some antiseptic effect. It is mild, and not very injurious when
swallowed by necessity or mistake. In diphtheritic conjunctivitis it
is valued highly, and in nasal injections I have found it very useful.
It is less repugnant than most other substances administered in that
way.
Sodium benzoate cannot be relied on either as an anti-diphtheritic nor
as an anti-febrile. The doses which were recommended were two scruples
or a drachm daily for a child a year old.
Sulphur has been used locally. It gives rise to coughing and vomiting.
Cubebs have been given in incredible doses, two drachms of the powder
to a child a year old. The drug disorders the stomach and kidneys.
Local Treatment.--The mechanical removal of the membranes is not
permissible unless they are almost detached. It is best to avoid their
being cast off, unless partly loosened membranes in the larynx or
trachea afford an indication for an emetic. Scratching and eroding the
mucous membrane of the neighborhood give rise to new deposits. Even
after spontaneous elimination of a membrane a new one may be formed
within a few hours.
To cauterize a diphtheritic membrane or infiltration I consider wrong,
unless I shall be able to do so thoroughly and to limit the action of
the caustic to the diseased surface. Therefore potassa or chromic acid
cannot be utilized, because of the impossibility of limiting their
effect. Nitrate of silver and mineral acids can be restricted in their
effects, but these are not sufficiently thorough, particularly as but
few patients will consent to have the remedy applied properly. When I
do cauterize, I prefer a mixture of equal parts of carbolic acid and
glycerine or the undiluted acid. The membrane crumbles and falls off
in pieces. Force must never be used. Where it would be required in the
case of obstinate children mild washes must be employed instead of the
caustic. Besides, the internal medication detailed above meets every
indication. When there is a slight swelling of the lymphatic glands,
cold water or ice applications are usually all that is needed. The
latter should be made according to general indications. The glandular
and peri-glandular swellings are less the result of an actual filling
up with foreign matter than of secondary irritation. Ice has a happy
effect in such cases, both on internal administration, in the form of
frequent small quantities of ice-water, ice-pills, ice cream, and iced
medicaments, and also externally by ice-cold cloths or india-rubber
bags filled with ice.
In general, the treatment of the swelled glands must be both based on
its causes and adapted to the present condition. The adenitis and
peri-adenitis is of secondary nature, the irritation being in the
mouth, pharynx, and nares. In these localities is where the main
treatment is required. The sooner the primary affection is removed or
relieved or rendered innocuous, the better it is for the secondary
complaint. Frequent doses of chlorate of potassium or sodium, or
biborate of sodium in mild doses frequently repeated, according to the
principles laid down in another part of this article, mouth-washes,
gargles, nasal injections with water, salt water, or solutions of
disinfecting substances, are not only {710} indicated, but highly
successful. When the case is recent, cold applications are required,
but no washes. When it is of older date, stimulant embrocations are in
order. Iodine ointments are absorbed but slowly; mercurial plasters do
good in some cases; iodide of potassium dissolved in glycerine
(1:3-4), frequently applied, iodine in oleic acid (1:8-12), iodoform
in collodion or flexible collodion (1:12-15) applied twice daily, the
latter frequently with very good result, are beneficial. Copious
suppuration is very rare. Cases in which a free incision meets with an
abscess ready to heal are very uncommon. But numerous small abscesses
with gangrenous walls and pus mixed with a sero-sanguinolent or
sero-purulent liquid, are more frequently found. In such cases a probe
introduced into the lancet wound enters easily into the broken-down
tissue in every direction, to a distance even of three to six
centimetres, (several inches), according to the size of the
tumefaction. I have seen fatal hemorrhages from such gangrenous
destructions; therefore the treatment must be both timely and
energetic. The incision must not be delayed too long. When the skin
assumes a purplish hue or is simply discolored, it is time to incise
and to apply concentrated or nearly concentrated carbolic acid to the
interior, unless the neighborhood of very important blood-vessels or
nerves yields a contraindication to concentrated applications. In that
case a milder preparation is advisable, but the application should be
repeated often, until the suppuration becomes more normal. Then mild
disinfectant injections into what has now become a cavity will be
found satisfactory, particularly when meanwhile the general condition
of the patient has been improved.
