Abstracts and Extracts

S & EXTRACTS. DIPHTHERIA & CROUP IN INDIA. By Norman Chevers, c.i.e., m d. He who would hope to throw a clear light upon the nature of the disease or diseases which, early in my career, usee to he placed under these designations, ought to be an antiquarian as well as a pathologist. In this enquiry, it is to be asked, (i) How far these diseases used to be accurately dift'erentiited forty years ago ; and (2) Have changes since taken place in their type ? I shall consider three points very briefly ; but, having been in youth a victim to the neurosis laryngismus stridulus, or spurious croup, I may claim the questionable advantage of having some practical insight into this question?(1) It is certain that many observers, misled by the formidable character of the symptoms of false croup, have mistaken their cases of this disease for examples of the " membranous" exudative type. An eminent authority on Indian disease wrote as follows, five and thirty years ago:?" Croup is a most frightful disease, attacking the strongest children, and attended with the most agonising and convulsive efforts at respiration. It comes on quite suddenly, often in the middle of the night, and requires prompt attention and careful watching : for real inflammation of the larynx is apt to follow it. In common cases, however, all this hard barking clangor disappears after an emetic and a sleep." How came this generally very thoughtful pathologist to designate as " croup" that which, by his own showing, was merely the ordinary type of laryngismus stridulus?spurious croup. Some years before his remarks were published, another Calcutta authority took a more just view of the case,* observing, " Spasmodic croup is a disease common to infancy from one part of India to the other, and not unfrequent at the Presidency" (Calcutta). " Dr. H. H. Goodeve must have been often summoned from his couch to prescribe for this disorder, to quiet the alarm of agitated parents. This, in appearance, is a very alarming disease, but is not dangerous unless neglected, and is very tractable." "The characteristic symptoms are?loud wheezing and difficulty inbreathing. This disorder attacks suddenly, and generally between 11 at night and 2 o'clock in the morning, frequently precisely at midnight. The child starts from its sleep with the loud wheezing which may he heard throughout and without the house; we have known the sentry outside give the first alarm to the slumbering domestics. The child generally sits up in bed, and cries more from fright than pain or difficulty in breathing. There is a predisposition in some families to this complaint, every child being subject to it. Dentition predisposes to it. Disorder of the bowels acts sometimes as a remote and occasionally as a predisposing cause. It is common in India, from the Himalayas to the sea, though it seems to be more so in the Upper than in the Lower Provinces ; and in some parts of these it occurs more frequently than in others. We would instance Rohilcund. During a residence of four years at Bareilly, we met with more cases than during an equal length of time in any other part of India. Its attacks are more confined to the cold season, or to the months ushering in the commencement and termination of this period of the year; we would fix upon October and March, when there is the greatest range of the thermometer in its diurnal changes, as themonths in which it most frequently occurs, and for this reason probably the disease is more frequent in the Upper than in the Lower Provinces. * Finch's hid. Jour, of Med. and Phys. Science, vol. ii., p. 428. 1 We believe that, like inflammatory croup, it is often excited by a cold northerly or easterly wind, or by a wind blowing across a tank or river." The writer adds, that he knew of only one fatal case?a young infant died of convulsions, to which it was predisposed from a weakly constitution inherited from a delicate parent. (2) Has any change taken place in the type of this class of diseases within the last forty years? I can declare positively, from my own personal and professional experience, that no material alteration has occurred in the type of spurious croup within that period. If membranous croup he diphtheria, its type may have undergone some change in Europe and in India ? but I do not know that we have evidence of such change. We have always been told, until lately, that true croup attacks the healthiest children, and that it is essentially a " sthenic" disease, attended with high fever. Mothers used not to be pleased when the healthy appearance of their young children was remarked. " Yes," it would be said, " such children are very liable to croup !" In the first quotation given above we see it emphatically stated that the disease " attacks the strongest children" Here it is to be borne in mind that, althouiih^I think it will be found that subjects of spurious croup are mostly rather pallid and deficient in muscular power, very fine-looking children suffer from this neurosis. Again, has there ever been a " sthenic type of diphtheria . I think not , but my experience in India?where the strongest Europeans have not always a very robust appearance?shows that many of the healthiest looking people fall victims to diphtheria. A lady, who appeared to be in the enjoyment of the most perfect health 'was attacked with diphtheria in Calcutta. I opened the trachea of a most beautiful