"On distortions of the chest and spine in children, from enlargement of the abdomen"

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By John Snow, M.R.C.S.

(For the London Medical Gazette.)

Read at the Westminster Medical Society on March 13, 1841.

It is not my intention to describe the various deformities to which the chest and spine of children are liable, but only to speak of one or two distortions which arise from enlargement of the abdomen--a cause of deformity which, hitherto, has not, that I can find, been recognised by authors.

I shall relate only one, out of a few cases that I have witnessed, which will serve sufficiently to illustrate the points that I wish to establish. [112/113]

Aug. 16, 1839.--Hugh Lynch, a twin child, aged two years and five months, has had a double scrotal hernia from birth. He has been ill for the last four months; his mother says much in his present condition. The abdomen is very large and tympanitic; the chest is broad behind, very narrow in front, and flattened at the sides; the sternum projects forwards very much, especially at the lower end. The cartilages of the ribs, instead of passing outwards from the sternum on each side, leave that bone at another angle by no means very obtuse, and pass backwards to meet the osseous part of the ribs at another angle; and the cartilages of the false ribs project laterally from the bony portion, so that the lower part of the chest is much expanded where it unites with the enlarged abdomen. The last of the dorsal and first of the lumbar vertebræ project backwards, whilst the lower lumbar vertebræ project forwards and the sacrum backwards. The child is emaciated and feverish; its bowels are disordered, and its appetite is craving. Its mother feeds it chiefly on potatoes. The breathing is quick, the inspiration being easy, but the expiration difficult, and attended with all effort approaching to a cough; the upper part of the air–passages being closed after each inspiration, and then the air escaping with a slight sound, similar to that which takes place after the breath has been held for the performance of any muscular exertion. During each inspiration the abdomen descends and protrudes, and the cartilages of the ribs are forced inwards on each side of the sternum. During expiration, on the contrary, the abdomen retreats, and the ribs return to their previous situation. There is loud puerile respiratory murmur, and the chest yields a clear sound on percussion at all parts.

To take some Hydrargyrum cum Creta, and be fed in a more rational manner.

Sept. 27th.--The child is more emaciated. His belly is still large, but much less than before. His chest is of the same form, but the cartilages of the true ribs do not fall in so much during inspiration; those of the false ribs, however, are drawn inwards by the diaphragm at each inspiration, and so project towards the lower end of the sternum, whilst a hollow is left just beneath at the scrobiculus cordis. The thorax yields a clear sound on percussion, but there is a mucous rale.

The child died on Oct. 29th.

Examination, seven hours after death--The spine is now pretty straight. Abdomen very much less than formerly, but yet tumid. The chest yields a dull sound on percussion throughout the greater part of its extent, although a few hours before death it sounded clear. On opening the abdomen, the diaphragm, instead of its usual arched form is found to be stretched horizontally across the body, so that it is not so high as the seventh rib. The lungs are healthy in structure, but the whole of the left lung and the lower lobe of the right are collapsed and totally void of air, and gorged with dark fluid blood; the remainder of the right lung is crepitant and healthy. The heart is healthy, but the pericardium contains three or four drachms of serum. Each rib is enlarged into a spongy head at the part where it unites with its cartilage.

The large intestines are distended with flatus, except in portions where they are firmly and preternaturally contracted. The colon is so much lengthened that it crosses the abdomen three or four times. The cœcum is in the usual position, and from this the colon extends to the left side and back again, then passes upward to the stomach, across the abdomen, and down the left side in the usual route to the sigmoid flexure; which flexure extends into the right iliac fossa, and back to the median line, where it unites with the rectum. The remainder of the abdominal viscera were healthy. The head was not examined.

In order to show satisfactorily that this deformity of the chest is caused by the enlargement of the abdomen, I must prove that the space within the thorax is increased by any great distension of the abdomen, and not diminished, as is generally supposed. As the belly increases in size, the false ribs, with their cartilages, are pressed upwards, and approaching to a right angle with the spine; the circumference of the chest is thus increased, and the abdominal muscles, which by drawing down the ribs are the chief agents of expiration, can but ill perform their duty; they are kept on the stretch by the bulging out of the viscera, or whatever they enclose. Moreover, the diaphragm, [113/114] being attached to the base of the chest all around, has its borders drawn further apart by the increased circumference of the thorax, and thus its natural arched form is removed; it approaches to a plane partition, and the chest, so far from being encroached upon by the abdominal cavity in this direction, has its perpendicular length increased.

