On Whooping Cough: Its Great Fatality, and the 
Necessity for Isolation and Rest in its Treat- 
ment. 
BY 
WILLIAM W. JOHNSTON, M.D. 
Washington, D. C. 
FROM 
ARCHIVES OF PEDIATRICS, 
April, 1895. ON WHOOPING COUGH: ITS GREAT FATALITY, 
AND THE NECESSITY FOR ISOLATION 
AND REST IN ITS TREATMENT* 
BY WILLIAM W. JOHNSTON, M.D., 
Washington, D.C. 
The reasons for the selection of whooping cough as 
the subject of the monthly essay will be more apparent, 
I trust, at the end than they may seem to you at the be- 
ginning of this paper. 
It is strange in the general revival of the study of the 
infectious contagious diseases that pertussis should have 
come in for such a small share of attention and that so 
little change should have taken place in plans in treat- 
ment which have been the same for an indefinite period. 
It is true that we do not bleed and give nauseating eme- 
tics, as in the days of Cullen, but has the discovery of 
the infectious nature of the disease led to the employment 
of the modern methods of prevention which we use with 
other diseases of the same class ? 
Moreover whooping cough above all other diseases is a 
people’s disease ; its diagnosis, management and treat- 
ment are largely in the hands of the laity. Boards of 
Health have no control over it ; there are no rules regu- 
lating its diffusion, and the medical profession have ab- 
dicated the field to the nostrum vender or to domestic 
medicine. 
Such being the position of the medical profession and 
the sanitary authorities toward whooping cough, the 
question arises whether the position is justified by the 
nature and extent of the disease as it affects communities. 
Is its mortality so slight that it should not receive the 
advantages of modern preventative science ? I propose 
to show that not only is this not the case, but that it 
stands along with scarlet fever and measles as a death 
producing disease. The strange anomaly is presented of 
* Monthly Essay ; read before the Medical Society of the District o f 
Columbia, January 23, 1895. JOHNSTON : Whooping Cough. 
the utmost expenditure of effort in the case of one con- 
tagious disease and the utmost indifference as regards 
one equally contagious. 
What can be more exact than the present management 
of a case of scarlet fever with all the refinements of isola- 
tion, disinfection and excessive attention to details ; on 
the other hand what can be more full of negligence, more 
absolutely empty of all precautionary measures than the 
system with which we deal v/ith whooping cough. 
Let us examine into the actual and relative mortality 
of whooping cough in order to discover the reason, if 
there is any, for this difference ; let us see if the world 
has been right in this or if it has paradoxically controlled 
the spread of the one disease and contributed to the spread 
of the other. 
From 1848 to 1855, 72,000 deaths or one-fortieth of the 
whole number of deaths were due to whooping cough in 
England and Wales. In one year in England there were 
500,341 deaths ; of these 10.318 were due to whooping 
cough. In 1876 in England scarlet fever had 11,045 v'c_ 
tims, measles 9252, whooping cough 10,201; 844 less than 
scarlet fever and 949 more than measles. 
In Basle, according to Hagenbach, the mortality of 
whooping cough was greater than that from any other 
disease except typhoid fever and diphtheria. 
In Berlin in 1887 there were 257 deaths from scarlet 
fever, 223 from measles and 535 from whooping cough ; 
about the same proportion continued during subsequent 
years. 
In 1893 in London there were 2,330 deaths from whoop- 
ing cough. 
In the year ending June 1, 1870, whooping cough had 
9,008 victims in this country. 
In the United States, according to the Census of 1880, 
diphtheria leads the list of infectious diseases with 19,854 
annual deaths, whooping cough comes next with 10,313, 
scarlet fever is third with 10,142, while measles has only 
5,481 deaths. 
The Census of 1890 gives the same place to whooping 
cough ; measles stands first with a mortality of 9,256, Johnston : Whooping Cough. 
3 
whooping cough second with 8,432, and scarlet fever last 
with 5,969 deaths. Diphtheria and croup have a much 
greater mortality of 41,677. These figures are admitted 
not to be exact as regards the actual number of deaths, 
being underestimates, but the relative proportion between 
the different diseases may be assumed to be correct. 
A ten year record in New York City shows 4,094 deaths 
from whooping cough and 4,062 from typhoid fever. 
Mortality in New York, Brooklyn, Baltimore and Washington, from diphtheria, scarle 
fever, measles and whooping cough and the rate of death from each cause to 10,000 inhabitants 
for year ending May 31, 1890. 
TABLE I. 
