r 
 IjOS 
 
 if^7 
 
 PRIZE ESSAY 
 
 OHOLEEA IKFA:t^TUM^ 
 
 By JAMES JSTEWART, M. D., 
 Author of " A Practical Treatise on the Diseases of Children." 
 
 Si quid novisti rectius istis, 
 Candidas imperti ; si non, his utere mecum. 
 
 Hor., Epist. vi. 67. 
 
 Cholera Infantum is usually regarded as a disease pecu- 
 liar to the United States ; and its appearance in the cities 
 throughout our land is expected with as much certainty as is 
 the season to which it owes its existence. With this certainty 
 as to the time of its appearance, is to be added the uniformity 
 it observes in its prevalence at a distinct period of life ; both 
 showing the unchangeable nature and uniform operation of 
 the agents which are active in its production. No summer 
 passes without leaving evidences of the power a season can 
 exert over human life, and how remarkably that power is 
 active in the development of a peculiar affection at a distinct 
 period of existence. 
 
 Most endemic diseases attack indiscriminately at all ages; 
 this one, as its name indicates, is confined to the tenderest 
 age, while there is no disease that simulates it in its most 
 marked characteristics at any other age. The kindred affec- 
 tion that has of late scourged so many countries, is uncer- 
 tain as to the time of its invasion, and erratic in its course in 
 different countries, yet apparently observes some law of pro- 
 21
 
 286 Essay on Cholera Infantum. 
 
 gression ; while the cholera of infants never yet has failed to 
 commit its ravages when the proper atmospheric condition 
 for its development exists, and is as steadily fixed to its local- 
 ity as any of the natural products of a climate. Such is the 
 experience of American physicians, and it is by them alone 
 that any description of the disease has been given. 
 
 It has been stated that a disease exists in England among 
 infants, similar to that which has so much occupied the atten- 
 tion of practitioners in our country. If this be so, it must be 
 vastly less in extent and virulence than the disease as it pre- 
 vails in the United States ; for we find nothing in the way of 
 description, but in its place, surmises that an infantile affec- 
 tion of the bowels existing there, is the same as that called 
 cholera infantum. Had there been the same certainty of the 
 annual return of the disease or any approximation to its mor- 
 tality, there would not have been wanting numerous essays 
 on BO interesting a subject from the profession in Great Bri- 
 tain. It is also said that Dr. Cleghorn described among the 
 diseases of Minorca, one similar to that which prevails so 
 extensively here during the summer among infants ; if so, it 
 would appear to prove that the like disease did not exist in 
 Great Britain, or it would certainly have been noticed by the 
 distinguished Dublin Professor, who was at one time an asso- 
 ciate in London of those world-renowned observers, Fother- 
 gill, Cuming, and Kussell.* 
 
 French writers say that there is nothing analogous to this 
 disease in France ; and when considering it in systematic 
 works on children's diseases, give a description of it derived 
 from American authors.f 
 
 In the absence, therefore, of testimony to the contrary, 
 there seems to be some foundation for the opinion that it is 
 peculiar to the United States. 
 
 * See Appendix, A. 
 
 I " Cholera is not generally noticed in our climate ; it is a disease peculiar 
 to infants in the United States; and as I have not observed any thing analo- 
 gous to this affection, I must be indebted to Dr. Dewees for the principal de- 
 tails of the symptoms." — Billard on Infanta. American edition, p. 828.
 
 Essay on Cholera Infantum. 287 
 
 In the course of our remarks on the nature of the disease, 
 it will be seen that at a particular period of life an exaltation 
 of certain functions will arise in the course of the natural de- 
 velopment of the body, which often results in derangements 
 of the alimentary canal. This action becoming aggravated, 
 will bear a very close resemblance to the disease in question, 
 especially in its first stage, yet still wanting some of its char- 
 acteristic symptoms. These symptoms appear to be the 
 result of the combined action of the different external causes 
 of the disease, which constitute the physical conditions of a 
 country in its relations to organic life. The presence of these 
 agents is necessary to produce the disease in all its power : 
 when they are absent, an imperfect development of it occurs, 
 as is doubtless the case in the instances referred to above. 
 
 Etiology. 
 
 That a clear idea of the causes of this disease may be 
 obtained, with a view to investigate its pathology and the 
 strictly practical application of remedial measures, it is pro- 
 posed to subject all the circumstances which are observed to 
 control its development to a careful examination. There is 
 no disease which appears to demand so close an investigation 
 of this nature, for there is none which has its pathology so in- 
 timately connected with the action of the agencies which are 
 in constant exercise in its production, and in its maintenance 
 throughout its course. The combination of these active 
 agents, — constituting what is known as climate, the more spe- 
 cial local agents, and the physiological peculiarities of the 
 period of life at which the disease occurs, it will be seen are 
 all connected in the production and maintenance of the same 
 pathological results, so formidable in their action, and so ob- 
 stinate in their management. These circumstances are not to 
 be regarded as mere isolated facts, but as an important group, 
 which are essential, when connected with the phenomena of 
 the disease and its morbid anatomy, to illustrate the morbid 
 condition of the system : none of them can be separated
 
 288 Essay on Cholera Infantum. 
 
 without impairing the relation they bear to the nature of the 
 disease. 
 
 Observation 1st. — Aim^ospheric Heat. — ^The most com- 
 mon attendant on the development of the disease, is a high 
 temperature. 
 
 In the city of Kew York, during a period of eleven years, 
 out of twelve hundred and forty-five deaths from cholera 
 infantum, ten hundred and sixty-one occurred during the 
 months of July, August, and September, the three hottest 
 months, — and but six during the three coldest. 
 
 The next highest in number as influenced by a high range 
 of temperature, but which includes all ages, is dysentery. 
 
 The depression of temperature exhibits a diflference also 
 in its effects, but nothing in comparison with that caused by 
 a high range. Thus croup presents the greatest difference 
 from this cause, and of twelve hundred and thirteen deaths 
 presents in no month less than sixty-six, — in the three summer 
 months, two hundred and twenty, and in the three winter 
 months no greater increase than three hundred and ninety- 
 eight.* 
 
 In the entire number reported, none shows so great a dif- 
 ference from temperature as the disease under consideration. 
 
 So uniformly has this disease existed in the city of New 
 York during the hot months alone, that there is no year of 
 which there is any record of diseases, that deaths from it are 
 not reported as steadily increasing in number with the in- 
 crease of temperature. For fifty years past, from 180i to 
 1854, a large number of deaths has been officially reported 
 from cholera infantum during the summer season, with the 
 exception of one year, when there appears in the official reg- 
 ister but one death from this cause. This occurred in the 
 year 1816. On looking over the periodicals and newspa- 
 pers of that year, it appears that the summer of 1816 was 
 singularly cold, the thermometer up to the 25th of July being 
 from 15° to 20° below the summer temperature, and after 
 that period the mean temperature was but 61° — that, of the 
 
 * See Appendix, B.
 
 Essay on Cholera Infantum. 289 
 
 three months 68° ; a sudden elevation for a day or two raising 
 the mean, while the actual continuation of the cold for the 
 season was without a parallel.* Cholera infantum appears 
 scarcely to exist when the mean temperature is about 60°. 
 
 Although the mean is usually given as an evidence of the 
 effect of temperature in producing disease, yet it is obvious 
 that it is more correctly attributable to the diurnal range. 
 The mean temperature of a week, can give but little informa- 
 tion as to the effects of heat when the thermometer has been 
 at or above 90°. The high temperature of 95° will produce 
 serious and often suddenly fatal disease, while the mean of 
 75° could furnish no explanation. 
 
 The invasion of cholera infantum occurs immediately 
 after a period of excessive heat, and is one of its most marked 
 effects. 
 
 Obsekvation 2d. — Excessive humidity of the air. — ^The 
 condition of the atmosphere with respect to its humidity is 
 one of the elements which imparts to a country its pe- 
 culiarity as regards disease. There does not appear to be 
 much difference in the annual mean in various parts of the 
 northern section of our country, and the diseases incident to 
 it present much the same characters. The humidity, however, 
 is much modified, and often immoderately developed under 
 the occasional changes which occur in the atmosphere ; but 
 more especially is it increased in circumscribed localities and 
 in crowded dwellings. 
 
 The temperature at which moisture is deposited, is usually 
 taken to ascertain the amount of moisture in the air. When 
 the temperature of deposit, or as it is termed dew-point, is 
 high, and especially when it continues high for some time in 
 hot weather, the system feels its depressing influence. All 
 persons suffer from a sensation of lassitude and sweltering 
 oppression at such times ; but no class equal to young chil- 
 dren. During the sultry nights of summer, in the over- 
 
 * See Appendix, C.
 
 290 Essay on Cholera Infamium. 
 
 crowded habitations of tlie poor, they show the effects in their 
 excessive pallor, languor, and exhaustion. 
 
 In our investigations on the subject of atmospheric hu- 
 midity, and its relation to the disease under consideration, we 
 have examined various localities, and found as was expected, 
 that a great difference existed. As to the city of J^ew York, 
 we have carefully compared the observations made for the 
 Smithsonian Institution by Prof. O. W. Morris, of the Deaf 
 and Dumb Asylum, with those which we have taken ; and 
 have come to the conclusion that ordinary climatic humidity 
 has but limited influence on the development of cholera in- 
 fantum. The same amount of moisture often exists in coun- 
 try places as is found in the city, and where the disease was 
 never known to originate. We therefore directed our atten- 
 tion to the occasional state of the dew-point as it occurred 
 where the disease was most prevalent, and discovered a great 
 difference within-doors, between it and the general dew-point 
 of the external air, continuing often for a long time. 
 
 The first observation made was that the moisture was 
 always greater nearer the surface of the earth ; the difference 
 we have ascertained to be at times 4°. Cellars and baselnents 
 must therefore always be in a state of excessive humidity, 
 as is known to most persons, requiring no philosophical in- 
 strument for its detection. 
 
 The second is that in very hot weather in excessively 
 crowed houses at night, when all are within, the dew-point is 
 very nearly at the temperature of the air, consequently the 
 air is saturated with moisture. With a temperature of 90° to 
 95° and a dew-point in a crowded room almost equal to the 
 temperature, a feeling of suffocation is experienced, which is 
 easily accounted for when it is known that the dew-point of 
 the breath as it is expelled from the lungs is 94°, and that 
 the mean dew-point of the atmosphere is 38° ; and also, that 
 in the hottest weather it rarely exceeds 70°. When the air 
 is loaded with moisture and deposited easily at a temperature 
 approaching to that of the living body, inspiration is difficult 
 and unsatisfactory, while the system suffers great depression.
 
 Essay on Cholera Infantum. 291 
 
 The effects will be again referred to, when the pathology of 
 the disease is considered. 
 
 It is in such heated and moist places that we have found 
 the greatest number of instances of cholera infantum. 
 
 Obsekvatiout 3d. — Malaria. — This cause has been regard- 
 ed as the principal agent in the production of cholera infant- 
 um ; meaning by it an atmosphere infected by marsh efflu- 
 vium. It is ascribed to this by some writers, and also by the 
 Committee " On the Epidemics of Tennessee and Kentucky," 
 in their report to the American Medical Association in 1853. 
 This report, and that made in 1854, are the most recent pub- 
 lished remarks upon the subject. It would seem, however, 
 more in accordance with well-known facts to consider the 
 malaria of crowded places, as the kind of malaria which pro- 
 duces the disease. The report first referred to appears to 
 admit this to a certain extent, as it speaks of the air of apart- 
 ments that have been carefully closed at night to keep the 
 external malaria excluded, as being the places where the 
 medical practitioner is frequently called to see the disease. 
 
 Cholera infantum in some mitigated form may arise in 
 the country, since it will appear in the course of this essay 
 that many of its causes will exist in different places under the 
 influence of a high range of temperature, and different grades 
 will probably be found in places remote from each other. 
 There is, however, so great a modification and so peculiar a 
 type out of the cities as to make it more of a severe diarrhoea, 
 complicated with fever, receiving its characteristic type from 
 the condition of the air producing it, but differing much from 
 the virulent disease as it occurs in cities. 
 
 Inasmuch as the usual cause of endemic fevers in the 
 country has been regarded as the cause of this disease, a ref- 
 erence to the nature and source of the two kinds of malaria, 
 with the mode in which their effects are manifested, will be 
 necessary to exhibit them in their proper character, and by 
 comparing them, endeavor to ascertain whether there exists 
 any dissimilarity. This can be very briefly done by avoid-
 
 292 Essay an Cholera Infantum. 
 
 ing tlie consideration of every thing that can complicate the 
 inquiry, especially of all subjects connected with the discus- 
 sion of the pathology of miasmatic diseases, and by keeping 
 closely to the inquiry into their origin and their effects. 
 
 The malaria of the country is produced by emanations 
 from marshy places, and by a dessication of the surface of the 
 ground both by solar heat and by the passage of currents of air 
 over it, carrying into the body of the atmosphere the minute 
 gaseous results of vegetable decomposition. That which is 
 exclusively of the city, it is obvious, cannot be produced in 
 the same manner, the surface of the streets not admitting of 
 such constant evaporation by the solar rays or by the passage 
 of currents of air ; indeed the absence of the sun's rays, and 
 that also of the movements of the air, are always considered 
 as the principal causes of the diseases that are peculiar to 
 cities. If air from malarious districts is borne into the cities, 
 it must be very considerably modijfied by the mixture with 
 that which is always found in cities and other crowded places. 
 
 That of the country is derived principally from a vegeta- 
 ble source, together with the saturation of the soil from time 
 to time with rain, and its evaporation and diffusion. The an- 
 imal element forms the principal part of that of the city ; 
 arising from the changes which the air undergoes from the 
 depuration from the bodies of living animals where many are 
 crowded together, and the decomposition of dead animal mat- 
 ter. Slaughter-houses, soap manufactories, the refuse of sta- 
 bles, sinks, cess-pools and other receptacles of a similar kind, 
 are among the common sources of the bad air of cities, and 
 which impart to the mass of the air qualities not elsewhere to 
 be found. 
 
 The sensible effects of the two are different. In general 
 there is no odor in that of the country, while in the malaria of 
 cities it is decidedly manifest. 
 
 It has been remarked (History and Cure of Fevers, by R. 
 Jackson, part i., chap, iii.) that the miasma of crowded places 
 differs from that of a paludal nature, by being less volatile, 
 and confined to a more limited space ; and that it is more con-
 
 Essay on Cholera Infantum. 293 
 
 centrated in its effects, producing an exhausting and depress- 
 ing action in a more decided manner. 
 
 The morbid effects are different. 
 
 In all parts of the world, the tendency to diseases in the 
 country is to an intermittent or remittent type, such as fevers, 
 the common head-ache, and neuralgic affections. Those of 
 the city assume more frequently a continued form, even where 
 there is no specific contagion manifest. 
 
 The action of malaria from the soil is remarkable also for 
 the production of epizootic diseases. From the time of the 
 Latin poets and historians to the most recent medical reports 
 and essays of the present day, in every country, we hear of 
 extensive diseases that have prevailed at different times 
 among quadrupeds, from paludal effluvia. Such diseases and 
 such mortality are very rare in cities. We have heard of 
 sickness among horses in the vicinity of a city during a pes- 
 tilence ; but a decided epizootic is of rare occurrence and of 
 very limited extent within its bounds ; and where an epi- 
 demic prevails in such places, the simultaneous sickness 
 among quadrupeds is recorded as a remarkable event.* 
 
 In the country, malaria would seem to require a tempo- 
 rary or transient cold state of the air, or of the body, to pro- 
 duce its effects on the system. So universally remarked is 
 this, that the exposure to the cool night air is considered as 
 sure to produce a malarious fever ; and it has been referred 
 to the cooling of the body by terrestrial radiation, when sol- 
 diers have been taken sick who slept on the ground without 
 tents or other covering, while those who have had bushes, 
 trees, or tents over them have escaped. It cannot be the same 
 malaria that produces cholera infantum as witnessed in cities, 
 inasmuch as it always attacks the greatest number while the 
 heat is greatest, and no danger is apprehended from its tem- 
 porary mitigation.f 
 
 In the country, disease from malaria mostly attacks adults ; 
 
 * See Appendix, D. f See Appendix, E.
 
