INTERMITTENT FEVER 
IN CHILDREN, 
WITH SPECIAL REFERENCE TO ITS 
ORIGIN IN NEW YORE. 
BY 
HERMAN B. SHEFFIELD, M. D., 
Instructor in Surgery at the New York School of Clinical 
Medicine; Physician to the Hebrew Sheltering 
Guardian Society Orphan Asylum, etc. 
BEPBINTED FROM TEH 
■Meto Vorit ^[HeUical Soucncl 
for October S3, 1897. Reprinted from the New York Medical Journal 
jor October 23, 1897. 
INTERMITTENT FEVER IN CHILDREN, 
WITH SPECIAL REFERENCE TO ITS ORIGIN IN NEW YORK. 
By HERMAN B. SHEFFIELD, M. D., 
INSTRUCTOR IN SURGERY AT THE NEW YORK SCHOOL OF CLINICAL MEDICINE ; 
PHYSICIAN TO THE 
HEBREW SHELTERING GUARDIAN SOCIETY ORPHAN ASYLUM, ETC. 
The words of Koheleth, " An increase in knowledge 
brings an increase of pain/' are thoroughly appreciated 
by those who watch the rapid revolution of theories 
concerning the nature, etc., of the diseases caused by 
specific micro-organisms. Views which previously have 
been considered indisputable facts are now painfully 
looked upon as ridiculous hypotheses. For instance, 
malarial disease, until the discovery of its plasmodium, 
was supposed to be thoroughly understood, requiring no 
further study; indeed, whenever the symptoms of an- 
other disease were obscure, the snap-diagnosis " ma- 
laria " was quite convenient to fall back on. At pres- 
ent it is a subject of great controversy obscured by 
numerous fancy theories. The author, therefore, be- 
lieves that an effort toward its elucidation from a prac- 
tical standpoint will not be considered superfluous. 
That the patience of the reader may not be over- 
taxed and no doubt raised as to the genuineness of the 
Copybight, 1897, by D. Appleton and Company. 2 
INTERMITTENT FEVER IN CHILDREN. 
cases in question, the writer proposes to contribute his 
observations made in cases of typical intermittent fever 
in children only, leaving those of the adult and the 
cases of remittent and irregular fever for future dis- 
cussion. 
From January 5, 1896, to June 15, 1897, sixteen 
cases of intermittent fever were admitted to the hos- 
pital of the Hebrew Sheltering Guardian Society Or- 
phan Asylum. This institution is situated on Washing- 
ton Heights, at One Hundred and Fiftieth and One 
Hundred and Fifty-first Streets and Western Boulevard, 
upon dry, rocky ground, about five hundred feet dis- 
tant from, and one hundred feet above the level of, 
the Hudson River. A great part of its neighborhood is 
as yet but little cultivated. • The locality, taken as a 
whole, ranks among the finest and healthiest in New 
York city. The comparatively little sickness occurring 
in the asylum substantiates this assertion. 
As a minute description of each and every case would 
certainly prove tedious to the reader, the writer there- 
fore prefers to enumerate them in tabular form, ex- 
cepting the following two cases, which offer a few points 
of special interest: 
Case II. Quartan-quotidian.-S. S., aged thirteen 
years (see chart), who has been an inmate of the insti- 
tution about four years, always having enjoyed perfect 
health, was admitted to the hospital on the 10th day of 
January with severe headache, nausea, and vomiting. 
He was soon attacked by a marked chill of fifteen min- 
utes' duration, followed by a hot and sweating stage. 
The temperature rose to 105° F., and fell to normal 
after sixteen hours. After a brisk cathartic, the admin- 
istration of quinine in large doses was begun the next 
day (January 11th). On the 13th, 14th, and 15th of INTERMITTENT FEVER IN CHILDREN. 
3 
January, at about the same hour, the paroxysms oc- 
curred again, while a slight elevation of temperature 
continued until the 17th. 
