Diseases of children

Front matter

Class i

Book tsA i /)

Copyright)) .

Preface To The Fourth Edition

In the preparation of this edition the author has attempted to keep thoroughly abreast of the recent advancement in pediatrics without unduly enlarging the book.

Additions have been made to almost all of the chapters, and the author feels that everything has been included which has proved to be important.

Several articles have been rewritten. New photographs have been added. The recent progress in infant feeding has been marked, and the latest accepted methods have been incorporated, including the preparation of the foods and mixtures.

Articles on acidosis; the mechanical disorders and irregularities of the heart; dehydration; stools; idiocy; encephalitis lethargica; pellagra, etc., have been added.

He wishes to thank the publishers for their many acts of kindness, the Children's Hospital for the new photographs, and the many friends the book has made for their favorable reviews and their timely advice.

He hopes the fourth edition will receive the approval granted the previous ones.

Robert S. McCombs.

124 S. 1 8th Street,

Philadelphia, Pa.

Preface

The need for a book on children's diseases for nurses was called to the author's attention while giving a course of lectures to the nurses at The Children's Hospital of Philadelphia.

It was his original intention to have only the notes of the lectures printed, so that some form of condensed material might be at hand for purposes of study. This volume has grown from the original notes. Incorporated in it are the methods employed at the Children's Hospital. A short description of each disease found in infancy and childhood has been given. It is hoped that the descriptions are clear enough to enable a nurse to know what symptoms to expect and what complications to guard against. The author believes that enough anatomy and pathology have been included to give a clear understanding of the structure of the body and the changes which take place during disease. Treatment has been included where a thorough knowledge of its underlying reason is necessary for intelligent application. Treatment for emergencies will be found under the different diseases and in the chapter on Therapeutics. Prophylaxis, infant feeding, and the methods of nursing employed in childhood are dwelt upon.

8 PREFACE

The author is most deeply indebted to Miss Jennie A. Manly for practically all the points on nursing, together with the receipts for infant feeding used in this book.

The original photographs for this volume were taken at the Children's Hospital.

In compiling the notes, the author has had frequent recourse to most of the text-books on children's diseases. For many definitions throughout the book, and the description of the diseases of the kidney, he has consulted Stevens' Manual of Medicine. In the chapters on Gastro-intestinal Diseases and Infant Feeding, Holt's Infancy and Childhood was often consulted.

Robert S. McCombs.

Chapter I Peculiarities Of Children's Diseases

A child's life is divided into definite periods, namely, the "newborn," " infancy," " childhood," and "youth."

The Newborn. — It is customary to designates babe as "newborn" until all traces of its prenatal or intra-uterine existence have disappeared. This is usually accomplished by the end of the first month,

Infancy follows the newborn period and continues until the eruption of the first or milk teeth is completed; it is, therefore, limited to the first three years of life.

Childhood extends from the third to the seventh year, at which time the permanent teeth make their appearance.

Youth includes the years from seven to puberty.

Weight. — The normal infant should weigh about seven and a half pounds at birth. During the first week there is a slight loss, but from that time on the increase should be steady.

The curve during the first year is represented in the chart and shows approximately the proper weight for the different ages of the infant.

ii

INFANT'S WEIGHT CHART.

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Fig. 2. — The above chart was designed by Miss Rena C. Fox, Head Nurse, Children's Department of Philadelphia Hospital. It is very useful in cases where it is desirable to keep account of a child's weight over a short period of time. In the larger charts a month's time would appear as a very small line. The heavy lines may represent any pound desired ; the figures being given according to first weight of child during period it is to be used. Each subdivision equals two ounces.

Average Weight.

Girls. Boys.

Birth 7.16 pounds 7.55 pounds.

12 " 20.05 " 21.00 "

18 " 23.00 " 24.00 "

6 " 43.08 " 45.01

7 " 48.00 " 49.05

8 " 52.09 " 54.05 "

10 " 64.01 " 66.06 "

11 " 70.03 " 72.04 "

13 " • 91.02 " 88.03

14 " 100.03 " 99.03 "

15 " 108.04 " 110.08 "

Between the ages of twelve and fourteen years girls gain weight faster than boys.

