect composure and graceful postures exhibited by a hearty child during profound sleep.

It needs, however, but a slight disturbance of the health of a child to break in upon its ordinarily calm and peaceful sleep, and to render this restless, fitful, interrupted by startings, cries, or dreams, or insufficient. The most trifling irritations, as the pressure of a tooth against the gum, the presence in the digestive canal of a little imperfectly digested food, or of one, two, or three lumbricoides, or the slightest fever from any cause, are sufficient to produce this effect, and hence it is that the character of the sleep will often become to a watchful practitioner the first sign of disorder held out by nature.

The degree of disturbance of this function will vary with the nature and severity of the disturbing cause. When slight, the child will continue to sleep throughout the ordinary period, but the sleep will be somewhat uneasy. The countenance will be disturbed. There will be contractions of the brow, aud momentary workings of the features, which express the perception of some uuhealthful sensation. Often the child will toss and turn, and change its position more frequently than natural. Sometimes it will cry out, and appear distressed by some dream or painful sensation. When the cause of disturbance is more serious, the sleep is more broken, the child wakes often, and lies awake for a longer or shorter time, and it becomes very difficult to lull it to sleep again. Or it has painful dreams or nightmare, causing it to scream and struggle in sleep, and then to wake in the most violent affright. In severe instances it becomes almost sleepless. We have very often known teething children not to sleep more than half as much as in health, and to wear out, by the long continuance of this sleeplessness, the patience and even the health of their attendants. In some instances they will no longer sleep in the bed or crib, and the nurse is obliged to get up and walk with them, or soothe them by the movement of a rocking-chair or cradle. In other cases, the derangement of the health is shown by grinding of the teeth, and by the most violent tossing and tumbling about the bed. We have frequently seen a child lying with its head where its feet should be, or across the bed, and with all the coverings thrown off, in spite of the most careful arrangement of the bedclothes.