it is impossible to doubt, it does not betray itself outwardly by a general

be a sus trembling. It is in this that the intermittent fever of young children

of differs from the intermittent fevers of the second age, and it is this
다섯
This anomaly

which renders the diagnosis of the disease difficult.

ceases in the course of the third year; for I have observed intermittent rigors in a subject two years and a half old.

uling I have not seen sufficient children in the course of the stage of

is 201

occur

the concentration of the strength to determine its duration. It would even be impossible for me to give an opinion on this subject, for the information afforded me by the mothers is insufficient. Most of them had paid no attention to the phenomena which indicate the commencement of the febrile attack or were incapable of giving an account of it.

At this stage the phenomena of calorification succeed, which might be very readily taken for the commencement of fever, if it be not observed with great attention. The children become flushed and burning; the skin is dry, the pulse rises and acquires a force which it did not possess in the preceding stage, in which it was difficult to appreciate. It rises to 120 and 130 pulsations. At the end of an hour or an hour and a half the heat diminishes and sweating commences; it is Titles Stag not very plentiful; it is rather a moisture than a true secretion of perspiration.

These two last stages together are generally the only ones of which mention is made to the physician. The mothers state: at such an hour yesterday my child became feverish and it afterwards had slight at perspiration; these symptoms lasted about two hours, then all disappeared. We should then carefully inquire into the succession of the phenomena, and direct attention to, or ourselves observe, the stage which precedes the appearance of the heat.

The urine of children at the breast, attacked with intermittent fever, does not present any very appreciable modifications; although it may be difficult to collect it, we may judge of its state by the reddish colouring of the linen, in the case in which it would contain the red sediment of febrile urine.

[M. Heimbrod (Med. Zeitung.; 1851; No. 43), while he cannot on the one hand agree with Neumann, that one half of the cases of convulsion that occur in children under three years of age are due to intermittent fever, yet believes on the other, that the opinion expressed by several physicians, that young children are not liable to the disease, is the result of superficial observation. During the severe prevalence of the fever in Oberschleisen, in the year prior to the outbreak of the cholera, he met with twenty-five cases, occurring in children from five months to two years of age. In all these there was a distinct preliminary stage, exhibited by loss of appetite, indigestion, sleeplessness, quick pulse, &c. In fifteen of the number, the conditions of shivering, heat, and sweating, were as distinctly separated from each other as in the adult.

The paroxysm commenced with pallor of the face, a remarkable blueness of

the lips, and diminished temperature of the surface, the pulse becoming small, and the child apathetic. In from a quarter to half an hour restlessness came on, accompanied by redness of the surface and excessive thirst, the pulse being full and the urine high coloured. Vomiting occurred; and in plethoric children the symptoms sometimes resembled those of meningitis. This stage continued in a greater or less degree for one or two hours, when the burning heat ceased, the child became sleepy, and the pulse soft; and a profuse sweat broke out, which continued for a variable period, during which the child usually slept. Even in infants this sweat was sometimes so profuse as to soak through all their linen. At the end the child would wake up, drink, and continue free from ailment until the next paroxysm set in.

Cases like the above are easy of diagnosis; but the greatest care is required in distinguishing those which are termed vage or erraticæ, and the type of which observes no regular rhythm. Seldom as such a variety is met with in the adult, As its occurrence is frequent in the child; and M. Heimbrod has observed it with

exactitude in ten out of his twenty-five cases. After a longer or shorter period

of uneasiness, a severe paroxysm comes on, usually in the morning. The cold stage, as a rule, is either absent or so slight as to be overlooked; but the hot one is more severe and of longer duration, and is followed by a slight degree of,

or even by no sweating. The pulse retains its frequency for the whole day, the lack.

child remaining restless, excitable, thirsty, and sleepless. In the evening the careful observer will perceive signs of a remission, although these may be very slight, and may also be present at the same time on the ensuing morning, as the paroxysm occurs on the other day. No complete intermission occurs, and the case may be easily mistaken for one of remittent instead of intermittent fever-especially as gastric complications are common. The prevalence of intermittents among adults, and the occurrence of the paroxysm in the forenoon and of the remission in the evening, are the most important aids for enabling us to decide.-P.H.B.]

DIAGNOSIS.

The symptoms just described ought to be sufficient, I think, to pilotora. ensure the diagnosis of the intermittent fever of the children at the breast. When in one of these little patients we observe a general decoloration, with emaciation of the entire body, and when there is Emailing every day a fit of decided fever, according to the account of the parents, suspicion should be directed to the disease we are now considering. We then find daily irregular fits, similar to those above described, combined with decided hypertrophy of the spleen, and often more or thy less marked oedema of the limbs. If no other change in the organism exists, we may, without fear of being deceived, conclude in the existence the existence of intermittent fever. These symptoms present great analogy with those which are observed in the chronic diseases of children. Thus in tubercular pneumonia, chronic entero-colitis, &c., we also observe quotidian fits of fever, either single or repeated twice a day.

These fits are easily distinguished from the fits of intermittent miasmatous fever. They do not present at the commencement the

Maym concentration of the strength, and there is no enlargement of the spleen.g

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Besides, other symptoms are discovered which reveal the deeply-seated alteration of the organs and indicate the cause of this symptomatic fever.

COMPLICATIONS.

Anæmia is the most serious complication of the intermittent fever of children at the breast. It is characterized by excessive pallor of the integuments, serous effusion in the limbs, and probably by a modification of the sounds of the heart which we have not been able to detect. Purpura hæmorrhagica observed in one of our children ought to be ve considered as a complication of intermittent fever. It depends on the alteration of the blood caused by this disease.

