bedding should be changed, when requisite, by removing him to one side
of the bed while the other is renovated. If the patient's night-shirt
becomes soiled and disagreeable, it may be cut so as to remove it, and
another, cut in the same manner, may be substituted and stitched
together. The room must be kept quiet, and useless visiting entirely
forbidden.
Cool and grateful drinks may be given in any stage or state of yellow
fever if demanded by patients. The quantity allowed at one time should
be small, since over-distension of the stomach almost certainly causes
vomiting. Effervescing drinks are nearly always grateful, and are
better tolerated than others. Seltzer-water and lemonade, or Seltzer
or Apollinaris on shaved ice, are to be recommended. Sometimes
patients call for sparkling wines or beers. I never refuse them or any
other alcoholic drink asked for in any stage of the disease. Wine
surely possesses valuable therapeutic effects in yellow fever.
Alimentation must be severely controlled by the physician, and the
tolerance and effects constantly watched. Even to the most experienced
physician the kind of food to be selected, and the time and manner of
administration, constitute difficult problems. In simple forms of the
disease food had better be strictly withheld during the continuance of
the paroxysm. Even after the stage of calm has been reached,
sufficient time should be allowed to elapse to enable the physician to
form some estimate of the degree of damage his patient has suffered
and his competency to retain foods and be nourished by them. This
question can seldom be answered in a decided manner, except through a
cautious trial of some bland and inoffensive food.
{655} On the third or fourth day of sickness a single tablespoonful of
iced milk may be given, and the immediate consequences closely
watched. If no retching or gastric uneasiness should ensue, it may be
repeated at the end of thirty minutes. Some physicians prefer to begin
with spoonful doses of equal parts of sweet milk and thin
barley-water. In my own experience chicken-water has proved to be the
most universally acceptable, as well as the most beneficial, of all
the various forms of nutriment to be chosen as a first venture. I have
frequently combined this with barley-water when first given. In this
cautious and tentative manner even the most experienced physician
prefers to proceed, rather than to attempt to prescribe rules of diet
in an abstract and arbitrary manner.
If these light articles of diet are well borne, they are to be
gradually and watchfully exchanged for beef-essences, the blood of a
rare beefsteak, and the more substantial broths. Solid articles of
food should not be allowed during the first ten days after an attack,
and for still longer periods patients should be admonished against
excesses in eating, and especially in respect to indigestible
articles. Those lesions of the blood and of the stomach, and those
grave disorders of nerve-function which occasion hæmatemesis in yellow
fever, are slowly repaired. Instances are reported in which black
vomit and death have followed excessive eating and drinking ten or
twenty days after dismissal from treatment.
There are, however, certain conditions which are liable to complicate
yellow fever which demand a course of dietetic procedure different
from that which I have recommended. Thus, children cannot bear
privation of food until the paroxysm is over if its duration is long.
In like manner, a more supporting course is required in most of those
cases in which yellow fever occurs as an intercurrent affection, in
all those cases which are termed typhoid or adynamic per se, and, more
emphatically still, in every case in which hemorrhages are occurring.
A failing pulse should in all instances admonish us to resort to
nourishment and stimulants.
It is a fortunate circumstance that in yellow fever the lower bowel is
generally in a state favorable for the retention of nutritious enemas.
In the most trying and critical hours of desperate cases I have seen
patients tided through by the use of skilfully prepared and skilfully
administered injections of some suitable meat-essence. When insomnia
exists, chloral hydrate or bromide of potassium may be conveniently
given in these vehicles.
It is evident that the discussion of the vastly important sanitary
questions pertaining to the prevention of yellow fever cannot be
appropriately discussed in the present article.
{656}
DIPHTHERIA.
BY A. JACOBI, M.D.
DEFINITION; SYNONYMS; HISTORY.--Diphtheria is a specific, infectious,
and contagious disease, characterized principally by epithelial
changes in, and the exudation of fibrin on and into mucous membranes,
the surface of wounds, and the rete Malpighii, thereby constituting
the so-called pseudo-membrane. Under the names ulcus syriacum, ulcus
ægyptiacum, garotillo, morbus suffocans, morbus suffocatorius,
affectus suffocatorius, pestilentis gutturis affectio, pedancho
maligna, angina maligna, angina passio, mal de gorge gangréneux,
ulcère gangréneux, angina polyposa, angine couenneuse, cynanche,
croup, diphtheritis, and diphtheria, the disease has been known and
described at different periods by the writers of different nations.
