THE EXACT TREATMENT OF 
MALARIAL FEVERS. 
BY 
1 
CHARLES D. SLAGLE, M.D., 
PORTSMOUTH, OHIO. 
REPRINTED FROM THE THERAPEUTIC GAZETTE, OCT. 15, 1807. 
DETROIT, MICH. I 
WILLIAM M. WARREN, PUBLISHER. 
1897. THE EXACT TREATMENT OF MALARIAL 
FE VERS. 
Charles D. Slagle, M.D. 
In the treatment of malarial fever a two- 
fold object must constantly be kept in mind: 
first, the treatment of the disease in question; 
and second, to prevent further infection. By 
what mode the plasmodium malaria gains en- 
trance to the system is at present unknown. 
It is thought, however, that infection is more 
liable to occur at night. The disease shows 
no preference to either sex and attacks all 
ages. In the treatment of regular forms of 
intermittent and remittent malarial fevers of 
whatsoever type, it is the duty of the physi- 
cian never to allow the recurrence of a parox- 
ysm after once the diagnosis has been made. 
Injury may be done to the blood. The treat- 
ment of malarial fevers in general may be 
divided into that for the cold, hot, and sweat- 
ing stages, and for the permanent cure of the 
disease. 
During the cold stage the patient should 
either be put to bed and wrapped well in woolen 
blankets, and hot-water bottles put to his 
limbs and body, or should remain in a very 
warm room having a temperature from 85° 
to 90° F. A ten-grain dose of Dover's pow- 
der should be given early in this stage. 
Stimulants may be given if this stage be 
severe, but one objection arises to their use, 2 
on account of their causing severe headaches. 
They should be given in amount to affect the 
vasomotor system only. None is better than 
the old French brandy. The cold bath has 
been recommended during the cold stage. 
This was practised as early as 1835, and 
good results seem to have followed its use. 
Some physicians employ hypodermically, at 
the close of this stage, pilocarpine in pretty 
good doses, and it is said that it cuts the hot 
stage shorter. Its use should be guarded. 
As to the hot stage: Do not give quinine at 
the beginning of this stage; it may cause de- 
lirium. The patient should be made as com- 
fortable as possible. He should be placed 
in a well lighted and ventilated room and 
cool refreshing drinks be given. The ice- 
bag or cloths wrung out of ice-water may 
be applied to the head. The body may be 
sponged with cold or tepid water, or even 
the cold bath be given, which affords great 
relief. A diaphoretic may be given, such 
as Dover's powder or pilocarpine. Prepa- 
rations should be made for the oncoming 
sweating stage: When this stage arrives the 
patient should, if not before, be placed in 
bed and hot drinks, such as hot lemonade or 
a hot whiskey toddy, be given to promote a 
free flow of perspiration. Other treatment 
is not really needed, except the change of 
the clothing and sponging of the body after 
this stage has subsided, taking care to avoid 
any undue exposure to cold. 
When the diagnosis of malarial fever has 
been made, what is the exact treatment 
which the physician should pursue ? The 
first thing to be thought of is to prevent the 3 
next paroxysm. If you have not treated the 
patient through the various stages of the 
first paroxysm-and in a large proportion of 
cases the physician is not called until a few 
hours after the first paroxysm, or possibly he 
may be called during the sweating stage- 
you learn from the history of the case the 
nature of the trouble and at once institute 
your treatment. In quinine there is a specific 
in the treatment of malarial fevers. Of the 
very few drugs in the physician's armamen- 
tarium which are called specifics, quinine in 
my estimation should rank first. It is the 
one specific which may be relied upon and 
good results expected to follow its use. As 
soon as the paroxysm is at an end commence 
its use. It was formerly believed that the 
administration of quinine in large doses 
(twenty-five to forty grains) was productive 
of the very best results, but later research 
has revealed two objections to this radical 
treatment: First, the poisonous effects that 
may be produced and even profound fatal 
cinchonism that may prevail, some patients 
being very susceptible to its effects; second, 
it is not necessary to give such large doses 
of quinine. We can reduce the temperature 
without such treatment. The sole influence 
of the quinine is to cause the death of the 
plasmodium malaria or germ producing the 
malarial fever; the object being to saturate 
the blood and by such means kill the little 
germ, arresting the next paroxysm. The 
ordinary rule is to administer the quinine in 
small and frequently repeated doses-two to 
three or four grains every hour or two-so 
that by the time for the next paroxysm the patient may have taken from half to one 
drachm. It should be continued until the 
effects of cinchonism are produced. This is 
ascertained by the tinnitus aurium which the 
patient experiences. 
