QUININE 



II93 



directly at the end of the meal, so that it can enter the blood with 

 the products of digestion, and so obtain its fullest action. It has 

 been our rule in most cases to advise that it should be taken directly 

 after the early morning meal. 



The hsemolytic action of quinine must be remembered, and the 

 fact that it may by this action give the liver more work by extra 

 bile production. Consequently, it is most necessary to remind the 

 above class of patients to take care that the bowels are open regu- 

 larly, and to correct by suitable aperients any irregularity that may 

 exist. 



With regard to mild quartan and tertian fevers, there is not the 

 slightest doubt that excellent effects are obtained by giving the 

 drug four hours before the attack — i.e., before the sporulation of 

 the parasite is due. In this way the merozoites are most likely 

 to be killed. This may be modified by giving the drug twice daily, 

 one dose of lo grains by the mouth in the morning, and the other 

 dose of 10 grains at the above-stated time. This method we have 

 found most useful, as it allows for irregularity in sporulation. 



In many cases, however, we give the drug three times a day, 

 without regard to the conditions of parasitic life, and this method 

 is apparently not less successful. 



In more severe forms of quartan and tertian, and in cases of 

 subtertian fever in which the patient is seen for the first time during 

 the attack, the drug should be given intramuscularly or by the 

 mouth, when it may be administered on the fall of the tempera- 

 ture, when the gastric irritation is lessening, and then continued by 

 one of the above methods. 



In cases of serious and of pernicious attacks, time must not be 

 wasted in waiting for temperatures to fall or for symptoms to im- 

 prove, otherwise the patient will die, and there must be no hesita- 

 tion in giving either an intramuscular or an intravenous injection, 

 according to the severity of the symptoms. 



Method of Administration.— For practical purposes there are 

 only four methods of administration: — 



1. By the mouth. 



2. By the rectum. 



3. By intramuscular injections. 



4. By intravenous injections. 



By the Mouth. — ^If expense is no object, take the most soluble 

 drug that can be got, and use either the bihydrochloride or the 

 bisulphate; otherwise the sulphate must be used. In cases of 

 women and children, euquinine may be used with advantage, but it 

 should be remembered that it is very insoluble and expensive. 



The forms in which the chosen drug maybe administered are: — 



1. Powder. 



2. Solution. 



3. Tabloid, tablet, or pill. 



4. Cachet or capsule. 