 294 Essay on Cholera Infantwm. 
 
 infants born in such places are in general exempt. The re- 
 verse is the case in cities ; children are the most subject to its 
 malarious influences, and the natives are the first to experi- 
 ence their effects when the season arrives to set them in ac- 
 tion. The great mortality from cholera infantum shows that 
 there is but little exemption from its effects among them. 
 
 If this disease is caused by the same influences that pro- 
 duce malarious fevers, it would prevail at the time such fevers 
 exist. On the contrary, the greatest number of cases occur 
 in July and August, and when they begin to lessen in num- 
 ber, the paludal fevers increase. "We should also expect to 
 find it prevail more during the season when cases of autumnal 
 fever occur in the greatest number. This, however, is not the 
 case, where we have had opportunities of obtaining the most 
 reliable information. Whatever amount of sickness exists in 
 the country surrounding the city of ISTew York, cases of chol- 
 era infantum observe a remarkable uniformity as to numbers, 
 evidently under influences different from those producing the 
 febrile affection. In the year 1828, malarious fever prevailed 
 very extensively and with great severity in the country 
 around that city, proving fatal in a great number of instances. 
 Many of the villages were nearly destitute of inhabitants, 
 farms were offered for sale or to lease by their terror-stricken 
 owners, and persons unaffected by the disease were scarcely 
 in sufficient numbers to attend upon the sick. Hundreds fled 
 from all parts, even from the immediate vicinity of the city, 
 and took refuge within its precincts. Yarious parts of New 
 Jersey, Staten Island, Westchester county, and the regions 
 particularly near the city, were the principal places affected 
 by the disease. It also prevailed with great severity on Long 
 Island, where it was attributed to malaria from decaying vege- 
 table substances exposed to great heat. Several communica- 
 tions appeared in the daily newspapers on the subject, and 
 they speak of noxious vapors of which a single inspiration was 
 injurious.* 
 
 * S«e Appendix, F.
 
 Essay on Cholera Infantum. 295 
 
 During that year, the mortality from cholera infantum in 
 the city of New York was one hundred and sixty-one, or one 
 in thirty -one of the whole number of deaths ; not so great as 
 in the two previous years, when they amounted respectively 
 to two hund red and twenty-two and two hundred and thirty- 
 eight, or one in twenty-two of the deaths. This was also the 
 case in other years ; a reference to which is made in the Ap- 
 pendix.* 
 
 The disease we are considering appears to differ essentially 
 in miasmatic places from that which occurs in cities. The 
 number of cases of cholera infantum " under 15 years," of 
 which the statistics are given in the report above referred to, 
 as occurring in 1852, in the States of Kentucky and Tennessee, 
 is fifty-two. The average attendance of fourteen of them was 
 four days, and of seven, nine days. The period of attendance 
 required by the remainder is not given, while the mortality 
 of the whole number was four. It would seem therefore to 
 differ from the disease known by the same name in cities.f 
 
 In the report on the diseases of the same district for the 
 year 1853, one hundred and thirty-five is the number given 
 for the entire State of Kentucky. The necessity there stated 
 for using quinine in its treatment indicates also a very essen- 
 tial modification of the disease in the western part of the Uni- 
 ted States. The repor t also states that on a comparison with 
 other diseases that prevail there, cholera infantum has a near- 
 er relationship to dysentery and typhoid fever than to bilious 
 fever ; from which there would seem to be an admission that 
 there is some other exciting cause than that which produces 
 paludal fever. 
 
 Cholera infantum appears in diminished numbers in pro- 
 portion to the distance from crowded places, and is most suc- 
 cessfully trea ted when the patient is removed out of the lim- 
 its of the city even to a short distance ; but if the disease 
 came from one and the same cause, and that cause marsh 
 miasm, no mitigation would occur by moving into the air 
 
 * See Appendix, G. f See Appendix, H.
 
 296 Essay on Cholera Infantum. 
 
 which, from its greater proximity to the source of the poison, 
 would be more active in producing its deleterious effects. 
 
 From the facts now stated, so far as cholera infantum is de- 
 pendent on external causes, it is evident that in addition to 
 high range of temperature and inordinate atmospheric humid- 
 ity combined, it has for its cause the peculiar malaria of 
 crowded places. 
 
 Observation 4th. — Period of Life. — Cholera infantum 
 prevails more before the first year than during any other pe- 
 riod. Although there are no published statistics that show 
 the mortality at the early months, yet it is well known to all 
 practical men that the disease prevails less during the first 
 six months and more from that time to half of the first year. 
 From the first to the end of the second year it exists with 
 varied intensity in different individuals, and after the second 
 year the number is small. 
 
 In the city of Philadelphia, during a period of twenty 
 years, prior to 1827, there were three thousand eight hundred 
 and twelve deaths reported from disease designated under the 
 general title of cholera, among persons of all ages — cholera 
 morbus or cholera infantum. Of this number three thousand 
 three hundred and eight were under the age of two years ; all 
 of which were doubtless the cholera of infants^ as that term 
 is used to designate a specific disease.* 
 
 In the city of New York of fifteen hundred and twenty- 
 five deaths from this cause in 1854, thirteen hundred and 
 sixty -four were under the age of two years, and of three thou- 
 sand one hundred and sixty deaths which occurred in three 
 years, two thousand seven hundred and forty-seven were un- 
 der that age. 
 
 The time, therefore, at which the disease is at its height is 
 that of the period of second infancy, when important physiolo- 
 gical changes occur, manifested by the appearance of the teeth, 
 the development and activity of the salivary glands, together 
 
 * See Appendix, I.
 
 Essay on Cholera Infantum. 297 
 
 with alterations in all the organs of digestion ; a state of sys- 
 tem which, it will be seen, when considering the pathology of 
 the disease, is inseparably connected with its development. 
 
 Observation 6th. — Inappropriate Food. — This is an occa- 
 sional exciting cause, acting with those already mentioned. 
 "Where a child is artificially fed, there are often indigestible 
 substances of a farinaceous or starchy nature given, that 
 greatly disorder the digestive organs, from the impossibility 
 of assimilating them ; these organs beiug unfitted for the re- 
 ception of vegetable aliments. There is another formof food, 
 which does not appear to have attracted the notice of writers 
 on cholera infantum, but which is of importance when consid^ 
 ered in connection with the causes already mentioned. It 
 is the deterioration of the mother's milk from the debilitating 
 effects of the atmospheric influences already considered. The 
 mother suffers as well as the child, and it appears quickly in 
 the secretion of the milk, manifested principally in its lessened 
 quantity, while the process of nursing is one of fatigue and 
 exhaustion. Even if it is difficult to prove any alteration in 
 the chemical qualities of the milk, yet the fact is well estab- 
 lished that the milk will undergo changes at times of such a 
 nature as to impart injury to the child. We have proved this 
 by withdrawing the child from the breast, although in gene- 
 ral opposed to weaning children that are sick. 
 
 General Phenomena. 
 
 At the present stage of the investigation we shall state the 
 symptoms in a general way, and those only which impart a 
 character to the disease, and from which it derives its distinctive 
 name, and not those which are the result of its varied forms of 
 manifestation or of its complications ; the object being to con- 
 nect the signs of derangement which distinguish this disease 
 from every other, with the causes which produce them. The 
 statement of the phenomena in detail will be reserved for a
 
 298 Essay on Cholera Infantum. 
 
 section on the semiology, immediately preceding that devot- 
 ed to the treatment. 
 
 The disease is characterized by inordinate evacuation from 
 the bowels, generally accompanied by vomiting. Whatever 
 be the different modes of its invasion, whether with or with- 
 out febrile action or the existence of nausea, diarrhoea is usu- 
 ally the first symptom. The simultaneous existence of vom- 
 iting and purging at the beginning of the disease indicates 
 its severity ; and under such a mode of attack, it will often 
 terminate fatally in a few days. In the greatest number of 
 instances, the diarrhoea alone is its earliest manifestation, at 
 first consisting of the ordinary fsecal matters, changing soon, 
 however, to a serous fluid of different hues. At intervals the 
 discharge consists of the mucous secretion of the intestines, 
 mixed with undigested food. The odor differs from ordinary 
 faeces ; sometimes, when it contains the ingesta, it is indescri- 
 bably offensive. At other times it is in a state of fermenta- 
 tion which imj)arts an acid odor, not unlike that of tlie chyle 
 before it has reached that part of the primge vise where the 
 biliary duct opens into the intestines, it being diluted 
 only with the follicular secretion. "When the disease is fully 
 established, the absence of bile is one of its distinctive marks, 
 while the discharges indicate ulceration. Yomiting, or attempts 
 at vomiting, is another prominent symptom, and is one of the 
 most uncontrollable and obstinate of all the phenomena. The 
 discharges by this act never consist of any thing more than 
 the food or drinks that have been given. All these symptoms 
 are accompanied by inordinate thirst. 
 
 Next appear a dry and flabby state of the skin, with in- 
 tense heat on that covering the abdomen. Kapid emaciation 
 follows, and the body becomes attenuated to a most frightful 
 extent. As the disease advances toward a fatal termination, the 
 natural stools are retained, and the mucus becomes gelatinous, 
 and often pink-colored. The disease usually lasts a month or 
 six weeks. 
 
 Lastly, evidences of cerebral disturbances show them- 
 selves, with occasional convulsions. These and other compli-
 
 Essay on Cholera Infantum. 299 
 
 cations, being additions to the essential symptoms of the dis- 
 ease, are not here particularly noted, although constituting a 
 necessary part of the ultimate development. 
 
 MoKBiD Anatomy. 
 
 In the different parts of the intestinal tube there are found 
 numerous granules having at their external surface a minute 
 pore, from which the mucus secreted by the gland is exuded. 
 They are known as the mucous glands or granules, and also as 
 the muciparous follicles. Although they are very numerous 
 in the upper part of the intestines, yet they exist detached 
 from each other ; while fi'om the jejunum downwards they 
 appear in groups. But one function is discharged by them 
 all, that of furnishing mucus to the surface of the intestines, 
 although they are distinguished by different names in different 
 parts of the intestines. They will be considered in this Essay 
 with reference only to the functions they perform, and de- 
 nominated mucous follicles. 
 
 These follicles rarely make their appearance until about 
 the time of teething, when a general development of all the 
 parts connected with the asimilating process takes place. 
 When the teeth appear, the mucous follicles are brought into 
 action, and are apparently connected with the necessity of a 
 change of food for the child. 
 
 In cholera infantum the most remarkable anatomical 
 change is found in the excessive development, the functional 
 activity, inflammation, and occasional ulceration, of these fol- 
 licles. 
 
 Instead of pursuing an elaborate detail of the appearances 
 presented on postmortem examination in every organ and 
 cavity of the body, many of which are secondary and the 
 effects of complications, we will refer to two lithographic 
 representations of the actual anatomical changes in parts 
 which are primarily affected, and which continue to be the 
 principal parts diseased, whatever modifications the disease 
 may assume ; the symptoms of the local derangement which
 
 300 Essay on Cholera Infantum. 
 
 characterize the affection always being aggravated the nearer 
 the approach to a fatal termination. As the fairest method 
 also of ascertaining the morbid changes, we propose also, to 
 exhibit an analysis of all the postmortem examinations that 
 have been recorded, so far as we have been enabled to find 
 them in the different medical periodicals. 
 
 Anatomical Illustrations. — No 1. The colon of a child, 
 aged 6 months, that died of cholera infantum. The mucous 
 follicles were all enlarged, but scarcely any of them were 
 ulcerated — the whole mucous surface appeared to be covered 
 with white elevated spots. 
 
 No 2. The colon of a child, aged 1 year and 8 months, that 
 died of cholera infantum. A large number of the glands 
 were not only enlarged, but ulcerated ; indicated in the ac- 
 companying representation by the central dark spot. 
 
 Anatomical Analysis. — On examining most of the med- 
 ical periodicals which have been published within the past 
 fifty years, we have found recorded the postmortem ex- 
 amination of thirty cases of cholera infantum.* Of this 
 number there were twenty-eight reported as presenting 
 the liver diseased, either by being congested, enlarged, 
 or altered either in color or texture. Its color was in 
 many instances lighter than usual, and in others " variega 
 ted." It was in most instances firmer than is the case in 
 health. Dr. Horner observes that the liver is generally en- 
 larged and of a more firm and solid texture than is the case 
 in the natural, healthy condition. Only in two cases, the 
 liver was reported healthy, or, as it is termed in one instance, 
 " appeared healthy." 
 
 The next fact to be noticed is, that in the whole number, 
 the mucous membrane of the intestines was found diseased, 
 inflamed with mucous exudation, congested, or ulcerated. 
 These statements were made before Dr. Horuer published the 
 
 * By Drs. Jackson, N, E. Jour. Med., v. 1 ; Horner, Am, J, Med. Sci. v. 20; 
 Stuart, Coxe's Med. Mis. v. 3 ; Baxter, K Y. Med. and Phys. Jour. vi. N. S, ; 
 Lindeley, Am. Jour. Med. Sci. v. 24 ; Hallowell, Am. Jour. Med. Sci. v. 40.
 
 No. 1, 
 
 No. 2.
 
 Essay on Cholera Infantum. 301 
 
 results of his examinations. He observed the same condition 
 of tlie mucous membrane ; but on removing tlie mucus and 
 blood by a little maceration, he was enabled to note the true 
 organic changes that had occurred, by discovering the delicate 
 prominences of thousands of inordinately developed mucous 
 follicles — a large number of them in a state of ulceration. In 
 the examination of two cases by Dr. Baxter and twelve by 
 Dr. Hallowell, the same condition was found, and which is 
 also represented in the lithographs accompanying this 
 Essay. 
 
 The disease, therefore, exists mainly in the mucous follicles 
 and in the liver. The effusions and congestions in the brain and 
 other organs are clearly complications of the original disease; 
 and although exhibiting serious affections of those parts, yet 
 these organs do not, so far as we have been able to ascertain, 
 present any decided alteration in the structure itself, as 
 is found in the liver and mucous surface of the intestines. 
 
 Pathology. 
 
 The pathology of a disease should be studied closely in con- 
 nection with the causes which produce the morbid changes ex- 
 hibited on postmortem examinations. It is evident that an an- 
 atomical investigation can give us only the morbid results of 
 diseased action, and is therefore to be regarded as but one 
 extremity of the continuation of a morbid condition of parts ; 
 the other exists inscrutable to us, except in the symptoms 
 which characterize it, and in the immediate results of the 
 causes in operation to effect the changes which produce these 
 symptoms. While the anatomical alterations show us the 
 terminations, we must seek for something else anterior to them 
 for instruction as to the actual condition of the living parts 
 at the commencement, and thus endeavor to ascertain 
 what it is that leads to these changes. Often in the examina- 
 tion of the philosophy of disease, we are obliged to be con- 
 tented with learning from the symptoms during life, and the 
 anatomical condition after death, on wiiat to found its pathol- 
 22
 
 302 EssoRi on Cholera Infantum. 
 
 ogj. If it be possible to add to them tbe known causes, and 
 if these are not only clearly established, but are found to be 
 peculiar in their immediate effects, we obtain a starting point 
 of great importance, which if carefully studied and the course 
 indicated by them be as carefully pursued, will add much to 
 our ability to interpret the revelations of the scalpel. 
 
 As cholera infantum can be referred to well-ascertained 
 canses, and as these agents are in action to maintain the dis- 
 ease, when established, by their constant and positive influ- 
 ences, there can scarcely be found a disease that can so well 
 elucidate the imj)ortance of endeavoring to establish the 
 connection between the early morbid action and the ultimate 
 morbid results. 
 
 It is for this reason that the causes already exhibited will 
 be taken up in their order, their philosophy examined, and 
 the morbid conditions produced by them studied in connec- 
 tion with the alterations revealed after death. 
 
