Chapter LII: Part II: , Showing Predominance of Malarial Element . . . . 617 (51)

SYMPTOMS.--The disease begins usually with an ordinary catarrh, preceded by malaise and slight laryngeal irritation, which may be overlooked; in fact, during the first stage there is nothing to attract special attention, unless a direct history of exposure be known and suspicion be aroused on that account. Meigs and Pepper state that the earliest period at which they have known the distinctive whoop of the disease was three days, though in a great many instances it was delayed as late as three weeks. The same authors state that the ordinary duration of a paroxysm or kink is from one-fourth to three-fourths of a minute. They mention a case where the paroxysm lasted fifty-five minutes. Ordinarily they number about thirty-five or forty during the twenty-four hours at the height of the disease, differing greatly in individuals. Their number is most frequent in the course of the third or fourth week, after which they remain stationary, and then gradually decline. The paroxysms may occur spontaneously, or they may follow some irritation, either direct or reflex, or they may be induced by nervous excitement. Toward the end of the attack, after the catarrhal irritation has greatly subsided, or in fact has entirely disappeared, the paroxysmal kinks may be provoked by irritation of the fauces, and also by nervous excitement; and there is no question but that at this time they can be controlled by will-power. In many cases a distinct relapse occurs after the disease has been apparently cured.

Dolan believes the phenomena of the cough or kinks to be due, as suggested by Laennec, to a "spasmodic condition of the muscular or contractile fibres of the bronchi and their branches." He remarks that the lungs are supplied from the anterior and posterior pulmonary plexuses, formed chiefly of branches from the sympathetic and pneumogastrics. The filaments from these accompany the bronchial tubes upon which they are lost. Irritation of these nerves is said to have the effect of producing contractions of the bronchial canals sufficient to expel a certain quantity of air. If this theory is true, it helps us in explaining why the large, mediate, and smaller bronchi are closed during the expiratory stage of the paroxysmal cough of pertussis. The general opinion seems to be that the pneumogastric nerve is not inflamed, as has been asserted by some.

The highly sensitive condition of the nervous system, which is probably in a great measure intensified by the anæmia, and by the interference with nutrition due to the disturbance of the circulation by the cough, will show itself in many ways, and even when no secondary nervous affections complicate the attack or follow it. Some time will elapse after the disease has passed away before the child will recover its self-control, or its nutrition will show the influence of a healthy nervous system. The total duration of the affection is said to vary from six weeks to three months in ordinary cases; though probably, if active treatment could be instituted early enough and kept up with thoroughness, there is no specific disease more capable of being shortened in its course than the one under consideration; this remains, however, for future statistics to decide.

During the second stage of the disease the symptoms are sufficiently {841} marked to attract attention and render a diagnosis easy to make. Frequently the catarrh seems to extend to the bronchioles, and gives rise to symptoms that are alarming; and the intensity of the paroxysm will cause the engorgement of the blood-vessels to get relief in profuse hemorrhage; this is the period for caution. Complications may arise, the strength may fail, the secretions may become too abundant, and asphyxia may ensue; emphysema may show itself, or catarrhal pneumonia may gradually supervene.

The period of decline is very gradual; the secretions become less in quantity and more viscid, the paroxysmal cough is less frequent, but may at times be equally severe, the child's strength is usually exhausted, and its nutrition is greatly impaired. The expected paroxysm throws it into a state of intense nervous excitement; it is sleepless--in fact, worn out. Probably at this period of the disease treatment will show the most marked results, and the long lists of sedatives, tonics, etc. which are presented to us by their zealous advocates owe much of their popularity to their value at this stage of the disease. The catarrhal symptoms are the first to subside; the nervous disturbances remain for some time, and gradually fade, and the constitutional symptoms, or those from exhaustion, are the last to leave the patient.

Strange as it may seem, the heart appears to suffer but little in the long run from the great strain upon it; the palpitation and irregularity of its actions are not followed by structural changes as a rule, though we may state that feebleness of the circulation has remained in most of our bad cases for some months after recovery.

As regards the ulceration of the frænum linguæ, which has given rise to so much discussion as to its exact value as a symptom of this disease, our own experience leads us to believe that though it is nearly always present in the severe cases, its almost invariable absence before dentition and in milder cases shows it to be of traumatic origin. Roger's exhaustive report before the French Academy supported this view, and showed how clearly it is caused by the violent rubbing of the frænum on the free border of the incisors. On the other hand, Delthil of Paris and Blake of England believe that it is a pathological feature of the disease. The former reported cases in which it occurred before dentition. The ulcer is not always found on the frænum linguæ, but is found on either side of it. Bouffier noted severe cases of ulceration in children who had no teeth, but he attributed it to the injury produced by the mother in detaching the mucus with the finger.

Examinations of the urine have been carefully made by many observers. The appearance of sugar, about which so much has been said, does not seem to be constant, or even very frequent. Out of 50 cases, Dolan found traces of it in but 13. This coincides with our experience also, for we have frequently tested the urine in seven cases with negative results. Since, as is well known, irritation of the pneumogastric centre may cause glycosuria, it was at one time attempted to show that the paroxysms in whooping cough were due to congestion of the pneumogastric nerves, a condition which is said to have been occasionally found in this disease. Dolan says he has never seen hemorrhage from the kidneys during the course of whooping cough, nor blood in the urine.