I may here state I have always observed that the difficulty of breathing arising from enlarged abdomen, whether in human beings or quadrupeds, consisted in obstructed expiration, and not obstructed inspiration when there was no other cause of dyspnœa.

The bellies of children are subject to a very much greater proportional enlargement than ever obtains in the adult, and the cartilages and ligaments of the ribs being more flexible and distensible, the expansion of the base of the chest becomes very great; and as the lungs are compelled by the atmospheric pressure to occupy every part of the chest, they must either be preternaturally distended, or the chest must be depressed in some other direction. Now, as the ribs and their cartilages are slender and flexible in children, the latter takes place; the chest becomes depressed laterally, and the sternum projected forwards, whilst a channel is left down each side of the chest where the cartilages unite to the bony portion of the ribs. The action of the diaphragm, which presses down the abdomen, and at the same time draws up the cartilages of the lower ribs, during each inspiration, makes room for more air than the lungs are inclined to receive, and the sides of the chest are pressed further in during each inspiration, and return again during expiration: thus the motion of the ribs becomes the reverse of the natural one. I do not conceive this arises from the mechanical resistance of the lungs, but from the sudden stoppage at the throat to the further access of air, which I have observed to be never absent during this deformity with inverted motion of the ribs. It is made evident by the slight explosive sound when the passage is again opened at each expiration. This check to the further ingress of air is no doubt a voluntary or instinctive effort to avoid the uneasy sensation arising from too great distension of the lungs. I do not think it consists in a closure of the glottis, but in the approximation of the posterior palatine arches, and the pressure of the root of the tongue at the same time against the palate of the mouth: the method by which, as Dzondi has discovered, the breath can be held. It is the office of the serratus magnus and the pectoral muscles to expand the sides of the chest during inspiration, but the diaphragm enlarging the chest more powerfully in another direction, these muscles yield to the atmospheric pressure, and eventually, so far as respiration is concerned, become paralysed.

I have never seen enlargement of the abdomen to great extent in a child under three years of age, that was not accompanied with this deformity of the chest. The degree of deformity is always in proportion to the enlargement; and in observing any individual case, the deformity is found to increase with the increasing size of the abdomen. Even when the enlargement of the belly is not great, there is a tendency to this deformity observable in the slight lateral projection of the cartilages of the false ribs. After the age of three or four years I have not observed this deformity to commence, probably because the ribs become of a strength which prevents it; besides that the abdomen is not so liable to become tumid.

The other deformity, that of the spine, seems to be only an occasional, and not a constant attendant on enlarged abdomen: I think it is in the worst cases that it prevails. It consists in a projecture, frequently an angular one, of the last dorsal, or great lumbar vertebræ, or both. In the case I have just detailed it was accompanied by a secondary projecture of the sacrum; and in another case it was attended with a slight lateral deviation. This projecture of the spine is probably caused by the stretched abdominal muscles and integuments, drawing, by means of the pelvis and chest, on the opposite ends of the spinal column, whilst the increased contents of the abdomen make a resistance in the centre. That this angular projecture of the spine depends on disease of the bodies of the vertebræ in the first instance, we are forbid to suppose, by the fact that the projecture subsides as the abdomen diminishes.

In one child, an angular projecture [114/115] for which the formation of issues had been previously recommended, perfectly disappeared as the child resumed his health, under tonic and alterative medicines, with attention to diet, and bandaging of the abdomen. It most likely depends on partial absorption of the intervertebral substance, or bending of the bodies of the vertebræ at the affected part, and, if continued, might no doubt lead to permanent disease.

Baron Dupuytren, in a paper published in the "Repertoire Géneralé d'Anatomie et de Physiologie," in 1828, described a deformity of the chest of children, which I believe, in many of his cases at least, to be the one of which I am speaking. It occurred in children badly clothed and fed, born of unhealthy parents, and living in damp situations, and was accompanied, in most cases, by enlarged tonsils, requiring sometimes to be extirpated. He said that there was a keel-like projecture of the sternum in front, and a sharp prominence of the spine; that the ribs were not only flattened, but that they were sunk into the chest as if they had been compressed from one side towards the other. This deformity was accompanied with great difficulty of breathing. He did not mention the abdomen, except in his preliminary remarks, to say that there was projecture forwards of the sternum and belly; and he only alluded to it, I think, in one of his illustrative cases, in which, however, he said the belly was five times as large as the chest. In another case he spoke of the width of the chest at the base. He appeared to attribute the deformity to arrest of ossification, and softness of the bones; and recommended some mechanical measures and exercises, in addition to medical treatment, for its cure. He spoke of some cases in new–born infants, which, I think, could not have the same origin as the cases I have seen. The nature of the connection between these deformities and the enlargement of the tonsils, he could not tell.

