THE 
SYMPTOMS AND DIAGNOSIS 
OF 
MALARIA IN CHILDREN 
BY 
L. -EMMETT HOLT A M M.D., 
Attending: Physician to the North Western Dispensary in the Department 
of Diseases of Children. 
NEWYORK, 
Reprinted from The American Journal of Obstetrics and Diseases 
r” f-VU* 
of Women and Children, Vol./XVL, Nos. I. to TV.,' 1883^2*./- 
NEW YOi ilv ; 
WM. WOOD & CO., PUBLISHERS, 56 & 58 LAFAYETTE PLACE. 
1883. THE 
SYMPTOMS AMI) DIAGNOSIS 
OF 
MALARIA IN CHILDREN. 
BY 
L. EMMETT HOLT, A.M., M.D., 
Attending Physician to the North Western Dispensary in the Department 
of Diseases of Children. 
NEWYORK, 
Reprinted from The American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XVI., Nos. I. to IV., 1883. 
WM. WOOD & CO., PUBLISHERS, 56 & 58 LAFAYETTE PLACE. 
NEWYORK: 
1883. The Symptoms and Diagnosis of Malari/ in Children 
BY 
L. EMMETT HOLT, A.M., M.D., New York, 
Attending Physician to the North-Western Dispensary in the Department of Diseases of 
Children. 
The peculiar manifestations of malaria in children is a field 
of observation which has been much neglected. This is espe- 
cially true of this country, where the opportunities for its 
study are so much more extensive than have been enjoyed by 
either English, French, or German writers. Many of our 
foreign text-books on diseases of children do not even allude 
to malaria. Of our American authors, most have contented 
themselves with a brief description of a remittent and an in- 
termittent variety, divided into stages like the classical cases 
in adults. The organism of the child is peculiarly susceptible 
to all acute infectious diseases, and malaria forms no excep- 
tion to the rule. Thus, it has been often observed in epidem- 
ics that young children are the first who are affected. The 
poison acts not only more rapidly, but more generally and 
more profoundly in these cases than in adults. Again, the 
susceptibility of the nervous, digestive, and respiratory sys- 
tems produces such variations in the form and type of the dis- 
ease as to mislead, at times, even those most careful in diag- 
nosis. Often, symptoms referable to one of these organs may 
overshadow completely the real disease, and give an entirely 
new clinical picture. The attacks are so incomplete and so 
fragmentary, that even death may follow, in the masked forms, 
before the diagnosis can be made. Another reason for obscu- 
rity in the diagnosis is the fact that the symptoms often come 
on insidiously, and that even the family doctor is not called 
until it has made some progress. 
The closest observation on the part of both physician and 
attendants is often required, in order to establish the fact of 
periodicity in the symptoms, or the existence of a cold or 
sweating stage. Occurring at the time of dentition, its symp- 
toms are often referred to that source; in winter, to diseases 
of the lungs or bronchi; and, in summer, to gastro-intestinal 
disorders. My own experience abundantly confirms the state- 4 
Holt: The Symptoms and Diagnosis 
merit made by Schmiedler, that there is scarcely any disease 
so changeable, so obscure, and so indefinite as intermittent 
fever in children. 
Fortunately for both the physician and the patient, when 
once the diagnosis of malaria is established, prognosis and 
treatment usually present no difficulties. 
I shall, therefore, in this paper, confine myself to sympto- 
matology and diagnosis, as the etiology, pathology, and treat- 
ment of malaria in children do not differ materially from the 
same in adults; and this subject has been already pretty thor- 
oughly investigated. 
I have no theories to establish, but will simply give my ex- 
perience as drawn from a study of 184 cases, whose histories 
have been pretty carefully recorded. Nearly all of them have 
been observed at my clinic at the North-Western Dispensary, 
which draws its cases mainly from the district west of Ninth 
avenue, between Eighteenth and Fifty-fifth streets—a district 
which I believe to be acknowledged to be the most malarial 
in New York. As far up as Forty-second street it consists of 
made ground for a distance of from one to two blocks from the 
river. Above this point, the district covers what was once a 
large pond and several small streams which have been filled up. 
In regard to sex, there seems to»be very little predisposition 
shown. Of ray cases, ninety were males and ninety-four 
females. Six patients were under one year old. Of these, 
only one was under six months. Between one and four years 
there were forty-five cases; between four and seven years, 
fifty-four; between seven and nine years, thirty-seven; over 
nine years, forty-eight. The greatest predisposition, according 
to these cases, would seem to be between the ages of four 
and nine years. Bohn, from 465 cases, found it greatest between 
two and seven years, and most of all between two and three • 
years. The discrepancy is to be explained by the fact that his 
cases are taken largely from hospital and private practice, 
while those children who are brought to dispensaries are of an 
older class. He saw twenty-one cases under one year of age, 
seven of these being under six months.1 He calls attention to 
1 Any one interested in the subject of malaria in intrauterine life, will 
find a resume of the reported cases in Bohn’s article, in Gerhardt’s Hand- 
buch der Kinderkrankheiten. of Malaria in Children. 
5 
the fact that one-third of the cases under one year were of the 
irregular or masked type. 
The invasion of malaria is frequently much more gradual 
in children than in adults. In 117 cases in winch I have re- 
corded the manner of invasion, it was abrupt in forty-five and 
gradual in seveny-two. In the abrupt cases, the symptoms noted 
have been convulsions, vomiting, drowsiness and prostration, 
fever, severe pains in the head atid in the epigastrium, less fre- 
quently over the liver or spleen, splenic enlargement and often 
tenderness, occasionally also hepatic tenderness. 
The following case will serve as an illustration of the usual 
course. 
Case I.—Wm. M., aged sixteen mos., was brought to the Dis- 
pensary Nov. 10th. He was reported to have been as well as usual 
until the afternoon before, when he became very drowsy and 
heavy, and developed a high fever, which lasted all night. Dur- 
ing the night he was thirsty and restless, often crying out. The 
fever remitted this morning, but without perspiration. It re- 
turned again this afternoon with all the symptoms of the previous 
day. The bowels are constipated, and the child has no appetite. 
Eectal temperature is found to be 103£°. The spleen is enlarged, 
and seems to be tender on pressure. The tongue is heavily coated. 
The child was put upon cinchonidia in doses of gr. v. The fever 
continued, the mother reported, until about midnight, when it 
subsided as before without a sweat. On the following morning 
the temperature was 10CHo. The medicine was continued, and 
no further paroxysms of fever occurred. 
In cases with a gradual invasion, I have noted anemia; 
frontal headache; constipated bowels, or diarrhea, more fre- 
quently the former; complete anorexia; muscular weakness, 
tiring on slight exertion ; face pale or of icterode hue, with dark 
rings around the eyes; nausea, with occasional vomiting; a 
tongue heavily furred, usually of a dirty brownish color; epi- 
gastric pains, and often tenderness ; drowsiness by day, rest- 
lessness at night; slight cough ; hot and chilly by spells. In 
many cases, these symptoms recur rhythmically every day or 
every other day, but very often they occur without any 
periodicity. The spleen, in the great majority of cases, but 
not in all, will be found to be enlarged. 
The following case shows very well a not infrequent type of 
the disease, and illustrates how quickly relapses occur when the 6 
Holt : The Symptoms and Diagnosis 
medicine is not continued for some little time after the fever is 
controlled, and when the patient remains in the malarial dis- 
trict : 
Case ll.—Julia M., aged six years, was first seen August 31st. 
She was reported to have been well up to one week before, since 
which time she had been drowsy and heavy; had vomited occa- 
sionally, and several times had been noticed to have fever, 
especially in the afternoon, but not coming regularly. When 
this came on, she always complained of great pains at the epigas- 
trium. She had had two previous attacks of a similar nature, 
and in both she complained of severe pains in the stomach. Had 
had no chill; bowels reported regular. She had vomited occa- 
sionally, and complained of headache. She is now worse about 
noon. The temperature was 100°, and the tongue heavily coated. 
Cinchonidia ordered. She returned four days later, having taken 
only gr. x. of the medicine, and with no improvement. Bowels 
now constipated. Ordered cinchonidia in full doses, and a 
cathartic. She was not seen again for six weeks, as she got relief 
in a few days after taking the medicine. She was then brought 
back for a relapse of one week’s standing, with the former symp- 
toms, but more severe in type, the temperature being about 103°. 
The bowels were constipated. Cinchonidia again controlled the 
fever. She subsequently had two paroxysms with a seven-day in- 
terval. The medicine was, however, kept up, and no more fever 
occurred while she was under observation—a period of three weeks. 
The spleen was much enlarged, and epigastric pains and tender- 
ness were prominent symptoms throughout the whole course of 
the disease. Sweating and chills were noticed only with the 
later paroxysms. 
The next case shows how insidious, at times, the invasion 
may be, and how the cumulative effects of the poison were 
finally manifested in distinct and unmistakable paroxysms. 
The case was to me a very instructive one, so I will report it 
in full. 