Treatment of Nasal Diphtheria.--Especially during the prevalence of an
epidemic of diphtheria must we be careful not to allow a nasal catarrh
to have its own way; we must likewise guard against considering the
thin and flocculent discharge in infected cases as a mucous secretion.
Whatever be the origin of nasal diphtheria, whether primary or the
result of a similar affection in the throat, local treatment should at
once be instituted, and if this be done the great majority of cases
will terminate favorably. The danger in this form of disease consists
in an excessive absorption of putrid substances and in the breathing
of contaminated air. The interior of the nasal cavities must be
thoroughly cleaned and disinfected. If this be commenced early, the
original seat of the affection may be reached, and the disinfectant
process will, as a rule, have good results. It is not necessary to
select very energetic disinfectants; a solution of twelve to
twenty-five centigrammes (two to four grains) of carbolic acid in
thirty grammes (an ounce) of water is at once mild and effective, and
hardly gives rise to more discomfort than lukewarm water. Nasal
injections must be made very frequently, until each time the stream of
fluid has a free exit through the other nostril or through the mouth.
They must be made at least every hour, and even oftener if necessary;
at the same time it is advisable to be careful that the fluid does not
enter the Eustachian tube. This can be prevented, to a certain extent,
by compelling the patient to keep the mouth open during the procedure.
I have seldom seen evil or even disagreeable results from the
administration of nasal injections in diphtheria. It is likely that
the mucous membrane of the pharynx is swollen as far as the openings
of the Eustachian tubes to such a degree as to render the entrance of
fluids into the latter improbable. {711} The hardness of hearing,
which is of so frequent occurrence in the course of a severe catarrh
or of a diphtheritic attack, seems to indicate that the mucous
membrane of that part is in a state of swelling. An ordinary syringe
will suffice. However, when administered by parents or nurses the
blunt nozzle of an ear syringe is preferable. Occasionally here, as in
local applications to the mouth and pharynx, the atomizer may be used
to advantage, but the tube must be properly introduced into the
nostrils. There are cases of nasal diphtheria, however, which are far
more troublesome to manage than the foregoing would seem to indicate.
I have seen cases in which the nasal cavities, from the anterior to
the posterior nares, were filled and completely occluded by a dense,
solid membranous mass. I was then compelled to bore a passage with a
silver probe, to gradually introduce a larger-sized one, and then to
apply the pure carbolic acid, in order to remove the densest and
thickest masses, and finally was able to make injections; even in such
cases I have had the gratification of being able to give a favorable
prognosis. The dangerous secondary swelling of the glands will often
subside after a steady employment of disinfectant injections for from
twelve to twenty-four hours. It will be found that children frequently
do not object to this method of treatment; I have even met with some
who, after convincing themselves of the relief afforded thereby, asked
for an injection. When we are about to bring each injection to a close
it is well to press together the nasal cavities for an instant with
the fingers. By this procedure the fluid is forced backward to the
pharynx, and is swallowed or ejected through the mouth, and thus
washes the pharynx and mouth at the same time. Frequently, however,
this latter object is obtained with every injection; for, the palate
being swelled, oedematous, and paretic, the fluid is not prevented
from reaching the pharynx, even in the average case. In regard to the
choice of a disinfecting agent, I have but a few words to say. I
believe that no one of them has important qualifications above the
others. I avoid those which stain or which produce firm coagula. For
the latter reason I do not use the subsulphate and perchloride of
iron; for the former, the permanganate of potassium. I employ, as a
rule, carbolic acid in solution, of the strength above mentioned.
