Paludisin in Children in New York. BY HENRY DWIGHT CHAPIN, M. A., M. D., Professor of Diseases of (ftffilren at the New York Post-Graduate Medical School and Hospital. REPRINTED FROM THE Neto York fHelitcal journal for June 16, 189 If. Reprinted from the New York Medical Journal for June 16, 189f PALUDISM IN CHILDREN IN NEW YORK* HENRY DWIGHT CHAPIN, M. A., M. D., PROFESSOR OF DISEASES OF CHILDREN AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. The rarity of true paludism in New York and the fact that children do not appear very susceptible to malarial poisoning renders this subject a somewhat difficult one for accurate study in this locality. The present notes are based upon an analysis of fourteen cases in which the diagnosis was based, not upon clinical manifestations, but upon the presence of the plasmodium in the blood. Dr. Koplik has recently presented an excellent and thorough study of this subject. The ages of my cases were as follows: Six months, eight months, eleven months, two years, three years (two cases), four years, five years, six years (two cases), ten years, twelve years (two cases), fourteen years. In order to bring out some of the clinical features, a few histories will be submitted : Thomas M., aged five years, 343 East Thirty-third Street, October 11, 1893. No history of any previous illness. Two * Read before the Medical Society of the County of New York, April 23, 1894. Copyright, 1894, by D. Appleton and 2 PALUDISM IN CHILDREN IN NEW YORK. weeks ago he fell out of a small wagon while playing on the street. This was followed in about two hours by vomiting, and that night he was seized with a fever preceded by chilliness. Since then he has had a fever every other day. He had a chill yesterday, and vomits after the chills. His bowels have been loose and watery for the past twenty-four hours, having had eight movements. He takes nourishment well, but the tongue is cov- ered with a thick white coating. No enlargement of spleen Temperature, 100'2° F.; pulse, 114. Diet regulated and bis- muth and pepsin administered to correct intestinal fermenta- tion. October 15th.-Gastro-intestinal symptoms improved. No more vomiting and one movement from the bowels daily. The fever ceased for two days, but returned yesterday. Has com- plained of a cold feeling to-day. On October 16th he had had chilly sensations and on October 17th at 4 p. m. there was a dis- tinct chill, followed by a slight fever. An examination of the blood now showed a few malarial plasmodia. On October 18th he was brought to Demilt Dispensary at 2 p. m. and the tem- perature was 99'6° F. Almost at once his mother called my attention to the fact that he appeared to be having one of the "cold" turns. Inspection showed the lips and hands to be quite cyanotic, but no rigors. Ten minutes after his first tem- perature was taken, the thermometer was again inserted under the tongue and found to register 102'4° F. A drop of blood was drawn from a finger during the chill and about half the globules in the field showed malarial organisms. Most of the organisms in the corpuscles showed many pigment spots, but some only one or two. There was a slight enlargement of the spleen. Bowels costive. Quinine, eight grains daily, was ordered. 20th.-Temperature, 98'5° F.; pulse, 100. Yesterday had a very slight chill and fever in the evening. Brighter and better to-day. Quinine continued. 25th.-Temperature normal and appetite good. 29th.-No fever and complete recovery, but anaemic. Qui- nine stopped. Iron was administered for a few weeks, during which there was no return of malarial symptoms. PALUDISM IN CHILDREN IN NEW YORK. 3 Agnes M., aged three years, Third Avenue and Forty-sixth Street, March 20, 1894. The mother had lost three children, two dying of pneumonia during infancy. The third, eleven months old, had an intermittent fever for four weeks, and was said by a doctor in attendance to have died of " malaria." On March 18th, after playing on the street, the child was seized with a high fever, which continued through the 19th, with sweating in the afternoon, upon which the fever abated somewhat. Tem- perature, IOTA0 F., axilla; respiration, 50; pulse, 140. No appreciable enlargement of the spleen. Slight cough. Lungs negative. A blood examination showed the pigmented bodies of the plasmodium with some segmentation. Acetanilide, one grain every three hours, was ordered. March 22d.-Temperature, 98° F. Fever left upon second dose of medicine. She played around yesterday with no fever. No plasmodium found. 28th.-Temperature, 98° F. Appears well. April 13th.-Has had no return of the fever, having been perfectly well. The following two histories show the disease as it oc- curred in young infants: Alice C., aged eight months, No. 311 East Fortieth Street, October 24, 1893. Baby is healthy and has always been on the breast. She spent last summer at Mount Vernon, and during the first week in August grew fretful and averse to nursing. After a few days of these indefinite symptoms, she had a chill lasting about fifteen minutes, followed by a fever and cold sweat. Medicine was administered for two weeks, which the doctor said contained quinine, and there was no more fever, but some failure in general health. The mother returned to New York on October 6th, and on October 8th the baby was noticed to get cold for about half an hour, followed by fever and sweat- ing. There was no rigor, as in the first attack. She then had mild daily attacks, but about October 20th the fever grew worse, preceded by a much milder cold stage. The fever ap- peared to get higher and last longer each day. The baby was very anaemic and iron was given, but no quinine. 