MORTALITY.--It is an extremely difficult matter to reach, with any {842} degree of certainty, the true mortality of this affection. Meigs and Pepper say: "Of the 208 cases observed by ourselves, 143 were simple, all of which recovered;" and, again, "Some form of complication occurred in the 65 of the 208 cases observed by ourselves; of these 65, 12 died." The mortality seems greater under five years; thus: Of the 9008 deaths attributed to it in the United States during the census year ending June 1, 1870, the number of persons under one year of age was 4424, and 8396 were under five years. There were 1784 deaths from it recorded in Philadelphia from 1860 to 1876; of this number, 1724 were under five years of age. The census of the United States for 1880 gives a return of 11,102 deaths from this disease.

Females seem more liable to die of it than males; of the 1784 deaths in this city, 766 were males and 1018 females. As we have already seen, females are more liable to the disease than males.

Robt. J. Lee, M.D.,[4] says that from the Registrar-General's report of 1876 it is seen that in a total mortality in England of 510,315, whooping cough was returned as the cause of death in 10,554 cases, or nearly 2 per cent.

[Footnote 4: In a paper in the _British Med. Jour._, 1879, vol. i. p. 307.]

As for the time of year, we quote the following: "Thus, according to the census statistics, most deaths occur in the spring, there being a rise up to the middle of May. From the middle of May the number lessens largely until August, when a rise occurs and continues until October, when a decline sets in and continues until December, when a rise begins and goes on increasing until the middle of May. This rise in mortality from August to October is attributed to the wear and tear of a hot summer and the intestinal troubles then so prevalent."

The mortality statistics of this disease are uncertain. It is fatal in its complications or by inducing a debilitated condition which invites degenerative processes. The severity of the symptoms is no guide for prognosis as far as uncomplicated cases are concerned, and there is no doubt but that at present we are able to greatly reduce the mortality-rate by care and medical treatment, as well as to shorten the attack. Sporadic cases are apt to be neglected until they become complicated. When the disease occurs in epidemic form, measles is often prevalent simultaneously, and in consequence children who become affected by both diseases have a greater tendency, from debility, to become the victims of those affections of the respiratory organs which are such frequent and fatal complications of both maladies.

Instead of surprise at the mortality of this affection, the marvel is that so large a percentage of recoveries take place, when we consider that we are dealing with a disease whose lesion is a catarrh of the air-passages which seldom lasts less than two months, with a tendency to involve the lungs in one way or another, and then witness the carelessness with which, among the lower classes, the child is often treated--exposed to all weathers, under-clothed, under-fed, and probably allowed to pass through the whole attack without medical treatment. Taking this into consideration, the probability is that the mortality of this disease could be reduced to a very small figure by careful management, even if the investigations of those now seeking the microbe of pertussis do not lead to any plan, in accordance with Pasteur's teachings, which will still further lessen the gravity of the disease. Until {843} then, we can but insist upon a rigid quarantine of schools, a registration of all cases, and the seclusion of them, as we have done to-day in the case of variola and scarlatina.

MORBID ANATOMY.--Although whooping cough is a serious disease, the cause of death is generally found to be dependent upon its complications, and there is no lesion at all characteristic of it. The chief complications and sequelæ are--bronchitis, which may become capillary; lobular collapse, which, according to Alderson,[5] is frequently found; emphysema, usually marginal, probably due, as suggested by Jenner, to violent expiratory exertions; rupture of air-vesicles, with subcutaneous emphysema; catarrhal pneumonia, pleurisy, phthisis, acute tuberculosis, croup, cerebral apoplexy, meningitis, etc. As any of these complications, and others which may arise from debility, may be the cause of death, independent of the action of the specific poison itself, it is usual to divide the post-mortem appearances into those that are the result of the extension of the catarrh itself and those produced by the interference with the circulation and with nutrition from mechanical violence. Of the former, the usual causes of death are pneumonia, gastritis and enteritis. Of the latter, we have thrombosis of the cerebral sinuses, hemorrhages, emphysema, and exhaustion following constant vomiting.

[Footnote 5: _Medico-Chir. Trans._, pp. 90, 91, 1830.]

Tubercular disease of the lungs or of the brain is apt to be a cause of death. Convulsions carried off 5 of the 12 fatal cases reported out of 208 by Meigs and Pepper. This may be due to congestion of the brain, especially in teething children. Spasm of the glottis with sudden death is occasionally found. In such cases there is found intense congestion of the brain, also of the liver and kidneys, and at times of the mucous membrane of the stomach and intestines, as well as of that of the respiratory tract.

In all cases, especially at the teething age, sudden death may occur because effusion into the ventricles of the brain or the formation of heart-clot has taken place. It is important to know this, that active treatment applied early enough may save the patient.

PROPHYLAXIS.--Should the interesting and seemingly conclusive statements of Dolan and the microscopic investigations of Carl Bruger[6] receive the endorsement of future workers, the subject of prophylaxis will assume a degree of importance which hitherto it has only maintained with the medical profession. No one has doubted that the disease was contagious, and yet there is no affection which has attached to it a corresponding fatality that is so carelessly dealt with as pertussis.

