434

SPASMODIC AFFECTIONS OF THE LARYNX.

MM. Rilliet and Barthez have described a spasmodic cough that returns in paroxysms, is loud, attended with an imperfect hoop, and may be easily taken for hooping-cough by the inattentive observer. It is, however, a symptom of bronchial phthisis, due to the extension to the larynx of irritation seated in a distant part of the respiratory organs.

Intestinal irritation is a frequent cause of nervous cough in

breathe hurriedly for some time after they had passed off. From about the ninth month, slight cough was almost constantly present, though still unattended by any febrile disturbance: the head was sometimes very hot, and the difficulty of deglutition, the dyspnoea, and the convulsions, increased both in severity and in the frequency of their recurrence. The child now cut the two lower incisors, but without any change taking place in his general condition. Two or three weeks before his death, which happened when just a twelvemonth old, he had an attack of coryza, with abundant puriform discharge, which, by its hardening, blocked up the nostrils, and caused a good deal of distress in breathing, though unattended by any really grave symptom. He was recovering from this, when, one morning early, a paroxysm of dyspnoea came on, which was followed by a slight fit that left him pale and exhausted. About two hours afterwards, his breathing not having become as quiet and natural as before the first paroxysm, another attack came on, in which he died.

On examining the body after death, the lividity of all the depending parts was very remarkable.

The pericranium stripped off very easily from the bones of the skull, which were exceedingly vascular. There was considerable vascularity of the dura mater, the sinuses of which, and the cerebral veins generally, were gorged with fluid blood. There was no injection of the pia mater; sections of the brain presented a rather greater number of bloody points than natural, but its substance was firm, and the lateral ventricles contained but little fluid.

The first object seen on opening the chest was the thymus gland, which occupied the whole of the anterior mediastinum, and nearly concealed the heart. Its structure was apparently natural; its length was 33 inches, and it weighed 328 grains.

The heart was extremely large, as large as the heart of a child three years old. Its auricles and the veins, both the cave and the pulmonary veins, were full of fluid blood. The organ was not well contracted; its structure was perfectly healthy, and the fœtal openings were closed.

There was a good deal of thick mucus in the trachea and bronchi, but they were perfectly healthy; and the rest of the body presented no remarkable appearance, except that a considerable extent of both lungs was in a state of carnification.

Now, notwithstanding some points of difference between this case and those in which spasm of the glottis has been induced by a different cause, yet we recognise in it the grand symptoms of that affection, and those the same as make up the spasmodic element in cases of inflammatory croup. The enlargement of the thymus appears to have induced permanent irritation about the windpipe, which betrayed itself by the frequent cough and the constant wheezing. To the same cause, too, must be referred the difficult deglutition, while the convulsions were probably much favoured by the enlarged gland pressing upon the superior cava and right auricle, and thus impeding the return of blood from the head: nor must we forget, among the probable causes of the child's sudden death, the remarkable degree of cardiac hypertrophy. The fatal event, however, might possibly not have occurred but for the attack of coryza, and the consequent impairment of the respiratory function, which naturally tended to increase the congestion of the brain.

SPASMODIC AFFECTIONS OF THE LARYNX.

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childhood. It is sometimes a loud, solitary, ringing cough-the tussis ovilla, tussis ferina of medical writers: at other times it is a short dry cough, attended with no particular inconvenience, but teasing from its frequency. Both of these forms appear to result in many instances from the presence of worms, and speedily cease under the judicious employment of purgative medicines.

Lastly, I may once more remind you of the cough which is occasionally heard in the early stage of inflammatory affections of the brain. It is a very short, hoarse cough, which sometimes continues for a few minutes almost incessantly, then ceases for a time, and then, after a pause, returns again. The disturbance of the brain is sympathised with by the larynx, and the depletion which relieves the former organ, removes the irritation of the latter.

LECTURE XXVI.

HOOPING-COUGH.-Course of the disease in its simplest form-subject to great variations in its mode of onset and degree of severity.-Signification of the hoop.Course of the disease when declining-Its danger depends on its complications— Complication with bronchitis-at its outset, or when it has continued for some time-Complication with disorder of the nervous system-sometimes exists from the first, and causes death even before characters of disease are fully developed --but may come on at any period-various forms assumed by disorder of nervous system-great danger when paroxysms of cough terminate in convulsions-caution as to nervous character of dyspnea in many cases, and as to danger of overtreating it.—True hydrocephalus rare as a complication.