Where there is but a slightly fetid odor I have frequently employed
lime-water or water with glycerine, or a solution (1:100, 1:50) of
chloride of sodium, or of bicarbonate of soda or of borax, or a
saturated solution of boric acid. Disinfecting agents and antiseptics,
whether carbolic acid, salicylic acid, or iron, are of no service when
administered internally only, unless the seat and cause of the septic
infection be attended to previously. Under the local employment of
antiseptics, as described, or by simply washing out with water or salt
water, most cases recover; without them, death will result. Of late,
in many cases, the local applications, injections, etc. of the
corrosive chloride of mercury in water (1:5000-10,000) has proved very
effective. It has this advantage over carbolic acid, that the
swallowing of the former is not so dangerous. This much, after all, my
experience has assured me of, that there is a certain number of cases
which terminate fatally; but it is likewise true that the mortality
need not be excessively great. I cannot grant that it is hard to carry
out the exact and apparently barbarous treatment necessary for a
favorable result, for it is certainly more barbarous to sacrifice than
to save life.
{712} It is a positive fact that when children suffering from nasal
diphtheria, with its peculiarly septic character, are permitted to
sleep much--and they are apt to be drowsy under the influence of the
poison--they will certainly die. To allow them to sleep is to allow
them to die.
The first symptom of improvement is often a rapid diminution of the
glandular swelling wherever it exists. It is not present in all cases,
but chiefly in those in which a bloody serum was discharged in an
early period of the disease. In these the blood-vessels appear to be
very vulnerable, superficial, and apt to absorb; these are also the
most dangerous cases, and require the greatest attention and care, and
also prompt disinfection.
Treatment of Laryngeal Diphtheria.--The severest form of diphtheria is
that located in the larynx, constituting membranous croup. Its general
treatment, whether the disease has originated primarily in the larynx
or trachea or has been communicated from the pharynx, does not differ
from that laid down for diphtheria in general. Naturally the larynx
calls for special treatment on account of the symptoms of suffocation
which result from its stenosis. The main indication of removing viscid
mucus or partly-detached membranes is best met by the administration
of an emetic. Such is their only indication in my experience. The
selection of the emetic, when indicated, is of great importance.
Antimonials ought to be avoided because of their depressing and
purgative effect. Ipecacuanha is but rarely effective. The sulphates
of zinc and copper, and particularly the latter, deserve preference.
Turpeth mineral acts promptly and satisfactorily. When no emesis can
be obtained the prognosis is decidedly bad. Recourse must then be had
to tracheotomy, the good results of which are however only too often
delusive and transient.
When, after the operation, there is scarcely any relief, and
particularly when the case takes a very rapid course, it is probably
one of ascending croup which commenced in the trachea. Mechanical
relief by pushing down a hen's feather or a bundle of them, and
turning it about and twisting, must be tried. It is a much better
instrument than pincers of all sorts and shapes. But what relief will
be accomplished is but of very short duration. When fever sets in
within a few hours it means very much more frequently pneumonia than
diphtheritic fever. It is apt to be soon complicated by that
disproportion between pulse and respiration so characteristic of
inflammatory diseases. Then quinia in larger doses, 0.25 or 0.5 (grs.
iv-viij) every two, four, eight hours, at the same time doses of
sodium salicylate 0.25-0.40 (grs. iv-vj) every hour or two hours until
the temperature goes down, and small doses of digitalis where the
heart requires it, must be given at once. Procrastination is
dangerous; the patients want careful watching; many of them die within
two days after the operation.
Diphtheritic conjunctivitis requires great attention and permits of no
loss of time. Cold applications to the affected eye must be made
constantly. Pieces of linen or lint kept on ice (better than in
ice-water) of little more than the size of the eye, must be changed
every minute or two day and night. The danger to the cornea is so
imminent that constant watchfulness is required. Boric acid in
concentrated solution should be dropped into the eye once every hour.
Care must be taken that the well eye shall not get infected; for that
purpose it is best to cover it {713} with lint and collodion, or with
lint or cotton held in place by adhesive plaster.
