Clinical studies of diseases of the lungs in children

Front matter

LIBRARY

Medical Classics

OF

Chapter I.— Introduction. Peculiarities of constitution in early life, 4

Children not exempt from degeneration of tissue, 5

Excitability of the nervous system in the child, 5

Wide diffusion of symptoms in acute disease, 5

Intensity of symptoms no guide to their cause, 5

General and local symptoms, 5 Local symptoms sometimes deceitful, 5 Frequency of functional derangement, 5

Effect of chronic disease on nervous excitability, 6

Clinical examination of young children, 6

Value of the mother’s account of the illness, 6

Method of taking the temperature, 7 Respiration in infants, 7 Examination of chest, 8 Examination of mouth, 8 General remarks on the diagnosis of disease, 8

General remarks on prognosis, 9 Treatment of disease in children, 10 Objects of treatment, 10 Indications for treatment, 10 Evils of too early stimulation, 10 Value of alkalies, 10 Tolerance of childreM for certain drugs, 11 Doses, 11

Chapter II.— Collapse of the Lung — (Post-Natal Atalectasis). Collapse of lung a common lesion in the child, 12

Method of production, 12

Causes, 12

Inability to cough and expecto rate, 12

Weakness of the inspiratory act, 13 Mechanical impediment to expansion of the chest, 13 Influence of rickets, 13 Morbid anatomy, 13 Symptoms , 14

If collapse extensive may cause sudden death, 14 Convulsions, 14

Insufficient aeration of blood. 14 Difficulty of swallowing, 15 Physical signs, 15

Sometimes absent, 15 Case I. — Sudden death from pulmonary collapse in a weakly wasted infant, 15

Case II. — Collapse of the lung occurring in a case of pertussis, 15 Comment, 16

Mechanism of collapse in pertussis, 16

Case III. — Collapse of the lung with laryngismus stridulus, 16 Case IV. — Bronchitis and pulmonary collapse in a rickety child, 17 Comment, 18

Diagnosis of pulmonary collapse, 19 of diffused collapse, 19 of lobular collapse, 20 Treatment , 20

Mechanical treatment, 20 Emetics, 20 Stimulation, 20

Chapter III.— Croupous Pneumonia. 1 Not uncommon under two years, 21

DISEASES OF THE LUNGS IN CHILDREN.

Symptoms, 21

Temperature, 21 Pulse-respiration ratio, 21 Prostration, 21 Physical signs, 21

Seldom complete before the third day, 22

Importance of two fingers in percussion, 22

Sequence of physical signs, 22 Situation of physical signs, 22 Resolution of the inflammation, 22 Sudden fall in the temperature, 23 Date of the crisis, 23 Mode of beginning with convulsions, 23

Pose V. — Pneumonia introduced by a convulsive attack, 23 Cerebral pneumonia, 24 Case VI. — Pneumonia of apex with severe cerebral symptoms, 24 Comment, 25

Value of irregularity of pulse as a symptom, 26

Case VII. — Pneumonia of apex without cerebral symptoms, 26 Case VIII. — Pneumonia complicated by gastro-intestinal catarrh, 27 Comment, 27

Diagnosis from typhoid fever, 27 ■General redness, 27 Postponement of resolution, 28 Prognosis, 28

Case IX. — Rapid course of pneumonia of the apex, 28 Secondary pneumonia, 28 Diagnosis , 28 Treatment, 29

Avoidance of depressing remedies, Poultices, 30 [29

Tepid compresses, 30 Aperients, 30 Diet, 30 Quinine, 30

Treatment of secondary pneumonia, 30

Chapter IV.— Pleurisy. Physical signs very similar to those of pneumonia, 31

Usually limited to one side of the chest, 31

Not uncommon under two years of age, 31 Symptoms, 31 Pain, 31 Respiration, 31 Pulse, 31

Pulse-respiration ratio, 31 Digestive derangement, 31 Cough, 31 Temperature, 32 Complexion, 32 Degree of prostration, 32 Physical signs, 32

Displacement of organs. 32 Dilatation of the side, 32

Alteration of shape of chest, 33 Vocal fremitus, 33 Dulness, its quality and distribution, 33

Movability of dulness, 33 Auscultation, 33 Friction, 33 Breath-sounds, 34

Case X. — Ordinary attack of pleurisy, Comment, 35 [34

Circumscribed pleurisy, 36 Case XI. — Circumscribed pleurisy, 36 Comment, 37

Termination of pleurisy, 38 Case XII — Empyema — absorption of fluid, 38 Comment, 39 Empyema — symptoms, 39 Its consequences, 40 Case XIII.— Empyema — spontaneous evacuation of the fluid, 40 Retraction of chest, 40 Case XIV.— Great retraction of chest from pleurisy, 41 Comment, 41

