A guide to the diseases of children

Front matter

A GUIDE

TO THE

THE WORKS OF LOUIS STARR, M.D.

Preface To The Second American Edition

In preparing the second American edition of Dr. Goodhart's work, the Editor has taken the liberty of re-arranging the original matter so as to secure greater symmetry and ease of reference. In doing this especial care has been employed to alter, in the least possible degree, the author's forcible descriptions of disease, and to preserve a feature, possessed by the first edition and highly praised by American reviewers, namely, the close resemblance of the text to actual bedside teaching. The brackets ([ ]) originally surrounding the suggestions of the Editor have been omitted, as he believes his additions to be in the spirit of the author's writing and entirely in accord with his views.

The subject of " Feeding infants and children " has been greatly elaborated, and this important question, together with the whole of the work, brought thoroughly abreast with the recent advance in pediatric science.

The insertion of typical temperature charts is a new feature in works on children's diseases, but remembering the need of such graphic representations of thermic ranges in his early years, the Editor hopes by their use to help the student and junior practitioner.

The many admirable su^o-estions of the reviewers of the first edition have been treated with due respect, and their hints must claim a share in whatever improvement there may be in this second venture.

The Editor also wishes to acknowledge his indebtedness to Dr. W. M. Powell for his most efficient aid in the preparation of the copy and index.

Louis Starr.

1818 S. RitteiiJiouse St/., Philadelphia, Xov., 1889.

V

Preface To Second English Edition

The present edition has been thoroughly revised, and some slight but important additions and re-arrangements made, which will, I think, enhance the value of the book. Not least of these is a much more copious index, which has been in great part compiled by Mr. C. H. Wells, and which deserves a full acknowledgment. In several places hints have been obtained from the American edition, which has been brought out under the able and sympathetic guidance of Dr. Louis Starr, Physician to the Children's Hospital, Philadelphia. Full consideration has also been given to such criticisms as have reached me. But in truth these have been so few and kindly, and the sale of the work has been so rapid, that but little suggestion for revision has been thus derived. It is a pleasure to add that in this, as in the former edition, the experience, the sound judgment and active interest of my friend Dr. Lewis Marshall, of the Nottingham Hospital for Children, have been of the utmost help to me.

James F. Goodhart.

August, j 8 86.

VI

Preface To Third English Edition

The present edition has been revised throughout, but has undergone no material alteration. Some slight re-arrangement has been made in the earlier chapters, and I have endeavored to make it more useful to the student and young practitioner by amplifying the directions relating to diet in infancy, and generally by inserting, where possible, such recent methods of treatment as have either proved, or promise to be, successful.

James F. Goodhart.

Septei7iber, 1888.

Vll

Introduction

What is a child, and how the diseases of children differ from the diseases of adult life, are questions which must have confronted all who have written upon the ailments of childhood, and not a little puzzled them for an answer. By the pathologists, indeed, it may well be doubted if any valid reason can be given for making a separate group of the diseases of children, for there are but few morbid changes found in childhood that are not to be seen at one time or another in the bodies of adults.

If we run over the various regions of the body, the brain, heart, lungs, lymphatic glands and so on, few, and those but minor, differences can be pointed out between the products of disease in a child and of the same disease in an adult. Some diseases are more common at one time of life than at the other ; but should they overstep the limit of age usual to them, they appear in their old form, or with but slight modifications, such as would certainly not justify any one in devoting a " manual " to their description.

The bones form the most notable exception to this rule : in rickets, acute ostitis, and some forms of enchondroma we have examples of constancy of peculiarity of morbid deposit ; 2 13 of constancy of limitation to the growing age ; of constancy of peculiarity of distribution of the disease, and so on. Certain diseases of the skin and teeth might equally be advanced, but having said even this, we should still be at fault for material for a book. The difficulties and differences which render it advisable that these diseases should receive special study are mostly those of semeiology and treatment, and from the fact that the student, when first introduced to this branch of practice, finds himself thrown upon his own resources. In the adult he can ask questions and obtain clues to the furtherance of his diagnosis. With infants and children he must find out what he can for himself — the history is faulty or often quite wanting — and here he fails. For instance, it is a common occurrence in hospital practice to find that no account is forthcoming from the clinical clerk of some child that has been admitted since the last visit. He has not yet seen the mother, is the explanation offered for the omission. Supposing,' now, that we change the venue, so to speak, of this illustration to that of the veterinary surgeon, and one of the lower animals, and such an answer, were it conceivably possible, would be ludicrous. Yet, there is not so very much difference between the student who has to investigate the diseases of children and one who has to do with diseases of the lower animals. In both cases the diagnosis will chiefly rest upon the doctor's own observation and examination. In both intelligible speech is wanting. Any history that a parent or a relative can give, is by no means to be underrated ; on the contrary, an intelligent mother and nurse are to be listened to patiently and attentively — they are often acute observers of early signs of ill health, or changes in the symptoms. What is important to enforce is, that the previous history occupies a subordinate, not the chief, position, and the student is at all times to consider himself as independent of it. Any help that can be obtained in this way is all well and good, but it is secondary to a personal examination.