Cities of 
Diphtheria. 
Ratio 
to 10,000 
Pop. 
Scarlet 
Fever. 
Ratio 
to 10,000 
Pop. 
a 
0> 
S3 
Ratio 
to IO.oOO 
Poo. 
Whooping 
Cough. 
Ratio 
to 10,000 
Pop. 
New York. 
io,i34 
66.88 
4,367 
28.82 
3822 
25.22 
2,820 
18.80 
Brooklyn 
5,018 
62.24 
1,840 
22 82 
767 
9-5t 
t-134 
14.07 
Baltimore 
1,188 
27-34 
296 
6.82 
733 
16.88 
501 
n-54 
Washington. 
515 
25-49 
274 
13-50 
175 
8.62 
358 
17.72 
FROM THE UNITED STATES CENSUS OF 1890. 
In Table I. the number of deaths from diphtheria, 
scarlet fever, measles and whooping cough for the six 
years ending May 31, 1890 (Census of 1890) is given for 
the cities of New York, Brooklyn, Baltimore and Wash- 
ington. It will be seen that diphtheria leads the list in 
all ; of the other three diseases scarlet fever comes first 
in New York, then measles with 545 fewer deaths than 
from scarlet fever and last whooping cough with 1,880 
deaths one thousand less than measles. In Brooklyn 
scarlet fever had 1840 deaths, measles 1,075 less, but 
whooping cough had 367 more than measles and 606 
less than scarlet fever. 
In comparing the deaths from different causes in the 
various states, according to the Census of 1890, it is inter- 
esting to note that whooping cough claims as many, often 
more victims than the other more dreaded diseases. In 
the following list of ten States whooping cough has more 4 
JOHNSTON : Whooping Cough. 
atal cases than scarlet fever and in most of them more 
than measles. 
In Baltimore measles is first with 733 deaths, whooping 
-cough second with 501 or 232 less than measles, scarlet 
fever is last with 205 less than whooping cough. 
In Washington whooping cough leads the list with 358 
deaths ; scarlet fever is next with 274, 84less, and measles 
has 175, 183 less than whooping cough. 
The ratio of deaths from whooping cough to 10,000 in- 
habitants is 18.10 in New York ; 14.07 in Brooklyn; 11.54 
in Baltimore and 17.72 in Washington. 
It will be seen, therefore, that although as compared 
with scarlet fever and measles the mortality from whoop- 
ing cough is higher in Washington than in any of thefour 
cities, yet the ratio of deaths from whooping cough to 
10,000 population is greater in New York than it is here. 
Washington, comes next to New York, then Brooklyn 
and last Baltimore. 
Total mortality in the District of Columbia from scarlet fever, measles, and whooping cough 
lor ten years from 1884 to 1894. Compiled from the report of the Health Officer. 
TABLE II. 
Year. 
Scarlet Fever. 
Measles. 
Whoop. Cough. 
1884. 
168 
179 
104 
I885. 
137 
9 
70 
1886. 
48 
3 
63 
I887. 
15 
14 
46 
1888. 
19 
159 
17 
1889. 
31 
4 
lf)2 
I89O. 
14 
10 
31 
189I. 
13 
70 
38 
I892. 
26 
5 
76 
I893. 
7 
10 
45 
Totals 
478 
463 
652 
In Table II. compiled from the records of the Health 
Officer, the total deaths from scarlet fever, measles and 
whooping cough in the District in the ten years, 1884 to 
1894, are given in parallel columns. The whole number of 
deaths from whooping cough was 652, from scarlet fever 
478 and from measles 462 ; 174 more children died from 
whooping cough than from scarlet fever, and 189 more 
than from measles during the ten years. The average 
annual death rate was 46.3 from measles, 27.8 from scarlet Johnston : Whooping Cough. 
5 
fever and 65.2 Irom whooping cough. See Chart /. for 
illustration of these differences in the death rate. 
Chart I.—Mortality in the District of Columbia”from 
scarlet fever, measles, and whooping cough for ten years 
ending May 1893. 
MORTALITY IX THE 1)1 ST.OP COLUMBIA 
POll Till? TEN Y12A11S KXDIXU MAY iV^y) 
AUf ART I 
The facts given in these figures are of immense import- 
ance. They bring home to us the consciousness that the 
disease of which we have so little concern, which we do 
but little to cure and still less to prevent, is annually de- 
stroying more lives in our city than scarlet fever of which 
we have such dread that there is no precaution too pre- 
cise and no regulation of the Health Office too severe 
which do not meet with our unqualified approval. 6 
Johnston : Whooping Co7tgh. 
