was apparent to some of the early writers. As has been pointed out,
the high mortality of some of the older epidemics is to be explained
by the venesections practised at the beginning, and even during the
course, of the attack. It has no favorable effect upon the catarrhal
processes, and but little upon the subjective symptoms. The fever is
not relieved by it; the {876} nervous depression is increased and the
risk of lung-congestion is augmented. Bleeding is not likely to be
practised in epidemic catarrhal fever while the present views of its
place in therapeutics continue to influence practice. Cautious local
bloodletting for the relief of local inflammatory trouble is spoken of
in most of the modern books. The occasions for its employment are so
rare in the treatment of this disease that even this statement should
be henceforth omitted. In influenza, as it is known to medical men of
the present from the descriptions of the old and personal experience
of the few recent and milder epidemics, bloodletting, either general
or local, is clearly uncalled for.
Emetics hold a high historical place. It was of old customary to begin
the treatment with a vomit. As late as the epidemic of 1837, Lombard
of Geneva believed that they shortened the attack and lessened the
intensity of the symptoms when administered at the beginning. In cases
attended by early gastric disturbance and nausea they are said to be
especially of use. They sometimes set up great irritability of the
stomach, with vomiting that it is difficult to control. On the whole,
the cases in which an emetic would do good are extremely rare.
Purgatives were formerly regarded as important in the treatment. This
view no longer prevails. In case of constipation gentle purgation, ex
indicatione symptomaticâ, is a necessary part of the proper management
of the case. For this purpose the laxative mineral waters, as
Friederichshalle, Hunyadi, Pullna, are excellent. Castor oil may be
given, and calomel is in some cases, and particularly in childhood, of
great service. Simple enemata of warm water or soap and water will
often suffice. The tendency in some cases to exhausting and
troublesome diarrhoea, and the fact that diarrhoea occurs
spontaneously some time in the course of most cases, should inspire
caution in the use of purgatives. Repeated purgation during the
progress of the attack is not only useless--it is also positively
injurious.
In the severe cases quinine is to be given early and in full doses. It
exerts at the same time a powerful influence upon the temperature,
upon the tendency to local hyperæmias, and upon the nervous symptoms,
and in particular the headache. Rawlins,[23] as early as 1833, found
that excellent results followed its administration, the effect being
the better the earlier it was given. It has even been lauded as a
specific for influenza.
[Footnote 23: _London Medical Gazette_, May, 1833.]
The mineral acids may be given with a view to realizing their tonic
effects.
For the most part, the foregoing measures, directed against the fever,
will exert a favorable influence upon the catarrhal processes.
Expectorants are of advantage; ipecac is useful. The preparations of
antimony are inadmissible by reason of their tendency to depress.
Ammonium chloride is indicated in the earlier stages of the
bronchitis. Among recent drugs, yerba santa (Eryodiction glutinosum)
and the oil of eucalyptus are of use in mitigating the symptoms in
epidemic catarrh, as they do in certain forms of simple sporadic
catarrh.
The peculiar dry, racking cough so often present in the early days of
the attack should be relieved. It is not useful in removing bronchial
accumulations, being, as has been shown, in most instances out of
proportion to the lesions of the bronchial mucous membrane; on the
other {877} hand, it tends to increase the hyperæmia of the upper
air-passages by the mechanical violence of the cough-paroxysms.
Further, it is distressing and exhausting, and contributes to the
muscular and nervous prostration. Benefit will be derived from keeping
the air of the apartment moist, and from the occasional inhalation of
the steam from hot water, either used alone or poured upon the
compound tincture of benzoin, a pint to the teaspoonful, or upon
paregoric, a pint to the tablespoonful, in a proper vessel or inhaler.
No drugs are more potent to this end than opium and its derivatives,
and in particular morphia and codeia. The hypodermic use of the
morphia salts, judiciously resorted to, constitutes our most valuable
therapeutic resource in fulfilling the threefold indication of
relieving cough, alleviating both the head-pain and the pains in the
extremities, and in procuring sleep. The old-time dread of opium in
influenza was not well founded. The administration of this drug in
moderate doses is attended with advantages that far outweigh any
danger of increasing the tightness across the chest and retarding
expectoration. It is necessary to observe the same caution in giving
it to infants and aged persons in influenza that is necessary under
other circumstances. The influence of carbolic acid in restraining
cough makes it a useful addition to soothing draughts in this disease.