 1st. Heat. — The effects of atmospheric heat on the sys- 
 tem are direct and indirect. By the direct effects are to be 
 understood those sudden disorders which are the results 
 of an accelerated action of the circulatory organs, or the 
 more rapid exhaustion of the nervous power. This sud- 
 den invasion of disease during the intense heat of summer in 
 temperate regions, and in all hot countries, among those not 
 accustomed to them, is well known. The consideration of 
 this class not being a proper subject for this paper, it will of 
 necessity be passed over ; while the indirect efl'ects, or such as 
 are less prompt in their manifestation, as in the disease now 
 before us, will form the proper subject for investigation. 
 
 There is one organ which exhibits before all others the 
 effects of heat, and that to a remarkable extent. From the 
 earliest period the liver has been regarded as the one that 
 suffers most from this cause ; and a host of writers on the in- 
 fluence of tropical climates and their diseases, refer to atmos- 
 pheric heat as the principal source of hepatic affections. 
 
 Such affections prevail to so great an extent in hot 
 climates that those who have practiced in temperate regions
 
 Essay on Cholera Infantum. 303 
 
 alone, will find it difficult to belicA^e in their extensive preva- 
 lence, among natives as v^ell as among strangers. Although 
 there may be auxiliary causes, yet it is by the most accurate 
 observers attributed to atmospheric heat as the principal 
 cause. Thomas, Johnson, Moseley, Saunders, Larrey, Fitz- 
 patrick and others, who have resided in hot countries, refer 
 to heat as the agent to which the alterations in the action and 
 organization of the liver are to be attributed. There is no 
 other organ on which caloric appears to be concentrated in its 
 efiects, and none whereon the consequences are so marked.* 
 
 In some instances an active condition of this viscus is 
 produced, marked at times by an inordinate secretion of bile ; 
 in many of them a want of action ensues, following this ex- 
 cessive action a? a state of collapse follows that of inordinate 
 excitement. 
 
 Among the effects of heat on the liver is that which is 
 denominated chronic inflammation. This term appears to 
 have been applied to various afiections of this organ, which 
 differ from the acute or active inflammation. A score of 
 morbid conditions are referred to chronic inflammation. 
 These morbid states, it is plain, may differ very essentially 
 from chronic inflammation, and yet collectively tliey have 
 been so denominated. Among these derangements is found 
 a simply sluggish or congested state ; when it becomes slowly 
 indurated, with or without enlargement, and when it no 
 longer performs its office of secretion of bile. This is a very 
 common condition in the East and "West Indies ; a torpid 
 condition of the liver and a paucity of its biliary secretion, are 
 very frec|uent disorders in those places, attended with consti- 
 pation and indigestion. 
 
 These are the consequences of disease protracted for years ; 
 but in affections of this organ arising during a shorter period, 
 alterations less marked are to be looked for ; and such are 
 revealed in cholera infantum. 
 
 * Soe Appendix, J.
 
 30i Essay on Cholera Infantum. 
 
 As heat exhibits its action on the hepatic system, so cold 
 shows itself upon the respiratory organs, less extensively ; but 
 it is much more decided in its manifestations. Affections of 
 the liver are more or less obscure ; as this organ is less under 
 our cognizance, both in its condition of liealth and of dis- 
 ease, little evidences of its diseased condition exist, and ob- 
 scurity and uncertainty often attend its derangements, both 
 in the young and the adult. 
 
 Summer and winter show their effects very promptly on 
 the tender and susceptible system of the infant ; the winter 
 not among so many individuals, partly perhaps on account of 
 the ability of most people to shield themselves and their off- 
 spring from the extreme cold, while from the intense heat of 
 summer there is no escape. 
 
 Infants yield quickly to the influences of cold, and suffer 
 greatly from affections of the respiratory organs during the 
 winter; while there is no marked disease among them during 
 the excessive heat of summer, unless it be derangements of 
 the chylopoetic viscera. The "summer-complaint" is the 
 popular name for one form of these derangements, from its 
 extreme prevalence during the existence of a high range of 
 temperature. In the absence of any facts to show that heat 
 will produce a decided effect, among a large number of indi- 
 viduals, on any other part of the system than the hepatic, it 
 would seem to be but reasonable to suppose that the gland 
 which is so generally affected by it would not escape in the 
 infant, but would be the part that would be primarily diseased 
 under the circumstances which produce so violent a disorder 
 as cholera infantum, or " summer-complaint." 
 
 The first effect of heat upon the system is through the 
 lungs, and by interfering with the proper discharge of the res- 
 piratory function ; this act being the introduction of oxygen 
 during inspiration, and the ejection of carbonic acid during 
 expiration. It has been proved by experiments on small 
 animals, that a much less amount of atmosplieric air is de- 
 composed during hot than during cold weather. In an expe-
 
 Essay on Cholera Infantum. 305 
 
 riment by Crawford, it was found that a guinea pig under a 
 temperature of 55° consumed twice tlie quantity of oxygen 
 than when confined to a temperature of lOi". 
 
 The connection of the process of respiration with affections 
 of the liver, will be considered when the effects of the next 
 two causes are examined, 
 
 26?. Excessive atmospheric humidity.- — This is one of the 
 principal causes of the extreme languor in hot and crowded 
 places. One of the modes by which extreme moisture, with 
 heat, acts unfavorably upon the body, is by preventing the 
 ordinary amount of exhalation from the lungs. This is most 
 decidedly seen when the excess of moisture arises from great 
 crowding, and the usual domestic occupations in houses where 
 several families reside. The houses of the poor are loaded 
 with vapor from these causes ; the temperature at which 
 moisture is deposited scarcely differing from that of the air. 
 We have tried the experiment with a wet bulb thermometer 
 where the temperature was at 90°, and could not make the 
 dew-point lower than 88°. It has been probably often at the 
 point of saturation, when they will both range at the same 
 degree. 
 
 The air always contains moisture, and in proportion to the 
 amount is the quantity of moisture exhaled from the lungs. 
 Thus, air containing moisture that is dej^osited at 38°, the aver- 
 age in this climate, will allow of a much greater evaporation 
 from the lungs than when the temperature of the "dew-point" 
 is at 70°. 
 
 It is shown by the experiments of Dalton that the quan- 
 tity of vapor contained in a cubic inch of air when the dew- 
 point is at 88°, is .00166852 grain ; when at 94° the amount 
 is .00938243 grain. The last mentioned is the dew-point of 
 the vapor as it is expelled from the lungs, whatever may be 
 the temperature of the surrounding air ; and this is the amount 
 of vapor contained in a cubic inch of air as it passes from 
 the lungs of an adult. If the air before inspiration be over- 
 loaded wath vapor, it is obvious that it must prevent to a cer- 
 tain extent the depuration from the lungs. We have found,
 
 306 Essay on Cholera Infantum. 
 
 however, that unless the amount of vapor in the air very 
 nearly approaches to that passed from the lungs, no very 
 marked effects are produced, but a sense of oppression and 
 suffocation arises when it approaches that point. 
 
 The weight of a cubic inch of vapor at 88° is .00789288 
 gr. which is .00622436 more than the mean of the climate, and 
 .00158153 less than the amount contained in the pulmonary 
 vapor. If these be multiplied by 1,152,000, the number of cubic 
 inches inhaled in a day by an adult, according to Thompson, 
 Minzies, and others, the result will be respectively 7170 and 
 1811 grains ; the difference between the two-5359 grains-will 
 give the lessened amount of transpiration of pulmonary vapor. 
 When at 70°, the highest in this climate, the weight of a cubic 
 inch of vapor is .00461639 ; if this is subtracted from .00938243, 
 which is the quantity in a cubic inch of respired air, it will 
 leave .00476604, which multiplied by 1,152,000 will give 5490^ 
 grains of water evaporated from the lungs when the air is 
 inhaled at a dew-point of 70°. These statements will show 
 how much an excessively high dew-point must interfere with 
 a proper depuration from the lungs. 
 
 Another source of embarrassment to the full healthy de- 
 puration from the lungs is the increased elastic force of vapor 
 at a high temperature. According to Dalton, this power at 
 38°, is .264, and at 88° 1.286, in inches of mercury. 
 
 There are, therefore, two obstacles to a free pulmonary ex- 
 halation in an inordinately moist state of the air. 
 
 The lessening also of the transpiration from the skin, from 
 the same causes, has an important influence upon the 
 healthy action of the body, as is known by daily experience ; 
 but the arrest of cutaneous depuration by means of exces- 
 sive moisture of the surrounding air differs in its effects from 
 that produced by cold. 
 
 The principal results of an arrest of the ordinary pulmo- 
 nary depuration is to cause some movement of compensation 
 in another part; the consideration of wliich will be deferred 
 until the next subject has been investigated. 
 
 Zd. Malaria. — There are two alterations in the air when-
 
 Essay on Cholera Infantum. 307 
 
 ever there exists any deterioration ; one is the chemical 
 change, and the other, a simple mixture of foreign and dele- 
 terious ingredients. In all crowded places the chemical 
 change must be principally that of an excess of carbonic acid 
 from the constant respiration. This arises from the process of 
 respiration being that by which oxygen is introduced into the 
 system through the blood, and thereby causing in the ultimate 
 tissues the combustion of carbon, which escapes from the 
 lungs as carbonic acid. 
 
 According to the experiments of MM". Dulong and Des- 
 pretz, the quantity of carbonic acid thus produced is the same 
 as would result from the combustion of an amount of carbon 
 equal to that of which the body is deprived by the act of ex- 
 piration ; the carbonic acid passing into the surrounding air, 
 and taking the place of the oxygen which is removed by in- 
 spiration. By respiration alone, an adult will transform into 
 carbonic acid in the space of an hour, all the oxygen contained 
 in twenty-five gallons of atmospheric air ; which in a house, 
 and especially in a sleeping apartment, is a matter of great 
 importance. 
 
 From this process, also, arises the increased heat of a crowd- 
 ed room ; the union of the carbon and oxygen producing an 
 additional heat, which is added to the atmospheric tempera- 
 ture already existing, — the body of every animal being a 
 constant generator of heat. The same changes occur outside 
 of our dwellings, but are less injurious, from being more easily 
 diffused and dissipated. 
 
 Another change in the surrounding air is produced by 
 transpiration both from the skin and lungs. It is a mixture 
 solely, and is independent of any chemical change. This 
 addition eludes altogether chemical tests, and exists, it would 
 seem, only as suspended in the atmosphere, and is conveyed 
 by it as a foreign body, or rather by the vapor that is always 
 present in the air. The transparent fluid exhaled from the 
 lungs is in every respect the same ; the taste is saltish, the 
 color peculiar, and it becomes insupportably offensive when
 
 308 Essay on Cholera Infantum. 
 
 kept in a warm place ; showing that it consists of animal mat- 
 ter in a state of decomposition. 
 
 The perspiration is sometimes differently scented ; it has 
 had the odor of musk, violets, sulphur ; and it has also been 
 extremely foetid and occasionally acid. It has also been vari- 
 ously colored, — red, saffron, black, or blue. 
 
 These facts would appear to show that the substances 
 transpired possess properties derived from the body, and eject- 
 ed as not proper to be retained. This transpiring process is 
 indeed one of depuration, and to the extent of twenty-eight 
 ounces in twenty-four hours. It must be, therefore, injurious 
 to be receiving into the body by inspiration that which its 
 necessities have previously required to be removed. Who but 
 infants would be the greatest sufferers ? a class among which 
 the effects of external influences, of whatever kind, are so 
 promptly experienced, and to which they so promptly yield. 
 
 All the conditions of the atmosphere which have been con- 
 sidered, directly interfere with the ultimate object of respi- 
 ration, and when they are all present in a marked degree, the 
 effects will sometimes appear in the embarrassment of the 
 act itself. 
 
 When any organ is disturbed in the exercise of its appro- 
 priate functions, and a morbid action arises, the system strug- 
 gles, as it were, for relief; and under this derangement, some 
 other will be found either to be involved in the derangement, 
 or to have assumed its functions, and thereby to have relieved 
 the morbid condition of that one which was primarily af- 
 fected. 
 
 This is of so ordinary occurrence that when a morbid 
 functional change arises, we naturally look for a vicarious 
 movement, which either affords relief, or by too great a de- 
 mand on the energies of the body for that purpose, passes 
 into a diseased action in a part of the system distant from that 
 originally affected. Tliis movement of compensation is 
 familiarly illustrated in the reciprocal affections of the skin 
 and kidneys, skin and lungs, etc., in a low temperature.
 
 Essay on Cholera Irtfanium. 309 
 
 That between the lungs and the liver is no less remarkable, 
 and equally important in its results. 
 
 When the air becomes unfit for the necessary renovation 
 of the blood through the medium of the lungs, or when the 
 usual amount of depuration from them is prevented, their 
 functions are but imperfectly performed, and the requirements 
 of the system inadequately supplied. Under this condition, 
 especially when the interference is slight, but is at the same 
 time protracted, no sudden evidence of derangement presents 
 itself, but a decided action will be established in a part that 
 evidently bears a reciprocal relation to the lungs. This part 
 appears to be the liver, for the following reasons : 
 
 According to the experiments of Tiedemann and Gmelin, 
 it has been found that the quantity of venous blood sent to 
 the liver increases as the pulmonary system is less perfect. 
 In the mammalia the vena portse conveys blood from the intes- 
 tines alone ; in reptiles it is also brought from the posterior 
 extremities, tail, kidneys, and other parts. In connection with 
 this, is the fact that the temporary suspension of the functions 
 of the lungs, and the consequent arrest of the flow of blood 
 through them, in hybernating animals during their period of 
 sleep, is not attended by a suspension of the functions of the 
 liver, bile is secreted as usual ; corresponding with the human 
 foetus, where the total inactivity of the lungs appears to be 
 compensated by some action of the liver. 
 
 The vicarious action of the liver, is also manifest in the 
 pathological condition of that organ from the eflects on the 
 respiratory process. Some of them occur in malarial districts, 
 and are well known to residents of those places. Hepatic 
 diseases aifect hogs and sheep that are exposed to paludal 
 effluvia, while "gall sickness " is a popular designation for 
 similar disorders among men. One of these results, which 
 exhibit m a strong light the connection of the morbid de- 
 rangement of the lungs and liver from malaria, is the compli- 
 cation of pneumonia with hepatic disease, known as bilious 
 pneumonia. 
 
 Another illustration of the vicarious action of the liver,
 
 310 Essay on Cholera Infantum. 
 
 wlien the functions of the hmgs are impaired, appears in 
 the fact that fattj livers are frequent in pulmonary phthisis, 
 of which M. Louis and Dr. Horner give several examples. 
 The former mentions forty-nine cases, of which number forty- 
 seven were dependent on tbat aflfection. Fat, it is well 
 known, abounds in carbon. 
 
 That morbid hepatic affections will arise from breathing 
 in a confined atmosphere, where the lungs are forced, to re- 
 ceive air deprived of a portion of its oxygen, appears from 
 the results that have followed experiments on animals purpose- 
 ly confined, where the air could not be freely renewed. Dr. 
 Baron placed several young rabbits where they could not ob- 
 tain fresh air, feeding them on cabbage and grass. One of 
 them died in a month, and presented a morbid condition of 
 the liver, consisting principally of vesicles over its external 
 surface. In nine days another died, with tubercles in the 
 same viscus. In four days another died, with the whole of 
 the liver diseased ; and in two days another died, exhibiting the 
 liver in the same condition. The three that remained were 
 removed to an open situation, and recovered. 
 
 Physiology, and the comparative anatomy of this organ, 
 support the opinion that it does perform a function supple- 
 mentary to that of the lungs, and that, with respect to the 
 venous blood that enters it by the portal vein, it is an organ 
 for depuration, being the only one in the body in connection 
 with the lungs, if we may except the skin, that acts in remov- 
 ing the carbonic acid from the system. The skin, however, is 
 very limited in its excretory function in this particular. 
 
 That which appears to be the most prominent fact when 
 considering the external causes of cholera infantum is, that 
 they all are connected with some interference with the proper 
 discharge of the functions peculiar to the lungs, and conse- 
 quently with an imperfect removal of carbonic acid from the 
 system. 
 