The Hippocratic writings and some remarks in the Talmud allow of some
doubt in regard to their explanation. Whether their authors observed
or recognized diphtheria cannot be proven. There is less doubt in
regard to Archigenes, quoted by Oribasius. Aretæus of Cappadocia is
notably the first, if we except Asclepiades only, who is said to have
performed laryngotomy. The description of the pharyngeal and laryngeal
manifestations furnished by the former, however, can leave no doubt in
our minds that he knew diphtheria and recognized it. Galen, in his
remarks on the Chironian ulcer, tells us that the pseudo-membrane was
gotten rid of by coughing when the respiratory passages were affected
by the disease, and by hawking when the disease was in the pharynx.
Cælius Aurelianus recognized diphtheria of the pharynx and larynx, as
well as the diphtheritic paralysis of the soft palate; it is to him we
are indebted for the information that Asclepiades resorted to
scarification of the tonsils, and even to laryngotomy. Aëtius in the
fifth century distinguished white and grayish patches and gangrenous
degeneration, observed paralysis of the soft palate, and advised
against energetic local treatment and the forcible removal of the
deposits before they were in a condition to fall off spontaneously.
The Arabs and Arabists contain no allusions to the subject, but early
chronicles tell of an epidemic raging in St. Denis in 580, subsequent
to a great inundation. There appear to have been memorable epidemics
in Rome in 856 and 1005, in Byzantium in 1004. The former are
mentioned by Baronius, the latter by Cedrenus.[1]
[Footnote 1: Haeser, _Lehrb. a. Gesch. du Med. u. d. Epidem. Krankh._,
3d ed., vol. iii., p. 434.]
According to Morejon, Gutierrez wrote his _Tradado del enfermedad del
garrotillo_ in the second half of the fifteenth century. A malignant
form of angina raged in 1517 in Switzerland, along the Rhine, and in
the Netherlands; in 1544 and 1545 in Northern Germany and on the
Rhine; {657} in 1557 in France, Germany, and Holland; to the latter
refer the reports of Tetrus Fosterus. Antonio Soglia, quoted by
Chomel, describes an epidemic in Naples and Sicily (1563), which
spread in the following year as far as Constantinople; Joannes Wierus,
epidemics in Dantzic, Cologne, and Augsburg (1565); Ballonius
(Baillon), in Paris (1576). At the same time this disease was frequent
in Denmark. From Spain there are reports on severe epidemics between
the years 1583 and 1618; the year 1613 was long known as the year of
diphtheria (anno de los garrotillos).
Mercado (1608) speaks of a child that had communicated the disease to
his father by biting his finger. Casealez advised gargles containing
alum and sulphate of copper. Herrera described diphtheria of the skin
and of wounds, and looked upon the pseudo-membrane as the essential
characteristic of the disease. Heredia, in 1690, recognized the
suffocative and asthenic forms, as well as the paralysis of the soft
palate, the pharynx, and the limbs; he also called attention to the
occurrence of relapses, which he attributed to the absorption of the
morbid products, and endeavored to prevent by cauterization.
Naples had diphtheria 1610-45, in its worse form 1618-20, together
with erysipelas, and diphtheritic affection amongst cattle. About
those times tracheotomy was often performed by Severino, the same who
found pseudo-membrane in the larynx at a post-mortem examination made
in 1642. In 1620 the disease was in Portugal, Sicily, and Malta; in
1630 in Spain, according to Fontechu, Villa Real, and Herrera. It was
remarked that in some instances no membranes were perceived in the
throat, but the cases were liable to terminate fatally with large
glandular swellings round the neck and general symptoms of adynamia.
Sicily was again invaded in 1632, Rome in 1634, Italy from 1642 to
1650, Spain in 1666. The Italian reports emphasize the marked
contagiousness of the disease and its tendency to depress the vital
powers, also the weakness of the mental faculties left behind. In
Germany the disease was described by Wedel in 1718. The epidemics
observed by him were not very instructive, yet they sufficed to teach
the importance of isolating the sick.