and healthy-looking little European boy of four, almost in articulo mortis from diphtheria, whom one of my colleagues requested me to take charge of. At the Medical College, ten years ago, the youngest and apparently the most vigorous of our stall" succumbed to diphtheria. This disease may attack the strongest, but it is not, on that account, "sthenic; further, those who to ordinary observation appear to be the most robust are often weak?A'imio tie crcde colori. I am strongly inclined to believe that true croup " has always been diphtheria of the air passages, and that the natural destructiveness of the disease was, generation after generation, largely aggravated by heroic, depletory, and depressant measures, employed under the false idea that the malady is ?? sthenic while many a little weakly but flushed-faced victim of spurious croup, who would have been asleep and well by sunrise had he been properly treated, has been bled, leeched and blistered to death. Until treated, the subjects of spurious croup are generally feverish and flushed, but the skin acts freely after ipecacuanha and a warm bath. There is no inflammatory fever; no organic disease whatever throughout the progress of this neurosis. Writing in 1S60, Morehead did not allude to diphtheria or croup. Hence I infer that he had not seen the former and did not believe in the later as a distinct entity. In his book, published four years latter, Dr. Pcet states that, " in the Western Presidency of India diphtheria in an epidemic form is quite unknown." I'eet " never met with nor heard of croup in a native child in India," and he held that 41 it may, without hesitation, be affirmed that native children in Bombay," and " perhaps in other parts of tropical India, arc quite exempt from this disease, while resident European children are frequently attacked." I do not, however, infer confidently from his description that this authority was able to draw a clear line of differentiation between "true sthenic membranous croup" and "spurious croup." Mackinnon considered that croup is far less prevalent in India than in colder climates. Writing in 1S55 t he cited an account of an outbreak of croup (?) which had just occurred at Darjeeling. During the first sixteen years of the occupation of that hill station as a sanatorium, croup had never shown itself, except on one previous occasion. The superintendent of Darjeeling called the outbreak "the infantile epidemic," and denied that it was a croup epidemic. Croupy symptoms did not appear at the beginning There was " an epidemic in which the mucous membrane of the fauces, throat, larynx, and trachea was affected in various degrees of intensity, from malignant sore throat, fatal in one boy of seven years, and croup with a false membrane, fatal in two cases under five years of age, to the slightest coughs, colds, and sore throats, which were general among half the children of the place. t Inti. A11. M. S., No. Si p. 131. 24? THE INDIAN MEDICAL GAZETTE. [August, 1884. Here diphtheria and croup are, to fay the least, simultaneously incidert upon a small community. Total of children, say go. Here, too, we cannot but observe the alliances of this expression of disease on one side, to diphtheria, and on the other, to the epidemic bronchitis of children in Lower Bengal described under the heading of Influenza. I have seen many cases of diphtheria of the air passages, and three marked cases of " membranous" laryngitis ; but I never saw a case of sthenic "membranous croup" of the kind described in text books of medicine some years ago. In none of my cases was the " brassy cough " present ; but in all there wa; more or less of that harsh sound which is fairly represented by breathing hard and blowingly through the tube, made by bringing the last phalanx of the thumb against the backs of the last phalanges of the fingers. The hill station of Nynee Tal long had an evil reputation for croup. Dr. Francis states, from three years' experience, that the children there were very liable, in the spring and autumn, to "attacks of bronchitis, croup, influenza, and cynanche.'' He observed that in 1855 " croup of a sthenic character" (the italics are mine) "and bronchitis were epidemic at both the above seasons ; whilst there only occurred two or three cases of simple cynanche tonsillaris. But in September, 1856, the cynanche cases were more numerous, and in one family they assumed a decided diphtheritic character. Here, again, we notice a close approximation of cases of "true crcup" (diphtheria of the air passages?) and of ordinary diphtheria. I, as I have said, suffered much in childhood from neurotic spurious croup, and I saw a great deal of that disease among children in Bengal. One damp and stormy night, at a boarding-house in Calcutta, I was busy placing one of my own children, violently attacked with spurious croup, in a warm bath, when I was urgently called to see two children of an officer, in the next apartment, who were similarly attacked. The same hot water kettles served for both families. I passed nearly the whole of one night at Bishop's College with a very fine boy, the son of a clergyman. The boy looked so healthy, and was so hot and flushed, and the cough had so loud a brassy clangor, that I, for some hours, doubted whether I had not, at length, met with a case of genuine sthenic membranous croup. Treatment, however, showed that it was merely the