Case histories in pediatrics

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Preface

The author has found this method of case teaching so useful in the instruction not only of undergraduates but also of graduate students, who, although older and wiser than in their undergraduate days, are still students in the best and widest sense, that he felt that there was need for the utilization of this method for the presentation of the subject of pediatrics to the practitioner.

Case teaching, which had been in use for a number of years in the Harvard Law School, was introduced into the Harvard Medical School in 1900 at the suggestion of Prof. W. B. Cannon, then a student in the school. The author believes that this method of teaching is far superior to recitations, quizzes, and conferences. One of its greatest advantages is that it compels the student to think for himself. It is almost as valuable as the clinical lecture, in which the patient is shown, and, except in special instances, is more instructive than the didactic lecture. It is surpassed only by bedside instruction to small groups of students.

Table Of Contents

Diseases of the New-born. page.

Case i. Icterus Neonatorum . 12

2. Obstetric Paralysis 14

Section I. Diseases Of The New-born

CASE I. Sidney K. was the first child of healthy parents. There was no history of syphilis and there had been no miscarriages. He was born May 28, about a week premature. He weighed six pounds and was put at once on a weak modified milk. Jaundice developed on the second day and became very marked. He took his food well and had not vomited. The movements consisted at first of meconium; later the bowels were very constipated, but the movements were yellow and smooth. The temperature was normal or slightly subnormal. The urine had not stained the diapers. He was seen in consultation June 5, when eight days old.

Physical Examination. He was small and somewhat emaciated, having lost a pound. There was deep jaundice of the skin and conjunctivae. He did not seem especially feeble. The fontanelle was level. The mouth and throat were normal. The heart, lungs and abdomen were normal. The umbilicus was healed. The liver was palpable 2 cm. below the costal border in the nipple line. The spleen was not palpable. The extremities were normal; there was no spasm or paralysis; the knee-jerks were equal and normal. The genitals were normal. There were no ulcerations about the anus. There was no eruption or enlargement of the peripheral lymph nodes. The rectal temperature was normal.

The urine was not examined, but the diapers were not stained by it.

The movements were small, constipated, brownish-yellow and well-digested.

Diagnosis. When jaundice develops during the first few days of life it is always a temptation to call it icterus neonatorum and to dismiss it without further consideration. There are other causes of jaundice at this age, however, and while a snap diagnosis of icterus neonatorum will be correct in the vast majority of cases, it will occasionally be wrong, and wrong often enough to justify a careful differential diagnosis in every instance. The diseases to be considered are, septic infection of the newborn, congenital obstruction or obliteration of the bile ducts, acute duodenal indigestion, congenital syphilis and congenital icterus.

The early appearance of the jaundice, the presence of deep jaundice without cyanosis, the good general condition and the absence of fever and of enlargement of the liver and spleen rule out septic infection of the newborn. The absence of enlargement of the liver and spleen and of bile in the urine, together with the presence of bile in the stools, rule out congenital obliteration of the bile ducts. Acute duodenal indigestion is very uncommon at this age. It is excluded by the absence of bile in the urine and the presence of bile in the stools. Congenital syphilis is suggested by the prematurity. There are, however, other causes for prematurity than syphilis. The good family history and the absence of miscarriages are against it. The normal size of the liver and spleen, together with the absence of all signs of syphilis, rule it out. Congenital icterus is an extremely rare condition and is excluded because the jaundice was not present at birth and the spleen is not enlarged. The diagnosis by exclusion is, therefore, Icterus Neonatorum. The development of the jaundice on the second day, the good general condition, the presence of bile in the stools, its absence in the urine, the normal temperature and the absence of enlargement of the liver and spleen are all consistent with this diagnosis.

Prognosis. Icterus neonatorum does not affect the general condition. The jaundice will probably not increase in intensity, but will not disappear entirely for several weeks.