 The importance of this depurative process is evident from 
 the physiological history of all animals ; they all require 
 oxygen, and the effect of its use is uniformly the presence of
 
 Essay on Cholera Infantum. 311 
 
 carbonic acid in the air, with which they are surrounded, 
 when the circumstances are such as to prevent the results of 
 respiration from being dissij)ated. 
 
 It cannot be supposed that whenever so general a law of 
 animal nature is interfered with, the system would retain 
 its healthy vigor, and discharge with suitable energy its varied 
 functions. It would seem as if the retention of carbonic acid 
 is the retention of an effete substance possessing peculiarly 
 injurious qualities, and which, by the action of some of the 
 organs, must be removed. So virulent, indeed, is the poison, 
 that if all the oxygen is removed, so as to preclude the possi- 
 bility of its action on the body, speedy death ensues ; if a 
 less quantity than is required be supplied, uneasiness, debil- 
 ity, and fainting follow. In an atmosphere containing more, 
 but still less than would satisfy the requirements of the body, 
 a protracted derangement of one or more of the organs is the 
 result. 
 
 Now, the lungs perform the function of relieving the sys- 
 tem from this pernicious ingredient ; and all the causes which 
 have been considered do, each in its own way, interfere with 
 this process. Thus, it has been proved by direct experiment 
 on small animals, that a lessened consumption of oxygen oc- 
 curred as the temperature increased, and that a difference of 
 49° made a difference of one half of the amount consumed. 
 Excessive humidity added to this high temperature, also in- 
 terferes with the proper action of the lungs, by preventing a 
 full exhalation. Malaria, especially in crowded places, also 
 interferes with the function of respiration, by supplying air 
 deficient in oxygen, and charged also with foreign ingredients. 
 All these causes of the disease unite in interfering with the 
 normal results of respiration, either by rendering the air defi- 
 cient in what may be denominated the vital ingredient, or by 
 some physical modification which prevents a sufficient quan- 
 tity from being inhaled. 
 
 There being no proof that the active causes of cholera 
 infantum directly affect the mucous membrane of the intes- 
 tines, but abundant evidence that they do produce a morbid
 
 812 Essay on Cholera Infantum. 
 
 change in the liver, this organ is probably the first of the 
 abdominal viscera that is afiected in the disease, by the esta- 
 blishment of a vicarious action ; the Imigs not freely reliev- 
 ing the system, and the liver being a supplementary organ 
 performing a part of their functions. 
 
 The transition from an over-excited state of this organ to 
 one of collapse or congestion, and to other morbid conditions, 
 is a subject familiar to every medical practitioner, and requires 
 no illustration. 
 
 The morbid state of the mucous surface of the intestines 
 follows next, being the result of the morbid condition of the 
 liver, as will appear when the influences of the fourth cause 
 are considered. 
 
 Uh. Period of Life. — ^This may be regarded as the pre- 
 disposing cause, for the disease never appears but during the 
 period of teething. When children that have passed that 
 epoch are exposed to the causes already considered, the re- 
 sult is dysentery. This the writer has repeatedly seen in the 
 same house, during a hot season, where cholera infantum has 
 prevailed. When the affection of the bowels that was excited 
 in the older children continued for a few days, it always as- 
 sumed the form of dysentery, but never that of the peculiar 
 disease of infancy. 
 
 When the morbid condition of the intestines was stated, it 
 was shown that the source of the flow was the mucous folli- 
 cles that studded the greater part of the intestinal surface, and 
 that these follicles presented an appearance of inordinate de- 
 velopment, inflammation, and ulceration. Their development 
 is peculiar to the period of life at which cholera infantum ap- 
 pears, is the result of the natural movement of the system, 
 and is simultaneous with the eruption of the teeth. The in- 
 flammation and ulceration of the follicles are superadded 
 morbid action, constituting the disease under consideration. 
 
 In the infant and child, the active process of development 
 is an important predisposing cause of disease. In them' 
 everythinji; predominates that is connected with organic 
 growth. The desire for food is frequent, the digestion rapid,
 
 Essay on Cholera Infantum. 313 
 
 the blood and fluids are in excess ; capillary action, secretion, 
 and interstitial increase proceed with great vigor ; while the 
 nervous sensibilities are in high activity. Growth of parts 
 seems in truth to differ from inflammation only in degree, 
 which may very speedily be induced upon any disturbance 
 of the developing process. 
 
 It has been remarked that infants grow more during the 
 first year, the increase becoming less rapid as the child ap- 
 proaches the fourth or fifth year ; and it is well known that 
 during the first-mentioned period, violent disease and sudden 
 mortality more frequently occur than at any other time of 
 life. Here, then, is a direct relation subsisting between the 
 rapid increase of the body and its tendency to severe and 
 fatal disease ; the naturally exalted action of the capillaries 
 in developing a part being easily made to pass the boundaries 
 of the healthy process of growth, and become the active 
 agents of inflammation ; the effects of which are of marked 
 peculiarity, — prompt serous effusions from some membranes, 
 and in others the exudation of lymph, as in the trachea in 
 inflammations of that tube. 
 
 The diseases of the brain furnish an evidence of the tran- 
 sition from health to disease during the process of growth ; it 
 is well known that at the time of birth the cerebral organ, 
 although large, is exceedingly imperfect in its organization, 
 consisting of a mass almost like jelly. It is not complete in 
 its parts until a year or more has elapsed, during which period 
 the vital energy of the part is in great activity, carrying on 
 the process of development. Congestions, effusions, and con- 
 vulsions, are more common at this time than at any other. 
 
 In other instances there is an excess of action in one set 
 of organs, which gives a preponderance of one system over 
 others, as in the lymphatic ; producing congestions and ob- 
 structions in the different glands of the body. 
 
 Another illustration of the effect of the development of 
 parts in the production of disease, is that afforded by the 
 mucous follicles of the intestines. When, in the order of the 
 natural development of the infant's frame, these follicles for
 
 314 Essay on Cholera Infantum. 
 
 the first time show themselves in connection with other parts 
 concerned in nutrition, they are in a high state of activity, 
 pouring forth an abundance of their natural secretion. Thus 
 far the action is a natural one, and one of health. Should it 
 become excessive, a serous diarrhoea takes its place, demand- 
 ing the interference of the physician for its removal. This 
 same condition of the development of the follicles, when com- 
 plicated with other derangements of the system, and kept in 
 a state of morbid activity by the continual operation of cer- 
 tain exciting causes, terminates in producing one of the most 
 fatal diseases of our climate, the cholera of infants. 
 
 Dissections of infants that have died of various diseases, 
 have exhibited the development of the mucous follicles, com- 
 mencing at the time of the appearance of the teeth, while 
 before that time they are rarely to be seen. Numerous post- 
 mortem examinations* show that the follicles experience an 
 increase of vital energy which augments their secretion, and 
 renders their size larger and their number greater, but which 
 still does not produce any redness, tumeftiction, or ulceration. 
 Their activity in secretion during the time of dentition is the 
 true cause of the ordinary diarrhoea in teething infants, usu- 
 ally ascribed to sympathy with the gums, and which to a 
 moderate degree is not to be regarded as disease, but is the 
 result of the physiological action of the period of life. 
 
 The follicles, in the natural course of development, having 
 just passed into a state of activity, are thereby prepared to 
 have an additional or excessive development, on the applica- 
 tion of a sufficient cause ; and then the transition is both rapid 
 and easy from a healthy to a diseased state. 
 
 The normal follicular action passing into an abnormal 
 state, under the influence of the three atmospheric causes of 
 the disease, is effected through the agency of the liver ; 
 which, we have seen, is the part on which all these causes ex- 
 ercise their power. They produce disease and alterations in 
 its density or texture, and thereby the passage of blood that 
 
 * Billard, Malad. des Enf., p. 306.
 
 Essay on Cholera Infantum. 315 
 
 is returned through it from the intestinal surface is obstruct- 
 ed. Congestion of the mucous membrane and its follicles 
 takes place, and nature seeks relief by an inordinate secre- 
 tion from them, already in an exalted state of action. When 
 morbid action is once established, congestion, inflammation, 
 or ulceration is the course naturally to be expected. 
 
 It appears, therefore, that cholera infantum is a disease 
 connected with the development of the body, and is the most 
 remarkable instance of the relation subsisting between the 
 growth of parts and the diseases of childhood and infancy. 
 The effect of growth shows itself in the violence of inflam- 
 matory diseases, as connected with the exalted state of inter- 
 stitial nutrition, so characteristically rapid at an early period 
 of life. At one time, it is exhibited, as we have seen, in a 
 peculiar exudation from the blood, abounding in fibrin, as 
 in croup ; again, in the morbid action connected with the 
 changes in the cerebral organ ; at another time, in the suc- 
 cession of diseased action of the different parts of the glandu- 
 lar system ; and in the disease now under investigation, in 
 the morbid development of the mucous follicles of the intes- 
 tines during the period of second infancy. 
 
 bth. Ina/piwojpriate food. — ^There is little to be said upon 
 the action of food that is digested with difficulty. The por- 
 tion not disposed of by the action of digestion becomes, it is 
 well known, an irritating body, which, of course, must irritate 
 all the parts through which it passes. That kind of food 
 which is the most quickly absorbed is least likely to add to 
 the causes already in operation to develop the disease, which 
 must be promoted by intestinal indigestion. 
 
 S EMEIO LOGY . 
 
 The division of diseases into different stages, is both natu- 
 ral and useful. Like all other natural phenomena, disease 
 has its peculiar signs in its incipiency, maturity and decline ; 
 exhibiting phases which indicate the kind of interference 
 which it is necessary to adopt in its management. Without
 
 316 Essay on Cholera Infantum. 
 
 availing ourselves of these as a guide, the practical employ- 
 ment of remedies would be equally unscientific and unsafe. 
 The boundaries, however, of the different stages do not always 
 appear so distinct as to enable us to detect clearly the pro- 
 gress of the disease from one to the other, and the complica- 
 tions add their influence in rendering the actual knowledge 
 of the condition of the affected parts obscure, and thereby 
 often tend to embarrass the judgment. 
 
 Cholera infantum, in its progress, appears in three differ- 
 ent conditions or stages. The first is marked by an increased 
 activity of the bowels, the second by inflammation and ulcer- 
 ation, and the third by complications. 
 
 The evacuation in the first stage consists, at the beginning, 
 of the usual fsecal matters, more largely mixed with watery 
 fluid than in health. Indeed when the disease is gradual in 
 its invasion, no difference will be observed between it at the 
 early stage and the diarrhoea of teething infants, which al- 
 ways precedes cholera infantum, and is in truth its commence- 
 ment. The discharges consist largely of serum, mixed with 
 mucus or minute shreds, or colored with bile ; but in all its 
 forms it is characterized by copious watery evacuations, 
 which, at the period of teething, are often so abundant and de- 
 bilitating, that the child is in a few days exceedingly emacia- 
 ted and exhausted. This is probably the form that is known 
 as the '' watery gripes " in England, when it has not passed into 
 the decided morbid condition which will be more particularly 
 noticed as the second stage. 
 
 To a moderate extent, diarrhoea at the time of teething is 
 salutary ; should it, however, increase in severity, and exhibit 
 a diminution of bile, we may regard this increased action of 
 the mucous follicles as evidence of the congestion of the mu- 
 cous surface of the intestines, from some degree of congestion 
 of the liver; the morbid action of both these parts being the 
 pathological condition of cholera infantum. 
 
 Although for the most 2>art serous, the consistency of the 
 passages will often differ in the course of the day, — sometimes 
 thick and pasty, or frothy, at other times bearing a resem-
 
 Essay on Cholei'a Infantum. 317 
 
 blance to the yolk of a hard-boiled q^^ beaten up with 
 water. 
 
 This diarrhoea affects the system both by the debilitating 
 effects of the increased peristaltic action and by the prostra- 
 tion occasioned by the great secretion from the mucous sur- 
 face. 
 
 In this diarrhoea the color of the discharges will be differ- 
 ent, not only in different individuals, but also various in the 
 same patient at different times of the day — yellowish, light 
 green, or of the peculiar color of serum, and equally as trans- 
 parent. This last condition we have frequently seen, and so 
 destitute of any additional substances, as to have been mis- 
 taken by the nurse for the urinary discharge, and the fact 
 mentioned of the excessive amount of urine passed by the 
 child, when in truth there had been none. 
 
 It is rare that vomiting occurs very early in the disease ; 
 yet, when it arises simultaneously with the first appearance of 
 excessive purging, the disease is proportionately severe, and 
 exhaustion and death will often ensue, without any complica- 
 tion, in a very short time. "We have witnessed death under 
 these circumstances in twelve hours. Such instances, how- 
 ever, are rare, and it is umisual for a fatal termination to occur 
 during the first stage. 
 
 The vomiting, or efforts at vomiting, is a marked feature of 
 the disease. All observers must have noticed its obstinacy and 
 the peculiar kind of action attendant on the attempts at vom- 
 iting. This effort is sometimes connected with a powerful ac- 
 tion of the abdominal muscles ; and they will be found at times, 
 on placing the hand over the abdomen, to be in a convulsive 
 or rolling motion, generally simultaneous with the action of 
 the stomach. At other times when the disease is severe, this 
 movement of the muscles will take place without any at- 
 tempts at ejecting any thing until the paroxysm is about end- 
 ing, when the efforts to vomit will occur. 
 
 The tongue is moist, and covered with fur of a light 
 brown hue at its base. The thirst is invariably very great. 
 The febrile condition does not arise from an essential or 
 23
 
 318 Essay on Cholera Infantum. 
 
 primary fever, but is clearly of the class of irritative fevers; 
 it rarely appears at the beginning, but increases with the pro- 
 gress of the disease, occurring in irregular paroxysms of dif- 
 ferent degrees of intensity. The heat of the surface of the 
 body augments in the course of the disease, especially in the 
 abdominal region. 
 
 The pulse is small, quick, and frequent, sometimes sharp 
 and wiry. 
 
 The second stage is the period of inflammation and ulcera- 
 tion. Tlie general heat of the body decreases, while that of 
 the abdominal surface increases to a high degree of intensity. 
 
 The tongue is parched and heavily laden with petechia at 
 the sides and at the commissure of the lips. The child seizes 
 with frantic eagerness any drink that may be offered. 
 
 The serous diarrhoea increases, with great variety in the 
 appearance of the evacuations, and with the addition of mu- 
 cus. While before, the predominating color was yellow, 
 it is now frequently of various hues of green. At times the 
 serum appears to be replaced by masses of mucus, of a greenish 
 tinge to a deep hue of that color. Although a yellow or green 
 color may indicate the presence of bile, yet the alvine evacu- 
 ations may, in disease, assume this appearance without the 
 presence of bile. The jelly-like mucus derives its color from 
 the alterations in the secretion produced by inflammation, as 
 is occasionally found in mucous discharges in disease in other 
 parts of the body. In bilious evacuations, there is a decidedly 
 faecal odor ; in the colored mucus, none. The color is also 
 changed to a brown or white, and frequently pink. During 
 their evacuation the usual fs&cal matter is retained. 
 
 These discharges are at times peculiarly offensive, at other 
 times they exhibit no other odor than that which is derived 
 from acid. The offensive odor is not that of ordinary faeces, 
 but of the nature which attends the decompositions of animal 
 tissues in ulceration and sloughing 
 
 The evacuations present different appearances, according 
 to the part of the intestines the most affected ; thus when the 
 upper part is that principally diseased, they are frothy and
 
 Essay on Cholera Infantum. 319 
 
 acid, and when the food is passed, it appears almost unaltered 
 by the process of digestion. When the lowest portion of the 
 intestines is the part, the disease bears a resemblance to dys- 
 entery, and the evacuations are bloody and slimy, and attend- 
 ed with tenesmus and pain. 
 
 In inflammatory afflictions of the bowels in children, 
 there is always some sympathetic affection of the brain ; and 
 serious disease of this organ will follow an inflammation in 
 the digestive system ; a fact well known to the ancients, but 
 more particularly pointed out by modern observers. These 
 pathological sympathies are in general proportionate to the 
 violence of the primary disease, and are indeed so uniform 
 that the meninges of the brain participate in an equal degree 
 with the affections of the bowels, having at one time an acute 
 and at another a chronic action. The brain, in confirmed 
 cholera infantum, never escapes. 
 
