SPECTS OF THE DIAGNOSIS ANDTREATMENT OF.THE CHRONIC COUGH

By C. H. FITTS, M.D., F.R.C.P., F.R.A.C.P.Physician, Royal Melbourne Hospital

What is a cough? Sir Thomas Browne in I650defined coughing as a natural and voluntarymotion including expectoration and spitting out.' It may,' he said, ' be as proper unto mankind asbleeding at the nose.' The definition occurs in aletter of condolence to a friend, which broadensinto a clinical and philosophical dissertation oncough and phthisis. On seeing the patient in hislast illness, Sir Thomas gave the prognosis to therelatives ' that in my sad opinion, he was not liketo behold a grasshopper, much less to pluckanother fig.'The Oxford Dictionary defines cough as a

violent expulsion of air from the lungs with acharacteristic noise. R. A. Young (I940) des-cribed cough as a sensitive reserve mechanism todeal with any abnormal increase of fluid in the airpassages and with foreign bodies. ChevalierJackson (i933) called the cough reflex the watch-dog of the lung. This places the right emphasis onthe role of cough which is to prevent entrance ofnoxious agents rather than to provoke their exit.The afferent paths by which this reflex may be

initiated are widespread. The most important arethrough the sensory branches of the glosso-pharyngeal nerve to the pharynx and the vagalbranches of the larynx, trachea and bronchi. Thereflex diminishes as the bronchial tree ramifies andis absent in the finer bronchioles and alveoli. Thereflex appears to be quite active, however, if thepleura is inflamed and pain is present. Stimula-tion of the central end of the superior laryngealnerve causes reflex swallowing as well as cough.Perhaps for this reason the gastric mucus maysometimes be the best source for tubercle bacilliwhen pulmonary tuberculosis is suspected.Cough is composed of three distinct phases

(Coryllos, I937). These are inspiratory, com-pressive and expulsive. Each of these presentsspecial physiological characteristics. Though itcan be started voluntarily it is almost as impossibleto stop a cough after a certain stage as to stopdeglutition, micturition, vomiting or sneezing.

The first or inspiratory phase is short. In thisthe glottis is closed whilst a mounting pressure israised in the chest up to 8o or even ioo mm. ofmercury. A study of the movement of the chest bycinematography during the cough gives the im-pression during inspiration of a process akin to thetensing of a strong bow, and the quick spring backwith the onset of expiration heightens this im-pression (Franklin and Janke, 1938).The second or compressive stage marks the

beginning of expiration. The important expiratorymuscles are abdominal. Under their influence thecapacity of the chest is reduced by the downwardmovement of the ribs and sternum. Thus pressureis exerted'upon the air imprisoned in the lungs bythe closure of the glottis. The diaphragm con-tracts in this stage, giving a rigid floor to thethoracic cage and preventing the thrust of theabdominal viscera into the chest.Cough is a physical effort and, on reflection, it

is apparent that inspiration and compression arecommon components of many different types ofeffort. Singing, laughing and crying are examples.On what slender emotional threads sometimeshangs the decision as to which path expressionwill take.

In the third, or expulsive phase, the glottisis opened and successive contractions of theabdominal muscles take place. Nature does nottake a sledge hammer to crack a nut. Theabdominal contractions vary in force and magni-tude according to the real or imagined resistancewhich has to be overcome in the bronchial tree.Again the diaphragm contracts and acts as theantagonist to the abdominal muscles. Thevelocity of the blast of air passing through theglottis has been estimated to reach 30 miles perhour, and those who have stood in its path mightnot think it fanciful to compare it to a gale.

Physical signs in respiratory diseases provideprecarious means for diagnosis and it is worth re-membering the physiological and pathologicalantecedents of cough. They add point to the

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JanuarYy 1955 FITTS: Aspects of the Diagnosis and Treatment of the Chronic Cough 3

