WCB REPORT f>S H4Sf THE COMMITTEE OF fflE MEDICAL. SOCIETY OF PHILADELPHIA, ON EPIDEMIC CHOLERA. Read and approved at a Special Meeting held on the 30th of May, 1832. PHILADELPHIA: PRINTED BY LYDIA R. BAILEY, NO. 26 NORTH FIFTH STREET. 1832, AT a special meeting of the Philadelphia Medical Society, held April 14th, 1832. The following communication from the Board of Health was read. Health Office, ~) Philadelphia, Jipril 12th, 1832. 5 To the President and Fellows of the Medical Society of Philadelphia ; Gentlemen, — At the request of the Board of Health, we transmit you the subjoined resolution, being an extract from the Minutes, April 11th, 1832. 11 Resolved, That this Board recommend to the Medical Society of Philadelphia, the appointment of a committee to institute an impartial examination into all the facts in relation to the Epidemic Cholera, and to report in detail the result of their investigation, for the benefit and satisfaction of the unprofessional as well as the Medical part of the community." W. BINDER, President. M. E. ISRAEL, Secretary. On Motion, made and seconded, the following Committee was appointed in accordance with the above request. Doctors Condie, Emerson, Hays, Jackson, Bond, Homer, and Huston. May 30, 1832 — At a special meeting of the Society held this day, the above Committee presented their report, which on motion was adopted, and a copy thereof ordered to be transmitted to the Board of Health. EDWARD PEACE, Junior Recording Secretary. A Health Office, Philadelphia, June 15th, 1832. Extract from the Minutes of the Board of Health of this date. 11 The Committee to whom was referred the Report of the Philadelphia Medical Society on Cholera, which was drawn up at the recommendation of this Board, beg leave to Report, that they are of the opinion that it possesses much interest and value, and ought to be extensively disseminated. In investigating the subject, the Medical Society have restricted their inquiries to the five following heads: — " Ist. The origin and subsequent spread of the Epidemic Cholera. "2d. The character of the localities where it has generally appeared, and where it has produced the greatest ravages. " 3d. The description of persons most liable to its attacks. "4th. The influence of Quarantine, and the other sanatory restrictions adopted by various governments to guard against the introduction of the disease. " sth. The Municipal regulations best adapted to lessen the violence, and to limit the prevalence of the disease, should it appear in this country. " It will, therefore, be perceived, that this Report on Cholera has been prepared more for the information and benefit of the unprofessional than the Medical part of the community, and as a very large portion of it relates to those Municipal regulations which tend to control the production and propagation of the disease, and cause it to assume a more mitigated form, we think our citizens should be furnished with information which may prove of vital importance to the welfare of our port. We would, therefore, suggest the adoption of the following resolution — "Resolved, That the Report on Cholera, drawn up by the Philadelphia Medical Society, at the recommendation of the Board of Health, be published.' 7 Signed. WM. D. BRINCKLE, M.D. JOHN T. SHARPLESS, M.D. The foregoing Report and Resolution were adopted. WM. A. MARTIN, Clerk, Attest. REPORT Of the Committee of the Philadelphia Medical Society, appointed to investigate the subject of Cholera. The Committee of the Medical Society of Philadelphia, appointed, in pursuance of a request from the Board of Health of the said City, "to institute an impartial examination into all the facts in relation to the Epidemic Cholera," now prevailing in Europe, having carefully examined numerous official and authentic documents in reference to the disease, as it first made its appearance in Asia, and subsequently in various parts of Europe, beg leave to submit to the Society, the following summary, as embracing the most interesting facts connected with the Epidemic, together with such municipal regulations as would be called for, should it make its appearance in our City. In drawing up their report, the Committee have carefully abstained from indulging in conjectures or speculations, but have restricted themselves to an enumeration of what, from the weight and concurrence of the authorities furnishing the best accounts of the disease, may be received as the best established facts ; the details from which these facts are derived, the Committee have avoided inserting, in order not to extend their report to too great a length. In pursuing their investigations, the Committee have adopted the following arrangement. 1. The origin and subsequent spread of the Epidemic Cholera. 2. The character of the localities where it has generally appeared, and where it has produced the greatest ravages. 3. The description of persons most liable to its attacks. 4. The influence of Quarantines, and other sanatory restrictions, 6 adopted by various governments, to guard against the introduction of the disease. 