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Additional comments:/ Commentaires supplAmantairas: Variout pagings. Wrinklad pages may film slightly out of focus. This item is filmed at tha reduction ratio checked below/ Ce document est filmi au taux de reduction indiqui ci-dessous. 10X 14X 18X 22X 26X 30X y 12X 16X 20X 24X 28X 32X Thtt copy film« ujGifi^lfi* • 1 •<«- 1«* of Book G.'^^"/ » Reoeived. lie ive g: H0...3-C-LSL. 7 iiibrary of WeGill College . . ,, FACULTY OF MEDICINE, t- MONTREAL. , ~j Fellow of the College of Physicians in Ireland. of " We stronsfly recommend all our younij friends who wish to know what is most excellent in the modern patholoj^y of France to lose no time in adding; this translation to their stock of Medical autliorities. ' — British and Foreign Medical Review. " We reoommend Dr. Spillan't translation to our readers."— i.ancet. •VvN -^^ > iX.;*.^. J-^;-; mmm ;t..'.. X^-^-^-^ ^^^*^^ ^^ ^^*^*^L^ A TEEATISE OK HOOPING-COUGH. I » ": ■' ' \\ LA '^J- <•- ^' ,*./ ^ A TKEATISE ON HOOPING-COUGH; ITS COMPLICATIONS, PATHOLOGY, AND TERMINATIONS. WITH ITS SUCCESSFUL TREATMENT BY A NEW REMEDY. ^ , GEORGE D. GIBB, M.D. r UCBNTIATE OF THB BOTAL COLI.BOB OF SCBGEONS IV IBELANDj FBLI.OW OF THE COLLBGB OF PUTSICIANS AND STTBGBOirS, I.OWBB CANADA; LATB tBCTVBBB ON INSTITnTES OF MEDICINE, ST. LAWBENCB SCHOOt AT MONTBBAI,. HENRY RENSHAW, 356, STRAND .-, MDCCCLIV. ^ V ' '^ ^- ^ :^^ Mi::DrjAL FACULTY,; { TO TEE RIGHT HONOURABLE THE EAEL OF ELGIN AND KINCAEDINE GOVERNOR-GENERAL OF BRITISH NORTH AMKRICA, EIC. ETC. My Loud, It is with great pleasure I avail myself of your Lordship's kind permission to Dedicate to you the present work, the basis of which was commenced — when in the practice of my profession in Canada — during your Lordship's administration. I hope your Lordship will excuse my taking advantage of this occasion, to point to the universal prosperity and happiness of the people, everywhere manifest at the pre- sent time throughout the Canadian empire, which, under the blessings of Providence, have been mainly brought about by the wisdom and beneficence of your rule. That your Lordship may long continue to hold the high position which adds lustre to your already distinguished name, is the sincere wish, My Lord, Of your Lordship's faithful servant, Geoege D. Gibb. 3 Ic3. ii PREFACE. Very early in my career I was an attentive ob- server of the vexatious and tiresome difficulty experienced by the practical physician in the treatment of the Hooping-cough, and after the application of remedies, too, recommended by that experience which should entitle to confidence in their use. But how often, indeed, huj the use of one medicine followed another, to be in its turn rejected, and, finally, to leave the little patienl only worse in the degree of severity of the disease, but perhaps attended with some fata^ complication. The anxious physician, therefore, hails the advent of some new remedy, if not with pleasure, at least with hopeful anxiety that it may prove that which it is declared to be, a certain remedy for the disease. I had long watched this affection, and the various forms of treatment to wbfch it was sub- mitte(?, by men of the greatest intelligence and professional distinction, in the hospitals of this 62 Vlll PREFACE. kingdom, and in the French and Irish capitals; and, although the treatment was so varied in its scope and range, my convictions were not such as to lead me to adopt any one form of treatment in preference to another on commencing my labours in a more distant and severer clime. I have witnessed the palliation of the severer symptoms, the enjoyment of a certain amount of eaae and comfort to the child, but seldom, very seldom, has the disease been completely cut short in its course. In a patient under my care, after having, as I thought, on one occasion, succeeded in curing the disease, to my mortification its progress continued the full period of six months, when its disappearance might be justly attributed to the change in the seasons, in the advent of spring upon a long and severe winter. The four children of a medical friend, who was my neighbour, were ill the greater part of a winter from this aflfection ; their sufferings were most dis- tressing, the infant in arms being affected equally with those of elder years. Treatment was in vain, and uneasiness was taking possession of the minds of the parents, when another medical friend acci- dentally stepped in, and recommended nitric acid in solution. The children were kept indoors owing PREFACK IX to the inclemency of the weather, and were all perfectly cured in three weeks. For the knowledge of this new remedy in hooping- cough I am indebted to my late colleague and personal friend, Doctor Amoldi, of Montreal, who was the first to use it in the treatment of this disease ; how successfully, the sequel of this little book will show. As the study of hooping-cough has occupied my attention many years, and entertaining some new views in regard to its nature and pathology, being also desirous of advocating this new remedy, of great value in its treatment, I have therefore pre- pared the present imperfect essay. The first chapter gives a brief summary of the minute anatomy of the lungs, and their nervSe, to assist in the explanation of the pathological phe- nomena of the disease. A consideration of its history follows, interesting to those in favour of its antiquity, and which, I believe, may be dated from an extremely remote period of time. The chapter on the mortality contains many accurate tables of value upon the statistics of deaths in the Metropolis, and in the whole of England, which have been carefully prepared from the volumes of the Registrar-General, and which PREFACK have not before appeared in relation to the present disease. The general features of the disease are particu- larly described in the chapter on the symptoms ; and all the complications which have ever arisen in the progress of the affection have had more than an ordinary amount of attention bestowed upon them, and some of them are described for the first time. Following these is a chapter on the numerous terminations of hooping-cough, which contains many facts of interest. In the pathology of pertussis a solution has been attempted, which, from the plan adopted in carry- ing it out, may be received favourably. Most cer- tainly some points in connexion with it are set at rest, and a careful perusal of the chapter upon it, together with the one following, on its nature and seat — in the latter of which this question is summed up — will be necessary to fully compre- hend the conclusions arrived at. The opinions of others* have been freely given as assisting in a very great measure the solution of this diflficult sub- ject, which, as rendered according to my own views, is simple in its nature, easily comprehensible, and explained with facility by the phenomena during life and the appearances after death. * Ninety-three in number. PREFACE XI The assertion that pertus. is a disease of all climates is for the first time practically con^Mered in a separate chapter, and the evidence adduce! to prove this is of great value indeed. I am in- debted for a portion of it to the kindness of those whose names are mentioned in this chapter, and I avail myself of this occasion to return them my grateful acknowledgments. In relation to the Canadas and South America, facts are communi- cated not before published, for which I am per- sonally responsible. The details of this chapter lead me to believe that they will not prove unin- teresting. Not less than three chapters have been devoted to the consideration of the treatment recommended by almost every writer; the work would have been incomplete without these, and no apology is neces- sary for their introduction. Chapter XVIII. contains a description of the treatment of the simple affection by the new reme- dial agent, with cases; together with remarks upon its general utiHty; and the following and con- cluding chapter refers to the treatment of the various complications. A very copious and complete index is added, and also an index of names. Every effort has been made, compatible with the '.'S7 ■'* lifVifH';"**'- Xll PREFACE. scope of the work, to condense as much as pos- sible the immense mass of facts connected with the elucidation of the subject, and if my remarks are necessarily brief, this must be my excuse. Nothing has been omitted having the least pos- sible bearing upon it, and many new facts have been embodied so as to render the whole a volume, not only of practical utility but of especial refe- rence. With these observations it is not without some diffidence and considerable hesitation that I ven- ture to submit to the indulgence of the profession a book which I feel convinced contains many imperfections, but as my motives are honest and conscientious in their natui , I humbly trust that these deficiencies will not be too harshly dealt with. G. D. G. 59, Guildford Street, Russell Square. May, 1854. CONTENTS. Preface PAOB vii CHAPTER I. Summary of the Anatomy of the Lungs, Bronchial Tubes, Air-cells and Nerves of Respiration 1 Physiology of the Respiratory nerves 6 CHAPTER II. History of Pertussis 10 Opinions of writers on the subject 11 A disease of remote antiquity 12 Authorities on this disease 17 Its nomenclature 19 CHAPTER III. Mortality from Pertussis 21 Comparison with the Exanthemata 23 Deaths in the Metropolis 26 „ England 27 „ Ireland 28 „ Glasgow 29 „ Sweden 32 „ Other parts of Europe 34 „ North Anidica 35 ,/• — IH XIV CONTENTS. CHAPTER Symptoms of Simple Pertussis The first stage The second stage The third stage Physical signs ■•ji eneral considerations [V. • • • • • c 37 37 42 49 51 56 CHAPTER V. Complication of Pertussis with 1. Bronchitis 2. Pneumonia and Pleuritis... 67 71 CHAPTER VI. Complication of Pertussis with 3. Congestion of the Brain, Convulsions and Hydrocephalus 80 4. Sanguineous Apoplexy 89 CHAPTER VII. Complication of Pertussis with 5. Infantile Remittent Fever 93 6. Diarrhoea and Intestinal Disorder 96 7. Softening and Inflammation of the Stomach ... 99 8. General Dropsy 102 CHAPTER VIII. Complication of Pertussis with 9. The Exanthemata ... Measles Scarlet Eever . . . 103 104 106 CONTENTS. Complication of Pertussis with Chicken-pox Small-pox Other forms 10. Tuberculosis XV FAQB ... 105 ... 108 ... 109 ... 109 CHAPTER IX. Complication of Pertussis with 11. Pregnancy 12. Hysteria 13. Other diseases 116 119 122 CHAPTER X. Terminations of Pertussis Dilatation of the Bronchial Tubes . . . Emphysema of the Lungs Emphysema of the Neck (Edema of the Lungs Struma Pidmonary Phthisis Hydrothorax Pneumothorax Marasmus Tabes Mesenterica Diseases of the Bones Hernia and Prolapsus of the Rectum Epilepsy Ophthalmia Affections of the Ear Asthma 124 125 132 134 140 141 141 141 141 142 142 142 143 144 145 145 147 XVI CONTENTS. CHAPTER n. Pathology of Pertu ssis Simple form of the affeetion Complicated form of the affection . . . Of the Bronchi » I^ungs „ Pleura; „ Nervoiis System Apoplexy of the Brain and Lungs . . , Of the Heart „ Blood . „ Abdominal Viscera „ Urine Tuberculosis Of the Exanthemata Other conditions Consideration of all these and deductions therefrom PAOB 149 149 154 154 159 162 163 166 167 168 169 170 171 171 172 172 CHAPTER XII. Opinions of various writers as to the Nature, Pathology, and Seat of Pertussis 177 Review of all these 205 Unanimity of the more recent writers on certain points 205 Willis and Sydcnliam, two of the early writers, correct in tenning it a Blood Disease 206 Application of recent views 206 Views of the Author upon its Nature and Pathology ... 211 CONTENTS. XVll m PlOB 149 149 154. 154 159 162 163 166 167 168 169 170 171 171 , 172 . 172 ... 177 ... 205 pertain ... 205 lorrect ... 206 ... 206 m- 211 CHAPTER XIII. Pertussis a Disease of all Climates Europe Asia Mriea "North America West Indies South America Australia Polynesia Its antiquity therefore established CHAPTER XIV. Causes of Pertussis 1. Age 2. Sex 3. Temperament, Predisposition, and Manner Life 4. Climate and Season 5. Contagion and Epidemics Diagnosis from 1. Bronchitis 2. Laryngismus Stridulus 3. Croup ... 4. Tuberculosis of the Bronchial Glands , . . 5. (Edema of the Glottis Prognosis PAGE 213 214 218 221 222 225 225 226 228 228 of 229 229 230 232 233 236 245 245 246 246 246 246 '/i XVUl CONTENTS. /. !i li /. J ! I ( wv CHAPTER XV. VA0I Remedies recommended by various writers in the treat- ment of Pertussis 251 1. Venesection 253 2. Leeches 261 3. Emetics ♦ 265 4. Antimonials 267 5. External applications 269 6. Change of Air and Regulated Temperature . . . 272 7. Warm Baths 275 CHAPTER XVI. Continuation of the remedies recommended . . 276 8. Hydrocyanic Acid ... » . . 276 9. Laurel Water ■ • * . • * ■ 281 10. Belladonna ■ ( • ... 282 11. Opiimi and its compounds • * • . . • 287 12. Hemlock ... * • . 289 13. Henbane . • * a • 4 290 14. Digitalis ... ... 290 15. Tobacco • . . ... 290 16. Arsenic 291 17. SUver • * . ... 293 18. Iron ... * . . 294 19. Zinc * . * . > • 295 20. Lead • . • ■ ■ . 29- 21. Copper • • • ... 297 22. Cauterization by Nitrate of Silv er ... • •. *•■ 297 ; I CONTENTS. XIX lire 251 253 261 265 267 269 272 275 276 276 281 282 287 289 CHAPTER XVII. Continuation of the remedies recommended 23. Inhalations 24. Coffee 25. Peruvian Bark 26. Quinine 27. Hydrochloric Acid 28. Sulphuric Acid 29. Nitric Acid 30. Cochineal 31. Alum 32. Tannin 33. Vegetable Acids 34. Alkalies 35. Vaccination 36. Cantharides 37. Musk 38. .issafoetida 39. Meadow Narcissus 40. Cup Moss 41. Castor 42. Nux Vomica 43. Miscellaneous other remedies . . . PAoa 302 302 306 308 308 309 310 311 3] 2 315 318 319 320 323 324 327 327 328 328 329 329 329 CHAPTER XVIII. Treatment of Simple Pertussis Treatment by Nitric Acid Therapeutical effects Illustrative cases Mode of administration Hygienic measui-es Chloroform inhalations with Nitric Acid Prophylaxis 333 334 335 338 342 344 348 350 sRwesev I XX CONTENTS. CHAPTER XIX. PAoa Trcatminit of the Complications of Pertussis . 352 1. lironchitis . 352 2. 8. Pneumonia Pleiiritis . 356 . 860 4. Congestion of the Brain . 360 5. Convulsions . 361 6. Hydroeephalus . 364 7. Sanguineous Apoplexy . 365 8. Infantile llcmitteut . 366 9. Diarrhoea and Intestinal Disorder . . . 368 10. Softening of the Stomach . 370 11. General Dropsy . 371 12. The Exanthemata . 372 13. Tuberculosis . 373 U. Pregnancy . 374 15. Hysteria * . 375 Index of Names 376 General Index , . . 382 ON HOOPING-COUGH. CHAPTER I. SUMMARY OF ANA '•MY OF THE LUNGS. The organs contained within the cavity of the chest consist of the lungs and heart, the numerous blood- vessels and nerves passing into and out of the chest, the oesophagus and thoracic duct, much cellular tissue, and many lymphatic glands. The lungs, the organs of respiration, two in [number, are situated on either side of the spine, land when filled or distended with air, as they con- stantly are during life, they so exactly fill each side of the chest, that the pulmonary and costal pleura are always in perfect apposition, so that there never can be any immediate cavity. They are conical in their form, with the apex round and often irregularly bulged, and when dis- tended rise into the neck to a height varying from one to two inches above the level of the first rib ; this bone can be occasionally seen to press upon it anteriorly. B ON HOOPING-COUGH. The apex of the right lung usually rises higher than that of the left, and on both sides is beneath the anterior scalenus muscle and subclavian artery. The base of the lungs which is directed down- wards, is concave, particularly of the right, and is accurately moulded to the convexity of the dia- phragm. This concavity of the base is increased on the right side owing to the position of the liver. It is sloped off obliquely downwards and back- wards, so that it projects much lower by its poste- rior than its anterior border. Although both of a conical form, the right lung is wider and shorter than the left, which is due to the position of the liver below, and the direction of the heart to the left side. It is divided into three lobes, and the left into two only. This division of the lungs into lobes constitutes the interlobular fissures, which penetrate to a great depth, excepting the middle fissure, and the oppo- sed surfaces are smooth and serous. Sometimes both lungs are divided into three lobes ; occasionally there is an absence of this division in the right, and cases have been recorded of three or four lobes in the right, and three or four in the left. The lungs themselves are made up of the ramifications of the bronchial tubes, and of minute arteries, veins, nerves, and lymphatics. This has been divided into two systems of apparatus, the first, the vascular or circulatory apparatus, consisting (^ arteries and mi ANATOMY OF THE LUNGS. 3 ises higher is beneath ian artery. Dted down- ^ht, and is >f the dia- 5 increased )f the Hver. and back- y its poste- ! right lung jh is due to direction of 1 into three constitutes to a great the oppo- 1 Sometimes jccasionally b right, and lur lobes in The lungs Lcations of ^ries, veins, sn divided lie vascidar rteries and veins, together with the plexuses formed by the union of the capillaries proceeding from both sets of vessels ; the second, the respiratory or seriferous system, which includes the bronchial tubes, the air cells, and the ciliate" '^^pithelium. All these united constitute the parenchyma or substance of the lungs, which is held together by cellular tissue, which on a section is seen to consist of small polygonal divisions, or lobules, which are connected to each other by an inter-lobular tissue. These lobules again consist of smaller lobules, and the latter are formed by a cluster of air cells, in the parieties of which the capillaries are distributed. Of the circulatory apparatus, the vessels engaged [in the formation of this, are the ramifications of [the pulmonary artery and veins, the former termi- ^nating in capillary vessels, which form a minute network upon the parietes of the bronchial or air- -cells, and then by their convergence foixu the pul- imonary veins, by which the purified art<^rial blood lis returned to the left side of the heart. The respiratory or a3riform system consists of [the bronchial tubes, which divide and subdivide, [but without anastomoses, like the branches of a tree, and send branches to every part of the )rgan. The walls of the tubes contain distinct longitudinal and circular layers of fibrous structure ; )ut the latter alone, according to Professor Kol- liker, contain muscular fibre cells. One pecu- B 2 TV i i l /, I )t fi ■• ii 4 ON HOOPING-COUGH. liarity exists worthy of notice in relation to these fibres ; — the muscular fibres which exist in the trachea are continued down even to the terminal bronchi, but instead of filling up the gap in the cp'^ilaginous framework, posteriorly, as in the trachea, they form a uniform layer encircling the canal, but excessively thin. '■ These tubes retain all their ordinary characters until they are by successive branchings reduced to the thirtieth or fiftieth of an inch in diameter, when these structures — the longitudinal and annular fibres, together ^^dth the ciliated epithe- lium, abruptly terminate ; their walls are then formed of only a tough elastic membrane, with traces of fibrous, perhaps muscular structure, over which the capillaries are spread in a very dense network, and on v nous parts of which air-cells irregularly open. The tubular form of the air- passages beyond the termination of the longi- tudinal a,nd circular fibres is retained for some distance ; but it is gradi.„lly changed by the irregular branches of the passages and by the in- crease of the number of apertures in their walls which lead to the air vesicles. These tubes have been named by Mr. Rainey intercellular passages. The air-cells opening into these are placed singly on their walls, like recesses from them ; but oftener are arranged in rows like minuter succulated tubes, so that a succession or series of ANATOMY OF THE LUNGS. on to these ist in the e terminal ^ap in the IS in the ircling the characters reduced to diameter, dinal and ed epithe- 1 are then •rane, with icture, over rery dense air-cells the air- the longi- for some by the )j the in- leir walls ibes have passages. placed tn them ; minuter series of cells, all opening into one another, open by a common orifice into the tube, and thus forms a lobule. The cells of adjacent lobules do not com- municate ; and those of the same lobule or pro- ceeding from the same intercellular ^age, do so as a general rule near the angles ot oifurcation ; so that when any bronchial tube is closed or ob- structed, the suppl}'^ of air is lost for all the cells opening into it or its branches. The cells are of various forms, according to the mutual pressure to which they are subject; they are smaller in the centre of the lung, and their network of capillaries is there closer than those nearer to the circumference. The walls of the air- cells are formed of a very thin and transparent membrane, which is folded sharply at the orifices of communication, so as to form a very definite border to them, and which is lined by an epithelial layer, composed of minute polygonal cells of from 1-1 600th to l-2250th of an inch in diameter. This lining membrane is distinctly fibrous ; and its fibres are particularly strong and well marked around the apertures of communication between the contiguous air-cells. These fibres have not any resemblance to muscular tissue, but rather corre- spond with those of yellow fibrous tissue. The capillary plexus is so disposed between the two layers which form the walls of two adjacent air-cells as to expose one of its surfaces to each, ~..|i>>HV ^IW ON HOOPING-COUGH. (15 ( !V i I I •^i i •'I by which provision the full influence of the air upon it is secured. The network of vessels is so close that the diameter of the meshes is scarcely so great as that of the capillaries which enclose them. The Nerves supplying the lungs are derived from the pneumogastric and sympathetic. They form two plexuses — the anterior and posterior pulmonary plexus. The branches from the anterior supply the substance of the lung along the great vessels, whilst those of the posterior follow the course of the bronchial tubes, and are distributed to the air-cells. The source from which the nervous influence is derived, as necessary for the respiratory movements, is the medulla oblongata, and the spinal cord is, as it were, the trunk of the nerves which arise from it. The respiratory movements and their re- gular rhythm, in their being ordinarily involuntary and independent of consciousness, are under its absolute governance, which, as a nervous centre, receives the impression of the " necessity of breath- ing," and reflects it to the phrenic and such other motor nerves as will bring into action the muscles necessary to inspiration.* That part of the interior of the medulla oblon- gata, from which the pneumogastric nerves arise, is the centre whence the nervous force for the production of combined respiratory movements * Kirkes and Paget's Physiology. U't J1 ANATOMY OF THE LUNGS. appears to issue. With care, the medulla oblongata may be divided to within a few lines of this part, and its exterior may be removed without the stop]f)age of respiration ; but it immediately ceases when this part is invaded. The chief " exciter" of the respiratory movements is imquestionably the pneumogastric nerve ; its trunk, however, is not endowed with sensibihty, as when it is pinched or pricked the signs of pain are not nearly so acute as when the trunks of the ordinary spinal nerves, or of the fifth pair, are treated so. Its power as an excitor of respiration is very great, and must arise from impressions made upon its peripheral ex- tremities. The impression is probably due to the presence of venous blood in the capillaries of the lungs, or, as Dr. Marshall Hall thinks, to the pre- isence of carbonic acid in the air-cells.* Both may Ibe true. Among other exciters of the respiratory muscles are the nerves distributed to the general surface and particularly to the face ; and in exciting the first impression, the fifth pair seems the principal agent The sympathetic nerve, also, which derives many filaments from the cerebro-spinal system, and which especially communicates with the pneu- mogastric nerves, may be one of the exciters of this function. This is due not only to its ramifi- * Carpenter's Human Physiobgy. Fourth Edition. f ON HOOPING-COUGH. cr 'oris in the lungs, which are considerable, but ai. ) its distribution on the systemic vessels, so that it may convey to the spinal cord the impres- sion of imperfectly-arterialized blood circulating through these, such as the pneumogastric is believed to transmit from the lungs. The motor or " efferent" nerves concerned in the function of respiration are those which Sir Charles Bell has grouped together in his "respiratory system."' The most important of these — the phrenic — arises from the upper part of the spinal cord ; the intercostals, much lower down ; whilst the facial nerve and the spinal accessory, to the latter of which the motor powers of the pneumo- gastric are chiefly due, take their origin in the medulla spinalis itself. Bronchial Tubes. — Much of the force exerted in inspiration is employed in overcoming the re- sistance offered by the elasticity of the walls of the chest and of the lungs. It is probable that in the ordinary quiet respi- ration, which is performed without consciousness or effort of the will, the only forces engaged are those of the inspiratory muscles and the elasticity of the walls of the chest and lungs. And it is not known under what circumstances the contrac- tile power is brought into action by means of their organic muscular fibres, which the bronchial tubes, and perhaps the air-cells, possess. It may I . ANATOMY OF THE LUNGS. d assist in expiration, but there is no evidence to prove it ; and it is more likely that its purpose is to regulate and adapt in some measure the quan- tity of air admitted into the lungs and to each part of them according to the supply of blood. The muscular action in the lungs, morbidly ex- cited, is probably the chief cause of the pheno- mena of spasmodic asthma ; and I may with pro- priety add also, the cause of the spasmodic kinks in hooping-cough. This may be demonstrated by galvanizing the lungs shortly after removal from the body ; under such a stimulus they contract so as to lift up water [placed in a tube introduced into the trachea, as shown by Dr. Williams. And Volkmann has shown that they may be made to contract by letimulating their nerves. He tied a glass tube, Irawn fine at one end, into the trachea of a )eheaded animal, and when the small end was burned to the flame of a candle, he galvanized the [pneumogastric trunk ; each time he did so, the ime was blown, and once it was blown out. * * See Dunglison's Human Physiology, Todd and Bow- Iman's Physiology, and others. Also Hassall's Microscopical [Anatomy. ■J.. 10 ON HOOPING-COUGH. CHAPTER II. HISTORY OF HOOPING-COUGH. lie Although no authentic record is found among the Greek, Roman, or Arabian writers, of this dis- ease, it is not too much to suppose that it must have existed from the very earliest of ti^.nes, as one likely to affect individuals once in tl e course of their livea It must have been familiar to Hippocrates, not- withstanding no reference whatever is made to it in his writings, being alluded to most probably by him in his aphorisms, under the general term of coughs on the different ages, and the diseases peculiar to thenL Very likely also it may have presented itself to the notice of Galen, as he gives some ingenious remarks on the causes of coughing. The Arabian physician, Avicenna, gives an account of violent epidemic coughs, sometimes attended with spitting of blood, and during the paroxysms of which the patients became black in the face. He speaks of the treatment of coughs, particu- larly of infants, and recommends emetics and demulcents. Rhazes has given a receipt for cough pills. HISTORY OF HOOPING-COtJOH. n id among f this dis- t it must les, as one course of rates, not- nade to it obably by Ell term of diseases may have s he gives coughing, n account attended Can such diseases as asthma, phthisis, pleuritis, pneumonia, empyema, and others, have been fami- liar to them, and pertussis remain undescribed, unnoticed, and looked upon, very probably, as a form of curable asthma in the child, or possibly a strong cough simply? Syphilis and some other peculiar affections are not described by any ancient author, and yet the fact must be considered indis- putable from biblical and other evidence that such diseases existed at a very remote period. The same reasoning will hold good with respect to hooping-cough. There is, however, some difference of opinion among medical writers on this subject Dr. Gre- j gory states it is impossible to suppose that a dis- jease so strongly marked as this could have escaped ithe attention of the ancient physicians, had it then dsted. We must presume, he says, therefore, that it was not known in Europe before the thir- [teenth or perhaps even the fourteenth century.* [Dr. Mackintosh, again, says it is probable that it [is not a disease of such recent origin as has been hitherto imagined. Gardien very sensibly states that if it has not been described in France until the year 1414, it is because it has always been [confounded with other species of coughs, f In the history of this disease given by Dr. Charles * Theory and Practice of Medicme, 1839. t Practice of Physic, 1832. / '' ! i ! ( :: 'I ' m ii 12 ON HOOPING-COUGH. Aberle, he believes it to be coeval with all those diseases resulting from the effects of the vicissitudes of cHmate on the human frame. He assigns to it an antiquity as venerable as belongs to sore-throat and cold in the head. It is true, he says, that the ancients make no distinct mention of this disease ; but it must be remembered how many disorders were frequently included under one general term. The ancient authors, too, whose works have descended to us, lived in a bland and genial atmosphere ; and the disease, when it appears there at the present day, is much modified by the climate.* In the ancient chronicle of Celleusus, mention occurs of an epidemic cough attacking children^ which spread through all Germany in the year 1173 ; but no detailed account, or accurate descrip- tion of it, is extant. Some of the older writers take notice of epi- demics, which have been considered to have been hooping-cough, especially those of 1239 and 1311. But they may have been severe catarrhal epidemics, or influenza. Epidemic spasmodic coughs, therefore, seem to ave existed in all ages ; and although "the best writers agree with the eminent medical historian, Curtius Sprengel, that the hooping-cough was first * De Tussi Convulsiva. See also Keview in Lancet, Vol. i.. 1846. t ■,>^i■*"'P— - * " w^ HISTORY OF HOOPING-COUGH. 13 accurately noticed and described at the beginning of the fifteenth century," yet, even a perfect silence on the part of medical writers respecting it, prior to this time, should no more exclude it from the list of then-existing diseases, than the non-descrip- tion of a plant by Dioscorides should cause its rejection from his " Flora" of his age, and should make us believe it a species lately arisen from some patent source of spontaneous generation. It is a strong argument in favour of the antiquity of the disease, that those writers who speak of it in the fifteenth century do not seem to consider it as any- thing new.* Dr. Watt,t who was one of the first to write a treatise on this disease, and mainly induced to do [so from deaths by it in his own family, states that it appears pretty certain this disease vas v/hoUy lunknown to the Greeks, and he is fully of opinion Iwith Astruc and others, that hooping-cough, as it now exists, has not been described by any of the Greek, Roman, or Arabian authors. That it was not especially described as an individual disease is perfectly true, but still it must have been met with as we must all believe. Some writers believe it to be, as Aberle mentions, of modern origin, like small-pox and measles. Of these authorities, one party (Rosen) would place its * Aberle's Op. cit. t Treatise on Chiucough, Glasgow, 1813. -■••"rrr. "V7 1^ ON HOOPING-COUGH. cradle in Africa or the East Indies ; whilst another would assign it a birth-place, about the sixth century, on the shores of the northern seas, from which locality they believe it to have spread into the southern regions of Europe, with those hordes of barbarians whose countless multitudes gradually made spoil of the dismembered portion of the empire of Rome. Ace jrdiug to Mezeray, it first appeared in France in 1414 ; and he has been generally considered as having given the earliest account or description of the disease. But Dr. Copland considers that there is nothing characteristic about his description but the name coqueluche. Ihe epidemics described by De Thou and Pasquier, to which the same name was given, and which occurred in 1510 and 1537, were, he also remarks, evidently influenza, and not hooping-cough. And the same remark is applicable to most of the supposed epidemics of this latter disease, during the sixteenth and seventeenth centuries.* If we discard testimony which appears to be of some value in the history of this affection, merely because there may not have been that clearness of description which is adopted at the present day, then I am afraid we shall convert it into a disease of unusually modem origin. I must, therefore, differ with Dr. Copland, for this reason : that per- * Dictionary of Medicine. HISTORY OF HOOPING-COUGH. 16 tussis has been known traditionally to be a disease existing among the French inhabitants of Canada from the period of their first settling in that country, now upwards of three hundred years ago, and if we will acknowledge that it was imported from France at that time, under its generic name, then we cannot deny the truth of the epidemics described by the French writers as being most truly those of hooping-cough. However little, Dr. Watt says, may have been said of this disease by the ancients, it is uncertain how long it has continued to affict the human race. We have no certain account of its origin in [any one country. In Britain, it has prevailed from time immemorial; and in other countries, par- [ticularly those of Europe, we have reason to suppose that it has done the same. One of the earliest a\ithors who has described iiooping-cough is Willis, who practised first at Oxford and afterwards in London, and died in 1 675. He speaks of it as being well known at that time, and was the first who accurately de- scribed it under the name of " Tussis puerorum convulsiva, seu suffocativa, et nostro idiomate chin- cough vulgo dicta;" that it was a disease to which cliildren were liable; that it was epidemic, and ^occurred most commonly in spring and autumn. Le remarks that physicians had then very little )pportunity of being acquainted with the disease; ^ Ff 16 ON HOOPING-COUGH. '/! ( for old women and quacks were oftener consulted than regular pli3'sicians, and rational modes of cure gave place to empirical prescriptions. He pub- lished his description of it in 1664, and it is only from his time that we have any account of the disease that can be relied upon. Sydenham, who was partly the cotemporary and partly the successor of Willis, in giving an account of the measles, in 1670, incidentally mentions the chincough. At that time it appears to have been well known in London, and considered in so for- midable a point of view, as to require the most vigorous treatment. Dr. Kosen mentions in his book on Diseases of Children, that the disease was well known in Sweden, and gives an account of the mortality, from 1749 to 1764 But he confesses that he cannot determine when it first appeared in that country. As respects Britain, there is no account than earlier that of Willis which can be received. Hoffman relates that the hooping-cough was epidemic at Berlin in the year 1709 ; and, from the extraordinary severity of the season, it became extremely malignant. I In the Medical History of Epidemics, by Oza- nam, he states that it was without doubt rare, and unknown in the countries inhabited by the ancients. It seems also, he says, that it existed only in a por- tion ol Europe, and that it never showed itself HISTORY OF HOOPING-COUGH. 17 sr consulted )des of cure He pub- id it is onlv )unt of the iporary and an account lentions the > have been i in so for- •e the most Diseases of known in mortahty, jes that he red in that no account received. cough was d, from the it became cs, by Oza- )t rare, and le ancients, ly in a por- owed itself between the tropics. It has been coifounded up to the eighteenth century itself, with other catarr- hal affections; but since then its nature has been better understood, and we have isolated this malady from the others. If reference be made to the chapter in which hooping-cough is considered as a disease of all climates, from the evidence there brought forward in support of this view, it cannot but strike the observer that a disease which is so remarkably uni- , versal in its nature, and one which is not a stranger [to any known climate, not excepting that of the tropics, must most assuredly have existed from the I remotest of times, and can with the grta,test pro- priety be dated as far back as that of the first Ipeopling of our orbit. This opinion is pretty gene- *^rally shared in by medical historians of the present tday. * Of writers who have followed Willis, may be J* mentioned Sydenham, Millar, Alberti, Brendel, ^ Butter, Danz, Paldam, Perrada, Watt, Marcus, &c. ; and more recently Guibert, Desruelles, Blaud de Beaucaire, Blache, Guersent in the Dictionnaire de Medecine, Duges in the Diet, de Mdd. et Chir. Pratique, C. Johnston in the Cyclopsedia of Practical Medicine, Copland in the Dictionary of Medicine, Dr. Roe, a treatise on the disease, a work most justly esteemed by the profession for its lucid and clear views, — besides excellent notices in c i ' ' i rv i i . i i : 1 i i ! 1 'i '■11 ! ■ |!. ■ 18 ON HOOPING-COUGH. the systematic works of Dewees, Meigs, Eberl^, Stewart, Condie, Maunsell and Evanson, Coley, Barrier, Underwood, Barthez and Rilliet, Rees, Bouchut, Churchill, West, and others. The chap- ters on Pertussis in the works on Diseases of Chil- dren, by Drs. Churchill and West, are in them- selves complete and able treatises, and remarkable foi- the ability and research displayed by their learned authors. It has obtained the follomng various popular and learned names. In England, it is known as the hooping-cough or whooping-cough, from the peculiar noise attendant upon the cough. Also it is sometimes called chincough, kincough, kink- cough, kindcough, from the German word " kind,'' a child. But Dr. Johnson thinks that the first part of the term, in kinkcough, may probably come from the Dutch word " kinckin," which sig- nifies to pant. Chincough is supposed by some to be a corruption of the original word chaincough, given to it from the belief of its being an affection of the spine, which latter consisting of several parts joined to one another, like so many links, has beei) supposed to resemble a chain. In Scotland, kink- hoast ; but Dr. Watt says that the term kinkcough is mostly confined to Scotland, and the word chin- cough is the ancient English expression for the disease. In France it is usually termed coqueluche. This word is supposed by many to be derived from ;/ ■IB HISTORY OF HOOPING-COUGH. 19 igs, Eberlfe, ison, Coley, illiet, Rees, The chap- ises of Chil- re in them- remarkable 3d by their ous popular is known as ;h, from the ough. Also cough, kink- rord " kind,'' lat the first ay probably which sig- by some to chaincough, an affection everal parts ks, has beec tland, kink- kinkcougli word chin- lion for the coqueluche, erived from 3oqueluchon, a sort of cowl worn on the head [during the epidemics of 1414, 1510, &c. Others igain think it derived from the abundant use of the flower of the coquelicot (wild red poppy) in the treatment of this affection. Others in fine attri- )ute the origin of the word to the loud respiration luring the coughing, which imitates the crowing of cock.* It is known there also, as maladie cuculaire, toux quinteuse, catarrhe ou bronchite Convulsive of Laennec, and paroxysmes quintes. ^n Germany, keichhusten, stickhusten, eselshusten the hoop being likened to the braying of an ass or the bleating of a sheep), kikhusten, and kram- ^fliusten. In some parts of Germany, also, from 3rtain peculiarities accompanying the access of )ughing; as, for instance, the discoloration of the Ijfcce, the name of bluecough has been given to it. t. Sweden, kikhosta. In Italy, pertosse. Besides ese, it has been called tussis quinta, or quintana, by Schenck. Tussis clangosa, by Bourdelin and Jasseville. Tussis convulsiva, by Sauvages and ^ilhs. Tussis ferina, by Hoffman. Tussis delas- ms, T. suffocans, T. amphimerina, T. tussiculosa, stomachalis, T. spasmodica, T. perennis, T. lerilis, T. pueros strangulans, by various authors, bronchitis epidemica, by Marcus. Bronchitis con- Isiva, by Brunei and Bourdet. Broncho-cepha- * Dictionnaire des Dictionnaires. c 2 1 ' ( >; i: i < 'Ai I. / 20 ON HOOPING-COUGH. litis, by Desruelles. Bex convulsiva, by Good, ^itfection pneumo-gastro-pituiteuse, by Tourtelles. And lastly pertussis, which was given by Sydenham, was retained by Huxham, and adopted by Culleii in his nosology as the distinctive technical appella- tion of the disease in this country, as hooping- cough is the popular. All these names have been derived from some circumstance supposed to be peculiar to the disease, or in some way expressive of its nature. 21 , by Good. Tourtelles. Sydenham, I by Cullei) cal appella- as hooping- [ from some > the disease, li CHAPTER III. MORTALITY FROM HOOPING-COUGH. |It is a matter of considerable moment, and fur- lishes food for very serious reflection, to glance )ver some of the tables of statistics in the present chapter of mortality from this disease. If the lumber of deaths appears large for all England, )r even for London alone, with its teeming popu- ition, what may not the number amount to of Children carried off annually in other countries? ["he su^ total, in the number of deaths annually fom this disease alone, throughout the world, or ^en in one of its great divisions, were it possible to obtain it, would appear fabulous. And it is only by drawing attention to such facts as these a statistical form, that efforts can be made by governing bodies to improve the sanitary condition )f towns and cities throughout the world. Can it )e doubted for a moment, that hooping-cough, in pommon with many other diseases, depends upon luses removable in a sanitary point of view, diich every now and then, under the influence )f certain seasons, produce its appearance as an r ; 4'f ■ ' 22 ON HOOPING-COUGH. ! / ■' I .» I i -It. f !■ i epidemic. That it does occasionally reign as an epidemic, and is contagious in an eminent degree, are facts now too well known and generally ad- mitted by the profession, to admit of dispute. It is equally as much so as scarlet fever or measles. Its fearful ravages are confined also to a class of beings who are helpless of themselves, and whose tender age appears especially liable to its invasion. This will not be found the case scarcely with any other epidemic disease, as will be shown hereafter; and so destructive at certain seasons, that nume- rous children of entire families are swept off by it To parents, then, who are endeavouring to rear | their youthful brood, the importance of immediate resort to medical aid must appear evident, and valuable time should not be heedlessly lost in trusting to the futile and miserable efforts of quacks and charlatans, who are ever ready to thrust themselves upon the unwary, and whose impostures are certain to hurry the little patients sooner or later to destruction. The following tables I have carefully compiled from the Abstracts of Diseases and Ages, which are published in the Annual Reports of the Regis- trar-General : — MORTALITY FROM HOOPING-COUGH. eign as an 3nt degree, aerally ad- lispute. It measles. ,0 a class of and whose ts invasion. ly with any 1 hereafter; that nume- pt off by it ing to rear immediate vident, and 5sly lost in efforts of r ready to and whose tie patients y compiled Lges, which the Regis- 1. MortalUi/ from four diseases in London, for 8 years, 1842 to 1849. Bi Disease. Males. Females. Total. Sraall-pox Measles Scarlatina Hooping-cough . . . 3059 5G11 8515 G332 3205 5138 79G7 7901 C8G1 11,019 16,183 11,233 2. Ages at which the deaths from the first three diseases occurred, in the above table. Disease. Under 1 year. Between 1 and 2. Under 5 years. Between 5 and 10. Over 10 years. Smallp-ox 1585 1296 4700 1190 974 Measles . 17G2 3922 10,1G0 827 G2 Scarlatina 1153 3110 11,245 4555 682 3. Ages at which the deaths from Hooping-cough occurred in London, during the eight years, 1842 to 1849- Uuder 1 year .... 1 year and under 2 years 2 ye 3 , 4 , 5 , 10 , 15 , 20 , 25 . urs 3 J » 4 > » 5 > » 10 i; » 15 >» » 20 >> 5> 25 „ and upvvai'ds Males. 2167 1956 985 626 291 249 47 4 2 5 G332 Females. 2328 2460 1385 818 418 404 71 7 2 8 7901 Total. 4495 4416 2370 1444 709 653 118 11 4 13 14,233 ■^1— rn r ■ ' 24 ON HOOPING-COUGH. ■ I Of these there were under 5 years of age, males 6025, and females 7409; from 5 to 15 years, there were males 296, and females 475; and above 15 years, in both sexes, 28. The mortality appears to be the greatest under 2 years of age, amounting to the large number of 8911 cases; and under 5 years 13,434 ; leaving 799 cases above the last age. A most terrible proof of the fatality of this disease in early childhood. Now, if these results are compared with those of the three other diseases, we find that hooping- cough is more fatal under 5 years of age than is either small-pox, measles, or scarlet fever. The mortality from scarlet fever for the 8 years was much greater in the total number than hooping- cough ; but it was less by upwards of 2000 under 5 years of age : small-pox and measles, in propor- tion also to their total number of deaths, are much less fatal than hooping-cough under the same age. This establishes pretty clearly that hooping-cough is more especially the disease of early life, and is more fatal under 5 years of age than any of the eruptive diseases, which may sometimes prove more fatal in ^he aggregate during the prevalence of epidem_^rf. If we again take the mortality under one year, we find that hooping-cough is 4495 ; whilst small- pox is 1585, measles 1762, and scarlet fever 1153- Between 1 and 2 years, hooping-cough is 4416^ ^' MORTALITY FROM HOOPING-COUGH. 25 age, males years, there d above 15 T appears to nounting to der 5 years ist age. A is disease in ith those of iit hooping- age than is fever. The \ years was m hooping- 2000 under I, in propor- s, are much ) same age. )ping-cough life, and is any of the prove more evalence of whilst small-pox is 1296, measles 3922, and scarlet fever 1153 : showing again how much more and infinitely fatal is hooping-cough than the other diseases under two years, and more particularly under one year. But if hooping-cough is very much more fatal under 2 years than the other three diseases, it is less so between 2 and 5 years than scarlet fever ; for while it is 4523, scarlet fever is 6982; and measles is 4476, approaching to it. The fact, however, is satisfactorily established, that hooping-cough is more fatal under five years of age than any other disease, and is very much more so in infancy, compared with other diseases, which may prove more fatal than it in their aggre- gate number. I shall now give the total number of deaths in [London at all ages from the four diseases for a [period of sixteen years, 3838 to 1853, for the pur- pose of determining the per-centage upon the total number of deaths from all causes, and also of show- ing which is the most fatal of the four : — r one year, hilst small- Ifever 1153- is 4416' 26 ON HOOPING-COUGH. 4. Mortality from four diseases and from all causes, in London, for IQ years, 1838^1853. Year. Small-pox. Measles. Scarlet Fever. Hooping- cough. AU Causes. 1838 3817 588 1524 2083 53,546 1839 634 2036 2499 1161 46,100 1840 1235 1132 1954 1069 46,281 1841 1053 973 663 2278 45,284 1842 360 1293 1224 1603 45,272 1843 438 1442 1867 1908 48,574 184.4 1804 1182 3029 1292 50,423 1845 909 2318 1085 1816 48,332 1846 257 747 928 2035 49,089 1847 955 1778 1433 1600 60,442 1848 1620 1135 4767 1630 57,628 1849 521 1154 2149 2349 68,432 1850 498 977 1178 1572 48,579 1851 1066 1322 1269 2161 55,354 1852 1166 600 2549 1565 54,213 1853 Total 229 1018 2068 2644 61,202 16,562 19,695 30,186 28,766 838,751 '\ il From this table it appears that scarlet fever and hooping-cough are the most fatal diseases out of the four in the metropolis; both are one-third more so than measles, and nearly twice as fatal as small-pox. The number of deaths from scarlet fever exceeds that of hooping-cough for the six- teen years by only 1 420, a small amount compared with the excess in the whole of England, presently to be shown. The mean annual number of deaths for the six- teen years, together with the proportion to the total number from all causes, stands as follows : — MORTALITY FROM HOOPING-COUGH. 27 Small-pox 1035^ or 1 in 50| Measles 1231 or 1 in 50^ Scarlatina 188G| or 1 in 27^ Hooping-cough . . . 1796| or 1 in 29|- Of tho entire class of zymotic diseases, although we find the mortality from typhus fever and diar- rhoea to be very large, it is still less than that of scarlet fever and hooping-cough. Tho following table gives the number of deaths in England from hooping-cough alone, for the period of eight years, 1838 to 1849, with the intermission of the years 1843, 4, 5, and 6, there being no returns of diseases published for those years. 5. Mortality from Hooping-cough, for S years, 1838 to 1840 (exclusive of 1843, 4, 5, 6) throughout England. Year. Males. Females. Total. 1838 4036 5071 9107 1839 3683 4482 8165 1840 2750 3382 6132 1841 3626 4473 8099 1842 3645 4446 8091 1847 4126 5134 9260 1848 3065 3797 6862 1849 Total 4257 5358 9615 29,188 36,143 65,331 The number of deaths for the same period throughout England from small-pox is 60,691 ; from measles, 63,434 ; from scarlet fever, 111,221. As in the metropolis, so is it in the whole of I 5< I !«^'^vr 28 ON HOOPING-COUGH. England, that scarlet fever and hooping-cough bear the largest proportion, but the former vastly preponderates over all the others. To the total amount from all causes for the same period in England, scarlet fever is in the proportion and hooping-cough 1 in 45yV The m 26, ^ of 1 latter is therefore more fatal in the metropolis than throughout England ; for whilst in the first it is in the proportion of 1 in 29^, in the second it is in that of 1 in 45 yV The average of the eight years in the table above is 8166f ; if, therefore, we wish to estimate the mortality from hooping-cough for a period of sixteen years, to the end of the year 1853, from this average number it will give, as the total deaths from this cause alone throughout England, the enormous sum of 130,662 deaths ! In the report of the census for Ireland for 1841, and classified by Mr. Wilde, of Dublin, in 1843, the number of deaths registered as occurring from all causes in the ten years, 1831-41, amounted to 1,187,374. Amonr epidemic class, the total number of deatl' -ited to 381,249. Out of this number thei jre from hooping-cough, 36,298 deaths (21,325 within the first year's age), the propor- tion of sexes being 100 males to 115*43 females. " It has proved most fatal in the rural districts, being there in proportion to all other diseases as MORTALITY FROM HOOPING-COUGH. 29 the same ■ )roportion ■ h%- The fl polls than 1 rst it is in fl nd it is in jfl the table m 3 estimate 1 period of 9 .853, from V the total m ) England, M for 184], 1 1843, the 1 g from all ^ runted to lumber of is number 18 deaths e propor- J females. districts, WK^ iseases as »mI 1 in 3048, and to those of the epidemic class as 1 in 9'09; while in the civic district ^ it is 1 in 36"76 of the deaths from all other causes, and 1 in 1404 of those denominated epidemic or contagious. Its general mortality, in comparison with all other affections for the entire kingdom, is 1 in 3271, and of the total epidemic diseases, 1 in 10'5. In the metropolis, this affection was to the total epi- demics, 1 in 1747 ; in the province of Leinster, 1 in 1224 ; in Munster, 1 in 11-24; in Ulster, 1 in 9*4 ; and in Connaught, 1 in 9"L"* 6. M^rtaUti/ in Glasgow from Hooping-cough, fot ^0 ^ears, from 1783 to 1812.t 1783 153 ' 1793 112 1803 60 1784 13 i 1794 51 1804 52 1785 34 1 1795 180 1805 129 1786 173 i 1796 60 1806 162 1787 57 i 1797 76 1807 85 1788 17 I 1798 98 1808 92 1789 45 1 1799 95 1809 259 1790 177 I 1800 27 1810 147 1791 117 1801 125 1811 62 1792 68 i 1802 90 1812 103 Deaths in first 10 years from Hooping-cough 854 Second 10 years . . . 914 Third 10 years . . .1151 Total 2919 Total deaths from all causes .... 17,607 Second 10 years . . 16,685 Third 10 years . . 20,184 Total 54,476 * Report upon the Tables of Deaths ; also Review of, in Brit, and For. Med. Rev. t Condensed from Dr Watt's Tables. I ^^ so ON HOOPING-COUGH. On looking over the annual mortality, during the thirty years, it will be observed how the num- ber varies, the greatest number of deaths during one year beinp^ 259, or something more than 11^ per cent, of v- •. -^hole deaths of that year, which were 2114 ; ^1 "Ist the lowest number of deaths is 13, the dea^' s of which year were 1623. This circumstance is of course due to variations in the severity of the epidemic, and to other causes sub- ject t*^ atmospheric influences. Tl: t^ riiean annual average of deaths during the thirty years, from hooping-cough, is 91*3. The ratio of deaths from which cause, as compared with the total number of deaths from all other causes, amounts to 5f per cent, or as 1 in 18 1. Dr. Watt remarks as somewhat singular that, in the last twenty-five years, there had been only six single months in which some have not died of chincough; and in the last twelve years, not a month has elapsed without a death. He cojq eludes that, next to the small-pox formerly and measles now, chincough is the most fatal disease to which children are liable. He gives the following table of the ages at which death from hooping-cough occurred in Glasgow, during the thirty years above enumerated : — ) ( ■■■ ^Z'rr^-.fnr-'v • by, during the num- hs during than 11 I 3ar, which f deaths is 123. This ons in the sauses sub- during the )l-3. The compared L all other p ISf. ar that, in n only six ot died of sars, not a concludes id measles e to which 3S at which Glasgow, M:— 7. MORTALITY FROM HOOPING-COUGH. Under 6 months in 135 cases. 31 Above 6 „ 1 year 2 years „ 3 3 „ „ 4 4 „ „ 5 5 „ „ 6 6 „ „ 7 7 „ ,,8 8 „ „ 9 9 » „ 10 A.\J jj • • • • • Males, 842 ; females, 975 . and under 1 year „ 357 2 years „ 596 ,,333 ,,186 ,,109 „ 37 „ 34 „ 12 10 5 3 „ „ It „ » » „ ,» 1817 Dr. Watt states that this number may be [considered as about the half of the deaths in [Glasgow from this cause, in which the ages wefe )btained. In the year 1835, the deaths in Glasgow from the same cause were 483; in 1836, they were 454; lind in 1837 they were 457 ; a total of 1394, of ''^' which 1298 were under five years, and 96 ovar that age.* In the year 1852 the deaths were 639, and in 1 853 they were 908 from the same cause, in a [Population assumed to be 385,000. The deaths among cliildren under five years of age, Li I the latter year, amounted to — from all causes — 17046, being 49 '23 per cent, of the whole, or in * Lancet, vol. ii., 1837-38, p. 116. -^-kr,-«/nw;jr,T-^^yT.- ^^W-'^f" 1: li ( I / 1 1 ! [ I J -I •/ ]r\ 32 ON HOOPING-COUGH. other words, one half of the whole deaths has been among children under the above-mentioned age.* The bills of mortahty in Sweden show, that in the course of sixteen years, from 1749 to 1764, the large number of 43,393 children — 21,543 males and 21,850 females — have died from hooping- cough, an amount which averages 2712 children in each year. In the year 1755, 5832 children were carried off by this scourge ; but in years when it has raged with less fatality, about 1700 or 2000 were lost by it in that kingdom.f No information has been furnished as to the cause of its origin, or of its subsequent decline. The mortality in Sweden has been quoted most extensively by many writers as enormous for a period of sixteen years, viz. 43,393 ; but what is it compared to England for half that time, which presents the modest number of 65,331 ? Or, if an equal period of 16 years is taken for comparison, we find the really frightful number of deaths to be 130,662. It may be presumed that the Swedish tables will not hereafter be quoted as enormous in their mortality, when the present English tables appear iii their condensed form. * London Times, 12th January, 1854. f On the Diseases of Children. By Dr. Rosen. MORTALITY FROM HOOPING-COUGH. 33 deaths has -mentioned low, that in 1764, the ,543 males Q hooping- 12 children 3 carried off t has raged i^ere lost by 1 as to the decline, [uoted most mous for a 3ut what is time, whicli Or, if an comparison, »f deaths to tables will Lis in their ibles appear Rosen. 8. The following Table shotcs the Mortality in the same Country^ Sweden, for twenty five years, from, 1806 to 1830.* Year. Males. Females. Year. Males. Females. 1806 2274 2272 1821 1363 1627 1807 1194 1435 i 1822 1149 1301 1808 276 287 1823 681 673 1809 313 315 1824 723 790 1810 1811 435 523 1825 1826 1043 1228 4492 5332 4959 5619 987 1155 1477 1584 1812 1630 1828 1827 1244 1477 1813 953 1174 1828 979 1138 1814 461 551 1829 1031 1058 1815 1816 532 642 1830 1806-10 1015 1130 4563 5350 5746 6382 792 839 4492 5332 1817 947 1123 1811-15 4563 5350 1818 598 747 1816-20 3856 4523 1819 810 991 1821-25 4959 5619 1820 709 823 1826-30 Total 5746 6382 3856 4523 23,616 27,206 Giving a total of 50,822 deaths in the 25 years, — 23,616 males, and 27,206 females ; or an annual average of 2032 1 deaths. The Reports of the Council of Health for the City of Paris represent the mortality from hoop- ing-cough to be, in * Brit. Med. Almanack, in Sixth Annual Report of Registrar-General. D < !] ) I ! 11 34 ON HOOPING-COUGH. 1827 1828 54 boys 78 „ 64 girls 82 ,. total 118 ,. 160 278 The total number of deaths from all causes in 1827 was 23,241, and in 1828, 24,299. The pro- portion of deaths from hooping-cough to that from all causes is 1 in 171.* But it appears that in those years, in 1827, the number of 756 boys, and 736 girls, died from con- vulsions ; and in 1 828, 889 boys, and 852 girls, died from the same cause. The greater number of these were in the three first months of life, and from the first to the fourth year of age, and which may account for the remarkably small mortality from hooping-cough. In Prussian Pomerania, the deaths were as 1 in 25^ of the entire mortality. In Denmark, as 1 in 21 1. In Brandenburgh, as 1 in 29^. In Sweden and Finland, 1 in 13|. In Strasburgh, 1 in 94. In London 1 in 29^ ; in England, 1 in 45^^. In Ireland, 1 in 3271. In Glasgow, 1 in 18|. In the city of Philadelphia, with its suburbs, the deaths from hooping-cough, for a series of twenty years, viz. : — from 1st of January, 1807, to * Amer. Jour. Med. Scicuces, vol. iv. p. 528. I I ■ MORTALITY FROM HOOPING-COUGH. 35 total 118 „ im^ 278 I causes in The pro- )that from 1827, the [ from con- 852 girls, ' number of Df life, and , and which 1 mortality ere as 1 in in 45A. ts suburbs, a series of 7, 1807, to 528. 1st of January, 1827, inclusive, were 805. The highest number in a single year is 151, in 1819; the lowest 6. The whole amount in twenty years, 805, is as ] in 22 of the whole number of deaths under puberty, from other diseases.* 9. Mortality from Hooping-cough in the City of Montreal, for the years 1846 and 1847, and first quarter of 1848, with a population o/'48,000.f Year. Males. Females. Total. Under 1 year. Between 1 and 3. Between 3 and 5. Between , 6 and 10. 