Treatment. No treatment is indicated. Icterus neonatorum is a physiological condition and is due to the mere mechanical difficulty which the bile encounters in passing through the bile capillaries. There is, therefore, no object in. giving cathartics. Cleaning out the intestine cannot affect the conditions in the bile capillaries. It has been shown that calomel, like the other so-called " cholagogues," does not increase the flow of bile. If it did, it would be contra-indicated rather than indicated in this condition. There is no indication for changing the food, because sufficient bile to carry on digestion enters the intestine, only the excess passing into the circulation.

CASE 2. William P. was the second child of healthy parents. The position was 0. D. P. He was delivered by high forceps and weighed eleven pounds. The physician in charge pulled very hard on one shoulder, probably the right, during the delivery, and thought that he felt something give way. The baby was somewhat white at birth, did not respond to artificial respiration, and mouth-to-mouth insufflation was necessary. He then cried and seemed perfectly normal except that it was noticed at once that there was some trouble with the face and the right arm. He did not close the right eye and there was no motion of the right side of the face. The right arm hung limp at the side and was used but little. There had been some improvement in the condition of both face and arm. He was seen in consultation when one week old. He was not nursed, but took the bottle well and had no disturbance of digestion.

Physical Examination. He was well-developed and nourished. His color was good. The fontanelle was 3 cm. in diameter and level. The head was of good shape. There was no rigidity of the neck. There was a hemorrhage into the right conjunctiva. The pupils were equal and reacted to light. The left eye could be closed entirely; the right only partially. The mouth was drawn to the left when he cried. There were forceps scars on the left forehead, but none on the right. The heart and lungs showed nothing abnormal. The level of the abdomen was that of the thorax. The cord was still on, but was healthy. The liver was palpable 3 cm. below the costal border in the nipple line ; the spleen was not palpable. The genitals were normal. The right arm hung limply by the side, extended at the elbow and wrist, and with the palm turned backward. He made no active motions with this arm except at the wrist and with the fingers. His grip was strong. Passive motions were not limited. The arm was not tender, and there were no evidences of fracture or dislocation. The left arm and the legs were normal and showed no signs of spasm or paralysis. The knee-jerks were equal and lively. There was no Kernig's sign. There was no enlargement of the peripheral lymph nodes. The rectal temperature was normal.

DISEASES OF THE NEW-BORN.

Diagnosis. The diagnosis of facial paralysis is evident. The inability to close the eye shows that the upper branch of the facial is involved and that the paralysis is, therefore, peripheral in origin. It was undoubtedly caused by the pressure of the forceps blade on the trunk of the nerve. The hemorrhage into the right conjunctiva is presumably also due to injury from the forceps blade.

The flaccidity of the right arm at once rules out cerebral paralysis, in which the paralysis is spastic. Moreover, in cerebral paralysis due to injury at birth, the paralysis is never limited to one extremity, and if an extremity is affected,

Fig.

Facial Type. Case 2.

Fig. 2. Arm Type. Case 2.

it is always affected as a whole, not in part. If the baby was older, infantile paralysis (poliomyelitis) might be considered, but, as the paralysis was present at birth, is an impossibility. It corresponds perfectly to the so-called " obstetric paralysis " of the upper- arm type, in which there is a paralysis of certain muscles from injury to the brachial plexus during labor. The stretching of the plexus caused by the pulling on the shoulder was presumably the cause in this instance. The characteristic position of the arm is due to the fact that only certain muscles are involved, namely, the deltoid, biceps, brachialis anticus, supinator longus, infraspinatus, supraspinatus and serratus magnus.

This baby, therefore, shows both the facial and arm types of Obstetric Paralysis.

Prognosis. The prognosis of the facial paralysis is almost absolutely good. Recovery almost invariably takes place in a few weeks.

The prognosis of the paralysis of the arm is not as good. There will certainly be a great deal of improvement, but equally certainly some permanent disability. How great this disability will be cannot be told for a year or two, after which time little improvement can be expected.

Treatment. The facial paralysis requires no treatment. The only treatment indicated for the arm at present is a sling to take the weight of the arm off the shoulder muscles. Massage and electricity may be begun in about three weeks. The object of them both is to keep up the tone of the muscles until the nerves regain their power. Faradism should be used, if the muscles react; if they do not, galvanism. If, at the end of a year, there has been but little improvement, operation on the nerve trunks is worthy of consideration.