5. The municipal regulations, best adapted to lessen the violence, and to limit the prevalence, of the disease, should it appear in this country. I. The Epidemic Cholera commenced its destructive ravages in various parts of the Delta formed by the mouths of the river Ganges, in India, during the summer of 1817. Presenting many of the features of ordinary Cholera Morbus, it has still some symptoms superadded, which distinguish it from that disease. The chief of these latter are, the suddenness of the onset, and the rapidity of its course ; the extreme exhaustion of the animal powers ; the distressing cramps or spasms of the muscles of the limbs and body, which commonly attend it ; and, more especially, its strongly marked epidemic character. Continuing its ravages from the period already mentioned, by the end of 1818 the disease had pervaded nearly the whole of Hindostan, from the Himalayah mountains on the north, to Cape Comorin on the south ; and from Bombay and Surat on the west, to Sylhet on the east. In 1819, it broke out in the kingdom of Arracan on the east ; Penang and Java on the southeast ; and in the isles of France and Bourbon on the south-west. The effects of the epidemic were, also, experienced still further to the south and east, over the whole, of the Indio-Chinese peninsula. In 1820 it prevailed in Siam, Malacca, the Philippine Islands, the southern provinces of China, and at Guzzerat in India. In 1821 it occurred in Muscat, on the southern extremity of the Arabian peninsula, and again in the island of Java. During this year, Bushire, Schiraz, and other parts of Persia ; Bassora and Bagdad in Arabia ; the island of Bahrien in the Persian Gulph ; and in a south-easterly direction, the island of Borneo, suffered severely from the presence of the epidemic. During the succeeding winter, the disease became dormant in both Persia and Syria, but in the spring of 1822 again revived, and made its appearance, among other places, in Ispahan, Teheran, Tabriz, Moussul, and Diarbeker. By the end of the year, indeed, almost every place of note in Persia had been ravaged by the pestilence. In the 7 spring of the ensuing year (1823,) it broke out in Latokia, Antioch, Tortosi, Tripoli, and in other towns along the eastern shores of the Mediterranean, and in the Spice islands, as well as still farther south, in the island of Timor near New Holland. Previously to the autumn of this year, the disease had prevailed throughout Asiatic Turkey, from Bassora and Bagdad, to Erzeroum and Antioch. Egypt, however, escaped until a much later period. In August of this year, the epidemic prevailed in the province of Shirvan and in Baku, as well as in other places on the western side of the Caspian sea ; and it, finally, made its appearance in the city of Astracan, near the mouth of the Volga. Subsequently to the year 1823, the disease continued its ravages throughout China, and in various parts of India ; and towards the close of 1826, it almost depopulated several cities in Mongolia, occurring as far north as the borders of Siberia. In 1824 it appeared at Tiberias in Judea. In Persia, the epidemic reappeared several times; the city of Teheran being ravaged by it in 1829. In 1828, the epidemic once more broke out in the Russian dominions, appearing unexpectedly at Orenburg, a town situated on the Ural river, four hundred and eighty miles north-east from Astracan. On the setting in, soon after, of cold weather, it however completely and promptly ceased. But in the summer of 1829, it recommenced its ravages with greater severity, and occurred in many places, also, in the neighbourhood. About the middle of June 1830, the Cholera made its appearance in Tiflis, a city in Georgia, and, in the mean time, re-occurred at Baku. By the 20th of July, Astracan was for the second time a sufferer from the epidemic. The disease occurred successively in various towns and villages, situated along the shores of the Volga, from the south of the Caspian sea, to Tver and Vologda; in a short period the disease made its appearance at Archangel on the north, and over the greater part of Poland to the south ; ravaging, in fact, the principal places from the borders of Prussia to Odessa, and from Odessa to the White Sea. In April 1831, Warsaw was attacked, Riga in May, Archangel in June ; in the latter month the disease appeared likewise in St. Petersburgh, and in July at Cronstadt. In Dantzig in Prussia, the epidemic broke out in May 1831, and at the same time in Brody and Lem- 8 burg in Austria. In Berlin the disease commenced in August, in Vienna in September; it likewise occurred in various parts of Hungary, and before the close of the year, had desolated nearly fourteen thousand towns and villages. In October it suddenly appeared in Hamburgh, and in different parts of the kingdom of Hanover. In the month of August, it made its appearance on the eastern coast of England, at Sunderland, a seaport town, in the county of Durham, situated at the mouth of the River Wear. The disease did not, however, attract any especial attention until near the end of October. In December, it prevailed at New-Castle on the Tyne, to the north of Sunderland, and at Gateshead to the south. It likewise appeared subsequently in various places to the west, and in different parts of Scotland. London became subject to the epidemic in 1832, and accounts have reached us, of its appearance also in Dublin, and other parts of Ireland, while at the present moment it is prevailing to an alarming extent in the city of Paris and its neighbourhood. 