ever been cured by quinia alone. In the early prevalence of the
disease it was treated by large doses of cinchona, but unavailingly,
and subsequently smaller doses were given during the convalescence, as
it was in that of other acute diseases. In some parts of this country
where miasmatic diseases prevail, and epidemic meningitis, like all
other acute, and especially febrile, disorders, displayed more or less
of a periodical or paroxysmal type, quinia was used in large doses,
but the expected result was not realized. Upham states that in some
instances it was given to the extent of sixty, or even eighty, grains
within twelve hours from the beginning of the attack, but without
effect. In Europe it was extensively tried and unanimously condemned.
It may very properly be left out of the list of medicines suitable for
this disease, particularly since it is no longer probable that any
physician would be rash enough to employ it in the so-called
antipyretic doses with or without their usual associates, cold baths.
According to Karl Jaffé, the medicinal antipyretics (quinia, salicylic
acid, and also sodium benzoate) may be entirely discarded, because
they ruin the already weakened digestion.[59]
[Footnote 59: _Phila. Med. Times_, xii. 600.]
Common sense has also proved stronger than theory in excluding
mercurials from the treatment of epidemic meningitis. At one time they
were extensively used, especially when it was learned that the disease
in its full development included a paramount inflammatory element. But
it was soon found that the results of their use were far from uniform,
and farther still from being demonstrably beneficial. In this, as in
many other similar cases, it is quite impossible to reach a definite
judgment unless it were known what was the type of the cases in which
the medicine was given, whether they were asthenic or inflammatory,
and again whether it was used during the active or during the
declining stage and toward convalescence. In the absence of any
trustworthy testimony upon the subject it is only possible at present
to state that in the treatment of this disease mercurials should not
be used. This conclusion is all the more imperative because the
medicine is not an indifferent one. If it is not necessary--and it
certainly is not--it is too dangerous in its immediate and ultimate
effects for its employment to be warranted.
Since belladonna and ergot were shown to diminish vascular action in
the cerebro-spinal axis by contracting its capillary blood-vessels,
they have {834} been put forward as having a specific virtue in this
disease. If the fact be so, how is that other fact--a clinical one,
moreover--to be disposed of, which is that opium, the physiological
antagonist of belladonna and ergot, is more efficient than they are in
curing the disease? It is possible, indeed, that they may have that
curative power, and that opium possesses it also, and that the
explanation given of the action of all of these agents is erroneous.
Upham states that, in 1863, Haddock recommended ergot upon theoretical
grounds, and that during an epidemic at Newbern, N.C., several cases
treated by it recovered. Three cases recovered in which it was
prescribed by Borland. Read used it in 1873-74 at Boston, Mass., and
out of 19 cases 16 recovered and 3 died.[60] This mortality of about
15 per cent. is not more than half of that which has generally been
met with, and if it can be attributed to the treatment would go far to
prove the efficacy of the latter. One grain of ergotine, with
one-tenth of a grain of extract of belladonna, was administered every
three hours. Considering the exiguity of the dose of belladonna, it is
not surprising that, except in one case, it did not dilate the pupil;
and the dose of ergotine is likewise far smaller than the average
medicinal dose of that preparation. Moreover, all of the cases except
the fatal ones appear to have presented the disease in a subacute, and
certainly not in an aggravated, form.
[Footnote 60: _Philadelphia Med. and Surg. Reporter_, Jan., 1875, p.
68.]
In 1872, Dr. S. N. Davis,[61] moved by the success of Calabar bean in
tetanus, employed it in this disease. A mixture of one ounce of
tincture of Calabar bean with one and a half ounces of fluid extract
of ergot was administered in doses of half a teaspoonful every two
hours, and with better results than had followed other remedies. Here,
again, it is to be noticed that the analogy suggesting the use of
physostigma is not a logical one. That drug indeed relieves the spinal
spasms of tetanus--a disease in which there is an irritation of the
spinal axis, but no exudation from its meningeal vessels, as in the
affection we are studying. Moreover, it is a disease of extraordinary
power, as shown not only by the spasms, but by the exceptionally high
temperature, and thus again is in direct contrast to epidemic
meningitis. If, therefore, Calabar bean benefits that disease, it
cannot do so in the manner suggested by the author.
