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DIPHTHERIA AND ITS MANAGEMENT, -:o:- Diphtheria was but rarely lectured on in any medical school when I received my professional education, and the best text- book of the day — Wood's Practice of Medicine — devoted a scanty four pages to what is now one of the leading diseases. Sir Thomas Watson, too, the Macaulay of British Medicine, gave it just thirty-two lines in his justly celebrated work. And 80 it came that when one bright morning in September, 1858, I received a call to a patient in Woodhouse, County of Norfolk, Ontario, I was greatly startled when I recognized the disease which had so recently crossed the channel and was even then raging in England. My only source of information as to the disease was the aforesaid four pages ; and for treatment I was confined to Jahr^s Symptomen- Codex, for none of our writers on Practice, not even the illustrious Hartmann, as muf't as mentioned the disease. To the well-thumbed, oft-conn'd ^ : t s of Jahr I turned, and, guided by the Law of Cure, I had little difficulty in selecting the remedy. The patient recovered, and this was, I believe, the first case of diphtheria in the county, the advanced guard of the fatal epidemic which devastated it for over six years. During that period I saw over twelve hun- dred cases, including every possible aspect of the malady, and adding to that experience that which I have obtained in Belle- ville and in Montreal, I feel quite competent to write a tractate on " Diphtheria and its Management" I will try to place before my readers a clear account of the disease, dwelling especially on the difference between it and other diseases, for the life of the patient often depends on the prompt recognition of the malady. Further, as I am writing for the public, not for the profession, I shall write in the very plainest of English. ti Diphtheria, then, is an acute febrile disease, produced by a specific poison ; epidemic and endemic ; usually but feebly con- tagious. There is an eruption, but it is not at all characteristic, for it is often altogether absent, and the distinctive feature of the disease is the deposit of lymph upon the mucous membrane of the throat and tonsils. At the same time the glands of the throat and neck swell, and the disease is accompanied by pros- tration of the vital powers out of all proportion to the local mischief I have said that diphtheria is endemic, that is, the specific poison takes possession of a house or neighbourhood and remains there for a longer or shorter period, and it is often very difficult to break up these local centres of contagion. An epi- demic of diphtheria is usually made up of a number of endemics. Many people have the idea that diphtheria is a modern disease — a disease of our own day — but in reality it is one of the most ancient. Some writers trace it to the time of Hippocrates, and there can be little doubt but that the writings of Aretseus, who lived in the second century of the Christian era, contain a minute account of a disease styled by him Ulcus Syriacum, which exactly corresponds with diphtheria. A Roman physician, named Macrobius, describes an epidemic of diphtheria which ravaged Rome in the year 380 of our era, but no record has been preserved of any epidemic during the long period of the Middle Ages. Ilecker describes an epidemic in Holland in the year 1337, and ever since the middle of the sixteenth century it has been noted in almost every country under the sun. It appeared in Holland in 1557, and passed through France and Switzerland to Spain, and after ravaging various parts of that country for forty years it passed into Italy. In both Spain and Italy it was characterized by a marked contagiousness and an extraordinary depression of the vital powers. In 1739 it made its first appearance in England, and soon after it broke out in France, Sweden and Norway. Its first recorded appearance on this Continent was at Roxbury, Mass., in 1643, and again in Maine in 1671. In 1735 it re-appeared at Kingston, N, Y., and in 1741 it raged in Cambridge, Mass. In 1771 Dr. Samuel Bard, of New York, wrote a treatise upon 9 an cpidomic soro-throat which soeras to havo hoen identical with diphtheria. From that date the disease was Httlo known till its outbreak at Tours, France, in 1818, though Dr. Aitken, one of the best medical writers of our day, affirms that " it terminated the life of the celebrated Washington, and of the Empress Josephine." Brctonneau, one of the keenest of observers, watched the Tours endemic, and his very accurate account of it appeared in 1821, and from that year till 1829 it was never absent from France and Switzerland, All memory of the dis- ease had almost passed from the English medical mind