4 PALUDISM IN CHILDREN IN NEW YORK. October 28th.-Baby no better. Daily fever. A blood ex- amination showed the plasmodium. Quinine, six grains daily, was ordered. November 2d.-Temperature, 98° F., rectum. No return of fever, but baby is weak and anasmic. Haemoglobin, fifty-five per cent., and no plasmodium. 14th.-No more fever and much better in every way. Qui- nine discontinued and iron given. February 27, 189 4.-The mother brings the baby for a slight cold and states there has been no return of any malarial symp- toms. Mary H., eleven months, No. 379 First Avenue, March 22, 1894. The mother has lost three children-one with pneu- monia, one with diphtheria, and one in convulsions. The baby is on the breast and healthy, with the exception of certain peri- odic attacks which began at the age of six months. In them the baby stops breathing, gets black in the face, with eyes open and staring, evidently unconscious, with hands and feet cold. Water is thrown in the baby's face and it comes out of the at- tack in from twenty to thirty seconds. The mother says a former child had similar attacks, beginning at the age of eleven months. The above account given by the mother points to laryngismus stridulus. The present illness began with vomit- ing on the evening of March 21st. followed by fever. There are no local symptoms. Temperature, 104° F.; respiration, 48 ; pulse, 150. An examination of the blood showed the pres- ence of the plasmodium, not abundant, and some eosinophile cells. Acetanilide, half a grain every three hours, was given. March 2^th.-Temperature, 100° F. No more vomiting. Fever broke March 23d. No enlargement of spleen. 27th.-Temperature, 98'8° F. Baby much better. No re- turn of fever. Nurses and sleeps well. Blood shows no plas- modium. Acetanilide continued. April 13th.-Has had no fever and been well except one or two of the periodic attacks described above. Four of the cases recovered without the administration of quinine, and a fifth continued well for a week, when it PALUDISM TN CHILDREN IN NEW YORK. 5 passed out of observation. When the malarial influence is not intense and continuous there appears to be a spontane- ous tendency to recovery, in some cases at least. The fol- lowing history illustrates this point: Paulina N-., aged six months, 489 Second Avenue, January 18, 1894. Five days ago the baby was seized with fever, pre- ceded by cold hands. The temperature lasted two days before abating. To-day she was seized with a fever for the second time. Temperature, 104° F. Plasmodium found. No enlarge- ment of spleen. Small doses of aconite given. January 19th, 20th, 21st, and 22d.-No fever. 25th.-Blood examined. Eighty-five per cent, haemoglobin and only one extra-corpuscular plasmodium found. February 5th.-Blood examined and negative. 15th.-Has continued well, with the exception of a slight cough, until two nights ago, when the hands and feet became cold, followed by a warm skin. She seemed sick the following day. Last night her hands and feet again became cold. To- day, temperature 101° F. at 3 p. m. Aconite given. 16th.-No temperature. 17th.-Does not appear very well, but no temperature. April 13th.-Has been perfectly well since she was last seen at the dispensary. No temperature, but a slight cough. The statement at the beginning of this paper that pa- ludism is not common in this city is borne out by the fact that these fourteen histories were obtained from a very large number of cases extending over a year and a half, princi- pally at Demilt Dispensary. Six of the cases had recently been brought from malarious districts in New Jersey and Long Island. Dr. Koplik states that in all of his cases de- cided by the blood examination to be malarial a history of sojourn outside the city limits in the adjacent country dis- tricts could easily be obtained. Almost any bodily disturbance in early life may simu- late malaria if one is looking for this condition. In in- 6 PALUDISM IN CHILDREN IN NEW YORK. fants and very young children the regular chill is usually replaced by cold hands and feet or a general pinched ap- pearance. The sweat is likewise not marked. The fever is, hence, the principal manifestation, and it is often diffi- cult to establish the sharply marked periodicity noted in the books. Several conditions, some grave and others trivial, are often mistaken for paludal infection. A form of tuber- culosis in children, with chills and irregular fever and without marked pulmonary symptoms, presents an appear- ance closely resembling malaria. William M., aged eight years, was brought to me with a history of fever and sweating, with an occasional cold stage- There was some cough, and auscultation showed mucous rales at the base of both lungs, but hardly fine enough to account for the symptoms. Temperature, 103'8° F. ; pulse, 138. A blood examination showed haemoglobin eighty per cent, and no plas- modium. An expectorant only was given. For the next few days he had a chill, followed by fever and sweating at about the same hour-6 p. m. Examinations showed no plasmodium. These symptoms continued about the same for ten days, the daily temperature, when taken, varying from 99 8° to 101'5° F. In spite of treatment the bronchitis seemed to grow worse, with more expectoration, and slight tubular expiration was now noted at the apex of the right lung. An examination of the