WHOOPING-COUGH.
It is singular that a malady so distinctively marked as whooping-cough is
should figure so little in the records of disease from former times.
Astruc could find no traces of it in the medical writings of antiquity or
of the Arabian period. In modern times the first known account of an
epidemic of it is under the year 1578, when Baillou of Paris included a
prevalent convulsive cough as part of the epidemic constitution of that
year, remarking in the same context that he knew of no author who had
hitherto written of the malady[1234]. Yet, if whooping-cough had been as
common in former times as it has been in quite recent times, it deserved a
high place among the causes of infantile mortality. Doubtless it occurred
in former times in the same circumstances in which it occurs now. Baillou
in 1578 speaks of it as a familiar thing; and it can be shown from an
English prescription-book of the medieval period that remedies were in
request for a malady called “the kink,” a name which survives in Scotland
(like other obsolete English words of the 15th century) in the form of
“kink host[1235].”
In Phaer’s _Booke of Children_ (1553) chincough is not named. It is
perhaps more singular that the disease should be omitted from the list in
Sir Thomas Elyot’s _Castel of Health_ (1541), of maladies proper to three
periods of childhood; for that list has every appearance of being an
exhaustive enumeration[1236]. Still, it would be erroneous to suppose that
the convulsive cough of children which is so common an epidemic incident
in our time, and in some impressionable subjects is the almost necessary
sequel of a coryza or catarrh, did not then occur in the same
circumstances as now. When Willis, in his _Pharmaceutice Rationalis_ of
1674, remarks that pertussis was left to the management of old women and
empirics, he suggests the real reason why so little is said of it in the
medical compends. Sydenham mentions it twice, and on both occasions in a
significant context. Under the name of pertussis, “quem nostrates vocant
_Hooping Cough_,” he brings it in at the end of his account of the measles
epidemic of 1670, without actually saying that it was a sequel of the
measles. His other reference to it, under the name of the convulsive cough
of children, comes in his account of the influenza of 1679. In both
contexts it is adduced as an instance of a malady much more amenable to
bloodletting than to pectoral remedies, the depletion being a sure means
of cutting short an attack that was else very apt to be protracted, if not
altogether uncontrollable[1237]. One glimpse of it we get among the
children of a squire’s family in Rutlandshire in the summer of 1661. On
the 26th of May the mother of the children writes to her husband then on a
visit to London[1238]:
“I am in a sad condition for my pore children, who are all so trobled
with the chincofe that I am afraid it will kill them. There is many dy
out in this town, and many abroad that we heare of. I am fane to have
a candell stand by me to goo in too them when the fitt comes.” On 2
June, the children are still “all sadly trobeled with the chincofe.
Moll is much the worst. They have such fits that it stopes theare
wind, and puts me to such frits and feares that I am not myselfe.” In
a third letter, the children “are getting over the chincofe. I desire
a paper of lozenges for them”; and on 30 June, the children are
better, but the smallpox is still in the village. It was probably from
the latter disease that many were dying.
In Dr Walter Harris’s _Acute Diseases of Infants_[1239], the convulsive or
suffocative coughs are mentioned in one place without being identified as
chincough, while in two or three other places the malady is briefly
referred to under its name. Thus, “corpulent and fat infants troubled with
defluxions, and having an open mould, are most subject to the rickets,
chincough, king’s evil, and almost incurable thrushes.” Again, chincough
of infants is one of the inflammatory diseases that are “not altogether
free from contagion”; and again: “Albeit that any notable translation of
the subject matter of the fever into the lungs, and chincoughs, do advise
bloodletting for the youngest infants, yet it is most evident that it is
not a remedy naturally convenient for them.... And therefore its help is
not to be invoked for all the diseases of infants except in the chincough
or any other coughs that do attend and are concomitants of fevers that do
suddenly begin”--showing his deference to Sydenham, his master.
Probably the “any other coughs” are those that he thus describes in
another place (p. 26):
“Moreover he is often troubled with a slight, dry cough, though
sometimes it is strangling and suffocative: with a dry cough because
of the sharpness and acrimony of the humours that continually prickle
the most sensible branches of the windpipe; but the choaking doth
proceed from the abundance of serous and watry humours that so fill up
and burden the small vesicles of the lungs that it cannot be cast off
and discharged. But also they being endued with a great debility and
weakness of nerves, and a superlative softness and delicacy of
constitution, they are not able to subsist with that violent trouble
of coughing, but do succumb under that unnatural and excessive motion
of their breast, and their face is blackish as that of strangled
people.”
