As often happens in the case of the adult, the attack may not come on for some considerable time after exposure to the malarious influence. In deed, cases are sometimes met with in which a child, who is free from fever while he lives in the agueish district, only begins to suffer after he is re moved to a more healthy situation.
The cold stage may begin with very violent symptoms or may give only trifling indications of its presence. The child may have a severe rigour like an adult, or may be taken suddenly with a convulsive seizure. If the latter the fit is rarely repeated, but is followed almost immediately by heat of skin and all the symptoms of the second stage. In infants neither rigours nor convulsions may be seen. Instead, the baby seems drowsy ; frequently yawns ; sometimes stretches itself ; is peevish and fretful, re fusing the bottle ; and looks pale and prostrate, with perhaps some lividity of the lips and finger-nails. In rare cases the hands and feet are cold to the touch. This stage is usually short. The temperature rises progres sively throughout, and even at the beginning, when the child feels cold or actually shivers, is above the normal level. Towards the end of the stage the mercury may register between 103 and 104 degrees of heat.
The hot stage is usually better marked. In this the skin is distinctly febrile ; the child is drowsy and looks ill ; if not flushed, the face is pinched and pale ; and the head is said to be tender. The tongue is covered with a yellowish fur, and according to Dr. Fruitnight it is not uncommon for the throat to be congested with a whitish deposit on the tonsils. The child is usually thirsty and drinks greedily ; he often coughs—indeed, a cough is said by Dr. Fruitnight to be a constant symptom of the attack ; the pulse is rapid, feeble, and compressible. Pressure on the liver and spleen elicits signs of discomfort, and both these organs on palpation are found to. be enlarged. The child often vomits, sometimes bringing up bile ; and the bowels may be relaxed. Occasionally an icteric tinge is noticed on the skin. There is one symptom sometimes met with in a marked case which must not be omitted. This is a general bright redness of the surface. Such a rash, accompanied by a high temperature, and following rapidly upon a rigour or an attack of convulsions, would strongly suggest scarlatina, espe cially if at the same time some redness of the throat could be detected.
Through this stage the temperature continues to rise progressively, and towards the end has reached its maximum, which may be 105° or higher.
The third or sweating stage is very imperfectly developed in the infant. Older children may burst out into a profuse perspiration like the adult. Still, ,whether the disease end in sweating or not, there is a remarkable fall of temperature at the end of the hot stage, and the thermometer will often mark 100° or 101° where a very short time before the pyrexia had been as high as 100° or 107°. At the same time that this diminution in the bodily heat is noticed there is usually a profuse secretion from the kidneys, and the child passes a large quantity of limpid urine. According to Dr. Gee's observations, the proportion of urea and chloride of sodium are greatly increased during the hot stage, while the phosphates are diminished. As the temperature falls the amount of urea and of chloride of sodium diminish, while the proportion of phosphates is augmented.
The duration of the attack varies. The hot stage, which lasts the longest, may occupy six or eight hours. After the attack is over, the child, if he is suffering from the intermittent form of the disease, seems quite well until the next attack begins. If the fever is of the remittent type, the patient remains more or less feverish in the interval. He is thirsty, has little appetite, is languid, peevish, and restless ; looks pinched and ill, and usually loses flesh. The wasting is sometimes increased by a troublesome diarrhcea. Often the fever, at first intermittent, may pass into the remit tent form ; and then, again, in its progress towards recovery return to the intermittent type. In many cases of the remittent form of the disease the fever runs a less acute course, and the temperature, although persistently elevated, does not reach the high level common in the shorter and sharper attacks. Thus during the paroxysms it may rise no higher than 102° or 103°, and during the remissions may be little over 100°.