We have not waked up to the knowledge that whoop- 
ing cough is such a fatal disease as it is here shown to be. 
We are lulled into security by the statements of the books 
and by a blind following of the traditional way of looking 
at the subject without seeing it. 
It is true that there are a larger number of cases of 
whooping cough than of scarlet fever and that the per- 
centage of deaths to the total number of cases is not so 
great in the former as in the latter disease ; but at certain 
ages the mortality is greater than scarlet fever and in 
certain epidemics it is quite as great at all ages. 
The ratio of deaths is variously given by authors ; the 
lowest is 2.7 per cent. (Kutlinger), the highest is 15 per 
cent. (Whitehead). In epidemics it has reached 48 per 
cent. Under one year the rate is 25 per cent.; from-one 
to two years 13.8 per cent. ; from two to five years 3 
per cent.; five to ten years 1.18 per cent. Thirty per 
cent, of all the fatal cases occur in the first year of life. 
The mortality rate differs also very much at different 
periods of the year. In Table III. the number of 
by months for the six years ending May 31,-1890, is given 
in parallel columns in the cities of New York, Washing- 
ton and Baltimore. In each of these cities the deaths 
were more numerous in July, August and September than 
in other months. JOHNSTON : Whooping Cough. 
7 
TABLE III. 
Mortality from whooping cough by months for six 
years ending, May 31, 1890. From United States Census 
of 1890. 
Month. 
New York. 
Washington. 
Baltimore. 
January 
227 
27 
33 
February 
210 
17 
29 
March 
243 
28 
4i 
April 
230 
23 
37 
May 
182 
17 
28 
June 
182 
20 
39 
July 
313 
45 
60 
August 
• 327 
55 
69 
September 
301 
48 
45 
October 
213 
36 
49 
November 
161 
19 
33 
December 
217 
23 
38 
Totals 
2,810 
358 
50i 
Chart II. shows the variation of mortality by months in 
the three cities during six years. 
Chart III illustrates the varying mortality by months 
in 31 large cities of the United States in one year. 
Chart IV. shows the different fatalities from whooping 
cough, measles and scarlet fever in New York City. 
The discussion of the causes of the high summer mor- 
tality from whooping cough will be considered later. The 
main point to which attention is desired here is that per- 
tussis holds its own with scarlet fever and measles as a 
life destroying disease. 
What are the causes of this immense destruction of 
child life which has been going on for centuries. It was 
estimated that from 1749 to 1764 a period of 15 years 
43,000 children died from it in Sweden alone. 
An estimate based on the Census of 1880, adding noth- 
ing for the increase of population, would show that in ten 
years more than one hundred thousand children had died 
from whooping cough in the United States, which would 
make a total of over 200,000 in the twenty years ending 
in 1900. 8 
Johnston : Whooping Cough. Johnston : Whooping Cough. 
9 10 
Johnston : Whooping Cough. 
Through the courtesy of the Health Officer a very 
careful study of all the death certificates in the Health 
Office during the last ten years has been made, and the 
causes of death in each reported case of whooping cough 
have been noticed and tabulated. The chief causes of 
death can be included under the following heads in the 
order of their frequency : 
1. Cerebral Causes—Convulsions, Meningitis, etc. 
2. Pulmonary Causes—Congestion, Inflammation, etc. 
3. Asphyxia and Syncope. JOHNSTON: Whooping Cough. 
11 
Causes of Death. 
AGE. 
SEX. 
COLOR. 
W. C. 
MONTHS. 
i year,i to 2 
under, yrs. 
2 to 5! over 
i five 
yrs. 1 yrs. 
M. F. 
Totals 
Jan. 
Feb. Mar. April. May. June. 
July. 
Aug. 
Sept. 
Oct. 
Nov. 
Dec. 
Convulsions 
80 35 
21 
4 
56 51 
24 
83 
107 
IO 
7 
12 9 II 6 
25 
23 
19 
9 
S 
3 
Congestion of the Brain. 
10 5 
I 
4 12 
10 
6 
l6 
I 
i i i 3 
4 
I 
I 
3 
I 
I .... 
1 
I 
I 
Meningitis and Cerebritis 
13 5 
3 
- 1 
14 8 
14 
8 
22 
2 
1 
3 
2 3 
3 
I 
4 
I 
1 
I 
//. Pulmonary Causes 
Congestion of the Lungs. 