when, in 1849, a Welsh surgeon, named Brown, practising at Haverford- west, announced its appearance on British soil ; he reports 200 cases, with 40 deaths. In 1856 it prevailed in Boulogne in a very fatal form, and the following year it crossed the Channel, and during the years 1858 and 1859 it caused no less than 20,000 deaths in England alone. In 1856 it appeared simultaneously in the States of New York and California, and in 1858 it passed into Ontario from Michigan, It would be a monotonous task to give a detailed history of the disease since 1858, for the cases were innumerable and the literature almost unlimited, but I think that nothing is more certain than that we will have recurrences of the disease periodically for a number of years, when it will depart to return after an absence of half a generation. There has been much •;;!>.,, ate concerning the essential nature of diphtheria, but at prebSut the generally received opinion is that certain minute vegetable organisms, spoken of as bacteria or micrococci, are quite inseparable from the disease, that in fact, in the words of an acute German observer, " without mi- crococci there can be no diphtheria.'''' These minute organisms, which are really exceedingly small fungi, first attach themselves, as a general rule, to the mucous membrane of the throat or nostrils, and from these points of inoculation they spread them- selves through all the adjoining tissues with astonishing rapidity till all the tissues and all the membranes are thronged with them. Thus it is that diphtheria, in the first place a local dis- ease of the throat or nostrils, soon becomes a blood disease^ at mm 8 times so virulent that many patients die at the very beginning of the process of exudation. The precise manner in which these hacteria act upon the blood is as yet unknown. It may be by consuming the very life of the blood, thus causing a kind of decomposition, or it may be by producing a poisonous action peculiar to itself. I incline to believe that the bacteria are not themselves the poison of diphtheria, but that they are merely the bearers of the poison into the interior of the system. At any rate a change takes place in the blood which I have repeat- edly had an opportunity of verifying ; the blood loses its red colour and assumes a brownish tint like plum juice, staining the fingers purplish-brown. This profound change in the blood is undoubtedly the cause of the sudden and extraordinary loss of strength, and probably of the semi-paralytic state which so often follows the disease. Quite a number of physicians hold that the contagium of diphtheria is not a micrococcus, but that it is of a gaseous nature, the result of decomposing faecal and other organic matters. Still another section maintain that diphtheria is a purely local disease. la diphtheria contagious ? This question is of great moment to the friends of the sick, and the answer is not altogether con- soling. Diphtheria is contagious, but, as a rule, only in a moderate degree. But it must be noted that at times it is exceedingly contagious. The diphtheria poison is by no means as virulent as that of scarlet fever or small-pox, for a healthy person generally requires close and somewhat prolonged contact in order to acquire the disease. Some patients take the disease twenty-four hours after exposure, and, according to excellent authorities, the period of incubation may last from one to two months. Tl>e poison clings to the patient and all his surround- ings, his clothes, bedding, books, and especially to the carpets. But I know of uo authentic case in which diphtheria has been carried from one family to another by the passage to and fro of persons who were themselves unaffected by the disease. Con- valescents carry the poison about with them for a considerable length of time. About two years and a half ago a young girl, in the County of Argenteuilj had a very severe attack of (liphtlioria, and on her recovery she found much difficulty in {^cttin;^ a temporary homo. 80 six weeks after recovery she came to Montreal and took service in a family living in the west end of St. Catheriuo street. No diphtheria prevailed in town at that time, and her cmployor9,.