Height. — The average height is about twenty and a half inches at birth. The growth during the first year is about eight inches.

The growth of the extremities is much more rapid than that of the trunk. The head measures in circumference about thirteen and a half inches. The posterior fontanels should close at the end of the second month and the anterior about the eighteenth month.

The special senses of sight, hearing, smell, and touch are developed at birth.

A normal infant is able to hold up its head during the second month and sit up about the sixth month. It begins to recognize objects during the fifth month. From the eighth to the sixteenth month it should learn to walk. The age at which an infant begins to talk varies greatly. In the majority of cases by the end of the first year it is able to form certain words, and from this time on the development of the function of speech is rapid. At times perfectly healthy children have made little progress in their ability to talk by the end of the second year. Teeth. — Average table of eruption of the milk teeth:

Centrals 5 to 8 months.

Laterals 7 to 10

First molar 14 to 20

Cuspid 14 to 25 "

Second molar 24 to 36

At three years all of the milk teeth should be in place. The lower teeth usually erupt first. The milk teeth demand the same attention as the permanent teeth.

Average table of eruption of the permanent teeth:

First molar. 5 to 7 years.

Centrals 6 to 8 "

Laterals 7 to 8 "

First bicuspid 9 to 10

Second bicuspid. 10 to 12

Cuspid 12 to 13

Second molar. 12 to 14

Third molar. . , 16 to 35, to 40 years.

In strumous or rickety children the eruption is frequently delayed and the teeth are often brittle and furrowed. The enamel may be of poor quality, so that they easily decay.

Hutchinson's teeth are seen in hereditary syphilis. The second or permanent upper central incisors have a single shallow crescentic notch in the center of the edge. In

Fig. 3. — Normal dentition (Friihwald and Westcott).

Fig. 4. — Hutchinson's teeth in hereditary syphilis: a, The two upper central incisors (second dentition) exhibit deep transverse and longitudinal furrows and a concave notch in the edge. Although the teeth are normal in length, the width is less than normal, thus producing a broad interspace between the central incisors; b, the upper central incisors (second dentition), immediately after eruption, and the four lower incisors. The lower surface of the upper incisors is rough from the presence of projecting points of dentine. The upper teeth are short and diverge, leaving a broad interval between them. The four lower incisors present a number of small excrescences like nails from imperfect enamel formation. The base of the excrescences is everywhere in the same plane (after Hutchinson).

PECULIARITIES OF CHILDREN'S DISEASES l?

addition the teeth are small and pegged. They are sometimes called " screw-driver " teeth.

Laminated and pitted teeth are seen at times after the acute infectious diseases of childhood, such as measles,

Fig. 5. — Rachitic teeth. Boy nine and a half years old. The teeth are poorly developed, considerably eroded and grooved. Their position is very irregular; the lower incisors occupy a frontal position (not in the arch of the jaw) and the inferior maxilla makes an angular turn at the canine teeth (Hecker, Trumpp, and Abt).

scarlet fever, and diphtheria. When these diseases occur at an early age the formation of the enamel may be affected. This causes such defects as irregular pits upon the crowns of the teeth, particularly the incisors. The pitting is so marked in some cases that it gives a general honeycombed appearance to the crowns. To ascertain if irregularities are due to the eruptive fevers it is necessary to know the age of the rhild at the period of the disease. Pits upon the incisors caused by the eruptive fevers between the ages of four and five occupy about the central area of the crown face. The enamel about the cutting edge of the teeth has already formed at this age, so that alterations of nutrition would not affect it. The crowns of all the teeth in process of formation at this age are affected in a similar manner.

Diseases Peculiar to Children.— Children need different environments, different management, different medical and surgical care, and different nursing from that required for adults. One-third of a physician's patients are children.

Diseases of infancy and of early childhood differ in many respects from those of adult life, but after the seventh year children resemble adults in their ailments more than they do infants.

The following diseases are seen chiefly in infancy and childhood: congenital anomalies of the heart, such as "blue babies," due to a patulous foramen ovale; congenital atelectasis or failure of a part of a lung to expand; ophthalmia neonatorum or a gonorrheal conjunctivitis in the newborn; traumatic hemorrhages and birth paralysis due to injuries during birth; umbilical hernia; noma or gangrenous stomatitis; cholera infantum; laryngismus stridulus; enuresis; chorea; tubercular meningitis; hydrocephalus; infantile cerebral and spinal paralysis; coxalgia; scarlet fever; measles; rubella; varicella; pertussis; mumps, and diphtheria.

