SOME POINTS IN THE PATHOLOGY AND TREATMENT 
OF 
CHOLERA INFANTUM. 
By EDWARD WALDO EMERSON, M.D. 
OF CONCORD. 
READ JUNE 13 , 1 876 ./ SOME POINTS IN THE PATHOLOGY AND TREAT- 
MENT OF CHOLERA INFANTUM. 
If during the last year out of every twelve deaths in 
Boston one had been from yellow fever, Asiatic cholera, or 
plague, every one would be alarmed; the legislature, city 
government, and medical societies would bestir themselves. 
But that was the actual proportion of the deaths reported 
from cholera infantum to the whole number of deaths of 
persons of all ages, and but little comment was excited. Yet 
the mortality from either of the dreaded diseases first men- 
tioned, should they get a foothold in Boston, probably would 
never approach that from this common affection. We have 
got so accustomed to it that it is regarded as a necessary 
evil. But the advance of sanitary science and physiology 
may make it worth while to consider carefully from time to 
time our every-day diseases, and see if we are not better 
prepared to prevent or to fight them with the new tactics 
and weapons drawn from these sources, instead of using the 
consolations of philosophy for the annual loss under the old 
traditional methods. 
With regard to this disease there is an opinion fast gain- 
ing ground that much if not all of it is due to causes largely 
within our power to prevent. As I do not propose to go 
into this branch of the subject, which is happily beginning to 
excite much attention here and abroad, I will quote but one 
passage from the excellent little book of Dr. John Simon, 
the chief medical officer of the Privy Council of Great Brit- 
ain, on Filth Diseases, which was republished by the State 
Board of Health. He says, "In all filthy districts one 
particular class of diseases seems specially apt to stand in 4 
PATHOLOGY AND TREATMENT 
relief—the diseases, namely, which in respect of their lead- 
ing symptom may be generalized as diarrhceal. . . . The 
mucous membrane of the intestinal canal seems peculiarly 
to bear the stress of all accidental putridities which enter 
the blood. Whether they have been breathed, or drunk, or 
eaten, or sucked up into the blood-vessels from the surface 
of foul sores, or directly injected into the blood-vessels by 
the physiological experimenter, there peculiarly the effect 
may be looked for; just as wine, howrever administered, 
would 'get into the head,’ so the septic ferment, whenceso- 
ever it may have entered the blood, is apt to find its way 
thence to the bowels, and there, as universal result, to pro- 
duce diarrhoea.” 
In view of the great prevalence and fatality of this disease 
which the next month brings with it, under our present 
sanitary conditions, as surely as it does the white azalea or 
the water lilies, I have thought it might not be uninterest- 
ing to consider briefly in this paper its pathology and treat- 
ment, to see if these fields may afford anything new and 
profitable. Many of the standard books are somewhat 
disappointing in their chapters on cholera infantum. The 
pathology is not often very definitely stated. Were this 
done, perhaps modes of treatment more in accordance with 
the physiological indications thence deducible, and offering 
better prospect of success, would supersede the more or less 
blind and unsatisfactory methods often recommended. 
Pathology.—The name cholera infantum is often loosely 
applied to various summer diarrhoeas, but should be confined 
to that violent choleriform, gastro-intestinal catarrh of young 
children of which Leube says, in his article on the subject 
in Ziemssen’s Cyclopaedia, that "its symptoms so closely 
resemble those of Indian cholera that if one were confined 
to the observation of the individual case he could not say 
which it was.” However the irritants or occasioning causes 
may differ, the weight of testimony of the best modern au- OF CHOLERA INFANTUM. 
5 
thors is so great for the entire identity of the symptoms and 
of the post-mortem appearances in a severe case of this 
disease and of cholera morbus with those in Asiatic cholera, 
tfyftt I may safely treat of the pathology of the choleraic 
state in general, drawing my instances from cases of epi- 
demic cholera also. 
