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Attacks more young persons than More adults than young
adults. persons.
Generally occurs in winter. Epidemics irrespective of
season.
Eruptions are absent in at least Eruption rarely absent, and
half of the cases; they occur within appears about the fifth day.
the first day or two.
The eruptions are various; they Eruption always roseolous, and
include erythema, roseola, then petechial. Ecchymoses are
urticaria, herpes, etc. Ecchymoses rare.
are common.
Headache is acute, agonizing, Headache dull and heavy.
tensive.
Delirium often absent; often Delirium rarely absent; usually
hysterical, sometimes vivacious, muttering. Rarely begins before
sometimes maniacal. Generally the end of the first week.
begins on the first or second day.
Pulse very often not above the A slow pulse exceedingly rare.
natural rate; often preternaturally Its rate usually between 90 and
frequent or infrequent. Is subject 120.
to sudden and great variations.
"The temperature is lower than The temperature is always
that recorded in any other typhoid elevated, and does not fall until
or inflammatory disease." It is also the close of the attack. "The
very fluctuating. skin is hot, burning, and
pungent to the feel."
The body has no peculiar smell. The mouse-like smell is
characteristic.
The tongue is generally moist and The tongue is generally dry,
soft, and if dry is not foul. Sordes hard, and brown, and the teeth
on teeth rare. and gums fuliginous.
Vomiting is an almost constant and Vomiting is rare and not urgent.
urgent symptom, especially in the
first stage.
Pains in the spine and limbs of a The pains, if any, are dull, and
sharp and lancinating character apparently muscular.
are usual.
Tetanic spasms occur in a large Tetanic spasms are unknown in
proportion of cases and within the typhus. Convulsions sometimes
first two or three days. They are occur, due to pyæmia.
due to an exudation on the
medulla oblongata and spinalis.
Cutaneous hyperæsthesia is a The sensibility of the skin is
prominent symptom. generally blunted.
Strabismus is common. Strabismus is rare.
The eyes, if injected, have a light The blood in the conjunctival
red or pinkish color. vessels is dark.
The pupils are often variable and The pupils are equal and
unequal. contracted.
Deafness and blindness are often Deafness almost always ceases
complete and permanent. with convalescence. Blindness
never follows typhus.
Duration very indefinite, but Duration from twelve to
generally from four to seven days. fourteen days.
Relapses are common. Relapses are rare.
The blood is often fibrinous. The blood is never fibrinous.
The lesions, except in the most In typhus no inflammatory
rapid cases, consist of a plastic or lesions exist.
purulent exudation in the meshes
of the cerebro-spinal pia mater.
Mortality from 20 to 75 per cent. Mortality from 8 to 40 per cent.

PROGNOSIS.—In the section relating to the mortality of epidemic

meningitis it has been seen that its death-rate varies at different
times and places between widely remote extremes. This fact must
be borne in mind in estimating the influence of various
circumstances in controlling the issue of the disease. The relative as
well as the aggregate mortality is far greater in childhood than in
adult life. After the age of thirty or thirty-five it decreases rapidly
until old age, when recovery from the disease is quite exceptional. A
sudden or rapidly developed attack is generally unfavorable,
especially when the symptoms are adynamic and there is a purplish
discoloration of the skin. Indeed, even apart from evidences of
blood-change, cerebral are, on the whole, of graver importance than
spinal phenomena, and the more so the more typhoidal their type.
Of still more serious significance is a want of perception of the
gravity of the situation or unconcern about its issue. A
preternaturally slow and compressible pulse implies danger, and so
does coolness of the skin, especially if it grows purplish from a
diffusion of blood beneath it or even from venous stasis. The various
eruptions that have been described including petechiæ, are not
necessarily dangerous signs. Profuse sweats during a soporose state,
bullæ and gangrenous spots, obstruction of the bronchia with mucus
or serum, pneumonia or pericarditis,—these are all grave indications.
So, too, are a dry, fissured, shrivelled, and pale tongue or a
fuliginous state of the mouth, swelling of the parotids, obstinate
vomiting, and profuse diarrhoea at an advanced stage of the
disease. Among the most unfavorable nervous symptoms are great
restlessness, rigid retraction of the head, spasms of other than the
spinal muscles, general convulsions, extensive hyperæsthesia, deep
coma, dilatation and insensibility of the pupils or their rapid change
from a dilated to a contracted state, retention or incontinence of
urine, and all cerebral paralyses, including that of the muscles of
deglutition. The favorable indications comprise a general mildness of
the symptoms, a moderate loss of strength, a slight degree of pain
and muscular stiffness, the absence of petechiæ or vibices (although
in many grave epidemics they are of rare occurrence), a desire for
food and the ability to digest it. Yet it is imprudent to make an
absolute prognosis in any grave case of this disease. Recovery has
sometimes occurred when it appeared impossible, and some have
died when the period of danger seemed to have passed on the
sudden accession of cerebral or spinal nervous symptoms.

