symptom of ague at all ages, but it rarely reaches such an extreme in adults as is sometimes the case in childhood. It is said to come on very rapidly. Enlargement of the spleen is a common disease in children in the malarial regions of the tropics. The spleen under such circumstances will attain an enormous size, and many children die from this cause. [As above stated the first and last stages of the disease are frequently not as marked as in adults. The first stage is often overlooked by the parents, but when the rigor is absent there are slight tremors or the face becomes shrunken and pallid and the lips and finger-tips livid. The second stage is much prolonged, while the third is usually very short and sometimes altogether absent. During the interval between the paroxysms the child does not regain its usual buoyant spirits, but remains dull, fretful and feverish. After the fifth year the disease presents about the same features as it does in adults.] Diagnosis. This must be arrived at first of all by bearing in mind the possibility of the occurrence of ague, and next by inquiring into all the circumstances of the case. There are no means by which to distinguish the enlargement of the spleen due to ague from that due to other causes. But as regards the anæmia, the skin has a simple or sallow pallor with a bluish tint of the lips, which may help to suggest the nature of the case. Prognosis.-Ague is difficult to eradicate thoroughly at any time of life. With this qualification, it answers to the same remedies as in adults. But the enlargement of the spleen may be troublesome and slow to disappear. Treatment. Quinine and arsenic are the remedies to apply to. Quinine is usually taken readily by children-it may be given in sweetened milk or with syrup and liquorice. Arsenic should be commenced after the quinine is discon tinued. Five or seven drops of the liquor arsenicalis* may be given in syrup of orange and water, three times a day after meals. It is often good to combine it with iron. With the syrup of the lacto-phosphate of lime and iron it makes a good tonic. *Fowler's solution.-ED. 25 CHAPTER XIX. DISEASES OF THE RESPIRATORY SYSTEM. THE physiological differences in the respiratory organs between the child and the adult are numerous, and, as regards the examination of children, they are by no means unimportant. The breathing is diaphragmatic in children, and as it is difficult sometimes to detect the movement of the upper part of the thorax, it is very necessary to have the chest thoroughly bare for the purpose of examination. Infants under two years breathe quicker than adults, thirty or more to the minute, but above that age the respirations are at about the same rate as in older people, though quickening at very slight disturbing causes. Children, also, breathe irregularly; often paroxysmally; after what may be called a modified Cheyne-Stokes type. The Cheyne-Stokes rhythm consists of a series of short but gradually lengthening inspirations culminating in a deep-drawn breath, from which in a descending scale the respiratory movements flutter down to an elongated pause; and this type of respiration, though much modified, and its sharper characteristics destroyed, may often be seen in infants. Pauses in respiration are a feature of childhood, and they are particularly marked when the child is crying. To auscultate a chest at such a time requires the greatest patience, the pauses are of such long duration, but the information gained from the inspiration at these times is peculiarly valuable, each longdrawn breath after the temporary arrest is so full and deep. Infants and children not only breathe irregularly, but they breathe often with asymmetry. It is quite a common thing to find a child breathing fully, now with this side, now with that, and unless this is ever present to the examiner he will be not unlikely to make mistakes when it comes to be a question, as so often happens, of the nature of the disease; nay, even of the side upon which it is located. I take this to be due not to the muscular weakness, as some aver, but to the as yet imperfect education which is seen in all the muscles, whether of speech or of voluntary movement. Hence also the Cheyne-Stokes type of respiration, which is a paroxysmal one. Children work paroxysmally, whatever the movement in hand. The nervous discharge takes place, and then comes a pause-another discharge, and another pause—and so on; and it is only as the nerve centres reach a higher state of training that the discharges are so regulated as to become more continuous. I know a little child, and this is not uncommon, who learning to talk will carry on a conversation to the full extent of his knowledge of words, for a few minutes, and then he becomes quite fuddled for a while, and after a rest, on he goes again. The same child, if he is at all out of sorts, will stammer badly; he becomes in fact aphasic intellectually, and his wordmemory is for the time exhausted-or his ill-nourished brain loses its discharging force, and acts intermittingly. It is but little otherwise with the respiratory centres, they act irregularly, and soon become exhausted. A point or two connected with the physical examination of the chest may next be mentioned. Percussion is always to be gentle apart from the reason that there is the likelihood of frightening the child, heavy percussion may lead to quite an erroneous conclusion. It will often elicit resonance, whereas the note is really dulled. This more readily occurs in dealing with fluid in the chest, and is probably due either to the heavy percussion displacing the fluid-bringing the stroke down upon air containing lung beneath-or else to the greater readiness with which, in young subjects, the stroke is transmitted to other and sounder parts of the lung. The chest of a child is said to be more sonorous than that of an adult-all that this means is that a more resonant note is more easily elicited; and all that this can mean in turn is, that the percussion acts upon the lung more readily. Probably this is largely due to the more yielding nature of the ribs in young people, and to a thinner covering of soft parts over them. Again, it is not difficult to obtain a dull note which is not due to the condition of the lung underneath. A very little difference, for instance, in the level of the two shoulders will effect this, and the irregularity of respiration so noticeable in children will do the same. Therefore, in cases where the differences are slight, it is always as well to be cautious in our opinion, and probably to wait until a second examination has confirmed or negatived the original conclusion. Percussion should be carried out by one finger laid firmly on the chest, and one or two fingers tapping it vertically, slowly and lightly. With these precautions, a good resonant note ought to be elicited anywhere, although, as in adults, the apices and scapular region vary much in different children. I see no reason for confining the examination. to the back, or for postponing percussion until after auscultation. There is but little difficulty with children if they are left unrestrained and the percussion is gentle. It is usually well to commence with the examination of the back, so that, if the child is shy, the more important part of the examination may be conducted out of sight; but in a very large number of cases it is perfectly easy to even auscultate the front of the chest if the examiner sets to work with patience, and allows a child to play with the end of the stethoscope at intervals. Nor do I agree that auscultation is better conducted by the ear than by the stethoscope. The chest |