When the coma becomes complete, the flush usually subsides and the face becomes very pale. The insensibility is not, however, always pro found. Often it varies in degree, and the child may seem to wake up for a time and look round with some intelligence in his glance. Still, it is difficult to say whether at these times he is always conscious. In some cases the stupor clears off completely for some hours, and the child may sit up, apparently infinitely improved, and again show some interest in his toys. These cases are very distressing in their effect upon the relatives, who had given up the child as hopeless, but now conclude that all danger has passed. Unfortunately, if the eyes be examined, it will be found that the pupils continue sluggish, dilated, and unequal in size ; the squint, if it had been present, still persists, and little hope can be entertained that the improvement will be lasting. After a short interval, to the infinite grief of the friends, the coma returns as profoundly as before, and then con tinues until the close.
Increase in the coma is usually associated with effusion into the ven tricles. If ossification of the cranial bones is still incomplete, the fonta nelle, when the effusion occurs, generally becomes elevated and tense. Still, it is important to be aware that a large effusion in the ventricles is quite compatible with a level or even a depressed fontanelle.
Convulsive movements generally come on early in this stage. They are often partial, and may be confined to twitchings on one side of the face or in one arm. Often, however, they are general and more severe. Between the seizures the joints are often stiff, and paralysis is more or less distinctly marked. Squinting of one or both eyes is seldom absent, and there is frequently ptosis, but general paralysis of the face is rarely seen.
Loss of power in the limbs usually assumes the form of hemiplegia. The arm is sometimes affected alone, but the paralysis is said never to be confined to one leg. At the end of this stage, when the coma is com plete, the head often becomes retracted upon the shoulders, and the tonic rigidity may affect the whole spine ; the joints are stiff ; there is more or less complete paralysis of one side ; the pupils are dilated and unequal ; there is, squint of one or both eyes ; the eyeballs often oscillate ; and tre mors and twitchings may be noticed in the muscles of the face and limbs.
Before death the pulse usually becomes very rapid ; the constipation is replaced by diarrhoea ; aphthm appear upon the mouth ; the retracted abdomen swells out again with gaseous distention ; ophthalmia may occur, and the cornea often ulcerates ; there is generally profuse sweating, and acute oedema occurs in the lungs. On the last day the temperature may
fall to a subnormal level or may rise very high, and sometimes it reaches a surprising elevation. Thus, in a little girl, five years of age, the tem perature on the morning before her death was 97.6' ; but from that point it rose progressively through the day and night, until at 7.45 A.M. on the following morning, the time at which she died, it was 110°, and two hours after her death had only sunk to 107°.
The average duration of the illness, counting from the first clay of vomiting, is twelve days. It may, however, run a shorter course, and sometimes comes to an end on the sixth or seventh clay. In other cases it lasts over a longer period, but is seldom prolonged beyond the end of the third week.
The sequence of the phenomena, as given in the preceding description, is that ordinarily met with in cases of the primary form of the disease, but there are occasional variations in the symptoms which it is impor tant to be aware of: Thus, in exceptional cases the illness begins with diarrhoea, and I have known the looseness to persist, with occasional inter missions, throughout the course of the attack, although no ulceration was present in the bowels. Vomiting, also, may be a far from prominent symptom. Sometimes it is quite absent ; at other times the child vomits once or twice, and not afterwards. Again, the pulse may be slow from the beginning, or, on the contrary, may be rapid at the onset and never afterwards fall in frequency. Still, as a general rule, repeated observa tions will usually detect a slow pulse at some period of the illness, even if it only last a few hours. It is always important in ascertaining the. state of the pulse to do so at a time when the child is perfectly motionless. The headache, too, varies greatly in severity. It may be excessively severe or comparatively slight. The intolerance of light is also a variable symptom. Sometimes it is extreme. In other cases the child can bear the light with out apparent discomfort. Lastly, the temperature is not always high. It may be little raised above the normal level, and in most cases the pyrexia lessens at the beginning of the second stage. Indeed, at this period the reduction in the fever, together with the diminished fretfulness of the pa tient as he becomes more stupid and drowsy, may excite in the minds of the friends false hopes of improvement. It is generally the case that the fever is higher in the third stage than at an earlier period. If it rise to a high level in this stage it is a sign of approaching death.