TREATMENT IN MALARIAL FEVER 57 



Some of the Indian authorities before using the quinine 

 injections inject antitetanus serum. 



(4) Intravenous injections are used in pernicious cases 

 by some ; it is doubtful if the results are better than 

 those obtained by rectal injection. In the strengths 

 often used Semple has shown that much of the quinine 

 is precipitated and that much greater dilution is required 

 for the quinine solution to be miscible with the blood. 

 W. M. James advocates such dilute solution as i in 150 of 

 normal saline, either subcutaneously or by intravenous 

 injection. He gives 30 gr. of the bihydrochloride in 

 10 oz. of normal saline and uses it when the infec- 

 tions are large, or when for other reasons he suspects the 

 probability of the onset of cerebral or other crisis. 



Dosage. This is most important. It may be stated 

 with confidence that, where the diagnosis is verified by 

 blood examination, treatment with quinine never fails if 

 the doses be sufficient and there is time for the drug 

 to act. 



In many cases small doses will suffice ; even the amount 

 of quinine contained in a drachm of Easton's syrup may 

 bring the temperature down to normal. Ten to fifteen 

 grains of any of the salts of quinine daily will usually 

 suffice for benign tertian and quartan, and sometimes 

 for subtertian. It is more uniformly satisfactory to give 

 30 gr. daily till the fever is down and then reduce the 

 amount. Where it is absolutely necessary to economize 

 the quinine, it will be better to give a single dose before 

 an expected rigor, as a smaller dose will then suffice 

 to relieve the pyrexia. 



In severe cases with pernicious symptoms no time 

 should be lost ; moderate or even large doses so often 

 fail, that if life is to be saved the risks of quinine poison- 

 ing must be faced. In such cases in adults a single 

 dose of 20 gr. should be given at once, preferably 

 per rectum, and repeated in an hour, and 10 gr. given 

 every hour till improvement takes place, usually a matter 

 of some four or six hours. Even in young children 



