CLINICAL OBSERVATIONS 
ON 
PERIODIC FEVER, 
ON 
SAMPgfe EAGON, M. D., 
JEFFERSON CITY, TEXAS. 
From the October [Number, [New Orleans Journal of Medicine. 
Although we are not prepared to go all lengths with those who 
hold that all diseases are forms of ague, jet the importance of 
the subject is not likely to be appreciated in its full extent if we 
fail to recognize the fact that, the malarial principle, the acknowl- 
edged cause of Periodic fever, is reasonably inferred to exist in 
greater or less amount, in the atmosphere of every region of the 
globe j that over a large extent of the territory of our own coun- 
try, it is present in a concentrated form, producing, as an effect, 
during the greater portion of the year, a disease of grave charac- 
ter and more general in its prevalence than all others together ; 
that, in such districts, when not productive of the disease, 
per se, its influence may be impressed upon every other disease of 
the nosology, whether inflammatory, febrile or neurotic, functional 
or organic, either in their acute or chronic course, thus not infre- 
quently sufficing to obscure or to mask them, and presenting a 
distinct and special indication for treatment. 
If the subject be a trite and homely one, it is not the less im- 
portant to those upon whose resources it will make everyday 
demands in the ordinary exercise of their calling. 2 
Within the last decade, most valuable accessions have been 
made to onr means of cure, and several erroneous opinions re- 
specting the nature and treatment of this affection, the meanwhile 
have yielded to a more enlightened theory, as the basis of a more 
successful practice. 
We do not propose in this brief communication, to enter at 
large into the discussion of the treatment of periodic fever, but 
only to offer some xmactical observations on several x>oints con- 
nected with its management deemed of more than ordinary im- 
portance. 
In order to avoid confusion, it is x>roper to state that in the 
term periodic fever, is embraced all of the divisions and subdivi- 
sions usually made by authors, of this disease, viz; intermittents, 
remittents or bilious remittents, congestive, etc. All of these 
we consider essentially identical, and we base this proposition on 
the following facts: 
Ist. The same causative agency is productive of all alike. 
2d. The several forms are mutually convertible, the one into 
the other. 
3d. The paroxysmal tendency is a trait common to them all. 
4th. They are all controlled by the same curative means. 
There is, doubtless, a practical convenience gained by these 
divisions, but it is at the risk of propagating an error; for the 
student and young practitioner are too prone to regard what may 
be treated of under separate heads, as separate and distinct enti- 
ties. 
With these facts before us, we are almost driven to the conclu- 
sion at which Bouillaud arrived on the subject, that these divis- 
ions of periodic fever are a “real nosological superfcetation.” 
Notwithstanding the vast amount of research which has been 
expended on the subject of the primary or essential fevers, we 
possess but little positive knowledge to-day respecting their na- 
ture and causes, and of periodic fever, we are scarcely better 
informed than of its congeners. That they all have their seat in 
the blood is the most logical conclusion in the present state of 
knowledge on the subject; that each one has its own special 
cause, which is capable of producing it and none other, is more 
nearly certain; of these special causes again, we have but imper- 3 
feet information as respects tlieir generation, entrance into th® 
system, and primary action in the body. 
The ague-poison is doubtless of terrestial origin, and the 
cryptogamic theory so ably enunciated by the late Prof. J. K. Mit- 
chell, has lately received very strong confirmatory support from 
the results of Prof. J. H. Salisbury’s elaborate investigations on the 
subject, it not yet being treated as an established fact. As to the 
mode of entrance of the poison into the blood, it is most probably 
by absorption from every absorbing surface of the body, but re- 
specting its operation in the blood, we know positively nothing. 
Its effects on the system are all we can appreciate or understand. 
The effects of the malarial poison in deteriorating or contamina- 
ting the blood, are singularly uniform and distinctive. This is ex- 
emplified in a striking manner in pernicious periodic fever, es- 
pecially in that variety called necraemial, in which the cause is 
so intensified, or the susceptibility so great,—or it may be from 
these two circumstances together,—that a series of destructive 
changes, septic, or zymotic, are set on foot, whereby the vital 
fluid is rendered unfit for the grand purposes of nutrition and 
secretion. 
Anaemia is an almost uniform effect even in the primary career 
of the malady, and on its chronic course, an invariable attendant. 