This condition becomes all too familiar to the physician 
during the weeks when the thermometer reaches 90° Fahr., 
when he may see a rosy, well-nourished, active child, with 
perhaps no warning beyond a very short stage of indiges- 
tion, suddenly seized with violent and profuse watery dis- 
charges, and soon after with vomiting of quantities of clear 
or slightly tinged liquid. There is coldness, pallor, pinched 
appearance, and even cyanosis of the surface, beginning at 
the extremities, but rapidly spreading to the trunk and head 
(which was at first remarkably warm), and the abdomen is 
a little distended. Notwithstanding the great apparent cool- 
ing, the deep rectal temperature rises to normal or above, 
according to the best authorities. The pulse is rapid, and 
becomes momentarily more difficult to feel. The thirst is 
great, the drink vomited. At the end of two days, or in 
extreme cases even of twelve hours, the child may be hardly 
recognizable as it lies faintly fretful or drowsy, the fontan- 
elles sunken, the lids half shut over rolled-up eyes, pulseless, 
pale, and cyanotic, with sharp features and cold, clammy, 
and apparently wasted limbs, the abdomen relaxed, the skin 
wrinkled and inelastic, the urine suppressed, the upward and 
downward discharges less frequent or stopped, the respira- 
tion shallow, the breath cold, and perhaps alarming little 
premonitory twitchings of the limbs. In old times, wdien 
they used to bleed, it was found that only a drop or two of 
thick, dark-red blood would flow. 
When matters have reached this state, the child will 
almost surely die, either by increasing sopor or by convul- 
sions. Or, under favorable circumstances, before extreme 6 
PATHOLOGY AND TREATMENT 
algidity and coma are reached, reaction may set in. In fact, 
one striking point about the state is that it seems to be self- 
limited if the patient can survive until the turning-point 
comes, which is usually not more than two and a half days at 
farthest from the onset. Then the patient usually begins to 
recover with great rapidity, unless a relapse occur or entero- 
colitis or other complication arises. The vomiting ceases, 
the pulse returns, the stools are less frequent and contain 
more fecal matter, the pinched and wasted appearance of 
face, body, and limbs disappears, with the return of warmth, 
color, and natural perspiration. Urine reappears, the rectal 
temperature falls to normal, or a little below, as the surface 
temperature rises. After death in the extreme algid state 
the surface temperature may slowly rise to normal or above, 
the body cools off very slowly, and rigor mortis comes on 
late and persists long. 
The post-mortem appearances show no structural changes 
except a swollen condition of the solitary follicles and 
Peyer’s patches. Sometimes thickening of the blood and 
occasional slight ecchymoses under the serous membranes 
are found. The intestinal walls are injected. The large 
abdominal veins, the right side of the heart, and the pul- 
monary arteries are found distended with dark blood. The 
kidneys are congested, and sometimes the tubules are full 
of epithelium. The left side of the heart and the arteries 
are very empty, the membranes of the brain a little injected, 
the brain itself bloodless and sometimes cedematous. The 
lungs seem empty and dry, and collapse greatly. The in- 
testine is full of clear or slightly turbid fluid like the dis- 
charges, consisting mainly of water and chlorides, with a 
little albuminous flocculent matter, showing under the 
miscroscope swollen epithelium and granular matter. 
What, then, is the pathological condition that occurs? 
The collective symptoms of paleness, coldness, cyanosis of 
all the surface, and probably too of the lungs, together with OF CHOLERA INFANTUM. 
7 
the internal objective and subjective heat and the immense 
activity of movement and transudation in the bowel, the 
suddenness of the collapse and apparent emaciation, and the 
equal suddenness of the recovery and the reappearance of 
heat and turgor vitalis would alone demonstrate, as plainly 
as any clinical phenomena could, that the main pathological 
condition was an entire change of the equilibrium of the 
circulation, namely, engorgement of the abdominal at the 
expense of the peripheral and respiratory organs. The post- 
mortem appearances put the matter beyond all doubt. In 
fact, it is a condition in many respects analogous to two other 
circulatory disturbances, syncope and shock, the pathology 
of which states are set forth at length in an interesting arti- 
cle in the Practitioner for October, 1873, by T. Lauder 
Brunton. Just how this disturbance of circulation is wrought 
is not certain, but a physiological explanation may be haz- 
arded. To do this more clearly I will venture to very briefly 
state the received theories as to the innervation of the 
intestines. 
A. Local ganglia have been demonstrated in the intes- 
tinal walls. 
B. The vagi and the splanchnic nerves jointly preside 
over the stomach and intestines. 