11. The very numerous official and other authentic documents we now possess relative to Epidemic Cholera, all concur in showing, that the disease exhibits a striking partiality for low, damp, and marshy situations, rarely appearing in the more dry and elevated districts. It manifests an evident preference for the banks of rivers, whether these be navigable or not. Districts of country or particular spots, favourable to the production of remittent, bilious, and other fevers, are those in which the Cholera is most liable to occur, where it produces the greatest ravages, and continues to prevail for the longest period. In cities, the disease invariably breaks out in those parts where ventilation is defective, and the air is the dampest and most contaminated. Hence, it commonly makes its first appearance, and produces the greatest amount of mortality, in the lowest and most confined streets, courts, and alleys, contiguous to rivers or canals, especially when these localities are, at the same time, damp, filthy, and crowded with a depraved or indigent population. After these, the places in which the Cholera has prevailed to the greatest extent, are the narrow, crowded, and filthy alleys, in 9 other parts of the town, or in its suburbs ; particularly when these happen to be in the vicinity of ponds of stagnant water, and other sources of foul and unwholesome exhalations. The dry, clean, and less densely inhabited portions of cities, have almost entirely escaped the more violent forms of Cholera. So true is this, that in the towns visited by the Epidemic, where cleanliness and free ventilation were conspicuous, it sometimes happened, that only a few individuals were attacked, out of a population of many thousands; the disease remaining but a few days, and producing, comparatively, a trifling mortality; whilst, under opposite circumstances, it has produced the most frightful ravages, and continued to prevail for a much longer period. 111. The constitutional conditions which have been found to increase the susceptibility of persons to Cholera, are, in general, very nearly the same as those which predispose to the attack of other diseases of an epidemical character. In every country it has been found that a large class of persons have either entirely escaped the disease, or have had it very slightly. The greatest immunity has always been experienced by persons in easy circumstances, who, possessing the comforts of life, have had the good sense not to abuse them. Whenever persons of this description have been attacked by the disease, it has almost invariably been owing to a want of proper care in avoiding the exciting causes. The children and females of this description of persons, have been almost entirely exempt from the disease. The classes of society most liable to Epidemic Cholera, may be designated under the five following heads. 1. The indigent inhabitants, of low, damp, and ill ventilated portions of cities, and particularly those who suffer from a deficiency of food and clothing, or whose diet is composed, in great part, or entirely, of indigestible articles, and those containing but little nutriment, or possessed of unwholesome properties. The aged and infirm of this class have been among the principal sufferers from Cholera. 2. Persons habitually addicted to the use of spirituous or other 10 intoxicating drinks, have been especially liable to attacks of the disease. Drunkards, and the debauched of every class, have been among the chief sufferers, wherever the epidemic has prevailed, and those who sank the most rapidly under an attack. 3. Individuals exposed to wet, or to damp and cool air, particularly during the night, and especially when badly or insufficiently clothed, exhausted by fatiguing employments, or exercises, by want of sleep, long fasting, intemperance, or other debilitating causes, have seldom escaped the disease. Exposure whilst sleeping, or during a state of intoxication, to the open air, has always proved peculiarly dangerous. 4. Valetudinarians, or persons with broken down constitutions, particularly those subject to affections of the stomach and bowels, are peculiarly liable to the attacks of Cholera. 5. Those under the influence of fear, intense anxiety, grief, and other depressing passions, have been enumerated by nearly all the writers on Epidemic Cholera, as among the most predisposed to the disease. The baneful influence of these causes was exhibited, not only in rendering those who indulged in them more susceptible to an attack, but by their increasing the violence of its symptoms, and accelerating its fatal termination. IV. In relation to the quarantine and other presumed sanatory restrictions, which have been adopted by the different governments of Europe, as safeguards against the Cholera, your Committee, after a careful and cautious examination into all the numerous facts connected with this branch of their inquiry, would simply state, without adverting to points, the consideration of which it has been thought unadvisable