Diseases of children : a manual for students and practitioners

Front matter

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Preface To The Third Edition

THE senior author, in the first edition of this work, planned a well-balanced text-book, and determined that it should reflect with honest accuracy all of the essential phases of pediatric knowledge then current. With each subsequent edition he has endeavored to perfect that idea, and it is his hope that the book in its present form will be found more reliable and useful than ever before. While his primary purpose has been studiously maintained, almost every topic has been completely rewritten and somewhat extended to accommodate recent advances. For this task the original author has been so fortunate as to secure the assistance of his associate, Dr. Phelps G. Hurford, upon whom the greater part of the burden of the revision has fallen.

All of the important literature relating to the subject that has appeared during the past ten years has been carefully reviewed, and the deductions therefrom, checked and rechecked by personal experience, have been amalgamated with the earlier text in the construction of the new chapters.

The authors hope that the volume in its new form will be - found to merit all of its past popularity, and that it may win many new friends, among both students and practitioners.

G. M. T.

Sr. Lovis, Missouri. P.-G.-n:

Contents

‘see . - CHAPTER I. Regn hae SnMENEnwe AT BIR 4 a a be CHAPTER II. aera

” CHAPTER III.

Examination eee Cue oo et er ea ee | CHAPTER IV.

Chapter I. The Infant At Birth

Respiration.—How Established.—In beginning extra-uterine life, breathing is a child’s first new function. Previously its lungs have been impervious to air and to other than nutritive blood. Now the placental circulation is stopped and the blood must pass into the lungs to be oxygenated. By the reflex stimuli of comparatively cold air on the skin and of venous blood feeding the respiratory centre in the medulla, respiration is begun, usually with a cry. Each breath is deeper than the preceding one, until the whole lung gradually passes from a state of physiological atelectasis to complete expansion.

External Signs.—This change is beautifully demonstrated by observing the chest wall, which, being very elastic and yielding, will stay depressed, in inspiration, over wnexpanded lung, while those parts over expanded lung will rise and fall with the motions of the chest in breathing. To be satisfied that respiration is fully established, one should see that no part of the chest wall sinks during inspiration.

Rate.—The child should now breathe about forty-five times to the minute, but the respiratory rhythm is likely to be irregular. ,

_ As aids to effecting natural respiration, slapping the but- ~ tocks, blowing on the skin, or alternate applications of hot and cold water are usually all that are necessary.

Circulation.—In this another marked change occurs. ‘The umbilical vein and ductus venosus, leading from the umbili-

18 THE INFANT AT BIRTH cus to the inferior vena cava, are closed, dwindling to a fibrous cord (the round hepatic ligament) in two to five days. The Eustachian valve, which guided the blood from the right auricle to the left auricle, disappears at once; the foramen ovale, through which the blood passes from the right auricle to the left auricle, closes in ten days, by a fold of endocardium growing over it from below; the ductus arteriosus, which carried the blood from the pulmonary artery to the descending aorta, becomes an impervious cord in four to ten days; and the umbilical arteries, which carried the blood from the internal iliacs to the navel, become the anterior vesical ligaments above, and remain as the superior vesical arteries below.

The pulse at birth varies from 140 to 120 per minute, and is frequently irregular. The higher rate is found in girls and small infants; the lower in boys and large infants.

Temperature.—At birth the temperature is about 99° F. It may sink rapidly directly after birth; but in the healthy child it soon returns to normal. The newborn infant is naturally very sensitive to cold, having lived so long in a temperature of 98° F., and great care must be taken to prevent chilling.

Skin.—Vernix Caseosa.— The child at birth is covered, to a greater or less degree, with a slippery, white substance, the vernix caseosa, a mixture of epithelium, down, and secretion from the sebaceous glands.

Lanugo.—In addition to the vernix caseosa, the skin shows an abundant growth of very fine downy hairs, the lanugo, which soon disappears.

Desquamation.—Shortly after birth the skin is frequently very red, and later decided desquamation may occur.

This desquamation and the frequent presence of rashes which appear during the early days of the infant’s life are due to the irritation of the skin by the marked change in the surrounding medium. The warm fluid of uniform temperature of intra-uterine life is exchanged for an atmosphere of uneven temperature, and for the various mechanical and chemical irritants which come in constant contact with the delicate skin.