[Footnote 6: Bruger of Bonn, in the _Berliner klinische Wochen._, describes at length the special micro-organisms of pertussis. They appear as small elongated elliptical bodies of unequal length, the smallest being double as long as broad. High powers show subdivisions in the largest specimens. They are generally isolated, but may appear in groups. They bear some resemblance to _Leptothrix buccalis_, the spores of which are often found in whooping-cough sputa. Occasionally the bacillus is seen inside the mucous corpuscle in the sputum. They stain in the usual way, fuschin and methyl violet. This bacillus is not found in any other kind of sputum, is very abundant in pertussis, and increases in direct proportion to the severity of the disease.]

Within the past few days we have heard on two occasions in crowded railway-cars the characteristic paroxysm of the third stage of the disease, and yet people will endeavor to convince themselves that unless contact with the child takes place the danger is little.

{844} The atmosphere in school-rooms, railway-cars, and places of amusement which are badly ventilated, is an excellent medium for the propagation of the contagious matter, and many extraordinary cases are on record of momentary exposure being sufficient to contract the disease. Believing that the contagium or virus resides in the mucus and air thrown off by the child, and also in the vomited matters, which contain a large amount of ropy mucus, and also that it gains entrance by means of the respiratory organs, protection from contagion divides itself as follows: thorough disinfection of the exhaled air, of the mucus remaining within the bronchial tubes and air-passages, and of the clothing, together with exposure to fresh air and thorough cleansing of all furniture and household utensils, including cups, silverware, and toys, used by the child. Oxygen is said to have this effect, and thorough, constant ventilation, with the breathing of fresh air by the child, the thorough washing of its surface, and disinfection of its clothing, are the first indications; while the impregnation of the atmosphere with the spray of well-known germicides by means of the steam or other atomizer and the frequent inhalation of such materials by the patient are no less important. Every case of whooping cough should be compelled to use two or three times daily the spray impregnated with a substance of this sort, either carbolic acid, the oil of eucalyptus, a solution of quinia, or thymol. Chlorine (from chloride of lime) used thus has of late been followed by excellent results, and the spray of a solution of corrosive sublimate or of ammonium chloride has been found very useful. The protective treatment should be applied to those exposed to contagion. Such children should be guarded from exposure to colds; their diet should be simple and nourishing, their clothing warm; they should be kept as much as possible in the open air. The breathing of air impregnated with such substances as above mentioned will no doubt act upon the virus before it comes in contact with the mucous membranes so as to be absorbed, and probably the severity of the attack might be mitigated by modifying the germ of the disease.

TREATMENT.--As can be readily imagined, a disease which is so universal, so distressing, and at the same time so obscure in its pathology, as the one under consideration, would have in its literature a mass of recommendations for treatment from zealous advocates, based upon theory or experience, as numerous as the authors themselves. It would be impossible for us to dwell at length upon all of these, but we will confine ourselves especially to the consideration of a few of the most important. It will be convenient to consider first those remedies which have been used with the view of relieving the congestion and irritability of the respiratory mucous membrane and of promoting more free secretion. It will also be observed that many of these remedies may now be regarded as of value for destroying the special germ which is thought to be the essential cause and real virus of pertussis. Allusion has been made above to the importance of inhalations as a prophylactic for those who have been exposed to the contagion, as well as for the purpose of rendering the secretions less contagious; and so too we find that the inhalation of various substances has received favor with many as a method of treatment. Thus, hyoscyamus, belladonna, ammonium bromide have been used. Helenke and Serbaud say that bromide of {845} potassium is best for inhalation. Letzerich recommended the insufflation of quinia twice daily, using the quinia muriate with potassium bicarbonate and gum-arabic. Forchheimer[7] reports 97 cases of whooping cough treated by the insufflation of the quinia muriate; of the 97 cases, 52 were females, 45 males--the youngest three weeks, the oldest nine years old. Five cases gave no results, while in the others benefit was shown by a shortening or amelioration of the disease. The vapor of benzole has been used with good results. The vapor of carbolic acid has of late been highly recommended, either administered with the atomizer several times daily, or used by saturating flannels in carbolic acid solution and placed around the child's bed at night. It is said that the inhalation of the vapor of a few drops of carbolic acid on some hot coals will ensure a night of freedom from violent coughing. Probably in this way we may account for the belief that proximity to gas-works is beneficial to a child with this disease. As is well known, Niemeyer and others in the north of Germany believed in the value of the inhalation of oxygen, and the experience of every one who has had much to do with this disease favors an out-door life. We may here also mention the value of a small quantity of chloroform or ether, by inhalation, in allaying the severity of the paroxysms of cough. We have also tried the nitrate of amyl, but without marked result.

[Footnote 7: _New York Jour. Obstet._, 1882.]

Others have recommended the use of solutions of various substances, applied directly by a brush to the interior of the larynx. Quinia has been used in this way also by Hagenbach; but the most satisfactory results have been obtained by the application of very weak solutions of nitrate of silver, as first recommended by Watson in 1849.

After the secretions have been fully established and the characteristic whoop has appeared, the indications in the treatment are to relieve the respiratory tract of its burden by occasional emesis with alum or ipecacuanha, to give freely antispasmodics and sedatives, as belladonna, chloral, the bromides, hydrobromic acid, or, as recommended by some, digitalis; to give quinia freely, and to use counter-irritants to the neck and chest with liniments composed of oil of amber, croton oil, or turpentine.

