Chapter XIX. the various therapeutic measures em- (Part 2)

ment (see page 379), the moist atmosphere soothing the inflamed mucous membrane and thus shortening the attack ; it also diminishes the chances of recurrence. The steam may be medicated with compound tincture of benzoin, which increases the efficiency of this plan of treat- ment. 54 DISEASES OF CHILDREN FOR NURSES LARYNGISMUS STRIDULUS Laryngismus stridulus, also called child crowing, is purely of nervous origin (a neurosis), and does not depend upon a catarrhal condition of the larynx, like spasmodic croup. It is due to a complete spasmodic closure of the larynx, making it impossible, for a time, for the child to breathe at all. The spasm then relaxes and the air is drawn through the contracted larynx with a shrill, crowing sound. It is seen in children of a rachitic tendency between the ages of six and eighteen months and seems to be more common in males than females. The attacks are frequently seen in children who have been closely confined in warm, stuffy rooms, and are often associated with enlarged tonsils and adenoids. The attack may be excited by a sudden draught of cold air, or, reflexly, from teething and gastro-intestinal disorders. Symptoms. — The child may have a few mild attacks during the day or extending over a period of several days. This condition is very often confounded with whooping- cough, the "crowing" of the mild attacks closely simu- lating the whoop of pertussis. When the attack is fully developed the child is awakened from sleep by a sudden arrest of the breathing and a tonic spasm of the muscles. (Tonic spasms are continuous spasms in which the patient remains rigid until the spasm relaxes.) The face is at first pale and later bluish, the neck rigid, the eyes rolled up, the body arched, the thumbs turned into the palms of the hands, the legs extended, and there is a complete absence of breathing. In about fifteen or twenty seconds the spasm relaxes and the air is drawn through the larynx with a shrill, crowing sound. At times the spasm is longer, and in a few instances asphyxia DISEASES OF THE RESPIRATORY TRACT 55 has resulted before it has relaxed. Several such attacks may occur on the same night, and, gradually decreasing in severity, they may extend over a period of one to two weeks unless proper medicinal measures are instituted. To distinguish this affection from spasmodic croup remember that in laryngismus stridulus there is no croupy cough, hoarseness, or fever, but there is present a tonic spasm and the peculiar crowing sound. Treatment and Prophylaxis. — Fresh air and cold sponging unless the shock of the sponging frightens the child into an attack; the rachitis should be treated; hyper- trophied tonsils and adenoids should be removed, and gastro-intestinal disorders corrected. For the attack the best treatment is to dash cold water on the face and neck, in an attempt to break the spasm. Mustard tubs (no° F.) may be resorted to, and inhalations of chloroform in severe cases. At times it is necessary to perform intubation. EDEMA OF THE GLOTTIS This is a rare condition in childhood. It is dropsical in character, due to a serous infiltration into the submucous tissues of the larynx. It occurs sometimes in the course of scarlet fever, diphtheria, and facial erysipelas. It may occur abruptly in the course of Fright's disease. Symptoms are those of suffocation due to the swelling of the tissues lining the larynx and to the consequent closing of the passage. It demands the immediate atten- tion of a skilled physician, intubation being necessary in many cases. 56 DISEASES OF CHILDREN FOR NURSES BRONCHITIS This is an inflammation of the mucous membrane lining the bronchial tubes. The three main divisions are acute bronchitis, chronic bronchitis, and fibrinous bronchitis. Acute bronchitis presents such a difference in the grade of severity with which it attacks children that it is necessary further to subdivide it for comprehensive study. In children under two years of age bronchitis is always serious, hence we divide it into bronchitis of the very young, two years and under, and bronchitis of children over two years of age. The reason that bronchitis is such a severe affection in the very young is on account of its tendency to extend into the smaller bronchi and verge upon pneumonia. The smaller the caliber of the tube affected, the more severe the attack of bronchitis. Therefore, it is also subdivided into bronchitis of the large tubes, bronchitis of the medium-sized tubes, and capillary bronchitis, or, as it is usually termed, bronchopneumonia. Symptoms in the mild form, or bronchitis of the larger tubes in a child under two years of age. Here the respi- rations will average about forty or fifty to the minute. The temperature ranges from ioo° F. to 102 ° F. There is cough, hard and tight in character at first, but rapidly becoming loose. While the cough may be loose in char- acter there is no expectoration. Children rarely expec- torate before four years of age; previously the mucus is swallowed; sometimes this causes vomiting. There is some dyspnea and often a co-existing catarrhal condition of the nose and throat. An attack of bronchitis lasts about a week. In children DISEASES OF THE RESPIRATORY TRACT 57 subject to colds, who develop a bronchitis during the winter months, the attacks are liable to recur until warm weather. In the severe form, or bronchitis of the medium-sized tubes in a child under two years of age, the symptoms can hardly be distinguished from pneumonia. The onset, however, is not so abrupt, and the temperature does not Fig. 20. — Diagram of bronchial terminations: a, Smaller bronchus ; b, terminal bron- chus ; c, alveolar duct ; d, constriction, or neck ; e, space of inf undibulum outlined by dotted lines ; /. infundibula ; g , ciliated columnar cells lining small bronchus ; h, nonciliated columnar cells lining alveolar ducts ; *, fiat epithelium lining alveoli (Leroy). remain high so long. The attacks last three or four days and are accompanied by constitutional symptoms, such as prostration, apathy, and loss in weight. In this form of bronchitis there is always danger of an extension of the inflammation to the capillary tubes. Capillary bronchitis is bronchopneumonia, and will be considered under that title. 