Diseases of children presented in two hundred case histories of actual patients selected to illustrate the diagnosis, prognosis and treatment of the diseases of infancy and childhood, with an introductory section on the normal development and physical examination of infants and children

Front matter

Class.

Book._

fopyiightN^,

Preface To The First Edition

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 utiHzation 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 cHnical 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.

Preface To The Second Edition

The number of case histories has been doubled in this edition in order to cover the subject of Pediatrics more fully. An introductory section on the Normal Development and Physical Examination of Infants and Children has been added, because it was beheved that the readers would be able to study and analyze the cases better, if they were familiar with the normal development and methods of examination. Several reviewers of the first edition found fault because the diagnosis was not given at the head of each case, not realizing, apparently, that it was omitted in order that the reader might study it out for himself. The main object of the book is to present a series of problems to be solved by the reader. This object would be defeated, if the diagnosis was given in the beginning. Several reviewers have complained that there was

6 PREFACE

nothing to show whether or not the diagnoses and prognoses were correct. It never occurred to the writer that any one would suppose that they were not. Consequently, nothing was said about it. As a matter of fact, the diagnoses are correct in every instance in which a positive diagnosis is made. In a few, in which a probable diagnosis only is made, the children are still ahve. The prognoses are all absolutely correct, except in a few chronic cases in which, the children being still ahve, it is impossible to give exact data as to the duration of Hfe. The treatment recommended in the text was that actually employed.

Preface To The Third Edition

In this edition the book has been thoroughly revised and such methods of diagnosis and treatment as have proved themselves worthy of adoption in the interim since the last edition suggested or advised. On this account the statement made in the second edition that "the treatment recommended in the text was that actually employed" is now not strictly true. The section on the diseases of the gastro-enteric tract has been rewritten and a number of new cases substituted for old in the other sections. The general plan of the book remains the same.

Table Of Contents

Pagb

The Normal Development and Physical Examination of Infants AND Children 11-62

Diseases of the New-born.

Section I

THE NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION OF INFANTS AND CHILDREN,

A CAREFUL and complete physical examination is of even greater value in diagnosis in early life than in adult life, because the baby and young child can tell little or nothing as to their subjective symptoms. In fact, except in the diseases of the gastroenteric tract, the diagnosis must be made almost entirely on the findings of the physical examination. It is, moreover, easy to misinterpret these findings, unless the normal development at different ages is known, because what is normal at one age is abnormal at another. Unless due attention is paid to these differences, mistakes are almost certain to arise. While the methods of examination employed are the same at all ages, tne relative value of these methods varies with the age of the patient, and due allowance must be made for these differences. These methods also have to be modified in many ways before they are applicable to infants and young children. The attempt has been made in the following pages to give the chief points in relation to the normal regional anatomy and development of children and to describe the proper methods of examination.

Growth in Height and Weight. The rate of growth is very rapid in the beginning, especially in the first year. It is still rapid, but less so, up to six years. It is then comparatively slow until the prepubertal acceleration, which begins in girls at about eleven years and in boys at about thirteen years, and lasts several years.

The rate of growth in height and weight are not synchronous during childhood, but show marked seasonal differences. Growth in height is most rapid during the spring and the first half of the summer and is often associated with an actual

Xi

CASE HISTORIES IN PEDIATRICS.

loss of weight. It is least rapid during the latter part of the summer and autumn. Growth in weight is most rapid during the late summer and autumn and least rapid during the late spring and early summer. In fact, there is often a loss of weight during this period which is equal to, or greater than, the gain during the winter and early spring.

Growth during First Five Years. .The average weight of American babies at birth is between seven and seven and one-half pounds, the boys averaging a little heavier than the girls. The average length of American babies at birth is about twenty and one-half inches, the average length of the boys being somewhat greater than that of the girls. There are numerous statistics as to the rate of growth during the first two years, but very few as to that during the next three years. The average growth in length during the first year is eight inches, and during the second year four inches. In general, the birth weight is doubled at five months and nearly trebled at a year. The most reliable figures as to the rate of growth of American children during the third and fourth years are those of Holt (Diseases of Infancy and Childhood, 1 91 6, p. 20) which are based on observations on about 800 children. They are given in the following table.

TABLE I. — GROWTH IN HEIGHT AND WEIGHT DURING FIRST

FOUR YEARS.

Age.

Birth .

1 year.

[Height.

Boys.

Girls.

82.8 80.1

Weight.

Boys.

Poimds.

Kg.

3-43

9-54

12.27

14-55 16.36

Girls.

The heights and weights in this table are net; i.e., without shoes or clothes.

