(PERTUSSIS; TUSSIS CONVULSIVA)
=Definition.=—It is a specific, epidemic, infectious, contagious
disease affecting the respiratory organs, characterized by a cyclic
course, a severe convulsive cough, paroxysmal, with the characteristic
“whoop.”
=Etiology.=—It usually occurs in children, most frequently during
the fourth year, and extremely seldom after the twentieth year. It
appears to be slightly more frequent among girls, and most cases occur
in March and April. Pertussis is highly contagious, being carried by
direct contact and by fomites. The Bordet and Gengou bacillus is the
specific cause. This is found in the sputum most abundantly during the
first week, the most infectious period, and becomes gradually less. One
attack usually confers immunity.
The incubation period is from seven to ten days. The patient may be
considered non-infectious five weeks after the first whoop.
Lesions of the cervical and upper dorsal vertebræ and of the
first, second and third ribs, affecting the vagi, the phrenic, the
sympathetic, the recurrent laryngeal or the vasomotor nerves predispose
to the disease.
The bacteria were found by Mallory and Horner to be characteristically
between the cilia of the trachea and the bronchi. They interfere,
mechanically, with the movements of the cilia, preventing the normal
removal of secretions.
=Symptoms.=—The disease is divided into three stages: 1. The catarrhal
stage, which lasts one to two weeks; 2, the spasmodic stage, three to
six weeks; 3, the declining stage, three weeks.
=The Catarrhal Stage:= Characterized by headache, photophobia,
conjunctivitis, coryza and a cough which becomes drier and harder
toward the end of this stage. Often the invasion is insidious and
sometimes well marked with a temperature of 100° to 102°. Frequently
this stage cannot be differentiated from a “hard cold,” except toward
the end of the stage when the cough becomes worse instead of better,
and the child will seek some support to steady itself during the
coughing paroxysm. Also the eyes will water freely during the coughing
spell and the child will not be able to “get his breath” between
coughs, but will have a number of coughs without inhaling.
One to two weeks.
=The Spasmodic Stage:= This stage dates from the “first whoop.” The
fever now usually ceases, unless there are complications. The cough
becomes paroxysmal, consisting of a succession of fifteen or more
short, rapid expiratory puffs with no intervening inspirations,
immediately followed by a deep, loud inspiration, which is the
characteristic “whoop,” and is due to the partial closure of the
glottis. Each paroxysm is composed of three or more such spells, the
last one often followed by the expectoration of a small plug of mucus
or by vomiting. During the paroxysm the facies presents a swollen,
dusky appearance, eyeballs protruding, eyes reddened, and puffy,
pinkish lids. The child is well except for the paroxysm, which has
an aura, tickling in the larynx, thoracic constriction, a creeping
sensation, when the child attempts to brace himself, or runs in terror
for support. The “whoop” is a deep, singing or whistling inspiration
which is absolutely characteristic. During the cough the child’s body
is bent forward and he is perfectly helpless, often passing urine and
feces involuntarily. Cyanosis often occurs from the strain.
After the attack patient regains control of himself, the respiration
is fast, and there is fatigue, sweating and often pain in the abdomen
from the strain of coughing. During the severe cough petechiæ of the
forehead, ecchymosis of the conjunctivæ, epistaxis, bleeding of the
external auditory meatus or from the frenum of the tongue may occur.
Ulcer of the frenum of the tongue is quite common. The parosyxms vary
from four to a great many per day, averaging about twenty.
Three to six weeks, usually four weeks.
=The Terminal or Declining Stage:= This stage is longer in proportion
in the mild cases. The paroxysms occur at longer intervals, are of
shorter duration and of less intensity, the catarrhal symptoms are
more marked, the expectoration becomes thinner, fluid, mucopurulent,
and looser. The “habit cough” may follow. It is during this stage
that complications are most likely to occur, therefore it is the most
dangerous.
=Complications.=—Catarrhal inflammations are common in the initial
stage. =Bronchopneumonia= is the most frequent and severe complication.