1846 1847 1848 9 3 8 14 4 8 23 7 16 9 6 12 11 1 2 2 1 1 1 20 26 46 27 14 3 2 Total deaths from all causes in 1846 Ditto „ „ 1847 Ditto first quarter in 1848 2118 3005 375 5498J The mortality from this disease, as compared with the general deaths is 1 in 119|, or not quite seven- eighths per cent. The amount is ridiculously small, and must be incorrect, as the returns were not made by medical men, and almost every com- * Med. Statistics of Mortality in PhUadelpliia. By Dr. Gouverneur Emerson, f Tlie population now is 75,000. X Brit. Amer. Med. and Phys. Jour. D 2 « ! 36 ON HOOPING-COUGH. / plaint with the slightest cough is put down by the French-Canadians as "la phthisie/' when it is notorious that a large number of these were cases of pertussis. These were the only tables compiled to my knowledge. I think I may safely pronounce the mortality to be 1 in 30. In Boston the mortality is 1 in 82 In Charleston „ „ 1 in 46*6 In Baltimore „ „ 1 in 95*38 In New York „ „ 1 in 647 In Philadelphia „ „ 1 in 631* * Condie, On Diseases of Children, p. 329. ' 1 i] 87 own by the when it is were cases es compiled T pronounce CHAPTER IV. n82 in 46*6 in 95-38 in 64-7 in 631* ,329. SYMPTOMS OF SIMPLE HOOPING-COUGH. The disease has been divided into three stages by some, and into two by others. Desruelles and Lombard have a period of invasion, a period of increase, and a period of decline ; Blache and Williams divide it into the inflammatory, con- gestive, and nervous stage ; Dr. Golding Bird into inflammatory and nervous stage ; Dr. Churchill has adopted a catarrhal and spasmodic stage ; Aberle into catarrhal, convulsive, and period of decrease ; and Dr. West recognises three stages, the catarrhal, spasmodic, and the period of decline. I think the two last the most convenient, for many reasons, and will, therefore, adopt them. 1st stage — Catarrhal. 2nd stage — Spasmodic, nervous, or convulsive. 3rd stage — Period of decline. The first stage of an attack of hooping-cough usually begins with symptoms of catarrh, seldom so severe as that preceding measles, and presents at first little or nothing to distinguish it from a common cold ; the child is languid, restless, feverish, J 38 ON HOOPING-COUGH. ! 1 and irritable without cause. There is loss of appetite, sneezing, coughing, turgescence of the face, slight redness of the conjunctiva, watering of the eyes, and an extra secretion of mucus from the membrane lining the nose and bronchial tubes after the first day or two. Sometimes the cough is at- tended almost from the outset with a peculiar ringing sound ; it is more or less frequent, comes on in fits, is at first dry, but with profuse expectoration afterwards, and may be taken for a common catarrh, or catarrhal affection of the trachea and bronchi. This is the most general mode of invasion — a well marked but not very severe catarrh. Occa- sionally we find the patient suffering much more ; the fever intense, great thirst, the pulse quick, the oppression and general distress considerable, the cough very frequent and painful, a sense of con- striction in the chest, and a feeling of weight in the head. The anterior part of the neck is sometimes uneasy, or even painful ; the bowels are generally out of order. The cough is more sonorous and more acute than in bronchitis; expectoration is scanty, even with adults, and the matter brought up is limpid, as at the commencement of catarrhal affections. There is scarcely any fever, sometimes only for twenty-four or thirty-six hours ; but in some cases, ■m ilj. ij m|i;i|n|ni ii»i is loss of nee of the svatering of us from the [ tubes after ough is at- a peculiar it, comes on :pectoration a common rachea and invasion — a rrh, Occa- Quch more ; 3 quick, the erable, the Qse of con- eight in the sometimes e generally norous and 3toration is er brought )f catarrhal les only for some cases, 1 SYMPTOMS OF SIMPLE HOOPING-CX)UGH. 39 the fever is more marked, and may assume a quotidian or tertian type. Occasionally there may be no evidence of the existence of a first stage, as mentioned by Dr. Churchill; the child is at once seized with the characteristic cough, without any irritation of the mucous membrane.* An example of this occurred to the child of Dr. Tavernier, aged two years, who was brought home from the country without the slightest cold. The next day she was playing with children who had the disease, and on the evening of the second day she had an attack of shrill spasmodic cough, which proved to be hooping- cough, and continued for two months without any complication.f On the other hand, Dr. Roe says| that very mild cases of this disease retain the character of unusual expirations, followed by a forced inspiration, throughout their whole course, and the hoop may never be heard. He has met with several instances in which one child in a family who were suffer- ing from distinctly-marked hooping-cough, went through the disease without hooping, and others in which the hoop was never heard more than * Diseases of Children, p. 200. f Diet. Gen. des Sciences Med. Art., " Coqueluche," p. 21 X Treatise On Hooping-cough, p. 8. 40 ON HOOPING-COUGH. II oriv^e. Dr. Watt mentions that he had met with similar instances,* and refers to observations made by Dr. Cullen and Dr. Burns to the same effect. The former writes, " I have had instances of a dis- ease which, though evidently arising from chin- cough contagion, never put on any other form than that of common catarrh."t Dr. Burns observes, " In young children, even death may take place, although the disease never fully forms \' and his observation is confirmed by M. Duges. Were this more generally known among parents, that the disease may exist unaccompanied by a A-oop, they would not wait till this symptom appeared before they made any attempt to arrest its progress, par- ticularly when hooping-cough is reigning as an epidemic disease. Dr. Churchill, however, thinks that in such cases there must ever remain a doubt as to the true natiure of the disease. The catarrhal symptoms constitute the period of incubation, and usually continue from four to twelve or fifteen days, when they subside gradually into the second stage. The average duration of the catarrhal stage of hooping-cough in 55 cases under Dr. West's care, J in which the date of the occurrence of the first distinct hoop was ascertained, was 12*7 days. In * On the Chincough, p. 37. t First Lines of the Practice of Physic. X Lectures on Diseases of Infancy and Childhood. 2nd edit. tR II SYMPTOMS OF SIMPLE HOOPING-COUGH. 41 1 met with tions made ame effect. es of a dia- from chin- r form than s observes, bake place, \' and his Were this ;, that the yioop, they red before •gress, par- ing as an er, thinks n a doubt le period n four to gradually I stage of st's care,J the first ays. In 2nd edit. 19 of these cases, the first hoop was heard within 7 days from the commencement of the catarrhal symptoms, and in 19 more cases during the suc- ceeding seven d&.ys ; but the extreme limits of the duration of the premonitory stage are very wide apart — since on one occasion it lasted only two days, and in another 35 days. In 18 cases. Dr. West remarks, the catarrhal stage lasted on the average only 8*3 days, when the cough assumed a distinctly paroxysmal cha- racter ; but no hoop occurred till the fifteenth day. In four cases, after the catarrhal stage had lasted on the average 11*5 days, the cough became paroxysmal, but no hoop occiu-red during the whole course of the affection. In one case the cough had a distinctly paroxysmal character from the first, but no hoop occurred during the whole course of the affection. In six cases the cough was paroxysmal from the outset, and continued so on the average 9*3 days, at the end of which time distinct hoop accompanied it. In three cases a dis- tinct hoop attended the cough from the commence- ment. Unusual protraction of the catarrhal stage of hooping-cough is, Dr. West believes, usually met with either at the commencement of an epidemic of the disease, or towards its close. Epidemic hooping-cough very frequently succeeds to epidemic catarrh ; the former disease becoming gradually 42 ON HOOPING-COUGH. 'I' ! II ^1 1 developed out of the latter, and the persistence of the cough in several cases long after the decline of all other indications of catarrh, is often one of the first signs, he says, of the commencement of an epidemic hooping-cough. The second stage is known by the gradual abatement of most of the catarrhal symptoms ; the fever and other disturbance to the child's health diminish, or altogether cease, but the cough, never- theless, continues. It may even appear aggra- vated, but its character is changed. It it no longer a simple cough, with few succussions, but is pro- longed by a succession of expiratory efforts; and at its termination is occasionally heard a forcible inspiration, accompanied by a loud ringing sound. The prolonged paroxysm of coughing, or Icink, and the lioojp, mark the commencement of the present stage, as the subsidence of the catarrh does the termination of the first.* The cough is so remarkable that, when once heard, it is seldom either mistaken or forgotten. " It grows louder and lasts longer than before, and assumes something of a suffocative character, in all of which respects a tendency to exacerbation towards night becomes early apparent. As the cough grows severer, its peculiarities become more and more manifest ; during each paroxysm the child turns red in the face, and its whole frame is * Churchill, On Diseases of Children. SYMPTOMS OF SIMPLE HOOPING-COUGH. 43 rsistence of ( decline of one of the Qent of an le gradual )toms ; the Id's health ugh, never- lear aggra- t no longer )ut is pro- mts; and at a forcible ^ing sound. Idnk, and he present does the rhen once forgotten. before, and aracter, in acerbation As the ome more )xysni the le frame is shaken with the violence of the cough. Each fit of coughing is now made up of a number of short, hurried expirations, so forcible, and succeeding each other with such rapidity, that the lungs are emptied to a great degree, of air, and the child is brought by their continuance into a condition of impending suffocation. At length the child draws breath with a long, loud, sonorous inspiration — the hoop from which the disease derives its name, and the attack sometimes terminates. More often, how- ever, the hoop is followed by but a momentary pause, and the hurried expiratory efforts begin again, and are again arrested by the loud inspi- ration, perhaps only to recommence, until, after the abundant expectoration of glairy mucus, or retch- ing, or actual vomiting, free inspiration takes place, and quiet breathing by degrees returns.^'* These paroxysms vary both in frequency and severity in different cases; sometimes coming on every three or four hours, or rapidly succeeding one another, and lasting from one to fifteen mi- nutes ; Dr. Churchill has known them occur every h, If hour during the day and night; in other cases, they may return every five or ten minutes during the day, and less frequently at night, though the paroxysms are rather more severe.f As a general rule, however, they are more frequent during the * Dr. West, On Diseases of Infancy and Childhood. f Marley, On Diseases of Children. Twr i..\ m I ffl ii ' i *il / ON HOOPING-COUGH. night than the day. In proportion to their vio lence and length will be the breathlessness and fright of the child, and its efforts to inspire ; if lying down, it will suddenly jump up and seize hold of whatever is nearest, — its nurse, or a chair, or table, so as to make a fulcrum, as it were, for the whole muscular force of the body, which is employed in overcoming the spasm, and to diminish the shock and jar by which its whole frame is shaken. The attack is frequently so severe that the lips and eyes become encircled with a bluish appear- ance : this I have occasionally observed, but am inclined to believe is more often met with in colder climates than that of England. My friend, Dr. Arnoldi, of Montreal, describes the cases of two boys, aged about ten years, living at a great dis- tance from one another, in v/hom the cough was so violent, that both of them had the circumference of their eyes ecchymosed, as though they had been "pommelled in pugilistic combats."* Dr. Von Iflfland, of Quebec, also describes this bluish ap- pearance, and mentions that not unfrequently the tongue is found to bear the same choleric tinge.f Dr. Mackintosh remarks, that it is no uncommon thing for a small bloodvessel to give way in the conjunctiva, producing ecchymosis ; and he says * Canada Med. Jour. 1852. Vol. i. p. 212. t Montreal Med. Gaz. 1814. Vol. i. p. 194. ■MMi*<><4Mi SYMPTOMS OF SIMPLE HOOPING-COUGH. 45 the straining during a paroxysm is sometimes so severe as to produce the involuntary discharge of faeces and urine.* And Dr. Copland repeats, that during the paroxysm the face and neck are swollen, injected, and violet-coloured, and the jugular veins are gorged. Dr. Watt describes the face in one set of patients as becoming swollen and of a dark purple colour ; the veins of the head and neck are distended, as if ready to burst, and the patient gasps, and has the appearance of impending suffocation. During these violent efforts, the extremities become cold, and the forehead and temples are covered with perspiration ; blood is forced from the nose, mouth, ears, and eyes; in many cases, he observes, the patient is actually suffocated, falls into a faint, or is seized with convulsions. In older and more robust pa- tients, in another set of cases described by him, the expirations are so very violent and rapid, that they look as if they would burst. The face in such cases is of a bright scarlet colour ; the eyes fiery, as if they would start from their sockets ; but the inspirations are performed as soon, and apparently with as much ease, as if nothing were the matter. The appearances presented in this stage might be multiplied ad inji7iitum, according to the in- tensity of the attack. The duration of this, and the rapid succession of coughing, will produce the * Path, and Prac. of Physic, vol ' n. 403. 4G ON HOOPING-COUGH. - i- 1 1 1 ' iiii most severe congestion in the face and neck, approaching almost a black colour, and it is at this period sometimes that death is imminent, not from suffocation merely, but actual apoplexy. The expectoration of a quantity of glairy mucus, or the act of vomiting, terminates the attack of coughing. The child now appears exhausted, and requires rest for recovery, the breathing being ex- ceedingly rapid ; during the interval, until the next cough, it appears as gay and lively as if nothing had been the matter with it, and returns imme- diately to the amusements or the occupation which the fit of coughing had interrupted. Sometimes, however, it will remain paJe, thin, and languid, and seems much frightened. The principal cause of the return of the pa- roxysms of coughing is the accumulation of mucus in the bronchial tubes, if the secretion is profuse. Now, as this collects, so does the child feel a tick- ling in the throat, and a sense of tightness, both in the larynx and chest ; occasionally uneasiness or pain under the sternum : efforts are now made to expel it, and, if easily got rid of in sufficient quan- tity, the fit will be light and the interval easy. If it be scanty and tenacious, the paroxysm will be violent, the efforts great, and the cough renewed almost immediately, or it will occur in double pa- roxysms. In the early part of this stage, the mucus expelled is scanty and thin j and in proportion as m K >.— 't y nd neck, I it is at inent, not iexy. ry mucus, attack of usted, and being ex- II the next if nothing , rns imme- tion which jometimes, nguid, and )f the pa- L of mucus is profuse. 3el a tick- ss, both in Basiness or w made to ient quan- 1 easy. If !m will be 1 renewed louble pa- tlie mucus )portion as m SYMPTOMS OF SIMPLE HOOPING-COUGH. 47 this is the case, the fits are longer and the more violent. Later, it becomes more abundant, and sometimes is very copious; at the same time, thicker and more viscid, and more easily brought up, and OQ that account the fits of coughing are less protracted. The vomiting and profuse expectoration which terminate the paroxysm, cause the rejection of a ropy and limpid fluid, which comes partly from the bronchi and partly from the stomach, as shown by the presence of portions of ingesta, and of bron- chial mucus. This fluid, Dr. Copland observes, in some cases may proceed from the air-passages when vomiting does not take place ; in others, again, particularly ir ^hose accompanied with vomiting, it is chiefly from the stomach.* It is sometimes sanguineous, either in streaks or specks. Vomiting is usually considered a good sign, and in its absence children are said to get worse. When it does terminate the paroxysm, the appetite is immediately keen for food. If no vomiting occurs, the f^xpectoration in young children is scarcely ever ^pat it ; it is generally swallowed as soon as dis- charged from the air passages. I must not overlook a condition, mentioned by Sir Henry Marsh, as occurring in many cases after the paroxysm; and this he has described as "regurgi- * Med. Diet., vol. i., p. 237- 48 ON HOOPING-COUGH. W\ I ill tation."* He has found that the rejection of food after the paroxysm of coughing was effected by the act, not of vomiting, but of regurgitation. Dr. Copland uses the term also, ir. expressing the non- cessation of the cough, " until the patient rejects, by a sort of regurgitation, a ropy and limpid fluid,'' &c. I have sometimes witnessed after a paroxysm the apparent evacuation of matters from the stomach, without any retching at all, or any effort whatever on the part of the child ; and doubtless many others have done so. On this subject. Sir Henry Marsh observes, " Regurgitation is a very remarkable irregularity, and perverted — I might say reverted — action of the nerves and muscles of the stomach. As far as my observations have reached, I have been enabled to trace it with cer- tainty, in many instances, to the strumous diathesis, to an imperfection of function, connected, I know not how, with struma. In treatment, the know- ledge of this fact is valuable.'' Mental irritation, as crying or laughter, fright, a fit of anger, opposition, or even a full meal, will generally bring on the cough. Even the sight of another in the paroxysm, from the force of sym- pathy, will induce it in those affected with this disease. The fits are generally much more severe after a meal, or after running, or other very active exercise, or exposure to cold. The desire for food * Dublin Quarterly Journal, May, 1851. pilMilJJ -^ i^jiipUfMi;^ ' SYMPTOMS OF SIMPLE nOOPING-COUGH. 49 is more craving than usual in this disease, and chil- dren, if not watched, will eat a great deal too much. This stage usually continues for a considerable time, varying generally from fifteen days to six weeks or two months, but often three or four months, or even longer. I attended a child in whom this stage alone lasted fully seven months. Dr. West mentions, that in twenty-five cases, in which he watched the patients from the time when the cough first assumed the paroxysmal character, or the hoop first became audible, until the final cessation of all cough, he should be dis- posed to estimate the average duration of hooping- cough to be ten weeks ; of which period nearly two would be occupied by the first stage ; four for the second; and the cough occasionally in the third stage, to four weeks.* The third stage is known as the period of decline; it may last for a few days only, or may extend to two or three months. One of the first indications of the decline is usually afforded by a diminution in the severity of he nocturnal exacerbations. The paroxysms become less frequent and less intense ; they are much shorter in duration also than in the preceding period, and terminate in an easy and copious expectoration, which is thick, opaque, of a white or greenish colour, and occasionally puriform, * Diseases of Infancy and Cliildliood, p. 272. E ]m 50 ON HOOPING-COUGH. j ■' ! as in the last stages of catarrh; and in the vomiting of alimentary matters. The fits become insensibly feebler during this stage ; the cough gradually loses the characteristic hoop, and approximates nearer that attending the last stages of catarrhal affec- tions. Meanwhile, if not too much exhausted, the con- stitution begins to recover its healthy condition; tranquil sleep restores the nervous system ; the food becomes well digested from the absence of vomiting; the child recovers flesh and spirits ; the circulation is quite unimpeded, and the surface of the skin assumes its natural aspect. Occasionally in this stage the paroxysms have assumed a periodic character, returning at a given hour every day, or every two, or even three days. Dr. Mason Good mentions a case of this kind; it occurred daily at a certain hour, continued obsti- nately for several months, and returned at the same season for two years. Laennec remarks, that the return of the cough observes a more marked periodicity in this affection than in any other variety of pulmonary catarrh. As the disease approaches its termination, the fits sometimes re- appear only on alternate days. During this stage, the patient will remain for a day or two, or even longer, without cough; but exposure to cold, change of temperature or weather, neglect of the state of the bowels, errors of diet, or — -H SYMPTOMS OF SIMPLE HOOPING-COUGH. 51 mental excitement, will suffice in many cases to bring back the hoop, and to increase the previously diminished severity of the attack. In particular seasons, as during autumn, and at other times during a prevailing easterly wind, the paroxysms of cough will return, with the same character, after a fortnight, a month, or even two or three months of perfect and apparent recovery.* The cough loses its spasmodic character many days before it ceases altogether; and you may even find a child, says Dr. West, otherwise in good health, who, some six weeks after an attack of hooping- cough, still has occasional returns of cough, which a slight cause would once more convert into an ailment with all the characters of fully developed pertussis. Guersent has frequently seen the parox- ysms return fifteen days or a month after the cough had ceased.f Physical Signs. — On applying the stethoscope, or the ear, to the chest during the Jirst stage, we will find the mucous or sibilant rhonchi charact^ '•- istic of the catarrh ; and the respiratory murmur somewhat weaker than usual. The chest, also, is clear and sonorous on percussion. During the second stage, when the nooping- cough is fully developed. Dr. West observes that, " If you listen to the chest during a fit of hooping- * Copland's Diet, of Med. f Diet, de Med. Tom. vi. E 2 ,||:ni|T, liH I JJii ii ' L ii 52 ON HOOPING-COUGH. cough, you will have no sound whatever in the lungs ; but when the hoop occurs, you will once more perceive air entering, thoXigh not penetrating into the minuter bronchi. It is not till the fit is over, and respiration once more goes on quietly, that the air reaches the j)uhnonary cells again ; but then you will hear vesicular murmur as clear as if nothing ailed the child, or at least interrupted only by a little rhonchus, or slight mucous ra-le. If the cough be severe, quiet breathing does not return, nor the vesicular breathing become audible, till some time after the paroxysm is over ; and, oc- casionally, short and laborious breathing ushers in each fit of coughing/'* The following is Laennec's description : — " During the intervals between the paroxysms, only the ordinary signs of catarrh are met with, that is to say, the respiratory murmur is rather feeble, or even absent in some points, which, however, yield a good resonance ; in others, there is puerile respiration, and sometimes a little snor- ing, or sibilant mucous rale. During the paroxysms, on the contrary, nothing more is perceived than the concussion impressed on the trunk by the shocks of the cough, and one hears a slight degree of rale and respiratory murmur only, in the very brief intervals between the expulsive jerks of the cough ; but the whistling and prolonged inspiration, which consti- tute the pathogn' ^onic character of hooping-cough, * Lectures on Diseases of Iiifancy and Childhood. I ir 1^ SYMPTOMS OF SIMPLE HOOPING-COUGH. 53 r in the vill once letrating .he fit is quietly, rain ; but ear as if pted only ). If the )t return, iible, till and, oc- ushers in Laennec's iween the Ltarrh are nurmur is its, which, lers, there Lttle snor- aroxysms, 1 than the I shocks of if rale and f intervals but the ich consti- ing-cough, liood. appear to take place solely in the larynx and trachea. Neither the pulmonary nor bronchial respiratory sound is then heard, even in those parts of the lungs which, some seconds before and after the fit, yield the puerile respiration."* Dr. Wil Hams' t observations are very similar to both of the above writers: — "On applying the ear to the chest during a fit of hooping-cough, one is surprised, with such violent external emotions, to hear so little sound of respiration within the chest; and during the sonorous back-draught there is scarcely any sound of air entering the lungs. This is to be ascribed to the continued contraction of the glottis and large bronchial tubes preventing the air from entering the pulmonary texture with sufficient force to produce the ordinary respiratory murmur," The difference in this respect between children and adults is clearly shown by the following : — " In the convulsive cough of adults there is no obstructed hooping inspiration, but a full, forcible one, which is heard loudly in all parts of the chest." So far as this general description goes, all writers seem pretty much agreed when the disease is un- complicated. Dr. Churchill, however, thinks more can be heard during the intervals in well marked cases than has been mentioned. He has examined a great many children at intervals, from one * Diseases of the Chest. By Herbert, p. 85. f Diseases of the Chest, 4th edit., p. 89. I': i;l I i m i ,Ji 54 ON HOOPING-COUGH. pai'oxysm to another, and has, in a great many cases, found that after the chest had been cleared by the last cough and vomiting, the respiratory murmur or inspiration was louder and more rough than usual, nay, in some cases, that it had a rather loud, brazen sound, something resembling a loud sonorous rale, as if the air was passing thrjugh tubes narrower than usual. It is perceptible, also, in expiration, though more feeble. This sound may continue until the mucus begins to accumulate, and then it will be exchanged for the large, mucous, bubbling sound, which increases until the next cough, and is almost universal. In milder cases, the rough dry sound is more feeble, though generally audible, and Dr. Churchill thinks this loud rough murmur of inspiration and expiration quite peculiar to pertussis. Throughout this stage, in simple cases, the chest is clear upon percussion. A sudden increase of fever and permanent dyspnoea are sometimes present at the commence- ment of this stage, and depends upon some disturb- ance of the nervous system, as auscultation furnishes no indication of disease of the lungs. The most remarkable peculiarity in all these physical sounds is the inspiration or hoop precipi- tating the air by a loud hissing sound, as far as the bifurcation of the bronchi, where it seems to en- counter some obstacle. The bronchial tubes to this iJYMPTOMS OF SIMPLE HOOPING-COUGH. 55 point must, during the paroxysm, be very much compressed spasmodically, in the contraction of their entire diameter. There is one other peculiarity in this affection which has not been noticed by any writer, and which I have frequently satisfied myself of the truth of ; it is this — on applying the stethoscope to the jugular veins on either side of the neck imme- diately after the paroxysms have ceased, a distinct musical murmur is heard, more marked on the right side than on the left, which disappears again when the circulation and respiration have become tranquil, to re-appear each time on the subsidence of the paroxysms. These venous murmurs were first observed by Dr. Ogier Ward in other diseases, but, so far as I can learn, they have not before been observed in pertussis. In the third stage, many of the physical signs of the second will at times appear. But, generally, they here do not present any great difference from those of mild bronchitis, there being often variable humming, whistling, and bubbling rhonchi in the upper and middle reg .ns of the chest. The expectoration in the Jirst stage, which is usually a frothy mucus, assumes in the second stage a very viscid and tenacious character; it may be clear and transparent, white or yellow, and mixed with air-bubbles, but still thick, tenacious, and ropy, so that it may be drawn out of the 56 ON HOOPING-COUGH. infant's mouth with the fingers. In the third stage, it is very loose and more copious again, it is thick, opaque, of a white or greenish colour, and occasionally puriforra, as in the last stages of catarrh. GeTieral Considerations. — Hooping-cough is pre- eminently an affection of infancy and childhood, and has the peculiarity in common with many of the eruptive diseases, that it occurs once, and generally but once in a life-time, very few children escaping from it. Rare instances have happened where it has occurred a second time in the same individual, and some say even a third time; but this must be looked upon as doubtful. It is as unusual as the occurrence of measles or small-pox twice in the same subject. Dr. West relates, that only one instance of hooping-cough affecting the same patient more than once came under his notice. In that case the patient was a girl aged seven years, who, when three years old, had very severe hooping-cough, which lasted for several weeks, the paroxysms of cough being frequent, and the hoop loud and often repeated. In March, 1845, hooping-cough being then epidemic, she experienced a return of the disease in a very severe form, and continued to suffer from it until the end of June. Mr. Streeter informs me that his brother, and his brother's child, have each had pertussis twice. All ages are liable, but its most common age is between two and ten years. After the age of five SYMPTOMS OF SIMPLE HOOPING-COUGH. 67 years its frequency rapidly diminishes, and after ten it becomes so extremely rare, that out of 1,367 cases in which Dr. West noticed the patients' age, he found only eleven in which it exceeded ten years. Of these 1,367 cases — 41 "2 per cent, occurred during the first 2 years of life, 00 7 „ „ „ o ,) 82*9 „ „ „ 5 98-4 .. „ .. 10 » »> It is supposed to be very uncommon in early infancy, that is, the first two months, an opinion which is generally true ; Dr. Hood mentions having seen a child of a fortnight old, and Dr. Johnson has seen more than one instance of an attack in children three weeks old. Dr. Watson relates in his Lectures, that his bedmaker's daughter in Cam- bridge had a child ill with hooping-cough in the house with her during the last weeks of her pregnancy, and the new comer hooped the first day he came into the world. Heberden speaks of having seen it in a woman of seventy, and in a man of eighty years of age ; Dr. Roe has seen it in a lady of sixty-five. Dr. EUiotson mentions, that the last Archbishop of Canterbury had it a short time before he died. Eberl^ mentions two cases occurring after fifty years. A gentleman, in Baltimore, aged 76 years, had it in August, last year.* Dr. Todd has wit- * Vol. II., New York Illustrated News, p. 98. \ 58 ON HOOPING-COUGH. f'; :i it nessed the disease in the persons of an old married couple, aged 80 and 72 years respectively, and who safely got through this trying malady.* In the table of the ages at which death has occurred, which I have given at page 23, in the number of 14,233 cases, 13 occurred at and above the age of 25 years, and four of these were over 60 years of age. When an adult is attacked, it generally wants the hooping inspiration, and the same thing is said to be usually, but not constantly, observed in the cases of very young children. Dr. Elliotson speaks of the case of a lady with this disease, who always fainted instead of hooping. Dr. West remarks, that it may be laid dovtrn as a general rule, that these cases in which the catarrhal stage is of long continuance, seldom be- came severe during their subsequent progress, and the same holds good with reference to the majority of those cases in which thd hoop doss not come on until after the cough has for some time assumed a paroxysm: J character. There are, however, he says, some instances, where the long duration of the paroxysmal and suffocative character of the cough, unrttended by any hoop, is a sign of the peculiar intensity of the disease, rather than of its mildness ; on the other hand, the rjreternatural shortness of the catarrhal stage, or its total absence, is not of * Med. Times and Gaz., 4 March, 1854 SYMPTOMS OF SIMPLE HOOPING-COUGH. 59 itself any proof that the disease will be more than usually severe. This is usually observed in very young children, who are but little liable to catarrhal affections, and who are not so often attacked by hooping-cough as elder children.* When the disease has been uncomplicated, the effects upon the jhild are seldom of serious import- ance. TheT-e may be loss of flesh and some debility, from the loss of nutrition, owing to the frequent vomiting which has disturbed digestion. The sleep, hitherto very much disturbed from the severity of the nocturnal paroxysms, which are more nume- rous by night-time than by day, is now much more composed and tranquil. Sometimes, however, it remains uninterrupted, the circulation has become deranged by the cough, and the skin either slightly or profusely perspires. The duration of the three stages is from two to four months, but it is a matter of some difficulty to calculate correctly the time. Dr. West is dis- posed to estimate the average duration of hooping- cough at ten weeks ; deduced from twenty cases, in which he had the opportunity of watching the patients from the time when the -.ough first assumed a paroxysmal character, or the hoop C ^. became audible, until the first cessation of all cough. Of this period, nearly two weeks would be occupied by the preliminary catarrh of the first stage ; for four * Lcctm'cs on Diseases of lufaucy and Cliildhood. I ! 11 11 I s\ m ■tv -:^'^r,^-ir^i. :-rt ir^^ I ' ',- ^',;, I 60 ON HOOPING-COUGH. I|! '^Jill I weeks the cough would present the characteristic hoop in the second stage ; and the cor jh would continue for about the same period to occur oc- casionally in the third stage, gradually losing its paroxysmal character. Season has a great influence over the duration, as in the warm weather of a genial spring, hooping- cough is generally milder and much shorter than during cold weather. The direction of the wind also produces a sensible diminution or increase, both in the severity and duration also. As to the longe. period of its extension, it may certainly reach six or even nine months under peculiar cir- cumstances. Dr. Dewees and others mention its continuance for twelve months, and Marley men- tions a case in which the symptoms did not dis- appear for two years. In Chapter IX. I have given the details of a case, combined with hysteria, which certainly exceeded the last-mentioned period. This simple and uncomplicated form of the com- plaint seldom destx-cys by its own violence. The child may die. however, from the intensity of the kinks — this is in very young children, as shown by Barrier;* it may, in short, be suffocated; I have witnessed one striking example of this, the par- ticulars of which will be found in another chapter. The disease may also prove fatal from exhaustion, and the child die, utterly worn out, according to * Maladies de I'Enfauce, vol. i., p. 140. r-^UFT SYMPTOMS OF SIMPLE HOOPING-COUGH. 61 Hamilton, Barrier, and others; or what is more common, it may lay the foundation of numerous other diseases, such as dilatation of the bronchial tubes, emphysema and oedema of the lungs, phthisis, marasmus, struma, epilepsy, ophthalrr'a, hernia, rickets, deafness, &c., all of which are specially con- sidered in the chapter upon the Terminations of Hooping-cough. Dr. West mentions that a child sometimes scarcely has recovered from the struggle of a severe spasm, which has quite exhausted it, when another seizure, and then another succeeds, till one at length proves fatal. The explanations given of the cough and the hoop by Dr. Roe, have been so much commended and considered satisfactory by writers on this dis- ease since the appearance of his work, that I shall give them entire. " Any one who will make the experiment will perceive that by the exercise of the voluntary muscles of respiration, hr cannot either continue DUghing loudly for so long a time, or empty the lungs so completely of air, as a person does in a paroxysm of hooping-cough; it must, therefore, be inferred that the involuntary muscles — namely, those pointed out by Reisseissen as connecting the extremities of the cartilaginous rings of the trachea and bronchise — powerfully assist in accomplishing both these objects. They seem, by acting spasmo- dically, to expel the air from tho lungs, and to excite, 62 ON HOOPING-COUGH. by sympathy, the voluntary muscles of inspiration ; the combined action of both sets of muscles appears to produce this peculiar cough/' I hope to prove the truth of this by pathological observation, when I come to speak of the pathology of uncompli- cated hooping cough, and I will go further in stat- ing, that the spasmodic action does not only involve the smaller bronchial tubes as well as the larger, as pointed out by Dr. Churchill, but also their minute ramificatior^ terminating into the intercellular pas- sages of 11... Kainey. " The whoop takes place in the larynx and trachea, and appears to be caused by a rush of air through a contracted passage, for no sudden or violent inspiration could produce this sound in the natural healthy state of the air-tubes. The lungs are so completely emptied of air, by long-continued expirations, that a most distressing sense of suffoca- tion is produced, to relieve which, a full inspiration is instinctively made, and at the same moment the rima glottidis is contracted, and the air passing quickly through a very narrow opening, causes the whoop."* In the signification of the hoop as considered by Dr. West, he observes : — " Its occurrence indicates on the one hand the existence of spasm of the glottis ; and hence in those cases which are very slight it takes place but seldom, while it hardly * On Hooping-cough, pp. 44 and 45. SYMPTOMS OF SIMPLE HOOPING-COUGH. 63 )iration ; 1 appears to prove m, when ncompli- r in stat- y involve larger, as ir minute lular pas- rynx and rush of air sudden or ind in the The lungs continued of suff oca- inspiration loment the [ir passing I causes the Isidered by indicates 3m of the are very it hardly ever comes on until the disease has lasted a certain time, and acquired a certain degree of intensity. It shows, however, on the other hand, that air does enter when the child endeavours to inspire; and, therefore, in cases of severe hooping cough a loud, long-drawn sonorous hoop, instead of adding to our apprehension, tends rather to quiet it, for it assures us that the spasm does not amount to actual closure of the glottis, and that, for this time at least, the child will not choke in the fit of coughing."* During natural expiration, the action of the heart is slightly increased over that of inspiration, as has been shown by Magendie and others ; and when coughing takes place, the heart's action is further increased by the force of the expiratory movements. In hooping-cough these expiratory efforts are carried to the most extreme degree, and the blood in the air-cells, for a time at least, does not receive its supply of oxygen ; we find, therefore, from these two causes, that the heart's action is tremendously increased, so much so that its pal- pitation is quite visible for some minutes after the cessation uf the paroxysm, and the number of respirations may amount to as many as 100 per minute, the pulse during the paroxysm ranging from 120 to 200 beats. We can well imagine, when death takes place from a succession of spasmodic attacks, that exhaustion, commencing at the heart, * Lectures on Diseases of Infancy and Chiklliood. 64 ON HOOPING-COUGH. is one of the most important agents in producing it, and oftentimes inducing, as its subsequent effects, convulsions, or else fatal syncope and suffocation. In this disease, that is, the simple form of it, there is evidently also an increase of fibrine in the blood, the result of a super-oxidation, from the increased action of the lungs and heart after each paroxysm; and when death does occur sometimes from pure syncope or suffocation, either doubtless may be produced by a fibrinous concretion in the heart being slowly, or it may be possible, suddenly, formed in that organ. This view is confirmatory of those entertained by my friend, Mr. B. W. Richardson, who has so prominently brought forward on several occasions the subject of the fibrinous constituent of the blood in relation to disease. V»«<|(ll|,lll.lll|IUI9l".>'i'.'t'^: ' '',||!W^f|V>W. 65 CHAPTER V. COMPLICATIONS OF HOOPING-COUGH. The simple form of pertussis — that is, without any complication, which has just been considered — runs its course as regularly almost as any exanthematous disease, and very rarely destroys life of itself alone. The variations in its course, which have just been described, too, depend for the most part either on the greater or less intensity of the disease, or on some idiosyncrasy of the patient, or on some pecu- liarity in the epidemic constitution of the year. The complications of the disease, however, are an essential element in its history, and will now come under special notice. The treatment, which is comparatively simple in their absence, now be- comes more difificult and more complicated, and requires more than ordinary care and good judg- ment in its management. A very large proportion of the cases, during, at least, some part of their course, are complicated with other secondary affec- tions, which are more or less numerous, and it is mostly to these that the large amount of mortality elsewhere shown is principally due. 1 ilf •1 1 il 1^ ) m^ eii ON HOOPING-COUGH. The complications which are met with, and which I shall notice, are : — 1. Bronchitis. 2. Pneumonia and Pleuritis. 3. Congestion of the Brain, Convulsions, or Hydrocephalus. 4. Sanguineous Apoplexy. 5. Infantile Remittent Fever. 6. Diarrhoea and Intestinal Disorder. 7. Softening and Inflammation of the Stomach, 8. General Dropsy. 9. The Exanthemata. 10. Tuberculosis. 11. Pregnancy. 12. Hysteria. 13. Other complications noticed by writers. Of these numerous complications, the most fre- quent and most perilous are those which it presents with bronchitis and pneumonia, on the one hand ; and with convulsions, congestion of the brain, or hy- drocephalus, on the other. Their importance, too, as Dr. West justly remarks, is greatly increased by there being no period of the disease to which we can look as bringing with it any immunity from either; but from the commencement of the cough to its complete disappearance, we are at any moment exposed to the risk of disease, either of the lungs or of the brain, converting a trivial into a most formidable affection. COMPLICATIONS OF HOOPING-COUGH. 67 1. Pertussis, comiilicated with Bronchitis. — Bronchitic symptoms may precede the attack of hooping-cough, they may commence with the first stage, or they may subsequently come on in the second. The occurrence of the first is often met with at the commencement of epidemics of this disease, or in children, the mucous membrane of whose air-tubes may be supposed to have acquired a peculiar susceptibility from many previous bron- chitic seizures. When these symptoms come on in the second stage, after the r jugh has assumed the character of hooping-cough, the cases are considered generally to be more serious ; this form, too, is the most common. When they commence simultaneously, rigors and other symptoms of fever usher in the attack of inflammation of the bronchial tubes. These, in a few days, abate a little, when expectoration of frothy mucus commences, the face swells and assumes a bluish hue, and the lips become thick and dark-coloured. The breathing is accompanied with loud wheezing, and the cough is more frequent, and comes on in paroxysms, assuming the character of hooping-cough, though the hoop may be absent. The expectoration is increased in quantity, and be- comes muco-purulent. At the end of four or ten days the hoop is heard, and the paroxysms recur at short intervals. If the chest is examined, percussion is found to be clear ; the ear detects the respiratory F 2 08 ON IIOOPING-COUOII. I 1 I /I I ! ! ( i I t t hi murmur in the greater part of the lungs, accom- panied hy loud, sonorous, sibilant, and nmcous rUles; it is t)ccasionally absent in some parts, and is again )ieard when the obstructing mucus is removed ; these rales are as audible immediately after a fit of coughing, and during the interval, as just before the cough comes on, therein differing witlely from simple pertussis. When the bronchi of both lungs are generally affected, the child is unable to lie on either side, or is incapable of lying down at all. Should all these symptoms become very much aggravated, the cough will be more frequent and more severe, and the hoop more violent ; the cough is unattended with expectoration, or if a little mucus is spit up, it is almost always streaked with blood. Though they may be very violent, the fits of coughing ai*e not very long, and they seldom or never terminate in vomiting. The ear will here de- tect mucous rales through nearly the whole of both lungs. On a deep inspiration, still smaller sounds, the sub-mucous rales are heard, showing the ex- tension of inflammation to the minuter air-tubes ; and the case is one of pertussis, complicated with capillary bronchitis. When the paroxysms are longer, as well as more frequent and violent, the patient looks as if he were being suffocated, the veins of the neck ai*e turgid, the face and ears are livid, and the matter expecto- rated is purulent and frothy. COMPLICATIONS OF HOOPING-COUOH. 69 As the disease advances, the pulse becomes more frequent, weaker, and often irregular, the difficulty of breathing increases, the skin of the body as- sumes a livid hue, and is covered with a cold per- spiration, the ala3 nasi are alternatf^ly contracted and dilated, and there is great prostration of strength. The respirations are rapid, sometimes as many as 60 or ] 30 in a minute, and if, after having maintained this frequency for twenty-four or thirty- six hours, they come down to 40 or 50, the change sometimes indicates recovery, but not always. Dr. West mentions the case of a little child, two years old, whose inspirations, ,^wo days before her death, were 130 in the minute, and then on the following day they sunk to 80 ; but her feet were now cold, her face was livid, and her pulse very feeble. This was a case of vesicular bronchitis. The chest is now almost motionless, a free inspira- tion cannot be made, and will not expand the chest, owing to the collection of mucus in the bronchial tubes, the rale arising from which can be heard at some distance from the patient. At length, worn out by exhaustion and dyspnoea, the child expires from suffocation, as quietly as if going to sleep. When the attack terminates favourably, all the severe symptoms gradually cease and disappear, the breathing becomes easy and not so hurried, the wheezing diminishes, and the cough, after a period of suspension, returns. The countenance *-—»-» IMAGE EVALUATION TEST TARGET (MT-3) ^ ^4^. 1.0 I.I 1.25 118 2.5 2.2 ui lis us lis IIIIIM 1.4 1.8 1.6 Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ■; ^■■'.'"' ' ^ ^';:i'jii /'f^: ■■-• ' A.:.'^'' V''^ ■■'^' ' ' ^ '■ '"" -■■ ■■_'■' 1.^ ^ ^ #■ ^v HE I 1 1 1 n ir r i r'n 1 1 1 i 1 1 j ; ! 70^ ON HOOPING-COUGH. assumes a more healthy appearance, and quiet sleep succeeds to distressing restlessness. Exposure to cold or damp, may, at almost any period, induce an exacerbation of the cough, or a distinct attack of bronchitis. If, however, the per- tussis has already lasted for some ten days or a fortnight without having presented any grave features, such intercurrent bronchitic seizures are usually very tractable. Barrier states that cases sometimes occur in which we could very easily believe in the existence of phthisis, which was not present. A child, for instance, who had been emaciated and weakened by an attack of pertussis of long standing, in whom there would be an abundant fluid secretion in the bronchial tubes, attended with a true gurgling sound; and if the expectoration was purulent, a case far from being of rare occurrence, we might believe that there were caverns in the lungs. The mistakable symptoms which might be observed are due, he says, to dilatation of the bronchial tubes — a termination which I shall consider in a future chapter. Pertussis may be confounded with bronchitis pnd bronchial catarrh, when accompanied with spas- modic cough. Valleix gives the following as the distinctive signs between the two : — * * Rdsum^ G6ierale de Path. Interne, Par P. J. L, Valleix. 10 vols. 1842-47. COMPLICATIONS OF HOOPING-COUGH. 71. Let sleep lost any [gh, or a the per- lys or a y grave ores are )ccur in sxistence ;hild, for eakened n whom in in the gurghng nilent, a re might rs. The Tved are tubes — a future aitis end th spas- y as the J, Valleix. -V ... . . Pertussis. Commences with catarrh. Fits of coughiag terminate with whistling inspiration, tenacious expectoration and vomiting. No fever in uncomplicated cases. Respiration natural; the nor- mal respiratory murmur being heard in the inter- vals between the fits of coughing. Only occurs once in the same subject. Symptoms intermittent. Acute Bronchitiswith spasmodic cough, ' Commences suddenly, often with cough. Fits of coughing less severe ; no whistling, inspiration, tenacious expectoration or vomiting. Much icver at the com- mencement. Different rales in the chest. May attack persons fre- quently. Symptoms continuous, 2. Pertussis, complicated with Pneumonia and Pleuritis. — This disease very frequently supervenes, and destroys a great number of children. It is an affection not so easy of diagnosis as in the adult, the physical signs not being the same in the pre- ciseness of their character ; it is more common in the second stage of pertussis than in the first, and usually attacks children of a plethoric or full habit of body. I believe, however, that the children of the poor who possess the reverse of this state, are peculiarly liable to this form of complication ; who are much emaciated, and suffer from debility, one, indeed, which in the majority of cases becomes fatal, unless the treatment i^ commenced before '*r\ ■r •.f, ,..,-, HP 72 ON HOOPING-COUGH. the inflammation is established^ or at the onset of its invasion. The symptoms will vary according as the pneu- monia and pertussis are coeval affections, or as the one may supervene upon the other. Again, the pneumonia may follow upon an attack of bronchitis in pertussis, the minute bronchi becoming involved in the inflammatory mischief, and bronchial breath- ing and dulness on percussion may reveal, during the patient's lifetime, the nature of the mischief which will be disclosed after death. Tho presence of pneumonia in the first stage may be suspected by the greater amount of constitu- tional disturbance, the quick pulse, high fever, loss of appetite, dyspnoea, and increased cough. These, aided by percussion and auscultation, will most pro- bably establish the fact. During the second stage, when the catarrhal fever has subsided, the occurrence of pneumonia will generally be marked by the return of fever, loss of appetite, increase of the cough, and the addi- tion of difficult or hurried respiration during the intervals, as well as by constitutional disturbance in proportion to the intensity of the disease. In some cases, however, the inroad of the dis- ease is so very gradual, and marked by so few symptoms, that the child is often beyond the reach of human aid, unless we have been sufficiently watchful to detect it. ■ COMPLICATIONS OP HOOPING-COUGH. 73 The observance of the following symptoms — as laid down by Dr. Copland, Dr. Churchill, Billard, Dr. Roe, and other writers — will lead to a correct diagnosis of this complication. In addition to the symptoms of fever, &c., which have been already described as likely to occur in the first and second stages of pertussis, we shall find, when the affection of the lungs and pleura is present from the commencement, the cough occurd frequently in short paroxysms, and is seldom fol- lowed by the rejection of the contents of the stomach. The pulse is quick and hard, the re- spiration hurried, the nostrils and diaphragm labour much during respiration, and the cough is with- out the attendant hoop, and does not terminate in vomiting as the complication becomes deve- loped. The expectoration, if there be any, ia swallowed, if the child is a very young infant, or ia under five years of age : it is in general not pecu- liar up to that age. Over that period, from five to fifteen years of age, it may be observed rusty in character, or thick, opaque, gelatinous, or puriform. But this last condition of the sputa is observed in pneumonia, consequent upon the bronchial complication, with the addition of wheezing and difficult expectoration. Very often the cough is not accompanied with pain in the ohest, but L^ometimes it is found cir- cumscribed, if the child is old enough to complain. ^1. 74 ON HOOPING-COUGH. At other times it is diffused and obscure. If the child should be an infant, pain may be suspected, by the action of its hand frequently touching or passing over some particular spot on the chest There is more or less dyspnoea, but this, I will observe, must not be taken as a sign of consequence alone, as it is observed now and then in the simple form of hooping-cough. It is, however, when pneumonia is present, greater, as Barrier remarks, than in adults, and the respirations may increase from 40 to 60 per minute, a frequency which would require extensive disease to produce in the adult The respirations therefore are short and rapid. The pulse becomes very quick from the beginning, seldom under 120, even in cases where the distress does not appear very great; but it often exceeds this, and may reach 140, 160, or even 180, especially with young children. At the commence- ment it is pretty full and strong, and in favourable cases it gradually becomes softer and slower ; but in unfavourable, it preserves its frequency, becomes extremely small, irregular, and at length insensible. The skin bears a relation to the rapidity of the cir- culation, being hot and dry at first, and afterwards cool and clammy. The physical sign, are of great importance, even though they may not be quite so definite and certain as in adults. The dulness on percussion is only present over the diseased portion of the lung, ^ COMPLICATIONS OF HOOPING-COUGH. 75 If the spected, hing. or est 5, I will jquence I simple , when emarks, increase which e in the Drt and om the s where it often en 180, imence- ourable er; but )ecomes ensible. the cir- Brwards )rtance, lite and ssion is le lung, but resonant in other parts. Now, should it assuiae the form of lobular pneumonia, which is very un- common in young children, this dulness will be really difficult to detect until the disease becomes more advanced, and a portion of the lung becomes solidified; then we may expect absolute dulness. In the early stage of lobular pneumonia, a very cai-eful examination of both sides of the chest will be absolutely necessary to determine with exactness the points in which the sound is dull. Barrier states that, in "disseminated lobular pneumonia," the results of percussion are completely negative, and that there is no dulness, unless from some complication.* According to both Drs. West and Churchill, there is a manifest dulness usually most evident in the infra-scapular region. If this is absent, the lower parts of the chest yield a some- what duller sound than the upper, and the im- pression communicated to the finger is that of greater solidity below than above the scapulae. The stethoscope will now detect, in this early period of the inflammation, a soft sub-crepitating rale, which, according to "^illiet an 1 Barthez, is the only sound to be heard throughout the course of the disease. But, in this disseminated or partial form of the disease, we find also an occasional mix- ture of the sibilant, as well as the sub-crepitating and mucous rales. It is generally heard at the * Mai. de I'Jlnfance, vol. i., p. 105. 76 ON HOOPING-COUGH. 1 .11 !'•■: back of the chest, sometimes in front, and at different points, according as the lobules affected may be distant or near. The true crepitant rlile is much rarer in infants than in adults ; but it may occasionally be audible for a few moments. If one lung be affected, we shall find the sub-crepitant rale on one side, and puerile respiration on the other ; but if both be affected, we may overlook the disease, owing to the absence of contrast, unless the disease of one lung be so far advanced as to give rise to bronchial breathing, whilst in others nothing but the sub- crepitus can be detected. If the inflammation has spread, and involves more than a few lobules which have coalesced, and the lung is in a more generally solid condition, we find bronchial breathing in one or both lungs posteriorly, both in expiration and inspiration, and even bronchial rMes and bronchophony. The sub- crepitant rale has changed a good deal, the bubbles are smaller, and the crackling much finer. The more defined phenomena of pneumonia are masked occasionally by the great amount of moist rMes ; but even these have a sort of metallic sound in this disease, which, taken along with the vocal resonance, and the dulness on percussion, may prevent an error in our diagnosis. If the child live until suppuration be established, which is very seldom the case, there may be heard COMPLICATIONS OF HOOPING-COUGH. 77 a large mucous bubble, or a large crepitus, with, perhaps, cavernous respiration, and the dulness on percussion may diminish. This complication, how- ever, often terminates unfavourably in a short time. During its continuance, the hooping-cough presents characters much less distinct, but which become more pronounced as the inflammation is subdued, and the complaint will pursue its usual course. We may rejoice to hear, in fact, the nervous elements of hooping-cough return, the well known hoop, because it is a favourable symptom, and denotes a favourable disposition towards the cure. Barrier remarks, that pneumonia complicated with pertussis, is a much more serious disease than pneumonia alone. Of twenty-eight cases, ten were complicated with pneumonia, and proved fatal. Three cases out of the ten had convulsions previous to death ; he, therefore, does not consider in these that pneumonia was the immediate cause of death. These two complications, bronchitis and pneu- monia, appear to be the most common in this country ; and, I may say, they are also the most frequent, during the cold season, in Canada ; of the two, I have met with more cases in which bron- chitis was the complication. Of twenty-seven cases under Dr. West's care, thirteen died from bronchitis or pneumonia.* The forty cases, variously compli- cated, which M. Blache examined, presented the * Lectures on Diseases of Infancy and Childhood. , ^ , -.v. i w ON HOOPING-COUGH. complication of lobular pneumonia twelve times, and inflammation of the bronchi ten times. In twenty-eight cases observed by Constant, ten were from inflammation of the pulmonary parenchyma.