[Footnote 61: _Richmond and Louisville Med. Jour._, xiii. 711.]
Bromide of potassium and hydrate of chloral have also been employed to
allay the spasmodic symptoms; but the former is too feeble for the
purpose, and the depressing action of the latter upon the heart
renders it dangerous. Bromide of potassium has been given to children
of two and five years in doses of four and six grains every two hours;
but these doses appear to be quite too small even for the purpose in
view--viz. to prevent convulsive attacks. Whatever remedies may be
suggested hereafter, none should be employed that tend to reduce the
power of the heart, which, as we have seen, is dangerously depressed
by the disease.
During the decline and convalescence of the affection it is probable
that iodide of potassium may be advantageously used to promote the
removal of the exudation-matter on the brain and spinal marrow, and
probably to prevent the hydrocephalus which sometimes follows the
attack, and is attributable to the pressure of effused lymph upon the
cerebral veins.
DIET.--The mildly febrile character of epidemic meningitis, and the
{835} remarkable debility which characterizes so many cases of the
disease, and which, as was before pointed out, conferred upon it the
name typhus syncopalis, plainly justify what experience has taught,
that appropriate food for the subjects of this affection is at once
the most digestible and nutritious that can be taken. It is true that
this regimen is interfered with by the vomiting, but, as that symptom
is of cerebral and not of gastric origin, it is more apt to be allayed
by suitable food than by abstinence. It has been our custom to observe
in this disease the same rules respecting diet that are recognized as
the most suitable in typhus fever. In doing so, indeed, we did,
without at the time knowing it, follow the example of the early
American physicians. Strong, who wrote in 1811, advised "soup made
from chicken, veal, mutton, and beef, richly seasoned with pepper and
savory herbs." These articles were prescribed by him during the height
of the disease. Later on he says: "The stomach soon begins to crave
something more solid than soup; oysters, beefsteak, cold ham, or
neat's tongue are received with peculiar relish. Often I have seen
convalescents, when they had hardly strength enough to raise
themselves in bed, make a hearty meal of the above-mentioned articles,
which were received with great satisfaction, sat well upon the
stomach, and were well digested and assimilated." This method is
substantially the same that was found successful in the earlier, as it
has been in the later, epidemics in this country, and we have no
hesitation in attributing to it and the appropriate use of opium and
blisters the degree of success we enjoyed in the treatment of the
disease in the Philadelphia Hospital and elsewhere.
During convalescence from epidemic meningitis the patient should
carefully abstain from physical exertion and mental excitement, and
before this state is fully established he should even very cautiously
change his position from a recumbent to an erect posture. And,
finally, he should return to his ordinary occupations, mental or
physical, as late as possible, on account of the danger of a relapse,
which has already been described.
{836}
PERTUSSIS.
BY JOHN M. KEATING, M.D.
HISTORY.--A careful study of this disease from the various writings
since the time of Hippocrates leaves little doubt in the mind of the
reader as to its antiquity, so little indeed has it changed in its
various characteristics. Whether the affection passed to continental
Europe from Africa, or whether its starting-point was India, are
questions difficult to solve, and, except for the medical historian,
of little import. Desruelles probably truthfully asserts that the many
differences which mark the descriptions of the disease, especially by
the early Grecian writers, may be due, not to the non-existence of the
disease as we know it, but to the influence which climate exerted then
as now, and to the unrecognized fact that it is only fatal in its
complications. The writings of Hippocrates, Galen, and Avicenna,
though undoubtedly referring to the many affections in which
paroxysmal cough is a prominent symptom, contain many expressions that
would point clearly to the existence of a specific disease. Dr. Watt
believed that the disease was not known to the Greeks, and other
writers claim that it came from the north and spread southward over
Europe about the sixth century; nevertheless, it first appears on
record as a distinct affection, disentangled from the confused mass
with which it was involved for centuries, about the middle of the
seventeenth century. Steffen mentions the first well-established
accounts as coming from Baillou in the year 1600, and Schenck in 1650,
and Ettmüller in 1685. Sydenham casually mentions it in 1670. Since
the time of Willis the definition of the disease has remained
unaltered, and so accurate was the description then given of it that
we can but naturally conclude that for many centuries at least it has
varied but little.