TREATMENT.—The difficulties that attend the solution of therapeutical

questions regarding diseases which are comparatively regular in
their evolution, and are produced by definite causes acting in an
intelligible manner, are very numerous and often insuperable. They
become multiplied in relation to a disease which, like this one,
stands alone in many respects; whose causes, phenomena, and
lesions—in a word, whose laws—are specific; and whose varieties of
type are as numerous as can be formed by the combination, in a
constantly varying proportion, of a special (hypothetical) alteration of
the blood, deranging the molecular actions of the economy, and at
the same time of an inflammation of the cerebro-spinal meninges,
and even of the substance of the great nervous centres. These
reasons are sufficient to account for the diverse and often opposite
methods of treatment that have been applied to the disease. As in
almost all other cases, the methods have consisted in using
remedies to counteract certain symptoms—now a stimulant or tonic
regimen to combat the debility which conferred the name of "sinking
typhus" on the disease; now an antiphlogistic course to allay the
inflammation of the brain and spinal marrow denoted by the
neuralgic pain and the tetanoid phenomena; and, again, large doses
of narcotics to blunt the pain and subdue the spasm. Still other
medications have been used with a similar purpose, and some, as
we shall see, with more or less theoretical views. It may be said,
with Von Ziemssen, "that we are far from having it in our power to
decide whether a rational treatment of the symptoms has cured the
disease or lessened its mortality;" but a review of the methods that
have been employed and their results leads to no doubtful
conclusion that some are mischievous and others more or less
salutary.

Emetics were among the first medicines used in the treatment of this
affection, and were probably suggested by the vomiting which is one
of its most constant initial symptoms. But we can readily understand
why they failed to afford relief. The vomiting and retching are not
gastric symptoms at all, but, as already stated, are due to the
irritation of the congestive or inflammatory process at the base of
the brain. These medicines may therefore be omitted. The
employment of purgatives is even less rational; they debilitate
without affording any relief.

Venesection was probably employed as a part of a routine treatment

which neither sound reason nor clinical experience justified. It was
generally found to fail of its curative purpose, and often induced,
especially in young persons, dangerous exhaustion. No better
illustration is needed to show that the disease we have been
studying is far more than a local inflammation of the cerebro-spinal
meninges. On the other hand, local depletion is often of marked
utility. Our own experience would lead us to conclude that in the
more sthenic cases scarified cups, applied to the nape of the neck
and along the cervical vertebræ, are of essential service in mitigating
—and generally, indeed, in wholly removing—the neuralgic pains
which form so prominent and severe a symptom in many cases of
this disease. When any abstraction of blood appears to be
contraindicated by the patient's debility, even dry cups will afford
him signal relief. Leeches have been applied to the parts mentioned,
and over the mastoid processes have sometimes been used with
advantage, but their depletory surpasses their revulsive action, and
is, so far, injurious. Cold to the head and spine is among the most
efficient means of relieving certain symptoms. In the Massachusetts
Medical Society's Report of 1810 we read: "Cold water, snow, and ice
have been applied to the head when there was violent pain in that
part with heat and flushed face, and when there was violent
delirium. They afforded great comfort to the patient, and mitigated
or removed those important symptoms." It is probable, however,
that the value of the remedy is almost entirely restricted to the
forming—or at least the early—stage of the attack, when the pain in
the head is most intense. Its soothing influence is then very marked,
as well as its indirect action in promoting sleep. Heat of head is not
an essential condition for its use, for even in the most violent cases
it is rarely extreme, and is often entirely wanting. Pain calls more
distinctly for the application, and when that symptom has subsided
cold is apt to be more annoying than grateful to the patient. Cold is
best applied to the head in the form of pounded ice enclosed in a
bladder or rubber bag; but cold affusions are also very valuable,
especially for children. For the application of cold to the spine the
most efficient apparatus is the long, flat rubber bag, either single or
double.