Etiology, — Heredity, accidents at birth, infection through the umbilical cord, improper food, and bad hygienic surroundings are the principal causes of disease or of a delicate constitution in the newborn and during infancy.

Inheritance is a very strong factor in infancy. Such diseases as syphilis and tuberculosis can be directly trans-

PECULIARITIES OE CHILDREN'S DISEASES 1 9

mitted from the mother to the child. Syphilis very frequently is congenital. While a child is rarely born with tuberculosis, the undermined constitution and the feeble resisting power of an infant born of tubercular parents make it very likely that the disease will develop early in life, at times so soon after birth as to be practically congenital. This is especially so if they breathe the same atmosphere as, or are nursed by, tubercular mothers. Children of parents suffering with rheumatism, gout, Bright 's disease, or alcoholism are apt to have poor resisting powers and yield easily to infection.

Improper food and bad hygiene are the greatest causative factors of disease in infancy. To these are due not only such diseases as rickets, scurvy, and marasmus, but also the great class of gastro-intestinal disorders.

Diseases of the Newborn. — The newborn babe faces a series of accidents and infections at birth which may end its career before it is fairly begun.

Asphyxia may result during birth. This may be caused by pressure upon the brain or umbilical cord, the winding of the cord about the neck, early separation of the placenta (the after-birth), and various maternal causes, such as prolongation of labor, convulsions, hemorrhages, and death of the mother. After birth has been accomplished and the child has cried vigorously there usually is no danger, unless there has been some injury or some intra-uterine disease of the organs of respiration, circulation, or the brain. Premature infants may die soon after delivery due to the feeble development of the respiratory mechanism. (For Method of Resuscitation, see page 480.)

Congenital atelectasis is a failure of the lungs to expand after birth. It is most often seen in babies that have had symptoms of asphyxia at birth, or who are poorly developed. The principal symptoms are cyanosis and prostration. These attacks may come on suddenly. They may be mistaken for "blue babies." (See page 174.)

It is necessary to have the babe cry vigorously several times a day to fully expand its lungs. It is desirable to stimulate crying if it does not show a tendency in this direction. If sudden cyanosis should occur, the same treatment as is used in asphyxia should be instituted.

Icterus^ Jaundice. — About one-third of all infants develop jaundice within the first few days after birth. It increases in severity for one or two days and then gradually disappears.

In cases where it becomes persistently worse and shows no signs of abating, there is probably a congenital obstruction of the bile-ducts or an inflammation of the liver (hepatitis), usually due to syphilis.

The acute pyogenic diseases of the newborn are due to infection through the umbilical cord; more rarely, through the mouth or any wound of the skin.

After the micro-organism enters the system it may cause a local cellulitis or abscess; it may attack the various serous membranes, giving rise to meningitis, peritonitis, pericarditis, and joint involvements; or it may cause pneumonia, gastro-enteritis, and inflammation of the bones (osteomyelitis).

Erysipelas, tetanus, epidemic hemoglobinuria, fatty degeneration of the newborn, and pemphigus neonatorum are diseases which are due to a like method of infection.

Ophthalmia neonatorum (see page 254) must be considered a pyogenic infection of the newborn, the conjunctiva being the seat of the local infection.

Prophylaxis. — As the infection takes place after the child is born, the responsibility rests with the physician and nurse — with the physician at the time of cutting the cord, and more frequently with the nurse in the process of dressing the cord, bathing, or cleansing the mouth or eyes, possibly after having cared for a septic mother or another child.

Infection may take place either before or after the separation of the cord.

The dressings of the cord should be dry and sterile. If suppuration occurs at the time the cord separates, a wet bichlorid dressing should be applied.

Ligatures, instruments, and everything which comes in contact with the umbilical wound should be sterilized. Careful attention should be given to the mouth, genitals, and all surfaces which are liable to charing or excoriation. A nurse in charge of a septic mother should not have the care of the infant. In an institution every septic case should be isolated. This includes all of the above-mentioned diseases.