If the type of malarial fever be the quo- 
tidian intermittent, the chances that the par- 
oxysm will or will not return again are about 
even. If of the tertian or quartan type, it 
may safely be said that the paroxysm will 
not return. Cinchonism is a sign that the 
system is fully under the influence of the 
quinine and that the plasmodium malaria has 
been destroyed, although in a few hours, if 
of the quotidian type, the patient may have 
a paroxysm. This can only be explained by 
the fact that a new set of hematozoa have 
reached a certain period of development be- 
fore the effect of the quinine was fully ex- 
erted upon their growth. Give preferably 
the sulphate of quinine in divided doses and 
during the intermission of the paroxysm. It 
is best administered in solution. One drop 
of the aromatic sulphuric acid to the grain of 
quinine makes a very good pill mass. Three 
drops dissolves it readily, to which water may 
be added to form a solution. The same is 
true of tartaric, lactic, citric and nitric acids. 
If the taste is too intensely bitter for the pa- 
tient a syrup may be used, as that of licorice 
or yerba santa. A favorite prescription is the 
following: 
9 Quinine Sulphate, I % drachms; 
Syrup yerba santa, 4 fluidounces. 
M. Sig.: One teaspoonful every two to three or four 
hours for an adult. The bottle should be shaken well 
before using. 
4 If still too bitter give in capsule or konseal 
form. Sometimes fruits or candies may be 
used to destroy the taste. To children the 
preferable mode is to employ the quinine in a 
syrup, as in the above prescription, in doses 
proportionate to age. The following serves 
well and should be tried: 
9 Tincture iron chloride, 2 fluidrachms; 
Quinine sulphate, % ounce; 
Tincture chinoidine, 6 fluidrachms; 
Distilled water, I fluidrachm. 
M. Sig.: Ten to twenty drops for an adult should be 
taken in some water every three or four hours. 
The effects of cinchonism may be reduced 
by combining caffeine citrate (half a grain) 
with quinine (two grains). Antipyrin, anti- 
febrin, and phenacetin in three- to five- or six- 
grain doses also reduce the effects of quinine 
upon the system. These remedies have a 
tendency to relieve muscular pain, headache, 
etc. Their effects should be carefully watched. 
Opium in some form, as Dover's powder, may 
also be used. To reduce the temperature 
aconite may be used per se, or it may be com- 
bined with an opiate, as the tincture of Do- 
ver's powder. Some of the above mentioned 
coal-tar derivatives may also be used. The 
fluid extract of pilocarpine or jaborandi may 
be used to advantage in doses of five to ten 
drops. Aromatic sulphuric acid in four- or 
five-drop doses in water every two hours acts 
well as an antipyretic. A warm bath may be 
given. If the paroxysms be postponed it is 
good evidence that results are being pro- 
duced. If the patient grows worse it shows 
that quinine is not being used, or that it is 
adulterated, or that a complication has set 
5 6 
in. When the paroxysms have been stayed 
a purgative may be given as follows: 
9 Calomel, 3 grains; 
Sodium bicarbonate, 12 grains; 
Sugar of milk, 12 grains; 
M. Make into 12 powders. Sig.: One powder every 
hour until bowels move freely. 
Jalap in small doses may be combined with 
the calomel. Salicin may be given in fifteen- 
grain to one-drachm doses until effects are 
produced, and repeat pro re nata. A saline 
may also be employed. 
Large doses of purgatives and emetics 
were formerly used in the beginning of the 
disease, from the belief that the gastro-intes- 
tinal tract should be cleansed before com- 
mencing the antimalarial treatment. Now- 
adays we first begin with the antipyretic 
treatment and defer the purges until later. 
