An American text-book of the diseases of children / By American teachers. Ed. by Louis Starr ... assisted by Thompson S. Westcott.

  • Starr, Louis, 1849-1925.
Date:
1895
Catalogue details

Licence: Public Domain Mark

Credit: An American text-book of the diseases of children / By American teachers. Ed. by Louis Starr ... assisted by Thompson S. Westcott. Source: Wellcome Collection.

Provider: This material has been provided by the Harvey Cushing/John Hay Whitney Medical Library at Yale University, through the Medical Heritage Library. The original may be consulted at the Harvey Cushing/John Hay Whitney Medical Library at Yale University.

    31/1302 (page 15)
    Inspection.—The sitting posture, the child being stripped and in a good light, is the best for this process. Note is to be taken of the shape of the ohest, the character of the breathing, and the positioo of the apex-beat of the heart. In the new-born baby the chest is nearly circular in shape; later, the lateral diameter considerably exceeds the antero-posterior. The intercostal spaces are poorly marked, and the scapulae lie so dose thai their outline is scarcely perceptible. The circular shape of the chest allows of little lateral expansion, and for this reason the respiration is chiefly abdominal in type. Together with the movement of the abdominal walls, every act of inspiration is attended by a certain amount of recession of the lower part of the chest- walls, the yielding ribs being forced inward by the pressure of the external air before they can be sufficiently supported by the expanding lung. The rise and fall of the cardiac apex can be seen—except when there is a great accumulation of fat—a short distance below and to the right of the left nipple. Disease may alter all of these conditions. The tuberculous diathesis is characterized by a small chest, and one which has either the alar or the flat shape. In rickets the thorax becomes irregularly triangular in outline. Em- physema causes a barrel-shaped chest, with stooping shoulders and round back. Pleuritis with large effusion produces bulging of the affected side, and some- times prominence of the intercostal spaces. After absorption has taken place there may be marked retraction, sinking of the interspaces, falling of the shoulders, and curvature of the spine toward the healthy side. Cessation of the costal respiratory movements indicates inflammation of the lung or pleura or a large pleuritic effusion ; cessation of the abdominal play, inflammation of the peritoneum or of the intestines: excessive ascites and gaseous accu- mulations produce the same effect. Rachitic softening of the ribs, and those diseases of the lungs which offer a direct obstacle to the entrance of air, are associated with a great increase in the normal recession of the lower portion of the chest on inspiration. The position of the apex-beat is altered by car- diac diseases, by pleuritis, and occasionally by gaseous distention of the stom- ach. When the left ventricle is enlarged, it is shifted downward and to the left. Transmitted epigastric pulsation shows enlargement of the right ventricle. An extended impulse is not necessarily a sign of disease, since the chest-walls are so elastic in childhood that the normal impact of the apex is apt to affect a wide area. The effusion of pleurisy pushes the heart to the right or left, while the retraction, after absorption or evacuation, draws it in one or other direction. The apex is pushed upward and to the left in gastric flatulence. Emphysema, by pushing the heart away from the thoracic wall, diminishes or hides the impulse. Auscultation.—With infants the back of the chest is most conveniently ausculted when the child is held in the nurse's left arm, with his breast against hers, his chin resting upon her left shoulder, his left arm around her neck, and his head kept in position by her disengaged hand; the front, when reclining on the back on a pillow ; the sides, when sitting upright on the lap, first one arm and then the other being lifted up to allow the observer's ear to be applied. Older children may be made to take the same position as adults. It is not suf- ficient to auscult the posterior aspect of the thorax alone, as is stated by some authors. The whole chest should be examined, particularly in doubtful cases. The signs of croupous pneumonia are most frequently discoverable at one or other base, posteriorly ; the friction-sound of pleuritis at the junction of the middle and lower third of the chest, laterally; and the signs of emphysema at