The substernal and other chest-pains may be combated with sinapisms,
turpentine stupes, repeated inunctions of fatty substances containing
extract of belladonna, and the like. Pleurodynic stitches call for
similar measures; a long strip of machine-spread belladonna plaster,
about five centimetres (two inches) in width, applied very firmly to
the side of the chest from the spine in a direction downward and
forward parallel with the ribs, and reaching to the median line in
front, affords great relief to the lateral chest-pains.
The control of the debility must be regarded as the most important
indication in old and feeble persons. Wine, spirits, milk-punch,
ammonia, spirits of chloroform, are to be used, not in accordance with
fixed rules, but as occasion may require. In many cases wine or
whiskey will be indicated from the beginning, the quantity being
determined rather by the effect upon the circulation and the general
condition of the case than by rule. Women and others unaccustomed to
the use of alcoholic drinks often take wine and brandy in considerable
quantities, with striking benefit and without flushing or other
evidences of its disagreeing.
Chloral is inadmissible as a hypnotic by reason of its depressing
effect upon the heart. Paraldehyde may be used, or the bromides in
connection with opium if the latter alone is not well borne.
Diarrhoea must be managed in accordance with general principles. If
slight, it does not require special treatment. It is apt to occur at
one period or another in the course of most cases, and not
infrequently marks the beginning of convalescence. Colic may be
treated with warm fomentations and carminatives; if it be due to
constipation, mild laxatives are to be combined with them.
Severe cases of influenza demand the careful attention of the
physician, who must be on the alert to detect the inflammatory lung
complications which so often lead up to the fatal issue as early as
possible. Their treatment must be regulated by the circumstances of
the case, the nature {878} of the particular complication, the age of
the patient, and so on, in accordance with general therapeutical
indications.
Finally, all measures, of whatever kind, that tend to depress the
general nervous system or the functional activity of the respiration,
and especially the heart-power, are to be sedulously avoided in the
management of influenza. During the convalescence unfavorable
influences of the weather are to be guarded against. It is important
to warn the patient that a severe attack of influenza renders him
liable for some time afterward to pulmonary disorders. The sequels,
and in particular those implicating the respiratory tract, are to be
appropriately treated. After severe cases a course of tonics is
commonly of advantage, and a change of climate often necessary to
re-establish the health.
As bearing on what is stated in the foregoing pages on the causation
of influenza, reference may be made to the investigations of
Seifert,[24] who claims to have found in the mucus expectorated by
patients with influenza numbers of a peculiar micrococcus. It is
evident, however, that no conclusions can be based upon these
observations until the results have been subjected to careful
examination in other epidemics.
[Footnote 24: _Volkmann's klinische Vorträge_, No. 240, June 20,
1884.]
{879}
DENGUE.
BY H. D. SCHMIDT, M.D.
SYNONYMS.--Break-bone fever, Dandy fever.
HISTORY.--The history of this disease dates only from the second half
of the last century, though it appears very probable that previous to
this time dengue existed in the tropical regions of Africa and Asia,
whence it was carried to Europe and America.
In Spain the disease has been known since 1764, when, up to 1768, it
prevailed in Cadiz and Seville under the name of la piadosa or la
pantomina.[1] In 1780 it appeared in the form of an epidemic in
Philadelphia, where it was first noticed and described by Rush under
the name of bilious remitting fever, commonly called break-bone fever
on account of the violent pains attending it. Next it prevailed in
Calcutta in 1824, and two years afterward it made its first appearance
on the southern coast of the United States, in Charleston and
Savannah, where it prevailed to 1827. Toward the close of 1827 another
dengue epidemic broke out in the West Indies, whence the disease
proceeded to the American continent, reaching New Orleans in the
spring, and visiting Charleston and Savannah in the summer and autumn
of 1828.[2] In 1844 it showed itself in Mobile, and in 1848 in
Natchez, whilst in 1850 it reappeared along the Southern seacoast,
particularly in Charleston, from which it proceeded even to inland
towns, such as Augusta, Ga.[3] In 1865 dengue appeared in Teneriffe
and other Canary Islands, whilst at the same time and through the
years 1866 and 1867 it prevailed in Andalusia and in some other
Spanish provinces.[4]
[Footnote 1: R. H. Poggio, _La calentura roja observada in sus
apariciones epidemicas de los anos 1865 y 1867_, Madrid (reported in
_Virchow und Hirsch's Jahresbericht für das Jahr 1871_, vol. ii. p.
