23RCHIVESOFDISEASEINCHILDHOODsameteston42newbornbabieswithnegativeresultsOnebabywastakenfromthebreastonhis7thdaybecauseofhighfeverthecauseofwshichwasneverascertainedHewasthenfedonrawcowsmilk ID: 954947
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THEINCIDENCEOFUNDULANTFEVERINCHILDRENBYPARKERDOOLEY.M.D.PhvsiciantoKentSchool.Connecticut.U.S.A.InthedecadesinceBevan'suggestedthattheorganismresponsibleforcontagiousabortionincattlemightbepathogenicforman,innumerablecasesofundulantfeverhavebeendiagnosedamongthepopulationsofmostcivilizedcountries.During1923,therewereonl-24casesreportedintheUnitedStates,buteachsucceedingyearthereafteranincreasinglylargenumberwasreporteduiLtil.in1929.thereweremorethan1,300.Completestatisticsfor1930arenotyetavailable,butitissafetoassumethatthereweremanythousandsofcases.Thereiseveryreasontobelievethatthisincreaseisonlyapparent,andnotreal,ascasesarebeingreportednowwhichcouldnothavebeenrecognizedbeforethepresentmethodsoflaboratorydiagnosiscameintogeneraluse.IntheUnitedStatesatleast,thenumberofcasesreportedfromany-givenregionseemstodependmoreonthealertnesswithwhichthephysicianssearchforthediseasethanonanyotherfactor.Withtheincreasingappreciationoftheubiquityandgravityofthisdisease,itseemsadvisableforstudentsofchildren'sdiseasetotrytoevaluatetheimportanceofundulantfeveramongthediseasesofchildhood.Severaltheoreticalconsiderationssuggestthatahigherincidenceofinfectionprevailsamongchildrenthanamongadtlts.TheBrucellaabortuscausesalow-grade,febrileillnessofatypewhichisfrequentlyundiagnosedunlessspecificlaboratorytestsaremade.Suchlow-gradefeversaresomuchmorecommoninchildrenthaninadultsthatitwouldseemreasonabletoexpectahigherincidenceofBrucellainfectionamongchildrenthanamongadultswhenspecifictestsaregenerallyapplied.Alsothefactthatrawmilk-customarilyconstitutesalargepartofthedietofinfantsandlittlechildrensuggeststhatinfectionmaybefoundtobecommoninchildhood.Despitetheseconsiderations,ithasbecomethemoreorlesstacitopinionofwritersonumdulantfeverthatthediseaseisrelativelvuncommoninchildren.Infact.someauthorshavegonesofarastoarguethatBrucellainfectionisnotcausedbydrinkingmilkbecausechildrenseemtocontractthediseasesoinfrequentlyinspiteofdrinkinglargequantitiesofmilk.Previousinvestigations.-In1913.LarsonandSeduewick2tested423childrenwithboneorjointdiseaseforcomplementfixation.usinaBrucellaabortusasantigen.Thistestwaspositiv-ein73instances.Atthattime.itw-asnotknowinthatthisorganismcouldactasoneofthehumanpathogens.Thesestudiesw-erecarriedoutasapartofaproblemrelatingtothetransmissionofantibodiesthroughtheintestinalwall.Nothingissaidabouttheagesofthechildrennorabouttheprobablesourceoftheinfection.Laterthesesameworkers3usedthe 23RCHIVESOFDISEASEIN-CHILDHOOD.sameteston42new
-bornbabies.withnegativeresults.Onebabywastakenfromthebreastonhis7thday.becauseofhighfever,thecauseofwshichwasneverascertained.Hewasthenfedonrawcows'milk.Onhis21stdayhisreactionw-aspositive.Anotherbaby,19monthsold.hadapositivereaction.In1915NicollandPratt4raisedthequestionofhumaninfectionwithBrucella.Thevperformedagglutinationtestsonanunstatednumberoftheinmatesofafoundlingasylum,includingfcasesofmarasmus.rickets.enlargedlymphnodes,andhvpertrophiedtonsilsandadenoids,aswellasonabout100supposedlvnormalinfants.Presumablythesepatientsweregettingrawmilk.One3yearoldchildhadapositivereactionto1:100;onechildof21yearshadaslightlypositivereactionto1:10;a3yearoldchildhadapositivereactionto1:10.Otherwisetheywereallnegative.Thesesamewritersalsofoundapositivereactioninthe7monthsoldbabyofawomanwhoseownserumreactionw-aspositiveindilutionsupto1:300.Hardy5.insummarizingallcasesofundulantfeverreportedintheUnitedStatesuptoJuneof1929,foundvervfewinstancesinchildrenunder10yearsofage.Among354casesinIowa,thisauthornotedonly4inchildrenunder4years.and8inchildrenbetweentheagesof3and9vears.Ofthese,6wereinonefamily.thediagnosisbeingmadeonthebasisofdriedbloodspecimensalone.Hisdataw-erecollectedchieflyfromvariousStatelaboratoriesandconsequentlyarenotveryusefulinanattempttodeterminetheincidenceofthediseaseamongchildren.'Mostofthebloodspecimenssubmittedtosuchlaboratoriescomefromruralpracti-tionerswhorarelytakebloodspecimensfromyoungfchildren.Extensivebacteriologicalandserologicalstudiesofthebloodofvoungfchildrenareveryinfrequentlymadesaveincityclinicswhere,ofcourse,thegeneraluseofpasteurizedmilkprecludesthesatisfactorystudyofBrucellainfection.ThesamecriticismappliestothestatisticsofBayne-Jones'whofoundnopositiveagglutinationsininfantsunderoneyearinsome3,700routinebloodspecimensonwhichBrucellaagglutinationtestsweremadeintheNewYorkStatelaboratorv.InsimilarspecimensintheOhioStatelaboratory,Ey7foundpositiveagglutinationreactionsinonechildof19months,inwhosefamilytherewerethreepersonssickwithundulantfever;andinanotherchildof2vearswhowassickwithanundiagnosedfebrileillness.InDenmarkKristensenshasmadeacarefulstudyof500casesofundulantfeverandcon-cludedthatyoungchildrenarenotaffected.Guest'carriedoutagglutinationtestson250patientsintheChildren'sHospitalofBoston.andfoundonlyonewhoreactedpositivelyindilutionsupto1:40.Hedoesnotstatewihetherthesechildrenusedraworpasteurizedmilk.Giordanoand,Sensenich`0havereported35cases,theyoungest-being16yearsold.Hartmanumentionsaninfectionocc
urringinan8yearoldchild.Bonyngel2hadacaseinan11monthsoldinfantwhohadbeenusingcertifiedmilkfor9months.Threeotherchildreninthesamefamilyhadbeenusingthismilkbutwerenotaffected.King13notedfourcasesinchildrenunder6yearsofage.includingone2yearoldchildwhohadw-hatwasbelievedtoberheumaticfeveruntilachanceagglutinationagainstBrucellawasfoundtobepositiveindilutionsupto1:1280.Thischild.however,hadbeentransfusedwithbloodfromtwoadultswhohadagglutininsintheirsera.Simpsoni4studied90casesofundulantfever.nineofwhichoccurredinchildrenbetweentheagesof6and10years.Kling1.inSweden.foundonlyonecaseunder10vears.achildof8years.Levini6madeintradermaltestson33childrenbetweentheagesof6monthsand14years.Onlvonechild,a3yearoldgirlwithsinusitisandmastoiditis.gaveapositiveskinreaction.HerserumdidnotcontainBrucellaagglutinins.Kohlbrv-isaw-thediseaseinaninfantof1yearThediagnosisw-asmadeonthebasisofpositiveagglutinationtestdonethreedaysafterthebabywastransfusedwithitsmother'sblood.Koschatel8considerschildhoodinfectiontobesorarethathereportsthecaseofa12yearoldboyasacuriosity.Tobler1'hasreportedBrucellainfectioninan8yearoldgirl.Presentinvestigations.