analysis of the history. In an American study ofundiagnosed cough in 200 patients (Voorsangerand Firstone, 1927) a list is given of the patho-logical conditions causing cough, This includespulmonary fibrosis, emphysema, sinusitis, tonsil-litis, thyroid insufficiency and enlarged bronchialroot glands. Why should pulmonary fibrosis oremphysema cause cough? Neither will do so unlessthere is an associated bronchitis to excite the coughreflex. Why does the so-called dry bronchiectasisremain a silent disease unless the patient coughs upblood? Because it is in a region where the sensorypaths of the cough reflex do not penetrate. Whydoes the patient with wet bronchiectasis sleeppeacefully in his bed at night? Because the secre-tion lies undisturbed in the insensitive saccules.On rising in the morning the sputum is splashedinto the sensitive larger tubes and the patientcoughs and only ceases for lack of sputum. Onemight make a generalization from this. Beyond acertain point in the bronchial tree, cough is not asymptom unless sputum or blood, hydatid orother fluid is able to move from its source to anarea where. the reflex can be initiated. Tubercu-losis, carcinoma of the lung parenchyma, lungabscess and silicosis are examples of diseases of thelung substance in which there is no cough untilthere is material to be evacuated. It is a commonexperience to find that a foreign body havingpassed beyond the frontier of the protective coughreflex will lie unheeded in the finer divisions of thebronchial tree until infection brings purulentsputum to excite the cough reflex and draw atten-tion to its presence. The evacuation of purulentsecretion or blood from a lung abscess or a tubercu-lous cavity by means of cough may not be complete.If one observes the fate of lipiodol instilled into thebronchial tree it will be seen that a cough that doesnot expel it may be followed by another cough, andin the inspiratory phase the oil is drawn into thealveoli. If the material is pus rather than lipiodolthen a spread of infectionsmay ensue. This maybe the mechanism of the bronchogenic spread oftuberculosis. The term 'spill-over' is graphic,but perhaps it is too simple an explanation of thespread of infection in healthy tissue, It followsfrom what has been said that the bifurcation of thetrachea and not the mouth should be the target ofpostural drainage. Once get the secretion to thisarea and the cough reflex will do the rest.

If diseases of the finer bronchioles and thelungs do not produce cough unless there is sputumto evacuate, the converse is true that inflammationor irritation in the larynx, trachea or larger bronchiand, indeed, stimulation of afferent nerves in thepharynx or stomach will produce a cough withlittle or no sputum. These are the territories ofthe dry cough. The paroxysms of whooping

cough or of what is loosely termed 'virus infec-tion' are examples of the unproductive cough.The distinctive characteristics of the cough oftuberculous laryngitis, of laryngeal palsy and ofmediastinal pressure are well known.There are certain features about cough which

should be sought in taking the history. The firstof these is the time of occurrence. The morningcough of bronchiectasis has been mentioned.Lovett Doust and Schneider (1952), in a study ofanoxia and the levels of sleep, observed that withlight sleep and deep sleep the arterial oxygensaturation lay between 91 per cent. and 87-per cent.They describe these as the noisy periods of sleep;groaning, mumbling, grunting, gasping, snoring,sighing and sometimes coughing being individu-ally representative responses for any given subject.Each of these activities is closely correlated withoximetric changes. A child may sleep throughcough and fever whilst his parents burn withanxiety in the next room. None the less, it is wellto regard nocturnal cough as being associated withasthma until proved otherwise. A cough duringworking hours may be due to the real or supposedhazards of industry. The fumes of chemicals maybe unpleasant but harmless. Yet once sow theseeds of doubt in a worker of unstable tempera-ment and he becomes convinced that his lungs arebeing damaged. The really dangerous substancesare silica dusts: The particles which cause thedamage are less than ten microns in size, do notprovoke cough and so penetrate to the recesses ofthe. alveoli. Irritant gases may provoke oraggravate a bronchitis. One cannot overcomethese problems with gas masks nor by any meansthat depend on the wishes or attention of theworkman. A cough may be periodic, quite apartfrom clinical or seasonal variations. An exampleof this is furnished by lung abscess. With theevacuation of the abscess contents, the temperaturefalls and improvement occurs. After a time thecough and sputum may diminish to nothing. Bythis time the temperature is slowly rising to fallagain when the abscess, which has pocketed, rup-tures and cough and sputum return.Some people complain of a cough chiefly or

only when in the recumbent position. This is notquite the same as a nocturnal cough. I have seenyoung people complain of an irritating dry coughwho, when placed in the recumbent position forexamination, involuntarily sit up because of theonset of cough. I think the cause is sometimes tobe found in the personality of the patient.A second point of enquiry should be for the

presence and the character of sputum and theamount which should be measured. The suddenevacuation of a quantity of purulent sputum canmean only the rupture of a lung abscess or of an

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4 POSTGRADUATE MEDICAL JOURNAL January 1955

empyema into a bronchus. Let it-never be for-gotten that the sputum accompanying any chroniccough should be examined repeatedly for themycobacteria of tuberculosis.

