Diseases of the digestive organs in infantry and childhood

Front matter

Shelf JjAS

UNITED STATES OE AMERICA.

^m m m

Preface To The Second Edition

In preparing this issue of "The Diseases of the Digestive Organs in Infancy and Childhood," the author, while endeavoring to bring the general subject-matter thoroughly abreast with the times, has deemed it advisable to make some re-arrangement of the original text and to add a quantity of new material. The chief additions consist of a section on alterations in the odor of the breath in disease ; a section on urine alterations ; a chapter on massage in paediatrics, and a detailed account of second dentition and its influence on the health in late childhood — a subject heretofore greatly neglected.

The author wishes to thank the critics of the first edition of his book for many valuable suggestions, from which he has profited greatly. His thanks are also due to Dr. Wm. M. Powell for his untiring assistance in preparing the copy and in making the index ; to Dr. Robert J. Hess for his aid in proof-reading, and to Prof. Charles B. Nancrede for the diagram illustrating the extended connections of the dental nerves.

LOUIS STARR.

1818 South Ritlenhouse Square, Philadelphia. January 1st, 1891.

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Preface To The First Edition

It is the author's object, in this book, to give prominence to a class of disorders constituting a large proportion of the ailments of childhood, but often too briefly considered in works on paediatrics. For the successful treatment of the diseases of the digestive organs in infancy and childhood, attention to the general regimen is quite as important as the administration of drugs, and it is upon the former that the student and young practitioner are usually the least thoroughly instructed.

So much may be done by the selection of suitable food, by artificial digestion, by regulating the clothing, bathing and other elements of hygiene, that the author, without neglecting therapeutics, has given greater prominence to these points.

The chapter on the investigation of disease does not necessarily belong to a work on disorders of the digestive organs, but as so much difficulty is experienced by students in the study of disease in children, it has been incorporated as an aid to such. In the article on the general management of children, the effort has been made to present to the inexperienced results that can only be obtained by much study and practical work.

The author is indebted to Dr. Henry D. Harvey for his aid in

preparing the index, and to the pencil of Dr. John Madison

Taylor for the illustrations.

LOUIS STARR.

Philadelphia , April, 1886.

Vlll

Chapter I

1. Catarrhal Stomatitis, 124

2. Aphthous Stomatitis, I2 6

3. Ulcerative Stomatitis, 13 *

4. Gangrenous Stomatitis — Noma, 136

ix

CONTENTS.

PAGE

5. Parasitic Stomatitis — Thrush, 141

6. Dentition, 148

7. Simple Pharyngitis, , 183

8. Superficial Catarrh of the Tonsils, 186

9. Follicular Tonsillitis, , 187

10. Suppurative Tonsillitis, 190

11. Hypertrophy of the Tonsils, 194

12. Retropharyngeal Abscess, 197

Chapter II

1. Acute Gastric Catarrh, 199

2. Chronic Gastric Catarrh, 202

3. Ulcer of the Stomach, 211

4. Softening of the Stomach (Gastro-Malacia), 212

5. Chronic Gastro-Intestinal Catarrh, 213

6. Acute Intestinal Catarrh, 227

7. Chronic Intestinal Catarrh — Chronic Entero- Colitis, .... 235

8. Entero-Colitis, 248

9. Cholera Infantum, 258

10. Inflammation of the Colon and Rectum — Dysentery, . . . 264

11. Tubercular Ulceration of the Intestines, 268

13. Habitual Constipation, 273

14. Simple Atrophy, 279

15. Typhlitis and Perityphlitis, 287

16. Intussusception, 296

17. Intestinal Worms, 311

Part I.— Introduction The Investigation Of Disease

The clinical investigation of disease in children, usually considered so difficult, is in some respects easier than the same study in adults.

It is easier because in the child disease is commonly uncomplicated, rarely has its course and symptoms modified by tissue lesions the result of previous affections, and never by vicious habits, such as the abuse of stimulants and narcotics, or by mental over-work and nerve-strain. The confusing element of mis-stated subjective symptoms is also absent, while correct diagnosis is greatly aided by the facility with which physical examination of the whole body may be practiced.

