When ague assumes the remittent type, as it is apt to do in feeble, badly nourished children, the diagnosis is less obvious. In malarious_dis tricts it is well to suspect ague in all cases where pyrexia appears in a young child without evident cause. Still, the sources of error are numer ous ; for a probable cause of elevation of temperature, such as dentition, may be present in a child who is suffering from a real agueish attack. Perhaps the best rule in doubtful cases is to prescribe quinine. We can do little harm by this practice, and may do great good by putting a stop at once to attacks which in weakly subjects, if not arrested early, may pro duce very serious consequences.
Prognosis.—If the disease be recognised and treated promptly it can usually be controlled with ease. The fatal cases are those in which the real nature of the illness has been misapprehended and specific treatment consequently withheld. Also, the exceptional cases where the child ap pears to be overwhelmed by the violence of the malarious poison, and passes rapidly into a state of coma, are said rarely to end in recovery. But even in these cases, if the cause of the symptoms were recognised in time, it is possible that energetic stimulation and the use of quinine in large doses by enema or hypodermic injection might be successful in averting a fatal issue. It must not be forgotten that in malarious dis tricts the specific fevers, and indeed acute illnesses generally, tend to run a more severe course than in healthier neighbourhoods, and that as a rule epidemics have a high rate of mortality. Children who suffer from the ague cachexia are bad subjects for the eruptive fevers ; and in all such cases we should speak with considerable caution as to the patient's chances of recovery.
Treatment.—Directly the existence of ague is recognised in a child spe cific treatment should be had recourse to without unnecessary delay. Chil dren bear quinine well. A child of twelve months old will take a grain and a half of the sulphate of quinine three times a day, and the fever will quickly yield to this treatment. The best way of administering the remedy is to rub it up with glycerine and give it either in a spoon or in a wine glassful of milk ; for milk helps to conceal the bitterness of the drug. The medicine should be continued for a few weeks after the attacks have ceased, but be in diminished quantity or less frequent. doses. At the same time it is desirable to remove the child from the malarious neigh bourhood. If this be impossible, it is well to give a dose of quinine twice a week for a considerable time after the subsidence of the seizures.
In cases where the child vomits the quinine, or where from other rea sons it is not desired to administer the remedy by the mouth, it may be thrown up the, bowel suspended in a small quantity of mucilage, or may be given by hypodermic injection. In the former case the dose must be
double that previously recommended for administration by the mouth. If the remedy is administered subcutaneously, Dr. Ranking recommends that the neutral sulphate of quinine be used freshly dissolved in warm water ; that the syringe and solution be both warmed before use ; and that the injection be made very slowly, distributing the fluid at the same time amongst the interstices of the cellular tissue by the forefinger of the left hand, so that no lump is left to mark the site of the puncture. It is found that warming the solution and the syringe not only lessens the pain of the operation, but also reduces the tendency of the quinine to deposit itself quickly in the cellular tissue. If used cold the quinine is almost always deposited at once in a solid mass before absorption of the solution can take place. This is, however, not injurious, but it retards the beneficial effect of the operation. The quantity of the drug thus administered should be a fifth of that given by the mouth. For an adult the dose is half a grain. Probably one-sixth of a grain would be a suitable quantity for a child of two or three years old. ILI order to prevent corrosion of the syringe it is advisable directly after the operation to wash the instrument in hot water and dry it carefully, and afterwards• to oil the screw well. Instead of the sulphate the kinate of quinine may be used. Mr. H. Collier has recommended this salt as the more suitable on account of its solubility for hypodermic administration.
In some cases, especially in the older children, where there is much acute enlargement of the liver and spleen, quinine seems to be useless. In these cases it is of great importance to reduce the congestion of the liver before beginning the quinine treatment. The child should take at night a dose of gray powder (gr. iv.) with jalapine or compound scammony powder, and the action of the bowels should be kept up for a week or two by doses of some aperient saline. Sulphate of magnesia is very useful for this pur pose, given with dilute sulphuric acid and half a grain of quinine for the dose. The medicine can be made palatable with spirits of chloroform, glycerine, and tincture of orange peel. After the liver has been unloaded, the quinine treatment in full doses can be returned to, or the child can take arsenic (tq, v.—x. of the solution three times a day for a child ten years of age), with or without quinine, directly after meals.
In the more chronic cases, a combination of quinine and arsenic with iron is very useful. It is also of great importance that the child be re moved from the malarious district to a bracing seaside air. Moreover, he should be dressed from head to foot in flannel or some woollen material.