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of varying the examination; that which I have described is in my l
opinion the best. The child may, moreover, be left at the breast, and 7
auscultated when it is in this position, but then the respiratory move-
ments are too feeble, the air entering the lungs imperfectly, and
the bruits are difficult to appreciate. In other cases the child must
be placed flat on the belly on its mother's knees, or it should be taken
in the hand and the chest applied to the ear.

It is generally observed, and every one repeats it, that the respiration .aumu
of children is puerile, that is to say, that the inspiration is sonorous and
roaring. “It appears," says Laënnec, “that in children the air cells.
are distinctly felt dilating to their fullest extent; whilst in the adults,
it might be imagined that they only half fill with air, or that their
more dense walls cannot allow so extensive a dilatation.”
This may be correct as regards children who have attained the age of

age of Puerile two years, and we have been enabled to corroborate it; but in the newlyborn infant and in the child at the breast this is no longer. the case. Here are The respiration is neither sonorous nor roaring, it is accompanied with a bruit of slight intensity, which possesses nothing soft in its character, bu is analogous to the bruit of hard respiration, and which it is impossible to refer to the complete dilatation of the air cells. We have directed t o very great attention to the study of this subject. We have daily repeated it, and we have never heard anything which bore resemblance to puerile respiration. This is explained by the difficulty which the air experiences in readily penetrating the lung, which is either caused w by the density of the organ or by the construction of the pulmonary vesicles. The density of the lung diminishes with age, and at the Hul same time the diameter of the vesicles increases, a circumstance favourable to the production of the puerile bruit.

A close relation exists between puerile respiration and resonance of the thorax. These two phenomema coexist. If one of them happens lyglass to be wanting, the other disappears. This might be readily imagined,

hann since the rarefaction of the pulmonary tissue is the cause which produces both of them.

The chest of children at the breast is then but slightly resonant. This is a fact which may be easily verified. Nevertheless, the resonance varies much, even in the normal state. It is very feeble in healthy children, in those who possess the plumpness natural to infancy; it is more considerable in those who, without having any affection of per Luistes the chest, have an emaciated thorax. . It is very variable, and it presents singular alterations at the same moment, in the same child, without any derangement of health being present. Thus, on percussing the chest for a long time in succession, the sound obtained alternately increases and diminishes in intensity. It increases during inspiration, and diminishes, on the contrary, during expiration. This phenomenon

of Puerite.

is a very curious one ; it is very decided in the deep respiratory movements observed in children who are agitated and shed tears. The explanation of it is easy : the sound is clear in inspiration, that is to say, when there is much air in the chest; it is dull in expiration, when nearly the whole of the contained air has been driven out.

The direct examination of the chest should always be commenced b ullul-by auscultation, and the chest should only be percussed after having land accomplished this prior method. In fact, percussion agitates children

very considerably, and it would be impossible to auscultate them 2 otadanladvantageously afterwards.

en The walls of the chest are subject to considerable vibrations at the

moment of efforts, whether of the voice, the speech, or the cries. It is right to be aware of the normal force of these vibrations, in order to judge of their increase in pneumonia, of their diminution and of their complete disappearance in pleurisy. In this latter affection

this symptom is one of the most evident that can be met with and til lensed It results then from the physiological study of the respiration of

children at the breast : Ist, that the respiration is not regular, and

that we must not fall into error with respect to the phenomena of the * frequency, the irregularity, and the intermittence of the respiratory 16, movements, which it would be a mistake always to consider as the

consequence of a pathological state ; 2nd, that the respiration of the newly-born infant and of children at the breast is not accompanied by the puerile bruit which exists in children of a more advanced age, and that the absence of puerile respiration should not be considered as a morbid condition ; 3rd, finally, that the results of the percussion of the thorax are uncertain if they are not well defined, since, in the normal state, the resonance of the chest is obscure.

Such are the ordinary phenomena of the respiration of young children in the physiological state. It was necessary to point them out in order to render what follows intelligible. We shall now treat of the important aids furnished to the diagnosis of certain diseases of infancy by the study of the external phenomena of respiration.

OF THE EXTERNAL SIGNS OF RESPIRATION IN THE PATHO

LOGICAL STATE. In order to ascertain the force, the frequency, and the rhythm of the respiratory movements in children at the breast, for they have all

abdominal respiration, it is especially necessary to examine the abdomen, y stripped of clothing, from a distance.

* This study is not only useful to the diagnosis of diseases of the 2chest; it is further indispensable to those who desire to obtain correct * information of certain diseases of the abdomen and of the brain.

In the diseases of the chest, in bronchitis, commencing pneumonia,

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pleurisy, the respiration is simply accelerated. Its frequency is in relation with the intensity of the inflammation; it does not present any sign peculiar to one rather than to another of these affections.

In confirmed pneumonia, on the contrary, the respiration is accom- . panied by external phenomena, highly important and exceedingly sh valuable, which are often the certain index of the disease. The respiratory movements are very frequent without considerable efforts of the abdominal muscles and without agitation of the alæ nasi. From the sixty to eighty inspirations may be counted in a minute. This extreme bune, acceleration of the respiration presents a striking analogy with that of a dog from the chase. This state is perfectly well expressed by the term panting respiration.

"Pauliud Moreover, the disturbance of the respiratory movements is still further increased; these movements, less rapid than in the preceding

1 grenity case, are changed in their rhythm.

ihertades The respiration commences by an active and decided movement of k ey. groaning and jerking dasal expiration, followed by an inspiratory effort, after which a short moment of repose is observed. Each expira

nhau tion is accompanied by lateral constriction of the base of the thorax, enormous projection of the abdomen, and sub-clavicular and sternal depression. To the ensemble of these phenomena I apply the name of expiratory respiration. Let the reader himself perform a decided expiratory movement, immediately followed by an inspiration, and he will perfectly comprehend what my words cannot express.