23 
I 
7 
3 
I 
12 22 
17 
17 
34 
4 
2 
1 
1 3 
7 
2 
3 
4 
2 
S 
Pulmonary Haemorrhage 
I 
I 
I 
I 
j i I 
.... 
Bronchitis 
18 11 
8 
I 
l6 
22 
7 
31 
38 
2 
3 
3 
4226 
1 
6 
2 
I 
s 
Pneumonia 
61 33 
28 
6 
59 
69 
42 
86 
128 
is 
IO 
8 
12 8 5 s 
II 
12 
l6 . 
7 
20 
Atelectasis Pulmonum. . 
I 
I 
I 
2 
2 
. 
I 
III. Asthenia & Marasmus 
52 
20 
9 
3 
40 
44 
3° 
54 
84 
2 
8 
6 
4 4 
8 
19 
l6 
6 
3 
5 
3 
IV. Asphyxia and Syncope. 
*3 
4 
5 
9 
12 
8 
13 
21 
4 
3 
3 
I 2 
2 
*♦ 
I 
I 
V. Diarrhoea and Dysentry 
l6 
6 
I 
3 
is 
II 
'7 
9 
26 
. . 2 
4 11 
4 
I 
I 
I 
VI. Tuberculosis 
I 
5 
6 
4 
6 
9 
2 
4 
15 
I 
2 
2 
I 
2 
I 
I 
2 
VII. Pericarditis 
I 
I 
I 
1 
I 
VIII. Nephritis 
I 
I 
I 
1 
IX. Measles 
I 
I 
I 
I 
I 
I 
I 
I 
I 
XI. Overdose of Cough Syr. 
I 
I 
1 
I 
; 
1 
1 
TABLE IV. 12 
JOHNSTON : Whooping Cough. 
4- Asthenia, Marasmus, etc. 
5- Diarrhoea, and Dysentry, etc. 
6. Tuberculosis. 
7- Pericarditis. 
8. Nephritis. 
9. Measles. 
10. Malarial Fever. 
11. Overdose of cough syrup. One case. 
A glance at table IV. which contains records of five- 
hundred cases will show that causes connected with the 
lungs were more common than others being 203, as com- 
pared with 146 from cerebral causes, and 84 from exhaus- 
tion, marasmus and like conditions. Next in order of 
frequency comes diarrhoea and dysentery with 26, and 
asphyxia and syncope with 21 deaths. Tuberculosis, 
following whooping cough, is given as a cause in 15 
cases 
Pericarditis; nephritis, measles, malaria, and an over- 
dose of cough sy.iup claimed one death each 
Of the pulmonary conditions, to which death was at- 
tributed, broncho-pneumonia was responsible for nearly 
two-thirds of the cases ; bronchitis and congestion of the 
lungs each for one-sixth ; atelectasis is mentioned in two 
cases only and pulmonary haemorrhage in one. 
Convulsions bear the same relation to cerebral causes 
that broncho-pneumonia does- to the pulmonary ones, 
causing 107 of the total deaths. Meningitis and cerebritis- 
22 and congestion of the brain 16; apoplexy is mentioned 
once only. 
As compared with these causes death from slow wast- 
ing and exhaustion is not so common ; 54 children out of 
the five hundred cases died of it. Sudden death from as- 
phyxia and syncope is a much rarer cause, occuring in 21 
instances only. 
An enumeration of the causes of death with reference 
to age does not confirm the usual statement that cerebral 
congestion with convulsions is the most common cause 
of the tremendous mortality in the first year of life. Out 
of the whole 500 deaths, 207 were under the first year. JOHNSTON : Whooping Cough. 
13 
'Of these 104 were connected with the brain and 103 with 
the respiratory organs so that there is little or no differ- 
ence between the efficiency of the two causes in infancy. 
other interesting facts might be mentioned which 
are seen by comparing the influences of age, sex and 
color, but figures may become wearisome and I pass on to 
speak of what bears more directly upon the purposes I 
have in view in connection with the treatment of the dis- 
ease—I mean the influence of season in bringing about 
the development of cerebral and pulmonary causes of 
death respectively. 
The deaths from pulmonary causes, especially from 
broncho-pneumonia occur in about equal numbers at all 
seasons of the year ; while convulsions and other cerebral 
causes are much more common in summer—See Chart 5. 
DEATHS FROM WHOOPING COUGH IN 
WASHINGTON FROM THREE GROUPS OF 
CAUSES, 1IY MONTHS FOR TEN YEARS 
Tort><\5 
CHART V 
PuLMlIXUlY, 
CliHUItUAL. 