 When the disease has proceeded thus far, the general 
 aspect of the child is that of distress from pain in the head as 
 well as in the abdomen, indicated by the lineaments of the 
 face. Pain is indicated as existing in the abdomen by a 
 pinched expression of the face, by a fold in the commissure of 
 the lips outside of the orbicularis muscle, and by a lineament 
 extending from this part to the inside of the alse nasi, and 
 sometimes surrounding the orbicularis muscle. Pain in the 
 head is known by a frequent corrugation of the skin below 
 the eye-brows. These most usually occur upon the awaking 
 of the child, and will continue for a minute, or shorter period, 
 before it evinces pain by crying. Added to these, the languor, 
 paleness, sunken eyes, with their dark areola and general 
 shrunken condition of the body, complete a picture of distress 
 which it is in vain to attempt to describe. 
 
 The third stage is that of complication and death. 
 
 The skin becomes dry and ash-eolored. It hangs loose, in 
 folds, about the body, while over the forehead it is tight and 
 smooth. The cheeks become shriveled, and the general as- 
 pect of the cheeks and lips imparts an appearance of old age, 
 while the muscles in every part of the body are flabby, and
 
 320 Essay on Cholera "Infantum. 
 
 friglitfullj attenuated. The eyes are strained, and the adnata 
 are injected ; drowsiness, stupor, and partial paralysis suc- 
 ceed, to be followed by death after a protracted term of 
 suffering. 
 
 Such is the usual course of the development of the disease 
 in its progress to a fatal termination, "When it does not reach 
 the stage of complication, it is often exceedingly protracted ; 
 and when the usual secretions are to a certain extent restored, 
 it assumes more of a mixed character, resembling a chronic 
 diarrhoea, and is as obstinate and as diflScult to manage as 
 any disease of childhood ; terminating fatally from mere 
 exhaustion. 
 
 The discharges frequently change their character — be- 
 coming serous, mucous, flaky, bilious, and purulent, by turns. 
 This chronic diarrhoea affects the system both by the debilita- 
 ting effects of the irritation of a large diseased surface, and 
 by the uninterrupted secretion from the mucous membrane ; 
 to which may be added the almost total loss of the power 
 of digestion. Whatever is the character of the alvine evacua- 
 tions, a want of tone in the affected parts appears to be their 
 pathological condition, with occasional ulceration of them. 
 
 Treatment. 
 
 In the treatment, it must be kept in mind that the use of 
 therapeutic means is of little avail while the active agents in 
 the production of the disease are in continued action upon 
 the system. Often have we experienced how disheartening 
 it is to be required to administer medicine for the cure of this 
 disease, when the circumstances of the patient are such as to 
 preclude the possibility of applying to any extent the meas- 
 ures demanded by the laws of our physical nature. Even 
 the temporary relief sought during the day is productive of 
 little benefit by a return at night to the close and stifling air 
 of the over-crowded dwelling. 
 
 To exhibit by facts in as strong a light as is in our power,
 
 Essay on Cholera Infantum. 321 
 
 the important influence exerted by a pure atmosphere in 
 overcoming the morbid action in this disease, we will give 
 the results of several cases; those only of a large number, 
 occurring both in public and private practice, of which we 
 have any memoranda. The circumstances under which they 
 happened were so marked, as* to admit of their being divided 
 into three classes. 
 
 Of ninety-four, forty-four occurred where the concentrated 
 effluvia of about five times more people than ought to have 
 occupied the space of their dwellings, existed, in addition to 
 the refuse produced by them. The odor of the air was at all 
 times distinctly offensive to the senses amidst the stifling heat 
 of the weather. Of these forty-four, twenty died. The next 
 class occurred among persons possessing the ordinary com- 
 forts of such as usually apply at the dispensaries, and w^ere 
 about half as much crowded as those already mentioned ; 
 they numbered thirty-five ; of whom ten died. The last con- 
 sisted of private patients, and numbered fifteen ; of these, 
 two died. 
 
 Could we add to these numbers, it would, without doubt, 
 add an abundant testimony in corroboration of the prevailing 
 opinion of the necessity of pure air as a curative agent. 
 
 Both as a preventive, and as a remedy when the disease 
 exists, it will be necessary to adopt suitable means to modify 
 the excessive heat and to purify the vitiated air. It is indeed 
 difiicult, if not impossible, among such as are exposed to the 
 sufferings and have to endure the privations of poverty, to 
 accomplish any thing of this nature. An attempt, however, 
 may be made by exposing the child daily tcrthe reviving in- 
 fluences of the fresh air, hy a walk in the suburbs, or if the 
 situation permit, by an excursion on the water. The causes 
 of the disease are clearly obvious ; and these measures it is 
 the duty of all physicians to urge, during the intense heat of 
 summer, that nothing may be omitted in the way of prevent- 
 ing so formidable and fatal a scourge. 
 
 It is surprising how often is witnessed among the more 
 intelligent, who are removed from the effects of poverty, an
 
 322 Essay on Cholera Infamtum. 
 
 entire disregard of the simplest rules of hygiene. Frequently 
 we have seen young children suffering from the effects of 
 heat and impure air, languid and sweating, from being 
 crowded in one bed or in one room while the external air is 
 carefully excluded. Placing children to sleep in a low bed- 
 stead that has been kept throughout the day beneath another, 
 and only brought out at night, is fraught with the direst of 
 evils, never thought of by those having the immediate care of 
 the children. 
 
 There is no difficulty among those whose condition in life 
 enables them to use the simple prophylactic means necessary, 
 to anticipate this and other affections of children that arise 
 from heat and impure air. The doors of all the bedrooms 
 should be left open, while the upper sash of the window should 
 be let down ; no danger can arise from the external air ad- 
 mitted in this way, if the bed is removed from the direct 
 current. During the day, in summer, the freest circulation 
 ought to be encouraged by keeping opposite windows open. 
 
 Children should never sleep on a feather bed : a hard mat- 
 rass that will not accumulate the heat is the only kind of bed 
 they should use ; while the body ought to be lightly covered. 
 
 The prostrating effects of heat in summer are particularly 
 distressing to young children, in whom the activity of the 
 nutritive process is great ; and in proportion to this activity 
 of the capillary system, is the demand for fluid ; while the 
 increased cutaneous excretion increases greatly this demand 
 for fluid, l^othing will supply this necessity so well and be 
 so refreshing, as a draught of cold water. All persons have 
 experienced this*desire ; and the uneasiness and fretfulness 
 of young children, who are unable to express their wants in 
 any other way, arise very often from intense thirst, which 
 nothing will quench but cold water. To allay this irritabil- 
 ity, is itself of importance, and they may often be calmed at 
 night by a drink of water. This we have always placed 
 among the general preventive measures. 
 
 Diet is a very important subject, both in the prevention 
 and management of the disease. One of the greatest evils in
 
 Essay on Cholera Infantum. 323 
 
 its treatment is the use of vegetable food, either of a farina- 
 ceous or starchy nature. The last mentioned, so often given 
 in the form of arrow-root on account of its soft mucilaginous 
 consistency, is especially objectionable. All vegetable sub- 
 stances are unsuited to young infants ; but those of an amyla- 
 ceous nature being altogether insoluble, are with difficulty ab- 
 sorbed, and when the mucous membrane is diseased, scarcely 
 ever are, but pass as foreign substances quite through the 
 bowels, and may be detected in tlie discharges by iodine, the 
 usual test for starch. Farinaceous articles are very likely to 
 become acid, and excessively so in this disease. We regard 
 all such articles for food in early infancy as highly pernicious, 
 whether the child be sick or well. 
 
 The food that nature supplies is the best, and, if there is 
 no deterioration either in quantity or quality, should be the 
 only food given. When, for any reason, it is necessary to 
 make a substitute for it, milk properly prepared for the child 
 should still be given.* 
 
 In cholera infantum, we have been in the habit of combin- 
 ing a solution of gelatine with the milk, as the most appro- 
 priate food for the child ; and, where the stomach is excessively 
 irritable, to give nothing for a while but the jelly, prepared 
 thick or thin, as the child will take it the most freely. The 
 use of this substance has so frequently been followed by deci- 
 ded benefit, that we regard it as a valuable remedy. It' gela- 
 tine comes under the class of respiratory food only, then it 
 must be regarded as a therapeutic agent. It is so perfectly 
 soluble that it is absorbed as easily as water, and no doubt 
 has passed into the circulation before it could reach the dis- 
 eased part ; in which respect it contrasts very remarkably 
 with arrow-root, so frequently given in this disease. 
 
 As regards the indications of a want of proper nourishing 
 or stimulating power in the nurse's milk, we have been much 
 in the habit of being guided by the instincts of the child, 
 which will cause it at times eagerly to seize some animal sub- 
 stance and suck it with avidity. Following this suggestion, 
 
 * See Appendix, K.
 
 324 Essay on Cholera Infantum. 
 
 we have directed cow's milk to be given, either diluted, 
 pure, 01- combined with gelatine, changed occasionally for 
 chicken water, and when the child is especially eager for 
 animal food and has suffered much from debility, beef tea 
 or a piece of fat pork, according to the instinct of the child. 
 These last-mentioned articles, and even salted meat, are espe- 
 cially beneficial in the more advanced forms of the disease 
 and during convalescence. Iji some form animal substances 
 are necessary in every stage. 
 
 Like all other obstinate diseases, cholera infantum, is not 
 without its specific remedies. In succession, alkalies, qui- 
 nine, the stronger mineral acids, nitrate of silver, acetate of 
 lead, oil of turpentine, etc., have been reported as invaluable 
 in the treatment of this disease ; some of them administered 
 for the accomplishment of a definite object, and some, ap- 
 parently upon no medical principles whatever. When 
 given as specifics, they have all in their turn disappointed 
 the practitioner, and the necessity of less reliance on the re- 
 ported efficacy of some one agent, and of more upon the indi- 
 cations of a correct theory, becomes more evident in propor- 
 tion to a more extended experience in their employment. It 
 is by no means intended to question the accuracy of the state- 
 ments made as to the success of these various articles ; but the 
 numerous failures in other hands, show clearly that the dif- 
 ferent modifications of the disease in different places, or the 
 use of the remedy under other conditions of the system than 
 that in which it was successfully employed, such, for instance, 
 as a different stage of development, have doubtless been 
 the reasons for want of success of a medicine which perhaps 
 has been so much extolled, as to convey the idea that the 
 remedy for the disease was at last discovered. The use of 
 astringents is generally indispensable, but an exclusive reli- 
 ance on them will certainly eventuate in failure ; such reme- 
 dies also as are applicable to an ulcerated condition, would be 
 positively injurious under any other circumstances. 
 
 The success, therefore, of a specific agent is not to be re- 
 ferred to the power it possesses over the disease, like that of
 
 Essay on Cholera Infantum. 325 
 
 an antidote to a poison, but to its adaptation to the morbid con- 
 dition existing at the time ; hence its failure under a different 
 state of the system in the same disease. 
 
 The action of the known causes of the disease, and the 
 morbid condition produced by them, are to be our sole guides 
 in its management. The modifications in the general phe- 
 nomena in a protracted case, the predominance of some 
 symptom tending to divert the attention from the compre- 
 hensive view necessary always to take of the disease, and 
 the complications which arise, will indeed tend much to 
 embarrass the practitioner in his judgment, and to lead to a 
 vacillating mode of treatment. But while these untoward 
 symptoms are duly estimated and judiciously met, the main 
 pathological condition and characteristic development of the 
 disease must always be kept in mind, that we may not be 
 induced to rely too much upon auxiliary remedies. 
 
 First Stage. — When the diarrhoea peculiar to teething in- 
 fants becomes inordinately copious and frequent at the season 
 vp'hen cholera infantum prevails, it is our habit to regard its 
 probable termination in that disease. K there are evidences 
 of acidity in the primae vise, it is best to neutralize it by some 
 fixed alkali. Soda or potass appears often to exert a direct 
 sedative influence on the gastro-intestinal mucous surface, and 
 thereby equalizes and lessens the excessive peristaltic motion of 
 the bowels ; perhaps this effect is produced by simply neu- 
 tralizing the acid which stimulates the affected part. The bi- 
 carbonate of soda combined with gum arable and sugar, — 
 about one-twentieth part of the alkali, — makes a good form 
 to administer an alkali to a young infant. If this should fail 
 to control the discharge, the carbonate of lime, in the form of 
 chalk mixture, may be used. It sometimes happens that 
 chalk, like other alkalies, will form with the acid in the stom- 
 ach a purgative salt, and the discharges will be thereby in- 
 creased. When this is the case, or if the diarrhoea is in no 
 degree controlled, the mild vegetable astringents may be 
 used. They may be freely employed, provided there exists 
 no febrile action nor any heat of the abdominal surface. The
 
 326 Essay on Cholera Infantum. 
 
 root of the common blackberry, Rubus villosus, or the root 
 of geranium maculatum, or the bark of the white oak, Quer- 
 cus alha, — in the proportion of half an ounce to a pint of milk, 
 made into an infusion by boiling, is a convenient form for 
 their administration. To an infant of six months, a teaspoon- 
 ful may be given five or six times a day ; a desert spoonful 
 to a child of two years, at the same time using frictions with 
 stimulating substances over the liver. Whenever it is at- 
 tempted to arrest any copious discharge from the bowels, it 
 is important to establish by such means some cutaneous re- 
 vulsion by the use of a simple stimulating embrocation. At 
 the same time the gums should be examined, and if found to 
 be swollen, freely cut. Such is the mode of managing too 
 excessive a diarrhoea from teething. 
 
 When there is reason for believing that the affection will 
 result in cholera infantum, the discharge exhibiting less the 
 presence of bile, frictions with mercurial ointments may be 
 advantageously used, with or without the addition of pow- 
 dered camphor, which need not be employed if any stimula- 
 ting application to the skin has been previously used. 
 
 In mild forms of cholera infantum, we think the Hydrar- 
 gyrum cum creta is a useful medicine, when it is deemed advi- 
 sable to resort to the mercurial management. Objection has 
 been made to it on account of its alleged uncertainty of ac- 
 tion ; this, however, can only arise from its being carelessly 
 prepared, which may also be the case with any other com- 
 pound medicine. It may be prescribed with advantage in 
 doses of five grains every two or three hours, either alone or 
 combined with Dover's powder and carbonate of magnesia, 
 guided by the presence of abdominal pain or of excessive acid. 
 
 IJ . Hydr. c. creta 3 ss. 
 Pulv. ipecac, comp. 9j. 
 Magn. carb. gr. xv. 
 M. Divid. in pulv. xij. 
 
 One of these powders to be given to an infant once in four 
 or six hours. If these should completely arrest the alvine
 
 Essay on Cholera Infantum. 327 
 
 discharges, aa enema ought to be given, and at least one 
 passage secured in twenty-four hours. If vomiting be pres- 
 ent, the Dover's powder may be omitted. 
 
 Dover's powder is often useful early in the disease ; its 
 employment being indicated when there exists much fever 
 and pain in the bowels. The addition of a warm bath before 
 prostration has commenced, will soften the cuticle and cause 
 a dilatation of the cutaneous exhalants, and a diaphoresis will, 
 almost of necessity, follow its use. 
 
 When the disease is fully formed, mercury becomes indis- 
 pensable in its management, and the best form is calomel. 
 It should not be given in large, purging doses, which only 
 irritate the mucous membrane, while it passes off" without 
 producing any other effect than increasing the secretion which 
 it is one object to restrain. From the twelfth to the eighth 
 of a grain should be administered every two, four, or six 
 hours, intimately combined with some inert substance, as fine 
 sugar. Medicines, it is well known, will often act with more 
 efficiency when minutely divided; and calomel in this disease 
 will be found to be far more effective in producing its specific 
 action when carefully divided by being rubbed and well mixed 
 with the purest sugar. The combination should be reduced 
 to the finest impalpable state, and in this condition made 
 into syrup with water. Calomel is especially useful in the 
 first stage of the disease ; at a later period, when the evacu- 
 ations have become excessive, and inflammation and ulcera- 
 tion exist, it will pass with the evacuations, and produce no 
 effects on the liver. 
 