That there are difficulties to be encountered, and very grave ones too, is equally certain. The absence of speech in the infant deprives us of the important assistance afforded by correctly

2 17 l8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN.

described subjective symptoms, and renders it necessary to look to the mother or nurse for the history of an illness. In older children the case is not much better, since with them words are not prompted by sufficient knowledge or judgment to be of great service. Further, the wilfulness, dislikes, fear and agitation of the child are impediments which must be overcome before a satisfactory examination can be made, and which will often tax the skill and patience of the physician to the utmost in the overcoming. Another source of difficulty lies in the activity of growth and development in infants, which renders them liable to be affected by slight causes, and makes disease sudden in its attack, short in its course and intense in its symptoms. The rapid development of the nervous system especially leads to confusion. The nerves bind every portion of the frame in a sympathy so close that an affection of a single part may cause marked general disturbance, and local symptoms are often reflected, directing attention to organs very distant from those really diseased. Finally, the extreme excitability of the nervous system of healthy children often causes a trifling illness to assume an aspect of the greatest gravity, while, on the contrary, the depression of nervous sensibility that attends chronic wasting diseases so obscures the symptoms that a dangerous intercurrent affection may appear trifling or remain altogether latent.

The plan of conducting the clinical investigation in children differs materially from the method adopted in adults. It is best to proceed in three regular stages, as follows : ist. Questioning the attendants ; 2d. Inspecting the child \ 3d. Physical examination.

1. Questioning the Attendants.

When the patient is under eight or ten years of age, the only way of obtaining a knowledge of the previous history and of what may occur between visits, is carefully to question the mother or nurse. The account must be patiently elicited and listened to, and credited with due reference to the narrator's intelligence. It is well' never entirely to discredit a statement without good reason, for many women, though weak and foolish in other respects, are excellent observers when their powers are guided by affection. Besides, being thoroughly acquainted with their children's habits and dispositions, they will often detect deviations from health that the physician might overlook entirely. This part of the examination, particularly when the acquaintance and good will of the child has not previously been obtained, should, if possible, be made before entering the sick-room. By taking this precaution the agitation produced by the prolonged presence of a stranger, and its consequent trouble and delay, will be avoided to a great degree.

As there are certain points about which it is always necessary to be informed, the adoption of a definite order of questioning is advisable.

The family history as far back as the parents should first be ascertained. Inquiry being chiefly directed to the detection of chronic maladies and transmissible diseases, as tuberculosis and syphilis. If any deaths have occurred, their causation should be investigated, and an inquiry into the occurrence, or the reverse, of previous still-births is often important.

Next, an outline of the child's life from birth up to the date of the illness in question must be obtained. This should include the following items : The manner of feeding during infancy ; whether at the breast, or from a bottle, and if the latter, whether cow's milk, condensed milk or the farinacea have formed the basis of the diet. The date of commencement and the regularity of dentition. The general state of health in regard to strength or weakness and liability to illness. The time of occurrence and the nature of any prominent attack of illness, especially of the eruptive fevers. Whether vaccination has been performed or no. The hygienic surroundings; for instance the healthfullness of the locality of residence, the sort of house and room occupied—if large, well ventilated, light and dry or the reverse, and the character of the clothing and food. In older children, if at school, the time devoted to study, and if at labor, the nature and the hours of work.

After this it is necessary to fix the time the attack in hand began. The occurrence of some striking symptom, as convulsions or violent vomiting, often establishes this point beyond a doubt, but when there is any uncertainty the best plan is to question back, day by day, until a time is reached at which the child was perfectly well, and to date the onset from this period. The most common of the general indications of commencing illness are disturbed sleep and irritability of temper. A perfectly well child sleeps quietly and continuously at night, and is never cross.

Having determined, as nearly as possible, the exact time of onset, the next step is to learn the mode of attack and the symptoms and course of the disease prior to the first visit. The questions now must be general, never leading. They must be sufficiently exhaustive to touch upon all the functions of the body, and when a trail is started it must be patiently followed to the end. Alterations in sleep, bodily strength, surface temperature, appetite, digestion, urine elimination, respiration and so on, must be sought for, and the account of such deviations from the normal state as vomiting, diarrhoea or cough, will suggest further questions as well as point out the path to be followed in the future examination.