The value of emetics has been long recognized in this affection, although we are told by Vogel that the continuous use of emetics in the early stage for several days causes harm. Copeland ordered an emetic every third day in ordinary cases. All writers agree that the milder emetics should be used by preference; that tartar emetic should be avoided, except as an external application where a counter-irritant is desired; and that ipecacuanha is the safest, though alum is also safe and as an astringent useful. Trousseau preferred the sulphate of copper. In the earlier stages of the disease emetics are not, as a rule, indicated; it is only when the secretion has become extremely tenacious, and the paroxysms so frequent and severe as to greatly strain the patient and endanger his lungs, that they are of value. There seems to be a close connection between the amount and tenacity of the secretion and the severity of the paroxysm. The potassium carbonate has been recommended as an active agent in the amelioration of this affection; it is probably valuable in rendering the secretion less tenacious. Alum has been used with success, as has tannin, probably owing to their local action on the mucous membrane. Macartan[8] says that in the East {846} Indies the disease is treated in the first stages by astringent and tonic gargles.

[Footnote 8: _Dictionnaire des Sciences Méd._, 1813, vol. vi.]

Belladonna certainly receives the endorsement of the greatest number of writers. Vogel considers it superior to all other drugs, and regards dilatation of the pupil as the only sure guide in its administration. He says it does not cut short the attack, but mitigates the paroxysm. Trousseau was also an advocate of this form of treatment. When combined with alum[9] it is considered by Meigs and Pepper to be one of the most valuable drugs recommended. They also advise the use of potassium carbonate. Seiner trusted belladonna more than any other remedy; so also Rilliet and Barthez. William Lee, in an interesting paper in the _New York Medical Journal_, 1883, advocates the use of atropia hypodermically; he believes that atropia chiefly acts in these cases on the laryngeal branches of the pneumogastric nerves, and that it is probable that it has a decided effect also on the medulla oblongata itself, and renders it less capable of exciting reflex action. Kroon's experiments led him to conclude that the valerianate of atropia was the most useful. Evans[10] gave the 1/120 of a grain of atropia to a child aged three years until the pupils were dilated, then reduced the dose; this stopped the paroxysm in twenty-one days. At the commencement of the treatment the child had twenty-three paroxysms in the day, and twenty-seven at night. Case No. 2 under same circumstances recovered in fourteen days. In case No. 3 the paroxysms were reduced from twenty-six to two or three a day. Arthur Wiglesworth[11] used a solution of sulphate of atropia, administered in the morning fasting; the dose he advises for children from one to four years is gr. 1/120, given only once a day except in some cases. The results are as follows: There is a steady diminution in the number of paroxysms; a change in the character of the whoop as if the vocal cords were not so closely approximated. If atropia is withheld, the beneficent effect derived from it subsides.

[Footnote 9: Golding Bird, _Guy's Hosp. Rep._, April, 1845.]

[Footnote 10: _Glasgow Med. Jour._, 1880.]

[Footnote 11: _Lancet_, April 12, 1879.]

West advises dilute hydrocyanic acid, and many writers agree with him, ranking it next to belladonna.

Harley and others are strong advocates for the bromide of ammonium; it is supposed to have a local anæsthetic action on the pharyngeal and laryngeal mucous membrane. Fordyce Grinnell[12] during four months treated 223 cases with this remedy, and highly recommends it. The doses were in accordance with those of Dr. Kormann--3/4 to 4 grains, as indicated by age, three or four times a day and at night when the paroxysms were severe. No other treatment was used in these 223 cases, except camphorated oil to the throat and chest in some cases. Potassium bromide has been recommended by Helenke, Beaufort, Erlenmeyer, and others. Henry Field[13] recommends sodium bromide.

[Footnote 12: _Med. News_, 1882.]

[Footnote 13: _Brit. Med. Jour._]

Probably next to belladonna in the treatment of this disease we should place chloral hydrate.

Hebner, after an elaborate study of the relative value of potassium bromide, quinia, salicylic acid, chloral, and belladonna, says: "Salicylic acid and chloral tend to relieve the paroxysms--belladonna and quinia to shorten the disease." Kennedy[14] writes: "I cannot doubt {847} its specific effects on the cough. Chloral seems to me to yield the best and most constant results. The advantage of chloral hydrate seems to exist in producing sleep; it should be given in from 2- to 5-gr. doses, at night." If there is much irritability or fretfulness, or any premonition of eclampsia, it should be associated with potassium bromide.

[Footnote 14: _Dublin Jour. M. S._, 1881.]

Croton chloral has received much praise from those who have used it; we have had no experience with it.

We have already alluded to the value of quinia, which has been used largely in this disease, both internally and as a local application. Originally recommended in the latter manner on account of its power of controlling the development of low organisms, it has not proved so satisfactory or valuable as when given internally. Binz in 1870 was perhaps the first to recommend quinia given frequently and in solution, and Dawson in 1873[15] reports excellent results from the sulphate or muriate of quinia given in full and frequent doses, and in such solutions as will not prevent its acting on the mucous membrane in its passage through the pharynx. Breidenbach[16] gives the quinia muriate in larger doses--one and a half to fifteen and a half grains per diem. The effects were surprising as soon as the proper dose for each person had been determined; this, he says, is the keynote of success. To prevent complications he continued it for a long time in small doses.

[Footnote 15: _Am. Jour. Obstetrics._]

[Footnote 16: _Practitioner_, Feb., 1871.]