58 DISEASES OF CHILD REX FOR NURSES In children over two years of age bronchitis is not so severe an affection, although here we find the same con- ditions existing as in younger children; namely, a mild form due to an inflammation of the larger tubes and a severe form due to an inflammation of the smaller tubes. Symptoms oj acute bronchitis in children over two years of age consist in chilliness, malaise, some fever, cough, and dyspnea. The cough is worse at night; at first it is dry and painful, but later becomes loose and is accompanied by free expectoration of mucopurulent sputum. Children often complain of soreness and pain in the chest during an attack of bronchitis, which is aggravated by coughing. Treatment. — Abortive. — A case of incipient bronchitis can be aborted by hot foot-baths, the application to the chest of a turpentine stupe or a mustard plaster to relieve the congestion of the bronchial mucous membrane, and the internal administration of hot drinks, quinin, and Dover's powder, from | to i gr. of quinin and 2\ gr. of Dover's powder being the proper dose for a child of four years. When Dover's powder is administered the child should remain indoors for the subsequent twenty-four hours to avoid taking fresh cold. A laxative is always a safe adjunct to this plan of treatment. In younger children mustard paste applied to the chest for ten minutes and covered with a towel will often abort a forming cold. Treatment during the course of the attack is aided by having the child live in a moist atmosphere. This can be accomplished by steam generated by a special apparatus or by the heating of a pan of water over a small gas stove in the room. Compound tincture of benzoin added to the water increases the efficiency of this method of treat- ment. An oiled-silk or cotton-batting jacket, as an DISEASES OF THE RESPIRATORY TRACT 59 adjunct to the treatment of bronchitis in children, is at times employed. In severe cases of bronchitis children sometimes have an attack of suffocation and respiratory failure. The indications here are to remove any obstructing mucus, to compel the child to take deep respirations, and to get as much blood to the surface and into the extremities as possible, in order to relieve the overloaded right heart. Inverting the child will often cause the mucus to run from the mouth, and a mustard tub (no° F.) will accomplish the rest. Some writers (Jacobi) advise continued flagel- lation or spanking. This forces the child to cry, causing deep inspiration, the expulsion of the mucus, and con- gestion of the surface, relieving at once the respiratory failure and the cardiac congestion. The flagellation may be continued for several hours. Oxygen and heart stimulants must be given in these emergencies. In the milder forms of bronchitis the children should be confined to the house, but not necessarily to bed. In the more severe attacks it is better to put the child to bed, and in the very severe cases it should be placed in a' croup tent. Nursing. — The sleeping-room of the infant must not be too cold, never below 60 ° F. It should be well venti- lated, receiving a thorough airing two or three times a day. An open fire is a good adjunct. The child should receive frequent tub-baths at a tem- perature of nc° F. The clothing should be warm, the night-dress of flannel, and the feet should be protected against cold. The bed covers should never be tucked in too tightly. The mouth and nose should be kept clean with anti- 60 DISEASES OE CHILDREN FOR NURSES septic sprays and douches, all mucus should be cleared from the throat, and the chest thoroughly rubbed with camphorated oil or a similar counterirritant. At times the chest may be enveloped in a cotton or oiled-silk jacket. The child should be allowed to sleep as much as it will, but should be awakened for its food and medicine at regular intervals. It is always best, when possible, to com- bine these two periods, to avoid unnecessary disturbance. Infants can be held in the arms and older children can be about the room, unless fever is present. The temperature, pulse, and respirations should be taken twice a day, unless the temperature is over ioi° F., when it should be taken every three hours. Chronic bronchitis is caused by repeated attacks of acute bronchitis following one another so closely that the mucous membrane does not become entirely normal between attacks, each one leaving something behind. This causes the mucous membrane to become thickened by an overgrowth of connective tissue, as in all chronic inflammations. Symptoms. — A chronic cough which is worse at night and expectoration which is most profuse upon arising in the morning are the main symptoms. The children are pale and thin, but do not become emaciated. Fibrinous bronchitis is a rare disease in childhood. It is sometimes seen associated with diphtheria, when it is due to an extension of the membrane into the bronchi. At other times it is unassociated with that disease and is due to an inflammation of the bronchial mucous membrane and characterized by the formation of a false membrane. This membrane is dislodged by coughing and expectorated as little whitish balls, which, when unrolled under water, DISEASES OF THE RESPIRATORY TRACT 6 1 Fig. 21. — Large bronchial coagulum; chronic fibrinous bronchitis (Vierordt). present the mold of the branching and ramification of the bronchial tubes affected. Acute and chronic forms are recognized. Fig. 22. — Bronchiectasis: a, saccular ; b, rylindric ; one-half natural size (Orth). BRONCHIECTASIS Bronchiectasis is a dilatation of a bronchial tube. The whole tube may be involved or only a small portion may 62 DISEASES OF CHILDREN FOR NURSES be affected. It is caused by a weakening of the walls of the bronchi from inflammation. While in this weakened condition cough causes the stretching and dilatation. It may produce a cylindric or a sacculated enlargement of the tube. ASTHMA Asthma is a paroxysmal dyspnea, due to a spasm of the bronchial tubes or to a swelling of the mucous mem- brane lining them. In children it is associated with marked catarrhal symptoms. In young children true asthmatic attacks are not often seen, the condition resembles a severe bronchitis with an asthmatic tendency; that is, there are catarrhal symptoms present, with difficult, wheezing expiration. Such an illness may persist for three or four weeks. Attacks resembling asthma in adults do occur in child- hood, usually in older children. Symptoms.- — In those subject to asthma the attack may be excited by a cold draught, the inhalation of dust, and by an overloaded stomach. The paroxysms appear suddenly and especially at night. There is such intense dyspnea that the patients have to sit upright with their arms in such a position as to bring into play all the muscles used in respiration. The respirations are not necessarily fast, but they are labored, and there is a loud, noisy, wheezing expiration. Cough is often present. Several attacks may occur in the course of a few days or they may be a month or more apart. Treatment. — During the attack prompt relief often follows the inhalation of a few drops of chloroform or amyl nitrite. Asthmatic attacks occurring in the course of cardiac DISEASES OF THE RESPIRATORY TRACT 63 or renal disease are named cardiac asthma and renal asthma, respectively. Hay Asthma or Hay Fever. — In this condition, besides the asthmatic attacks, there is a coryza and a catarrhal condition of the nose and throat. Hay fever is seen in the Spring and in the Fall. When it begins in May or June it is spoken of as rose cold. This lasts until the end of July. The time when hay fever is most prevalent is in the Fall. It makes its appearance in August and continues until the first frost. A peculiarity about hay asthma is that it is excited by the pollen of plants. PULMONARY EMPHYSEMA Abnormal distention of the lungs with air may result from two causes. The first to be considered is known as compensatory emphysema. Compensatory emphysema is not a diseased condition of the lung affected; it is an extra expansion of the air-cells to accommodate more air. There is a certain amount of work to be done by the lungs at all times. Although a number of air-cells may be disabled from some cause, such as consolidation from pneumonia or pressure from a pleural effusion, the amount of work does not diminish; therefore, it is necessary for the healthy air-cells to distend and perform not only their own task, but also that which should be done by the diseased area. Consequently, these cells have a greater capacity for air than they did when all the lung structures were performing their normal functions. If the disablement persist, the compensatory enlargement is permanent. Pathologic Emphysema. — The other cause is purely a pathologic condition in which we have a permanent 64 DISEASES OF CHILDREN FOR NURSES distention of the air vesicles from stretching and thinning of their walls. Causes. — These include cough, asthma, whooping- cough, laryngismus stridulus, and bronchitis. In such conditions there is some resistance to the free exit of air from the lungs and it requires a certain amount of extra effort on the part of the lungs to force the air out. This extra exertion falls upon the walls of the air vesicles and the strain causes them to stretch. Any condition where the walls of the air vesicles have to stand the strain of forcing the air out of the trachea is likely to cause emphysema. Pertussis is the greatest cause of emphysema in childhood; the condition usually disappears, however, with the paroxysms of cough. Symptoms. — There is great shortness of breath on account of the damage to the walls of the air vesicles. The distention and the loss of resiliency makes the effort to empty the lungs of inspired air very difficult, renders expansion impossible, and the chest immobile. The typical barrel-shaped chest seen in adults is not common in childhood. Compensatory emphysema does not produce symptoms. Emphysema occurs in young children on account of their undeveloped condition and because the lung tissues are not strong enough to withstand sudden and violent strains. HEMOPTYSIS Hemoptysis is the name applied to the spitting of blood. The blood is ejected by coughing, is bright red in color, and frothy; it is mixed with sputum, and the subsequent expectorations are tinged with blood. DISEASES OF THE RESPIRATORY TRACT 65 PULMONARY EDEMA Edema of the lungs is an effusion of serous fluid into the air vesicles and into the interstitial tissue of the lung. Pulmonary edema is a common cause of death in many- acute and chronic diseases which end by heart failure and the accumulation of blood in the lungs. At the termina- tion of a disease which ends by heart failure the heart -beats gradually become weaker and weaker, the blood-current becomes slower and slower, and as the pressure within the arteries becomes less from the failing force of the heart, there is a leaking of the blood-serum through the walls of the blood-vessels into the air-cells which they surround, or into the tissue of the lung itself. This gradually continues until the accumulation of fluid practically fills the entire lungs, and death results. Treatment. — If this condition should arise in the course of an acute illness such as pneumonia, heart stimu- lants should be given immediately, especially strychnin, •^Q-gr., digitalis, 3 to