to enter upon in the present report, that all such measures have failed in effecting the grand object for which they were established. In proof of their inutility, we have the experience of the whole of that portion of Europe where the disease has prevailed. In Russia, Austria, Hungary, and by almost every other government, they have been unavailingly resorted to. By Prussia their effects were tried to the greatest possible extent ; her rigorous measures being enforced by no less than sixty thousand of her choicest troops — the 11 result is before the world. So far from proving salutary — quarantine and sanatory" restrictions, as they are termed, in addition to the immense expenditure they necessarily involve, have by suspending or interrupting commerce, and depriving of employment thousands of those who are directly or indirectly dependent upon it for their means of daily subsistence, rendered multitudes of individuals and families more favourable subjects of the disease. As regards the supposed conveyance of Cholera by means of clothing and merchandise, the following facts, contained in the Report of the Central Board of Health of England, may be adduced as strong, if not conclusive, testimony. " There is no question, perhaps, in the whole range of sanatory police, on which so many and such irrefragable facts can be brought to bear as on this ; derived, too, from the most authentic and recent sources. " Seven hundred and thirty ships, loaded with flax and hemp, from infected ports in the Baltic, arrived at the different quarantine stations in this country, between the Ist of June and the 3d of December, 1831. "Many vessels, also, arrived laden with wool and hides, yet not a single case of Cholera occurred on board any of these ships outside the Cattegate Sea, nor amongst the people employed in opening and airing these cargoes in the lazarettos. "At the hemp and flax wharves, in St. Petersburgh, where several thousand tons of these articles arrived during the spring and summer of this year, from places in the interior, where Cholera existed at the time of their departure for the capital, the persons employed in bracking or sorting, and who generally passed the night among the bales, did not suffer so early in the season, nor so severely, as other classes of the general population. "The same observation holds good with respect to all the rope walks of St. Petersburgh, and the imperial manufactory of linen cloth at Alexandrofsky, where all the yarn is spun from flax bracked and hackled on the spot." The quarantine of persons has proved equally unavailing with that on merchandise. In evidence of this, the following, among numerous other facts, may be quoted. R 12 Ist. In very many villages and towns, to which the inhabitants of cities where the Cholera was prevailing, fled in crowds for shelter, and to which numbers of the sick were also conveyed, no new cases of the disease occurred. 2d. Cases of Cholera have rarely or never occurred in the lazarettos, where the crews of vessels, and individuals, from infected parts, have been detained. 3d. In twenty of the most extensive hospitals for the reception of patients affected with Cholera, in India and Europe, no one of the medical attendants, nurses, and assistants, who were day and night in close contact with the sick, contracted the disease. In six other Cholera hospitals, of the physicians, nurses, and assistants employed in constant attendance upon the patients, and amounting in all to five hundred individuals, but eight cases of the disease occurred, and in the majority of these the attack was manifestly induced by irregularity, fatigue, or imprudent exposure to cold and damp. 4th. Multiplied instances are on record, where one member of a family has been attacked with cholera and died, while the relatives and friends, who nursed the patient, even occupied the same bed at night, and performed the usual offices to the body after death, have remained free from the disease. V. It being proved by the most conclusive evidence, that restrictive measures are ineffectual in preventing the occurrence of Epidemic Cholera, the only question which remains to be considered, is that in reference to the municipal and other regulations best calculated to remove or correct the causes which would tend to increase the violence and mortality of the disease, and to extend its ravages, should it make its appearance amongst us. The measures calculated to produce this effect, may be arranged under the three following heads. First. Those by which the insalubrity of the air of neighbourhoods and dwellings may be remedied, and the sources of disease destroyed or diminished. 