Our own experience favors the view that quinia, when given in solution or suspended in mixture, is valuable in many cases of this disease; it can be ordered in powder, and given in a spoonful of simple syrup or of the preparation known as the syrup of yerba santa, which makes an excellent vehicle. Liquorice also disguises the taste of quinia admirably for children.

Albrecht[17] has found from an experience of ten cases of whooping cough in children between the ages of one and a half and nine years, all of a marked scrofulous type, much benefit from the muriate of pilocarpine, given in small doses after every fit of coughing. To prevent collapse, he advises that it should be given in a mixture containing a little brandy. After twenty-four hours of its administration an obvious change for the better takes place in the appearance of the mucous membrane of the throat, velum palati, and uvula, which becomes paler, less swollen, and more moist; laryngoscopic examination shows a similar improvement. During the catarrhal period cold compresses to the neck and sweetened milk containing potassium chlorate are used instead of the pilocarpine, which is to be resumed as soon as a whoop recurs.

[Footnote 17: _London Med. Rec._, March 15, 1882, p. 110.]

Dr. Tordeus, of the Hospice des Enfants Assistés, Brussels, states that he has found the sodium benzoate useful in whooping cough, diminishing the frequency and violence of the paroxysms, and by its action on the pulmonary mucous membrane preventing those pulmonary complications which so frequently supervene and constitute the danger of the disease.

Sulphur has been largely used by the Germans in two- or three-grain doses, and is said to be greatly esteemed by them. Cantharides has been recommended, and it is stated that when strangury is produced the whoop will cease; we should consider this rather severe treatment. The {848} fluid extract of castanea is used by many with undoubtedly good results, though this also has been somewhat of a disappointment in the way of treatment, as at one time it was looked upon almost as a specific. Many claim that an infusion of the fresh leaves gives a better result. Dewar[18] regards ergot with great favor in the treatment of pertussis. Certainly in those cases where, from violent straining, hemorrhages have taken place we have found it to be highly valuable. We have had no experience with it in the treatment of ordinary cases, though Dewar claims that it shortens the attack. The ammonium picrate, and recently resorcine, have been used with success.

[Footnote 18: _The Practitioner_, London, May, 1882.]

Counter-irritation to the neck and chest has always been found useful in the treatment of this disease. Autenreith[19] recommends tartar emetic to the epigastrium till vesicles appear and even ulcerate. Milder forms of counter-irritation over the chest seem equally efficacious if continued for some time. The oil of amber, when used in liniment with camphor or turpentine, is by some considered almost a specific. Great care should also be observed in the dress of children with whooping cough. Warmth about the chest is always indicated, while there should be nothing close or tight about the throat allowed.

[Footnote 19: _Dict. des Sciences Med._, 1813.]

In the third stage, when there is the nervous element remaining, tonics, such as cod-liver oil, iron, the phosphates and hypophosphites, are required.

The diet should be nutritious, easy of digestion, and abundant, and the bowels should be kept regular by fruits or laxatives. Over-feeding should of course always be avoided, and the attempt at weaning a babe with this disease would certainly meet with unfavorable results.

Bicarbonate of soda or lime-water should be given freely with the milk taken by children with this disease. Milk certainly should form the basis of the diet of children with pertussis, and reliable meat-extracts are to be recommended in this disease even for older children, who from the severity of the attack would vomit more solid food. If the vomiting be so severe as to affect nutrition, the child should be sustained by peptonized milk, soup, or gruel, given by the bowel.

The importance of a proper regulation of the temperature of the air which the patient breathes is especially recognized in France. If the attack occurs in mid-winter and the seashore be inaccessible or inexpedient, the child should be restricted to a well-ventilated nursery or suite of rooms, the temperature of which should be kept uniform.

Salt air is recognized to be of great value in advanced cases of this disease; this has been attributed partly to the effects of stimulation of the mucous membrane in rendering less viscid and more copious the bronchial secretions, and also to the balmy softness and great purity of the atmosphere at the sea-shore. But probably there is another element in the local action of the chloride of sodium, either in establishing a resistance on the part of the patient or in modifying the germ of the disease.

The most serious complication of whooping cough is pneumonia. It occasionally happens that an attack of croupous pneumonia may develop during the course of whooping cough, but in the vast majority of cases the disease is of the catarrhal type. When, indeed, it is remembered that a bronchial catarrh, which is the invariable precursor or accompaniment {849} of catarrhal pneumonia, is a constant factor in whooping cough, and, further, that all conditions of debility, and especially of enfeebled or embarrassed respiration, dispose to this form of pneumonia, it is not surprising that this complication should be of such frequent occurrence. It is not impossible that in aiming at securing sufficient fresh air and out-door exercise to maintain the general health, an injudicious degree of exposure may be permitted which will aggravate the existing bronchitis and induce an extension of inflammation to the alveoli. But usually the catarrhal pneumonia develops in a subacute and more or less insidious manner, and without being traceable to any such exposure. It may happen occasionally that in the violent inspiratory efforts at the close of the paroxysms irritating secretions may be sucked from the bronchioles into the alveoli, and there excite inflammation. Or, again, it doubtless happens frequently that, with the existence of swelling of the bronchial mucous membrane and of viscid secretions in the bronchial tubes, collapse of portions of lung tissue is developed by the forcible expulsion of air during the paroxysms of cough, which cannot be replaced owing to the relative weakness of inspiration and to the ball-valve action of the plugs of mucus in the obstructed bronchioles. The intimate relation between pulmonary collapse and catarrhal pneumonia is familiarly known. It is not to be considered that the mere occurrence of collapse will induce pneumonia in the areas affected, but certainly it will aid in rendering effective the other irritating causes. As a consequence, it usually happens that when catarrhal pneumonia occurs in whooping cough it is associated with more or less collapse. When, then, especially in children of debilitated or rachitic constitution, or in those who are subjected to unfavorable hygienic influences, such as overcrowding, bad air, and the like, there is a rather gradual development of dyspnoea, with increasing debility, emaciation, and evidences of impaired oxygenation of the blood, it is to be feared that this serious complication has developed. The physical signs are often difficult of interpretation, but if careful examination of the chest be conducted, together with thermometric observations, the approach of this danger or its actual presence may be detected. The result is fatal in a large proportion of cases, so that suitable treatment--for the details of which reference is made to the appropriate section--must be instituted without delay.