Cutaneous diphtheria requires the destruction of the membrane or of
the infected surface by carbolic acid, either concentrated or somewhat
diluted with glycerine, or the application of the actual cautery.
After that the use of ice or iced cloths, or diluted carbolic acid, is
indicated. As soon as the surface is no longer diphtheritic the local
and general treatment is to be continued on general principles.
Diphtheritic paralysis is invariably complicated by anæmia and
debility, and the diet and medical treatment must be regulated
accordingly. However, neither overfeeding nor a sameness of diet are
to be permitted, for not rarely the muscular coat of the stomach
suffers with the rest of the muscular tissue, and the secretion of
gastric juice is very deficient in anæmic individuals. While,
therefore, iron is indicated, we must not neglect to pay particular
attention to nutrition and digestion, and to aid the latter with
pepsin and moderate amounts of muriatic acid, well diluted. Quinia in
small doses and stimulants are appropriate whenever there is no
contraindication to their employment. The treatment of the paralysis
itself will naturally depend on the diagnosis of the condition present
in each individual case, which we have seen to differ considerably.
This alone can explain why various modes of treatment, the electric
current among others, after being recommended by some authors, are
branded by others. Where we have to deal with those rare changes in
the brain and spinal cord, the utmost care is necessary in order not
to make the condition still worse; and in such cases there would be a
contraindication to the use of the faradic current, though this would
not hold true with regard to the use of the galvanic current in short
sittings. Besides, central paralyses are by no means so frequent as
peripheral ones. In most cases there is not the slightest elevation of
temperature during the course of the paralytic phenomena. I lay great
stress upon this point, for I am aware that many cases of central
congestion and even of inflammation exhibit but very insignificant
elevations of temperature. But, as the diagnosis will depend on a
positive knowledge of whether there have been changes of temperature,
I rely on the rectal temperature only, for many a myelitis runs its
course with no greater elevation above the normal than one-half or one
degree. In all cases in which the temperature is normal or subnormal,
I do not hesitate for a moment to employ the faradic or the galvanic
current. In addition to the internal administration of iron I advise
by all means the employment of strychnia. When there is no necessity
for haste, we may give moderate doses, gradually increasing them, and
using iron in combination. When there is danger in delay, recourse
ought to be had to subcutaneous injections of the sulphate of
strychnia, once or twice daily. They are mainly indicated in paralysis
of the muscles of deglutition and of respiration. Of course, where the
former are affected it is necessary to nourish the patient
artificially, partly perhaps by nutrient enemata, but principally by
means of the stomach-tube. In using the latter it is unnecessary to
introduce it into the stomach, as it only requires to be passed a few
inches below the affected parts, when the oesophagus will usually be
found able to undertake the further disposal of the food. In these
cases strychnia should be injected subcutaneously in the neck, {714}
once or twice daily. In a similar manner it should be injected in the
region of the chest, diaphragm, or neck in paralysis of the
respiratory muscles or of the glottis. In paralysis of the muscles of
accommodation (in which Scheby-Buch claims to have seen the process
cut short by the use of the Calabar bean, considered as inert by
Hassner) they may be given in the forehead or temples.
Frictions dry and alcoholic, hot bathing, friction with hot water,
kneading of the affected parts, will be found beneficial and pleasant.
{715}
CHOLERA.
BY ALFRED STILLÉ, M.D., LL.D.
DEFINITION.--Cholera is an epidemic disease, characterized by the
transudation of serum into the stomach and bowels, and usually by the
profuse discharge by vomiting and purging of a liquid resembling
rice-water, followed by a tendency to collapse. It is endemic in
India, but has been conveyed thence to almost every part of the world.
SYNONYMS.--Cholera algida, C. asiatica, C. asphyxia, C. maligna, C.
spasmodica. In English it is generally spoken of as Asiatic cholera.
