ACUTE ERUPTIVE FEVERS, MUMPS AND WHOOPING COUGH (continued 2)

Treatment.—The patient should be kept away from other children, and should remain in a well lighted, well ventilated room of even temperature, and if the temperature is high or moderately high he should be kept in bed.

The correction of all interosseous lesions is indicated, especially of the upper cervical area, though the second and third dorsal should be given attention because of the influence of these dorsal nerves upon the submaxillary glands. Also correct upper rib lesions that may exist. As mumps is an infective disease the channels of elimination should be watched and stimulated. Build up the body resistance by treatment at the mid-dorsal area to affect circulation and respiration; and lower dorsal area to affect kidney and adrenal function. Watch the bowels and keep this avenue of elimination functioning freely, using enemata if necessary.

The diet should be liquid, of fruit juices, thin gruels, milk and plenty of water. Tepid sponging allays the fever and restlessness. Relaxation of the deep muscles of the neck and shoulders will do much to make the patient comfortable, also the muscles under the angle of the jaw. A very gentle relaxing of the tissues around the gland itself, by crowding them toward the gland, assists in relieving the tension by securing a better venous and lymphatic drainage.

Hot applications to the swollen glands will give a considerable relief; these may consist of hot fomentations, hot salt bag, electric heating pad, hot water bottle, etc. The mouth is kept in good condition by the use of a mild antiseptic mouth wash.

Orchitis should not occur if the boy is kept warm and in bed. If it does occur the best treatment is relaxation of the lower dorsal and upper lumbar spinal muscles, rest in bed, support and protection of the scrotum with cotton wool, cold applications, correction of any bony lesions affecting the pelvic viscera.

If mastitis occurs, rib lesions will be found and should be corrected, as they are probably the predisposing factor to this complication. Treatment would consist of correction of these lesions, if it can be done without irritating the inflamed glands. The manipulation of the surrounding tissues, with gentle crowding of the normal tissues toward the inflamed glands, without exerting any pressure on the gland itself, is helpful and comforting. Free tissues back to the axillary lymphatics.

Prognosis.—The outcome is usually favorable. In the rare fatal cases, meningitis is the usual cause of death. Under osteopathic care the duration of the swelling, fever and pain is usually greatly lessened.

Quarantine of twenty-four days is necessary.

Whooping Cough

(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, vomiting, viscid expectoration. Paroxysms without whoop, expectoration or vomiting.

4. Respiratory sounds normal. Signs of enlarged glands sometimes present.

5. Respiration normal in interval; apyrexia if simple. Asthma in some cases, febrile 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.