Article V.—Remarks on the Prophylactic Treatment of Cholera Infantum. By Joseph Parrish, M. D., one of the Surgeons to the Pennsylvania Hospital.

The great mortality of cholera infantum renders it one of the most interesting diseases, which come under the notice of the physician. Its ravages among the infant population of our large cities, are too well known, and too strongly felt, to require any comment. No disease contributes so largely to swell our bills of mortality during its prevalence; and were it not restricted to the summer season, it would prove a greater scourge to the community than consumption itself.

This mortality is owing less to our ignorance of the nature of the complaint, and the proper mode of treatment, than to the continued operation of the causes by which it is produced. I have often compared our endeavours to cure cholera infantum, while these causes remain, to an attempt to relieve inflammation in a part, while a thorn is sticking in the flesh. We may resort to bleeding and leeching; we may restrict our patient to the lowest diet, and the most perfect rest; we may employ all those remedies, which are ordinarily best calculated to reduce inflammation: but so long as the thorn continues in the wound, our efforts will be fruitless. Thus it is with cholera. We may obviate the more violent symptoms; we may procure temporary relief; we may even flatter ourselves that a cure has been effected: but the original causes have not lost their power; an increased susceptibility to their operation remains; relapse upon relapse is experienced; and at last the little sufferer, worn out by the successive attacks, sinks beyond the reach of medicine, and expires. Unhappily, the nature of the causes is such, that, in very many instances, their removal is exceedingly difficult, if not altogether impossible; and, under such circumstances, the patient who has once been severely affected, seldom recovers in the end. Hence it becomes of the greatest importance to prevent the occurrence of the disease; and attention to the prophylactic treatment is no less essential than the adoption of curative measures. It is with the view of calling the attention of the profession to this subject, that I have been induced to offer the following observations.

It is obvious, that, in the preventive treatment, two objects demand attention; first, to remove, as far as possible, the causes of the disease; and secondly, where their entire removal is not attainable, to fortify the system against their influence. On each of these, I shall offer a few observations.

I. Excessive and continued heat is, perhaps, the most fruitful source of cholera. Thus we find, that the disease makes its first appearance in the commencement of the hot weather, increases and becomes more fatal with the rise of the thermometer, and declines with the return of cool weather in autumn. During its continuance, it may be observed to vary with every permanent change of temperature. A few very hot days in succession, in the 6th month, are sufficient to call it into action; and during the height of its prevalence, a spell of cold weather will diminish, if not suppress it. In the summer of 1806, which was remarkably cool and pleasant, there was very little of the disease; and generally in moderate summers, it is much less prevalent than in those of a contrary character.

I believe that it is by a direct operation on the system, and not by the generation of miasmata, that heat proves so deleterious to the infant. In the country, where miasmata are most abundant, there is comparatively little cholera; for the heat of the sun is there moderated by the free circulation of the air; and the debilitating operation of the high temperature of the day is counteracted by the refreshing coolness of the morning and evening. It is in the close air of cities, that the complaint flourishes with greatest vigour; and the most confined situations are the most favourable to its production. Let any one take a walk, in a summer's morning, through the thickly built lanes and alleys of Philadelphia. He will be struck with the appearance of the children, reclining their heads, as if exhausted, upon the breast of their mothers, with a pale and languid countenance, a cool and clammy skin, a shrunk neck, and other signs of debility, arising from their confinement, during the night, to close and hot apartments. It will readily be believed, that such places are the very hot beds of cholera.

Heat, therefore, connected with confined air, being among the most frequent causes of the complaint, it is necessary, as far as possible, to counteract them. Should a strong predisposition to cholera be suspected, the best plan will be to send the child into the country during the summer. Both as a preventive and a remedy, country air is decidedly the most effectual, to which we can resort. But in most instances, it would be exceedingly inconvenient, sometimes impossible for mothers to leave their homes and occupations in the city; and, under such circumstances, it becomes necessary to substitute measures, which may produce, as nearly as possible, the same effects. To keep the child cool, and expose him to the fresh air, are the ends to be obtained. For this purpose, he should be carried frequently into the open squares, or beyond the suburbs of the city. I am in the habit of recommending to parents, whose circumstances will not allow of a removal from the city during the summer season, to make frequent excursions across the Delaware, and into the neighbouring woods of New Jersey. The refreshing effects of the air on the river are truly surprising. The brightened eye and animated countenance of the infant, give speedy proof of their favourable influence; and when labouring under the disease, even in its lowest stage, the little patient will often exhibit immediate signs of amendment.