From the earliest history of epidemic meningitis in this country

blisters formed a conspicuous element in the treatment. They were
used, as they had been in other forms of meningitis, to relieve the
pain and diminish the congestion in the cerebro-spinal centres. The
results of their use were by no means uniform, for not only were
they employed in many of the cases which must almost necessarily
have been fatal before inflammation could be established, but even
in the inflammatory cases they were often applied when time
enough had elapsed to allow the exudation to be fully formed, and
when, therefore, they were too late to be useful. Again, they were
sometimes used so as to vesicate too deeply, and thus by the pain
they caused at first, and by the exhaustion that resulted from the
excessive discharges they maintained, the patient was more injured
than benefited. Our own experience proves that in the early stage of
the inflammatory form of the disease blisters applied below the
occipital ridge and upon the back of the neck, and only allowed to
vesicate superficially, not only remove the pain in the head, but
diminish the delirium, spasms, and coma, and therefore contribute
as directly as other remedies, if not more so, to the favorable issue
of the attack. But such salutary effects are not to be looked for when
the disease assumes a malignant type nor after its constitution has
become definitely fixed. The application of stimulant and even
vesicating agents to the spine below the neck has not been generally
practised because, probably, the seat of the spinal lesions was
known to be chiefly at the upper part of the organ. Still, the
neuralgic pains felt in the spinal nerves may be mitigated by
stimulant and anodyne liniments applied with friction to the spinal
column.

American physicians early recognized coolness of the skin among the

most striking phenomena of the disease; and this probably
suggested their use of diaphoretic remedies, among which were the
external application of moist heat in baths and warm wrappings, as
well as "bottles of hot water or billets of wood heated in boiling
water and wrapped in flannel," or the patient "was wrapped in
flannel wrung out of boiling water, sinapisms were applied to the
feet, while hot infusions were administered, made from the leaves of
mint, pennyroyal, and other similar plants, and also wine-whey, wine
and water, wine, brandy, and other ardent spirits more or less
diluted, camphor, sulphuric ether, and opium. It was not generally
thought useful to excite profuse sweating, but important to maintain
the activity of the skin from twenty to forty hours, and even longer
in some instances. Soup and cordials were at the same time
administered. Under this treatment most commonly the violent
symptoms, and not very rarely all the appearances of disease, have
subsided" (Jackson). Beyond all doubt, this method was a rational
one, for it tended to promote an elimination of the morbid poison,
while it depleted the blood-vessels and acted revulsively upon the
local inflammation of the cerebro-spinal meninges. Yet it seems not
to have been revived during the more recent epidemics of the
disease, unless, partially, by Gordon (1867), who says: "What I have
seen most useful in the stage of collapse is external warmth applied
to the entire surface by means of flannel bags containing roasted
salt, applied along the spine, along the chest, inside the arms, and
to the feet and legs and between them."