200).]
[Footnote 2: G. B. Wood, _Practice of Medicine_, 4th ed., vol. i. p.
444.]
[Footnote 3: S. H. Dickson, _Elements of Medicine_, 2d. ed., p. 747.]
[Footnote 4: R. H. Poggio, _Virchow und Hirsch's Jahresbericht für das
Jahr 1871_, vol. ii. p. 200.]
One of the most extensive epidemics of dengue prevailed from July,
1870, to January, 1871, in Zanzibar,[5] on the East Coast of Africa,
whence it extended to Aden in Arabia and Port Said in Egypt. In
December, 1871, the disease appeared simultaneously at Bombay and
Calcutta,[6] to which place it had been carried by transport-ships
from Aden. Proceeding from Bombay in a northern direction along the
railroad, it spread {880} over the central regions of the
North-western Provinces, the Rajputana states, Cashmir, and the
Punjaub. From Calcutta it passed over Assam and Bhotan to Thibet, and
thence downward into Burmah and to all the large cities along the
coast; while it also extended along the coast of Malabar over
Visigapatam to Madras and Pondichery, finally arriving at Mysore. Thus
the disease had actually spread over the whole Peninsula from Cape
Tutikorin to the foot of the Himalayas, attacking equally all races or
nationalities without regard to age, occupation, or position. Forty
years previously, however, an epidemic of dengue had prevailed in
Burmah. In 1873 it appeared on the island of Mauritius, to which it
had been carried from India by an emigrant ship. In the same year a
considerable number of cases of dengue were observed in New Orleans.
In 1877 it appeared again in Egypt, where it prevailed in Ismailia.
[Footnote 5: J. Christie, "Remarks on Kidniga Pepo, a peculiar form of
exanthematous disease epidemic in Zanzibar, East Coast of Africa, from
July, 1870, to January, 1871," _Brit. Med. Journal_, July 1, 1872, p.
577 (reported in _Virchow und Hirsch's Jahresbericht für das Jahr
1872_, vol. ii. p. 203).]
[Footnote 6: _Virchow und Hirsch's Jahresbericht für das Jahr 1873_,
vol. ii. p. 208.]
Finally, in 1880, dengue, in the form of a very extensive epidemic,
prevailed once more along the Southern coast, visiting equally
Charleston, Savannah, and New Orleans. A number of valuable
observations concerning the nature and symptoms of the disease were
made during this epidemic by Drs. D. C. Holliday of New Orleans, J. G.
Thomas of Savannah, and F. T. Porcher and J. Forrest of Charleston.[7]
At the same time it prevailed at Alexandria[8] (Egypt) to such an
extent as to affect nearly the whole population.
[Footnote 7: The papers of Drs. Holliday, Thomas, and Porcher were
read before the American Public Health Association at its annual
meeting, December, 1880, and published in the _Proceedings_ of the
Association. Dr. Forrest's paper was published in the _American
Journal of Med. Science_, April, 1881.]
[Footnote 8: A. Vernoni, "Le Dengue à Alexandrie d'Égypte en 1880,"
_Gaz. hebd. de méd. et de chir._, 41, 42 (reported in _Virchow und
Hirsch's Jahresbericht für das Jahr 1880_, vol. ii. p. 5).]
Dengue has been known under various popular names which it received
from the people of the particular localities where it appeared in
epidemic form. Even the designation, dengue, itself, by which the
disease is at present generally known to the medical profession of the
leading civilized nations, is of popular origin,[9] for it is supposed
to be a Spanish corruption of the word dandy, the name of dandy-fever
having been jocosely conferred on the disease by the negroes of St.
Thomas from the stiff carriage of those affected with it. At Zanzibar
it received the popular name of kidniga pepo, signifying spasmodic
pains.