Bleeding was at one time thought to be pro- 
ductive of very good results, but such treat- 
ment is no longer considered. 
Occasionally a patient is found who has an 
idiosyncrasy to quinine. In such cases what 
is to be done? The cinchonidia sulphate 
in doses twice the size of 'those of quinine, 
or the cinchona sulphate in doses about 
three times the size, may be given. If 
the idiosyncrasy be still too great something 
else must be given. Arsenic in the form of 
Fowler's solution, in doses of five to ten 
drops, well diluted, three times a day, is very 
good. It should be commenced as soon as 
possible after an attack, and continued. It is 
impossible to bring the system under the full 
effects of the arsenic soon; hence it should 
be continued for some length of time. Eupa- 7 
torium perfoliatum (thoroughwort, boneset) 
may be used as a substitute for quinine in 
such cases on account of the intensely bitter 
principle it contains. This is "the poor 
man's quinine." Administer it preferably in 
the form of the fresh fluid extract, in doses 
of a half to one fluidrachm. It is a good 
expectorant, cathartic, and emetic, a high 
diaphoretic, and very good antiperiodic. The 
sulphate berberine in fifteen- to thirty-grain 
doses during the apyrexial period seems to 
yield good results. It does not produce the 
bad effects that the cinchona salts do. Ferro- 
cyanide of iron (Prussian blue) was formerly 
thought to be good; it is probably inert. 
Chloride of ammonia in half- to one-drachm 
doses acts very well during the intermissions. 
Nitric acid in three- to eight-drop doses, well 
diluted, may be given every four to six hours. 
Strychnine in to doses may be 
used. Potassium iodide was formerly thought 
to be curative, but it is doubtful if it has any 
effect upon the plasmodium. Piperine with 
cinchona may be used. In all cases the car- 
diac action should be closely watched. 
Oftentimes a patient is found whose stom- 
ach is so irritable that it will not tolerate the 
quinine. In such cases use the quinine or 
antiperiodic enema per rectum in twice the 
size doses as per os. Only use hypodermic 
injections of quinine in the more malignant 
types of the malarial fevers. 
What shall be done during the period of 
convalescence to prevent the recurrence of 
another attack, and to prevent further in- 
fection ? It is not correct nor is justice done 
to the patient to interrupt the treatment at 8 
once. Keep the patient under the influence 
of the remedy until the plasmodium has been 
entirely abolished. This may be ascertained 
by a microscopical examination of the blood. 
If none be found, and after a few weeks' con- 
tinuous treatment, it may be safely said that 
the patient is free of malaria, although some 
cachexia may remain. A tonic should al- 
ways be given. Prescribe iron and gentian 
or Cornus florida (dogwood). Of the latter 
give the fresh fluid extract of the bark. 
The phospho-muriate of quinine is a good 
tonic. It contains iron, quinine, strychnine, 
and the phosphates in a pleasant vehicle. 
Strychnine in appropriate doses is often pre- 
scribed. The tonic should be continued for 
some time after convalescence has been es- 
tablished. The above line of treatment 
answers very well in the ordinary or regular 
intermittent and remittent forms of malarial 
fevers. The dose of the antiperiodic should 
be larger in that of remittent fever. 
To prevent further infection in a malarious 
district, it is well for the patient to continue 
the quinine in one- or two-grain doses three 
times a day, or its succedaneum in propor- 
tionate doses, for a considerable length of 
time. The patient should be removed, if 
possible, from the infected district until the 
malarial taint has been entirely eradicated 
from his system. Send him to a community 
where malarial fevers are unknown. 
A few words in regard to the diet for a 
patient suffering with malarial fever. Only 
those articles of food which are completely 
dissolved in the stomach and those which 
leave little residue should be given. Milk contains all the elements of nutrition in a 
concentrated form. One may live on a milk 
diet for a considerable length of time. If 
the patient dislikes milk, give something 
else. Liquid food is one which is produced 
by artificial means and subserves the use of 
solid foods. It should be given to a pa- 
tient in a condition to convey the greatest 
amount of nutritive material in the smallest 
bulk. It should be as near a solution 
as possible. Beef - juice and broths, eggs 
poached or lightly boiled, soups, jellies, 
toasted bread, with cream and sugar; oat- 
meal in large quantities acts as a laxative; 
rolled oats, rice well cooked, and some fruits. 
