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CHAPTER III.

ON CHOLERA.

Many writers very improperly include under the name of cholera certain forms of enteritis of young children, accompanied with prostration, emaciation, and considerable evacuations. These are severe forms of choleriform enteritis, if we may make use of this term metaphorically, but they are not true examples of cholera. There is as much difference between the flux of cholera and the flux of intestinal inflammation, however abundant it may be, as there is between the lachrymal flow of corneitis, and that of measles or of moral emotions. It is specificnesss which characterizes and distinguishes diseases, and a secondary phenomenon can never conduce to this end.

Cholera morbus, the true epidemic cholera, may exist in children at the breast, and I have observed several cases of it at the Hôtel Dieu, during the epidemic of 1849. It appeared with its principal characteristics slightly modified by the tender age of the children. Entire families rapidly died, with all their children rapidly carried off by the scourge. Thus, in this epidemic I have seen a child two years and a half old, labouring under diarrhoea for eight days, who was suddenly seized with vomitings, cramps, spasms, and cyanosis, and died at the end of forty-eight hours. Whilst the child was being buried, the mother remaining with her nursling one year old, observed it suddenly swoon in her arms, commence vomiting, void copious stools, utter cries, and at length die after two hours of horrible suffering. In her turn, the same evening, she, having had diarrhoea for four days, was seized with vomitings, cramps, and asphyxia, and died at the Hôtel Dieu. The father soon followed; seized two days after his wife, he died at the end of forty-eight hours.

A woman

2nd Case. Epidemic cholera in a child seventeen months; death. in the seventh month of pregnancy, nursing a child seventeen months old, was admitted in the Hôtel Dieu with all the symptoms of epidemic cholera. She died two days afterwards.

The child enclosed in the uterus had ceased to move; it had died, it was said, three days since.

The other child, seventeen months old, has also the cholera.

The face is red, suffused, the eyes brilliant, the hands bluish, contracted, warm; the feet bluish, warm; the limbs rigid, the gastrocnemii muscles very hard, in a state of permanent contraction; all the skin of the body tolerably warm. It cries, and becomes contracted every instant; vomits aqueous matters, and passes frequent stools, consisting of a colourless liquid.

The pulse, which is appreciable, is 120. The child died four hours after admittance.

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I could here relate three cases of epidemic cholera in children at the breast, but it is not my wish to lengthen this chapter, and I shall confine myself in comprising them in the recapitulation of the disease.

The cholera of infants and of children at the breast may become developed primarily amongst them under the epidemic influence, and may afterwards propagate itself to the mother who gives them the breast; or, on the contrary, commencing by the mother, it secondarily attacks the nursling. The cholera of children is, then, epidemic; it is probably contagious, but there is nothing well established on this head.

It commences by colic, diarrhoea, vomiting of watery inodorous matters, which have nothing characteristic like the epidemic cholera of adults. The colic is frequently very violent, and appears to cause much suffering to the children, as far as can be judged from their cries. General cramps accompanied by tonic contractions of the limbs, fingers, and toes, afterwards come on; the face becomes pinched and shrivelled, and the eyes excavated; the skin loses its colour, or else becomes of a livid red, bluish, without true cyanosis; the chilliness is little marked, the languishing circulation persists to a feeble extent, even at the approach of death. Then, only, does the cry lose its force, and ends by becoming extinguished. At this period also, the cramps become general, and are accompanied by general tetanic spasms. They last until death closes the scene.

I have never seen the epidemic cholera of young children last more than forty-eight hours, and all the patients attacked with it died.

At the post mortem examination I have never observed any alteratiou in the mucous membrane of the ileum and of the large intestine, not even that hypertrophy of the follicles which is sometimes noticed in the adult and in the child in many cases of ordinary enteritis.

To recapitulate, then: the epidemic cholera of children at the breast presents itself with most of the ordinary characteristics of this disease; it has appeared to me to differ in a marked manner from the epidemic cholera of adults by the slight intensity of the cyanosis, the slight degree of cold, the aqueous nature of the alvine dejections and of the vomited matters, a more sustained persistence of the circulation, and an exaggeration of the cramps, the extent and form of which appear to approach very closely those of true tetanus. It also differs from it, in possessing a much greater fatality than in the adult, for all the children who were seized with it died, without the possibility of anything curing them.

CHAPTER IV.

ON THE DYSENTERY OF INFANTS.

Dysentery is a very rare disease amongst young children. Its cerra existence might even be denied if it had not been observed at the periods to of some severe epidemics of dysentery.

Strack relates having observed an epidemic of dysentery in 1757,

at Mayence, when he met with several cases of this disease transmitted his Aufrom the mother to the child, and thus presenting themselves in a congenital form. Zimmermann relates the history of a woman of Frauenfeld, who, having had a dysentery for fourteen days, was confined of a child labouring under the same disease, who died at the tenth day. Strack distinctly states that a child born of a dysenteric

mother cannot live.

These are rare cases, which I can neither call in question nor criticise, and which I simply cite on account of their peculiarity. Probably the authors above named have described as dysentery a simple intestinal hæmorrhage, frequent enough amongst infants, as will be described further on.

