AN
INAUGURAL DISSERTATION
ON
CHOLERA INFANTUM.
SUBMITTED TO THE EXAMINATION OF THE
REV. JOHN EWING, S. T. P. PROVOST,
THE
TRUSTEES and MEDICAL FACULTY,
OF THE
UNIVERSITY OF PENNSYLVANIA,
ON THE TWENTY-SECOND DAY OF MAY, 1798,
FOR THE DEGREE OF
DOCTOR OF MEDICINE.
BY HENRY DISBOROUGH, OF NEW JERSEY,
HONORARY MEMBER OF THE PHILADELPHIA CHEMICAL SOCIETY.
" A man perhaps, the moment of his breath,
" Receives the lurking principle of death,
" The young disease, that must subdue at length,
" Grows with his growth, and strengthens with his strength."
POPE.
PHILADELPHIA:
PRINTED BY BUDD AND BARTRAM,
N° 58, NORTH SECOND STREET.
MAY, 1798.



TO
NICHOLAS ROMAYNE, M. D.
OF NEW YORK,
A PERSON eminently distinguished for his
extensive acquaintance with the whole circle of
Medical Science, and for his politeness as a gen-
tleman;
This Dissertation is inscribed,
With sentiments of gratitude and respect,
By his obliged Friend,
And former Pupil,
THE AUTHOR.

 

TO
DOCTOR BENJAMIN SAY,
FELLOW OF THE COLLEGE OF PHYSICIANS,
PRESIDENT OF THE HUMANE SOCIETY
OF PHILADELPHIA, &c.
SIR,
IN departing from you, under whose directions
have been continued my studies with pleasure and
satisfaction, accompanied with numberless oppor-
tunities for improvement in practice—Permit me
thus publicly to return you my sincere thanks for
the favours you have been pleased to confer:—
And as a person distinguished for your humanity;
and usefulness in the practice of your profession;
This Dissertation is respectfully inscribed,
As a small tribute of gratitude,
By your Friend and Pupil,
THE AUTHOR.

 

TO
THE MEDICAL PROFESSORS
OF THE UNIVERSITY OF PENNSYLVANIA.
GENTLEMEN,
PERMIT me, in leaving the school where I have
had the honor to finish my medical education,
thus publicly to return you my warmest acknow-
ledgements for the useful information I have re-
ceived from your valuable lectures; and, believe
me, I shall ever bear a lively recollection of the
pleasure with which I attended you. To your
reputation as men of science, I can add nothing:
the high estimation of the University is sufficient
to distinguish you as worthy professors, justly me-
riting honor and respect.
That the whole family of mankind may share
the salutary effects of your improvements, is the
sincerest wish of,
Gentlemen,
Your very humble Servant,
THE AUTHOR.

 

INTRODUCTION.
NO diseases to which the human species are sub-
ject, in the different progressive stages of
life, more particularly claim our compassion, and
the extension of medical aid, than those which are
incident to the period of infancy and childhood.
The great irritability of their delicate frames, and par-
ticularly the mismanagement of those to whom the
immediate care of them are intrusted, render them
the subjects of much pain and misery.—So great
is the mortality among children, especially in large
cities, that it has been found from pretty accurate
calculations, that above one half die within the first
four or five years.*
The causes and seats of infantile disorders are
various: none of these diseases are more common
and distressing than those which affect the alimen-
tary canal; of such importance has been deemed
C
* Gregory and Black. Comp. View.

x INTRODUCTION.
the due action of these parts, that many Physicians,
both ancient and modern, have considered a mor-
bid or diseased state of them as the principal
source of destruction among children. From the
regularity of their appearance in most seasons, and
from the different forms which they assume, prov-
ing very frequently mortal, I think but few disea-
ses deserve greater attention.
Before I proceed to take notice of one particu-
lar state or grade of the disease to which this dis-
sertation will be confined, I shall take a short view
of the diversified character which it occasionally
assumes.
Of Diarrhœa. This, it must be obvious to every
person, differs only in its violence—it attacks chil-
dren at the same season of the year, of the same age
and habit of body, and when left to nature, general-
ly continues to increase in its violence till it puts on
every appearance of a true Cholera:
Cholera Infantum, does not appear to be a di-
stinct disease, from intermitting or remitting fever
and cholera morbus in adults, but a variety of the
same—this I infer from the same causes inducing