* Dr. Copland attributes the frequency of these complications to the prevalence of easterly and northerly winds, and the variable climate of these countries.t Age has \h tie to do with the complications now described. They are met with in children of all ages, but most frequently from one to six or seven years, and often creep on very insidiously,' so as to deceive the physician as well as the nurse, unless the proper precaution of auscultating the chest very frequently is adopted. On this point, Dr. Churchill remarks, " I would strongly recommend that this should be done at each visit, as a matter of duty, in all cases of hooping-cough, and minutely and thoroughly whenever we suspect the existence of more than the simple affection." Here is the proper place to refer to the dulness which frequently arises from the collapse on carni- fication of some of the lobules, and which has been frequently mistaken for hepatization. The diagnosis will be much assisted by observing the absence of the usual signs of pneumonia — such as the * Diet, des Diets., Art. " Coqueluche.'* f Medical Dictionary, p. 238. ■^T- \ } times, les. In en were chyma.* )f these (rly and of these COMPLICATIONS OF HOOPING COUGH. 79 constitutional disturbance, the quick pulse, fever, dyspnoea, and increased cough. But we must not overlook the fact, altogether, that lobular pneumonia does occasionally arise in the progress of the affection, as well as the lobar form, the distinctive features of which have been described. ms now n of all or seven so as to e, unless be chest )int, Dr. Dmmend I matter ninutely existence s dulness Dn carni- has been diagnosis absence 1 as the i 80 ON HOOPING-COUGH. i' aii I I If h CHAPTER Vl. COMPLICATIONS OF HOOPING-COUGH, CONTINUED. 3. PeHussia, complicated with Congestion of the Brain, Convulsions, or Hydrocephalus. — The complication of serious disorder of the ntrvous system is almost as frequent as its association with grave mischief in the lungs and air-tubes, and even more dangerous and perplexing. We might anti- cipate their occurrence, even before experience had proved the fact. " If we watch a child," observes Dr. Churchill, "during a paroxysm of hooping-cough, and notice the great congestion of the vessels of the head, face, and neck, during the fit, and observe how often this is repeated during the day, for weeks together, and remember the delicate con- dition of the brain in young children, and especially in infants, our wonder will be, not that the cerebral affections occur at all, but that they are not more frequent.''* These attacks, experience has shown, may occur at any age, particularly in young infants, about the period of dentition, or from six months to two or three years of age. In these, various forms of con- * Diseases of Children, p. 208. COMPLICATIONS CF HOOPING-COUGH. 81 vulbions, spasm of the glottis, screaming, and other peculiarities, are of frequent occurrence, and indi- cative of this complication, which is often more prevalent in some epidemics than in others. They are exceedingly dangerous, and often become fatal; the testimony of some writers, however, is to the effect, that they rarely carry off the patient. Dr. West mentions that fourteen of his twenty-seven fatal cases died from congestion of the brain, con- vulsions coming on in a fit of coughing, or from hydrocephalus. All who have had much experi- ence, says Dr. Churchill, will admit the rarity of cure, and the rapidity with which they run on to a fatal termination. So far as my own experience goes, I have looked upon them as the severest complications which we mer^ with in hooping- cough, and necessarily requi^. he utmost energies of the physician. No period of ""lie three stages is exempt from their influence : they may accompany the disease at its commencement, or may arise therefore at any part of its course. Dr. West most properly re- marks — " The nervous system sometimes suffers so severely from the very first, that death takes place almost before the disease has had time to assume its usual characters. At other times hooping-cough comes on naturally; its two elements, the bronchitic and the nervous, if I may be allowed the expres- sion, increase daily in intensity, till all at once the G '. 82 ON HOOPING-COUGH. symptoms of tlie former recede, and are almost lost in those of the latter, which in a day or t.vo bring on the fatal termination of the case. Or lastly, no symptoms referrible to the nervous system call for our solicitude until after the hooping-cough has continued many weeks; but then the long con- tinuance of the disease seems to excite mischief in the brain, and death overtakes the patient when we had already begun to hope that nothing more than time was needed to perfect his cure/'* The following circumstances may lead us to fear the supervention of convulsions : — The tender age of the child, from seven months to two years of age; the paroxysms becoming sud- denly increased in violence and severity, without any of the former complications ; producing con- gestion of the brain, and subsequent drowsiness, which, if followed by convulsions, are succeeded by fatal coma. Carpopedal contractions, or flexures of the thumbs, on the palms, and the great toes drawn apart from the others; with attacks of spasm of the glottis, from excitement of the spinal system of nerves. Lividity after each fit of coughing, and remain- ing in that condition longer than usual ; the pupils becoming dilated; with a sudden arrest of the hoop, an absence of vomiting, and no apparent accession of bronchial inflammation. * Lectures on Diseases of Infancy and Childhood. COMPLICATIONS OF HOOPING-COUGH. 83 ■ Swelling of the top of the fingers and toes, noticed by Dr. Kellie, of Leith, either of itself alone, or combined with other conditions. The previous occurrence of nervous affections, any hereditary taint, or the occurrence of convul- sions in other members of the family. Now, should convulsions arise from these various conditions, they may be of short continuance, leav- ing the child in a state of stupor, to be followed again in a little time, on the mere effort of coughing, by a fatal convulsive seizure. At another time the cough may not return, but convc^isions recur inde- pendently of it, and the child die in twenty-four or thirty-six hours from their first occurrence : or the child may completely recover, without a recur- rence of a second attack. Sometimes, again, a con- vulsion may occur in one of the paroxysms, and carry off the child when the physician is the least prepared for it, and where there may be an absence of any dangerous symptoms to account for its sudden appearance. Instead of convulsions, fits of temporary asphyxia, which are not infrequent, and which have been mis- taken for convulsions, sometimes instantly carry off the child. When death occurs from a fit of convulsions, after a paroxysm of coughing in severe pertussis, it takes place as the result of spasmodic closure of the larynx, and consequent congestion of the brain. G 2 84 ON HOOPING-COUGH. ill You watch for a few moments, remarks Dr. West, the fruitless expiratory efforts of the child, and then all is over, just as in many fatal cases of spasmodic croup. The relation between hooping-cough and spasmodic croup, indeed, is sometimes very appa- rent; and you may observe, he says, after some unusually violent fit of coughing, the thumbs drawn into the palms, the hand flexed on the wrist, or the great toe drawn apart from the others. At first, probably, the symptoms will be slight, and will soon pass away ; but their import, he truly remarks, is most serious. It may be of importance to determine, whether the convulsions depend upon disease commencing, or already existing, in the brain. Should they affect one side of the body more than the other, and especially if one side or Hmb be paralyzed, softening of some of the more central parts of the brain and serous effusion may be inferred. If not one-sided, as they rarely are, and should they be attended with spasms, they are indications of dis- ease of the substance or membranes, and may ter- minate in softening or in serous effusion either into the ventricles, or at the base of the brain, and in their subsequent course produce hydrocephalus. They do not necessarily constitute an existing state of disease in the brain, for we know congestion will produce them. But it is almost certain, however, that if they continue for any length of time without COMPLICATIONS OF HOOPING-COUGH. 85 proving f *al, they will terminate in hydrocephalus. Dr. West nas shown that the long continuance of hooping-cough, and its t-Aci*-ement of the spinal nervous system, will give rise to the development of acute hydrocephalus. To consider some of the symptoms whici.. may indicate disease of the brain, probably some of tu'> earliest will be an unusual sleepiness and heaviness after the fits of coughing, with an uncertain look of the eyes, or a stare, or spasmodic twitchings of the extremities, or carpopedal spasm. Supervention of dyspnoea, or the sudden aggravation of difiiculty of breathing which had existed previously; this is one of the earliest indications of severe affection of the nervous system, according to Dr. West. Increased irritability of the stomach, which becomes almost unable to retain food or drink, is sometimes the first indication that the head suffers. Dr. West attaches great importance to this, and re- marks that if it should persist for above twenty- four hours, and not be referrible to the remedies employed, nor to gastric disorder, it should always excite our solicitude, and direct attention most anxiously to the head. If to thp foregoing be added the supervention of fever, with pain in the head; a fixed and brilliant, dry eye ; unusual redness or palor of the face, and torpid bowels, added to aversion to light and noise, grinding of the teeth, or sudden starting or shocks 86 ON HOOPING-COUGH. of the body in sleep, with rolling or tossing of the head, moaning, and screams; we have manifesta- tions, without convulsions, of irritation of the brain or its membranes, which may soon produce organic mischief or effusion. If there be stupor or coma, without convulsions, also, we may feel equally anxious. After a child has been attacked with convulsions, the hoop often ceases, and returns when the head is relieved; but when hydrocephalus has taken place, both cough and hoop always cease, and the child lies in a state of unconsciousness. The approach of hydrocephalus. Dr. Johnson observes in these cases, has been occasionally over- looked, in consequence of mistaking the laborious respiration arising from oppressed brain, and con- sidering it to be the effect of bronchial inflam- mation. The assistance of the stethoscope would be here most valuable, but unfortunately the rest- lessness and crying of young children renders its application in many cases difficult, if not altogether impossible, and we are often obliged to form our opinion from the character of the breathing. In hydrocephalus, the breathing is not permanently quick; it is irregular and sobbing : occasionally the child sighs heavily, expanding the chest in a manner that never takes place in inflammatory affections of that cavity.* * Cyclopcod. of Pract. INred., vol. i., p. 431. COMPLICATIONS OF HOOPING-COUGH. 87 We have thus seen how meningitis, hydro- cephalus, organic disease of the brain, and other nervous aifections, may creep on most insidiously, until they become manifest by some of the usual symptoms of these aflfections, or suddenly even pre- sent themselves with scarcely any warning whatever. Dr. West saw a considerable degree of stiffiiess of the whole spinal column precede, for twelve hours, the death of a little boy, who fell a victim to hoop- ing-cough thus sadly complicated with disorder of the nervous system. He gives a striking example of the insidious manner in which tubercular meningitis may come on during hooping-cough, and prove fatal, without affording an opportunity of suitable treatment This will be found at length in the complication of tuberculosis with pertussis, in Chapter VIII. The progress and course of these complications, which are most ably considered in Dr. ChurchilFs work, independent of their connexion with per- tussis, will be partly modified by the presence of the cough, as a permanent exciting cause, partly by the influence they in turn exercise upon the cough, and partly by the state of the health of the child. They are described as even more unmanageable than in their ordinary form, in consequence of the repeated cerebral congestions ; they may diminish the frequency of the cough, but not its violence ; or, by increasing the force of the spasm, produce death 88 ON HOOPINO-COUOH. by suffocation — the result of the sudden closure of the larynx. Or, if the child's constitution is harassed and broken down, from a long existing pertussis, it will offer but little resistance to the secondary attack.* ; Notwithstanding all these, however, it does seem remarkable that sometimes children do escape with the most perfect impunity, whose cough is so vio- lent, and cerebral congestion apparently threaten- ing, that it forces blood from the eyes, ears, and nose. Whilst other children, again, are speedily attacked with affections of the head, whose cough is so slight as to attract but little attention. When pertussis prevails epidemically, it often becomes complicated with one form of disease in a large number of cases ; this is the case with con- vulsions, sometimes. An epidemic which reigned at Copenhagen, in 1775, was remarkable from con- vulsions attacking so many infants. The same thing was often remarked by Ludwin, during an epidemic of pertussis, which reigned at Laugen- Saltz in 1768 and 1769. During the epidemics of 1780, at Erlangen, pertussis was complicated by a nervous fever, with delirium, convulsions, and other cerebral affections, which destroyed a large number of children.f * Diseases of Children, p. 209. •f Barrier, Mai. de I'Eufaiice, vol. i., 148. wsm COMPLICATIONS OF HOOPING-COUGH. 89 4. Pertussis, complicated with Sanguineous Apoplexy. — Immediately after birth, or at any period of subsequent childhood, cerebral haemor- rhage may occur, under the influence of causes that favour congestion of the brain, or even, it may be remarked, independently of any cause that we can discover. It cannot, therefore, surprise us to find, says Dr. Churchill, in a disease involving such frequent congestion of the vessels of the head, that occasionally cases occur in which the vascular fulness produces not merely convulsions, but a true apoplectic attack. " The same result may take place from a higher degree of pressure, under which the texture of the vessels gives way, and effusion of blood takes place between the membranes, or into the cerebral sub- stance." Although, from the repeated force of the cough, this may appear as a natural result of the pres- sure exercised upon the brain in this disease, so far as general experience goes, it does not seem to be a frequent complication, unless we suppose, with Dr. Churchill, that the sudden deaths on record are really such cases. It is mentioned by Marley,* Dr. Watson, t Dr. Gurney Smith, | and others. * Diseases of Children, p. 159. f Lectures on Practice ' f Physic, vol. ii., p. 65. X Compendium of Medicine, &c. V / ;l ' i; 9a ON HOOPING-COUGH. Heberden, in describing the violent manner in which adults are attacked with the kinks, says, " they fall down instantly, as if in an apoplexy." The following case from Barrier illustrates the mode of attack, and, in some degree, countenances the observation of Dr. Churchill, above, that some, at least, of the sudden deaths may have been owing to sanguineous apoplexy : — " Claude Charmillon, a child seven years old, had suffered six weeks from hooping-cough when ad- mitted into the Hopital des Enfans, May 5, 1838. The first stage had lasted about fifteen days, and for a month past the cough had been accompanied with hoop, and followed by vomiting of glairy matters, more frequent during the night than the day, free from complications, and the condition good during the intervals. " During the first few days he was under M. Barrier's observation, the cough was forcible and frequent, sometimes followed by epistaxis. Aus- cultation gave evidence of fluid in the bronchial tubes. — May 9. The patient, being feverish, was bled. — May 10. Considerable catarrh. — May 11. Slight eruption of scarlatina. After this the eruption continued quite as usual, but the bronchitis increased, and the bleeding was repeated, with benefit. But the patient became emaciated, and phlebitis set in where the vein had been punctured, and two abscesses formed in the fold of the arm. WlJilU.BWP J»._U ! •jj.n^^ in M. and Aus- ichiial was 11. tlie cliitis with I, and tured, arm. COMPLICATIONS OF HOOPING-COUGH. 91 The hooping-cough had evidently diminished, when, in the night of the 31st May, the patient died suddenly, after a severe fit of coughing. On making a post Tnortem examination, the lungs were healthy, the bronchial mucous membrane inflamed. The smaller bronchial tubes were dilated, and filled with frothy mucus. The bronchial and thymus glands, the head, and abdominal viscera, were healthy; but on opening the cranium, a great effusion of blood was found in the cavity of the arachnoid, covering the convexity, and also at the base of the right hemisphere of the brain and cerebellum, with some blood infiltrated between the pia mater and arachnoid of the same side."* The symptoms of cerebral haemorrhage in per- tussis, in the child, are extremely obscure; and one good reason for this is, that the haemorrhage almost invariably takes place into the arachnoid cavity ; and blood is sometimes poured out there in very large quantity, but it is so generally diffused over the surface of the brain, that the pressure which it exerts over that organ is nowhere very considerable. The special symptoms, then, which ought to excite alarm, are a continuance of the congestion about the head and face, unusual drowsiness ; the sudden occurrence of violent convulsions, and their frequent return, alternating with spasmodic contraction of the fingers and toes in the intervals. We mav * Mai. de I'Eufauce, vol. i., p. 142. 92 ON HOOPING-COUGH. find, also, that the attack will either occur suddenly, proving instantly fatal, as in Barrier's case, or the drowsiness may degenerate into stupor and coma, equally fatal, but less rapidly so. Fortunately, this complication is not a frequent one, as it is in all cases a most dangerous and fatal one. In tubercular hydrocephalus, which is occasion- ally met with as a complication of pertussis, as Dr. West has shown, the form of capillary apoplexy, may possibly present itself, but only noticeable after death, as it is seldom extensive, and has but little share, probably, in hastening a fatal termina- tion. Small effusions of blood will be found m these cases, in the midst of the softened cerebral matter which surrounds the deposit of tubercular disease of the brain.* * Lectures on Diseases of Infancy and Cluldliood, Nos. 4 and 22. ("I ■Si^-WT* -J.^,*^. SET' 93 CHAPTEL VII. COMPLICATIONS OF HOOPING-COUGH, CONTINUED. 5. Pertussis, complicated with Infantile Re- mittent. — Although this is not so formidable a complication as those which have been already described, it however often renders the affection very troublesome, and of tedious duration, and adds much to the annoyance of the physician.- Dr. Churchill thinks, in our anxiety about the prin- cipal affection, we are liable to neglect the condi- tion of the stomach and bowels, which is known to be variable in hooping-cough, in their being either pretty regular or much disordered. He observes that, during the first stage, the effect upon the concurrent disease, and upon the infant, may be comparatively slight ; but in the second stage, when the constitution is somewhat shaken, it may prove more serious, and require great attention and prompt treatment to prevent it running on into infantile remittent and its consequences. Should the bowels be in a disordered condition, it will be marked by a foetid breath, a foul and loaded tongue, appetite impaired, tumid or tym- ^^^^nK^^r^TTWamMHOHNV^^i 94 ON HOOPING-COUGH. I I ■ panitic abdomen, and unhealthy and offensive evacuations. The complexion is lost, and the eyes appear more sunken and heavy than in health. " After the symptoms just enumerated have con- tinued for a longer or shorter time, the fever makes its appearance, sometimes commencing with a rigor; more frequently, however, it comes on so gradually, that we do not kaow precisely when to date its commencement. The paroxysms of cough- ing become more frequent, and the breathing is quickened and oppressed ; but still it may be, with a little care, distinguished from the attack of bron- chial inflammation. The stethoscope affords us useful, though negative, evidence. Tlie usual symp- toms of bronchial inflammation are absent. The frequency and force of the respiration are found increased, but this increase is not a,ccompanied by any rale indicative of bronchial inflammation ; while the daily remissions, the loaded tongue, the nature of the alvine discharges, the aspect of the child, constantly picking his nose and lips, all serve to determine the true character of the disease."* So gradual, and sometimes so insidiously, does the fever steal onwards, that its approach may escape notice; rigors, though rare, will now and then very distinctly usher in the fever. Unlike that also which accompanies hydrocephalus, it has a distinct remission in the morning, and an * Dr. C. Johnson, Cyc. of Pract. Med., vol ii., p. 430. COMPLICATIONS OF HOOPING-COUGH. 95 t30. exacerbation towards evening. In the majority of cases of inflammation of the membranes of the brain, it is nearly equal, and without distinct re- missions. The hurried respiration of this form of f "er differs remarkably from that of pneumonia; ii "^hc fever, it is quicker at one time than another, hurried, it may be unequal, but it is not difficult; and on applying the ear to the chest, the respira- tory murmur is heard clear and distinct. la the inflo,. imation of the lungs, the frequency of the respiration is at all times the same, the breathing may be quick and hurried, but it is difficult, and the physical condition of the respiratory organs prevents the free admission of air. The cough, although more frequent, ceases to terminate in vomiting, and the expectoration at the termination of the paroxysms is very scanty. Dr. Roe considers infantile remittent as an accidental circumstance, arising from neglect of the child's bowels, or diet, either previously to the attack, or during its continuance. In this opinion Dr. Watson coincides, and remarks that the com- plication is more accidental, and less a consequence of the hooping-cough, than a disordered condition of the bowels ; but it may materially add to its peril.* Dr. Roe gives the case of a little girl, aged five years, as the only instance of this complication * Lectures on Practice of Physic, vol, ii., p. G5. ■\f •-tussa^irrKtrsasm ^MM-fiK' P5i ■H : M » m /■■ ii I ■c I i ■■(, 96 ON HOOPING-OOUGS. which he ever met with ; but he does not consider it one of genuine remittent fever.* Remittent fever may occur in the third stage, as well as the second ; and should it continue for a period of time, without apparent relief, the child gradually becomes weak and emaciated, a degree of delirium comes on, the continuance of the cough increases the debility, and death may occur from exhaustion, as in low fever. It is very liable to terminate in hydrocephalus, and ultimately prove fatal, or it may produce disease of the mesenteric glands. 6. Pertussis, comiiilicated with Diarrhoea and Intestinal Disorder. — Barrier notices these com- plications, as also does Dr. Copland, Dr. West, and other writers. Diarrhoea is not only a trouble- some, but a frequent complication in the different stages of hooping-cough, and in its continuance greatly reduces the strength of the child. " It sometimes sets in with preliminary catarrh, and abates as that subsides ; but, in other cases, it harasses the patient at intervals during the whole course of the affection. It is, however, when it supervenes in the course of an attack of hooping- cough which has already attained considerable severity, that it should excite our chief solicitude. It does not, indeed, in the majority of instances, betoken the sup^^-'vention of disease in the intes- * Ou Hooping-cough, pp. 137 and 188. Hi COMPLICATIONS OF HOOPING-COUGH. 97 tines, but is one of the forms of constitutional dis- turbance that attends upon a congested state of the brain, or it indicates the advance of serious mis- chief in the lungs/'* The presence of diarrhoea conceals or masks many other important symptoms, so that they may be overlooked; it is therefore a complication that should not be disregarded, nor prevent our being prepared for a second, such as inflammation of the lungs, or bronchitis, a condition in which life is in great danger, and death likely to happen. Dr. West mentions a case of severe hooping-cough, in which diarrhoea was the most prominent symptom, and the bowels for days so irritable, that their action was excited by the slightesi: article of food or drink, while the abdomen was exquisitely tender ; and yet when death at length took place, unusual redness and prominence of the glands of Peyer were the only morbid appearances in the intestines, while the signs ^f intense bronchitis and inflam- mation were discovered in the lungs, which in some parts had advanced to suppuration. Diarrhoea, when prolonged, may become attended with more or les« fever of a c .ntinued type, and a dry hot skin, with some slight pain, and then take on the characters of dysentery, the discharges becoming slightly sanguinolent and mixed with mucus. Should inflammation of the bowels set in, * West, On Diseases of Infancy and Childhood. Lect. 23. fi -JD* 98 ON HOOPING-COUGH. I fl ' I t which does happen sometimes, it may extend to the peritoneum and mesentery, as has been ob- served by some authors, and prove fatal. The hoop in these cases is either totally absent or very mild, but the distress of the child is very great indeed ; there is very little expectoration, and the vomiting, which is absent in some of the previous complica- tions, becomes particularly distressing and frequent when any of the abdominal viscera are inflamed. Rare cases are mentioned, in which the liver, the spleen, and even the kidneys have participated in the diseased action going on, most probably by extension, from contiguous structures. Another complication, and of some importance, is an irritable state of the stomach, with occasional vomiting, symptoms which are almost constantly observed at some period or other in the course of hooping-cough. " In cases of a mild character, they usually occur only when the cough has reached its acme, and vomiting succeeds to none but the severest fits of coughing, while it is one of the earliest symptoms to cease as the severity of the disease declines. Sometimes,however, very distressing nausea harasses the patient, and efforts to vomit not only follow the paroxysms of coughing, but are excited by food or by the blandest fluid."* This symptom is one of serious importance in * West, On Diseases of Infancy and CMldLood. Lect, 23. COMPLICATIONS OF HOOPING-COUGH. 99 occur and I fits of jptoms Iclines. passes follow food ice in It. 23. many instances, and often is an early indication of disease in the brain, as has been shown in the sixth chapter. It may, however, be a solitary symptom of nervous di^+iirbance, without the child's health being serioi impaired, nor the cough very severe. In two instances that Dr. West met vnih, it ap- peared to be the result of a state of extreme irri- tability about the fauces, so that the cough, which hardly ever occurred at other times, was imme- diately excited by any attempt at deglutition, and the effort to cough terminated almost directly in vomiting. • - Other examples of intestinal disorder, are nausea and vomiting, sometimes associated with diarrhoea ; there is equal evidence of disorder of digestive organs, in a constipated state of the bowels, a red tongue, with, perhaps, numerous small aphthous ulcers about the mouth, or in the large quantity of frothy mucus rejected by the stomach at each effort to vomit.* Pertussis complicated with Softening and Inflammation of the Stomach. — This must evi- dently be a complication of an extremely rare nature, but as it is mentioned as occurring in hoop- ing-cough, by Wunderlichj-f* it shall be noticed. I shall premise by saying that, in pertussis, inflamma- tion of the stomach may be present, which will * West, On Diseases of Infancy and Childhood, f Pathology and Therapeutics. Stuttgard. II 2 !' ■■■ 100 O^ HOOPING-COUGH. be manifested by scarcely a single symptom during life, unless the simple act of vomiting, which, in itself alone, cannot be taken as testimony of its presence. In this view I am supported by the observations of Barrier, who goes a step further, and declares, that during a certain period of the disease, there is general gastritis, which cannot be (observed either during life or by examination after death.* What becomes of the inflammation ? It must have either terminated in healthy resolu- tion, in which case no trace of it will be found after death ; or else in softening. Can the state or condition of softening of the stomach be diagnosed during the life of the child ? We are informed that it can. As this complication, therefore, is one of grave importance, we ought to be prepared to meet it, should it arise in the course of the disease. The following symptoms are enumerated by Billard as cliaracterizing " gelatinous softening." " An attack of violent gastritis in the commencement, such as tension and pain in the epigastric region ; vomiting of not only the milk and drinks, but yellow and oreen fluids, occurring either immediately or long after eating or drinking. Sometimes there is a diarrhoea, varying in different subjects. It will return after having ceased for one or two days. The stools are often green, like the matters dis- * Mai. de rEufance, tome i. p. 147. COMPLICATIONS OF HOOPING-COUGH. 101 [■ave it, The as tack as charged by vomiting. Skin is cold at the extremities ; the pulse, generally irregular, is, however, very in- constant ; the face continually expresses pain, and is wrinkled, as if the child was crying ; the cry is* painful, and the respiration jerking, and the general restlessness induces a belief of the existence of a cerebral affection. To these s3rmptoms succeeds a general state of prostration and insensibility, occa- sionally disturbed by a return of the pain, producing, from time to time, the same restlessness which appeared at the commencement of the disease ; and, lastly, at the end ,. W^ W"*^^ ^"^'"^'^^rngt^iKm 110 ON HOOPING-COUGH. I n it may become complicated with affections of the lungs, and, among others, the deposition of tuber- cles, and this state may not be discovered until it has made some progress. Thxs will be much favoured if there be a scro- fulous habit, or any hereditary predisposition to phthisis. The frequent occurrence of haemoptysis, also, is an equally significant omen of its threat- ened invasion ; or a narrow, badly-formed chest. Independently of these causes, however, it may arise in the wake of bronchitis or pneumonia ; or, again, from the debility arising from a protracted hooping-cough, where the vessels of the lungs have been unable to recover their healthy state, from the harassing nature of the cough inducing chronic disease, terminating in ulceration of the mucous membrane, or in tubercular deposit. Dr. Copland thinks this complication is frequent from six to seven months upwards, and especially during the second, third, and fourth years of age. Dr. Watt gives the particulars of a case of much interest, in a little girl aged four and a half years, in whom the hooping-cough was so severe that " the expirations were the most violent and rapid " he had ever seen. This was attended with a vio- lent cough, hectic, and profuse expectoration. The hooping ceased in the course of the disease, and the cough assumed that of pulmonary consumption. COMPLICATIONS OF HOOPING-COUGH. Ill She died on the 2tst of February. On dissection, the lower part of the right hmg extensively adhered to the pleura costalis. It was of a whitish colour, had lost its cellular structure, felt hard and gristly in some parts, and soft and pulpy in others. A large abscess ramified through this part of the lung in all directions, partly filled with purulent matter. The parietes of the abscess were of a dense cheesy consistence, varying from a quarter of an inch to an inch in thickness. Beyond this solid portion, the whole substance of the right lung v/as inter- spersed with tubercles, in size smaller than peas up to that of hazel-nuts, and some in a state of ulcera- tion and suppuration. The whole surface of this lung was covered with a layer of inflammatory exudation, and here and there the pleura appeared to be destroyed. The left lung contained nearly as many tubercles as the right, varying in size, but few of them in a state of suppuration. Lr. Watt, his observations on this case, conceives that in there can be no manner of doubt that the lungs were sound when pertussis commenced. The figure and general appearance of the patient could not be more remote from a phthisical habit. There might be, however, he says, some predisposition to phthisis, as her mother died of that disease. " Be that as it may," he observes, " it shows how readily the chin- cough may rouse that predisposition into action dn 112 ON HOOPING-COUGH. those where it already exists, and how readily, per- haps, even the predisposition itself may be excited in others."* This diathesis may show itself, in the form of true tubercular hydrocephalus, as a complication in pertussis. It is not of frequent occurrence, but should not be overlooked in weakly children who have long suffered from this disease. Dr. West has met with two instances of it : in one, the cere- bral disease was associated with such a large amount of mischief in the chest as would of itself have suf- ficed to destroy the child. The second case was one of much importance, and presents so many instructive features in its progress, as showing the insidious manner in which this fatal disease may steal on, presenting little to excite serious apprehension, he observes, until long after the possibility of doing good has passed away, that I hope I may be excused in transcribing it entire. " The patient, a boy five years old, of a phthisical family on his mother's side, was attacked by hoop- ing-cough, from which he suffered severely. The disease weis attended with great dyspnoea, with general oedema, and great lividity of the surface. No auscultatory signs of serious mischief in the lungs existed at any time ; but the oppression of breathing was so considerable, and the child seemed * Treatise on Chincough, pp. 159, 170. COMPLICATIONS OF HOOPING-COUGH. 113 lisical hoop- The with irface. m the lion of 3eme(l so completely overwhelmed by the disorder, that I feared he would not recover. After he had suf- fered from the cough for about five weeks, and three weeks before his death, matters seemed to take a more favourable turn ; his cough diminished greatly, both in frequency and severity, and his strength returned under a tonic plan of treatment. He still, however, continued low-spirited and very much disposed to sleep, and this condition of de- pression progressively increased, until, about a week before his death, he sank into a state of complete stupor ; but no convulsions occurred, either as pre- cursors of the stupor, or during its continuance. He lay on his back, either sleeping, or in a state of stupor, from which, however, he could be partially roused, when his pupils, before contracted, would become suddenly dilated to the full, and he would stare wildly about for a few moments : the pupils would then oscillate for a short time between dila- tation and contraction, but soon revert to their former contracted condition. The bowels were not constipated at any time, neither did vomiting occur, and the pulse continued frequent till within a day or two of his death. Strabismus came on a day or two before he died, and two days before his death deglutition became difficult, and he began to make slight automatic movements with his hands and arms. Paroxysms of cough continued to recur to I 114 ON HOOPING-COUGH. I , !* ; the very last : they were suffocative in character, but unattended by hoop. At the end of the eighth week from the commencement of his cough, the child, who was extremely emuciated, died quietly. " After death, the membranes of the brain were found much congested; there was a large quantity of fluid in the ventricles ; the central parts of the brain were diffluent, and its lower parts were like- wise considerably softened. The membranes at the base of the brain presented an opalescent appearance, and were bestudded with numerous minute granules, while about the optic nerves they were greatly thickened, and infiltrated with the hyaline matter to which I have so often called your attention. " There was much congestion of the bronchi and pulmonary substance. The lungs contained a good deal of tubercle, mostly in the state of grey granu- lations, and a small cavity occupied the lower part of the left upper lobe '"* Pertussis may be confounded with tuberculosis of the lungs, and especially of the bronchial glands, particularly when accompanied with a spasmodic cough, strongly resembling that of pertussis, and when the physical signs do not clearly indicate the presence of tubercles. Valleixf gives the following as the distinctive signs between the two : — * Lectures on Diseases of Infancy and Childhood, f Resume Generale de Path. Interne. The COMPLICATIONS OF HOOPING-COUGH. 115 [IS of [nds, )dic land the I'mg Pertussis. A contagious and often an epidemic disease. The fits of coughing pro- longed, terminating with a whistling inspiration, tena- cious expectoration, and vomiting. No general symptoms, in com- plicated cases. Voice natural. Tuberculosis of the Bronchial Glands. Neither contagious nor epi- demic. The fits of coughing very short, and not terminated with whistling inspiration, tenacious expectoration, or vomiting. Symptoms of hectic fever. Voice often altered. I 2 116 ON HOOPING-COUGH. CHAPTER IX. COMPLICATIONS OF HOOPING-COUGH, CONTINUED. ii fi 11. Pertussis complicated with Pregnancy. — We find that when in infancy and childhood there has been an immunity or exemption from the dis- eases incident to those periods of life, there is after- wards a predisposition to their invasion during the prevalence of epidemics or from contagious influ- ences. Under such circumstances, the pregnant female is especially liable. Instances are frequent in which she is a sufferer, during that eventful period, from either scarlatina, measles, or small-pox, the last perhaps more rarely. I have, however, witnessed examples of each. She is not exempt from hooping-cough more than any other disease, but perhaps she is in some degree more especially liable to abort or miscarry from it, owing to the severity and long continuance of the spasms of coughing, and their depressing influence on the entire system. Dr. Von Iffland, of Quebec, speaks of a case of this kind in the first volume of the Montreal Medical Gazette, 1844. He says — "But a few il ■ COMPLICATIONS OP HOOPING-COUGH. 117 days ago, 1 0th September, such had been the vio- lence of the convulsive cough, that my attendance was called to a young woman (set. 17) in the sixth month of pregnancy, sinking under great flooding — th€' waters had been evacuated three days before. I lost no time in effecting the delivery of a living child — it was her first/' I find also that Dr. Butter gives the case of a woman, aged 30, the mother of several children, who was in a state of pregnancy when attacked «vith hooping-(Jough. She suffered so much at times from the paroxysms of cough, which were very severe, as to threaten suffocation. She com- plained of pain in the right side, which would sometimes shoot through to the other, and some- times downward, so as to imitate labour pains. This affection was subdued, and the patient was afterwards delivered of a healthy child, and she made a good recovery.* Dr. Simpson, of Edinburgh, has met with such cases in the course of his extensive experience, and he kindly informs me that he has never, to the best of his recollection, seen hooping-cough in the pregnant female produce abortion ; but he observes that some years ago he attended a case where he had every reason to believe that the severity of the paroxysms of coughing would c ause premature labour. The lady, however, went * Treatise on Kinkcough, p. 61. ^■n ^i^mm 118 ON HOOPING-COUGH. on to the full time. Several of her children had hooping-cough at the time ; it was her own second attack. The child she bore did not take the dis- ease, and never has had it, though several years old, and exposed to it. It appears there is a common prejudice in Scot- land that a child born vjhile its mother has hooping- cough does not subsequently catch it, the disease being supposed to be passed through during intra- uterine life. He mentions, also, that some months ago the same idea was expressed by several persons in relation to a case, and where the mother was affected with hooping-cough at and for some time before the birth of her child. It was a question with some of the relations as to whether the mother and child should be parted ; it was declared by others to be quite unnecessary, in consequence of the above alleged law. This is a question of much interest, and I am inclined to think that general testimony will be found to support the truth of it. No ma,tter how young an infant may be, it is liable to have the disease if placed in circumstances favourable to it ; the case of Dr. Watson's bed-maker's daughter, referred to in the fourth chapter, may be men- tioned as an example — the mother not being affected with the disease, but some of her other children having it — the moment the child was born it COMPLK^ATIONS OF HOOPING-COUGH. 119 it hooped. The case tends to prove the truth of the question. 12. Pertussis complicated with Hysteria. — This singular and veiy rare complication has been noticed by some French writers, who have described it under the name of Pertussal Hysteria. I have witnessed one case oi it in the General Hospital at Montreal, of which rbe following is an outline : — Mary L , aged 20, a native of Ireland, was admitted February l?ith, 1845. Is unmarried, of short stature, her booy fat and plump, apparently well in every respect, exhibiting no indication of any disease whatever. She has suffered from a very severe cough for thirteen weeks previous to admission, coming on at a regular period towards the evening of each day, which has remained unchanged up to the time of her admission. The catamenia appeared for the first time two years ago, on her first arrival in Canada, and has at all times been perfectly regular, without any inter- mission. Has never been sick in her life before. Does not know whether she has had any of the diseases of childhood. After being in hospital for some months, it was found that, after enjoying tnmquillity during the day, on retiring to her bed, generally between eight and nine o clock, and lying down, the cough commences, of a very violent and distressing TVS J 20 ON HOOPINO-COUGH. character, and when once heard never to be for- gotten ; it is continuous without intermission, and at every prolonged inspiration produces a loud and ringing hoop, as in pertussis. Its duration is from twenty minutes to an hour, and at its termination there is a wsll-marked hysterical fit, with fainting, crying, screaming, &c. This ends aftor a while, and she goes off to sleep much exhausted. Pre- xdous to the invasion of the cough, she has symptoms of the globus and clavus, and complains of a "great smothering and weakness." This cough does not commence whilst she is sitting up, nor does it cease again if she does so after it has commenced. Should she be asleep in bed before her usual time, the cough is as certain to appear at its appointed hour. She suffers almost constantly from pain in the forehead and eyes, and occasion- ally in the back and sides. Her bowels keep regular. There is some tenderness over the upper dorsal vertebrae. July 4th. Very recently, the hysterical fits have ceased after the cessation of coughing. A blister to the front of the neck at 2 p.m. on the 3rd caused her to cough at 5, as well as at her usual hour. The cough twice a day has happened on two or three previous occasions. This state of things continued for many months, the cough sometimes being better and not so severe, at other times worse, particularly when ' 11 I : COMPLICATIONS OP HOOPING-COUGH. 121 undergoing some new medicinal treatment. It also came on later p.i night, between 10 and 11. Its character never varied ; it constantly possessed the series of loud expirations and the well-known hoop, and at its termination appeared to be followed by a little expectoration. She was finally dis- charged uncured, to try change of air; but the cough continued for upwards of two years, and dis- appeared as suddenly as it came. The medicines which she had taken would have sufficed to supply a whole dispensary ; all were powerless, scarcely producing any effect whatever. She was treated for taenia, but no worm came forth. The plans and forms of treatment used would fill a book. It was not suspected at the time, but I believe now, that in this rare case, hooping-cough attacked the patient for the first time in her life, and, owing to some peculiar diathesis, it assumed the form which has just been described. Its long duration will not invalidate the truth of this supposition, because in hysteria we may often expect unusual and singular phenomena, which time alone appears to cure. The loud, harsh, dry cough of hysteria, more like a bark than a cough, and without any hoop, described by many writers, must not be confounded with the affection already described, although this barking cough of simple hysteria resembles some- ( ( 122 ON HOOPING-COUGH. times the most suffocating forms of croup. Two good examples of it will be found in Tate's work on Hysteria. Dr. Watson speaks of it in his Lec- tures, and so does Dr. Marshall Hall in his work on Diseases of Females.* 13. Pertussis complicated with other diseases. — Intermittent fever is now and then met with associated with pertussis. In Sweden, in 1769, many cases were affected with this fever, and during its existence the paroxysms of coughing would temporarily cease, to return again when the fever had terminated. This is mentioned by Kosen. In the epidemic of Milan, in 1815, described by Ozanam, hooping-cough was in many cases accom- panied by a double tertian fever ; during the strongest accessions of the fever, the cough and paroxysms absolutely ceased, to return again with unusual violence at the decline of the febrile attack. At Billingen, in 1811, hooping-cough followed upon attacks of periodical ophthalmia ; these were often associated with convulsive move- ments, with delirium, and with remittent and irregular fever.f Asthma, although very rare in children, has been known to prove a complication. As illustrative of the importance of drawing attention to the complications just concluded, the * Commentaries on Diseases of Females, p. 114. f Barrier, Mai. de I'Enfanee, vol. i., p. 148. COMPLICATIONS OF HOOPING-COUGH. 123 following table, taken from Wunderlich, shows the different, ways in which the disease may prove fatal — Death in cases of pertussis may take place, A. — During the paroxysm of the cough ; 1 . By suffocation ; 2. In very rare cases by extravasation of blood into the brain. B. — By complications ; namely, 1. By convulsions ; 2. By broncho-pneumonia ; 3. By meningitis and acute hydrocephalus ; 4. By softening of the stomach ; 5. By general dropsy. C. — By secondary diseases ; 1. By tuberculosis; 2. By pulmonary emphysema and dilatation of the bronchial tubes ; 3. By marasmus.* 1 * Quoted in Brit, and For. Med. Chir, Rev., vol. ix. 124 ON HOOPING-COUGH. CHAPTER X. !; fM I' TERMINATIONS OF HOOPING-COUGH. Pertussis, either in its simple or in a complicated form, may terminate in certain affections which will sooner or later produce a fatal result. Some of these may occasionally exist as complications, and may be the immediate cause of the fatal ter- mination. But more commonly they are to be met with as secondary eflfects, and as unhappy evidence of the trying influence of a protracted hooping-cough in a necessarily weakened and debilitated constitution. They clearly point out, also, that our work is not over when we have cured the pertussal disease, but that something more has to be encountered, which may baffle our art, and render nugatory the most skilful treatment which may be employed. These terminations are : — Dilatation of the bronchial tubes. Emphysema of the lungs. Emphysema of the neck. (Ed'^ma of the lungs. Pulmonary phthisis. «' I TERMINATIONS OF HOOPING-COUGH. 125 Hydrothorax. Pneumothorax. Marasmus, Tabes mesenterica. Diseases of the bones. Hernia and prolapsus of the rectum. Epilepsy. Ophthalmia. Affections of the ear. Asthma. It is not my intention to consider all of these, but I shall make some observations on the more important. As consequences of pertussis, also, and becoming in a measure diseases foreign in their nature to the present work, I shall not say any- thing about them when I come to consider the treatment. Dilatation of the bronchial tubes. — The ex- istence of this pathological condition is altogether denied by some physicians as a result of hooping- cough, and others go so far as to say that it never does occur in young persons. To .set this matter right, therefore, I shall quote a few authorities to prove the reverse of this, and that its presence is more common than is generally supposed. I have seen it as the result of chronic chest disease in old people, in some of the hospitals of Paris, the dia- gnosis during life being verified by examination 120 ON HOOPING-COUGH. I' after death ; I have never seen it in children, but am quite prepared to meet with it in them as a termination of hooping-cough. The argument brought forward by those who do not believe in its existence is due entirely, I am quite satisfied, to their not having seen it. Laennec says it is a lesion which, though not very common, is much less rare than he was for a long time disposed to think. It is not unfrequently met with in children after hooping-cough, and in elderly persons.* I have seen it, says Billard, on one occasion in a child aged fifteen months, who died from pertussis, and it presented at the extremity of the larger bronchi a species of vesicle filled with a creamy and inodorous pus ; unequal dilatation and fissures of the bronchi have likewise been met with among certain children, as also has emphysema, f M. Blache considers this dilatation is due to the violent efforts of the patient to free the lungs during the spasms. Dr. Copland says, " Dilatfttion of the bronchi is sometimes observed ; but I have not met with it so often as Laennec believes it to occur. It is to be looked upon as a remote consequence of pertussis in prolonged cases."| * On Diseases of the Chest, by Herbert, p. 99. t Diet, dcs Diet, de Med. I Diet, of Med. Part V., p. 210. TERMINATIONS OF HOOPING-COUGH. 127 Dr. Williams writes, " They have been observed especially to succeed to hooping-cough and other bronchial affections in which the cough is particu- larly violent and long-continued."* Dr. Golding Bird has found that the bronchial tubes were, not uncommonly, dilated, even in children, and particularly in those who had suffered from protracted hooping-cough. He had found this dilatation at all ages, from the period of dentition to puberty. In this opinion Dr. Willshire agrees with Dr. Bu-d.f Barrier relates the following most convincing case : — " During my residence in La Pitid, in 1839, a little girl was brought for advice to M. Clement, reduced almost to marasmus by a long- standing pertussis, and who presented under both clavicles well-marked gargouillement Every per- son present believed in the existence of tubercular cavities ; but having expressed my doubts to my superior, he agreed with me in opinion. In fine, the child was submitted to a treatment of a strengthening nature, which restored her by de- grees, and a month later the dilatation of the bronchi, which had not, doubtless, completely dis- appeared, furnished no other stethoscopic signs than a blowing respiration."^ * Diseases of the Chest, p. 99. t Lancet, vol. i., 1845, p. 137. J Maladies de I'Enfanee, torn, i., p. 145. 128 ON HOOPING-COUGH. i The case of Claude Charmillon, aged 7 years, at page 90, which terminated by apoplexy, pre- sented dilatations of the smaller bronchial tubes, which were filled with frothy mucus. Dr. Watson mentions in his lectures " when the disorder (pertussis; has been long drawn out, and has at last terminated fatally, dilatation of the bronchi, such as I have described in the last lec- ture, is often found upon dissection ; or, still more commonly, I believe, what is called emphysema of the lungs."* Dr. Strohl, of Strasburg, attributes dilatation of the bronchial tubes to, among other causes, hooping- cough, f Further testimony is unnecessary, the fact of its presence in pertussis is too well established by a large number of respectable writers to require any comment. I shall content myself, therefore, with relating the following case from Laennec, neces- sarily abridged, and which has been already quoted by many writers of authority : — "H. A. Lajoie, a boy aged three and a-half years, was admitted into the Hopital des Enfans on January 30th, 1808. He had hooping-cough for three months ; the paroxysms of cough were fol- lowed by copious expectoration of very offensive purulent matter, at times mixed with mucus ; it * Practice of Physic, vol. ii. p. 65. t Gaz. Med. de Paris, Sept., 1849. POP TERMINATIONS ov HOOPING-COUGH. 129 had the smell of pus from an abscess by congestion ; it was not expectorated in the usual manner, but continued to run by mouthfuls from the mouth for several seconds. On Feb. 3rd, it was remarked that he was always Ijdng on the left side, which on percussion emitted a dull sound ; he was bhstered over it without rehef, and on the 1 4th had an issue in the arm. From that day the child declined very rapidly, the expectoration commenced di- minishing, and on the 15th it ceased altogether, when he died. "Dissection. — No effusion into the serous cavi- ties; the lungs collapsed very little ; the left adhered slightly to the costal pleura in its inferior half; its upper lobe was of a clear yellow colour, unat- tached, light, and crepitating, but the inferior lobe was heavy, hard, of a purplish coloiur, and livid on its exterior ; on a deep incision, an ounce and a half of a purulent and fetid liquid escaped, similar to that ex] ctorated. This liquid was contained in a number of round, smooth cavities, close to, and communicating frequently with, each other; the largest would contain the tip of the finger ; there were a great number of others, which might hold a large pea. Upon minute examination, all these cavities were found to be prolonged into canals which terminated, by a longer or shorter course, and in different directions, in the bronchiae, of which they were evidently the continuation. I 130 ON HOOPING-COUGH. opened eight or ten of these ramifications, with a bistoury and director, in their whole length, and I saw distinctly that each branch of the bronchise, after a course of about half an inch, dilated con- siderably, ncreasing in diameter as it separated from the trunk, and terminating at last in a large cul de sac, at the distance of a line or two from the surface of the lung; near their extremities, the greater part of them would admit the little finger ; others would receive a common-sized quill. In their course, they gave off some branches which terminated also in culs de sacs, after a course of two or more inches; all of them contained more or less of the purulent liquid already desrribed. These canals formed at least three-fourths of the volume of that portion of the lung; an incision could not be made into it without dividing a great number of them. Here and there were seen ten or twelve red lymphatic glands, in size from a pea to a bean ; they were all applied upon the bron- chial ramifications, and penetrated with them into the middle of the lung. The right lung presented nothing similar ; its inferior lobe was heavy, red, livid, sunk in water, and had no cellular appear- ance, except a little at its surface; it was much gorged with blood."* A more perfect and masterly description than this is nowhere to be met with, and for the more * Treatise on Diseases of the Chest, by Herbert, p. 100. TERMINATIONS OF HOOPING-COUGH. 131 minute details of the case, I must refer to the work of Laennec ; but it quite sufficiently proves the genuine existence of this lesion as a consequence of pertussis. In the dissections of two of Dr. Alderson's cases, the bronchial tubes were found much dilated, and he says, in all of them (four) the divisions of the tubes were somewhat dilated. This dilatation of the bronchial tubes, he remarks, is an organic lesion frequently overlooked, and can be detected only by tracing the individual tubes to their ulti- mate ramifications.* In two cases of pertussis described by M. Blache, the ramifications of the bronchial tubes were found dilated, together with other lesions. An ordinary director was easily introduced to their extremities. A female sound entered readily two of these last ramifications, which terminated in a large cavity that was found at the base of the middle lobe of the right lung, in one case; this cavity was capable of receiving a large egg, and contained about two spoonfuls of a greyish liquid.f The latest writer. Dr. West, remarks that this dilatation of the bronchi, which sometimes is very remarkable, arises from inflammation of the air- tubes, just as it does in ordinary bronchitis, and is * Medico-Chir. Trans., vol xvi. t Arch. Gen. de Med., vol. xxxiii., pp. 235 and 239. K 2 132 ON HOOPING-COUGH. not due, as has been erroneously supposed, to the violence of the child's inspiratory efforts. EmphyseTna of the Lungs. — This condition is sometimes associated with the lesion last described, more commonly it is present separately from it, and most generally in connexion with the remains of broncliitis. I believe it is very much more com- mon than dilatation of the bronchial tubes in per- tussis, although its existence is denied by some. Dr. Chow ne does not believe its production possible in hooping-cough, and Dr. Golding Bird observes, that emphysema does not occur as the consequence of hooping-cough.* In the reverse of this, again, Professor Hasse declares, "of all forms, hooping- cough appears most liable to engender emphysema of the lungs, and is capable, in a very short space of time, of effecting the highest degree of dilatation in the pulmonary cells."t On carefully examining Dr. Watt's cases of per- tussis, in which bronchitis, &c. were complications, I find that, out of the eight cases described by him, interlobular emphysema was present in six after death. There were found cells var3dng in size and shape, continuous and isolated, filled with air, and with fluid, scattered over the exterior of the lungs, producing flat vesicles, with irregularity of surface of lung. In one case, they occupied * Lancet, vol. i., 1845, p. 137. f Pathological Anatomy, Syd. Soc, pp. 267 and 304. ■^ ^fimmt TERMINATIONS OF HOOPING-COUGH. 133 two-thirds or more of the whole surface of both lungs, pressure incr^uaed their size a ad number, forcing along the air and mucus under the invest- ing pleura.* Blache and Dr. Watson have been already mentioned as describing its presence in pertussis, and many other writers notice it. Barrier says, the violence of the cough explains the pre- sence of emphysema of the lungs, and slso, some- times, that of the cellular tissue generally.f In a case imder Dr. Roe's care, following upon measles, and subsequently proving fatal from small-pox> with other lesions after death, were obseiTed em physematous vesicles in the margin of both lungs. J: He remarks, that emphysema of the lungs is pro- bably the most frequent organic change that this disease produces in tolerably healthy childi en ; and the symptoms which it occasions are, he says, a chronic cough, and constant oppression of breath- ing : those in whom such a state is induced as the consequence of hooping-cough, are gjener^'lly doomed to labour all their lives under an incurable asthma. Of nineteen cases f^ interlobular emphj^ema, of which a record was kept by Dr. Gross, of Louisville, U.S., three occurred in association with hooping- cough. <> * Treatise on Chincough, 110 ei seq. f Mai. de I'Enfance, torn, i., p. 147. X On Hooping-cough, pp. 3 and 31. § Elements of Path. Anatomy, p. 440. 