Hemorrhages. — These are frequent during the first days of life. They may be due to injuries at birth or they may be spontaneous. They are primarily due to the fact that the blood-vessels are extremely delicate and that there are great changes transpiring in the blood and the circulation at this period. The most frequently seen hemorrhage is that which occurs beneath the scalp (cephalhematoma) , which causes a swelling on the vertex of the head. This increases in size gradually for a week or ten days and then slowly disappears.

Hemorrhages may also occur in the various viscera, from the umbilicus, stomach, intestines, mouth, nose, conjunctiva, female genitals, bladder, and subcutaneously.

Cerebral hemorrhages are due to pressure upon the child's skull during delivery, which causes a rupture of an artery, with the formation of a clot on the surface of the brain. The pressure of this clot causes paralysis of the parts controlled by the damaged portion of the brain. From this source we may have the various forms of paralysis seen.

Facial paralysis is due to an injury of the facial nerve. It is usually caused by pressure of the forceps along the course of the nerve, and not to a hemorrhage in the brain.

Erb's paralysis is due to an injury about the shoulderjoint. The affected arm is paralyzed. (See page 233.)

Intestinal obstruction may be due to an absence of the anal opening of the rectum (atresia of the anus) or to a strangulated hernia.

Every child should be examined carefully immediately after birth to see if the rectum is patulous. If the bowels move, all doubt, of course, is removed. As they should open several times during the first twenty-four hours, any failure to do so should arouse suspicion and a thorough examination by the physician should be made.

Umbilical hernia and swelling of the breast {mastitis) should be protected by pads. On no account should squeezing of the breast be permitted.

Congenital stridor is characterized by noisy inspirations which have been likened to a crowing sound. It may last for six or eight months, when the growth of the larynx causes it to steadily diminish until it entirely disappears, usually by the end of the second year. In spite of the apparent difficulty in breathing the child seems comfortable.

The chief danger is from some intercurrent disease like pneumonia. It may cause pigeon breast, which may persist.

Sclerema is a rare condition characterized by hardening of the skin and subcutaneous tissues, together with symptoms of malnutrition.

In the treatment of these cases the physician will keep the child in an incubator.

Inanition fever is described on page 27.

The Most Frequent Diseases of Infancy and Childhood. — Diseases of the gastro-intestinal tract and bronchopneumonia are seen more often than any other diseases before the second year. The other common conditions met with during this period are affections of the lymph-glands, tubercular meningitis, pertussis, and measles.

After the second year the following diseases are most frequently seen: Disorders of nutrition, such as rickets and scurvy; bone and joint diseases, these being usually tubercular and more rarely syphilitic; diseases of the blood; organic diseases of the heart; pneumonia, typhoid fever, the acute contagious diseases, such as measles, mumps, pertussis, varicella, scarlet fever, and diphtheria.

COMPARISON OF CHILDREN'S DISEASES WITH ADULT

CONDITIONS

The respiratory tract during infancy is undeveloped. The air-cells in the lungs are not so far advanced in their structure, nor so important in the function of respiration, as are the bronchial tubes. This causes an ordinary inflammation of the bronchial tubes, or bronchitis, to be a much more serious condition in infancy than in the adult. When the smallest tubes are involved it is called capillary bronchitis or bronchopneumonia.

Pneumonia is very common in infancy and childhood. Before two years of age it is usually of the type of a bronchopneumonia. Next to gastro-intestinal disease this form of pneumonia causes more deaths than any other condition during childhood. After two years of age the pneumonia is usually croupous in type, and, in contradistinction to bronchopneumonia, is very rarely fatal. In this respect it differs from pneumonia in the adult, in whom the mortality ranges from 20 per cent, to 50 per cent. The frequency of empyema as a complication of pneumonia and the frequency of bronchopneumonia as a complication of the acute infectious fevers are peculiarities of children's diseases.

Gastro-intestinal disorders in childhood are the most fatal of all diseases. This is in direct contrast to adult life. The reason lies in the delicate digestive power of infants. Toxins or poisons are formed in the intestines from their inability to digest and assimilate properly the food given. This poison is absorbed and produces grave results. During infancy the stomach and intestines are more intimately associated than later in childhood. Hence one is rarely affected without involving the other. This causes an increase in the severity of the symptoms, with consequent deleterious results to the child. Throughout childhood gastro-intestinal conditions are characterized by the severity of the symptoms.

