of varying the examination; that which I have described is in my Ausculta. opinion the best. The child may, moreover, be left at the breast, and Tienauscultated when it is in this position, but then the respiratory movements 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 Que on a of children is puerile, that is to say, that the inspiration is sonorous and cucule roaring. "It appears," says Laennec, "that in children the air cells/ are distinctly felt dilating to their fullest extent; whilst in the adults, fra it might be imagined that they only half fill with air, or that their more dense walls cannot allow so extensive a dilatation."

Querile

This may be correct as regards children who have attained the age of two years, and we have been enabled to corroborate it; but in the newly- Grint born infant and in the child at the breast this is no longer. the case. not heard The respiration is neither sonorous nor roaring, it is accompanied with a bruit of slight intensity, which possesses nothing soft in its character, 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 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 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 same time the diameter of the vesicles increases, a circumstance favourable to the production of the puerile bruit.

المان

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

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 sussulla by auscultation, and the chest should only be percussed after having accomplished this prior method. In fact, percussion agitates children very considerably, and it would be impossible to auscultate them advantageously afterwards.

u that d Ches. 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 In this latter affection of their complete disappearance in pleurisy. oral Bu this symptom is one of the most evident that can be met with. Tes de Creased It results then from the physiological study of the respiration of children at the breast: 1st, 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 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.

The walls of the chest are subject to considerable vibrations at the moment of efforts, whether of the voice, the speech, or the cries.

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, stripped of clothing, from a distance.

This study is not only useful to the diagnosis of diseases of the chest; 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,

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 ends, as

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valuable, which are often the certain index of the disease. The respiratory movements are very frequent, without considerable efforts of the abdominal muscles and withes agitation of the ala nasi. From sixty to eighty inspirations may be counted in a minute. This extremely acceleration of the respiration presents a striking analogy with that of a dog from the chase. This state is perfectly well expressed by Chines the term panting respiration.

Moreover, the disturbance of the respiratory movements is still further increased; these movements, less rapid than in the preceding case, are changed in their rhythm. The respiration commences by an active and decided movement of ** groaning and jerking nasal expiration, followed by an inspiratory effort, after which a short moment of repose is observed. Each expiration 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, possesses a certain importance in the diagnosis of pleurisy, and which' may lead to the discovery of its existence. When this characteristic. 4, is observed, then a pleuritic pain is present. In these cases the respiration is restrained, it stops suddenly, and a quick almost convulsive effort is observed in the muscles of the chest, which appears to.. 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

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observed peritonitis in young children, and in these two cases one could ng have diagnosed the disease by the study of the respiration. It was in Pritinil short, incomplete, and of a jerking character; it appeared painful; the respiratory movements were short, feeble, and rather frequent; Fainkul they rapidly succeeded each other, but were separated, at the end tuble herof six or eight inspirations, by a slow and deep respiration, capable of supplying the insufficiency of the preceding respirations.

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I cannot affirm that this should always take place; observation alone 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 was short and feeble; it was insufficient for hematosis, for, at 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 convulit sive stage is about to appear, the respiration is short, incomplete, and This sort of internal convulsion of the respiratory libus intermittent. muscles is a characteristic symptom of acute meningitis, either simple 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 lest conthat which is peculiar to rachitis; it is useless to return to it. The other deformities are the consequence of acute or chronic diseases formalens of the lungs; they are definitive, and usually only occur on one side. Asunsy

I refer either to the constriction or the dilatation of the chest.

Dilatation usually accompanies acute pleurisy, when the effusion is dul's considerable. It exists on the diseased side. The constriction, on the contrary, is observed a long time after the cure of the disease, and me t when all the liquid is reabsorbed. These semeiologic characters are 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 dyspnoea. 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 and sternal depressions. This deformity is pathognomonic of the pneumonia of children at the breast. I ought not to pass it over in silence; it exists on both sides, it is consequently general; moreover it is transient, like the dyspnoea which it accompanies.

* The symptoms revealed by auscultation had disappeared; a slight cough still indicated the affection of the thoracic organs.