AsTIIliXIA 
V OTAIj s. 1*,','m,,nauv" }?}' 
(/■inKH uiiJ. ItO. 
AsTMUklA—4 H • Johnston : Whooping Cough. 
In the six months of autumn and winter beginning in No- 
vember and ending with April, there were 121 deaths 
from cerebral causes ; in the six months of spring and 
summer and early autumn there were 53 deaths, the 
fatality being half as great in winter as in summer. 
Lesions in the respiratory system are as common how- 
ever in the one season as in the other, winter having 105 
and summer 98 deaths, a difference of only 7. July and 
August included by far the greatest number of deaths 
from eclampsia, and December the largest number from 
broncho-pneumonia, but the deaths from pulmonary 
lesions are distributed much more equally during the year 
than are those connected with the nervous system. 
The deaths from intestinal causes as might be supposed, 
happened almost wholly in the summer months. More 
deaths also occur in summer than in winter from wasting 
and exhaustion. 
In the effort to interpret these facts and to find the 
reason for the great fatality of whooping cough and in 
order to determine how it may best be prevented and 
cured, attention must first turn to the pathological changes, 
and then to the characteristic symptom—the convulsive 
cough and to its etiology. 
There is no lesion which can be considered character- 
istic of whooping cough, that is no distinct, causal lesion 
around which all the symptoms and complicating lesions 
are grouped. In the beginning there is catarrh of the 
naso-pharynx, and this may be the only lesion coincident 
with the development of the characteristic cough. 
In advancing cases this naso-pharyngeal catarrh be- 
comes generalized by extension to the lachrymal ducts, 
the conjunctivae, the eustachian tube and the middle ear, 
to the glottis, trachea, large and small bronchi and air 
vesicles. The more decided pulmonary lesions, emphy- 
sema, pulmonary collapse, pulmonary congestion and 
oedema and broncho-pneumonia areadvanced pathologi- 
cal conditions accompanying the later stages or more in- 
tense forms of the disease. 
The symptoms connected with the nervous system— Johnston : Whooping Cough. 
15 
blindness, convulsions, hemiplegia, coma, etc., are due to 
congestion, transuded fluid in the ventricles, oedema of 
the brain and meningeal haemorrhage. 
The gastro-intestinal lesions are congestive and catarr- 
hal ; the changes in the kidneys are first congestive and 
then inflammatory. 
Without going into questions which are attractive and 
interesting and in order to learn something of the reasons 
of this great mortality I would like you to fix your atten- 
tion upon two points in connection with this disease. I. 
The violent paroxysm of cough and their effect upon the 
heart and circulation. 2. The influence of the resulting 
heart weakness in the production of the conditions of the 
brain and lungs which are the most efficient causes of 
death. 
Authors like Osier and Henoch have, from time to time, 
alluded to the temporary and even permanent injury to 
the heart in this disease, but the subject has been brought 
out with greater fullness and force in the papers of Drs. 
E. Helen Knight and Koplik, recently published, and by 
the experiments of Muller and Valsalva. These two ex- 
perimenters have demonstrated ; (i) That in the long 
drawn inspiration there is dilatation of the right heart, 
congestion of the lungs, diminution of blood in the left 
heart, and in the systemic circulation, and (2) that in the 
expiratory cough the heart is compressed, the venous 
system is engorged, the blood is forced into the left ven- 
tricle and into the aorta, the heart is emptied, its sounds 
and the pulse beat are weakened. The paper of Dr. 
Knight, based on the careful daily study of forty cases, 
dwells upon the disturbance of the heart and circulation 
and the great and continual strain to which the heart is 
subjected by the recurring violent pressure of the parox- 
ysms ; this disturbance is shown by the increased rapidity 
and irregularity of the pulse, its dicrotism and sustained 
tidal wave, seen in the sphymographic record, and due to 
the abnormal distension 3nd relaxation of the coats of the 
arteries. 
Both in this paper and that of Koplik, the more impor- JOHNSTON : Whooping Cough. 
tant fact is insisted on that the ultimate effect of this me- 
chanical disturbance of the heart is to bring about a per- 
manent dilatation of the ventricles (the increased area 
being demonstrable by percussion) with great and neces- 
sary weakening of their walls, which continues to effect 
the circulation during the intervals of the paroxysms. 
This is shown by the weakness of the heart sounds, the 
feebleness and irregularity of the pulse, the persistent 
dyspnoea, the oedema of the face and eyelids, and other 
-evidences of venous stasis of organs. 
