\ \ J If REPORT OF THE COMMITTEE OF THE KAPPA LAMBDA SOCIETY, APPOINTED FOH TUB ITIiPOSE OP PREPARING AN ACCOUNT OF THE MODE OP TREATMENT OF EPIDEMIC CHOLERA JUNE. tui;i;tiiek with AN ADDITIONAL REPORT, Presented August 1"', IS HJBMSIIED DV OIIDEU OF THE SOCIETY. iT> 1 4 8 * NEW-YORK: PETER HILL, 91 BROADWAY. 1832. I REPORT. In compliance with the requisition of the Society, your mmittee have prepared the following abstract of the mode treatment of Cholera, as directed by the best authorities hin their reach. They have felt it to be their duty carefully to abstain from any remarks of a speculative or theoretical character ; and in regard to the treatment of the disease, have adopted nothing which did not come recommended by the highest authority. They have thought it best to present you with a pretty full account of the mode of practice which appears upon the whole to have been found most successful in Europe, and also a brief outline of the practice generally adopted in India ; to which they have prefixed a sketch of the symptoms peculiar to each stage of the disease. PRECURSORY SYMPTOMS. I Epidemic cholera appears, from the testimony of the best servers, to be almost invariably preceded by premonitory nptoms. Of these the most uniform and remarkable is irrhcea — with frequent stools of a black or dark brown our, changing by degrees to an appearance of dirty water. lusea, vomiting, or other derangement of stomach than slight in or uneasiness, are not common. There are indications disordered nervous system, as slight headache, spasms, and mps, and weak and quick pulse ; also general weakness 1 lassitude. PREVENTIVE TREATMENT. Et this time, if suitable attention be given, it is perfectly agcable. It is, therefore, in the highest degree important, medical advice should be taken upon the slightest threatg of the disease. It is warded off with great ease by the following treatment: — The patient should be purged freely with calomel and aloes or scammony, or with pil. cochice, until the discharges from the bowels assume a more healthy appearance ; should be kept warm in bed, and confined to a light and nutritious diet. By the prompt adoption of this treatment, the disease is with certainty averted. If the person attacked is of full habit and strong constitution, the loss of some blood is of service, but it should never be carried to the extent of syncope. tfost persons attending the sick have had these symptoms, in almost all cases the disease has been prevented. 5 P of diarrhoea, as by attention to this the disease may y instances be wholly averted. A simple wateryly be safely checked with opium at once. All discharges should be immediately removed, and the air purified by the chloric liquids, as the smell is found to produce a similar diarrhoea when this precaution is neglected. ADVANCING DISEASE. I There next appear in order, when the disease advances, mps and spasms of the extremities and other parts, pain at stomach, restlessness, nausea, vomiting, thirst, and frequent ections of an appearance like gruel, or rice or barley boiled vn in water, and sometimes serous like pure water — great dness, external and internal. IFhe tongue at this time furnishes no indication of the state the system. Ehe features are sharp, and the expression anxious. The is of a dark brownish or lurid cast. Sn the worst cases the vomiting and frequent dejections are ictimes not found. In some cases death is preceded by a iquative sweat. E^he disease is found to change its form and its degree of lity with sudden changes of weather, as from dry to wet, rom hot to cold, he. And generally, the changes are such that every succeeding twenty-four hours will call for a decided modification of the treatment. There are, however, many instances, especially in the commencement of the epidemic, in which this stage appears to be wholly wanting, and the disease passes at once to the stage of collapse. In such cases, the mode of treatment hereafter to be pointed out, as suited to this form of the complaint, must be resorted to without delay. 6 TREATMENT IN THE ADVANCING STAGE. The most pressing indications at this period appear to be, the quieting of the stomach, and the restoration of the suspended circulation, and of the animal heat. To meet the first of these, and to relieve the distress and vomiting, large sinapisms should be applied over the epigastrium or over the whole abdomen, which shouUl be kept on until the symptoms have yielded. To effect the same objects, the effervescing draught, frequent Sail draughts of soda water, or cold water, or pieces of ice, ye been found most successful. IPhirty or forty drops of laudanum in mint tea, or a few ps of spirits of ammonia in cold water, or a little weak ndy and water have been found to answer the same pure, although not so