When a deep breath is taken the chest-walls rise and the shoulders are elevated ; but there is little expansion of the upper part of the thorax, and the constriction at the base is exaggerated. On percussion, general hyper resonance is found in the front of the chest and the cardiac area of dulness is lessened. With the stethoscope we find that the breath sounds are loud and wheezing above, weak although very harsh below, and more or less sonoro-sibilant rhonchus is heard at various parts of the chest.
The symptoms vary according to the condition of the pulmonary mucous membrane ; for, with such a state of lung, the child is excessively sus ceptible to fresh catarrh. At his best his breathing iS habitually short and oppressed, but he coughs little and his appetite and spirits may be good. It is when a new catarrh comes on that his troubles begin. When this ac cident happens, the breathing at once becomes difficult and wheezing, and he is subject to attacks of dyspnwa which appear sometimes to be of the nature of asthmatic seizures. There is, however, another cause for these attacks. In scrofulous subjects the bronchial glands of the mediastina and lungs are apt to enlarge as a result of pulmonary irritation ; and these by their pressure upon the vagus, or directly upon the air-tubes, may produce serious impediment to the entrance of air. The child's cough is husky and often occurs in paroxysms. He cannot lie down in his bed, and is much troubled at night by cough and dyspinea. If these symptoms con tinue, the patient passes into the condition which is described elsewhere under the name of chronic bronchitis, and a case is there narrated in which chronic pulmonary catarrh was associated with permanent emphysema of the lungs.
In cases where the attacks of catarrh are only occasional and pass com pletely away, the habitual state of the child is not unsatisfactory ; but he is liable at any moment to be laid by under the influence of a fresh chill.
I may cite as a good example of chronic pulmonary emphysema the case of a little boy, aged three years, stout and thick-set, with large ends to his bones. The child only finished cutting his teeth at the age of two years and nine months, and was no doubt slightly rickety. He was said to have been wheezing off and on for eighteen months. Ten months pre viously he had been ill for a month with a severe attack of bronchitis, and had since that time been a constant sufferer from wheezing and short ness of breath. In this boy the upper part of the chest was full and
rounded, and there was some considerable constriction at the base. The heart's apex could be seen and felt in the epigastrium and between that point and the left nipple. The percussion note was drum-like all over the front of the chest, and much whistling and snoring rhonchus was heard over both lungs. The heart-sounds were healthy.
Another little boy, aged two years and nine months, was said to have had a cough all his life, although it was better in the summer than the winter, and might even cease altogether for about six weeks in the warmest weather. The child was twelve months old before he cut his first tooth, and did not walk until the end of his second year. The ends of his long bones were full ; but his limbs were straight, and he was not a marked specimen of rickets. The breathing was not much oppressed ; the cough was hoarse, and the voice husky. He was not subject to attacks of dis tressing clyspncea, and was said never to have lost his voice. This little lad's chest was perceptibly retracted in the infra-mammary regions, and the lower part of the breast-bone projected. The spine was straight and the back rather flattened between the scapuhe. At each breath there was a slight sinking of the epigastrium. On percussion there was general hyper-resonance of the front of the chest, especially along the sternum. Some sibilant and large bubbling rhonchi were heard at each base behind.
In such cases as the above the emphysema is no doubt kept up by the repeated attacks of pulmonary catarrh. It is possible that if by residence in a suitable climate such intercurrent attacks could be prevented, the emphysema might subside and the lungs return to a normal condition ; but upon this point I cannot speak with certainty.
It is not often in the child that serious secondary effects, such as passive congestion of the liver and kidneys, dilated hypertrophy of the right heart, cedema, etc., are noticed, although in some cases I have thought that the right ventricle was larger than natural. The danger of the disease consists principally in the repeated attacks of bronchitis from which these patients almost invariably suffer, and in the tendency of such attacks, if not immediately fatal, to run a chronic course. Usually, sooner or later, the life of the patient is brought prematurely to a close by this means.