C. The vagi (sensory in their function) are the accel- 
erating nerves of the intestinal tract. Their irritation 
produces increased movement of the intestines and also 
heightened secretion, and after their section, as demonstrated 
by Brodie and lately more completely by H. C. Wood, of 
Philadelphia, even the most irritant cathartics fail to act. 
D. The splanchnic nerves are the restraining nerves of 
the stomach and intestines. They are so, probably, through 
their being also the vaso-motor nerves of the intestinal 
tract. Their section, as the experiments of Moreau proved, 
causes increased secretion and movement; in other words, 
corresponds nearly in effects to the irritation of the vagi. 8 
PATHOLOGY AND TREATMENT 
Would not the following theory, then, meet the exigencies 
of the case, namely :— 
That the cholera poison or irritant acts with special force 
on the places where it is most concentrated, namely, the 
gastric and intestinal mucous membrane; that there its first 
action would probably be on the local ganglia, producing, 
we may suppose (since the existence of vaso-dilators is not 
yet proved) a local vascular spasm, which soon exhausts it- 
self, and is succeeded by relaxation of the walls of the vessels, 
through temporary paralysis of the splanchnic nerve, result- 
ing in strong congestion. This would cause greatly increased 
transudation into the alimentary canal and heightened per- 
istaltic action. Moreover, the vagus, which, as above said, 
represents the sensory nerve of the stomach and bowels, 
would undoubtedly be irritated, hence causing increased 
movement of the bowels. The possibility of phenomena 
due to irritation of the vagi and splanchnic paralysis occur- 
ring at once from the same cause can be imagined when one 
considers how much sooner the contractility of the small mus- 
cles of the vessels innervated by the splanchnic would 
probably be exhausted than that of the larger constrictor 
muscles of the bowels. The poison, if absorbed to some 
degree into the circulation, could cause directly (or, if not 
absorbed, by reflex action) spasm of vessels remote from 
the seat of its extreme and paralyzing action, namely, the 
peripheral and pulmonary vessels. The blood, then, al- 
most stagnating in the large central vessels and driven from 
the systemic arteries and left heart by their continued con- 
traction, would accumulate in the right heart and pulmonary 
arteries. Hence the carbonic acid would increase and the 
oxygen diminish in the blood, and both of these circum- 
stances have been found by experiment to increase peristaltic 
action. Finally, from prolonged irritation the vagus be- 
comes paralyzed, and the stomach and bowels cease to act, 
and the left heart, not having blood enough to contract OF CHOLERA INFANTUM. 
upon, and suffering also in its nutrition from the condition 
of the coronary arteries, becomes paralyzed, or else the 
brain becomes oedematous, and convulsions occur. In 
cases that recover we may suppose that much of the 
poison having been eliminated, or having worn out its effects 
or lost its activity, relaxation succeeds the spasm in the ex- 
hausted muscular walls of the peripheral and pulmonary 
vessels, while those of the abdomen, after long dilatation, 
relieved of their load by the equalization of the circulation, 
gradually recover their tone. 
So much for hypothesis as to the method of production 
of this pathological disturbance of equilibrium occasioning 
the alarming symptoms ; of the fact we may feel reasonably 
sure. 
Treatment.—The most ardent advocate of expectancy 
would admit that were it possible to remove the condition 
upon which all these phenomena depend, instead of trying 
to repress them individually, the former course would be as 
much more wise and desirable than the latter, as the mend- 
ing a leak in a roof would be than the constant renewal of 
the rain-spoiled wall-paper, plaster and carpets. 
1 think it is not too much to say that we know enough of 
the main pathological condition to justify us in attempting 
to treat it directly, and that the newer treatments that have 
aimed at this object seem to have had success enough to 
justify a continuance of them. Certainly no patient looks 
a more unpromising subject for treatment than a child in 
advanced collapse from cholera infantum, and yet the change 
from all but death to life that may occur in a few hours, 
should reaction be brought about, is a fact as encouraging as 
it is surprising. 
Steiner, in his excellent little hand-book of children’s dis- 
eases, says of this disease, " Let the physician treat early 
and actively ; inactive expectancy is nowhere more punished 
than here.” 10 
PATHOLOGY AND TREATMENT 
Prevailing Treatments.—Before speaking of the modes 
of treatment that seem most indicated by the known and 
suspected pathological conditions and to have stood the test 
of experience, I will briefly allude to those more in vogue, 
purposely omitting prophylactic treatment as a branch 
which opens too wide a field for the limits of this paper. 