1 134 ON HOOPING-COUGH. Dr. Townsend says he has frequently found the lungs emphysematous in children dying from hoop- ing-cough ; and in one instance, where the hooping- cough had not lasted longer than three weeks, he saw several cells dilated to the size of garden peas, of a glootdar form, and with their parietes evidently hypertrophied.* The vesicular form I have no doubt is often associated with dilatation of the bronchial tubes; at least, so far as the description of many of the dissections goes, it tends to favour this belief And in the complications of bronchitis and pneumonia, owing to the violent expiratory efforts made by the child during the paroxysms, we cannot be sur- prised to meet occasionally this form of emphysema. In fact, the vesicular form is described by some as dilatation of the minute bronchi and air-cells. Messrs. Barthez and Rilliet and Dr. West observe, that emphysema is found only in those cases in which the affection has been complicated with bronchitis or pneumonia. Emphysema of the Neck. — This may be pro- duced by rupture of the air-cells and interlobular cellular tissue, without any injury to the pleura, and the air escaping through the roots of the lung and mediastinum, passes into the cellular tissue of the neck, and perhaps other parts of the body. This form of emphysema has been noticed by some * Cyc. Pract. Med., vol. ii., p. 25. m¥sm ^^fm TERMINATIONS OF HOOPING-COUGH. 135 writers, as likewise occasionally produced by vio- lent paroxysms of hooping-cough. Dr. Johnson, of Dublin, has known it occur in three cases of this disease ; and Dr. Mackintosh, of Edinburgh, and the late Dr. Beattie, of Dubhn, " mentioned to us similar cases that had fallen under their observa- tion."* It is noticed by Dr. Copland. It has been observed to occur most frequently in women during parturition, and in children severely affected with hooping-cough. As a terminating complicatioD,j then, it must not be disregarded. Very few cases appear to be recorded: one I have been enabled to meet with, is that described by Dr. Herapath, of Bristol, and as it possesses un- usual interest, I shall transcribe it without abridg- ment. Dr. H. remarks, that emphysema of the lung is by no means an uncommon occurrence in hooping-cough, an assertion in which I must cor- dially agree; the peculiar form under consideration could not arise without it. " Mary H , aged 18 months, was placed under my care, August 1st, 1848. She was suffering from a spasmodic cough, with an occasional whoop of an indistinct kind ; symptoms of bronchitis also existed at the time. She was ordered to have two leeches on the sternum, and small doses of tartarized antimony at short intervals. " The bronchitis was controlled in the course of * Dr. Townsend, Cyc. Pract. Med., vol. ii. p. 15. ■ L * •irm.jm 136 ON HOOPING-COUGH. four or five days, by persisting in this treatment ; the febrile symptoms diminished ; and the whoop became more fully formed. The antimony was continued, but at longer intervals, during the whole of the subsequent week, in consequence of which the cough became less teasing and troublesome, and by the 15th, the whoop had almost entirely dis- appeared, but the spasmodic cough remained at this time. All fever had vanished. The child had lost its appetite, and its strength was considerably diminished ; the pulse was small, weak, and rapid ; the respirations were short and frequent, and more dyspnoea existed than the symptoms warranted ; but little mucous rMe remained ; the face was pale and exsanguine; the lips almost white. I pre- scribed one grain of the citrate of iron and quinine three times a day. " No improvement resulted ; the dyspnoea steadily and rapidly progressed ; the axillary muscles of respiration were brought into play, but the counte- nance did not become livid until after a fit of coughing; the chest sounded -^ell on percus^sion everywhere. I, at first, attributed this dyspnoea to excitement, until the friends assured me she was always so. The cough was almost nothing at this period, it was readily smothered by the child. "On the 17th of August, after a more than usually violent fit of coughing, a swelling made its appearance in the neck just over the sternum ; TERMINATIONS OF HOOPING-COUGH. 137 i the depression between the origins of the stemo- mastoid muscles disappeared, and was converted, in shape and appearance, into an enormous goitre ; but the boundaries were more diffused and ex- tensive than this disease usually assumes. I saw it some hours after its first origin. It then appeared very prominent and diffuse ; the inferior extremity stretched downwards over the first and second bones of the sternum, and terminated in an acute point ; from hence the two external marG;ins took a curvilinear direction upwards and outwards to the middle of the clavicle on each side, so that the tumour had a triangular appendage to it inferiorly. This appendage was elevated about three-eighths of an inch above the surface of the surrounding skin. Above the stemo-clavicular arti'^ulation it was a rounded prominent tumour, extending even up to the larynx, and outwards to the margins of the sterno-cleido mastoids on each side ; it had a very transparent appearance ; ' it looked watery,* as the relations expressed it, but the crepitant feel- ing experienced on handling it at once declared it to be air in the cellular tissue — emphysema. Whence came this ? I was at a loss to conjecture. It struck me as probable that one of the muciparous follicles of the trachea had ulcerated through all the coats, and permitted an escape of air under the fascia. The dyspnoea rapidly increased, as also did the swelling; it at length extended to the \ 138 ON HOOPING-COUGH. ramus of the lower jaw ; the face became livid, and the extremities cold. The child gradually passed into asphyxia, and died quietly on the 19th of August, at ten, A.M. "A carefully conducted post-mortem examination was made on the 21st. Decomposition had not commenced. The dissection of the neck clearly showed the air to be in the cellular tissue, beneath the deep cervical fascia, and around the trachea. The whole of the cellular tissue here was emphy- sematous ; it passed downwards, behind the ster- num, into the anterior mediastinum, the cellular tissue in which was excessively distended by air. The lungs were also broken up by emp^^ysematous dilatations. The upper lobe on the right side was most extensively disorganised by it; many of the cells were as large as currants and grapes, and all of them larger than natural. Air was proved to pass from the root of the upper lobe of the right lung into the anterior mediastinum, be- hind the pleura ; therefore, one of the distended emphysematous lobules at the root of this lung must have given way, and allowed the air to escape into the cellular tissue in the manner described. The other organs of the thorax and abdomen pre- sented no appearance worthy of remark ; they were all ansemic. No ah' existed in either of the pleuritic cavities."* * Lancet, vol. ii., 1849, p. 31. TERMINATIONS OF HOOPING-COUGH. 139 The condition of the air cells most particularly deserves notice, many being as large as currants and grapes, and all of them larger than natural ; there were evidently both the vesicular and inter- lobular forms of emphyseiiict present in this case, and it proves one of some instruction from many facts connected with it. As might be expected, it proved fatal, and very probably all the other casas referred to at the commencement of this section, must have terminated in the same way. Dr. Hera- path most correctly observes, that from the urgent dyspnoea, and the irremediable nature of the injury, it is almost impossible to be otherwise than a very fatal accident This form of emphysema may be a more common termination than is supposed, but has not been so frequently described ; very probably, from its being looked upon as an accident, and not the result of a disease. M. Bonino has shown how rare it is to meet the two forms of vesicular and interlobular emphysema together, and accounts for the presence of both in hooping-cough, to the suddenness with which the air cells give way, thus precluding condensation of the intervesicular tissue.* I find the following case of recovery described by Mr. George S. Lilburn, of a child four years old, labouring under hooping-cough, whom he found, on being called in consultation, lying in a state of * Gazette Medicale de Paris, No. 31, Aug.. 1835. 'fe 140 ON HOOPING-COUGH. coma consequent on convulsions. Emphysema existed above the left clavicle, which, in a few days, extended through the cellular texture of the whole body, and was so extensive over the abdomen and ribs as to raise the skin at least one inch in that situation. From the pufifed appearance of the face, the child's friends could not recognise him. The main treatment consisted in keeping the child as quiet as possible, giving a solution of tartar emetic, with tincture of foxglove, in frequently repeated dosea, to reduce the circulation and respi- ration to the lowest possible ebb ; and having the bowels reheved daily by a gentle cathartic. The diet was confined to one pint and a half < " asses' milk per diem. After about a fortnight, the crepitus began to subside, and continued to do so, gradually but slowly, until it entirely disappeared.* This is a more remarkable case than that of Dr. Herapath, inasmuch as the r^mphysema extended above the left clavicle, i?nd thence over the whole body, and added to the fearful eompUcation of coma consequent on convula-'C'S. V/ith this fearful state of things, the child perfectly recovered. (Edema of the Lungs most frequently supervenes with any form of dropsy which may be present in pertussis. It is rarely to be found alone, and is more common from the increased exhalation super- vening on exanthematous diseases, more particu- * Medical Gazette, 16th Sept., 1837, p. 913. IJ ol I ^ TERMINATIONS OF HOOPING-COUGH. 141 larly scarlet fever and measles, than in hooping- cough. It is mentioned by Dr. Copland, and others, as one of the most common complications. It is not unusually present when bronchitis or pneumonia are compHcations, and, as one of the terminations, may give great trouble, owing to the embpjrassed state of the breathing. Should it increase, from the rapid disappearance of dropsical accumulations elsewhere, the event may prove directly fatal. Struma. — Under this head may be placed pul- monary phthisis and its consequences, hydrothorax and pneumothorax ; marasmus, and tabes mesen- terica. It has been previously shown that Phthisis may come on during an attack of pertussis, and go through some of its stages with great rapidity, and terminate in hydrothorax or pneumothorax. These, therefore, may be looked upon, as Dr. Cop- land remarks, more as unfavourable terminations in the far advanced stages of pertussis, than com- plications of the disease arising out of neglect, or inappropriate treatment, or constitutional pre- disposition. Dr. Watt believes, in the two cases he speaks of, that the phthisical affection spread from the mucous membrane of the bronchi to the substance of the lungs. He considers they illustrate one of the most uiifortunate terminations of the disease — unfortunate, because they are attended with so much suffering. smmfm^mmm W 142 ON HOOPING-COUGH. I have seen more than one instance of children becoming phthisical on the cessation of the hooping- cough, — which, in the course of time, carried them off, — attended by the usual phenomena of that disease ; and when it may come on in the course of pertussis, its progress becomes more rapid, the softening of the tubercles is much hastened, and the result is a fatal tv^rmination. Marasmus and Tabes Mesenterica are other conditions depending upon the debilitating and exhausting effects of this disease, more particularly if there has been much loss of blood from frequently recurring epistaxis, or from some other cause. This engenders great feebleness, emaciation, and loss of appetite ; the child becomes hectic, and tumbles into either of these states, a most pitiable object, and a picture of great suffering from the conco- mitant enlargement of the mesenteric or absorbent glands, and finally dies from pure exhaustion. Diseases of the Bones. — Of these, rickets, cur- vatures of the spine, and affections of the joints, may be met with in protracted cases, or in the stage of decline, particularly if there has been neglect of means to break the chain of disordered action. They are very frequently indeed the im- mediate consequences of hooping-cough, and may show themselves when the disease is just at its termination. Mr. Tamplin, surgeon to the Royal Orthopoedic Hospital, informs me that many of TERMINATIONS OF HOOPING-COUGH. 143 the deformities of the human body, of the feet in particular, arise from the effects of protracted hooping-cough as their principal cause, in common with measles, scarlet fever, and other diseases of a similar class. Dr. Copland remarks that affections of the spine are generally owing to weakness of the muscles and ligaments of the vertebral column, induced by this disease ; or to scrofulous inflam- mation of some portion of the column itself. Hernia and Prolapsus of the Rectum. — There appears to be a facility towards the formation of these in very young children affected with per- tussis, but more so of the former, as the inguinal and umbilical hemiae. Or a hernia may reappear after having become cured, from the paroxysms of coughing. Watt, Barrier, and several others men- tion these surgical accidents. Dr. Watt says that where it has existed before the pertussis, it be- comes much aggravated, owing to the flatus in the bowels and the stress of the kinks. He speaks of a very troublesome case of this kind, where the patient had laboured under umbilical hernia from her infancy. Dr. Lettsom reports a case in a boy seven years old, with inguinal hernia, and who, during an attack of pertussis, had the misfortune to break his thigh. The cough was so violent that it displaced the fractured thigh, and caused death five days after the accident.* * Medical Memoirs of the Loudon Dispensary, p. 304. 144 ON HOOPING-COUGH. Epilepsy. — This is said to be a termination of hooping-cough, but I think it must be a very rare one, and may occur, if it already exists in the family, as an hereditary disease, or may come on if there is a well-marked strumous diathesis. Dr. Watt mention three cases, at the ages of five, three, and two years, which terminated fatally from epileptic convulsions ; as, however, they may have been the ordinary convulsions of children, from congestion of the brain or other cause, and not truly epileptic, I shall not give any portion of them.* In a paper on the Etiology of Muscular Retrac- tion, by my friend Mr. Brodhurst,t he mentions the following very interesting case : — " Feb. 10, 1852. I divided the tendons of the tibial muscles and the tendo-Achillis, in a strong plethoric in- fant of fourteen months, affected with double con- genital varus. I had scarcely commenced the ope- ration before the child was seized with an epileptic attack. I then learned that, at seven months old, it had suffered with hooping-cough and the first attack of epilepsy, and that at intervals since this time, on crying or coughing, the epileptic fit re- curred." He presumes that the epilepsy was first developed in utero, as the child's father was sub- ject to the disease. * Treatise on Chincough, pp. 59, 142, and 157. f Med. Times and Gazette, 4th Feb., 1854. TERMINATIONS OF HOOPING-COUGH. 145 tic ' Ophthalmia. — Many affections of the eyes ap- pear to be as common a consequence of pertussis as diseases of the bones prove to be. The catar- rhal form, however, seems to be the most frequent, and occurs in children of a strumous diathesis, often as the symptoms of pertussis are at their termination, and is much protracted in its dura- ration and treatment. Sometimes inflammation arises in consequence of the rupture of some of the vessels of the conjunctiva, during the severity of the paroxysms, producing chemosis ; but most generally this latter condition quickly disappears. Affections of the Ear. — The violent efforts at coughing will sometimes produce a rupture of the tympanum, and haemorrhage from the ears, which is sometimes profuse. The nature of the injury can be seen by examining the ear, when a rent will be observed in the membrane near its margin. This, however, does unite and heal up perfectly, so as to rend r the membrane in' in rare cases, from some untoward cause, it doL uot. In answer to a question of i " le at a meeting of the physiological section of the Ucal Society of London, in February, Mr. Pilcher mentioned these facis. and stated that he had observed such acci- dents very frequently indeed, and related a case occurring a short time back, of a little girl, the daughter of a nobleman, ill with hooping-cough, who threw herself upon the floor during one of the L 146 ON HOOPING-COUGH. paroxysms, when haemorrhage took place from the ears in consequence of a rupture of the tympanum, the injury being observable at the margin of this membrane, which afterwards was healed. Should deafness become a termination from the rupture remaining permanent, it may prove a matter of much inconvenience to the child, from its incurable nature. In Mr. Wilde's practical and instructive work on Diseases of the Ear,* at pages 220 and 326, he refers to bleeding from the ears during violent paroxysms of hooping-cough, and supposes the source of the haemorrhage to be from the ruptured tympanal membrane. In relation to the subject of deafness being pro- duced by this disease, he remarks at page 489 — " In what way hooping-cough produces deafness, whether by local injury to the ear, such as often occurs during a violent paroxysm of that disease, or from its effects on the nervous system, I am unable to determine. Every nurse is aware of the many anomalous consequences which follow per- tussis, and popularly denominated the ' dregs of the hooping-cough.' This disease has been specified as a cause of acquired deaf-muteism in all the tables which I have examined." I ■i * Practical Observations oil Aural Surgery and the Nature and Treatment of Diseases of the Ear. By W. 11. Wilde. London. 1853. ♦ TERMINATIONS OF HOOPING-COUGH. 147 i i In a statistical table of the causes of deaf- dumbness, compiled from the Irish census of 1851, by Mr. Wilde, and published at page 486 of his work, five cases — 3 males and 2 females — are set down as caused by hooping-cough under four years of age. These five cases occurred in a total num- ber of 503 cases from other causes. Asthma. — This is only mentioned here, as an ultimate consequence of the disease where recovery has been effected, uotwithstanding the presence of dilated bronchi and emphysema, superadded to some affection of the lungs. I am not singular in this opinion that such circumstances may produce asthma in later years. Dr. Alderson, Dr. Roe, and some other writers, speak of it. Dr. Watt, after giving the diagnosis between asthma and pertussis, observes : — " It must be granted, however, that chincough sometimes terminates in asthma, and iiiat many of the remedies which relieve the one are beneficial in the other." The following case, under the care of Dr. More- head, in which a child was reported to have been subject to asthma, and occurring as a complication, may with propriety be given here: — "Henry Wal- lace, aged seven years, a feeble boy, reported to have been subject to occasional attacks of asthma, was admitted into the General Hospital at Bom- bay, ill with pertussis, on the 23d of May, 1840, and died on the 26th. Inspection. — Chest : Both L 2 wmr^m 148 TERMINATIONS OF HOOPP, «h-COUGH. lungs were pale and emphysematous, and com- pletely occupied the chest. The right one pre- ' sented, here and there, in all the lobes, the com- ! mencement of tuberculous deposition, either in the form of occasional grey miliary tubercles, or grey i tubercular infiltration. A small quantity of frothy mucus exuded trom the cut ends of the bronchial tubes. The left lung was white and dry, with very little tubercular deposit; there was little vascularity of the bronchial lining, but at the bifurcation of the bronchi there was a calcareous concretion, the size of an almond. The left ven- tricle of the heart was somewhat hypertrophied. Abdomen : The liver filled the epigastrium and projected beyond the ribs. The mesenteric glands ranged from a horse-bean to an almond in size, and some of them were cretaceous."* * Traus. of Med. and Phys. Soc. of Bombay, No. 6, 1843. 149 CHAPTER XL PATHOLOGY OF HOOPTNG-COUGH. In dwelling upon the pathology of the disease, and to facilitate the simplifying of its solution, I shall first give the appearances noticeable in cases of death from the perfectly simple and uncompli- cated form of the affection, and will subsequently, in rotation, present examples of those most gene- rally observed, as consequences of the various in- tercurrent or simultaneously arising complications, giving many of the latter from authors who have specially brought them forward as evidences, in some cases, of what they believed to be the patho- logy of pertussis generally. This will be a novelty, if it may be so called, in the treatment of this question, which it is hoped will meet with ap- proval. Simple Pertussis. — If a case proves fatal from asphyxia, suffocation, exhaustion, or syncope from sudden arrest of the heart s action, cessation of breathing, or the gradual cessation of the powers of life, in fact, the vital principle, what must we expect to observe as the consequences and the necessary results after death of this disease, in a mm 150 ON MEDICAL F^^;^ rtv^. ^. - \ similar manner to a ca^--ef> JuieasliM, small-pox, or some other aflfection, which may succumb from the peculiar nature of the malady itself? Now, as death from these causes is more or less rare in the simple form of pertussis, we cannot appeal to such a mass of evidence as has been afforded when it has been produced from other and very different causes again, but the careful testimony of those who have investigated the subject furnishes the following : — The general substance of the lungs healthy, with no absence of crepitation. The bronchial tubes more or less completely filled with a greyish drab or fawn-coloured watery mucus, mixed with minute bubbles of air, and much confined to the smaller branches and minute ramifications. The mucous membrane of the larger bronchi and smaller tubes, varying in colour from a well- marked drab to a shade of pink, the latter occa- sionally darker and varying towards a red, but not a redness of inflammation from the absence of in- flammatory congestion. Hypertrophy of the longitudinal and circular muscular fibres of the bronchi, extending into the smaller branches, and visible to the naked eye as far as they can be slit up ; the longitudinal hyper- trophy being more marked in the larger bronchi and the annular in the smaller. PATHOLOGY OF HOOPING-COUGH. 151 One or more fibrinous clots or concretions in the right ventricle of the heart, but their presence not constant. ' Congestion of the pia mater and minute blood- vessels surrounding the medulla oblongata and origin of the nerves arising from it. This conges- tion varying in degree, but rarely If ever absent, and most generally very sli^nt These are the only appearances to be met with in death during simple pertussis. There is another condition, however, which may be mentioned as occurring and noticeable during life, before any complication has set in, and which has been also found after death. I refer to enlargement of the glandulce concatenatce near the trachea, which has been observed by Dr. Ley and others, and an unusual swelling of the bronchial glands, which is frequently mentioned in the descriptions of post- mortem examinations. Much importance shall not be attached to this state at present, until it is supported by further investigation; but I would draw attention to the fact. When observing these glands enlarged in four children brought to Dr Ley's house, labouring under pertussis, it induced him to ask the question : " May it not be that an enlargement of these glands, from a specific animal poison, similar to that of the parotid glands in mumps, is, after all, the essence of hooping-cough?" The following instructive and very important ^Il ■ 152 ON HOOPING-COUGH. case occurred in my own practice, and proved fatal from asphyxia ; it was free from any local compli- cation during life, and possesses features of more than ordinary interest : — Mary H , a female child, aged sixteen months, had an attack of hooping-cough in the beginning of December, 1849. Nothing unusu' 1 presented itself in the way of complication, the paroxysms were severe and frequent, and often followed one another in succession. She continued ill for three months and a half, when she was attacked in the evening, on the 11th of March, 1850, with a series of these paroxysms, following rapidly one after another, when she became asph^ xiated, and died from syncope. Autopsy, ten hours after death. — The lungs were healthy in colour and structure, and possessed the usual crepitation ; they partially collapsed on opening the chest. The smaller bronchial tubes, and a few of the larger, were filled with a drab frothy mucus, which could be squeezed out of them on section ; there was no sanguineous congestion. On slitting up the bronchi to some extent, and washing them with clean water, a number of circular rings were seen which increased in size uowards the larger branches ; but in the largest bronchi they were not so remarkable as a number of longitudinal lines, which became smaller again as they approached the smaller divisions; these i \ \ PATHOLOGY OF HOOPING-COUGH. 153 ii were the circular and longitudinal organic muscular fibres of the bronchi, in a state of hypertrophy. The circular were not at all visible above the bifurcation, and the longitudinal disappeared, and could not be diistinguished an inch and a half above the same. The larynx and trachea presented nothing abnormal, the colour of the membrane was the natural shade of pale pink near the former. The heart contained a fibrinous clot of a pinkish colour, which nearly filled the right venticle, and extended by shreds into the auricle. The bronchial glands were not enlarged, and the pneumogastric nerves were quite white and natural. The brain and its membranes were healthy, without any vascularity. The pia mater, in comparison with the rest of the brain, appeared congested around the medulla oblongata and its nerves, as also did the minute vessels at the origin of the latter. All the viscera of the abdomen were healthy, the bladder was half filled with urine. This case is as fair an example as could be desired to illustrate simple pertussis. There was no dangerous complication ; produce death, ^nd li. .ve carefully examine it, the only appearanc account for its occurrence is the fibrinous deposit m the right venticle. But the formation of this has been induced again, by the spasmodic contraction of the muscular fibres of the bronchi, which, con- tinuing without scarcely any intermission, Y/ith the 154 ON HOOPING-COUGH. almost total absence of respiration, was favourable to its deposition, which, again, when once com- mencing to form, death is certain. There is in this affection an exaltation of respiration immediately after the paroxysms, which over-supplies the blood, so to speak, with oxygen ; and thus produces the state of super-oxidation. During the paroxysms there is, unquestionably, a stagnation in the process of decarbonization, but if that state was more or less constant, as some suppose, we might have the heart becoming diseased, which is rarely, or I may say never, the case. The complication of inflam- mation in some form occasionally arising, may be, in a great measure, due to the predisposition to its occurrence from the excess of fibrine already exist- ing in the blood. The appearances which the heart may present in all forms of the disease will be described further on; and the explanation of those appearances in the simple form, which have been just described, will be considered at the con- clusion of the present chapter, after the complica- tions have received their share of attention. Complications of Bronchitis, Pntumonia, and Pleuritis. — As the fatal cases most commonly terminate from the disease in the lungs, or in the brain, nearly all the structural lesions of import- ance are found in one or other of these organs. Of the Bronchi. — The most constant alterations in the mucous membrane of the bronchi and PATHOLOGY OF HOOPING-COUGH. 156 minute ramifications, are slight vascularity or much injection, more or less redness, sometimes intensely red, the redness may be scarlet or purple. These may extend to the trachea, larynx, and epiglottis ; or even to the pharynx and oesophagus. The red- ness in the ventricles of the larynx was found very marked in one of Blache's cases. The mucous membrane may be thickened, soft, and pulpy, feeling like velvet to the touch ; it may be ulcerated in the glottis, and in the larynx and trachea, as mentioned by Astruc, Macintosh, and Alcock ; and the latter has found the inflammation of the larynx so great as to close the glottis mechanically. The lungs collapse imperfectly, or they may completely fill the chest, and even bulge out on opening it. When cut into, the bronchial tubes and air-cells are found to be more or less filled, sometimes completely so, with a quantity of ropy or viscid mucus, and either frothy or purulent, or sanguinolent, and which exudes from them on pressure. The trachea and larynx may be lined with adherent puiiform mucus, or with flakes of coagulable lymph. The bronchitis may be accompanied by a con- siderable swelling of the bronchial glands situated at the bifurcation of the trachea ; some may be as large as a nut, of a brown colour sometimes, or even red, and, occasionally, tubercular at their 156 ON HOOPING-COUGH. \\ 1)1' \:> centres. The lymphatic glands in the substance of the lungs, also, may become enlarged and inflamed, of a red colour, varying in size from a pea to a bean, and applied over the bronchial ramifications. The thymus gland is often found enlarged. Dilatation of the bronchi is often met with. Sometimes it occurs at the extremity of the tubes, and is owing to a development or distension of the air-cells, which take the form of little sacs or pouches filled with pus or mucus, varying in size from a pea to a small marble, or even larger; sometimes it may exist in the minute branches only, which are often dilated, and their calibre increased in such a manner as to receive the body of a crow-quill, or even a goose-quill, near their extremities ; they may also give off branches, which again terminate in little culs-de-sacs or pouches filled with fluid ; these dilatations may occupy as much as three-fourths of a lobe, as occurred in one of Laennec's cases. Sometimes, again, but more rarely, it is the larger bronchi which become dilated, aud occasionally in a very irreg liar manner ; the lungs presenting, on sections, ? number of fissures, compared by Guersent, to the stone from a mill-stone quarry. The two forms of Emphysema, the vesiculai and interlobular, are met with, the latter most com- monly. All of Dr. Watts' cas(>s had this complica- tion ; it may spread over the entire surface of a PATHOLOGY OF HOOPING-COUGH. 157 lung, and present an appearance of bad confluent small-pox, as described by him. In one of his cases, where the lungs were of a purple colour, a mixture of air and mucus existed under the pleura. Dr. Macintosh, who made upwards of fifty dissec- tions, remarks that the anterior surface of the lungs, in almost all cases, presented spots of a whitish appearance, as if coated with lymph ; but this was found, upon closer examination, to depend upon emphysema, air being effused beneath the pleura, from the rupture or enlargement of the air-cells. The rupture of the air-cells and inter- lobular cellular tissue, may permit of emphysema extending to the mediastinum, neck, and thence to the general surface of the body. For a further description of emphysematous conditions of the lung, I must refer to the Chapter on the Termina- tions of Pertussis. The dilatation of the bronchi, unquestionably, must be preceded by inflammation of the air-tubes, and as it is more frequent in pertussis than in ordinary bronchitis, the natural inference would be that the violent and continued efforts at coughing must assist towards its formation, and I feel con- vinced that this is the case. Granting that the efforts made during the paroxysms of coughing are expiratory, I am not prepared to admit that the lungs are completely emptied of air ; if that were the case, we should S 158 ON HOOPING-COUGH, have a vacuum in the chest, which cannot exist ; and, therefore, a certain portion of air remains in the air-cells, notwithstanding the most powerful efforts of coughing. In what manner does the dila- tation occur, and vesicular emphysema arise ? A portion of some of the tubes may be blocked up by either viscid tenacious mucus, or else lymphy or croupy exudation, the cells and tubes beyond this exudation are filled with air, which is, as it were, imprisoned, and cannot be expelled, owing to actual paralysis of the annular muscular fibres. The quantity of the air may be increased by a sudden inspiration (not, however, during the hoop- ing) forcing itself through the mucus during the general expansion of the lungs, and therefore un- able to return ; to compensate for which we find the air-cells dilated into pouches or sacs, and this dilatation extending to the minuter bronchi, which, after death, are found not only filled with fluid of some kind, but even firmly plugged up, The dilatation of the air-cells may proceed to such an extent, — which extent, however, is not absolutely necessary to do so, — as to produce rupture in some, and effusion of air, and perhaps fluid, into the interlobular cellular tissue, a condition so constant where bronchitis has been a complication, as to prevent the lungs from collapsing, and even permit- ting their extension beyond the natural boundaries of the chest. Granting, as I said before, that the efforts at B.'i' PATHOLOGY OF HOOPING-COUGH. 159 , lies at cougliing in pertussis are expiratory, it is to these expiratory eSbrts that the dilatation of the tubes and emphysema are due, and not to any forcible inspiration. This is explained by the pressure of the surrounding portions of lung, which are ex- pelling the air and mucus during the paroxysms upon and around those blocked-up tubes and cells with imprisoned air, if I may be allowed the expression, and producing a general and unequal expansion upon them ; this pressure is exerted in a similar manner to that of the hand on a small India-rubber bladder filled with air. These conditions, I admit, cannot be produced unless preceded by inflammation ; and this is borne out by the examination of cases after death which have been free from complication during life, in which they have not been discovered. The error which has been committed by so many in account- ing for their presence here, has been in attributing them to the forcible inspiration, an observation which is in accordance with the opinion of Dr. West and MM. Rilliet and Barthez ; but they, in their turn, have supposed them due to the bron- chitis or pneumonia alone. It must not be forgotten that dilated bronchi are common in pertussal children, with inflammatory chest affections, and extremely rare in adults and old people, a fact which is further confirmatory of the view I have taken of their formation. 0/ the Lungs. — These organs rarely collapse in J60 ON HOOPING-COUGH. consequence of their increased solidity, arising from the extension of the inflammation from the mucus membrane of the bronchi to their sub- stance, or attacking both structures simultaneously. They may contain much air, which is pressed out with difficulty ; the inflamed parts may be of a livid, purple, or even red colour externally, and when pressed by the finger, owing to an cedematous condition, they retain its mark ; again, they may be so hard and knotty as scarcely to be affected by pressure. Dr. Watt says the lung has felt like a piece of spleen or liver, and Dr. Elliotson has compared it to the latter; Dr. Copland uses the term splenification ; the inflamed lung is harder and heavier than in the natural state. A form which is peculiar to this disease, and the most common, is that termed carnification, the condensation affecting one or more lobules in diffe- rent parts of the lung, but chiefly in the lower and posterior portions of all the lobes. These lobules are defined by well-marked septa constituting their boundaries, are of a dull red colour, free from air, sink in water, and are not changed by ablution. The smaller bronchial tubes are much dilated and lined with fibrine, or thick puriform and rusty mucus. The inflammation of the trachea or larger bronchi is absent. These appearances of lobular carnification were present in Dr. Alderson's four cases. He says PATHOLOGY OF HOOPING-CX)UGH. 161 J the individual lobules were more dense than in hepatized lungs, and the cellular membrane between them retaining its natural structure, con- veyed to the touch the same sensation that is felt on handling the pancreas. He apprehends that the appearances detailed differ from those found in peripneumony, and remarks, " In hooping-cough the lung is always dense and contracted, as if the air had been expelled, and from the throwing out of adhesive matter the sides of the air-cells had been agglutinated together, while, in hepatization, the lung is less dense than in hooping-cough, and is rendered more voluTninous than in its natural state. The dilatation of the tubes and air-cells takes place in forcible expiration, in consequence of the plugging up of the bronchial tubes by false membrane, or dense mucopurulent secretion : a foundation for future asthma."* I am happy to find that the view entertained by Dr. Alderson, as to the production of dilatation of the tubes and air-cells, agrees with my own in their origin from forcible expiration. I had not read this part of his valuable paper before my own observations were written. It is not imusual to find the circular muscular fibres hypertrophied in dilated bronchi, and Dr. Wilhams mentions as one consequence of their dilatation, a defective tone of * Med. Chir. Transac, vol. xvi., p. 91. M .«.—.'- ■ tUPUiJ'' 162 ON HOOPING-COUGH. I ' V : the circular fibres, as well as a loss of elasticity in the longitudinal. The peculiar state of the lung, so well described by Dr. Alderson, has only recently received the name of collapse, or carnification, on account of its close resemblance to a piece of muscular tissua Four years later it was mentioned by Rufz and Gerrard ; and the explanation of its occurrence, as given by Dr. Alderson, Dr. West remarks, has been proved not far from the truth, as shown by the more recent researches of Bailly and Legendre. Instead of the lobules alone, or a portion of lung being affected with inflammation and true hepati- zation, independent of caruification, we sometimes find an entire lobe inflamed in pertussis, but this is rare ; the three stages of congestion, hepatization, and purulent infiltration, may be observed at one and the same time, or the two latter may be mixed, a section giving exit to pus and blood from the surface. In one of Dr. Watts' cases a consider- able margin of the lower edge of each lung was inflamed, of a bright red colour ; and the incised surface of the lung, which was not hepatized, how- ever, in a case of Dr. Roe's, presented a vermilion red colour ; and Dr. Mackintosh has found large portions of the lungs gorged with blood. The nine cases examined by Blache were complicated with pneumonia. Of the Pleurae. — The pleura is sometimes in- PATHOLOGY OF HOOPINO-COUGH. 163 in in- flamed, covering the afifected portion of lung, or it may be simply vascular; Dr. Watt l sntions the pleura costalis as being very vascular in one of his cases. The pleura may be covered with lymph and form adhesions, as noticed by Dr. Mackintosh in a couple of instances ; in a few, also, he has noticed the pleura-costalis covered with lymph like an unctuous secretion. There may be effusions of serum with numerous flakes of lymph, or mixed with blood. Marcus has observed these effusions. Ozanam has met cases with inflamn ation of the lungs and pleura combined ; Guerseno has fre- quently observed the two together, followed by effusion ; in one case complicated with pleuro- pneumonia, with sanguinolent effusion, he found gelatinous softening of the stomach and diaphragm, the fluids in the stomach and pleura were so much alike that they were confounded with one another. It may be remarked that pleurisy and oedema of the lungs are more or less rare. The Nervous System implicated. — This will comprise congestion and inflammation of the brain and its membranes, hydrocephalus, convulsions and affections of the medulla oblongata and its membranes. The vessels of the cerebrum and cerebellum, particularly the veins, are often found distended and gorged with black blood, accompanied by extreme vascularity of the membranes. These M 2 IMAGE EVALUATION TEST TARGET (MT-3) ^ .5^^. % 1.0 I.I |50 ™^ 2.5 S.M» 2.2 1^ - lis lllllio 1.8 1.25 1.4 L6 ^ 6" ► V] <^ /}. v: ■c^ ^>^ 7 % >.'> 'V-i* ^ < ^ '/ \ Photographic Sciences Corporation # y^ 4 ^^^;. <\!^^^ ^\ % V ^'h :a? 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ^ 4> /!; .■ ■^^^v ^ ^ I^^ r:ssmm ^^BH^^Ifl n 164 ON HOOPING-COtJGH. characters may be altogether absent, or much less marked than might have been expected in cases where death has taken place from convulsions, or has been preceded by a cotaatose condition. There may be inflammatory irritation of the membranes^ as found by Dr. Webster ; opacity of the arachnoid^ by Dr. Armstrong; adhesion between the dura mater and cranium, as in one of Dr. Watts' cases ; and deposits of tubercular matter on the surface of the arachnoid, neal* the base of the brain or superiorly. The convolutions of the brain may be found obliterated, as noticed by Dr. Webster; softening of the cerebral substance, particularly the centre of the hemispherco , irregular venous marbling of the medullary matter in one of Dt. Alderson's cases : the puncta vasculosa numerous and large on a section of the brain being made ; and the choroid plexuses of a deep purple colout from congestion. Occasionally, there may be effusion of serous fluid into the ventricles, in th6 meshes of the pia mater (Watson), beneath and between the dura mater and arachnoid. Purplish serum infiltrated in the subarachnoid tissue was found in one of Blache's cases. In one case, which was accompanied by violent and intractable con- vulsions, with considerable rigidity of the superior extremities. Dr. Mackintosh found the substance of the brain of a rosy tint ; on making sections, larg6 drops of blood quickly exuded from numerous ' i' PATHOLOGY OF HOOPING-COUGH. 165 points on the cut surfacea On exposing the lateral ventricles, the left corpus striatum and thalamus were observed to be enlarged, parti- cularly the former ; insomuch that in measuring the depth of the brain on each side, it was dis- covered to be nearly half an inch deeper on the diseased side than the other ; when cut into it was found rather harder than the corresponding parts on the opposite side. The child had previously enjoyed a good state of health, and even after death did not appear much emaciated. Inflammatory appearances have been observed in the medulla oblongata, or in its membran(3s, by Dr. Copland, even when no other remarkable lesion was present within the cranium. The pneumogastric nerves were observed in two instances by Breschet to be injected, producing a red tint on the exterior ; the tissue itself he found yellow ; he found nothing in other cases examined by him. Inflammation of these nerves has been observed twice by Autenrieth, and fifteen times by Herman Kilian. The most careful dissections of Marcus, Jadelot, Guersent, Baron, Billard, Blache, Copland, Barrier, G. A. Bees, and myself, have found these nerves unchanged. Professor Albers, of Bonn, out of forty-seven examinations, found that jn forty-three the nerve was healthy ; in one it was reddish on the left side, and in three on the right Slide ; i^hese four cases were scrofulous and lym- mmmm mmmmm^^f^ ^P 166 ON HOOPING-COUGH. W phatic, and the redness was found on the side on which the body had inclined, and in no respect, it appears, differed from what is observed in the bodies of plethoric persons, and of patients who have died of typhus fever. Out of eighteen careful examinations, Dr. West once only observed any alteration in the appearance of the vagus ; in this instance both nerves seemed to be of a decidedly redder colour than natural, although they were not otherwise altered. Holzhausen and Clarus found in the body of a boy who had died of pertussis the ^renic nerves loose in texture and somewhat swollen ; the trunks of the vagi likewise looser, thicker, and broader than natural ; the great sym- pathetic and splanchnics, especially the latter, of a firmer consistence than usual ; and the coeliac plexus firmer and somewhat elevated. Apoplexy. — Brain. — Extreme congestion and vascularity of the substance of the brain, or san- guineous eflfiision with the formation of a clot may arise, as in the case described by Barrier at page 90. As many cases of sudden termination are not often examined, the latter may be a more common result than is generally imagined. Lungs. — Apoplexy of the lungs may arise in cases where death has happened from asphyxia, during the paroxysms; Dr. Mackintosh mentions two cases of this kind, in which the lungs were found to be gorged with blood ; the whole lung, when put into water, show- PATHOLOGY OP HOOPING-COUGH. 167 ing far less buoyancy than natural, and large por- tions, when cut off, v^ere found to sink to the bottom of the vessel, it was proved, however, that this increase of gravity was not owing to alteration in the texture of the organ, which resumed the natural colour, appearance, and buoyancy, when deprived of the blood by washing. Of the Heart. — This organ ia very rarely, or in fact never, found diseased, as a complication or consequence of pertussis. Sometimes serum is pre- sent in the pericardium, and very frequently fibrinous concretions and clots of blood are found in the right side of the heart. Inflammation of the pericardium is very rare, but Dr. Copland has met with it. The following are the cases in which some of these were observed, with the names of the authors attached : — lexy has Lettsom Ditto . Watt . Ditto . Ditto . Ditto . Alderson. Ditto 293. Pericardium distended with an aqueous fluid. 304. Ditto very full of liquor, somewhat of the colour of bilious blood. Ditto more serous fluid than usual. Ditto larger quantity than iisual. Ditto ditto ditto. Ditto ditto ditto. Case 1. Bight ventricle. Coagulum free from red particles. 4, Heart healthy; a small flattened cyst was situated ai the apex, five or six lines in diameter, which contained a limpid fluid. 123. 131. 167. 181. » i.-. "' — ■.•■ I • 168 M'lntosh. ON HOOPING-COUGH. \ \ Eight side of heart and large vessels near it, were distended with dark blood. Blache . . 1. Right cavities contained fibrous coagula of blood. Ditto ... 2. Right cavities contained soue white fibrin- ous clots. s;v . , Ditto ... 3. Aorta reddish internally; no clots. Morehead . Tlie left ventricle was somewhat hypertrophied. Author . . Fibrinous clot, of a pinkish colour, nearly filled the right ventricle, and extended by shreds into the auricle. - We have in this table five cases with concretions found in the right side of the heart, and I believe them to be very commonly present after death, but very probably unnoticed, from the mistaken notion of their unimportance. Of the Blood. — As described by Dr. Watt in one of his cases, obtained by venesection ; it was of a dark colour at first; after standing twenty-four houjs it did not separate intj crassamentum and serum ; it was then a soft, tender, gelatinous mass, the greater part red, but interspersed with large distinct portions of a bluish semitransparent sub- stance Uke starch. Dr. Sims has found the blood very sizy, containing a quantity of fibrine.. These tend to confirm the view I entertain that the blood is overchaxged with fibrine, a? can be proved by bleeding in any simple case, when it will be found after a while to have a remarkably well-developed pinkish yellow crust, erroneously considered by some as essentially inflammatory. • .»>iftW PATHOLOGY OF HOOPING-COUGH. 169 The researches of MM. Andral and Gavarret, of Simon, Lehmann, and Becquerel and Rhodier, do not furnish any information in regard to the state of the blood in this disease. Further investigations are still necessary to the more thorough elucidation of this important question. Abdominal complications. — These will include the appearances found in infantile remittent fever, diarrhoea, and intestinal disorder, inflammation and softening of the stomach, and dropsical effusions. Inflammatory appearances have been noticed in the oesophagus by Dr. Copland and Ozanam, of Milan. The former has found also the mucous membrane of the pharynx and epiglottis, parti- cularly the latter, more or less inflamed, and the subjacent cellular tissue, especially at the base of the epiglottis, infiltrated and oedematous. The mucous membrane of the stomach and bowels presents various degrees of vascularity and patches of redness, extending to actual inflammation ; Dr, Copland has met with inflammation of the ccecum and colon occasionally ; ulceraaons hav3 been in some instances found also in the ccecum and colon ; unusual redness and prominence of the glands of Peyer in the small intestine; mucous follicles isolated and strongly developed ; stomach covered with brown patches externally, half an inch broad, as if laid on with a brush, red streaks inside, and (lymphatic exudation in upper parts from recent 170 ON HOOPING-COUGH. \ i inflammation, in a case of Dr. Watts'. The stomach may present a state of softening of all the tissues, •with sometimes attenuation, and a total absence of bloodvcLisels, and perforation may be found, which, perhaps, has been the immediate cause of death. I have mentioned before that Guersent found in one case gelatinous softening of the stomach and diaphragm. This last condition — gelatinous softening — I believe, in common with many other writers, to be a consequence of a pre-existing gastritis in pertussis; and redness in other parts of the stomach may be found, which are not in a state of softening. The peritoneum and mesentery have been found inflamed ; the meso-colon redder and more vascular than natural, or dark coloured and approaching to gangrene, in two of Dr. Watts' cases ; enlargement of the mesenteric glands, with redness and engorge- ment in protracted cases; the liver, spleen, and kidneys may participate in the inflammatory action as observed by Mackintosh and others. Lbbenstein Lobel met with a case in which a considerable portion of the diaphragm was covered with pustules. Effusions of serum sometimes are found in the peritoneum, with or without traces of inflammation. Of the Urine. — When accompanied with in- flammation in some form it is diminished in quantity, of a deep brown, or very high coloured ; liL-l L p J. J „H. PATHOLOGY OF HOOPING-COUGH. 171 lich a )vered axe 3es of h in- in ured ; ed it lias a strong urinous odour, and is thick and muddy : these characters were present in three of Dr. Watts' cases. On one occasion I noticed the urine to be albuminous ; it was only temporary, and disappeared in a few days. Tuberculosis. — llie mucous membrane of the trachea and bronchi may present the usual cha- racters of inflammation, with chronic thickening and ulceration at different points from tubercles. Tubercles in all stages of development and soften- ing may be scattered through the substance of the lungs, accompanied with ulcerated excavations and vomicsB. Adhesions between the pleurae, the sur- faces of the lungs covered with inflammatory exudation, effusion of serum, with or without air, constituting either hydrothorax, pneumothorax, or the two combined, hydro-pneumothorax, may be present. (Edema of the cellular tissue in the mediastinum has occurred; also enlarged fatty liver and spleen in one of Dr. Watts' cases ; tubercles in the liver in one of Dr. Lettsom's cases ; and enlargement and induration of the mesenteric glands. Combined with some of these, tubercular hydrocephalus may terminate the case, and the membranes at the base of the brain be the seat of tubercular deposits, with a good deal of thickening and infiltration about the optic nerves, as in a case described by Dr. West. Of the Exanthemata. — There is nothing very ( I i\ i\ 172 ON HOOPING-COUGH. particular to be found in these as complications. In a case under Dr. Eoe, of death from small-pox, inflammation of the bronchi and lungs was prcr sent, with tubercles in both lungs. The trachea was very pale, excepting at its upper part, where a few small-pox pustules were scattered over it ■ Other Conditions.— GirtsLnneT lays some stress Upon his having found the parts of generation in a morbid condition upon these occasions ; in fact, we mighi almost believe from his observations that this state is the cause of pertussia We have now seen the various conditions which offer themselves in all the forms of this affection, and they present a very numerous and important series of pathological phenomena. We have here an explanation of the views of the seat of the dis-^ ease of so many authors in the subsequent chapter ; one party attributing it to diseased lungs, another to diseased bronchi, a third to the throat, a fourth to the brain, a fifth to the brain and lungs com'- bined, a sixth to the genital organs. It becomes quite clear, however, that none of these are the seat of the disease, any more than they are the seat of scarlet fever or measles ; it is impossible that pertussis can depend upon such 9. varied amount of severe disease, and it is a matter of choice for any one to select a special organ as the seat of it. "■ l^ m^Sfm mm^sr^r^^^^ PATHOLOGY OF HOOPING-COUGH. 173 cations. iU-pox, as prer trachea , where r it. e stress Loniu a [act, we us that s which Section, portant ve here the dis- hapter j another fourth ;s coi3aT lone of re than s; it is such a matter 1 as the ' If we were to examine a large number of cases at one time, it would be observed how many would be suffering from the simple form of the affection, and how many might have the addition of compli- cations. The latter would be subdivisible again^ into their different varieties, and all could not possess the same individual complication ; this, then, overthrows the argument as to its being con- fined to any one organ, or set of organs ; possibly in particular localities, during certain seasons, owing to atmospheric causes, a number of cases might be complicated with affections of a special organ, but this is not a general rule, and too much importance need not be attached to it The affection, therefore, resolves itself into a simple disease, with a complication (when present) superadded to it ; or, to use the expression of Dr. Churchill, " hooping-cough, plus the peculiar com- plication." Morbid anatomy, therefore, furnishes little or no clue as to the nature of the disease, and the large mass of evidence which it affords becomes of little practical value or utility, and must be rejected altogether. How, then, are we to explain the nature of the disease, since pathology furnishes nothing ? We must investigate and examine minutely the cases free from local complication ; we must turn Qur attention to the blood, and observe the absence It. I 174 ON HOOPING-COUGH. \\ I i •II •J ■ I - i • fi rather than the presence of pathological phenomena after death. Death is rare, as has been shown, in the simple form of the affection, and it has been the reason, in a great measure, of the diversity of opinion which has prevailed. But when oppor- tunities for dissections have been afforded, nothing remarkable has been noticed, and certainly no inflammatory appearances have been found ; most of the recent authorities agree in this respect. The appearances observed in the simple form which have been described in the first part of this chapter, may be taken as representing the pathology of pertussis, and will help to explain the pheno- mena of the disease ; they are given as the only conditions to be met with in the simple form of the affection. A few words may be necessary in relation to the state of hypertrophy of the bronchial muscular fibres. This may be explained by the spasmodic contraction of the circular fibres of the bronchi, "which from morbid excitement commences and continues unceasingly, with scarcely any relaxation, imtil the offending mucous secretion is expelled in the acts of expectoration and vomiting combined. The longitudinal fibres are equally influenced in the retractation of the bronchi themselves during the expiratory efforts, and assume a similar condition. As the spasm is of an exceedingly active kind, the continued action produces an increase in volume, PATHOLOGY OP HOOPING-COUGH. 175 omena twn, in 3 been sity of oppor- LOthing Qly no ; most t. e form of this thology pheno- tie only a of the to the Luscular ismodic >ronchi, 163 and ixation, jUed in ibined. Lced in ing the idition. id, the iolume, in the same manner as an external muscle becomes developed from continual use. One feature of great interest in the case in which these fibres presented this condition, is the termi- nation of the hypertrophy at the bifurcation, which proves very satisfactorily that the contraction of the bronchi ceased at that spot during the severe expiratory efiforts, having the trachea remaining more or less free, or in a state of contraction and retractation for about an inch only above it. This hypertrophied condition cannot be regarded here as a truly pathological phenomenon, for it would as surely disappeit.* again when the hooping- cough will have become cured. The absence of respiration d' - ig the kinks, which Laennec supposed to be due to either a momentary congestion and thickening of the mucous membrane, producing obstruction in these canals, or to a spasmodic affection of the bronchi, is unquestionably owing to the latter cause, as pathology in reality distinctly proves, and which I feel satisfied will be confirmed by future observers. There is a strong analogy between asthma and hooping-cough in this respect, for, although there may be an absence of the paroxysms in the former, there is an irritability of the bronchial tubes par- ticularly remarkable, which manifests itself by their atonic contraction, thus producing a similar hyper- trophied state of these fibres. This was singularly M ' f ■RiRHIIi! ^ l^.'i (II i i'i ' /. 1 >\ !-li '/ f . fl I i Ui i L^^u. 176 ON HOOPING-COXJGH. w verified in the case of a gentleman under my care, who had passed a large portion of his life in the Hudson's Bay Company's territories, and who was a suflferer from asthma; the longitudinal fibres were found, however, in him, in a greater state of hypertrophy than the circular. A still further analogy exists between the two diseases in the fsict that, although there is an absence of the cough in asthma, the severe dyspnoea, occurring in paroxysms and probable congestion of the lungs, is reheved by a copious secretion of mucus, similarly to the pro- fuse expectoration at the termination of the paroxysm in hooping-cough. The concretions in the heart are due to the fibrinous state of the blood, and are especially liable to form, should any cause arise to impede the circulation through that organ, a tendency which is present during the paroxysms. The congestion of the minute vessels around the medulla oblongata and nerves arising from it, and the condition of the bronchial mucous membrane and its secreting processes, are both produced by the same cause, whatever that may be, — most pro- bably reflex nervous action, — ^manifesting itself at the two extremities of the pneumogastric nerves, and induced by the introduction of some unknown poisonous principle into the blood as inexplicable in its nature as that producing any other zymotic disease. m ; I OPINIONS, ETC., AS TO PERTUSSIS. 