CASE 3. Catherine E. was delivered at full-term by low forceps after a long labor, and weighed nine pounds. Her mother had been married twice. Her only pregnancy by her first husband had resulted in a miscarriage at two or three months, after an accident. She thought that he had not had syphilis and had had no symptoms of it herself. Her second husband denied having had syphilis. The patient was the first child by the second husband. She is said to have cried vigorously immediately after birth. The nurse noticed, a few hours later, however, that she did not breathe naturally. The trouble with the breathing continued. When quiet, she breathed quickly and her color was fair. If disturbed, or if she made any exertion, she usually became very cyanotic. Sometimes she at first became very pale and then cyanotic. She seldom cried. The respiration was never noisy. She usually kept her mouth shut and was able to suck. She had apparently never had any fever and had never had any disturbance of the digestion. She was seen in consultation when about five weeks old.

Physical Examination. She was fairly developed and nourished. When quiet, she breathed quickly but quietly. The alse nasi did not move, she kept her mouth shut and her color was good. There was, however, moderate retraction of the epigastrium and of the sides of the chest. When disturbed, the respiration became more rapid and labored, but not noisy. She kept her mouth open and was evidently distressed. She tried to cry but was unable to make much noise. She became very cyanotic, and the retraction of the epigastrium and sides of the chest was much increased. A probe was easily passed through both nostrils. There were no snuffles. The throat was normal both to inspection and palpation and no adenoids were felt with the finger. There was no increase of the thymus dullness, and the thymus could not be felt in the suprasternal notch. The cardiac impulse was indistinctly palpable in the fourth left space Si cm. to the left of the median line. The right border of dullness was 2 cm. to the right of the median line. The action was regular; the rate varied between 140 and 180 according to the difficulty in breathing. The sounds were normal in character and there were no murmurs. There was marked dullness and diminished broncho-vesicular (much nearer vesicular than bronchial) respiration, with an occasional medium moist rale in the left front down to the cardiac area and in the upper left axilla, and over the whole right back except at the apex. There was hyperresonance and exaggerated vesicular respiration over the rest of the lungs, and numerous fine moist rales were heard. The abdomen was normal. The liver was palpable 2 cm. below the costal border in the nipple line; the spleen was not palpable. The extremities were normal. There was no spasm or paralysis. The knee-jerks were equal and normal. There was no enlargement of the peripheral lymph nodes. There was no eruption and no scars of any old eruption. There were no mucous patches about the anus. The rectal temperature was normal.

Diagnosis. The problem is to find the cause of the difficulty in respiration and cyanosis. This cause is the diagnosis. The physical examination rules out obstruction in the nose, nasopharynx, pharynx and larynx, as well as pressure from an enlarged thymus. The heart shows nothing abnormal. Sometimes, however, the examination of the heart shows nothing abnormal in congenital heart disease even when there are marked symptoms. The signs in the lungs are so definite in this instance, however, that it is not necessary to take refuge in this explanation. The signs in the lungs show partial solidification. The possible explanations of this solidification are resolving pneumonia, syphilis of the lung and congenital atelectasis.

Resolving pneumonia is mentioned merely because this was the diagnosis of another consultant. It can at once be ruled out because there was never any fever and the symptoms appeared within a few hours after birth. Syphilitic involvement of the lung sufficient to give such marked physical signs is very unusual and is found only in the severest cases in which there are many other signs of the disease. The negative family history and the lack of any other signs of syphilis rule it out in this instance. The early appearance and the persistence of the symptoms without fever are most characteristic of atelectasis. The only point against it is that the baby is said to have cried vigorously at birth. This jnay have been an error of observation, but, if true, does not rule out atelectasis, because it is perfectly possible for a baby to cry loudly and yet not completely expand the lungs. The diagnosis is, therefore, Congenital Atelectasis. The fine moist rales heard over the rest of the lungs are undoubtedly due to edema.

Prognosis. The prognosis is very grave. There is very little chance of expansion of the atelectatic areas after five weeks, and the child cannot live long in its present condition.

