suggested by Laennec, to a "spasmodic condition of the muscular or
contractile fibres of the bronchi and their branches." He remarks that
the lungs are supplied from the anterior and posterior pulmonary
plexuses, formed chiefly of branches from the sympathetic and
pneumogastrics. The filaments from these accompany the bronchial tubes
upon which they are lost. Irritation of these nerves is said to have
the effect of producing contractions of the bronchial canals
sufficient to expel a certain quantity of air. If this theory is true,
it helps us in explaining why the large, mediate, and smaller bronchi
are closed during the expiratory stage of the paroxysmal cough of
pertussis. The general opinion seems to be that the pneumogastric
nerve is not inflamed, as has been asserted by some.
The highly sensitive condition of the nervous system, which is
probably in a great measure intensified by the anæmia, and by the
interference with nutrition due to the disturbance of the circulation
by the cough, will show itself in many ways, and even when no
secondary nervous affections complicate the attack or follow it. Some
time will elapse after the disease has passed away before the child
will recover its self-control, or its nutrition will show the
influence of a healthy nervous system. The total duration of the
affection is said to vary from six weeks to three months in ordinary
cases; though probably, if active treatment could be instituted early
enough and kept up with thoroughness, there is no specific disease
more capable of being shortened in its course than the one under
consideration; this remains, however, for future statistics to decide.
During the second stage of the disease the symptoms are sufficiently
{841} marked to attract attention and render a diagnosis easy to make.
Frequently the catarrh seems to extend to the bronchioles, and gives
rise to symptoms that are alarming; and the intensity of the paroxysm
will cause the engorgement of the blood-vessels to get relief in
profuse hemorrhage; this is the period for caution. Complications may
arise, the strength may fail, the secretions may become too abundant,
and asphyxia may ensue; emphysema may show itself, or catarrhal
pneumonia may gradually supervene.
The period of decline is very gradual; the secretions become less in
quantity and more viscid, the paroxysmal cough is less frequent, but
may at times be equally severe, the child's strength is usually
exhausted, and its nutrition is greatly impaired. The expected
paroxysm throws it into a state of intense nervous excitement; it is
sleepless--in fact, worn out. Probably at this period of the disease
treatment will show the most marked results, and the long lists of
sedatives, tonics, etc. which are presented to us by their zealous
advocates owe much of their popularity to their value at this stage of
the disease. The catarrhal symptoms are the first to subside; the
nervous disturbances remain for some time, and gradually fade, and the
constitutional symptoms, or those from exhaustion, are the last to
leave the patient.
Strange as it may seem, the heart appears to suffer but little in the
long run from the great strain upon it; the palpitation and
irregularity of its actions are not followed by structural changes as
a rule, though we may state that feebleness of the circulation has
remained in most of our bad cases for some months after recovery.
As regards the ulceration of the frænum linguæ, which has given rise
to so much discussion as to its exact value as a symptom of this
disease, our own experience leads us to believe that though it is
nearly always present in the severe cases, its almost invariable
absence before dentition and in milder cases shows it to be of
traumatic origin. Roger's exhaustive report before the French Academy
supported this view, and showed how clearly it is caused by the
violent rubbing of the frænum on the free border of the incisors. On
the other hand, Delthil of Paris and Blake of England believe that it
is a pathological feature of the disease. The former reported cases in
which it occurred before dentition. The ulcer is not always found on
the frænum linguæ, but is found on either side of it. Bouffier noted
severe cases of ulceration in children who had no teeth, but he
attributed it to the injury produced by the mother in detaching the
mucus with the finger.
Examinations of the urine have been carefully made by many observers.
The appearance of sugar, about which so much has been said, does not
seem to be constant, or even very frequent. Out of 50 cases, Dolan
found traces of it in but 13. This coincides with our experience also,
for we have frequently tested the urine in seven cases with negative
results. Since, as is well known, irritation of the pneumogastric
centre may cause glycosuria, it was at one time attempted to show that
the paroxysms in whooping cough were due to congestion of the
pneumogastric nerves, a condition which is said to have been
occasionally found in this disease. Dolan says he has never seen
hemorrhage from the kidneys during the course of whooping cough, nor
blood in the urine.