Case lll.—Annie T., aged five years, came home from the 
country about September Ist in splendid condition. She was 
plump and hearty, with an excellent appetite, and a picture, in 
fact, of perfect health. In about a month, she began to lose 
appetite and flesh, and the school-teacher sent a note to the 
mother stating that the child must be sick, as she wanted to 
sleep so much during the day, and was noticed to sweat pro- 
fusely. The dxWsiness began soon after the school commenced 
in the morning. The mother whipped the child, and sent her 
back to school. She began to complain much of her head being 
hot, soon after this. At night, she was restless, and often per- 
spired. When these symptoms had lasted about two weeks, she of Malaria in Children, 
7 
was taken with a diarrhea, the passages soon changed to a 
dysenteric character, and were accompanied by much tenesmus 
and griping. These symptoms were severe by day, but absent 
entirely at night. Squibb’s diarrhea mixture was administered, 
and the child ordered to be kept in bed. This gave considerable 
relief, but did not wholly check the bowels. Vomiting was soon 
added, and for two days was persistent in spite of treatment. 
The passages again became more frequent, occurring every few 
minutes during the day, and very often at night. A slight 
febrile movement accompanied the diarrhea. Treatment directed 
to the bowels reduced the number of passages to four or five a 
day, but the child’s general condition was growing steadily worse. 
She now began to complain much of epigastric pains, and still 
had her spells of drowsiness. 
She gradually failed, until November 13th, when she was seized 
with a severe chill at about 3 p.m. It was so severe as to make 
her teeth chatter. High fever followed, lasting until the night, 
when she was found in a profuse sweat, so as to necessitate her 
clothes being changed. The question of diagnosis seemed now to 
be settled definitely. Dextro-quinine, cinchonidia, pills and sup- 
positories of quinine were all tried in succession. These she 
either refused to take, or immediately vomited or expelled, so 
that very little effect was obtained. I saw and examined the 
child for the first time on November 18th, having treated her 
until then according to the mother’s account of the symptoms. 
The spleen was neither enlarged nor tender. There was some 
epigastric tenderness; the tongue Avas heavily furred, and of a 
yellowish-brown color, and the child was pale and anemic. The 
temperature was normal. •That same afternoon, six days after 
the first, she had a second severe chill, folloAved by fever and 
sweat; the paroxysm being milder than the preceding one. Fow- 
ler’s solution was noAV begun, lU v. t. i. d. 
Dec. 3d. The child has taken the arsenic until two days ago, 
when she was so well the mother took the responsibility of 
stopping it. She has regained her appetite, the bowels are regular, 
she is lively, and complains of nothing whatever. She has had no 
repetition of the chill, and no fever has been noticed for a long 
time. She is ordered to continue the arsenic in tti iij. doses t. i. d. 
Another child in the same family, and still another in the same 
house had, meanwhile, come under observation with well-marked 
symptoms of malarial poisoning. 
In 106 cases In which the hour of the invasion, or the exacer- 
bation, was noted, it took place in the forenoon in thirty-five 
cases, and in the afternoon or evening, in seventy-one ; a pro- 
portion of one to two. It differs thus from the disease in adults, 
where the order is reversed. Bohn found, likewise, a great 
preponderance of cases in which the paroxysm came in the 
afternoon. 8 
Holt ; The Symptoms and Diagnosis 
The division of the diseases into stages, as in adults, I think 
might he advantageously dropped altogether. Those who 
look, in children, for the regular succession of chill, fever, and 
sweat to establish the diagnosis, will be led astray in the vast 
majority of cases. 
In 150 cases, I have noted the chill being present in nineteen 
and in only about one-half of these was it at all pronounced, 
these being in almost every instance over eight years of age. 
In fifteen other cases, chilly sensations, coldness of hands or 
feet, etc,, were observed, making thus only thirty-four in which 
anything resembling a cold stage was present, or a little more 
than one in five. I admit that statistics taken from private or 
hospital practice, where children are more closely observed, 
might show a somewhat larger proportion than I have in- 
dicated. 
Fever is one of the most important and undoubtedly the 
most constant of all the symptoms. Very few cases occur 
which, on close observation, do not show some rise in tempera- 
ture by the thermometer at some period during the twenty- 
four hours. We have all shades and variations, as in adults. 
As regards the course of the fever, and this of necessity must 
be studied while the patient is not under the influence of qui- 
nine, my cases seem to fall into one of three groups, viz.: 
First, those in which the temperature rises quite high at the out- 
set, and remains so with very little variation for twenty-four, 
forty-eight, or even seventy-two hours, when a marked remis- 
sion occurs, and the fever thereafter assumes a distinctly remit- 
tent type. 
Secondly, those in which the fever is at first slight, and only 
noticed at some particular part of the day, usually towards 
evening or at night, but gradually increases in its intensity and 
loses its periodic character until it may become a continuous 
fever, usually with slight daily remissions, not going above 
103° at any time. 
Thirdly, those in which the fever assumes a distinct type from 
the outset, remittent or intermittent, and recurs regularly until 
controlled by the quinine. 
The last is the rarest form. 
Out of one hundred and fifty cases, I have found the quo- 
tidian, in the proportion to the tertian, of five to one, and not a of Malaria in Children. 
9 
single instance of the quartan type. In nearly one-third of the 
cases, no distinct type could be said to exist. 
My own opinion is, that the general impression regarding the 
temperature is too high. I must admit that I myself was 
somewhat surprised to find, on analyzing my cases with refer- 
ence to this point, that in only twenty-six, or about one-seventh 
of the whole number, was the temperature before the use of 
quinine above KM°. In only three cases did I see it above 
106 Q. The highest recorded was 106f°. This occured in an 
infant of ten months, and fell the next day to 101|°. The 
usual range of temperature has been from 101° to 103^°. 
Sweating was noted in a little more than one-fourth the 
cases. It is thus more frequent than the cold stage. It comes 
later, and is very much less marked than in adults. It is stated 
to have been profuse in seven cases. 
Cerebral symptoms of some form or other can be said to be 
the rule. They are noted to have been present in ninety-seven 
out of one hundred and fifty cases ; they are noted absent 
in only four of my cases. Pain in the head is the most fre- 
quent. Of my ninety-seven cases, this was present in sixty- 
two. It has been almost invariably frontal in children old 
enough to describe their sensations. It has been seen quite as 
often in the chronic as in the acute cases. I have no doubt in 
my own mind that some of these were cases of supraorbital 
neuralgia; but in children under eight years of age, the differ- 
ential diagnosis is extremely difficult. 
The next most common head symptom is drowsiness or, as 
it is sometimes described, dullness, heaviness, or apathy. In 
certain cases it may amount to stupor even. In several cases 
children have been sent home from school because of this dis- 
position to sleep during the day. This is usually noticed to 
come at some particular part of the day, and to be accompanied 
by fever; or it may mark the time of the paroxysm when 
febrile movement is altogether absent. It is always a signifi- 
cant symptom. 
Convulsions have been recorded in four cases. In two 
cases the convulsion was not repeated, and occurred at the 
onset of the disease. One patient was a boy of eleven months, 
and another a boy of four years. Another case was in a girl 10 
Holt : The Symptoms and Diagnosis 
of twenty-one months, in which three convulsions took place 
on the same day, within a few hours of each other. 
The fourth case, which I propose to report, presents so 
many points of interest that I will detail it in full. It illus- 
trates what the natural course of the disease may be when 
uninfluenced by medicine. 
Case IY.—Daniel K., aged four months, was first seen October 
4th. The mother was a very intelligent woman, and gave the 
following history; 
The child had not been well for over a week, had a short cough, 
seemed to be losing flesh, and was not nursing as well as formerly. 
Four days before, about midnight, he was taken with a general 
convulsion, which was repeated twice that night. This was fol- 
lowed by fever, which lasted all the next day. The following 
night the convulsions were repeated early in the evening. On 
the third day they recurred in the afternoon. During the inter- 
val the child had been drowsy and sleepy, especially in the morn- 
ing; later in the day he was very cross and restless. There had 
been no vomiting, and the bowels were regular until a dose of 
castor oil was given, which was followed by five or six evacua- 
tions. There had been more or less fever all the time. The 
cough had continued. 
On examination he was found to be a well-nourished child, 
quite drowsy, and had a disposition to hold the head back. The 
extremities were quite cold, while the body was hot, the tempera- 
ture being 105°. The respirations were eighty per minute. Phy- 
sical examination revealed rude respiration over both lungs and a 
few fine riiles, but no bronchial breathing anywhere. The diag- 
nosis was obscure, but was thought to lie between pneumonia, 
meningitis, and malaria. The latter was recorded as the most 
probable, and treatment by cinchonidia begun. 
The next morning, the temperature had fallen to 102° and 
the respirations to sixty, notwithstanding the fact that he had 
vomited every dose of the medicine. He seemed much brighter 
than on the day before, and the general prostration was decidedly 
less. The cough was loose, and the pulmonary signs much less 
marked. Powers & Weightman’s “ cinchonia alkaloid” was 
ordered, gr. v. q. 3 h. 