13 Secondly. Those by which the human body may be defended from the influence of deleterious agents; and, Thirdly. Those adapted to lessen the violence and mortality of the disease. Ist. Under this head are included all measures adapted to ensure cleanliness, free ventilation, and dryness of the streets, courts, and alleys, and of the houses in those situations where the disease is most liable to occur. To this intent, every street, court, and alley, both public and private, throughout the city and its suburbs, should be daily inspected by competent agents, and measures promptly adopted to ensure the complete removal of all offal matter, and collections of filth of every description. The dwellings of the poor, particularly in crowded, damp, and confined situations, should be thoroughly cleansed and whitewashed at the public expense, and care taken to secure the constant maintenance, both in and about them, of perfect cleanliness and free ventilation. Wherever a too crowded population exists, it should be thinned by removals and dispersion ; to effect which, temporary habitations, consisting of sheds or tents, would be found convenient and cheap, should there be a deficiency of houses in eligible situations. The poor who reside in cellars, or in damp and badly aired apartments, should, if possible, be removed at once, or have such reformations made in their accommodations, as will ensure to them a dry and pure air. Lime should be freely used, not only to whitewash the walls, but, also, to spread over places where offensive vegetable or animal substances are, or have been. The lime, or what is still better, its chloride, required for such purposes, ought to be supplied to the indigent at the public expense. Citizens in general, should be recommended and urged to have their cellars thoroughly cleansed and whitewashed. Wherever there is an accumulation of substances liable to undergo putrefaction, or to emit an offensive effluvium, as in workshops, store-houses, vaults, and cellars, the free use of the chloride of lime or of soda should not be neglected. 14 When, from the nature of any particular situation, or other circumstances, cleanliness and ventilation cannot be secured and maintained, without great expense and difficulty, the only effectual means to prevent the occurrence there of the disease, will be the removal of the inhabitants, and prohibiting the dwellings from being occupied until the approach of winter. Every exertion should be made by the proper authorities, to fill up or effectually drain, without delay, all ponds or other reservoirs of stagnant water, in the city and in its precincts. 2d. The means adapted to defend the human body from the influence of deleterious agents, are, sufficient clothing, proper food and drinks, cleanliness, temperance, and the careful avoidance of damp, of excessive fatigue, and of all improper exposure. It should be strongly recommended, therefore, to people of all classes, to adapt their clothing to the state of the weather, and to the amount of exposure, so as to guard the person from chilliness, and at the same time to prevent a too sudden check of the perspiration, both of which have been found very promptly to induce attacks of cholera. When from the indigence of individuals or families, suitable clothing cannot be obtained through their own means, public provision might be made for this purpose. The public should be informed what articles of diet have been found most wholesome, as well as cautioned against the use of such as have been found liable to induce disease. It may be stated, in general terms, that the food universally recognised as most wholesome, consists of light, nutricious, and easily digested articles ; such as beef or mutton, poultry, and game of almost every description, plainly cooked, and eaten in moderation ; soft boiled fresh eggs, good potatoes, spinage, asparagus; wheaten bread, when well baked and a day old; biscuits; milk, fresh or boiled; oat-meal, rice, barley, arrow root, &c, &c The following articles may be enumerated as among the chief of those which have been found liable to induce attacks of cholera. Rich, high seasoned, and greasy food of every description; heavy puddings; pork and fish, particularly salted and dried ; fried oysters; lobsters and crabs; cheese, pastry, &c, flatulent vegetables, and especially the watery fruits and vegetables, when 15 too freely indulged in, as green corn, peas, cucumbers, melons, radishes, and the like ; as well as all unripe, acid, and decayed fruits. — Every thing, in fact, which is difficult of digestion, notwithstanding it may have been eaten, during ordinary states of health, without occasioning any perceptible inconvenience, should be abstained from. In regard to drinks, the habitual use of spirituous liquors has been found highly injurious, and malt and vinous drinks, if admissible at all, should be of a good quality, and used only in very moderate quantities. Cold drinks should be taken with great caution, particularly when the body is in a state of profuse perspiration, or exhausted by labour or fatigue: acid drinks, in general, are to be avoided. f i Depots of wholesome nutritive food, for the benefit of the indigent, would be useful. Strict cleanliness of the person and clothing, is an indispensable precaution for the preservation of health. The cleanliness of the person will be best preserved by the use of baths, or ablutions, followed by frictions over the whole surface with a fleshbrush, or a coarse towel. The bath and frictions, have the double advantage of removing all extraneous matter from the skin, and at the same time, of promoting the healthy functions of that organ, as well as of increasing the energies of the stomach and bowels, and of the system generally. Upon