Case XV. Tertian-quotidian-tertian.-After show- 
ing signs of ill-health for two days, J. M., a girl aged 
four years, was brought to the infirmary June 1, 1897, 
at 12.30 P. m. The countenance was livid, appearing 
swollen; the eyes were slightly congested and the eyelids 
were puffy. The child complained of being cold and 
shivered violently. Hands and fingers were cold, and fin- 
ger and toe nails blue. After twenty minutes the rigor 
ceased; the child vomited. The temperature, 105° dur- 
ing the chill, fell to 104° after the vomiting. Lividity 
disappeared. Skin was very hot and dry; face sallow, 
and temperature rose again to 105°, with pulse 140, 
respiration 34. Child delirious and experienced great 
thirst. Hot stage lasted three hours, when sweating 
set in. Temperature declined, and patient was perfectly 
comfortable after six hours. At 10.30 a. m. on June 
3d she was again taken with chill of twelve minutes' du- 
ration, followed by severe nausea and vomiting. Hot 
stage lasted until 2 p. m., during which time tempera- 
ture rose to 106°, respiration 62, with pulse 180 to 200 
(repeatedly counted). At 8 p. m. attack was over. Ad- 
ministration of quinine begun; child sweated more or 
less continuously until June 5th, when at 12.30 p. M. a 
slight lividity and temperature-rise of 104° (respiration, 
38; pulse, 148) occurred. Three hours of hot stage 
was followed by sweating, and at 9 p. m. the patient 
again felt comfortable. No recurrence of the parox- 
ysms. Quinine in smaller doses continued until June 
16th, when the child was discharged. 
Four days later, readmitted with parotiditis (there 
being several cases of it at that time), presenting no 
constitutional symptoms. 
June 28th, 5 P. M.-Attacked with chill lasting ten 
minutes. Vomiting, hot and sweating stage the same 
as in previous attacks. Temperature continued mod- 
erately high until 6 a. M. the following day (June 4 
INTERMITTENT FEVER IN CHILDREN. 
* ADMINISTRATION OF QUININE BEGUN Table of the Author's Cases of Intermittent Fever. 
No. 
Name. 
Age. 
Birthplace. 
DATE OF ADMISSION TO 
Type of fever. 
Duration. 
Variety of plasmo- 
dium in the blood. 
Remarks. 
Asylum. 
Hospital. 
1 
B. G. 
11 
New York. 
Dec., '93. 
Jan. 1, '96. 
Quotidian. 
4 days. 
Intracellular. 
No chill nor sweating. 
2 
S. S. 
13 
Russia. 
Sept., '92. 
Jan. 10, '96. 
Quartan and quotidian. 
8 " 
it 
See chart. 
3 
E. L. 
13 
New York. 
May, '95. 
Jan. 18, '96. 
Tertian. 
4-6 " 
Intracellular and 
crescentic forms. 
Three attacks within two 
months. 
4 
R. D. 
11 
u 
May, '92. 
Feb. 22, '96. 
Quotidian. 
3 " 
Intracellular. 
5 
E. L. 
7 
u 
Aug., '93. 
Mar. 5, '96. 
u 
3 " 
u 
6 
B. M. 
6 
ii 
Nov., '95. 
Mar. 5, '96. 
it 
4 " 
u 
7 
S. W. 
14 
n 
Feb., '93. 
Mar. 22, '96. 
u 
3 " 
ll 
8 
N. K. 
12 
Germany. 
July, '91. 
Mar. 31, '96. 
u 
5 " 
ll 
No chill nor sweating. 
9 
F. W. 
14 
New York. 
Nov., '93. 
April 8, '96. 
Tertian. 
5 " 
ll 
No chill. 
10 
F. C. 
13 
u 
June, '94. 
May 1, '96. 
Quotidian, 
u 
3 " 
ll 
No chill nor sweating. 
11 
A. S. 
7 
u 
Aug., '93. 
Nov. 17, '96. 
9 44 
ll 
12 
S. S. 
8 
ii 
April, '93. 
Nov. 17, '96. 
u 
8 " 
ll 
No chill; spleen enlarged. 
13 
I. c. 
9 
u 
March, '93. 
Nov. 17, '96. 
u 
6 " 
ll 
14 
D. D. 
6 
(I 
May, '95. 
Jan. 4, '97. 
cc 
4 " 
ll 
15 
J. M. 
4 
n 
Dec., '96. 
June 1, '97. 
Tertian, quotidian, 
tertian. 
6 " 
ll 
Spleen enlarged. Two at- 
tacks within five weeks. 
16 
S. Sch. 
7 
u 
June, '94. 
June 14, '97. 
Tertian. 
6 
ll 6 
INTERMITTENT FEVER IN CHILDREN. 
