NOTES ON AN EPIDEMIC OF PNEUMONITIS. By ALEX. FAULKNER, I.M.S. The 19th Bombay Infantry, after a fortnight's march from Deesa in Rajputana, arrived in Pishin Fort, S. Afghanistan, on the 8th December 1886. From this date to the end of February 1887, no less than 42 cases of acute pneumonia occurred amongst the men and followers of the regiment, causing in all twelve deaths. The following are the notes, in short, of a few of the most severe cases :? Havildar Baladin Awasti, a Hindu, cetat. 33 years, service 15 years, was admitted into hospital on December 12th, suffering from fever (temperature 103*6?), and complaining of cough, dyspnoea, headache, and pain in his States that his illness commenced with chest. a distinct chill and subsequent pains all over his body and fever. On physical examination, I found the patient iu a very weakly condition ; he had a quick pulse, and a dry furred tongue. On percussion there was slight duluess over the base of his right lung and capillary crepitation on auscultation. His cough, which was most distressing, was accompanied with rusty muco-puruleut sputa. This man refused to take any meat or soups, and only depended He daily on milk and grain for nourishment. became worse and died on the 20th instant. Post-mortem examination 3 hours after death? no rigor mortis. Thorax?right lung greatly enlarged, friable, hardened and sinks in water, the diseased portions being in a state of red hepatization and weighed 2 fb 13 oz. Left lung slightly enlarged and weighed 1 tt>
Heart?slightly hypertrophied, weight Abdomen?spleen congested, but otherwise normal. Liver?enormously enlarged and 1
oz.
9
oz.
weighed 4 lb. Intestines?slight congested patches at lower end of small intestines, but no
No entozoa in intestinal caual. Private Bullee, a Hindu, cetat. 29 years, service 7 years, was admitted on December 29th, with cough and pain in his chest. Previously, this mau was constantly an out-patient and al-
ulceration.
April,
AN EPIDEMIC OP PNEUMONIA.
1887.]
ways complained of cough and general debility. A short time after he was admitted, symptoms of acute pneumonia supervened, his tempera" " ture rose, sputa became rusty in appearance, with blood, and he had all being highly tinged the physical signs of the disease affecting both bases. Copious sweats, with consequent prostration and exhaustion acting on a constitution already debilitated, tended greatly to bring ou a fatal termination in this case, and the patient succumbed on the 3rd January. Private Appa Selha, a Hindu, cetat. 26 years, service 8 years, was sent to head-quarters from Kanazai, where he was on outpost duty, and admitted into the Regimental Hospital on January 4th. This mau was brought in a camel kajawah for a distance of 24 miles on a cold night, and when admitted was in an extremely exhausted condition and suffering from acute pneumonia. He is still iu hospital and is now convalescent. Recruit Rugobir Dyal,a Hindu, cetat. 18 years, service 6 months, was brought in a dooly to hospital on the 6th of January, suffering from fever, cough, and pain in his chest. On the 8th instant he was much worse, and on physical examination of his chest, it was found he had coarse crepitation over both bases with tubular breathing and marked dulness over both bases. The most prominent symptoms during his illness were great exhaustion and prostration, delirium, dyspnoea, copious sweats and cough with rusty aud muco-purulent expectoration. He continued in a critical condition till the end of the month, after which convalescence was slow and tedious, and he was ultimately discharged to his duty on February 14th. Private Maharee Molay, cstat. 24 years, service 6 years, was admitted on January 13th, suffering from catarrh, distressing cough with
copious frothy sputa. tion
Slight capillary crepita-
audible over the base of his right luug, but little or no dulness on percussion. On the loth instant his temperature rose; he hail marked dyspnoea and his sputa were now highly tinged with blood. On examining his chest all the physical signs of acute congestion were present over his right base. This patient expired ou January 18th. ?st~moTtem examination 9 hours after death. 0.rigor mortis. Right lung weighed 3 lb 14 oz., and was in a state of red contained little oi no air and sank hepatization, in water. It was noncrepitant but friable, and on section was of a reddish blown colour aud granular in appearLett ance. lung?slightly congested. Heart? Liver normal. enlarged and weighed 4fb was
__
4
oz.