I have only seen one case since I read Baron Dupuytren's paper, and in this there was no enlargement of the tonsils. I can, however, suppose that the obstruction to inspiration from enlarged tonsils, might cause the ribs of a child to be pressed inwards by the atmosphere, and produce a deformity of this kind.

In the Medical Gazette of January 12th, 1839, is a letter by Mr. Rees, describing the deformity of the chest of which we are treating as occurring in four or five children seen by him at the Tower Hamlets Dispensary. He describes the depression at the line of union between the ribs and their cartilages, producing a channeled appearance external to the sternum on each side; and he likewise describes the inverted action of the ribs in respiration. Mr. Rees does not mention the abdomen, except in the case he relates for illustration, in which he incidentally says it was tumid. He attributed the deformity to chronic pneumonia, which causing the lungs to shrink and become solidified; the ribs are forced in by the atmospheric pressure to occupy the space. We can perceive that shrinking of the lungs might have this effect, but in the cases I have witnessed there was no disease of consequence in the lungs, except in one child that had hooping-cough.

Mr. Amesbury describes this deformity, and the enlargement of the abdomen in connection with it; but he does not speak of them in the relation of cause and effect. He attributes this deformity to weakness of the muscles. He says, "Deformity of the chest, arising from weakness of the muscles, commonly takes place during teething, but may be produced by any complaint that tends to debilitate the system. This distortion usually assumes the form called 'chicken–breast.' In this variety of deformity the chest is usually more or less contracted laterally, the sternum is thrust forward, and the abdomen is preternaturally enlarged. The intercostals muscles act very little in respiration, the breathing being principally abdominal." Together with medical treatment for the improvement of the general health, Mr. Amesbury recommends bandaging the abdomen for the cure of this deformity.

Baron Dupuytren and Mr. Amesbury do not mention the reversed action of the ribs in breathing. Mr. Rees and Mr. Amesbury do not allude to any deformity of the spine; and the projecture to which Baron Dupuytren alludes appears to be one of the whole spine, and not of particular vertebræ. [115/116]

In two or three of the cases I have seen, the inferior extremities became deformed under the weight of the enlarged belly, but it was the joints which yielded, and not the shafts of the bones; and there was only in one case the enlargement of the heads of the bones peculiar to rickets: where rickets exists it may assist to aggravate the deformity, but cannot of itself cause it. A scrofulous diathesis, by predisposing to mesenteric disease, may be considered favourable to the development of these deformities; but in the cases I have seen, I do not remember to have observed enlarged glands, or other decided marks of scrofula. And in the only two cases in which I have had the opportunity of an examination after death, there was no disease of the mesenteric glands, and the enlargement depended chiefly on the elongation and distension of the colon.

I have generally been able to trace the increased size of the belly to improper food, and have found it mostly amongst those infants who, from the poverty or intemperance of their parents, are, after weaning, fed almost entirely on potatoes. I believe the best treatment to consist in alteratives and tonics, with occasional purges, and the careful avoidance of crude and indigestible food. At the same time the abdomen should be firmly bandaged, as recommended by Mr. Amesbury, which measure, whilst it assists to reduce the belly to its natural size, will relieve the breathing by aiding the efforts of expiration; and by pressing the diaphragm upwards, will reduce the capacity of the base of the chest, and thus lessen the cause of the contraction higher up. If this deformity be left to itself, and should not prove fatal, the serratus magnus, and other muscles, may not recover their power of expanding the ribs, or the ribs may have become firm in their abnormal shape, and the deformity may continue, after the enlargement of the abdomen, which gave rise to it, has subsided. I have seen two or three cases of this deformity in grown–up persons, which, so far as I could gather the history, appear to have originated in this manner.

Thus, then, I have endeavoured to establish that enlargement of the abdomen in children leads to deformity of the chest, and occasionally of the spine; and that although the deformity of the chest, or one nearly resembling it, may now and then arise from other causes, yet that this enlargement is of itself sufficient, and will never fail to induce it, if proceeding to any great extent in young children.