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CHAPTER V.

ON SOFTENING OF THE MUCOUS MEMBRANE OF THE STOMACH.

Some years ago, the gelatiniform and pultacious softening of the mucous membrane of the stomach amongst children was described as a distinct disease. It must now be confessed that this was a serious mistake, and that in this instance an unfortunate application of the study of pathological anatomy had been made. In fact, amongst young children, softening of the stomach never constitutes an isolated disease, and what has been written on this alteration relates to entero-colitis, as has been previously described.

This mistake would never have been made if the nature of the alteration had been taken into consideration, and if, at the same time, attention had been paid to the other alterations which exist in the same individuals.

Be that as it may, softening of the mucous membrane of the stomach is not a special disease-1st, because the alterations, which are looked upon as the fact of a pathological state, are only the result of putrid

decomposition; 2nd, because the gastric mucous membrane is easily dissolved by the acids of the stomach, which are very abundant in some diseases, such as pulmonary phthisis, entero-colitis, &c.; 3rd, because observation of disease demonstrates that this softening never exists alone, and that it is, on the contrary, always allied to other alterations, which are the cause of it, and hold it under their immediate dependence.

Amongst children who are said to have been attacked with softening of the mucous membrane of the stomach, there always exists at the same time a more or less violent inflammation of the large and of the small intestine. Now, this coincidence well deserves being indicated. It is evident that if the two alterations exist simultaneously there is an occult connection between them, which it is the duty of the physician to endeavour to discover. It is evident that they cannot be separated from each other, and that it is only necessary to seek to We discover what is their reciprocal influence, and what is that which, by its anteriority, may have been the determining cause of the second. Now, here is a case where we can demonstrate the advantages of reflection and judgment over the absolute conclusions which are sought to be drawn from the direct observation of facts.

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Thus, softening of the mucous membrane of the stomach is the consequence of entero-colitis. This is the proof: a constant phenomenon accompanies the inflammation of the alimentary canal amongst children at the breast-this is the very great acidity of the liquids secreted by the stomach and by the intestine. This phenomenon is demonstrated by the acidity of the excrementitious matters, and by the green colour of these matters. Besides, it is known (Carswell) that the acid state of the liquids of the stomach is sufficient to cause the artificial digestion of the mucous membrane, that is to say, its softening; it is then certain that all the diseases which have as a result the increased acidity of the gastric fluids should determine softening of the mucous membrane of the stomach. This is precisely what occurs in entero-colitis; this is what may equally happen in the course of other diseases.

Thus, the softening of the gastric mucous membrane, which exists simultaneously with entero-colitis, appears, then, to be under the absolute dependence of this latter disease; but that cannot suffice.

We must show that this softening is really and truly the result of the digestion of the mucous membrane by the gastric acids, and that it is not the manifestation of a particular pathological state, inflammation of the stomach for example: this is what is established by the cha/racters of the alterations themselves. In fact, this white gelatiniform softening of the depending parts of the viscus, or even of its totality, does not in any way resemble the red softening termed inflammatory. It appears to be placed entirely without the ordinary laws of pathological anatomy; its nature is little known, it appears to be much rather the result of inorganic than of organic phenomena.

More is not required in order to demonstrate that in the cases of coincidence of softening of the mucous membrane of the stomach and entero-colitis; it is to this last alteration that the existence of the first must be referred. Consequently the description of the disease should be especially applied to the principal affection, that is to say, to entero-colitis; and then the concomitant diseases should only be feared as a complement placed in the chapter of complications.

To resume, then: softening of the mucous membrane of the stomach in children at the breast is not a special disease which it is necessary to describe by itself.

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This alteration is always connected with other diseases, and especially dis

with disease of the large intestine, the knowledge of which fact has been too long neglected.

It is the consequence of the acidity of the liquids contained in the digestive tube of young children, liquids which are very acid in the disease we have above referred to.

It is then useless to describe the symptoms, progress, diagnosis, prognosis, and the treatment of this disease; this would be an error of location. This recital would only be applicable to the principal disease, which determines the softening of the stomach, that is to say, to entero-colitis. We refer the reader then to this chapter, where he will find all that relates to this alteration which should disappear from the nosology of children, as far as regards its consideration as a special and isolated disease.

[Dr. Meissner gives a table of one hundred and seventeen cases in which softening either of the stomach, oesophagus or intestines, or of the lungs, or hæmorrhagic erosion of the gastric mucous membrane existed; he arrives at the following conclusion: "The so-called softening of the alimentary canal and lungs is a result of the fermentative action which occurs primarily in cholera and secondarily in the other affections of children. Softening can invade the mucous membrane during life; perforation of all the coats occurs first after death. It is rarely an object of diagnosis, never one of therapeutics."-P.H.B.]

CHAPTER VI.

ON HICCOUGH.

Hiccough is very often observed amongst young children in good health. It often gives rise to too much uneasiness, for it is a symptom of little importance. But this is no longer the case in sick children; Julie it acquires a great value as an unfavourable symptom in the prognoses.

The convulsive state of the diaphragm which is the cause of hiccough is often determined amongst children who are well, by the avidity

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