Case XV. — Empyema — Secondary acute tuberculosis, 41 Comment, 43 Fibrinous pleurisy, 43 Basic lung disease, 43 Case XVI. — Fibroid induration of lung from pleurisy, 44 Comment, 44 Diagnosis, 45

From morbid growths, 46 From hydro-thorax, 47 Prognosis, 47 Treatment , 47

Hypodermic injection of morphia, 48

Counter-irritants, 48 Dry diet, 48 Paracentesis, 48 Method of operating, 48 Case XVII. — Traumatic pneumo-thorax from puncture of the lung • during paracentesis, 49 Temperature after operation, 49 Reproduction of the fluid, 49 Retention of canula, 49 Case XVIII. —Empyema — repeated paracentesis, 49 Drainage tube, 50 Avoidance of chills, 50 Amount of deformity, 50 Pointing of empyema, 51 Results of the operation, 51 Diet, 51

Secondary pleurisy, 51 Chapter V. — Acute Catarrhal Pneumonia.

Especially the pneumonia of infancy, 51

Distinction between croupous and catarrhal pneumonia, 52 ’athology, 52

Contents

Modes of origin, 52

Extension of catarrhal process, 52 From collapse of lung, 52 Always a secondary lesion, 53 Symptoms and course, 53 Temperature, 53 Pul se-respi ration ratio, 53 Cough, 53 Physical signs, 54 Case XIX. — Ordinary case of acute catarrhal pneumonia in an infant, 54

Case XX.— Acute catarrhal pneumonia secondary to collapse of the lung, 54 Comment, 55 Apathy of the patient, 56 Subacute course of the disease, 56 Case XXI. — Subacute type of catarrhal pneumonia, 56 Comment, 56 Favorable termination, 57 Case XXII. — Favorable ending of acute catarrhal pneumonia, 57 Comment, 58 Dilatation of bronchi, 59 Case XXIII. — Acute catarrhal pneumonia with dilatation of bronchus, 59 Comment, 59

Chapter VI. — Chronic Catarrhal Pneumonia and Un absorbed Pneumonic Deposits — Pneumonic Phthisis

The principal form of chronic lung disease, 63 Pathology , 63

Origin of caseous masses, 63 Process of chronic catarrhal pneumonia, 63

Caseation of pulmonary deposits, 64

* ‘ Tubercular infiltration of Laennec,” 64 Softening, 64 Excavation, 65 Calcification, 65 ,

Fibroid induration, 65 Secondary changes, 65 Ulceration of bowels, 65

Secondary Tuberculosis, 65 Symptoms, 65

Conformation of body, 65 Peculiarities of chronic lung disease in children, 65 Sources of error in diagnosis, 66 General symptoms mild, 66 Physical signs, 67 Temperature, 67

Case XXIV. — Chronic catarrhal pneumonia. Rapid absorption of the deposit, 67 Comment, 68 Seat of consolidation, 68 SymptoUis of softening, 68 Signs of excavation, 68 Diagnosis of cavity from a dilated bronchus, 68

Imperfect evidence of cavity, 68 Cavernous breathing without a cavity, 68

General symptoms of softening, 69 Rarity of haemoptysis, 69 Case XXV. — Chronic catarrhal pneumonia.—Softening and excavation, 69 Comment, 70

Case XXVI. — Caseous consolidation with dilatation of bronchus, 70 Comment, 72

Absorption of pneumonic deposits, 73 Secondary tuberculosis, 73 Case XXVII. — Chronic catarrhal pneumonia, with plastic pleurisy and secondary tuberculosis, 73 Comment, 74 Diagnosis, 75

In the early stage, 76 From acute tuberculosis, 76 In the advanced stage, 76 From empyema, 76 Prognosis , 76 Treatment, 77

Dry air and soil, 77 Diet, 77 Medicines, 78

Chapter VII. — Fibroid Induration of the Lung (Cirrhosis). Pathology, 78

A result of catarrhal pneumonia, 79 of pleurisy, 79 Fibroid phthisis, 79 Case XXVIII. — Fibroid thickening of lung following an attack of catarrhal pneumonia, 79 Comment, 83 Physical signs, 84 Symptoms, 84