Except typhus fever, there is no disease in which a due

administration of alcoholic stimulants may become more important.
In cases of the inflammatory type they are rarely needful, and are
frequently hurtful, but in those which exhibit signs of blood disorder
with nervous exhaustion they are often indispensable. Nothing
demonstrates their necessity more clearly than the extraordinary
tolerance of alcohol exhibited in some cases of the disease. Among
the earlier American authorities may be found many illustrations of
this statement. Woodward (1808) observed that very large quantities
of wine or ardent spirits may be given without injury. Arnell said: "In
some cases I have given a quart of brandy in six or eight hours with
the happiest effect." Haskell maintained that "the bold and liberal
use of diffusible stimuli is the only safe and efficacious mode of
treatment." In Ireland the habitual use of alcohol in the treatment of
typhus fever no doubt suggested its liberal employment in this
disease, but such stimulants have never been in vogue among the
physicians of France or Germany. This difference may in part be
accounted for by the generally asthenic type of the disease in the
first-named country and its more inflammatory character in the
others. Similar contrasts of type mark different epidemics, and
individual cases during the same epidemic. We have no doubt that
while these agents are indispensable in the treatment of cases of the
former type, they must even then be exhibited discreetly, for their
too lavish exhibition entails the gravest peril by intoxicating the
patients and oppressing instead of arousing their vital energies. In
1866, on taking charge of the medical wards in the Philadelphia
Hospital, we found that the patients were using as large quantities
of alcohol as are given in typhus fever, but a very short period of
observation showed that this use of the stimulant was excessive;
consequently the dose of it was first reduced, and finally it was
omitted altogether unless special indications for it arose. This change
was followed by a manifest improvement in the general aspect of
the sick and the subsidence of symptoms which, it then became
evident, were due to a lavish use of stimulants rather than to the
gravity of the disease. Alcohol is no more essential to the treatment
of epidemic meningitis than of any other acute affection; it is a
cordial to be held in reserve to meet those signs of failure of the
heart and nervous system which may arise in all acute diseases
attended with changes in the condition of the blood.

The use of opium in the treatment of this disease was strongly

advocated by nearly all of the early American writers upon the
subject, and by many of them enormous doses were given. It was
observed not to produce narcotic effects in ordinary doses. In one
case, marked by excruciating pain in the head and maniacal
delirium, sixty drops of laudanum were given every hour until nearly
half an ounce had been taken within eight hours (Strong). Haskell
states: "We have been obliged frequently to exhibit ten grains of
opium for a dose in some of the violent cases attended with strong
spasms, and have never known it to produce stupor in a single
instance." Miner relates that "a few cases imperiously required half
an ounce of the tincture of opium in an hour, or half a drachm [of
opium] in substance in the course of twelve hours, before the urgent
symptoms could be controlled, and even some cases required a
drachm in the same time. All these patients recovered." In Europe,
Chauffard administered opium in doses of from three to fifteen
grains, and Boudin frequently prescribed from seven to fifteen grains
at a single dose at the commencement of the attack, and
subsequently one or two grains every half hour, until the patient
grew sleepy or his symptoms subsided. This tolerance of the drug is
remarkable, and so is the fact that it does not cause constipation.
These and many similar statements agree entirely with our personal
experience. We were in the habit, during the epidemic above
referred to, of prescribing one grain of opium every hour in very
severe and every two hours in moderately severe cases, and in no
instance was narcotism induced, or even an approach to that
condition. Under the influence of the medicine the pain and spasm
subsided, the skin grew warmer and the pulse fuller, and the entire
condition of the patient more hopeful. It seemed probable, however,
that the benefit of the opium treatment was most decided in the
early stages of the attack, and hence in those in which the
inflammatory and spasmodic elements predominated. The
hypodermic injection of morphia is to be preferred before the
internal administration of other preparations of opium, not only on
account of its prompter action, but because it avoids the rejection of
the medicine by vomiting. On the whole, Von Ziemssen is within the
bounds of truth when he says, "Beyond all doubt morphia may be
considered the most indispensable medicine in the treatment of
epidemic meningitis."

There is no evidence sufficient to show that epidemic meningitis has

ever been cured by quinia alone. In the early prevalence of the
disease it was treated by large doses of cinchona, but unavailingly,
and subsequently smaller doses were given during the
convalescence, as it was in that of other acute diseases. In some
parts of this country where miasmatic diseases prevail, and epidemic
meningitis, like all other acute, and especially febrile, disorders,
displayed more or less of a periodical or paroxysmal type, quinia was
used in large doses, but the expected result was not realized.
Upham states that in some instances it was given to the extent of
sixty, or even eighty, grains within twelve hours from the beginning
of the attack, but without effect. In Europe it was extensively tried
and unanimously condemned. It may very properly be left out of the
list of medicines suitable for this disease, particularly since it is no
longer probable that any physician would be rash enough to employ
it in the so-called antipyretic doses with or without their usual
associates, cold baths. According to Karl Jaffé, the medicinal
antipyretics (quinia, salicylic acid, and also sodium benzoate) may be
entirely discarded, because they ruin the already weakened
digestion.59
59
Phila. Med. Times, xii. 600.

