Chapter XIX. the various therapeutic measures em- (Part 3)

5 minims, and nitroglycerin, ^ gr., hypodermically, the doses being for a child of four years. In addition some form of counterirritation should be applied to the chest at the same time, in order to draw as much blood to the surface as possible. The best counter- irritant is dry cups or a mustard plaster. ATELECTASIS The absence of air from a portion of the lung due to collapse of the air vesicles. It may be congenital — due to deficient respiration. Children of low vitality, and especially premature babies, do not expand their lungs sufficiently, owing to feeble efforts at breathing. The air vesicles which are not fully 5 66 DISEASES OF CHILDREN FOR NURSES expanded by the inspired air collapse, preventing any air from gaining access to such areas. In order to overcome any tendency in this direction it is necessary to see that young children expand the whole of their lungs. The best way to accomplish this is to have the baby cry with vigor once or twice a day, and not allow it to remain perpetually in its crib. A certain amount of handling daily is necessary and overcomes the tendency toward shallow respiration. Atelectasis may be acquired by the occlusion of a bron- chus from some cause or other, or it may result from the pressure of a tumor or pleural effusion compressing portions of the lung. PLEURISY This is an inflammation of the serous membrane cover- ing the lungs. In children pleurisy may be dry or there may be an effusion. The effusion consists of a collection of fluid in the pleural cavity which is poured out by the inflamed serous membrane. It is composed of serous fluid and flakes of lymph. Such a collection of fluid is termed a serous effusion. This effusion may be purulent in charac- ter, when it is termed an empyema. Serous effusions are less common in children than in adults; under three years of age this form is not seen. Empyema, however, is much more frequent in childhood than in adult life. Pleurisy may involve one side of the chest, when it is termed unilateral pleurisy, or it may attack both sides of the chest, bilateral pleurisy. A sacculated pleurisy is the term applied to a liquid effusion in the pleural cavity which is circumscribed and DISEASES OF THE RESPIRATORY TRACT 67 confined to pockets formed by adhesions. In all pleurisies there is a deposit on the membrane of a butter-like exudate of fibrin; this may form adhesions {adhesive pleurisy). These adhesions subdivide the pleural cavity into small pockets or they may completely separate one portion of the cavity from another by extending across from the costal to the pulmonic surfaces. Fig. 23. — Diagram of pleural cavities: a. Ribs; i, costal pleura; c, pleural cavities; d, lungs ; e, diaphragm ; /, pulmonic pleura. Chronic pleurisy is an effusion of any nature remaining unabsorbed. Causes. — Pleurisy in infants is probably caused only by extension of the inflammation from the lungs. Through- out childhood the most frequent cause is pneumonia. In nearly every case of consolidation in the lung there will be an inflammation of the pleura over such an area. 68 DISEASES OF CHILD REX FOR NURSES Pleurisy is also seen in connection with tuberculosis. It is secondary to scarlet fever, typhoid fever, measles, and influenza, occasionally. In older children it may be due to rheumatism, and at times, though rarely, to cold and exposure. Pleurisy is most often seen between the ages of one and five. It is more common in boys than in girls. Pathology. — In the first stages of the attack the mem- brane becomes congested and is covered with a thin film of lymph. If the process now ceases, it is termed a dry pleurisy. This is the usual type in children under seven years of age. If the inflammation continues, an effusion will form, composed of straw-colored serum with flakes of lymph floating through it. The quantity may range from a few ounces to several pints, which in favorable cases is gradually absorbed. In large effusions the organs are displaced and the lungs compressed. Symptoms. — Dry pleurisy. — The principal symptoms are pain in the side, increased by inspiration, and a dry cough, partially suppressed on account of pain. The patient lies on the affected side to keep it as quiet as possible, and also to allow the other side to fully expand. There is some fever, ranging from 102 ° F. to 103 ° F. The symptoms continue until the inflammation subsides. Adhesions may form and cause some retraction of the affected side. Serous Pleurisy. — The symptoms resemble pleurisy in the adult. At first there is a typical picture of a dry pleurisy, with its accompanying symptoms. To this is added, on the third or fourth day, the signs of an effusion consisting of bulging of the interspaces of the chest, the relief from pain as the inflamed surfaces are separated by DISEASES OF THE RESPIRATORY TRACT 69 the accumulation of the fluid, and the appearance of cyanosis and dyspnea. The ordinary effusion is absorbed in a week or ten days, but at times it persists from delayed resolution for a much longer period. Treatment. — This is the same in dry and serous pleurisy. It consists in the application of counterirritants and hot poultices for the pain. Sometimes strapping the side with adhesive strips will give relief. Heart and respiratory stimulants, such as strychnin, atropin, digitalis, and nitroglycerin, should be given hypodermically in case of emergency. At times it is necessary to aspirate the collection of fluid. Nursings — The room should be kept at an even tempera- ture of 68° F. and be well ventilated. Bathing should be restricted to sponging. The clothing should be flannel and protection of the feet is necessary. The bed covers should never be tucked in too tightly. Sleep is often disturbed by pain, so that some counter- irritant may be required to give relief. Feeding should be at regular intervals. The patient may be allowed to sit up after the fever subsides, but in large effusions exertion must be avoided, as sudden death has taken place under such conditions. The temperature, pulse, and respirations should be taken every three hours as long as there is fever; later, twice a day is sufficient. As primary cases of pleurisy are often tubercular, extra care must be taken with this form of the disease. If the child's chest is tapped, a specimen of the fluid should be collected in a sterile test-tube with an aseptic cotton stopper. Empyema or purulent pleurisy is common in children. /l DISEASES OF CHILDREN FOR NURSES It is most often a sequal of pleuropneumonia. After seven years of age it sometimes occurs in connection with tuberculosis. It also is a complication of scarlet fever, measles, and any of the acute infectious diseases. 