For the regular intermittent types of the disease (tertian and quartan ague) 15 grs. Quinine Hydrochloride should be given by the mouth, though often a smaller close is sufficient, and 5 grs. twice a day afterwards meet the indications in all cases.
The irregular intermittent, the remittent, the continuous and pernicious types Nv 1 I require a more prompt and thorough saturation of the blood.
grs. of the Acid I hydrochloride should be injected deeply into the buttock, or, better still, into a vein, and 5 grs. given by the mouth every 4 hours after. Rarely is it necessary even in the worst cases to exceed a daily dose of 45 grs. A man of 140 lbs. weight who has received an intravenous injection of 15 grs. will have sufficient quinine in his blood to correspond to a solution of 1 in 5,000, and i in so,000 is quite sufficient to destroy the allied amceboid organisms in hay infusion.
When even double the above amounts of the insoluble sulphate of quinine are administered by the mouth they are slowly absorbed by the gastric mucosa, and the constant elimination of the drug by the kidneys prevents any high degree of saturation of the blood by the drug. so that it is quite possible for the victim of pernicious malaria to perish with a large amount of unabsorbed quinine in his stomach: hence the necessity in all grave and urgent cases to place the whole dose at once in his circulating fluid.
Quinine has apparently no influence over the gametocytes, hut as these bodies only appear after the asexual forms have reproduced themselves in the blood, it is probable that early resort to treatment diminishes the chance of their formation and tends to prevent the spread of the disease by the mosquito.
Cohen advocates the deep injection of f grs. Quinine-Urea, which, like the acid hydrochloride, is soluble in its own weight of water. and he states that after a single injection there is an apyrexial period of either six and a half or thirteen days, which is of important diagnostic significance.
Upon the whole the best injection for intravenous use is the following formula: B. Quinincc Hvdrochlor. Acidi gr. XV.
Sodii Chloridi gr. j.
.-Iquce Destillake 5iij.
For intramuscular or deep injection. grs. of the acid hydrochloride should be dissolved in r dr. water and administered after the solution has
been sterilised by boiling in a test-tube.
The " Koch " treatment of malaria is carried out by commencing with a preliminary dose of 5 grs. Calomel, followed by a saline purge in 6 hours. If a blood-film shows parasites 15 grs. sulphate of quinine are given by the mouth, and this dose is repeated each morning for 5 days. r s grs. are given on the tenth, eleventh and twelfth day. and repeated every tenth day for a period of 13 weeks.
Whichever method or plan of employing the drug is to be accepted. the guiding principle should be to produce a rapid saturation of the blood and to keep up the effect till all traces of the parasites have disappeared from blood-films taken periodically. When this latter technique has to be dispensed with in practice, the drug should be continued for long periods, since its administration can do no harm save in some cases of Blackwater fever (which see).
It is useless to print the long list of drugs which have been, and still are, recommended for the treatment of malaria. The action of quinine must be regarded as of the nature of a true specific. Enesol or Salicyl-Arsenate of Mercury, Methylene Blue, Tartar Emetic, Arsenic, Salvarsan, various Cinchonine salts, and the Cacodylates and Warbur,cfs Tincture may be tried when from any reason quinine cannot he tolerated.
In the treatment of the so-called Malarial Cathexia Quinine is often of little use if given alone ; Arsenic and Iron are always indicated, hut they should be combined with quinine. A pill containing the following answers most cases, whether of enlarged spleen, anmmia, neuralgia, or cardiac weakness supervening upon old attacks of malaria: . Ferri Arsenatis gr. 1.
Ferri Redacti gr. j.
Ext. Voiniere gr. ss. Quininte Sulphatis gr. iij.
pa. St. noant ter in die post cibion.
The splenic enlargement, like most of the other sequelce, often resists every form of treatment till the patient is removed from the malarious district. A long sea-voyage or a sojourn at a spa where hydropathic measures may be employed with the internal use of a weak arsenical water, as at Bourboule, Vats, Mont Dore, and Plombires, or at Woodhall in Lincolnshire.