Thirdly, one should ask whether blood has beencoughed up and in what quantity. It is not merelyacademic to probe the distinctions between haemo-ptysis and haematemesis. The person who coughsblood commonly has blood-stained sputum duringthe succeeding days. There are times apparentlywhen the threshold of excitation of the cough re-flex is not crossed by what would seem to be morethan adequate stimuli. I am thinking of patientswho say that blood or hydatid fluid welled into themouth without the preliminary aid of cough. Con-versely, a patient may deny a cough but admit thathe has sputum, and it cannot be taken for grantedthat there is no sputum if there is no cough.

Fourthly, it is wise to enquire whether there iswheezing as well as cough. Very few asthmatics donot wheeze and most people who do wheeze haveasthma. Many asthmatics pass unrecognized be-cause of the failure to recognize the periodicnature of the cough, to ask for the presence ofwvheezing and through a too rigid belief thatasthma manifests itself only by the classicalattack.

Most, but not all, people who wheeze haveasthma. Sufferers from pulmonary tuberculosismay wheeze and present as asthmatics when, inactual fact, the wheezing is due to tuberculousbronchitis with stenosis. People with emphysemadevelop bronchial spasm during the course of theirdisease. Too often the emphysema is regarded assecondary to asthma when, in fact, the spasmcomes comparatively late in the course of thedisease. In the course of mitral stenosis withpulmonary hypertension the patient may com-plain of cough and wheezing dyspnoea.

Lastly, it is to be remembered that the issue maybe confused by a number of possible causes forcough existing in one person and that prominencegiven to the cough by the patient in stating hiscase may lead to a false estimate of its importance.A man of 6o may complain of cough and purulentsputum. The history and perhaps the physicalsigns suggest that he has chronic bronchitis, butthe cough and dyspnoea are at their worst at night.The patient wheezes, His blood pressure is high.Is one to conclude that his nocturnal dyspnoea andcough are due to bronchitis, to bronchial asthma orto cardiac asthma? More often than not I believe thenocturnal dyspnoea is due to left heart failure andthat the best treatment for both the cough and thedyspnoea may be the relief of congestion bydigitalis and diuretics. Patients with congestiveheart failure may be greatly distressed by a coughwith a desire to expectorate some secretion from

the region of the larynx or trachea. The expectora-tion of a little mucus brings a very temporary re-lief. Relief of the cardiac failure is often morefruitful than midication directed to the cough.

TreatmentWhat of the treatment of cough? Remedies for

cough seem only less popular than purgatives forconstipation. The latter is not subject to seasonalvariations and while it is difficult to maintaincough by means of a mixture it is easy to perpetuateconstipation with a pill. There are numerous ex-pectorants all of doubtful value, though connois-seurs (Boyd and MacLachlan, I944) state thatparegoric which has been allowed to mature forthree years is superior to others. Though thereare objections to the use of sedatives, on the wholethey are more useful than expectorants. Notheoretical objections should deny morphia to apatient suffering the alarming experience of aserious haemoptysis, nor do I think I have cause toregret its judicious use in pneumonia. A linctusmay provide the only solace from a racking cough.It is described by the Oxford Dictionary as asyrupy medicine to be licked up with the tongue.It should be treated with a certain respect and re-tained in the mouth for a time before swallowing.Though not as rewarding as old brandy, attentionto this may enhance the action of the linctus. Iwould put in a plea for a neglected drug-valerian.The ammoniated tincture of valerian in combina-tion with bromide is a valuable preparation when apatient is nauseated by food and inclined to retchwith coughing. It is best given before meals. Bedrest and silence may be excellent sedatives. In-halants and steam kettles are soothing and perhapseven have a psychological effect. Aerosol inhala-tion of antibiotics is out of fashion and I thinkrightly so. Wool, red flannel and thermogene nextto the skin, camphor worn as an amulet, closestuffy atmospheres are all met with even in thesedays. Sir Thomas Brewne remarked that 'Theancient inhabitants of this island were less troubledwith coughs when they went naked and slept incaves and woods than men in chambers and featherbeds.'

Expectorants, sedatives, charms and amulets havegiven place to the use of antibiotics. Ostensiblyjustified because of the presence of infection, oftenthey are given because the patient complainsbitterly of his cough. We are in no position tolaugh at our predecessors.As cough is under the control of the will so it

may be the expression of an emotional disturbance.Some people do not know whether to laugh or tocry and evade the dilemma by coughing. Politiciansand public speakers are not above a paroxysm inmoments of difficulty, and warning, disapproving

