CHAPTER XVI
CONSTITUTIONAL AND NUTRITIONAL DISEASES
Constitutional Diseases
rheumatism
Rheumatism, as a whole, has varied manifestations in childhood. It may be articular, muscular, and neural. Rheumatic affections of the serous membranes, of the mucous membranes, and of the skin are found. The disease is uncommon under five years of age.
The two most prominent types of rheumatism are articular rheumatism and muscular rheumatism.
Acute articular rheumatism or inflammatory rheu- matism is an acute general disease characterized by irregular fever, inflammation of joints, and a marked tendency to affect the heart. In children the acute course with marked inflammation of the joints is uncommon.
The cause of the disease is unknown. Some writers attribute acute articular rheumatism to bacterial infection, the germ being undiscovered. The more generally accepted theory is that it is due to the accumulation of uric acid in the system. Poor hygienic surroundings, damp houses, and a sudden chilling of the body are the factors concerned in the onset of the disease.
Symptoms. — In children under ten years of age the disease begins slowly. There is fever, ioo° F. to ioi° F., and stiffness in several joints. Marked inflammation with swelling and pain of the joints involved is uncommon.
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The ankles, knees, wrists, elbows, and small joints of the feet are the ones most often affected. The stiffness may move from joint to joint or one alone may be involved. At times the joints are so stiff that they make the child lame; more often these pains are designated as "grow- ing pains." Sweats are uncommon. The muscles arc painful and there may be rigidity in more severe cases. The duration is from a few days to several weeks. One attack seems to predispose to others and anemia may result.
After ten years of age the symptoms closely resemble rheumatism in the adult.
Complications. — Endocarditis is the most common complication and may occur in very mild cases. About 40 per cent, of all cases of rheumatism have this com- plication. Pleurisy, pericarditis, pneumonia, chorea, iritis, meningitis, and certain cutaneous phenomena, such as pur- pura and urticaria, are also seen.
Pharyngitis, tonsillitis, laryngitis, and bronchitis are sometimes caused by rheumatism.
Muscular rheumatism is an affection of the voluntary muscles characterized by pain, tenderness, and rigidity.
Types. — Different names have been applied, according to the location.
Torticollis or wry -neck, when it involves the sterno- mastoid muscle.
Lumbago when it involves the lumbar muscles.
Pleurodynia when it involves the intercostals.
Cephalodynia when it involves the occipitofrontalis.
Exposure to the cold and wet, combined with muscular strain, usually excites it.
Symptoms. — Pain is the chief symptom, aggravated by
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the use of the muscles, and is associated with tenderness. Sometimes the muscles are rigid and contracted, such a condition being frequently seen in torticollis.
Torticollis. — The head is fixed and inclined to one side, every effort to turn it being accompanied with severe pain. The recovery is spontaneous in a few days.
Treatment. — Ironing the neck gives great relief. A small iron, not too hot, is the best implement to use. A piece of flannel should be laid upon the skin for protection.
Lumbago. — There is a dull, aching pain across the loins which is aggravated by turning the body or attempting to rise from a sitting posture.
Pleurodynia. — The pain is felt in the side and is increased by deep breathing, coughing, or twisting of the body. The respirations are restricted on the affected side and there is tenderness to the touch. The absence of fever will serve to distinguish it from pleurisy.
Cephalodynia is characterized by superficial head pains which are increased by movements of the scalp and are associated with tenderness on pressure.
Rheumatism frequently appears to be the cause of neuritis.
Treatment. — The salicylates and the alkalies are the remedies used in rheumatism.
Nursing. — The room should be kept warm and at an even temperature. On account of the danger of endo- carditis the child should be kept in bed as long as there is fever. "Growing pains" should never be allowed to explain stiffness and discomfort in children. Involve- ment of the heart may follow such trivial symptoms, rheumatism not being suspected until a heart lesion is found.
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DISEASES OF CHILDREN FOR NURSES.