Growth from Five to Fifteen Years. There are several large series of observations as to the growth of American children after the first five years. Boas (Science, 1895, N. S., Vol. I, p. 402) has calculated a table of heights from all the available American material, comprising 45,151 boys and 43,298 girls, while Burk (American Journal of Psychology, 1897-8, Vol. 9, pp. 262-3) has calculated one of weights from about 68,000 children. Their results are combined in the following table.

TABLE II. — GROWTH IN HEIGHT AND WEIGHT FROM 5 TO

Age at last birthday.

Height.

Boys.

Inches. Cm.

159-7 164.8

Girls.

Inches.

121 126

156.4

157-9

Weight.

Boys.

295 32.1

Girls.

Pounds , 39-6

28, 31 35 40, 44. 48. 51

The heights in this table are without shoes.

The weights are with indoor clothes. These make up for boys approximately 8%, and for girls 7%, of the gross weight.

The term, " age at last birthday," is liable to give a wrong impression, because the figures given are really average figures taken from all the children from that birthday to the next. A more accurate term is the succeeding half-year, i.e., sh years instead of 5 years, the age at the last birthday.

Relative Growth of Extremities and Trunk. It is well known that at birth the legs make up a much smaller proportion of the total length of the body than they do in the adult. There are, however, very few observations as to the relation between the length of the legs and that of the body at different ages. Grover's (Archives of Pediatrics. 191 5. XXXII, 473) figures show that the distance from the lowest point of the anterior superior spine of the ilium to the sole of the foot is approximately 42.5% of the total length at birth, 45-5% at one year, 48% at two years, 53.5% at five years, 56% at ten years and 57% at twelve years. His figures also^show that the length of the arm, measured from high in the axilla to the tip of the middle finger, is approxi-

CASE HISTORIES IN PEDIATRICS.

mately 34.5% of the total length at birth, 35% at one year, 36% at two years, 37.5% at five years, 38.5% at ten years and 40% at twelve years.

Head. The head is relatively large at birth, its circumference being greater than that of the chest. It increases in size very rapidly during the first year. The rate of growth then becomes progressively slower and is very slow after five years. Excepting in rare instances, such as marked hydrocephalus, the absolute size of the head is of less importance in determining whether the head is of normal size or not than the relation between that of the head and chest. The chest grows faster than the head and surpasses it in size sometime during the third year. The following table, copied from Holt (Diseases of Infancy and Childhood, 1906, p. 20), shows the relations between the head and chest at different ages.

TABLE III. — CIRCUIVIFERENCE OF HEAD AND CHEST.

Age.

Birth

6 months .

1 year. . .

5 years. . 10 years . . 15 years. .

iiead.

Boys.

Inches.

Cm.

Girls.

Inches.

195 20.2 20.7 21. 5

Cm.

Chest.

Boys.

25.8

Cm.

34 42

45 48

52.8

54-8

65.6

76.6

Girls.

53-5 63.0 76.8

The circumference of the head is the occipi to-frontal.

The circumference of the chest is at the level of the nipples, midway between inspiration and expiration.

Babies are usually able to hold up the head alone, if the back is supported, when they are eight or ten weeks old.

Shape of Head. Deformities resulting from compression during labor are often present at birth, but disappear within the first two to four weeks. The head is then rounded and symmetrical. Flattening of the back or side of the head from constant lying in one position is common and is easily overcome by changing the position. Marked asymmetry of the head may be present at birth. It usually disappears during the first five or six years. The most common abnormalities in the shape of the head are caused by rickets and hydrocephalus. Those due to rickets are the result of overgrowth at the centres of ossification in the frontal and parietal bones. These overgrowths form prominences on the forehead and sides of the head which are often called ^* bosses." When they are large and are associated, as they usually are, with flattening of the top of the head, the so-called *' square head" of rickets results. The hydrocephalic head, on the other hand, is rounded and enlarged symmetrically, while the whole forehead overhangs.

Fontanelles. The posterior fontanelle is between one-quarter and three-eighths of an inch (i cm.) in diameter at birth. This fontanelle closes at six weeks.

The anterior fontanelle is smaller at birth than a few days later, when the head has come into shape. It is then approximately one inch (2.5 cm.) in length and seven-eighths of an inch (2.2 cm.) in width. It apparently increases somewhat in size with the growth of the head during the first six to nine months. There is some doubt, however, as to whether there really is an absolute increase in size. It then gradually diminishes in size and closes at about eighteen months. Early closure may be due to a small brain or may be an individual peculiarity. Delay in closure is usually due to rickets, but may be the result of hydrocephalus or merely an individual or family peculiarity. The level of the anterior fontanelle is that of the surrounding bones or a little below it. Bulging of the fontanelle means an increase in the intracranial pressure. When chronic this is usually due to chronic internal hydrocephalus; when acute, to meningitis. Depression of the fontanelle means a decrease in the intracranial pressure. This is usually due to a diminution in the amount of fluid in the brain as the result of general loss of fluid in diarrhea or malnutrition.