Private Noor Khan, a Mussulman, cetat. 26 years, service 5 years, admitted ou the 16th
January with cough and States that whilst on duty
pain
in his chest.
on some
earthworks
99
outside the fort 011 the previous evening, he remembered having bad a distinct " chill" afterleaving off work. Fever and severe cheat symptoms supervened. On physical examination, it was found he had coarse crepitation over both bases with dulness on percussion. Great prostration, most distressing cough with rustysputa, marked dyspnoea, delirium, complete anorexia, a dried furred tongue and sleeplessness were the most prominent symptoms during his illness. The patient is still in hospital, and although extremely weak and thin, he is now convalescent. Private Bhena Telee, a Hindu, cetat. 24 years, service 6 years, admitted on January 16th, with the following symptoms : High temperature, great prostration and exhaustion, cough with rusty muco-puruleut expectoration, extreme dyspnoea and thoracic pains. He had coarse crepitation over the base of his right lung and dulness on percussion. Dyspnoea was his most severe and distressing symptom, and at times he seemed almost unable to breathe and died of syncope on the 19th instant four days after admission. Post-mortem examination 3 hours after death. No rigor mortis. Left lung collapsed and completely adherent to the pleura, indicating old pleuritia. Right lung?highly congested and engorged, of a dark reddish brown colour, slightly crepitant but friable, and pits 011 pressure, weight 1 fb 8 oz. Heart?hypertrophied, but otherwise normal and weighed 10 oz. Private Bager, a low caste Hindu, cetat. 28 years, service 6 years, was also admitted on the same day with fever and chest symptoms. States he was sitting by a fire in the open, very early iu the morning when he experienced a sudden chill which affected his whole body to such a degree that he was conveyed in a dooly to hospital. He also states that he had been suffering from catarrh for some time previously. On physical examination, it was found he had congestion over the bases of both lungs. He remained in hospital in a critical condition for many weeks, but always willingly took all his nourishment and stimulants, and is now convalescent, although extremely weak and reduced. Private Powaskar, Hindu, cetat. 30 years, service 11 years, was admitted on the 16th February, suffering from congestion of the bases ot both his lungs. ?He had the following symptoms: Constant cough, with rusty muco-purulent expectoration, dyspnoea, thoracic pain with a feeling of tightness across his chest, extreme prostration with delirium and copious sweats, anorexia with a dry furred tongue and pyrexia. The patient was for many days in a most critical condition, but is now on a fair way to recovery, and is still an iu-patieut in the hos-
pital.
THE INDIAN MEDICAL
100
Remarks. General.
?
Altogether
42
of
cases
acute
besides 105 cases of simple and bronchial catarrh, were treated from December 8th, 1886, to the end of February 1887. That such a number of lung affections prevailed in a localized area in a given time has led me " to epidemic" to this outapply the term break. Etiology.?With reference to the moot question, viz., the etiology of pneumonia, I am convinced, from practical experience that its causation is to be found in climatic influences acting on predisposed or debilitated constitutions, and I consider that theories and hypotheses, referable to the existence of a contagium, which constitutes the inflammation of pneumonia either contagious or infectious, are unreliable, and not in accordance with practical observations of this disease. It will be interesting, with reference to this outbreak and in support of the above remarks, to refer to some further details. Caste.?This regiment is composed of the following castes, viz. :?
pneumonia,
Hindus of all castes Mussulmans Native Christians, Jews, &c
697 93 30
Total
...
820
Of the 42 cases of pneumonia treated, 40 were Hindus, and only 2 Mussulmans. As will be shewn below, it will be seen that " caste pre-
judices" innocently play an important part in, at any rate, helping to solve the etiology of this disease, which apparently is still a vexed and moot subject. Hindus, with few exceptions owing to
caste customs, cook their food in the open air bathing, and without any covering ou tlie
after
upper part of their bodies, they never touch meat and rarely stimulants. (In this regiment they continued these practices on the march and even after their arrival here, when it was found necessary to issue stringent regimental orders prohibiting their continuance.) These facts relating to caste customs are in themselves ample and cogent reasons, at any rate, for the supposition that these men predisposed themselves to this disease especially when subjected to
unnatural climatic influences.
and others
to
the contrary, who
Mahomedans
are
not bound
Hindus, are not prejudices peculiar do not suffer and consequently predisposed,
down so
on
the
to
to
same
extent.
to the climate of South Afghanistan, the cold in the winter months is very severe, and is quite unsuited Iu December, frost octo natives of India. curred every night, the extreme variations of temperature being 10? and 40?. In January the cold was almost as severe, the extremes being 14? and 40?. In February it became perceptibly
Climate.?With reference
GAZETTE.
\
April, 1887.
warmer, ami during this month there was a marked decrease of all diseases of the lungs and respiratory tract?clearly shewing the connection of climatic influence and the prevalence of these diseases. Treatment.?As regards Hindus who refuse nourishment and often stimulants, the treatment must naturally be more or less expectant, but with others extra nourishment and stimulants to a certain extent are the principal means of supporting and sustaining life during the acute and convalescent stages?medici-
nally.