Supposing, now, that a child is before us, what is to be done in making a thorough examination ? Our first care will be not to frighten the child, a task which at once calls into play tact, patience, and control of feeling. A strange face is alone sufficient to make a child cry, but when that face belongs to the doctor, a word very early added to the child's small repertory, and when these are associated indelibly with memories of castor-oil or other bad-tasting medicine, inexperienced nature can hardly be expected not to revolt — and revolt it often does, regardless sometimes of the most exquisite tact. But much can be done to soothe matters by the expenditure of a little trouble ; never be in a hurry ; take time, that the child may become accustomed to you ; talk to it, play with it, and show it any glittering thing that may be at hand. A stethoscope or other instrument that it maybe necessary to use should first be made a plaything, the subsequent examination being often much facilitated by so doing. Do not touch a child till it has had a good look at you. Plenty of occupation is afforded in the meantime in questioning the mother or nurse. Then, with regard to special instruments, the thermometer, for instance, which is constantly in use, put it into the axilla and hold it there gently, with your eye on the column of mercury, talking to the child all the while, and even drawing its attention to it. If the forearm be not restrained, it will be possible to do this for a minute or two, during which you may watch the mercury quickly rise to a certain height, and then proceed more leisurely. If the child become restless, withdraw it ; the half degree or so which it may rise afterward will be of little importance to you in drawing conclusions, whereas a fit of crying or any fright will render all further observations difficult. In infants, however, it is best to take the temperature in the rectum, since the surface heat varies greatly with that of the surrounding atmosphere, and since it is difficult to maintain quiet long enough for an axillaryobservation. The well-oiled bulb of a thermometer should be gently inserted through the anus, and kept in place for three minutes. The normal temperature in this position is from i° to 2° higher than in the axilla. The temperature may also be taken in the groin or between the scrotum or labium and thigh ; the reading will not be so high as in the axilla, and of course much lower than in the rectum. In older children, the mouth is a very convenient and certain locality for observation ; here the normal reading is at least i° higher than in the arm-pit. Some of the peculiarities of the temperature in infancy will be referred to later.

With the ophthalmoscope again try to get the child to consider the instrument a toy, the examination a game of play, and — with plenty of patience, for a child's eye partakes of the restlessness of its whole muscular system, and no fixed look at any object, however attractive, can be counted upon for more than a second or two — there are few children or infants in whom the optic disks cannot be seen. It is essential to success in some cases not to touch the child. As soon as a finger is placed on the forehead to steady the lens used for the indirect method, many a child will rebel. The same remark applies still more forcibly to pulling up the upper lid to obtain a view of the pupil. The attention must be attracted by playing the light on and off the eye ; and skill will come with practice in ascertaining the state of the fundus by repeated momentary glimpses rather than by any one prolonged view. Even the hsemacytometer, for which it is necessary to prick the finger, may be used without making a child cry, by making a rapid prick with a needle and showing the resulting drop of blood to the child as a wonderful thing. To make a rule, the child is to be restrained as little as possible in any examination that may be necessary. The mother or nurse will often hold its hands or. its legs, or both, as the first step to auscultation, and there is nothing which a child resists more than restraint of this kind. Let it kick about, if it will, till it becomes unmanageable, and this will but seldom be the case if we take care not to make it so. Let it play with the end of the stethoscope, if it likes ; it is quite possible to distinguish the respiratory sounds, and after a time those of extraneous origin can be as readily ignored as can the noise made by a crying child. The fact that the child is crying is no excuse for not examining the chest — crying necessitates deep respiration, and is often advantageous for this reason. All that we need is more patience. In auscultation, also, it is often necessary to listen to the respiratory or heart sounds in snatches, and to fill in by repeated observations what is not permitted by continuous examination ; and in many cases it is advisable to examine the back of the chest first.