perfectly. E Emetics, although used by some practitioners, are of very btful utility. A little warm water, or salt and water, are icient, when any is thought necessary. K?he next great indication, the restoring the functions of the ulatory system, and the animal heat, is answered by the stant application of caloric externally. This may be effected by various means, as by friction with heated flannels, by flat shallow bags, like small mattresses, filled with heated sand or salt, which should be placed under and around the patient. Jugs and bottles of hot water, hot bricks or stones, or blocks of hard wood soaked in boiling water and wrapped in flannel, should be placed in contact with the patient, who should be placed upon and covered with hot blankets. Over these, warming-pans of hot coals may be passed. Or the hot air-bath may be used, as described under the head of remedies in the stage of collapse. The pains-, cramps, and spasms, as well as the general torpor of the skin, may be most easily removed by frictions, long-continued and very constant, with the naked hand, or a little hot camphorated oil, or with dry flannel, tincture of 7 K pepper, spirit of camphor and ammonia, or oil of turpcn, in which peppers may 'be infused, and which may be lied hot. Ehe feet and hands may be covered with sinapisms from the nning of the attack. Small anodyne injections, or suppositories of opium maybe used with benefit, if the diarrhoea is urgent. I^he internal remedy most depended upon for restoring the Ithy action of the alimentary canal is calomel, in doses of 1 two to four grains, combined with from one-fifth to one' of a grain of opium, to be administered every half-hour, rom that to two hours, according to the urgency of the ptoms. This treatment is to be continued until the remisi of the symptoms. If the pulse will bear it, the loss of a little blood by leeches venesection has sometimes been found useful ; but it is a tedy of a questionable character at any period before reacl has taken place. Such is a brief outline of the mode of treatment most approved by experienced physicians in all parts of Europe, during the first or forming stage of the disease, which rarely exceeds from six to eighteen hours in duration. All writers agree in the opinion, that the doses of all medicines should in this state of the disease be small. The drinks should also be administered in small quantities, and frequently repeated ; and if the thirst is urgent, cold or iced water, or ice in small quantities, is never injurious. A horizontal position should be rigorously insisted upon. Kf decided marks of dangerous congestion in any part, as head /Or the chest, appear, leeches may be applied with efit. ¦n its progress, the following means may be advantageously 1 for the purpose of producing perspiration : i small doses of Dovers' powders, spiritus mindereri, spirits nitre, or a few grains of carbonate of ammonia frequently eated, in any mild drink. And the vapour or steam bath, >lied by pouring vinegar and water upon hot stones, irons, 8 or shot, the heat of which is occasionally moderated by sprinkling with cold water. (See Note A.) In milder cases this practice has been found highly succesful. In bad cases the former is preferable. tl general, dry heat in all forms seems to have been prcsd to moist applications. It is also worthy of remark, that c is great danger of doing too much, and thus at the same rendering experience uncertain, and destroying the useess of one remedy by the interference of another. Let the plan of treatment be simple, decided, and persevering, and the remedies few. THE STATE OF COLLAPSE. 111 the more advanced stages of the disease, or earlier, in most violent cases, we find the pulse, the voice, the heat of body, to be almost entirely gone : the purging and vomiting are dreadful, or in some cases cease entirely, the thirst is often urgent, the nervous symptoms increase, and death too frequently closes the scene. In this stage of the disease, the greatest energy and decision are demanded ; the period for action is brief. Bleeding and large doses of opium and brandy are now inadmissible. Bhe first indication to be fulfilled is to restore the lost heat c body, and renew its suspended vital functions. All the means of creating and applying external heat must in this stage be resorted to, and persevered in with tenfold energy. B addition to those before mentioned, we will only speak c hot air mattress, and the hot air or spirit bath. The former is a tin vessel in the form of a mattress, filled with hot air by means of a spirit lamp and tube or funnel, the orifice of which is afterward stopped, covered with blankets, and upon which the patient should be placed. This Stlie back, which cannot so easily be done in any other 9 As a means of restoring the heat of the surface, the hot air Or spirit bath may be applied. The apparatus for the appliplication of this is very simple, and may be easily procured. It also possesses the great advantage, that it may be applied without moving, and thus farther exhausting the patient. The bedclothes may be elevated by two semicircular hoops, while the hot vapour and air pass into the bed.