Treatment.?The
appropriate treatment of appear seems to me the most rational method instead of adopting, as is the practice of some, a like treatment, based on theories in all cases. Locally, nothing is more grateful to a native patient in this disease than a blister which I generally order, however, as a last resource, and after such local applications as mustard plaster, dry cupping and turpentine stupes have already been tried.? Instead of linseed meal poultices, I find that fomentations by means of heated constant bricks is much appreciated by patients. This method,although so simple, has many advantages, and is cleaner anil safer than poultices which are apt so soon to get cold in which state they possibly do more harm than good.
symptoms
as
they
Pishin Fort, South
Afghanistan.
\
Heart?slightly hypertrophied, weight Abdomen?spleen congested, but otherwise normal. Liver?enormously enlarged and 1
oz.
9
oz.
weighed 4 lb. Intestines?slight congested patches at lower end of small intestines, but no
No entozoa in intestinal caual. Private Bullee, a Hindu, cetat. 29 years, service 7 years, was admitted on December 29th, with cough and pain in his chest. Previously, this mau was constantly an out-patient and al-
ulceration.
April,
AN EPIDEMIC OP PNEUMONIA.
1887.]
ways complained of cough and general debility. A short time after he was admitted, symptoms of acute pneumonia supervened, his tempera" " ture rose, sputa became rusty in appearance, with blood, and he had all being highly tinged the physical signs of the disease affecting both bases. Copious sweats, with consequent prostration and exhaustion acting on a constitution already debilitated, tended greatly to bring ou a fatal termination in this case, and the patient succumbed on the 3rd January. Private Appa Selha, a Hindu, cetat. 26 years, service 8 years, was sent to head-quarters from Kanazai, where he was on outpost duty, and admitted into the Regimental Hospital on January 4th. This mau was brought in a camel kajawah for a distance of 24 miles on a cold night, and when admitted was in an extremely exhausted condition and suffering from acute pneumonia. He is still iu hospital and is now convalescent. Recruit Rugobir Dyal,a Hindu, cetat. 18 years, service 6 months, was brought in a dooly to hospital on the 6th of January, suffering from fever, cough, and pain in his chest. On the 8th instant he was much worse, and on physical examination of his chest, it was found he had coarse crepitation over both bases with tubular breathing and marked dulness over both bases. The most prominent symptoms during his illness were great exhaustion and prostration, delirium, dyspnoea, copious sweats and cough with rusty aud muco-purulent expectoration. He continued in a critical condition till the end of the month, after which convalescence was slow and tedious, and he was ultimately discharged to his duty on February 14th. Private Maharee Molay, cstat. 24 years, service 6 years, was admitted on January 13th, suffering from catarrh, distressing cough with
copious frothy sputa. tion
Slight capillary crepita-
audible over the base of his right luug, but little or no dulness on percussion. On the loth instant his temperature rose; he hail marked dyspnoea and his sputa were now highly tinged with blood. On examining his chest all the physical signs of acute congestion were present over his right base. This patient expired ou January 18th. ?st~moTtem examination 9 hours after death. 0.rigor mortis. Right lung weighed 3 lb 14 oz., and was in a state of red contained little oi no air and sank hepatization, in water. It was noncrepitant but friable, and on section was of a reddish blown colour aud granular in appearLett ance. lung?slightly congested. Heart? Liver normal. enlarged and weighed 4fb was
__
4
oz.
Private Noor Khan, a Mussulman, cetat. 26 years, service 5 years, admitted ou the 16th
January with cough and States that whilst on duty
pain
in his chest.
