TREATMENT OF CHRONIC MALARIA 



1199 



should be placed on a tonic with iron and arsenic in some form, and 

 if he has been seriously ill he must have a change to a colder climate. 

 The patient must be impressed with the fact that he must not dis- 

 continue the quinine on arriving in a cooler climate, as an attack 

 of fever will surely take place if he does so. 



Treatment of Chronic Malaria. — -If a person is constantly 

 suffering from attacks of malarial fever, he should be sent, whenever 

 possible, for a change to a cooler climate in the hills or to the tem- 

 perate zone, but should, of course, continue the quinine treatment. 

 If he cannot afford a change of climate, he must be placed in bed 

 and given rest from work, and a course of quinine therapy by intra- 

 muscular injections carried through. Arsenic is useful. 



Treatment of Malarial Cachexia. — -The most important fea- 

 ture, in addition to quinine treatment, is to send the malarial 

 cachectic for a change of climate, as mentioned above, and treat 

 the anaemia with iron and arsenic. A course of injections of 

 cacodylate of quinine is often useful. 



Theoretieal Considerations. — There are a number of theoretical consider- 

 ations with regard to the treatment which may perhaps interest the reader, 

 and these may be divided into : — 



1. Quinine. 



2. Effects on man. 



3. Effects upon malarial parasites. 



4. Immunity of parasite. 



5. Prophylactic use. 



6. Other drugs. 



Quinine. — The aim of the treatment of malaria is to kill the parasites 

 and to aid the excretion of the toxins and relieve the symptoms of the patient. 



Fortunately, since the days of the Countess del Chinchon, the world has 

 known the value of cinchona bark in malaria, and later it learnt that this 

 important action was due to an alkaloid, quinine, which exists in the bark in 

 the form of a hydrate. In 1867 Binz showed that quinine killed infusoria, and 

 he believed that this action was due to its checking oxidation. 



Quinine is usually sold in the form of the sulphate, [(C2oH24N202)2. 

 H2S04J2.I5H20, which is only soluble i in 800 of cold water, but is readily 

 soluble in water acidulated with a mineral acid. The solution gives a bluish 

 fluorescence. 



It must be remembered, however, that it may not be pure, and may contain 

 lime, chalk, magnesia, starch, etc. It is also important to remember that it is 

 incompatible with alkali, alkaline carbonates, and astringent infusions. 



Quinine sulphate is by no means the best preparation, for the hydrochloride, 

 (C2oH24N202).HC1.2H20, is soluble i in 40 of water; but better than this are 

 the acid salts of the sulphate, called the ' bisulphate,' (C2oH24N202)H2S04. 

 7H2O, which is soluble i in 11 parts of water, and of the hydrochloride, called 

 the ' bihydrochloride,' (C2oH24N202)2HCl, which is soluble i in i of water. 

 Numerous other preparations are on the market, of which quinine bihydro- 

 bromide is recommended in persons who suffer from deafness, and quinine 

 valerianate in those who are very nervous ; while quinine tannate, which is not 

 nearly so bitter as the other compounds, especially when made up with choco- 

 late, has been used by Celli in quinine prophylaxis for children and in cases 

 of haemoglobinuria, 



Euquinine, which is quinine ethylcarbonate, C2H5O — CO — OC20H23N2O, is 

 also not so bitter as the ordinary preparations, and is therefore suitable for 

 administration to women and children, but it has the disadvantage of being 

 expensive and very insoluble in water, and must be given in cachets or dis- 