|nito unsuspicious, allowed one of the children, a delicate little fellow of live years, to share her bed. At once the child was attacked with diphtheria, and only recovered after a desjierate struggle. It must he noted that a very mild case may communicate the disease in a very serious form, and on the other hand exposure to a bad case may bring on a mild attack. The severity of the attack depends upon the exposed person's state of health, and especially upon the age. Again, a diflferencc of susceptibility exists oven in members of the same household, and this ditlerence cannot be recognized beforehand. Ex|)osuro to fresh air seems to dissipate the poison, and yet I have known instances in which, in spite of disinfection, the poison clung tenaciously to houses, promptly attacking all newcomers. And yet the poison is not capable ot any very wide diffusion in the air. How does the poison obtain access to the system ? Breton- neau, a great French authority, thought that the disease could not be communicated unless the poison came in contact with the mucous membrane or with the skin when denuded of the epi- dermis. But hero he is most certainly mistaken, for I have often had eyes and lips and nostrils covered with diphtheritic secretions while examining patients, witJ.out taking the disease. In very many cases — perhaps a majority of the whole — inha- lation of the poison is the first step in the development of the disease, and hence the constitutional symptoms, such as fever, malaise and nausea, are often noticed before any visible symptoms in the throat. Mr. W. B. Power, of London, has proved that milk may be the vehicle of the poison, and I am certain that danger often lurks in the curious compound which Montrealers style water. Still, in spite of all that I have said, I would repeat that, as a rule, diphtheria is but moderately contagious. Sir William Jenner describes a number of different forms of U 10 diphtheria ; the mild form, the inflammatory, the insidious, the laryngeal, and the asthenic. But amid all these diversities of form and all the variety of the local aifections, it is always the same disease which we encounter. For it is certain that diphtheria is a unit, and it is always diphtheria just as it is always scarlatina, whether the form be simple or anginose, mild or malignant. The differences in the disease depend upon the peculiarities of the individual, precisely as in small-pox or measles. Diphtheria is not caused by defective drainage, though defec- tive drainage is the evil soil in which the diphtheria poison ger- minates. During the present winter (1883-4) the best built and best drained quarter of Montreal has been severely scourged while low lying, ill-drained parts of the city have escaped in great measure. I feel certain that, as a rule, the vicinity of large bodies of water favours the development of the disease, and dwellers on the banks of Lake Erie suffered far more than those at some distance from the lake ; damj), marshy districts are supposed to be favourite haunts of diphtheria ; but I have often seen it sweep over dry, rolling lands which had always been exceptionally healthy. The truth is that it prevails alike in lonely farm-houses and in the crowded streets of a large city, in the poor homes of the needy, and in the mansions of the rich. One of the worst local outbreaks I ever saw was in an isolated farm-house in Charlotteville, Norfolk, Ontario. The family consisted of father, mother and ten children, and I was first called to a fine boy of seven years who lay, silent and stupid, on his mother's lap with livid face and bluish forehead. They had had no intercourse 'vith infected districts yet all had a virulent type of the disease. No one, except myself, went near the house, and no one left it till the endemic burnt itself out, and the pestilence spread no further. Three died, including the child, hopeless when first seen, and the results were fairly good. Again, it may be endemic in one quarter of a town for some time, and then suddenly shift its (quarters to another part. In the year 1879 the Witness newspaper published a most remark- able document entitled " A Health Map of the City of Montreal, 11 showing the annual death rate per thousand for the average of the years 187G, 1877 and 1878, resulting from Small-pox, Tyi)hoid fever and Diphtheria. Prepared by Messrs. Bovey and Dawson." In this curious document, for the accuracy of which almost the entire profession can vouch, St. Bonaventure street and the neighbouring streets are credited with a death rate of 25 to 30 per thousand from these diseases, while St. Catherine street and its vicinity get credit for a death rate not exceeding 5 per thousand. But during the present winter, the dwellers on the line of St. Bonaventure street have enjoyed comparative immunity, while th ., on the line of Ste. Catherine have suifered severely. Season has but little influence in causing the disease, and yet my own experience leads me to believe that most cases occur in winter. Some observers hold that want of cleanliness does not produce the disease, but while this is true in a certain qualified sense, it is certain that filth contributes to its development and its spread. The less care that is given to ventilation and clean- liness, and especially to the