177 iiy care, ! in the jvho was d fibres state of further the fact cough in Lroxysms Lievedby the pro- of the 3 to the 3specially ipede the cy which 'ound the m it, and lembrane luced by nost pro- itself at nerves, unknown xplicable • zymotic c CHAPTER XII. OPINIONS OF VARIOUS WRITERS AS TO THE NATURE, PATHOLOGY, AND SEAT OF PERTUSSIS. It may be necessary, to render the present work as complete as its prescribed limits will permit, in giving the opinions of different writers as to the nature and seat of pertussis, tj go as far back as the time of Willis, following, in this re- spect, the example of Dr. Watt. It is not at the same time intended, however, to combat all these, but some remarks will be made upon them as I proceed, wherever it may appf.ar advisable and proper to do so. By thus giving the views, how- ever brief, of almost every writer of authority to the present time, it will render the present chap- ter especially useful, as one of reference, as fur- nishing the means also of contrasting those views with one another, and at the same time affording at a glance a picture of the conflicting opinions entertained by so many upon the true nature of a disease which, after all that has been said, is not in reality of that great importance as essential to its therapeutical treatment, in so far as to what may be the specific essence of the disease. These will be concluded by a consideration of the patho- N f Vi 1 '.I, H II li I 178 ON HOOPING-COUGH. \r logy of simple pertussis, given in the preceding chapter, and an epitome of my own views as to the nature and seat of the disease. Willis considered it a quick, vehement irritation of the lungs, stimulating them to throw off the serum from other parts of the blood, thus pro- ducing a convulsive cough, exceedingly injurious to the function of respiration. This serum he looked upon as being distilled into the cavity of the trachea and bronchi.* Hoffmann attributed it to an acrid serum in the blood. Sydenham imputed its presence to some irri- tating effluvia in the blood, thrown upon the lungs, in consequence of suppressed transpiration, and exciting the paroxysms. Harvey looked upon it as a disease of the stomach and alimentary canal. Huxham thought it was owing to a morbid condition of the intestinal canal. Dr. Butter that it depended upon derangement of the bowels and liver from miasmatic influences. Boelime conceived it to proceed from a peculiar miasm, acting chiefly on the nerves. Girtanner has advanced the notion also that the disease owes its origin to a specific miasm, analogous to that of marshes.t Waldschmidt, StoU, Friborg, and Brouzet that it was caused by crude and bilious matters in the stomach. * Operation of Medicines on Human Bodies, part ii. p. 40, f Uber die Kraukheiten dor Kinder. Berlin. 1794. OPINIONS, ETC., AS TO PERTUSSIS. 179 ceding 8 as to itation off the IS pro- jurious um lie ivity of ributed ne irri- >on the )iration, ed upon nentary morbid ter that i^els and peculiar irtanner ise owes to that rg, and bilious Danz and ^^entin place the seat of disease in the lungs as well as the stomach , *hey admit that the other symptomatic disorders accompaiiying it vary exceedingly, whilst the respiratory function? are more constantly disturbed. Linnseus* maintained that it arose from in- haling, in respiration, the minute eggs of a pecu- liar species of insect ; this view, somewhat modi- fied, was advanced by Kiverius, Desault, Rosen, and others. Rosen believed that it was propa- gated by contagion from affected individuals, the particles of the disease being absorbed by the respi- ratory organs and stomach, the consequent affec- tion of those viscera producing a great secretion of phlegm. MiUar thinks it may be owing to the same peculiarities in children by which asthma is pro- duced.! Astruc affirms that it principally consists of inflammation of the mucous membrane of the pharynx and larynx, particularly the former, which he says is sometimes ulcerated.f Strong, Cullen, Lettsom, and Darcey have found similar evidences of inflammation of the mucous mem- brane of the larynx and trachea ; Cullen, however, placed it among the neuroses, and considered it as a specific irritation of the nervous system. Jones u. p, 1794. 40. * Dissert. Exanth. viva iu Amoenit. Acad., vol. v. p. f On Asthma and Hooping-cough, p. 11^8. 1709. I Diseases Incident to Children, p. 142. N 2 82. ) 'l' lit 180 ON HOOPING-COUGH. \\ defines it to be a disease of debility in persons of a lax fibre.* Burton says it is caused by a laxity of the fibres, producing a quantity of thick phlegm obstructing the lungs. Chambonf and Tourtellef considered it a species of catarrh. Its seat was placed in the stomach, by the former, who, supposing it of an asthenic nature, imagined the cough and other nervous symptoms to depend on the affection of this organ. The latter extended the gastric disorder to the lungs, and regarded the disease as a pituitous pneumo-gastric affection. Styx held a similar opinion. GarJien refers it to a nervous irrita- tion, sui gencns, causing a pituitous or increased mucous secretioi. from the bronchi and stomach with convulsive action of the glottis and diaphragm, and believed that it differs from catarrh chiefly in its course and the periodicity of its character. § This nearly agrees with the opinion of Tourtelle. The opinion of Millot also was not materially different from the foregoing, in referring the disease to a spasmodic irritation of the stomach primarily, and of the lungs symptomatically. Broussais is another who places the source of the disease in the stomach ; he believes that it consists of inflammatory irrita- * On the Tussis Convulsiva, by J. G. Jones, p. 12. f Maladies des Enfans, torn, ii. X Elemens de Med. Thdoretique et Pratique, torn. ii. § Traite des Mai. des Enfans, p. 391. OPINIONS, ETC., AS TO PERTUSSIS. 181 J tion, producing an increased secretion of mucus, and that the termination of the fits in vomiting disembarrasses the affected surfaces, and assuages the irritation for a time.* Dr. Watt states that it is in all cases an inflam- matory disease, and that its chief seat is in the mucous membrane of the larynx, trachea, bronchi, and air-cells ; in other words, bronchitis. But the inflammation may be so mild as to cause no incon- venience, or so severe as to cause death. He asks the question as to whether there may not be some eruptive disease of the mucous membrane, so minute as to escape observation, but so consider- able as to excite the inflammation, which is appa- rently the principal part of the disease, f Dr. Badham, Darwin, and Marcus, of Bamburg,J agree with Dr. Watt. Messrs. Broussais (already quoted), Boisseau, Rostan, and Duges, regard it as a specific inflammation of the bronchi; Dr. Dawson limits the inflammation to the mucous membrane of the glottis and larynx. Dr. Dewees looks upon it as a catarrhal inflammation of the respiratory mucous membrane, with an augmented secretion of mucus. § Albers, of Bremen, denies its being essentially * Copland's Diet, of Medicine. f Treatise on Chincough, pp. 191 and 151. J Traits lie Coqueluehe, 1816. Trad, par M. Jacques. § Treatise on Management of Children, 1825. ■J "1.! u 182 ON HOOPING-COUGH. ! .'! tl I w n ;i . i r, inflammatory, and that it is never so rapidly deve- loped as bronchitis. He considers it a disease of the nerves of the chest, frequently occmrl ag spas- modically, and generally admitting of cure without the assistance of art, unless when appearing in a complicated form, or when inflammation super- venes during its progress. Fourcade-Prunet looks upon it as a variety of bronchitis. He attributes the convulsive paroxysms of cough to the morbid sensibility of the mucous membrane of the air- passages in their inflamed state, and to the irrita- tion occasioned by the respired air and the secre- tion formed on this membrane. The opinion of Dr. Mackintosh is, that the ner- vous system is seriously involved in this affection, but he cautiously receives the doctrine of spasm. The essence of the disease, he says, consists in irritation and inflammation of the mucous mem- brane of the body, but more particularly of the air- passages. This is proved, he observes, by the pectoral or catarrhal symptoms, which are to be observed from the very onset of the disease ; by the increased secretion; and by the result of dissec- tions.* [ Hufeland supposed it to be a disease chiefly affecting the pneumo-gastric nerves. His explana- tion is, that the irritation of the nerves suppljdng the larjrnx and bronchi is extended to the diaphragm * Pathology and Practice of Physic, vol. i. p. 408, • • 1 . • • ' - • » OPIXIONS, ETC., AS TO PERTUSSIS. 183 ' ly deve- isease of ag spas- without ng in a L super- let looks ^tributes I morbid the air- le irrita- le secre- bhe ner- iffection, spasm. Lsists in s mem- the air- by the e to be ; by the dissec- chiefly xplana- pplying Dhragm 38. • by the intimate sympathy existing between these parts, throwing this muscle into convulsive action ; and owing to its action on the cardia, and the irritation extending to the stomach through the medium of the eighth pair of nerves, this organ undergoes energetic contraction, and evacuates its contents; the vomiting thus produced removing the irritation of the respiratory organs, and thereby terminating the paroxysm. Thus, the vomiting is / the antagonist of the spasmodic state of the organs / of respiration; and as observed in practice, a salu- / tary occurrence. Jahn considers it an affection of the phrenic nerves, occsisioned by a peculiar miasm, too subtle to be recognised. Lobenstein-Lobel contends that the disease originates in a peculiar affection of the nerves of the diaphragm; that in its second stage the phrenic nerves are in a state of irritation ; and in its third, the irritation is expanded throughout the system ; thus commencing with a morbid affec- tion of the diaphragm, which extends itself by nervous connexion to the rest of the respiratory apparatus and stomach, and sympathetically to the whole economy.* Dillon, Breschet, Eberle,t and Pinel regard it also as a nervous disease, perhaps of the brain, or pneumogastric nerves; Pinel gives it a place among the pulmonary neuroses. M. Guibert views it as essentially nervous. He * Copland's Med. Diet. f Diseases of Children, p. 479. » ^ . ■-»— ^.._... 184 ON HOOPING-COUGH. I H u {I li i remarks ^hat a commcn cough may pass into this affection, from spasm of the muscles of the larynx and diaphragm supervening upon it. The spasm arising from the nervous susceptibility and par- ticular disposition, to it arising in children, and from individual idiosyncrasy.* Paldamus supposes the lesion to be in the phrenic and pneumogastric nerves, but thinks that it depends upon exalted irritability of the lungs, and of the organs most closely sympathising with them, as the stomach and diaphragm.i- / Dr. Webster looks upon it as essentially a / cerebral disease, and the actual seat of it may be \ in the head. He considers the affection of the respiratory organs as only a secondary effect, or an effort of nature to relieve herself, by expanding the lungs to an unusual degree, in order to allow a greater quantity of blood to flow into them, and thus diminish the fulness and congestion of the brain. He observes that the pectoral symptoms are preceded oi' accompanied by pain of the head and fulness about the temple and eyes ; and notices particularly the relief which epistaxis affords, and the fact that hydrocephalus sometimes occurs as a sequela to the complaint. He considers his view of the pathology also confirmed by the marked success of his plan of treatment, the application * K.6clierches sur la Croup et la Coqueluche, 1824-. t Der Stikhausten. Halle. 1805. ; .) OPINIONS, ETC., AS TO PERTUSSIS. 185 nto this 3 larynx e spasm nd par- md from OSes the logastric exalted ns most stomach tially a may be 1 of the ct, or an panding D allow a em, and of the mptoms le head notices ds, and irs as a lis view marked lication J24. of leeches to the forehead and behind the ears, in 111 cases of the disease.* Alphonse Leroy expressed a similar opinion to that adopted by Dr. Webster, in 1803. He thinks it should be classed amongst the diseases of the membranes of the brain, by reason that its characteristics are essentially nervous; that it is epidemic ; very often intermittent ; and that it comes on at stated periods. f Boisseau, Otto, and Begin admit the frequency of the association of cerebral affection with hooping-cough, even from the commencement ; whilst they oppose the infer- ence that the latter is dependent upon the former. Dr. Webster is, however, as Dr. Copland remarks, the first writer who fully appreciated the influence of the cerebral irritation in the respiratory organs in this disease, and excited attention to an important and early complication of it. Dr. Alcock states that he invariably found the larynx inflamed, and sometimes so much so as to close the glottis mechanically; that the mucous membrane of the trachea and bronchi were very vascular ; and that the cavities of the latter were filled with fluid, mixed with air. From these facts he infers that the cough is a mere natural effort to expel the offending matter, when it has accumulated to such a degree as to impede respiration, and that * Loudon Med. and Phys. Journal, vol. xlviii. t Med. Maternelle, 1803. Paris. ' (T* -> m ■, J Si 7 186 ON HOOPING-COUGH. its violence is in direct ratio with the tenacity of the phlegm.* Dr. Alderson conceives himself justified in con- sidering inflammation of the lungs, which he has found on dissection in all the cases he has examined, to be the effects of the continued and uncontrolled action of hooping-cough. He does not, however, explain the nature of the disease.f Wendt places this among the neuroses ; he does not believe in a secretion peculiar to it, but thinks \ it is produced by a certain miasm, arising from the particular season and constitution of the atmosphere, and prevailing generally in an epidemic form. The branches of the intercostals, the eighth pair, and the recurrent nerve, he believes, are chiefly affected. The solar plexus he views as affected secondarily.j I Dr. Gregory remarks, from the various facts which might be adduced, a reasonable presumption exists that it has its origin in a specific contagion or miasm, which, like that of the measles, has a direct determination to the membrane of the bronchi, though it is not, like the rubeolous germ, associated in all cases with fever. § J Dr. Fife looks upon the disease as a neurosis altogether distinct from bronchitis, and has taken * Lectures on Surgery, p. 132. f Medico-Chir. Trans., vol. xvi. p. 79. J Die Kinderkrankh. System 1822. § Theory and Practice of Medicine, p. 474. '.,^_ OPINIONS, ETC., AS TO PERTUSSIS. 187 a good deal of pains to prove that the two diseases cannot co-exist. He institutes a series of compari- sons between the two in support of his doctrine, in the form of six propositions.* These have been ably reviewed in a subsequent paper on pertussis, by Dr. Ogier Ward, with whom I agree in many particulars.t The question of the co-existence of the two diseases is so well established by the testimony of writers of no mean authority, and — what is still of more value — by experience, that it is unnecessary to go into the subject further than simply to refer to the fifth chapter of this book, in which bronchitis as a complication is especially considered. M. Guersent, in common with many others already mentioned, pronounces it to be a catarrhal affection of the trachea and bronchi, consisting of a specific inflammation, and accompanied with spasm of the glottis.{ Hasse says, experience would, indeed, rather lead to the conclusion of its being nothing more than chronic catarrh, which, in persons prone to strong nervous reaction — like children, and equally excitable adults, especially of the female sex — provokes the well-known paroxysms. He considers it not fatal in itself, but only through the complications that beset ordinary * Prov. Med. and Surg. Jour., 16th June, 1847. t Ibid. 20th October, 1847. { Diet, de Medecine, vol. vL, p. 15. 188 ON HOOPING-COUGH. ( : catarrh.* Dr. Wagstaff is inclined to the con- clusion that it is nothing more than chronic catarrh, agreeing in this respect with Hasse, and, with this view of its pathology, treats it by topical applications to the pharyngo-laryngeal mucous membrane.f Desruelles, again, looks upon it as bronchitis complicated with irritation of the brain, the former always preceding the latter, and from the union of the two, calls it broncho -cephalitis. As this view is partly approved of by the writer who succeeds, I shall quote the following ; — " So long as the bronchitis is simple, the cough is without any peculiarity ; but when the diaphragm, muscles of expiration, and of the glottis, larynx, and posterior membrane of the bronchi, and the air-cells of the lungs, come into action, and are simultaneously affected with spasm, under the influence of the cerebral irritation, the cough changes its character, and becomes convulsive, and every time that an afflux of blood takes place into the bram, the cough returns, and appears in paroxysms. This inter- mittent congestion precedes the kink of coughing, and disappears along with it, to reappear shortly, and to bring on a fresh paroxysm."^ Upon this theory of Desruelles, Dr. C. Johnson remarks, that * Path. Anat., Syd. Soc, p. 267. •}■ On Dis. Muc. Mem. of the Tliroat, p. 164. j Traite de la Coqueluche, p. 77. OPINIONS, ETC., AS TO PERTUSSIS. 189 the con- chronic «sse, and, y topical mucous )ronchitis le former 1 union of this view succeeds, g as the liout any Quscles of I posterior lis of the taneously of the character, 3 that an the cough lis inter- coughing, ir shortly, Upon this arks, that 64. it has the great recommendation of being in accordance with the practice which has ])een found most beneficial in the treatment of the disease ; and it h^s been justly remarked, he observes, that the eifec .• of remedies, if accurately observed, are like chemical tests, frequently the means of detect- ing important differences in objects which, other- wise, could not have been distinguished from each other.* ii >m these observations of Dr. Johnson, it will* appear that he inclines to a similar view with Desruelles. The work of the latter was translated into German, in 1828, by Dr. Gerhard von dera Busch, accompanied by most copious notes. Although he does not furnish any clear exposition of his own views in his notes, yet we are led to believe, from many of his remarks, as well as from the general tendency of his arguments, that he adopts the opinions of Hufeland and others of his countrymen, already cited — namely, that pertussis consists in an irritation of the mucous membrane of the bronchi, accompanied by a diseased condition of the eighth pair of nerves.f I believe Desruelles' work has been translated into English in the United States, where many other excellent foreign works appear in the same language, and, unfortunately, are not to be met with in this country. * Cjxlop. of Pract. Med., vol ii. p. 429. f Ainer. Jour. Med. Sciences, vol. x., 1832, ]). 220. "P^fWH" asmsmemfmi ^mmmmmm .... f, « fU iV:l i; ' Ji r fi 190 ON HOOPING-COUGH. Messrs. Maunsell and Evanson very cautiously a])stain from any positive opinion, but they freely confess their entire ignorance as to the intimate nature of the affection. They observe, " All we know is, that the symptoms in the first stage show the bronchial mucous membrane to be in a state of irritation, if not inflammation ; and that in the second, they assume a, distinctly spasmodic cha- racter."* Dr. Eben Watson, of Glasgow, adopts the theory that the poison of the disease first causes inflamma- tion of the respiratory surfaces, and very speedily affects the nerves, so as to render the glottis peculiarly irritable. He believes that, in a case of uncomplicated pertussis, the morbid poison first influences the mucous membrane lining the pharynx and upper part of the larynx, affecting there the extreme branches of the sensory nerve, tho superior laryngeal, in some peculiar way ; and iiiA, finally, the motor nerve, the recurrent laryngeal, is excited into reflex action. Hence, he says, the ordinary progress of the symptoms, which fiist resemble those of a common cold, or slight bronchitis. Along with this symptom may also he ranked certain peculiar pains of the throat and neck, which are often complained of, and seem to indi- cate the effect of the poison on the sensory nerve of these parts. Then follows the distinctive * Diseases of Children, 5th edition, p. 340. OPINIONS, ETC., AS TO PERTUSSIS. 191 symptom of the affection, the whoop, or draw- back, which is produced by the excitement of the inferior laryngeal nerve, and consequent spasm of the muscles of the glottis.* M. ^Jaud, of Beaucaire, considers the primary cause of the disease to consist in an irritation of the mucous membrane of the bronchi, the result of a specific secretion poured out by the glands and follicles of that membrane, saturated with hydro- chlorate of soda The irritation from this produces the kink, when it reaches the upper part of th'^ trachea and larynx, throwing the muscles of the glottis and of respiration into spasmodic action for its expulsion, in a similar manner to that arising from any foreign body which may accidentally enter the larynx.f Mr. Streeter is the only writer I can meet with who adopts this theory, but with the exception, that he re^rj^rds the primary affection of the bronchial membrane as inflammatory in its nature. The saline mu^^us, he says, acts precisely as a foreign body on the sensitive membrane ; and he regards it as the true and exciting cause of the suffocative paroxysms of the second stage. He supports the truth of the mucus bei. ig saline, by the testimony of adults who have been attacked by the disease, who speak of the unusual and exces- * Monthly Jour, of Med., Dec. 1819 ; and Lancet for 1851, vol. ii. p. 368. f Revue Medicalc, March, 1831. P: :! i( II 'vy I il I. ;) i :\ 192 ON HOOPING-COUGH. sively saline taste of the expectoration, so long as the paroxysms are severe.* An objection to this theory is the frequency of a distinctly saline tasted expectoration, occurring in many diseases of the chest, in phthisis for example, which does not necessarily produce violent efforts to get rid of it. Besides, I have treated cases, in elderly children, in whom there was a notable absence of the saline taste. I quite agree with Dr. Eoe, here, that the presence of this salt must be proved chemically by those who desire to maintain this position. Dr. R. H. Alnatt, again, considers the morbid irritability of the stomach, which engenders an irritating secretion, as the immediate cause of the spasmodic action of the glottis. This secretion, involving the bronchial tubes, trachea and fauces, spurs their exhalent vessels to inordinate action. He says, if the excretions of the stomach be ex- amined in this stage of the disease, they will be found intensf^^"" acid, so much so as to excoriate in their passage the oesophagus, and roughen the teeth as effectually as would a dose of dilute hydrochloric acid.f Autenrieth believes the origo Tuali to be a determination of morbid matter towards the bronchi, and hopes to divert it away by exciting morbid pustules upon the skin. Dr. Volz has * Medical Gazette, vol. i., 1814, 1815, p. 195. f Lancet, vol. i. 181G, p. 62G. OPINIONS, ETC., AS TO PERTUSSIS. 193 3 long as m to this ine tasted 3es of the does not b rid of it. hildren, in the saline , that the chemically tion. be morbid renders an ,use of the secretion, ,nd fauces, ate action, ich be ex- ey will be xcoriate in ighen the of dilute li to be a rards the )y exciting Volz has 195. given many reasons why it should be classed among the exanthemata. For instance, its epidemic nature, its contagious character, its attraction to children, its occurri^": only once in a lifetime, its relationship to me ' s, its regular progress, and its uninterrupted career in the individual, are all points in which it has as little resemblance to a catarrh as it has to convulsions, but which show a great similitude between pertussis and acute exan- themata. That it is seldom that any eruption is perceived in pertussis is no proof to the contrary, since in the other epidemic exanthemata, he says, cases frequently occur where there is no external eruption, but in which, nevertheless, the nature of the disease is unquestionable ; and in others, again, the eruption is so transient that it is frequently not observed. Since the time of Autenrieth, the relationship between pertussis and the other acute epidemic contagious exanthemata has been sus- pected. Neumann (Krankheit des Mensch. Bd. i. s. 648) has seen pertussis accompanied by an eruption resembling measles in form, but having the colour of scarlatina, and appearing chiefly on the breast and arms. This eruption is rare, but Volz also has seen something of the same kind in pertussis. Besides the ordinary morbid appear- ances, Volz mentions certain changes on the mucous membrane of the intestinal canal; these are observed chiefly in the glands of that organ, o 1.94 ON HOOPING-COUGH. ■1. m ' i and are of the exudative kind, and such as are con- sidered by Kokitansky as peculiar to certain patho- logical processes, among which are included the exanthemata. Volz argues, therefore, if this pecu- liar alteration in the glandular apparatus of the intestinal mucous membrane is found not only in scarlatina, measles, cholera, and typhus, but also in gangrene, purulent deposits, &c., then it is evident that it is not the characteristic of a specific disease, but of some abnormal changes in the blood. Per- tussis is therefore to be classed among the diseases produced by an abnormal change in the blood, and from the account of its occurrence as a contagious epidemic, and the numerous coincidences between it and scarlatina or measles, as already mentioned, it is improper that it should invariably be classed among the neuroses.* The resemblance between pertussis and the exanthemata has been noticed also by Jos. Frank. Dr. Watt has a leaning towards the hypothesis of its being one of the exanthemata, as shown in his observations on the third case in his book. Dr. James Duncan has also proposed to class this affection with exanthematous diseases, and asserts that it exhibits all the more constant characters of that class of diseases. The essence of the disease he conceives to be a turgescence of the * Haser's Archiv., Bd. iv., Hft. 3, in Monthly Journal of Medical Science, Dec. 184)6, p. 461. 3 are con- in patho- uded the ;his pecu- is of the >t only in lit also in s evident c disease, Dd. Per- 3 diseases (lood, and ontagious ; between entioned, )e classed between noticed leaning of the on the to class ses, and constant 5sence of e of the ouraal of OPINIONS, ETC., AS TO PERTUSSIS. 195 bronchial glands, coinciding with or arising from a peculiar fever, and the result of a specific poison ; and acting upon the pneumogastric nerves, in the way Dr. Ley supposed in the case of spasm of the glottis — viz., a reflex action caused by irritation of these nerves. Dr. Duncan gets over the difficulty of the paroxysmal character of the symptoms by assuming that the turgescence of the bronchial glands is intermittent.* This extraordinary doctrine has been considered too hypothetical for notice by some writers ; as it is not more so than that of many others, and wish- ing fairly to represent the views of all here, it has received its share of attention, notwithstanding Dr. Duncan admits his opinion to be hypothesis. Allied to the foregoing is the opinion of Dr. Guyot, the advocate for the use of coffee in the treatment. The efficacy of this remedy, he says, seems to show that the seat of the disease is not in the bronchial tubes or larynx — nor in their vascular or nervous network — but exclusively in the digestive organs, and especially in the pharynx and stomach. The cough and convulsive movements of the larynx are excited by a pruriginous irritation of the pharynx, which, again, probably depends on some special affection of the stomach, f M. Blache is of opinion that hooping-cough is * Dublin Quarterly Jomnal of Medical Science, Aug. 1847. t Union Medicale, April, 1849. o 2 /{ ,' . I ;1 ' } 196 ON HOOPING-COUGH. a nervous aflfection, having its seat both in the mucous membrane of the bronchi, and in the pneumogastric nerves : an affection very frequently complicated with bronchitis and pneumonia, but which may exist without them ; and, like all other diseases of the same kind, having no appreci- able anatomical character.* Dr. Roe, MM. Barrier, Rilliet, and Barthez, and many other writers, coin- cide in this opinion of Blache. r My friend Dr. Arnoldi, of Montreal, considers the / characteristic feature of pertussis to be the double paroxysm. The hoop he places little reliance on, as it is a symptom, he says, common enough in chronic catarrhs or stomach coughs. What he means by the double paroxysm is the invariable return of the cough within thirty seconds, when the symptoms, probably from the previous ex- haustion, are more severe, though the patient ex- presses less terror on its approach than he does for the first. In contradistinction to laryngismus stridulus it is due to the eighth pair and phrenic nerves — the suffocation taking place as the result of long continued expiration; whereas in laryn- gismus it is the recurrent solely — the suffocation taking place at the instant of an attempted natural inspiration, without any previous unnatural expi- ration. Dr. Watson, in his Lectures on Medicine, does * De la Coqueluclie. ArcMv. Gen. de Med., 1833. OPINIONS, ETC., AS TO PERTUSSIS. 197 I in the in the equently )nia, but like all appreci- . Barrier, ers, coin- iders the e double iance on, lough in Nhsit he nvariable ds, when lous ex- tient ex- he does mgismus phrenic le result Q laryn- ffocation I natural al expi- ne, does .833. not give his own views of the pathology, but makes the following important observations relating to it • — " This conjecture that the crowing inspiration of infants, and the crowing inspiration of hooping- cough — though quite distinct affections — may both depend upon irritation of the recurrent nerves, or of the pneumogastric nerve generally; and that even the irritation might in both cases arise out of enlargement of the glands which lie in the course of that nerve.''* * * * " In coiToboration of this conjectural view of what Tnay ultimately prove to be the true pathology of hooping-cough I may remark, that among the morbid appearances described as being met with after death from that ^ disease, ' an unusual swelling of the bronchial glands' is set down." The view entertained by Laennec might have followed with propriety that of either Dewees or Hasse ; but as I shall refer to his opinion, and that of the subsequent writers, in giving my own views of this affection, his may be given here. Laennec regards it as a variety of pulmonary catarrh, inter- mediate between the phlegmorrhagic or pituitous and the mucous catarrh; and from the nature of the cough has called it convulsive catarrh. The absence or suspension of inspiration during the kinks may be accounted for in two ways, " it may be owing either to a momentary sanguineous or serous congestion of the mucous membrane of f li {{ ■ ; Hi 198 ON HOOPING-COUGH. the air-passages, causing a thickening and conse- quent obstruction to these canals, or by a spas- modie contraction of the bronchi, which would have the same effect. The discovery made by Reisseissen of a circular muscular apparatus in the branches of an inferior diameter to that of the bronchi, where the cartilaginous rings cease to be visible, will satisfactorily account for the spasm admitted by many practitioners without any other proof than the symptoms attendant upon the different diseases of the lungs.* ' The facts related above, and the phenomena of several species of asthn a make him regard as certain the possibility of the temporary closure of the smaller bronchial branches by a spasmodic contraction of their parietes ; and he observes that the spasmodic character of pertussis is very clear from the phenomena which occasionally arisse in the glottis, larynx, and even in the velum pen- dulum palati. The learned author of the Dictionary of Prac- tical Medicine, Dr. Copland, an authority most certainly of some importance in this interesting inquiry, thus enunciates his views : — " The medulla oblongata, or its membranes, are very early impli- cated in this disease; evidences of inflammatory irritation of these parts having been very generally * Diseases of the Chest, by Herbert, p. 86, OPINIONS, ETC., AS TO PERTUSSIS. 199 d conse- a spaa- h would nade by us in the t of the ise to be le spasm my other pon the enomena regard as ilosure of jasmodic rves that ery clear arise in im pen- of Prac- ity most eresting medulla ly impli- nmatory generally observed in the post mortem inspections I have made. I conceive that the morbid impression or irritation occasioned by the exciting cause in the upper parts of the respiratory surfaces, particularly the glottis and its vicinity, affects the respiratory nerves, especially the pneumogastric ; and that the irritation is extended to the origins of these nerves, where it aggravates and perpetuates the primary affection. " I believe that the disease is chiefly nervous in the simple cases ; that it preserves this character more or less throughout, even when inflammatory complications ensue ; and that in the uncomplicated state, the nervous affection never proceeds beyond irritation. The impression made by the causes, is followed by functional lesion of the respiratory nerves, particularly the nervus vagus ; and, owing to this lesion, the mucous surfaces they supply fre- quently experience consecutive changes, as respects the state of the circulation, exhalation, and secre- tion." In a paper on the pathological treatment of per- tussis by Dr. Pidduck, he observes that : — " Patho- \ logical anatomy has supplied the principle which | leads to a rational practice in this disease. It has demonstrated the existence of a congested state of the vessels at the origin of the pneumogastric and other respiratory nerves, and a more copious effu- ] sion of serum aroimd the medulla oblongata than in ' 200 ON HOOPING-COUGH. ^i II I '' / iii lii death from other causes, excepting those involving disease of the lungs and heart." This state of the vessels at the origin of these nerves was the discovery of the late Dr. Sanders, of Edinburgh. In the great majority of these cases, Dr. Pidduck remarks, heat, redness, and ten- derness on pressure indicate the state of the part subjacent, over the junction of the occiput and the ' atlas vertebra. The symptomatic proof, he says, 1 of the congested state of the vessels surrounding i the origin of the pneumogastric nerves is the \' vomiting, which frequently terminates the paroxysm — a symptom which almost invariably attends an injury done to this part of the cerebro-spinal sys- tem by the contre-coup, from a fall, or heavy blow on the head.* Dr. Ogier Ward entertains the following views of the pathology of pertussis, and pronounces it " a zymotic disease affecting primarily the mucous membrane of the air-tubes and the blood, and secondarily, the medulla oblongata and respiratory nerves, producing a violent and convulsive cough, attended with a peculiar sound characteristic of the disease." He concludes that the first stage consists in an irritation of the mucous membrane of the air- passages, which, producing an increased secretion of mucus, excites the cough to remove it, as an impediment to the free access of air. The hoop, * Lancet, vol. i. 1849, p. 640. OPINIONS, ETC., AS TO PERTUSSIS. 201 involving L of these . Sanders, of these , and ten- f the part it and the , he says, rrounding es is the paroxysm ittends an spinal sys' eavy blow ing views nces it " a mucous ood, and espiratory ive cough, Lstic of the ^e consists of the air- secretion it, as an The hoop. the peculiar feature of the second stage, he explains by the well-known excito-motory physiology of the larynx. He considers congestion or irritation of the medulla oblongata sufficient to produce the spas- modic contraction of the glottis during the hoop; and the persistence of the paroxysms to depend upon the irritation produced by either mucus in the bronchi, or food in the stomach. He thus con- cludes the pathology of pertussis : — " From what has been stated, we may briefly recapitulate the series of events that constitute the pathology of pertussis in the following order of sequence : — spe- cific toxication of the blood, inducing irritation of the bronchi and increased secretion of mucus, and consequent congestion of the lungs ; toxication, and congestion of the brain and medulla oblongata by the blood, now renderf d still more vitiated by the pulmonary congestion, which, producing specific irritation of the respiratory nerves, renders them more easily affected by slight stimuli, and causes irregular contractions of the muscles under their influence, so as to produce a spasmodic cough of a peculiar kind."* The views of Dr. Ward are, in some measure, allied to my own, which I hope presently to show. Dr. West, in the last edition of his work on Dis- eases of Children, published in 1852, refrains trom discussing the theory of the nature of the disease; * Prov. Med. and Surg. Jour., 20tli Oct. 1847. '1' I 9 I (' 202 ON HOOPING-COUGH. Dr. Churchill, however, whose work preceded that of Dr. West above mentioned, enunciates his own views as follows : — " Now, without attributing it to organic disease of the brain or spinal marrow, we cannot but refer the peculiarity of this cough and whoop to a state of the nervous system analogous (shall I say) to that which gives rise to spasm of the glottis. In other words, that hooping-cough is also a case of reflex irritation of the nervous sys- tem, excited, no doubt, by other and different causes, but experiencing a similar transference of effects."* Dr. Churchill believes that we are at present quite ignorant of the nature of the peculiar exciting cause; we know that it exists, and that when it is applied, the primary irritation of the mucous membrane arises, followed by the reflected nervous irritation which gives rise to the peculiar phenomena of the disease. In a clinical lecture delivered by Dr. Todd, at King's College Hospital, on hooping-cough, f he pronounces it a disease depending upon some pecu- liar irritation, of the vagus nerve, the irritation being quite as complete as when the nerve is jmechanically stimulated. The cough differing, \ however, from that produced by mechanical irrita- tion of the nerve, in its coming on in paroxysms * Diseases of Children, p. 215. f Medical Times and Gazette, 4th March, 1854. This work was ready for the press when Dr. Todd's lecture was published. OPINIONS, ETC., AS TO PERTUSSIS. 203 at longer or shorter intervals from each other, the patient's h'.alth during the intervals beiiig good. "This paroxysmal character of the disease, \ *^h the complete state of health in the intervals, ex- cept when the constitution or the lungs have become damaged by the effects of the cough, associates hooping-cough with other diseases, the peculiar phenomena of which depend upon some poison in the blood, manifesting its presence by the specific action which it exercises upon some particular tissue, and by the interference which it seems to offer to the due performance of healthy function. " For certain poisons undoubtedly appear to have a peculiar affinity for certain tissues, thus the poison of measles appears to hs'e a special affinity for the mucous membrane of the bronchial tubes and bowels, that of scarlatina for the throat, and so on of the other acute specific diseases. In like manner the poison, which gives rise to the phe- nomena of hooping-cough, seems to have a pe- culiar affinity for the vagus nerve; but whether throughout the whole course of that nerve, at its centre or its periphery, it is impossible, in the pre- sent state of our knowledge, to affirm with any degree of accuracy. " The poison in hooping-cough, whatever it be, produces no structural lesion in the nerves, and leaves nothing behind it, of which our senses can take cognizance.'' 204 i ON HOOPING-COUGH. Dr. Todd concludes his views of the pathology as follows: — "Hooping-cough, then, as far as pre- sent knowledge enables us to speak, is a disease which runs a certain course, can be communicated from one person to another, and is probably due to the influence of a poison which gets into the sys- tem, and produces its local manifestations on the vagus nerve. It is not an inflammatory affection of any part, being simply dependent on a morbid state of the blood, caused by the introduction into it of some poison from without; and whatever /inflammations may occur in the course of it must be regarded in the light of complications of the disease.'' I shall appropriately conclude the series of obser- vations just given, from so many writers, with the following from Dr. Carpenter, taken from his Recapitulation of the Functions of the Nervous System.* There are many spasmodic affections of a more limited character, he states, which are trace- able to a morbid affection of some particular divi- sion of the spinal axis. " Thus in the various forms of spasmodic asthma, the medulla oblongata would seem to be alone involved ; the attacks of this dis- order usually resulting from some internal irrita- tion, either in the air-passages themselves, or in the digestive system, producing a reflex contraction of the muscular fibres of the bronchial tubes. In * Principles of Human Physiology, 4th edit., 1853. OPINIONS, ETC., AS TO PERTUSSIS. 205 the purely spasmodic stage of hooping-cough, again, which frequently persists long after all inflammatory symptoms have subsided, we have another example of spasmodic action limited to the respiratory centres; and here we have distinct evi- dence that the morbid condition originates in the introduction of a poison into the blood." If we now review the numerous and varied opinions just given, of the many writers who have devoted much research in estimating the nature and seat of pertussis, we are at once struck with the diversity which prevails. We cannot affect surprise at this, however, when we reflect upon the time at which many of their observations were made, as it is comparatively only of late years indeed, that such onward progress has been made in our knowledge of both physiology and pathology, more particularly in relation to the functions of the different organs. But there is one very important fact nevertheless, which cannot escape notice, and which proves the truth of the last remark, when it is observed that there is a good deal of unanimity on certain points, among the more recent writers, in their notions of this disease; this is a fact which affords matter for much congratulation, and will tend in a great mea- sure to settle a question which has appeared to prove an enigma for so long a time. The views i I 206 ON HOOPING-COUGH. of Churchill, Ogier Ward, Todd, Pidduck, Car- penter, Blache, Roe, Thomas Watson, Copland, and Laennec, may be mentioned as examples of this. By this remark, it is not intended that the opi- nions of many who have preceded these, are to be disregarded, or considered as of no value ; on the contrary, they have assisted in some measure also in the solution of the question. It is not unworthy of notice, that the earliest writers on the subject, Willis and Sydenham, should have considered the blood influenced by the disease, — the latter more particularly, who re- garded it as the seat of it. Not a few, again, have attributed it to causes of a miasmatic nature ; in other words, toxication of the blood. And the causes which induce asthma have been pronounced also likely to produce it ; and laxity of the fibres has not been overlooked. These are here indirectly mentioned, as bearing, to some extent, on the modern views of its nature and pathology. Tlie observations of Dr. Ogier Ward have tended pretty clearly to establish some important points in relation to the affection, and which may be now looked upon as settled, as modem investigation and research appear to confinn them. What he describes as " toxication of the blood," is so significant and distinctive of the certain pre- ■•••■ f n^r^t^^i/^^^, i-i^™«;^t.»jjt»i"v ' I OPINIONS, ETC., AS TO PERTUSSIS. 207 :, Car- opland, iples of the opi- re to be on the ure also earliest denham, need by who re- lin, have ,ture; in ind the )nounced tie fibres bearing, iS nature e tended it points T be now stigation e blood," tain pre- sence of a something in that fluid, whose nature never can be determined or explained, unless mi- nute analysis hereafter may throw some light upon it, that we are justified in accepting this expression as signifying the first condition or essential essence of the disease. This very important point in the commencement of the chain is therefore set at rest. " The toxication of the blood indujjes irritation of the bronchi and increased secretion of mucus, and consequent congestion of the lungs." The fact is undisputed about the irritation and mucus secre- tion; but I am not prepared to admit the con- / gestion of the lungs in the full sense of the term. / How is this irritation produced? The blood having thoroughly imbibed the poisonous influ- ence, is exposed in the air-cells of the lungs for the purpose of oxygenation, when the peculiar nature of this unknown influence commences to develop itself, by irritating the terminal loops of the nerves supplying the mucous membrane in the minute tubes at first, and subsequently spreading ' to the larger branches. This irritation is followed i by increased vascularity, and, as a consequence of '•■ both combined, the secretion of mucus arises, which is natural to the membrane itself, but much in- , creased in quantity, constituting in its manifesta- tion the first or catarrhal stage of the disease. Such, I feel persuaded, is the natural explanation of this phenomenon. i^-Tr„ ESr^TOTOH K« 208 ON HOOPING-COUGH. i 'IK' 1 i I 1 The continued presence of this secretion now acts in its turn as a direct irritant on the minute branches themselves, which furnish the terminal loops; and they convey in their unity, by reflex action, this sensation to the medulla oblongata and origin of the respiratory nerves, which, being fol- lowed by congestion at those parts (and not in the brain generally), produces, as a consequence, vio- lent and strong expiratory efforts, and a spasmodic contraction of the circular and other muscular fibres of the bronchi to get rid of it. These spasmodic contractions will continue, followed by the hoop or sonorous back draught, so distinctive of the disease, until the whole of the offending mucus has been expelled, with the assistance also of the act of vomiting, which appears to be the concluding phe- nomenon of reflex action. . I do not believe that the pharynx and larynx are primarily affected at all, because, if the chest is examined at the onset of ohe disease, the phy- sical signs clearly point out the presence of mucus secretion in the smaller bronchi. The views of Dr. Todd are very clear and satis- factory, and equally express the truth of the prin- cipal peculiarities of the disease, the toxication of the blood, and the irritation of the pneumogastric nerves as the consequence of, or the resulting con- dition of the manifestation of the former. It is satisfactory also to have the testimony of such an OPINIONS, ETC., AS TO PERTUSSIS. 209 m now minute 3rmmal J reflex ata and ing fol- t in the Lce, vio- asmodic ar fibres lasmodic hoop or disease, las been e act of ing phe- larynx he chest the phy- )f mucus nd satis- bhe prin- cation of nogastric ting con- r. It is such an authority as Dr. Todd, in support of there being no inflammatory element in the disease, unless it may occur as a complication. Dr. Copland has not overlooked the state of the medulla oblongata or its membranes, having found evidences of inflammatory irritation of those parts ; I conclude, however, that when the appearances have been distinctly inflammatory, the disease has been complicated, and that congestion only, which may be pronounced inflammatory irritation, if it is thought proper, is a necessary accompaniment of the disease. Dr. Pidduck and Mr. Sanders main- tain this view, with the addition of serous effusion around the cord, free from disease of the lungs or heart Under such circumstances, should serum in small quantity be found with congestion, and free from any complication, coupled with the manner of death — say from asphyxia — it is not unreasonable to suppose that the eflusion may be post-mortem. I agree with Dr. Copland, also, in the observation that the pneumogastric and other respiratory nerves are affected at their terminal extremities primarily, and subsequently by extension to their origin ; and that there is a lesion in function of the former. I cannot go so far as to pronounce with Dr. Ward that congestion of the brain is present, for I think there would be some remarkably prominent symp- tom to show it, — the mere violence of the cough will not prove it r 210 ON HOOPING-COUGH. Laennec appears to be the first writer who sup- posed the absence of respiration was due to spas- modic contraction of the muscular fibres of the bronchi, although the term spasm has been used by others before him, without knowing its true seat ; he, however, refers to the circular muscular apparatus described by Reisseissen, to explain it These fibres are particularly described in the chapter upon the Anatomy of the Lungs. I have adopted this view, and have confirmed the truth of it, by the discovery of these fibres being hy- pertrophied in the simple form of the affection. Laennec's reference to the phenomena of several species of asthma also supports the analogy which exists to some extent between these two affections. The hoop is a mechanical phenomenon again, consequent upon spasmodic contraction of the glottis. The series of expiratory efforts driving the air against the margins of the glottis may be the cause of the reflex action, producing spasm and partial closure the instant they have ceased, and permitting this single but sonorous inspiratory sound. That able physiologist. Dr. Carpenter, adds his testimony to the presence of spasmodic action limited to the respiratory centres, and persisting often after inflammatory symptoms have subsided. To sum up, then, my own views of the nature, seat, and pathology of hooping-cough, arrived at 10 sup- spas- of the Q used ts true uscular lain it in the 1 have 6 truth ing hy- Jection. several f which fections. : again, of the driving may be sm and ed, and 3iratory dds his action rsisting hsided. nature, ived at OPINIONS, ETC., AS TO PERTUSSIS. 211 after long and mature deliberation, they amount to the following declarations : — 1. Toxication of the blood, produced by some unknown spejific influence, peculiar in its nature, not unlike that of measles and scarlet fever, in the circumstance (yf its affecting persons once during their lives, generally children under five years of age. 2. Irritation of the terminal loops of the nerves supplying the mucous membrane of the bronchial tubes, producing vascularity and consequent secre- tion of a greater or lesi?er quantity of mucus. 3. Reflex action of the pneumogastric and respi- ratoiy nerves, followed by congestion of the vessels of the medulla oblongata and pia mater surround- ing it, and also at the origins of its nerves. 4. Spasmodic contraction of the circular and longitudinal muscular fibres of the bronchi, conse- quent upon the foregoing, manifesting itself in the series of sudden expiratory efforts, and the well known, sonorous back draught or hoop. 5. The immediate result of which is frequent and rapid respiration to compensate for its tem- porarjr absence, producing a highly oxygenated or super-oxidized state of the blood, with a tendency to the formation of fibrinous concretions in the h^art during the spasms. 6. As a secondary result of the spasmodic mus- cular contraction of the bronchi, we have a tempo- p 2 "ip^ 212 ON HOOPING-COUGH. rary hypertrophy of the muscular fibres thus acted upon, which disappears again after the cure is esta- bHshed. 7. The disease is at first irritative and catarrhal, and afterwards nervous and spasmodic, both due to the unknown peculiar exciting cause, present in the blood. 8. It manifests the peculiarity of running a spe- cial course, through its different stages, three in number, but which may be cut short, or greatly diminished by medicinal treatment. \ m 'F 213 CHAPTER XIII. PERTUSSIS A DISEASE OF ALL CLIMATES. It has been stated by some writers of authority that pertussis is a disease of all climates; by others, again, this has been disputed, particularly by those who deny the antiquity of the disease. That it is a disease of almost every habitable portion of the globe, whether civilized or barba- rian, cold, warm, or temperate, north or south, I am very firmly convinced, and shall endeavour, so far as my means of information will permit me, to prove the correctness of this assertion. The plan most useful for adoption will be to consider the subject geographically, taking the continents first, with their subdivision into king- doms, and the islands scattered over the globe either isolated or in connexion therewith. If it will be admitted that all climates and re- gions are under the influence of hooping-cough, then I will be bold enough to declare that, taken with other evidence, for which I refer to the chap- ter on the History of the Disease, that its antiquity will date as far back as the earliest periods men- tioned in the sacred volume of Holy Writ, and ?- i fi lii ■■ H '. iw^ .i 214 ON HOOPING-COUGH. I I that, in its antiquity, it is by far more ancient than small-pox or measles, both of which diseases can be traced by recorded evidence to a very remote period of time. Assuming thus much, the continent of Europe shall be first noticed. Europe. — Almost every country in Europe nas had its epidemics of this disease noticed by various writers, whose names alone would occupy many pages. If the testimony was as numerous in other quarters of the globe, it would not have been ne- cessary to write the present chapter, short and imperfect though it is. I shall therefore glance over its recorded evidence, and mention here and there writers of particular countries. Of the epidemics described by De Thou, Sen- nert, Sauvages, Riverius, Baillou, and many others, in 1510, 1557, 1580, 1757, 1767 and 1769, many of them spread over almost the entire extent of Europe, and w^ere very fatal indeed. That men- tioned by Riverius, in 1557, is described as espe- cially spreading almost over the whole of this con- tinent ; and that by Baillou, in 1578, was equally migratory. Of individual nations, however, commencing at the north, we j&nd that Norway and Sweden ap- pear to be most particularly favourable to its deve- lopment. In Sweden the records of mortality at all times appear high, as shown elsewhere in the PERTUSSIS A DISEASE OF ALL CLIMATES. 215 present work. Rosen has described the number of deaths in that country alone *'rom 1749 to 1764 to have been 43,393; Linnaeus Has written also on the disease in the same country. In Finland it is equally prevalent with the two last-named countries ; the deaths in Sweden and Finland were as 1 to 1 3^ of the entire mortality ; and it is no stranger throughout the immense em- pire of Russia, extending to the borders of the Black Sea, not even excepting Circassia and Georgia. A work on the disease in that empire, by F. C. Metzer, was published at St. Petersburgh in 1791. The German empire has furnished a vast num- ber of writers on this affection, which appe?,rs to have specially engaged their attention in almost a spirit of rivalry. This proves that in Central Europe it is a very prevaiUng malady. Of the towns in Germany, the disease, mostly in an epi- demic form, has been described in Gottingen by Klluger, Brendel, and Klinge ; in Wurtemburg by Nurnberger; in Frankfort by Hartmann and MeUin ; in Hamburg by Unzer ; in Helmstadt by Holdefreund, who speaks of several epidemics ; in Bemerkungen by Thilenius; in Leipsic by Pohl and Lobenstein Lobel ; in Mayence by Arand in 1769. Dans, Kopp, Marx, Jahn, Haller, and numerous others, have scarcely excepted a single town or village from its influence. I IP II f I 1 J 1 1 i ^ l' 1 216 ON HOOPING-COUGH. In Prussia, Paldamus, Hoffman and Albert! describe epidemics in their works published at Halle; Geller, one in 1757, in the duchy of Mag- deburg. Hufeland, of Berlin, has also added to the literature of the subject ; and Styx, Schaeffer, Michaelis, Hargens, Streuve, Hinze, Koitum, Con- radi, Sulzer, Winckler, and a great many others, have not left an isolated spot in Prussia, or even in many of the minor kingdoms of Germany, free from this disease. In the Austrian empire, the literature has been nearly as extensive in the description of various epidemics of hooping-cough. In Vienna and Hun- gary, these have been particularly dwelt upon by StoU and Frank; in Saltzburg by Schaeffer and Wezler; and in Prague by Kochler. All the pro- vinces of the empire, extending to the confines of Turkey, are influencf^d to a greater or lesser degree, as is shown by the German writers. Holland and Belgium have had their writers upon the disease ; it has engaged the attention of Eyerel, Ranoe, Strom, Von Berger, De Meza and others. Lando has described the epidemic of 1806 at Geneva, in Switzerland. In Denmark epidemics have raged with great severity at Copenhagen and other places, as men- tioned particularly by Aaskou, who describes the one at that capital in 1775, as also does Bang in 11 _ ; Buckhaave is another Danish writer. ll PERTUSSIS A DISEASE OF ALL CLIMATES. 21 7 This conducts us to the British Isles, where, unfortunately, the disease is not only too pre^^a- lent, but very severe indeed at certain periods, in every village, town, and city throughout the em- pire : no testimony is required to prove this. In a north-westerly direction, the island of Ice- land, which, from its isolated position, some might consider to be exempt, no immunity from the affection is manifest, and the mortality amongst children, in proportion to other affections, is tre- mendous. Madame Ida Pfeiffer, when travelling in that country in 1845, writes under the date of the 20th of June : — " The kvef, a kind of croup, pre- vailed this spring to such an extent that scarcely any one escaped it. Wherever I went I found the people afflicted with this complaint ; and here this was also the case, the noise of groaning and coughing was quite deplorable." The affection she describes is most clearly the hooping-cough, as no other disease possesses such universal characters, and her description suffices to prove it In France the disease is as well known as in Britain, and is equally universal in its distribution ; a very numerous body of writers have enriched the literature of the subject. Spain and Portugal possess it, but we do not hear of the severe epidemics in those countries which have prevailed in others. This may be owing to the same reason that will apply to i i 218 ON HOOPING-COUGH. Turkey, — that very few, if any, have written upon the subject. In Italy, epidemics have been described by i nzani in Istria; Straack and Mettemich at iicino ; Boehmer and Kreysig a* Viterbo ; Penada at Verona, in 1815 ; and Ozanarn ai Milan, and other parts of that country. All the northern shores of the Mediterranean, with their various towns, and the numerous islands, particularly of the Grecian archipelago, are visited by the disease. And Turkey and Greece are not more exempt than any other European state. Hooping-cough, therefore, certainly bears a very strong European aspect, as no part whatever of this continent has been left free from its invasion ; our knowledge of this fact is due to the state of medical literature, which appears to have its sup- porters in almost every kingdom, and is daily adding to our information upon so many important subjects, in relation more particularly to epidemics and their causes. Of Asia generally, our knowledge will for some time remain limited, but from the nature and severity of the climate in various portions of it, together with the remarkable changes in tempe- rature, we may most reasonably assume that pertussis is not unknown, but equally prevalent in Siberia, Tartary, China, and other portions of that great continent. The accounts of travellers i. PERTUSSIS A DISEASE OF ALL CLIMATES. 