Treatment. There is no direct treatment for the atelectasis. The best that can be done is to feed the baby carefully, give it plenty of fresh air, administer oxygen when there is cyanosis, and stimulate it, if necessary.

CASE 4. Harriott H., the first child of healthy parents, was born at full-term after a difficult forceps delivery, and weighed eight pounds. She breathed at once and seemed normal in every way except that her head was much swollen and out of shape. The general swelling went down in twenty-four hours and then a circumscribed swelling was noticed on the right side of the head. This had diminished a little in size and had apparently caused her no discomfort. She had seemed normal in every way except for the swelling on the head. She was seen in consultation when a week old.

Physical Examination. She was well developed and nourished and of good color. There was a swelling, the size of a duck's egg, over the right parietal bone. This swelling was soft and fluctuating, but neither red nor tender. Pressure on it caused no bulging of the anterior fontanelle and no discomfort or signs of increased cerebral pressure. It did not extend beyond the borders of the right parietal bone. The pupils were equal and reacted to light. There was no rigidity of the neck. The anterior fontanelle was level. The heart, lungs and abdomen were normal. The liver was palpable 2 cm. below the costal border in the nipple line; the spleen was not palpable. The extremities were normal; there was no spasm or paralysis; the knee-jerks were equal and normal; there was no Kernig's sign.

Diagnosis. This tumor corresponds in every way to a Cephalhematoma and undoubtedly is one. The caput succedaneum is hard, does not fluctuate and is not limited to a single bone. It disappears in from twenty-four to forty-eight hours. The swelling first noticed in this instance was undoubtedly a caput. A meningocele protrudes through one of the normal openings in the skull, a fontanelle or suture, and is most often situated at the root of the nose or in the occipital region. Pressure on it causes bulging of the anterior fontanelle, discomfort and symptoms of increased cerebral pressure, such as spasm or twitching of the extremities. An abscess is hot, red and tender, and is accompanied by fever and symptoms of general constitutional disturbance.

Prognosis. The prognosis is absolutely good if the tumor is let alone. It is sure to disappear in from three to six weeks.

DISEASES OF THE NEW-BORN.

If it is aspirated or opened it may become infected and an abscess result.

Treatment. The treatment is to let it alone. External applications cannot hasten the absorption of the blood. Aspiration will hasten the disappearance of the tumor, but is unnecessary and carries with it the danger of infection. An incision is unnecessary, will leave a scar and is very likely to result in infection and the formation of an abscess.

Fig. 3. Harriott H. Cash

CASE 5. John B. was the first child of healthy parents, except that his mother had always been anemic. There had been no miscarriages. His father denied syphilis and showed no signs of having had it. There had never been any " bleeders " in either family. He was delivered at 6 a.m., August 4, at full term, by low forceps, after a short labor, and weighed nine pounds. He was normal except for a slight abrasion on the right cheek and another on the back of the neck, and breathed at once. He was put to the breast that afternoon, took hold well, but got nothing. The next morning he was ordered one-half ounce of a mixture containing 1% of fat, 5% of sugar, 0.25% of whey proteids and 0.25% of casein every two hours, but as this was vomited it was stopped after three feedings. Since then he had had only boiled water. Oozing of blood began about midnight, August 5, from both abrasions, and a hematoma, the size of half a walnut, appeared at the site of each of them. The oozing continued and he lost about half an ounce of blood during the night. The bleeding was then controlled by pads soaked in a 1-10,000 solution of adrenalin chloride. Several small hemorrhagic areas appeared in the roof of the mouth and one, the size of a dime, on the back that morning, August 6. He had not vomited blood or had any blood in his movements. The highest rectal temperature was 99 F. He had been given 10 ccm. of fresh rabbit's serum at 3.30 p.m., August 6. He was seen in consultation at 5 p.m.

