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Diseases of the Organs of Respiration

chest, child, patient, lower, lungs, left and consequence

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affections of the lungs constitute a very important branch of the dis eases of childhood. The study of these complaints must no doubt present peculiar difficulties, for persons who are fairly conversant with the ordinary maladies of early life will often profess their inability to understand them. In many cases an examination of the chest in a child cannot be carried through without much tact and management ; in others the utmost gentle ness will not reconcile the patient to a procedure of which he only per ceives the inconveniences ; and even in the most favourable cases the ob server meets with peculiarities in the physical signs which in one unaccus tomed to such youthful patients may give rise to considerable perplexity.

In order to examine the chest of a child with success the patient must be raised up to a convenient height. If we stoop down to a child as he sits upon his nurse's lap, our own position is cramped and uncomfortable. Fully to appreciate minute deviations from a healthy state the attitude of the observer should be one of ease. In the case of an infant, to examine the front of the chest the child should be laid upon his back on a cushion placed upon the table. Some babies, however, cry at once when laid upon the back. In such cases the patient may be placed in a sitting position on the cushion supported by the nurse. When the back is examined the nurse should stand up and take the child on her left arm, so that his head and right arm hang over her left shoulder, and his left arm is loosely ap plied round her neck. In this position the muscles of both shoulders are relaxed. An older child can be seated upon a table for examination. It is needless to say that in both cases the patient should be completely stripped to the waist.

Much may be learned from mere inspection of the chest. In the case of an infant the points to which attention should be directed have already been referred to (see page 12). In children of four or five years old and up wards we can often ascertain by this means the existence of a constitutional predisposition. In children of consumptive tendencies the lungs are small. As a consequence the thorax is forced to adapt itself to the size of its con tents. The shoulders are narrow and sloping ; the ribs are very oblique.

and the chest elongated ; and the scapula; project backwards like wings. The prominence of the shoulder-blades has given the name of " alar " or " pterygoid " to this variety of chest. In small-lunged children, and chil dren with vulnerable chests, the thorax is often flattened anteriorly, so as to diminish the antero-posterior diameter. The flattening is due to yield ing of the costal cartilages under the pressure of the atmosphere when the lungs are expanded in the act of inspiration. It is usually the consequence of narrowing of the air-tubes from catarrh of the mucous membrane. If we notice the shape of the chest to correspond to either of these types, we must examine the apices very carefully for signs of disease. Moreover, in the treatment of even the simplest pulmonary derangement in such cases we must be careful to follow up any special medication by invigorat ing measures, and wait for complete cessation of the cough before per mitting the child to resume the ordinary habits of health.

If we notice an infra-mammary depression on each side of the chest, with some prominence of the lower part of the sternum, we infer that the patient has been subject to long-continued or frequently repeated attacks of pulmonary catarrh. In these attacks the air-tubes are narrowed by the presence of catarrh, so that air penetrates insufficiently into the lungs, and expansion, especially of the inferior lobes, is incomplete. As a consequence the lower ribs, corresponding to the imperfectly inflated tissue, are re tracted at each descent of the diaphragm. As the lower ribs fall in, the lower end of the breast-bone is forced forwards, so that a horizontal sec tion of the chest at this point, instead of elliptical, would be triangular. After a succession of these catarrhs a certain amount of permanent collapse is induced in the lower lobes, and the deformity becomes a permanent one. The prominence of the sternum from this cause constitutes one of the varieties of "pigeon-breast." The rickety chest is also pigeon-breasted, as, is explained elsewhere (see page 139).

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