DIABETES MELLITUS
This disease is characterized by the presence of sugar in the urine, polyuria, and loss of flesh and strength. The exact cause of diabetes is not known. It is uncom- mon in childhood, but when it exists the course is very rapid.
Symptoms.— Urinary.— The urine is increased in quantity, varying from three or four pints to six or eight quarts in twenty-four hours. It is light in color and of high specific gravity, 1030 to 1040, and leaves a whitish residue. In summer it attracts flies and has an aromatic odor. The total amount of sugar excreted in twenty-four hours can be from a few ounces to half a pound or more.
General.— The most prominent symptoms in childhood are loss of flesh and strength. The temperature is normal or subnormal and the thirst is unquenchable. The tongue and mouth are dry, the bowels are constipated, the skin is dry and harsh, and frequently the seat of intense itching. This is especially observed at the genitalia and may be the first symptom of the disease. There are also attending nervous symptoms, such as headache, disturbed sleep, enuresis, and abscess formations.
The course of diabetes mellitus in childhood is very rapid, much more so than in the adult, from two to four months being the average duration. The disease ends in a condition, analogous to uremia, called acetonemia, which is characterized by epigastric pain, dyspnea, a fruity odor to the breath, headache, delirium, stupor, and coma.
Nursing.— The room should be light and cheerful. Bathing should be frequent. Thirst should be satisfied.
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A specimen of urine should be saved daily unless otherwise ordered, and the amount voided in twenty-four hours measured. Symptoms of acetonemia must be reported immediately. The temperature, pulse, and respirations should be taken once a day.
Diet. — In diabetes the diet is of the utmost importance, all sugars and starches must be eliminated as far as possible.
Food-stuffs permissible in diabetes are: cream, curds, milk, eggs, buttermilk, fish, oysters, clams, all meats except liver, all green vegetables, unsweetened jellies, almonds, walnuts, butternuts, and pecans, tea and coffee with cream, but without sugar, and plenty of water. The bread should be made of gluten flour.
The food-stuffs that must be avoided are: all sugar, potatoes, white and sweet, rice, beets, carrots, turnips, peas, and beans. Pastry, unless made with gluten flour, and liver.
It is not necessary that the children should remain in bed, unless so ordered by the physician.
HEMOPHILIA OR BLEEDER'S DISEASE
This is an hereditary disease characterized by a tendency to bleed excessively from slight wounds or spontaneously. It is probably the worst condition with which a surgeon can be confronted. Children afflicted can bleed to death from a pin scratch, nothing apparently being of use to stop the hemorrhage. It usually runs in families, several brothers and sisters being affected.
Symptoms. — The symptoms are free and persistent hemorrhage after a trivial injury. Spontaneous hemor- rhages from mucous membranes of the nose, stomach,
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and bowel, and subcutaneous extravasations of blood arc common.
Treatment consists in ligation, application of styptics, and plugging of the nose in epistaxis.
PURPURA HEMORRHAGICA
This is a condition arising without obvious exciting cause and produced by extravasations of blood in the skin and bleeding from mucous membranes.
Symptoms. — The onset may be marked by some fever, headache, malaise, and pain in the limbs, but these may be absent and the disease ushered in by copious crops of small hemorrhages in the skin followed by bleeding from the mucous membrane. Anemia and its associated phenomena develop in severe cases. The cause is un- known. It occurs at times in connection with rheumatism. Certain drugs, such as phosphorus, quinin, and potassium chlorate, may produce purpura when long continued.
Nutritional Diseases scurvy, scorbutus, or barlows disease
This is characterized by bleeding, spongy gums, swelling and extravasations of blood around the joints, especially the knees and the ankles. There may be pseudoparalysis, immobility of the legs, extreme tenderness of the skin surface with swelling of the body and extremities, a thickening of the bones, marked anemia, and weakness.
Cause. — Prolonged use of condensed milk, sterilized milk, and proprietary foods.
The symptoms may come on slowly and last over several months. If the character of the disease is not recognized it may prove fatal.