neurosis. We place the child in a warm bath, wrap it in a blanket, make it vomit with ipecacuanha, and give it a brisk purgative (in these cases, and almost in these alone, I gave calomel, which acts very kindly). Sleep generally follows vomiting, and, when the cathartic acts, the child is well, but rather weak. % Although nearly up to the time of my entrance to the Indian Service ill 1848, I was an office bearer at the Pathological and South London Medical Societies, and a steady worker at other societies, and visited Guy's Hospital almost daily, I knew very little indeed of diphtheria, except that which I learnt from French authorities on the Diphtherite of Bretonneau. I first saw typical cases of this disease in India. According to Kenneth Mackinnon, diphtheria "seems to have first shewn itself in Calcutta in 1852, when it destroyed several children at the Martiniere School and elsewhere."* ?Although this school is a very fine building, it stands almost at the extreme east of the city?a position which has always been regarded as unfavourable. The close vicinity of a very extensive and full Mahomedan burial ground was another evil, but Dr. Webb attributed the outbreak to the foul state of the drains, and to the presence of numerous sheep pens in the immediate vicinity. Mackinnon says that it appeared again in 1855 in Calcutta, but not in the same locality. He mentions that there had been one fatal case, a most sudden and afflicting visitation, occurring in a young married lady. He knew of another young lady, from whose fauces flakes of the exudation were removed by the forceps. From that time sporadic cases, with a distinct tendency to spread in families, have rather frequently occurred in Calcutta ; but, as far as my own observation extends, there has not been an epidemic outbreak in that city. It is, however, very noteworthy that, a year later, 1856, diphtheria attacked four members of a family resident at Nynee Tal, a delightful hill station at an elevation of 6,450 feet above the level of the sea, upwards of 600 miles north-west of Calcutta.t Nearly every Indian writer on diphtheria moots the question, is this disease * 11 On the Epidemics of Bengal and the North-West Provinces, Imi. An. Med. Sc., No. 3, p. 176. + Dr.,Francis,, " Diphtheria and the Malignant bore throat of Scarlatina," Ind. An. Med. Sc., No. 13, P9. closely allied to scarlatina? Mackinnon states the barely noteworthy fact, that one of the Calcutta young ladies mentioned above as suffering from diphtheria in 1855, had a scarlet eruption, not preceded by fever, some weeks after recovering from the throat affection." The late Dr. Peet, of Bombay, states,J that during a severe epidemic of scarlet fever, which raged in the southern part 01 Australia in the year 1853? diphtheria was very prevalent and fatal ; and, indeed, in some of the cases which he saw, it was difficult tc say which of those diseases was present. _ Until scarlet lever was introduced into Australia, diphtheria had never occurred there. He adds that, in the Western Presidency of India, where scarlet fever did not prevail when he published his work in 1864, diphtheria in an epidemic form was quite unknown. Dr. Francis witnessed an outbreak of diphtheria at Warley Barracks in 1857, scarlet fever being epidemic at the same time. He alludes to this after describing the four cases of diphtheria which he saw at Nynee Tal, where no suspicion of the existence of scarlatina existed. He suggests the question: Is diphtheria scarlatina without the eruption ??a question which, I believe, most observers will answer in the negative. We lia/e seen that, of late years, scarlatina has appeared in the Bombay and Madras Presidencies, having been imported in troopships ; but the fact that diphtheria has prevailed in Calcutta for upwards of thirty years, although no unimpeachable case of scarlatina has been observed in Lower Bengal, goes far to show that these two diseases are, to say the least, very separate entities. I lie returns of our British Force in all India, for 18S0, show two deaths from diphtheria; for 1S81, only one death ; and fc>r 1 ?>82, no death, in a force 57,269 strong. There was not any case of diphtheria among the women during the three years ; but among the children, numbering from 6,208 to 7,596, there were, in 1880, 18 cases of diphtheria, with 11 deaths, and 40 cases of " croup and laryngitis," with 14 deaths. In 1SS1, diphtheria did not occur among the children, but there were 388 admissions for croup and laryngitis and 28 deaths. In 1882, no mention is made of diphtheria, but 26 children were treated for croup and laryngitis and 7 died. During the three years, only two admissions for diphtheria occurred in thcjail population. In 1S80, their average strength was 106,763, and, in that year, one case (fatal) was registered in the Bengal, and one in the Bombay Presidency. There was only one admission (in 1S80) for diphtheria in the Native Army in the three years. In 1882, this force was 114,894 strong. In my time diphtheria was rather common in and out 01 CalcutU, and probably is so still. As I have already mentioned, one of our hospital surgeons fell a victim to the disease, contracted in examining a patient in his ward. I opened the trachea in two cases?in that of the European boy alluded to above, and of a young native man. My colleague, Mr. Partridge, requested that I would (my residence being in the