In the New England States diphtheria appeared in the seventeenth
century. Samuel Danforth lost the four youngest of his twelve children
by the "malady of bladders in the windpipe" within a fortnight in
December, 1659, in Roxbury, Mass. John Josselyn mentions an epidemic
in New England, mainly in Maine, which lasted at least until the year
1671. Mr. Douglass reports another, which commenced on the 20th of
March, 1735, in Kingston township, about fifty miles east of Boston,
and extended all over, and also to Boston, where it was mild at first.
But in 1738 it was very severe, and remained so for some time. Indeed,
it did not abate for a long time, to judge from a letter of Cadwalader
Colden written in 1753 to Dr. Fothergill, and the two letters of Dr.
Jacob Ogden, written in 1769 and 1774 to Mr. Hugh Gaine of New York;
as also from John Archer's "Inaugural Dissertation on Cynanche
Trachealis, commonly called Croup or Hives," published in 1798.[2] In
1809 there was a severe epidemic in Philadelphia;[3] in 1816 in Crete.
[Footnote 2: For extensive quotations from these and other writers on
diphtheria at a very interesting period of our medical literature, see
A. Jacobi, _A Treatise on Diphtheria_, New York, 1880.]
[Footnote 3: Caldwell, in ed. of Cullen's _First Lines of the Practice
of Physic_, Philadelphia, 1816, 1, p. 260.]
{658} The reports of Le Cât concerning epidemics in Rouen in 1736 and
1737 being doubtful, the first great epidemic must be set down, in
France, for 1745. It commenced in Paris, and invaded the provinces
afterward. Chomel gave an accurate description of the diphtheritic
paralysis of the soft palate, and reports a case of strabismus.
Epidemics are reported from the Netherlands in 1745, 1746, 1769, 1770,
1778-86; from Spain in 1764-71; from England in 1744-48 (by Starr),
from Plymouth, England, in 1751-53 (Thurham) and 1776. Dropsy and
glandular swellings were frequent; emetics and pure air were the
sheet-anchors of treatment. The Netherlands, France, and the West
Indies were invaded from 1770-80 by the disease, which was found often
complicated with scarlatina; Portugal in 1786 and 1787; France again
in 1787 and 1788; Northern Germany in 1790. At that time, particularly
in France, the main reliance was had on the internal administration of
cinchona and the insufflation into the throat of alum.
Epidemics have been described since from different localities in
different years: in Glasgow, 1812 and 1819; Switzerland, 1823-26;
Norway and St. Helena, 1824; New York and Kentucky, 1826 and 1828;
French provinces, 1834; Paris, 1841; several parts of Europe and North
America, 1845-56; Paris, 1853-55; England, 1854 and 1859, when 95 per
cent. of all the cases of nasal diphtheria proved fatal; Netherlands
and Sweden, 1855; all Western Europe, 1855-65, up to the present time,
and all Europe since; California, 1856 and 1857; Portugal and France,
1856; Eastern Prussia, 1850, 1852, 1856, 1857; and all the countries
with a cold or moderate climate to this very day.
During the second half of the eighteenth century but two writers are
worthy of especial notice--Home, a Scotchman, 1765, and Samuel Bard,
an American, 1771.
Home deserves credit for having distinctly drawn the line between the
pseudo-membranous and the gangrenous affections. He also endeavored to
prove that croup and angina maligna were two distinct diseases,
notwithstanding all that had been said since the time of Aretæus in
favor of their identity. The false membrane of croup he looked upon as
an aggregation of mucus. He sought for it exclusively in the
respiratory tract, and disregarded any connection between it and the
false membrane found in the pharynx.
