Of these symptoms the most important are the combination of head ache, vomiting, and confined bowels, with irregular breathing. Even if the latter be absent, the occurrence of vomiting and obstinate constipation with headache in a child who for some weeks has shown signs of failing nutrition is always to be regarded with anxiety.
In the second stage—the stage of irritation—the symptoms become more aggravated. The headache increases in severity, and the child often becomes delirious. He lies in his bed with his eyes closed—often squeezed together, and his eyebrows contracted—making chewing movements with his jaws or grinding his teeth loudly. Sometimes he screams out as if in pain. If called, the child usually opens his eyes, but he answers questions unwillingly or stares at the speaker angrily and makes no attempt to reply. 'Whether from headache or irritability, the eyebrows often have a scowl which gives a peculiarly forbidding expression to the face of the patient.
The pulse generally falls in frequency at this stage and becomes inter mittent. It varies in rapidity from 60 to 80, and the finger pressing the artery finds the rhythm of the pulsations interrupted at irregular intervals by the complete omission of one beat. It is important in examining the pulse in these cases to seize an opportunity when the child is lying quietly and has not recently made a movement ; for a pulse which is slow and ir regular during repose may become quick and regular for a time upon the slightest change of position. The temperaturels generally lower by a de gree than in the first stage, and may rise no higher than 99°. The respi rations continue irregular as before, and often at this time assume the Cheyne-Stokes type. The pupils now become dilated and are often slug gish. Sometimes there is a slight squint, but this is seldom more than a passing deviation. Examination by the ophthalmoscope, if it can be man aged, shows a congested state of the retinal vessels and disk, and some times small bodies like gray granulations can be seen projecting from the sides of the small retinal arteries. Towards the eud of this stage the vomiting usually ceases, but the constipation continues, and the child shows no desire even for liquids. There is often retention of urine, and the motions are passed in the bed after an aperient. The pulse generally
quickens again, and the temperature rises. The abdomen usually becomes markedly retracted, but still remains soft, doughy, and compressible. Be sides, a singular tendency to flushing of the skin is noticed. The cheeks suddenly become red, then the flush dies away leaving them apparently whiter than before. Slight pressure on the skin, especially of the face, abdomen, and front of the thighs, produces a bright redness—the " cere bral flush " of Trousseau, which remains visible for a considerable time.
The principal symptoms of this stage are the fall in the pulse and tem perature, the apathy and drowsiness of the child, the violent headache, the irregularity of breathing, the excavation of the abdomen, the dilatation of the pupils, and the passing strabismus. The cerebral flush, unless very vivid, is an uncertain symptom, for it is often well marked in cases where there is no reason to suspect tubercular inflammation of the cerebral meninges.
In the third stage the temperature gradually rises again, and towards the end may attain a high elevation. The pulse also increases in rapidity and becomes regular, but the irregularity of breathing continues. The most prominent symptoms of this stage are the increasing coma and the occurrence of convulsions and paralysis. The child, who before could be roused by loud calling, now makes no sign of response, or if for a mo ment he raises the lids, he closes his eyes again almost immediately. The aspect of the child at this period is often very characteristic ; for if, as often happens, the disease have been preceded by few signs of ill-health, and the patient have retained his plumpness, he presents to the unedu cated eye the appearance of a healthy child in quiet slumber. His cheeks are brightly flushed, his countenance perfectly placid, his features rounded as in health; but it will be noticed that the eyelids close imperfectly, and that the respirations are very irregular and disturbed by deep sighs and long pauses. On raising the eyelids with the finger the pupils are seen to be widely dilated, they act sluggishly or not at all, and are often un equal in size. There may be nystagmus or a distinct squint.