TREATMENT 



1189 



very much in the degree of pain or discomfort which they produce, but some 

 (in pre-war preparations) caused very little pain if given, as should always 

 be done, with the strictest antiseptic precautions. For fuller instructions 

 see Method of Administration, p. 11 93. 



Do not hesitate to give intramuscular injections of quinine. They 

 have saved many lives, but the strictest antiseptic methods must 

 be used. 



III. In Pernicious Malaria. — In pernicious fevers give quinine 

 at once by intravenotis injection. 



The quinine injection should be made into the median basilic or median 

 cephalic veins, and not less than i gramme (15 grains), dissolved in sterile 

 5 CO. of physiological salt solution, should be injected at a time. The 

 skin over the selected vein should be rendered thoroughly aseptic by 

 soap and water and carbolic lotion, or by painting with tincture of iodine, 

 and then a bandage tied round the arm, so as to retard the flow of venous 

 blood and make the selected vein stand out. Then the needle should be 

 inserted into the vein (care being taken that there is no air in needle or syringe) 

 in a sloping direction, with the point towards the heart, so that the injection 

 can flow with the circulation. The point of the needle should be felt to be 

 loose {i.e., in the vein). The bandage must now be loosened and the injection 

 made slowly, the effect on the pulse being noted. The needle is now with- 

 drawn, and an aseptic pad fixed in position by a bandage. 



The effect of quinine on the circulation must be remembered, and if the 

 pulse is bad, it is advisable to give an injection of ether as a preliminary. 



If the serious symptoms persist the intravenous injection may be 

 repeated in four hours, and further medication may then be carried 

 on by intramuscular injections. Not more than two intravenous 

 and two intramuscular should be given, under any circumstances, 

 in twenty-four hours. 



When the serious symptoms abate the intramuscular injections 

 alone should be used, and should be given once or twice a day, 

 and supplemented by oral administration, as indicated above. 



B. During the Course of the Fever. 



I. // the symptoms are abating the dosage of quinine may be 

 reduced slowly to about 30 grains per diem, but this must not be 

 done too ^quickly, and care must be taken to increase this dosage 

 at once if there are any signs of a return of the symptoms. 



During the course of the fever the bowels must be kept regularly 

 open, the urine must be carefully watched as to quantity and colour, 

 and tested chemically from time to time, while blood examinations 

 should also be made at times and the pulse carefully noted. 



II. If the symptoms are not abating the probability is that in- 

 sufficient quinine is being administered, and in such cases the drug 

 should be carefully increased. 



If only oral administration has been used it should be at once 

 supplemented by intramuscular injections. 



Care should als6 be taken that the bowels are kept well opened, 

 that a sufficiency of fluid is drunk to provide a good flow of urine, 

 and that the heart's action is well supported by stimulants and by 

 drugs if necessary. 



