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 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 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 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.
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.
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 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.
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.
Dolan believes the phenomena of the cough or kinks to be due, as 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 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 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.
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 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.
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 Bruger6 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.
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.
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 potassium is best for inhalation. Letzerich recommended the insufflation of quinia twice daily, using the quinia muriate with potassium bicarbonate and gum-arabic. Forchheimer7 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.
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. Macartan8 says that in the East Indies the disease is treated in the first stages by astringent and tonic gargles.
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 alum9 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. Evans10 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 Wiglesworth11 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.
9 Golding Bird, Guy's Hosp. Rep., April, 1845.
10 Glasgow Med. Jour., 1880.
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 Grinnell12 during four months treated 223 cases with this remedy, and highly recommends it. The doses were in accordance with those of Dr. Kormann—¾ 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 Field13 recommends sodium bromide.
12 Med. News, 1882.
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." Kennedy14 writes: "I cannot doubt 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.
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.
We have already alluded to the value of quinia, which has been used largely in this disease, both internally and as a local application. Originally recommended in the latter manner on account of its power of controlling the development of low organisms, it has not proved so satisfactory or valuable as when given internally. Binz in 1870 was perhaps the first to recommend quinia given frequently and in solution, and Dawson in 187315 reports excellent results from the sulphate or muriate of quinia given in full and frequent doses, and in such solutions as will not prevent its acting on the mucous membrane in its passage through the pharynx. Breidenbach16 gives the quinia muriate in larger doses—one and a half to fifteen and a half grains per diem. The effects were surprising as soon as the proper dose for each person had been determined; this, he says, is the keynote of success. To prevent complications he continued it for a long time in small doses.
15 Am. Jour. Obstetrics.
16 Practitioner, Feb., 1871.
Our own experience favors the view that quinia, when given in solution or suspended in mixture, is valuable in many cases of this disease; it can be ordered in powder, and given in a spoonful of simple syrup or of the preparation known as the syrup of yerba santa, which makes an excellent vehicle. Liquorice also disguises the taste of quinia admirably for children.
Albrecht17 has found from an experience of ten cases of whooping cough in children between the ages of one and a half and nine years, all of a marked scrofulous type, much benefit from the muriate of pilocarpine, given in small doses after every fit of coughing. To prevent collapse, he advises that it should be given in a mixture containing a little brandy. After twenty-four hours of its administration an obvious change for the better takes place in the appearance of the mucous membrane of the throat, velum palati, and uvula, which becomes paler, less swollen, and more moist; laryngoscopic examination shows a similar improvement. During the catarrhal period cold compresses to the neck and sweetened milk containing potassium chlorate are used instead of the pilocarpine, which is to be resumed as soon as a whoop recurs.
17 London Med. Rec., March 15, 1882, p. 110.
Dr. Tordeus, of the Hospice des Enfants Assistés, Brussels, states that he has found the sodium benzoate useful in whooping cough, diminishing the frequency and violence of the paroxysms, and by its action on the pulmonary mucous membrane preventing those pulmonary complications which so frequently supervene and constitute the danger of the disease.
Sulphur has been largely used by the Germans in two- or three-grain doses, and is said to be greatly esteemed by them. Cantharides has been recommended, and it is stated that when strangury is produced the whoop will cease; we should consider this rather severe treatment. The fluid extract of castanea is used by many with undoubtedly good results, though this also has been somewhat of a disappointment in the way of treatment, as at one time it was looked upon almost as a specific. Many claim that an infusion of the fresh leaves gives a better result. Dewar18 regards ergot with great favor in the treatment of pertussis. Certainly in those cases where, from violent straining, hemorrhages have taken place we have found it to be highly valuable. We have had no experience with it in the treatment of ordinary cases, though Dewar claims that it shortens the attack. The ammonium picrate, and recently resorcine, have been used with success.
18 The Practitioner, London, May, 1882.
Counter-irritation to the neck and chest has always been found useful in the treatment of this disease. Autenreith19 recommends tartar emetic to the epigastrium till vesicles appear and even ulcerate. Milder forms of counter-irritation over the chest seem equally efficacious if continued for some time. The oil of amber, when used in liniment with camphor or turpentine, is by some considered almost a specific. Great care should also be observed in the dress of children with whooping cough. Warmth about the chest is always indicated, while there should be nothing close or tight about the throat allowed.
19 Dict. des Sciences Med., 1813.
In the third stage, when there is the nervous element remaining, tonics, such as cod-liver oil, iron, the phosphates and hypophosphites, are required.
The diet should be nutritious, easy of digestion, and abundant, and the bowels should be kept regular by fruits or laxatives. Over-feeding should of course always be avoided, and the attempt at weaning a babe with this disease would certainly meet with unfavorable results.