* But the most important remedy for the purpose of restoring the vital energies is the hot enema, consisting of three or four pounds of water as hot as the hand can bear, to which two drachms of laudanum and six ounces of brandy maybe added. At the end of an hour it must be withdrawn by means of a tube inserted in the rectum, when it will be found to have become quite cold. This must be two or three times repeated, according to circumstances, and all ideas of quieting irritation of the bowels must give place to the absorbing interest of the restoration of animal heat, and the renewal of the vital functions. After the second or third injection is withdrawn, if there be no remission of the symptoms, a tobacco glyster may be thrown t consisting of an infusion of two drachms of tobacco in a t, or pint and a half of boiling water, and cooled to the )e temperature as the last. This remedy appears to have afforded decided relief in some cases, but it is not confidently recommended. If the stomach seems to be the seat of more than usual distress, the sinapism may be removed, and a blister raised at once by the application of scalding water, or by a decoction of cantharides in strong acetic acid. In the mean time the following remedies may be adminis-tered : viz. Calomel in doses of from two to three grains, with or without the addition of a quarter of a grain of opium, every ? This apparatus may be procured of Mr. Gran!, tinplate worker, Broadway, near the City Hospital. The Inrge cup should be half filled with water, the small tme with alcohol. The one is then placed in the other, and net under the funnel, and the alcohol is ignited 2 10 second hour ; or even to the extent of a similar dose every fifteen minutes, if the urgency of the symptoms require it. I After every fit of vomiting, let the effervescing draught be ministered, or soda water in small quantities, or iced water, small pieces of ice, if great internal heat is complained of. the vomiting is excessive, thirty drops of laudanum or black op, and a few drops of some essential oil, as mint, cajeput, :., may be added to each draught of soda water or efferscing mixture. I When the stools become feculent, calomel and jalap, or itor oil, must be freely administered. I Sudorific medicines, when the stomach is quieted, will assist restoring the balance of the circulation. (For this purpose, camphor mixture, or spiritus mindereri, y be used, to which spirits of nitre, or carbonate of aramoi, or paregoric may be added. BBut they are better omitted than to incur any risk of dishing the stomach. Drinks, cold or warm, may be given according to circumstances. Ice may be used at any period before reaction occurs, but not after that. Ef the case terminates fatally, there is a clammy sweat — the se and temperature are both sometimes found to become ;er — but the vomiting and purging are excessive — the voice nges to a low moan, the spasms cease, and the muscles are xed in death. On the other hand, if the case is to terminate in accordance with our wishes, the stools become less frequent and more natural, the vomiting ceases, the pulse rises, the warmth and speech return ; but now a new danger awaits the sufferer in the appearance of REACTION. With returning strength, as in all cases of exhaustion from sudden disease, fever, congestion, and inflammation make their appearance. 11 ilf the head is found to suffer most, leeches or cups must applied to the temples ; the head may be speedily blistered the decoction of cantharides above mentioned, or ice may applied to the scalp. Free purging should also be resorted f[f the lungs be the seat of congestion, the patient must be d freely, placed in a half-sitting posture, and thirty drops antimonial wine given every third hour. Ilf there should be a vomiting of green fluid, an emetic of rm salt water will be efficacious in removing it. KlMie urine is often retained during and subsequently to the apse, and must be drawn off if necessary. In general, the fever is more dangerous, if possible, than collapse. Calomel should be given ; three grains every •th hour, till the gums indicate its effect upon the system, itor oil or other purgative should follow the calomel, and lancet not be feared. Kn children, this stage of the disease turns to hydrocephalus tvs, and demands decisive treatment. B'he following is a sketch of the treatment found most sucful in India. (See note B.) li'he first indication