Having given these few hints upon what to avoid, a few may follow concerning what has to be done — and first we must be careful to maintain an attitude of close observation. The points to be observed are often apparently trivial and difficult to keep in mind in any systematic way. There is the complexion of the child ; the formation of its bones ; the state of its skin and muscle — is it fat, spare, firm, or flabby ; its size in proportion to its age ; its general build ; the shape of its head ; the state of its fontanelle ; the relative proportions of head and face ; the condition of corneae and pupils ; the lines upon the face ; the state of the no*strils ; the gums, the teeth, the tongue ; the ears ; the shape of the chest and its movement ; the abdomen and its movement the character of the cry and the state of the nervous system. All these facts and many more, indicating as they do points negative and positive which are absolutely essential to the formation of a diagnosis, and for forecasting the issue of the case, and for treatment, must yet, being but preliminaries, often be taken in hurriedly, almost at a glance. To allow of this being done in any sense completely, it is well to take each step in a regular method. Start, however, where you like, adopt your own plan, but always proceed as much as possible upon this plan : and while rapidity of execution comes with practice, abundant compensation will be obtained for any trouble that may be involved, in the frequency with which, by so doing, conclusions will be arrived at, and results obtained, which had not previously been expected, and would in all probability have been missed by less methodical observation.

It is impossible, in a short manual, to go much into detail in a preliminary chapter,* but one or two points may be selected to illustrate the importance of what has been said. For instance, the cry of a child may help to distinguish the ailment under which it is laboring. There is the noisy, passionate cry of hunger ; the wail of abdominal disease ; the whine of exhaustion ; the short, sharp shriek of cerebral disease ; the hoarse, whispering cry of laryngitis.

Much may be learned by a glance at the shape of the head. The hydrocephalic head is one which bulges in all directions. The forehead projects, the temporal fossae become convex ; the fontanelle and vertex more vaulted ; even the occiput becomes more rounded, and, in this general tendency toward the assumption of a globular form in place of an ovoid, the inter-ocular space is widened outward, and the eyes are rendered too divergent. The rickety head is usually an elongated one, and often laterally compressed,

* For a detailed plan of examination, see " Diseases of the Digestive Organs in Infancy and Childhood." — Starr.

INTRODUCTION. IQ

and although the forehead may be overhanging, it wants the width and general rounding seen in hydrocephalus. In other cases it is square, being flattened anteriorly, posteriorly, superiorly, and laterally. The frontal eminences are prominent, the sutures are depressed, and the fontanelles are late in closing. There is also apparent enlargement, due to comparative smallness of the face from arrested development of the facial bones, though actually the cranium measured about the same as at the corresponding age in health. The head of the syphilitic child is sometimes of irregular shape, almost lobulated in appearance, and betrays its component bones by the position of the enlargements. The disease is one of osteophytic growth, which forms upon the bones round the anterior fontanelle, and spreads thence over their surfaces. The fontanelle may thus appear to lie in a hollow, the frontal bone being unusually prominent, and the inter-frontal suture converted into a vertical ridge, from the exuberant bone formation along it ; while the parietal bones become bossed irregularly. This skull has been called the natiform skull, from the appearances produced by the bony elevations. It is still an open question whether the osteophytic growth is due to syphilis or to rickets. The scaphoid skull is a narrow skull, in which the frontal region is boat-like, and slopes away from the median line, betokening the small brain of an imbecile or idiot.

The fontanelle, by bulging, may indicate excess of blood or cerebro-spinal fluid within the cranium ; by its size it may indicate defective ossification, and so rickets ; but of more importance, because of almost invariable significance, is the depressed fontanelle of starvation and exhaustion : it indicates the immediate necessity of food or stimulants.

As to the face, various shades of pallor are most suggestive — a dirty white stands for congenital syphilis ; a sallow white for splenic disease ; a pallor with a sub-tint of blue for tuberculosis ; a livid, leaden, or earthy tint for collapse from abdominal disease.

There are certain markings upon the face, Jadelot's lines, as they are called, from the French physician, who has described them very fully. These lines are: 1st, oculo-zygomatic, indicating disease of the brain. This begins at the inner angle of the eye, and extends outward beneath the lower lid, to disappear a little below the projection of the malar bone; 2d. The nasal, pointing to gastro-intestinal disorders, or affections of the abdominal viscera. This rises at the upper part of the ala of the nose, and passes downward, to form a semicircle around the corner of the mouth ; 3d. The labial, denoting disease of the lungs and air-passages. Beginning at the angle of the mouth, this line runs outward and downward, to be lost at the lower part of the face.