Fetid expectoration, 84 State of nutrition, 84 Absence of pyrexia, 84 Interference with pulmonary circulation, 84 CEdema, 85

Case XX [X. — Fibroid induration of

DISEASES OF THE LUNGS IN CHILDREN.

apex of lung witli contraction of chest, 85

Case XXX. — Fibroid induration of apex of lung with contraction, 85 Comment, 86

Case XXXI. — Extreme fibroid induration and contraction, 87 Comment, 88

Case XXXII. — Extreme fibroid induration without contraction of side, 88 Comment, 92

Excavation of lung, 93 Case XXXIII. — Fibroid induration with extensive excavation of lung, 93 Comment, 95 Diagnosis, 95 Prognosis, 96 Treatment, 96

Avoidance of chills, 96 Inhalations, 96 Tonics and astringents, 96 Emetics, 97

Preface

The substance of the following pages has already appeared in the columns of the Medical Times and Gazette. In the republication new cases have been added, parts have been re-written, and the whole has been thoroughly revised.

The subject of Disease in Children is a large one, for although there are few disorders special to early life, yet the peculiarities of the childish constitution pervert and distort the ordinary phenomena of disease, so that even familiar complaints assume unfamiliar features, which may give rise to uncertainty or misapprehension.

The object of the writer has been to produce a practical work suitable as a guide to students and others engaged in the study of children’s diseases. — With this view he has endeavored to illustrate the more important symptoms of each complaint by a selection of cases with commentaries interspersed through the text, in the hope that the introduction of the clinical element might relieve the formality of the systematic treatise, and at the same time present the subject in the most practical form before the reader.

The present volume comprises the principal diseases of the lungs. It had been the wish of the writer to produce a more complete work on the Diseases of Children, but the difficulty of finding cases sufficiently typical to furnish satisfactory illustration has at present prevented him from accomplishing this object.

The writer desires to express his obligations to his colleagues at the East London Children’s Hospital for their kindness in placing their cases at his disposal, and also to the House Surgeons of the Hospital (past and present) for their valuable assistance in preparing many of the cases for publication.

George Street, Hanover Square, February 1&76.

CHAPTER I.— Introduction

Disease in early life often rendered obscure by the peculiarities of the childish constitution— Intense vital activity of organs and excitability of the nervous system — Wide diffusion of symptoms in cases of acute diseases — Intensity of symptoms no guide to their cause — Importance of local symptoms — But these sometimes misleading.

Frequency of functional derangements — Loss of normal nervous excitability under the influence of chronic disease.

Clinical examination of young children — Method of proceeding — Order of examina- ,, tion — Pulse — Temperature — Examination of chest.

• ' General remarks on diagnosis, prognosis and treatment — Indications for treatment — Evils of too early stimulation — Drugs — Tolerance of children for certain drugs and susceptibility to others — Doses.

The diseases of infancy and childhood are often regarded as presenting peculiar difficulties; and certainly, to one. accustomed only to disease as it presents itself hi the adult subject, the symptoms will frequently appear obscure and sometimes contradictory. Children differ from adults in many ways. The intense nervous excitability in a robust child will often communicate a false appearance of gravity to a trivial ailment, while the lowered nervous sensibility which is found in a child much depressed by chronic disease will so obscure the symptoms that a serious intercurrent malady may excite little notice, or even be completely overlooked.

Introduction

,5

The diseases of children are in some respects simpler, in others more obscure, than those of elder persons. In the first place, children are less subject than adults to degenerations of tissue. They are not, however, exempt from such degenerations, for all the consequences of impaired nutrition may be found in the child, as in the adult ; and not only may morbid products undergo a degenerative process, but also the normal tissues of the body may become the seat of structural changes such as in older persons are ascribed to the influence of advancing years. Thus, commencing atheroma of the aorta may be found in children of two or three years old ; amyloid degenerations are far from uncommon in early life ; and the degenerative processes occurring in pulmonary morbid deposits may he present in the youngest infants.

Still, as compared with the adult, degenerations are rare in the child; growth and development are in active progress, and the organs are gathering strength and maturing themselves for the efficient performance of their duties. The intense vital activity of organs, to which the child owes this comparative immunity, increases his susceptibility to disease by(rendering him more liable to be affected by slight causes ; it also renders the course of disease more rapid, the attack more sudden, and the symptoms more severe. Besides, the rapid development through which the whole nervous system is passing seems to link together the different organs into a closer sympathy, so that disease of one of these will often cause a general commotion throughout the body, and the most prominent symptoms may emanate from some distant organ, and not from the part which is the actual seat of trouble.