Its features are best defined in those cases of protracted exposure 
to the operation of the poison, in which that dyscrasial state has 
been induced, known as the malarial cachexia. 
Prom the phenomena presented in this condition, it is fair to 
conclude that, an active morbid material or process, has been at 
work in the blood whose most prominent effect is to disintegrate 
and despoil it of its essential solid constituents, its fibrine, albu- 
men, and haematin. 
The sequelae of periodic fever (and their name is legion), may 
nearly all be traced to this peculiar anaemic constitution of the 
blood as their direct, or indirect cause. “ The effects of anaemia 
are pallor, collapse, and shrivelling of the textures, weakening 
and eventual extinction of their functions.” (Rokitansky.) 
The spleen suffers more, perhaps, than any other organ of the 
body, from the direct effects of the poison, and as one of the 
functions of this yiscus is supposed by physiologists to be, the 4 
elaboration of fibrine, this interference with its functional activity 
may thus indirectly add to the general bydramia. 
The foregoing brief summary of the principal concomitants and 
pathological effects of periodic fever, embraces the fundamental 
teaching of the most recent authorities on the subject. Un- 
fortunately, a great deal yet remains to be verified or re- 
futed by future research and observation. In the absence of 
positive information, the mind naturally strives to erect some 
plausible theory in explanation of the phenomena presented. We 
must have some sort of theory, indeed, on which to base a ration- 
al practice. “ Experience without theory is blind.” 
It is matter of wonderment, that the old plan of treating this 
disease should have held its ground so long, after the more mod- 
ern, and infinitely more safe and successful one of the present 
time, had been established and promulgated to the profession ; 
and not less remarkable is it, that there are those among us 
who still adhere to the ancient dogmas of their early masters, 
with no less tenacity on this point than on many others long 
since obsolete. 
To prepare the system for the reception of anti-periodics or 
tonics, even in the simple intermittent form of periodic fever, is, 
strange to say, still regarded as of paramount necessity by a few 
practitioners of the country, and the general course is to vomit, 
purge, mercurialize, and even bleed, before the system is consid- 
ered in fit condition to receive quinia or its succedanea. Some 
carry the use of this class of remedies much further, regarding 
mercury and antimony as essentially curative in their effects, and 
with this view continue their use throughout the whole course of 
treatment, which, under such circumstances, is generally quite 
protracted. 
But a much larger number at the present day, hold to the doc- 
trine that in the treatment of that form of periodic fever, called, 
with doubtful propriety, bilious remittent, autiphlogistics, espe- 
cially mercury and antimony, together with various eliminative 
means, are of indispensable utility. 
This practice is based on the assumption that the liver is pri- 
marily and largely implicated in this form of disease, presenting a 
special indication for chologogues, etc., and, that the emxfioymeut 5 
of quinia during the acute stage of this affection, whilst it prom* 
ises no good as an ectrotic, is fraught with danger. 
We believe it is not going far enough in condemnation of the 
antiphlogistic or non-abortive plan of treatment of periodic fever, 
to assert that this class of remedies is not indicated, or that their 
employment may do infinite negative harm, by standing in the 
way of appropriate means—as when they are vainly relied upon 
in ordinary periodic fever, which, in either of its forms, may, at 
any time, assume a pernicious character, but to this we should 
add, that they are directly and positively injurious. 
Antimony and mercury may fairly be taken as typical of the 
class of antiphlogistic medicines, and whilst they possess neither 
tonic nor anti periodic properties, their direct effect is to break 
down and impoverish the blood. Their operation in the blood 
must be analogous to that of the ague-poison, since the results of 
the operation of the two agencies, as respects the blood are very 
similar. 
The correctness of these conclusions granted, we know of no 
principle on which their administration could be considered ad- 
missible, except the rule of the disciples of Hahnemann— 
“ similia similibus curantur,” a doctrine not in favor with the 
orthodox sect, and opposed alike to logic and common sense. 
While the antiphlogistic, or non-abortive system of medication, 
as applied to periodic fever, is not tenable on theoretical grounds, 
clinical observation furnishes irrefragible evidence of its inutility. 
In his admirable work on the “ Principles and Practice of Medi- 
cine, 2d edition,” that pre-eminent author and teacher, Prof. 