was to rally the system, and to restore almost suspended functions. This was effected chiefly by prompt resort to the application of external heat by the of the methods before described. Ecalding blisters, and rnoxa by tow soaked in tar or turpenand burnt upon the epigastrium, were also used in severe s. I'o effect the same object, laudanum and sulphuric ether : administered in doses of from fifty to sixty drops in an :e of hot brandy and water; and if rejected, the dose was ediately repeated, and administered every fifteen minutes the vomiting was relieved. Sometimes a pill of three ns of opium, alone or in combination with carbonate of lonia or cayenne pepper, was given, and followed by small s of hot brandy and water or mulled port wine. 12 Eut the success depended not so much upon the kind of ulant, as upon the promptness with which it was applied. Essential oils were also used in doses of twenty drop* occaally repeated. |[n severe cases, when there were symptoms of congestion >ut the stomach and liver, and in all cases in which the %ptoms did not yield to the stimulant and restorative mode oraclice, in addition to the most persevering application of ernal heat, Sec. calomel was administered in doses of one jple or half a drachm, repeated every second hour, in comation with from one to three grains of opium, with the hap;t effect. When it did not succeed, it was owing to the ;lect of the proper measures for restoring the animal heat. ¦t could not, however, he " depended upon" until reaction commenced. And it was always observed, that when calomel had been freely used, bilious and feculent stools were much sooner procured, and convalescence was more speedy, than when it was omitted. In all bad cases then it is invaluable, but most so when the system, from the use of the above means, has begun to react. From the documents annexed (see note B) it would appear that this mode of treatment was found to be more successful than the average of the European treatment ; but whether this would be equally the case in any other climate, is by no means certain. Your Committee have also examined the partial and imperfect accounts, as hitherto published, of the modes of treatment adopted by the Canadian physicians in this disease, without finding any important addition to their stock of practical information. luch is a brief sketch of the mode of practice which appears aye been found most successful in this disease, as it has pre;d in Europe, and to be recommended to us by the highest ical authorities. Your Committee will only remark in relation to it, that 13 there is reason to infer from our experience in analogous diseases in this country, that the doses of medicine in general may be found too small to be suited to our own climate. JUthough, therefore, they are not prepared to recommend employment of the very large doses of opium and calomel scribed with great apparent success in India, yet they will ture to suggest that it may be found expedient, upon trial, ucrease the dose of calomel from two or three to six or eight ins, and the dose of opium from a half to one, two, or three ins, or of laudanum in proportion. In the remainder of the practice recommended they are unato see that any changes could be made with a prospect of rovement. A short experience will inform us as to any modifications circumstances may render necessary. Ind while we unite with the public in fervent prayer to Almighty Disposer of events, that it may please him to t from us so dire a calamity, we would still urge upon faculty and upon the public at large, the most careful aton to any of those symptoms which have been found to he precursors of this fatal disease, and the strictest care to rd against all the causes of sickness, of every description tever. ADDITIONAL REPORT OF THE COMMITTEE UPON CHOLERA. AUGUST 15, 1832. Your committee having had extensive opportunities to inquire into the results of various modes of treatment, both in private practice and in the cholera hospitals in this city, and thus to ascertain the relative value of the remedies used, as well as the doses most suited to this climate in cases of cholera, have thought it their duty to make the following additional report. They remark in the first place that a premonitory diarrhoea has been almost universally found to occur, and that it has been treated with great success by means analogous to those recommended in their first report. They will only observe farther upon this subject, that powdered charcoal, in doses of a table spoonful, has been found to produce the happiest effects in relieving the pains and uneasiness of the stomach and bowels, which often occur in the premonitory stage of this disease* The dose can be repeated if necessary, and is best given after mixing the charcoal with water by brisk