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incomplet observed peritonitis in young children, and in these two cases one could Enghave diagnosed the disease by the study of the respiration. It was in Piritant short, incomplete, and of a jerking character; it appeared painful; the respiratory movements were short, feeble, and rather frequent; Chinkeed they rapidly succeeded each other, but were separated, at the end uble 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 convulsive 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 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 Conthat which is peculiar to rachitis; it is useless to return to it. The

other deformities are the consequence of acute or chronic diseases formations of the lungs; they are definitive, and usually only occur on one side. in Heurisy

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

Dilatation usually accompanies acute pleurisy, when the effusion is dulls considerable. It exists on the diseased side. The constriction, on the

contrary, is observed a long time after the cure of the disease, and Ques 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

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under the influence of the muscular contraction in very intense dyspnoea. Artly

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.

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

CHAPTER VII.

EXAMINATION OF THE CIRCULATION.

It is impossible to exxmine carefully the heart of children at the breast, without immediately provoking an agitation difficult to calm, and one which increases the frequency of the pulsations of this organ. This study fortunately is not very important, for diseases of the heart are very rare in young children, and on the other hand, we can appreciate the frequency of circulation by the rapidity of the pulsations. We shall consequently proceed to study the pulse, and we shall arrive at the knowledge of fevers and of febrile reaction.

ON THE FREQUENCY OF THE PULSE AND ON FEVER IN
CHILDREN AT THE BREAST.

We no longer live in an age in which the seat of disease is determined by the modifications of the pulse, which no one could appreciate now-a-days. The ideas of Galen on this head are abandoned, and the whimsical expressions made use of in order to distinguish the numerous varieties of the pulse, have finally succumbed under the weight of the ridicule cast upon them on the stage. Another system, of which Bordeu was the promoter, rose up on these ruins, and when this physician published his researches, it was for the time thought sufficient to recognize the cephalic, nasal, guttural, pectoral, stomachal, intestinal, hepatic, hæmorrhoidal pulse, &c., the pulse of irritation and the pulse of non-irritation, with numerous others, in order to specify the morbid states which correspond to these different denominations. Such an excess of sub-division in a subject not divisible to this extent ruined the doctrine. Modern physicians did not wait for the criticism and the raillery of another Molière, they themselves exercised justice on those erroneous assertions which, by spreading, could only throw discredit on science.

Thenceforth, they were satisfied with feeling the pulse in order to appreciate the principal sensations it communicates to the fingers, to recognize its feebleness or its force, its fulness or its smallness, its regularity, &c., and they have finally decided on specifying its rapidity by figures. This is the best manner that could have been adopted. We now confine ourselves to feeling and counting the pulse in adults.

In children at the breast the feeling of the pulse is nearly impossible. It must be counted. We can scarcely recognize either its force or

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its feebleness, its fulness or its hardness: intermission is the only phenomenon on which there can be no doubt; it is also the only one which presents any value.

We shall first proceed to determine the frequency of the pulse in young children in a state of good health, so as to possess an indispensable limit of comparison in the study of the frequency of pulsations in the course of diseases; we shall then treat of some of the characteristics which the pulse presents at this period of existence.

The numeration of the pulse scarcely presents more difficulties in children at the breast than in adults. The pulsations are sometimes difficult to appreciate when they are feeble; the least movement of the fingers or of the hand of the child permits them to escape us, but with a little patience we may always succeed in counting them.

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Authors who have paid attention to this subject have arrived at very different results. Thus, Haller fixes the number of pulsations of a child at 140 a minute. Sommering very properly gives figures varying according to the ages of children-the pulsations number 130 or 140 in the first year, 120 in the second, 110 in the third, &c., and 80 46 at the period of puberty. Dr. Gorham, who appears to have carefully

studied this subject, has observed in children from one day to one week /2, old, a minimum of 96 and a maximum of 160. In M. Valleix's treatise we find the numbers 76 and 104, extreme figures taken in children from two to twenty-one days old, and in children from seven to eight months the average figure of 124. It is Billard who, in his Recherches, has observed the most extensive variations: in thirty-nine children, of from one to ten days, he he has observed a minimum of 80 and a maximum of 180. If no error exists, this result may possess an immense importance, as we shall see further on. The figures published by M. Trousseau nearly approach those of Gorham; he has found a minimum of 96 and a maximum of 152, in children from fifteen to thirty days old.

It seems a difficult matter to explain such differences in the observations of men equally trustworthy. I do not believe that any error exists on the part of these physicians; for Haller, Sommering, and Billard were not ignorant that in the numeration of the pulse we should take into consideration the acceleration caused by internal emotion, agitation, muscular movements, and alimentation; in fact, by numerous other circumstances the value of which we all know how to estimate, and which it is useless to indicate here. They were aware that allowance should be made for these influences in their observations in the adult, why should they have neglected them in children? I believe, consequently, in the correctness of the numbers given by these authors, who are sufficiently enlightened not to be considered, without injustice, as superficial or inattentive observers.

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If these differences are real, and we cannot doubt it, they must be referred to the age itself of the children, and we must conclude that at this period of existence the arterial pulsations are not yet regulated as they are at a later period. It is this, moreover, which ought to result from the facts about to be detailed.

MM. Jacquemier and Lediberder, in their interesting researches, have calculated the frequency of the pulsations of the heart in the fœtus while yet in the mother's womb, at the last term of pregnancy, in the foetus at the moment of birth, and in children at the first day of existence. In fifty-one subjects of the first category, that is to say, in the foetus while yet in the mother's womb, M. Jacquemier has observed from 108 to 160 pulsations in a minute, and from 96 to 156 in children near twenty-four hours old.

M. Lediberder could only count the pulse in the first minute of life in six children, and he has observed from 72 to 94 pulsations. This number rapidly increased after birth, doubtless under the influence of the establishment of the functions. At the fourth minute it became raised to the enormous amount of 140 and 208.

The pulsations of the heart, then, very frequent in the course of foetal existence, are much diminished at the moment of birth, and become slightly accelerated in the first day of existence.

In children of more advanced age it is necessary, in order to effect Pa numeration of the pulse, to make choice of subjects in good health; they should be taken in a moment of calm, a long time after lactation, their attention being distracted by the sight of an object which interests them, thus preventing any momentary acceleration of the circulation. Separate observations should also be made on children awake and on children asleep. Lastly, if a complete table is desired, the frequency of the pulse should be ascertained in children who are agitated, and in those who obstinately cough, weep, or cry.

M. Valleix, in his work,* has only especially referred to children from two to twenty-one days old; we shall presently allude to the results which he has obtained.

It is impossible for us to profit by the tables which the second part of this treatise contains, for we there find children of seven months and those of six years united in a single class. Moreover, if we would appreciate the influence of age on the acceleration of the pulse, we must proceed in a different manner, and treat separately, in little categories, children of six months, of one year, of two years, and so on. It is true M. Valleix thought he could dispense with this process by taking the mean of the age of all the children submitted to his observation, and by calculating the mean of the pulsation of the heart. But this method is imperfect, and would necessarily lead to error. The

* Va'eix, Memoires de la Société médicale d'observation; t. ii.

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