In the prevention of cholera, much may also be expected from a proper attention to the lodging of children. Many parents have a great dread of the night air; and exclude it from their chambers, as sedulously as if it were infected with poison. But, in guarding their children from taking cold, they expose them to a much greater danger. Observe their mode of treatment. The doors and windows are carefully closed; the child is placed in a feather bed, with his parents on each side, and almost smothered with the bed-clothes. Perhaps other children are lodged in the same apartment; and thus the delicate system of the infant is exposed to the debilitating influence of great heat and stagnant air, combined with the effluvia, which, in such a situation, must be abundantly generated. Simply to enter such a room in the morning, is almost sufficient to sicken a healthy individual; how much more injurious must be its effects upon the lodgers themselves. Examine in the morning a child, who has passed the night thus confined. You will find him limber as a rag, exhausted by perspiration, wholly destitute of animation, without appetite, and on the very verge of cholera. I should recommend an entirely different plan of management. Instead of a feather bed, the child should be placed on a hard mattress, or on blankets folded and laid upon the floor. The covering should be light, but comfortable. The doors and windows should be open; so that fresh air, that pabulum vitæ, without which health cannot be sustained, may be freely admitted. Thus treated, instead of the feeble and sickly appearance before mentioned, he will present a lively countenance, with all that activity of motion, and enjoyment of existence, which are natural to his age, and afford the surest criterion of vigorous health. Experience has fully convinced me of the great importance of attention to the lodging of children, as a prophylactic measure; and this renders me desirous of impressing upon the profession generally, the truth of my own convictions on the subject.

With the same design of obviating the injurious effects of a high temperature upon the infantile system, I advise frequent ablutions with cool water, and its free employment as a beverage. Infants, unable to make their wants known, often suffer exceedingly from the inability of their attendants to understand them. During the heat of summer, the increased evaporation from their surface is necessarily productive of increased thirst, which, if unsatisfied, renders them uneasy and restless. To quiet them, the breast or bottle is offered. Aliment is thus given, where drink only was required; and the stomach, overloaded and oppressed, is apt to become irritable, and is thus brought into a condition most favourable to the occurrence of cholera. By attention to the peculiar language of infants, expressed not by words, but by signs, I have often been able to detect their wants; and, in many instances, have afforded the most decided relief, by simply giving them a little cool water for drink. From the dread which some individuals have for cool air and cold water, it would seem that they were considered rather as destructive poisons than as absolute necessaries. I have no fear of either, when judiciously employed; and as prophylactics in cholera, I do not think their place can be supplied.

But heat is not the only cause of this complaint. Dentition is well known both to predispose the system to its attack, and, after it has occurred, to increase its violence, and diminish the chances of recovery. In the employment, therefore, of preventive measures, it is highly necessary to attend to the state of the gums, and to remove or counteract this source of irritation. If at all swelled or painful, they should be lanced freely, and the operation should be repeated as often as their inflammatory condition may demand. In severe cases, much good may be expected from the application of blisters behind the ears. The irritation thus receives an external direction, and the stomach and bowels are in less danger of an attack. I was led to this practice, by observing that the eruption, which, during dentition, is apt to make its appearance behind the ears, often proves a most salutary effort of nature; and that, while it continues, the infant generally enjoys an exemption from those dangerous disorders, incident to this critical period of life. To imitate nature as closely as possible, the discharge from the blistered surface should be maintained for some time by stimulating dressings. I have witnessed the most beneficial effects from the practice, and can strongly recommend it to the attention of the profession.

II. At the same time that we endeavour to remove or diminish the causes of cholera, we should not neglect to put the system of the child in such a condition, as may enable it most effectually to resist their operation. As cholera is a disease of irritation, originating generally in a debilitated state of the alimentary canal, I believe this end may be most easily attained, by preserving the natural tone of the digestive organs. For this purpose, all flatulent and indigestible food should be carefully avoided. During the first year, the mother's milk is, in general, the most appropriate nutriment. When the stomach of the infant is very delicate, the diet of the mother should be strictly regulated; and, in all cases, it would be adviseable for her to avoid articles of a flatulent nature. While the child is still at the breast, if a predisposition to cholera be suspected, I would recommend the occasional use of nutritious animal juices. The sucking of small pieces of salt meat, as ham or dried beef for example, will sometimes be found productive of advantage. After weaning, animal food should always enter into the diet of the child. Many parents, fearing to render their children gross and unhealthy, restrict them altogether to vegetable aliments; and thus, by weakening the powers of digestion, prepare the way for that very result which they are most anxious to avoid.

With the same view of giving tone to the stomach, aromatics should be used habitually during the summer, in those cases, in which there is strong reason to apprehend the occurrence of cholera. While they produce a cordial impression on the stomach, and invigorate generally the digestive powers, they are liable to none of those objections which may be urged against the employment of the narcotic stimulants. Indeed, nature herself seems to have pointed them out as prophylactics against the diseases of hot weather. Our most powerful and valuable spices are the products of warm countries. Cinnamon, ginger, pepper, the clove, the nutmeg, are to be found only in tropical climates. In this arrangement, we see the hand of a beneficent Creator, who has provided, that, by the same high temperature, which renders the equatorial regions so fruitful of cholera, and other disorders of the bowels, the growth of those plants should be promoted, which are best calculated to invigorate the alimentary canal, and to fortify it against the inroads of disease. Facts are not wanting to prove the efficacy of spices in preventing intestinal complaints. We are informed by Dewar, in his treatise on the Diarrhœa and Dysentery, by which the British army in Egypt was attacked, that among the Mamalukes of that country, it was a universal practice, when they apprehended the approach of these disorders, to make use of cinnamon or ginger, with the almost uniform effect of averting them; and where the same practice was followed by the British soldiers, equal advantages were experienced. In the French army, so highly was the prophylactic power of the aromatics estimated, that every soldier was provided with a box of spices, which he was directed to use freely with his diet of fruit and melons.