Austin Mint, Sr., of New York, makes the following just obser- 
vations on this subject: u For the cure of intermittent fever, 
medicine possesses specifics, if any remedies are entitled to this 
appellation. This statement applies especially to the salts of 
quinia, of which the sulphate is the one almost universally used. 
The sulphate of quinia will promptly interrupt the recurrence of 
the paroxysms of intermittent fever in the vast majority of cases. 
It is always desirable to arrest the disease as speedily as possible. 
Its morbid effects are less in proportion as it is quickly arrested, 
and the liability to relapse is diminished. There is no need of 
preparatory treatment. This position was taken by the author 6 
in an article published twenty-five years ago. An experience em- 
bracing many hundred cases in different climates, since the date 
of that publication, has abundantly confirmed the correctness of 
this position. Aside from the delay in arresting the disease, the 
measures heretofore employed to prepare the system for the sul- 
phate 'of quinia or other special remedies were injurious. The 
measures were, mercurial cathartics, emetics, and sometimes bleed- 
ing. These measures are not indicated in the treatment of inter- 
mittent fever. A consideration of no small importance, as enforc- 
ing an immediate employment of the abortive treatment, is the pos- 
sibility of an intermittent fever, at first simple or ordinary, be 
coming, after several paroxysms, pernicious.” 
On the subject of treatment of remittent fever, the same dis- 
tinguished authority gives the following sound precepts : 
u The first and leading object in the treatment of simple remit- 
tent fever, is the arrest of the disease by anti-periodic remedies, 
of which the preparations of cinchona are by far the most reliable, 
the sulphate of quinia being the preparation to be preferred. As 
soon as the character of the disease is determined by the occur- 
rence of a remission, the sulphate of quinia should be given in a 
full dose, viz., from ten to twenty grains to an adult. # # #• 
If ciuchonism be not produced during the remission, the remedy 
may be continued during the exacerbation of fever, * * * . 
In short the treatment is essentially the same as in cases of inter- 
mittent fever. And this plan of treatment will succeed, in a 
large proportion of cases, in promptly arresting the disease.” 
For a period of more than ten years, and in a field somewhat 
more extensive, we have adopted this abortive method in periodic 
fever, with results such as to enable us to add our unqualified 
testimony in favor of its adaptability, and efficiency, beyond all 
other plans; and this applies not less to remittents than to iuter- 
mittents. 
Formerly, our mode of treating periodic fever during the cold 
stage of the paroxysm, embraced little more than palliative 
means, abortive measures not then having been discovered. 
Eecent discoveries and improvements in therapeutics, how- 
ever, have supplied us with ectrotic remedies, by means of 
which this fever may be jugulated in the very height of its vio- 7 
lence. No greater benefaction we believe, has been conferred on 
humanity during the present century, than the discovery, in 1852, 
by Prof. A. P. Merrill, of New Ycrk, of the value of chloroform 
internally administered, in the cold stage of fever. It is, indeed, 
a most fitting honor with which to crown a long, successful, and 
laborious life of devotion to science and humanity. In order to 
obtain the full measure of its therapeutic influence, chloroform 
should be given, as insisted on by Dr. Merrill, in u physiologic 
doses,” of f. 3i, to be repeated at the interval of fifteen minutes, 
or half an hour, till its full hypnotic effect is experienced. Em- 
ployed in this way, it will, in a large proportion of cases, arrest 
the paroxysm in the first stadium, and when it fails to do so, it 
will almost invariably diminish its intensity, and to that extent, 
lessen the severity of the succeeding hot stage. We have em- 
ployed the remedy largely in this condition for the last eight 
years, in the manner above specified, and we take pleasure in 
offering our feeble testimony as to its perfect safety and efficiency, 
in bringing about reaction from the cold stage of fever, beyond 
all other remedies with which we are acquainted. 
Chloroform is not incompatible with other agents known to be 
useful in the treatment of periodic fever; it may, therefore, be 
employed in conjunction with other appropriate means, or, it may 
be assisted by such adjuvants as may be deemed advisable. If 
not retained by the stomach, it should be given pier enema, sus- 
pended in glycerine or olive oil. It is quite as well adapted to 
the cases of children as to those of adult subjects, but, of course, 
the dose should be proportioned to the age. 