These were cases of whooping-cough, although they are not so called. Among
his eleven cases, Harris gives two in infants of the Marquis of Worcester;
one had been “very often troubled with an acute fever,” and was found to
be much weakened by a chincough when the physician was called to him; the
other, an infant of eleven months, had at the same time an acute fever
“and a cough almost convulsive.”
This inclusion, under the generic name of cough, of cases that had all the
signs of whooping-cough, namely, the paroxysmal seizures, choking fits,
and blackness of the face, is found also in the London bills of mortality.
Although “coughs” are entered as the cause of a not very large number of
deaths in the earlier annual bills, with an occasional special mention of
whooping-cough among them, it is not until 1701 that “hooping cough and
chincough” becomes a separate item, with six deaths in the year; next year
the entry is “hooping cough” alone, with a single death, and so on for a
number of years in which the deaths are counted by units; in 1716 they
rise to eleven, and continue to be counted by tens until 1730, when 152
deaths are set down to “cough, chincough, and whooping-cough.” It would be
a mistake to suppose that these figures during the first thirty years of
the 18th century are anything like a correct measure of the number of
infants in London who suffered from whooping-cough, or are at all near the
number who might have reasonably been returned as dying from it. It was in
that generation that the entries of the Parish Clerks became most
indefinite as to the causes of death in infants, five-sixths of the
enormous total of deaths under two years being entered under the generic
head of “convulsions” and “teeth,” while the item “chrysoms” received the
deaths under one month old.
The increase of whooping-cough in the following table, from units to tens,
from tens to hundreds, and thereafter to a somewhat steady total of
hundreds year after year, can hardly be explained except on the hypothesis
of more exact classification of infantile deaths, corresponding to the
actual decline of the article “convulsions” in the second half of the
century.
Years Whooping-cough
1701 6
1702 1
1703 5
1704 0
1705 0
1706 2
1707 3
1708 3
1709 1
1710 5
1711 7
1712 3
1713 6
1714 6
1715 7
1716 11
1717 15
1718 24
1719 17
1720 33
1721 20
1722 21
1723 38
1724 25
1725 53
1726 37
1727 67
1728 21
1729 35
1730 152
1731 33
1732 65
1733 97
1734 139
1735 81
1736 130
1737 160
1738 69
1739 72
1740 280
1741 109
1742 122
1743 92
1744 46
1745 135
1746 95
1747 151
1748 150
1749 82
1750 55
1751 275
1752 188
1753 65
1754 336
1755 93
1756 199
1757 239
1758 84
1759 227
1760 414
1761 197
1762 300
1763 291
1764 251
1765 225
1766 213
1767 364
1768 262
1769 318
1770 218
1771 249
1772 385
1773 235
1774 554
1775 206
1776 181
1777 529
1778 379
1779 268
1780 573
1781 165
1782 78
(Continued in the table of measles deaths, p. 655)
It is not without significance that the vital statistics of Sweden were
the first to give whooping-cough something like its rightful place among
infantile causes of death: from 1749 to 1764 the deaths set down to that
cause were 42,393, or an annual average of 2600, the epidemic year 1755
having 5832. In this we should find merely the influence of systematic
nomenclature. Nosology, or the scientific classification of diseases, may
be said to have begun under Linnaeus, who was for many years professor of
medicine at Upsala before he became professor of botany, and was teaching
a somewhat rudimentary nosology to the Swedish students of medicine before
the great work of his friend and correspondent Sauvages made
classifications general.
Concerning the year 1751, which has 275 deaths from whooping-cough in the
London bills, Fothergill writes in May: “Great numbers of children had the
hooping cough, both in London and several adjacent villages, in a violent
degree. Strong, sanguine, healthy children seemed to suffer most by it;
and to some of them it proved fatal where it was neglected or improperly
managed”--the deaths having become more numerous towards the end of the
year[1240]. At Edinburgh, during the second year of high mortalities in
the famine-period 1740-41, whooping-cough has 101 deaths to 112 from
measles, having had only a fourth part as many the year before (see p.