MORTALITY.--It is an extremely difficult matter to reach, with any
{842} degree of certainty, the true mortality of this affection. Meigs
and Pepper say: "Of the 208 cases observed by ourselves, 143 were
simple, all of which recovered;" and, again, "Some form of
complication occurred in the 65 of the 208 cases observed by
ourselves; of these 65, 12 died." The mortality seems greater under
five years; thus: Of the 9008 deaths attributed to it in the United
States during the census year ending June 1, 1870, the number of
persons under one year of age was 4424, and 8396 were under five
years. There were 1784 deaths from it recorded in Philadelphia from
1860 to 1876; of this number, 1724 were under five years of age. The
census of the United States for 1880 gives a return of 11,102 deaths
from this disease.
Females seem more liable to die of it than males; of the 1784 deaths
in this city, 766 were males and 1018 females. As we have already
seen, females are more liable to the disease than males.
Robt. J. Lee, M.D.,[4] says that from the Registrar-General's report
of 1876 it is seen that in a total mortality in England of 510,315,
whooping cough was returned as the cause of death in 10,554 cases, or
nearly 2 per cent.
[Footnote 4: In a paper in the _British Med. Jour._, 1879, vol. i. p.
307.]
As for the time of year, we quote the following: "Thus, according to
the census statistics, most deaths occur in the spring, there being a
rise up to the middle of May. From the middle of May the number
lessens largely until August, when a rise occurs and continues until
October, when a decline sets in and continues until December, when a
rise begins and goes on increasing until the middle of May. This rise
in mortality from August to October is attributed to the wear and tear
of a hot summer and the intestinal troubles then so prevalent."
The mortality statistics of this disease are uncertain. It is fatal in
its complications or by inducing a debilitated condition which invites
degenerative processes. The severity of the symptoms is no guide for
prognosis as far as uncomplicated cases are concerned, and there is no
doubt but that at present we are able to greatly reduce the
mortality-rate by care and medical treatment, as well as to shorten
the attack. Sporadic cases are apt to be neglected until they become
complicated. When the disease occurs in epidemic form, measles is
often prevalent simultaneously, and in consequence children who become
affected by both diseases have a greater tendency, from debility, to
become the victims of those affections of the respiratory organs which
are such frequent and fatal complications of both maladies.
Instead of surprise at the mortality of this affection, the marvel is
that so large a percentage of recoveries take place, when we consider
that we are dealing with a disease whose lesion is a catarrh of the
air-passages which seldom lasts less than two months, with a tendency
to involve the lungs in one way or another, and then witness the
carelessness with which, among the lower classes, the child is often
treated--exposed to all weathers, under-clothed, under-fed, and
probably allowed to pass through the whole attack without medical
treatment. Taking this into consideration, the probability is that the
mortality of this disease could be reduced to a very small figure by
careful management, even if the investigations of those now seeking
the microbe of pertussis do not lead to any plan, in accordance with
Pasteur's teachings, which will still further lessen the gravity of
the disease. Until {843} then, we can but insist upon a rigid
quarantine of schools, a registration of all cases, and the seclusion
of them, as we have done to-day in the case of variola and scarlatina.
MORBID ANATOMY.--Although whooping cough is a serious disease, the
cause of death is generally found to be dependent upon its
complications, and there is no lesion at all characteristic of it. The
chief complications and sequelæ are--bronchitis, which may become
capillary; lobular collapse, which, according to Alderson,[5] is
frequently found; emphysema, usually marginal, probably due, as
suggested by Jenner, to violent expiratory exertions; rupture of
air-vesicles, with subcutaneous emphysema; catarrhal pneumonia,
pleurisy, phthisis, acute tuberculosis, croup, cerebral apoplexy,
meningitis, etc. As any of these complications, and others which may
arise from debility, may be the cause of death, independent of the
action of the specific poison itself, it is usual to divide the
post-mortem appearances into those that are the result of the
extension of the catarrh itself and those produced by the interference
with the circulation and with nutrition from mechanical violence. Of
the former, the usual causes of death are pneumonia, gastritis and
enteritis. Of the latter, we have thrombosis of the cerebral sinuses,
hemorrhages, emphysema, and exhaustion following constant vomiting.