Sutiires. Separation of the cranial bones after birth is abnormal, except that the frontal suture may be open in its upper part for a few days or weeks. Mobility usually persists for six months and sometimes for nine months, at which time bony union is usually fairly firm. Overlapping of the bones at the sutures is very common in early infancy as the result of malnutrition.

Softening of the bones of the skull, craniotabes, is usually due to rickets but sometimes to syphilis. It usually appears first along the sutures, about the anterior fontanelle and in the occipital bone. The parietal bones are often involved; the frontal and temporal, relatively rarely. The best method of determining craniotabes is by placing the heels of the hands on the forehead and then pressing on the head with the tips of the fingers. Imperfect ossification of the bones of the skull at birth is a manifestation of delayed or imperfect development and is not due to rickets or syphilis.

Superficial Veins of Scalp. The superficial veins of the scalp are usually visible if the hair is not too thick. They are always enlarged in chronic internal hydrocephalus and frequently so in disturbances of nutrition, especially rickets. Enlargement of the veins of the scalp without evident cause should always suggest the possibility of syphilis.

Macewen's Symptom, Macewen's symptom is the change in the cranial percussion note as the result of certain gross changes in the intracranial contents. It is best elicited by listening, with the bell of the stethoscope placed on the middle of the forehead or over the occipital protuberance, while the skull is lightly percussed with the finger tip. The resonance is increased and somewhat tympanitic in character when there is an accumulation of fluid in the lateral ventricles and there is sometimes dullness over a tumor, if it is situated near the surface.

Hair. The first hair is sooner or later replaced by a new growth. It sometimes begins to come out in the first few weeks and sometimes is retained for several months. The new hair may come in quickly or slowly, so that some babies always have a considerable amount of hair, while others are bald for a long time. Loss of hair on the back of the head is sometimes due to rickets but is more often merely the result of too soft a pillow, of turning the head from side to side in order to see, or of lying too much in one position. Coarse hair should always suggest an insufiiciency of the thyroid gland.

Face. The face is relatively small and the cranium relatively large at birth, the relation at that time being about I to 8, while at five years it is i to 4 and in the adult i to 2. If the part of the head below the orbital arches is designated as the face and that above them as the cranium, the relation of the face to the cranium at birth is approximately i to i, and in the adult approximately 2 to i. The shortness of the face is due principally to the rudimentary condition of the jaws and teeth. The face is relatively much broader in relation to its length at birth than in the adult, the relation of the breadth to the length at birth being as 10 to 4 and in the adult as 9 to 8.

Nose. The nose is relatively small in infancy and early childhood and the bridge rudimentary and relatively wide. It is especially wide in cretinism and Mongolian idiocy. A depression at the root of the nose in infancy is never due to syphilis, but may be in later childhood.

A nasal discharge is not uncommon in infancy and childhood. This is, in the vast majority of instances, due to a simple rhinitis and not to diphtheritic rhinitis or syphilis. A thin, irritating discharge, especially if tinged with blood, suggests diphtheritic rhinitis, while a muco-purulent or purulent discharge, especially if bloody, suggests syphilis.

Smell. It is probable that the sense of smell is present in a rudimentary condition in the newly-born. It develops slowly, however, and the ability to detect fine differences in odors is not acquired until late in childhood.

Motion of the alae nasi in respiration points toward some disease of the respiratory tract, which is not necessarily pneumonia, as is often supposed. It is often present in infancy, however, when there is no trouble in the respiratory tract and is, therefore, of relatively little importance.

Lips. Fissures and rhagades are usually manifestations of syphilis, but may be due to malnutrition and infection from any cause.

Mouth. The examination of the mouth and throat is best left until the last, because infants and young children are often much disturbed by it. If it is done first they are very likely to become frightened and resist further examination.

The mouth is normally kept closed. An open mouth is usually due to obstruction in the nose or nasopharynx. The most common cause of this obstruction is adenoids. It must be remembered, however, that babies and young children are very likely to open their mouths, if they are interested. Idiots are also very likely to keep their mouths open.

A rounded swelling is often visible on each side of the mouth between the jaws during infancy. These swellings are the so-called ''sucking pads," which are collections of fat, enclosed in a capsule, lying outside the buccinator muscles. They become much smaller after infancy, but are often visible throughout childhood.