* * * * *

Our investigations of this disease have led us to the conclusion that we have to deal with an affection caused by a specific germ, which is usually, after a period of incubation, made manifest by a catarrh of a portion of the air-passages; that this catarrh, existing for an indefinite period, is capable of being influenced by medication, applied either by means of inhalation or by acting on the mucous membrane after absorption by the stomach. In this way we have known the administration of quinia and of alum diminish the number of paroxysms, to all appearance checking the excessive secretion to a marvellous extent. The other element of the disease, the neurosis, which soon follows the initial catarrh, and seems to last for an indefinite time after the mucous membrane has regained its normal appearance, is also capable of being controlled by the use of drugs, especially belladonna, chloral, the bromides, and hydrocyanic acid, not to speak of the other antispasmodics and sedatives, and by the {850} analgesic effect of carbonic acid gas, or by the spray of bromide of ammonium, carbolic acid, and other substances upon the larynx.

Vogel tells us in his classical work on children, "If now, as a résumé, I would give an explanation of my views, it would go to show that there never has been, and most probably never will be, a remedy by which whooping cough may be abridged, any more than we are able to cut short the acute exanthemata or typhus fever or pneumonia." And yet the experience of many whom we have quoted in this article tends to support the view that by a form of treatment calculated to act on the two elements of the disease which we have just noted, the affection can be greatly modified in its intensity, and probably the attack be somewhat shortened. Certain it is that the recent studies of this disease give us hope that the day is not far distant when the cause, whatever it is, will be definitely known, and if it is found to reside in the secretions from the larynx, that treatment by inhalation or atomization will modify or destroy it, and prevent its dissemination.

{851}

INFLUENZA.

BY JAMES C. WILSON, M.D.

DEFINITION.--A continued fever, occurring in widely-extended epidemics, and due to a specific cause; it is characterized by early catarrh of the mucous membrane of the respiratory tract, and in many cases also of the digestive tract; by quickly oncoming debility out of proportion to the intensity of the fever and the catarrhal processes; and by nervous symptoms. There is a strong tendency to inflammatory complications, especially of the lungs. Uncomplicated cases are rarely fatal except in feeble and aged persons. An attack does not confer immunity from the disease in future epidemics.

SYNONYMS.--Febris catarrhalis; Defluxio catarrhalis epidemicus; Catarrhus a contagio; Rheuma epidemicum; Cephalalgia contagiosa; Epidemic catarrhal fever; Tac; Horion; Quinte; Coqueluche; Ladendo, also written La Dando; Baraquette; Générale; Coquette; Cocotte; Allure; Follette; Petite poste; Petit courier; Grenade; La Grippe; Ziep; Schaffhusten and Schaffkrankheit; Huhner-Weh; Blitz-Katarrh; Mödefieber; Mal del Castrone. There are also several names indicating its supposed origin; thus it has been called in Russia, Chinese catarrh; in Germany and Italy, the Russian disease; in France, Italian fever, Spanish catarrh, and so forth.

It is a remarkable fact that in two instances at least the popular name for the disease under consideration has found its way widely into medicine and medical literature, almost to the exclusion of the studied terms by which science has sought to designate it; these are influenza and la grippe.

Such obsolete and now meaningless terms as Peripneumonia notha (Sydenham, Boerhaave), Peripneumonia catarrhalis (Huxham), Pleuritis humida (Stoll), have been omitted from this list of synonyms as being of interest rather to the student of medical history than to the student of medicine.

Febris catarrhalis, Defluxio catarrhalis epidemicus, Rheuma epidemicus are terms which no longer retain the place given them in the literature of influenza by the older medical authorities.

Catarrhis a contagio (Cullen) and Cephalalgia contagiosa are derived from a view of the nature of the disease, which has been the cause of no little controversy.

Epidemic catarrhal fever is, with its Latin equivalent, the most satisfactory of the so-called scientific names by which the disease is at present known.

In the popular names for the affection there is to be noted an {852} indication of the national character of some of the peoples who have suffered from its frequent visitations.

Among the English it is known as cold or epidemic cold, or, in deference to medical authority, as catarrh or epidemic catarrh; and at present, both among the folk and the doctors, as influenza. Englishmen are neither quick to see in the disease a resemblance to some common circumstance or thing, nor are they disposed to make a joke about it.

