PEDIATRICS Vol. V. I' JANUARY 1st, 1898. ORIGINAL ARTICLES. PERTUSSIS. By THOMAS M. DOLAN, M.D., F.R.C.S., Ed. No. 1. T is now eight years since my article on Pertussis appeared in Keating's Cyclopedia of the Diseases of Children, and since that time I am sorry to say that very little light has been thrown on the pathology of the disease, though as regards treatment we have numerous new remedies, some of which are certainly an improvement on our old ones. I shall now pass in review all that we have been able to find out from our own experience or from that of others working in the same field during the past eight years, but I must first repeat that whooping-cough may be defined as a communicable disease, depending on a specific poison prevailing epidemically and sporadically. It is characterized by fever, malaise, irritation of the respiratory tract, catarrh, and subsequently by a hard, dry, convulsive, paroxysmal cough. It attacks both sexes and all ages, but especially children, rarely occurring more than once. Usually it runs a course varying from three weeks to three months. It may be complicated with other lesions, as ulceration of the frænum linguæ, enlargement of the tracheo-bronchial glands, capillary bronchitis, lobular collapse, emphysema, various hemorrhages, paralysis, convulsions, jaundice, catarrhal pneumonia, tubercular meningitis, and other diseases of children. Drs. Cohn and Neumann' examined the expectoration in 24 cases of whooping-cough from one to ten years of age. At 1 Arch. für Kinderheilkunde, Stuttgart. Vol., I p. 24. the end of a spasm the sputum was placed in a Petri glass, thoroughly washed with distilled water and a small portion dried and stained with carbolic methylene blue. Under the microscope, diplococci and short chains of small cocci were seen, but the authors do not assume that these are positively the specific germs of the disease. Drs. Wells and Caire' believe the pertussis microbe fabricates some virus, which, taken into the circulation, acts as an irritant poison to the nervous tissues, especially the respiratory and vagal centers, rendering them far more excitable than normal. They regard the catarrhal stage as the period of microbic activity, and the whooping one as due to the after effects of a poison generated by the microbe. This affords, if true, a complete reconciliation between the vacillary and the neurotic theories of the disease. The practice of these authors is to give doses of hydrochlorate of cocaine in water, based on the standard of a one grain dose for an adult, three or four times a day, by the mouth. No marked evil effects were seen from the use of cocaine, and the average duration of the cases was about three weeks. According to Unruh' the malady is to be considered as an infectious catarrh of the respiratory organs, caused by a specific germ leading to infection, and swelling of the lymphatic glands of the respiratory tract, accompanied by and causing severe reflex symptoms, viz.: the attacks. For the relief of this condition he advises the insufflation of quinine eight or ten grains once a day into the nose and pharynx accompanied or not by the internal administrations of quinine. I In order to test the question of the bacterial origin of whooping-cough, Raubitschek treated several cases with a solution of corrosive sublimate, using a strength of 1 in 1,000, applied to the tonsils, uvula, epiglottis and adjacent membrane either with a brush or a plug of cotton wool. Severe cases were treated every day, milder ones every other day. The condition was as a rule improved on the second, or at the latest the third day. Treating a child in the convulsive stage, it would be well after four or five applications. 2 Lancet, Vol. I, p. 23, 1893. 3 Jahrbuch für Kinderheilkunde, Leipsig, 1896. 4La Semaine Medical, April 26, 1894. The latest study is that of Kurloff on fresh and unstained sputum. Kurloff discovered an ameba characterized by a finely granular protoplasm and great capability of movement, and he believed this to be the infecting agent of the disease. This organism as it grows attains considerable size, bright large granular spores appearing on its body, arranging themselves in concentric layers. When the cell is ruptured the spores escape, increase in size until finally and, partly within the body of the patient, young amebæ are thus set free by the rupture of the capsule. These young amebæ are provided with cilia, and are capable of active movement. Besides these there were other bacteria present in the sputum; however, no special significance was attached to them. However, the importance of these with regard to the secondary phenomena and complications of the disease cannot be denied. As I have said before, though, we do not find any rough pathognomonic change in simple uncomplicated whoopingcough, yet it cannot go on long without leaving some impression on various parts of the frame. There is one important lesion, viz.: the imperfect aeration of the blood and disturbance of the circulation. In very severe paroxysms the incessant, harassing cough, the vomiting, the very concussion produced by the above, must in some way alter the texture of the mucous lining of the throat, bronchia, or bowels, or the structure of the lung, the heart or the brain, and the meninges. We have also to fear from whooping-cough, pulmonary collapse. In whooping-cough the lung is generally more or less dense and contracted, but collapse often follows as the result of bronchitis at the same time. Air is expelled, but none is taken in, the consequence being the air cells collapse. An expedient for cutting short the paroxysms of whooping-cough is described by Nægely. It consists in seizing the two greater cornua of the hyoid bone with both thumbs and holding the bone, together with the larynx, up from sixty to ninety seconds. The author does not attempt to explain the modus operandi of the relief obtained, but thinks it calls an inhibitory reflex into play. Central, für Bakteriology, Vol. XIX, 1896. Much can be done, if taken at the beginning of the disease, in the way of shortening its duration, and also to lessen the paroxysms, and we shall now pass in review all the modern remedies put forth for the alleviation of this malady. Dr. Rothschild' used tussal in an epidemic of pertussis. He states that in patients who were treated with tussal from the outset, and took their doses regularly, the duration of the disease was notably shortened and its whole course was much milder. In a few of them it lasted not longer than a fortnight. Dr. Marfan' believes that bromoform is still the best specific for pertussis. He employs the following formula: Bromoform.. Oil of sweet almonds. 48 drops. Gum tragant... 20 grammes. 2 Mix first the bromoform and oil, and shake vigorously, then add the other ingredients. A coffee spoonful contains two drops of bromoform. For a child of five years of age he prescribes as a daily dose four drops for each year of the age. From five to ten years the beginning dose is twenty drops daily. These doses should be gradually increased by two to four drops a day until they are doubled. Under six months the initial dose should be two to three drops; from six months to one year from three to four drops. I had lately under my care some very severe cases of whooping-cough, one especially in a girl about eleven years old. The paroxysms were so severe that people round her thought she must die, as it seemed impossible for her to get her breath again. I found the greatest possible use in bromide of potassium given in small and frequent doses. 8 Variot, I find, recommends much the same formula. I have myself used it with splendid results, as it shortens the spasms and takes away the dread of the approaching cough. The little patient, when feeling as though the cough was coming on, will invariably run for its dose of medicine. Rev. Mens. des Mal de l'Enfant, April, 1893. 8 Journal de Chirurgie et de Therapeutique Enfantile, April, 1894. |