219 tend to prove this, for, although they may not describe the affection, they speak (Hue particularly) of the " horrible climate, ever gloomy and frozen," and the extreme rigour and severity everywhere met with.* So far as our important and large possessions in India relate to the question, something more positive can be pronounced. In the Medical Keport of the 22nd regiment of Native Infantry, stationed at Malligaum, (a town situated about 120 miles in a north-easterly direction from Bombay,) in 1843, the following appears : — " Hooping-cough first showed itself in January, and continued to prevail for several months among children: attacking, also, very severely, a number of grown-up persons, with whom the whoop was as distinct as in children."t Mr. James Ranald Martin, whose name, as an authority upon medical matters in the East, stands deservedly in such high estimation, informs me that hooping-cough, in common with all other diseases of infancy, goes through its course mildly in India. Such was his experience during several years of practical observation in Calcutta, where he found that in its nature and ( aration the disease was mild as compared to its course in Europe. He found, also, that the complications in * Hue's Travels in Tartary, &c., vol. ii. t Trans. Med. and Phys. Soc. of Bombay, No. 7, p. 126. ^f!rsm^m-a.iv.jnmji^jt m 220 ON HOOPING-COUGH. ( ^ -' 'lii ■I si its progress were of very rare occurrence in India, and when they did occur they proved comparatively- mild and tractable. He observes that the favour- able course of infantile diseases in general within the tropics, may be referred to the equable deter- mination to the surface of the body there, caused by a high temperature. And thoracic disease in every form is, moreover, of comparatively rare occurrence within the tropics, where the great majority of diseases affect the abdominal organs. We have no reason for supposing that Persia, Arabia, and Asiatic Turkey possess an immunity from it. If it reaches the confines of the last, and extends to the northern shores of the Black Sea, it may equally affect the southern shores, and the coimtries adjacent. I could have wished to have given more positive testimony in regard to Turkey and Arabia from the number of associations which connect themselves therewith, more particu- larly in relation to the antiquity of the disease. The entertaining and instructive volumes of Dr. Layard do not contain any passing notice of this affection, and the author himself informs me that he never met with any case of the disease among the children of the Arabs. The testimony of Mr. Wilde is equally negative, his entertaining volume of travels does not mention it ; and he likewise informs me that he never saw it. Small-pox, on the other hand, is a common PERTUSSIS A DISEASE OF ALL CLIMATES. 221 } disease in Persia and Arabia, and, in fact, all parts of Asia ; Hue, Madame Ida Pfeiffer, and others, speak of having seen it. Hooping-cough has nothing about its appearance to attract the notice of travellers. In relation to the northern part of Africa, at the present time, I have been unable to glean any positive intelligence: Mr. Wilde, who has visited Algiers and Egypt, can afford no information as to the disease being one of that part of the continent. The inference, however, might be drawn, that if it is met with in the northern shores of the Mediter- ranean, most probably it will be found as an affec- tion equally prevalent in the southern shores, more particularly when the geographical peculiarities of this sea are considered ; besides, this part of Africa is in the latitude of from 30 to 37 degi'ees north, and, therefore, distant from the tropic of Cancer, a circumstance likewise favourable to the suppo- sition of its presence here. In the Island of Madeira, which may be con- sidered as belonging to this continent, an epidemic of hooping-cough has been described by Dr. Fretis, which prevailed in 1808, and which is said to have spread immediately after the landing of British troops under General Beresford, and destroyed a large number of the inhabitants. My friend. Dr. Alex. Gibb, of the Army Medical Staff, who served for many years in Southern Africa, 222 ON HOOPING-COUGH. it \ informs me that he has seen it there towards the eastern frontier and KafFraria. He remarks that it is not endemic, but is propagated and introduced by arrivals in the colony from other parts of the world, and thence spreads by contagion through the different districts. The general features of the disease resemble the European form, especially among European children; a much milder form prevails among the natives, who are very slightly affected, and few of them take it at all ; which, he says, is perhaps owing to their living in well venti- lated huts, and their being so much in the open air. The chief danger is from pneumonic congestion, which is the most fatal chest disease in the country, many natives dying from pneumonia. Pertussis is sometimes very protracted among the European children ; and change of air is most necessary for a cxrte. From the nature of the climate, which, he says, is almost the finest in the world — the air being remarkably pure, clear, and unusually dry — the disease is extremely mild, and very rare. North America. — The children of the vaiious Indian tribes scattered throughout this continent are subject to the disease. In the large territories of the Hudson's Bay Company, I am informed that hooping-cough is no stranger, and very few families escape its influence. I can speak from experience of the fact of many of the tribes in the Canadas, particularly on the banks of the Ottawa River, at PERTUSSIS A DISEASE OF ALL CI TMATES. 223 the Lake of Two Mountains; at Caughnawauga, opposite Lachine, a distance of nine miles from Montreal; at Lorette, some miles below Quebec; and numerous other places; and no appreciable difiference is found between the disease in them and in the children of the white man. Sir John Kichardson, who is so well known as an Arctic traveller, informs me that in 1819 hooping- cough was endemic, and very fatal among the Cree Indians that frequent the banks of the Saskat- chewan and Nelson Rivers. It affected old and young, and in some instances carried off entire families. It was said to have been imported from England. He never heard of it among the Esqui- maux, nor is he aware that it has ever prevailed in the country of the Tinnfe nation, that intervenes between the Cree and Esquimaux lauds. It cer- tainly did not, he observes, during the seven years that he spent in those countries, but may have done so at intermediate periods. ])r. Barclay, the respected secretary of the Hud- son's Bay Company, tells me that the Esquimaux are free from this disease, and that no informa- tion has been obtained that they are subject to it The Esquimaux are some distance from the Cree Indians. In the Canadian provinces, both Upper and Lower, the disease is well established, and often rages with great severity, particularly in the Lower. <^ 224 ON HOOPING-COUGH. ': • I I I When travelling in the country parts in the "winter time, I have come across whole families among the habitans — the French Canadian settlers — who were suffering from it, and without visible com- plications, although ^t is well known that a large number are carried off by this disease in the Lower Province. It is said also to infect the Indians and settlers on the Labrador coasts. The Provinces of Nova Scotia, New Brunswick, Newfoundland, and the Island of Prince Edward, have it to an equal extent with the Canadas. And even the Island of Anticosti, situated in the Gulf of St. La^vrence, and which seldom has more than two or three families upon it, does not escape, as I was informed by a relative who passed a winter upon it for the purpose of hunting. The testimony of the many respectable writers in the United States clearly proves it to be com- mon to eveiy state in the Union, not excepting those most recently acquired ; and notwithstanding the magnitude and extent of country which is com- prised within the area of this great kingdom, the enterprise of its people promises a future know- ledge on every branch of medical science, not in any way inferior to the extensive literature of Europe. It is a most gratifying circumstance to observe also, that owing to the spirit of topogra- phical and medical inquiry, which is becoming everywhere manifest throughout the almost as yet I ! PERTUSSIS A DISEASE OF ALL CLIMATES. 225 e •winter ong the 3 — who le com- a large 3 Lower lans and mswick, Edward, s. And bhe Gulf ore than scape, as a winter 3 writers be com- scepting tanding I is com- lom, the know- not in iture of tance to topogra- ecoming 3t as yet unexplored portions of Canada and the United States, we may expect to reap in the course of time a most abundant and ripe field of literary harvest. Of Mexico and Central America nothing certain can be said, but there is no reason for supposing them to be exempt. West Indies. — The islands constituting this group have been proved on the testimony of medi- cal writers to be subject to the disease, but whether it is modified to the same extent as in other warm climates, it is impossible to determine. Dr. Hillary mentions that it is equally as infec- tious in Barbadoes among children, as either small- pox or measles is. He writes that it appeared in the month of July, 1753, after a great fall of rain, when there could be no suspicion of the infection being brought there by any person whatever. Sloane and others have described the disease in Jamaica, the first as far back as 1707. South America. — The regular commercial inter- course between the varioi o states of this continent and those of other countries has been the means of affording inforniation which otherwise might not have been available. The personal testimony of travellers, and residents of respectability in the republics of South America and the empire of the Brazils, has satisfied me of their non-exemption, in common with other lands, from this affection. But so far as I have been enabled to learn, it is more 226 ON HOOPING-COUGH. prevalent in the southern part of the continent than elsewhere, attributable possibly to the more varying nature of the climate. In the northern portion, Guayana for instance, whose unhealthy climate has proved the grave of so many, it is prevaleDt among the natives and settlers. The natives are in the habit of using a plant for the cure, known by the name of coro- watti, as described by Dr. John Hancock, in the Lancet, in 1831. It will be remembered, that the southern confines of Guayana are upon the verge of the equator; and although the disease may pos- sibly be here modified by climate, the great heat does not necessarily prevent its existence. Ozanam has stated that it never shows itself between the tropics, with what truth, this chapter illustrates. Australia. — If a description of the climate and the nature of the diseases which are prevalent on that continent be considered, so far as they have become known, the conclusion that hooping-cough is occasionally present will most certainly be adopted. The dry, warm, and elastic atmosphere has been pronounced peculiarly favourable to asthmatic and pulmonary complaints; and chil- dren and infants not only appear to be free from many of the severer diseases of other countries, but increase and multiply to an astonishing degree. In a work published by a medical writer on that country, he observes: — " Rheumatism and catarrhs will prevail according as the indi\ 'dual's system is PERTUSSIS A DISEASE OP ALL CLIMATES. 22? capable of resisting the influence of atmospheric changes;" and he mentions, further on, that pre- cautions will be necessary there, as elsewhere, to guard against the effects of alternations of tem- perature. We find in consequence that hooping-cough in a disease of Australia, and for the knowledge of this fact, in completing a very important link in the chain of evidence, I am indebted to the Rev. David Mackenzie, of Edinburgh. This gentleman has spent eighteen years in AustraHa, but never met nor heard of an example of the disease. He, however, has very kindly taken some trouble to ascertain that it is an Australian malady, but ex- ceedingly mild, and most probably comparatively rare. He informs me that he had learned from the wife of a clergyman, who had recently returned with her family after a residence of some years in New South Wales, that two of her children had the dis- ease in the colony, which was well authenticated, but extremely mild as compare'^ to what she had formerly witnessed in Scotland. The two children of another lady had something like it, but they never hooped. It has not been observed aniong the black aborigines, but as they suffer severely from other European diseases, we cannot consider them to be exempt from this. Q 2 228 ON HOOPING-COUGH. In Van Diemen's Land, out of 3475 cases of disease treated in the hospitals in 1848, 357 were of the lungs, 47 of which died, the entire mortality from all causes being 166. The winter approaches more nearly to thp' of Europe, but is infinitely milder than in the British Isles. In New Zea- land, again, the climate is several degrees colder than in any part of Australia. These circumstances, taken together with the fact, that affections of the chest form so large a proportion of the diseases of the former country, and proving at the same time the most mortal, conviiicingly proves that hooping- cough is not a stranger to these colonies.* Polynesia. — Small-pox has ravaged many of the islands of the Pacific almost to the extinction of their inhabitants. The presumption is, that hoop- ing-cough may not be unknown among them, but we have no direct evidence to prove it. * "Uliile these pages were passing through the press, I liave been informed by a lady and gentleman, who have just returned from Melbourne Avith their family, that hoopmg-cough is not only a frequent, but a very severe and fatal disease in Australia. A large proportion of the children die of this disease, complicated with convulsions. So severe are the paroxysms that ha;morrhage is produced from the nose, mouth, eyes, and ears. It appears also that the disease is more severe in the warm summer season, owing to the arid and hot atmosphere. One of their own children, a little girl, suffered so much from the disease, that her life was despaired of, being complicated with hsemorrhages and threatening con- vulsions. w 229 CHAPTER XIV. CAUSES, DIAGNOSIS, AND PROGNOSIS. ^ Causes. — In dwelling upon the causes of per- tussis, the age, sex, predisposition, temperament, constitution, and manner of life must be consi- dered, as well as climate and season, and more especially epidemic and contagious influences. 1. Age. — Though sometimes met with in adults and old people, it is for the most part almost ex- clusively the disease of early life, and if met with in the former it is because they have not had it during their childhood, and therefore are readily affected when exposed to contagion. The disorder protects the system, as it were, with very fev/ ex- ceptions, from its future recurrence, I have men- tioned instances elsewhere of second attacks, and I believe again individuals may pass through life without an attack of it, should they have been ushered into the world when the mother \as been suffering from the disease, as has been already referred to in the chapter of complication with pregnancy. There does appea-r to be something in the con- stitution of the child, which renders it peculiarly susceptible to its influence ; and Barrier remarks ^ 230 ON HOOPING-COUGH. that this predisposition is similar to that which favours the development of the eruptive fevers. Dr. Watt says that it is more than probable that the remarkable change which takes place at the age of puberty in the larjmx, trachea, and bronchi, may have no small share in either rendering the system less susceptible of the disease, or in render- ir.g it less fatal when it does occur. And Dr. West, again, observes that still fewer of those who escape it when children suffer from it in after life. There occurred in London during the eight years 1842 to 1849 inclusive, 14,233 deaths; of this number 13,434 were under five years of age, 8911 were under two years of age, and 4495 were under a year old. Above ten years there were 146, and above fifteen there were twenty-eight. Age, therefore, is undoubtedly a predisposing cause, and especially under two years. 2, Sex. — Boys and girls are of course equally exposed to the attack ; but we find that, according to the researches of Blache and Constant, a p-eater number of boys arrive at maturity without having had the disease. Blache proved the proportion of such cases to be seven boys to six girls, and Con- stant three boys to two girls. This may probably account for the fact that among adults and even old people, males appear to be more numerously affected than females, and most of the instances mentioned as examples turn out to be males. CAUSES, DIAGNOSIS, AND PROGNOSIS. 231 Dr. Copland, however, mentions that females are oftener attacked among adults than males. Guer- sent thinks that among men it particularly affects those who are irritable and nervous, and who, from their temperament, very much resemble the con- stitution of females, and therefore are more sus- ceptible to it. As to its frequency. Dr. West obstjves: of 100 cases of hooping-cough at the Children's Infirmary, 65".3 per cent occurred in females, only 447 per cent, in males ; although the total number of female children to the total number of males among his patients at that institution was only as 502 to 49 8. He says also that female children are not only more liable to the affection, but it proves more fatal to them than boys, in the pro- portion of about three to two. Of 27 fatal cases that came under his notice, 16 occurred in female and only 11 in male children. Aberle mentions that in 31 deaths under his care, only 10 were males. In Sv/eden the deaths for 25 years, from 1806 to 1830, were 50,822, or 23,616 males and 27,206 females ; although the sexes were nearly equal in the deaths from 1749 to 1764, there being 21*543 males and 21-850 females. In Ireland, for 10 years, 1831 to 1841, the deaths in the proportion of the sexes, were 100 males to 115*43 females. ryiiW*"«wv,wfr«"-»'»WM,-7'^ni^'^.i^n»rr'' ff!*^ff^f!fifW!f^^ysr 232 ON HOOPING-COUGH. In London, for 12 years, 1838 to 1849 inclu- sive, the deaths were 20,824, of which 9290 were males and 11,534 were females. And in England, for a period of eight years, the deaths were 65,331, of which 29,188 were males and 36,143 were females. The fact is perfectly clear that it is not only more frequent in the female sex, but also much more fatal than in the male sex. i 3. Temperament, Predisposition, and Manner of Life. — Lymphatic and nervous children are more especially predisposed to the disease. A nervous temperament combined with a weak and irritable constitution particularly favours its deve- lopment. Dr. Butter observes that "the nervous system bears a much larger proportion to the other solid parts in children than in adults ; the solid parts are like- wise of a much softer texture and of a much quicker growth ; the human body is then endued with much more irritability than at any other period of its ex- istence," and consequently more easily affected. "One can hardly doubt," says M. Gendrin, " that, owing to the development and extreme activity of the circulation and the permeability of their tissues, that infants are in the most favour- able state for the absorption of miasmata." These conditions also influence to some extent the nature of the complications which so often CAUSES, DIAGNOSIS, AND PROGNOSIS. 233 arise during its progress, and especially produce convulsions. The sanguine temperament predis- poses to the occurrence of epistaxis and many of the inflammations, particularly pneumor ; and if the lymphatic temperament is strongly marked it may increase the catarrhal affection, and some- times lead to dropsical effusions. The children of the rich, brought up with every comfort and luxury, are equally affected with the children of the poor. Damp habitations, however, which are also gloomy and unwholesome, a want of proper clothing, noxious vapours and improper sewerage, seem to exercise a real influence in pro- ducing the disease. The last of these appeared to be an exciting cause of the fatality in the son, aged nine months, and two daughters, aged respectively four and five years, of a brewer, who died on the 4th, 2nd, and 10th of February, at 6, Waterloo-street, Camber- well, of this affection, influenced doubtless by an open sewer a few yards from the house where these children died, and which emitted a most offensive smell. In the last case the pertussis was followed by scarlatina maligna.* 4. Climate and Season. — It is observed to be much milder in warm than in cold climates ; and it is also more frequent in the cold than in the * Weekly retutu v>f births and deaths in London, ending Feb. 11th, 1854. 284 ON HOOPING-COUGH. warm months of the year. Climate has much in- fluence upon the mortality, but very little upon its presence or extension. In the cold countries of the north, as shown in the chapter devoted to climate, it is not only very prevalent but very fatal ; it is less frequent and much less severe in the south and near the tropics, as a general rule, although there may be exceptions, as in the fatal epidemic in Madeira, in 1808, but the climate of that island is modified from its isolated position in the Atlantic Ocean. It would seem to be in conformity with this law, that the disease is found to be more severe in this country during winter and spring (some say it is of longer duration in autumn and winter), than in summer and autumn. Dr. West mentions that the epidemic of 1841-2 reached its acme in the months of December and January; while in 1845, cases of hooping-cough were by far more numerous in the morths of June and July than during any other pe>nod of the year. One year it may be very mild, simple, and rapid in its progress ; the year following, or even another part of the same year, it may be accompanied with serious complications, and may last many months. Dr. Watt's tables show that March was the most fatal month, and July, August, and September the least. CAUSES, DIAGNOSIS, AND PROGNOSIS. 235 Notwithstanding the following observations of Ozanam, temperature most certainly does influence the frequency and the severity of the disease, else why should cold climates produce opposite efifects to those of warm : — " This disease does not depend upon any defect in the air, nor in the atmospheric variations; be- cause it reigns at all seasons of the year, and when it shows itself in the country, it may continue for a long time, in spite of the changes in the seasons. It is equally met with in the cold countries of the north, in the temperate climates of Europe, and in the warm regious of Italy. " If it depended upon modifications of the atmo- sphere, it would declare itself at the same time in all those countries submitted to the same influence, whilst sometimes it confines itself to a town only or its environs, or even is restricted to certain families, or to certain asylums for children. Cold does not render it more severe, because we fre- quently see it cease on the approach of winter, and in giving cold baths, and drinks of ice-water, it quiets the paroxysms.'' His reasoning is not logical, and if he draws his conclusions from the severity of the epidemics at Milan, which were not in the winter season, and that in consequence, cold and a low temperature produce no effect in increasing both the severity and the frequency of the disease, he is in error. I ^ i /i. /I I ■ 236 ON HOOPING-COUGH. The records of this disease in colder climates, and the mortality in the colder seasons of the year, as compared with the warm, are a sufficient answer to his remarks. And although the disease may reign at all seasons of the year, it is most unquestionably severe when the temperature is low, and if the season is cold. In France, it appears that the disease is more prevalent in spring and autumn, throughout the years which are cold and damp; and the agency of a cold and moist atmosphere in its production is much insisted upon by Richter, Marcus, Desruelles, and others. There can be no doubt, also, that it is in some way connected with other epidemics, often appearing just before, during, or immediately after an epidemic of measles or influenza. 5. Contagion and Epidemics. — Pertussis is un- questionably a contagious and an epidemic disease, and in some instances would appear to be an endemic or sporadic affection. The contagion appears to be communicated with great facility. When once it gets into a family, it generally attacks every child ; mothers, nurses, and even fathers, who have not had the disease, will often contract it from their children; and it has under such circumstances occiured twice, and instances are mentioned of three times. Mothers, who have had it in their childhood, will become affected a second time through the child at the breast, or the other chil- CAUSES, DIAGNOSIS, AND PROGNOSIS. 237 dren suffering from it. Guersent, Copland, and others, mention such instances. It is quite clear that children who have not had it, are predisposed to take it in consequence, either from contagion or when it is reigning as an epidemic. This is borne out by the fact, that perfectly healthy children, without any cough or cold, are attacked by it, after playing with other children suffering from it, and this again has been communicated soon after to all the other children in the same house, as well as to many others, both children and adults, who come in contact with them ; I have met with such instances, and so has almost every writer. Cases have been removed to a distant part of the country and into families where it did not exist, and it has been readily communicated to those who had not previously had it. Dr. Hamilton mentions that infants a few days after birth have been affected, in consequence of being handled by persons who had been in a house where the disease was prevailing. This is a striking proof of contagion by transportation from one place to another. Barrier gives the history of a family of three persons, the parents and child, who took the dis- ease from contagion. He relates that the child at school sat next to two others affected with hooping- cough, and in three days caught it from them, and l^i ■/' 238 ON HOOPING-COUGH. 1 !^' ! ! it turned out very severe. The child's bed was next to that of its parents, and in consequence the mother, who was constantly attending its wants, during the night particularly, and whose age was twenty-four years, took it; her husband also, aged thirty-seven, did not escape, and all continued hooping for the space of six weeks, when they got well.* Rostan gives the following instance of its con- tagious nature, which has been quoted by Dr. Roe.t "A family on going to their country seat found their gardener's children in the hooping-cough ; in a few days one of the family, a boy of four years of age, who had been playing with the infected children, contracted the disease, but the other chil- dren, who were kept separated from them, did not then take it; and afterwards the whole family — father, mother, servants, and children — who had any communication with the infected family, went through the disease." Rosen admits without hesitation its direct trans- mission. He says he himself has transported it from one house to another. Duges gives instances of it, and Blache a dozen well-established exam- ples, most of which were observed by himself He mentions the case of a child giving it to its grand- father and grandmother. Another child to its * Maladies de I'Enfance, torn. i. p. 135. f Clinique Medicale, torn. ii. p. 552. CAUSES, DIAGNOSIS, AND PKOGNOSIS. 239 grandfather, an old man aged seventy. Guersent gives the case of a little boy, who, having played with another child for half an hour, who had the disease, the second child returned to his home in the country, when the disease showed itself and he gave it to his mother, who had already had the disease when young. But the following instances, recorded by Dr. McGregor, most convincingly illustrate the con- tagious nature of this affection : — " E. and A. P , two young ladies, sisters, the former aged ten years, the latter seven, took hoop- ing-cough in London, in January, 1846, during the first stage of which they were sent to school in the suburbs. Two other young ladies, K. M and A. G , returned to the same school at the same time, perfectly free from cough, but, in about ten days, exhibited the usual symptoms, which terminated in the second stage, the pecuhar phe- nomena of which serve to esignate the diseas- At this period, every child in the school, who previously had it not, took it; clearly proving tl ' contagious and not epidemic influence was in operation. At the end of six weeks from the beginning of the first, stage, and a month after the hoop commenced, M. M , aged seven years, who had never had the disease, with two other children similarly circumstanced, came to school, but not one of them took it, the poison being I, I hi / ■ I ' ' I ' 1/ , I / ■ .■ ' I 'i 1 240 ON HOOPING-COUGH. exhausted, thus proving the very limited nature of its existence."* ; Dr. McGregor thinks, on the average, about two months appear to form the limit of its con- tagious properties, after which there is little or no danger. CuUen, and many others, believe it dis- appears in from four to six weeks ; but this is in reality a matter of some difficulty to determine positively. Dr. Copland j^ays the infectious property seems to diminish as the disease declines ; Aberle, on the contrary, observes that the time when its contagious character is in its highest intensity, appears to be when the patient is recovering. I am inclined to agree with Aberle, because, so far as my own experience goes, I have seen instances where the disease has been particularly contracted, on the first exposure to contact, when the child has been on the verge of convalescence. I quite agree with Dr. West, that so long as the child continues to cough at all, even though only once or twice a- day, we should be unwilling to restore him to the society of children who have not already had the disease. Guersent, and others, relate that it is often necessary to infection to inhale the breath of the affected child, and the disease should be fully developed at the time. Dr. West thinks that infants under six months * Lancet, vol. ii. p. 146, 1846. CAUSES, DIAGNOSIS, AND PROGNOSIS. 241 old appear to be especially indisposed to receive it, either by association with other children, or as the result of atmospheric influence. If carefully kept from contact with other children, infants of tender age will very often escape during the general pre- valence of the disease ; and in n early half of the cases that he had met with in infants under six months old, other children in the family had suffered from it for a week or ten days before the infants showed any sign of it. The latest period of its miasm or sanguineous toxication previous to declaring itself, is not as- certained. Dr. Gregory thinks it must be about eight or ten days ; Guersent, ordinarily, five or six days. Copland says it is generally from five to seven or nine days, or even longer, after exposure to infection that the cough commences. The question of the undoubted contagious nature of pertussis has been settled by every recent writer of authority in the affirmative, and among these may be mentioned CuUen, Sims, Hillary, Watt, Hamilton, Underwood, Dewees, Gregory, Eberle, Stewart, Johnson, Copland, Koe, Guersent, Blache, Barrier, Duges, Thomas Watson, Von dem Busch, Aberle, McGregor, Ogier Ward, Churchill, West, Todd, &;c. On the other hand, Desruelles, Laennec, Billard, Gardien, Wendt, StoU, Ozanam, and some others, either absolutely deny its contagious nature, or R 242 ON HOOPING-COUGH. doubt it altogether, while some of these maintain its epidemic character. The settlement of such a question becomes of importance in relation to the prophylaxis. That it reigns also as an epidemic we have fearful instances on record, as many passages in the present work will show. It may be more severe and fatal at one time than another, influ- enced by climate and season ; or it may be terribly severe at its commencement, carrying off large numbers, and become quite mild and tractable towards its decline, imitating in this respect many other forms of epidemic disease. Dr. West says, that the outbreak of an epidemic of hooping-cough, though little influenced by the season of the year, seldom, if ever, takes place suddenly, and altogether without warning. Some- times it succeeds to an epidemic of measles, but still more frequently it follows an unusual pre- valence of catarrh, which gradually assumes a paroxysmal chaiacter, and puts on the characters of hooping-cough. In a similar way, epidemic hooping-cough sometimes resolves itself into simple catarrh ; the signs of disturbance of the nervous system by degrees disappearing, and the cases presenting the indications of mere bronchial irritation. If we refer to almost any work treating upon the disease, we shall meet with numerous instances CAUSES, DIAGNOSIS, AND PROGNOSIS. 243 upon ances of epidemics spreading over extensive districts, or even whole countries. According to Desruelles, Pasquier mentions an epidemic of this kind in 1411, in Paris, which attacked more than 100,000 people. De Thou and Sennert mention another in the same city in 1510. The previous chapter affords fruitful evidence of numberless epidemics in various parts of the world, in Europe particularly, which have been described by the authors mentioned. Partial epidemics, limited generally to a city or town, are of frequent occurrence in our own empire, which must be familiar to all, and now and then we find them spreading over a tract of country more or less extensive. When considering the complications of hooping- cough, it was shown that very many may arise dming the prevalence of epidemics, and may assume more or less uniformity in their nature and character. Of these, convulsions, nervous fevers with delirium, erysipelas, epistaxis, eruptive diseases, intermittent and remittent fevers, or some Other form of visceral inflammation, often attacked the patients, and greatly added to the mortality. Diagnosis. — The well marked hoop and the paroxysmal character of the cough are the principal signs by which it may be readily distinguished from all other diseases. But these must not be R 2 "f 244 ON HOOPING-COUGH. looked for until the catarrhal stage has subsided, although it is possible they may be present from the very onset in some instances. Some writers mention that the hoop is generally absent in adults, and usually, but not constantly, in very young children ; this is true to some extent, and the possibility of its absence cannot be denied, and may influence our diagnosis ; this, however, will not prove difficult if other children or even adults in the same family or assembly of persons are affected at the same time with the genuine form of the disease. In very young infants a common cough is often accom- panied by an occasional hoop, if they are at all alarmed at the cough ; this might produce an error in diagnosis, unless caution is observed. The kink is almost never absent, in fact, the hoop and kinks cannot both be absent, or the disease would not be pertussis ; and the series of con- vulsive, forcible, and rapid succussions, without intervening respiration, is observed in no other disease to the same extent, except, as Dr. Churchill remarks, asthma, which is not an affection of childhood. The intervals of rest, and the vomiting after the paroxysms, will equally render clear the accuracy of the diagnosis. If called to a case with complications of the lungs, brain, or other organ, and the hoop has in consequence disappeared for the time, the previous "^T" CAUSES, DIAGNOSIS, AND PROGNOSIS. 245 history will have to determine whether it is or is not pertussis. Pertussis may be confounded with bronchitis, with spasmodic cough, laryngismus stridulus or spasm of the glottis, croup, tuberculosis of the bronchial glands, and oedema of the glottis. 1. Bronchitis. — In Chapter V., the distinctive signs between the two were given from Valleix. The following are from Rilliet and Barthez :— Pertussis. Catarrhal stage generally pre- ceding the kink. The hoop following the kinks, with glairy tenacious expec- toration, and almost always vomiting. Little fever, no hurry of re- spiration during the inter- vals, and the inspiratory murmur free. ICinks continue for a time, then decrease until the cough becomes simple, and child convalescent. Bronchitis. Paroxysm of coughing coin- cident with the commence- ment of the disease. Kinks shorter and less in- tense, no hoop, but little expectoration, and no vo- miting. Fever is intense, resphration hurried and increasing in frequency, rales sibilant and mucus, afterwards sub- crepitant. Smallness of pulse, extreme dyspnoea, paleness of face, persist or increase, and the disease almost always ter- minates fatally. 2. Laryngismus Stridulus. — It is easily dis- tinguished, although there is a great resemblance between the sounds of the hoop and the crowing r 246 ON HOOPING-COUGH. /, ! inspiration, owing to both resulting from the same mechanical condition of the larynx, viz., more or less perfect closure, terminating in a forcible inspiration. But in spasm of the glottis there is very rarely any accompanying cough, and the spasm occurs quite independently. There is no kink, no expectoration, nor vomiting, nor any catarrhal sounds in the lungs. 3. Croup. — In pertussis there is hurry of respi- ration, but neither the difficulty nor the sibilant sound ; the cough, though loud, has not the peculiar metallic sound of croup, and in the intervals there is complete relief, neither hoarseness nor dyspnoea as in croup. In croup, also, there is wheezing, and no intervals of rest, and an absence of many of the important s3maptoms of pertussis. 4. Tuberculosis of the Bronchial Glan(P :. — As the distinctive differences between the two are given at page 115, it will not be necessary to introduce them here. 5. (Edema of the Glottis. — The inspiration only is attended with an abnormal sound, arising from the swollen edges of the rima glottidis being forced inwards, obstructing the passage. There is some- times a strangling cough following the act of sw^lloiving; with the presence of dysphagia and dyspnoea. Prognosis. — When the disease is simple, the prognosis is favourable. In other words, so long lL CAUSES, DIAGNOSIS, AND PROGNOSIS. 247 as it is uncomplicated, free from inflammation of any kind, or fever, unless that attending mild catarrh ; possessing the characters of the simple form exclusively, and occurring in a healthy child ; whose dentition also has been completed, or who has no determination or irritation of the internal organs ; the season of the year being mild and dry, and no recent convalescence from any other infantile affection ; it will not prove a dangerous disease. It will, under the most favourable circum- stances, however, run a certain course. Should a second invasion arise, after apparent cure, it may under unfavourable conditions give rise to complications which may prove troublesome. Or, should they arise during the progress of the afSection, according to their nature and severity will be the nature of the prognosis. But when it is recollected that these constitute the items in the cause of the frightful number of deaths in all bills of mortality, they must necessarily invest the disease with a serious aspect. Complications, therefore, of every kind are dangerous, in "proportion to the age of ....e child, in veiy young cnildren, for instance, in those just weaned or suffering from dentition, or in those again of very delicate health, or naturally unsound constitution. With a good nurse, a healthy child, under six mont' -. old, in whom the intervals are complete ir mm>.m^rr imVH „■- "'fWfiF^jf. 'T'^vfsnww.ii^r^wv-' 248 ON HOOPING-COUGH. /ik and of some duration, and whose paroxysms are followed by vomiting and free excretion of mucus, combined with rest at night, good appetite and little or no fover, will get through the disease much better and easier than one a few months older, who may present some of the last-mentioned conditions. Head affections are to be dreaded, particularly in scrofulous children ; and in any children during the first dentition. If a frequent and violent cough be present, with hurried respiration, dyspnoea, fever, scanty expectoration, no vomiting, loss of sleep and appetite, and any indication of local complication, the prognosis will be more or less unfavourable. A preceding attack of some of the exanthe- mata, as measles or scarlet fever, which favour some form of pulmonary complication, renders the prognosis unfavourable also. In adults, who possess greater strength of con- stitution and a lesser liability to the diseases which usually produce a fatal result in pertussis, the prognosis will be favourable. Should there be a plethoric habit of body, there is great danger that the violence of the cough may produce apoplexy ; or, if th constitufion be debilitated, there is a risk of the occurrence of pneumonia, bronchitis, and pleuritis, which may prove unusually severe ; and in young adults, of a scrofulous diathesis, iisemop- \ and CAUSES, DIAGNOSIS, AND PROGNOSIS. 249 tysis or phthisis may be produced ; these will require a cautious or reserved opinion as to the result. If, however, the disease be present in advanced life, with debility and a want of the ordinary sta- mina and natural powers of adult age — when osseous deposits have taken place in or have re- placed the various cartilaginous structures of the body, the chest and larynx particularly, which now lose their elasticity, and in consequence the concussions of coughing give shocks to the system to which children are scarcely liable, the result will most probably prove serious, the aged patient sinking under the violence of the disease before any organic affection has been produced. Under the most favourable circumstances in old people, this affection will present a more or less serious aspect. In pregnant females the danger of abortion is increased, and the subsequent condition may re- quire more than ordinary care and prudence in preventing any ulterior complication; the prog- nosis here must be guarded. Hysteria may produce an obstinate continuance of the pertussal cough which may baffle treatment, but the prognosis is nevertheless favourable. If th3 disease is raging in an epidemic form, it acquires a certain amount of gravity from the sometimes fearful number of complications which ( 1^ 11 Mi! I 250 ON HOOPING-COUGH. present themselves ; the danjor therefore is great; and even under otherwise favourable circumstances we must here be very cautious in giving our opinion. All the circumstances just mentioned must be taken into consideration in giving a prognosis, but so long as no serious interruption interferes with the natural progress of the simple affection in the child, we may be warranted in pronouncing favour- ably as to the result. /' H ii ,/. 7 251 CHAPTER XV. REMEDIES RECOMMENDED BY VARIOUS WRITERS IN THE TREATMENT OF PERTUSSIS. Although a host of remedies and various forms of treatment have been recommended at different times f 3r this disease, it would be acting unfairly and unjustly to many physicians of high star ding and respectability, and who were the first to origi- nate or discover their use, to exclude them from even a brief consideration here. In a work specially devoted to the consideration of a particular subject, as this is, those who have contributed to the further elucidation of it should not be neglected, nor merely receive a passing notice. And however foreign it might perhaps appear, at first sight, to introduce other forms of treatment when a particular one is advocated, it nevertheless would be censurable to a great degree to omit them. These shall be considered, there- fore, in the present and two following chapters, giving particularly the views of some who first recommended them, and the opinions of others who, after trial, have either confirmed those views or have condemned them. These chapters will also serve for the purpose of reference to those > I V i\ i 252 ON HOOPING-COUGH. who may feel desirous of observing at a glance the names of writers who have added to the literature of this branch of the subject. I have not condemned any of these remedies, even though many of them have not proved so successful in my hands as they appear to have done in others. It requires a large and very ex- tensive hospital experience to pronounce judg- ment. But when a single remedy has been used by a number, even in private practice, their united testimony proves of value. I should be sorry to build up the reputation of my own remedy by an attempt to promote the downfall of that of an- other, which so far has been recommended with judgment, and the test of experience as to its value. In its partial application here, the following may be quoted from Dr. Watt : — " In the present state of our knowledge, it would be absurd to reject a medicine which has the sanction of experience, merely because we cannot see or cannot explain its operation on the human body." The remedial means which have been recom- mended for the treatment of hooping-cough are — 1. Venesection. 2. Leeches. 3. Emetics. 4. Antimonials. 5. External applications. 6. Change of air, and a re- gulated temperature. 7. Warm baths. 8. Hydrocyanic acid. 9. Laurel water. REMEDIES RECOSIMENDED IN PERTUSSIS. 253 biace the berature jmedies, •oved so to have very ex- !e judg- 3en used J united sorry to iy by an i,t of an- led with i,s to its oUowing present to reject perience, explain recom- gh are — r, and a re- iperature. acid. 10. Belladonna. 27. Hydrochloric acid. 11. Opium and its com- 28. Sulphuric acid. pounds. 29. Nitric acid. 12. Hemlock. 30. Cochineal. 13. Henbane. 31. Alum. 14. Digitalis. 32. Tannin. 15. Tobacco. 33. Vegetable acids. 16. Arsenic. 34. Alkalies. 17. Silver. 35. Vaccination. 18. Iron. 36. Cantharides. 19. Zinc. 37. Musk. 20. Lead. 38. Assafoetida. 21. Copper. 39. Meadow Narcissus. 22. Cauterization by Nitrate 40. Cup Moss. of Silver. 41. Castor. 23. Inhalations. 42. Nux vomica. 24. Coffee. 43. Miscellaneous other 25. Peruvian bark. remedies. 26. Quinine. . I, The first seven will be considered in the present chapter. ] . Venesection. — This was strongly recom- mended by Sydenham in hooping-cough, who had an exalted notion of its benefits in other diseases. The following extract is from his " Medical Obser- vations on Measles :"* — " Let no one wonder that I recommend bleeding with tender infants. As far as I have observed, it is as safe with them as with adults. ****** At present, too, I say nothing about the immense relief afforded in the pertussis — or the hooping-cough — of infants by * Sydenham Society's Edition, vol. i. i 254 ON HOOPING-COUGH. ("■ t: venesection. Here it leaves far behind it all pec- toral remedies whatsoever." In Swan's edition of his works, he specially remarks : " By this practice of venesection and repeated purges, and by this only, is conquered the convulsive or hooping-cough ; an obstinate disorder, which scarcely any other method will subdue." "We shall find many authors who approve of bloodletting in this affection, even to the present time. Willis speaks of it as a very useful remedy. Hoffman, after describing very clearly a malignant epidemic hooping-cough, which prevailed at Berlin in 1709, remarks that when the fever was violent, with great difficulty of breathing, bleeding was highly useful ; but, under other circumstances, he dissuades from the use of it, as not only unneces- sary but hurtful.* When the chincough is violent, says Astruc, we should have recourse to bleeding, for though the lungs are not inflamed, the oesophagus, «fec. are. A child of eight or nine months old may be blooded once ; if he exceeds two years, twice.f Dr. Sims remarks that bleeding was extremely beneficial during the first stage, and the blood when drawn showed much siziness.^ * Opera, edit. Geneva, 1740, torn. ill. f Treatise on all the Diseases of Children. J Observations on Epidemical Disorders. (; i' REMEDIES RECOMMENDED IN PERTUSSIS. 255 ^11 pec- ►ecially )n and quered (stinate Dd will rove of present •emedy. Jignant t Berlin violent, ing was ices, he mneces- Tuc, we ugh the lare. A Dlooded tremely 3 blood Dr. Lettsom is a strong advocate for bleeding. This disease very rarely appears, he says, without a cough having previously existed for some days or weeks, and hence it will be less necessary to take away blood from infants already weakened ; but there are instances where children of a consider- able degree of strength and health have been attacked by the hooping-cough, which hath been early accompanied with fever, haemorrhage, con- tractions of the extremities, pains in the breast, hard pulse and bloated face, indicating congestion in the vessels ; under which circumstances, I pre- sume, he says, no reasonable objections can be urged against venesection, proportioned to the strength of the patient and the violence of the symptoms.* He says Dr. Lieutaud recommends it when the fever is high and the breathing labo- rious ; and he further observes that Willis, Syden- ham, Aijtruc, Huxham, Home, Sauvages, Hillary, Bisset, and other physicians, lay considerable stress upon the advantage of bleeding in this disease. To a person who is accustomed to consider the uniformity and simplicity of all nature's works, writes Dr. Millar, it may indeed seem inconsistent to recommend large and repeated evacuations in any disease, of which the cure is chiefly to be accomplished by astiingent and strengthening K Med. Memoirs of the London Dispensary. fj- f I ' ' ' ■I' I'M i' I is hi /•' 256 ON HOOPING-COUGH. I I medicines. He is opposed to bloodletting in hoop- ing-cough.* If the fever is high when I am first called, and the child of a sanguine habit, I advise bleeding ; and if the patient is costive I direct a cooling clyster to be administered, and the body to be kept open by some gentle purgative. This is the method, observes Dr. Armstrong, I have lately adopted for curing this disease, f In plethoric subjects, or in others when, from the circumstances of the cough and fits, it appears that the blood is with difficult transmitted through the lungs. Dr. CuUen says, bloodletting is a neces- sary remedy ; it may be even necessary to repeat it, especially in the beginning of the disease.f Dr. Hillary recommends venesection in the cli- mate of Barbadoes, as not only useful, but in many cases absolutely necessary. § When the breathing is very difficult and the violence of the cough occasions a blackness of the face and neck, with symptoms of suffocation, it is necessary to take away a little blood, says Mr. Hayes, either from the arm or the application of leeches to the temples. I have known, he re- marks, an ounce or two of blood from the nose * Obser. on Asthma and Hooping-cough, p. 174. f Diseases most incident to Children. X First Lines of Pract. of Physic. § Observ. on Air and Diseases of Barbadoes. I I EEMEDIES RECOMMENDED IN P^ rUSSIS. 257 in hoop- Qed, and fleeding ; I cooling ly to be bis is the ve lately len, from t appears I through s a neces- to repeat ise.f a the cli- in many and the ss of the tion, it is says Mr. ication of he re- the nose n 174. give a critical turn to the disease. The blood being detained in the lungs and the great vessels leading to the head, when the breathing is long sus- pended by coughing, makes it necessary to bleed in proportion to the age and strength of the patient, and to repeat it if the difficulty be not removed.* Dr. Watt has devoted not less than sixteen pages to the consideration of bleeding, in his book on Chincough. He remarks that bleeding, in general, is not to be regarded as a regular part of the treat- ment. It only becomes necessary, he says, on the accession of certain symptoms, and when these are removed, or when there is no longer any hope of their removal, bleeding should be abandoned, of course. The symptoms requiring bleeding are chiefly such as show congestion, increased action, or actual inflammation in the head, chest, or ab- domen. Dr. Mason Good says : " Throughout the first stage our attention should be directed to whatever will moderate the influence of the contagious stimulus, retard the return of the convulsive paroxysms, and mitigate their violence." Bleed- ing, he says, in severe cases, will be found neces- sary for this purpose; but it should be avoided except in severe cases, as spasmodic affections are often rather increased than diminished by the use of the lancet ; and it will in general be found * A Serious Address respecting Coughs, &c. IMAGE EVALUATION TEST TARGET (MT-3) „, i a copious crop of pustules is produced on the epigastric region. Dr. Mackintosh he i seen it very serviceable in this disease, so much so, that he always had recourse to it. He says it is preferable to blisters because it is more permanent ; he has observed many pecuhar effects from the use of it. Dr. Graves never derived any advantage from its use, either over che stomach or the spine. Barrier does not approve of it. Tartar emetic and cantharides, one scruple of the former dis- solved in two ounces of water, and one ounce of tincture of cantharid3S added, was prescribed as a liniment by Dr. Streuve, of Gorlitz, about 1798, in hooping-cough; this rubbed in every two .^^•.«. — «., 270 ON HOOPING-COUGH. K 1 ' fV hours, over the stomach, produced the best results.* Dr. Gregory recommends a similar liniment, but the antimony is doubled in quantity, and advises the rubbing along the course of the spine as well as the chest. Tartar emetic solution. Dr. Von Iffland, of Quebec, uses a solution of a drachm of tartar emetic in an ounce of water (recommended by Dr. Leon Rousseau, of the same city), to be rubbed actively upon the neck until small pustules are formed. They are less painful, and better suited to young children and infants.t Embrocations and Li/ni/ments. — Roche's em- brocation has long been and still is a favourite remedy with mothers. This (Dr. Paris tells us) consists of olive oil, mixed with half its quantity of oil of cloves and oil of amber. Dr. Copland recommends a liniment of camphor, turpentine, tincture of capsicum, and oil of cajeput, to be rubbed on the chest twice a-day. Dr. Churchill, compound camphor liniment and laudanum, two ounces of the former to two drachms of the latter, rubbed into the chest and back, alternately morn- ing and evening. Dr. Hamilton seems to approve of garlic to the soles of the feet ; and a popular use of it is to steep it in brandy and rub the spine. A poultice containing scraped horseradish is re- * Med. and Phys. Jour., vol. i. t Montreal Med. Gaz., vol. i., 1844. REMEDIES RECOMMENDED IN PERTUSSIS. 271 results* ent, but I advises le as well Dr. Von Irachm of mmended ty), to be II pustules md better ocbe's em- a favourite is tells us) ts quantity )r. Copland turpentine, eput, to be •. Churchill, danum, two f the latter, lately mom- 8 to approve a popular lb the spine. [adish is re- commended by Henning; and the tincture of ginger to the epigastrium by Zadig. Lobenstein Lobel advises a liniment containing a solution of phosphorus in oil of cummin and camphor, to be rubbed over the epigastric region. Rubbing the spine with rectified oil of amber, or of soap lini- ment and oil of amber, or of garlic ointment, are said to be useful in lessening the cough. Dr. Little and M. Blache have used frictions of turpentine. Dr. Fife, soap liniment, with opium or campho- rated oil, to the spine. Blisters have been used by Willis, Dr. Watt, Cullen, and others. Dr. William J. Waller, of Virginia, used a single bhster to the nuchae in six most severe cases of hooping-cough. All recovered rapidly, and without a vestige of cough remaining.* Dr. Meyer, of Minden, applies morphine to a blistered surface every evening, over the epigastrium, first removing the epidermis. The morphine, half a grain, is triturated with starch. He relates five cases cured in eight days, without any other remedies.f M. Brendt has been equally successful with it. If necessary, the blister should be removed every third day. Dr. Bow recommends the external use of narcotics, but it is a dangerous plan. Of sixteen cases treated by Professor Brendt, no less than six * Stethoscope and Virginia Med. Gaz., vol. ii., 1852. t Amer. Jour. Med. Science, vol. v., and A rchives G^n^rale, Oct. 1829. 272 ON HOOPING-COUGH. I •■ ( I I exhibited symptoms of narcotism from opium end morphine.* Mr. "Warren says that liquid laudanum rubbed all over the abdomen and pit of the stomach twice a day gives great relief. Dr. Cop- land speaks very highly of the mustard foot or hip bath, and dry cupping on the nape of the neck or between the shoulders. 6. Change of Air and a Regulated Tempera- ture. — Pure air, says Mr. Hayes, is of the greatest importance in hooping-cough. It is necessary in all its stages. The air of large towns and populous places always aggravates the disease. Dr. Watt has met with many severe cases that got better every hour as the patients proceeded on their journey in the open air, scarcely a cough occurring, and the fever going away. Dr. Ferriar tliinks the bene- ficial effects of the limestone soil of Derbyshire have long been known to the old practitioners of Manchester in the cure of hooping-cough. He has frequently verified this in some striking instances.! Dr. Thomas advises a change of air. Dr. Armstrong recommends a bland diet, a regulated temperature, 68° to 64°, and mild aperient medicine.f Dr. Merriman remarks, " I am not acquainted with many, if with any, instances in which the force of * Lancet, vol. ii., 1837-38. f Med. His. and Rcflec., Review of, in Ed, Med. Jour., vol. vii. J Lectures in Lancet, 182G. adanuin of the Dr. Cop- ot or hip 3 neck or Tempera- e greatest cessary in I populous ..Watt has etter every journey in ag, and the the bene- lerbyshire Ationers of tb. He has instances-t Armstrong ■mperature, Anted with the force of I. Med. Jour.: REMEDIES RECOMMENDED IN PERTUSSIS. 27^ the disease has be^r abated by change of air. I should not recommend it lo» this purpose, but I have often witnessed its usefuhiess 1::^ shorteniDg the stay of the distemper after its loroe was abated."