HISTORY.--It is sometimes stated that Hippocrates, Galen, Celsus, and
the Greek, Roman, and Arabian medical writers generally record "the
fact of the presence of cholera in the various countries in which they
lived" (Macnamara). Nothing could be more contrary to the truth. All
of these writers describe "cholera morbus" in nearly identical terms;
they all include bilious discharges among its symptoms, and no one of
them speaks of it as a mortal or even as an epidemic disease.
(Compare, especially, Celsus, Aretæus, Cælius Aurelianus, and Paulus
Ægineta.) Their description of sporadic cholera morbus is very
precise. For example, Cælius Aurelianus says: "Cholericam passionem
aiunt aliqui nominatam a fluore fellis, per os et ventrem effecto."[1]
[Footnote 1: _Acut. Morb._, lib. iii. cap. xix.]
Asiatic epidemic cholera is a very different disease. It seems to have
been known in India from a very remote period, but no detailed account
of it was published until the beginning of the sixteenth century.
During that century many successive descriptions of the disease
exhibited its extreme violence and mortality. It is believed to have
occurred repeatedly, if not annually, in the same localities down to
the present time. The invasion of India by the Portuguese, and
afterward by the English, contributed to spread the disease throughout
the Peninsula, partly by military occupation and partly through
commercial channels, by which it was also carried to the islands in
the Indian Ocean. It prevailed in Batavia in 1629. Between 1768 and
1790 numerous epidemics of cholera occurred. About the former date no
less than 60,000 persons are said to have perished near Pondicherry,
and in 1783 it is reckoned that 20,000 victims to the disease fell in
a single week during the religious gathering at the sacred city of
Hurdwâr, where, as will be seen hereafter, it became in later years
more fatal still. The English armies extended their conquests in
Hindostan, and established commerce between that country and Western
Asia and Europe, and by the year 1817 opened new channels of {716}
communication in every direction, both within and beyond the
Peninsula. Along them the disease was carried; it invaded Ceylon and
the Burmese empire, and extended to Batavia, Java, and China on the
east, and advanced westward to Persia in 1821. In that year also it
was carried from Arabia into Africa, and at various later periods
penetrated more and more deeply into the Dark Continent, always
following the track of pilgrims returning from Mecca, the routes of
armies engaged in war, or those of trading caravans.[2]
[Footnote 2: Christie, _Cholera Epidemics in Africa_, 1876.]
In these cases, as in others elsewhere, the spontaneous origin of the
disease has been assumed by certain writers, but at every stage of its
progress careful investigation led uniformly to the conclusion that it
was propagated directly or indirectly from pre-existent cases of
cholera. From Persia it moved northward as far as the shores of the
Caspian Sea, and westward to the Levant in 1823, and there for a time
its ravages were stayed. Meanwhile, it prevailed at various places
throughout Hindostan, and, assuming a greater degree of violence in
1826, it advanced steadily in a north-western direction across
Afghanistan and Persia in the following year. In 1829 it reached
Orenburg, to the north of the Caspian Sea, and was speedily conveyed
into the interior of the Russian empire, where it raged with great
violence in 1830. In 1831 it prevailed at Mecca among the pilgrims,
who had brought it from India, and so virulently that one-half of them
are computed to have perished. Hence it speedily passed with returning
pilgrims to Alexandria and Constantinople, and was carried to St.
Petersburg, to Sweden, to Hamburg, and other places in Northern
continental Europe. From Hamburg and other seaports it was conveyed to
commercial towns on the eastern coast of England, whence it extended
to Edinburgh in the north and London in the south.
In 1832 cholera prevailed in France, and within the year caused
120,000 deaths, 7000 of which occurred in Paris in the space of
eighteen days. In the spring and summer of that year it was reproduced
in England, and extended to Ireland. From Liverpool, Cork, Limerick,
and Dublin five vessels filled with emigrants sailed for Quebec,
Canada, and they, together, lost 179 passengers by cholera during the
voyage.