college) watch the latter. He had come in much exhausted, thin rags of dark-coloured exudation matter, like sodden brown paper, hanging from his soft palate. As I stood at the foot of liis bed looking at him, foam gathered at the corners of his lips, and in a moment I saw that he died. I did not lose an instant in making the first incision with my penknife, while I called for the scalpels and canula, which were close at hand. A large tube was inserted, and Sylvesterism was immediately employed, and long maintained, but quite in vain. This case forcibly illustrated the almost instantaneousness with which death from exhaustion occurs in this disease. It was in strong contrast with that of a patient of Sir Joseph Fayrer's, who, having some considerable time previously had his trachea opened, suddenly pulled the canula out and appeared to die immediately. A nurse ran out of the ward into the operating theatre and called Sir Joseph, who was operating and could not leave. I went at his request, put in the tube, and, as a matter of routine, but without any hope of saving the man, I employed Sylvesterism, and was astonished to find that breathing was restored. I published the diphtheria case some time ago, and think that a hint was made soon afterwards, that I had forced the exudation down the trachea and so arrested respiration. This positively did not happen. I examined the case very carefully post-mortem. There were mere traces of thin exudation in the air-passages, but nothing that could occasion obstruction ; and, as we worked the chest, mechanical + 41 Principles and Practice of Medicine : designed chiefly for Students of Indian Medical Colleges," p. 357. August, 1-584.] HOOPING COUGH & MUMPS IN INDIA. 241 espiration was perfectly free, air passing through the canula a every stroke as if through the nozzle of a bellows. This was the only case of diphtheria which I saw in a native. Anglo-Indian children and adults returned from the East o ten suffer severely from aphthous exudative inflammation of he palate and fauces, which, at first sight, suggests the idea of diphtheria, and which has, I believe, been mistaken for that disease, much to the detriment of weak and nervous patients. ^ I have seen a good deal of thrush in patients, mostly ^ged, dying from exhausting diseases ; the alliance of this con*?n t.? diphtheria appears to be very close. Nothing but the discovery of exudation in the air-passages of one whose symptoms I had observed to be those usually ascribed to true croup?not those of ordinary diphtheria? would convince me that I had seen a case of deadly croup. ?Never having seen such a case, I remain in a state of agnosticism on this important point; but, as I have already said, with a strong bias towards the opinion of those observers who regard membranous croup " as "diphtheria of the air-passages." HOOPING COUGM, PAROTIDES AND INFLUENZA IN INDIA. ^lackinnon describes Hooping Cough as being epidemic in India (p. 12S). In his experience, it was not extremely prevalent or aggravated in type in the plains of the North-Western Provinces. But, when he wrote, it was very severe at the hill stations, "where," he says, "many deaths take place from ft yearly among the Furopean children." This was written just as I went to India. I did not hear of the occurrence of SUch deaths in my time. He adds, "It prevails as an epidemic all over the plains of the Ganges, usually in a very mild 'orni, and most commonly showing itself at the same time of the year with the exanthemata so allied to it in many particulars." In a later communication* Mackinnon stated his opinion hat the exanthemata and hooping cough are all known most commonly to show themselves at the change of season which ushers in the hot weather. He has sometimes seen the disease 'so mild as to render it difficult to distinguish it from common cough, although the manner in which the cough attacks, in fits more or less violent, and the specific hoop ought to be enough lo guide us." Noting the fact that an attack usually renders the individual exempt from future visitation, he observes, that he has known children, who have had well-marked hooping cough in India, have the disease again severely in Europe. He again notices that, at some of the Indian hill stations, the disease severe and even fatal; which, he adds, seems to be another proof that, in the plains, it owes its generally mild character to the high range of temperature. In a return, showing that the average strength for three years ?f European soldiers' children was 2,291, he found that there were only 23 cases of pertussis, being about eight per annum out of that strength. There was only one death. In his invaluable statistical tables, so frequently cited in these chapters, my friend, Surgeon-General Hugh Macpherson, shows that, during the four years ending 1853-54, there occurred, in the European regimental hospitals in the Bengal Presidency, six cases of hooping cough among soldiers, but no deaths. No cases of officers or women ; 29 cases among children, or per cent, of strength, and two deaths or 6rV per cent, of treated. Dr. T. Farquhar reported that, at Mussoorie in 1862, there were 45 cases of hooping cough and one death from pneumonia. Among the 7,596 children of European soldiers in India in 1880, there were 104 admissions for hooping cough and three deaths. In 1SS1, there were admitted in Bengil 27 children, in Madras 12, and