[Footnote 9: G. B. Wood, _Practice of Medicine_, 4th edit., vol. i. p.
444.]
DEFINITION.--Dengue is a peculiar febrile disease, generally appearing
epidemically in tropical or semi-tropical regions, and characterized
by a single paroxysm with or without remissions, severe pains, and
stiffness in the joints and muscles, a peculiar exanthematous
eruption, and almost never terminating fatally.
SYMPTOMS, COURSE, AND DURATION.[10]--Dengue never commences with a
decided chill, though in many cases the attack of the disease is
preceded by a feeling of general uneasiness and depression, vertigo,
and headache, or even by a slight chilliness--a condition which may
last from a few to twelve or even eighteen hours. In the majority of
cases, however, the disease appears suddenly, very frequently at
night, and announces itself at once by pains and a feeling of
stiffness in the muscles, joints, back, and loins; in severe cases the
pain may even extend to the {881} bones.[11] The larger and smaller
joints are equally affected, either simultaneously or successively,
and frequently swollen, those of the hands and feet generally before
the others. The pain in the joints is increased by motion, and is
therefore justly regarded by most authors as rheumatic in nature. The
same may be said of the muscles. Sheriff even observed redness of the
skin covering the joints. According to the degree of severity of the
case these pains may be more or less intense. In some cases
hyperæsthesia of the skin of the palms of the hands and of the soles
of the feet has been observed.
[Footnote 10: Judging from the various accounts rendered by a
considerable number of observers, it appears that the clinical
symptoms of dengue had been the same in all the different localities
on the globe where it has hitherto prevailed epidemically.]
[Footnote 11: M. Sheriff, "History of the Epidemic of Dengue in Madras
in 1872," _Med. Times and Gazette_, Nov. 15, p. 543 (reported in
_Virchow und Hirsch's Jahresbericht für das Jahr 1873_).]
Simultaneously with the affection of the joints and muscles the fever
commences; its duration is from four to five days on the average, with
one or, in exceptional cases, even more remissions. The temperature of
the body during the first and second days of the fever rises to 102,
103, or even to 105° F; it then declines, to return to the normal
standard on the fifth day. According to the measurements made by the
late Dr. D'Aquin[12] of New Orleans, the temperature curves of dengue
showed a continuous and steady rise until the highest point was
reached on the first, second, or third day of the attack; then comes a
short stadium of a few hours, and then a remission, soon to be
followed by another rise of temperature, which, however, never reaches
the maximum point of the first. The pulse rises with the temperature
of the body, generally to from 80 to 120 beats a minute, and
subsequently declines with the temperature. Delirium is very rarely
observed in adults, but frequently in children, though without
aggravation of the other symptoms. The face is generally flushed, the
eyelids swollen, and the eyes injected and watery. The tongue in the
beginning of the disease is covered with a white fur; its edges are
red and its body swollen. As the disease advances the coating
increases in thickness and assumes a dirty yellow color. The appetite
is lost, without excessive thirst. In many cases there is slight
irritability of the stomach, accompanied sometimes with nausea, though
vomiting rarely takes place. The condition of the bowels is variable.
The urine is small in quantity, and highly colored in some cases,
whilst in others it has been reported to be pale and copious, and rich
in phosphates in the beginning of the disease; it seldom shows any
sediments and very rarely contains albumen. The disease generally
reaches its acme on the third or fourth day, when the fever commences
to subside, and an amelioration of the other symptoms takes place, so
that the patient feels greatly relieved. This, however, is only of
short duration, for not many hours afterward the fever rises again,
while the other symptoms also increase in severity. At this time an
exanthematous eruption appears upon the upper part of the body, the
face, neck, breast, and shoulders, which in the course of two days
extends over the whole body. Simultaneously with the appearance of the
eruption the lymphatic glands of the back of the head and those of the
neck, axillæ, and groins commence to swell; in severe cases the mucous
membranes of the nose, mouth, and pharynx also become congested. The
eruption, which is attended with much heat, itching, or even pain, is
not uniform in character; for while in some cases it may {882}
represent a simple rash or erythema, it resembles in others the
eruptions of scarlatina, rubeola, lichen, or urticaria. Frequently it
is very light and evanescent, showing itself only for a few hours, and
perhaps in the majority of cases it does not appear at all. In the
severer cases it generally remains two days, when it commences to fade
and disappear with desquamation, while at the same time the fever
subsides and disappears entirely, though the stiffness and soreness in
the joints and muscles, together with the inflammatory condition of
the superficial lymphatic glands, may persist for many weeks. In
exceptional cases the eruption, after an intermission of a few days,
reappears, generally with greater intensity and with an aggravation of
the other symptoms. In others, again, it has been observed to remain a
whole week.