Then there are the various complexions which are supposed by many to indicate particular diatheses or tendencies to disease — the pretty, thin-skinned children of tubercular proclivities; the sallow, muddy appearance of children prone to glandular abscesses ; the dark-haired, pallid, but, on the whole, well-looking children of nervous habit, and so on. Of these, though they have in former times occupied much of the attention of writers of books, it is necessary to say but little, because there is now considerable want of unanimity upon the subject, and because their importance is hardly measurable by facts, but depends upon observations, the accuracy and worth of which the student must test for himself. There is the sunken eye, the dark-colored and depressed areola around it, indicative of collapse ; the dilating alae nasi of acute lung disease ; the lividity of lips of chronic lung disease; the puffy, congested eyelids, and ecchymosed face of whooping-cough.

For the chest, we have the immobility of pleurisy ; the unnatural precordial bulging of a large heart; the sinking in of the lower ribs of atelectasis.

Of the abdomen, it may be said that enlargement is not necessarily due to disease. Children will constantly be brought to you for "consumption of the bowels," because they have diarrhoea and a large abdomen. In the great majority of cases, the enlargement is due to flatulent distention from defective feeding ; sometimes to displacement of the liver and spleen by distortion of the thorax in rickety children. In many such there will be but few cases of organic disease, and of mesenteric disease, it may be said that it is seldom associated with sufficient abdominal enlargement to attract the attention of the child's mother. Increase in size of the abdomen, when the result of disease, may be due to a large liver or spleen, sometimes to ascites, sometimes to tumors connected with the kidney.

On coming to the more direct examination of the child, it is even more necessary to follow a definite plan. It matters not how one proceeds, so long as this be done. Supposing, as is probable, that some idea of the nature of the case has been gleaned from the preliminary survey, a good method is to start with the organ which we suspect to be involved. If there be any reason for suspecting disease of the nervous system, it is as well at once to examine the eyes with the ophthalmoscope, lest any subsequent action on our part may frighten the child, and render the fundus oculi inaccessible. It is impossible to make any satisfactory use of the ophthalmoscope if the child is, or has been recently, crying. This done, and the state of the pupil and movement of the eyeball ascertained, the sight and hearing can be tested by a watch, and the precision of the various muscular movements of the extremities, by giving the child something to hold or pick up, and by making it walk, if old enough, or by watching the movements of the limbs in infants too young to walk, as they lie on the mother's lap. The gums can be examined, and the progress of dentition ascertained by gently rubbing the surface of the gums with the finger. The chest and abdomen should be examined in all cases. Some advise that the child should be stripped for this purpose, and this is a necessary measure in some cases, but is not advised as a rule, for the reason that the child is to be frightened or put out of temper as little as possible.

Children, all but the youngest infants, resent the process of undressing, and it is usually sufficient for the purpose of examination that all the clothing be loosened. The greater part of the front and back of the chest can be, by this means, exposed, and a thorough investigation made. Percussion must be light or it will mislead. A light vertical tap with one or two fingers upon a finger of the other hand placed flat upon the chest is all that is necessary, and special attention is to be paid to the intervertebral grooves, as parts which are more frequently implicated in children than in adults. In auscultation it is very essential to make careful comparison of the two sides ; of the bases with the apices ; and to remember that it sometimes happens that the more abnormal sounds are heard in the healthier lung. A student will often describe as bronchial breathing, the exaggerated, puerile respiration of the over-acting, but sound lung, and consider as healthy, the soft and deficient vesicular murmur of the diseased side, and indeed there is abundant excuse for his so doing. Again, disease may be ascribed to the apex of the lung from the existence of bronchial breathing, whereas the primary disease is really at the base. Therefore, the whole of the chest must be auscultated : above and below the clavicles ; the supra-spinous fossae behind ; the intervertebral grooves and bases ; and we must be on the alert to detect even slight differences between the two sides.

The examination of the abdomen is chiefly conducted by means of palpation — enlargement of the spleen and liver are ascertained in this way. So, also, other abdominal tumors. But there are other points of detail which are well worth attention. In the first place it is often worse than useless to put a young child on its back and uncover it for examination. It will kick and scream, put its muscles into a state of rigidity, and nothing can be made out. One must often be content with an examination while it is sitting up and by placing the hand beneath its clothes. It is equally useless to poke the abdominal wall with the tips of two or three fingers, as the muscles are provoked to action by this means also, and nothing can be felt behind them. Palpation can only be properly conducted by placing the warm palm perfectly flat and open upon the abdominal wall and making pressure at any part that requires examination with the flat of one or two fingers. Any abnormal tumors can in this way be readily detected, and their edges defined — be they hepatic or splenic or what not. Splenic and renal tumors are best examined by one hand being placed flat beneath the body supporting the hinder wall of the abdomen, while the other, flat and open as before, makes pressure from above upon the abdominal wall supported by the hand behind.