Common sense has also proved stronger than theory in excluding

mercurials from the treatment of epidemic meningitis. At one time
they were extensively used, especially when it was learned that the
disease in its full development included a paramount inflammatory
element. But it was soon found that the results of their use were far
from uniform, and farther still from being demonstrably beneficial. In
this, as in many other similar cases, it is quite impossible to reach a
definite judgment unless it were known what was the type of the
cases in which the medicine was given, whether they were asthenic
or inflammatory, and again whether it was used during the active or
during the declining stage and toward convalescence. In the absence
of any trustworthy testimony upon the subject it is only possible at
present to state that in the treatment of this disease mercurials
should not be used. This conclusion is all the more imperative
because the medicine is not an indifferent one. If it is not necessary
—and it certainly is not—it is too dangerous in its immediate and
ultimate effects for its employment to be warranted.

Since belladonna and ergot were shown to diminish vascular action

in the cerebro-spinal axis by contracting its capillary blood-vessels,
they have been put forward as having a specific virtue in this
disease. If the fact be so, how is that other fact—a clinical one,
moreover—to be disposed of, which is that opium, the physiological
antagonist of belladonna and ergot, is more efficient than they are in
curing the disease? It is possible, indeed, that they may have that
curative power, and that opium possesses it also, and that the
explanation given of the action of all of these agents is erroneous.
Upham states that, in 1863, Haddock recommended ergot upon
theoretical grounds, and that during an epidemic at Newbern, N.C.,
several cases treated by it recovered. Three cases recovered in
which it was prescribed by Borland. Read used it in 1873-74 at
Boston, Mass., and out of 19 cases 16 recovered and 3 died.60 This
mortality of about 15 per cent. is not more than half of that which
has generally been met with, and if it can be attributed to the
treatment would go far to prove the efficacy of the latter. One grain
of ergotine, with one-tenth of a grain of extract of belladonna, was
administered every three hours. Considering the exiguity of the dose
of belladonna, it is not surprising that, except in one case, it did not
dilate the pupil; and the dose of ergotine is likewise far smaller than
the average medicinal dose of that preparation. Moreover, all of the
cases except the fatal ones appear to have presented the disease in
a subacute, and certainly not in an aggravated, form.
60
Philadelphia Med. and Surg. Reporter, Jan., 1875, p. 68.

In 1872, Dr. S. N. Davis,61 moved by the success of Calabar bean in

tetanus, employed it in this disease. A mixture of one ounce of
tincture of Calabar bean with one and a half ounces of fluid extract
of ergot was administered in doses of half a teaspoonful every two
hours, and with better results than had followed other remedies.
Here, again, it is to be noticed that the analogy suggesting the use
of physostigma is not a logical one. That drug indeed relieves the
spinal spasms of tetanus—a disease in which there is an irritation of
the spinal axis, but no exudation from its meningeal vessels, as in
the affection we are studying. Moreover, it is a disease of
extraordinary power, as shown not only by the spasms, but by the
exceptionally high temperature, and thus again is in direct contrast
to epidemic meningitis. If, therefore, Calabar bean benefits that
disease, it cannot do so in the manner suggested by the author.
61
Richmond and Louisville Med. Jour., xiii. 711.

Bromide of potassium and hydrate of chloral have also been

employed to allay the spasmodic symptoms; but the former is too
feeble for the purpose, and the depressing action of the latter upon
the heart renders it dangerous. Bromide of potassium has been
given to children of two and five years in doses of four and six grains
every two hours; but these doses appear to be quite too small even
for the purpose in view—viz. to prevent convulsive attacks. Whatever
remedies may be suggested hereafter, none should be employed
that tend to reduce the power of the heart, which, as we have seen,
is dangerously depressed by the disease.