xi INTRODUCTION. 
these several disorders;—with this difference only,
that the exciting cause, with less force, will produce
morbid action in children and persons pre-disposed
to the disease. * Dr Cleghorn describes this com-
plaint as invading children some weeks sooner in
the season, than similar affections are discovered in
adults. This he very justly attributes to the greater
excitability and tenderness of the alimentary canal in
the infantile system.—Further, in speaking of the
tertian intermittent fever (page 163) he says " as
" the cold fit goes off some bilious matter is com-
" monly discharged by vomit or stool." " † From
" the discharge of bile which generally introduces
" the disease, from the remissions and exacerbati-
" ons of the fever which accompanies it, and from
" its occurring nearly in the same season with the
" cholera and remitting fever in adults, I am dis-
" posed to consider it as a modification of the
" same diseases. Its appearing earlier in the season
" than the cholera and remitting fever in adults,
" must be ascribed to the constitutions of children
" being more pre-disposed from weakness to be act-
* Cleghorn on the Diseases of Minorca.
† Dr. Rush, 1st. vol. of Medical Inquiries.

xii INTRODUCTION.
" ed upon by the remote causes which produce
" those disorders."
From these considerations, I am induced to be-
lieve, that all the intestinal complaints in warm
seasons are modifications of the same primary affec-
tion and constitute the febris introversa of Dr.
Sydenham.

AN
INAUGURAL DISSERTATION
ON
CHOLERA INFANTUM.
HISTORY.
THIS disease becomes most prevalent, and is
attended with symptoms of the greatest dan-
ger, during the warmer months of summer and
beginning of autumn, when it is known by the
common name of the disease of the season. It
prevails in most of the large towns of the United
States: and "it is distinguished in Charleston,
South Carolina, by the name of the April and
May disorder, from its occurring in those two
months." It seldom appears in Philadelphia or New
York until June or July, and continues till the
latter end of September—though from the pre-
mature heats of summer it may occur much ear-

(14)
lier or from the unusual continuance of the same,
it may be considerably protracted.
It generally spreads and assumes a more danger-
ous aspect, in proportion as the heat of the season
increases.
The temperature of the weather has a very con-
siderable effect on this disease.—Great vicissitudes
of heat and cold—sudden and long continued
rains, after a very dry state of the atmosphere, ge-
nerally favour the operation of the exciting
cause;—hence the reason, why in some years, it
proves so alarming and distressing among children,
whilst in other years, from the mild and more uni-
form temperature of the atmosphere, it is compa-
ratively a rare occurrence.
This disease may arise at any period of the in-
fant life, and few children, especially those in large
cities, entirely escape some of its various forms.
It is my intention to describe one form only,
which consists in a nausea, vomiting and purging.
Although this complaint may attack children at
any age, we find that, most frequently, it affects
them from the second or third week after birth, to

(15)
the third or fourth year. It is not unfrequently
preceded by the usual precursors of the common
bilious intermitting and remitting fevers of warm
seasons. It comes on, and is continued with evi-
dent symptoms of pyrexia, loss of appetite, oc-
casional fits of nausea, and sometimes vomiting
without the purging, though more usually the
contrary—but it most commonly comes on with
violent purging and vomiting, which continue to-
gether or alternately with each other.
The matter evacuated is more or less mixed
with bile; its appearance is green or yellow. The
stools, however, vary in their appearance and
have been distinguished into * "sour, curdled,
slimy, clayey, watery, and bloody." Dr Rush in-
formed me, that he had a case in which they were
black; and I have heard of two other similar ca-
ses. In many instances, the stools are large and
fœtid, but in others they are without smell, and
consist chiefly of the aliment as taken in, without
having undergone any material change in its pas-
sage; (this in adults is called Lientery). Some-
times in violent cases, where the disease has run
to a considerable length, some degree of tenesmus
* Underwood on the Diseases of Children.

