t it is very seldom
_instantly_ fatal. The onset is usually sudden, and sometimes the
individual may be struck down in an instant, senseless and motionless,
"warranting those epithets, which the ancients applied to the victims of
this disease, of _attoniti_ and _siderati_, as if they were
thunder-stricken or planet-struck" (Sir Thomas Watson). The attack,
however, may be less sudden and, not infrequently, attended by a
convulsion; while occasionally, in the condition termed _ingravescent
apoplexy_, the coma is gradual in its onset, occupying hours in its
development. Although unexpected, various warning symptoms, sometimes
slight, sometimes pronounced, occur in the majority of cases. Such are,
fulness in the head, headache, giddiness, noises in the ears, mental
confusion, slight lapses of consciousness, numbness or tingling in the
limbs. A characteristic apoplectic attack presents the following
phenomena: the individual falls down suddenly and lies without sense or
motion, except that his pulse keeps beating and his breathing continues.
He appears to be in a deep sleep, from which he cannot be roused; the
breathing is laboured and stertorous, and is accompanied with puffing
out of the cheeks; the pulse may be beating more strongly than natural,
and the face is often flushed and turgid. The reflexes are abolished.
Although apoplexy may occur without paralysis, and paralysis without
apoplexy, the two, owning the same cause, very frequently co-exist, or
happen in immediate sequence and connexion; consequently there is in
most cases definite evidence of paralysis affecting usually one side of
the body in addition to the coma. Thus the pupils are unequal; there may
be asymmetry of the face, or the limbs may be more rigid or flaccid on
one side than on the other. These signs of localized disease enable a
distinction to be made from the coma of narcotic poisoning and
alcoholic intoxication. It must be borne in mind that a person smelling
strongly of liquor and found lying in the street in a comatose state may
be suffering from apoplexy, and the error of sending a dying man to a
police cell may be avoided by this knowledge.

If the fit is only moderately severe, the reflexes soon return, and the
patient may in a few hours show indications of returning consciousness
by making some movements or opening his eyes when spoken to, although
later it may be found that he is unable to speak, or may be paralysed or
mentally afflicted (se