Bard's experience was very extensive; he saw membranous pharyngitis,
laryngitis, and pharyngo-laryngitis; he speaks of the membrane as met
upon the skin, of paralysis of the muscles of deglutition and of the
larynx, and likewise of paralysis of the lower extremities, as
sequelæ. He looked upon the morbific process as the same whichever
were the mucous membranes attacked, and made a distinction only
according to the localization of the disease. The influence which he
might have exercised in shaping the professional opinion on the nature
of the disease did not make itself felt, partly because of his
classical modesty, and partly because of his remoteness from the
centres of European learning. Not before 1810 was his book translated
into French (by Ruette). While his style is classical in its
simplicity, his observation is astonishingly correct, and his
conclusions as to the actual identity of all the diphtheritic
processes in the most various clinical symptoms unimpeachable this
very day. His description of the various forms of pharyngeal
diphtheria is painfully {659} good, his observations on cutaneous
diphtheria very accurate, his few dissections well recorded,
particularly when he speaks of tracheal and tracheo-laryngeal
diphtheria, and his historical reviews very judicious indeed. "Upon
the whole, I am led to conclude that the morbus strangulatorius of the
Italians, the croup of Home, the malignant ulcerous sore throat of
Huxham and Fothergill, and the disease I have described and that first
described by Douglas of Boston, however they may differ in symptoms,
do all bear an essential affinity and relation to each other, or are
apt to run into each other, and, in fact, arise from the same leaven.
The disease I have described appeared evidently to be of an infectious
nature, and, being drawn in by the breath of a healthy child,
irritated the glands of the throat and windpipe. The infection did not
seem to depend so much on any prevailing disposition of the air as
upon effluvia received from the breath of infected persons. This will
account why the disorder sometimes went through a whole family, and
yet did not affect the next-door neighbors. Here we learn a useful
lesson--viz. to remove young children as soon as any one of them is
taken with the disease, by which many lives have been saved and may
again be preserved."
Jurine, in his prize essay of 1807, denies the gangrenous nature of
angina maligna and emphasizes the frequent complication of membranous
croup with membranous pharyngitis. It was reserved for Bretonneau to
enforce attention to the ideas of Bard by asserting (though he did not
mention either his monograph or its French translation of 1810) the
identity of angina maligna, or by whatever other title it may be
known, with membranous laryngitis, and by inaugurating his theory with
a new name for the disease to perpetuate the views expressed therein.
First and foremost, he called attention to the continuity of the
membrane (according to him, composed of coagulated mucus and fibrin)
of the nose, pharynx, and respiratory tract, its identity with certain
morbid conditions of the skin, and promulgated the theory that
"diphtherite"--the name dates from that time--is a specific disease,
an affection sui generis, and differs both from a catarrhal and a
scarlatinous inflammation.
The modern history of diphtheria may be dated from June 26, 1821, when
Bretonneau read his first essay on that subject before the French
Academy of Medicine, and gave to the disease the name it now bears.
His second and third (Nov. 25th) papers belong to the same year; his
fourth was read in March, 1826; his fifth appeared in the _Archives
gén._ of January and September, 1855. It was only in 1826 that the
material, previously gathered, was summed up in his celebrated
monograph.[4] Before this time, however, the separate essays had
received prominence from the reports and commentaries of Guersant, who
laid particular stress on the statement that diphtheria was a
non-gangrenous affection, identical, and even synchronous, with croup
in the majority of epidemics. Since that epoch the literature on the
subject has assumed enormous proportions. It is a matter of regret
that the limited space allotted to this subject should exclude much
historical detail of the etiology, pathology, and therapeutics of
diphtheria. If the history of any disease is interesting, and the
neglect of its study has ever punished itself, it is diphtheria. {660}
Particularly would the treatment have been more successful if the
knowledge of former times had been available and more heeded. As long
ago as in the seventeenth century depletion in diphtheria was
condemned, and in the seventeenth and eighteenth centuries the local
treatment with muriatic acid and the internal administration of
cinchona, camphor, and roborant diet were held to be the only
admissible ones. Bretonneau urged the same principles, and still in
our own times, for want of historical knowledge, we had to learn the
old lesson over again.[5]
[Footnote 4: P. Bretonneau, _Des Inflammations spéciales du tissu
muqueux, et en particulier de la Diphthérite, etc._, Paris, 1826.]