Diarrhoea is met with rather frequently in the course of the disease we are now considering. It is a phenomenon which depends on the general state of weakness, or even cachexia caused by the action of miasmatous emanations on the individual. The diarrhoea is often a transient and purely nervous; in other patients it is the result of well characterized entero-colitis.

Such are the usual complications of intermittent fever. I shall not enumerate lobular pneumonia, which caused the death one of our patients in the course of this fever, for no relation can be established between these two diseases which are entirely independent of each other.

PROGNOSIS.

Intermittent fever is not of itself a serious disease in young children, but it is of sufficient importance in this sense that it very much interferes with the growth of the body and with the accomplishment of the nutritive functions. Moreover, when it is prolonged, it necessarily leads to a state of cachexia which may place the children in great danger. However, not one of those who fell under my observation died in consequence of the disease. One of them died from intercurrent pneumonia. Another, three months after its recovery, was seized with pleurisy which terminated in death. Consequently, of fifteen patients, one only died in the course of the disease, and that one from a different affection. All the others perfectly recovered. This is the usual termination of intermittent fever when it has not been too long established.

[Of fifteen males and thirteen females who died in London, in 1849, from ague, five males and three females were under five years of age.-P.H.B.]

TREATMENT.

In this disease antiperiodics, general tonics, and alteratives, should be administered. The combined use of these remedies has always succeeded

with me.
In the morning a spoonful of the antiscorbutic syrup should
be given, the subcarbonate of iron in the middle of the day, and
quinine brute towards the evening or after the end of the fit.

[The quinine brute or impure quinine is said to be much more active than the sulphate of quinine, it is insoluble in the saliva, and has not much taste-100 parts of it contains sixty-five of pure quinine, thirty of cinchonine, and only five of water; while in 100 parts of sulphate of quinine there are thirty of water. This preparation is soluble in lactic acid, and is quickly changed into soluble salts in the stomach by the acids which exist in that viscus. Its resinous consistence is another advantage, since it admits of being rolled into pills, in which form it may be mixed with sago, or given in any vehicle which contains no acid, since they would at once convert it into bitter and insoluble salts.—P.H.B.]

This last mentioned medicine, which I saw administered for the first time by M. Trousseau, forms the basis of the treatment of the intermittent fevers of infancy. It possesses the advantage over the sulphate of quinine of being less soluble and less bitter, and consequently it may be swallowed without repugnance by the little patients.

The quinine brute, which must not be confounded with pure quinine, presents the appearance of a greyish resinous mass, easily softened in the fingers and cut in small grains by means of a knife. It should thus be reduced into granules, and administered to the children, immediately after the fit of fever, in the dose of from three to six grains a day. This quinine powder should be mixed with a spoonful of gruel or of jam. The same dose of the medicine should be given every day until the febrile phenomena cease and until the disappearance of the volume of the spleen is effected.

The quinine brute completely supplies the place of the sulphate of mution quinine in its antiperiodic febrifuge properties. Its influence on the' diminution of the spleen is very nearly similar to that of this other medicine. In this case the spleen gradually diminishes in size, but the diminution is only complete when the febrile attacks have dis-! appeared. It would not be correct to state that the diminution of the organ takes place in some minutes. In young emaciated children it is observed to form a projection beneath the skin, its outline may be traced with a pen, and when the quinine brute is adminis-du tered it may be examined for a length of time before any change u is observed in its dimensions. Nevertheless, I repeat, if this diminution is not instantaneous, which is true, it is not the less one of the constant physiological phenomena of the administration of quinine; only its action is not produced until after several days, and then very slowly.

In absence of the quinine brute, the sulphate of quinine may be employed as an enema in the daily dose of from one and a half to three grains, dissolved in a few drops of vinegar and 3 iss of decoction of marshmallow, or, as a suppository, with the same dose of the salt mixed up with butter of cacao.

The sulphate of quinine has been employed in frictions, three times a day, in the dose of forty-five grains to 3j of lard; or internally, prepared in the following manner:

It is not an easy matter to make use of these remedies in children, and for my part I prefer the quinine brute or enemata of the sulphate of quinine.

Whilst the quinine is administered with the intention of warding udi off the attacks of fever, the cachexia and the debility of the patients may at the same time be treated by the preparations of steel. These Mu preparations ought to be continued after the cure of the fever until the yellow tint of the skin is replaced by a more healthy looking carnation. The subcarbonate of iron should be administered in the dose of from three or five grains. Under the influence of this remedy the appetite increases, the strength returns, the oedema of the limbs disappears, and the red colour of the cheeks indicates the return to health.

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The action of the steel may be assisted by several adjuvants, such as the syrup of bark or the syrup of orange peel; but these medicines are not absolutely necessary. It has been proposed to treat the serous effusion of the limbs by diuretics, and especially by the nitrate of potash. This precept is rather the result of a theoretical view than of a precise knowledge of the course of the oedema. In fact, as this symptom is the consequence of the anæmia, it is this general disposition of the economy which must be treated by tonics and by the ferruginous preparations, and the oedema itself need not be attended to. In this case, therefore, it is useless to employ diuretics.

To resume, then: the intermittent fever of young children differs much from that of adults.

The attacks are quotidian, and come on at indeterminate hours. They only possess two very evident stages-the hot stage and that of perspiration.

The stage of rigors or of trembling is entirely wanting; it is replaced by a sort of concentration of the strength, indicated by the general and momentary decoloration of all the tissues.

This disease determines the enlargement of the spleen, and renders this organ apparent through the anterior abdominal wall.

Intermittent fever may nearly always be cured; it is the cause of very decided cachexia, with oedema of the limbs and cutaneous hæmorrhages.

Bark very easily cures it. In children the quinine brute is the most useful remedy to prescribe.