523). In the Kilmarnock register from 1728 to 1763, “kinkhost” is credited
with a total of 116 deaths, about 3 on an annual average, measles having a
total of 93 during the same thirty-six years. In Holy Cross parish, a
suburb of Shrewsbury, chincough has 9 deaths in the ten years 1750-60, and
6 in the next ten years, measles having 4 and 15 in the respective
periods, and convulsions 9 and 31. In Ackworth parish, chincough has no
deaths in the ten years 1747-57, and 2 in the next ten years, “infancy”
having 13 in each decade, “convulsions” and measles none in the first, 6
and 2 respectively in the second. Warrington, in the disastrous smallpox
year, 1773, had 16 deaths from chincough and 34 from convulsions. In the
two years 1772 and 1773, Chester had 33 and 10 deaths from chincough, 70
and 69 from convulsions, 17 and 13 from “weakness of infancy.”
Watt’s researches in the registers of all the Glasgow burial-grounds
brought out the fact that whooping-cough during a period of thirty years,
1783 to 1812, had been a common and somewhat steady cause of death among
infants, having made 4·51 per cent. of the annual total of deaths at all
ages in the first six years of the period, and 5·57 per cent. in the last
six years[1241]. This was a higher annual average ratio than in the London
bills for the same period (see the tables at p. 647 and p. 655), and was
probably the maximum in Britain, inasmuch as the Glasgow death-rate of
infants was the worst from all causes.
Whooping-Cough in Modern Times.
When the causes of death began to be registered, in July, 1837,
whooping-cough was found to have the following relative place among the
principal maladies of children during the latter six months of the year in
London and in all England and Wales.
_Mortality by diseases of Children, last six months of 1837._
London England and Wales
Convulsions 1717 10729
Measles 1354 4732
Whooping-Cough 1066 3044
Smallpox 763 5811
Scarlatina 418 2550
Throughout the whole registration period, whooping-cough has kept its
place steadily among the chief causes of infant mortality, neither
decreasing nor increasing notably in the successive periods from 1837 to
the present time. Its mortality has varied a good deal from year to year,
owing to occasional great epidemic years such as 1866 and 1878; but on the
mean annual average of decennial periods, it has varied little:
_Annual Deaths by Whooping-cough per million living at all ages._
Males Females Both sexes
1851-60 460 545 503
1861-70 487 566 527
1871-80 474 547 512
1881-90 -- -- 451
No other epidemic malady has shown the same excess of female deaths in
proportion to the numbers of the sex living, diphtheria being the only
other that shows an excess at all.
The excess of deaths by whooping-cough among female infants was roughly
shown by Watt in 1813, viz. 975 females to 842 males in the registers of
the Glasgow High Church, College Church and the North-Western Cemetery,
the relative numbers of the sexes living at the respective ages being then
unknown. In all Scotland in 1889 the ratio was 1043 male deaths to 1225
female. The singular difference between the sexes in this respect is
almost certainly related to the corresponding differences in the formation
and development of the larynx, the organ which gives character, at least,
to the convulsive cough of children. The expansion of the larynx in boys,
which becomes so obvious at puberty and remains so distinctive of the male
sex, is one of those secondary sexual characters which begin to
differentiate quite early in life, and are probably congenital to some
extent. It is not known whether female children are more often attacked
than males; but it is probable that they are predisposed both to acquire
coughs of the convulsive suffocative kind and to have their lives
shattered by the attack--for the same anatomical and physiological
reasons, namely, the imperfect development of the posterior space of the
glottis with the spasmodic closure by reflex action[1242]. The deaths have
been nearly all under the age of five.
_Deaths by Whooping-cough per million living at the respective
age-periods._
0-5 5-10
1851-60 3624 174
1861-70 3766 152
1871-80 3652 135
These proportions are almost the same as those given by Watt in 1813 from
three of the Glasgow registers.