on some
earthworks
99
outside the fort 011 the previous evening, he remembered having bad a distinct " chill" afterleaving off work. Fever and severe cheat symptoms supervened. On physical examination, it was found he had coarse crepitation over both bases with dulness on percussion. Great prostration, most distressing cough with rustysputa, marked dyspnoea, delirium, complete anorexia, a dried furred tongue and sleeplessness were the most prominent symptoms during his illness. The patient is still in hospital, and although extremely weak and thin, he is now convalescent. Private Bhena Telee, a Hindu, cetat. 24 years, service 6 years, admitted on January 16th, with the following symptoms : High temperature, great prostration and exhaustion, cough with rusty muco-puruleut expectoration, extreme dyspnoea and thoracic pains. He had coarse crepitation over the base of his right lung and dulness on percussion. Dyspnoea was his most severe and distressing symptom, and at times he seemed almost unable to breathe and died of syncope on the 19th instant four days after admission. Post-mortem examination 3 hours after death. No rigor mortis. Left lung collapsed and completely adherent to the pleura, indicating old pleuritia. Right lung?highly congested and engorged, of a dark reddish brown colour, slightly crepitant but friable, and pits 011 pressure, weight 1 fb 8 oz. Heart?hypertrophied, but otherwise normal and weighed 10 oz. Private Bager, a low caste Hindu, cetat. 28 years, service 6 years, was also admitted on the same day with fever and chest symptoms. States he was sitting by a fire in the open, very early iu the morning when he experienced a sudden chill which affected his whole body to such a degree that he was conveyed in a dooly to hospital. He also states that he had been suffering from catarrh for some time previously. On physical examination, it was found he had congestion over the bases of both lungs. He remained in hospital in a critical condition for many weeks, but always willingly took all his nourishment and stimulants, and is now convalescent, although extremely weak and reduced. Private Powaskar, Hindu, cetat. 30 years, service 11 years, was admitted on the 16th February, suffering from congestion of the bases ot both his lungs. ?He had the following symptoms: Constant cough, with rusty muco-purulent expectoration, dyspnoea, thoracic pain with a feeling of tightness across his chest, extreme prostration with delirium and copious sweats, anorexia with a dry furred tongue and pyrexia. The patient was for many days in a most critical condition, but is now on a fair way to recovery, and is still an iu-patieut in the hos-
pital.
THE INDIAN MEDICAL
100
Remarks. General.
?
Altogether
42
of
cases
acute
besides 105 cases of simple and bronchial catarrh, were treated from December 8th, 1886, to the end of February 1887. That such a number of lung affections prevailed in a localized area in a given time has led me " to epidemic" to this outapply the term break. Etiology.?With reference to the moot question, viz., the etiology of pneumonia, I am convinced, from practical experience that its causation is to be found in climatic influences acting on predisposed or debilitated constitutions, and I consider that theories and hypotheses, referable to the existence of a contagium, which constitutes the inflammation of pneumonia either contagious or infectious, are unreliable, and not in accordance with practical observations of this disease. It will be interesting, with reference to this outbreak and in support of the above remarks, to refer to some further details. Caste.?This regiment is composed of the following castes, viz. :?
pneumonia,
Hindus of all castes Mussulmans Native Christians, Jews, &c
697 93 30
Total
...
820
Of the 42 cases of pneumonia treated, 40 were Hindus, and only 2 Mussulmans. As will be shewn below, it will be seen that " caste pre-
judices" innocently play an important part in, at any rate, helping to solve the etiology of this disease, which apparently is still a vexed and moot subject. Hindus, with few exceptions owing to
caste customs, cook their food in the open air bathing, and without any covering ou tlie
after
upper part of their bodies, they never touch meat and rarely stimulants. (In this regiment they continued these practices on the march and even after their arrival here, when it was found necessary to issue stringent regimental orders prohibiting their continuance.) These facts relating to caste customs are in themselves ample and cogent reasons, at any rate, for the supposition that these men predisposed themselves to this disease especially when subjected to
unnatural climatic influences.
and others
to
the contrary, who
Mahomedans
are
not bound
Hindus, are not prejudices peculiar do not suffer and consequently predisposed,
down so
on
the
to
to
same
extent.
to the climate of South Afghanistan, the cold in the winter months is very severe, and is quite unsuited Iu December, frost octo natives of India. curred every night, the extreme variations of temperature being 10? and 40?. In January the cold was almost as severe, the extremes being 14? and 40?. In February it became perceptibly
Climate.?With reference
GAZETTE.
\
April, 1887.
warmer, ami during this month there was a marked decrease of all diseases of the lungs and respiratory tract?clearly shewing the connection of climatic influence and the prevalence of these diseases. Treatment.?As regards Hindus who refuse nourishment and often stimulants, the treatment must naturally be more or less expectant, but with others extra nourishment and stimulants to a certain extent are the principal means of supporting and sustaining life during the acute and convalescent stages?medici-
nally.
Treatment.?The
appropriate treatment of appear seems to me the most rational method instead of adopting, as is the practice of some, a like treatment, based on theories in all cases. Locally, nothing is more grateful to a native patient in this disease than a blister which I generally order, however, as a last resource, and after such local applications as mustard plaster, dry cupping and turpentine stupes have already been tried.? Instead of linseed meal poultices, I find that fomentations by means of heated constant bricks is much appreciated by patients. This method,although so simple, has many advantages, and is cleaner anil safer than poultices which are apt so soon to get cold in which state they possibly do more harm than good.
symptoms
as
they
Pishin Fort, South
Afghanistan.
\