Bicarbonate of soda or lime-water should be given freely with the milk taken by children with this disease. Milk certainly should form the basis of the diet of children with pertussis, and reliable meat-extracts are to be recommended in this disease even for older children, who from the severity of the attack would vomit more solid food. If the vomiting be so severe as to affect nutrition, the child should be sustained by peptonized milk, soup, or gruel, given by the bowel.
The importance of a proper regulation of the temperature of the air which the patient breathes is especially recognized in France. If the attack occurs in mid-winter and the seashore be inaccessible or inexpedient, the child should be restricted to a well-ventilated nursery or suite of rooms, the temperature of which should be kept uniform.
Salt air is recognized to be of great value in advanced cases of this disease; this has been attributed partly to the effects of stimulation of the mucous membrane in rendering less viscid and more copious the bronchial secretions, and also to the balmy softness and great purity of the atmosphere at the sea-shore. But probably there is another element in the local action of the chloride of sodium, either in establishing a resistance on the part of the patient or in modifying the germ of the disease.
The most serious complication of whooping cough is pneumonia. It occasionally happens that an attack of croupous pneumonia may develop during the course of whooping cough, but in the vast majority of cases the disease is of the catarrhal type. When, indeed, it is remembered that a bronchial catarrh, which is the invariable precursor or accompaniment of catarrhal pneumonia, is a constant factor in whooping cough, and, further, that all conditions of debility, and especially of enfeebled or embarrassed respiration, dispose to this form of pneumonia, it is not surprising that this complication should be of such frequent occurrence. It is not impossible that in aiming at securing sufficient fresh air and out-door exercise to maintain the general health, an injudicious degree of exposure may be permitted which will aggravate the existing bronchitis and induce an extension of inflammation to the alveoli. But usually the catarrhal pneumonia develops in a subacute and more or less insidious manner, and without being traceable to any such exposure. It may happen occasionally that in the violent inspiratory efforts at the close of the paroxysms irritating secretions may be sucked from the bronchioles into the alveoli, and there excite inflammation. Or, again, it doubtless happens frequently that, with the existence of swelling of the bronchial mucous membrane and of viscid secretions in the bronchial tubes, collapse of portions of lung tissue is developed by the forcible expulsion of air during the paroxysms of cough, which cannot be replaced owing to the relative weakness of inspiration and to the ball-valve action of the plugs of mucus in the obstructed bronchioles. The intimate relation between pulmonary collapse and catarrhal pneumonia is familiarly known. It is not to be considered that the mere occurrence of collapse will induce pneumonia in the areas affected, but certainly it will aid in rendering effective the other irritating causes. As a consequence, it usually happens that when catarrhal pneumonia occurs in whooping cough it is associated with more or less collapse. When, then, especially in children of debilitated or rachitic constitution, or in those who are subjected to unfavorable hygienic influences, such as overcrowding, bad air, and the like, there is a rather gradual development of dyspnoea, with increasing debility, emaciation, and evidences of impaired oxygenation of the blood, it is to be feared that this serious complication has developed. The physical signs are often difficult of interpretation, but if careful examination of the chest be conducted, together with thermometric observations, the approach of this danger or its actual presence may be detected. The result is fatal in a large proportion of cases, so that suitable treatment—for the details of which reference is made to the appropriate section—must be instituted without delay.
Our investigations of this disease have led us to the conclusion that we have to deal with an affection caused by a specific germ, which is usually, after a period of incubation, made manifest by a catarrh of a portion of the air-passages; that this catarrh, existing for an indefinite period, is capable of being influenced by medication, applied either by means of inhalation or by acting on the mucous membrane after absorption by the stomach. In this way we have known the administration of quinia and of alum diminish the number of paroxysms, to all appearance checking the excessive secretion to a marvellous extent. The other element of the disease, the neurosis, which soon follows the initial catarrh, and seems to last for an indefinite time after the mucous membrane has regained its normal appearance, is also capable of being controlled by the use of drugs, especially belladonna, chloral, the bromides, and hydrocyanic acid, not to speak of the other antispasmodics and sedatives, and by the analgesic effect of carbonic acid gas, or by the spray of bromide of ammonium, carbolic acid, and other substances upon the larynx.
Vogel tells us in his classical work on children, "If now, as a résumé, I would give an explanation of my views, it would go to show that there never has been, and most probably never will be, a remedy by which whooping cough may be abridged, any more than we are able to cut short the acute exanthemata or typhus fever or pneumonia." And yet the experience of many whom we have quoted in this article tends to support the view that by a form of treatment calculated to act on the two elements of the disease which we have just noted, the affection can be greatly modified in its intensity, and probably the attack be somewhat shortened. Certain it is that the recent studies of this disease give us hope that the day is not far distant when the cause, whatever it is, will be definitely known, and if it is found to reside in the secretions from the larynx, that treatment by inhalation or atomization will modify or destroy it, and prevent its dissemination.