[Footnote 5: _Medico-Chir. Trans._, pp. 90, 91, 1830.]
Tubercular disease of the lungs or of the brain is apt to be a cause
of death. Convulsions carried off 5 of the 12 fatal cases reported out
of 208 by Meigs and Pepper. This may be due to congestion of the
brain, especially in teething children. Spasm of the glottis with
sudden death is occasionally found. In such cases there is found
intense congestion of the brain, also of the liver and kidneys, and at
times of the mucous membrane of the stomach and intestines, as well as
of that of the respiratory tract.
In all cases, especially at the teething age, sudden death may occur
because effusion into the ventricles of the brain or the formation of
heart-clot has taken place. It is important to know this, that active
treatment applied early enough may save the patient.
PROPHYLAXIS.--Should the interesting and seemingly conclusive
statements of Dolan and the microscopic investigations of Carl
Bruger[6] receive the endorsement of future workers, the subject of
prophylaxis will assume a degree of importance which hitherto it has
only maintained with the medical profession. No one has doubted that
the disease was contagious, and yet there is no affection which has
attached to it a corresponding fatality that is so carelessly dealt
with as pertussis.
[Footnote 6: Bruger of Bonn, in the _Berliner klinische Wochen._,
describes at length the special micro-organisms of pertussis. They
appear as small elongated elliptical bodies of unequal length, the
smallest being double as long as broad. High powers show subdivisions
in the largest specimens. They are generally isolated, but may appear
in groups. They bear some resemblance to _Leptothrix buccalis_, the
spores of which are often found in whooping-cough sputa. Occasionally
the bacillus is seen inside the mucous corpuscle in the sputum. They
stain in the usual way, fuschin and methyl violet. This bacillus is
not found in any other kind of sputum, is very abundant in pertussis,
and increases in direct proportion to the severity of the disease.]
Within the past few days we have heard on two occasions in crowded
railway-cars the characteristic paroxysm of the third stage of the
disease, and yet people will endeavor to convince themselves that
unless contact with the child takes place the danger is little.
{844} The atmosphere in school-rooms, railway-cars, and places of
amusement which are badly ventilated, is an excellent medium for the
propagation of the contagious matter, and many extraordinary cases are
on record of momentary exposure being sufficient to contract the
disease. Believing that the contagium or virus resides in the mucus
and air thrown off by the child, and also in the vomited matters,
which contain a large amount of ropy mucus, and also that it gains
entrance by means of the respiratory organs, protection from contagion
divides itself as follows: thorough disinfection of the exhaled air,
of the mucus remaining within the bronchial tubes and air-passages,
and of the clothing, together with exposure to fresh air and thorough
cleansing of all furniture and household utensils, including cups,
silverware, and toys, used by the child. Oxygen is said to have this
effect, and thorough, constant ventilation, with the breathing of
fresh air by the child, the thorough washing of its surface, and
disinfection of its clothing, are the first indications; while the
impregnation of the atmosphere with the spray of well-known germicides
by means of the steam or other atomizer and the frequent inhalation of
such materials by the patient are no less important. Every case of
whooping cough should be compelled to use two or three times daily the
spray impregnated with a substance of this sort, either carbolic acid,
the oil of eucalyptus, a solution of quinia, or thymol. Chlorine (from
chloride of lime) used thus has of late been followed by excellent
results, and the spray of a solution of corrosive sublimate or of
ammonium chloride has been found very useful. The protective treatment
should be applied to those exposed to contagion. Such children should
be guarded from exposure to colds; their diet should be simple and
nourishing, their clothing warm; they should be kept as much as
possible in the open air. The breathing of air impregnated with such
substances as above mentioned will no doubt act upon the virus before
it comes in contact with the mucous membranes so as to be absorbed,
and probably the severity of the attack might be mitigated by
modifying the germ of the disease.