(16)
will occur. Prolapsus ani has been noticed by
some writers; but this is by no means a common
case: where it does occur it must be owing to a
relaxation of the Levater and Sphincter ani mus-
cles and will mostly disappear as the patient gains
strength. Worms are often discharged in diffe-
rent stages of this disorder.
The symptoms enumerated arc accompanied with
a fever "which is of a remitting kind and disco-
" vers evident exacerbations, especially in the even-
" ings," and like many other bilious diseases of the
season, is marked withmorning remissions. The pulse
in the beginning of the disorder is quick, and consi-
derably tense, full, and hard, but in the advanced
stage of the disease, from the excessive evacuations,
it soon loses its force and becomes weak, frequent
and quick; great thirst is pretty constant through
the disease; the skin hot and dry—though some-
times during the nausea, and perhaps of vomiting,
a moisture breaks out, mostly about the face;
the abdomen often swells, and is remarkably hot,
whilst the extremities are much colder than natu-
ral. One of the most frequent and distressing symp-
toms in this formidable complaint is a severe pain
or griping in the bowels: this may be known by
the child starting, by frequent fits of crying, and

(17)
the forcible contraction of its arms and feet to-
wards the stomach. "This disease affects the
head so much, as in some instances to produce
symptoms not only of delirium but of mania."*
The duration of this disease is various, depend-
ing much on the manner in which it comes on, the
habit, and changes of weather, &c. If the first
attack is with violence and left to nature, all the
alarming symptoms rapidly increase till the strength
of the patient is suddenly diminished, when a
fainting comes on, attended with cold extremities,
cold sweats and subsultus tendenum, which some-
times put an end to the unhappy sufferer, in the
term of one day. A hot, dry and moist atmos-
phere seldom fails to increase all the violence of
the disease, whereas a cold day very frequently
abates its violence, and disposes it to a favourable
termination. It continues, in some instances, with
but few occasional alterations, five or six weeks,
and even three or four months, before any consider-
able change is effected, when the symptoms grow
more numerous and distressing: the body becomes
emaciated to such a degree, that the bones, in some
cases, almost protrude through the skin;—a con-
C
* Dr Rush's 1st. vol. of Medical Inquiries.

(18)
stant inclination to stool takes place, though but
little matter can be voided, and that is of a wa-
tery or green colour—the eyes become languid, and
sink deep within their sockets—the features are
contracted—livid spots appear—a sore mouth—hic-
kup—convulsions—and a strongly marked hipocra-
tic countenance, generally precede the fatal termi-
nation of the disorder.
DIAGNOSIS.
THE diseases with which cholera infantum,
may be confounded are, hydrocephalus
internus, dysentery, and affections arising from
worms in the alimentary canal.
To distinguish it from hydrocephalus internus
it is necessary to remark, that the pulse in the lat-
ter generally continues more full, tense, and fre-
quent, and the evacuations, when they do occur, are
not so copious, nor accompanied with any discharge
of bile. It is more commonly attended with an ob-
stinate pain in the head, the pupils of the eyes
much dilated, strabismus or squinting, much dis-
turbed with noise, and pretty constantly preced-

(19)
ed by or accompanied with a constipation of the
bowels.
It is distinguished from dysentery by its not be-
ing contagious in any stage; nor is it attended with
that degree of pungent pain and griping, so dis-
tressing in dysentery, and from the latter being
a more rare occurrence among children.
The cholera infantum has been blended with
affections arising from worms in the alimentary
canal, though some physicians have thought it
sufficiently distinguished, from worms not having
been discharged in the first attack of the complaint;
but it has been observed, that worms are sometimes
evacuated in the different stages of the disease—
which I conceive to be owing to the violence of
the diarrhœa suddenly repelling them.
In cholera the excretions are very different,
nor is it preceded by, or accompanied with, that
voracious appetite and disturbed sleep: the pick-
ing or rubbing of the nose, and most of the cha-
racteristic symptoms of worms, will be found want-
ing.