29th). In the evening, 5.30, lividity of face and hands; 
temperature rose to 106°. This condition continued for 
about two hours, profuse sweating followed, and tem- 
perature was normal at 6 a. m. No paroxysm the next 
day.* Vomiting at 6 p. m. (about the time the chill 
was to have taken place). On the following day, July 
1st, 4 p. m., temperature rose to 104°, fell again two 
hours later to 102.5°, and was recorded normal at 12 
M. Administration of quinine begun (July 2d) and 
continued for two weeks. The last attack took place on 
the 3d of July. 
Reviewing the foregoing table, it will be found that 
of the sixteen cases the quotidian type was met with 
eleven times, the tertian three times, quartan and quo- 
tidian once, tertian and quotidian once. Chill, as well 
as sweating stage, was absent in two cases. 
Chill alone absent in three cases. Enlargement of 
spleen in three cases. 
Frequent examinations of the blood, undertaken at 
different stages of the disease, universally revealed the 
presence of the endoglobular pigmented and, at times, 
also the non-pigmented variety of the plasmodium. The 
blood of Case III contained in addition to the intra- 
cellular also the crescentic form of the protozoon. 
The examinations were conducted with the greatest care, 
and the diagnosis was verified by Dr. H. T. Brooks, 
pathologist to the Post-graduate Medical School of this 
city. 
This finding supports the view of most authorities 
that the blood in every genuine case of malarial disease 
does and must present the parasite. This assumption, 
however, is not conceded by all, and we find that not a 
* Fever changed from quotidian to tertian without the influence of 
quinine. INTERMITTENT FEVER IN CHILDREN. 
7 
few just as eminent men-among them recently Dr. Thin 
(1) and Dr. Lawrie (2)-declare that not infrequently 
severe typical malarias do fail to show the organism. 
Of the same opinion is Dr. Ross (3), who observed the 
plasmodium in only sixty-nine out of a hundred and 
twelve typical cases of malaria in India, and Dr. Morse 
(4), who failed to find the organism in two out of twen- 
ty-six cases. While not in the least doubting the ability 
of these observers as hasmatologists, it may, neverthe- 
less, be asserted that the parasite may have escaped 
their notice through some technical error. Indeed, at 
times, the failure to detect the plasmodium may be 
attributed to the lack of skill on the part of inexperi- 
enced assistants often intrusted with the microscopical 
examination of the blood. The very fact that the 
plasmodium is not found in the blood in any disease 
but malaria (5), and that transfusion of the blood of 
a patient into a healthy person often transfers the dis- 
ease (6 and 7), proves beyond doubt that this proto- 
zoon is the specific cause of malaria, and that it mi- 
grates in the blood, and consequently must be seen 
there by means of the microscope. 
Not quite as convincing is the assertion that each 
type of intermittent fever depends upon a special vari- 
ety of the plasmodium. Dr. Golgi (8) and his followers 
distinguish two principal varieties of it: one which con- 
sists of fifteen to twenty spores and maturing in two 
days, producing febris tertiana; the other, made up 
of six to ten segments and maturing in three days, 
producing febris quartana. The quotidian type, they 
believe, is caused either by two crops of the former or 
three of the latter, one crop maturing every day. Dr. 
Laveran (9), the discoverer of the plasmodium, after 8 
INTERMITTENT FEVER IN CHILDREN. 
examining the blood of patients suffering from the fever 
contracted in Tonquin, Dahomey, Senegal, and Madagas- 
car, declares that he has never found the varieties of 
the organism described by some authors as peculiar to 
those types of malaria. The supposed peculiarities in 
the morphological structure of the parasite, he con- 
tends, are merely due to the difference in the degree 
of its virulence, which is comparable to the difference 
exercised by the climate upon the ordinary protozoa. 
Dr. Lenhartz (10), with others, to a great extent cor- 
roborates the view of Dr. Laveran. 
Admitting that Dr. Golgi's theory is correct, the 
questions naturally arise: First. How can paroxysms of 
quotidian fever follow, as in Cases II and XV, the quar- 
tan or tertian types at the time when large doses of 
quinine (the recognized specific) are administered? Or, 
in other words, how can new crops of the organism 
develop under the influence of their specific germicide? 