TREATMENT.--As can be readily imagined, a disease which is so
universal, so distressing, and at the same time so obscure in its
pathology, as the one under consideration, would have in its
literature a mass of recommendations for treatment from zealous
advocates, based upon theory or experience, as numerous as the authors
themselves. It would be impossible for us to dwell at length upon all
of these, but we will confine ourselves especially to the
consideration of a few of the most important. It will be convenient to
consider first those remedies which have been used with the view of
relieving the congestion and irritability of the respiratory mucous
membrane and of promoting more free secretion. It will also be
observed that many of these remedies may now be regarded as of value
for destroying the special germ which is thought to be the essential
cause and real virus of pertussis. Allusion has been made above to the
importance of inhalations as a prophylactic for those who have been
exposed to the contagion, as well as for the purpose of rendering the
secretions less contagious; and so too we find that the inhalation of
various substances has received favor with many as a method of
treatment. Thus, hyoscyamus, belladonna, ammonium bromide have been
used. Helenke and Serbaud say that bromide of {845} potassium is best
for inhalation. Letzerich recommended the insufflation of quinia twice
daily, using the quinia muriate with potassium bicarbonate and
gum-arabic. Forchheimer[7] reports 97 cases of whooping cough treated
by the insufflation of the quinia muriate; of the 97 cases, 52 were
females, 45 males--the youngest three weeks, the oldest nine years
old. Five cases gave no results, while in the others benefit was shown
by a shortening or amelioration of the disease. The vapor of benzole
has been used with good results. The vapor of carbolic acid has of
late been highly recommended, either administered with the atomizer
several times daily, or used by saturating flannels in carbolic acid
solution and placed around the child's bed at night. It is said that
the inhalation of the vapor of a few drops of carbolic acid on some
hot coals will ensure a night of freedom from violent coughing.
Probably in this way we may account for the belief that proximity to
gas-works is beneficial to a child with this disease. As is well
known, Niemeyer and others in the north of Germany believed in the
value of the inhalation of oxygen, and the experience of every one who
has had much to do with this disease favors an out-door life. We may
here also mention the value of a small quantity of chloroform or
ether, by inhalation, in allaying the severity of the paroxysms of
cough. We have also tried the nitrate of amyl, but without marked
result.
[Footnote 7: _New York Jour. Obstet._, 1882.]
Others have recommended the use of solutions of various substances,
applied directly by a brush to the interior of the larynx. Quinia has
been used in this way also by Hagenbach; but the most satisfactory
results have been obtained by the application of very weak solutions
of nitrate of silver, as first recommended by Watson in 1849.
After the secretions have been fully established and the
characteristic whoop has appeared, the indications in the treatment
are to relieve the respiratory tract of its burden by occasional
emesis with alum or ipecacuanha, to give freely antispasmodics and
sedatives, as belladonna, chloral, the bromides, hydrobromic acid, or,
as recommended by some, digitalis; to give quinia freely, and to use
counter-irritants to the neck and chest with liniments composed of oil
of amber, croton oil, or turpentine.
The value of emetics has been long recognized in this affection,
although we are told by Vogel that the continuous use of emetics in
the early stage for several days causes harm. Copeland ordered an
emetic every third day in ordinary cases. All writers agree that the
milder emetics should be used by preference; that tartar emetic should
be avoided, except as an external application where a counter-irritant
is desired; and that ipecacuanha is the safest, though alum is also
safe and as an astringent useful. Trousseau preferred the sulphate of
copper. In the earlier stages of the disease emetics are not, as a
rule, indicated; it is only when the secretion has become extremely
tenacious, and the paroxysms so frequent and severe as to greatly
strain the patient and endanger his lungs, that they are of value.