in Bombay 28, of whom two died. In 1SS2, there were 22 admissions and one death in all India. In the three years only one of the large body of native prisoners was attacked?in 1SS1 ; in 18S0, two Bengal Sepoys had hooping cough ; and in 1881, a Bombay man was admitted. No other cases occurred in our native army in the three years. Hooping cough prevailed from time to time in Calcutta. Few of the cases which I had were severe, but, when tracheotomy was recommended in pertussis, I opened, ineffectually, the trachea of an East Indian infant at the moment when it ceased to breathe. A man in my ward was in considerable danger from pneumonic complication. I never saw phthisis set * Ind. Ah. Med. Sc., No. 3, for 1855, p. 17S. up by pertussis in India, and I did not hear of European children sent home to recover from its effects. Morehcad says, " In Dr. Coles's Report 011 Measles in the Byculla Schools, allusion is made to the presence of three cases of hooping cough at the same time. I do not find any account of the epidemic prevalence of this disease in these schools : but my impression is that it has occurred, from time to time, during the last twenty years. In a note to the case of a child who did, as he considered, after recovery from hooping cough, Webb remarked, "Thisis the only fatal case which I have met with in hooping cough in India. The disease has twice gone through the children of the Government Orphan .School during the last four years, and once through La Martiniere Institution." Parotides.?Mumps are occasionally epidemic in India, the disease usually assuming the ordinary mild European type, and being unattended with severe fever or grave complications. But, on one occasion, I witnessed an unusual outbreak of this malady. There was, at Howrah, a single row of unhealthily situated detached houses, leading down to Tel Khal Ke Ghat, principally inhabited by respectable Europeans. In front, separated only by the highway, ran an open, ill-dug earthen ditch, which was intended to carry the excreta of the large native jail tu the river Hooghly, but was practically an elongated reservoir of stagnant filth. Several European children in this row were attacked with mumps. The disease appeared to be endemic ; I did not see or hear of any cases elsewhere. In most of the cases the attack was mild and the children did well; but, in one of the houses, two fine little European boys became the subjects of acute membranous laryngitis, without the constitutional symptoms of diphtheria, when the parotid swelling was subsiding. There was no exudation about the fauces, but vomiting ietached shreds from the air passage. The younger boy died suddenly while in the act of coughing. I found that the exudation tube, having become detached below, had been forced upwards and rolled together, and had completely filled and blocked the larynx. Ilad I been present when the accident occurred, laryngtomy would probably have saved him. The elder brother did well. The coincidence of diphtheria with mumps has been observed elsewhere. Morehead says,+ that cynanche parotidaia attacked the Byculla girls' school, Bombay, in March, 1837. Seventyfour girls were affected, not a single boy. Mr. Carter reported that it broke out among the boys in October and November, 1851. Seventy-five boys were affected, but only two girls. The returns show that, in 1SS1, there were 23 admissions of European soldiers'children, for mumps, in all India. During that year the admissions of sepoys, under this heading, were i,iSo, in a strength of 114,612. Of the 100,844 prisoners, 785 had mumps. It is noteworthy that in this year sepoys were attacked in all the Presidencies, so also was the jail population, who are much isolated. There were some cases among the prisoners in British Iiurmah and in the Andaman Islands. It is not shown whether the European soldiers were attacked ; their wives were not. Cases occurred among their children in each of the Presidencies. In 1882, 2 soldiers' wives and 14 of their children were admitted, and 901 sepoys and 769 prisoners had mumps, the disease occurring throughout British India and Burmah, but not in the Andamans. Influenza.?Dr. John Adam placed on record^ an account of what he termed an "epidemic bronchitic fever" of infants and young children, which prevailed in Calcutta during the rains, or' months of June, July, and August, 1S28. This was preceded by a perhaps less general epidemic in 1S28. In Dr. Adam's experience, not one child under four years of age out of a hundred escaped an attack. The victims were, for the most part, fine infants at the breast. Death did not occur in any child above two years old. The symptoms were those of capillary bronchitis, ushered in by a febrile paroxysm. In convalescence, there was a " degree of weakness which was extremely protracted and difficult to remove." This epidemic was not confined to the city and suburbs of Calcutta, but extended to many stations in Lower Bengal. It prevailed at Chinsurah, Burdwan and Bhauleah, and even as far northward as Maldah. In Calcutta native children do not appear to have been attacked ; but at Burdwan they suffered considerably. Ilere the adult natives had fever similar to that of the children with the difference that " it was accompanied by a troublesome ophthalmia." t o/>. at., p. 201. t Traits. Med. & Phys. Scey. 0/ Calculi*, vol. iv., p. 320. 242 THE INDIAN MEDICAL GAZETTE. < i -' r