The paroxysm, whose duration (usually 2 to 5 minutes) is apt to be overestimated by the awe-stricken, helpless layman, having terminated with the evacuation of tenacious mucus or without it, stronger and hardier children may be seen quietly resuming their interrupted play, their meal, or even speech, without any sign of distress. Others, on the contrary, after the attack exhibit lassitude, sweating, and acceleration of the pulse and respiration. Generally, if there are no complications, the subjective condition of the children is very good, far better than in the catarrhal stage, the cough-free periods affording them the quiet of full health. Subjective distress during the pauses, great exhaustion in spite of a small number of paroxysms, and especially elevations of tem perature are always the first symptoms of incipient complications.
The number of attacks depends above all on the gravity of the affection and on constitutional factors, as well as on climatic and general hygienic conditions. In vigorous children and in uncomplicated cases the paroxysms may be only ten or even less in 24 hours, while on the other hand there arc children who have to endure forty, or even fifty and sixty spasmodic attacks. The number of these paroxysms may be easily controlled and the attending nurse should be instructed to mark each attack by a sign on the history sheet.
The convulsive stage in its course is characterized by three phases —an increase, an acme, and a decrease of the wave. The decrease man ifests itself rather in a change in the severity of the single paroxysm than in a diminution of the number of attacks. The latter run their course entailing less effort on the part of the patient.; the inspirations being more marked and effective, the spasmodic cough more rapidly draws to an end, and an earlier expulsion of the sputum with choking and vomiting occurs. Without sharp delimitation and gradually, the course of the disease begins to improve, reaching the stage of decline which is a second catarrhal phase.
The duration of the convulsive stage cannot be easily fixed, fre quent exacerbations, even in uncomplicated cases, being apt to modify the course. Thus, we can determine the normal duration only in those cases which run a rapid course. Two to three weeks may generally be set down as the shortest duration of the second stage. But right here we have to emphasize that damage due to careless conduct., climatic conditions, severity of the infection, constitutional and especially com plicating diseases may prolong the convulsive stage for weeks and months.
The last stage (stage of decline) marks the disappearance of the symptoms. The attacks occur more rarely, their course is milder and more rapid, a few coughing efforts constitute the whole paroxysm sug gestive of a severe productive bronchial catarrh, with mucus or muco purulent expectoration. The daily number of paroxysms decreases, dropping to 3, 2, 1, until finally there occurs only one every few days. During this phase of whooping-cough the children feel quite well. But even in this period adverse conditions may cause a relapse into the paroxysmal stage and revive for days and weeks, all the symptoms of the convulsive attacks. In light cases this last phase of decline lasts
from one to two weeks (Fig. 109).
In the pauses that are free from paroxysms, especially during the convulsive stage, we meet with symptoms of great diagnostic value. During a paroxysm there curs a great congestion in the region of the superior vena cava and the tributary veins and lymphatics. This stasis, during a paroxysm, causes not only the cyanotic discoloration of the face and mucous branes already described, but also a permanent distention of the lymphatic ducts and blood vessels, which may be seen in the pauses. ingly, the faces of children become bloated, particularly where there is loose neous cellular tissue; the upper and the lower eyelids stand out like pillows, and sometimes the eyeballs protrude slightly. In thin children the contrast between the scant fat of the body and the full, puffy face is often surprising. Hremorrhages occurring during an attack, especially in the conjunctiva, are a quence of the greatly increased pressure in the venous circulation. They may be so profuse that the sclera, so far as visible, appears blackish red.
Rarely, and only in cachectic children, does the skin of the face and body become blackened through extravasations of blood. In children with visible veins on the head and forehead, these vascular trunks become swollen as thick as a raven's quill.
Characteristic of whooping-cough is a sublingual ulcer or ulcer of the frfenum. In children that have their lower incisors, we find a rhom boid or lancet-shaped ulcer of the frenum, with a thick white coating. This ulcer is formed during paroxysms by the protrusion of tongue, which at each coughing effort sweeps its under surface over the edges of the lower incisors. The sublingual ulcer occurs only in whooping cough and at times becomes an important diagnostic aid. [This ulcer is seen also in other severe paroxysmal coughs in young children and is not diagnostic.—La F.] A physical examination after a prolonged duration of the convul sive stage, reveals on percussion the signs of a certain pulmonary em physema, the diaphragm standing deep, the intercostal spaces being fuller, and the upper clavicular fosse vaulted forward. On ausculta tion, especially immediately before a paroxysm, we discover here and there a rhoncus, a fine rattling rale which disappears during the attack. As to the heart, provided an existing pulmonary emphysema does not affect the conditions on percussion, we notice an increase of the area of cardiac dulness towards the right, due to a dilatation of the right ven tricle, frequently also an increased intensity of the second pulmonary sound, which is an expression of increased pressure in the lesser circu lation. This congestion gives rise to intense venous hyperemia in the whole respiratory tract and predisposes to hemorrhages that are fre quently observed. Owing to small vascular ruptures the expectorated mucus often appears flecked with blood.