The access of acute disease in the young child is always accompanied by signs of general disturbance ; and it is very important in the examination to distinguish between the general and the local symptoms— for the latter, although sometimes obscure, are yet much more exact than are those which arise from the general perturbation of the system. Thus, in the beginning of an attack of pneumonia, the cough, the rapid breathing, and the indications of pain in the side point pretty clearly to the lungs as the part attacked, while the high temperature, the vomiting, the headache, the rapid pulse, and in many cases the convulsions, are not special symptoms of chest disease, but are common to the beginning of many other febrile affections.

In entering upon the study of children’s diseases it is very important to bear in mind this wide diffusion of symptoms, and also to remember that their severity bears no relation at all to the severity of the local disorder of which they are the manifestation. A mere functional disturbance will often, for the time, excite as wild a tumult in the system as the severest organic lesion ; and we often find it necessary in diagnosis to wait for the general symptoms to diminish before we are able to gather from the local symptoms any sufficient tokens of the cause and nature of the ailment. Local symptoms, are not, however, always present. In infants, the weakness of the organism is so great, and the hold upon life so feeble, that death may take place before the more special symptoms have had time to reveal themselves ; and thus a child thrown into violent convulsions by some trifling disorder may actually die from the shock to the system, and no post-mortem appearances may be afterwards found to account for the illness.

Even local symptoms themselves are not always to be trusted. The organ from which the more decided symptoms appear to arise may not be, as has been already stated, the organ in which the morbid process is actually seated, and these decepti ve manifestations may throw the real lesion completely into the shade. Thus, in some cases of pneumonia the more prominent symptoms may be those of cerebral disturbance; violent convulsions, delirium, and stupor may so disguise the real nature of the complaint that the slight cough may be either unnoticed or unregarded, and active measures may be taken for the suppression of a supposed meningitis, to the neglect of the organ which is the real seat of disease.

Again, the local symptoms, although arising from the actual seat of trouble, may convey by themselves no trustworthy indication of the extent, or even the nature of the mischief. A child who went to bed healthy, except for a slight cold, wakes up suddenly after a few hours’ sleep with fever, stridulous breathing, and a hoarse, barkmg cough. His breathing is very difficult, and sometimes becomes completely arrested, and we ftee the child with head thrown back, open mouth, and nostrils widely expanded, making ineffectual efforts to draw a breath, while his staring eyes, his frightened look, and the lividity of his face prove the reality of the impediment to the entrance of air.

DISEASES OE THE LUNGS IN CHILDREN.

The spasm after a time relaxes, the symptoms subside, and the child falls asleep. In the morning he may appear as well as on the eve of the attack, or may have a slight hoarseness and some cough, which subside after a few days. In this example the real morbid condition is merely catarrh of the laryngeal mucous membrane, while all that is alarming in the symptoms is produced by functional spasm from excentric irritation : it is an instance of the important part played by mere disorder of function in the diseases of childhood. This frequency of mere functional derangements is another peculiarity of early life, which it is important to be aware of. On account of the extreme impressionability of the nervous system in young children, and the delicacy of their organs- — especially their singular sensitiveness to changes of temperature— -such disturbances form a large proportion of their ailments, and it is of the utmost importance for both prognosis and treatment that we should be able to form an accurate estimate of the real nature of such complaints. In this way gastric, intestinal and pulmonary catarrhs arise, and a violent ' attack of vomiting or diarrhoea will soon reduce an infant to a very dangerous state of weakness. Even in cases where the derangement is less acute and severe it may still be attended by actual danger to life. An infant is so dependent, not only for growth and development, but for actual existence, upon a frequent supply of nourishment, that any derangement which temporarily checks the assimilation of nutritive material is an event always to be regarded with anxiety. Such a condition is not an uncommon sequence to severe operations, and often causes death, even after the more immediate effects of the operation have been recovered from. In the case of pulmonary catarrh there is a special danger which is independent of the severity of the catarrh. Collapse of the lung is always threatened in every case of cold on the chest in a weakly infant ; and if the collapse be extensive and quickly produced, the child may die suddenly. It is a consequence of this dangerous character of mere functional disorders that post-mortem examinations in young children are so often unsatisfactory. Nothing at all may be found to indicate the cause of death, or the appearances observed may be quite insufficient in themselves to account for the fatal result.