Deaths by
Period whooping-cough Under five Five to ten Above ten
1783-1812 1817 1713 98 3
Most of the deaths are in the first year, and in a rapidly declining ratio
until the fifth, according to the following rates per million of male
children living at each age-period (these figures are for a single year,
1882):
Under one One to two Two to three Three to four Four to five
3039 2115 826 433 248
The mortality from whooping-cough falls very unequally on town and
country. Thus, in Scotland in 1889, it caused 2268 deaths, being 3·13 per
cent. of the deaths from all causes, and equivalent to a rate of ·58 per
1000 living. The death-rate varied as follows: ·91 in the eight principal
towns, ·46 in the group of large towns, ·45 in the group of small towns,
·25 in the mainland rural districts, and ·08 in the insular rural
districts. In England, the capital has more than its share of deaths from
whooping-cough, Lancashire coming next, while the death-rates of
Monmouthshire, Cornwall and Warwickshire are also a good deal above the
mean of the whole country. The lowest death-rates are found in the purely
agricultural counties.
During the last half-century there has been a decline in the death-rate
from all causes, including the infectious diseases as a group; but it can
hardly be said that whooping-cough has had a due share in this decline.
Notably in Ireland, where the decline of infectious disease has been most
marked, it has been, as it were, pushed to the front of its class by the
shrinkage of the other items. In Scotland it is now decidedly at the head
of the list, and in England it has shared the first place with measles
since the great diminution of scarlatina deaths.
_Annual average Death-rates per 100,000 living._
Whooping-cough Measles Scarlatina
England { 1871-80 51·2 37·7 71·6
{ 1881-90 45·1 44·1 33·8
Scotland { 1871-80 63·1 37·0 79·5
{ 1881-90 60·7 38·3 28·8
Ireland { 1871-80 34·8 21·0 43·5
{ 1881-90 28·5 19·2 20·8
There is a small decrease in the death-rate of whooping-cough within the
last decennial period, whereas in that of measles there is a slight
increase (except in Ireland). The comparative steadiness of whooping-cough
among the causes of death is doubtless owing to the fact that the bulk of
its fatalities are among infants, and that there appears to be an
irreducible minimum of the deaths from all causes at that age-period.
Whooping-Cough as a Sequel of other Maladies.
Although it is convenient to group whooping-cough among the infectious
diseases, and although it is a clear case of a malady that comes in
epidemics, yet its pathology is peculiar. It seems to be more a sequel of
other diseases than an independent or primary affection. The whoop of the
breath, from which it is named, is really proper to any convulsive cough
of some infants or children. Adults, having undergone the change in the
form and relative size of the larynx at puberty, have the convulsive cough
usually without the whoop if they have it at all. After the successive
influenzas of recent years (1889-92), many adults suffered from convulsive
paroxysmal cough which was whooping-cough in all respects but the whoop,
the choking fits, the blackness of the face, and the vomiting being, of
course, all kept in subjection by the greater control of adults over their
reflex actions.
It has been often remarked that the ordinary whooping-cough of children
has followed epidemics of influenza, or widely prevalent catarrhs. Thus,
Hillary records in July, 1753, an epidemic of whooping-cough, or “the
fertussis,” all over the island of Barbados following the epidemic catarrh
which was at a height in January of the same year. Whooping-cough had not
been known in the island for many years past, “neither could I find by the
strictest inquiry that I could make that any child or elder person did
bring it hither[1243].” Willan, in his corresponding records of the
succession of diseases at the Carey Street Dispensary, London, from 1796
to 1800, has the following:
“There was also among infants and children during the month of January
[1796], an epidemic catarrh attended with a watery discharge from the
eyes and nostrils, a frequent though slight cough, a shortness of
breath, or rather panting, a flushing of the cheeks, great languor
with disposition to sleep, and a quick small irregular pulse.... It
was succeeded in February by the hooping cough.”
Measles, which is usually a catarrhal malady, has undoubtedly been
followed by whooping-cough in many individual cases and in epidemics as a
whole; and it may be that there is a closer association of whooping-cough
with measles than with any other infectious disease. In the table on p.
