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.