INTESTINES 19

Length.—The average length is about 20 inches. Below eighteen is evidence of prematurity.

Weight.—Boys average 7} pounds; girls, about 7 pounds. Below 53 pounds shows a low vitality and suggests prematurity.

Head.—Measurements and Fontanelles.——The head measures about 13 inches in circumference in the occipitofrontal line. The anterior fontanelle, at the juncture of the coronal and sagittal sutures, is open 13x44 inch. The posterior fontanelle, formed by the sagittal and lambdoid sutures, is also plainly to be felt.

Caput Succedaneum.—The head is apt to be much misshapen from pressure during its passage through the pelvis, and on one place is a thick, boggy swelling, the caput succedaneum, formed by serous infiltration into the tissues of the scalp over the part presenting in the birth canal, and hence escaping pressure. The caput disappears in a few days, and the shape of the head rights itself, both without assistance.

Thorax.—Measurements.—The average circumference of the chest at the nipple line is 13 inches, the same as that of the head, the anteroposterior and transverse diameters being about equal. With the addition of the shoulders, we have a decidedly larger-sized body than head, a point of importance in connection with the birth of the shoulders over the perineum.

Abdomen.—The average circumference of the abdomen is 14 inches. The navel represents the midline of the body’s length, being equidistant from the top of the head and the sole of the foot.

Intestines.—At birth the intestines contain a very dark green, pasty substance called meconium, made up of bile, epithelium, intestinal mucus and lanugo. This is expelled in considerable quantities shortly after, and sometimes during birth; and, through the influence of the colostrom, for the next four days. It is found to be absolutely sterile -and free from bacterial life.

The relative positions of the stomach and. the colon differ from the positions of later life. The stomach is much more

20 THE INFANT AT BIRTH nearly vertical, so that vomiting occurs more readily; the transverse and splenic portions of the colon form an oblique section extending almost directly from the hepatic flexure to the sigmoid.

Kidneys.—Urine.—Constantly, after birth, the bladder empties itself of a small quantity of limpid urine of low specific gravity.

Uric Acid and Urates.—In the kidneys themselves there are deposits of uric acid and urates, the so-called infarcts, crystals of which pass down the ureters and are found as pink or reddish-yellow stains on the napkin. They may be so large as to cause sharp pain in their passage down the ureters; this is sometimes the cause of prolonged crying spells in early infancy and shows the lack of sufficient water in the system.

Umbilical Cord.—Pulsation——The umbilical cord should be found to be strongly pulsating at birth, and it is best to wait for this to stop before ligating. An exception to this rule is made in congestive asphyxia, where the withdrawal of some blood from the child is desirable. It has been found that when the cord has not been tied until after pulsation has stopped, the infant gains, on an average, 3 ounces of blood, and its initial loss of weight is lessened.

Ligation—The cord should be tied 2 inches from the navel, very tight, with narrow, aseptic bobbin, and cut beyond with sterile scissors. Before leaving, the stump should be examined, as it is quite common to find it bleeding: a little. Dress the stump with dry, sterile gauze, dusting with powdered bismuth. Some time within a week the cord should drop off by a process of dry gangrene, leaving a healthy ulcer at the base which is healed by the tenth day.

Bathing.—After tying and cutting the cord the infant should be greased thoroughly with oil or vaseline to soften the vernix caseosa, and laid aside in a warmed woolen blanket, with a soft towel next the skin, until the mother has been entirely attended to.

Then the baby should have a general bath, in a warm room, before an open fire if possible, in water of a tempera-

CLOTHING 21 ture of 100° F. Castile soap, a soft sponge, and a soft towel should be the adjuvants. After drying, all the flexures and creases in the skin should be dusted with talcum or some similar dry powder.

Eyes.—Infection.—There is always danger of some form of infection to the conjunctive from the uterine and vaginal - secretions. It is therefore wise to follow the prophylactic treatment introduced by Credé; first washing the eyes with clean water or saturated boric acid solution, and then instilling into each eye a couple of drops of 1 per cent. silver nitrate solution, being sure that the lids are open so that the silver reaches the whole conjunctiva, bulbar and tarsal. The baby should be kept in a darkened room the first few days.

Strabismus.—It is well to remember that codrdinate movements of the eyeballs are imperfectly performed in infancy and hence strabismus is frequently present.