In what follows, for reasons before mentioned, I shall 
speak of the choleraic condition, whether from sporadic or 
epidemic causes, as essentially the same state, and remedies 
effective in the worst form would probably, a fortiori, 
promise even more in the milder form. 
Too many of the treatments proposed are symptomatic 
in the narrowest sense of the word. This is not true, how- 
ever, with regard to the old eliminative treatment, which 
was at one time popular on theoretical grounds in the evacu- 
ant stage. Dewees is dissentingly quoted by Churchill as 
recommending " warm water to encourage the puking and 
cnemata of warm water to clear the bowels,” and even at 
present Goldbaum, a German writer, goes so far as to 
maintain that transudation is a favorable occurrence, and not 
to be interfered with. 
It is difficult to see, with the now commonly accepted 
theories of the emeto-catharsis being due to an irritant, 
organic or inorganic, working specially on the intestinal 
tract, why this is not a conservative process by which the 
body endeavors to rid itself of the offending presence. It 
is not improbable that it is so to a certain extent, but clini- 
cal experience shows that this process may continue until it 
becomes the main source of danger. 
Energetic diaphoresis is frequently recommended at the 
very beginning of the attack. 
Either at the outset or after one artificially produced 
catharsis, almost all writers recommend opiates to check the 
discharges, some combining them with astringents, and 
some with chalk or lime-water, on a theory that an injurious OF CHOLERA INFANTUM. 
11 
acidity prevails in the alimentary canal. These are con- 
tinued, even in large quantities, into the stage of collapse. 
Calomel was until very lately almost universally given in 
the first stage, with a view that it either was, or ought to 
be, beneficial in some way. The medical adviser, like 
Holmes’s Hip Yan Winkle, finished his directions thus :— 
“ Last, with a dose of cleansing calomel 
Unload the portal system,—that sounds well! ” 
Niemeyer, who considers it a sheet-anchor in cholera infan- 
tum, thinks that its good effect is only to be explained by its 
power to arrest decomposition and hasten the removal of 
irritating ingesta. Leube, in Ziemssen’s Cyclopaxlia, re- 
commends it as an efficient cathartic. Meigs and Pepper 
hold that it acts in the large doses commonly given as a 
powerful sedative, too powerful, they urge, for a depressing 
disease. 
Subnitrate of bismuth in large doses is much recom- 
mended to allay irritation by its mildly astringent and 
sedative action. Small doses of nitrate of silver are tried 
with similar object. 
Hydrochloric and sulphuric acids, the latter combined 
with ether as the elixir Halleri, carbolic acid, and benzoin 
are all recommended on antiseptic grounds. 
Chloral hydrate has been given by subcutaneous injection 
for its sedative effect. Of its good results more will be 
said later. 
Now all writers recognize the importance of water, but 
many fear to give it in any other form than ice-pills. 
Spice poultices or sinapisms to the abdomen are recom- 
mended to check vomiting, and Niemeyer urges the applica- 
tion of frozen compresses to the belly. In the stage of 
collapse most authors advise alcoholic stimulants, usually 
the most rapidly diffusible ones, to be given frequently, in 
small doses, together with opiates, if the discharges persist. 12 
PATHOLOGY AND TREATMENT 
Warm or hot baths have been recommended in this 
stage, sometimes with the addition of mustard. Intra- 
venous injections of water, or salt and water, or of milk, 
have been resorted to in the worst cases, and even trans- 
fusion of blood. 
Finally, the bad percentage of recovery when marked 
collapse has been reached, either in the sporadic or in the epi- 
demic form, under almost all treatments, has led some writers 
to believe that the patient has the best chance of recovery who 
is let alone to wait for the natural turn of the disease, should 
his strength hold out, and only given a little ice, with per- 
haps mild opiates and very thin, bland nourishment. 
In the third, or reactionary stage, great care is advised 
in the administration of nourishment and stimulants, for 
fear of occasioning relapse or favoring secondary inflamma- 
tions of the bowels or other organs. 