The child was not brought back to the dispensary, and on 
November 15th I visited the house to learn the result of the 
case. The child was plump and hearty-looking, showing no 
evidence of present or previous disease. The mother said the 
fever had continued for about ten days after I saw the case, but 
it assumed after a little a tertian type, coming regularly every 
other day, so that the father had said “it must be the chills.” 
The medicine I ordered was kept up only about a couple of days, 
and after that the child took no medicine except a little lime- 
water for his vomiting. The fever gradually wore off, appetite of Malaria in Children. 
11 
returned, and the child rapidly regained his flesh. He had been, 
when I saw him, perfectly well for nearly four weeks. The 
family lived on the first floor of a house situated half a block 
from the North River. 
All of the cases in which convulsions occurred terminated 
favorably, and only one was especially severe. 
Yertigo, so characteristic a symptom in the adult, seldom 
occurs in children. I have only noted its presence in three 
cases. 
Pains in various parts of the body are usually complained 
of by children who are old enough to talk at all. The most 
characteristic of these is the pain at the epigastrium. My 
attention was first called to this symptom by Dr. Ripley, 
who told me he regarded it as quite diagnostic. Since that 
time, I have carefully noted its presence or absence in all my 
cases. In one hundred and twenty-eight patients, I have 
found it present in one hundred and one and absent in twenty- 
seven. In about one-third of these, it is stated to have been 
severe. 
lam well aware of the liability to error when looking 
for particular symptoms in any disease. I have sought to 
escape this by avoiding direct questions altogether. In the 
majority of instances, I am sure, the parents volunteered the 
information. If it was not mentioned in reply to the question, 
whether the child complained of anything else than the head- 
ache, as that was usually the first thing mentioned, I put it down 
as absent. I have often found that the mothers had come to 
consider it a pathognomonic symptom, where several cases had 
occurred in the family or repeated attacks in the same child. 
As a few illustrations take the following: One little boy of 
twenty months, who could hardly speak as many words, it was 
said, every afternoon about four o'clock would put his hand to 
his stomach, and say “ Oh! ” This occurred with the other 
symptoms, well marked, of the onset of a paroxysm. Another 
little fellow of two years complained constantly, the mother 
said, of being “ sore in his stomach.” In two or three cases, 
the pain was described as gnawing; very often it was so severe 
they cried from it, and not unfrequently it formed the most 
prominent symptom of the disease. The pain seems to have 
no relation to the taking of food, coming on indifferently at 
any hour when the paroxysm begins, or if slight before, now 12 
Holt : The Symptoms and Diagnosis 
becomes more severe. In twenty-nine cases, epigastric tender- 
ness was also present. In some patients it was so acute that 
they could not even bear the weight of the clothing. 
I believe the epigastric pain to be neuralgic, depending per- 
haps upon congestion of the stomach, which is found as one of 
the lesions in most of the fatal cases. The pain, in almost 
every instance, has been promptly relieved by antiperiodic 
treatment, so that its dependence upon the malarial poisoning 
was unquestionable. 
Pains in the splenic and hepatic regions are occasionally 
complained of, but much less frequently than at the epigastrium. 
Splenic tenderness is more frequent. I have noted it in 
about one-fifth of the cases, in many it was acute. But it 
is by no means so • characteristic as many writers would 
lead us to suppose. Hepatic tenderness was seen in a few 
instances. Neuralgic pains in the back, the extremities, the 
neck, and general soreness have all been noted occasionally. 
This general cutaneous hyperesthesia is often acute, and, when 
accompanied by fever, may lead to the diagnosis of some affec- 
tion of the central nervous system. In the subjoined case, the 
febrile symptoms were slight. It, however, illustrates well the 
point under consideration. 
Case Y.—Robert M., aged eleven years, was brought to the 
Dispensary May 19th, 1882. His mother stated he had been com- 
plaining for several weeks of headache, and of late had seemed to 
be growing stupid. She thought he was losing his memory. 
For two days he had been having very severe pains in the calves 
of both legs of a neuralgic character, and had also complained of 
the parts being sore to the touch. His limbs were so weak he 
could scarcely walk a block and a half. A slight fever had been 
noticed to come on toward evening, but there had been no chill, 
no sweating, and no vomiting. 
His axillary temperature was found 101°; he was pale and 
anemic; pulse regular; pupils normal. He walked unsteadily, not 
clearing the floor well with his feet, and seemed inclined to drag the 
left limb slightly. On testing the different muscular groups sepa- 
rately, no real paralysis could be discovered, but all the muscles 
seemed weaker than normal. Over the whole of both lower 
extremities there was great hyperesthesia, so that even moderate 
handling caused him to cry out with pain. This was much more 
acute in the thighs than in the legs. None was present in the 
upper extremities. Cinchonidia was ordered, and two days after 
he reported. There was then no hyperesthesia to be found, and he 
said the pains were much less severe. He could walk much better of Malaria in Children. 
13 
than before. Slight fever continued for a few days, and the 
pains steadily improved, the medicine being kept np. 
He was not seen, after a week from his first visit, until Hov. Bth, 
when he was found walking perfectly well, and said he had had no 
return of the symptoms since I last saw him. 
The condition of the spleen was recorded in seventy-nine 
cases; in sixty-four, it was found enlarged, and in thirty-eight 
of these very markedly so; in four, doubtful enlargement is 
stated ; and in eleven, no increase in size was found. 
A word with reference to the size of the spleen in children. 
Canteteau gives the following dimensions, taken mainly from 
Sappey. 
At birth, the spleen is inches long, T9¥ broad, thick; 
from four months to one year, 3 inches long 1J broad, \ thick; 
at live years, long, 2| broad, 1 inch thick; at eleven years, 
inches long, 3¥ broad, 1 inch thick. At birth, the weight 
of the spleen is to the weight of the body as 1:288 ; from four 
months to one year, as I : 103; at five years, as 1 : 88 ; in the 
adult, as 1 : 403. 
The spleen is thus relatively larger at five years than at 
any other period of life. The capsule being less resistant 
than in the adult, the organ undoubtedly enlarges more 
readily and quickly in children. It, however, subsides quickly, 
and hence may be absent at the time of the examination 
unless this be made at the height of the paroxysm, or after 
the disease has existed for some time. Hence too much 
stress should not be laid upon the absence of splenic enlarge- 
ment at a single examination. My own experience accords 
with the teaching of Dr. Janeway, that the spleen, unless en- 
larged, does not come in front of the middle axillary line. In 
children, the enlargement may be overlooked from the fact 
that it takes place in a considerable number of cases chiefly 
upwards and backwards. This occurs oftener, I think, than 
in adults. I have frequently found its upper border, as made 
out by percussion, as high as the seventh rib, and, in several 
cases, it has reached the height of the nipple, while it has been 
found below the free border of the ribs in a very much smaller 
proportion. This explains the fact why palpation does not 
give us more information in children. We are also deprived 
here of the advantage to be derived from a forced inspiration. 14 
Holt ; The Symptoms and Diagnosis 
Personally I have found palpation without value except in an 
extremely small proportion of cases. 
Most authorities assert that splenic enlargement is a more 
constant symptom of malaria in children than in adults. My 
own experience in adults has not been sufficiently large to en- 
able me to generalize upon this point. 
Enlargement of the liver is often present, but is less marked 
and less constant than the changes in the spleen, 
Disturbances of the digestive system are almost uniformly 
present and are usually pronounced. Yomiting was present in 
seventy-eight out of one hundred and twelve cases in which 
it was mentioned. It most frequently occurred at the onset 
of the paroxysm; in nineteen it was persistent. In almost 
all cases complete anorexia exists. 1 have recorded the appe- 
tite as being unaffected in only eleven cases. The condition 
of the tongue is to be reckoned among the diagnostic symp- 
toms. Almost all writers agree upon this point. The typical 
tongue is normal or slightly reddened at the edges and tip, 
while the centre is heavily furred, of a brownish-yellow color, 
which shades off into a dirty-white. A clean tongue I have 
noted in only nine cases. Dr. Fruitnight has called attention 
to the fact that the clearing up of the tongue is one of the 
best guides to the fact of cure. I can fully indorse this 
statement from my experience. 
In one hundred and forty cases in which the bowels were 
mentioned, they were reported regular in fifty-eight. In fifty- 
five cases there was constipation; in many it was obstinate. 
Looseness of the bowels or diarrhea was present in twenty- 
seven cases. My statistics on this point are somewhat at 
variance with those given by other writers. Season and locality 
may explain the discrepancy. The diarrheal cases wrere usually 
in the younger children, and constipation in the older ones. 
The countenance and the appearance of the skin are usually 
altered in malaria. The face is pale and anemic, occasion- 
ally of an icterode hue. Dark-bluish rings beneath the eyes 
and about the mouth are very common, and the features have 
a sunken aspect. This is usually marked only in the subacute 
or chronic cases. 