The intense excitability of the nervous system, which under ordinary circumstances impresses their peculiar character upon the disorders of early life,

Sradually diminishes and disappears under the influence of chronic enfeebling isease, and in its stead we find a condition exactly the opposite to that which has been described. Here, the nervous system appears nearly insensible to all sources of irritation ; the general symptoms are almost completely absent, and the local symptoms are so slight and obscure that they may easily escape notice. Thus inflammation of the lungs occurring secondarily in a cachectic child may present hardly any symptoms at all. The temperature may be only slightly elevated, and quickly falls ; the cough is rare or absent ; and an increase in the general weakness is the principal sign by which this serious complication is manifested.

In the child, then, we must be prepared for these two very opposite conditions ; in the one case, a violent reaction of the whole system against the most trifling disturbance ; in the other, a profound insensibility to nervous impressions, the system assuming for the time many of the physiological characters of old age, and responding faintly, if at all, to the stimulus of local irritations.

The clinical examination of infants is seldom difficult, for very young children as a rule can be easily managed with a little patience. Older children, however, are often very suspicious of “the doctor,” and sometimes, especially if badly brought up and petted and spoiled, may resist all our efforts to examin them; but even in these cases much may be done by gentleness and deliberation. It is important not to be in a hurry ; and, besides, it is well to accustom the patient to our presence in the room before proceeding to a physical examination. This interval may be conveniently occupied by inquiring into the history of the attack ; and, if there be other children of the same family, it is advisable to see them, for information may in this way be gained as to constitutional and hereditary family peculiarities. The information to be derived from the mother is often of the greatest value, and her account of the symptoms should be always received with attention and carefully weighed. If she be a person of intelligence, many minute points in the history of the beginning of the attack can thus be collected ; and these, in an obscure case, may be of the utmost importance. If the patient be an infant,

INTRODUCTION.

it is advisable to see him first during- sleep, for those parts of the examination during which perfect quiet is indispensable can seldom be satisfactorily conducted unless the child is unconscious of what is passing around him. At this time, then, we can note the expression of the face, can observe the attitude and any involuntary movements of the body ; we can count the number of respirations, feel the pulse, and ascertain the temperature of the body by gently introducing the ball of the thermometer, wetted or oiled, into the rectum. It is better to take the temperature in the rectum rather than in the axilla; for, besides that the result thus obtained is more to be relied upon, as the skin of infants is quickly cooled by slight exposure, and does not therefore always furnish trustworthy information as to the heat of the body generally, the method is also more convenient. Infants usually resent very strongly the amount of constraint necessary to keep the arm firmly in contact with the side, and are often so noisy and unmanageable in consequence that little afterwards can be done with them in the way of examination. With regard to the temperature of children, it may be noted that we must not allow ourselves to be deceived by sudden and rapid rises of temperature into the belief that the patient must necessarily be suffering from serious disease. Very slight causes will in infants produce a remarkable increase of heat; and during natural dentition, just before the passage of the tooth through the gum, a temperature of 104° or 105° Fahr., even in the morning, is not at all an uncommon circumstance. Besides, the normal temperature of young ckildren is rather higher than that of the adult. In a perfectly healthy child of three or four years old the thermometer will often register a morning temperature of 99 1-2°.

The pulse of infants can seldom be counted except during sleep, and even then involuntary movements of the arm and twitching of the tendons of the wrist render the operation not always an easy one. The finger should be laid very lightly upon the artery, and any temporary restlessness which may be excited in the limb by the touch should be allowed to subside before we begin to take the number of pulsations. The pulse is rather slower during sleep, and i^ then often irregular in force; but the slightest movement of the body causes a sudden quickening in the number of beats, and at the same time the force of the beats becomes equalized, and remains so for a few seconds, or as long as the increase in rapidity is maintained.

Whatever may be the disease for which we are called to see an infant, we should always make a thorough examination of the whole body ; and therefore, when we have satisfied ourselves as to the points which can only be successfully noted during sleep, it is well to have the clothes entirely removed, so that we may have the whole body exposed to view. If the child cry during1' this process, we should pay attention to the quality of the voice, for hoarseness is one of the early signs of inherited syphilis.

Placing the infant naked on the nurse's lap, the body must be examined for signs of eruption or any appearance of swelling or local inflammation; the condition of the skin must also be noted — as to softness and suppleness, dryness, or moisture — for a harsh, dry skin is a frequent accompaniment of chronic abdominal disease. At the same time the condition of the belly can be ascertained, paying attention to the hardness or softness of the parietes, and to the size, whether normal or otherwise, of the liver and spleen. The existence of abdominal pain or tenderness can also be detected without much difficulty.