When attending surgeon of the Alms-house hospital in this city, I had occasion frequently to prescribe in a syphilitic ward, which being situated directly under the roof, in a large garret, was liable, in the summer season, to become very much heated. As the patients were numerous, and the windows insufficient to admit of proper ventilation, the air became much contaminated; and the consequence was, that bowel complaints were very frequent and troublesome. I have often entered the ward on a summer's morning, and found almost every patient affected more or less with diarrhœa or cholera. It occurred to me, that the free use of some of the aromatics might be found serviceable in preventing the occurrence of these complaints. I accordingly directed, that every individual in the ward should drink a portion of strong ginger tea daily. I also ordered, that salt meat should be used twice in the week. By the steady pursuit of this plan, a very considerable change for the better was effected.

The employment of aromatics as prophylactics is not less beneficial in children than in adults. I would not, however, advise, that they should be given indiscriminately to all children, during the summer. It is only to those cases, in which a predisposition to cholera infantum exists, that I consider them peculiarly applicable; and here I believe they are capable of producing much good.

Before dismissing the subject of the paper, I will simply remark, in addition to what has been already said, that the occasional use of the cold bath, by the vigour it imparts to the system generally, and through it to the digestive organs, will often be found an excellent preservative against the summer complaint of children.

In this short account of the preventive treatment of cholera infantum, I have been less anxious to give a dissertation, embracing all that might be said on the subject, than to communicate those particular measures, which, according to my own experience, I have found most effectual. I will conclude the paper by the relation of a case, in which a strong predisposition to the disease was successfully counteracted. It will be proper, however, to premise, that the treatment of this case is by no means held out as an example to be generally followed with every infant, which may possibly become the subject of cholera. It is applicable in all its details only to those, in which, as in the present instance, there is every reason to apprehend, that the only alternative is between almost certain death, and the most careful prophylactic treatment.

Case.—A gentleman of this city, whose wife had arrived at a period of life, when she could not expect to be the mother of many more children, consulted me respecting an infant daughter, their only surviving child. I was informed, that they had already lost eight children, all of whom, with one exception, had died of cholera. It may readily be imagined, that every feeling of parental anxiety was awakened for their babe; and that no degree of attention on their part was considered too great, which might contribute to its preservation. It was placed under my care, not to be cured, but that I might, if possible, devise some plan of management which would avert the disease they had so much reason to apprehend. I felt the responsibility of the trust, and endeavoured to find it to the best of my ability. Every opportunity which I could desire was afforded me; for the infant, from its birth was submitted to my direction; and both the disposition and ability existed, on the part of the parents, to carry implicitly into effect every measure which I might recommend.

As the mother was unable to furnish sufficient nourishment, the first step was to provide a healthy wet-nurse, who might be willing to submit to the necessary regulations in respect to diet.

I believed the children of these parents to possess a constitutional weakness in the alimentary canal; and, on inquiry, I was told, that they had been kept upon a vapid diet, under the impression that it would contribute to their health. In the present case, therefore, the principal object was to communicate strength to the stomach and bowels. With this view, the child was accustomed, from an early period of infancy, to a generous diet. When very young, portions of ginger tea were given to it daily; and as soon as it was old enough to suck the juice of meat, it was encouraged to do so. The nurse, during the warm season, was kept upon a nutritious diet, consisting principally of animal food, with the occasional use of ginger tea; and every description of recent fruit and fresh vegetable food was forbidden. Under this management, the first summer was passed without any symptom of the disease; but I looked forward to the second with no little anxiety, when the child would have to struggle with the irritation arising from dentition.

The same plan was continued during the second summer, and still more rigidly enforced. The child was now old enough to take animal food freely in addition to the breast. It was allowed as much salt fish, ham, beef-steak, essence of beef, &c. as it desired; ginger tea was given daily; a little sound old port wine was occasionally directed; and both the child and the nurse were restricted from every species of flatulent and indigestible aliment. So anxious, indeed, were the parents, and so careful to carry my directions into full effect, that they allowed no forbidden article of food to enter the house, and denied themselves their wonted comforts, lest possibly their child might be injured.

The gums were carefully attended to, and lanced whenever the operation appeared to be requisite. All those measures, which I have before mentioned as serviceable in obviating the effects of great heat, so far as they were applicable to the case, were adopted. The second summer was spent wholly in the country.

Very little medicine was required, and none was administered, except of the mildest description. Frequently, when summoned to visit the babe, I have found the mother trembling with fear, and anxious that something might be done; and often, under such circumstances, have I begged it off from a dose of physic, having determined to avoid a resort to every thing of the kind, unless real necessity should demand it.

By a strict adherence to the plan above detailed, the period of dentition was passed in safety; and it is with heartfelt pleasure I can say, that no symptom of cholera afterwards made its appearance.