*Mouth.—The mouth should be freed from mucus, liquor amnii, or whatever may have entered it during birth. This may be done by sweeping the finger, covered with soft, dry gauze, carefully and gently over the whole cavity, going well back into the pharynx. Sometimes it will be necessary to introduce a catheter into the pharynx and suck out a considerable quantity of mucus lodged there.

Examination for Abnormalities —This examination should next be made, with special reference to the skin, head, spine, hands, feet, genitals, and anus. Examination for imperforate anus should never be neglected if the meconium does not appear in the first twenty-four hours.

Clothing.—This should be light, warm, unirritating, and should allow free movement of the body and limbs. A broad abdominal band should be worn until the navel heals completely. The other essentials are a woolen shirt, a flannel petticoat, a diaper and a dress. For night wear the dress is exchanged for a nightgown. Safety pins only should be used in fastening the clothing.

Babies are usually clothed too much, rather than too little, and in very warm weather fewer clothes than the above are needed.

22 THE INFANT AT BIRTH

Food.—Colostrom.—Nature- prepares no real food for the first two or three days, but during this time the breasts of the mother secrete colostrom, a thin, yellowish fluid, showing under the microscope the presence of large corpuscles in addition to a small number of the usual fat globules. This fluid is laxative in its action. Eight to ten hours after birth the baby should be put to the breast, and after this four times daily until the milk comes. This accustoms the baby to sucking, reflexly stimulates the uterus to contract, and hastens the discharge of the meconium. :

If there really seems to be need of food, as in weak infants, a 5 per cent. sugar solution is a good form until lactation begins. Excessive crying, as if from hunger, in a healthy baby can usually be stopped by simply giving boiled water.

Sleep.—The child should sleep almost continuously during the first few days. From the very start, training in good sleeping habits should begin. The baby should be taken up only to be washed and nursed, and taught to go to sleep when laid down. It should sleep in a crib by itself. No walking or rocking it, pacifiers, or other means of momentarily quieting should be permitted.

Premature and Delicate Infants.—An infant is said to be premature if born between twenty-six weeks’ gestation and full term. Few babies born at twenty-six weeks survive, and every week of intra-uterine life thereafter increases its chances considerably. Aside from the fact of prematurity, these babies are often weak and undeveloped from the same cause as produced the premature birth, as illness or malnutrition of the mother.

The length and the weight are usually more reliable as evidences of viability than the supposed term in weeks. Infants weighing only 2 pounds have survived. But a viable infant usually measures at least 31 em. in length, and weighs 3 pounds; most of them with these proportions die in spite of every care. Length is of more importance than weight, and vigor of the infant more important than either.

The vitality of premature babies is naturally very low,

PREMATURE AND DELICATE INFANTS 23 but the powers of heat production, digestion and respiration are least developed and need most attention. In treatment the most difficult problems are to properly nourish them and to maintain the animal heat. They should not be bathed but should be cleansed with oil and the body wrapped in cotton, all but the face being included. Warmth is maintained by wrapping in blankets, placing in a wellprotected basket, and surrounded by hot-water bottles. The temperature of the room should be between 85° and 90° IF. In the home this plan is better than the use of incubators. In hospitals a special room is arranged, much on the plan of the incubator, and in this the best results are obtained.

Feeding should be breast milk when possible, from the mother or a wet-nurse. The mother. cannot supply milk unless the infant has had about eight months of intra-uterine life. The milk must be pumped from the breast and given in small quantities, from 4 to 2 ounce every hour and a half or two hours. This is usually best done by feeding with a medicine dropper without removing from its “nest.’’ Gavage may be necessary. If breast milk cannot be obtained, the next best food is modified cows’ milk, with a formula of fat 1 per cent., proteid 0.5 per cent., and sugar 7 per cent. This should be increased in strength gradually as the child’s condition warrants it.

Chapter II. Normal Development Of The Infant

Weight.— During the first year the child should be weighed every week, and during the second year every other week. The gain or loss in weight from one weighing to another is the very best indication we have of the general welfare of the child. Frequently the first signal of beginning trouble is the absence of the regular weekly gain, or the presence of a slight loss. - .