This portion of the investigation is closed by an inquiry into the treatment that "may have been already adopted.

2. Inspecting the Child.

When the eye and ear of the physician are trained to their work, valuable information can be obtained by simply looking at an ill child and listening to its cry or spoken words. Even while the child is lying asleep or sitting quietly in the nurse's lap many facts may be learned, but this portion of the examination is never complete without an inspection of the naked body. The points thus ascertained consist in alterations in the expression of the face, in decubitus, in the appearances of the body and so on, and may be designated the features of disease. The relative position of the observer and patient during inspection is of importance. If possible the former should stand with his back to, and the latter be so placed that his face is toward, a window or lamp. The light must never be strong enough to dazzle when the countenance is the object of inspection, as this causes distortion of the features.

For convenience, the features of disease will be studied under different headings, and since to appreciate them it is necessary to have a knowledge of the healthy aspect, both the normal and abnormal appearances will be described.

Face. — The face of a healthy, sleeping child wears an expression of perfect repose. The eyelids are completely closed, the lips slightly parted, and while a faint sound of regular breathing may be heard, there is no perceptible movement of the nostrils. Incomplete closure of the lids with more or less exposure of the whites of the eyes is noted when sleep is rendered unsound by moderate pain and during the course of all acute and chronic diseases, particularly when they assume a grave type. Twitching of the lids heralds the approach of a convulsion, and at such times, too, there is often oscillation ot the eyeballs, or squinting. A marked smile, due to contraction of the muscles about the mouth, signifies abdominal pain or colic, and pursing out of the lips and chewing motions of the jaw, gastro-intestinal irritation. Dilatation of the alae nasi, with or without noisy breathing, points to embarrassed respiration, the result of extensive bronchial catarrh, pneumonia or pleurisy with effusion.

When awake and passive the healthy infant's face has a look of wondering observation of whatever is going on about it. As age advances the expression of intelligence increases, and every one is familiar with the bright, round, happy face of perfect childhood, so indicative of careless contentment, and so mobile in response to emotions.

The picture is altered by the onset of any illness, the change being in proportion to the severity of the attack. An expression of anxiety or of suffering appears, or the features become pinched and lines are seen about the eyes and mouth. Pain most of all sets its mark upon the countenance, and by noting the feature affected it is often possible to fix the seat of serious disease. Thus, contraction of the brows denotes pain in the head ; sharpness of the nostrils, pain in the chest ; and a drawing of the upper lip, pain in the abdomen. As a rule, the upper third ot the face is modified in expression in affections of the brain, the middle third in diseases of the chest, and the lower third in lesions of the abdominal viscera.

M. Jadelot has drawn attention to certain furrows that appear on the face in serious cases, and to the indications that these affond as to the part of the body to be further examined. There are three sets of furrows. First, the oculo-zygomalic, beginning at the inner canthus of the eye and passing outward beneath the lower lid, to be lost a little below the most prominent portion of the cheek. This points to primary or secondary disorder of the cerebro- nervous system. Second, the nasal, starts above the ala of the nose, and, passing downward, forms a semicircle around the angle of the mouth. This may be associated with another line, the ge?ial, which extends from its middle almost to the malar bone. These indicate disease of the gastro-intestinal tract, or other abdominal viscera. Third, the labial, commencing at the angle of the mouth and running outward, to be lost in the lower part of the face. This furrow is more shallow than the others. It directs attention to the lungs. These furrows are often present, and when met with are worthy of consideration, but their constancy and value have been over-estimated by their discoverer.

Pufflness of the eyelids and a fulness of the bridge of the nose, indicate dropsy and should direct attention to the kidneys as the seat of disease. Each of the two prominent diatheses is distinguished by a peculiar physiognomy. When there is a tuberculous tendency the face is oval and the features delicate ; the hair is fine and silky ; the skin smooth and transparent ; the temporal veins are visible ; the eyelashes are long and curving, the irides large and deep-colored and the sclerotics pearly white or bluish ; finally, a growth of fine hair is often noticeable on the temples and in front of the ears. The general expression is most intelligent. In the strumous diathesis, on the contrary, the face is round and heavy ; the complexion doughy ; the upper lip swollen ; the nostrils wide and the alae of the nose thick ; the eyelids are thickened and reddened at their edges ; the hair coarse, and the lymphatic glands of the neck enlarged.