no class of persons is it more important to urge the necessity of strict cleanliness, than upon labourers and mechanics. All persons should be cautioned against exposing themselves, when it can possibly be avoided, to wet, to cold, or to the night air ; especially in the localities which have been indicated as those most favourable to the production of Cholera } as well as against frequenting crowded assemblages in confined and heated apartments, and more particularly from subsequent exposure to the night air. Remaining long without food — a diminution of the requisite amount of sleep — and going out in the morning with an empty stomach, are so many causes capable of producing the disease, and against which, therefore, the public should be cautioned. They whose circumstances compel them to reside in the neighbourhood 16 of ponds, or other extensive collections of stagnant water, or in low, damp, and otherwise unhealthy situations, may, in a great degree, lessen the danger to which they are exposed, by the strictest cleanliness ; by occupying the driest and most elevated apartments of their respective houses ; by retiring within their dwellings, and carefully closing the windows and doors, before night-fall, and by keeping moderate fires when the weather is cool and damp. 3d. Under the head of means adapted to lessen the violence and mortality of Cholera in those attacked, it is not the intention of the Committee to enter into the consideration of its medical treatment. They would, however, remark, that the disease has been found to be so far under the control of appropriate remedies, that whilst there has scarcely been an instance of recovery where the subjects of it have been without medical assistance, a considerable proportion of those who have received such assistance immediately after being attacked, have recovered. In Epidemic Cholera, more perhaps than in any other disease, the chance of a successful termination of the case, depends upon the promptitude with which the administration of the remedies demanded, is resorted to : with the loss of a very few hours, the probability of the patient's recovery will be greatly diminished. It is important, therefore, that proper measures be taken by the public authorities, to secure to the indigent that prompt assistance, which, in the case of the disease appearing amongst us, will be the only means of saving the lives of a large portion of those who shall be attacked. To this end, the town should be divided into districts, and a sufficient number of competent medical attendants and assistants provided. Temporary hospitals should, also, be established in suitable situations, to which all patients, who, from their indigent circumstances require public aid, should be removed, the moment they are attacked, and placed under the charge of the physicians in attendance. The Committee think it proper to refer on this occasion to the fact, that no specific or preventive remedy has been discovered for Cholera — all, therefore, should be put upon their guard against the use of medicines recommended to the public as possessing either of those characters. Not a few instances are recorded of 17 persons, apparently not otherwise predisposed, being attacked with the disease immediately after taking some pretended specific. It is scarcely necessary to urge upon the proper authorities, the propriety of losing no time in adopting whatever measures may be decided upon as necessary for the prevention and amelioration of the disease, should it occur in this country. It must be recollected, that Cholera is a disease to which, during the summer and autumnal months, our city is, every year, more or less subject : cases often occur marked by the most violent symptoms. Should the disease during the present season assume an epidemic character, it would then be too late to carry into full effect all the necessary arrangements — the time lost, would at least, be severely felt, and perhaps lead to its increased prevalence and mortality. By taking promptly the necessary steps, the excitement of the public mind, which, on such occasions, is usually excessive, would be much relieved, and many other ill consequences obviated. In performing the duty assigned to them, your Committee have not been insensible of the deep responsibility under which they labour. They have acted, therefore, throughout, with the utmost caution and deliberation, expressing no opinions, nor venturing upon any recommendations, in which they have not been borne out by the fullest and most authentic testimony. They have, likewise, made it a primary object, to present the subjects embraced by this Report, with as much brevity as was consistent with clearness, bearing in mind, the intimation of the Board of Health, that the information requested is for the benefit f< of the unprofessional, as well as the medical part of the community." D. FRANCIS CONDIE, M.D. G. EMERSON, M.D. ISAAC HAYS, M.D. SAMUEL JACKSON, M.D. HENRY BOND, M.D. W. E. HORNER, M.D. R. M. HUSTON, M.D. Philadelphia, May 30, 1832. P. S. No authentic documents have been received by the Committee, in relation to the disease said to be Asiatic Cholera, as it has occurred in the Canadas. June 22, 1832.