The circulatory tract, except for the congenital malformations of the heart such as valvular disease and "blue babies," is usually unaffected during infancy. After two years of age heart diseases are common. A murmur should always be looked for in cases of chorea, rheumatism, and the acute contagious diseases. A peculiarity of childhood is the development of endocarditis following mild attacks of rheumatism. Aneurysms and arteriosclerosis are uncommon.

Anemia is often present in children.

The Genito-urinary Tract. — The kidneys are rarely affected in childhood except as a sequel of scarlet fever. As this is a very common complication of scarlet fever, all those suffering from the disease should be kept under close observation.

Enuresis is common in childhood.

The various malformations of this tract are common in childhood, especially phimosis.

Diseases of the Nervous System. — Hemorrhages are usually on the surface of the brain, and not within its substance. They usually occur at birth. Birth paralysis results. The portion of the cortex at which such hemorrhages occur fails to develop, and the injury is permanent.

Such conditions as chorea (St. Vitus' dance), laryngismus stridulus, nodding spasms, tetany, infantile paralysis, and tubercular meningitis are typically children's diseases.

One of the peculiarities of children is to have convulsions from trivial causes, without any lesion of the brain being present.

Diseases of the Eyes, Ears, Skin, and Glandular System. — Ophthalmia in the newborn is very often seen in the poorer classes and causes about 30 per cent, of all adult blindness. Conjunctivitis is often seen, especially associated with measles and catarrhal conditions of the nose and throat. Strabismus is not uncommon.

Otitis media and mastoid disease are more frequent in childhood than in the adult. Running ears, following the contagious diseases, especially measles, is a common complication. Eczema is often observed in artificially fed children.

Tubercular adenitis is seen more often in childhood than in the adult.

The Acute Infectious Fevers. — Most of the diseases seen in adults attack children. Malaria is common. Hereditary syphilis is observed in childhood, the majority

dying before they reach maturity.

Typhoid fever is quite a common disease in children living in large cities. It differs from typhoid fever in the adult in that its onset is usually more sudden, manifesting itself as often in the appearance of fever, vomiting, and prostration as in the usual slow, insidious beginning. In the course of the disease constipation is more frequent than diarrhea, tympanites is not so marked, the eruption is less constant, the nervous symptoms are not as apt to be found as in adults, hemorrhage and perforation are also met with less often, and the mortality is lower.

Tuberculosis is common in childhood. In infants under two years of age the lung is the part affected; beginning with the second year tubercular meningitis is more often found; and after the third year tuberculosis of the bones, the lymph-glands, peritoneum, and intestines becomes more frequent and are seen throughout childhood. Pott's disease and coxalgia are rarely seen except in childhood.

The contagious diseases are typically children's diseases. While they may attack unprotected adults, they are comparatively rare after fifteen years of age.

Constitutional and Nutritional Diseases. — Rheumatism is rarely of the acute articular type in children. It is often exhibited only by stiffness and slight aching pains in the limbs ("growing pains"). The frequency of endocarditis as a complication of rheumatism, even when no more severe symptoms than growing pains are present, makes it necessary that such cases should be put to bed and receive proper treatment.

Diabetes mellitus is uncommon in childhood, but when it does occur the course is very rapid and fatal.

Scurvy is seen in artificially fed infants.

Rickets and marasmus are typical nutritional diseases seen only in childhood.

Orthopedics. — Many children have deformities due to rickets, spinal curvatures, congenital dislocation of the hips, and contractions of the tendons. These deformities are overcome by surgical treatment.

Various terms are given to the different deformities:

Clubbed hands ; webbed fingers ; congenital dislocation of the hips; knock-knees or genu valgum; bow-legs or genu varum; bowing of tibia; club-feet or talipes varus; and talipes valgus; Polydactyly or six fingers.

Symptomatology. — In children the onset of disease is usually more sudden, the temperature higher, the pulse and respirations more accelerated, the physical signs more pronounced, the course shorter, and the recovery more rapid than in an adult.