A marked disfigurement of the face may indicate one of several diseases, according to its character. For example, broadness of the bridge of the nose, or complete flatness at this point, is significant of constitutional syphilis. A large, square head and projecting forehead with a face of natural size or smaller, shows that the child has suffered from rickets. An immense globular head, overhanging forehead, and diminutive face with eyeballs projected downward and irides almost concealed by the lower lids, are pathognomonic signs of chronic hydrocephalus.

Decubitus. — The complete repose depicted on the countenance of a sleeping child when free from illness is shown also by the posture of the body. The head lies easy on the pillow, the trunk rests on the side slightly inclined backward, the limbs assume various but always most graceful attitudes, and no movement is observable but the gentle rise and fall of the abdomen in respiration. In the waking state the child, after early infancy, is rarely still. The movements of the arms, at first awkward, soon become full of purpose as he reaches to handle and examine various objects about him. The legs are idle longer, though these, too, soon begin to be moved about with method, feeling the ground, in preparation, as it were, for creeping and walking.

With the onset of disease the scene changes. In acute attacks attended with pain, sleep is no longer restful. The infant is content only when rocked, fondled or "walked" in the nurse's arms. The older child tosses about uneasily in bed, or demands a constant change from the bed to the lap. During the waking hours the movements are purposeless, quick and impatient, the position is constantly shifted and frequent whining complaints are made. As a contrast to this condition of jactitation, at the beginning of the specific fevers, children often lie for hours quiet and drowsy upon the bed or lap.

In chronic affections attended with debility, the movements become slow and languid, and in stupor and coma there is perfect stillness and immobility.

There are certain positions and gestures which have especial significance.

Sleeping with the head thrown back, and the mouth open, is a frequent accompaniment of chronic enlargement of the tonsils. A tendency to " sleep high," that is with the head and shoulders elevated by the pillow, indicates impaired pulmonary or cardiac function. So, too, does an upright position in the nurse's arms, with the chest against her breast and the head hanging over her shoulder— a posture assumed by young children. "Sleeping cool," namely, resting only after all the bed-clothing has been kicked off, is an early symptom of rickets.

The position termed " en chien de fusil" is a symptom of the advanced stages of cerebral disease, especially tubercular meningitis. The child lies upon one side, with the head stretched far back, the arms pressed close to the sides and folded across the chest, the thighs drawn up toward the abdomen, the legs flexed on the thighs and the feet crossed. Restless movements of the head or boring of the head into the pillow also point to cerebral disease.

When there is an evident desire to retain one position, as on the back or one side, together with short, quick breathing, some inflammatory change in the respiratory or abdominal organs may be suspected. Persistent lying on the face is an evidence of photophobia.

Of the gestures, the frequent carrying of the hand to the head, ear or mouth indicates headache, earache or the pain of dentition respectively, and constant rubbing of the nose is a feature of gastro-intestinal irritation.

If the thumbs be drawn into the palms of the hands, and the fingers tightly clasped over them, or if the toes be strongly flexed or extended, a convulsion may be expected. The presence of clonic contractions of the muscles, with unconsciousness, indicates, of course, a convulsion ; while irregular, badly coordinated, jerky movements — consciousness being retained — attend chorea.

In infants the existence of colic is shown by repeated extension and retraction of the legs, clenching of the hands into fists, flexion and extension of the forearms, and a writhing movement of the trunk.

The fact of one limb remaining passive while the others are actively moved about, naturally suggests motor paralysis.

The Skin. — In the new-born infant the color of the skin varies from a deep to a light shade of red. After the lapse of a week this redness fades away, leaving the surface yellowish-white. Sometimes the yellow hue is so deep that it might readily be mistaken for jaundice were it not for the whiteness of the conjunctivae, and the absence of disordered digestion and other symptoms of ill-health. Usually in a fortnight all discoloration disappears, and the skin assumes its typical appearance. Allowing for the natural variations in complexion, the skin of a healthy child is beautifully white, transparent and velvety. The cheeks, palms of the hands and soles of the feet have a delicate pink color, and the general surface is rosy in a warm atmosphere, marbled with faint blue spots or lines, in a cool one. As age advances, the coloring becomes more pronounced, and until the completion of childhood the complexion is much fresher than in adult life.