(20)
PROGNOSIS.
IN most diseases it appears to be a difficult task
to lay down decided and unequivocal prognostic
symptoms; as patients have recovered under every
discouraging circumstance—whilst others have
died when the most favourable prognostics were
present. Under this impression, I feel dissident in
attempting to say much upon this head ; but it is
natural to conclude, that where the disease attacks
a very delicate habit in warm dry weather, when
the vomiting is excessive, the stomach and bowels
so extremely irritable as to retain nothing taken
into them, with a weak, quick pulse and cold ex-
tremities—we may safely inform the parents or
nurses of such, that life is suspended as by a thread,
and that the probability is, that the child will not
do well; and so, on the contrary, when the symp-
toms are more mild—when the vomiting can be
restrained or suspended, the fever and thirst not
very great, a moderate or mild pulse, we may en-
courage them to have confidence ; for it is proba-
ble, the patient will do well.

(21)
PREDISPONENT CAUSES.
PREDISPOSITION, is that state of the body
which renders it susceptible of the operation
of the exciting cause. This predisposed state of the
system is the same in all fevers, that is, general
debility; which is of two kinds, viz. direct and in-
direct; "the first depends on the abstraction of the
usual or natural stimuli, the latter upon the increase
of natural, or upon the action of preternatural sti-
muli upon the body." For a more particular ac-
count of these states of debility, and the causes
which induce them, I beg leave to refer to Dr.
Rush's fourth vol.* The cause which invites
morbid or excessive action, more particularly to the
stomach and bowels, is debility of the parts,
which is succeeded by an increased excitability or a
greater aptitude to be acted upon by stimuli, and
may arise,
1. From hereditary disposition, by weak organ-
ization.
2. A particular, irritable state of the stomach
and bowels, arising either from natural conforma-
* On the Proximate Cause of Fever.

(22)
tion, or a diseased state of the body, as some-
times happens from dentition, and which may take
place from worms.
3. Irregularity in diet, either in quality or
quantity.
4. Obstructed perspiration: sometimes this takes
place by exposing the child to a sudden current
of air, when the pores are open—by previous
confinement or clothing—instances of this are
related by Dr. Say.
EXCITING CAUSES.
AS debility is the predisposing cause, and is al-
ways attended with an accumulated excita-
bility, the exciting cause must be stimulants—and
are all such as induce fever, which is to be consi-
dered as the primary affection.—For the causes
which act generally on the system, I shall refer to
authors: those which act directly on the stomach
and intestines are,
1. An increased secretion of bile.

(23)
2. Aliments offensive from quality or quantity.
3. Sudden stoppage of perspiration.
4. Sudden repulsions of certain eruptions on
the skin.
5. The use of drastic purges, or the long and
too frequent use of rhubarb, magnesia alba,
&c. by irritating the stomach and bowels, may
induce diarrhœa and cholera.
PROXIMATE CAUSES.
IN establishing a proximate cause to this disease,
(as to many others) there has been great di-
versity of opinions among physicians. Some sup-
posed it to consist of spasmodic affections, arising
from debility of the parts; while others affirm, that
it arises from a laxity of the muscular fibres. Dr.
Brown classes it among the asthenic diseases, and
alledges, that it arises from direct debility.—But
a more plausible opinion is, that of Dr. Cullen,
who imputed it to an increased peristaltic motion
of the intestinal canal, arising from the action of
stimulants.—I shall now, without noticing any

(24)
further the different opinions which have been
entertained, give the theory which I mean to
adopt.
It is, that of fever in general, unduly determined
to the liver and intestinal canal, termed by Dr.
Sydenham the febris introversa.—It consists in a
morbid excitement in the vessels of the stomach
and bowels.
That an increased secretion of bile, will, by
acting on the alimentary canal, induce morbid or
excessive action, is evident—and as a proof that
a preternatural secretion of bile does take place in
this complaint, as in many other diseases of warm
weather, I shall mention a dissection, of which Dr.
Rush informed me, where the gall bladder was
found distended with black bile.—From this and
the evacuations, it must appear clear to every per-
son, that it is a bilious fever, and one of a pretty
high grade.
That particular diet or drink taken in, may,
from its quality or quantity, act by stimulating the
vessels of the stomach and bowels to an undue
action, is sufficiently established.—How a sudden
stoppage of perspiration, or the repulsion of erup-