* M. Sandras says, that one of the surest thera- peutic means against hooping-cough is change of air and place of habitation. It is the first thing he recommends, and considers himself authorized to do so from experience.f Dr. Mackintosh observes that change of air is often productive of great mischief, by occasioning a return of the disease. He remarked, in a severe epidemic, that all the children which were moved for change of air had the disease longest. Dr. EUiotson repeats that one of the best things is change of air. — *' Every old woman says so, and I believe they are perfectly right. I have known, and so must every one, cases which obstinately resisted all treatment cease after a change of residence. You will not find this at the beginning of the disease ; it is only after it has existed for some time." When the disease proves very tedious and obstinate, and has rooted itself in the system by force of habit, Dr. Gregory writes, change of air will be found eminently beneficial. The late Dr. Beatty made it a rule to keep his patients confined to their bed- * Underwood on Dis. of Cliil. p. 428. — Note. t Bui. Therapeutique, 1833. T \t ^i^^ h\ i 'I 274 ON HOOPING-COUGH. room until the cure was completed. Dr. Graves believes that the recovery of the patient, in the great majority of cases, is accelerated by this means. Dr. Chowne lays particular stress on the necessity of keeping the patient in a warm tempe- rature, and using every means to prevent his catching cold.* Mr. M'Veagh, of Dublin, says that one of the most frequent, and at the same time the most fallacious and injurious, ideas is, that change of air is of material benefit to the patient. He confines his patient to his bedroom the entire time, or to a well-aired room contiguous to it ^ Dr. M'Gregor enjoins a strict confinement to the house, and, if possible, to one room, except during the summer months. | Dr. Copland re- marks that for patients residing on the sea-coast, frequent excursions on the water will be highly beneficial, especially if nausea or vomiting be thereby produced. Dr. Churchill approves of an occasional walk or drive on fine days, and during the warm parts of the day; and a change from town to country, when the cough is fairly on the decline. I have observed the worst effects, followed by dreadfully severe attacks of coughing, from out-door exercise in the winter season in Canada, and this * Lancet, vol. i. 1845, p. 137. t Ibid. vol. i. 184-8, p. 336. X Lancet, already quoted. REMEDIES RECOMMENDED IN PERTUSSIS. 275 Graves in the 3y this on the tempe- ent his in, says le same ideas is, i to the bedroom ntiguous finement 1, except >land re- 5ea-coast, >e highly liting be particularly in cases of dispensary practice. I have frequently prescribed change of air and resi- dence in the warm summer season, with the greatest advantage, at different periods of the complaint, when free from complications. An absence in the country for a single day in summer I have known to completely cure a child of this disease. 7. Warm Baths are recommended with other treatment by many French writers, among others Blache, Guersent, and Barrier. While in the bath, the hooping, which was incessant before it, immediately ceases. Dr. Elliotson says a cold shower bath is useful after a time. Dr. Copland recommends salt-water bathing, commencing with the warm or tepid bath, and passing gradually to the cold or shower bath, as very serviceable, if no complication forbids it. 1 walk or parts of country, owed by out-door and this t2 =v 276 ON HOOPING-COUGH. I i '41 /,' li// ( i CHAPTER XVI. CONTINUATION OF THE REMEDIES RECOMMENDED. 8. Hydrocyanic Acid. — This remedy was first recommended in England by Dr. Granville in 1819, in a book entitled, " Further Observations on Prussic Acid in the Cure of several Diseases, &c" He had however, previously to that date, published a paper on the internal use of prussic acid in the Monthly Medical Repository. The " Pharma- copoeia Pauperum," for the Royal Metropolitan Infirmary of Sick Children, by Dr. Granville, and pubUshed in 1820, contains two formulae for the administration of prussic acid, which Dr. Granville says* (Oct. 1838) have been used in the treatment of hooping-cough at that institution since 1820 in some thousands of cases. On the Continent it had been used by M. Fontaneilles in hooping-cough, and subsequently by M. Coullon in 1808, and since by Heineken, Behr, Kahleiss m 1827 and 1829, Muhrbeck in 1829, and others. Fontaneilles states that he has cured four children in the same family in a few days by this remedy. Muhrbeck, of Demmin, * Lancet, vol. i. 1838, p. 115. w REMEDIES RECOMMENDED IN PERTUSSIS. 277 recommends, in Rust's Magazine, this acid as a specific in the second stage of hooping-cough, or when the breathing becomes difficult and the cough convulsive.* It has been given successfully in the United States of America by Drs. Edwin Atlee, Stewart, Condie, and others. In Canada, also, I believe it has been employed, on the recommendation of American writers. Dr. Edwin Atlee first used it in 1824, on his own child, aged eleven months, and gave a teaspoonful, morning and evening, of a mixture composed of two ounces of simple syrup and four drops of prussic acid. The second day the same quantity was taken three times a day, and so continued for one week, when she was entirely well. This decided success encouraged him to persevere in his experiments ; and from that year till March, 1832, he says he had treated more than two hundred patients in this manner. He had never failed, and the cure had always been completed in from four to ten days, or at furthest a fortnight.t Dr. Hamilton Roe, who has prominently brought forward the use of prussic acid in his excellent Treatise on Hooping-cough, observes at page 89 : — "The dose of hydrjcyanic acid for an infant is about three-quarters of a minim, of Scheele's *'Amcr. Jour. Med. Sci. vol. vii. p. 242. t Ibid. vol. X. p. 128. ••■> ^s^'^faermsmmmmmmmmmm I''/ 278 ON HOOPING-COUGH. H i \'i\ 'I li strength, gradually increased to a minim, which may be giv6n every fourth hour ; for a child of three years of age, about one minim, gradually increased, if necessary, to a minim and a half, every fourth hour ; for children of ten or twelve years of age, a minim and a half, increased to two minims, every fourth hour. It is safer to give this medicine in small doses at very short intervals, than to run any risk of producing too great depression by a large dose. The frequency of its exhibition must depend upon the strength of the patient and the severity of the attack. The dose should be repeated when the effects begin to sub- side, which, in mild cases, generally happens in three or four hours ; but when much fever is pre- sent, its influence is felt but a very short time : under such circumstances, a larger quantity may be given, and at shorter intervals, without any apprehension of danger, so long as the fever lasts. In some very severe cases, when the pulse was up to 120, with a good deal of fever and a very hot skin, I have given to a girl of ten years of age a minim and a half of this medicine every quarter of an hour for twelve hours ; at the end of twenty- four hours she was free from fever, and her strength was not in the least reduced by the effects of the remedy. As some catarrhal symptoms are gene- rally present, a few drops of ipecacuanha or anti- monial wine may be advantageously combined REMEDIES RECOMMENDED IN PERTUSSIS. 279 with the hydrocyanic acid; but the latter alone possesses the power of curing this formidable com- plaint." Dr. Roe says he is convinced, from the re- sult of all the trials he has made, that this drug wiP cure almost any case of simple hooping-cough ir. a shc-rt time ; that in all seasons it will abridge its duration; and in almost every instance, when it does not cure, that it will, at least, materially relieve the severity of the cough. Dr. Elliotson says much good, however, may be done, with respect to the spasmodic part of the affection, by good management — giving light food, and a very moderate exhibition of narcotics, but above all, prussic acid : its exhibition is not very satisfactory, though he is persuaded it is more so than that of any other narcotic. It does not sub- due inflammation, but it alleviates the cough.* Dr. George Augustus Rees has not met with the same relief from the use of prussic acid as Dr. Roe has, but he believes much of the severity may be mitigated, and the duration of the hooping-cough limited by this acid.f Dr. Crisp has found the use of prussic acid of service only for a day or two.]: Aberle entirely disapproves of this remedy in hooping-cough, both from its dangerous powers and the great uncertainty of its operation. Dr. Watson, in his Lectures, says prussic acid and bella- * Lecture on Prac. of Physic. t Diseases of Children. J Lancet, vol, i. 1845. -mmmmmmtti* mm^^-^^ma -^jr 280 ON HOOPING-COUGH. i •' tained results singularly beneficial He prescribes it in doses of from a sixteenth to a twelfth of a grain, at first three times, and afterwards four times a day : of course the remedy should not be adminis- tered in cases where the state of the digestive organs contra-indicates its employment* Before using the nitrate, he tried in various cases, opium, morphine, belladonna, hydrocyanic acid, the hydrocy- anates of iron and zinc, assafcetida, tobacco, and the sedum palustre, without finding the paroxysms mitigated by any of them. Volz has found it useful. The oxide of silver has been also recommended and tried in this disease. Triturated with extract of hop or of hyos- cyamus. Dr. Copland has given it with advan- tage in some cases. 18. Iron. — M. Lombard, of Geneva, recom- mended the use of subcarbonate of iron in the spasmodic stage of hooping-cough, in 1837, in the quantity of from twenty-four to thirty-six grains during the day.f Dr. Elliotson says many metallic tonics have been given, but he thinks iron is the best of them. The sulphate is a medicine which may easily be given to children, dissolved in various mixtures, or, if preferred, the carbonate mixed with treacle, as they are fond of sweets. I do not know, he says, that iron has any specific power; but * British-Anier. Med. and Phys. Journal, vol, ill. f Lancette I'ranjaise, in Lancet, vol. ii., 1837-38. REMEDIES RECOMMENDED IN PERTUSSIS. 295 when the disease has existed for some time, it will be found useful In the second stage of hooping-cough, when the inflammatory symptoms have been subdued by appropriate treatment, remarks Dr. Graves, " I have also found the carbonate of iron, as recom- mended by my friend Dr. Lombard, of Geneva, a most valuable remedy. Within the List two months, (December 1st, 1842,) it has succeeded in very effectually and rapidly curing the children of a distinguished physician of this city, and I am happy to add his testimony to its utility."* Dr. George Rees remarks, that in protracted pertussis, where a strumous diathesis is becoming developed, an i phthisis may be apprehended, then the use of stuel, the ferri sulphas, as recommended by Dr. Stanger, or the sesquioxide, or vinum ferri, two or three times a day, will be followed by as rapid an amendment, and often rescue the patient from the verge of consumption. t The ammonio-chloride and potassio-tartrate of iron have also been used. 19. ZiTic. — Dr. Moseley in his Treatise on Tropical Diseases, published in 1802, strongly re- commends this substance in the following formula, which he names " The Vitriolic Solution'^: — Take of white vitriol, 5iij ; rock alum, 5j ; cochineal, gr. iij ; boiling water Oj : mix, and when cool, * Clinical Medicine. f Diseases of Children. ON HOOPING-COUGH. filter. This he says is of great utiUty in all pulmonic oppressions where respiration is per- formed with difficulty, and where expectoration is to be promoted, and the bronchial glands are to be unloaded and cleansed ; — in nauseating, or slightly vomiting doses. In moist, pituitous habits, with phlegmatic asthmas, — in catarrhal coughs, and above all in the moist English hooping-cough, its effects are wonderful ; taken once or twice a day, particularly in the morning, fasting, in doses to cause a slight retching. The common dose, to create a slight retching, he states to be a table- spoonful for an adult, and a teaspoonful for a child of six months. Dr. Copland has given the sulphate with benefit. Barrier recommends the oxide of zinc as an antispasmodic, in the dose of from one and a half to three grains every two or three hours, without exceeding altogether fifteen grains in the twenty- four hours, for children of from five to fifteen years of age. A smaller quantity must be given to children of younger age.* Oxide of zinc has also been recommended by Guersent and Lombard, in doses of a grain every hour. It has been praised by Crell, Percival, and Hart. Scheidemantel employed it after evacuations. Winckler and Tode gave it with cinchona; and Storck with cream of tartar. * Maladies de I'Eiifance, torn. i. REMEDIES RECOMMENDED IN PERTUSSIS. 297 ;y in all L is per- Dration is are to be r slightly )its, with ghs, and cough, its ice a day, doses to L dose, to e a table- ifui for a ith benefit, sine as an md a half s, without le twenty- 'teen years given to nended by rain every rcival, and v^acuations. lona; and 20. Lead. — The sugar of lead has been noticed by Sauvages as a remedy for hoopii cough, in 1768, in Holland. The acetate has been highly recommended by Dr. Reece, who began its use on his own child, aged four years, by giving a icu spoonful of a mixture every six hours, composed of acetate of lead, five grains ; syrup of violets, two drachms ; rose water, two ounces. The cough being less frequent on the following day, he doubled the dose. After the first dose, the child was not heard to hoop, and after two days more, the cough entirely ceased. The child's health, which had been bad for some time, was evidently improved by it* He gave it aiterwards to hi? youngest child, and several others, with such success, that he really considers it a specific in this disease. 21. Copper. — In the second volume of the Lancet for 1839-40, Mr, Chavasse calls attention to small doses of the sulphate of copper in hooping- cough, which he has used in numerous cases with the happiest result. His formula is, sulphate of copper, half a grain ; S3rrup of poppies, half an ounce ; aniseed water, one ounce and a half. The dose one or two teaspoonfuls every four hours. 22. Cauterization by Nitrate of Silver. — Dr. Eben Watson, of Glasgow, published a paper in the London and Edinburgh Monthly Joiurnal of Medical Science, in December, 1849, on the * Med, Cliir, llevicw, vol, xv. p, 37. 298 ON HOOPING-COUGH. ( ', i I, application of nitrate of silver to the larynx in hooping-cough. The first case in which he attempted it, was that of a weakly boy, about eight years old, in ( whom the disease was already at its height. He ; had a severe paroxysm regularly every quarter of an hour; he was already much debilitated, and in constant danger of having some serious lesion ! produced in his delicate lungs. From the first j time that the solution was applied to the glottis, ^ the severity of the cough was mitigated, and after repeating the application every second day for about a week, he was found not to hoop at all. The boy then made a speedy and complete recovery of his ordinary strength under the use of the cod- liver oil. The sister of this patient was also seriously affected by the same disease, and the application of a solution of caustic was likewise used in her case. But its effects were not so striking as in the previous case, owing to the presence of lobular pneumonia of the posterior part of the left lung. Nevertheless, the paroxysms of the hooping-cough diminished in frequency and in violence unc'er its use ; and after the pneumonia had been subdued by pretty active measures, the child ultimately made a good recovery. Dr. Watson's third case was that of a boy, about REMEDIES RECOMMENDED IN PERTUSSIS. 299 irynx m i it, was 3 old, in jht. He Liarter of 1, and in IS lesion the first le glottis, and after day for op at all. 5 recovery ■ the cod- seriously pplication d in her as in the )f lobular left lung, ing-cough un^er its subdued iltimately )oy, about six years of age, in whom the disease had nearly passed without much treatment of any kind having been employed ; but he still was harassed with frequent and pretty violent fits of coughing, and when excited or frightened, he still had that mode of drawing in his breath, popularly known as the "drawback." Two or three applications of the solution to the glottis and larynx of this child were sufficient to accomplish a perfect cure of his symptoms; and a short sojourn in the country, with the use of a tonic, completed his restoration to health and ■ igour. He has since treated in a similar manner several other cases of hooping-cough. The results were equally favourable with those already mentioned. None of his patients continued to hoop more than eight or ten days after the solution of caustic began to be applied to the glottis ; and from the first of such applications the mitigation of the symptoms was very marked. In all these cases, he says, the topical treatment is remarkably efficacious as 'well as speedy in its action, a few applications of the solution sufficing, in most instances, to effect a cure. He combines with the above due attention to diet, and proper regulation of the functions of the alimentary canal. He also confines his patients strictly to one apartment, suitably heated and well ventilated, until the stage of hooping has been ) I ^i^p :i , 1! 1! / hi 300 ON HOOPING-COUGH. \ fairly overcome ; and then, if necessary, he recom- mends change of air, and the use of some tonic, — generally the cod-liver oil. The strength of the solution is gr. xv. to the \ ounce, applied every second day by means of whale- ;' bone tipped with sponge, at first to the pharynx ; only. Dr. Hislop, of Geneva, has also used this plan of treatment with success, and has communicated some cases in a letter to Dr. Watson.* In a subsequent paper in the Lancet,t Dr. Watson says his first cases, which occurred in summer (those above described), ceased to hoop in about ten days or a fortnight after the first appli- cation of the solution ; and of late (October), in our worst winter weather, he treated several cases to a favourable termination in from two to six weeks. The assertions of Dr. Wagstaffe on the topical application of caustic, in the relaxed and thickened condition of the mucous membranes, the result of hooping-cough and other diseases, have thus met with confirmation by the cases of Dr. Watson. M. Joubert has published the results of his experience of this mode of treating hooping-cough, He has treated in all ninety-eight cases in this manner, but he excludes thirty of these as not being worthy of reliance. The remaining sixty- * Monthly Journal of Medicine, Dec. 1849. t Vol. ii., 1851, p. 3G8. REMEDIES RECOMMENDED IN PERTUSSIS. 301 [le recom- e tonic, — LV, to the } of whale- s pharynx bis plan of 3ated some ncet,t Dr. ccurred in to hoop in first appli- her), in our cases to a ;ix weeks, the topical thickened e result of thus met atson. [Its of his »ing-cough. eight cases he divided into three series, according to the period at which the treatment was com- menced. Of these the general results were, that in forty the cure was rapidly effected, in twenty- one a marked relief was experienced, and in seven cases only the treatment failed altogether.* My friend Dr. Alison speaks favourably of this method in relieving the cough, in his instructive Httle work on the Medication of the Larynx and Trachea. * Gazette Medicule de Paris, in Canada Med. Joui., vol i., 1852. 19. 302 ON HOOPING-COUGH. / ■f CHAPTER XVII. CONTINUATION OF THE REMEDIES RECOMMENDED. 23. Inhalations. — The Vapour of Tar, Dr. Watt has devoted sixteen pages to the consideration of, in his work on Chincough ; he speaks favourably of its effects, and mentions that children when inhaling it will expectorate three or four ounces of mucus from the lungs with great relief It was useless in some cases, and injurious in others. The fumes are produced by means of red-hot pokers stirred up in tar, till the apartment is filled with a pretty thick fog. Mr. Wansbrough, of Fulham, has also strongly ecommended the vapour of Barbadoes tar in the same disease, and has cured some cases,* Mr. Waddington, of Margate, in a communication to the Lancet, advises, in the second stage, to confine the patient to a bed-room and sitting-room upon the same floor, communi- cating with each other. In these rooms Swedish tar should be kept boiling, night and day, over a small lamp, and the vapour of tar will pervade both rooms. He says, when the symptoms run * Lancet, vol. ii., 1828-29. REMEDIES RECOMMENDED IN PERTUSSIS. 303 oms run high, the effect of this simple remedy is almost miraculous.* Fumigations of aror/iatic herbs are praised in pertussis by Dr. Dohm, in Hufeland and Ossans' Journal for 1835. Cherry-laurel water inhalations are mentioned under that head, at page 281, as having been used by Dr. Pavesi. Dr. Stewart mentions that fumigation with the vapour of benzoin was accidentally discovered, a few years since, to allay, with remarkable quick- ness, the paroxysms of hooping-cough. Marley mentions that he has known, inhaling the steam of a decoction of the fresh leaves of hemlock, alone or with ether, to be of use. It is said that relief has been afforded by the fumes of warm spirits of turpentine. Mr. Paterson has used the nitrous ether. Dr. Churchill has used sulphuric ether most successfully. He thus speaks of it. — " Soon after the discovery of the anaesthetic effects of sulphuric ether, it struck me that it would be Hkely to modify or suspend the spasm in hooping-cough ; and having a case under my care, I directed that half a drachm should be poured over the nurse's hands and held before the child's nose and mouth at the commencement of the fit of coughing. The effect surpassed my expectations ; general]y the * Vol i., 1845, p. 722. 304 ON HOOPING-COUGH. paroxysm was shortened, often stopped imme- diately, and the duration of the disease was unquestionably diminished. Since this I have tried ether in fourteen cases and chloroform in six. In one or two cases no benefit ensued, in others great mitigation of the spasm, and in three almost complete relief followed, when the ether was commenced at the beginning of a fit of coughing. In two-thirds of the cases the course of the disease was much shortened. In no instance was insensi- bility or the least inconvenience occasioned."* In August, 1853, the following cases, treated by Dr. Churchill, appeared in the Edinburgh Monthly Journal : — Case 1. — Miss D , aged sixteen, liau had hooping-cough a month when I prescribed chloro- form. There was no complication, but the hooping was frequent, especially during the night. She was directed to have the chloroform in readiness, and to use it with each paroxysm, and she assures me that in two days the hoop ceased. The cough lasted a few days longer, but it was slight, and not in kinks. Case 2. — Miss A , aged twenty, had been ill with hooping-cough for about three weeks, when J prescribed chloroform. The cough was not very frequent, but there was no complication. Two days sufficed with her also to relieve her of the hoop ; * Diseases of Children. * REMEDIES RECOMMENDED IN PERTUSSIS. 305 and the slight cough which remained subsided after a week or ten days. Case 3. — Miss B , aged eighteen, took the complaint from her brother, whom I was attending, and I therefore had an opportunity of giving chloroform from the commencement. She did not hoop any time she coughed ; but she was directed to use the chloroform v/henever she felt the tickling in the larynx, without waiting for a cough. By doing so, she found that she could postpone the cough indefinitely; and if it came on suddenly, the use of the chloroform instantly suspended it. About three weeks elapsed before the tendency to cough and the use of chloroform ceased ; but during that time she lost neither appetite nor flesh. She slept well, was in good spirits, and able to follow her usual occupation. She went to the country quite well. Case 4. — Master E , aged sixteen, the brother of the last case, when I first saw him had the disease most severely. The kinks were violent and prolonged, the eflforts to inspire and the hoop excessive ; it really seemed as if he would be choked, or that something would give way. He had lost appetite, sleep, and spirits, although the disease had not lasted three weeks when I saw him. I tried chloroform with him, and it at once reduced the number of paroxysms one half, but without mitigating them when they did occur. X T 306 ON HOOPING-COUGH. He took the chloroform very freely, and as he was not readily influenced by it, the quantity seemed to give him a headache, and he begged to be allowed to suspend its use. I the more willingly agreed to this, as he had a severe attack of diarrhoea. I therefore substituted two drops of prussic acid with two or three black drops three times a day. The improvement begun under the chloroform continued under this treatment, and at the end of five weeks from the beginning of the disease the cough had ceased, and he had regained rest, spirits, and flesh. Dr. Willis speaks of the good effects of ether in hooping-cough, in the Medical Gazette.* He remarks that the paroxysms of coughing are posi- tively cut short by having the ether and the handkerchief in readiness, and using them when the fit is perceived to be coming on. He has sometimes allowed a fit of coughing to terminate, for the purpose of clearing the chest of accumu- lated mucus. My friend Mr. B. W. Richardson informs me that he has used inhalations of sulphuric ether for some years in pertussis with the very best results. 24. Coffee. — Dr. Jules Guyot, who advocates the use of this remedy, writes thus in the Union Mddicale, for 24th April, 1849 :— " Cafe ct Veau, * Feb. 12, 1847, p. 271. EEMEDIES RECOMMENDED IN PERTUSSIS. 307 hot, and well sugared, in suitable doses, taken four times, or oftener, daily, will cure, in from two to four days, the most obstinate cases. For a child of two years, the dose is a teaspoonful ; for a child of four years, a dessert-spoonful ; and for an elder patient, a table-spoonful. (?) To obtain a rapid and permanent cure, it is necessary to conjoin with the coffee treatment a diet of fried and roast meat, taking care to mince it, if the child cannot masticate it sufficiently. The quantity of milk used ought to be diminished ; and farinaceous food, con- fectionaries, and fruits must be entirely prohibited." He accidentally discovered the use of coffee by observing a child, aged four years, ill with measles and congestion of the lungs. The coughing was so severe that death was imminent, when a tea- spoonful of coffee was given, after a like quantity of beef-tea, which before this could not be retained. Two hours after, the child ate some cutlet with its dose of coffee. The night was passed well, and after a few days, under a continuation of the coffee, the child recovered. Seriously reflecting on this case. Dr. Guyot met M. Bouju, ex-notary of Fran- conville, who told him that he had been obliged to have double doors for his study, to keep out the terrible and incessant noise caused by his two children with hooping-cough. Dr. Guyot detailed the case above narrated ; and he cured both his children in four days by means of coffee. He has X 2 m I t ; I I 3()S ON HOOPING-COUOH. Hiuce tried the remedy successfully in above sixty cases.* A decoction of unroasted coffee was given by Hufeland in this disease. Coffee has been used by Dr. Pickford in the diarrha^a of children with success.t 25. Peruvian Bark. — Millar, Dr. Whytte, Dr. Sims, Cullen, and others, have recommended this in hooping-cough : the last-named author, in com- bination with opiates. Dr. Watt says it is a remedy which may be resorted to with great ad- vantage, at the conclusion of the disease. Quarin, Courbette, and many of the Germans use it. 26. Quinine. — Trousseau and Barrier approve of small doses of quinine, as an antiperiodic in hooping-cough. Dr. G. A. Rees says, " When, from the protrac- tion of the affection and violence of the cough, the constitution is shaken, and the digestive functions impaired, — when the flesh is flabby, the counte- nance anaemic, the tongue pale and flabby, — in such a child, give sulphate of quinine in doses repeated twice a day, and the symptoms will dis- appear most rapidly, and the cough may cease as if checked by some powerful specific."^ Dr. C. Johnston recommends it in the last stage when there * London Jour, of Medicine, Aug. 1849. f Medical Gazette, 1848. X Diseases of Children. REMEDIES EECOMMENDED IN PERTUSSIS. 309 Is debility. Dr. CcDland says, when the disease is protracted, Jiud assumes an intermittent or periodic type, (juinine or cinchona ought never to bo omitted. 27. Hydrochloric Acid was first proposed by Dr. Thiol in hooping-cough. He gave the pure acid in the dose of two or three drachms in six or eight ounces of water sweetened with simple syrup or the syrup of raspberries. He administered this by spoonfuls every hour throughout all periods of the disease, and in his enthusiasm for his specific, as Guersent remarks, he was not prevented from using it even when the disease was complicated with chest affections. Guersent has only slightly employed it, because the greater number of children did not appear to become accustomed to its use. During an epidemic which raged at Erlangen in the autumn and winter of 1819 and 1820, the ordinary methods, and above all belladonna, the golden sulphuret of antimony, and the different preparations of opium, were used unsuccessfully by Dr. Henke, and frequently increased the fever and the cough. He found on the contrary hydro- chloric acid to be very efficacious and of the greatest benefit. The Clinical Institute of the same town treated upwards of seventy children by this acid, and a very small number only of these continued its use i I I i t 1 'I 1 a /( 1 j, i H 1) i 310 ON HOOPING-COUGH. beyond fifteen days. All these children were cured, although many were dangerously affected, with the exception however of two patients; one aged a year, having the disease complicated with dysentery, and the other with scarlet fever. Guersent thinks that the powerful testimony in favour of this treatment by Dr. Thiel requires us not to neglect it entirely, but he says it is very dangerous to employ it in large doses when there is inflammation of the chest.* In the treatment of the third stage. Dr. West speaks as follows : — " In other cases in which the cough continues violent after the other symptoms have abated, and in which, though there is no superabundance of secretion in the air-tubes, yet the attacks of cough often end with the rejection of a considerable quantity of mucus from the stomach, and loss of appetite and general dyspeptic symptoms are present, the hydrochloric acid is often of much service. It has been recommended as a specific against hooping-cough, in doses of from two to six drachms daily ; but I have never em- ployed it in other than moderate doses, such as it would be administered in under other circum- stances.'' 28. Sulphuric Acid. — A writer in the Lancet f calls attention to the speedy relief afforded in * Diet, de Medecine, vol. vi. p. 20. f Volume ii., 1845, p. Ilk. . • REMEDIES RECOMMENDED IN PERTUSSIS, 31 1 hooping-cough, by a dose of from fifteen to twenty drops of dilute sulphuric acid, mixed in a tea- spoonful of moist sugar, taken three or four times a day. " I sometimes prefer," he says, " giving an ounce of this ' elixir' in a pint of water, with two ounces of simple syrup; the dose a tablespoonful, three or four times a day. This popular remedy has been found so useful here (Ipswich), during the last two or three years, as to be considered almost a specific." 29. Nitric Acid. — This acid was first recom- mended by my friend and late colleague, Dr. Arnoldi, of Montreal, as a remedy in pertussis, attended with the most remarkable success, and has been adopted by me at his suggestion before he published his observations. It is fully con- sidered in the Chapter upon the treatment of the uncomplicated affection, the (eighteenth. It may be remarked, however, that it has suc- ceeded over and over again when other means have failed, and it is not such a hazardous remedy, when administered with ordinary precaution, as many described in the preceding pages. His method of prescribing the acid for hooping- cough or asthma is as follows: — To a tumblerful of very sweet water (almost syrup) add u much acid as will bring the water to the strength of pure lemon juice, when it is ready for use. An adult may consume this quantity in w^sm mmm 312 ON HOOPING-COUGH. three or four hours. A child one year old may take a dessert-spoonful every hour. . . He has remarked that the efficacy depends on the amount taken, and that especially by the fre- quency of repetition, so that he confidently asserts there is not the slightest risk of an overdose. To save the teeth, he advises a solution of car- bonate of soda, two drachms to eight ounces of water, to be used as a gargle immediately after taking the acid. This of course is not required in infants. 30. Cochineal. — In consequence of seeing in an English paper the receipt for a very old English specific for hooping-cough, Dr. Cajetan Wachtl, of Vienna, was induced to give it a trial. The receipt was — cochineal, fifteen grc-olns ; carbonate of potass, fifteen grains; sugar, one ounce, and water, six ounces. A teaspoonful was given three times a day. He treated nine children with it in all stages of the disease, and its efficacy was so instantaneous and constant, that notwithstanding the paucity of cases. Dr. Wachtl felt authorized to regard cochi- neal as a specific in hooping-cough. The cure was produced in from two to eleven days, diminishing the number of fits from the first day it was taken. In Scotland it appears the above mixture has been used from time immemorial, but is made much stronger — namely, cochineal, ten grains; salt of tartar, twenty grains; water and simple syrup, of REMEDIES RECOMMENDED IN PERTUSSIS. 313 each half an ounce : a teaspoonful to be taken four times a day. The following is Dr. Wachtl's manner of ex- hibiting this remedy: — Take of cochineal, one scruple; sugar, one ounce. Dissolve in six ounces of warm water. The dose is three teaspoonfuls in the twenty-four hours. The solution ought not to be kept longer than thirty-six or forty-eight hours, because after that time it assumes a brown hue, and a sour taste, which renders it unfit for use * Dr. Charles Aberle, of Salzburg, in his Observa- tions on Epidemics of Hooping-cough, f states in relation to this substance : — Ammoniated tincture of cochineal, given in five-drop doses of the fol- lowing preparation, mornings and evenings, was found apparently to diminish the time occupied by the disease, and to render the period of conva- lescence less tedious. This tincture is made with powdered cochineai, half an ounce; liquor of am- monia, half an ounce; rectified spirits of wine, seven ounces : mix. Dr. Aberle remarks, with the before-mentioned do-^es. Dr. Wachtl, of Vienna, cured nine cases in trom three to eleven days ! It must be remembered that the je cases occurred in the summer months, when cure is generally more * Sec the Lancet ; vol. i., 1844 ; Edin. Med. Journal ; London Med. Gazette, January, 1844 ; and Pharmaceutical Journal. t Reviewed in the Lancet, vol. i., 1840. F ■■i,^'—' ;Ty7..r ry:;:v.\ H h \ 314 ON HOOPING-COUGH. rapid. How far might not the ammonia contribute towards the good effects of this mixture ? Dr. Aberle, I think, is in error, in supposing that Dr. Wachtl used the ammoniated tincture ; it was the simple infusion which he employed. In an estimation of the comparative value of cochineal, fumigations with cherry-laurel water, the use of vegetable acids, &c., in the treatment of hooping-cough, by Dr. Pavesi, in an epidemic of this disease which prevailed during the entire spring of 1850, at Candie (Lomelline) ;* of 122 children who were under his care, he treated 27, who were delicate, and the disease intractable, exclusively with cochineal. Signer Pavesi prescribed for his little patients the following mixture : cochineal and carbonate of potass, of each eight grains ; sugar, one ounce ; water, four ounces : mix. A table- spoonful to be taken every two hours. This treat- ment was employed alone, with the exception of a purgative when required. The results were satis- factory ; not that the disease was arrested in its progress or even shortened, but the paroxysms were rendered less intense ; and whenever the little patients omitted to take their cochineal, the attacks were more frequent and distressing. They all recovered. (See cherry-laurel in the last chap- ter, and vegetable acids further on.) * Giornale dell' Academia Medico-Chirurgica di Torino, and llankiug's Abstract, vol, xiv. contribute supposing . tincture ; loyed. 3 value of rel water, treatment 1 epidemic the entire ;♦ of 122 ,ed 27, who 3xclusively led for his hineal and as ; sugar, A table- This treat- ption of a were satis- sted in its paroxysms never the lineal, the ng. They last chap- i di Torino, REMEDIES RECOMMENDED IN PERTUSSIS. 315 A writer in the New York Medical Gazette recommends very highly the following prescrip- tion for hooping-cough, to be given in teaspoonful doses three times a day. He regards the cochineal as the active principle of the preparation, and hence gives it in larger doses than usual. Cochineal, in very fine powder • • 5ij' Carbonate of potash 5^- Sugar . . . 5i. Tincture of spearmint ^U- Water 5 ^iv- Mix. 31. Alum. — In reference to the therapeutic value of alum in hooping-cough. Dr. Golding Bird remarks : — " During the last three years I have extensively prescribed this drug in hooping-cough. Like all other remedies which have been consi- dered specific, its administration will end in dis- appointment, unless discrimination be used in selecting the proper stage for its exhibition ; but with this precaution I have no hesitation in ex- pressing an opinion, from the experience I have now had of its therapeutic value in hooping-cough, that in one stage of the disease alum will be found a most valuable remedy. "It is unnecessary to allude to the distinct stages observed in every case of pertussis, further than to remark that it is important to distinguish between the first, acutely inflammatory or catar- rhal, and the second, or nervous, in which the 316 ON HOOPING-COUGH. spasmodic cough, with a more or less copious bronchial flux, exist?.. In the first stage, the use of any reputed specific would of course be avoided by every experienced practitioner, the safest treat- ment being that of ordinary bronchitis. But after the persistence of the disease for a week or two, and all inflammatory symptoms have subsided, and when, with a cool skin and clean tongue, the little patient is harassed by a copious secretion from the bronchi, the attempt to get rid of which produces the exhausting and characteristic cough, alum will be found of much value. I have not yet met with any other remedy which has acted so satisfactorily or afforded such marked and rapid relief; the dose has generally ranged from two to six grains. For a child of two or three years the following formula has usually been employed : — Aluminis, grs. xxv; Ext. conii, grs. xij ; Syrup. Rhoeados, ^ij ; Aquse anethi, ^iij- M. ft. Capiat coch. j med. 6 quaque hora. Dr. Bird further states that no ill eflects are perceived upon the bowels from the astringent qualities of the medicine. He does not explain the modus operandi, but thinks that it acts by allaying spasm and restraining inordinate bronchial secretion. He has used alum with equal benefit in the bronchorrhcea of emphysema.* In the last edition of Underwood's Diseases of * Guy's Hospital Reports, 184-5, and Ranking's Abstract, vol. i. REMEDIES RECOMMENDED IN PERTUSSIS. 31 7 ' Infants, Dr. Davies thus speaks of the employ- ment of alum in pertussis ; — " After a long trial, I am disposed to attach more importance to alum as a remedy in hooping-cough than to any other form of tonic or antispasmodic. I have often been sur- prised at the speed with which it prrests the severe spasmodic fits of coughing ; it seems equally appli- cable to all ages, and almost to all conditions of the patient. I was formerly in the habit of taking much pains to select a certain period of the illness for its administration, and of waiting until the cough had existed at least three weeks, taking care that the bowels were open, the patient free from fever, the air-passages perfectly moist, and the disorder free from complication of any bruit. A continued observation of the remedy, however, has induced me to be less cautious, and I am dis- posed to think that a very large amount of collat- eral annoyance will subside under its use. The fittest state for its administration will be a moist condition of the air-passages and freedom from congestion, but an opposite condition would not preclude its use, should this state not have yielded to other remedies. It generally keeps the bowels in proper order, no aperient being required during its use. The dose for an infant is two grains daily, and to older children, four, five, and up to ten or twelve grains may be given, mixed with syrupus rhoeados and water. It is seldom disliked/' ' h I (l'< ■f , 818 ON HOOPING-COUGH. Mr. David Davies, of Bristol, speaks very highly of the use of alum in hooping-cough.* He be- lieves it e^'ts as a nervine tonic, and so removes the spinal excitability existing at the origin of the nerves of respiration. In the third stage, when the bronchi are loaded with secretion, the skin cool, tongue moist, soft but weak pulse. Dr. West prescribes alum in the doses of three or four grains every four or six hours, for a child of a year or eighteen months old. It proves of much service in this condition, dimin- ishing the secretion, arresting the sickness, and rendering the cough much less frequent. Alum was used by Dr. Moseley, in 1802, in combination with sulphate of zinc and cochineal. (See zinc in last chapter.) 32. Tannin. — M. Sebregondi has found decided benefit from the employment of this substance in the asthenic stage of hooping-cough. He has given it in doses of from a quarter to half a grain every two hours, in conjunction with sedatives, as hyos- cyamus, and also with purgatives.f Aberle has used tannin in the third stage, with the happiest effects. He gives it, either alone or in combina- tion with benzoic acid, in doses of one sixth, one half, or three quarters of a grain. Professor Fuchs, * Lancet, vol. i., 1849. t Ibid., vol. i., 184243. REMEDIES RECOMMENDED IN PERTUSSIS. 319 however, employed it with the best results, espe- cially in a case complicated with epistaxis, in doses of from one to three grains every second hour * Dr. Durr, in the Med^cinische Correspondenz Blatt, speaks of the beneficial action of tannin and benzoin in the latter stages of hooping-cough- He prepares powders, containing from two to five centigrammes of each, with fifty centigrammes of sugar. One is given every two hours.t The formula, as used in the Hopital des Enfans in Paris, is — tannin and benzoic acid, of each gr. ij; powdered gum arable 5j : to be divided into twelve powders; one every two hours in sweetened water.J Volz has found tannin useful. There is no doubt whatever that tannic and gallic acids, as astringents, are especially useful in checking ex- cessive bronchial secretion. 33. Vegetable Acids. — Dr. Pavesi treated six cases of hooping-cough of a mild form with these, out of 122 children who were under his care. They were employed as recommended by Dr. Schmidt, of Hengersberg, and by Geigel. Tama- rinds, vinegar, lemonade {ad libitum), apple juice with sugar, and syrup of barberries, were given in * Lancet, vol. i., 1846, f Prov. Med. and Surg. Journal, April, 1850. X Nelson's Northern Lancet (N. Y.), vol. iii. 320 ON HOOPING-COUGH, quantity according to circumstances. The efficacy of this plan was doubtful, and the disease, more- over, lasted six weeks.* 34. Alkalies were originally used for the pur- pose of arresting the acidity of the secretions of the stomach and bowels in this disease. Dr. Stutz was the first who used the carbonate of potash, as mentioned in Hufeland's Journal. Dr. Memmin- ger, of Keutlingen, successfully tried it, preceding its use always with emetics of ipecacuanha and vin. antim.f The carbonate of potass has been used for very many years in Scotland combined with cochineal, as has been shown when speaking of the latter. Dr. Pavesi used it with cochineal, in twenty-seven cases of hooping-cough. They all recovered. May not the potash have as much effect in curing the disease as the cochineal ? Dr. Gregory, in his work on Practice of Physic, recommends the combination of carbonate of potass or soda with aperient medicines when the latter are required. Dr. Kichard PearsonJ has spoken in high terms of the combined influence of an expectorant (vin. ipecac.) with an anodyne and absorbent, (carbonate of soda.) He strongly re- commends the following formula: Carbonate of soda, 24 grains ; ipecacuanha wine, 5j ; tincture of * Ranking's Abstract, vol. xiv. f Med. and Phys. Journal, vol. ix. j Medico-Cli . Tran., vol. i., p. 23. '1 ' ; REMEDIES RECOMMENDED IN PERTUSSIS. 321 opium iTivi, syrup 5iij, water one ounce ; a sixth part to be taken every six hours. He does not recommend this prescription to the exclusion of other remedies. Dr. Armstrong, in his Lectures, recommends carbonate of potash or soda in addi- tion to other means, to prevent acidity. Sulphu- ret of potash was recommended as a cure for hooping-cough, by M. Blaud, chief physician to the Asylum of Beaucaire. He states that, after giving one grain of the extract of belladonna to an adult, for eleven days, without any relief, he prescribed ten grains of the sulphuret of potash mixed with honey, night and morning, and the benefit was immediate, and in seven days the cure was complete. In another case, in which the symptoms were so violent as to require venesec- tion, and for which he had prescribed belladonna without any benefit, he gave ten grains of this medicine daily, and in twenty-five days the cure was complete. In six cases of adults in which he administered this remedy, the spasmodic cough, he says, ceased after th». second dose, and the catarrhal cough disappeared after a few days.* Mr. Kimbel has used the same remedy with advantage. Dr. Copland has preferred the liquor potasace, or Brandishes alkaline solution, especially in the scrofulous diathesis, and in cachectic habits. * Revue MM., and Lancet, vol. ii., 1830-31. Y 322 ON HOOPING-COUGH, Liquor Ammoniw has been recommended by Dr. Levrat-Perroton, of Lyons, in hooping-cough.* The following is his prescription : — 9) -a-q. destil. lactucce vir. „ flor. aurant. Syrup. pseonijB officii!. „ belladonnaj . . Ammon. liquor . . . 5iv. 5ij- 5ij. . gtt. vi. Misce, Four Dose, a tablespoonful every four hours, cases are quoted as proofs of its efficacy; the cure in all was rapid and complete. Barrier thinks from the narcotics entering into the foregoing formula, that the cure was in some measure owing to them, and not the ammonia only. Dr. R. H. AUnatt recommends a liniment composed of harts- horn and oil of amber, of each half an ounce ; to be well rubbed over the whole course of the spine, morning and evening, in addition to a mixture containing carbonate of potass and cochineal.f Muriate of ammonia was recommended by StoU with oxymel, at an early stage. Dr. Copland has found it an excellent refrigerant antispasmodic and tonic in several instances. He also speaks of the carbonate and other preparations in small doses, as frequently beneficial in cases of debility at an advanced period, or when the complaint is pro- tracted. * Eankiiig's Abstract ; and Barrier, Mai de I'Enfance. t La/ucet, vol. i., 184:6. REMEDIES RECOMMENDED IN PERTUSSIS. 323 35. Vaccination. — Various facts collected by MM. Thomson, Chevalier, Thomas Adam, Ferrari et Arabrosiis, Boccardi, Orlandini, Mattura, Fa- bronne, Durando, Gombette et Vacane,* have seemed to prove that vaccination has succeeded in cutting short the duration of the disease. But the numerous observations of Constant have shown that generally this method of cure is without any efficacy. M. Blache has met with the same want of success, and Barrier, during his residence at the Hospital for Sick Children in Paris, never observed the happy changes said to arise under the influence of vaccination.t Jumer has pointed out the efficacy of vaccination in mitigating, if not preventing, the extension of hooping-cough. The Italian physicians made some experiments in relation to this question which de- serve to be repeated on a more extensive scale. J M. Griva, director of vaccinations at Turin, in a memoir on Variola (il Severino), speaks of the cases of hooping-cough reported by Drs. Ferrari and Ambrosiis, which had been much mitigated by vaccination. During the course of the varicella the spasmodic cough gave place to a simple cough of slight bronchitis, and in some instances the disease was very manifestly abridged. During an * Gazette Med. de Paris, 1834, p. 539. t Mai de I'Enfance, vol. i., p. 158. X Lancet, vol. ii., 1833-34. Y 2 324 ON HOOPING-COUGH. epidemic of hooping-cough, Dr. Boccardi also employed vaccination on very young children, and found that the mortality previously caused by the disease was immediately arrested ; the cough as- sumed a milder character, and was in most cases limited to three or four weeks. Okes, Cleeve, and Moutain have recommended it as a preventative. Mr. Linacre has employed vaccination as a means of relief in two cases, with a cure in a month from its performance. The disease had existed fourteen days before he inserted the vaccine lymph. As the vesicle proceeded to maturity, tx. . severity of the paroxysms became remarkably mitigated, and in their frequency they were much diminished.* 36. Cantharides was first recommended by Dr. Burton, of York, in his Essay on Chincough, pub- lished in 1738. He prescribes a scruple of cantha- rides and a scruple of camphor, to be well mixed with three drachms of the extract of bar!"?: ; and eight or ten grains of this mixtare to be given to children every third or fourth hour, according to the circumstances of the case, in a spoonful of water, in which a little of the balsam of copaiba was dissolved. He cured many cases in from five to six days. Another form, but less disagreeable to children, has been recommended by Mr. Sutcliflfe, of Settle ; * Lancet, vol. ii., 1838-39. REMEDIES RECOMMENDED IN PERTUSSIS. 325 tincture of bark, half an ounce ; paregoric elixir, half an ounce ; tincture of cantharides, one drachm : small doses of this mixture to be given three or four times a day, and gradually increased till a slight strangury is excited ; then tho dose is to be diminished, or taken at more distant intervals. Sometimes it succeeded without any strangury, and the hooping generally ceases in three or four days. Mr. SutclifFe never lost a patient with hoop- ing-cough. Dr. Lettsom, who was a pupil of Mr. SutclifFe, states that the use of this remedy has been at- tended with similar success in his own practice. Hufeland drew attention to this medicine in 1803, and found it a most excellent remedy in hooping-cough. He gave it in the dose of from three to eight drops in mucilaginous and bitter remedies, sometimes with bark, three times a day. He found it of great use when combined with opium. It has been recommended by the late Dr. Beatty,* and subsequently by his son, my kind friend, Dr. Thomas Beatty, of Dublin. In Dr. Graves' Clinical Medicine it is highly spoken of. He says, many authors have mentioned the tincture of cantharides as a medicine which has occasionally proved useful in hooping-cough. Most practitioners, however, are prejudiced against its employment, and prefer remedies which are not so likely to excite anxiety in the mind of the physician during the period of V ■' i iii 1 1 / I il 826 ON HOOPING-COUGH. their exhibition. " Such I confess \7ere my former feelings upon this subject, and my antipathy to the tincture of cantharides would have probably continued, had I not been persuaded by my friend, Dr. Thomas Beatty, to give the medicine a fair trial. He alleged in its favour his own experience, and that of his father, who had for many years employed the tincture of cantharides in the follow- ing formula : — $t) Tinctura Cinchonse composita, %v. „ Cantharidis. „ Opii camphorat. aa ^ss. M. F;. Mistura. One drachm of this may be taken in linseed-tea or barley-water three times a day, and if no strangury is produced it may be increased. A smaller dose will be necessary for an infant.'* It proved very successful in Dr. Graves' hands, who further re- marks that it produced no urinary irritation in a great number of cases. Dr. Copland has prescribed it in a number of cases, and found it to diminish the frequency and severity of the fits in the nervous stage, especially when irritation of the urinary organs was present. Dr. M'Gregor has furnished additional testimony of the value of this formula in hooping-cough.* Dr. Hamilton Roe tried this remedy in a few cases, but did not perceive that it produced any * The Lancet, vol. ii., 1846. REMEDIES RECOMMENDED IN PERTUSSIS. 327 good effect on the disease. Dr. Watson, in his Lectures on Medicine, thinks that digitalis and cantharides are hazardous remed* \ 37. Musk — CuUen does not speak favourably of this remedy. Mr. Hayes has found it useful, and gave from ten grains to half a drachm, with sugar, three or four times a day. Wolff, Horn, Gesner, and others, have recommended it. Marcus combined it with the sulphuret of antimony and magnesia. The Artificial Musk, invented by Margraf, and sanctioned by Van Swieten and Steelier, has been strongly recommended by Hufe- land, and generally goes by his name. He gave it in the form of emulsion. Mr. Bartly, of Brad- ford, prescribed it with success in the form of tinc- ture. Dr. Bellamy, of Preston, found the same remedy beneficial in a very hopeless case.* Aberle writes that Hufeland's artificial musk was found to produce no effect in his hands, 38. Assafoetida. — Dr. Millar first recommended this in 1769 in hooping-cough and asthma, but it appeared to be only successful when the disease was mild. Dr. Durr praises its use in the form of a clyster, the cough ceasing in two or three weeks. f Kopp states that children take this remedy with pleasure, when associated with an equal quantity of mu'^^i'^^ge and syrup. J Aberle has found assa- * Watt's Treatise. f Lancet, vol. i., 1837-38. X Barrier, vol. i., p. 154, H,ii|iJ|iHJ|i"W'«Wll. P,f«. 328 ON HOOPING-COUGH. .', / I foetida to be one of the most valuable antispas- modics in hooping-cough, but says it must not be employed whilst any marked symptoms of fever or of bronchial congestion are present. The dis- agreeable odour and taste of this substance must render it exceedingly repugnant to infants and young children. 39. Meadow Narcissus cured, in the form of extract, forty-two children with hooping-cough, which was raging at Valenciennes in 1786, ac- cording to M. Dufresnoye. Laennec says, that the infusion of the petals of the same plant, and ""^e extract, prove a sort of specific in hooping-cough during some years. He has performed cures with this plant alone, rapidly, in five or six days. 40. Cup Moss, Muscus or Lichen pyxidatus, mentioned by Willis as a specific?, and noticed by other authors, was a common remedy in the hands of old women, according to !Mr. Kayes. Gerarde remarks, that " the powder of i\hj mosse, given for certaine dales together, is a most certaine remedy for that perillous malady, the chin-cough." Dilenius praised the powder of it, when fre- quently given, and supported his opinion by the authority of Williu and Gerarde. Other writers have prescribed it in the form of decoction in milk. Van Woensel recommended it in decoction, sweet- ened with syrup of mint. REMEDIES RECOMMENDED IN PERTUSSIS. 329 itispas- not be f fever he dis- 3e must its and 'orm of -cough, 86, ac- hat the md -"^e ^-cough res with idatus, iced by hands jrerarde given ;ertaine cough." en fre- by the writers n milk. sweet- Baglivi employed also the Muscus arboreus and M. quernus in pertussis, in the form of decoo tion; and a syrup prepared from the decoction exists in the Wirtemburg Pharmacopoeia, to faci- litate its exhibition to children. Stoll found these mosses or lichens, particularly that growing on the oak, very serviceable in the hooping-cough, which was epidemic at Vienna in the spring of 1775; Frank ako praises it* 41 . Castor was recommended by Dr. Morris in 1767, but Cullen found it ineffectual, It was much employed by Morris and Horn. 42. Nux vomica. — The extract was recom- mended by Michaelis and Hufeland, conjoined with the extract of carduus henedictus. Dr. Copland has used it with manifest advantage, in circumstances similar to those in which he em- ployed cantharides. But he says neither the one nor the other ought to be resorted to in the first stage, or in the inflammatory complications. 43. Miscellaneous other Remedies. — Lobelia in- flata has been praised by Eberle and Dr. Andrews. Two drachms of the tincture added to the same quantity of syrup of squills has been given in doses of from sixteen to twenty minims, four or five times a-day, for a child of two years of age. This remedy alone is used in emetic doses by the Thomp- * Copland's Medical Dictionary. 330 ON HOOPING-COUGH. I) sonian practitioners in the United States. As an emetic when required, it is both a safe and a very valuable remedy. Polygala SeneJca. — The Senega or Virginian snake root is a medicine of much value in the complications of pneur^ >nia and bronchitis, and has proved very serviceable in my hands. It is strongly recommended by many American writers, and among others by Dr. Dewees, in the form of Coxe's hive sjrrup, which is made by boiling half a pound of senega root and dried squills, in eight pounds of water, over a slow fire, until half is con- sumed, and then adding to the strained liquor four pints of strained honey, and again boiling down to six pounds, and adding a grain of tartar emetic to each ounce. The dose must be regulated according to the age of the child, from six to eight drops or upwards, every hour or two.* Coro-watti. — A medicinal plant used by the natives of Biitish Guyana, in hooping-cough and other diseases, form.ed the subject of a paper by Dr. John Hancock before the Medico-Botanical Society,t and possessing this name. The infusion and syrup of the bruised root of this plant were used, and speedily cured an entire family. Lactuca viroaa. — Dr. Gumprecht speaks most highly of the extract of this, in the second stage, * Dewees on Diseases of Children, p. 437. -^ t Lancet, vol. i., 1836-37, p. 719. REMEDIES RECOMMENDED IN PERTUSSIS. 331 As an [ a very irginian in the ;is, and . It is writers, form of 5 half a n eight ■ is con- lor four iown to netic to cording Irops or by the gh and aper by otanical infusion nt were ts most d stage, in doses of half a grain, with sugar, three times a day, for children of two years of age.* Oil of Amher was recommended by Under- wood internally, when the spasms were exceedingly urgent. Valerian has been used by Mr. Kimbel and others, combined with opium and squills.f Elder Barh, the Samhucus niger, has been used as a preventive of hooping-cough. Potato; an infusion of the leaves and flowers has been recommended by M. Reichnelt.J Turnips. — Slices of the common garden turnip, covered with Canadian (maple) sugar; concen- trated docoction of black pepper, with an equal quantity of maple syrup; onion and capillaire syrups ; are all mentioned as popular remedies, by Dr. Von Iffland, of Quebec. § Ouaiacum was recommended by Hufeland and Veizhans; sa/ro?i, by Theussink ; Geum urha/nunrii by Keck and Buckhaave ; Phellandrinum aquor' ticum, by Von dem Busch ; isinglass, by Heineken and Gautieri; marsh- mallows, by Wahlbom; acetic acid with sugar, by Hannes ; sulphur, by Sydenham, Quarin, and Unzer; wild rosemary, by Linnaeus and Wahlbom; colchicum, by Haden and Alcock; Rhus vernix, garlic, electricity, * Med. Chir. Trans., vol. vi. p. 608. t Lancet, vol. i., 1829-30, p. 162. j Gazette ties Hopitaux, Aug. 1845. § Montreal- Med. Gazette, vol. i. 332 ON HOOPING-COUGH. millipedes, spurge-laurel, camphor, sal ammo- niac, saladne, and chloride of barium, by others. Mr. Edmondstone advises the wearing of some conspicuous article of dress, so that those who felt inclined, might keep beyond the sphere of contagion.