In the inspection alterations of the skin of the face are chiefly noticeable. Lividity of the eyelids and lips is a sign of imperfect aeration of the blood, and points to pulmonary or cardiac disease. Marked blueness of the whole face is a symptom of morbus cczruleus, and indicates a congenital malformation of the heart. On the other hand, a faint purple tint of the eyelids and around the mouth shows weak circulation merely, or, more frequently, deranged digestion.

A decided yellow hue of the skin and conjunctivae is seen in jaundice ; an earthy tinge of the face in chronic intestinal diseases; a waxy pallor in renal diseases, and paleness in any acute or chronic affection attended with exhaustion.

Brownish-yellow discoloration of the forehead is significant ot inherited syphilis; a bright, circumscribed flush on one or both cheeks, of inflammation of the lungs or pleura, or of gastrointestinal catarrh, according to its occurrence with or without an elevated surface temperature.

The cutaneous lesions of certain of the eruptive fevers appear first upon the face ; each of these has its special characteristics. An eruption of herpetic vesicles on the lips may be mentioned as present both in pneumonia and in malarial fevers.

Some information may be obtained from the hands. Slight want of proper aeration of the blood is shown by blueness of the finger nails, a greater degree, by cyanosis of the whole hand. Deformity of the nails is a symptom of syphilis : clubbing of the finger tips of chronic lung disease; and redness, swelling and suppuration about the nails of struma. The dropsy of scarlatinal nephritis causes a puffiness and cushiony appearance of the dorsum of the hands. Often, too, in this condition, the finger ends are glossy, as if smeared with oil, and there is an exfoliation of the epidermis about the nails. The last two symptoms frequently serve to confirm a retrospective diagnosis of scarlet fever.

Mode of Drinking. — By watching a child taking the breast or bottle, some knowledge can be obtained of the condition both of the mouth and throat, and of the respiratory organs.

If there be any soreness of the mouth the nipple is held only for a moment, and then dropped with a cry of pain. When the throat is affected deglutition is performed in a gulping manner, an expression of pain passes over the face, and no more efforts are made than required to satisfy the first pangs of hunger. Under similar circumstances older children drink little and refuse solid food entirely.

An infant suffering from the oppression of pneumonia or severe bronchitis, seizes the nipple with avidity, swallows quickly several times, and then pauses for breath. In older patients the act of drinking, which should be continuous, is interrupted in the same way.

If the finger be put into the mouth of a healthy baby it will be vigorously sucked for some little time. The diminution of the act of suction during a severe illness is a sign of danger ; its reestablishment a good omen. In conditions of stupor and coma it is noticeably absent.

The Cry. — The vocal sound, termed crying, is the chief it not the only means that the young infant possesses of indicating his displeasure, discomfort or suffering. Even long after the powers of speech have been developed, the cry continues to be the main channel of complaint. It may be accepted, as a rule, that a healthy child rarely cries. Of course, some acute pain, as from a fall or accident or blow, will cause crying in the most healthy child, but the storm is quickly over. Nothing like frequent, peevish crying or fretfulness is compatible with health, consequently, when this disposition exists, the cause must be looked for in some disease.

Incessant, unappeasable crying is due to one of two causes, namely, earache or hunger, and the distinction may readily be made by putting the child to the breast or offering a properly prepared bottle. The hydr encephalic cry, denoting pain in the head, is a sudden, sharp and very loud shriek, occurring at intervals and audible at a considerable distance. Crying during an attack of coughing, or for a brief time afterwards, and attended with distortion of the features, indicates pneumonia. In acute pleuritis, the cry also accompanies the cough, but it is produced too by movements of the body and by pressure on the affected side. It is louder, indicative of greater suffering, and sometimes most difficult to check. Intestinal pain causes crying just before or after an evacuation of the bowels, and is associated with wriggling movements of the body and pelvis, and with the eructation or passage of flatus. Conditions of general distress or malaise predispose to fits of fretful crying, the paroxysms being excited by any disturbing influence, or even by merely looking at the little sufferer.