The Germans find obvious resemblances. In the labored respiration and the character of the cough they find a suggestion of a common epizoötic affecting the sheep, hence Schaffhusten and Shaffkrankheit; or, because the cough is like the crowing of a cock and the disturbance of respiration and rapid prostration suggest some resemblance to a common disease of the domestic fowl, it has been called Huhner-Weh (chicken disease, whooping cough), and Ziep, which is about equivalent to pip. They call it also, from its rapid invasion, Blitz-Katarrh, and from its diffusion, Mödefieber.

The French are disposed to make a jest of everything, and the more serious the subject the better the joke. Hence they have found a new name for almost every great epidemic, and each more trivial than the last. Thus, tac (rot); horion (in jest, a blow); quinte, because the spells occur at intervals of five hours (sic); coqueluche (a hood or cowl), from the cap worn by those suffering from the malady; and so on through the long list given above.

La grippe is said to be derived from the Polish Chrypka (Raucedo); it may, however, be derived from agripper (to seize).

Influenza is of Italian derivation. It is said that the disease received this name because it was attributed to the influence of the stars, or from a secondary signification of the word indicating something fluid, transient, or fashionable.

HISTORICAL SKETCH.[1]--Epidemics of influenza have been clearly recorded only since the beginning of the sixteenth century. There are numerous accounts of earlier epidemic diseases resembling it, but they are not sufficiently particular to warrant us in inferring its undoubted existence. It is supposed to be referred to in the writings of Hippocrates, who, however, gives no exact description.[2] An outbreak in the Athenian army in Sicily (415 B.C.), recorded by Diodorus Siculus, has been supposed to have been influenza. Despite these statements, and those of others to the effect that it is a disease known from a remote antiquity, it may be said that no accounts can be confidently established, as referring to the disease now known as influenza, in the writings of classical antiquity.[3]

[Footnote 1: See also _The Continued Fevers_, by the author of this paper, New York, 1881.]

[Footnote 2: Parkes, _Reynolds's System of Medicine_, vol. i., 1868.]

[Footnote 3: Zuelzer, _Ziemssen's Cyclopædia of Medicine_, vol. ii., 1875.]

As early as the ninth century several epidemics of catarrhal fever, Italian fever, and the like, which were probably influenza, were made matter of history. In the year A.D. 827 a cough which spread like the plague was recorded. In 876 there appeared in Italy a similar epidemic, which spread with great rapidity over all Europe. It is related that dogs and birds suffered with symptoms not unlike those characterizing the affection in man. In 976, Germany and all France suffered from a fever of which the chief {853} symptom was cough. No further epidemic is noted until two centuries later, when, in 1173, a widespread malady, of which the symptoms were chiefly catarrhal, raged throughout Europe; while less important epidemics of a like character are recorded as having occurred during the following century (1239-99).

In the medical writings of the fourteenth century there are to be found records of six epidemics, and in the fifteenth seven great visitations of influenza are described (Parkes).

Aitken[4] speaks of a very fatal prevalence of influenza throughout France in 1311, and of an epidemic in 1403 in which the mortality was so great that the courts of law in Paris were closed in consequence of the deaths.

[Footnote 4: Aitken's _Practice of Medicine_, vol. i., 1872.]

Influenza is mentioned in the _Annals of the Four Masters_ as having prevailed in Ireland in the fourteenth century, and a disease characterized by similar symptoms is alluded to in early Gaelic manuscripts under the name of Creatan (creat, the chest). The disease is described also in an Irish manuscript of the fifteenth century under the terms Fuacht and Slaodan.[5]

[Footnote 5: Theophilus Thompson, _Annals of Influenza_, 1852.]

The earliest epidemic that prevailed in the British Isles of which any accurate description remains is that of the year 1510. The disease came from Malta, and invaded first Sicily, then Italy and Spain and Portugal, whence it crossed the Alps into Hungary and Germany as far as the Baltic Sea, extending westward into France and Britain. Its track widened over the whole of Europe from the south-east to the extreme north-west, and it is said that not a single family and scarce a person escaped it. It was attended by a "grievous pain in the head, heaviness, difficulty of breathing, hoarseness, loss of strength and appetite, restlessness, retchings from a terrible tearing cough. Presently succeeded a chilliness, and so violent a cough that many were in danger of suffocation. The first day it was without spitting, but about the seventh or eighth day much viscid phlegm was spit up. Others (though fewer) spat only water and froth. When they began to spit, cough and shortness of breath were easier. None died except some children. In some it went off with a looseness, in others by sweating. Bleeding and purging did hurt."[6] Blisters were commonly employed--two each upon the arms and legs, and one to the back of the head. The description is sufficiently clear to place the nature of this epidemic beyond all doubt.

[Footnote 6: Thomas Short, _A General Chronological History of the Air, Weather, Meteors, etc._, London, 1749; quoted in the _Annals of Influenza_.]