-Sincetheliteratureontheoccurrenceofundulantfeverinchildhoodissofragmentaryandinconclusive,itseemsworthwhiletorecordanyitemwhichmaybehelpfulintheunderstandingofit.Intheautumnof1930asmallepidemicofundulantfeverappearedinaschoolcommunitywhichusesrawmilk-fromasingledairy.Severalmoderatelyseverecasesofthediseaseoccurredamongtheadultmilkconsumers.Ofsome.236 INCIDENCEOFUN-DUIANTFEVERINCHILDREN2300adolescentboysandyoungadultsusingthismilk,41percent.showedserumagglutininsforBrucellaabortusindilutionsover1:20.Severalofthecowsinthedairvwerefoundtohavepositivesera,andsomeweresheddingvirulentorganismsintheirmilk.Amongtheconsumersofthisheavilyinfectedmilk,werefifteenchildrenwhohadbeenrearedonthisrawmilksinceinfancv.TheagedistributionofthesechildrenwasasfollowsUnder1vear.........11-2vears............32-..........4146,...................46-8.......8_10...........Atleastthreeagglutinationtests,eachwithadifferentantigen,weredoneoneachoneofthesechildren.ThefirstantigenwasastockonemadefromfourstrainsofBrucellaofbovineorigin;thesecond,theso-calledHuddlesonantigen;thethird,aliveantigenpreparedfromastrainofBrucellaisolatedfromthebloodofapatient20whowasinfectedthroughdrinkingthesamerawmilkwhichthechildrenused.Thedilutionsintheseagglutinationtestswerefrom1:10to1:640.InnotoneofthesechildrencouldanyBrucellaagglu-tininsbedemonstrated.Allofthesechild
renhadbeenunderthecontinuouscareofthewritereithersincetheirbirth,oratleastforthetwoyearsprecedingthetesting.Inthattime,noneofthemhadanyillnesswhichcouldpossiblybesuspectedofbeingundulantfever.Althoughthisseriesisverysmall,theresultsseemtojustifvthesuppositionthatyoungchildrenarelesssusceptibletoinfectionwithBrucellathanarepersonswhohavepassedpubertyInthisconnection,itistemptingtospeculateontheapparentanalogybetweenBrucellainfectioninyoungchildrenandincalves.White2lstatesthatallcalves,regardlessofthereactionofthedams,arebornnon-reactors..Whenthevarepermittedtosuckpositivedamswithinthefirst24hoursoflife,thevbecomereactorsinaremarkablyshorttime,butagainbecomenegative,almostinvariablybeforetheendofthesixthmonthofage.Itisonlyaftersexualmaturitythatdefiniteinfectionisestablished.Summary.Areviewoftheliteratureofundulantfevershowsthatlittleisdefinitelvknownregardingtheinfectioninchildhood.Studyofserumagglutinationinyoungchildren,whohadbeendrinkinginfectedrawmilk,suggeststhattheyarerelativelyinsusceptibletothedisease.REFERENCES.1.Bevan,L.E.W.,Tr.Ray.Soc.Trop.Med.andlyg.,London,192-2,XV,213.2.Larson,W.B.&Sedgewick,J.P.,Am.J.Dis.Child.,Chicago,1913,VI,326.3.Larson,W.B.&Sedgewick,J.P.,Ibid.,1915,X,197.4.Nicoll,M.,&Pratt,J.S.,Ibid.,1915,X,203.5.Hardv,A.V.,etal.,Nat.In4.ofHealthBull.,Washington,1930,No.158.6.Bavne-Jones,S.,Am.J.Pub.Health,N.Y.,1930,XX,1313. 238ARCHIVESOFDISEASFEINCHILDHOOD.7.Ey,L.F.,SeeSimpson,W.M.,OhioStateMed.J.,Columbus,Jan.1931.8.Kristensen,M.,&Holm,P.,Zentralbl.Bakt.,Jena,1Abt.,1929,CXII,281.9.G;uest,G.M.,J.Med.,Cincinnati,1929,June.10.Giordano,A.S.&Sensenich,R.L.,J.Lab.andClin.3Med.,St.Louis,1930,XV,421.11.Hartman,F.W.,recordedindiscussionofreference10.12.Bonynge,C.W.,recordedindiscussionofreference10.13.King,M.J.,N,ewEng.J.Mled.,Boston,1929,CCI,918.14.Simpson,XV.M.,AnnalsInt.Med.,1930,IV,238.15.Kling,quotedbyLofler,W.,IVlrzburgerAbhandll.aus(le,ntCOesamoetgebiet(le,Jled.,Leipzig,1930,XXVI,ii,365.16.Levin,W.,J.Lab.andClin.Med.,St.Louis,1930,XVI,275.17.Kohlbry,C.O.,-Minn.Me(l..St.Paul,1929,XII,414.18.Koschate,J.,Jahrb.f.Kinderh.,Berlin,1930,CXXVIII,308.19.Tobler,Ibid.,1930,CXXIX,72.20.Dooley,P.New-Eng.J.lied.,Boston,1931,CCIV,759.21.WhiteG.C.,&Rettger,L.E.,StorrsAgric.Station,Conn.,9thRep.Bull.,1926,137.[EDITORIALNOTE.Sofartw%rocasesonly(fBrucellainfectioninchildrenhavebeenreportedinEngland:thefirstinachildof31yearsbyW.Broadbent,Lancet,Jan.10th,1931:thesecondbyB.WilliamsonanidJ1.Gibsoninachildofvlyears,B.Mi1.J.,May2nd,193