removal of the expectorated matter^ the more virulent does the disease become. Sex has no influence on the frequency of diphtheria, but age has a very strong influence in predisposing to the disease. Infants under one year are not so liable as older children, and most of the cases occur between the ages of one and seven. Diphtheritic croup is most frequent and most fatal in children under five, though no age is exempt from this disastrous phase of the disease. Diphtheria is the most insidious of all the acute diseases. I have seen children running about, apparently in perfect health, who were certain to die within twenty-four hours. I remember one Christmas morning I paid a flying visit at a friend's house on my way to a distant patient. I noted that my friend's oldest child, a fine boy of two and a half years, had a darkish sub- stance projecting from both nostrils. I called him to me and lound it to be a true diphtheritic membrane, and on examining the throat, he vomited half a saucerful of very offensive matter. Apparently there was little the matter, but prostration set in very 12 rapidly and he sank in forty-eight hours, and this was the com- mencement of a local outbreak of extreme malignity. But, most fortunately, the malady usually gives some warning of its advent, though the very trifling febrile symptoms might precede almost any acute disease. When you examine the throat during this slight fever you often find no morbid appearance whatever ; only occasionally you note a very slight inflammation of the tonsils. I have often noticed, too, that pain is more common in the mild cases than in the severe ones, and this presence of piiin, often alarming to the mother, is really a sign for good. The fever begins with a very slight chilliness, malaise and acliing in the limbs, headache, drowsiness, loss of appetite and sometimes nausea and vomiting. So frequent is the latter symptom, especially in the more severe forms, that its occur- rence in young children during an endemic of diphtheria should always excite suspicion. After this has lasted from twenty-four to thirty-six hours, you find on examining the throat that it is slightly red, and this redness, even from the commencement, differs from that of simple sore throat, in that it is bluish-red or even violet in hue. At the same time the neck feels a little stift", and on examining the glands at the angle of the jaw they are found to be swollen and tender. Very soon a patch of whitish membrane appears on this bluish-red base, almost like a patch of cream, and from this time the redness spreads rapidly. Even at this early stage, it must be noted that the depression of the patient is out of all proportion to the apparent danger of the sore throat. The face has a sad and wearied expression which is (juite characteristic. The swelling of the glands increases, but the nosLrils, in these milder cases, is seldom aftected. The tongue is thickly coated, with red, enlarged papillae, and the odour of the breath is offensive in most cases. The pulse varies from 120 to 140, and the fever always remits in the morning and rises towards evening. The other tonsil is speedily invaded, and they are often so much swelled that they touch each other. Swallowing is almost always easy, and the diphtheritic mem- brane rarely extends towards the front of the mouth. By the fourth or fifth day, or in some cases even earlier, the exudation 1 18 i begins to fall off, leaving behind very superficial ulcers which soon fill up, or else dark reddish patches. But after the first membranes drop oif, others may take their place, thus prolong- ing the disease to ten days or even two weeks. At the same time the fever declines, the swollen glands diminish in size, the tongue cleans, and the patient enters upon convalescence. But he continues weak for quite a length of time, in this respect differing from all other forms of throat disease. This is the course of the disease in the milder forms, and very many cases stop here and never go any further. But the membranes in the throat may keep on spreading and thickening, and the cream-like appearance is replaced by a dingy ash-colour, always of evil omen ; speech becomes thick, even when no croupous symptoms are present, while the prostration deepens rapidly. Sleep is restless and disturbed, and violent earache, coming on in paroxysms, adds to the child's discomfort. The glands at the angle of the jaw become very large, and all the neighbouring tissues participate in the swelling. A thin, offen- sive discharge escapes from the nostrils and the breath is very offensive. On placing the hand over the heart it will be noted that its action is very feeble, and the pulse, as might be expected, is small, weak and irregular. The tongue