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Treatment. — The disease yields readily to treatment. This consists in giving orange juice to the babies; in older children lemon juice is used.
RACHITIS OR RICKETS
This is a nutritional disease of early childhood, charac- terized chiefly by defective formation of the bony struc- tures. It usually develops during the first or second year; it is not congenital. Poverty, artificial food, and bad hygienic surroundings are the predisposing causes. Breast-fed children rarely have rickets. The bones are soft, being extremely deficient in lime salts, and when ossification finally results the bones become heavy, large, and irregular in outlines. This causes such deformities as bow-legs, knock-knees, spinal curvature, pigeon -breast, and square cranium. The liver and spleen are often enlarged. The negro race is especially prone to the disease.
Symptoms. — The early symptoms are restlessness and slight fever at night-, free perspiration about the head, diffuse soreness and tenderness of the body, prominence of the abdomen, pallor, slight diarrhea, delayed dentition, and the eruption of badly formed teeth.
Skeletal Phenomena. — The head is large and more or less square in outline; careful palpation may detect soft areas in the skull. The fontanel closes late. The sides of the chest are flattened, the sternum is prominent; nodules can be felt at the sternal end of the ribs called "rachitic rosary." There may be a distinct transverse groove at the level of the ensiform cartilage called "Harri- son's groove." The spinal column is frequently curved anteroposteriorly called kyphosis; or latterly when it is
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Fig. 90. — Rachitic boy of three years. A large and somewhat angular head. The typic posture of a rachitic child, with the arms supported at his side. Curvature of the clavicles and the spine causes the neck to appear short. Contraction of the lateral di- ameter of the thorax; abdomen protrudes; curvature of the bones of the forearm (Hecker, Trumpp, and AbO.
termed scoliosis. The long bones are curved and promi- nent at the extremities. This prominence leads to en- largements at the wrists and ankles.
The deformities of the legs may be marked. At times
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it is impossible for the child to stand erect and at others the whole skeleton is so deformed as to produce rachitic dwarfs. The usual deformities are knock-knees, bow-legs, and anterior, bowing of the tibia. These are corrected by operative measures. The bones are broken, set straight, and kept in place by the use of plaster casts.
Prognosis. — Rickets in itself is rarely fatal. Some intercurrent disease, like pneumonia, may cause death.
Treatment. — This consists in giving the affected children the best milk obtainable and all the fresh air and sunshine they can get. Salt baths, prepared by placing three to five ounces of rocksalt in a gallon of water in the baby's tub, and rubbing the child until the skin glows, is advantageous.
MARASMUS OR INFANTILE ATROPHY
When a child is unable to digest and assimilate food for any length of time a pathologic condition sets in. The symptoms arising from this are grouped under the names of malnutrition and marasmus. Marasmus is the extreme form of malnutrition, occurring so far as is known, without any constitutional or local disease. It is a re- sult of faulty nutrition only.
The symptoms of marasmus are the same as those of malnutrition, only in a more advanced form. They are loss of weight until the child literally becomes skin and bones, pallor, anemia, and subnormal temperature. The appetite in severe cases is almost entirely lost. The stools are sometimes normal, but more often contain curds and undigested food and are large in comparison to the amount of food taken. Bed sores frequently develop and the children die of exhaustion.
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Treatment. — This consists in discovering the food which is most easily assimilated and gradually increasing the strength of it until the normal percentages are properly digested. Such a diet may consist of egg-water, barley, arrowroot, and oat-meal water, malted soups, whey, buttermilk and milk mixtures, or, in a word, the entire subject of artificial feeding. Gavage may be necessary.
Nursing. — Nutritional diseases are due to a lack of proper food, consequently the careful preparation and administration of the proper diet is of the utmost impor- tance. The character of the stools and vomit should be accurately reported and a careful chart of the child's weight kept. Bed-sores and pneumonia should be guarded against, and the temperature, pulse, and respira- tion taken at least twice a day.