In regard to thoracic symptoms, we may say that there are 
none in the simple cases, beyond a little cough, from bronchial of Malaria in Children. 
15 
catarrh, which is exceedingly common. Occasionally the 
poison seems to be localized chiefly upon the lungs, giving rise 
to very obscure and very threatening symptoms, resembling 
much, both in symptoms and physical signs, the onset of acute 
pneumonia. This will be discussed more at length in speaking 
of complications and diagnosis. 
Symptoms referable to the genito-urinary system, so far as 
I am aware, have not been mentioned by authors. I have 
noted their presence in seventeen cases. Two cases of nephri- 
tis will be mentioned under the complications. The remain- 
ing fifteen were cases of functional disorders. It is a fact 
worth noting that eleven of these were in females, and that 
ten were in patients over six years of age. Five were over nine 
years. It will be evident that these symptoms in children 
under three }7ears of age would often pass unnoticed, hence 
their frequency is undoubtedly greater than the figures would 
seem to indicate. Retention of urine occurred in three cases, 
incontinence in six, and in six the micturition was reported fre- 
quent and often painful. Several cases were brought for 
treatment for this symptom. Examination of the urine was 
made in most of the cases, but gave no clue to the cause of the 
symptom. Prompt relief followed the use of antiperiodic 
remedies in almost every instance. 
Case Vl.—Honora 8., aged twelve years, was brought to the 
Dispensary Oct. 6th, with the history that for six weeks past she 
had been troubled exceedingly with her water, being obliged to 
pass it every ten or fifteen minutes during the day. At night she 
slept well, and was not disturbed from this cause. At no time 
had there been nocturnal incontinence. She had never been 
troubled in this way prior to the present attack. Examination of 
the genitals gave negative results. The bowels were regular and 
the appetite reported good, though she was pale and anemic and 
her face suggested strongly the malarial cachexia. She had had 
epigastric pains, but no headache. The spleen was found im- 
mensely enlarged, extending from the level of the nipple to near 
the crest of the ilium. There was also splenic tenderness quite 
well marked. A possible dependence of the urinary symptoms 
upon the malaria was considered, but a positive diagnosis reserved 
until the examination of the urine could be made. This was 
made the following day. Urine was of an amber color, spec. gr. 
1.012, neutral or faintly acid in i*eaction, a slight cloudy deposit 
of mucus, no albumen. Oinchonidia ordered. 
Pour days later she reported that she was feeling very much 
better, and that the trouble with the water had almost entirely 16 
Holt: The Symptoms and Diagnosis 
ceased. On October 13th, one week after coming under obser- 
vation, there was no trouble whatever with the urine, but epigas- 
tric pains and tenderness with marked splenic enlargement still 
existed. Ordered to continue the cinchonidia, 
Nov. 10. She reports that she is feeling quite well, and has 
bad no return of the urinary symptoms. Spleen still very much 
enlarged. Another child in the same family has been under 
treatment for malaria also, with well-marked symptoms, relieved 
entirely by cinchonidia. 
Case Vll.—Ella K., 7 years of age, was brought for treatment 
Oct. 23d by her mother, who stated that the child had been 
troubled with nocturnal incontinence of urine at intervals for a 
year. She had been much worse for a few months past, scarcely a 
night passing without incontinence. During the day, micturition 
was very frequent, often every few minutes. The child had been 
sent from school by the teacher, because of this annoyance. For 
the past few days she had complained of hypogastric pains while 
passing water. She had had much frontal headache and pains in 
the stomach. The tongue was coated, the appetite poor, and the 
general appearance one of anemia. Drowsiness in the afternoon, 
and occasionally slight fever had been noticed. The temperature 
was normal, but the spleen was decidedly enlarged. The urine was 
examined with the following result: Reaction faintly acid; spec, 
gr. 1.008; a dense yellowish-white turbidity, which, after stand- 
ing, subsided, forming a heavy deposit nearly one inch deep in 
a four-inch conical glass. The supernatant fluid gave albumen 
about five per cent by bulk. The microscope showed the deposit 
to be almost pure pus; there was some vaginal epithelium, but 
nothing else abnormal. The patient was put upon cinchonidia 
in moderate doses, and four days later, micturition by day was 
reported much less frequent. No incontinence at night since 
beginning the treatment. The urine was strongly acid, perfectly 
clear, no appreciable deposit after standing, no albumen, and 
only a few scattered pus-cells under the microscope. 
Two and a half weeks later, the mother reported that the medi- 
cine had been taken regularly until about a week ago, when the 
child was so much better she had discontinued it. The epigastric 
pains and the headache were relieved; the appetite had improved, 
and there had been no recurrence of the urinary symptoms. It 
was normal in frequency by day, and there had been no inconti- 
nence at night. Urine was examined both chemically and micro- 
scopically, with negative results. The spleen was still enlarged, 
and for a few days a disposition to sleep and slight fever had 
been noticed every day about three o’clock. Ordered to take the 
cinchonidia again. 
She was not seen until Dec. Bth, about seven weeks after the 
first visit. She had taken no medicine for nearly two weeks, and 
had had no incontinence until two days before, when it had 
returned accompanied by a fever, which came on every afternoon. 
This last case presents some difficulties in diagnosis which 1 of Malaria in Children. 
17 
myself have not been able satisfactorily to clear up. The 
amount of pus present is of course a sufficient explanation of 
the albumen which was found. The source of the pus may 
have been from a pyelitis, a cystitis, or some abscess rupturing 
into the genito-urinary tract. Its abundance and prompt dis 
appearance would seem to justify the last theory. Hypogas- 
tric pains would look more like cystitis. The fact that the 
urine remained acid throughout the disease, and the absence 
of mucus in any considerable amount, seem to support the 
supposition of a pyelitis. The examination of the external 
genitals threw no light on the case. The existence of ma- 
laria seems to me to be unquestionable. It seems quite as 
clear that the incontinence depended upon it. 
Under the complications of malaria, I shall include not only 
those which we see when the malarial symptoms are promi- 
nent, but also the cases sometimes termed the irregular or 
masked forms, which are due to the predominance of certain 
symptoms referable to the particular organ upon which the 
poison seems to be localized. 
We may divide the complications for the most part into 
three groups: the respiratory, the gastro-intestinal, and the 
nervous. These, of course, vary somewhat with season and 
with locality. The frequency with which the respiratory and 
gastro-intestinal tracts are implicated is partly explained by 
the fact, quite generally admitted, that the malarial poison 
may find access to the body by either of these avenues, and 
thus its effect may be considered as in a measure local. But 
far more important, it seems to me, is it for us to remember 
that these form the most vulnerable portions of the child’s organ- 
ism. Hence we should naturally expect them to be deranged. 
The peculiar susceptibility of the child’s nervous system, which 
we see daily demonstrated to us, is a sufficient explanation of 
the complications referable to those organs. 
Commencing with the respiratory tract, I would say that I 
have not met with any well-marked cases of laryngeal symp- 
toms of malarial origin. Bohn, in the Jahrbuch fur Kinder - 
heilkunde for 1873, reports the following case: 
Case VIII.—A child, eleven months of age, was brought to the 
Polyclinic May 7th, 1864, with very hoarse voice, short, hard 
hollow cough, in- and expiration labored, “ sawing,” and of 18 
Holt : The Symptoms and Diagnosis 
cronpy quality; skin hot; pulse 160; resp. 30; fauces reddened; 
tonsils swollen; glands at angle of jaw enlarged and painful; 
lungs and bronchi free from evidence of disease. A history was 
given of an ordinary cough for a few days, and since noon of the 
same day, high fever with laryngeal symptoms had come on, in- 
creasing until they had assumed their present severity. Ice ordered 
locally, emetics and senega internally. Toward evening, there 
was an improvement in the symptoms, and no return during 
the night. On the following morning when seen, the stridor was 
all gone, and all that remained of the symptoms was a slight 
catarrhal cough. Temperature normal, pulse about 100. The 
child remained in this condition until about 5 P.M., when a 
return of the severe symptoms of the previous day took place: 
high fever, great restlessness, dyspnea, hoarseness, stridulous 
breathing, etc. In spite of the use of emetics, these continued 
until about two o’clock the next morning, when they all passed off, 
and the child slept well until seven o’clock. On the morning 
of the third day, the same favorable condition was present as on 
the two preceding days. Treatment by quinine was now begun. 
Betwen seven and eight in the evening, a shorter and much 
milder paroxysm occurred, followed by a quiet night. The 
quinine was continued, with the effect of preventing any re- 
turn of the paroxysms. All that remained was the slight catarrh 
of the larynx and pharynx. The examination of the spleen was 
unfortunately omitted. “A new warning,” says Bohn, “to 
omit no organ in the examination of a child.” lie met with an- 
other similar case in the same month, of the tertian type, in an 
infant, also cured by quinine. 