No writer of any merit on cholera infantum fails to no- 
tice the main importance of dietetic treatment, but ideas on 
this subject differ widely. Niemeyer urges, as of primary 
importance, the necessity of absolute withdrawal of nourish- 
ment for a time, urging that whatever is given before the 
irritant has left the stomach will surely undergo abnormal 
decomposition and increase the mischief. Few others dwell 
on this point, but, if the child is being brought up by hand, 
recommend either barley-water or some similar mild farina- 
ceous nourishment, or else beef-juice, chicken-water, or 
finally raw beef, scraped and perhaps moistened with red 
wine. Others recommend artificial foods made with refer- 
ence to the deficient power of a child’s digestive fluids to 
convert starch into dextrine, in which that transformation 
has been made outside the bod}'. 
Treatment Recommended.—Now if the views set forth 
in the earlier part of this paper fairly represent the patho- 
logical facts, what would be a rational treatment of the 
choleraic state ? OF CHOLERA INFANTUM. 
13 
Waiving the question of prophylaxis and its corollary, 
the question how to directly destroy or neutralize the or- 
ganic irritant (if such exist) after its introduction into the 
body, the first indication is to correct the dangerous and 
unfair distribution of the blood in the body, to which the 
purging, vomiting, cramps and coldness, seem to be directly 
due, and later the greater danger of coma, convulsions, or 
paralysis of the heart. 
Second. If we fail in the first attempt, or do not succeed 
until late, we should supply the water and perhaps also the 
salts drained from the blood, as the thickening of the blood 
would prevent the good effects of the natural turn of the 
disease, should we have to wait for that, and perhaps dis- 
pose to various organic lesions. 
Third. We should attend to general hygiene, diet, etc., 
of the patients. 
As to the first indication, the problem is how to cause 
dilatation of the peripheral vessels and contraction of the 
overloaded abdominal ones, If we had any means of get- 
ting directly at the splanchnic nerves, we could probably by 
galvanization of them directly cause the contraction of the 
mesenteric vessels, Ludwig and Thiry found that after 
section of the spinal cord in the neck, whereby dilatation of 
the mesenteric vessels was caused, galvanization of the 
lower segment would cause extreme contraction of them. 
Possibly galvanization applied over the middle dorsal re- 
gion of a patient might produce the same effect. Chapman 
maintains that he can occasion it by ice-bags applied to the 
spine, which he uses to check diarrhoeas and reflex vomiting, 
Bruckner, a German writer, claims that cold sand-bags 
of moderate weight laid on the abdomen of cholera patients 
mechanically check the access of blood to the abdominal 
vessels and favor its escape. Transudation is thus hinder- 
ed, and perhaps absorption is favored ; moreover, the peri- 
staltic movements of the bowels would not be so free. 14 
PATHOLOGY AND TREATMENT 
These sand-bags might be used carefully, with hot applica- 
tions to the extremities. 
We have a much better chance of success, however, if we 
try to unload the abdominal vessels by relaxing the periphe- 
ral ones by means of strong derivatives applied to the sur- 
face. Steiner strongly urges baths of from 99° to 104° 
Falir. in the algid state, combined with stimulants internal- 
ly, and Leube, in Ziemssen’s Cyclopasdia, recommends the 
same. The distinction, too often neglected, between a 
warm bath and a hot bath is of vital importance here. No 
bath of less than 99° would be desirable. A writer in an 
English journal within a year or two, whose name I have 
lost, mentions his very gratifying success in treating the 
algid stage of Asiatic cholera by prolonged hot mustard 
packs. In accordance with this plan I treated three cholera 
infantum patients last summer, who were rapidly cooling 
off and assuming the characteristic pinched appearances of 
collapse, by suddenly wrapping them to the chin in cloths 
wrung out in hot water and mustard, with a blanket out- 
side, and while thus mummied feeding them with plenty of 
ice-water and a little brandy. The pack was kept up half 
an hour or more, and during that time the change in the 
child’s appearance was remarkable ; the color and warmth 
returned to the surface, the tissues filled out, the features 
lost their pinched and old look, a natural perspiration broke 
out, the vomiting ceased, and the discharges grew less fre- 
quent. The mustard sheet was then withdrawn, but the 
child left enveloped closely in the warm, moist blanket. 
The pack in one instance had to be renewed at intervals, as 
a tendency to relapse manifested itself after some hours, but 
the condition of all mended in a marked manner after the 
first application, and all made a good recovery. 