(25)
tions from the skin, act on the primæ viæ, to pro-
duce cholera infantum, must be imputed to the
sympathy that subsists between the surface of
the body and the intestinal canal.
CURE.
AS I did not conceive it necessary to take a
separate view of the different theories,
laid down by writers heretofore, I shall not at
present notice their different methods of cure. It
would be taking up time, to serve no other pur-
pose than only to show the progressive improve-
ments of medical science, which, I think, must be
sufficiently evident to every observer. I shall now
proceed to mention the remedies, according to the
present state of medical science.
Most physicians, and particularly those of the
United States, have agreed, that the first and most
important step towards a cure, (where the circum-
stances in life will permit it) is, to remove the patient
from the city to some healthy part of the adjacent
country, where medical aid is scarcely necessary.
On the utility of this practice, I beg leave to
refer to Dr. Rush’s Medical Inquiries, vol. I.
D

(26)
As this disease, like all other bilious disorders
of the same season, is attended with an inflammato-
ry diathesis in the beginning, the first indication
to cure must be, when we are called early, to lessen
the morbid excitement. The remedies for this
purpose are, to evacuate the bile from the sto-
mach and intestines.
Blood-letting.—This has been practiced by se-
veral physicians, lately in this city, with the hap-
piest effects; and it should be repeated occasional-
ly, as the pulse may indicate. The bile and other
acrid matters are to be evacuated by the use of
gentle emetics and cathartics. The mildest and
best emetic for this purpose, that we are acquaint-
ed with, is, Ipecacuanha in small doses; which
should be given early in the disease, when the
most beneficial effects are to be expected. The ad-
ministering of emetics, in my opinion, cannot be
attended with much, if any advantage, where the
spontaneous vomiting has been considerable: for
I believe the contents of the primæ viæ are sufficient-
ly evacuated in this way much oftener than has
been supposed.
The bowels should be opened by the use of
gentle laxatives; such as, manna, castor oil, mag-

(27)
nesia alba, and rhubarb, which I have seen given
in the beginning of the disease; and where the
stomach was not very irritable, have known it to
carry off the disorder effectually. Calomel has
lately been recommended by Dr. Miller of New
York, as claiming the pre-eminence over all other
evacuants in this disease. It is certainly preferable
to most other cathartics. For his method of ex-
hibiting it, and for what he has said in favour of
it, I refer to his paper.* Dr. Say has given the
calomel combined with rhubarb, with great ad-
vantage.
When the spontaneous discharge from the ali-
mentary canal has been considerable—when a pro-
stration of strength, feebleness of pulse, and a
coldness of the extremities are produced—we may
conclude, that the disease has already sufficiently
(or too much) evacuated the system—and that all
further evacuation, excited by artificial means,
would be highly improper; and that recourse
must then be had to remedies to subdue the vomit-
ing and diarrhœa, and to support the strength of
the patient.
* In the Medical Repository of New York.

(28)
The following mixture appears to be well cal-
culated for that purpose; a few drops of laudan-
um combined with prepared chalk into a julep,
with peppermint, or cinnamon water. I have re-
peatedly seen this used with the happiest effects.
It generally composes the stomach and intestines,
and frequently subdues the disease entirely. De-
mulcent and diluting drinks, such as thin barley
water, rice gruel, &c. &c. are highly useful.
Glysters made of mutton broth, or of flaxseed
tea, or of starch dissolved in water, with a few
drops of laudanum in them, will often give ease,
and produce other useful effects.—Dr. Say inform-
ed me, that where the disease was advanced to that
state, in which tenesmus is produced, he had
found the happiest effects from injections of flax-
seed tea, a little starch, and laudanum combined,
repeated two or three times a day, as occasion
might require; and at the same time he gave to-
nic medicines internally.
In addition to these remedies, I am of opinion,
from the nature of the disease, that cold water
might be injected with great advantage. The ap-
plication of cold, in various forms, has become
almost universal in diseases of excessive action, and,
I believe cold water might be drank, injected, and