* Ti'ocheotomy. — In the second volume of the Lancet for 1852, Dr. Marshall Hall has given a most important and valuable table of cases re- quiring tracheotomy. In the second division of this table, namely, cases of spasmodic laryngismus, it Avill be observed that " Pertussis threatening convulsions or hydrocephalus," forms its seventh division. He concludes his paper with the following questions : — 1. What is the abortive form of malady left by tracheotomy in the various convulsive diseases ? 2. What would be the abortive form of malady left by tracheotomy in formidable cases of per- tussis ? &c. &c. &c. The recommendation of this operation in certain forms of pertussis, as well as in other diseases, emanating from such high authority, is deserving of attention in those cases likely to prove fatal from their highly dangerous character, in their compli- cation with frequently recurring convulsions. * Edin. Med. Journal, vol. vii. 333 ammo- ' others. >f some )se who (here of of tJie given a ases re- ision of igismus, jatening seventh oUowing left by ases? malady of per- certain diseases, eserving tal from compli- is. CHAPTER XVIII. I - .V TREATMENT OP SIMPLE PERTUSSIS. One of the objects to be always kept in mind in the treatment of the simple form of this affection, is to keep it simple, and to guard as much as pos- sible against the danger of the complications — bronchitis and pneumonia especially. The disease, if left to itself, will in some instances run its usual course, and many physicians assert that this cannot be shortened or even interrupted by medicine. This is at variance with my own experience, and that of my friend Dr. Arnoldi. In one remarkable instance under my care, that of an infant nine months ol in the commencen the second stage, the disease was completely cut short in two days, followed by cure, i Roe entertains the same opinion as ourselves. On no account whatever should the child be allowed to cough it out, as is permitted by some mothers, who declare that it is only the hooping- cough tnat the child has. One of the causes of mischief, if not the prin- ciple one, is the violent and long-continued pa- roxysms of coughing, the consequences of which ^ \l 334 ON HOOPING-COUGH. have been already mentioned in other parts of this work — as congestions of internal organs and their subsequent results, the fertile sources of many of the complications, at a period of life, too, peculiarly favourable to their development. ^ Protraction of the disease is equally as dangerous as the severity of the symptoms. To mitigate these, and to shorten their duration as quickly as possible, is the aim to be held in view; and as a learned writer has properly re- marked, any remedy which can be found to arrest the disease, will be received with satisfaction. Dr. West remarks that there is nothing un- reasonable in the expectation that a remedy may some day or other be discovered, " which shall cut short its course with as much certainty as quinine arrests an intermittent fever, or which shall render the constitution insusceptible of its poison as in- fallibly as cow-pox preserves from variola.'' And Dr. Todd observes, that if we could find some material, which, when introduced into the system after it had received the poison, would neutralize that poison, then we should have the same power over this malady as we now possess over inter- mittent fever. It would be presumption in me to say that this substance has been discovered, but in its effects upon the disease, nitric acid, in whatever manner administered, not only arrests the paroxysms and TREATMENT OF SIMPLE PERTUSSIS. 335 j 8 of this Qil their many of jculiarly mgerous duration held in Derly re- to arrest Lon. ling un- ledy may shall cut I • • 3 quinine II render )n as in- " And . some system eutralize [le power 3r inter- :s that this effects manner rsms and removes the hoop, but shortens the disease almost as effectually as quinine does intermittent fever. It not only produces a powerful antispasmodic effect, but an equally tonic influence, and supplies to the blood an element — nitrogen — which removes or neutralises the excess of fibrine existing in that fluid— -one of the dangerous elements of the dis- ease — and so destroys the poisonous principle com- bined with it, which is the primary cause of the affection. If this remedy cures pertussis, it differs from the great majority of others, in the fact that its action in the economy can be explained upon rational grounds. Nitric acid possesses antiseptic properties in a high degree, and probably the influence of these assist materially in the cure by acting directly on the blood as well as supplying its nitrogen, and prevents the too rapid generation of the fibrine from the albumen. The nitrogen acts also as a sedative, in diminish- ing the stimulating effect of the oxygen so rapidly absorbed, and as an antispasmodic in allaying initation, and therefore lessening the severity of the paroxysms. If hydrocyanic acid is useful in many cases, it is as much owing to its nitrogen as the sedative and antispasmodic properties which it possesses. The presence of the excess of fibrine has been 336 ON HOOPING-COUGH. Vl! ,;■: u elsewhere explained to depend upon the frequent respirations, immediately after the paroxysms have ceased ; it may also be influenced by the peculiar poison itself which has contaminated the blood. Whatever remedy vill check this tendency mate- rially assists in the cure ; it is in this manner that ether and chloroform act by arresting the process of sanguineous super-oxidation, and, with the other properties possessed by those agents, equally assist in the cure. As a general tonic, nitric acid possesses the ad- vantages in pertussis of rapidly allaying the dys- pepsia, which is sometimes accompanied with sick- ness and irritability of the stomach. It restores the healthy state of the mucous membrane of the bronchi, it arrests the spasm,, diminishes the cough, and finally dispels the hoop altogether. Dr. Arnoldi and myself have never met with any ill effects from its use, and all the cases treated by it were carried to a successful issue, the cure in all being very speedy, with few exceptions, and the disease being at the same time abridged in the length of its ordinary duration. So far as expe- rience has shown, relapses after cure are very rare indeed. Should inflammation of the lungs or abdominal organs have set in previous to its employment, it must be avoided, and the treatment must be adopted as recommended for those complications in the next chapter. TREATMENT OF SIMPLE PERTUSSIS. 337 ■requent ms have peculiar e blood. !y mate- ner that J process he other [ly assist } the ad- the dys- rith sick- restores le of the le cough, aet with s treated 3 cure in and the i in the as expe- ^ery rare )dominal '^ment, it nust be lications But if we have reason to fear congestion of the brain or convulsions, the acid may still be safely given and with good results, for the purpose of lessening the paroxysms. It will also prove useful in the remittent fever, combined with other sub- stances, if there be no existing irritation. The details of a few cases only will now be given to illustrate the successful effects of this remedy, as all possess a similarity in their general features. My friend Dr. Amoldi has treated upwards of one hundred cases of pertussis with nitric acid, with the most satisfactory results, and since I com- menced its use, sixty-seven cases were cured at intervals varpng from two to fifteen days, but averaging between six and seven days. It may be as well to mention here that the ob- I ject entertained by Dr. Amoldi, in using this acid / as a remedy in pertussis, was to introduce the elements of the atmosphere into the blood by the process of gastric digestion, so as to enable the lungs to outstand the stage of temporary asphyxia, which always is induced during a severe paroxysm. Whether the theory be correct or not, the result, he says, of his practice has been almost universally successful. I think it not improbable that the greater por- tion of the oxygen is chemically appropriated be- fore the blood becomes sensibly relieved by the 3 K 338 ON HOOPING-COUGH. nitrogen, because if it were not so, a Rtill greater amount of fibrine would be formed, and a ten- dency to aggravation by inflammatory complica- tion would be the result. The following is an outline of a few of Dr. Amoldi's cases, kindly communicated to me by letter : — The four children of a medical confrere were violently affected in the depth of a very cold winter, three years ago, with all the disadvantages of being kept within doors in the intensely dry atmosphere of stove heat. In less than five days all were relieved by the use of the acid, and within three weeks they were all perfectly cured. At the post-office, the same winter, he saw two poor children in exactly the opposite condition, being turned out of house and home to beg, and who from their exposure were most alarmingly affected. To these was given a quart bottle of the acid mixture, which they took strictly, and when finished they applied for another, being very much relieved ; they were cured before the second mix- ture was taken. In his own family, his youngest child, aged six months, at the breast, was cured within a week. An elder child, who could not be prevailed upon to take it at first, suffered dreadfully for two months, after which he took a liking to it, and got well within a fortnight from the commencement of its use. TREATMENT OF SIMPLE PERTUSSIS. 339 He was called to two families residing at op- posite extremities of the town. Each had a lad about nine years of age so violently affected for several weeks that, besides bringing on bleeding from the nose, they were both ecchymosed round the eyes, as though they had been severely beaten. Both these boys were perfectly cured with three drachms of the acid, in two and three days. The case of a young lady. Miss S , aged fourteen, was very remarkable. She had been suffering for several days very much, and as she was of a very delicate habit of body, fears were entertained of the supervention of phthisis. She took the acid very freely ; she slept well the first night without a single paroxysm, and after the second day's treatment coughed no more. Another child at the breast, seven months old, was cured in eight days. As a good deal of similarity prevails in the general symptoms, it will be unnecessary to do more than to observe that the treatment was suc- cessful in all, at periods varying from two to twenty-one days. Dr. Arnoldi met with a few cases where the disease seemed to resist the action of the acid, owing to " spinal torpor at the track of the eighth pair and phrenic. In these the application of an ointment of the biniodide of mercury, so as tu z 2 I . /4 I 840 ON HOOPING-COUGH. produce the specific eruption, and this reproduced a second and a third time completely restored the efficacy of the acid/' Among my own cases were : — An infant nine months old, at the breast, and in the commencement of the second sta(_9, who was cured in the short space of two days. Other children were cured in three and five days. A child of Mrs. John D , aged two years, and ill six weeks, was violently affected with the di&ease, the paroxysms and hoop occurring fre- quently during the twenty-four houis, appearing to threaten suffocation. The acid on the first day lessened both their frequency and violence, on the third day they were greatly diminished, and by the eighth day the child was well. An infant a year old, at the breast, was severely affected for nearly two months, and when called to see the child it was in convulsions from the vio- lence of the paroxysms, and not from dentition. The acid was given to lessen the latter, which it did most effectually, with a recurrence once only of a second attack of the former. The cough and hoop entirely disappeared by the ninth day. A child aged three years, who had been Dl up- wards of three months in the winter season, and who was extremely emaciated, was put upon the acid, V hich improved the appetil 3 and strength, 1 TREATMENT OF SIMPLE PERTUSSIS. 341 reduced ored the )ast, ani k{_3, who and five vo years, with the ring fre- ppearing first day e, on the and by severely called to the vio- lentition. which it )nce only ugh and m Dl up- ison, and ipon the strength, lessened the cough and hoop, and on the mnth day produced convalescence. Of children between the second and fifth year, the cure was most generally effected between the fourth and fifteenth days. In infants the treat- ment was even more satisfactory, the duration of cure varying from the second and third to the tenth days. If the case became protracted, which it did in a few instances, it was entirely owing to the irregularity in the administration of the remedy. My own experience accords with that of my friend in the fact, that the disease is found to be invariably more tractable in infants at the breast txian in older children. His method of prescribing the medicine for hoop- ing-cough or asthma, will be found at page 311 of this work. In his paper on the subject in the first volume of the Canada Medical Journal, he mentions that he has given as much as one drachm and a half of tue acid during the day to a child o years of age, The following is the manner in which I have employed this powerful remedy for a child under two years of age :* — * The strength of the dilute acid of the London Pharnia- cop 1^ IS one part of the acid to nine parts of water, the ; .3 gravity being 1080. I prefer this lorm. r^.^wrr.. 342 5^ V^ ON HOOPING-COUGH. Acid. Nitrici dil 5xij. Tinct. Cardamomi Co 5"j- Spupi Simplicis Jujss. Aqu8B 5^- Fel, Acid, Nitrici dil 5^y- M. Tinct. Gentianse Comp. . . . . . 5is8. Mellis optimi . • 5ij- Syrupi Simplicis . . 5iss. Aquae • . 5i- M. Fiat Mistura. Capiat cochleare medium quaque hora, vel secunda quaque hora. For a very young infant, the dose may not exceed a teaspoonful every two hours. For children from two to five years of age, the quantity of the dilute acid may be increased to fifteen drachms for an eight-ounce mixture, well sweetened with the honey or syrup, and given in the dose of from two to three drachms every hour, or every second hour, during the day time par- ticularly. 9) Acid. Nitrici dil 5^^^- Tinct. Cardamomi Comp. . . 5^- Syrupi SirapUcis 5^vss. Aquse 5^- M- ^*- ^^^t. If the patient be an ad".lt, or above ten years of age, half an ounce of this mixture may be taken every hour. The enlightened practitioner will use his own judgment as to the proper dose, according to age and circumstances. m TREATMENT OF SIMPLE PERTUSSIS. 343 ss. M. M. hora, vel lay not ige, the 3ased to ire, well jiven in ry hour, ne par- Ft. Mist. years of e taken will use cording To prevent injury to the teeth, a gargle composed of two drachms of the carbonate of soda to eight ounces of water, may be used im/mediately after taking the acid mixture. When well sweetened and made very palatable, children get fond of this medicine, and eagerly look for its administration, when they find that it affords relief, by diminishing the frequency and severity of the paroxysms. It must be remembered that the more frequent administration of the medicine produces a more rapid effect in cutting short the disease ; and I have very seldom found it necessary to diminish the doses given, or even to caution the parents against its use. Nor have I seen any bad effects whatever from a persevering employment of it, in curing this disease. And its use has not been con- fined only to my friend Dr. Amoldi and myself, but many others employ it with equally beneficial results, in a climate, too, which severely aggravates the malady, necessarily from the lowness of the temperature in the winter season, and the variable alternations in the spring and fall of the year. As pertussis is not an inflammatory affection, no treatment of an antiphlogistic character is required, but if we see the disease in a plethoric child, with much congestion about the face and neck during the paroxysms, we may with propriety apply one or two leeches to the upper part of the back of .rB?0«F<»»IIJ(|!«llll« •JW"W«|W»«iUiHiH. v\ 344 ON HOOPING-COUGH. the neck, in the hollow which is so distinct in young children, and not trust to the acid alone. In like manner, if congestion of the lungs is found, the acid may be stopped, and leeches applied to the chest, but this has never proved necessary in the course of my experience. A troublesome s^-Triptom, which often causes anxiety, is the wheezing in the chest, from the mucous secretion in the lungs. It will be quite proper to give a mild emetic of ipecacuanha every evening, to unload the bronchial tubes, or as often as circumstances may render it necessary. This will prove very beneficial, and will add much to the comfort of the child. Over-treatment in the simple form of this affec- tion is particularly to be avoided. When the disease has nearly disappeared, if the season of the year will permit, the commencement of the summer, for instance, we may then aUow change of air, to renovate the health and restore the strength of the perhaps much weaken ^d child. A change from the town to the country will be desirable, and such other strengthening treatment adopted as may be considered proper. Hygienic measures are of great importance in hooping-cough, and assist most materially in ward- ing off the complications, as well as expediting the cure. The child should be kept in a well-regulated and TREATMENT OF SIMPLE PERTUSSIS. 345 Lstinct in ilone. lungs is leeches jr proved 3n causes from the be quite Liha every r as often ,ry. This much to bhis affec- ed, if the encement len allow d restore id child. Y will be ireatment Ttance in in ward- liting the lated and equable temperature of about sixty-four degrees, free from fluctuations of any kind, with an absence of both cold and moisture ; this is essential in the winter months especially, and in spring and autumn. A confinement to an airy nursery or bedroom, properly ventilated with pure air, with a careful avoidance of cold draughts, will be most proper ; or perhaps a large airy apartment to serve both as nursery and bedroom would be prefer- able, with attention to uniformity of temperature. Children should not be allowed to run aoout the house, upon the lobbies and staircases particularly, where draughts of air abound, and necessarily increase the severity and frequency of the cough, from the increased irritability of the bronchi. Attention to matters apparently so simple, proves oftentimes of great importance indeed. The popular error of exposure to cold and open air is to be avoided by every rational practitioner. In the warm months of summer, if the patient is a healthy child, absolute confinement to the house may not be necessary. The clothing should be warm and comfortable at all sea.st. The administration of — 1. Nitric acid; 2. Chloroform inhalations; 3. The same with Ether; and 4. Hydroc^ '^nic acid. The first requires little commc I have given it in a case complicated with convulsions, with the most perfect safety und the best results. It sup- plies nitrogen to the blood, and prevents the ten- dency to the formation of fibrine, with which that fluid is already supercharged. It is therefore pre- ferable to the three following : — The second and third are recommended by Dr. Churchill, and are not contra-indicated here ; they act in a similar manner to the nitric acid in relieving the cough, and also possess the remark- able tendency to prevent the formation of fibrine. Their depressing influence, however, requires cau- tion in their use. \ Ml V 364 ON HOOPING-COUGH. s^l / I The fourth, from its powerfully sedative action, will relieve the cough, but in the cases mentioned by Dr. Roe, it was of no avail for weeks, until the head was relieved. With regard to hydrocephalus, we must re- member, that in conjunction with pertussis, un- fortunately, this affection is more than usually fatal, and requires all our attention. Our treat- ment must be more active, to prevent, if possible, the accession of such a formidable malady. The means must be regulated to the age and constitu- ;tion of the child; and, in the event of possible recovery, a long and exhausting disorder has to be encountered. The hoop and cough almost always cease here, and the child lies in a state of more or less uncon- sciousness. If the attack is recent, leeching will be abso- lutely necessary, with cold applications to the head; blisters behind the neck or ears, or upon the head, or flying blisters upon the forehead and head; sinapisms to the legs; and purgative medi- cines. Above all, we must give a fair trial to mercury ill whatever manner it may be best borne by the child, combined with James's powder; and afterwards the iodide of potassium in small doses. Shoi^ld we be successful in controlling the second- ary jlSection, a more liberal use of tonics will be \ TREATMENT OF COMPLICATIONS. 365 required with a more generous diet, and change of air, at an earlier period than is usual in the idiopathic brain affection. In the treatment of all cerebral complications in pertussi;., we must remember how much more dangerous they are than those which occur pri- marily: our efforts must therefore be always early directed to the warding off such evils, rather than to wait until they have fairly shown themselves. Sanguineous Apoplexy. — If the symptoms of cerebral congestion manifest themselves, and threaten apoplexy, the immediate abstraction of a sufficient quantity of blood will be necessary, its repetition to be guided by the effects on the system of the first bleeding. Should the drowsiness and stupor diminish, and the child appear more conscious of what is passing, with a return of intelligence, the bleeding may either be repeated at an interval, or we must have recourse to counter -irritation by means of blisters, cold lotions to the head, and active purgatives. On the other hand, if there is no return of sen- sibility, or diminution of the stupor or coma with stertorous breathing, the case is then one of apo- plexy from effusion of blood or of serum — the former if the coma and stertor have been rapid — and any treatment employed will be in vain. Active measures may be tried by blisters and sinapisms, with free depletion by blood-letting, and IV (> . mfmmf m^ 366 ON HOOPINO-COUGH. the administration of calomel in small doses, with mercurial inunction. With all these, it is ex- tremely improbable any benefit will arise from their use. Infantile Remittent. — The cough becomes more distressing according to the increase of the fever, particularly if it follows upon a previously dis- ordered condition of the bowels; the fever therefore is what calls for relief in the treatment. Attention to the state of the bowels also is absolutely neces- sary. The observations upon purgative medicines in the next section will be applicable here. The torpor of the bowels is sometimes so great as to be unrelieved by ordinary medicines, until some of the local congestions have been removed by leeching to the epigastrium or temples. Calomel alone, or with rhubarb and jalap, given so as to produce three or four evacuations daily, will be proper. If, on the contrary, they are purged, or in a very irritable state, we must quiet them with chalk mixture and a drop or two of laudanum, or a little hydrargyrum cum cret4, rhubarb, and Dover's powder, given three times a day. If it depend upon teething the gums must be lanced. Warm baths are very beneficial and soothing; fomentations or poultices of linseed meal to the abdomen are of great use. If it is desired to J, with is ex- ! from s more } fever, ly dis- lerefore tention r neces- jdicines 30 great }s, until removed ^alomel 30 as to ■will be h or m a chalk a little Dover's Qust be »othing; to the ired to ' TREATMENT OF COMPLICATIONS. 367 produce mild counter-irritation, a fourth part of mustard may be added to the poult:c<^. A saline mixture of nitre and mild autiiiionials assists very much in abating the fever, but it mxic*- be omitted if it acts too much on the bowels. If no irritation is present, small doses of nitric acid combined with nitric ether, and cinnamon water, sweetened with syrup, will not only relieve the fever, but arrest the severity and frequency of the cough. The following prescription will be found of great benefit: — $t Acid. Nitrici dil 5^ss- .Athens nitrosi 5iss. Syr. Simp 5J- Aquse cinnam Ji^ss. M. A dessert-spoonful to be given every three hours, for a cliild of from three to four years old. If the fever is intense, and the exacerbations very severe, leeches to the abdomen have been, recommended. They will prove useful in com- bating the tendency to hydrocephalus in this affection. If it should persist after the regulation of the stomach and bowels, minute doses of quinine may also be given, and the diet carefully regulated. This should be light, such as milk in any form, with arrowroot, sago, tapioca, Indian-corn starch, &c., with cooling drinks ad libitum. SBf^TwpiTWPHy :// by I" /, .(y I i. 'Ml H 368 ON HOOPING-COUGH. As it is often necessary to support the strength from the debility which is present, a little wine and water, or wine and arrowroot, may be given with benefit ; and a more liberal diet of beef tea, chicken soup, &c. Careful attention will in many cases prevent the diarrhoea and intestinal disorder, which are so often concomitant in pertussis. Intestmal derange- ment should always excite our solicitude, and should be corrected by keeping up the regular action of the bowels. If they are constipated, we may give a brisk purgfi tive of calomel, scammony and rhubarb, foUowt I by an enema, if the medicine is in- effectual. It is not unusual to observe obstinate constipa- tion present when congestion of the brain or about the head is considerable, and this will not yield to medicine until after the head is relieved by bleed- ing, as already mentioned in the treatment of remittent fever. If the discharges from the bowels are unhealthy in colour or smell, without constipation, which are not infrequent, mild laxatives only, such as small doses of calomel or hydrargyrum cum creta with rhubarb, will be found sufficient to excite a beneficial action upon the mucous membrane, and restore the natural secretions. Purging miist never be carried too far, as it may produce tenesmus, scanty mucous stools, and tender- il i' TREATMENT OF COMPLICATIONS. 369 rength e wine ! given jef tea, ent the are so erange- l should n of the r give a hubarb, ! is in- onstipa- )r about yield to jr bleed- DQent of ihealthy liich are IS small 3ta with xcite a me, and 3 it may tender- ness of the belly, which will greatly aggravate the cough, and may lead to incurable marasmus. When diarrhoea is present, which is very often and very considerable, and induced sometimes by congestion of the brain or serious disease in the lungs, it is most important to stop it gradually ; it masks the presence of these diseases. For this purpose some mild astringent medicine should be given, such as chalk mixture, compound powder of chalk, powder of chalk with opiiun, &c. I prefer equal parts of hydrargyrum cum cret4 and rhubarb, with small quantities of Dover's powder, repeated three or four times a day. Dr. Churchill advises the following simple mixture for a child a year old : — 9* Mist. Cretee 5J' Confect. Aromat gr- v. Syr. Zingib 5^* .. TinctursB Opii gutt. ij. M. Cap. coch. j. parv. ter quarterve in die. Increasing the quantity of laudanum if the child be older, and adding a little tincture of kino or catechu if the purging be obstinate. Poppy or warm-water fomentations to the abdomen will allay irritation; or gentle frictions of compound camphor liniment and laudanum, or of very mild tobacco liniment, will prove useful. When aU other means fail, a small starch enema, B B II ! . i 370 ON HOOPING-COUGH. with a few drops of laudanum, will often arrest the diarrhoea. ' If the diarrhoea is proving a salut'^ry discharge, and not otherwise injurious, it may not be arrested unless it becomes violent. The irritability of the stomach, with occasional vomiting, is often very distressing, and trouble- some to arrest. The greatest care should be taken to feed the child in very small quantities at a time, and if it throw up its nurse's milk, to suspend it for a few hours, and give a teaspoonftil of water two or three times within half an hour, and if retained, to follow it by a little isinglass in water in the same quantity, frequently repeated, as recommended by Dr. West. It may be proper, if this irritability continues, to give very small doses of calomel upon the tongue, and to apply a mustard poultice to the epi- gastrium. If the symptoms assume those of remittent fever, it is to them our attention must be directed, and the treatment adopted as described in the last section. Softening of the Stomach. — There is no special treatment for this affection. Should we be enabled to diagnose the inflammation at the commence- ment, we might use the remedies for gastritis, and, if successful, prevent the stage of softening. Killiet and Barthez recommend chiefly the i m TREATMENT OF COMPLICATIONS. 371 gummy extract of opium, or, if this cannot be given internally, muriate of morphia is to be sprinkled over a small blistered surface at the epigastrium. Dr. Lion, of Breslau, depends principally upon external means and a suitable diet, very small quantities of food at a time, a warm bath, mild enemata, exercise in the open air, an aromatic plaster to the stomach, and internally the decoction of acorns, carbonate of iron, or the tinctura ferri muriatis.* General Dropsy. — Dropsies ordinarily disappear when the paroxysms have ceased, and the patients gain their strength ; we may promote absorption by diuretics, diaphoretics, but above all by tonics, with good diet and regimen. Should ascites prove troublesome and resist the ordinary treatment, diuretics may be tried ex- ternally, as recommended by Dr. Christison, of Edinburgh, and subsequently by my friend Dr. David, of MontreaLf A liniment composed of equal parts of tinctures of digitalis, squills, and soap, is to be rubbed into the abdomen three or four times a day. I can testify to the remarkable effects of this form of treatment, having used it * Eanking's Abstract, vol. i., aad Churchill on Diseases of Cliildren. f Canada Medical Journal, vol. i. p. 527. bb2 372 ON HOOPING-COUGH. successfully in a. case of renal dropsy, which had resisted all other means of cure. When the Exanthemata arise during pertussis, our aim must be to conduct them by proper management to the end of their course, without interruption ; their sudden subsidence may pro- duce extreme dyspnoea and a short harassing cough, with dangerous cerebral symptoms, and our efforts must be directed to prevent this. The presence of any of these will sometimes produce a temporary abatement in the paroxysms of the cough, and the eruptive disease itself will progress favourably. When measles or scarlatina are present, we must always apprehend an attack of bronchitis or pneumonia, and therefore be prepared to meet it. . . The treatment of measles will be very simple in mild cases, — confinement to a warm chamber, a spare diet, and gentle antiphlogistic remedies. Small doses of antimonial and ipecacuanha wine, with laudanum or the compound tincture of camphor, given every few hours, will relieve the cough. A blister the size of a shilling, applied to the trachea, at the point just above the sternum, for three or four hours, without vesication, and now and then repeated during the course of this affection, will prove useful. Scarlatina requires little interference ; all that is necessary being a cool, well-ventilated chamber. ^IP "■■p TREATMENT OF COMPLICATIONS. 373 a spare diet, mild antiphlogistic medicine during the progress of the fever, and occasionally sponging the surface with warm water to relieve the heat of skin. When the disease is small-pox we must adopt a cooling regimen, a spare diet, and inild antiphlo- gistic medicines. The bowels are to be kept gently open, and fresh air admitted into the chamber. Should convulsions occur, or frequently recur, or end in coma, we must use depletion with an unsparing hand, as cerebral congestion, which attends the onset of the eruptive fevers, if not speedily relieved, may prove very quickly fatal. Varicella requires no treatment beyond a mild antiphlogistic regimen. Tuberculosis, in its origin, may be often attri- buted to an attack of measles, preceding the per- tussis ; it may succeed to the intercurrent bronchitis or pneumonia, or it may develop itself in conse- quence of the existence of a scrofulous diathesis, in the course of the affection. It may not be sus- pected for some time, until haemoptysis or some other symptom will draw our attention to it. When we have a strong suspicion that it may subsequently show itself, or are satisfied as to the truth of its presence, our treatment must be either preventive, curative, — when the disease is incipient or limited in extent, — or palliative. In the child affected with pertussis, both the ..A 374 ON HOOPING-COUGH. preventive and curative treatment may be said to be the same, as what might be recommended for the former — such as change of climate, &;c. — in a grown-up child or an adult cannot be adopted here. . Cod-liver oil may be given with the most beneficial effects, and its influence on children will be often pretty certain and conspicuous. It will be of im- . portance to arrest the violence of the cough, and the phthisical symptoms need not prevent our giving the nitric acid, which of itself has proved of much value in relieving the cough in phthisis, according to the experience of my friend, Dr. Arnoldi, of Montreal. Such other remedies as are recommended in tubercular affections will be employed by iae enlightened practitioner as they may suggest them- selves, according to the indications present in the course of this complication. When the pregnant female is attacked with hooping-cough, our efforts must be directed to supporting the strength and relieving the effects of the pertussal disease. What has been said in the treatment of the simple affection will be applicable here, only the nitric acid must be given in the proper doses for adults, and proper attention paid to the general comfort and convenience of the patient In hysteria, likewise, the same treatment must be adopted ; it was not used in the case described, "W" TREATMENT OF COMPUCATIONS. 375 and therefore may prove successful in a similar one. The peculiarity of this complication is such, that it becomes a matter of no ordinary difficulty to pro- nounce what will be useful in the event of nitric acid, combined with other general and moral treat- ment, proving unavailing. INDEX OF NAMES. Aaskon, 216 Aberle, 11, 13, 37, 231, 240, 279, 286, 290, 313, 318, 327 A(1am, Thomas, 323 Albers, of Bonn, 165 Aibers, of Bremen, 181 Alberti, 17, 216 Alcock, 155, 186, 331 » Aldereon, 131, 147, 161, 162, 164, 167, 186 Alison, S. Scott, 301 Alnatt, B. H., 192, 322 Ambrosiis, 323 Amstein, 265 Andral, 169 Andrews, 329 Arand, 216 Armstrong, 164, 266, 266, 272, > 289, 321 NvAmoldi, Francis, 44, 196, 311, ^ 833, 336, 338, 343, 374 Astruc, 13, 165, 179, 264, 266 Atlee, Edwin, 277 Autenrieth, 166, 192, 269 Avicenna, 10, 291 Badham, 181 BagUvi, 329 BaiUou, 214 Bailly, 162 Bang, 216, 289 Barclay, 223 Baron, 165 Barrier, 60, 70, 74, 77, 90, 100, 127, 166, 196, 237, ?f)6, 323 Barth'-z, 18, 76, 134, 169, 196, 246, 370 Bartly, 327 Basseville, 19 Beatty, Francis, 136, 273 Beatty, Thoma/i, 326, 326 Becquerel, 169 Bedford, Gunning S., 280 Begin, 185 Behr, 276 BeU, Sir Charles, 8 Bellamy, 327 Berger, 293 Billard, 73, 100, 126, 166, 241 Bird, Qolding, 37, 127, 132, 316 Bisset, 266, 266 Blache, 17, 37, 77, 104, 107, 126, 131, 165, 195, 230, 238, 323 Blackett, 28:3 Blaud de lleaucaire, 17, 191, 282, 321 Boccardi, 323, 324 Boehme, 178 Boehmer, 218 Boisseau, 181, 185 Bonino, 139 Bouchnt, 18 Bourdelin, 19 Bourdet, 19 Bow, 271 Bowman, 9 Brendel, 17, 216 Brendt, 271 INDEX OF NAMES. 377 Brachet, 288 Breschet, 165, 183 Brodhurst, 144 Brofferio, 281, 282 BrouBsais, 180, 181 Brouzet, 178 Buci->iaave, 216, 282, 331 Burpn, 40 265 Burk?: loO, 324 Butter,' 17, 117, 178, 232, 289 Carpenter, 7, 204, 206, 210 CelleusuB, 12 Chambnn, 180 CharmiA. )n, Claude, case of, 90, 128 Chavasse, 297 Chevallier, 323 Chowne, 132, 274 Christison, 371 Churchill, 18, 39, 43, 63, 62, 73, 78, 80, 87, 90, 93, 202, 244, 280, 286, 303, 348, 363, 368, 363 aarus, 166 Cleeye, 324 Clement, 127 Closius, 268 Coley, 18 Condie, 18, 36, 277, 282, 289 Conradi, 216 Constant, 78, 230, 323 Copland. 14, 17, 47, 73, 96, 104, 110, 126, 135, 141, 165, 169, 185, 198, 209, 241, 264, 270, 274, 309, 321, 326, 329 CouUon, 276 Courbette, 308 Crell, 296 Crisp, 263, 279 CuUen, 20, 40, 179, 240, 256, 287, 327 Dans, 215 Danz, 17, 179 Darcey, 179 Darwin, 181, 290 David, Aaron H., 371 Davies, David, 318 Davies, Henry, 317 Dawson, 181 Debreyne, 286 De Haen, 268 De Meza, 216 Desault, 179 Deshays, Clemence, case of, 107 Desruelles, 17, 20, 37, 188, 236, 241, 243 De Thou, 14, 214, 243 Dewees, 18, 60, 181, 197, "41, 288, 330 Dilenius, 328 Dillon, 183 Dioscorides, 13 Dohm, 303 Drake, 290 Dufresnoy, 328 Duges, 17, 40, 181, 238, 241 Duncan, James, 108, 194, 195 Dunglison, 9 Durando, 323 Durr, 319, 327 Du Villard, 281 Eberle, 18, 67, 183, 241, 266, 329 Edmondstone, 332 EUiotson, 67, 160, 259, 266, 273, 279, 288, 294 Emerson, 35 Evanson, 18, 190, 267, 286 Eyerel, 216 Fabronne, 323 Ferrari, 323 Ferriar, 105, 272, 292 Fife, 186, 261, 266, 271 Fontaneilles, 276 Fothergill, 267 Fourcade Prunet, 182 Frank, Jos., 194, 216, 329 Fretis, 221 .vws''^' w.v:" r¥tt»>?!3F m\ 378 Friborg, 178 Fuchs, 318 Galen, 10, 291 Gardien, 11, 180, 241 Gautieri, 331 Gavarret, 169 Geigel, 319 Galler, 216 Gendrin, 232 Gerarde, 328 Gerrard, 162 Gesner, 290, 327 Gibb, Alex., 221 Girtanner, 172, 178 Gombette, 323 Gooch, 268 Good, Mason, 20, 50, 257 Granville, 276 Graves, 259, 269, 274, 295, 326 Gregory, 11, 186, 241, 260, 265, 270, 273, 320 Griva, 323 Gross, 133 Guersent, 17, 51, 156, 163, 170, 187, 231, 239, 241, 282, 309 Guibert, 17, 183 Gumprecht, 330 Guyot, 195, 306, 807 Haden, 331 Hall, Marshall, 7, 122, 332 Haller 215 Hamilton, 61, 237, 241, 265, 270 Hancock, 226, 330 Hannes, 268, 331 Hargens, 216 Hart, 296 Hartmann, 215 Harvey, 178 Hasse, 132, 187, 197 Hassall, 9 Hayes, 256, 272, 327 Heberden, 67, 90 Heineken, 276, 331 INDEX OF NAMES. Henke, 309 Henning, 268, 271 Herapath, 135, 139, 140 Hillary, 225, 241, 256 Hinze, 216 Hippocrates, 10 Hirschel, 268 Hislop, 300 Hoffman, 16, 19, 178, 216, 254 Holdefreund, 215, 268 Holzhausen, 166 Home, 255 Hood, 57 Horn, 327, 329 Hue, 219, 221 Hufeland, 182, 189, 216, 264, 282, 308, 325 Huxham, 20, 178, 255 Jackson, 282, 283 Jadelot, 165 Jahn, 183, 215 Joerdens, 290 Joerg, 281 Johnston, 18, 57, 86, 136, 188, 241, 308, 362 Jones, J. G., 179 Jones, of HaU, 293 Joubert, 300 Jumer, 323 Kahleiss, 276, 283, 284 Keck, 331 Kellie, 83 Keutsch, 268 Kilian, Herman, 165 Kimbel, 292, 321, 331 Kirkes, 6 Klinge, 215 Klluger, 215 Kochler, 216 KoUiker, 3 Kopp, 215, 285, 32 Kortum, 216 Kreysig, 218 Krimer, 281 Laei 1 2 Laj( Lan I L. Leh] Len Ler( Lett 2 Ley, Lieu Lilb Lina Lini Lioi Littl Lob< 2) Lom Lud' Lure Mag( Man 32 Mar^ Marl Man Mart Man Matt Maui Megl Mei$ Melli Mem Merr Mett Metz Meye Meze Mich Mille INDEX OF NAMES. 379 Laennec, 19, 50, 52, 126, 128, l£u, 175, 197, 206, 210, 214, 241, 327 Lajoie, H. A., case of, 128 Lando, 109, 216 I -ard, 220 L.^ondre, 162 Lehmann, 169 Lentin, 179 Leroy, 185 Lettsom, 143, 167, 171, 179, 255, 325 Ley, 161, 195 Lieutaud, 255 Lilbum, 139 Linacre, 324 LinnsBus, 179, 215, 331 Lion, 371 Little, 271 Lobenstein Lobel, 170, 183, 215, 271 Lombard, 37, 289, 294, 296 Ludwin, 88 Luroth, 269 Magendie, 63 Marcus, 17, 163, 165, 181, 236, 327 Margraf, 327 Marley, 60, 89, 303 Marsh, Sir Henry, 47, 48 Martin, J. R., 219 Marx, 215 Mattura, 323 Maunsell, 18, 190, 267, 286 Meglin, 282 Meigs, 18 Mellin, 215 Memminger, 320 Merriman, 272 Mettemich, 218 Metzer, 215 Meyer, 271 Mezeray, 14 Michaelis, 216, 329 Miller, James, 106 Millar, 17, 179, 255, 308, 327 Millot, 180 Miquel, 284 Morehead, 147, 168 Morris, 329 Moseley, 295, 318 Moutain, 324 Muhrbeck, 276 Mackenzie, Rev. D,, 227 Mackintosh, 11, 44, 103, 136, 155, 167, 163, 166, 170, 182, 258, 263, 269 McGregor, 239, 240, 274, 326 McVeagh, 274 Navier, 265 Neumann, 193 Nurnberger, 215 Okes, 324 Orlandini, 323 Otto, 185 Ozanam, 16, 122, 163, 169, 218, 226, 235, 241 Paget, 6 Pal dam, 17 Paldamus, 184, 216 Panzani, 218 Paris, 270 Pasquier, 14, 243 Paterson, 303 Pavesi, 281, 303, 314, 319, 320 Pearson, 288, 320 Penada, 218 Percival, 296 Pereira, 6Q Perrada, 17 Perroton, 322 Pfeiffer, Ida, 217, 221 Pickford, 308 Pidduck, 199, 206, 209, 264 Pilcher, 145 Pinel, 183 Platerius, 291 Pohl, 215 ^ 380 INDEX OF NAMES. § I- ' I * I S I I'M ill s. til II I ;j I, u Prunel, 19 Quorin, 268, 308, 331 Rainey, 4, 62 Raniie, 216 R66ce 297 R«e8,'Q. A., 18, 166, 279, 285, 295, 308 Reichnelt, 331 Reisseissen, 61, 198, 210 Rhazes, 10 Rhodier, 169 Richardson, B. W., 64, 306 Richardson, Sir John, 223 Richter, 236 Rilliet, 18, 75, 134, 159, 196, 245, 370 Riverius, 179, 214 Roo, 17, 39, 61, 73, 95, 108, 133, 172, 196, 238, 265, 277, 279, 288, 326, 333, 366, 362 Rokitansky, 194 Rosen, 13, 16, 102, 122, 179, 216, 238, 351 Rostan, 181, 238 Rousseau, 270 Rufz, 162 Sanders "^00, 209 Sandras, z73 Sauvages, 19, 214, 255, 297 Schaeffer, 216, 282 Scheidemantel, 296 Schenck, 19 Schlesinger, 268 Schmidt, 319 Schneider, 289 Sebregondi, 318 Sennert, 214, 243 Sigmond, 283 Simmons, 291 Simon, 169 Simpson, J. Y., 117 Sims, 168, 241, 254, 308 Sloano, 225 Smith, Gumey, 89 Spender, 289 Sprengel, 12 Stanger, 295 Stewart, 18, 241, 277, 282, 303 Stoeller, 327 Stokes, 359 Stoll, 109, 178, 216, 241, 290, 322, 329 Storck, 289, 296 Straack, 218 Streeter, 56, 191 Streuve, 216, 269 Strohl, 128 Strong, 179 Striim, 216 Stutz, 320 Styx, 180, 216 Sulzer, 216 Sutcliffe, 324, 325 Swan, 254 Sydenham, 16, 20, 178, 206, 253, 256, 331 TampHn, 142 Tate, 122 Tavernier, 39 Teman, 292 Theussink, 331 Thiel, 309, 310 Thilenius, 215, 290 Thomas, 262, 265, 272 Thompson, Theophilus, 285 Thomson, 323 Todd, R. B., 9, 67, 202, 204, 206, 208, 209, 241, 334, 346, 348 Tode, 296 Tourtelle, 20, 180 Townsend, 134, 135 Trousseau, 284, 308 Underwood, 18, 241, 831 Unzer, 215, 268, 331 Vacane, 323 ■tHP "^ 272 lus, 286 ', 202, 204, 1, 334, 346, INDEX OF NAMES. 381 7, 282, 308 , 241, 290, 178, 206, Valleix, 70, 114, 246, 267 Van de Sande, 268 Van Swieten, 327 Van Woensel, 328 Veizhans, 331 Volk, Wm. W., 284 Volkmann, 9 Volz, 108, 193, 194, 294, 319 Von Berger, 216 Von dem Busch, 189, 241, 331 Von Iffland, 44, 116, 267, 270, 331 Waohtl 312, 313 Waddinjj+on, 302 Wagstaff, l'<8, 30C Wahlborn, 331 Waldschmidt, 178 Waller, Wm, J., 271 Waller, Charles, 285 Wansbrough, 302 Ward, Ogier, 65, 187, 200, 206, 209, 241, 264, 266, 359 Warreu, 272 WatBon, Thos., 67, 89, 95, 118, 122, 128, 133, 164, 196, 206, 241, 261, 268, 279, 290 Watson, Eben., 190, 297-8, 300 Watson, Sir Wm., 268 Watt, 13, 18, 30, 46, 103, 106, 110, 132, 143, 147, 156, 168, 181, 194, 230, 262, 257, 272, 302 Webster, 107, 164, 184, 262 Wendt, 186, 241 West, 40, 49, 56, 58, 62, 69, 81, 84, 87, 92, 97, 99, 106, 112, 131, 166, 231, 234, 240, 242, 280, 310, 318, 834 Wezler, 216 Whatton, 263 Whytte, 308 Widemann, 282 Wigand, 290 Wilde, W. E., 28, 146, 147, 220, 221 Willan, 263 Williams, 9, 16, 37, 53, 127, 161, 284 Willis, 15, 17, 178, 206, 254, 265, 271, 328 Willis, Robert, 306 Willshire, 127, 266, 285 Winckler, 216, 296 Wolff, 290, 327 Wunderlich, 99, 102, 123 Zadig, 271 I, S31 31 1 GENEEAL INDEX. 11 .■I* Abdominal complications, 169 Abortion from hooping-cough, 116 Absence of the first stage, 39 ,, of the hoop, 39, 40, 58 Acetic acid, 331 Afiinity of poisons for certain tissues, 203 Africa, hooping-cough in, 221 Age, influence of, on the disease, 229 Ages at which the disease occurs, 56, 57, 58 ,, of deaths in London, 23, 24 in Ireland, 28 in Glasgow, 31 in Montreal, 35 Aged, the disease in the, 57 ,, ,, ,, prognosis of, 249 Air, change of, 272 Air-cells of the lungs, 4 their arrangement, 4, 5 forming lobules, 6 size and form of, 5 their walls, how formed, 5 lining membrane of, 5 fibrous character of, 5 disposition of capillaries on, 5 Alkalies, 320 Alum, 315 Amber, oil of, 331 America, North, hooping-cough in, 222 ,, South, ,, ,, 225 Ammonia, liquor of, 322 ,, muriate of, 322 Analytical Sanitary Commission, 354 Anatomy of the lungs, 1 Ancients, arsenic used by, 291 Antimouials, 267 > :! •P^ GENERAL INDEX. 383 Antiquity of the disease, 10, 12, 17, 213 overlooked by the ancients, 10, 11 allusion to, by Hippocrates, 10 probably confounded with asthma, 11 difference of opinion among modem writers, 11 to 17 ancient chronicle of Celleusus, 12 »> ft ft ft ft tt ft ft tt tt Apoplexy of the brain, 89, 166 ,, of the lungs, 166 ,, capillary, 92 ,, treatment of, 865 Appetite, excessive, 48 Arabs, disease unknown among, 220 Aromatic herbs, fumigations of, 303 Arsenic, 291 Artery, temporal, opening of, 363 Asia, hooping-cough in, 218 Assafoetida, 827 Asthma, 122, 147 ,, from emphysema, 133, 161 ,, analogy to pertussis, 176, 205 ,, spasmodic, cause of, 9 Australia, hooping-cough in, 226 Barium, chloride of, 332 Baths, warm, 275 Belladonna, 282 Benzoin, vapour of, 303 Blisters, 271 Blood, pathology of, 168 ,, increase of fibrine in, 64, 164, 168, 176 „ toxication of, 206, 211, 240 ,, disease, considered by the early writers, 206 Blue cough, 19 Bluish appearance of eyes and lips, 44 Bones, diseases of, 142 Brain, congestion of, 80 ,, treatment of, 860 ,, apoplexy of, 166, 89 ,, pathology of, 163 Bronchial glands, pathology of, 161, 165 ,, ,, tuberculosis of, diagnosis, 246 ,, enlarged, cause of pertussis, 197 Bronchial tubes, structure, 3, 4 their muscular fibres, 4 manner of termination, 4 T »» <9mipjfK^ipipp^qinifl|^jii^afV!>i| 384 GENERAL INDEX. ' ■■ V it Bronchial tubes, consequences of obstruction, 5 contractile power of, 8 nerves supplying, 6 pathology of, 164 spasmodic contraction of, 198, 208, 210 hypertrophy of muscular fibres of, 150, 152, 161 174 dilatation of, 125, 166 ,, ,, causes of, 157 to 159 ,, ,, how produced, 158, 169 Bronchitis, 67 treatment of, 352 diagnosis from pertussis, 71, 245 M >l »> >> If Camphor, 332 Canadas, hooping-cough in, 223 ,, ,, ,, its importation, 15 Cantharides, 269, 324 Capillaire syrup, 331 Capillaries of the lungs, 5, 6 Carnification of the lungs, 78, 160, 162 Cases treated by nitric acid, 337, 340 Castor, 329 Catarrhal stage, symptoms of, 37 ,, ,, duration of, 40 ,, ,, unusual protraction of, 41 ,, ,, effects of long continuance, 68 Causes of pertussis, 229 Cauterization of the throat, 297 Chest, contents of, 1 Chicken-pox, 105 ,, ,, treatment of, 373 Chloride of sodium in the lungs, a supposed cause of pertussis, 192 Chloroform, 304 ,, and nitric acid, 348 to 350 Circulatory apparatus of lungs, 3 Climate and Season, influence of, 233 Climates, a disease of all, 213 Clothmg of the child, 345 Cochineal, 312 Coffee, 306 Colchicum, 331 Cold water, splashing, 347 Complications of hooping-cough, 65 ,, ,, pathology of, 154 to 172 ,, of bronchitis, 67 >) >> 1 GENEBAL INDEX. 385 I* »» »> >» »> >» jf »» >i >* >» >> >» >» >> >> >> >» Complications of pneumonia and pleuritis, 71 congestion of the brain, convulsions, and hydro- cephalus, 80 sanguineous apoplexy, 89 infantile remittent fever, 93 diarrhoea and intestinal disorder, 96 softening and inflammation of the stomach, 99 general dropsy, 102 eruptive fevers, 103 tuberculosis, 109 pregnancy, 116 hysteria, 119 other diseases, 122 Conein, 289 Congestion of the brain, 80 f» „ ,, treatment of, 360 Conium, 289 Consequences of the disease, 61 Contagion as a cause, 236 ,, examples of, 237 to 239 ,, limit of, 240 Convulsions, 82 ,, treatment of, 360 Convulsive stage, 42 Copper, sulphate of, 297 Coro-watti, 330 Cough, explanation of the, 61 „ description of the, 42 Coxe's hive syrup, 330 Crab's-claws, 267 Croup, 246 Cup moss, 328 Cupping, 264 Deafness, hooping-cough a cause, 146 Death, causes of, 123 Diagnosis of hooping-cough, 243 Diaphragm covered with pustules, 170 Diarrhoea, 96 ,, treatment of, 368 Diet, attention to, 346 Digitaline, 290 Digitalis, 290 Dilatation of the bronchial tubes, 125, 156 >> >> ,j ,, causes of, 167 to 159 )} >> M M how produced, 1 58, 1 59 C C 386 GENEIUL INDEX. Dilatation of tho bronchial tubos, mistaken for phthisis, 70, 127 Discoloration of the face, 44, 45 Disease, a, of all climates, 213 Disorder, intestinal, treatment of, 368 Diuretics, externally, 371 Double paroxysms, 46, 106 Dressing, conspicuous, 332 Dropsy, general, 102 ,, treatment of, 371 Duration of first stAge, 40 ,, of second stage, 49 ^ ,, of the three stages, 69 ,, influence of season on, 60 Ear, affections of the, 145 Ears, hoamorrhages from, 45, 145 Ecchymosis of eyelids, 44 Effects of simple pertussis, 69 Eggs of insects, a cause of t!ie disease, 179 Elasticity of walls of the chest and lungs, a cause of respiration, 8 Elder bark, 331 Electricity, 331 Embrocations, 270 Emetics, 265 Emphysema, from parturition, 135 of the lungs, 132, 156 of the neck, 134, 157 of the whole body, 140, 157 ,, vesicular and interlobular CO -existent, 139, 156 Emphysematous goitre, 137 England, mortality in, 27 Epidemics of the disease, 12, 14, 16, 214, 242 with convulsions, 88 with cutaneous affections, 10 with dropsy, 102 with other diseases, 122 and contagion, as causes, 236 Epilepsy, 144 Eruptive fevers, 103 Erysipelas, 109 Esquimaux, hooping-cough among, 223 Ether, sulphuric, 303, 306 ,, nitric, 303 Europe, mortality in, 34 ,, hooping-cough in, 214 Exanthemata, 103, 171 i- .'./ GENERAL INDEX. 387 Exanthemata, treatment of, 372 ,, pertussis, said to be one of, 193 Excursions on sea-coast, 274 Exemption of infants from pertussis whoso mothers have the dis- ease when pregnant, 118 Expectoration in pertussis, 46, 55 External applications, 269 ,, diuretics, 371 Eyes, htemorrhago from, 4/), 145 Face, discoloration of, by coughing, 44, 45 Fainting, instead of hooping, 58 Fibrine in the blood increased, 64, 154, 168, 176 Fibrinous concretions in the heart, 64, 151, 163, 167, 176 Fissures, interlobular, 2 Food and diet, 346 France, disease first known in, 14 Gallic acid, 319 Garlic, 270, 331 General considerations, 56 ,, dropsy, treatment of, 371 Generation, organs of, diseased, 172 Geum urbanum, 331 Ginger, tincture of, 271 Glands, bronchial, enlarged, a conjectural cause of pertussis, 197 ,, tuberculosis of, 246 ,, bronchial, pathology of, 151, 155 Glandulse concatenatse, 151 Glasgow, mortality in, 29 ,, ages of deaths in, 31 Glottis, oedema of, 246 ,, cauterization of, 297 Goitre, emphysematous, 137 Golden sulphuret of antimony, 268 Guaiacum, 331 Haemorrhage from nose, mouth, ears and eyes, 45 Heart, action of cough on, 63 ,, fibrinous concretions in, 64, 151, 153, 167, 176 ,, pathology of, 167 Henbane, 290 , Hemlock, 289 Hernia, 143 Herpes, 109 History of hooping-cough, 10 cc2 388 GENERAL INDEX. »> »> Hooping cough, supposed origin in Africa or the East Indies, 14 t< stimony of French writers, 14 its importation into Canada, 15 ,, ,, the earliest English writer, 15 Hoop, the, 42, 64, 208, 210 ,, explanation of, 62, 210 Horseradish, 270 Hydrocephalus, 86 ,, treatment of, 364 ,, tubercular, 112, 171 ^ Hydrochloric acid, 309 Hydrocyanic acid, 276 Hydro-pneumo-thorax, 171 Hydrothorax, 141, 171 Hygienic measures, 344 Hypertrophy of muscular fibres of the bronchi, 150, 162, 161, 174 Hysteria, 119 treatment of, 375 prognosis in, 249 Iceland, hooping-cough in, 217 India, ditto, 219 Indian tobacco, 329 Indians, American, hooping-cough among, 223 Infancy, earliest, disease in, 67 Infantile remittent fever, 93 ,, „ treatment of, 366 Inhalations, 302 Insects, eggs of, cause of pertussis, 179 Intercellular passages of Rainey, 4 Intermittent fevers, 122 Intestinal disorder, 96 ,, ,, treatment of, 368 Intestines, pathology of, 169 Intra-uterine hooping-cough, 118 Ireland, mortality in, 28 ,, ages of deaths in, 28 Iron, preparations of, 294 Isinglass, 331 Kaffiraria, hooping-cough in, 222 Kermes' mineral, 268 Kinks, spasmodic, cause of, 9 Kvef, in Iceland, 217 Lactuca vlrosa, 330 ■ GENERAL INDEX. Laryngismus stridulus, 245 Larynx, pathology oi, 165 Laurel water, 281 ,, inhalations, 303 Lead, acetate of, 297 Leeches, 261 ,, in simple pertussis, 343 ,, in bronchitis, 352 ,, in pneumonia, 356 ,, in congestion of the brain, 360 ,, in convulsions, 361 Liniments, 270 Liver, fatty, 171 „ tubercles in, 171 Lobelia inflata, 329 Lobes of the lungs, 2 Lobules of ditto, 3 London, mortality in, 23, 26 ,, ages of deaths in, 23, 24 Lungs, anatomy of, 1 ,, situation and form of, 1 ,, apex of right higher than left, 2 ,, concavity of their base, 2 ,, division into lobes, 2 ,, structures composing, 2 ,, termination in h bules and air-cells, 3 ,, circulatory appp/atus, 3 ,, respiratory system, 3, 4, 5 ,, nerves, 6, 7, 8 ,, morbid muscular action of, 9 ,, effects of galvanizing, 9 ,, tubercles in the, 171 ,, oedema of, 140 ,, emphysema of, 132 ,, camification of, 78, 160, 162 ,, apoplexy of, 166 ,, pathology of, 59 Madeira, hooping-cough in, 221 Manner of life, 232 Marasmus, 142 Marshmallows, 331 Meadow narcissus, 328 Measles, 104 „ statistics of, 23, 26, 27 ,, treatment of, 372 389 390 GENERAL INDEX. Medulla oblongata, 6 ,, ,, effects of diviBion, 7 ,, ,, pathology of, 166 Miasm, latest period of, 240 Millipedes, 332 Montreal, mortality at, 35 ,, ages of deaths, 35 Mortality from hooping-cough, 21 in London, 23, 26 in England, 27 in Ireland, 28 in Glasgow, 29 in Sweden, 32, 33 in Paris, 33 in Europe, 34 in Philadelphia, 34 in Montreal, 35 in United States, 36 Mosses, 328 Mouth, haemorrhage from, 45 Muscu.^ar fibres of bronchi, 4 ,, their termination, 4 Musk, 327 artificial, 3?7 »» M f* » >i >t >> >> Nature of pertussis, opinions of writers on, 177 to 205 Neck, emphysema of, 134 Nerves of the lungs, 6 ,, pulmonary plexuses, 6 ,, medulla oblongata, 6 pneumogastric, 7 sympathetic, 7, 8 phrenic, 8 facial and spinal accessory, 8 effects of galvanism on the pneumogastric, 8 chief excitor of respiration, 7 causes of impression upon, 7 Nervous stage, 42 ,, system, pathology of, 163 Nitric acid, 311, 334 ,, therapeutical efiects of, 335 relapses after cure, rare, 336 number of cases treated, 337 details of cases, 338, 340 mode of administration, 341, 342 and chloroform, 348-9-50 >> >j »> >> >> t) >» >> >> >» >» »» \ GENERAL INDEX. Nomenclature of hooping-cough, 18, 19, 20 Nose, hsomorrhage from, 45 Nurse, change of the, 362 Nux vomica, 329 (Edema of the glottis, 246 „ ,, lungs, 140 (Esophagus, pathology of, 155, 169 Onion syrup, 331 Ophthalmia, 145 ,, periodical, 122 Opinions of writers on pertussis, 11 u M on the pathology of pertussis, 177 to 205 „ ,, review of these, 205 ,, ,, author's views, 211 Opium and its compounds, 287 Parenchyma of the lungs, 3 Paris, mortality at, 33 Paroxysms, frequency and severity of, 43, 44 „ cause of the return of, 46, 48 „ periodicity of, 60 „ double, 46, 196 „ arested by nitric acid 363 f, ,, by chloroform, 363 }, „ by sulphuric ether, 363 I, ,, by hydrocyanic acid, 364 Parturition, emphysema from, 135 Pathology of hooping-cough, 149, 172 ,, of the complications, 154 to 172 ,, opinions of writers on, 177 to 205 ,, review of these, 205 ,, author's views, 211 Pepper, decoction of black, 331 Pericardium, serum in, 167 Period of decline, 49 longest, of extension, 60 Fertusoal hysteria, 119 Peruvian bark, 308 Phellandrinum aquaticum, 331 Philadelphia, mortality at, 34 Phlegm, accumulation of, 348 Phosphorus, 271 Phrenic nerves, pathology of, 166 Phthisis, 141, 171 ,, diseases mistaken for, 70, 127 391 v^^^ 392 GENERAL INDEX. Physical signs of first stage, 61 ,, second stage, 52 ,, third stage, 55 „ of pneumonia, 74 ,, of bronchitis, 68 Physiology of respiratory nerves, 6 Pleura, pathology of, 162 Pleuritus, 71 ,, treatment of, 360 Pneumogastric nerves, pathology of, 166 Pneumonia, 71 •■ ,, expectoration in, 73 ,, physical signs of, 74 ,, treatment of, 356 Pneumothorax, 141, 171 Poisons,, affinity of, for certain tissues, 203 Polygala seneka, 330 Polynesia, hooping-cough in, 228 Position, change of, in sleep, 359 Potass, carbonate, 320 ,, sulphuret, 321 ,, liquor of, 321 Potato, flowers of the, 331 Predisposition to the disease, 232 Pregnancy, 116 ,, prognosis in, 249 ,, treatment of, 374 Prognosis oi pertussis, 246 Prophylaxis, 350 Prusfic acid, 276 Pulse, rapidity of, 63, 74 Quinine, 308 Recovery from general emphysema, 140 R«ctum, prolapsus of, 143 Recurrence of pertussis, 56 Regurgitation, 47, 48 ,, caused by struma, 48 Remedies recommended by various writers, 251, 276, 302 Remittent fever, 93 ,, treatment of, 366 Respiration, 74 increase of the, 63 par vagum, exciter of, 7 other excitors of, 7 f ^Wi ^ GENERAL INDEX. 393 Respiratory nerves of Bell, 8 ,, system ov'the lungs, 3, 4, 5 Rhus vemix, 331 Roche's embrocation, 270 Saffron, 331 Salacine, 332 Sanguineous apoplexy, 365 Scarlet fever, 106 „ statistics of, 23, 26, 27 ,, treatment of, 372 Season, influence of, 233 Seat of pertussis, opinions of writers upon, 177 to 205 Senega, decoction of, in bronchitis, and pneumonia, 355, 358 Sex, influence of, on pertussis, 230 Sexes, prevalence among, 24, 27, 28, 31, 32 Silver, nitrate of, 293 ,, oxide of, 294 ,, cauterization by, 297 Sleep, change of position in, 359 Small-pox, 108, 172 „ statistics of, 23, 26, 27 ,, treatment of, 373 Snake-root, Virginian, 330 Soda, carbonate of, 320 Sodium, chloride, cause of pertussis, 192 Softening of stomach, treatment of, 370 Spasmodic stage, 42 Spleen, enlargement of, 171 Spurge laurel, 332 Stages of hooping-cough, 37 „ ,, shortened by treatment, 333 Statistics of deaths from pertussis, 23 to 36 Stomach, gelatinous softening of, 99, 163, 170 softening and inflammation of, 09 irritable state of, 98 pathology of, 169 ,, treatment of softening of, 870 Struma, 141 Suffocation from intense coughing, 60 Sulphur, 331 Sulphuric acid, 310 Sweden, mortality in, 82, 33 Swelling of tops of fingers and toes, 84 Symptoms of hooping-cough, 37 ,, first stage, 37 )» >> n ■„J"«.,JJ»J» neWW^WBBP! 394 GENEBAL INDEX. \\ Symptoms of hooping-cough, second stage, 42 ,, ,, ,, third stage, 49 Synonymes of the disease, 18, 19, 29 Tabes mesenterica, 142 Tannic acid, 319 Tannin, 319 Tar, vapour of, 302 Tartar emetic ointment, 269 ,, solution, 270 Temperament in the disease, 232 Temperature, regulated, 272 Termination of coughing, 46 '. Terminations of hooping-cough, 124 Tobacco, 290 Toxication, latest period of, 240 Tracheotomy, 332" Treatment of simple pertussis, 333 ,, ,, ,, by nitric acid, 341, 342 ,, ,, „ by ditto and chloroform, 348 to 360 ,, ,, ,, of the complications, 352 to 375 Tubercular hydrocephalus, 112 Tuberculosis, 109, 171 ,, treatment of, 373 ,, of bronchial glands, 246 Turnips, slices of, 331 Turpentine inhalations, 303 Tobacco, Indian, 329 Unanimity of recent writers on the nature of pertussis, 205 United States, hooping-cough in, 224 ,, ,, ,, mortality in, 36 Urine, state of the, 171 Urticaria, 109 • Vaccination, 323 Valerian, 331 Van Diemen's Land, hooping-cough in, 228 Varicella, treatment of, 373 Vegetable acids, 319 Venesection, 253 Venous murmur, 55 Vesicular and interlobular emphysema co-existent, 139, 166 Views of the author on the nature of pertussis, 211 Vomiting, 47, 98 Zin( Zon GENERAX INDEX. 395 Water, cold, splashing, 347 West Indies, hooping-cough in, 226 Wheezing in the chest, treatment of, 344 Wild rosemary, 331 Writers upon the disease, 17, 18 Writers, opinions of, on the pathology of pertussis, 177 to 205 Zinc, salts of, 295 Zona, 109 ERRATA. Page 8 to 350 375 it it tt it >> a it It it n tt ti 1, line 12, for immediate read intermediate. 8, line 16, for spinalis read oblongata. 54, line 22, for depends read depend. 59, line 16, for uninterrupted read interrupted. 71, line 30 should exchange places with line 29. 78, line 21, for on read or. 99, line 21, insert 7. before Perti As. 115, line 9, for complicated read uncomplicated. 138, line 22, for lung read lobe. 139, Note, for 1835 read 1845. 190, line 16, for influences read inflames. 256, line 12, for difficult read diiiiculty. 342, line 10 (in second prescription), for 3j. read 3j> THE END. m :.L - t.. .. 1.. / .■i-- ~+ J., ■*--'•■ -*■- — -f- tOlTDOIf : BATttt AND EDWABSS, VJUKIttS, CHAirSOS STBEET. II ^^% "f-i "\ .:.'■'-. ..■'■■■; \1 MB. BENSHAW'S PUBLICATIONS. The Anatomist. By Henry Savage. 48mo. Price 2s. ' " The Outlines of Botany. By Gilbert Burnett. 250 "Wood En- gravings. In 8vo. Prioe 21s. The Nervous System of the Human Body. 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