Lobar pneumonia, exudative pleurisy, endocarditis, pericarditis,
meningitis and nephritis are infrequent complications. Spasms of the
glottis in nervous or scrofulous children is largely nocturnal, and
may cause death from asphyxia even in the lightest cases. Hemorrhages
may occur in the skin, conjunctivæ, nose, throat, ears or cerebrum.
The writer knows of one case where death was sudden from a cerebral
hemorrhage in an apparently mild case. Other complications are cardiac
dilatation, emphysema, bronchiectasis, pneumothorax, aneurysm hernias,
muscular ruptures, and visceral prolapses.
Spasmodic cough from diseased bronchial glands very closely resembles
whooping cough. Barthez and Sannee give the following differentiation:
=Whooping Cough vs Enlarged Glands=
1. Contagious, epidemic. Isolated, not contagious.
2. Three periods, 2nd parosyxmal. No distinct periods.
3. Paroxysmal cough with whoop, Paroxysms without whoop,
vomiting, viscid expectoration. expectoration or vomiting.
4. Respiratory sounds normal. Signs of enlarged glands sometimes
present.
5. Respiration normal in interval; Asthma in some cases, febrile
apyrexia if simple. movements, sweats, wasting, etc.
6. Voice natural. Voice sometimes changed.
7. Acute. Chronic.
=Treatment.=—Isolation of patient in well ventilated, sunny room where
there is plenty of fresh air day and night is essential. Children
exposed to infection should be disinfected and isolated for three
weeks, as the disease can not be diagnosed during the catarrhal stage.
If case is at all severe, patient should be put to bed.
Cases receiving early treatment are sometimes aborted. Treatment of the
whole respiratory tract with correction of vertebral and rib lesions,
and relaxation of the contracted muscles should be given. Treatments
for the first few days should be at least twice per day. Pay especial
attention to the vagi and phrenic nerves. Lesions of the first and
second ribs will affect the recurrent laryngeal nerves which will
aggravate the cough. The muscles of the shoulder girdle are always
very tense and should be kept well relaxed, as should the subscapular
muscles. Frequently after treatment the child will have a coughing
spasm and raise large quantities of mucus, after which there will be no
more spasms for several hours.
Children who play and live out of doors get along best. To support
the diaphragm and abdominal muscles from the strain of coughing a
muslin bandage tightly pinned about the trunk is very valuable, a pad
being placed over the stomach under the bandage. In a very young child
instruct the nurse to strongly flex thighs on abdomen during the severe
coughing. Inhalations of steam from water with a very few drops of
eucalyptus oil in it often relieves the first tickling sensations.
If cyanotic symptoms appear they may be relieved by raising the ribs,
especially those over the heart; by relaxing the subscapular muscles;
and by supporting the heart by application of cold cloth over the
heart. Elevating the abdominal viscera and diaphragm is, also, of
distinct benefit.
The diet should be nutritious and easily digested, restricted to
liquids during the fever. The child should be warmly clad and protected
from drafts. The excretory systems should be kept active by plenty
of water drinking and by diet. Treatment should be continued during
the terminal stage to prevent the possible complications. Irritants,
as beef-tea, stimulants, dry bread, cookies and overfeeding, provoke
coughing and vomiting. Food should be given at frequent intervals in
concentrated form—gruels, milk with lime water, zwieback in milk, eggs,
meat juice, etc. Older patients tolerate more solid food.
=Prognosis.=—With the complications, this is the most fatal of
the acute infections under five years of age. Infants and little
children should receive special care. Ordinary uncomplicated cases
are favorable for recovery. The prognosis depends upon the age and
strength of the patient, the severity and number of the paroxysms,
and the presence or absence of complications. No recurrence is to be
expected.
Death is due to spasm of the glottis or to extensive subdural
hemorrhage, occurring chiefly in the children of the poor and in
delicate infants.
Prophylaxis consists of isolation, disinfection of sputum and final
fumigation of the premises. Children should be protected from exposure
to infection from whooping cough. It must be realized that it is a very
serious disease.