These external disturbances of respiration are in relation with certain movements of the face and nostrils to which we have already referred ; they are indicated by a smothered groan, which escapes at each inspiration, and suffices to fix the attention on these characteristic phenomena of pneumonia.

Fresh observations will undoubtedly lead to the knowledge of the external signs peculiar to other affections of the chest ; but at present it is impossible to dwell longer on this subject without losing ourselves in the midst of hypotheses. We will, however, point out one characteristic, drawn from the examination of the respiration, which planee possesses a certain importance in the diagnosis of pleurisy, and which may lead to the discovery of its existence. When this characteristiche, is observed, then a pleuritic pain is present. In these cases the awidina respiration is restrained, it stops suddenly, and a quick almost convulsive effort is observed in the muscles of the chest, which appears to me be painful, so far as we can judge by the contractions of the face which accompany it, and by the cry which the children utter at the same moment.

In some affections of the abdomen these external signs of respiration may be very useful in the diagnosis ; thus I have as yet but twice

* thout ; terreah
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C o bserved peritonitis in young children, and in these two cases one could mling have diagnosed the disease by the study of the respiration. It was Tanítshort, incomplete, and of a jerking character; it appeared painful;

the respiratory movements were short, feeble, and rather frequent; mukul they rapidly succeeded each other, but were separated, at the end wie u bezof six or eight inspirations, by a slow and deep respiration, capable

C of supplying the insufficiency of the preceding respirations.

I cannot affirm that this should always take place; observation alone 1411 lay can demonstrate this. In these children it is evident that there was

some obstacle to the respiration and to the respiratory movements

of the abdomen which could not freely distend itself. Each respiration Mueze foto Liwas short and feeble; it was insufficient for hematosis, for, at the

The end of a certain time, the necessity of breathing, overcoming the

obstruction of the respiratory movements, forced the child to make a deep and complete inspiration.

These external disturbances of respiration are so thoroughly in relation, on the one hand, with the anatomical lesions of peritonitis, and on the other, with the pain of the abdomen which in this disease hinders the expansion of the walls of this cavity, that it is impossible for us not to consider it an important sign in the diagnosis of this affection. It is, moreover, the only abdominal disease in which an appreciable modification of the external respiratory phenomena exists.

In the acute affections of the brain, at the time when the convulLiterature sive stage is about to appear, the respiration is short, incomplete, and

intermittent. This sort of internal convulsion of the respiratory

muscles is a characteristic symptom of acute meningitis, either simple 041114, or tuberculous, of encephalitis, and, in a word, of all the acute cerebral

affections, but presents nothing peculiar as regards each of these affections.

In these cases the respirations are in turn slow or rapid, feeble or deep, regular or intermittent, silent or sighing. The child, that breathed calmly, suddenly hastens its respiratory movements, and stops entirely for eight or ten seconds; then it resumes them, and thus continues sometimes slowly, breaking off from time to time to utter a deep, sighing respiration, sometimes quickly, every now and then resting for some seconds.

As we have seen, the respiration presents external modifications peculiar to the diseases of the chest, the head, and the abdomen. They are perfectly distinct in these three orders of diseases.

We must then study them, not with the aim of restricting to these characters alone the knowledge of such or such a disease; but because it is not right that the physician should neglect any practical information which may in any way contribute to science that certainty which is so desirable.

We shall now proceed to consider the deformities of the chest. They are few in number. There is not one which has not been observed in the adult.

These deformities are singular. We have already pointed out that which is peculiar to rachitis; it is useless to return to it. The other deformities are the consequence of acute or chronic diseases of the lungs; they are definitive, and usually only occur on one side. I refer either to the constriction or the dilatation of the chest.

tiesy Dilatation usually accompanies acute pleurisy, when the effusion is onduell considerable. It exists on the diseased side. The constriction, on the contrary, is observed a long time after the cure of the disease, and an in when all the liquid is reabsorbed. These semeiologic characters are adulte common to the pleurisy of childhood and to that of adults.

In chronic pneumonia and in tubercular pneumonia, the pulmonary tubercles also bring on contraction of the chest. This is a fact well established by the researches made amongst the old. Is it well demonstrated in the diseases of the child ? This may be doubted. However, we have observed at the Necker Hospital, in the practice of M. Trousseau, a little child very evidently phthisical, with excavations in the right lung; it was provisionally cured at the end of two years ; * since that period I have met with him, and this side of the chest was found to be considerably narrower than the other. This fact is, I confess, insufficient to establish in a general manner the existence of the narrowing of the chest in chronic affections of the lungs, but it possesses sufficient interest to be alluded to.

Besides these partial, slow, and definitive deformities, others exist which are general, but transient, like the acute affection which causes them. Thus, by slightly straining the value of terms, we may include, under deformity of the chest, the changes of form which it undergoes under the influence of the muscular contraction in very intense dyspnea. Mittlu In well characterized pneumonia, each expiration is accompanied by a considerable lateral constriction of the base of the thorax, an enormous projection of the abdomen, and by a violent sinking of the sub-clavicular teda and sternal depressions. This deformity is pathognomonic of the

a pneumonia of children at the breast. I ought not to pass it over in o wumanas silence; it exists on both sides, it is consequently general ; moreover it is transient, like the dyspnea which it accompanies.

The symptoms revealed by anscultation had disappeared ; & slight cough still indicated the

affection of the thoracic organs.

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