Bronchitis is, perhaps, the most frequent of all the compli- 
cations. I have found it in about one-fifth of my summer cases, 
and in fully one-half of my fall and winter cases. Again and 
again, after treating bronchitis with the usual remedies for a 
considerable time without making any impression upon it, have 
I found, upon more careful examination, an old malaria as the 
underlying cause. It accompanies both the acute and the sub- 
acute cases. In the former, occurring with acute febrile symp- 
toms, it frequently leads to the diagnosis of broncho-pneu- 
monia. In the latter, it often, by its protracted course, brings 
about an anemia and a cachexia, in which condition the chil- 
dren fall a ready prey to the acute pulmonary diseases. 
The pulmonary congestions which we sometimes find in the 
most acute cases have been in my experience among the most 
misleading in diagnosis. They are analogous in their path- 
ology to the congestions of the spleen and the liver. Occur- 
ring in a severe form in the adult, they are described as one of of Malaria in Children. 
19 
the types of pernicious fever. I have not found them well 
described by any author who has written on malaria in children. 
I have seen seven well-marked cases without a fatal result. 
These, I believe, often pass under the diagnosis of malaria 
complicated by pneumonia. 
The symptoms in my case have been quite uniform, and 
very characteristic. The invasion has been always acute, the 
temperature high, from 104° to 106° • the respirations exceed- 
ingly rapid, in three or four instances reaching 100 per minute, 
and resembling more the superficial panting breathing of lobar, 
than the labored breathing of lobular pneumonia; the face is 
often cyanotic, and the pulse very rapid, from 160 to 200 per 
minute. There have been in one or two cases head symptoms, 
generally marked drowsiness. 
The physical signs which I have usually found have been a 
slight increase of vocal fremitus, dulness on percussion, some- 
times marked, but usually slight ; respiration always high- 
pitched, sometimes broncho-vesicular; resonance of the cry ex- 
aggerated, sonorous rales, and occasionally coarse and fine 
mucous rales, all of these likewise of a high pitch. The signs 
have been sometimes general on both lungs, but usually most 
marked behind and toward the apices. In two instances, they 
have been more marked in the axillary region of one side than 
elsewhere. I have seen them confined to a single lung, and 
once to a single lobe. 
Some may be inclined to take issue with me in regard to the 
diagnosis of these cases. To such I would say that in several 
of them my first diagnosis was unhesitatingly made of pneu- 
monia ; only the subsequent progress and termination of the 
cases convinced me of their true nature. When I have seen 
patients in the afternoon with the symptoms and signs such as 
I have above described, and found them on the following 
morning running about the house, with temperature, pulse, and 
respiration normal, and only the signs of an insignificant bron- 
chial catarrh found in the chest; when 1 have seen these recur on 
the following days until quinine was administered, or the disease 
cut short with a single paroxysm by full doses of this drug; and 
when I have found marked splenic enlargement co-existing, I 
have become convinced that the explanation 1 have offered 
best accords with the symptoms. 20 
Holt: The Symptoms and Diagnosis 
A few illustrations will make the subject a little clearer. 
Case IX.—Hugh M., aged three years, came under observa- 
tion May 15th, for slight eczema of ear, naso-pharyngeal catarrh, 
and bronchitis, which had existed since March, lie was pale and 
anemic, and had no appetite. There was no fever. Cod-liver 
oil and tonics were ordered. Two days later, he was brought back 
with the history that he had been as well as usual until the evening 
before, when he was taken quite abruptly very ill, the cause of 
which was thought to be an exposure to cold upon the roof of 
house, in the afternoon. He had a very high fever, which lasted 
all night, and, in fact, until he was seen in the afternoon. This 
was accompanied by a cough, great restlessness, and complete 
anorexia. On examination, there was noted a good deal of pros- 
tration, the temperature was found pulse 160, and respira- 
tions 70 per minute. Well-marked signs of engorgement at the 
apices of both lungs were present, and also in the right axillary 
region. Here were heard very high-pitched breathing, some 
sonorous, and a few mucous rales, but no bronchial breathing. 
There was slight dulness on percussion. 
The diagnosis of pneumonia was unhesitatingly made. Poultices 
were ordered to the chest, a mixture of amrnon. carb, to be given 
every two hours, and, in view of the height of the temperature, cin- 
chonidia gr. x. to be taken at night, and repeated in the morning. 
My friend, Dr. Cauldwell, visited the boy the next day. He 
found him lively, playing about the bed, with a temperature of 
99°, and respirations 35. The fever was reported to have kept up 
until about four o’clock in the morning, when it passed away, 
with a profuse sweat, and had not been noticed since. The signs 
in the chest had all disappeared, except a few scattered rales, 
probably the result of his previous bronchitis. The cinchonidia 
was continued, and no return of his febrile symptoms took place. 
Case X.—Mary S., aged fifteen months, was brought to the 
dispensary, August 18th, with the following history : She had 
been well until April last, when she had, the mother reports, 
“ pneumonia,” fromwhich she recovered in a week, without being 
very sick at any time. A slight cough has persisted since that at- 
tack. For four days before she was seen, she "had had fever, 
which had been quite high, and accompanied by a short cough, 
and very rapid breathing. The bowels were reported loose. Xo 
more satisfactory history can be obtained, as the child has not 
been very carefully observed. 
On examination, she was found a stout, well-nourished child. 
Countenance somewhat cyanotic. Respirations 100 per minute, 
pulse 120, temperature 104°. There seemed to be very little pros- 
tration. An attempt was made to examine the chest, but the child 
made so much disturbance, nothing satisfactory was obtained. A 
positive diagnosis was reserved until the temperature could be 
watched for a day or two, the absence of prostration being the 
chief point against the diagnosis of pneumonia. 
On the following morning, the temperature was found 104|°, of Malaria in Children. 
21 
respirations 100, as before, but very superficial, and much less 
labored than is usually seen Avith pneumonia. Occasionally 
they sink to 60 or 70, but soon rise again, the child remaining 
quiet all the Avhile. The cry is strong, but short and interrupted, 
On examination of the chest, nothing is found anteriorly 
but exaggerated breathing, and nothing posteriorly, except over 
the middle lobe of the right lung, where the breathing is very 
high-pitched, and at times broncho-vesicular; the resonance 
of the cry is exaggerated, and a few sonorous and fine mucous 
rales are heard. The rational symptoms are no more severe than 
yesterday. The child was not seen the next day, but the mother 
reported she was free from fever and played about during the 
whole day, and A\ras not drowsy, as she had been on the previous 
days. 
On the folloAving day, August 21st, the fever was reported 
to have come on again, about noon, and when seen in the after- 
noon, she had a temperature of 103°, and the respiration had be- 
come accelerated to 96 per minute. Cinchonidia was now begun 
in gr. iij. doses every three hours. The next morning, the tem- 
perature Avas 100°, and respirations 48. The breathing over the 
right middle lobe behind is still high-pitched, but no rales and 
no dulness. She is ordered to continue the cinchonidia gr. iij., 
t. i. d. The case Avas not seen for two Aveeks, when the mother 
reported there had been no return of the fever, but that some 
cough had been present up to the present time. All the former 
pulmonary signs had disappeared, and only a feAV coarse sonorous 
and mucous rales were heard scattered over the whole of both 
lungs. Tavo or three other members of the family had been sick, 
meanwhile, Avith fever, Avhich, from the meagre accounts given, 
seemed to be malarial. They lived on the ground floor of a tene- 
ment house, about one block from the North River. 
Schmiedler seems to have seen at least one case belonging to 
the abovm category, if we may judge from the meagre history 
winch is given in his article, in the Jahrbuch fur Kinderheil- 
kunde for 1879. 
It is as follows : 
Case XI.—A girl, aged seven years, daily about six o’clock 
Avas taken with high fever, great restlessness, severe dyspnea, 
Avith asthmatic attacks, great precordial oppression, no known 
cause. All these symptoms subsided Avith sweating. The spleen 
was found enlarged, the temperature reached 1044°. Daily com- 
plete apyrexia. Treatment by quinine begun on the third day, 
abortive attack the same evening. Quinine was continued Avith 
the effect of accomplishing a complete cure by the fifth day. 
That pneumonia, both lobar and lobular, do occasionally 
complicate malarial fever, there can be no doubt. I have seen 
examples of both varieties in which the physical signs were 22 
Holt : The Symptoms and Diagnosis 
typical. The following case affords an excellent illustration of 
the way in which the symptoms of the two diseases may be 
blended. The fever was at first distinctly remittent, then 
became continuous as the pneumonia developed. It declined 
abruptly when resolution began on the tenth day, but rose 
again without any change in the physical signs, being finally 
and permanently controlled as soon as full doses of quinine 
were retained. 
Case Xll.—Mary 0., aged twenty months, was brought to the 
dispensary for treatment November Bth, with the history that she 
had not seemed well for five days ; no fever was noticed until 
three days before. It came on every day about 10 a. si., and lasts 
all day and most of the night. There had been slight delirium at 
night occasionally. During the day much drowsiness accompa- 
nied the fever. The child had vomited once; the bowels were 
regular; the tongue was heavily coated. Rectal temperature was 
1041°, respirations 40. The lungs and the throat were examined, 
with negative results. There was not much general prostration. 