Physiological Loss.—During the first three days of life there is a so-called physiological loss in weight, averaging about 10 ounces. This is due to loss of urine, meconium, and vernix caseosa, and the lack of food the first few days. With the advent of milk in the mother’s breast, the normal gain. begins, and, by about ten days, the birth weight should be regained.

At six months the birth weight is about doubled, and at the end of a year about trebled. During the first six months the gain should average 4 to 8 ounces per week; and from 2 to 4 ounces during the second six months. From 4 to 6 pounds per year is about an average gain for the next ten years.

Sickness of any kind, and particularly digestive disturbances, stop the normal gain, and usually substitute a loss. Even the physiological process of dentition is often accompanied by a diminished weekly gain.

Height.—During the first year the growth is about 8 inches, an average of 2 of an inch per month, the increase being somewhat greater during the first quarter. During the second year the growth is about 4 inches, and during the next ten years it averages about 2 inches per year. This growth, in infancy, takes place more rapidly in the extremi-

RESPIRATION iD ties than in the trunk, although at birth the trunk was relatively longer than the limbs.

Head.—During the first year the occipitofrontal circumference of the head should increase about 4 inches, and about 1 inch more during the second year. A gain of 14 inches more should take place by the fifth year, at hich time the head attains a size only 1 inch less than that of the adult.

The cranial sutures ossify by the sixth month, the posterior fontanelle closing by the second month, but the anterior not till the eighteenth month, having often increased some in size during the first nine months. Larly closing fontanelles and sutures suggest premature ossification, or cerebral defects; while fontanelles and sutures remaining open over-* time are suggestive of rickets or hydrocephalus.

Thorax.—The thorax grows more transversely than from before backward, keeping pace with the growth of the head, and not until the third year is it distinctly larger than the head. A chest of a three years’ child not larger than its head points to extreme delicacy.

Abdomen.—The abdomen at birth is larger than either the head or chest; at two years it should be about the same size, and afterward the smallest of the three.

Muscular Acts.—Voluntary but incodrdinate muscular movements are made about the fourth month. The head is held erect about the same time. The child sits erect about the seventh month. The first attempts at walking are made about the twelfth to the fifteenth month, some children learning to cre p three or four months earlier.

Pulse.—The force and rhythm in infancy are the important factors rather than the rate. During the first year the frequency varies from 110 to 140, reaching 100 by the end of the second year. By the eighth year the adult rate is present. The rate is markedly influenced by very trivial causes, such as crying, struggling, or excitement, making its value unimportant. It is helpful to remember that the pulse can be easily counted in the anterior fontanelle.

Respiration.—Respiration is chiefly abdominal, and the rapidity very variable. During sleep it averages consider-

26 NORMAL DEVELOPMENT OF THE INFANT ably less than during wakefulness. The rate in the first months is 35 to 40; during the second year it falls to 28; during the third, to 25; and by puberty it reaches the adult rate, 18 to the minute.

In health the rhythm—ainspiration, expiration, pause—is unchanged. The ratio between pulse and respiration is about 33 to 1. .

Temperature.—After the more or less marked fall succeeding birth the temperature immediately assumes the adult range, the main point to be kept in mind being the extreme fluctuations under slight causes, the heat centres being very unstable. In the chronic wasting diseases a subnormal temperature is quite common.

Dentition.—At birth the teeth are enclosed in the dental sacs in the alveoli of the jaws, and their growth is outward by calcification of their roots, this growth beginning at birth. ~The milk or deciduous teeth are 20 in number, and are cut in the following order, although quite wide variations are frequent:

(1) Two lower central incisors, at six to nine months. (2) Four upper incisors, at eight to twelve months. (3) Two lower lateral incisors and four anterior molars, at twelve to fifteen months. (4) Four canines at eighteen to twenty-four months. (5) Four posterior molars, at twenty-four to thirty months.

Early teething usually means early ossification ef the cranial bones; and late teething usually means rickets, or other form of malnutrition.

In a healthy child dentition is usually not accompanied by any constitutional disturbance, the tooth very gradually foreing its way through the overlying gum by a process of pressure absorption, first showing its presence as a lump under the reddened mucous membrane, this growing whiter as the tooth nears the surface.

If any symptoms are present, they are only restlessness, fretfulness, disturbed sleep, salivation, a disposition to put objects into the mouth, and possibly a little fever.