During the decline and convalescence of the affection it is probable

that iodide of potassium may be advantageously used to promote
the removal of the exudation-matter on the brain and spinal marrow,
and probably to prevent the hydrocephalus which sometimes follows
the attack, and is attributable to the pressure of effused lymph upon
the cerebral veins.

DIET.—The mildly febrile character of epidemic meningitis, and the

remarkable debility which characterizes so many cases of the
disease, and which, as was before pointed out, conferred upon it the
name typhus syncopalis, plainly justify what experience has taught,
that appropriate food for the subjects of this affection is at once the
most digestible and nutritious that can be taken. It is true that this
regimen is interfered with by the vomiting, but, as that symptom is
of cerebral and not of gastric origin, it is more apt to be allayed by
suitable food than by abstinence. It has been our custom to observe
in this disease the same rules respecting diet that are recognized as
the most suitable in typhus fever. In doing so, indeed, we did,
without at the time knowing it, follow the example of the early
American physicians. Strong, who wrote in 1811, advised "soup
made from chicken, veal, mutton, and beef, richly seasoned with
pepper and savory herbs." These articles were prescribed by him
during the height of the disease. Later on he says: "The stomach
soon begins to crave something more solid than soup; oysters,
beefsteak, cold ham, or neat's tongue are received with peculiar
relish. Often I have seen convalescents, when they had hardly
strength enough to raise themselves in bed, make a hearty meal of
the above-mentioned articles, which were received with great
satisfaction, sat well upon the stomach, and were well digested and
assimilated." This method is substantially the same that was found
successful in the earlier, as it has been in the later, epidemics in this
country, and we have no hesitation in attributing to it and the
appropriate use of opium and blisters the degree of success we
enjoyed in the treatment of the disease in the Philadelphia Hospital
and elsewhere.

During convalescence from epidemic meningitis the patient should

carefully abstain from physical exertion and mental excitement, and
before this state is fully established he should even very cautiously
change his position from a recumbent to an erect posture. And,
finally, he should return to his ordinary occupations, mental or
physical, as late as possible, on account of the danger of a relapse,
which has already been described.
PERTUSSIS.
 BY JOHN M. KEATING, M.D.

HISTORY.—A careful study of this disease from the various writings

since the time of Hippocrates leaves little doubt in the mind of the
reader as to its antiquity, so little indeed has it changed in its various
characteristics. Whether the affection passed to continental Europe
from Africa, or whether its starting-point was India, are questions
difficult to solve, and, except for the medical historian, of little
import. Desruelles probably truthfully asserts that the many
differences which mark the descriptions of the disease, especially by
the early Grecian writers, may be due, not to the non-existence of
the disease as we know it, but to the influence which climate
exerted then as now, and to the unrecognized fact that it is only
fatal in its complications. The writings of Hippocrates, Galen, and
Avicenna, though undoubtedly referring to the many affections in
which paroxysmal cough is a prominent symptom, contain many
expressions that would point clearly to the existence of a specific
disease. Dr. Watt believed that the disease was not known to the
Greeks, and other writers claim that it came from the north and
spread southward over Europe about the sixth century;
nevertheless, it first appears on record as a distinct affection,
disentangled from the confused mass with which it was involved for
centuries, about the middle of the seventeenth century. Steffen
mentions the first well-established accounts as coming from Baillou
in the year 1600, and Schenck in 1650, and Ettmüller in 1685.
Sydenham casually mentions it in 1670. Since the time of Willis the
definition of the disease has remained unaltered, and so accurate
was the description then given of it that we can but naturally
conclude that for many centuries at least it has varied but little.
In studying affections of this kind, occurring in epidemic form
especially, and which are increased in intensity by whatever means
the contagious element, whether gaseous or parasitic, is made more
virulent, much allowance is to be made for the climate, customs, and
habits of the people whence our data are derived. Thus, most of the
diseases of antiquity, the descriptions of which have reached us,
have been drawn from types modified by mild climates where the
people have led an out-door life, and though the disease we see at
the present day is one and the same so far as its causation is
concerned, the indoor life and close confinement, the bad
ventilation, and the artificial existence in our large cities must
weaken the individual, intensify the poison, and exert an influence
on the disease.