sputum showed the tubercle bacillus. For over a month this case could have passed for an almost typical malarial attack in the absence of the discovery of the bacillus. Later on, the physical signs alone would easily have established the diagnosis. I believe a form of intestinal fermentation and catarrh is a condition most often mistaken for malaria in early life. This is accompanied by languor, coated tongue, ab- dominal or epigastric pain, headache, and a more or less irregular fever, doubtless caused by the absorption of ptomaines. Such symptoms may easily assume somewhat of a periodic type. PALUDISM IN CHILDREN IN NEW YORK. 7 Joseph C., aged seven years, was brought February 9th complaining of headache, pains in his limbs, with chills up and down his back and some fever. Sleep very restless at night. No appetite. Occasional vomiting. Bowels al- ternately costive and loose. February 11th : No improve- ment and complains of feeling very tired. Blood exam- ined and no plasmodium found. Small doses of calomel, followed by nux vomica and pepsin, with careful regulation of diet, produced marked improvement within a week's time. If such a case is allowed to run on unchecked, anae- mia and general prostration produce a similar picture to true malarial cachexia, but dosing with quinine only aggravates the condition by increasing the digestive disturbance. A young child with a certain amount of gastro-intestinal fer- mentation and insufficiently clad or exposed to cold is very apt to develop subacute rheumatism, with slight inflamma- tion of muscles and fascia and irregular fever, which again may simulate malaria. A certain form of amygdalitis, in which muco-pus forms deep in the follicles, but is seen only as pin points on the surface, may be overlooked upon a superficial examination, and the chills, fever, headache, and constitutional disturbance be referred to malarial influence. The mild typhoid fever that children sometimes contract, true walking cases, with no abdominal symptoms, are liable to be incorrectly treated for malaria. There is a condition often seen in badly cared for children in tenement houses to which the term civic malaria may be applied ; but the term is a bad one as implying a paludal infection. A combination of bad food and foul air may easily induce fever and general depression of vitality, but the plasmodium is not found, and quinine has no effect save from a tonic influence when ad- ministered in small doses. In making a diagnosis I do not believe that enlargement of the spleen can assume the same prominence in children as in adults. Enlargement 8 PALUDISM IN CHILDREN IN NEW YORK. may quickly take place from the less resistant quality of the capsule, but the size may as quickly subside. The soft texture of the gland renders the enlargement at times difficult to detect. I have not relied upon percussion, but upon deep palpation, placing the right hand below the twelfth rib on the back, with the fingers of the left hand upon the abdomen, and then bringing them in apposition. The diagnostic value of splenic enlargement in malaria is weakened, inasmuch as it occurs in many diverse ailments of childhood, such as rickets, tuberculosis, syphilis, diph- theria, typhoid fever, and other infections. Before making a diagnosis of paludism, especially in a non-malarial neigh- borhood, we must make a thorough search for all other pos- sible sources of the disturbance under investigation. We must remember the unstable condition of the vaso-motor centers in early life that renders fever, often irregular and intermittent, a constant symptom of very diverse local and general conditions. I have seen chills and fever from an otitis media in a child who complained more of his head than his ear, although an examination of the latter organ showed the tympanic membrane to be bulging, and a small incision, of course, relieved all symptoms. Quinine would have done much damage. If a careful and prolonged search does not settle the question, the diagnosis must finally rest upon an examination of the blood for the plas- modium. In order to learn the comparative frequency of true malaria in children and adults in places where it is seen oftener than in this locality, I wrote to Dr. William Osler, of the Johns Hopkins Hospital, Baltimore, who kindly sent the following reply: " Paludism is not very common here in children as compared with adults. Our statistics in the wards are as follows : Of the two hundred and forty-eight cases of malarial fever definitely deter- mined to be so by blood examination, there were seventeen PALUDISM IN CHILDREN IN NEW YORK. 9 cases in children. The youngest case was a suckling aged two months who had it very severely and nearly died. The majority of the cases were quotidians or tertians, a few of the aestivo-autumnal form. We have no experience of the spontaneous cure of paludism in children ; bn the other hand, several of our worst cases have been allowed to become chronic. Splenic enlargement was present in all of the cases. We have learned to place more and more reliance, year by year, upon the blood examinations as the only positive criterion in the diagnosis of the disease. Obscure malarial influences we do not recognize specially." In making blood examinations I have had the kind assist- ance of Dr. Doty and Dr. Menzies at the DemiLt Dis- pensary, and Dr. Brooks at the laboratory of the Post- graduate Hospital. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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