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January 1955 FITTS: Aspects of the Diagnosis and Treatment of the Chronic Cough

and apologetic coughs are the stock-in-trade ofthe novelist and playwright. What a powerfulweapon a cough can be in the throat of a neuroticperson l I cannot uncover the mystery wherebythe neurotic soldier of the 1914-I8 war developedeffort syndrome and of the. recent war dyspepsia,when one thinks of the havoc that can be wroughtby coughing.Coughs have been divided into productive and

unproductive and into useful and useless. Yet attimes nothing could be more fruitful than a uselessunproductive cough. It can be produced by ahealthy, person of his own volition. If, however,the stimulus be strong enough, a person withlaryngitis, tracheitis or bronchitis will cough des-pite himself. On the other hand the sufferer mayexercise some choice. The cough is halted in thecompressive stage so as to avoid drowning theparson's saws. Mark, too, how the veriest noviceat:an orchestral concert synchronizes his expulsiveblast as the conductor brings in the percussion orthe brass. Some of these coughs are unnecessaryeven in people who have some organic disorder.The secret lies in self control which must beexercised before the glottis is closed, for com-pression. One sees a hint of this in the rather freeinspiration and expiration of a person endeavour-ing to overcome a desire to cough.

Years ago (I876) Charcot described a conditionwhich he called laryngeal vertigo. It occurs mostfrequently in middle-aged males and is associatedwith largyngitis or bronchitis. There may be apersonal or family history of epilepsy but this isnot common. A frequent feature is an attack ofdizziness or loss of consciousness preceded by atickling sensation in the larynx and a cough whichmay be slight or severe. Epileptiform convulsionsor movements may occur during the attack.Whitty (I943) regarded the majority of cases asbeing due to a true reflex epilepsy or epilepsy witha laryngeal aura. One of Whitty's patients had anattack following hearty laughter. The evidence infavour of epilepsy is not convincing. I have re-cords of a patient whom I regarded as highlyneurotic who could initiate a laryngeal cough byscratching behind his right ear. This area issupplied by the auricular branch of the vagus,sometimes called the nerve of Arnold. It is wellknown that stimulation of this nerve can initiatecoughing.

I come now to a brief consideration of a fewcase histories which I think have a bearing uponthe remarks I have made.The first patient whom I shall mention I still

recall after a lapse of years. She was a girl in herlate 'teens living in London. She was referred tothe throat department of the hospital for con-sideration of tonsillectomy as the possible source

of an appalling cough of the useless unproductivevariety. I remember the cough penetrating the,consulting room door.. Indeed the girl by meansof her useless cough quickly displaced those aheadof her until she was allowed to see the throatsurgeon long before her turn; I do not think Iever heard such a cough, nor saw a victim lessperturbed. It was decided that the tonsils were;infected. She came into hospital and, of course,immediately after tonsillectomy her cough dis-appeared. She was asked to report progress in theoutpatient department after some weeks had-elapsed. On the day the noise of the approachingcough heralded her arrival in the department. Ishall not weary you with detail, but her story wasrevealed .eventually. Her father had remarriedand she .was the only child of the first marriage.The girl received scant recognition from her fatherunder the new regime until she developed thecough. This conveyed to him the fear of tubercu-losis and was sufficient to bring her the care andattention she had lacked. It was at her father'sinstigation that she came to hospital. The moralof the story is that the justification for tonsillec-tomy must lie in the presence of infection and notin the uncertain hope that it may banish a coughfor which no obvious cause can be found.The second history is that of a young man who

was 3 i at the time of our meeting. He was des-cribed by his doctor in the following terms: ' Heis known to most of his friends as the man withthe cough.. He is a troublesome kind of patient inthat.no one seems to get anywhere with him. Hewas on military service but was a worry to themfrom the time that he went in and was never wellenough to be sent on active service. His coughannoys all his friends who know at once if he is atchurch or the pictures.' His story was illuminat-ing. He began his working life on a farm and afterfive years he gravitated to Melbourne. Since thenhe had never been any length of time in one job.He was in a dairy for i8 months, then at a springfactory, then on the assembly line at a motor bodyworks where, after six months, he developedpneumonia. He left that job and was in a woollenmill for three months. He then joined the Armyand after a month developed pneumonia and wasoff duty for nine weeks. This period, I am sure,was unnecessary and might have been considerablyshortened. After that his legs began to' play up'and he was labelled as having synovitis and asthma.His worries when I saw him were cough, pains inthe limbs and a' wonky ' heart.