DEFINITION AND DESCRIPTION.—Whooping cough has been characterized

as an acute contagious affection, occurring usually in childhood,
though it may occur at any age, and lasting several weeks. It is
manifested usually by malaise, catarrh of the respiratory tract, and
subsequently by a convulsive cough occurring in paroxysms, the
peculiarity of which consists of a series of forcible expirations,
followed by a sonorous inspiration or whoop, which may be repeated
several times.

At the beginning of these paroxysms of coughing, there are

evidences of slight laryngeal irritation, attended by an effort at
suppressing the cough; then follow gradually increasing and more
audible inspirations, which become more and more difficult. The
child is agitated, the face becomes pale, and the countenance has a
mingled expression of supplication and fear. If it is old enough it will
seize the nearest object for support. As the spell advances, the eyes
become suffused and prominent and the loose tissue surrounding
the orbits appears puffy and congested. Finally, the paroxysm
reaches its height; the child, with a livid countenance, with veins
standing out like cords, gives a succession of violent expiratory
efforts, followed by a long inspiratory whoop. The same is repeated
several times, until finally almost complete cyanosis takes place; the
spasm relaxes, a glairy, tenacious mucus runs from the mouth, the
contents of the stomach are vomited, and the child falls back
exhausted. The lividity of the countenance is succeeded by a deathly
pallor; the face still appears swollen and puffy beneath the eyes; the
tears course down the cheeks, and frequently hemorrhage occurs
from the eyes, nose, ears, or throat, owing to the terrific strain upon
the circulation. As soon as the child has recovered from the fatigue
of the paroxysm all is apparently over, and were it not for the
characteristic expression of the eye, which is pathognomonic in a
well-advanced case, nothing would be noticed to even suggest the
disease when uncomplicated. The voice is clear; there is little or no
elevation of temperature.

The paroxysms which have given the name to this disease can only
be likened to an epileptic convulsion, which by gradually increasing
cyanosis is self-curable, the carbonized blood finally bringing about
an anæsthetic effect. The severity of the paroxysms is by no means
in proportion to the local catarrh, which latter may be superficial and
slight, not to be detected during life by the most careful laryngeal
examinations, and only after death by the aid of the microscope.
The frequency and intensity of the paroxysms are dependent in a
measure upon the degree of excitability of the nervous system,
which of course differs in individuals. It is evident that the success of
treatment must be powerfully influenced by this circumstance, and it
is partly owing to it that there are so many opinions as to the value
of remedies in this disease.

The complications are usually dependent upon outside causes, and

have nothing to do with the poison proper of whooping cough, as far
as we can tell. There are some which depend on an inflammation of
the mucous membrane, which may be limited to any portion of the
respiratory tract or may extend throughout it. Complications may
arise from mechanical obstruction to inspiration by the swollen
mucous membrane or from plugs of tenacious mucus, which may
cause pulmonary collapse and favor the development of catarrhal
pneumonia, and later even of phthisis; or from impediments to free
and easy expiration, whether from spasm of the bronchioles, from
forcible compression of the thorax through reflex nervous irritation,
or from other obstructions, all of which tend to produce emphysema.
Disturbances of the circulation, in the brain or elsewhere, may
proceed from thrombi or emboli and give rise to complications which
will render fatal an otherwise mild form of the disease. The
invariable disturbance of nutrition which accompanies every disease
affecting the nervous system is apt to show itself in the breaking
down of products which are simply inflammatory. Vomiting may be a
most serious complication, both from its immediate and remote
effects. It may be due to gastric catarrh, or more frequently to
irritation of the pneumogastric nerve.