agitation in a widemouthed bottle. It should be followed by castor oil after an interval of an hour or two. In general, in regard to the treatment of the disease, they 2 remarked, that a plan of treatment for the most part lar to that laid down in their first report, has been found c the most successful. X valuable auxiliary to the above treatment will be found ie use of frictions with strong mercurial ointment, in comtion with powerful external stimulants. This mode of 15 lictice, which the profession owe to the ingenuity and medical 11 of Dr. Roe, of the Greenwich hospital in this city, has ;n extensively used in all the hospitals, and has received most cases the highest commendation. His method is as lows : let the patient be very briskly rubbed from head to t (but less violently upon the chest and abdomen) with an tment composed of one pound of strong mercurial ointment, seven ounces of camphor finely pulverized, and an equal mtity of cayenne pepper, which should be intimately mixed, is operation should be repeated at short intervals, until reion takes place. The clothes of the patient, strongly im;d with the same ointment, are to remain about him. The cific effects of mercury generally show themselves in from to ten hours. If the skin becomes covered with a clammy at, it must be rubbed with hot chalk. When mercurial action is excited, the patient is comparatively safe ; and this further good effect is found to follow, that the secondary fever is hereby prevented. With the above remedy all the other means of cure should be vigorously combined. Venesection has been found useful in cutting short the disease at its commencement, when the state of the pulse would admit it, or when congestion in the head seemed to render it necessary. In these cases it has been most advantageously followed by a full dose of opium, as two grains of solid opium, or half a drachm of laudanum, to be followed, of course, with calomel, &tc. It has been useful chiefly in spasmodic cases, before collapse had taken place, when it was found to relieve the spasms, and to accelerate the operation of medicines. It has also been found highly advantageous in the consecutive fever, or stage of reaction, when there was great determination of blood to the head. In these cases a very full bleeding was found to answer far hctter than topical bleeding by cups or leeches. In regard to other remedies, the results have been various. general it may be remarked, that opium, in all forms, has ii found to be of less service than was probably expected. 16 I lias not been found so efficacious in allaying vomiting a 9 other means recommended in our report, or as calomel ne. In combination with the first dose, say twenty or thirty lins, of calomel, two or three grains of opium have been nd to relieve the spasms, and to render the disease subse?ntly more manageable. And a full dose of opium, as i>re mentioned, after venesection, has been found of great rice. But the repetition of doses of laudanum, or of solid urn, is at best a doubtful practice. In the stage of collapse, hot brandy and water has been nd a better anti-emetic than any form of opiate. Emong the remedies calculated to bring about reaction in stage, none has been found to serve a better purpose ice. Given frequently, in small quantities, it quiets the ach, checks vomiting, relieves thirst, and produces, or tly assists in producing reaction. As was anticipated in our former report, calomel has been found to be of most service in large doses ; in fact, the mode of exhibition of it which has been found most successful, accords very nearly with that recommended by most of the Anglo-Indian practitioners. It has been given in doses of from twelve or fifteen grains to half a drachm, every one or two hours, with decided benefit. It has generally been found to quiet the stomach, to lessen the irritation of the bowels, and to diminish the number of the discharges. It has, perhaps, been most successful when given alone, although a little camphor or capsicum has sometimes been added with advantage. After the system begins to react, and the calomel to operate, there is a discharge of immense quantities of dark porraceous bile, like boiled spinage ; and this often collects about the praecordia, creating great distress, even so as to prevent the patient from lying upon either side. This very troublesome symptom has been found to yield immediately to the operation of an emetic of warm salt water, or of siedlitz powders repeated at intervals. When there is great oppression about the praecordia, with sichiner anxiety and pain upon pressure topical bleedinc by 17 Blies or CUpfi at the pit of the stomach ha> been found of ;it service. lifuch good is said to have been cflcctcd by the use of the oholie tincture of camphor, in doses of from