 The use of opium in young children requires a great deal 
 of cautious judgment. It is a very valuable remedy when 
 judiciously given, and there is none so pernicious when indis- 
 criminately used. At the commencement of the disease, it 
 should never be employed. 
 
 One of the chief indications in the cure of the disease 
 being to induce an action on the liver, and tliereby relieve the 
 congestion of that organ by a free secretion of bile, the calo- 
 mel should be continued as the principal means of relief un-
 
 328 Essay on Cholera Infantum. 
 
 til freshly secreted bile appears in the evacuations. "What- 
 ever be the other measures used in the course of the disease, 
 the liver must be brought to its normal condition by this 
 remedy. When a free circulation of blood from the intes- 
 tines is secured, and the congested condition of the remote 
 branches of the portal vein relieved, the disease then comes 
 under control. 
 
 Such are the general measures the best adapted for the 
 cure of cholera infantum, and are those which should be 
 adopted in the onset of the disease, and, with occasional 
 modifications, used throughout its course. 
 
 Some alteration may be required in the general course, or 
 rather a suspension of the principal object maybe necessary, 
 from the appearance and persistence of some violent symp- 
 tom which may itself very materially interfere with the proper 
 use of the appropriate remedies, or become a source of severe 
 and protracted irritation, and which it will be necessary to 
 counteract by some special means adapted to the nature of 
 the existing symptom. 
 
 Among the most obstinate symptoms in the first stage is 
 vomiting, and while it continues incessantly tormenting the 
 child, the administration of the proper remedies for the 
 removal of the disease is of little avail ; it therefore claims a 
 large amount of the physician's attention. 
 
 For the control of this symptom a large number of rem- 
 edies of the most opposite nature has been advised ; all of 
 them at times successful, and again not only useless, but fre- 
 quently aggravating the symptom for the removal of which 
 they were given. 
 
 The difierent anti-emetics advised in this disease are, 1st. 
 The neutralizing, such as the alkalies. 2d. The neutralizing 
 and astringent, as the alkaline earths in the form of lime- 
 water or chalk mixture. 3d. Astringents ; vegetable, as kino ; 
 mineral, as the acetate of lead. 4th. Anodyne ; as opium. 
 5th. Stimulating ; coff'ee, spirits of turpentine, ether, wine, 
 brandy, etc. 6th. Revulsives and rubefacients, mustard, red 
 and black pepper poultice, camphor as an embrocation, or
 
 Essay on Cholera Infantum. 329 
 
 vesicatories over the gastric region, and stimulating enemata ; 
 and 7th. Remedies fulfilling the general indication for the 
 cure of the disease ; as mercury in various forms, either alone 
 or in combination with others for the accomplishment of the 
 same end ; as calomel or blue pill with Dover's powder or 
 prepared chalk. All of these have been recommended from 
 experience in their use, but it is plain that they could only 
 be successful from different conditions of the stomach at the 
 time of their employment, and are not applicable to other 
 cases where similar conditions do not exist. 
 
 Although vomiting, particularly when the disease is fully 
 formed in the first stage, may be regarded as essential to the 
 disease, yet it is evident, from the nature of the different rem- 
 edies, that some difference must exist in the pathological con- 
 dition of the organ which is its seat, and which can in general 
 be ascertained by carefully watching the symptoms attending, 
 and noting the state of the whole system, whether one of 
 excitement or exhaustion. 
 
 At the beginning of the disease there appears always to 
 exist acidity, and we invariably begin with some alkali ; lime- 
 water combined with milk rarely fails to arrest the vomiting 
 at the expiration of two hours, when given every half-hour in 
 the dose of one teaspoonful of the mixture, consisting of 
 equal quantities of the two articles. Although at times read- 
 ily arrested, it will recur, and will probably be arrested the 
 second and third time. If the disease progresses it cannot be 
 controlled by this simple means, other and more powerful 
 measures will be required. Applications of a stimulating 
 kind can then be used to the surface covering the stomach, 
 but blistering should never be employed. Blisters appear to 
 be always positively prostrating to young infants, particularly 
 when applied to this part of the body. Revulsives by stimu. 
 lating enemata will transfer the irritation ; and if dysenteric 
 symptoms appear, vomiting usually ceases ; it rarely occurs 
 when these symptoms arise early in the disease. Of the two, 
 irritation in the rectum isto be ch osen. Mildly stimulating
 
 330 Essay on Cholera Infantum. 
 
 enemata, are important remedies in severe vomiting wliicli 
 resists other measures. 
 
 But it often happens that great exhaustion follows a severe 
 and protracted vomiting, and stimulants are indicated and 
 often receive the appellation of specifics, when it is simply 
 the condition of the system that makes them efficacious, and 
 whatever is the last employed is usually regarded as possess- 
 ing anti-emetic properties. Strong coffee, or brandy, is among 
 these, and under the circumstances just mentioned, highly 
 useful in rallying the system and relieving the stomach by 
 the general stimulation of the circulation. 
 
 Thus, by endeavoring to ascertain the actual condition, it 
 may be in our power to control and manage to some extent 
 this obstinate difficulty to the general management of the 
 disease. 
 
 Instead of vomiting, tenesmus is at times the most distress- 
 ing symptom, and is exceedingly wearing to the young infant. 
 Irritation about the rectum is almost sure to relieve vomiting, 
 and may therefore be but little interfered with ; but when it 
 passes into severe tenesmus, mild anodyne enemata should be 
 used. They ought to be employed with great caution. The rule 
 in the adult is, to give three times the amount of the tincture of 
 opium by injection as it is usual to administer by the mouth. 
 This rule is inadmissible when young children are treated. 
 Children are peculiarly susceptible to the action of opium, 
 although a most decided advantage often follows its use in 
 the characteristically irritable condition of the system at this 
 period of life ; yet, from the great rapidity of absorption at 
 that time, a small quantity cannot be given without incurring 
 some risk. Let it be first given in an enema in the quan- 
 tity which would be given by the mouth, and repeated if it 
 should be returned, rather than increased in quantity. After 
 a few trials, the quantity may be cautiously increased. 
 
 During the continuance of the disease, although free 
 serous evacuations continue, the ordinary faeces are apt to be 
 retained. This may be suspected when the abdomen becomes 
 tumid, and the alvine evacuations have undergone no altera-
 
 Essay on Cholera Infantum. 331 
 
 tions. If the mercurial preparations have failed to procure 
 an evacuation of fseces, a laxative consisting of magnesia and 
 rhubarb, will be proper to remove the highly irritating con- 
 tents of the bowels. There is often acid existing in the sto- 
 mach and bowels in this disease ; for from the absence of bile 
 no neutralization occurs, and dissections have exhibited the 
 presence of a frothy, acid matter in different parts of the bow- 
 els. The combination, therefore, of some alkaline remedy will 
 be called for by this probable condition. When there is no 
 fever present, the aromatic syrup of rhubarb and magnesia 
 will be found a useful prescription. The object being simply 
 to relieve the bowels of the load of irritating fseces, such 
 measures are indicated as will at the same time tend to pro- 
 duce a lessened flow of the serous discharge from the exha- 
 lent vessels of the mucous membrane. 
 
 As to the employment of astringents a great deal of caution 
 is to be used, neither rejecting them, nor using indiscrimi- 
 nately such measures as will at once arrest the most promi- 
 nent and exhausting symptom of the disease. Although 
 astringent remedies are not to be regarded as the principal 
 mode of cure, yet when the child appears to be rapidly sink- 
 ing from excessive exhaustion produced by large serous evac- 
 uations, it will be advisable to employ some of those already 
 mentioned, or others of a more powerful efficacy. 
 
 Whenever it has been deemed advisable to resort to the 
 use of astringents, we have been in the habit of using them 
 as auxiliary remedies, and. that their action may not be inter- 
 fered with, to suspend for a short time the mercurial course. 
 Tannin, either pure or as it occurs in kino and catechu, will 
 often temporarily arrest the discharges. One of the most 
 efficacious astringents is the acetate of lead, combined with 
 Dover's powder in the proportion of the third of a grain of 
 the former to the twelfth of a grain of the latter, to a child 
 of fifteen months once every two hours. When the secretion 
 of bile is established, there is nothing so well adapted to 
 complete the cure as this combination. When using the 
 stronger vegetable astringents, as kino or tannin, it will be
 
 332 Essay on Cholera Infantum. 
 
 necessary to stop the animal gelatine which may have been 
 used as diet ; or it will form with them an insoluble compound, 
 and add to the existing disease the irritation of a foreign, indi- 
 gestible article. 
 
 Second Stage. — The treatment of what we have called 
 the second stage of the disease, is that which will be best 
 adapted to remove the inflammation and ulceration of the 
 affected parts. If the inflammatory period is early in its 
 invasion, and appears almost simultaneous with the appear- 
 ance of the disease, a leech to the verge of the anus will be 
 advisable. If this should not afford relief, one or two may 
 be applied over the region of the liver, or dry cupping may 
 be used to the same part, according to the ability of the child 
 to bear the depleting process. It is, however, exceedingly 
 rare that the loss of blood is required, — the inflammatory or 
 congestive stage appearing usually after a large loss of fluids 
 has debilitated the little patient, clearly forbidding the use of 
 sanguinary depletion. When these symptoms appear after 
 some days, the most that the child can bear is dry cupping 
 in different parts of the abdomen, followed by fomentations 
 of warm water. It is well known to practical men that in- 
 stances constantly occur where there exists local inflamma- 
 tion, and where it would be exceedingly rash to abstract 
 blood ; this is especially the case in the disease under consid- 
 eration. 
 
 In that state of the system which exhibits this affection 
 with inflammatory action and fever, the mercury which is 
 given may very advantageously be combined with Dover's 
 powder. There is not much danger of exciting vomiting by 
 its use ; for, as has already been remarked, when the disease is 
 exerting its force on the intestines with an inflammation of 
 these parts, there is but little disturbance of the stomach. 
 Half a grain of Dover's powder, with the sixth of a grain of 
 calomel, may be given every four or five hours. We have 
 thought that there is less irritation to the mucous membrane 
 in this stage of the disease, where the blue pill is substituted 
 for the calomel.
 
 Essay on Cholera Infantum, 333 
 
 It is in this stage of development especially, although 
 useful throughout the disease, that we have found gelatine, 
 either alone or combined with milk, highly beneficial in its 
 management. It is so soluble as to be easily and entirely 
 absorbed, and if it supply but partial nourishment to the 
 wasting body, or if it be altogether what is denominated 
 respiratory food, and indirectly prevents the oxidation of the 
 tissues, yet it is especially an unirritating substance to the 
 tender mucous surface, difiering altogether, in this respect, 
 from any of the vegetable mucilages or jellies, which, for the 
 most part are undissolved. 
 
 Combined with this inflammatory condition is a greater or 
 less ulceration, exhibited in the discharges already referred 
 to, when speaking of the symptoms. It is in this state that 
 the nitrate of silver is beneficial, and it is probable that it is 
 under the same circumstances that sulphuric acid or creasote 
 has been employed with advantage. The nitrate of silver 
 appears to be well adapted to the ulceration of the diseased 
 parts, and when judiciously used, is a very soothing and effi- 
 cacious remedy to the inflamed j^arts. It may be given in 
 the quantity of one-twelfth of a grain, with about one drop of 
 the tincture of opium, three times a day. 
 
 Third Stage. — This is the period of complication. When 
 the cerebral symptoms, such as congestion and stupor, appear, 
 very little if any treatment is of any use. We have often 
 resorted to the various modes of combating congestion of 
 this organ at this period, and have as often failed in obtaining 
 any relief We regard, therefore, the symptoms marking this 
 stage as preceding a fatal termination. 
 
 The Chronic form. — When the disease is greatly protract- 
 ed, it becomes mixed in its character, and often attended with 
 great prostration. In this chronic condition, the continuance 
 of an astringent course, with a judicious use of tonics, becomes 
 necessary. A close attention to the symptoms will be partic- 
 ularly necessary in this form, which partakes of the mixed 
 character of a chronic diarrhoea, and may properly be denom- 
 inated a sequel of cholera infantum 
 24
 
 334 Essay on Cholera Infantum. 
 
 This chronic condition will often continue without any 
 very decided symptom of inflammatory action, at least to 
 such a degree as to require direct anti-phlogistic remedies : 
 an inflammatory irritation will exist, keeping up the morbid 
 symptoms, and wasting the strength of the child by the con- 
 stant discharge from the bowels. Under these circumstances, 
 it will be necessary to resort to astringents, cautiously used, 
 or to some of the stimulants which possess astringent proper- 
 ties, and which appear to exert some peculiar power on the 
 mucous membrane. Nitric acid is a medicine of this kind, 
 and in tedious cases will often act in a favorable manner by 
 allaying the morbid action of the mucous membrane. Six 
 drops of this acid, with six drops of the tincture of opium, may 
 be diluted with an ounce and a half of water, of which a tea- 
 spoonful may be given once in three or four hours. When 
 there is excessive relaxation an infusion of simarouba bark 
 may be substituted for the water, and the mixture rendered 
 slightly stimulating by the addition of the syrup of ginger or 
 of oil of cinnamon, or a drop of the oil of cloves, rubbed up 
 with sugar, and added to the mixture. In similar cases of 
 atony, the sulphate of iron lias been found useful in doses of 
 one quarter of a grain three or four times a day. The tartrate 
 of iron is also useful for the same object, that of imparting 
 tone and astringing the parts. Ten grains may be dissolved 
 in half an ounce of water, with the addition of one of the 
 essential oils just mentioned ; of this mixture, twenty drops 
 may be given four times a day. 
 
 Throughout the whole of the chronic or secondary disease, 
 debility is a prominent symptom ; and while the discharges 
 are restrained by appropriate remedies, whatever can impart 
 tone by a proper stimulating influence should from time to 
 time be used. One of the best we know of, is the compound 
 tincture of cinchona, known as Huxham's tincture; the com- 
 bination of the stimulating ingredients makes it peculiarly 
 adapted to the restoration of the lost tone of the stomacli and 
 intestines. Tincture of kino, tannic acid, and other astring- 
 ents may also be resorted to, with the addition of one of the
 
 Essay on Cholera Infantum. 335 
 
 essential oils, as some stimulant will be, in most instances, re- 
 quired in the greatly relaxed and prostrated condition of the 
 patient; the astringents scarcely acting of themselves. When 
 alcoholic stimulants are needed, we always prefer brandy to 
 wine, and always commence with brandy and water ; if this 
 agrees well with the child, we then combine the brandy with 
 isinglass jelly, and if no untoward symptom arises from its 
 use, change it for milk punch, as supplying the most nourish- 
 ment. Often have we seen a child rally with surprising 
 promptness when a little brandy has been given. The symp- 
 toms are so varied and so combined, that a great variety of 
 medicines has been used to meet the different indications ; 
 most of them, however, of a tonic or stimulating nature, so 
 modified by suitable combinations as to meet the peculiar cir- 
 cumstances as they arise. Otber stimulants are of a specific 
 character, and act directly on the mucous membrane ; of this 
 kind is the balsam of copaiba, which may be given in doses of 
 three or four drops, twice a day. In this class, also, is nitrate 
 of silver, already mentioned. 
 
 The instinctive desire for animal food at this time, is 
 singularly craving, and may safely be indulged. Butter, fat 
 salted meats, fresh meats abounding in juices, are eagerly 
 seized by the child, and are, perhaps, the best stiinuhmts that 
 can be given — far more efiicacious than those ( f a therapeu- 
 tic nature. 
 
 In the management of this disease, our efforts must be 
 chiefly exerted in its incipiency, and during the stages when 
 it still exhibits as its most marked phenomenon, the condition 
 resulting from an excessive and morbid development of the 
 parts which constitute and characterize the affection. 
 