Beef-tea is a very good stimulant, but pos- 
sesses next to nothing in point of nourish- 
ment. Dr. Thudicum, of Liverpool, Eng- 
land, said a few years ago that beef-tea con- 
tained the elements of urine. This is no doubt 
true to a great extent, but nevertheless many 
physicians daily prescribe it as one of the 
principal constituents of the menu of the 
sick-room. 
The irregular forms of intermittent and 
remittent malarial fevers are more intract- 
able and do not yield so readily to treatment. 
The pernicious type is fortunately very rare 
in temperate climates, but is frequently seen 
in the south and tropical countries. There 
are several forms of this pernicious type, 
chief of which are the algid, gastro intestinal, 
comatose, delirious, and hemorrhagic. Two 
types may combine to form a new one. The 
treatment of all the types should be symp- 
tomatic during the paroxysm and through 
the intermission, to prevent the next one. 
9 10 
The quinine should be administered hypo- 
dermically in pretty free doses, care being 
taken not to cause an abscess. It is best 
to administer the muriate of quinine and urea 
in solution. This form of quinine and the 
urea seems to act more forcibly. A sufficient 
amount should be given to induce cinchonism 
as soon as possible. After the paroxysms 
have been stayed, then follow the course of 
treatment outlined above. 
The gastro-intestinal type is sometimes 
mistaken for cholera morbus. The disease 
soon yields to antiperiodic treatment. 
A word in regard to the treatment of the 
hemorrhagic type. It is in this form that we 
observe the malarial hematuria. This form 
is always found in malarial districts, and if 
the malarial fevers be treated properly a less 
number of these cases will be observed. Au- 
thors seem to differ in the treatment of this 
form. Quinine hypodermically, in five-grain 
doses every three hours, should be given to 
act early on the development of the parasites. 
Malarial hematuria or hemoglobinuria is 
due to a peculiar form of the parasite of 
Laveran, and if our line of reasoning be kept 
up, quinine should form an important part of 
the treatment. The patient should be placed 
in bed, kept warm, secretions opened freely, 
and the kidneys spared. Gallic acid in five- 
to ten-grain doses every two to four hours 
may be given. Tincture laricis cortex in 
twenty- to thirty-minim doses every three to 
four hours serves well. In this form there is 
a great tendency to heart failure. The car- 
diac stimulation and tonics with good food 
should be kept up. 11 
The mortality from any of the types of 
pernicious malarial fever is high, and if the 
treatment be not active from the outset, little 
or no results may be expected. 
The aestivo - autumnal or typho-malarial 
type, in which the paroxysms are little or not at 
all marked, and the fever more or less continu- 
ous for several weeks, appearing late in the 
summer or early autumn, usually yields readily 
to the antiperiodic treatment. After the 
paroxysms have been broken and some little 
pyrexia continues, the ordinary treatment for 
typhoid or other fevers should be carried 
out. 
The more irregular forms of malarial fevers, 
as diarrhea, brow or sun pain, or anesthesia 
of arm, neuralgia, especially of fifth, seventh, 
and sciatic nerves, and menorrhagia in women, 
are the most frequent. Look for the causes 
and remove them. The patient should be 
placed on larger doses of quinine than for a 
common attack, and in the course of a few 
weeks good results will be noted. 
Dyspepsia may occur in paroxysmal at- 
tacks. Use quinine in good doses or Fowler's 
solution in five- to ten-minim doses, well di- 
luted, three times a day until its effects are 
noted; it usually effects a cure. 
A pneumonia may complicate a malarial 
infection. Eliminate the malarial element 
with the antiperiodic treatment, and in thirty- 
six hours obtain the crepitus redux. 
Fractures should be watched in a malarious 
district lest union be slow. Better give a 
little quinine on general principles. In all, the 
exact treatment of malarial fevers consists 
in eliminating the plasmodium of Laveran from the system of the patient by whatever 
mode and means are best suited to the patient. 
Tonics and supporting treatment should fol- 
low in the wake. 
12