The spleen seemed tender, but the child was so irritable its size 
could not be made out with certainty. A brother was under 
treatment for malarial fever, and that diagnosis was made in this 
case. Cinchonidia, gr. xx. a day ordered. 
Two days later, it was reported the fever had been continuously 
high since the last visit. She vomited three or four times this 
morning ; bowels loose ; was too ill to sit up at all yesterday, and 
took nothing to eat. She lay drowsily upon the mother’s lap and 
made no resistance to the examination. Temperature, 101 ip; 
there was considerable cough, but nothing important was found 
in the lungs. The spleen was found by percussion to be much 
enlarged, and its lower border could be distinctly felt an inch 
and a half below the free border of the ribs. The same treatment 
was continued. When she was next seen, three days later, the 
temperature was 103P and the respirations 50°. There had been 
little or no remission in the fever, but every night about ten 
o’clock the hands and feet were noticed to be very cold. She is 
drowsy and stupid all the time. Has vomited about one-half of 
the medicine. There was found at the inferior angle of the right 
scapula a small area of marked dulness, bronchial breathing, and 
bronchophony. Elsewhere the lungs wore free from abnormal 
signs, except a few scattered rales. The diagnosis of pneumonia 
was now made unhesitatingly. Stimulants ordered in addition to 
the cinchonidia. On November 15th, two days later, the tempera- 
ture was 101p and respiration 78. Fever had continued until 
this morning, when a decided remission occurred. Dulness, 
bronchial breathing and voice are still present over the same 
area, but there are heard also moist, mucous, and subcrepitant 
rales. The pneumonia is evidently resolving. The next day the 
signs of resolution were more marked, but the temperature had of Malaria in Children. 
23 
risen to 102f°, the reason for which became apparent when it was 
learned she had had no cinchinidia for nearly three days. It had 
caused so much vomiting the mother had discontinued 
Dextro-quinine was ordered, gr. v., q. 4 h., and on the next day, 
the 17th, the temneratnre was 98£, respirations 32, and the spleen 
normal in size. This medicine was continued ;no further rise in 
temperature took place ; the lung cleared up completely in a few 
days, and a rapid convalescence took place. 
She was examined about two weeks later, and no relapse had 
occurred. 
I have seen another case in which malarial symptoms were 
so interwoven with those of lobular pneumonia as to obscure 
the diagnosis for a long time. 
The explanation of these cases, it seems to me, is that the 
repeated congestions which occur in the lung finally lead to 
the development of the inflammatory process, rather than that, 
debility induced by the pneumonia leads to a manifestation of 
malarial poisoning which had been latent. I have, however, 
seen one case which seemed to have developed in this way. 
Pleurisy with effusion I have seen in only one case; its 
occurrence with malaria seems to have been a coincidence 
merely.. 
True spasmodic asthma of malarial origin I have seen in 
six cases. I am indebted to Dr. Ripley for first calling my 
attention to this complication. Bohn merely alludes to it. I 
have been unable to find any description of it in any of the 
works on malaria in adults which I have consulted. In one of 
my cases it followed an acute pulmonary congestion and was 
accompanied by slight bronchitis. In four cases the febrile 
symptoms were very slight and in some absent entirely. The 
occurrence of repeated attacks with marked splenic enlarge- 
ment and the prompt relief on the exhibition of antiperiodics 
were the. characteristics of the cases. In most of them the 
paroxysms were accustomed to come on early in the evening of 
each day. It was for relief from these attacks that the patients 
usually applied for treatment. Their dependence upon malarial 
poisoning was not made out in some cases until several attacks 
had been observed, which were very slightly or not at all 
affected by the usual remedies. 
Case XIII.—James 0., aged six years, came under observation 
at the Dispensary October 15th, 1882, pale and anemic, with a 24 
Holt: The Symptoms and Diagnosis 
coated tongue and a loose cough ; slight fever reported at night, 
bowels regular. Only a hurried examination was made and a 
cough mixture and a tonic ordered. He was not seen again 
for two weeks when he came back with his cough aggravated, a 
history of marked febrile movement for a week, higher every 
night, and frequent sweats occurring irregularly. For the past 
two weeks he had had severe dyspnea which came on in parox- 
ysms every night, so severely he could scarcely lie down. Breath- 
ing was accompanied by a loud wheezing which could be heard 
all over the room. During the day he suffered little from dys- 
pnea, but complained much of pains in his stomach which he 
had never done before, and of severe frontal headache, gradually 
growing worse for the past week. Never any symptoms of asthma 
present before this attack. A maternal grandfather was reported 
to have had asthma, but no other cases in the family. 
The spleen was found enlarged. Over the whole chest, but 
especially behind, were heard an abundance of sibilant, sonorous 
and musical rales, and some of a mucous and subcrepitant variety. 
The breathing was somewhat labored and expiration was pro- 
longed. Temperature about 100°. On the following morning 
rales of the same character were heard, though much less abund- 
ant, and the temperature was normal. Diagnosis of asthma of 
malarial origin was now unhesitatingly made and cinchonidia 
gr. v., 4 t. d. ordered. 
A note made four days later, states that he had had little or no 
return of the fever. The dyspnea and wheezing at night had been 
much less marked though they had existed. A few mucous and 
sonorous rales were heard at the lower half of the chest behind, 
pain in the stomach was still present. Temperature was normal; 
ordered to continue the medicine. 
On November 6th, three days later, it was reported he had had no 
more pains, fever only once and then slight, still some cough and 
a little wheezing at times. Continue the medicine. 
November 9th, on examination of the spleen, a few days ago, 
no enlargement could be found. He has had no more fever and 
no more pains, the tongue is clean, the appetite good, and no 
abnormal signs found in the lungs. To continue the medicine 
in gr. iij. doses t. i. d. for a week, and then stop it altogether. 
Case XlY.—Peter K,, aged six years, was brought for treat- 
ment July 24th. The notes taken at that time state that he had 
been complaining for a month of attacks of dyspnea and had 
been worse for two weeks ; dyspnea being especially marked 
when he was lying down. He had had similar attacks previously. 
The lungs were not examined for lack of time, as I had thirty-two 
other new cases that afternoon. The case was regarded as one of 
chronic bronchitis, a simple cough medicine and a tonic ordered. 
The next morning the lungs were examined with some degree of 
care. Over the whole chest, in front and behind, were heard an 
abundance of sonorous and sibilant rales, some being musical in 
quality; no moist rales; there was considerable dyspnea mani- 
fest. The temperature was normal. No [history of asthma in of Malaria in Children. 
25 
either parent could be traced, but a maternal uncle was said to 
have suffered from this disease. The diagnosis of asthma was 
made and a belladonna mixture ordered. About a week later, he 
was reported a little improved. 
He was not seen again until August 30th, when the mother 
brought him back, saying that the previous attack had gradually 
worn off, the medicine not being continued. He had then been 
quite well until about five days ago when his symptoms returned. 
The mother volunteered the information that with each one of 
these attacks he had complained of severe pains at the epigas- 
trium, which seemed to her a singular coincidence. Our suspicions 
were aroused and on examining the spleen it is found immensely 
enlarged, extending downward to the crest of the ilium. The 
following history was obtained : 
The first attack occurred about three and a half years ago. She 
lived then in the same neigborhood as now. Since that time he 
has had frequent attacks, always more often in spring and fall, 
lasting usually from four to six days. Never has there been 
marked fever, but often slight; bowels usually regular; vomiting of- 
ten occurs in the attacks. No exciting cause known. All the attacks 
have been very similar to this one. Severe dyspnea always worse 
at night, at times amounting to orthopnea, when he assumes the 
characteristic asthmatic position. Attacks do not come suddenly, 
but are from twelve to twenty-four hours in developing. 
Physical examination of the chest reveals all the signs of spas- 
modic asthma. The breathing is loud and wheezingand can beheard 
some distance from the patient. The heart is slightly enlarged, but 
no valvular disease can be made out. He is very pale and anemic. 
The tongue has a dirty brownish coating. Temperature 
respiration 32, pulse 120. The bowels are loose. There is some 
tenderness over the epigastrium. Cinchonidia sulph. gr. v., 4 t. d. 
The next day the mother reported that the severe dyspnea 
which had been accustomed to come on about eight o’clock, often 
so as to prevent sleep altogether, was not seen yesterday and that 
during the night no wheezing whatever rvas present. His tem- 
perature was then 100°, the breathing was natural, and the pul- 
monary signs normal. He said ho was feeling much better. On 
the following day he was seen. His temperature was normal and 
he had had no return of his dyspnea. He did not appear again 
for a month. I visited the house and learned from his mother 
that the medicine had been discontinued a few days after I saw 
him and that he had had a relapse a few days before my visit. He 
did not come again under treatment. 
