About the second or beginning of the third day a herpetic eruption appears upon the face, and purpuric spots may come out upon the body and limbs. This eruption, which is not invariably present, has given to the disease one of its names—" spotted fever." When the disease is at its height, the child lies on his side in the cot with his head refracted, his limbs flexed, and his spine often rigidly curved. He is completely unconscious, but still remains uneasy and rest less, often moving one or both lower limbs monotonously. The pupils are now generally dilated, usually sluggish, and perhaps unequal. The belly is flattened ; the bowels are constipated ; the pulse and respirations are quickened. At intervals spasms are noticed ; the head is drawn more backward, and the curve of the spine is increased. When the stupor is complete the bladder is evacuated involuntarily, or there is retention of urine.
In fatal cases the coma continues, the breathing is accompanied by rattling within the chest, and the child sinks and dies. If the case is to end favourably, the stupor grows less profound and the restlessness dimin ishes. The rigidity is late in relaxing, and usually the mind becomes clear while the head is still retracted upon the shoulders.
The special symptoms above referred to vary considerably in severity in particular cases :— The fever is very variable and has no regular course. The internal heat, as tested by a thermometer introduced into the rectum, is generally higher than the surface of the body ; but even in the rectum the mercury may only mark a degree over the normal temperature. At other times it rises to 104° or If early collapse come on, the temperature may sink to below the normal level.
The skin eruption is a valuable sign. In some epidemics it is a rare symptom ; in others almost all the cases exhibit a number of purpuric spots. In every recorded serious outbreak both the maculated and the non-maculated forms of the disease have been observed, although one may have been more common than the other. The rash consists of dark purple spots or blotches due to effusion of dissolved Irematin into the true skin and areola tissue beneath it. They generally occupy the legs, hands, face, back, and neck. They are sometimes slightly elevated, and vary in size from a pin's head to a walnut. According to Dr. J. A. Marston's ob servations in the epidemic which occurred in Ireland in the year 1867, there is no necessary relation between the occurrence, the number, and the extent of the spots upon the skin and the amount of the intra-cranial and intra-spinal mischief. Dr. Mapother, referring to the same epidemic, states that the spots cannot be produced artificially by pressure on the skin as in true purpura. Besides the petechi, there may be herpes,
urticaria, and patches of erythema or roseola. The skin may have a dusky tint and is often moist. Cerebral flush is not a marked symptom.
The mental condition also varies in different cases. When the disease is violent and death occurs early, the child may be unconscious from the first. In other cases stupor comes on by the second or third day. In the mildest cases the mind may be little affected, or there may be slight de lirium with curious hallucinations. Thus, Dr. Lewis Smith refers to a case in which the child answered questions with perfect clearness, but constantly mistook his mother for another person. Usually, in all cases before death the coma is profound.
The pains referred to the head and spine are always a distressing and prominent symptom. They are often so severe that the child, until he becomes comatose, is constantly moaning and screaming. The pain is increased by movements of the back, and especially by attempts to press the head forward. The general tenderness of the skin adds greatly to the child's discomfort ; and sometimes a touch on the body, as in moving him to alter his position, causes the greatest distress.
In some cases paralysis is noticed. It is, however, a comparatively rare symptom, and is usually partial, being limited to one or more limbs. It may affect the cerebral nerves, especially the third, the sixth, and the facial. The lesion of the nerve-trunks is due to purulent infiltration of the neurilemma, or to contraction of the hyperplastic connective tissue of the nerve-sheath. In cases of recovery the paralysis may last through life, but sometimes it passes off as the patient improves.
Convulsions, general or partial, are comparatively common in the case of children, certainly much more common in them than in the adult. They are especially frequent in the more severe forms of the disease. The clonic spasms sometimes alternate with tonic contractions ; and may be general or limited to one-half of the body. Nystagmus may be noticed.
Vomiting is seldom absent at the beginning of an attack. It is often severe, and like all forms of nervous vomiting is independent of taking food. The thirst is great. Constipation is the rule ; although in some epi dendics the disease has been noticed to be ushered in by purging as well as vomiting. The tongue may be clean or furred ; towards the end of the disease it becomes dry. Abdominal pain, if present, is like the thesia of nervous origin. The belly is seldom retracted, and never to the degree observed in cases of tubercular meningitis. Occasionally it is full or even tympanitic. The spleen is sometimes enlarged.