becomes dry and dark, and the lips are cracked and hard. The passages from the bowels are usually normal, though diarrhoea may be caused by swallowing the fetid membranes, which may readily be detect- ed in the stools. As the disease advances the face becomes bluish in hue, especially on the forehead and around the eyes, and this I have learned to look upon as a most characteristic sign — not for good. The urine is scanty and often loaded with albumen. Ulceration of the throat often accompanies and succeeds the diphtheritic process in these severe cases ; I have even seen the uvula — that curious little tassel that you see on looking into the throat — wholly or partially destroyed by this ulcerative process. In spite of the prostration of the patient, he is generally able to walk, and he often persists in being up and dressed even when very ill indeed. If now the disease is about to terminate favourably, the swell- 14 IrolVr f 1 . ^™""«^^««' ^"J the diphtheritic membranes are detuehod and thrown off, often in large patches. Freciuently hese pa ches increase in thickness, apparently from an infiltra tion of thmmsh pus, just before they are detached, and the par which were he seat of false membrane continue red and swollen for a number of days. The pulse becomes fuller and sh^nger, the ever wholly disappears, the tongue cleans, the breath regams its sweetness, sleep becomes quiet and restful, and only the dreadful feehng of weakness remains. Such a case will last from ten days to a fortnight. But should an unfavourable issue bo at hand, the weakness mcreases hour by hour the skin becomes cool, the pulse almost or quite uncountable, the glandular swelling enlarges, a horrible smell .sues from the nose and mouth, and the plti^nt, uttert exhausted, passes quietly away. ^ not^comj"" """""■ '^'\''''' '^^'^ '^ '^' ^'''''''' f«^-t«"ately not common, remains to be described, in which from the very farst the false membranes in the throat are tough and elastic resembling moist kid-leather. In this form mLbraneTsoon' appear ,„ the nostrils, with profuse and fetid secretion and a h.ghly offensive camon-like odour. At times the secretions remind one of the old-time mercurial salivation, now quit re rhe glandular swelling is very great, often passing beneath thj hinand down the neck. I have numbers of times witnessed tiue gangrene m these terrible oases, and owing to the presence ^fpo.oned blood in the brain, but little pain i°s compla'ineTof! tt K '' T'' ^'^^'' ^''' '' '^' ^^''^'^ advances the pa ent becomes cooler than natural, with a feeble, fluttering fsgreat. ^^'"" ^''^ exhaustion, and the mortality throat aff.r''f!^ '''" '^^^'^^'^ RI{N, <'OMKA¥Klt'll«M»KN, AND IIYM!V*ROOKN, TIio I.EADIKtJ nxOAnSKH of Kuro|H« and America Hui>|»ll<>d t« Order at NUorteat Notice. Booh Procured to Orilef from Great Britain and tlie United States wltli Care and Despatcli, A well assorted Stock of Always on hand, also ALBUMS, POCKET-BOOKS, PURSES, CARD CASES, PHOTOSRAPH FRAMES, — AN1>— A. FULL LINK OF A-RXISTS' MATERIALS. Send for Catalogub and Price List. Mail Obdbrs Promptly Executed. lAT, DRirSDA.X.E: Oc 232 St James St , Montml. HOMCEOPATHIC WORKS. LadiGS Manual of Homeopathic Treatmont-Ru(iri(K'k '. '. . l OO Ruddock on I)i«oasos of Infants and Cliildron i on Ruddock on the Common Diseases of Women 50 Ruddock's Stopping Stonen to Homipopatli v " " q^ fchuldam's Family Homreopatliy ". . , o^ Bryant's JIanual of Homo'opathic ]\Iedicine ..'.'.'.'. '.'.'.'. 1 9^ Hughe's Pharmacodynamics r, 4^ Douglas' Practical Homa>opatln- 1 ? X Ellis' Family Hom(L'opath\- . . . ! , i- Guernsey's Homn'opathic Domestic Practice 9 7^ .loslin's Homo'opathj- " L'i Homrcopathic Physicians Visiting List o ca Rush's Veterinary Homccopathy f.^ Small's IManual of Homa-opathic Practice ! 07= The Homoeopathic World, monthly— per annum » nn The Monthly Homa'opathic Review 3 59 from E"7aTo;'{i^iSd'£ter ^"""'^"^' P^'"^^"^^" at.shoVt^^Vnotice W. DRYSDALE & OO., ^ix'blxsJn.eni's cSc Boolsisellex's 33a ST. JAMKS STREET, ' MONTREAI.. HoflKBopatMc Physician, Sargeon, and Accouclieur, 74 SHVTBR STREET, TOROXTO. OFFICE HOURS :-8 to 10 A. M. ; 4 to 6 P. M. DR. rRBDERICK MU1-1.BR, HomoBopatliic Plifsician, Surpon, Iccouclieur & Cliildrefi's Plijsician, U3 STANLEY STREET, MONTREAL. OFFICE HOURS :-8 to 10 A.M. ; 2 to 4 P.M., and 7 to 9 P.M. DR. THOlBiEAS NXCIIOI., Homfflopathic Physician, Surgeon, Accoucheur & Children's Physician 137 BLEURY STREET, MONTREAL. OFFICE HOURS :-8 to 10 A.M. ; 1 to 3 P.M., and 7 to 9 P.M (After October 1st, 1884, Dr. N's address will be 140 Mansfield Street.) ) On Oct. 1st, 1884, will ho published No. 2 of the Montreal Tracts on Homcropaihu, entitled "QUANTUM SUFFICIT," being a collection of cases treated with the material dose.