The pulse, in infancy, ranges from 90 to 130 beats per minute ; the least muscular effort or emotion of anger or fright being sufficient to increase the frequency of the heart's action from the former to the latter figure. As a test of physical strength, the pulse, at this age, is far less reliable than the condition of the fontanelle. After the age of two years, it becomes a more valuable guide. In health it rarely counts more than 100 during the waking state, and is some 10 or 20 beats slower in sleep, when, too, it is often irregular in rhythm. An increase to 130 occurs with any trifling fever, and is consequently not a serious symptom. Abnormal slowing, on the contrary, is a grave feature, a reduction to 40, for example, frequently attending tubercular meningitis.

The respiration varies in frequency with the age. At birth, the average is 40 per minute; from two months to two years, 35; and from two to twelve years, 18 during sleep, 23 while awake. The movements should be diaphragmatic ; if superior-costal, a painful abdominal disease, as peritonitis, is indicated; if abdominal, pleuritis or pneumonia. Very rapid breathing attends cardiac disease and inflammatory affections of the lungs or pleura ; slow, sighing respiration, interrupted by long pauses, tubercular meningitis. The normal ratio of respiration and pulse is 1 to 3 or 3.5 Should this be changed to 1 to 2, pneumonia or pulmonary collapse may be suspected.

The temperature of children is often puzzling. It is much more unstabLe than in adults, and abnormal heat is more liable to escape notice. Temperatures of 102 and 103 are frequently overlooked in infants, the child being said to be simply out of sorts, and fretful. So also in children of two or three years old. The temperature of some children is disturbed much more readily than that of others. Some there are who, in the first six or eight years of life, whenever they eat anything which is at all indigestible, and often at other times with no very definite cause, suffer from an acute febrile disturbance, with cough and foul tongue. A mild aperient stops the whole thing. Others, again, have sharp fever with a slight sore throat. A number of children have a simple continued fever of hectic type — viz., normal in the morning and up at night — which puzzles us by the absence of other symptoms, and the fear of typhoid fever or tuberculosis haunts the doctor. Dr. Goodhart offers the notes of a case which emphasizes these remarks and gives the student an idea of some of the difficulties, as regards temperature, which are every-day realities in practice. A child of six years was taken suddenly ill, his symptoms being slight sore throat, a croupy cough, high temperature, and a rapid pulse. His cough and sore throat gave ground for anxiety that an attack of diphtheria might be impending ; but he persistently complained of pain in the epigastrium, and this, with a short, catchy respiration, suggested the possibility of some diaphragmatic trouble.

His mother, many years before, had had rheumatic fever, and a careful examination of the child's heart revealed an undoubted systolic prolongation of the first sound about the base, which was compatible with the existence of an early pericarditis, but hardly less so with the long and thick first sound which is one of the accompaniments of sharp fever. The epigastric pain and peculiar breathing, with the altered heart-sound, and the family history, pointed to the possibility of the onset of acute pericarditis and rheumatism, while the sore throat and cough would also fit in with this presentation of the symptoms. On the other hand, the child was in no distress, nor did he appear to be seriously ill. He had a bright eye, a flushed cheek, dry, red lips, a pungently hot skin, and a frequent, short, dry cough, at least as suggestive of pleurisy or pneumonia ; and, with this idea in mind, there were some slight indications in diminished resonance at the left apex, and some questionable, because distant, bronchial breathing about the root of the lung, that acute pneumonia might have set in. Lastly, at any rate in his purview, the children of this family were markedly excitable or neurotic. Such children, from inexplicable reasons, are liable to sudden sharp febrile attacks, in which cough and rapidity of pulse are prominent symptoms, and which closely simulate the onset of acute thoracic disease. The problem speedily solved itself, for, on the third morning, an aperient and some alkaline draught having been given meanwhile, the fever had subsided, and the boy was practically well.

The ejecta of children should all be examined, whether they be vomited or passed from the bladder or rectum.

The sleep of a child should be watched if opportunity offer. A child sleeps quite calmly when in health, and for a long time at a stretch when the first few months are passed over and the necessity of frequent suckling has gone by, but it is quickly disturbed in disease. Slight attacks of fever, gastro-intestinal derangements, dentition, brain disease, etc., all make the sleep uneasy, although not much differentiation of disease can be accomplished by observations of this kind.

The manner of deglutition is another feature which often conveys an indication of disease. For in any interference with the freedom of respiration a child will take a few snatches of food and then turn away and splutter, or cough, or cry. If children refuse food without any definite reason, the mouth and throat should always receive a careful examination; stomatitis, tonsillitis, and even more serious troubles, such as post-pharyngeal abscess, may otherwise go unrecognized.