(29)
applied to the surface of the body, with immedi-
ate relief in all the symptoms.*
Plasters of venice treacle, applied to the region
of the stomach, have been found very efficacious
in stopping the nausea and vomiting; and flannels
steeped in infusions of bitter of aromatic herbs,
in warm spirits, or in Madeira wine, and applied
to the abdomen, often afford considerable relief.
Blisters applied to the arms, legs, and to the
region of the stomach, by taking off the deter-
mination from the alimentary canal, have been
attended with good effects.
When the violent, convulsive action of the sto-
mach and bowels is composed, the strength of the
patient must be supported by the use of tonic and
cordial medicines.
The principal tonic recommended in this (as in
* Dr. Cleghorn (page 243) says, the Spanish physicians
had often assured him "that they found nothing more be-
" neficial in violent, deplorable cholera's than the drinking
" of cold water."
Dr. Rush's Medical Inquiries, vol. i. says, the few cases
in which he applied cold water to the surface of the body,
were attended with good effects.
From the Memoirs of the Medical Society of London,
vol. ii page 82. it appears, that the use of cold water, in
complaints of the bowels, is of a very early date.

(30)
other diseases where debility is induced) is Peruv.
bark, either in decoction or in substance; in the
latter form, however, it can very seldom be taken
in sufficiently large quantities to be serviceable, as
children are averse to swallowing any thing nause-
ous—and when it is taken, the stomach will not
afterwards retain it. Therefore it appears to me,
that we ought Seldom or never to attempt the exhi-
bition of it to them.
The bark in decoction, with a few drops of lau-
danum, often repeated in small doses, has produc-
ed the most salutary effects: a valuable medicine
in this stage of the disorder, is columbo root, when
given in decoction or in tincture ; it is both a stimu-
lus and a tonic.
Calomel combined with opium, as recommended
by Dr. Miller of New York. I believe these may
be used with great advantage, as they are univer-
sal stimulants. Port wine or claret, mixed with a
little water, are likewise proper in this stage of the
disorder. Dr. Say informed me, that he has fre-
quently found weak brandy and water to sit better
on the stomach, thus disordered, than any other
kind of drink; though a very small quantity of
any kind should be taken in at a time, otherwise
the stomach will reject it.

(31)
What appears to be of great importance in this
disease (as well as in many others) is a proper re-
gulation of diet. This branch of the Materia
Medica has certainly been much neglected—and
how far a particular regimen would go in curing dis-
eases, is not known—nor am I prepared to deter-
mine in this disorder; but I suspect they would go
much further than has yet been tried. I believe,
in this stage of the complaint, our dependance may
rest much on diet, and particularly if we can with
it, have recourse to the country air—The patient
will, most frequently, with no other remedy, ra-
pidly regain strength.
The diet should be, first, of a nourishing and
gently stimulating kind: some of the farinaceous
substances might be employed with advantage, such
as salep, sago and tapioca : the diet from animals
should be, first, veal and chicken broth, beaf tea
and calf's-foot jelly: from these we may gradually
increase to a more nourishing, as meats boiled and
roasted.
I shall conclude this inaugural essay by mention-
ing the best means of preventing the occurrence of
the disease.
1. By avoiding the causes which induce debility
and all such as stimulate the system.

(32)
2. Regularity in diet and drink, with a faith-
ful attendance in guarding against the changes of
weather, by accommodating the dresses of chil-
dren to them.
3. To avoid costiveness by the use of gentle
laxatives—and to attend to cleanliness, both re-
specting the skin and clothes. 
4. " The daily use of the cold bath."
5. " The removal of children into the country,
" before the approach of warm weather: this
" advice is peculiarly necessary during the whole
" period of dentition."
It would be ingratitude in me, were I to conclude
this dissertation, without expressing my sentiments
of respect and esteem for those gentlemen, from
whom I have received repeated marks of friend-
ship and politeness. To Doctor Benjamin Smith
Barton, Professor of Materia Medica, Botany, and
Natural History, and to Dr. James Woodhouse,
Professor of Chemistry, I consider myself parti-
cularly obligated—and permit me to assure those
gentlemen, that as long as useful and disinterested
services merit regard—and while gratitude de-
serves to be viewed as a virtue—I shall retain a
grateful remembrance of their names.