After full examination, including X-ray in-vestigation of the chest, I could not fault him. Hethen told me some further details. He said that asa lad his attainments gave promise of a brightscholastic future. Family misfortunes necessitated

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6 POSTGRADUATE MEDICAL JOURNAL January x955

his leaving school at the age of I3 to help hisparents. His elder sister remained at school. Heremembered the very first occasion his cough wastroublesome. It was at the school break-up afterhe had left and his sister was receiving a prize.Perhaps his cough began as a protest. Pathetic-ally enough, I set him down as a slow-witted personwhose intelligence was under average. Since hisdischarge from the Army he had, for the first time,freed himself from manual labour. He had not,however, freed himself from anxiety and he wasattending night school to improve his position in aGovernment department where he had gained aprecarious foothold as a temporary clerk. I triedto banish his fears of arthritis and heart disease.His cough seemed to me another matter and I donot know what obscure but useful purpose it mighthave served during x8 years.The last example I shall give has to do with a

single woman of 34 whose health had been gooduntil the illness of which I speak. Her doctorsaid that this illness began with a cold three monthsbefore and he saw her after she had been ill for amonth. She then had a temperature of 99.4 and apleural friction rub in the left axilla. Her tempera-ture became normal in a few days but she was leftwith a spasmodic cough at night which, he said,nothing would relieve except an injection of anopiate. An X-ray taken in the early stage of herillness brought a report that both lungs in themiddle and lower zones showed accentuatedbronchovascular markings and increased patchydensity, suggesting incompletely resolved evanes-cent infection of the broncho-pneumonic type.There can be no doubt then that the patient hadan obscure infection of the respiratory tract andone can only admire the restraint of her doctor andthe radiologist, neither of whom ever introducedthe word virus. The doctor's letter ended with thestatement that she had, of course, had' Potassiumiodide and ammonium carbonate mixtures and allthe Lincti (Linctuses) I could remember. Shealso had penicillin.' He then said he was goingfor a holiday.When I saw her there were no abnormal signs

in the chest, an X-ray film showed no abnormalityand on screening there was no evidence of pleurisythough the movement of the diaphragm wasnegligible on both sides. In fact, inspectionshowed that she made very poor use of herventilating apparatus.

I discovered that she had worked as a mailsorter at the G.P.O. on night shift because she hadalways slept badly at night. She had not workedfor three months and had scarcely been out of thehouse in that time. Latterly she scarcely got out

of bed. She had despaired of ever getting betterand in the night panic drove her to ring her doctorfor relief. Re-education in breathing and restora-tion of her confidence, for which an understandingphysiotherapist must be given the credit, workedwonders in a fortnight and she then went away fora fortnight. She then resumed her occupation andhas remained well since.

I have a conviction that the greatest benefit adoctor can confer on a fellow mortal is to give himback his independence as quickly as possible. Istill remember with a shudder inheriting an in-valid pensioner in my outpatient clinic. He hadbeen attending for some years when I came. Dur-ing all that time he took senega and ammonia.Cough mixtures do nothing of real value for achronic cough. To teach a person how to use hisbreathing apparatus correctly and how to controlhis cough is, to some extent, to make him master ofhis own fate. An extra half hour spent on theinvestigation and explanation of a cough may savepints of cough mixture and much time. It may,indeed, save an operation, for the vaults of themind may be more potent sources of cough thanthe crypts of the tonsil. More than one person isinvolved in a cough and an unfortunate child maybe the victim of much unnecessary investigationand treatment for a cough that racks the parentsand not the child.

It is demoralizing for patient and doctor to con-tinue an association in which the only tie is a bottleof medicine and beneath which lies a sense offailure.To cure a cough sometimes it is necessary to

accept the challenge to throw physic to the dogsand ask yourself:'Canst thou not minister to a mind disease'd;Pluck from the memory a rooted sorrow;Raze out the written troubles of the brain;And, with some sweet oblivious antidote,Cleanse the stuff'd bosom of the perilous stuff,Which weighs upon the heart?'

BIBLIOGRAPHYBOYD, E. M., and MAcLACHLAN, M. L. (I944), Canad, M.A.J.,

50, 338.BROWNE, SIR THOMAS (x93I) 'Religio Medici and other

Writings,' Everyman Edition, p. 149.CHARCOT (x876), Gaz. Med. de Paris, 588; quoted by WHITTY

(1943).CORYLLOS, P. N. (X937), Amer. Y. med. Sac., 194, S23.DOUST, LOVETT j W., and SCHNEIDER, ROBERT A.

(19S2), Brit. med. 7., 449.FRANKLIN, K., and JANKER, R. (1938), Y. Physiol., 92, 467.JACKSON, C., and JACKSON, C. L. (x933), Amer. Y. med. Sc.,

186, 849.VOORSANGER, W. C., and FIRSTONE, F. (1927), J.A.M.A.,

89, x1137.WHITTY, C. W. M. (x943)' Brain, 66, 43.YOUNG, R. A. (x940), The Practitioner, I44, 434.

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