With regard to medication, if the choleraic state last 
any length of time, the blood must necessarily be altered 
by its drain of water and salts. Water, then, is the first OF CIIOLEKA INFANTUM. 
15 
medicine indicated, and should be constantly given in the 
form of ice-pills or spoonfuls of ice-water. Small enemata 
of slightly salt water immediately after a dejection might 
help to supply the lost fluid. Should vomiting and purg- 
ing go far enough to cause a fear that the blood was becom- 
ing too much thickened, intravenous injections of water 
should be tried, and if it were thrown in at a temperature of 
100° the heat might help relax the surface vessels. Milk 
and blood have also been used, but water seems more indi- 
cated, as in this disease the blood loses little albumen and 
no corpuscles. 
As to the administration of drugs by the mouth, the fact 
of the probable very slight power of absorption at that time 
is usually overlooked. It is found that belladonna introduced 
into the stomach in large doses will not dilate the pupils. 
The medicines, stimulants and food, then, can have little 
power in the present condition, nor yet help to bring on 
reaction, and if often repeated they may, when reaction sets 
in, be all greedily absorbed at once, and so do great harm, 
a fact to which Meigs and Pepper very properly call atten- 
tion with regard to pouring in opium and alcohol in the 
algid stage. Internal administration of antiseptics has not 
so far seemed to fulfil the expectations of its advocates. 
As for calomel, it seems hardly indicated in the pure 
choleraic stage, unless there is the best reason to believe 
that some crude ingesta still present in the intestine demand 
a cathartic. 
In the Practitioner of July, 1875, was a very striking 
article on the use of subcutaneous injections of chloral in the 
evacuant or algid stage of cholera, by Surgeon A. II. Hall, 
with accounts of cases treated by him and Mr. Iligginson, 
another English army surgeon. The number of cases 
treated by these two gentlemen was large, and the onset 
severe and alarming, but they hardly lost a case. They 
injected two-grain doses of chloral diluted with ten 16 
PATHOLOGY AND TREATMENT 
times as much water, into the arms and legs of patients, 
some in extreme collapse, and in almost every case good 
and speedy recovery ensued. Few patients had more than 
eight to ten grains in all. Mr. Hall’s theory was that the 
vascular condition was due to extreme vaso-rnotor irritation, 
and that the usual stimulant treatment only heightened the 
difficulty, as was shown by its small percentage of recover- 
ies, sometimes only eighteen per cent. So he looked about 
for a sedative to relax the general spasm, and tried chloral 
with the brilliant results above mentioned. It is interest- 
ing to know that the government in India have taken pains 
to publish and circulate Mr. Hall’s happy experience in the 
treatment of cholera collapse. His method seems to be 
well vouched for, and I see no reason why it should not be 
applicable to the choleraic state in children, if the injections 
were given progressively and carefully watched. 
One word, in conclusion, as to babies’ food, though that 
subject has been so well treated at recent meetings of the 
Society that it is almost superfluous to say a word more. 
There is a point which I wish to allude to, namely, the 
great popularity among the rich and poor of the nursing 
bottle with the jlexible tube. It is an invention of which 
Herod might have been proud. It is always in the baby 
wagon or the crib, in hot sun or close air. The child falls 
asleep with its nipple in his mouth. The mouth is usually 
never washed ; the bottle and tube are, "with scalding water 
and with soda,” so the mother says if you ask. Smell it and 
see what you think. Take a parallel case. What prospect 
could a man have of immediate and satisfactory recovery from 
cholera morbus, or even dyspepsia, who should eat soup, 
freshly made, perhaps, but out of a tureen which had been 
standing half a day with the remains of yesterday’s soup in 
it, in a close room with a temperature of 90° ; who, more- 
over, should never rinse out his mouth nor allow time for 
digestion, but should go to sleep with a piece of bread soaked OF CHOLERA INFANTUM. 
17 
in soup in his mouth, and, if'colic or oppression caused him 
to complain on waking, should at once take more soup out 
of the unscalded tureen ? This is not an attractive picture, 
but it is a fair analogy. Is a teething baby’s stomach 
stronger than a man’s, that the doctor should tolerate the 
form of nursing bottle which encourages and contemplates 
a management of his diet exactly parallel to that in the un- 
attractive picture I have just drawn ?