'Pathology. — In empyema the pleural cavity is filled with thick, non-offensive, greenish-yellow pus, amounting from a half pint to two pints. The left side is more commonly affected than the right, and at times it is bilateral. Symptoms. — Following one of the acute infectious diseases there is an effusion found in the pleural cavity which docs not show signs of absorbing. Before seven years of age any pleural effusion must be looked upon as the result of empyema, so rarely is serous pleurisy seen before that time. The child becomes pale and thin, the respirations become accelerated, there is fever, but often not of the hectic type, as is usually seen when pus is present. (A hectic temperature, is marked by a very irregular fever, alternating high and low, and is accompanied by sweats and chills.) The fluid gradually accumulates and dyspnea develops. If left to itself, the purulent effusion may kill by sepsis or it may perforate into the lung, the pus then being coughed up and expectorated. It sometimes perforates into the surrounding organs or tissues, causing a local abscess. Diagnosis. — If there is any doubt as to the character of the fluid in the pleural cavity, this may be cleared up by puncturing the cavity with an exploring needle; an ordinary hypodermic syringe is used for this purpose. At the point selected by the physician for puncturing, after the skin has been rendered aseptic by scrubbing with tincture of = -5 <« C O I .52 <U "O 1:1 c x> J I a £ Si o I o p « -5 H I ji 5 &3 ■£ « 3 la DISEASES OF THE RESPIRATORY TRACT J I green soap and alcohol, a sterile needle attached to the syringe is plunged through an interspace into the pleural cavity and the syringe is slowly filled. The character of the effusion will at once be apparent, pus showing as a creamy- white fluid. At times the needle, may not find pus, even when it is present. This may be on account of large flakes of lymph obstructing the needle or because the needle has penetrated too far and gone completely through the cavity. Care and repeated punctures will usually overcome this contingency. Treatment. — After it has been definitely decided that the case is one of empyema there are two procedures which the physician may follow. In the large number of cases he will have the child operated upon. In a fewer number of cases he will have the pleural cavity aspirated. Operation. — This consists in opening the pleural cavity, removing the pus, and draining. There are several methods employed. A simple incision or an incision and the removal of a portion of one or more ribs for better drainage are the methods usually followed. A rubber tube is inserted into the cavity to insure perfect drainage. Aspiration is accomplished by plunging a large needle or trocar and canula through the chest wall and having the instrument used attached by a tube to a vacuum pump. This method does not remove all of the pus nor the shreds of fibrinous material, and often has to be resorted to repeatedly, as proper drainage is not established. A)ter -treatment.- — This consists in methods employed to bring about the full expansion of the lungs. For this purpose two bottles connected by tubing are used. One bottle is filled with water, which may be colored if con- venient. The child is instructed to blow the water from J 2 DISEASES OF CHILDREN FOR XURSES one bottle into the other. This can be made a pastime, and it serves the purpose of expanding the lungs. Fig. 24. — Apparatus for aspiration (Kerley). Nursing. — The temperature of the room should be maintained at 68° F.; ventilation is necessary; bathing should be restricted to sponging. Sleep and feeding usually are undisturbed. The two precautions to be taken by the nurse in dressing a case of empyema which has been operated upon are: (1) To see that there is no danger of the tube slipping through the wound and being lost in the pleural cavity. This can be prevented by inserting a safety-pin through the end of the tube. (2) To see that the exit of the tube is covered with gauze. This covering acts as a valve DISEASES OF THE RESPIRATORY TRACT 7 3 which allows the pus to escape and prohibits air from entering. The presence of air in the pleural cavity prevents the full expansion of the lungs, which have been compressed by the fluid. The child should be allowed to move from side to side, but should be encouraged to lie on the side where the wound is situated, as long as there is any discharge. At the end of two weeks the child can sit up. A specimen of the pus from the wound should be obtained at the time of the operation and kept in a sterile test-tube with an aseptic cotton stopper. The temperature, pulse, and respirations should be taken every three hours if there is fever. The exercise of blowing water from one bottle to another should be carried out if the child is able to do it. If this fails, blowing soap bubbles is a good substitute. Hemorrhagic Pleurisy. — This is a bloody effusion into the pleural cavity. After seven years of age hemor- rhagic pleurisy is sometimes seen in connection with tuberculosis and severe anemias. It is also called hemo- thorax. Diaphragmatic Pleurisy is an inflammation of the pleura covering the diaphragm. In addition to the typical symptoms of pleurisy there is apt to be extreme dyspnea and hiccough. Pleurodynia is the name given to rheumatism of the intercostal muscles. The chief symptom is pain in the side upon deep inspiration. Prognosis of Pleurisy. — This depends largely on the character and amount of the fluid present. The aspirating needle is a great aid to the physician in settling this question. 74 DISEASES OF CHILDREN FOR NURSES In serous pleurisies the outcome is usually good. In adhesive pleurisy the outlook is favorable, but there may be some subsequent retraction and more or less impair- ment of the affected side. When the pleurisy is not a complication of an acute infectious disease and arises spontaneously in children over seven years of age it is usually tubercular in character. In empyema the prog- nosis is always grave, but recoveries often follow. Hydrothorax is an exudation into the pleural cavity of a clear, serous fluid. It is not due to an inflammatory condition of the pleura, but occurs in the course of a general dropsic condition of the body. Pneumothorax. — Air in the pleural cavity. Such a condition is caused by a rupture of the lung from any cause into the pleural cavity, allowing air to gain access from that source, or by a penetrating wound of the side, which forms an avenue of entrance for the external air. While the first condition may be one of pneumothorax, inflammation sets in very early and there is an exudation of serum; the condition then becomes pneumohydrothorax.