This being impossible, Dr. Golgi's theory must neces- 
sarily give place to a more probable one, as, for instance, 
the following: There is but one variety of the plas- 
modium which may attack the human system infected 
by it, either every day or every two or three days, etc.; 
the frequency of the paroxysms depending not alone 
upon the virulence of the organism, but also upon the 
power of resistance of the patient. Thus the weaker 
the system and the greater the virulence of the proto- 
zoon, the more frequent the attacks, despite, or perhaps 
because of, the administration of large doses of quinine 
(for quinine in large doses debilitates the system by in- 
terfering with oxygenation, weakening the heart and 
lowering the blood pressure, etc. (11)), unless the quan- 
tity of it be sufficient to completely destroy the parasite. INTERMITTENT FEVER IN CHILDREN. 
9 
Secondly. How, on the other hand, can there be a 
diminution in the paroxysms (as in Case XV, quotid- 
ian changing to tertian (see note))-that is to say, an 
arrest of development of the organism during the height 
of its vitality-without any influence of quinine, unless 
it be vanquished by the power of resistance of the pa- 
tient, as explained above? The latter theory is sup- 
ported by the fact that children whose systems are com- 
paratively feeble are mostly attacked by the quotidian, 
more rarely by the tertian, and very seldom by the quar- 
tan, etc., type of intermittent fever (12). Among the 
cases under discussion, only one boy, thirteen years 
old, was but partially attacked by febris quartana (see 
chart). 
Quite as doubtful is the mode of infection; for no 
sooner was it agreed that infection was conveyed 
through the air or by water, than a new theory was ad- 
vanced, putting forth the mosquito (13) as the heroic 
carrier. Dr. Rupert Norton (14) contends that there 
is at present no proof that the malarial organism lives 
in water, all evidence confirming the water-borne the- 
ory being insufficient to accept it as a settled fact. "We 
do not find," he says, " in towns or elsewhere, groups 
of patients whose infection can be traced to a single 
supply of water or milk." To refute this assertion, it 
may be noted that Dr. Harley (15) did observe an epi- 
demic of malarial disease in his own family which was 
traced to the water of an artesian well. The epidemic 
ceased when the water was carefully sterilized, and re- 
curred when this was omitted. Dr. Norton further 
confirms his view by remarking that drinking water 
from malarial regions does not produce the disease ex- 
perimentally. This seems valueless against the water- 10 
INTERMITTENT FEVER IN CHILDREN. 
borne theory, since not all water from malarial regions 
is necessarily impregnated with the malaria plasmodium. 
Thus, it may be assumed that the water experimented 
with was entirely free from the organisms, or that the 
parasite was destroyed in the stomach of the persons 
experimented upon. 
The theory recently advanced, that the mosquito 
is a means of conveying malarial infection, lacks as yet 
reliable substantiation by positive experiments. Why, 
among so many other insects afflicting mankind, the 
mosquito only has been selected as the " chosen one " 
of carrying malarial infection, the writer is unable to 
comprehend. The occasional demonstration of the ma- 
larial organism in the bodies of mosquitoes does not 
prove that careful research would fail to reveal the 
same organism in the bodies of other insects. It is 
just as difficult to understand why, if this theory is 
true, the mosquito should not be endowed with the 
property of carrying the organism of relapsing fever, 
splenic fever, etc., as well as that of malaria. Both of 
these questions, together with the fact that malaria 
also prevails at those seasons of the year (see table) 
when mosquitoes are not to be seen, tend to show that 
the mosquito-mode of infection is a mere hypothesis. 
As to the regional distribution of malaria, evidence 
is gradually accumulating that this disease is almost 
endemic in those places which have but a few years ago 
been considered exempt from it, except as an imported 
disease. New York is a good example in this country 
of the latter assertion. As recently as March, 1897, at 
the Academy of Medicine (16) the opinion prevailed 
that little, if any, malaria originated in New York city. 
In order to prove the prevalence of malaria in New INTERMITTENT FEVER IN CHILDREN. 
11 
York, two points must be taken into consideration: 
First, does malaria originate in New York at all? Sec- 
ond, if it does, can it be limited to but a few persons? 
In reply to the first question, the reader is referred 
to the eases under discussion; fourteen of these were 
born in New York city, and all but one child were in- 
mates of the institution for from two to four years previ- 
ous to the attacks of malaria. As the children were never 
outside of the city, infection must consequently have 
taken place along the Hudson River front at One Hun- 
dred and Fifty-first Street, where the orphan asylum is 
situated. According to Dr. Holt (IT1), the neighborhood 
of Central Park is also a malarial locality. 
