686 ACUTE INFECTIOUS DISEASES 



already described the difference between gastric catarrh due to inJi 

 gestion and the slignt dyspepsia accompanying most fevers which re- 

 quires no emetic, and does not prevent our giving quinine. Pfeufeft 

 recommendation, to give quinine in one large dose instead of in several 

 smaller one sduring the apyrexia, has very rightly become popular. 

 Usually, in adults, one dose of ten grains of sulphate of quinine suffices 

 to arrest the chills ; in children, five grains suffice, in still smaller chil- 

 dren, two or three grains answer. Another slight chill often occurs, 

 and the attacks then cease. It is best to give this dose of quinine 

 some hours before the expected chill, so that we may be sure of its 

 acting during the apyrexia. Small doses should only be preferred 

 when large ones are vomited by the patient ; in such cases we may 

 give two grains every two hours, till twelve or fifteen grains have been 

 taken during the apyrexia. Quinine is most frequently given in pow- 

 der or pill (quiniae sulphat. gr. x, ext. gentian, q. s. ut f. pill. no. iv). 

 Solution of bisulphate of quinine (quinise sulph. gr. x, aquae meliss. 

 % iij, acid, sulphur, dilut. 3 ss, syrup. ss) is said to be particularly 

 effective, but it is unpleasant to take, especially in large doses. If 

 quinine is not borne by the stomach, it may be given by injection, as 

 it acts just as well by the rectum (or by hypodermic injection). Other 

 salts of quinine have no advantage over the sulphate ; quinoidine and 

 tincture of quinoidine are cheaper, and hence may be preferably used 

 in poor practice ; of the latter remedy we may give twelve or fifteen 

 drops every two hours, or give a teaspoonful a short time before 

 the expected chill. According to Wunderlich, this is quite as effica- 

 cious as quinine. If the patient has escaped one chill under the above 

 treatment, he almost always escapes a second and third, or even a 

 number ; but it is advisable to continue small doses of quinine for a 

 few days longer, unless the spleen has distinctly and steadily de- 

 creased in size. The more perfectly the spleen returns to its normal 

 bulk, the greater is the probability that there will be no relapse. I 

 have already given my ideas about the custom of repeating the qui- 

 nine on the seventh, fourteenth, twenty-first, and twenty-eighth days. 

 When this is being done, the chill often occurs on the day just pre- 

 ceding the one when the medicine was to be given. I think it much 

 safer to tell the patient that he will probably have a relapse toward 

 the end of the second, third, or fourth week, and that at these times he 

 must watch carefully for any premonitory symptoms, and on the 

 slightest suspicion of a chill he must take a full dose of quinine. By 

 careful attention to the rudimentary attacks which almost always pre- 

 cede perfect relapses, most patients of moderate intelligence may pro- 

 tect themselves from the latter. The belief, that, in cases of relapse, 

 the patient must daily take an ounce of tincture of Peruvian bark ir 



