116 REVIEW — TROPICAL MEDICINE, ETC. 



Malaria — contain quinine solution (or soloids), castor oil for heating, and solution for sterilising the skin. The syringe is 



conliiiued sterilised by drawing the hot oil up into it three or four times. The oil is at the right temperature when a blade 



of grass tizzies the moment it touches its surface. I use an improvised case containing these things in a tobacco tin. 



I consider that the intramuscular administration of quinine is of most use as a preventive of frequently 

 recurring ague attacks, or to obviate relapse after the cure of an attack of malarial fever. I have known it to put 

 a stop to recurrent ague attacks, where dosage Ijy tlie mouth had failed. I have not found it of special advantage 

 in curing malarial fever. 



Moncrieff' remarks : — 

 My experience of the various quinine salts I used hypodermically was as follows : — 



1. Hydrobromidc. — Solubility 1 in 24 of water. Moder.ately irritating and not sufficiently soluble. Dissolved 

 with difficulty in hot water and became precipitated again as the fluid cooled. 



2. Acid hydrochloride. — Solubility 1 in 6 of water. I only used this salt once, as it caused much irritation 

 that persisted for a long time. I also injected it into my own arm and found it painful and irritating. 



3. Hydrochloro-carbamide or urea-quinine. — Very soluble and unirritating. 



4. Acid hydrobromidc. — Solubility 1 in 6 of water. I found this the least irritating of the salts I used. 

 I made an injection into my own thigh, and next day could scarcely find the place without looking for the 

 puncture mark. 



This quinine salt is quoted in few of the catalogues of drugs that I have seen. I found it described in 

 " The Extra Pharmacoposia," Tenth Edition. Treacher & Co. obtained it for me with some difficulty. 



If a solution be made of strength 1 grain quin. hydrobrom. acid to 74 minims of water, the excess of water 

 allows the thorough sterilisation by boiling without the risk of the salt becoming precipitated. Contrary to what 

 one would expect, quinine is more easily given to an infant hypodermically than by the mouth ; at least, such 

 was my experience when using the acid hydrobromidc or urea-quinine. For infants the needle should be sharp 

 and of small calibre and the syringe should have finger-grips. I found the fine Schimmel needles very 

 convenient. 



Till recently, I was under the impression that hypodermic injection is, next to intravenous injection, the most 

 rapid way of getting quinine into the circulation, but recent observations show that this is at least improbable. 

 With hypodermic injection, as compared with internal administration, the longer the continuance of the fever, the 

 comparative absence of cinchonism, the slow excretion of quinine and the not infrequent persistence of irritation 

 at the seat of inoculation, all these favour the view that quinine is absorbed slowly when given hypodermically. 



Fm-ther knowledge about this important matter is much needed ; for if this recent view be correct, the giving 

 of quinine hypodermically will only be indicated when its exhibition by the mouth is contra-indicated or in cases 

 of severity when the two methods might be combined, as suggested by Captain Megaw. 



Holt writes that relatively much larger doses of quinine are required for children than for adults, and that an 

 infant of a year will usually require from 8 to 12 grains of the sulphate or 10 to 14 grains of the bisulph.ate daily. 

 He occasionally gives double this quantity. 



Williamson- states that he finds "A. & H. 'Aseptic slab,' Is. &d., invaluable for any 

 such hypodermic administrations, as the depressions are easily sterilised by the flame and 

 aU measuring saved as they accurately hold 5 and 60 minims respectively, and hold the 

 syringe upright while the skin is being purified, etc." 



Symons' declares that he can fully endorse the efiioiency of administering the drug 

 " with the needle." 



The salt used is the acid hydrochloride of quinine which will dissolve in equal parts of distilkd water. 

 This solution is made up in the dispensary of the hospital, in an ounce bottle, and used when required. 



The technique is as follows : — 



1. A small hypodermic syringe is used, the needle of which is sterilised by boiling for 2-3 minutes in a test 

 tube. The syringe is washed out with 1 in 20 carbolic lotion by means of drawing up some of the lotion into the 

 syringe 3-4 times. A small spoon is also placed in the 1 in 20 carbolic lotion and is used to receive the quinine 

 lotion when it is poured out from the bottle previous to changing the syringe. The glass stopper, together with 

 the neck and mouth of the bottle, are thoroughly cleaned with a sponge dipped in 1 in 20, and the part, into 

 which the solution is to be injected is, of course, prepared in the usual way. I consider all the above details 

 absolutely essential, especially the cleansing of the bottle — a point likely to be forgotten. 



The dose is 10 minims, equal to 10 grains of the salt, intramuscularly in the deltoid muscle. If it be given 

 hypodermically, trouble in the shape of a superficial abscess m.ay arise ; never, however, when introduced into the 

 muscle. As to tetanus, such a disease should never deter one from intramuscular injections, if the above 

 precautions be taken. I have been injected in the deltoid on many occasions about 10 a.m., and have played polo 

 the same evening, which speaks for itself as regards after local effects. 



Sometimes a slight aching sensation occurs, whilst the solution is being injected, but it passes off immediately. 



To my mind there is no comparison in the two methods, i.e. by injection, and by the mouth. By the former 

 method you make absolutely sure of the patient receiving the dose of quinine which you adminster, and you do not 

 derange the digestive organs. 3rd, the patient must have quickly come under the influence of the drug — a very 

 important factor in " malignant " cases. The temperature comes to normal in 24-30 hours and stays there. In my 

 wards the usual practice is to inject on three successive days and then on alternate days for the week, to make sure 

 of the p.atient being quinised. 



> Moncrieff, W. E. S. (March, 1907), "The H^qoodermic Use of Quinine." Indian Medical Gazette, p. 114. 

 - Williamson, J. R. (March, 1907), "The Hypodermic Use of Quinine." Indian Medical Gazette, p. 115. 

 ' Symons, T. H. (May, 1907), "The Hypodermic Use of Quinine." Indian Medical Gazette, p. 191. 