There seems to be a close connection between the amount and tenacity
of the secretion and the severity of the paroxysm. The potassium
carbonate has been recommended as an active agent in the amelioration
of this affection; it is probably valuable in rendering the secretion
less tenacious. Alum has been used with success, as has tannin,
probably owing to their local action on the mucous membrane.
Macartan[8] says that in the East {846} Indies the disease is treated
in the first stages by astringent and tonic gargles.
[Footnote 8: _Dictionnaire des Sciences Méd._, 1813, vol. vi.]
Belladonna certainly receives the endorsement of the greatest number
of writers. Vogel considers it superior to all other drugs, and
regards dilatation of the pupil as the only sure guide in its
administration. He says it does not cut short the attack, but
mitigates the paroxysm. Trousseau was also an advocate of this form of
treatment. When combined with alum[9] it is considered by Meigs and
Pepper to be one of the most valuable drugs recommended. They also
advise the use of potassium carbonate. Seiner trusted belladonna more
than any other remedy; so also Rilliet and Barthez. William Lee, in an
interesting paper in the _New York Medical Journal_, 1883, advocates
the use of atropia hypodermically; he believes that atropia chiefly
acts in these cases on the laryngeal branches of the pneumogastric
nerves, and that it is probable that it has a decided effect also on
the medulla oblongata itself, and renders it less capable of exciting
reflex action. Kroon's experiments led him to conclude that the
valerianate of atropia was the most useful. Evans[10] gave the 1/120
of a grain of atropia to a child aged three years until the pupils
were dilated, then reduced the dose; this stopped the paroxysm in
twenty-one days. At the commencement of the treatment the child had
twenty-three paroxysms in the day, and twenty-seven at night. Case No.
2 under same circumstances recovered in fourteen days. In case No. 3
the paroxysms were reduced from twenty-six to two or three a day.
Arthur Wiglesworth[11] used a solution of sulphate of atropia,
administered in the morning fasting; the dose he advises for children
from one to four years is gr. 1/120, given only once a day except in
some cases. The results are as follows: There is a steady diminution
in the number of paroxysms; a change in the character of the whoop as
if the vocal cords were not so closely approximated. If atropia is
withheld, the beneficent effect derived from it subsides.
[Footnote 9: Golding Bird, _Guy's Hosp. Rep._, April, 1845.]
[Footnote 10: _Glasgow Med. Jour._, 1880.]
[Footnote 11: _Lancet_, April 12, 1879.]
West advises dilute hydrocyanic acid, and many writers agree with him,
ranking it next to belladonna.
Harley and others are strong advocates for the bromide of ammonium; it
is supposed to have a local anæsthetic action on the pharyngeal and
laryngeal mucous membrane. Fordyce Grinnell[12] during four months
treated 223 cases with this remedy, and highly recommends it. The
doses were in accordance with those of Dr. Kormann--3/4 to 4 grains,
as indicated by age, three or four times a day and at night when the
paroxysms were severe. No other treatment was used in these 223 cases,
except camphorated oil to the throat and chest in some cases.
Potassium bromide has been recommended by Helenke, Beaufort,
Erlenmeyer, and others. Henry Field[13] recommends sodium bromide.
[Footnote 12: _Med. News_, 1882.]
[Footnote 13: _Brit. Med. Jour._]
Probably next to belladonna in the treatment of this disease we should
place chloral hydrate.
Hebner, after an elaborate study of the relative value of potassium
bromide, quinia, salicylic acid, chloral, and belladonna, says:
"Salicylic acid and chloral tend to relieve the paroxysms--belladonna
and quinia to shorten the disease." Kennedy[14] writes: "I cannot
doubt {847} its specific effects on the cough. Chloral seems to me to
yield the best and most constant results. The advantage of chloral
hydrate seems to exist in producing sleep; it should be given in from
2- to 5-gr. doses, at night." If there is much irritability or
fretfulness, or any premonition of eclampsia, it should be associated
with potassium bromide.
[Footnote 14: _Dublin Jour. M. S._, 1881.]
Croton chloral has received much praise from those who have used it;
we have had no experience with it.