In studying affections of this kind, occurring in epidemic form
especially, and which are increased in intensity by whatever means the
contagious element, whether gaseous or parasitic, is made more
virulent, much allowance is to be made for the climate, customs, and
habits of the people whence our data are derived. Thus, most of the
diseases of antiquity, the descriptions of which have reached us, have
been drawn from types modified by mild climates where the people have
led an out-door life, and though the disease we see at the present day
is one and the same so far as its causation is concerned, the indoor
life and close confinement, the bad ventilation, and the artificial
existence in our large cities must weaken the individual, intensify
the poison, and exert an influence on the disease.
DEFINITION AND DESCRIPTION.--Whooping cough has been {837}
characterized as an acute contagious affection, occurring usually in
childhood, though it may occur at any age, and lasting several weeks.
It is manifested usually by malaise, catarrh of the respiratory tract,
and subsequently by a convulsive cough occurring in paroxysms, the
peculiarity of which consists of a series of forcible expirations,
followed by a sonorous inspiration or whoop, which may be repeated
several times.
At the beginning of these paroxysms of coughing, there are evidences
of slight laryngeal irritation, attended by an effort at suppressing
the cough; then follow gradually increasing and more audible
inspirations, which become more and more difficult. The child is
agitated, the face becomes pale, and the countenance has a mingled
expression of supplication and fear. If it is old enough it will seize
the nearest object for support. As the spell advances, the eyes become
suffused and prominent and the loose tissue surrounding the orbits
appears puffy and congested. Finally, the paroxysm reaches its height;
the child, with a livid countenance, with veins standing out like
cords, gives a succession of violent expiratory efforts, followed by a
long inspiratory whoop. The same is repeated several times, until
finally almost complete cyanosis takes place; the spasm relaxes, a
glairy, tenacious mucus runs from the mouth, the contents of the
stomach are vomited, and the child falls back exhausted. The lividity
of the countenance is succeeded by a deathly pallor; the face still
appears swollen and puffy beneath the eyes; the tears course down the
cheeks, and frequently hemorrhage occurs from the eyes, nose, ears, or
throat, owing to the terrific strain upon the circulation. As soon as
the child has recovered from the fatigue of the paroxysm all is
apparently over, and were it not for the characteristic expression of
the eye, which is pathognomonic in a well-advanced case, nothing would
be noticed to even suggest the disease when uncomplicated. The voice
is clear; there is little or no elevation of temperature.
The paroxysms which have given the name to this disease can only be
likened to an epileptic convulsion, which by gradually increasing
cyanosis is self-curable, the carbonized blood finally bringing about
an anæsthetic effect. The severity of the paroxysms is by no means in
proportion to the local catarrh, which latter may be superficial and
slight, not to be detected during life by the most careful laryngeal
examinations, and only after death by the aid of the microscope. The
frequency and intensity of the paroxysms are dependent in a measure
upon the degree of excitability of the nervous system, which of course
differs in individuals. It is evident that the success of treatment
must be powerfully influenced by this circumstance, and it is partly
owing to it that there are so many opinions as to the value of
remedies in this disease.