The roof of the mouth is, as a rule, flatter in infancy than in childhood, the arching becoming more marked as the alveolar ridges develop. The normal variations in the arch of the hard palate are, however, very great. An excessive degree of arching is in most instances the result of interference with the nasal respiration, this interference usually being due to adenoids. It is sometimes, however, a stigma of degeneration. The soft palate is more horizontal in infancy than later, while the uvula is very small.

One or more small white or yellowish-white nodules are often visible in the median line of the hard palate at or near its junction with the soft palate during the early weeks or months of life. These are accumulations of epithelial cells and are known as Epstein's Pearls. A small protuberance is often visible on each side of the soft palate. These are the tips of the hamular processes of the sphenoid bone. The mucous membrane over these processes is very thin, and, as the result of mechanical injury, erosions and ulcerations often occur in these areas. These lesions constitute the condition known as Bednar's Aphtha, and are not manifestations of syphilis or tuberculosis, as is often supposed. Similar lesions also frequently occur over and about Epstein's pearls.

The mouth is relatively dry during early infancy, because but little Saliva is secreted during the first three or four months. The secretion then increases rapidly in amount. A considerable proportion runs out of the mouth at first, however, because the baby does not know enough to swallow

NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. I9

it. When he learns how, drooling ceases. There is no etiological connection between drooling and dentition. They merely appear coincidently.

Koplik's spots J which are pathognomonic of measles, are situated on the buccal mucous membrane. They are rose-red spots, the size of the head of a pin, or somewhat larger, with a pearly white spot, the size of the point or shaft of a pin, in the centre.

Tongue. The tongue is lightly coated, especially posteriorly, during the early months. This coating is due to the fact that, owing to the deficiency of the salivary secretion, the desquamating epithelium is not washed away as it is later.

Enlargement of the tongue in infancy may be a congenital malformation, but is more often a manifestation of cretinism. The tongue is also enlarged in Mongolian idiocy in childhood, but not in infancy.

Ulceration of the under surface of the tongue at or near the frenum is not very uncommon as the result of the irritation of the lower incisor teeth or infection (Riga*s or F6de's Disease). It does not necessarily indicate whooping-cough as is sometimes taught.

Taste. The sense of taste is well developed at birth.

Teeth. Infants are sometimes born with teeth. The first tooth usually appears at six or seven months. The teeth usually erupt in groups with considerable regularity. There are so many normal variations, however, that it is difficult to lay down any hard and fast rules. In a general way the first, or temporary teeth, erupt as follows:

2 middle lower incisors, 6-8 mos.

4 upper incisors, 8-10 mos.

2 lateral lower incisors,

4 anterior molars,

4 canines, 18-20 mos.

4 posterior molars, 24-30 mos.

Delay or irregularity in cutting the teeth may be due to rickets or may be merely an individual or inherited peculiarity.

It IS not Wise to attribute delay in dentition to rickets, unless there are other signs of the disease present. Disturbances of nutrition, other than rickets, seldom delay dentition. They often result, however, in an imperfect development of the enamel and a tendency to early decay. Syphilis never produces any characteristic changes in the first teeth, its action being the same as that of other disturbances of nutrition. The first of the second, or permanent, teeth are the so-called "six-year old" molars, which appear at this time behind the posterior molars of the first dentition. The permanent teeth then begin to replace the temporary teeth, the bicuspids taking the place of the temporary molars, after which the permanent molars erupt posteriorly. The permanent teeth erupt in a general way as follows, the lower teeth usually preceding the upper:

4 first molars, 6 years

4 middle incisors, 7 years

4 lateral incisors, 8 years

4 first bicuspids, 9 years

4 second bicuspids, lo years

4 canines, 12-13 years

4 second molars, I2-I5vyears

4 third molars, 17-25 years

The permanent teeth often show, in the same way as the temporary, an imperfect development of the enamel and a tendency to early decay, if the nutrition has been disturbed during early childhood. They also show the typical lesions of syphilis, the so-called ''Hutchinson teeth."

Projection of the upper teeth, like crowding together of the upper teeth, is usually the result of imperfect nasal breathing, ordinarily due to adenoids, and not of thumb-sucking as was formerly supposed.

Throat. It is impossible to obtain a satisfactory view of the throat unless the child is held properly. It must, in the first place, be held so that the light shines into its throat, that is, facing a window or a light. It should be held in the

Method of holding infant for examination of the throat.

Method of holding child for examination of the throat.

