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 ord