From these disturbances of circulation especially from 
the venous congestion of organs we have, moreover, the 
cerebral congestion and oedema, the cause of fatal eclamp- 
sia and the albuminuria which Knight found in 56 out of 
86 tests ; albumen with blood being being seen in 8 cases 
with occasional hyaline and epithelial casts. 
The pulmonary congestion which precedes and causes 
the bronchial catarrh is of course a part of this same con- 
dition ; broncho-pneumonia comes from extension of the 
process to the small tubes and air cells ; the rarefaction 
of the air in the alveoli and its effect upon epithelial 
growth has some part in bringing about the catarrh of 
the air passages: the traumatism of the mucous membrane 
from the violent cough is not without effect also. 
The equal prevalence of pneumonia in summer as well 
as in winter in this city gives less importance to cold and 
exposure as a cause of bronchitis and pneumonia ; un- 
doubtedly they have some influence, but the feeble heart 
and mechanical congestion of the lung are more potent 
causes, at any rate, are preliminary and essential stages 
in the process of bronchial catarrh and broncho-pneu- 
monia. The fact that the deaths in the country from 
whooping cough are to deaths in the city as 16 is to 9, 
and that the poor die in larger proportion than those in 
comfortable homes (430 colored to 230 white are the 
numbers in the District for ten years) might be used as 
an argument that exposure to cold is an active agent in 
the production of catarrh. 
The one great danger, a danger which stands out Johnston : Whooping Cough. 
glaringly in the lurid picture of this disease is the feeble 
dilated heart and the venous congestion of the organs ; 
and the general disturbance in the arterial and capillary 
as well as venous circulation. 
The vomiting and inability to retain sufficient food is 
an added source of exhaustion, and to this must be at- 
tributed much of the asthenia and marasmus which char- 
acterise all bad cases and which are alone the cause of 
death in many. But here too the heart is made to suffe 
and an additional cause of heart exhaustion is found in 
the general inanition. 
TREATMENT. 
What are the data upon which a rational treatment of 
whooping cough is to be based ? 
1. That it is a specific disease, due to a micro-organism 
the action of which is local upon the mucous membrane 
of the naso-pharynx and upon the the terminal filaments 
of the nerves. 
2. That it is primarily an acute disease, with a tend- 
ency to chronicity in its later stages. 
3. That the special conditions which call for treatment 
are the feeble and dilated heart due to mechanical over- 
strain, and the resulting disturbed state of the circulation 
in the brain and lungs; cerebral congestion and pulmon- 
ary congestion with catarrh being the direct result of 
circulatory disturbance. 
The first step is to recognise it as a specific contagious 
disease. Being a specific disease with a restricted area 
of activity and that within reach, the search for specifics 
has been a rational effort; and we can but welcome every 
addition to our knowledge made by experiments with 
antiseptic inhalations, sprays and lotions, designed to de- 
stroy microbic activity in the respiratory passages. It 
would lead me very far from my purpose to go into the 
history of this part of the subject, but I firmly believe 
that in the effort to cure the disease by internal and local 
specific remedies, important if not the most important in- 
dications of treatment have been overlooked and lives 18 
JOHNSTON : Whooping Cough. 
sacrificed which might have been saved. Niemeyer many 
years ago said that “ the fact that in whooping cough we 
have to do with catarrh protects us against that hunt for 
specifics which is souseless and dangerous.” Since this 
was written the development of antiseptic treatment has 
been very great, but it is none the less true now than 
then, that the immediate demands of the attack are for- 
gotten and quite neglected. These immediate demands 
are the same that confront us in every acute specific dis- 
ease, which has a limitation in time, and the progress of 
which can be influenced by prompt and proper care in the 
beginning ; they are the acute nature of attack and the 
special condition of the heart and circulation. 
Trousseau has dwelt upon the febrile feature of whoop- 
ing cough as being diagnostic, and the study of the tem- 
perature in the early stages will show the more frequent 
incidence of fever than is seen in simple catarrh without 
the spasmodic element. The study of the temperature 
gives a test of the gravity of the case and is a means by 
which those catarrhal changes which are the forerunner 
of broncho-pneumonia can soonest be detected. In every 
case of whooping cough from its inception a daily record 
of temperature should be kept 
Whether there is fever or not, the processes which are 
going on are acute, the characteristic cough soon begins 
and the heart commences to feel the effect of overstrain. 