Having concluded that malaria does originate in 
New York, and that, as mentioned above, infection 
is carried through the air and by water, it appears 
highly probable that a great number of persons who fre- 
quent Central Park and the river fronts, often remain- 
ing there for hours, partaking of the drinking water 
and enjoying baths, etc., do contract the disease there, 
thus saving the trouble of " importing " it. It is cer- 
tainly ridiculous to read of the origin of hundreds of 
cases of malarial disease in adults being traced back to 
some locality outside of this city and State, simply be- 
cause the patients reported, perhaps ten years before, 
visited that place. 
Again, in children malarial disease is frequently 
overlooked, owing to the fact that the stages are so often 
masked, and the little patients rapidly recover under 
the panacea " calomel and quinine/' which is adminis- 
tered anyhow, even though no diagnosis has been made. 
That Dr. Walter B. James (18) could not find the 
parasite in the blood specimens of cases of possible 12 
INTERMITTENT FEVER IN CHILDREN. 
malaria sent to him by New York physicians need not 
be at all surprising when it is considered that typical 
malarias are diagnosticated without microscopical ex- 
amination, and are, therefore, very rarely sent to the 
bacteriologist, and that obscure cases requiring the diag- 
nosis of the hsematologist are, as a rule, treated, in con- 
junction with many other antiperiodics, with quinine, 
which destroys the plasmodium before the examination 
is undertaken. 
This explanation applies to Philadelphia, Baltimore, 
etc., as well as to New York. 
A few words regarding the administration of quinine 
to children will not be out of place. The writer has 
been in the habit of dissolving the sulphate of quinine 
in the white of an egg and administering it by the rec- 
tum. The white of the egg seems to prevent irritation 
and aid in the absorption of the quinine. The results 
were always excellent without unpleasant complications. 
The contents of this paper may be summarized as 
follows: 
(1) Intermittent fever in children is mostly of the 
quotidian type; the chill and sweating stage being often 
masked, it is not infrequently overlooked; the spleen 
is rarely enlarged if quinine is administered early. 
(2) Genuine intermittent fever always presents the 
malaria plasmodium in the blood; its absence is due 
either to a technical error on the part of the examiner, 
or to the administration of drugs which are detrimental 
to it. 
(3) The existence of the varieties of the plasmodium 
described by some authors as peculiar to quotidian, 
quartan, tertian, etc., types of the fever is still a sub- 
ject of great controversy. INTERMITTENT FEVER IN CHILDREN. 
13 
(4) Infection of malaria is conveyed through the 
air as well as by water. The mosquito theory of in- 
fection seems to be a mere hypothesis. 
(5) Malarial disease is endemic in most of the larger 
cities of the North, especially New York; all doubts 
raised against it are not based upon scientific investi- 
gation. 
(6) Intermittent fever yields promptly to large doses 
of quinine, a point of considerable value in the diag- 
nosis. Persistency of the attacks may be attributed 
either to the exhibition of quinine in too small quan- 
tities for too brief a period, or to its administration 
in the form of the mercantile, heavily coated pill, which 
is, as a rule, insoluble and hardly ever enters into the 
circulation. 
Note.-Since the completion of this paper, four new cases of quo- 
tidian intermittent fever have appeared in the asylum. The ages of the 
patients varied from three to five years. 
Bibliography. 
1. Lancet, 1895. 
2. Lancet, June 20, 1896. 
3. British Medical Journal, February 1, 1896. 
4. Boston Medical and Surgical Journal, January 16, 
1896. 
5. Gunther's Einfuhrung in d. Stud. d. Bacteriolo- 
gie, p. 409, 1895. 
6. Ibid. 
7. Strumpell's Text-book of Medicine, p. 90, 1894. 
8. Lenhartz's Microscopic und Chemie am Kranken- 
bett, p. 75, 1895. 
9. Semaine medicale, May 9, 1896. 
10. Microscopic und Chemie am Krankenbett, loc. ciL 
11. Bruce. Materia Medica and Therapeutics, 1890. 
12. Smith's Diseases of Infancy and Childhood, p. 
449, 1890. 14 
INTERMITTENT FEVER IN CHILDREN. 
13. Manson. British Medical Journal, March 14? 
1896. 
14. Bulletin of the Johns Hopkins Hospital, March, 
1897. 
15. Gould's American Year-book of Medicine and 
Surgery, 1897. 
16. Medical Record, March 6, 1897. 
17. Diseases of Injancy and Childhood. 
18. Medical Record, loc. cit. 
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