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The changes, relative to the form of the cries, are indicated by

their state of weakness and by their painful or smothered character.

'fi ft tsuj ^he weakness °f *ne cries is especially met with in young children

'who come into the world scarcely alive, in a state of seini-asphyxia, and

(t /TLiL-fi, m children who, at a more advanced age, are weakened by a chronic

I ' . i disease and nearly moribund.

\\amvi***- fne gmothered cry is principally met with in the affections of the

respiratory organs, and particularly in well characterized pneumonia.

■lUJnllAJ^ In this case each expiration is accompanied by a completely smothered

"'' T1u\*ma cry' '* k a we^ denned groan rather than a cry. However, it i

L. ^excessively rare to meet with it in the course of other diseases; Ha

presence should then be taken into consideration.

, ,:'|tZ*t /**• • The changes which affect the tone of the cry are sufficiently important;

thus the single, sharp, and very powerful cry, appearing at rather

distant intervals, has been referred by MM. Maunoir, Coindet, and

a great number of physicians, to acute cerebral diseases. The name of

hydrocephalic cry has been applied to it. It is too frequently wanting,

,. / / so that a great semeiologic value cannot be attached to it. The

/ 'following, moreover, is a fact which still further deprives it of a

, .<"/, portion of its importance: this is, that it is also met with in the

course of other diseases. Thus, according to MM. Auvity, Billard,

Valleix,* this sharp cry is met with in the oedema of the newly-born.

.'( . -fi^n Here, however, it is more feeble and much more frequent; it is repeated

every minute. But, granting that the modifications presented by these

-. n"-', cries are vory evident, and consequently even characteristic of a

particular morbid condition, it appears to me impossible to point them

out in a more precise manner.

','•;»/!-. There is scarcely but one disease in which the cry presents important

and characteristic modifications; I refer to croup. The cry is muffled,

.., . ,4 £ Hhe expiration hoarse, and there is sometimes a noisy inspiration which

authors have compared to the crowing of a young cock. At the last

, » ■ ** stage of the disease the inspiratory noise disappears; nothing remains

"^ . A but the hoarse and considerably enfeebled expiration; it may be truly

"", said that the voice is extinct.

Billardt speaks of a tremulous cry which he has only met with

•i0 three times in very young children affected with an oedematous angina.

He suspects that this modification belongs to the disease which ho

refers to, but he dare not affirm it; and he sagaciously remarks that

we must wait until further observations tend to confirm this fact.

The duration of the cry of children merely indicates a very acute pain, without any relation to the affection of such or such another organ. Billard believed that a prolonged cry was to be observed in diseases of the stomach, colic, ileus, peritonitis, <kc; but as these facts have not been established in a very definite manner, their precise value cannot be decided upon.

* CUnUptt da maladia da en/anlt Iiohivii«■»<■>; Paris, 1838; p. 027. t TraiU da maladiet da en/mitt noueeau-na.

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Although the signs furnished by the study of the cry of children have not furnished us with very splendid results, they must not be neglected. Future investigators may probably derive greater advantage than we have yet done. Not only is it necessary to hear the natural or spontaneous /r^

cry, but if the children do not cry when we examine them, they may be k^-frj, tiAM slighty shaken in order to compel them to utter some cries, which may enlighten the physician. In a word, the cries must be provoked, so that nothing may be neglected in the examination of the patients. The signs furnished by the provoked cry are much the same as those furnished by the spontaneous manifestation of pain.

CHAPTER V.

ON THE EXTERNAL SIGNS FURNISHED BY THE EXAMINATION
OP THE MOUTH AND THE ABDOMEN.

Op The Mouth.

The inspection of the mouth furnishes the physician with a great number of signs, which it is very important he should recognize. Thus, j J 7 . without reference to the deformities of this part which alter the \J> &L4-L4*' appearance of the face, and which have been previously discussed, we find objects of study in the colour, the heat, and the dryness of the '''■£■ buccal mucous membrane, its accidental productions, the manner in J . j which suction is performed, the products of secretion, the odour, &c.