When the cry has a nasal tone, it indicates swelling of the mucous membrane of th< or other obstru< til lition.

Thickening and indistinctness oa urs with pharyngeal affections. A loud, brazen cry is a precursor of spasmodic croup. Hoarseness points to a lesion of the laryngeal mucous membrane, either

catarrhal or syphilitic in nature. In membranous croup, and in some cases of extreme exhaustion, tin- cry IS taint and inaudible.

Finally, in severe croupous pneumonia, in extensive pleura] effusion and in rickets, ordinary disturbing causes are inoperative for the l I on of fits of < rying, and there is a -reining

unwillingness to cry, on account of the action interfering with the respiratory (unction.

The conditions of altered tone apply equally to the articulate

voice in children who aie old enough t.> spc\ik.

The COUgh, too, roust not 1 Many of its char-

acters correspond with the voice and cry. It is brazen in spasmodic croup, suppressed in true croup, hearse- in laryngeal catarrh, and so on. But it rtain featui its own. In

bronchitis it is more or !c>s paroxysmal, evidently dry in the

early stages, loose and rattling a- the catarrh 4 * breaks up." In the painful pulmonary affections, pneumonia and pleurisy, it

choked hack, and whenever it occurs, an ion of pain

pa>ses like a cloud over the IS, the peculiar

ismodic cough is the pathognomonic symptom, and wl.

once heard, immediately stamps the case. Con. always

unproductive, that is, unattended by <--\: lion, in children

under seven years of age

The formation of tear> rarely begins before the third or fourth month of life. Subsequently, an alteration in this secretion may be of aid in forecasting the result of disease. The prognosis is bad when the tears become suppressed ; good when the secretion continues during an illness, or when it reappears after being suppressed.

There are three other sources of information which can and should be investigated before proceeding to the physical examination, although, strictly speaking, they do not come under the head of inspection of the child. These are the characters of the faecal evacuations, of the urine, and of the material ejected by vomiting.

The Breath. — The breath of a healthy infant or child should be odorless, or as the nurse will say, "sweet," except perhaps immediately after taking nourishment, when it may, for a short time, have the smell of milk or any special food eaten. The persistent presence of an odor, therefore, is abnormal and indicates disease.

Any morbid condition of the system that prevents the elimination of metamorphosed nitrogenous tissue through the mucous membrane of the intestines, or retards the passage of decomposing detritus along the bowels, will cause an offensive breath. Under this head are conditions characterized by high temperature, catarrhal inflammations of the gastro-intestinal tract, chronic debilitating diseases, etc. The same result, also, frequently attends structural lesions of the kidneys. The reason for this is, that the system, in order to get rid of poisonous matter — for accumulated waste is poison — and to maintain the balance between the constant construction and destruction of tissue, must throw off elsewhere what the intestinal glands and the kidneys fail to excrete ; so the lungs take on vicarious activity and the expired air becomes tainted with the products of waste. Very often, by the way, the skin takes a part in the abnormal excretory process, and a similar odor is noticed in the perspiration.

Purely local causes of halitosis also exist. These are decayed teeth, caries of the nasal and maxillary bones, ulceration of the mucous membrane of the mouth, nose, larynx, trachea and bronchial tubes, and gangrene of the cheeks.

Chronic poisoning by lead, arsenic and mercury, though not very common in childhood, is another cause of ill-smelling breath.

To speak in general terms, the breath may become sour, catarrhal, fetid, gangrenous, ammoniacal and stercoraceous. This classification is a rude one, and many subdivisions can be

3Q DM .„ DIGE8T1VI OKGAM U CHILDREN.

made of some of the odow. Thus, .lK-rc arc man] wietia of catarrhal and fetid breath, which, whiten less distinctive

different conditions, cannot be differentiated in words and m be experienced by the observer's * cognised;

once this is done they become valuable symptoms.

r breath is nt, in it *ially, when there

ismost Bdedb nandvomitu

In chronic romiting, chronk - colitis and thrush the