In previously unhealthy children more serious symptoms may coincide with dentition, such as vomiting, diarrhea,

THE FECES ee fever, earache, eczematous eruptions, and possibly convulsions; but there is always the question whether the unhealthy condition as a predisposing factor is not more of a cause of the symptoms than the teething. The more carefully other causes are looked for, the fewer cases due to dentition only, even in these susceptible infants, will be found. Rarely, a case calling for lancing the gums will be discovered.

The second or permanent teeth are cut as follows: (1) First four molars, at six years. (2) Eight incisors, at seven to eight years. (3) Eight tricuspids, at nine to ten years. (4) Four canines, at twelve to fourteen years. (5) Second four molars, at twelve to fifteen years. (6) Third four molars at seventeen to twenty-five years. Except for the first four molars, the order is about the same as for the first set. In growing, the second set cause atrophy of the roots of the first set until they loosen and fall out.

Urine.—F or obvious reasons accurate results as to the quantity of urine in infancy are hard to obtain. During the first few days of life the daily quantity is 3 ounces; by two months it increases to 8 to 10 ounces; by six months to 10 to 16 ounces; by two years to 20 ounces; by five years to 26 ounces; by eight years to 40 ounces; and by 14 years to 48 ounces. The specific gravity averages from 1.005 to 1.010. The reaction is acid. Traces of albumin or of sugar may be found during certain periods, but rapidly disappear.

The Feces.—These partake of the characteristics of meconium for four or five days, when they change to milk stools. ‘These are yellow, of the consistence of semisolid butter, smooth, of acid reaction, and inodorous. The gases present are hydrogen and carbonic acid. The feces amount to about 3 ounces per day in quantity, and are passed from two to four times daily. Chemically they consist of 85 per cent. of water, and of fat, proteids, lactic acid, salts, and bile elements. Bacteria are present in large variety, especially the Bacillus coli communis. Stools resulting from cows’ milk are whiter, from the presence of more curds. When the child begins a mixed diet, the stools assume the adult type.

i

- 28 NORMAL DEVELOPMENT OF THE INFANT

Special Senses.—Sight.—This is present from birth and in the first week the eyes are very sensitive to light. Not till the fourth month do they seem to be used voluntarily.

Hearing.—Deafness is present for a day or two. This is probably due to the absence of air from the tympanum, but when respiration is well established, the hearing begins, and it is then extremely acute. The infant does not seem to locate sounds before the fourth month.

Touch.—Sensation is present, but is dull for three months. It is highly developed in the tongue and lips, where the temperature sense is also acute.

Taste.—This sense is highly developed from birth.

Smell.—We know scarcely anything about the ability of the newborn infant to distinguish odors.

Speech.—This function is very variable in its development. Very much depends on efforts at training, as- institution children always talk much later than those brought up at home. By the end of the first year, the child should begin to say a few words, and by the end of the second year should form a few sentences. If there has been no effort at speaking by the end of two years, probably some mental defect is present or “deaf-mutism’’ may be suspected.

Chapter III. Examination Of The: Child

History.—The family history should be carefully ascertained as a matter of routine, and then the personal history of the child. Ascertain if the birth was prolonged, precipitate, or instrumental; if previous pregnancies were abnormal, stillbirths, premature, ete. Particularly inquire about the feeding from birth, especially early feeding and most recent. Try not to ask questions that may be answered simply by “ves” or “no.” Gather together systematically all the facts about the present illness; ask if the child has had similar attacks of the same nature. Be willing to listen patiently to all ideas and observations of the mother or nurse about this and previous illness.

Inspection.—Observe the child carefully without touching or disturbing it, particularly if an infant. Notice the position, whether it is natural and easy, and whether movement of arm and leg is the same on the two sides; if asleep, whether sleep is quiet or restless; the respiration; the color of the skin, and if moist or dry; the facial expression, mouth open or closed when quiet; the nostrils, whether quiet or moving; the character of the cough, if any; the cry, whether whining or lusty, occasional or constant; the condition of the eyes and pupils; look for enlarged lymph glands; irregular muscular movements or twitchings; discharges from nostrils, genitals, ete. Compare the impression, as much as you can, with that given by the normal infant. Physical Examination.—In every instance make first that portion of the examination which will disturb the child the least, and let all handling be deliberate and gentle. Do not touch the bare body of a child with cold hands or cold