The immense value of this agent can be duly estimated, only 
by witnessing its operation in the cold stage of pernicious parox- 
ysm, in cases in which the patient is seen too late for the great 
anti-periodic quinia to be available. Such cases illustrate the 
fact, that u to know the natural course of disease, is more than 
half of medicine f and guided by such instruction, the veriest 
expectante, it would seem to us, could scarcely feel content to 
adopt u a masterly inactivity.” Perhaps, in no other pathological 
condition, is the curative power of medicine exemplified in a man- 
ner more positive and striking. 8 
The subcutaneous injection of quinia in the cold stage of 
periodic fever promises valuable results, since by this method, its 
certain and speedy absorption by the venous radicles is secured. 
Thus administered, the constitutional effects of the agent will be 
experienced in from ten to fifteen minutes, and the quantity re- 
quired to produce such results, is estimated at two-thirds the dose 
given by the mouth. Several examples of the success of this 
practice in the algid stage of pernicious paroxysm have been re- 
cently published in American medical journals. 
In some cases of periodic fever, the remission is imperfect, or of 
short duration, and, under such circumstances, it may become 
necessary to continue the use of quinia during the hot stage of 
the paroxysm. It is well known, however, that, administered 
during the stage of reaction, quinia produces distressing nervous 
excitement in many cases, and in some, even dangerous conse- 
quences, if it be not tempered in its operation by some agent 
capable of mollifying its effect upon the nervous system. This 
difficulty may be obviated by associating with quinia, a sufficient 
quantity of ant. et pot. tartras. to produce moderate sedation, as 
evinced by slight nausea. Used for this transient purpose, anti- 
mony produces only its neurotic effect, sedation, without being 
open to the objection applicable to its protracted employment, 
viz., that of disintegrating the blood. 
But an agent of more certain efficacy in tempering the harsh 
action of quinia administered during the pyrexial period of pe- 
riodic fever, we have found, from numerous trials, to be hydrocy- 
anic acid. This sedative, is, in like manner, applicable to those 
rare cases of idiosyncrasy, in which quinine, given even in the 
apyrexia, produces painful nervous phenomena. Under such 
circumstances, this agent will be found to act like a charm in 
procuring relief. Several instances have come under our obser- 
vation, in which this idiosyncrasy amounted to complete intoler- 
ance of quinia, and, in these same cases, we have administered 
the remedy in combination with hydrocyanic acid thus so effectu- 
ally softening its operation as to render the patient almost in- 
credulous of the assertion that he had taken a remedy which, 
when not thus guarded, had given such distress. 
To prove effectual, hydrocyanic acid should not be given in 9 
infinitesimal doses. Ten drops of the medicinal acid (v.S. P.) 
may be taken as a medium dose ; and this quantity may be safely 
repeated several times at the interval of fifteen or twenty minutes, 
if relief be not procured by the first dose. The one or two drop 
doses usually stated, will be found inadequate to produce any 
useful impression. 
Our task is but half accomplished when we have arrested the 
course of periodic fever, its known tendency to recur being one of 
its most marked characteristics. Judging from our own observa- 
tions, with reference to this point, we believe it is not an exagge- 
ration of the facts to say, that the liability to a return of fever 
after it has been arrested, the subject remaining in a malarial 
district, amounts to nine chances in ten, if attention be not paid 
to prophylaxis. A single paroxysm deteriorates the blood, and 
lowers the vital powers of resistance to disease. In view of 
these circumstances, we have been for several years in the habit 
of prescribing for our convalescing chill and fever patients, the 
following, or some therapeutic equivalent : 
Quinia sulphas, Ferri. pulv aa 3 i, 
Strychnia gr. i, 
Gentianss extract q. s. 
M. Ft. pil. No. xxx. S. One morning, noon and night. 
Provided, a few paroxysms only have been suffered, this will be 
sufficient to reinstate the system, but, if great hydrsemia exist, 
due to the protracted operation of the poison in the blood, it will 
be found necessary to continue the remedies above stated for a 
much longer period, in conjunction with the tinct. ferri. chloridi, 
gtt. 25 or 30, three or four times a day. Together with good 
alimentation, and a well regulated hygienic and calesthenic sys- 
tem, we have rarely failed with the combination referred to, of 
effectually warding off a recurrence of the troublesome disorder. 
In a future number of your excellent Journal, we hope to be 
able to give our experience with the sulphites in periodic fever, 
as we are now making them the subject of clinical study.