NOR^IAL DEVELOPMENT AND PHYSICAL EXAMINATION. 21

upright position; otherwise it is impossible to properly extend the head. The person that holds the child should look after the body and extremities. The examiner then holds the head with his left hand and takes the spoon or depressor in his right. If the examiner wishes to use both hands, as in taking a culture, the head also can be held by the person holding the child, or, if it is too strong to be held in this way, by a third person.

If the child refuses to open its mouth it can usually be made to do so by working the spoon or depressor in gradually from the side, by pushing it in when it cries, or by pinching the nose.

The throat cannot be properly examined unless the child is made to gag. This can be done by placing the spoon or depressor on the back of the tongue and pressing downward and forward. It is useless to press on the front or middle of the tongue. This merely pushes the back of the tongue upward and obscures the view of the throat.

Inspection of the throat is not sufficient, if there are any symptoms of obstruction to either respiration or deglutition. In such instances a digital examination of the throat should always be made, as it is perfectly possible to miss a retropharyngeal abscess if reliance is placed on inspection alone. A gag should never be used when the presence of a retropharyngeal abscess is suspected, because sudden death sometimes results if the jaws are widely separated in this condition.

The tonsils are relatively larger throughout childhood than in adult life and normally increase in size at the time of the eruption of the molars.

The epiglottis is visible in infancy and early childhood when the tongue is depressed and the patient made to

Esophagus. The distance from the gums to the cardia in the new-born is seventeen cm. (6f inches) ; from the incisor teeth to the cardia at three years, twenty-three to twenty-four cm. (9-9! inches); and at six years, twentyseven cm. (lof inches). After swallowing a gurgling sound is normally heard at the left of the spinous processes as far down as the eighth dorsal spine. In childhood the squirting sound of liquids passing through the cardia into the stomach is heard in the epigastrium about five seconds after swallowing.

Nasopharynx. The nasopharynx is very low at birth, but relatively long from before backward. It increases rapidly in height during the first six months, but very slowly during the rest of infancy. It changes gradually toward the adult type, but is relatively low during the whole of childhood. Adenoid tissue is present in the nasopharynx at birth and may even then be sufficient to cause obstruction.

It is impossible to examine the nasopharynx with the mirror until the child is old enough to assist. This is usually not before it is eight years old. Prior to this time the examination must be made with the finger. This is somewhat difficult in infancy because of the small size of the parts, but can almost always be done if the examining finger is not too large. Care must be taken not to use force and thus tear the soft palate. The best way to examine is to stand behind the patient, holding the mouth open with the left forefinger or a gag, according to the age of the child, and introducing the right forefinger into the mouth. When held in this position the child is unable to get away.

The maxillary antrum is present at birth and the ethmoidal cells develop at about three years. The frontal sinuses are not developed until seven years.

Ear. No physical examination is complete in infancy and early childhood, unless some satisfactory explanation of the symptoms has been found elsewhere, without an examination of the middle ear. Disease of the middle ear cannot be ruled out, as is so often done, because there is no discharge. The absence of pain, of putting the hand to the ear and of tenderness over the mastoid, do not at this age by any means exclude the presence of disease of the middle ear. In fact, these symptoms are more often absent than present. The ear must be examined with the speculum. In this way only can the condition of the middle ear be determined. A smaller speculum than comes with most sets is needed to examine a young infant's ears.

Method of examination for Adenoids.

Showing mouth-breathing and funnel chest as a result of Adenoids.

In infancy the external auditory canal runs downward and inward. The ear must, therefore, be pulled downward and a little forward to straighten the canal instead of upward and backward, as in older children and adults. It must also be remembered that the drum is more horizontal at this age than later.

Hearing. Infants hear little or nothing during the first few days of life, probably because of the swelling of the mucous membrane of the tympanum and the absence of air in the middle ear. The hearing rapidly improves, however, and in a short time becomes very acute.

The mastoid antrum is present at birth, but the mastoid cells are usually not developed. They are, however, fairly well developed at three years.

Eyes. The eye is anatomically developed at birth. Vision is, however, probably very feeble. A strong light evidently causes discomfort during the first few weeks. The baby does not usually fix its eyes until it is at least six weeks old and coordination is not well developed until three months or later, at which time it seems to recognize objects. It is, therefore, of little use to attempt to test the accommodation in young infants. The pupils react to light almost immediately after birth, and this test can, therefore, be used at once. It is best performed by bringing a light from above the head downward in front of the eyes.

The function of the lachrymal glands is not developed at birth. Tears are shed, as a rule, at about three months.

Neck. The neck is relatively short during Infancy, because of the large size of the head and its tendency to fall forward, the high position of the sternum and the large amount of fat tissue. The neck Is also short and thick in cretinism.