The number of paroxysms that occur in the twenty-four hours varies very much according to the severity of the attack, and partly, too, accord ing to the number of disturbing causes to which the child is exposed. In severe cases, where the slightest emotional or other influence will induce an attack, the number may be considerably diminished by quiet and judi cious amusement. The child often coughs more in the night than during the day, for the occurrence of the seizures appears to be favoured by the recumbent position. Between the paroxysms, when the spasm is violent, the child's face may remain permanently congested. The eyes are red and often bloodshot ; the eyelids are heavy and swollen ; the face and lips are dull red ; there is a dusky tint round the mouth and under the eyes, and the veins of the neck are full.
The attacks themselves vary in character. The whoop may be entirely absent throughout the disease. This is said to be common in very young infants. The number of expiratory efforts is very variable. Usually there are only two or three, but they may be much more numerous. As a rule the coughing fits are longer at the beginning of the spasmodic stage, when secretion is thinner and less copious, than at a later period, when it becomes abundant and more tenacious. After the whoop has lasted a fortnight it grows less violent and is less frequently heard. It only occurs with the more violent fits of coughing, and in the milder ones the breath is drawn more quietly and with greater ease. At the end of three weeks or a month it becomes very rare, and the complaint may then be said to have passed into the stage of decline.
The whole time occupied by an attack of whooping-cough varies from a fortnight or even less to two months or longer. The duration is often difficult to ascertain, for after the spasmodic cough has disappeared and the disease has again come to assume an ordinary catarrhal type, trifling accidents, such as a chill or an error in diet, may set up more active symp toms, and the whoop may even return for a time. In this way the com plaint may be prolonged for many weeks.
Complications.—There are certain accidents attendant upon the com plaint which may be a cause of distress or danger to the patient. Sub lingual ulceration is common ; hvemorrhage may be copious ; the vomiting may greatly interfere with nutrition ; bowel complaints may supervene ; the nervous symptoms may be exaggerated ; and various pulmonary dis eases may ensue and, if they do not prove fatal, injuriously affect the future welfare of the child.
The sublingual ulceration has been before referred to. It occupies the frmium of the tongue and may extend for some distance on each side of the middle line. The sore may vary from a mere abrasion to a deep fis sure with a gray or yellowish surface. It is only seen in cases where the Child has cut the lower incisors, and is the direct consequence of the scrap ing of these teeth against the under surface of the tongue as this organ is protruded and withdrawn during the paroxysms of cough. Blood often exudes from the abraided surface towards the end of a paroxysm. The ulcer is not a constant symptom. It never appears before the spasmodic stage, but may then be seen as early as the fourth clay of the whoop. It is most common in infants who have cut the two central lower incisors and no other teeth. In children who have cut all their teeth the symptom is much less common.
armorrhage must not be looked upon as in every case an untoward accident. When the spasm is violent and the congestion of the head and face extreme, the relief afforded by a discharge of blood from the distended vessels of the nose is no doubt often a salutary incident. If, however, the occur frequently and be very copious, great weakness may be occasioned ; and if the child be already reduced by the violence of the at tacks and the deficiency of nourishment occasioned by repeated vomiting, the loss of blood may be an additional reason for anxiety. Rupture of vessels elsewhere than in the nose seldom occurs to any extent. Blood ejected from the mouth during whooping-cough comes almost invariably from this source. Hamoptysis is rarely seen, for blood coming up from the lungs after an attack is usually swallowed by children, and is seldom, if ever, sufficiently considerable to be a source of danger.
Haemorrhage may also occur into the subcutaneous connective tissue of the eyelids and that beneath the Conjunctiva. The eyes are often blood shot from small ecchymoses, and occasionally we see little extravasations in the thickened eyelids.
Haemorrhage from the ears is the consequence of rupture of the tym panic membrane. Several instances of this accident have been recorded. It is occasioned by the blast of air which is forced through the Eustachian tube during the fits of coughing, and a certain amount of blood exudes from the torn surface. In two out of four cases published by Dr. Gibb the rupture occurred in both ears. • In very rare cases hemorrhage has been noticed in the brain and its membranes, causing death.