Physical Examination. He was well developed and nourished, but moderately pale. The respiration was a little rapid. He seemed uncomfortable and was inclined to moan. The fontanelle was level. There was no rigidity of the neck. There were slight ecchymoses in the right eyelids. There were several ecchymotic areas, varying in size from that of a split pea to that of a twenty-five cent piece, on the upper part of the right cheek. There was an abrasion, about 2 cm. long and 1 cm. wide, over the largest ecchymosis, where there was also some swelling. It was scabbed over and not oozing. There was an ecchymotic area, the size of a twenty-five cent piece, on the back of the left neck, where there was also a scab, but no oozing. There was an ecchymotic area, the size of a ten-cent piece, on the lower back, and half a dozen ecchymotic areas, the size of a pinhead or a little larger, in the roof of the mouth. The heart and lungs were normal. The abdomen was negative. There was no bleeding from the stump of the cord. The liver was palpable 3 cm. below the costal border in the nipple line; the spleen was not palpable. The extremities were normal ; there was no spasm or paralysis; the knee-jerks were equal and normal; Kernig's sign was absent. There was no enlargement of the peripheral lymph nodes. There was no bleeding from the point where the rabbit's serum was injected.

The movements which were seen were loose, dark-green and contained considerable mucus, but no blood.

Diagnosis. The diseases to be considered here are congenital syphilis, hemophilia and hemorrhagic disease of the newborn. Syphilis can be excluded on the negative family history, the absence of miscarriages, the good general condition, the absence of all signs of syphilis, such as enlargement of the liver and spleen and eruptions, and the fact that hemorrhage occurs only in the severest cases which show many other signs of the disease. Hemophilia can be excluded on the family history and the fact that the tendency to bleed in hemophilia almost never appears before the end of the first year. Larrabee, writing in 1906, was able to collect but thirty-six cases of hemorrhage in the newborn due to hemophilia, and in all but two of these there was a family history of the disease. The diagnosis is, therefore, Hemorrhagic Disease of the New-born.

Prognosis. The condition is, in general, a very serious one. Sixty per cent, or more, of the patients die, one half of them in the first twenty-four hours after the onset of the bleeding. If they survive a week they almost invariably recover. The symptoms cease in the first five days in two thirds of the cases that recover. The cases in which there is hemorrhage from the gastro-intestinal tract and in which there is a high temperature are more serious than those in which there is no gastro-intestinal hemorrhage and in which the temperature is low.

The following prognosis seems justified in this instance.

The baby has a very serious disease. It is impossible to say whether or not the hemorrhages will recur or others appear. The outlook is, however, fairly good because he has already lived seventeen hours, there has been no hemorrhage for several hours, the bleeding is all external where it can be reached, and the temperature is normal. Every day that he lives increases his chances materially. There is no reason to fear recurrence in after years because this is a self-limited condition and not the disease hemophilia.

Treatment. It is very difficult to know just how to treat the condition known as hemorrhagic disease of the newborn, because it is probably not a definite disease, but merely a combination of symptoms due to a variety of causes, the most common of which is presumably sepsis. The only definite point in the pathology is that the blood coagulates very slowly, or not at all. It is very probable, too, that the delay in the coagulation is due to the lack of something in the blood and not to the presence of some inhibitory substance.

Most of the methods employed in the past in the treatment of this disease have recently been proved to be useless. Ergot and iron cannot, of course, have any effect in increasing the coagulability of the blood. Adrenalin has practically no action unless given intravenously. Its action is then general and not local, and the increase of the blood pressure would tend to increase rather than to diminish the bleeding. Gelatine does not increase the coagulability of the blood either in vitro or in viro. There is no lack of calcium salts in the blood in these cases and, therefore, the administration of calcium salts can do no good.

A more rational treatment is the subcutaneous injection of fresh animal serum, preferably rabbit's, which contains all the ferments of the blood. Theoretically it would seem as if this could not do any good, because the blood contains antiferment enough to much more than neutralize the ferment contained in the ordinary doses of serum before it can be utilized in coagulation. Practically, it has seemed very useful in a considerable number of cases.