three to ten ps every half hour. But as your committee are not in session of the only proper proof, viz. reports of cases sucsfully treated in this manner, they cannot, of course, rccomid the practice. It is certain, however, that the above icdy will often put a stop to vomiting and hiccup in cases holera. Es a means of producing heat of the surface and reaction of system, dry heat has been found, as in Europe, preferable ie hot air or vapour bath, or the warm bath. IVith these additions, which comprise in a few words the ;t important rcsidts of our experience in this city, your imittee have been induced to think, that the report before nutted to you, will be found to constitute a safe guide for ctitioners in the treatment of cholera ; at the same time that conciseness renders it peculiarly convenient both for use distribution. They therefore recommend it to be published for the purpose of giving it a more extended circulation. 18 Note A. Iriie practice of administering the steam or hot vapour-bath, is sni ' The patient," said he, had " no sooner entered the vapour-bath, at smperature of from 100 to 150 Fahrenheit, than a moist vapour coed the whole body. An abundant sweat produced a cessation of the nitingr, diarrhira, &.C. ; and upon the return of the patient to bed, not y the bed-clothes but the mattresses were soaked with the profuse jat ; while he fell asleep amid the most agreeable sensations. To i sleep succeeded a perfect restoration to health." Bn 2000 cases treated in this manner, the loss was only eight or 2 per cent. He was physician to the Russian troops in the Crimea. Note B. Dr. Young was for many years in the service of the Honor rablc East India Company at the Bengal establishment, and during thirteen years was stationed at the Presidency as surgeon to the district of the twentyfour Purgunnahs, in which are situated the city of Calcutta, and its extensive suburbs. He was also Burgeon to the Calcutta militia of li! 00 men, and was besides in the charge of the Mysore princes, and their numerous respective establishments. It became his duty to offer advice to largo bodies of convicts employed on public works, and in prisons at Allipore, which in general contained not less than '1000 convicts. Among this latter class, especially during and subsequent to the rainy seasons, he never failed, throughout the whole period above stated, to meet with many distinctly marked cases of Cholera Morbus. Those rarely proved fatal ; nor had the disease appeared as an epidemic since 1707 (when it raged at Arcot) till the middle of the year 1317. In August of this year, the natives began to sutler severely from Cholera in the lower part of Calcutta, and several populous villages in its vicinity Europeans remained exempt from the disease from the beginning of September until the end of that month; the natives suffering so severely from its ravages as almost to threaten the depopulation of the city and its crowded suburb.-. In some cases, nearly whole families, who had retired to rest in apparent health, were found dead or dying in the morning ; and, in many others, several individuals of a household perished between sunrise and sunset. Native physicians' remedies were of a pernicious character, such as cold drink's, throwing rose-water over tho body, sprinkling sandlcwood dust over them, and offering up prayers and all sorts of incantations to their deities; every native indiviuual attacked by the disease considered himself struck by inevitable death. The European part of the population now suffered considerably. Under these circumstances the Bengal government, in hope of mitigating the public calamity, humanely authorized the employment of a great number of subordinate medical assistants, and placed them under the disposal of \h\ Young. In July, 1818, he laid before the proper authorii iea tlte following report of cades, in which assistance had been rendered by their means. 19 No. I. — Re|»rt of the DOtnbei of patienU attacked with the disease in the buliurds of Calcutta, to whom native medical assistance was given, i'roin September 1!), 1817, to January 31, 1818. Months. I Patient*. | Cured. | Hied. IConvalesc't Sep. 19 to Sep. 30, 1817 j 9190 1!I2O '2!.'? 27 Oct. Ito Oct. 31 :i275 I 3133 133 81 Nov. 1 to Nov. 30 I.VtT 1.V.1 10 ;] Dec. Ito Dec. "sl ] 1118 i 1368 4C> 4 Jan. Ito Jan. 31, 1818 1 690 ! (il3 46 2 Total !U7O i 8601 \ 507 I 57 No. ll.— Report of native villager! and others, who applied to the native medical assistants at Allipore, Bhowangpore, Soorab, Ruaaapuglab, and those of tho Mysore princes, fee, from September VJ, Iwl7, to January 31, 1818. 1);1 "- | No. lick. I Cured. Died. lOunvaleac't Month Sept. 1817 517 489 ;ttj gg October 485 164 11 ~7 November lfil 157 4 ;j December 163 153 (> U January 65 <;j ] 0 Total 1493 I 1397 |