[Footnote 12: D. C. Holliday, "Dengue or Dandy Fever," read before the
Amer. Publ. Health Assoc. at New Orleans, December, 1880.]
Hemorrhages from the nose and gums are also occasionally observed.
Holliday even observed the occurrence of black vomit in the cases of
two female children, aged respectively six and twelve, in the same
family, who had suffered from yellow fever in 1878; they both
recovered from the attack of dengue, though they were extremely ill
and much prostrated. In female patients an attack of dengue not
unfrequently causes the reappearance of the menstrual flow, while the
pains attending the disease equally predispose to premature labor in
pregnant women.
In severe cases of dengue the prostration following upon the
subsidence of the fever is very great, for the patient is affected
with a general weakness both of body and mind, indicating a great loss
of nervous energy. In some cases observed by Slaughter the memory for
names and words, as well as the ability for correctly writing even
short sentences, was lost for one or two weeks after the commencement
of convalescence. In children also cases are reported in which the
mind remained affected for a short time after the attack. The
convalescence in dengue, therefore, is comparatively slow,
particularly as the pains in the muscles and joints, as already
mentioned, pass away only gradually.
The duration of the disease, including the stage of convalescence, of
course depends upon the degree of intensity of the attack, and
accordingly varies in different cases. In a great number of cases
dengue manifests itself only in its milder form. The average duration
of the disease is from three to six days.
PATHOLOGY.--The pathological changes taking place in the different
organs during the course of dengue are unknown, on account of the
almost constantly favorable termination of the disease. From the
peculiar features of some of the clinical symptoms accompanying the
disease, however, we may speculate to a certain extent upon the nature
of the pathological processes to which they are due. The sudden
appearance of the characteristic pains in the muscles and joints, but
particularly those in the head, neck, and loins, accompanied by a
comparatively high fever, evidently point to the presence of an
infectious poison in the system, though the question whether the
noxious influence of this poison primarily affects the blood or the
nervous system will be difficult to answer. But, judging from the
early appearance of the pains, as well as from the physical and mental
depression of the patient, we may presume that the nervous system is
involved from the very beginning of the disease, and that the pains
depend upon a hyperæmic condition of the affected parts, probably
caused by a vaso-motor paralysis. The great resemblance of the painful
{883} affection of the muscles and joints in dengue to that of acute
articular rheumatism leads to the supposition that the pathological
condition in these joints is the same in both diseases; this view
appears to be held by the majority of medical observers. In dengue, as
in rheumatism, the pain due to the pressure of the hyperæmic and
swollen tissues upon the irritated sensory nervous filaments is
increased by motion--a phenomenon generally absent in neuralgia. The
persistent headache, restlessness, and want of sleep, as well as the
delirium and loss of memory observed in the severer cases, furthermore
indicate a hyperæmic condition not only of the pia mater, but even of
the brain-substance.
It is to be regretted that the literature of dengue within our reach
shows no record of a quantitative analysis of the urine, from which we
might have learned the quantity of urea secreted during the different
stages of the disease, and which might have enabled us to form some
idea of the extent of the destruction of the albuminous substances
during the febrile stage, though, judging from the high grade of fever
observed in the severer cases, we may well presume that the
interchanges of matter are considerably augmented during this stage;
while, on the other hand, the great nervous prostration of the patient
directly after the subsidence of the fever, as well as the tardy
convalescence, sufficiently shows that a large part of this waste is
derived from the nervous tissues. The exanthematous eruption,
representing a hyperæmia, or even an inflammation, of the skin,
furthermore contributes to depress the nervous system by the pain and
itching which it causes. This eruption, together with the inflammation
and swelling of the superficial lymphatic glands, we are inclined to
associate with the final elimination of the infectious poison from the
organism.