The epidemic of 1557, starting westward from Asia, spread over Europe, and then crossed the Atlantic to America. The malady broke out in England, after a season of unusual rain and great scarcity of corn, in the month of September. "Presently after were many catarrhs, quickly followed by a more severe cough, pain of the side, difficulty of breathing, and a fever. The pain was neither violent nor pricking, but mild. The third day they expectorated freely. The sixth, seventh, or at the farthest the eighth day, all who had that pain of the side died, but such as were blooded on the first or second day recovered on the fourth or fifth; but bleeding on the last two days did no service." "Some, but very few, had continual fevers along with it; many had {854} double tertians; others simply slight intermittent. All were worse by night than by day; such as recovered were long valetudinary, had a weak stomach, and hypped." Gravid women either aborted or died. This epidemic spread with frightful rapidity. Thousands were attacked at the same time. The entire population of Nismes, with scarcely an exception, fell ill of it upon the same day. It was extremely fatal. In Mantua Carpentaria, a small town near Madrid, it broke out in August, and so fatal were the bloodletting and purging which constituted the treatment at first, that, of the two thousand persons who were bled, all died. The disease raged in some parts till the middle of the following year (1558), and carried off, in Delft alone, five thousand of the poor. In all cases mild treatment was called for, with warm broths and speedy immersals, "to recall the appetite and keep the vessels of the throat open."

In 1580 a great epidemic of influenza spread from the south-east toward the north-west over Asia, Africa, and Europe. From Constantinople and Venice it overran Hungary and Germany, and reached the farthest regions of Norway, Sweden, and Russia. It spread into England, and has been described by Dr. Short. In Italy it prevailed during August and September, in England from the middle of August to the end of September, and in Spain during the whole summer. In most places its duration was about six weeks. As a rule, the termination was favorable, although the disease ran a somewhat protracted course. In the account of Dr. Short it is stated that "few died except those that were let blood of or had unsound viscera." In some places, on the contrary, the course of the disease was very severe. In Rome two thousand died of it, according to the author just cited, but Zuelzer informs us that the victims of this epidemic in the Eternal City were not less than nine thousand, and adds that Madrid must have been almost depopulated by it. This high mortality has been attributed to the bloodletting practised in the treatment of the disease. The symptoms were similar to those of the previous epidemics, with a greater shortness of breath, which continued in many cases for some time after the disappearance of the catarrhal trouble. There was great sweating at the end of the attack. The plague, measles, and small-pox prevailed also, and with considerable violence, during the year 1580.

Influenza, unfelt for several years, reappeared in Germany in 1591; an epidemic extending from Holland through France and into Italy occurred in 1593. In 1610 catarrh is said to have prevailed throughout Europe. In 1626-27 epidemic catarrhal fever made its appearance in Italy and France; in 1642-43 in Holland; in 1647 in Spain and in the colonies of the Western World; and again, in 1655 in North America. According to Webster,[7] this epidemic of 1647 was the first catarrh mentioned in American annals.

[Footnote 7: Noah Webster, _A Brief History of Epidemic and Pestilential Diseases_, London, 1800.]

In 1658 and 1675 it again visited Austria, Germany, England, etc. The first of these two epidemics is described by Willis,[8] and the second by Sydenham,[9] as they occurred in England, and the accounts are to be {855} found in the _Annals of Influenza_. It is about this period that the disease began to be known as influenza, and it is not without interest to observe that the influence of the stars suggested itself, in connection with its sudden appearance and wide prevalence, to the minds of the physicians of this date. Willis writes that "about the end of April (1658), suddenly a distemper arose, as if sent by some blast of the stars, which laid hold on very many together; that in some towns in the space of a week above a thousand people fell sick together."

[Footnote 8: Dr. Willis, _The Description of a Catarrhal Fever Epidemical in the Middle of the Spring in the Year 1658: Practice of Physick_, 1684.]

[Footnote 9: _The Epidemic Coughs of the Year 1675, with the Pleurisy and Peripneumony that supervened_: from the _Works_ of Thomas Sydenham, M.D.]

Epidemics are recorded as having occurred in Great Britain and Europe in 1688, 1693, and in 1709. The disease raged in 1712 widely over Europe from Denmark to Italy.

In 1729-30 a widespread epidemic swept over Europe. In five months it extended over Russia, Poland, Germany, Sweden, and Denmark. In Vienna sixty thousand persons fell ill of it. In the autumn it spread to England, and reached France and Switzerland; from there it extended to Italy, and by February it had reached Rome and Naples. Spain did not escape its ravages, and it is said to have found its way to Mexico. The symptoms did not differ in any important respect from those already described as characterizing previous epidemics. Pains in the limbs and fever marked the onset of the attack; catarrh, oppression, hoarseness, cough followed. In some cases delirium, drowsiness, and faintings occurred. A petechial eruption was observed, in some instances, between the fourth and seventh days. This renders it probable that typhus or cerebro-spinal fever prevailed at the same time. Turbid urine, copious sweats, bilious stools, and nose-bleeding were often noted. In Switzerland only children and old persons died. The disease was not very fatal.

Two years later (1732-33) an epidemic, starting from Saxony and Poland, overran Germany, Switzerland, and Holland, and invaded Great Britain in the month of December. Toward the end of January it spread in a south-easterly direction to France, Italy, Spain, and westward to North America, thence southward to the islands of the West Indies, and on to South America. The course of the disease in this epidemic was favorable. The attack terminated in from three to fourteen days, with sweating, bleeding from the nose, or an abundant discharge from the nasal passages. The aged and those suffering from chronic pulmonary diseases mostly perished. In Scotland three forms of the affection were described--namely, the cephalic, the thoracic, and the abdominal. The epidemic slowly spread over Eastern Europe and in a south-easterly direction, and may be said to have lasted till 1737.