In order to appreciate most of the characters we have just referred f * J to, it is sufficient to introduce the finger into the mouth of a very young child. We thus recognize the more or le68 intense heat of this / , . part, its state of dryness, which is never considerable, the swelling of v4*rt^ the gums, the number of teeth already pierced, and sometimes even #7

the cryptogamic mass of thrush developed on the surface of the mucous £uXu.v' membrane.

Ocular inspection now gives more value to this preliminary examina- 1 / u.' tion; the child becomes agitated, cries, opens the mouth widely, and we may then, by depressing the tongue with a spoon, perceive the »; redness, the ulcerations, and the accidental productions of the mucous "^^^ '* membrane.

By the introduction of the finger into the mouth of young children, Hl/H^ffl**we may to a certain extent judge of their natural vigour, and ascertain the state of weakness into which disease has thrown them. This ". i operation always deceives them; they believe they are seizing the i^A-^'

M:\un'7.

breast, and suck the end of the finger with more or less avidity. The efforts of suction are very violent in children in good health, and in those who have only a trivial affection. They are very feeble, on the contrary, and sometimes annihilated, in those whose constitution is ruined by a chronic disorder, or who are labouring under a very serious acute disease. >_ The examination of the mouth is not always very easy. Children

'•'*•' *•*■ , who are of a more advanced age struggle against the physician, "il^-JLc "^ "^ forcibly keep the jaws closed. The nose should in this case be i , pinched, so as to compel them to breathe through the mouth. They "cry, and we may then profit by this moment to make the exploration t / , JbuWu , of which we are now treating.

From the mouth an infectious odour may arise which offends the

.' >A T^ nose, and which, alone, by its presence indicates gangrene of a portion

of the buccal cavity, one of the most terrible affections of childhood.

We must not terminate what relates to the examination of the mouth,

^ 'ft H friU-C without mentioning a phenomenon which sometimes causes uneasiness

to parents, but which, nevertheless, is of no importance. I refer to the

secretion of saliva. The same is the case with this secretion as with

,' the secretion of tears. It does not exist during the first months of

existence. It only becomes established towards the fifth or sixth

'" ///•/• month, at the approach of the dental evolution, and probably under

the influence of the irritation caused by this process. The secretion

of saliva is rather a physiological fact than a morbid phenomenon.

This liquid only flows so abundantly externally because the teeth

,"i .' I .'It **- destined to retain it in the cavity are absent.

i

v t. U~ Of The Abdomen.

> '/ »'■/:). T^e abdomen is the most voluminous part of the child's body. Its extent is very considerable, and appears to be in relation with the activity of the digestive functions at this age. This disposition is quite natural and presents nothing which should occupy our attention.

In the state of disease, it is important to discover whether the belly

is tense and painful. The exploration is not always an easy matter,

for the agitation which it causes provokes cries and tension of the

.abdominal muscles, which prevent our arriving at the wished for

'' l J t •*' v result. The attention of the child should then be distracted, by showing

it an object in which it becomes interested. When its attention is

fixed, the hand may compress the abdomen, and discover if it is supple

and especially if it is painful. The gestures and the cries of the child

*''t ' i •'' arc in this case the index of pain which it experiences in consequence

L of the pressure of the hands, for they cease with the examination.

. \. Q '•' , The pain of the abdomen is never very intense in children, it exists

nevertheless, but to a slight extent. It is especially observed in ■'if til-' catarrhal diarrhoea and in entero-colitis.

CHAPTER VI.

ON THE EXAMINATION OF THE CHEST AND ON THE
RESPIRATION.

The examination of the chest has for its aim the recognition of external characters of the respiration, the different varieties of the respiratory bruits, the resonance of the chest and the various deformities to which the walls of this cavity may be subject.