If our specific methods of treatment could now abort the 
attack, or decidedly modify the character of the cough, 
the danger from heart strain would be obviated. But so 
far these methods have not reached a point of perfection 
and until this is done the principle of treatment should be 
to give to the heart all of the force we can by relieving it 
of unnecessary work. 
Rest therefore becomes the cardinal doctrine of treat- 
ment—a doctrine which has not been recognised at all, 
and which I believe stands at the foundation of all suc- 
cessful management. Oppolzer, many years ago, advised 
the confinement of the patient to one room, and Niemeyer, 
writing in 1864, said that he had followed this advice ever Johnston : Whooping Cough. 
19 
since he knew of it, “ with a rigorous exactitute and with 
the most favorable success and that he could not suffi- 
ciently recommend it. 
Niemeyer’s suggestion was based upon the dangers of 
adding to the catarrh by exposure to the external air, but 
I believe that the idea has a much wider application, and 
that keeping the child in one room and at rest in bed, if the 
paroxysms are at all frequent or severe, is the proper 
method of treatment in all cases. 
The definite method would be in the catarrhal first 
stage, if it is known or thought to be the onset of pertussis, 
to isolate the child absolutely from other children, to keep 
it as much at rest as possible and if there is any rise of 
temperature, to put it to bed. When the paroxysmal 
cough begins the patient if an infant should be treated as 
if it were already ill, notdressed, but wrapped in a blanket 
so as to be as equably warmed as if it were in bed; beyond 
infancy the child should be kept in bed if possible, if not 
possible in the arms, and cared for as if the worst symp- 
toms were present. During the last winter I had under 
treatment a case of whooping cough in a child four years 
of age, who had chronic mitral insufficiency, and no worse 
condition could have been present ; as soon as the 
“ whoop” began the child was put to bed and kept there 
for three weeks with the result of making her attack 
much shorter and much less severe than that of her 
older sister, who was not kept in bed but in the room 
during the same period. 
By such a method of treatment three things are ac- 
complished : 
1. Isolation of the patient, and the necessary reduction 
in the number of cases and deaths. 
2. The diminution in the intensity of the specific pro- 
cess; this is not a necessary but a probable result. 
3. The rest of the heart and the lessening of overstrain 
and dilatation. 
4. The avoidance of the effects of cold in exaggerating 
the existing catarrh. 
How long should isolation with rest in bed or confine- 20 
Johnston : Whooping Cough. 
ment in one room be continued ? So long as the case 
demands it, so long as the paroxysmal cough by its 
severity or frequency is distinctly a source of danger; 
that is for three weeks or four weeks or longer. What 
matter is it how long, if by such isolation and rest you 
are reducing the general mortality of the disease and 
avoiding all risks in the particular case. But it is one 
of the beneficial effects of seclusion and rest in whooping 
cough that the stages are shortened so that the duration 
is reduced to six weeks or less. Neimeyer insisted upon 
this as a direct result of confinement to the house alone, 
and during many years of experience with this method, 
the average of the violent paroxysmal stage has not 
been more than two weeks, making the whole attack of 
about six weeks duration. 
To what extent this isolation should be enforced un- 
der the supervision of the Health Authorities, I am not 
prepared to say. The practical difficulties in the way 
are very many, but I see no reason why regulations 
should not be made which would at least wake the com- 
munity up to the dangers of the unlimited diffusion of 
the disease from the absence of any attempt at restric- 
tion. 
This leads me to speak of the outdoor fresh air treat- 
ment of whooping cough—a treatment which I believe 
is based upon a tradition ingrained into our social or- 
ganization, part and parcel of inherited, unscientific 
modes of thought, aud entirely irrational. On general 
principles fresh air is antagonistic to germ life, and foul 
air favors its activity, but that in seeking fresh air we 
should put the patient to every risk of fatigue and cold, I 
believe to be entirely unscientific and lacking in common 
sense. There is no reason why free ventilation and 
fresh air should not be made an addition to the treat- 
ment by rest and seclusion, but the dangers of the propa- 
gation of the disease, the dangers of heart exhaustion 
and of cold are necessarily incurred in the outdoor 
treatment as at present practised. 
The time comes in whooping cough sooner or later Johnston : Whooping Cough. 
21 
when the final stage has been reached, the more acute 
symptoms have subsided, the patient continues to cough 
spasmodically more or less frequently, there is but little 
change from week to week ; it is possible that the belief 
that change of air is specific at this stage may be well 
founded, but I know of no facts from my own personal 
knowledge which assure me that it is so. 