ETIOLOGY.—Very numerous theories have been advanced as to the

nature of this interesting disease. Hufeland, Lebenstein, Pinel, Jahn,
Todd, Cullen and a host of others have regarded it as essentially a
neurosis. By many others it has been supposed to be due to a lesion
of the brain or of its membranes, but careful investigation has
established the fact that there is no lesion in whooping cough at all
constant or characteristic. By still others, and especially by Gueneau
de Mussy, it has been regarded as essentially an affection of the
tracheo-bronchial glands, a bronchial adenopathy, causing irritation
of the pneumogastrics and of their bronchial branches by pressure of
the enlarged glands. We have, however, seen many post-mortem
examinations of the bodies of children who have died of measles,
where marked enlargement of these glands was constantly found,
but where no symptoms of whooping cough had been present.
There are indeed many features of the disease which seem
inexplicable on any other theory than that the essential cause of
whooping cough is a specific poison, and such is the view now
generally adopted. This poison is capable of being carried by
fomites, though as it is highly infectious it is often communicated
through the atmosphere, and is most frequently conveyed from
individual to individual. Dolan,1 who has recently published a very
interesting and valuable monograph on this affection, quotes
Linnæus, who ascribed it to the irritation of insects, as the author of
the modern view that whooping cough is due to the presence of a
peculiar microbe, though it must be conceded that as yet it has not
been discovered. Most observers hold that the contagium is not in
the blood, but that it resides in the secretions of the respiratory
passages, and is most virulent during that stage of the disease when
the secretion is abundant. Letzerich states that he has succeeded in
producing whooping cough in rabbits by inoculating the trachea with
the sputa of the human subject. Dolan obtained similar results by
injecting the nasal secretions, and also by compelling rabbits to
inhale air impregnated with decomposing sputa and vomit of
patients suffering with the disease.
1
Dolan, Thos. M., Whooping Cough, London, 1882.

The following brief statement of his conclusions may be quoted as presenting the
most important facts concerning the pathology of the disease:

1st. Pertussis depends on a specific poison or contagion; this is universally admitted.

2d. This contagion is active and highly infectious; this is also granted.

3d. The contagion is analogous to the contagia which produce splenic fever, measles,
scarlatina, variola, etc.

4th. It has a peculiar determination to the lungs.

5th. Like all other contagia, it has its period of activity and decline.

6th. The period of greatest activity is in the first and second stages.

7th. Pertussis runs a regular course like measles, scarlatina, variola, etc., and rarely
attacks a person but once.

8th. It may thus be classed among zymotic diseases.

9th. The fact that there is no primary pathognomonic morbid change supports this
view.
 10th. There are various secondary lesions which are characteristic, as ulcerations of
the frænum linguæ.

11th. The mode of death harmonizes with this view.

I do not, however, feel entirely satisfied in adopting the view that

the contagium of whooping cough resides alone in the mucous
membranes of the air-passages.2 Children have been known to be
born with the disease, the mother having suffered from it some time
previous to confinement. The following case occurred under my own
observation: Mrs. F——, the mother of two children, was in her
eighth month of pregnancy; the two children had at the time a very
severe attack of whooping cough, which required the constant
attendance of the mother. She, though an extremely intelligent
woman, belonged to the poorer classes, and had no one to assist
her at this trying time. One day she complained that the movements
of her child in utero had entirely changed. Suddenly, without any
previous motion, the child would become very active; the force of its
movements was such as to make hazardous any attempt on her part
to walk in the street. The suddenness with which the movement
would come on would oblige her to seize the nearest object for
support. This continued until the child was born. Shortly after labor
my attention was called to the infant, which had a curious attack, it
became deeply cyanosed, seemed asphyxiated, as it were, for a
moment, had no convulsions, and within a few seconds resumed its
normal breathing and the circulation seemed once more established.
I saw the child in several of these attacks; its health did not seem to
be impaired, and without treatment, within a few weeks they
disappeared altogether. The mother insisted upon the fact that the
child had whooping cough, and the absence of the characteristic
whoop was the only thing that prevented the diagnosis from being
positive. This would show—and there are enough cases on record to
warrant our basing an opinion upon them—that the contagium of
whooping cough is found not alone in the matters expectorated,
notwithstanding the statement of Dolan and others that their
experiments failed to show its existence in the blood.