The complications are usually dependent upon outside causes, and have
nothing to do with the poison proper of whooping cough, as far as we
can tell. There are some which depend on an inflammation of the mucous
membrane, which may be limited to any portion of the respiratory tract
or may extend throughout it. Complications may arise from mechanical
obstruction to inspiration by the swollen mucous membrane or from
plugs of tenacious mucus, which may cause pulmonary collapse and favor
the development of catarrhal pneumonia, and later even of phthisis; or
from impediments to free and easy expiration, whether from spasm of
the bronchioles, from forcible compression of the thorax through
reflex {838} nervous irritation, or from other obstructions, all of
which tend to produce emphysema. Disturbances of the circulation, in
the brain or elsewhere, may proceed from thrombi or emboli and give
rise to complications which will render fatal an otherwise mild form
of the disease. The invariable disturbance of nutrition which
accompanies every disease affecting the nervous system is apt to show
itself in the breaking down of products which are simply inflammatory.
Vomiting may be a most serious complication, both from its immediate
and remote effects. It may be due to gastric catarrh, or more
frequently to irritation of the pneumogastric nerve.
ETIOLOGY.--Very numerous theories have been advanced as to the nature
of this interesting disease. Hufeland, Lebenstein, Pinel, Jahn, Todd,
Cullen and a host of others have regarded it as essentially a
neurosis. By many others it has been supposed to be due to a lesion of
the brain or of its membranes, but careful investigation has
established the fact that there is no lesion in whooping cough at all
constant or characteristic. By still others, and especially by Gueneau
de Mussy, it has been regarded as essentially an affection of the
tracheo-bronchial glands, a bronchial adenopathy, causing irritation
of the pneumogastrics and of their bronchial branches by pressure of
the enlarged glands. We have, however, seen many post-mortem
examinations of the bodies of children who have died of measles, where
marked enlargement of these glands was constantly found, but where no
symptoms of whooping cough had been present. There are indeed many
features of the disease which seem inexplicable on any other theory
than that the essential cause of whooping cough is a specific poison,
and such is the view now generally adopted. This poison is capable of
being carried by fomites, though as it is highly infectious it is
often communicated through the atmosphere, and is most frequently
conveyed from individual to individual. Dolan,[1] who has recently
published a very interesting and valuable monograph on this affection,
quotes Linnæus, who ascribed it to the irritation of insects, as the
author of the modern view that whooping cough is due to the presence
of a peculiar microbe, though it must be conceded that as yet it has
not been discovered. Most observers hold that the contagium is not in
the blood, but that it resides in the secretions of the respiratory
passages, and is most virulent during that stage of the disease when
the secretion is abundant. Letzerich states that he has {839}
succeeded in producing whooping cough in rabbits by inoculating the
trachea with the sputa of the human subject. Dolan obtained similar
results by injecting the nasal secretions, and also by compelling
rabbits to inhale air impregnated with decomposing sputa and vomit of
patients suffering with the disease.
[Footnote 1: Dolan, Thos. M., _Whooping Cough_, London, 1882.
The following brief statement of his conclusions may be quoted as
presenting the most important facts concerning the pathology of the
disease:
1st. Pertussis depends on a specific poison or contagion; this is
universally admitted.
2d. This contagion is active and highly infectious; this is also
granted.
3d. The contagion is analogous to the contagia which produce splenic
fever, measles, scarlatina, variola, etc.
4th. It has a peculiar determination to the lungs.
5th. Like all other contagia, it has its period of activity and
decline.
6th. The period of greatest activity is in the first and second
stages.
7th. Pertussis runs a regular course like measles, scarlatina,
variola, etc., and rarely attacks a person but once.
8th. It may thus be classed among zymotic diseases.
9th. The fact that there is no primary pathognomonic morbid change
supports this view.
10th. There are various secondary lesions which are characteristic, as
ulcerations of the frænum linguæ.
11th. The mode of death harmonizes with this view.]