- instruments. The child should be stripped and examined

30 EXAMINATION OF THE CHILD first for eruptions; this can always be done best by daylight. Palpate the abdomen with gentle touch, remembering that normally the liver can be felt below the ribs in young children, and that the spleen cannot be felt. Auscultate and percuss the chest carefully, being sure that the child is in such posi-— tion that the two sides are symmetrical; note the movement of the two sides and compare the fremitus. Inspect the genitals and examine any discharge for the presence of gonococci. Examine the bones for irregularities, and the extremities for any points of pain or tenderness. Ascertain the firmness and development of all the muscles. Investigate the mental development and the efficiency of the nervous system in general; if the fontanelle is open, see if it is bulging, flat or depressed. Make any measurements that seem indicated. ‘Take the temperature, if possible, in the rectum, as that is the most reliable. The pulse should be counted, but its rate in children is of comparative unimportance. ¢xamine carefully the ears, mouth, and above all never fail to examine the throat. This should usually be the last proceeding, as it is almost certain to make the child unmanageable.

Laboratory Aids.—The von Pirquet test should be made if there is any suspicion of tuberculosis. The Wassermann, in any case that might be syphilis. It is best to examine a culture for diphtheria in every doubtful case of sore throat or nasal discharge. In cases of suspected meningitis a lumbar puncture is of inestimable value and does no harm. Blood counts and blood smears will sometimes set one on the right track when nothing else will; employ their aid frequently. And the urine examination should never be neglected when there is any obscurity about the illness.

Chapter IV. Diseases Of The Newborn Infant

ASPHYXIA.

Forms.—There are two distinct forms of asphyxia after birth: (1) The congestive, and (2) the anemic. In the first the child is livid in color, appears swollen, and has good muscular tone and a full, strong pulse. In the second form the skin is pale, the muscles flaccid, and the pulse inappreciable.

Prognosis.—The prognosis in the congestive variety is far better than in the anemic. .

Treatment.—This is simple in the former; first allowing a little blood to escape from the cut cord to reduce the internal congestion, and then alternately dipping the baby into hot water (110° F.) and cold water. The reflexes being still present, the response is marked.

In the latter variety allow the child to get as much blood as possible from the placenta, and then perform artificial respiration, for a long time if necessary, at the rate of ten to fifteen times per minute. Sylvester’s method is undoubtedly the best, as the baby can be kept in a tub of hot water during the manipulations. Be sure that the mouth and pharynx are clear of any foreign substance. .

In some cases when artificial respiration fails, direct inflation of the lungs by the mouth-to-mouth method, the pulmotor, or by passing a catheter into the larynx, succeeds. In these cases, after respiration is established, attention is necessary for some time to prevent relapses and to be sure that atelectasis is overcome.

ICTERUS.

This common affection, of still unknown origin, appears from the second to the fifth day and lasts about a week.

It occurs in about one-third of all newborn infants. It is probably hepatogenous in origin and due to resorption of bile pigment. It requires no treatment, disappearing without other symptoms in a few days. —

In some cases an early jaundice increases in intensity and presents constitutional symptoms. In these cases the prognosis is bad, and there is usually either a septic infection from the umbilical vessels or a congenital malformation of the bile’ ducts.

OPHTHALMIA.

Definition—This is an infectious conjunctivitis, in the majority of the cases due to the gonococcus, less frequently to the ordinary pyogenic germs. All degrees, from a mild conjunctivitis to chemosis, corneal ulceration, and often total blindness, may occur. Gonorrheal ophthalmia is a very common cause of blindness.

Symptoms.—Redness, swollen lids, copious purulent discharge, pain, and photophobia usually are present.

Treatment.—Prophylaxis, as already described, is most important. After the disease is started, frequent and thorough cleansing with a saturated boric acid solution, normal saline, or sometimes 1 to 5000 bichloride of mercury, is the most important item. Twice a day a few drops of a 1 per cent. solution of silver nitrate solution should be instilled into the affected eye or eyes, and in the intervals ice-cold compresses, frequently changed, should be kept on the lids. If only one eye is affected, it is important to put a shield of some sort on the other to prevent its infection. It is always wise to call in the services of an oculist.