A system of practical medicine. By American authors. Vol. 1

by Unknown

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.