That the great majority of cases of whooping cough 
get well, that 2 to 15 per cent, only die is no reason why 
the rest treatment should not be employed in every in- 
stance. I have not attempted to illustrate the advanta- 
ges of this method by citing cases which have demon- 
strated its utility, but, as the public conscience has not 
been raised to the point of regarding whooping cough as 
dangerous, and as the outdoor treatment has such firm 
hold upon its faith, the difficulties of enforcing complete 
isolation and rest have been very great. 
In conclusion, the question of prevention must take 
precedence over every other. An infectious contagious 
disease can of course only be prevented by isolation. 
The seriousness of every infectious disease and the 
ability to control its spread by isolation determine the 
necessity and propriety of segregating patients. The 
seriousness, the great fatality of whooping cough has 
been shown, I think clearly shown; more fatal than 
measles, hardly less so than scarlet fever, it numbers its 
victims by thousands and involves incalculable suffering. 
There is every demand indeed, an imperative obligation 
upon us to meet this question if it be possible to meet it. 
We know that isolation alone will prevent its spread, 
and yet we make no effort to isolate it. Suppose that 
scarlet fever were half as fatal as it is now would we not 
be criminally responsible if we did not isolate our pa- 
tients. And yet with whooping cough, the cause of 
more deaths than scarlet fever in this community, we 
permit these children to frequent the public thorough- 
fares, the theatres, the churches, and we only smile when 
a large audience is disturbed by the shrill whoop of the 
little sufferer. Imagine a child with diphtheria, measles, 22 
Johnston: Whooping Cough. 
or scarlet fever carried about in public places; it would 
be a folly and a crime to permit it, and is it less a folly 
and a crime with thirty to one hundred deaths a year 
from whooping cough in this city. 
An average of many authors fixes the death rate at 7.6- 
per cent. This means that about one thousand children 
are diffusing the poison of whooping cough in the streets 
and public squares of Washington during every year, and 
not only are they allowed to do it, but they are ordered 
by their physicians to do it, in pursuance of the out-of- 
door treatment. 
In New York City over 6,000 children are allowed an- 
nually to disseminate the germs of the disease. In one 
month alone—August—in Washington there were 126- 
cases with nine deaths. Imagine these 126 children be- 
ing permitted to sow the seeds during August which 
were to be reaped in the deaths of eight children in Sep- 
tember, six in October, three in November, and lour in 
December, a total of twenty-one children whose lives 
might have been saved if isolation had been practiced. 
Or to make the figures more striking, imaginine 1,404 
cases in the month of August in the city of New York 
infecting the hundreds of children who were to be ill in 
September, October, November and December, 148 of 
whom were to die miserable deaths, deaths preceded by 
weeks of agonized suffering. 
If we were to relax discipline in the 500 to 1,000 cases 
of scarlet fever, or of measles which we have here every 
year we should justly consider ourselves culpable, and 
yet we deliberately expose the children of the city to 
decimation—nay we advise and encourage the dissemina- 
tion of the disease. 
I know what the difficulties attendant upon the quar- 
antining of a case of whooping cough are during the 
e ght to twelve weeks of its weary travail, but if life is to 
be saved; if life is not deliberately to be put in jeopardy, 
we must attack this question and secure some improve- 
ment upon our present methods. It has been shown how 
rest and isolation may be made to harmonize and how JOHNSTON : Whooping Cough. 
23 
in securing the best results in the individual cure, we are 
at the same time preventing the spread of the disease. 
Particular care should be taken to secure the removal 
from the sphere of infectious influence of all children who 
are tubercular, rachitic, syphilitic or who have bronchial 
catarrh, all sick or debilitated children. But the quaran- 
tine should be as strict as that for measles or scarlet 
fever. Why should it be less so ? If we will enquire 
into the reason for the difference which is made we will 
see that there is no scientific reason, but merely the rule 
of tradition and custom which influences us and no more, 
and we submit our science and our common sense to this. 
The practical points of this paper—the only points 
which I have dwelt upon and the only points which I 
would like to drive home with as stunning a blow as I 
can give are that whooping cough is a dreadfully fatal 
disease—and a terrible cause of suffering even where it 
does not kill, that we, as physicians—health guardians 
of the families of our patients, are directly responsible, 
almost wholly responsible for these deaths, and that 
every obligation of science and knowledge, every call of 
duty summons us at once and forever to inaugurate a 
new era in its prevention and cure. Archives of Pediatrics 
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