The gastro-intestinal disorders which accompany malaria 
have been, for the most part, considered under the symptoma- 
tology. It only remains for me to mention here a class of cases 
in which we have the following symptoms: Yorniting and 
diarrhea, or diarrhea alone, recurring periodically every day or 26 
Holt : The Symptoms and Diagnosis 
every other day, usually accompanying a febrile attack, the 
symptoms during the apyrexia being slight or absent en- 
tirely. The passages are often of a dysenteric character, 
being streaked with blood and accompanied by tenesmus. In 
some cases the febrile movement is absent entirely. The spleen 
is usually enlarged. The symptoms are but slightly affected by 
ordinary remedies, but yield readily to anti-periodic treatment- 
Case 111. reported above illustrates this point. I have seen 
several which resembled it. I. have not, however, met with 
any such typical cases as the following which are reported 
by Schmiedler. They occurred in Breslau, one of the most 
malarial cities in Germany. 
Oases XV., XVI. and XVII.—Two little girls, aged respectively 
eleven months and two and a half years, on returning to the city 
from the mountains, were immediately attacked with a severe 
diarrhea without any evident cause, and which would not yield to 
any of the ordinary astringent remedies. The youngest became 
very weak and emaciated. He found on close questioning that 
the diarrhea came on every night at about three o’clock, with con- 
siderable prostration and great restlessness, but without fever be- 
ing especially noticeable. Toward noon improvement always took 
place, the appetite returned and for the rest of the day they felt 
quite Avell, resting quietly until the hour named, when they 
awoke with crying, and diarrhea followed. Considerable enlarge- 
ment of the spleen was found in both cases. Full doses of quinine 
were ordered ; the attacks were immediately controlled ; the 
splenic enlargement disappeared and no relapse occurred in 
either instance. 
In the third case, in a girl of six years, every evening punctually 
at seven o’clock, severe diarrhea took place, the passages being 
streaked with blood and as many as a half-dozen occurring in the 
course of three hours. The spleen was enlarged, the temperature 
ranged from 103 to 104°, with the general symptoms of very 
great prostration. By day there was complete apyrexia. The 
ordinary treatment was without effect. Quinine in full doses was 
then given and controlled the attacks. One relapse occurred after 
a few days with the former symptoms. This also was controlled 
by quinine, and no further trouble followed. 
The derangements of the nervous system in children depend- 
ing upon malaria are numerous. Neuralgias, though by no 
means so frequent as in adults, yet do occur. I have notes of 
several cases of the supra-orbital type. The epigastric pains are, 
I think, often to be regarded as purely neuralgic. Schmiedler 
records a case of sciatica in a child of two years and a half re- 
curring in paroxyms of a tertian type until quinine was admin- of Malaria in Children. 
27 
istered. I have notes ol ten cases in which neuralgic pains in 
the extremities were prominent; in two cases it was for these 
that the patients were brought for treatment.1 In two instances 
the pains were associated with very marked hypersesthesia of 
both lower extremities, especially acute in the thighs; here 
handling the parts gave so much pain that they cried out. 
All these cases were in patients presenting other well-marked 
symptoms of malarial poisoning and were promptly relieved 
by quinine. 
Motor disturbances are less frequent than the sensory. 
I have met with three cases in which paresis of the lower 
extremities was present. In two cases it was associated 
with severe pains, and improved rapidly under anti-periodios 
until a perfect cure took place. The third case was not 
traced; when last seen there was some improvement, but 
some lameness existed. Various spasmodic disorders have 
been observed as complications. Cases of torticollis of mala- 
rial origin in children have been recorded by Thornberry, 
Schrniedler, and Bohn. My friend, Dr. Cauldwell, who had 
charge of my clinic in my absence last summer, met with a 
case in a girl, seven years old. It came on with acute febrile 
symptoms and had existed two days before the patient was 
seen. It was promptly relieved by the use of antiperiodics. 
The only case 1 have myself seen, has come under my observa- 
tion since I began the preparation of this paper. It occurred 
in a boy of eight years. Every afternoon about one o’clock 
he had fever and his neck became perfectly rigid and rotated 
to the left side. Both symptoms lasted until he went to bed. 
On awaking in the morning he was well and the neck was per- 
fectly mobile until the time of the paroxysm. He had an en- 
larged spleen and other symptoms of malaria. The paroxysms 
were immediately controlled by quinine, and up to the present 
time they have not returned. 
I have seen chorea as a complication of malaria in two cases 
iu which some etiological connection could be traced. May it 
not be that this occurs oftener than we imagine, and that the 
very prompt improvement which takes place under the use of 
arsenic is in part explained by this fact ? 
1 See case Y. 28 
Holt : The Symptoms and Diagnosis 
Epilepsy and malaria have been associated in one case ; this 
was probably a coincidence. 
Of nervous origin certainly are to be considered the dis- 
orders of micturition which have been mentioned as existing in 
fifteen cases. The cases of malarial asthma might also be 
classed under this head. 
Among the other complications occasionally met with was 
vaginitis, which was seen in three patients. It seemed to result 
only indirectly from the general debility produced by the ma- 
larial poisoning. In one of these, frequent small hemorrhages 
occurred from the vagina. Hemorrhages from the gums I 
have seen in two cases and epistaxis in one. Hone were 
severe. 
Nephritis was seen twice; in one case it was mild and dis- 
appeared in a short time under treatment. The urine in this 
case was scanty, about four ounces in twenty-four hours, sp. 
gr. 1016, and contained a small quantity of albumen, hyaline 
and blood casts, and also blood and pus corpuscles under the 
microscope. The second case also occurred in a boy of four, 
who came under observation on the fourth day of his illness 
with a temperature of 105f°. About five days later, just as 
his malaria was being controlled, almost complete suppression 
of urine took place, only three ounces being passed in forty- 
eight hours; persistent vomiting had been present for two days 
previous. There was no dropsy at any time. The examination 
of the urine showed : sp. gr. 1014, color reddish-brown, albumen 
about ten per cent bulk, and under the microscope large num- 
bers of hyaline, granular and epithelial casts, granular matter 
and blood in large amount. He subsequently passed out of 
my hands, was circumcised by another doctor for retention, 
under whose treatment he died comatose, the mother told me, 
on the sixteenth day of his illness. 
I have seen urticaria in two cases. Jaundice I have never 
met with, nor did Bohn among four hundred and thirty-five 
cases. Herpes about the mouth is not uncommon. Tonsillitis 
I have seen associated with malaria in a few cases. 
T\\o, prognosis of malaria in children is good in the vast ma- 
jority of cases. The acute attacks are usually readily controlled, 
provided only the patients can be made to take and retain the 
quinine or some of its substitutes, which is often a matter of a of Malaria in Children. 
29 
great deal of difficulty. When the disease is seen in its chronic 
form the system has usually become so saturated with the 
poison that, although we may relieve the symptoms for the 
time, relapses take place unless the medicine is continued for a 
long time, or the patient is removed from the malarial district. 
Neither of these latter conditions can be often fulfilled in dis- 
pensary patients and hence relapses occur in an immense num- 
ber of the cases. The general impression among authors seems 
to be that these are more frequent in children than in adults. 
Griesinger found relapses in sixty-four per cent of the cases 
from one to ten years of age; and in thirty-eight per cent of 
those from twenty to thirty years. 
The case which proved fatal by a complicating nephritis has 
just been referred to. The following is the only other fatal 
case I have seen, and is reported in order to impress the fact 
that even in this climate an uncomplicated intermittent fever 
may produce death. 
Case XYlll.—Lena M., ten years, came to the Dispensary 
Sept. 4th, 1882. She had lived on Staten Island until ten days 
before, when she came to the city. Was well until five days ago 
when she was taken in the afternoon with a severe chill followed 
by high fever. The fever had continued since, with morning re- 
missions and evening exacerbations everyday. The chill had not 
been repeated until this afternoon, when it came on tolerably 
well-marked. She complained, during the exacerbation of the 
fever, of pains in the back and extremities. Vomited occasion- 
ally. On examination she was found very weak, hardly able to 
walk. All the muscles in a state of tremor. Spleen greatly enlarged; 
axillary temperature 10(1°. Ordered cinchonidia gr. xl. a day, 
patient to bo put in bed and kept there. 
The following facts were learned from the aunt who came two 
days later for a death-certificate. She took her medicine regu- 
larly and kept it down, rested poorly on the night after her visit 
to the Dispensary, but the next morning felt so well she was 
allowed to get up and seemed to be free from fever. Vomited 
once. Lay about on the lounge the greater part of the day, 
feeling weak and very tired. Bowels moved and water passed 
normally. She took a little food, without much relish, however. 
About 7.80 in the evening had a very severe chill so that she shook, 
lasting about half an hour, followed by very high fever. Great 
pains in back and legs ; no vomiting ; mind clear. Took medi- 
cine at ten o’clock and kept it down; no marked dyspnea noticed; 
about an hour and a half later “ great cramps in the stomach,” 
so she groaned and rolled off the lounge where she was lying, 
and died easily in a few moments. Up to this time she had been 
lying quietly. 30 
Holt : The Symptoms and Diagnosis 
Autopsy made eighteen hours after death. 