647, the deaths by whooping cough in London from 1731 to 1830 have been
reduced to ratios per cent. of the deaths from all causes, in a parallel
column with the ratios of measles; it will be seen that the increase of
both is equally remarkable towards the end of the table. But the Glasgow
ratios abstracted by Watt show no such decided increase of whooping-cough
from 1783 to 1812, side by side with the astonishing increase of measles;
while his annual bills for the same period show that there were many
deaths from whooping-cough in Glasgow for years before measles began to
replace smallpox or to divide the mortality with it. The first high
monthly mortalities from whooping-cough in Watt’s bills were from
November, 1785, to the end of 1786; but there had been so little measles
for twenty-four months before that epidemic began, that only one death
from it is recorded all the time. Again, the great measles epidemic of
1808 in Glasgow was indeed followed by many deaths from whooping-cough in
1809; but, while the height of the measles epidemic was in May and June,
1808, it was not until April, 1809, that whooping-cough began to cause
many deaths.
_Glasgow: Deaths by measles and whooping-cough._
Whooping-cough Measles
1807
Nov. 18 2
Dec. 18 1
1808
Jan. 10 2
Feb. 20 2
March 12 5
April 18 71
May 9 259
June 9 260
July 2 118
Aug. 2 32
Sept. 2 22
Oct. 2 10
Nov. 4 4
Dec. 2 2
1809
Jan. 7 4
Feb. 6 4
March 7 2
April 16 1
May 22 4
June 25 4
July 22 6
Aug. 15 2
Sept. 35 4
Oct. 23 1
Nov. 36 2
Dec. 45 10
1810
Jan. 33 4
Feb. 32 4
March 19 3
Whatever correspondence or relation there may be between measles and
whooping-cough, (and it has been remarked by many in the ordinary way of
experience), it eludes the method of statistics[1244]. As for the
catarrhs of infants and children other than those which are part of the
actual attack of measles or influenza, they are so common from year to
year, and even from month to month, (perhaps coincident with teething, or
with chicken-pox or other slight febrile disturbance), that a statistical
study of whooping-cough in relation to them could lead only to an
empirical, and possibly bewildering, result. It may be more useful to
consider the antecedent probability of some such relationship, arising out
of the pathology of the convulsive cough.
Whooping-cough is not only a paroxysmal cough coming on in convulsive fits
at intervals, but the paroxysms, as they recur for many weeks, or, as they
say in Japan, “for a hundred days,” have none of the obvious occasions of
coughing, such as catarrh of the mucous membrane, congestion of the lungs
from hot or close air, irritation of the bronchial tubes from dusty
particles or vapours, or the presence of tubercles in the substance of the
lungs. Such irritants can, indeed, produce whooping-cough, as in the
following instance of “artificial chincough” related by Watt:
Two children having quarelled in their play, one of them thrust a
handful of sawdust into the mouth of the other. Some of the sawdust
passed into the windpipe. After a short time the child began to have
violent convulsive fits of coughing, in which the whoop was very
distinctly formed. Expectoration in the course of a few hours removed
all the irritation, and the coughing thereupon ceased.
But in natural or ordinary whooping-cough there is no mechanical
irritation, there is nothing to cough up, the reflex action, violent and
paroxysmal though it be, has apparently no motive. I have, in another
work, offered an original explanation of the paroxysmal cough of children
as being the deferred reaction, the postponed liability, the stored-up
memory, of some past catarrhal or otherwise irritated state of the
respiratory organs, to which I refer without attempting to summarize it
here[1245].
The epidemicity of whooping-cough presents no more difficulty if the
malady be viewed as the sequel or dregs of something else than if it be
taken for an independent primary affection. The many infants and children
that suffer from it together may have equally been suffering together from
one or other of the various things of which it is assumed to be the
sequel--influenza, measles, sore-throat, the bronchitis of rickets, simple
bronchial catarrh of the winter, simple coryza. Again, it may be a
secondary or residual affection with many, but a communicable disease to
others. Much of the whooping-cough of an epidemic is believed by good
authorities, such as Bouchut and Struges[1246], to be simply mimetic, or a
habit of coughing acquired by hearing other children coughing in a
particular way, just as chorea is sometimes acquired in schools or
hospital-wards through the mere spectacle of it. But it may be doubted
whether much of the whooping-cough which swells the bills of mortality is
acquired in that way. The children that die of it are probably most of
them such as had only escaped dying of the measles or other infective
disease, or of the non-specific catarrh, which had preceded the
whooping-cough.