The most rational method of treatment is transfusion, which not only replaces the lost blood but stops the hemorrhage by supplying new material for the production of the fibrin ferment. It has proved most satisfactory in the few cases in which it has been used. Before performing transfusion, however, it is necessary to be sure that the donor's blood does not produce hemolysis. Transfusion is a serious operation for both parties, and should not be undertaken lightly but only as a last resort. It must not on this account, however, be delayed too long.

This baby has already had an injection of rabbit's serum. If the hemorrhage recurs, it should be repeated in six or eight hours and again at the same interval, if necessary. If the serum fails to restrain the hemorrhage in these doses, or if at any time the baby's condition is becoming at all critical, transfusion should be done. The preferable donor is the father.

Locally, the adrenalin solution should be continued in connection with pressure. If this fails to stop the bleeding, the strength of the solution may be increased to 1-1,000, or the dry powder used. If this is not effective, Monsel's salt and pressure may be tried.

The baby should be given one to two teaspoonfuls of a mixture of one part of breast milk to three parts of water, or whey, every hour.

CASE 6. Baby G. was born at full term after a normal labor. He seemed healthy at birth but was not carefully examined. He was taken care of by a woman ignorant of the ordinary rules of cleanliness. The cord came off on the seventh day. The navel was healthy and at no time, before or after, was there any redness or inflammation about it. He was breast-fed and did very well until he was five days old, when he began to vomit a little and act as if he had pain in the abdomen. The vomiting and pain continued and increased in severity. He also began to have two or three loose yellow movements, containing fine curds and having a foul odor, daily. When he was nine days old a swelling, which seemed tender, was noticed in the epigastrium. The swelling in the epigastrium increased and by the twelfth day the whole abdomen was distended. He had apparently begun to have fever on the eighth day, but the temperature had not been taken. He was seen in consultation when two weeks old.

Physical Examination. He had evidently lost much weight and his color was pasty. His face bore an expression of suffering. The fontanelle was depressed. There was no rigidity of the neck. The pupils were equal and reacted to light. The tongue was dry and covered with a brownish coat. The heart and lungs were normal. The upper border of the liver flatness in the nipple line was at the fourth rib; the lower border was not palpable. The spleen was not palpable. The navel was healthy and there was no redness about it. The abdomen was generally considerably distended, but distinctly more so in the epigastrium. It was everywhere tympanitic, except over an area, the size of a silver dollar, in the median line midway between the tip of the ensiform and the navel. There was a marked sense of resistance in and about this area, but no definite muscular spasm. Tenderness was general throughout the abdomen, but much more marked over the resistant area in the epigastrium. There was no dullness in the flanks and no fluid wave. The legs were drawn up on the abdomen and extension caused additional pain. It was impossible to determine the presence or absence of the knee-jerks or Kernig's sign

DISEASES OF THE NEW-BORN. 2J

because of the baby's resistance. There was no enlargement of the peripheral lymph nodes. The rectal temperature was 104 F., the pulse 160, the respiration 60.

Diagnosis. The trouble is undoubtedly located in the abdomen. The liver is displaced upward. The fact that the baby is breast-fed and the mildness of the symptoms of indigestion in comparison with the high temperature, poor general condition and marked, local symptoms show that the trouble is outside the gastro-intestinal tract. The situation of the local symptoms and the age of the baby make appendicitis very improbable. The two possibilities are an inflammatory process, probably a localized abscess in the epigastrium, or a general peritonitis. The localization of the physical signs in the epigastrium and the absence of general muscular spasm and free fluid in the abdomen are much against general peritonitis and in favor of a localized abscess. A white count was not made because it could not help in the diagnosis, since both conditions are associated with leucocytosis. An inflammatory process in the upper or middle abdomen at this age is almost invariably due to infection through the navel. The navel in this instance shows no signs of inflammation at present, and has shown none in the past. This does not rule out infection through the navel, however, as it is not uncommon for this to occur without causing any local manifestations. The known ignorance and the uncleanliness of the woman who took care of the baby make an infection through the navel seem even more likely. The most reasonable diagnosis is, therefore, a localized inflammatory process, probably an abscess, in the epigastrium, as the result of an infection through the navel, i. e., a Septic Infection of the New-born.