"We should here only treat of the signs furnished to the diagnosis of certain diseases of childhood, by the study of the external phenomena of respiration; but in order to comprehend the disturbances which arise in the exercise of a function, it is necessary to have studied the action of it in the physiological state. Moreover, there are few who have performed this task ae regards the respiration of the newlyborn; and, as a general rule, any pecularity which this function presents at this age is unknown.

"We shall now proceed to treat of the normal respiration of young children, and we shall then return to the external characters which it presents in the pathological state.

Study Op The Respiration Of Children At The Breast.

The result of the respiratory movements is the revivification of the blood. They commence immediately after birth. The respiration becomes instinctively established; it takes place by virtue of influences as mysterious as those which surround generation, of which it is the necessary complement. Its action becomes combined with that of the brain and heart, already established in the womb of the mother, so as to form this indivisible and absolute trio, this vital tripod of Bichat, the indispensable base of the entire organism.

The respiration is not performed in the same manner at all ages; in the child who happens to breathe for the first time, as in the old * man who is near terminating his existence. The newly-bom infant, t*Li^r quite inexperienced, breathes instinctively as often as necessary, without ,|i . . f' regularity, as without method; it is interrupted at the least event, and , f is with difficulty quieted. It appears to essay its respiratory powers l^l tsVtt-tfi with an irregularity comparable to that which reigns in the movements h±ji * of its arms. Towards the age of two years these irregular movements cease; the respiration becomes regular, and finally resembles that of the adult.

The respiration of the newly-born infant and of children at the breast

is then irregular; it is, moreover, incomplete, the lung being at this age more dense and less permeable to air than in subsequent years. These external modifications are accompanied by similar modifications in the tone of the respiratory bruits as ascertained by auscultation. It is then of the highest importance, before studying the diseases of the lung and the disturbances of respiration which accompany them, to be perfecUv acquainted with the phenomena of normal respiration, i When the mechanism of respiration is considered, it is observed

. 'ji IX/lM-i "that it takes place by means of the muscles of the wall of the ft-^jjjj abdomen and of the diaphragm. The abdomen rises and sinks , in consequence of alternate movements, described under the name ifL rU.t ii 0f respiratory movements. The dilatation of the chest is feeble and / uj; ^^/'ia effected by the inferior ribs. It is the action of the diaphragm i which constitutes the active part of respiration. It has received the

k \ I ^W , name of abdominal respiration. J, .7.,,, .In the state of health the respiratory movements differ during waking

and sleeping. When the child is asleep his respiration is tranquil, is repeated twenty to thirty times a minute; the movements of ,' i . i inspiration and expiration succeed each other regularly and without , / effort. During waking, this appearance is incessantly disturbed. The ,":), h respiration calm, suddenly becomes intermittent, accelerated, and even 'hurried; then a period of repose arrives and all returns to the normal

condition. These modifications are repeated a thousand times a day; 5 C^4 t' **/ they appear to result from an agreeable internal emotion, betrayed by i the expansion of the features and by the smile, or by a distraction caused by external objects, for the attacked child remains with its mouth gaping, the breath suspended, which soon makes up for by precipitating , [A. r- its respiration. These modifications are produced in a still more decided manner at the time of the cries and sobs caused by suffering and anger. The number of inspirations is then very variable; we reckon - f • iJ a twenty-five, thirty, and even thirty-five respiratory movements in a * minute. .i^'i't.'***, Auscultation demonstrates still more perfectly than inspection from a distance all these variations of frequency, of momentary suspension, of irregularity in the rhythm of respiration. Only it gives a notion of excess, relative to the bruits which the air produces in entering the lung.

It is necessary to use great precaution when it is wished to auscultate the chest of young children. It should be examined during the state of calm and at the period of the agitation. The child is placed undressed in his mother's arms, and is examined at a distance; then we approach . / /_'* . ,/ and gently auscultate it. Soon the child, becoming cross, utters cries; we- should profit by this to auscultate it afresh, for the symptoms are often modified in these different situations. There are numerous methods

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