All temperatures in children are higher than in adult life. Frequently a temperature of 104 F. to 105° F. is seen in cases of ordinary pharyngitis and mild tonsillitis. Fever in children apparently results from the slightest cause. This is better understood if one realize that the nervous mechanism of a child is more sensitive than that of an adult. Consequently a fever in a child does not indicate as much as in an adult and need not cause anxiety unless prolonged. It is the continuous high temperature which indicates serious illness. On the other hand, the temperature is easily depressed, owing to the great vascularity of the skin, by exposure, by sleep, and by inactivity.

Inanition fever is a term applied to a peculiar elevation of temperature occurring in the newborn. It is generally seen during the first five days of life, and is apparently due to the fact that the infant gets very little, often nothing at all, from the breast. The temperature may rise to 1 02 ° or 104 F., and is associated with rapid loss of weight. As soon as milk is secreted in abundance, or when the child is placed upon a full breast, artificial food, or even water, if given freely, the temperature falls to normal. It is important that such a fever should be recognized, because it gives at times the first warning of a condition which may prove fatal. The temperature of every child should be taken during the first week.

The normal pulse in infancy and childhood is of lower tension than in an adult and varies in frequency according to the age. The first few weeks after birth it beats from 120 to 150 times per minute. In the second year the pulse falls to no; in the third or fourth year to 100; in the seventh to 90; and in the twelfth to 80. Slight causes may produce wide variations of the normal pulse due to the unstable nervous mechanism of a child.

The respirations during the same period likewise vary- In the newborn they are from 30 to 60 per minute; in the first year 28 to 30; at five years 22 to 25; at fourteen years 20; and in adult life 18. The peculiar variations of the respiration seen in childhood are due to the same nervous origin which influences the temperature and pulse.

The function of digestion in infancy is delicate and undeveloped. Infants are able to digest about 4 per cent, of fat, 6 per cent, of sugar, and 2 per cent, of proteid during the first year.

Infants cannot tell their symptoms, so it is necessary to study them to find out their ailments. The principal means a child has of explaining its wants, discomforts, or pains is by crying. A child cries from pain, hunger, discomfort, or habit.

The cry of hunger is usually fretful, is accompanied by the sucking of its fingers, and ceases when satisfied.

The cry of indigestion simulates the cry of hunger, but does not cease when the child is fed.

The cry of pain is usually sharp and is accompanied by contractions of the features, drawing up of the legs, and signs of distress. If the child fall asleep from exhaustion it soon awakens, usually with a scream. It is well to remember that a severe pain in infancy may be due either to colic or earache. The child simply moans when the pain is less severe.

The cry of weakness is a feeble whine.

The cry of temper is prolonged, violent, and is attended with stiffness of the body and the throwing about of the arms and legs.

The cry of habit ceases when the child is satisfied and may be caused by a desire for any familiar object, such as a doll, nipple,. or rattle.

There are also characteristic cries heard in certain diseases such as hydrocephalus, meningitis, marasmus, hereditary syphilis, and pneumonia.

In hydrocephalus and meningitis a child will scream out shrilly in the night. This is called the hydrocephalic cry and is also sometimes heard in chronic bone diseases, due to pain.

In marasmus there is the feeble whine; in hereditary syphilis a nasal cry; in pneumonia the cry is short, catching, and suppressed.

Feeding and Therapeutics. — The entire subject of feeding in infancy and childhood is one of the most important branches of pediatrics.

The therapeutic measures employed differ in many respects from adult treatment.

Prognosis. — The younger the child, the worse the prognosis. This is because of the feeble resisting power and lack of development. On the other hand, many conditions can be outgrown, as the structures and organs increase in size and strength develops.

Most deaths in the first year are due to marasmus, affections of the gastro-intestinal tract and to bronchopneumonia. Practically the only deaths due to nervous origin are from meningitis and convulsions. Of the acute contagious diseases, usually measles and pertussis are the only offenders. Of the chronic diseases, tuberculosis stands alone.

Sudden deaths occur from the following causes: malformations; internal hemorrhage; asphyxia from overlying; asphyxia from the aspiration of food into the larynx and trachea; asphyxia from enlarged thymus gland; atelectasis; convulsions; and marasmus.