Head not examined. 
Extensive adhesions over a great part of the left pleural sur 
face. Ho adhesions on the right side. Both lungs showed very 
marked edema and congestion, the left a little more than the 
right, but were in other respects normal. 
About half an ounce of clear serum in pericardial sac. The 
heart was flabby, empty and showed no valvular disease. Liver 
seemed enlarged and was markedly hyperemic. Spleen very 
much enlarged, measuring inches. It was of a dark color, 
friable and intensely congested. 
Kidneys seemed normal to naked-eye examination. 
With reference to the diagnosis of malaria, in children, it is 
evident from the foregoing that there is no single symptom 
which can he regarded as pathognomonic. The history of the 
symptoms is often far more important than the symptoms 
themselves. Yet we must not lay too much stress on period- 
icity. I have seen many well-marked cases in which it was 
wanting. The enlargement of the spleen is without doubt 
more important than any other single symptom; but this I 
have found absent in nearly one-seventh of the cases. Next in 
value to this symptom I would place the existence of fever, 
which careful thermometrical observation will show to be 
present in most of the cases at some time during the day, 
usually toward evening. The peculiar drowsiness with frontal 
headache, the severe epigastric pains, the brownish-yellow coat- 
ing of the tongue, the complete anorexia, the constipation of 
older children, the looseness of the bowels of the younger ones, 
the anemia and the peculiar sunken expression of the face 
with the dark rings about the eyes, are about all the other 
symptoms I have found valuable as a means of diagnosis. 
The recognition of the irregular or masked forms is often 
o o 
more difficult, because the fact of the frequent dependence ot 
these disorders upon malaria is not appreciated, even in a 
district so malarial as New York. 
Thus the bronchitis, the asthma, the neuralgias, the torti- 
collis, the urinary and gastro-intestinal disorders, may present 
nothing in themselves which at first would exite a suspicion of 
malaria. The fact of their dependence upon this is to be 
established mainly by four points : 
Ist. Periodicity in the symptoms. 
2d. The co-existence of splenic enlargement. of Malaria in Children. 
31 
3d. The failure of the usual remedies to relieve the symp- 
toms. 
4th. Their prompt disappearance under the use of anti- 
periodics. 
The differential diagnosis of malaria in children is to be 
made from intestinal worms, dentition, gastritis, gastro-enteritis, 
bronchitis, pneumonia, the exanthemata, typhoid fever, and 
meningitis. 
The coated tongue, the deranged bowels, the abdominal 
pains and the slight fever, are not infrequently referred to 
worms. The administration of anthelmintics is sometimes the 
only means of establishing the diagnosis. 
An examination of the gums will usually settle the fact of 
dentition. The gastritis which is so often accompanied in 
young children by a considerable febrile disturbance, and with 
fi-equent vomiting and abdominal tenderness, I have found ex- 
tremely difficult to differentiate from malaria. Often noth- 
ing but the effect of treatment will decide the question. The 
spleen should always be examined in doubtful cases, and the 
symptoms closely watched for any periodicity. The same may 
be said of many cases of gastro-enteritis. 
In differentiating between the pulmonary congestion which 
accompanies malarial fever and the invasion of pneumonia, 
there must always be a degree of difficulty. The condition of 
the lung in the two cases is very nearly, if not quite the same. 
The temperature in both is high, the pulse and respiration 
rapid. Either may begin with a chill or convulsion. The pain 
and tenderness in the region of the spleen or the liver may be 
thought to be pleuritic. The enlarged spleen and liver, and 
the consequent compression which these make upon the lung, 
give rise to dulncss, which may be mistaken for consolidation 
of the lower lobe of either side. The auscultatory signs may 
be identical in both diseases. 
To distinguish between them I have found two points of 
especial value. The amount of general prostration which 
exists in pneumonia is much greater than that which I have found 
in the malarial cases. This want of correspondence between 
the temperature, respiration and physical signs in the chest on 
the one hand, and the general symptoms on the other, forms a 
striking picture and should always arouse the suspicion of ma- 32 
Holt : The Symptoms and Diagnosis 
laria. In two or three cases I have been able to make a cor- 
rect diagnosis at the first examination by this fact. The second 
point is the existence of splenic enlargement. This will almost 
invariably be found, as these cases are acute, and it is only dur- 
ing the paroxysm that real obscurity exists. The difficulty of 
deciding positively regarding the condition of the spleen is 
much increased in children too young to take a forced in- 
spiration, As the disease advances, the course of the tempera- 
ture, and the variable character of the physical signs in 
malaria, place the diagnosis beyond all questions. 
The onset of measles is not often mistaken for malarial fever. 
An error is much more likely in the case of small-pox or scar- 
latina. In some cases we are obliged to wait for the eruption 
before making a positive diagnosis; but usually the course of 
the temperature, the fact that any one of these diseases is pre- 
valent, and the condition of the spleen are sufficient data. 
The headache, the attacks of drowsiness, the slight fever, 
the irritable stomach, the constipation, and the cachexia may 
lead to the opinion that tubercular meningitis is developing; 
while in the acute cases the initial convulsion, the high fever 
and the hyperesthesia, when taken with drowsiness, headache 
and stupor, may cause cerebro-spinal meningitis to be suspected. 
The symptoms above given must here be relied upon for the 
diagnosis; the especial points being periodicity in the head 
symptoms and the condition of the spleen. The experimenium 
crucis is the administration of a few full doses of quinine. 
Still more difficult is it to distinguish between typhoid and 
malarial fever. The mistake is much more often made of re- 
garding cases of typhoid as malarial, than vice versa. Typhoid 
in children is usually milder than in adults; its course is 
shorter, the temperature is more likely to be high at the out- 
set and the eruption is more often absent, especially in the 
mild cases. Prof. Janeway has called attention to the fact 
which he has often observed in epidemics of this disease in 
institutions, that in quite a considerable number of cases where 
it has come on with well-marked symptoms at the outset, it has 
aborted after four or five days or a week. Others beginning 
in the same way proved fatal, and autopsies revealed the 
characteristic lesions of typhoid. These considerations, taken 
in connection with the fact that bronchitis, looseness of the of Malaria in Children. 
33 
bowels, splenic enlargement and abdominal pains and tender- 
ness, are prominent symptoms in both diseases, show how ex- 
ceedingly difficult it may be at times to distinguish between 
typhoid fever and malaria. The course of the temperature 
and the effect of quinine are about all the differential points 
we have. A normal morning temperature, and an evening one 
below 102° on the third or fourth day of the disease almost 
certainly excludes typhoid. The different etiological factors 
should be carefully weighed in every doubtful case. 
From the foregoing discussion the following conclusions are 
drawn : 
Ist. Malaria in early life presents symptoms peculiar to that 
period, and differs from the same disease in adults as widely as 
does pneumonia. 
2d. The classitication of the cases as remittent or inter- 
mittent, and the division into hot, cold and sweating stages as 
in adults, leads to misapprehensions regarding the course of 
the disease and confusion in diagnosis, 
3d. In any acute febrile disease presenting an unusual course 
the spleen should always be examined, especially in a district 
as malarial as Kew York. 
4th. In obstinate cases of diarrhea or bronchitis not affected 
by ordinary remedies, especially if these symptoms show a 
tendency to periodicity, malaria should always be investigated 
as a possible cause. 
sth. Spells of drowsiness and frequent attacks of epigastric 
pains should always exite suspicion. 
6tb. In children, it is even more necessary than in adults 
carefully to interrogate every organ before making a diagnosis 
where the symptoms are at all obscure. 
Bohn: Gerhardt’s Handbuch der Kinderkrankheiten, Bd. 11., 
446. 
Jahrbuch fiir Kinderheilkunde, 1873, 136. 
Schmiedler: Jahrbuch fur Kinderheilkunde, 1879, 316. 
Griesinger; Handbuch Spez. Pathol, und Therap. Virchow, 
Bd. 11., 1864. 
Hertz: Ziemssen’s Encvclop. of the Practice of Medicine. Am. 
Ed., 11., 621. 
Bierbaum : Journal fur Kinderk., Bd. 38. 
Simon, J.: Eevue de Therap. Med. Ohirurg, 1881, 260. 
BIBLIOGRAPHY. 34 
Holt : Malaria in Children. 
Cantetean: Contribution a I’etnde de la Fievre Intermit, chez 
I’enfant. These. Paris, 1880. 
Cables: Des Fievres Intermit, chez les enfants. These. Paris, 
1881. 
Bartlett: Fevers of the United States. Philadelphia, 18.52. 
Murchison: The Continued Fevers of Great Britain. London, 
1873. 
Fruitnight, J. H.: Malaria in Infancy and Early Childhood. 
Am. Jour. Obstet., 1880, 961. 
Thornberry; Malaria in Children. Amer. Practitioner, 1878, 
145. 
For an extensive bibliography of Malaria in general, see the 
articles of Hertz and Griesinger.