I do not, however, feel entirely satisfied in adopting the view that
the contagium of whooping cough resides alone in the mucous membranes
of the air-passages.[2] Children have been known to be born with the
disease, the mother having suffered from it some time previous to
confinement. The following case occurred under my own observation:
Mrs. F----, the mother of two children, was in her eighth month of
pregnancy; the two children had at the time a very severe attack of
whooping cough, which required the constant attendance of the mother.
She, though an extremely intelligent woman, belonged to the poorer
classes, and had no one to assist her at this trying time. One day she
complained that the movements of her child in utero had entirely
changed. Suddenly, without any previous motion, the child would become
very active; the force of its movements was such as to make hazardous
any attempt on her part to walk in the street. The suddenness with
which the movement would come on would oblige her to seize the nearest
object for support. This continued until the child was born. Shortly
after labor my attention was called to the infant, which had a curious
attack, it became deeply cyanosed, seemed asphyxiated, as it were, for
a moment, had no convulsions, and within a few seconds resumed its
normal breathing and the circulation seemed once more established. I
saw the child in several of these attacks; its health did not seem to
be impaired, and without treatment, within a few weeks they
disappeared altogether. The mother insisted upon the fact that the
child had whooping cough, and the absence of the characteristic whoop
was the only thing that prevented the diagnosis from being positive.
This would show--and there are enough cases on record to warrant our
basing an opinion upon them--that the contagium of whooping cough is
found not alone in the matters expectorated, notwithstanding the
statement of Dolan and others that their experiments failed to show
its existence in the blood.
[Footnote 2: Colson, _Lancet_, July 2d.]
It must not be forgotten, in reference to cases which seem to have
arisen without any exposure to the specific poison, that the
characteristic whoop is not always present, and that consequently the
true nature of mild cases of the disease which may infect other
individuals may have been overlooked. Childhood probably acts as a
predisposing cause, though the disease occurs at all periods of life,
and as it usually occurs but once in the same individual, it is clear
that the apparent diminution of susceptibility in later years may be
largely due to the fact that most persons have had the disease in
childhood. More children are attacked from one to five years, and the
disease is more prevalent in summer and fall months. Causes which,
like exposure to inclement weather, give rise to irritation of the
bronchial mucous membrane, or diseases which, as measles, are
accompanied with catarrhal symptoms and susceptibility of the
bronchial mucous membrane, also may serve as predisposing causes. Sex
appears to exert some positive influence. Of 360 cases of pertussis by
Dessau,[3] the total number of males were 154, that of females 206.
Girls are more {840} frequently attacked than boys, in proportion of 2
to 1.50; this seems true at all ages; this statement is substantiated
by Unruh of Dresden, based on an analysis of 1952 cases.
[Footnote 3: _N.Y. Jour. of Obst._, 1881, xiv. 490-503.]
SYMPTOMS.--The disease begins usually with an ordinary catarrh,
preceded by malaise and slight laryngeal irritation, which may be
overlooked; in fact, during the first stage there is nothing to
attract special attention, unless a direct history of exposure be
known and suspicion be aroused on that account. Meigs and Pepper state
that the earliest period at which they have known the distinctive
whoop of the disease was three days, though in a great many instances
it was delayed as late as three weeks. The same authors state that the
ordinary duration of a paroxysm or kink is from one-fourth to
three-fourths of a minute. They mention a case where the paroxysm
lasted fifty-five minutes. Ordinarily they number about thirty-five or
forty during the twenty-four hours at the height of the disease,
differing greatly in individuals. Their number is most frequent in the
course of the third or fourth week, after which they remain
stationary, and then gradually decline. The paroxysms may occur
spontaneously, or they may follow some irritation, either direct or
reflex, or they may be induced by nervous excitement. Toward the end
of the attack, after the catarrhal irritation has greatly subsided, or
in fact has entirely disappeared, the paroxysmal kinks may be provoked
by irritation of the fauces, and also by nervous excitement; and there
is no question but that at this time they can be controlled by
will-power. In many cases a distinct relapse occurs after the disease
has been apparently cured.