[Footnote 5: See history and bibliography of diphtheria in Chatto;
Sanné, _Traité de la Diphthérie_, Paris, 1874; Jacobi, in _Gerhardt's
Handb. d. Kinderk._, vol. ii., 1877; Seitz, _Diphtheric und Croup
gesch. u. Klin. dargest_, Berlin, 1879; _Index-Catalogue of the
Library of the Surgeon-General's Office, U.S.A._, vol. iii.,
Washington, 1882.]
The following is a brief review of the main points of discussion upon
subjects connected with the symptomatology and pathology of diphtheria
since Bretonneau's first paper:
Bourquoise and Brunet express their belief (1823) in the contagious
character of this disease. Desruelles (1824) sees a diagnostic
difference between the sporadic and the epidemic forms in the
participation of the brain in the latter. Louis referred a number of
cases of croup in adults to pharyngeal diphtheria as their source.
Mackenzie considers that croup has its origin in the fauces, and urges
the employment of lunar caustic. Billard (1826) denies the specific
character of diphtheritic inflammation. Hamilton describes cases that
terminated in suppuration, and which he therefore distinguishes from
Bretonneau's cases. He describes two modes of termination of the
disease--one in croup, the other in a state of debility arising from
the effect of the absorbed secretion on the respiratory nerves. Pretty
looks upon those cases of croup that have their original seat in the
tonsils as contagious. Bland (1827) explains the difference between
croup and diphtheria. Deslandes declares them to be identical.
Bretonneau publishes a work in which he compares diphtheria with
scarlatina anginosa, and recommends the use of alum. Emmangard is the
first one of the physiological school who, likening diphtheria to
typhoid and claiming its origin in a malarial infection, calls it
angina gastro-enterica. Abercrombie is in favor of distinguishing
diphtheria from croup, but reports a number of cases of diphtheria of
the pharynx that terminated fatally by stenosis of the larynx. Ribes,
who encountered the disease in nine members of a single family,
asserts that croup rarely occurred without a preceding diphtheria in
his experience; he advises an examination of the throats of apparently
healthy individuals. Fuchs relates the history of epidemics of angina
maligna, and declares croup to be a genuine angina maligna trachealis,
which only does not run through all the stages. Broussais opposes the
identity of croup and diphtheria (1829), and gives a report of cures
by means of antiphlogistic regimen and laryngotomy. Diphtheria and
gangrenous angina are synonymous with him. Gendron expresses a belief
in the identity of diphtheria and gangrenous angina. Roche considers
the membrane rather of hemorrhagic than of inflammatory origin, and
consisting of discolored fibrin. About the same time Trousseau is
endeavoring to clearly establish the diagnosis between diphtheria and
scarlatinous angina. Shortly after (1830), he reports cases of
diphtheria which originated in blistering wounds, and of diphtheria of
the skin giving rise to throat affections, and {661} diphtheria of the
throat followed by skin disease. T. F. Hoffmann cites a severe case,
that ultimately recovered, with consecutive paralysis of certain
cranial nerves. Cheyne (1833) makes a stand against the "confounding
of croup and cynanche maligna under the name of diphtheritis."
Bourgeois witnessed an epidemic succeeding mumps.
Fricout and Burley (1836) declare their belief in the contagiousness
of the disease. Bouillaud attacks the theory of its specific character
on the ground that abstraction of blood produced favorable results.
Stokes makes a distinction between primary and secondary croup
according to the original seat of the affection (1837). Kessler
advocates (1841) the view of its contagious nature, and Rilliet and
Barthez adduce evidence of the occurrence of ulceration and gangrene
in the course of the disease. Taupin, like Ribes, enjoins a methodical
examination of the throat of every patient during the prevalence of an
epidemic of diphtheria, whatsoever be the disease from which the child
suffers. Boudet (1842) opposes Bretonneau's hypothesis that croup is a
descending diphtheria, and holds to the identity of diphtheria and
gangrenous angina. In this contest Durand (1843) also takes sides
against Bretonneau, and lays particular stress on the point that the
diphtheritic patient succumbs rather from the severity of the
constitutional symptoms than from suffocation. Rilliet and Barthez, on
the other hand, rally to the support of the attacked master, asserting
that the usual form of croup and that resulting from a descending
diphtheritis are one and the same, while they claim that diphtheritis
and gangrenous angina are distinct affections.