 The transition from a healthy state in a young child to 
 that of disease, is rapid, both from high nei-vous sensibility, 
 and from the quick interstitial growth of parts. Tiie effects 
 of the exciting causes show themselves promptly ; and early 
 in the disease are simple in their manifestation, decided in 
 their character, and with little or no complication. It there- 
 fore becomes a task promising more than ordinary results, to
 
 336 Essay on Cholera Infantum. 
 
 examine well and thorougHj into the nature of the exciting 
 agents, and their action on the economy of the system ; to 
 learn, if possible, in what manner the diseased development 
 is connected with the ordinary development of the affected 
 parts. 
 
 Regarding the process of growth as a great predisposing 
 cause of disease among children, we have endeavored to trace 
 the diseased condition in cholera infantum from its com- 
 mencement as a simple natural development, and to connect 
 this development with the well-known causes which are ac- 
 tive in the production of the morbid changes in the parts 
 affected in the disease, and have thereby been enabled to 
 present the subject in a strictly practical aspect. The pre- 
 ventive and hygienic measures for relief, so abundantly 
 proved by experience, have their full explanation in the phi- 
 losophical consideration of the subject ; while the same inves- 
 tigation bears directly to the establishment of the principles 
 on which the therapeutic management is founded.
 
 APPE NDIX. 
 
 A. 
 
 It is remarkable that Dr. Cleghorn should for the first time have made 
 the discovery referred to, in Minorca, and also that on his return to Great 
 Britain he should not have recognized the disease of which he speaks, if it 
 was a peculiar affection in his country. His talent for observation appears 
 to have been unequaled. Dr. Fothergill, in a letter to Dr. Cuming, August 
 14th, 1742, awards the following praises to him : " Thou wilt, no doubt, 
 admire the industry of our friend Ckghorn, who situated in a corner of the 
 world, has made greater progress than any of us who even do not want the 
 proper aids of study. Let us, therefore, stimulate one another, that we 
 may follow his footsteps, and become the worthy friends of so great a man." 
 — Mem. of John Fothergill, M. 2)., ly John Coakley LetUom, p. 104. 
 
 Dr. Cleghorn's observations in Minorca embraced a period of seven 
 years. In three of these he mentions the existence of " cholera morbus " 
 among children, in connection with several other diseases. In the other 
 four years no mention of such affection occurs. The following is his only 
 account : 
 
 1744. " From the end of June, the young children (who constantly 
 suffer first by excessive heat and cold) are attacked with vomiting, purging, 
 and periodical fever." 
 
 1747. 'About the end of the month [June], the cholera morbus carried 
 off" many children." 
 
 1748. " The ensuing summer proved very unhealthy to children, many 
 of them dying of cholera morbus." 
 
 It would appear from this that the disease was not uniform as to the 
 time of its invasion ; and the remark in the last mentioned year, seems 
 to convey the idea that it was an unusual season for sickness among chil- 
 dren. 
 
 The following extract is from the remarks of Dr. G. R. B. Horner, of
 
 338 
 
 Ajypendix. 
 
 the F. S. Navy, on the diseases of Minorca'raade from observations during 
 the period betvi'cen 1831 and 1838, inclusive: "Dysenteric and other dis- 
 orders of the alimentary canal prevail, but I am not aware that the former 
 does to such a degree as to be called epidemic ; and in this respect the cli- 
 mate seems to have undergone a material change since Cleghorn lived in 
 Minorca." 
 
 B. 
 
 The following table, taken from a paper by Drs. Nilcs and Russ, in the New 
 York Medical and Physical Journal, v. 6, gives the number of deaths for 
 eleven years of several prominent diseases, showing the influence of temper- 
 ature on mortality in that city. 
 
 Diseases. 
 
 Consumption 
 
 Acute Diseases of Lungs 
 
 Fevers, 
 
 Dropsies, 
 
 Cholera Infantum, 
 
 Dysentery 
 
 Croup 
 
 Tabes Mesenterica 
 
 Gastro-enteritis, 
 
 Hooping Cough, 
 
 Apoplexy, 
 
 Measles, 
 
 Intenoperanoe 
 
 Disease of Liver,. . . . . . 
 
 Palsv, 
 
 660 
 
 200 
 
 178 
 
 244 
 
 2 
 
 22 
 
 137 
 
 68 
 
 48 
 
 53 
 
 49 
 
 48 
 
 49 
 
 48 
 
 42 
 
 659 
 
 644 
 
 664 
 
 616 
 
 292 
 
 254 
 
 250|210 
 
 137 
 
 158 
 
 186 
 
 211 
 
 257 
 
 241 
 
 245 
 
 254 
 
 2 
 
 2 
 
 1 
 
 5 
 
 14 
 
 29 
 
 7 
 
 16 
 
 106 
 
 122 
 
 106 
 
 91 
 
 66 
 
 85 
 
 95 
 
 97 
 
 54 
 
 56 
 
 60 
 
 60 
 
 66 
 
 42 
 
 33 
 
 37 
 
 69 
 
 56 
 
 47 
 
 57 
 
 42 
 
 46 
 
 45 
 
 32 
 
 32 
 
 33 
 
 31 
 
 49 
 
 46 
 
 34 
 
 35 
 
 34 
 
 42 
 
 44 
 
 3l| 
 
 28 
 
 a 
 
 3 
 
 
 § 
 
 3 
 < 
 
 a 
 
 ■2 
 
 D. 
 
 m 
 
 z 
 
 o 
 
 o 
 
 u 
 
 o 
 
 S 
 
 § 
 
 25 
 
 i 
 
 i 
 
 
 
 519 
 
 591 
 
 663 
 
 579 
 
 588 
 
 645 656 
 
 114 
 
 117 
 
 105 
 
 92 
 
 141 
 
 152 172 
 
 245 
 
 262 
 
 374 
 
 497 
 
 441 
 
 305 211 
 
 259 
 
 241 
 
 272 
 
 308 
 
 269 
 
 259 245 
 
 32 
 
 246 
 
 527 
 
 288 
 
 108 
 
 14 18 
 
 28 
 
 233 
 
 489 
 
 378 
 
 203 
 
 79, 36 
 
 66 
 
 69 
 
 67 
 
 84 
 
 140 
 
 139 122 
 
 69 
 
 80 
 
 126 
 
 139 
 
 135 
 
 89 84 
 
 76 
 
 121 
 
 97 
 
 94 
 
 69 
 
 67 39 
 
 31 
 
 73 
 
 105 
 
 105 
 
 71 
 
 66 49 
 
 45 
 
 109 
 
 59 
 
 45 
 
 59 
 
 65| 67 
 
 49 
 
 65 
 
 77 
 
 45 
 
 34 
 
 24' 45 
 
 47 
 
 46 
 
 43 
 
 44 
 
 47 
 
 63' 47 
 
 39 
 
 57 
 
 44 
 
 36 
 
 64 
 
 41 50 
 
 28 
 
 31 
 
 38 
 
 25 
 
 41 
 
 39 
 
 44| 
 
 7466 
 
 2069 
 
 3205 
 
 3044 
 
 1245 
 
 1544 
 
 1239 
 
 1115 
 
 861 
 
 721 
 
 697 
 
 552 
 
 531 
 
 528 
 
 428 
 
 c. 
 
 The spring and summer of 1816 were remarkably cold. Various dis- 
 cussions appeared in the newspapers and philosophical periodicals, as to the 
 cause. It was attributed to spots in the sun ; to numerous ice-islands on 
 the coast; and to the existence of a vapor which filled the atmosphere, 
 " equally dense and yet diaphonous, all over the horizon, that existed at times 
 in the atmosphere." This cold existed till the middle of June, with repeated 
 frosts, which injured many wheat, rye, and corn fields in this and the neigh- 
 boring States. In the latter part of June the temperature arose to 87°, but
 
 Appendix. 339 
 
 again descended and continued to the 15th of July from 15° to 20° below 
 summer temperature.* 
 
 In the year 1816, there was frost on Long Island in every month of the 
 year, and the corn was killed almost universally by the 5th of September.! 
 
 Numerous reports were brought in by vessels arriving at New York, of 
 immense ice-islands in the Atlantic, near the coast. Up to the 1st of July 
 thirteen different accounts of these were published in the newspapers. 
 
 The temperature of the city of New York when compared with that of 
 London is very remarkable. In the former city the mean of the summer 
 is 75° : of the latter 60° . The highest range in London is 82° , in New 
 York 97° . It is said by some that the disease exists in London ; if so, it is 
 certainly to a very limited extent, if, as we have seen, excessive heat is essen- 
 tial to its development 
 
 D. 
 
 The dreadful pestilence that raged in Athens appears to have been of 
 malarial origin, and to have affected all living creatures at a distance from hu- 
 man habitations. The sheep died in solitude. Lucretius observes, that 
 even the birds in the woods, which they never deserted, and the beasts 
 near the streams of water, and in fields and pastures, died in excessive 
 numbers, — 
 
 "Nee tamen omnino temere illis solibus uUa 
 Conparebat avis, neque Doxia secla ferarum 
 Exibant sylvis : languebant pleraque morbo, 
 Et moriebantur."t 
 
 " Hsec igitur subito clades nova, pestilitasque, 
 Aut in aquas cadit, aut fruges presidit in ipsas, 
 Aut alios hominum pastus, pecudumque obatus; 
 Aut etiam subspensa manet vis aere in ipso: 
 Et, quom spirates mixtas bine ducimus auras, 
 Ilia quoque in corpus pariter sobere necesse est. 
 Consimili ratione venitbubus quoque esepe 
 Pestilitas ; etiam pigris balantibis 8egros."§ 
 
 In the year of Rome 290 a severe pestilential disease spread throughout 
 the city and country, affecting equally men and beasts. " Grave tempus 
 et forte annus pestilens erat urbi, agrisque, nee hominibus magis, quam 
 
 * Med. Repository, 3 vol. New Series. 
 
 t History of Long Island by Henry F. Thompson. 
 
 \ Lucretius, Lib. vi. 1217. 
 
 § Ihid, Lib. vi. 1125.
 
 34:0 Appendix. 
 
 pecori ; et auxere vim morbi tenore populationis, pecoribus agrestibusque, 
 in urbem acceptis.''* 
 
 Lancisi mentions that in the Roman States the epizootics are very prev- 
 alent, and exhibit much the same symptoms as malarious diseases do in the 
 man. McCulloch refers to their existence in Hungary, St. Domingo, 
 Guadaloupe, France, and Italy, to a great extent, in 1711, 1745, 1772, 1785 
 and 1795, and in other countries, among all kinds of cattle, flocks of sheep, 
 and wild beasts and birds, — all from paludal miasms. 
 
 Barron Larrey, in his surgical memoirs, speaks of the havoc made on the 
 cows and oxen during Napoleon's campaign in Italy from the effects of ma- 
 laria, thus: " Les reseignmens que je recueillie aupres des habitans, les 
 recherches aux quelles je me livrai, m'assurerent que I'epizootie reconnaissait, 
 pour principales causes, la mauvaise qualite des fourages, I'etat marecageux 
 des paturages, la chaleur excessive et prolongee qui avait succedee tout-a- 
 coup a un printemps pluvieux et orageux. Les pluies d'orage avaient con- 
 siderablement grossi les torrens, les rivieres, et en avaient cause le deborde- 
 ment : une partie de ces eaux, apres avoir nui aux recoltes, etait restee en 
 stagnation dans les lieux bas et enfonces ; ce qui avoit forme autant de 
 marecages."t 
 
 " Animals which feed in marshes where these fevers prevail, are found 
 to have diseased livers. In the town of "Wolcott, Seneca county, where 
 marshes and low lands abound, the hogs, when killed, are generally found 
 with corroded livers."^ 
 
 E. 
 
 The following remarks are from the report of the committee on the sub- 
 ject of the " Agency of the refrigeration produced by upward radiation of 
 heat, as an exciting cause of disease." It also gives the amount of existing 
 knowledge as to the immediate cause of the invasion of miasmatic diseases. 
 " Most authors who have treated upon atmospheric influences to which per- 
 sons are exposed, have confined their attention to the conditions of excessive 
 moisture or malarious effluvia, the products of putrefaction. During the ex- 
 istence of such circumstances, according to our view, let any one be sub- 
 jected to the chilling influences exerted through upward radiation from ex- 
 posure during the night to the clear open sky, and fever of the specific 
 character prevalent will be the result ; or, in the absence of such epidemic 
 
 * Tit. Liv. lib. 3, c. 6. 
 I Mem de Chir. Militaire, tome 1, p. 165. 
 
 X Inaugural Dissertation on the Lake Fevers and other Diseases of the 
 Genesee country in the State of New York. Edward G. Ludlow, 1823.
 
 Appendix. 341 
 
 agents, diarrhoea, rheumatism, or other inflammatory affections may occur 
 instead." 
 
 "In cities there is a compensation for the loss of beat through radiation. 
 The walls and pavements absorb more heat by day, than they can possibly 
 throw off at night. Hence the remaining heat prevents the detrimental ef- 
 fects of refrigeration from that partial radiation which alone can take place 
 in cities. Persons can, therefore, go about at night in cities with almost 
 as much impunity as by day, and this during the prevalence of epidemic 
 influences which intrude themselves no farther than the precincts." 
 
 F. 
 
 Two long articles are in the Evening Post of September 20th and October 
 1st, 1828, on the subject of the origin and extreme virulence of the miasm. 
 The Long Island Star of the 18th of September of the same year, has the 
 following editorial : 
 
 " Malaria. — The sickness which now prevails on Long Island, and 
 which suddenly attacks whole families, is considered by some to be the 
 malaria so well known in Europe, and which arises from heat, moisture, and 
 the decay of vegetables. Its effect in some places has been dreadful indeed, 
 and we trust will call forth the investigation of gentlemen of medical talent." 
 
 The following are from the New York Enquirer of the same year : Sep- 
 tember 2d — " In several parts sickness has made its appearance in the shape 
 of fevers, &c. Long Island particularly groans heavily, notwithstanding its 
 proximity to the sea." October 3d — "It is very sickly on Staten Island, 
 many families suffering for want of medical aid." 
 
 Journal of Commerce, October 3d, 1828 :— " The epidemic fever, both 
 intermittent and remittent, which has been mentioned as prevailing in some 
 parts of Long Island, still continues, and has increased of late, particularly 
 in the vicinity of Newtown, Bush wick, &c. It is probable that it will con- 
 tinue unabated until we are favored with frost, that sovereign antidote to au- 
 tumnal levers. This city has enjoyed unusual health, and many fam- 
 ilies that moved into the country from fear of sickness precipitately re- 
 turned. Our bills of mortality show that the number of deaths has fallen 
 below the average of years. It is a little remarkable, too, that all the 
 cases of bilious fever of obstinate character which have occurred in New 
 York, have been contracted in Long Island and New Jersey or neighbor- 
 ing country."
 
 342 
 
 Appendix. 
 
 In that year, it is stated in the '■'■ Statistical report on tJie sicTcness and mor- 
 tality in the army of the United States" that malarial diseases prevailed very 
 extensively around Fort Hamilton, L. I. "The laborers employed in 1828 
 in the erection of this post — a locality which had been previously exempt 
 from the effects of malaria — suffered greatly from intermittent and remit- 
 tent fevers. The elevated coasts of Long Island in the vicinity of the Nar- 
 rows, where a case of intermittent fever was unknown in the memory of the 
 oldest inhabitant, became so rife with intermittent and remittent fevers as 
 to drive the inhabitants from their possessions. 
 
 G. 
 
 By this table, made from the City Inspector's report, it will be seen what 
 little influence was exerted on the mortality by cholera infantum by mala- 
 rious epidemic of 1828, in the vicinity of New York. No remarkable sick- 
 ness existed in any of the other years. 
 
 WHOLE NO. OF DEATHS. 
 
 1825 
 
 1826, 
 
 1827 
 
 1828 
 
 1829 
 
 1830 
 
 1850 
 
 1851 
 
 1852 
 
 1853 
 
 1854 
 
 DEATHS FROM CHOLERA. INFANTUM. 
 
