cough, chest, time, breathing, rhonchus, boy and appetite

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In the milder form of the disease the child merely suffers from a chronic cough, which undergoes very noticeable exacerbations on any change of the weather, and on the occurrence of a chill is complicated for a time by the symptoms of an acute attack of pulmonary catarrh. These cases often give much trouble and are very difficult of cure.

In a severer form, when the emphysema is marked, the chest becomes barrel-shaped ; the skin is habitually dry and the fingers are slightly clubbed. These children are almost invariably short and thick-set, with coarse features, thick turgid lips, broad shoulders, and large bones. They often stoop as they walk. During the summer months they are fairly well, with a good appetite ; and although they may pant after exertion, do not suffer from noticeable shortness of breath. In the winter they have a per sistent cough, and cannot indulge in noisy games, as much movement pro duces instant dyspnma. The cough is loose and paroxysmal ; sometimes they expectorate frothy, yellow phlegm. The face is usually livid and puffy-looking. The appetite is capricious, and vomiting is frequent after cough. The bowels are costive.

On examination of the chest we find general hyper-resonance ; and the respiratory sounds are more or less concealed by a fine crackling rhonchus. If, as often happens, there is dilatation of the bronchi, the respiration in the inter-scapular region may be bronchial or even cavernous. As a rule the temperature is normal.

Chronic catarrh of the stomach or bowels, or both, often occurs in these cases. The appetite is poor ; the bowels are loose and contain much mucus ; and the loss of flesh is rapid. With great care the pulmonary catarrh may be kept under, and if the child's strength be properly sup ported, life may be prolonged until the return of more genial weather, when the patient very quickly begins to improve. In too many cases, however, death ensues as a consequence of an intercurrent attack in which the tem perature rises, and the symptoms which have been described as the conse quence of capillary bronchitis are noticed.

A boy, aged thirteen years, both of whose parents were said to be " weak in the chest," was healthy up to the age of eight years, when he had an attack of measles followed by pertussis. From that time he suffered from cough which was always worse in the winter. He was admitted into the Victoria Park Hospital in February for a severe bronchitis.

The boy was fairly nourished and well built, although short for his age. His chest was full and expanded above, but at the lower part on each side there was some infra-mammary depression. The spine was straight. The heart's apex was in the fifth interspace, three quarters of an inch to the inner side of the nipple line. Its impulse could be also felt in the epigas trium. The skin was dry and harsh ; the fingers were slightly clubbed ; the liver and spleen seemed pushed downwards. The face was congested, turgid, and more or less livid. The breathing was laboured, and the boy could not lie down in his bed. The temperature was normal and the urine healthy.

On examination of the chest the percussion note generally was hyper resonant ; and everywhere over the chest the breath sounds were concealed by a copious, fine, crackling rhonchus. This at the base was very super ficial and ringing. The boy remained in the hospital until June, being sometimes better, sometimes worse ; and the amount of rhonchus varied considerably from time to time. The temperature rarely rose above 99°. On his discharge, although his breathing was much better and his general condition fairly good, much rhonchus remained at the bases of the lungs.

Diagnosis.—There is little difficulty about the diagnosis of bronchitis. In the milder form a mistake is hardly possible unless from teething or other cause there is a high degree of fever. With considerable pyrexia the derangement may be mistaken for measles or broncho-pneumonia. In the first case the occurrence of the characteristic rash on the fourth day will clear up the difficulty. In the second, the absence of distress in the face, the normal pulse-respiration ratio, and the limited amount of rhon chus detected by the ear will furnish a sufficient distinction.

In capillary bronchitis the laboured breathing, the thick and often paroxysmal cough, the copious mucous rides heard with the stethoscope, combined with the absence of dulness on percussion and of bronchial or blowing breathing, are sufficiently distinctive. A point of great importance is the exclusion of atelectasis and of catarrhal pneumonia. The new feat ures introduced into the case by the occurrence of either of these complica tions are referred to elsewhere (see pages 467 and 436 ).

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