Children breathe more quickly than adults. Under the age of two years the number of respirations in the minute may be taken as about thirty. After that age the rapidity gradually diminishes, but at any moment in young subjects the respiratory movement is apt like the pulse to be temporarily quickened by trifling causes.

The respiration of infants is chiefly abdominal, on account of the shape of the thorax. In a new-born child the antero-posterior diameter of the chest is scarcely less than the lateral, and this nearly circular shape allows of little further lateral expansion. The circular shape, however, soon changes to the elliptical, and the chest becomes broad out of proportion to its depth. In a perfectly healthy child there is at each inspiration a certain recession of the lower part of the chest- walls, for the yielding ribs are forced inwards by the pressure of the air before they can be sufficiently supported by the expanding lungs. Disease, however, may greatly increase this recession, and in certain cases we notice a deep furrow appearing across the chest at each inspiration.

DISEASES OF THE LUNGS IN CHILDREN.

and marking the upper borders of the abdominal viscera. The extent of the recession is a sign of the degree of difficulty with which the air enters the lungs, and should always be noted during inspection of the chest. The impediment may be created by softening of the ribs, as in rickets, which renders difficult the proper expansion of the thoracic cavity, or by disease of the lungs and air-passages, which presents a direct obstacle to the entrance of air.

The examination of the chest in an infant is not attended with any great difficulty. In severe chest complaints the child is almost always quiet, as crying interferes with the respiratory act, upon which his whole attention is concentrated. Much noise and resistance, then, may be taken as a sign that the lungs are not seriously affected. If a child with any abnormal dulness at the base of the chest cry loudly, the disease is almost certain to be pleurisy.

The infant should be first placed in the nurse’s arms, with his chin resting upon her left shoulder, and his left arm around her neck. If necessary, the chin can be kept down by the nurse’s hand placed upon the child’s head. In this position the muscles of both shoulders are relaxed, and percussion of the supra-spinous fossae can be relied upon. As the resonance differs considerably, according as to whether percussion be made during inspiration or expiration, it is important that this should be made on each side at the same period of the respiratory movement. Infants are fond, when under constraint of any kind, of holding their breath in the intervals of crying ; and as they always do so at the end of an inspiration, this is a favorable opportunity for employing percussion of the two sides. Percussion should always be mediate, and it is by far the most convenient to use the first finger of the left hand as a pleximeter. It is best to use two fingers, as well as one, in striking; for by this means, without using any greater force, a larger volume of sound is elicited, and an amount of dulness which might escape notice were only one finger employed, can by this means be readily detected.

It must be remembered that during expiration the liver rises higher in children than it does in adults, and that, therefore, the right base is naturally less resonant than the left immediately before a fresh breath is taken.

In auscultation the stethoscope should always be made use of. It has the great advantage of limiting the area within which the different respiratory sounds are perceived; and this, when, as in a child, the area is small, and sounds from the nose and throat are so rapidly conducted, is a matter of considerable importance. If not seriously ill, the child usually cries during the examination ; but this will not prevent our acquiring all necessary information, for during inspiration the cry usually ceases, and in this interval of silence we can ascertain the quality of the breathing, and the presence or absence of adventitious sounds. Afterwards we notice whether or not the cry is unnaturally resonant.

To examine the front and sides of the chest the infant should be laid upon a pillow; and it is convenient to have this latter placed upon the table so as to raise up the patient to a convenient height. By this means the examination can be made thoroughly and without that inconvenience which the practitioner experiences when he stoops down to examine a child lying upon his mother’s lap. After exploring the lungs the heart sounds can be listened to during inspiration in the intervals of the cry.

In older children an examination of the chest should never be omitted, whatever may be the nature of the symptoms ; for inflammation of the lung often begins very insidiously, and the symptoms of pleurisy are frequently obscure.

The respiratory sounds are of a more blowing quality in children than they are in adults, and this quality is more remarkable in inspiration than it is in expiration, which latter, indeed, is often very weak, and sometimes hardly perceptible. In cases of inflammatory affections of the lungs the rhythm of respiration may become altered, the pause taking place at the end of inspiration, instead of at the end of expiration. This is not characteristic of any special disease, but is common to all cases where the function of the lungs is interfered with. During examination of the chest the patient’s mouth should, if possible, be open, as by this means the transmission of sounds generated in the throat is to a considerable extent prevented.