 5,018 
 
 151 
 
 4,973 
 
 222 
 
 5,118 
 
 238 
 
 5,181 
 
 161 
 
 5,094 
 
 119 
 
 5,537 
 
 168 
 
 16,978 
 
 713 
 
 22,024 
 
 721 
 
 21,601 
 
 915 
 
 22,702 
 
 922 
 
 28,568 
 
 1,525 
 
 1 in 33 
 22 
 22 
 31 
 42 
 32 
 23 
 30 
 23 
 24 
 19 
 
 H. 
 
 Extract from the report of the committee on the epidemics of Tennessee 
 and Kentucky. 
 
 *' Cholera Infantvm. — This is a disease which has almost disappeared 
 from considerable portions of this district, whilst it continues to prevail in 
 other portions as much as ever. Notwithstanding much attention has been 
 bestowed upon this disease in the United States, and especially in the west 
 and southwest, it is doubtful whether the diagnosis is not even yet in- 
 volved in some obscurity; whether in fact, other diseases are not frequently 
 called hy that name"
 
 Appendix. 343 
 
 "Cholera infantum usually begins early in the season, in May, for exam- 
 ple, and frequently continues until October."* 
 
 In the table already given in this Appendix, the entire number for eleven 
 years reported for the month of May, is five, out of twelve hundred and forty- 
 five for the whole period. 
 
 I. 
 
 Extract from Emerson's Medical Statistics of Philadelphia : — " Bowel 
 complaints, as the most destructive, stand first in this order (the mortality 
 among children) ; of these about two-thirds are under the general designation 
 of Cholera, nearly all of which were doubtless entitled to the specific appel- 
 lation of cholera infantum, a disease almost peculiar to the United States, 
 in many parts of which it exists endemically under the name of summer 
 complaint. Of three thousand eight hundred and twelve, the whole amount 
 of deaths reported from cholera, adults and children inclusive, three thou- 
 sand six hundred and thirty-nine were under the age of puberty, and three 
 thousand five hundred and seventy-six under the fifth year, viz. : two thou- 
 sand one hundred and twenty-two under the first year, one thousand one 
 hundred and eighty-six between the first and second years, and only two 
 hundred and sixty-eight over the second year. As this affection seldom at- 
 tacks them beyond the fifth year ; the balance of two hundred and thirty- 
 six, between the amount of that period and the total of all ages, may be 
 counted as cholera morhus.^ 
 
 The following, from " Essays Medical and Moral," etc. v. 2, by Thomas 
 Beddoes, M. D., will sufficiently prove the fact that heat alone will produce 
 affections of the liver : " I was informed by an officer from the spot, that 
 nearly all the men belonging to a regiment of horse in India, died within a 
 short space of time of a liver complaint, because the commanding officer 
 would persevere in exercising them in the face of the sun." In the appen- 
 dix to the same work are found remarks by M. Fitzgerald, Esq. : " A gentle- 
 man well known to have practiced long and very extensively at Madras." He 
 speaks, " from much experience of the facts," and states that great mortality 
 occurred among Europeans by reason of diseases of the liver from heat, espe- 
 cially among a detachment which joined Lord Cornwallis' army in 1790,which 
 
 * Transactions of the American Medical Association, vol. vi. p. 833. 
 \ American Journal of Medical Science, vol. i. 1827.
 
 344: Ajpjpendix. 
 
 lost most of its men from this cause. He adds, that although intemperance 
 may be a cause, yet " The natives, Dr. Beddoes may rely, sometimes sufifer 
 in very hot seasons, from acute inflammation of the liver without the assis- 
 tance of intemperance, to which they are very rarely addicted." A very 
 large accumulation of facts to the same point could easily be made, but 
 these are deemed sufficient. 
 
 K. 
 
 DIET OP INFANTS. 
 
 Extract from an article ly tlie Author, puilished in the ^'■New YorJc Jour- 
 nal of Medical Science" — July, 1844. 
 
 The period of infancy presents to our attention circumstances in connec- 
 tion with diet, which have no parallel at any other time of life. In child- 
 hood and infancy the desire for food is frequent ; capillary action, secretion, 
 deposition, and interstitial increase, proceed with great vigor, — all, in conse- 
 quence of this period being the period of growth ; wherein it differs very 
 essentially from the adult state, — as, in the latter, the action of vitality is 
 comprised in the preserving and recuperative processes ; to which is added, 
 in the former, that of the development of the body. Growth is much 
 greater during the first year ; and the constant desire for food during that 
 period is a circumstance of common observation. In young infants, the 
 whole time is occupied with receiving nourishment and repose. 
 
 With this peculiarity of early infancy, there is also another more worthy 
 of note, as it has a direct practical bearing on the subject before us ; and 
 that is in the fact that the food of all animals, in their earliest period of 
 existence, is derived from animal substances, — even in those which after- 
 wards subsist upon vegetable grains ; the chick, even after being hatched, 
 uses a part of the egg for its 3.<)urishment. Man, after infancy, obtains 
 his nourishment from both animal and vegetable substances ; and the great 
 variety of articles of food makes a curious exhibition of his omnivorous 
 nature, — the effect of custom, climate, religion, etc. The carnivorous pro- 
 pensities of the people at the extreme North, with their feasts of whale 
 blubber, and the Indian Brahmin, with his meal of rice ; the cannibal of 
 the South Pacific Ocean, and luxurious tables prepared by the most scien- 
 tific French cuisinier for the civilized convivialist; the oak-bark bread of 
 one nation, the flesh-feast furnished by dogs, rats, mice, of another ; — or 
 the snakes, lizards, caterpillars, locusts, worms, and other reptiles, of the
 
 Appendix. 345 
 
 African negro ; and even the meal of clay used by the Otomacs, as men- 
 tioned by Humboldt, certainly present a wide variety in the articles used 
 for sustenance, without considering the minutiae of our daily food, to prove 
 that man is omnivorous. But under all the circumstances of climate, 
 whether in the frozen region of the North, or under the burning sun of the 
 tropics, — of superstitious customs, or savage barbarity, — whatever be the cir- 
 cumstances influencing the character and quality of man's diet, there is for 
 him in a state of infancy, but one kind of food — and that of an animal nature 
 Milk is his sole article of sustenance until the time when a change in his sys- 
 tem takes place, — when a new arrangement of his organization requires 
 him to seek his food among more varied substances, and to which his in- 
 stinct invariably directs him. Comparative anatomy affords its evidence 
 to the necessity of adhering to this one kind of food. The form of the 
 infant's stomach is much more conical than that of the adult, and resembles 
 in this respect the stomach of carnivorous animals ; and the facility with 
 which an infant vomits, or rather regurgitates its food, is analogous to the 
 ease with which the dog or cat vomits whenever any thing is swallowed, even 
 in an inconvenient manner. In the horse, rabbit, or hare, — animals alto- 
 gether graminivorous, — the stomach differs very essentially in its form, resem- 
 bling much more the stomach of an adult ; vomiting can scarcely be excited, 
 even with the strongest emetics. The nature of the infant's food may very 
 rationally be inferred from this analogy. 
 
 if, therefore, nature has provided but one kind of food for the infant, a 
 sudden change to substances essentially different in their nature must be 
 injurious to a greater or less extent ; this is a natural and direct inference 
 from the facts already stated. In adults, where every species of food is 
 used, an entire change, and a restriction to one course of diet, are always 
 productive of important effects upon the general system; and where a 
 scarcity of food has compelled large numbers of men to alter their food, 
 and suddenly to adopt entirely different substances from what they were 
 accustomed to eat, — as was the case in some parts of France, in the year 
 1817, when a failure of the crops obliged the inhabitants to submit to great 
 transition, and to feed upon whatever vegetables could be found, — extensive 
 disease and serious permanent effects are the results. 
 
 The influence of an entire alteration of food, from its powerful effects 
 upon the system, causes it to be regarded as a measure of great value in the 
 treatment of many diseases; and the change to vegetable food is not unfre- 
 quently an important remedial measure. In the adult, such a change is but 
 the restriction of him to a class of substances that is natural to him, and 
 which he can easily assimilate ; and therefore does no violence to his phys- 
 ical nature. In the infant, on the contrary, the adoption of a vegetable 
 diet is actually contrary to the arrangement of his digestive organs, and to 
 the provision which is naturally made for his daily sustenance ; and in the
 
 346 Appendix. 
 
 diseases of the stomach and bowels, must, from the extra demand made 
 upon them to assimilate substances foreign to their nature, add to the exist- 
 ing derangement. Acidity, flatulency, gripings, diarrhoea, and other symp- 
 toms of indigestion, are of very common occurrence in young infants ; and 
 indigestion is the most ordinary affection at that early period, showing how 
 easily their digestion can be impaired. A very obstinate disease will some- 
 times arise in infants about the time of weaning, and particularly if the change 
 from the bland food furnished by the mother be sudden ; hence, the care usu- 
 ally taken to accustom the infant to a different species of food, by commencing 
 feeding it some time before this period, and thus gradually accustoming it 
 to the necessary alteration of diet. If this precaution is necessary to pre- 
 vent injury where nature indicates that a different kind of food is required, 
 how much more care is needed when greater injury is likely to arise on a 
 sudden change, at a period when there is no such natural indication, and 
 which it is so common a practice to disregard upon the invasion of any 
 affections of the bowels. Immediately upon the appearance of these, 
 arrow-root, tapioca or sago formed into jelly, rice or barley-water, is given, 
 from the supposed bland and soothing qualities of these various articles, 
 which, it is supposed, render them peculiarly applicable to the inflamed 
 mucous membrane of the parts affected. Such is undoubtedly the case in the 
 majority of instances in childhood and at adult age, but in infancy I very 
 much question whether this course is followed by any other than injurious 
 effect. I have watched carefully the influence of these substances for some 
 years past, and am satisfied that the additional labor the digestive organs 
 have to perform, in their attempts to assimilate an unnatural food, greatly 
 aggravates the disorder of the bowels ; and if they should fail in digesting 
 the entire quantity, the remainder must be a foreign substance to the bow- 
 els, and thereby become an additional source of irritation. It is Mell known 
 that vegetable food in general requires for its digestion more time and more 
 energetic action of the digestive organs than animal food ; flatulency and 
 acidity are more frequent upon its use. Under ordinary circumstances, 
 feculent nourishment passes much more quickly through the intestines than 
 gelatinous, albuminous, or fibrinous food. It very often swells and under- 
 goes some degree of decomposition, giving rise to the extrication of gas 
 either in the intestines or stomach ; and even when perfectly digested, 
 hunger returns very quickly, whenever the patient is kept exclusively upon 
 it. Some kinds of food are much more difficult to digest than others, and 
 although there are a variety of circumstances in the individual which influ- 
 ence the alteration of sustenance taken into the stomach, yet the diges- 
 tibility of food is very often affected by circumstances relating to the food 
 itself. Thus, fixed oils and fat are slow of digestion, as is known to all • 
 dyspeptics; so also vegetable substances exhibit this indigestibility in a 
 greater or less degree, when in a crude or raw state, or in a farinaceous or
 
 Appendix. 347 
 
 any other artificial condition. If these effects are produced in the adult, for 
 the reasons already mentioned, it must be much more the case in the infant ; 
 and many an instance of the obstinate perseverance of disease of these 
 parts may be referred to the injudicious system of feeding during its prev- 
 alence. 
 
 It is a rare event to have the secrets of the digestive process revealed, 
 and subjected to the test of actual experiment during life or on a postmor- 
 tem examination. The former has been exhibited to us in the case of an 
 adult, by Dr. Beaumont ; and the well-known facts there elucidated have 
 been considered of the most important character. Of no less value are the 
 facts exhibited by postmortem investigations of children, made at Paris a 
 few years since, by M. Natalis Guillot, for the purpose of ascertaining the 
 eonditionof the contents of the bowels of such as died under the use of the 
 ordinary diet of the hospitals. It is the custom at these and similar institu- 
 tions, whenever an infant is sick to withdraw it from the breast, and to 
 substitute for the milk some farinaceous substance made fluid by boiling ; 
 arrow-root, gummed rice water, or a thickened preparation of rice, known 
 by the name of " Creme de riz," and other preparations of a similar nature, 
 forming the diet of the sick infant. In the reported cases of the foundling 
 hospital, and those for the reception of sick children, prescriptions of this 
 nature form a very important part of the treatment, as will be seen by re- 
 ferring to the different treatises of French authors on diseases of children. 
 The mortality in the French hospitals is very great ; and opportunities are 
 continually afforded for examination, in such numbers as to establish to a 
 certainty almost any fact which requires the proof of anatomical demonstra- 
 tion. The attention of M. Guillot being directed to the changes which the 
 food given to children underwent, and to the excessive mortality among 
 them, he instituted a series of investigations in a number of cases of death, 
 with special reference to the state of the contents of the bowels. He was 
 struck with the uniform similarity ; a jelly-like substance being present in 
 the bowels, and in some instances lining both the small and great intestines. 
 This was subjected to the test of the tincture of iodine, which produced an 
 intensely blue color, thus proving it to be starch. 
 
 Here we have a direct proof of the deficiency of the digesting power; 
 the articles given for food had passed through the length of the intestines, 
 and had undergone very little change, and could only act as foreign and 
 irritating substances. The almost entire suspension of the digestive process 
 might indeed have occurred upon the use of any description of food ; but 
 when it is considered that a sudden change is usually attended with injury 
 even in the adult ; that vegetable substances are, under ordinary circumstan- 
 ces, more difficult to digest than animal; that the natural food of the infant 
 is entirely dissimilar in its nature to what was at once substituted in the in- 
 stances above mentioned ; we might very reasonably expect to find a sus-
 
 348 Appendix. 
 
 pension of the digestive powers a very serious aggravation of disease, and 
 the results already stated. 
 
 From all the facts here given, it appears to be the most rational course to 
 pursue, to preserve as much uniformity in the diet as the nature of the case 
 and attending circumstances will admit. If in health, when the digestion is 
 unimpaired, as we have seen food of an animal nature is the proper kind 
 for the infant ; in disease there can scarcely be any alteration to food of an 
 entirely different kind, without incurring some risk. It is not my intention 
 to assert that no alteration whatever is to be adopted, and because but one 
 kind of food is provided for the infant, that it would be hazardous to depart 
 from it under any circumstances; such a course would be to discard all 
 sound theory, to abandon all attempts at controlling disease, and if fully 
 carried out would reach even to the administration of medicine itself. While 
 we avail ourselves of the plain suggestions of science and the accumulated 
 experience of ages, let us so adapt them to the peculiar condition of a class of 
 individuals as not to do a positive injury by their injudicious and indiscrim- 
 inate application. The aged, the robust, the toil-worn laborer, the inhabi- 
 tant of the city or of the country, the delicate female and the tender infant, 
 all demand some modification in the application of the same universally 
 admitted principles of medicine. In the case of infants we can, without 
 removing them entirely from the breast, avail ourselves of the mild and 
 unirritative effects of substances of the same nature as that upon which the 
 infant feeds. One principal reason given for the adoption of vegetable muci- 
 lage, such as infusion of flaxseed, arrow-root, etc., is that it is a soft and 
 soothing application to the tender and inflamed mucous membrane. Now 
 if the same object can be attained by any substance that possesses the same 
 bland qualities, and is also of the same nature as the infant's food, there 
 will be no necessity for resorting to substances possessing such highly un- 
 digestible qualities as those of a vegetable nature. It is not that we may 
 alter the diet from the compound aliment, milk ; but to select from some 
 simple alimentary substances, which it is deemed advisable to employ as 
 medicinal agents, that which, from its essential composition, will be found 
 more nearly allied to the nourishment which nature so abundantly supplies, 
 and thus do no violence to the physical constitution. 
 
 NOTE TO PAGE 300. 
 We have to add to the postmortem examination, two cases recorded by 
 Dr. W. C. Roberts, in the N. Y. Med. Gaz., Nov., 1841, one by Dr. J. A. 
 Swett, one by Dr. Gross reported by Dr. W. Parker in the same journal, 
 in the paper of Dr. Roberts, and one furnished to the author in MS. by Dr. 
 J. L. Vandervoort. In all these five cases the mucous follicles were diseased ; 
 in three, the liver was abnormal ; in one, reported healthy ; and in one, that 
 it appeared in this condition. 
 
 M
 
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