WE pass to-day to the study of one of the most common disorders of childhood. Few persons attain to adult age without having experienced an attack of hooping-cough, and still fewer of those who escape it when children suffer from it in after-life.

Hooping-cough, then, claims our notice as being essentially a disease of early life; but as it is one which almost every old woman professes to cure, we might fairly expect not to be detained long with its study. We find, however, that in this metropolis it ranks fourth among the causes of death under five years of age; inflammation of the lungs, convulsions, and hydrocephalus, being the only more fatal ailments. A cursory enquiry will not suffice to make us thoroughly acquainted with all points of importance in the history of a disease that has so many victims.

The affection in its simplest form consists of a cough of spasmodic character, that usually succeeds to catarrhal symptoms, and having recurred at intervals for a few weeks, ceases without having occasioned any serious disturbance of the general health, or having required any active medical treatment. In its graver forms it is one of the most fearful diseases that we ever have to encounter, often keeping the life of the patient for days or weeks together in almost constant jeopardy, liable to be exaggerated by the most trivial cause, or rendered fatal by the slightest error in treatment; while the highest effort of our art is limited to mitigating the severity and warding off the urgent danger of symptoms which we

SYMPTOMS OF HOOPING-COUGH.

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are unable wholly to subdue, and which we must trust to time and nature thoroughly to cure.

Such great differences in the course of the disease in different cases have given rise to many ingenious theories as to its nature and seat, framed with the view of explaining that which cannot but strike all observers as so enigmatical in its character. None of these speculations, however, have led to any useful practical result, and we shall be better employed than in their study, if we confine ourselves to the simple observation of the phenomena of the disease. In doing this, we will begin with those cases in which it is most simple and least perilous, and will then examine in succession the different modes in which its course becomes complicated and dangerous.

An attack of hooping-cough usually begins with catarrh, and presents at first little or nothing to distinguish it from a common cold, except that sometimes the cough is attended almost from the outset with a peculiar ringing sound. By degrees the catarrhal symptoms abate, and the slight disturbance of the child's health altogether ceases, but nevertheless the cough continues; 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 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, however, the hoop is followed by but a momentary pause, and the hurried expiratory efforts begin again, and are again arrested by the loud inspiration, perhaps only to recommence; until, after the abundant expectoration of glairy mucus, or retching, or actual vomiting, free inspiration takes place, and quiet breathing by degrees returns. If you listen to the chest during a fit of hoopingcough, you will hear no sound whatever in the lungs; but when the hoop occurs, you will once more perceive air entering, though 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

438

COURSE OF THE DISEASE IN ITS SIMPLEST FORM.

the pulmonary cells again; but then you will hear vesicular murmur as clear as if nothing ailed the child, or at most interrupted only by a little rhonchus, or by slight mucous râle. If the cough is severe, quiet breathing does not return, nor the vesicular murmur become audible, till some time after the paroxysm is over; and occasionally, short and laborious respiration ushers in each fit of coughing. The child then seems to have a presentiment of the coming seizure; its face grows anxious, it looks up at its mother, and clings more closely to her; or, if old enough to run about, you may observe it, even before its breathing has become manifestly affected, throw down its playthings, and hasten to seize hold of a chair, or of some article of furniture, for support during the approaching fit of coughing.

If the case is uncomplicated, even though the attack be severe, the child's health continues good, and little or nothing ails it during the intervals of the cough. Its appetite is not impaired, but after throwing up the contents of the stomach in a fit of coughing, it asks for food almost immediately. It sleeps soundly, except when roused by the cough; the bowels act regularly, or are perhaps a little constipated, and slight complaint of headache or languor, with loss of the usual cheerfulness, are often all the permanent ill effects to be discerned between the seizures.

After the hoop has been heard, the disease goes on for about a week to increase in severity, the cough becoming more frequent, its paroxysms severer and more suffocating, and attended with more frequent hoop. After remaining stationary for ten days or a fortnight, it begins to decline; and one of the first indications of this is usually afforded by a diminution in the severity of the nocturnal exacerbations. We next find, either that the fits of coughing are less frequent, or, though they should occur as often as before, yet they are less severe, and sometimes cease without the occurrence of a hoop. When on the decline, however, exposure to the cold, neglect of the state of the bowels, or mental excitement, will suffice in many cases to bring back the hoop, and to increase the previously diminished severity of the attack. For the most part, the cough loses its spasmodic character for many days before it ceases altogether; and you may even find a child, 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.

Such is the ordinary course of the disease in those cases in which