To adults 0.3 to 0.5 quinin hydrochlorate or bihydrochlorate is administered three to five hours after the expected paroxysm. This is repeated four or five days, even when no further paroxysm occurs.
In order to prevent a relapse, a week after the last paroxysm a similar dose is administered two or three days in succession, at the same time of the day as previously. This is repeated a week later. After this, in cases of infection with parasites of the first group, we may reckon with considerable certainty on the non occurrence of a relapse, naturally omitting new infection.
In the case of malignant tertian, the paroxysms of which are very long, the intermissions or remissions short, the blood examination must act as a basis for the therapy. The occurrence of a large number of parasites with concentrated pigment announces the approach of a paroxysm. The remedy, therefore, is to be administered at this time.
After determining the diagnosis, 1.5 to 2.0 quinin is to be administered within two to four hours either per os, or, if vomiting results, hypodermically. Clysters are less efficacious. One gram should be repeated every twelve hours until a fall of temperature takes place, and later every twenty four hours for four to six days.
It must be remembered that these fevers usually relapse obstinately, and that the blood examination is the only basis for a rational therapy. As long as crescents alone are visible quinin is useless, but as soon as ameboid organisms appear, 1.0 pro die should be pushed until they have vanished. This must be repeated while the blood examination shows the continuance of the infection. In these cases we actually have to do with a fractional sterilization of the blood.
When not in the position to control the case by microscopic examinations of the blood, quinin should be administered in a similar way to that described for intermittent fever and continued from week to week.
Fevers with severe or pernicious symptoms demand immediate subcutaneous or intravenous injections. Doses of 1 or 2 gm., or at most 3 gm., should be given at once, according to the severity of the symptoms, and later 1.0 every six to eight hours, as long as the condition of the patient requires it. Afterward smaller doses at longer intervals should be exhibited. Individual peculiarities in any case may give reason for deviation from these rules; still, they represent the general principles of treatment.
In children under six years the rule of 0.1 quinin daily for each year is generally applicable. Children under one year, therefore, may be given 0.05 to 0.1; those from one to four years, 0.1 to 0.4 quinin pro die. In severe infections these doses may, in fact should, be doubled. Children bear subcutaneous injection quite as well as adults.
The treatment of blackwater fever requires a special discussion on account of the different standpoints from which it is viewed, and, looking at the literature at hand, we are compelled to say: "Quot capita tot census! "
These opinions may be divided into two chief groups: one insists on the energetic employment of quinin, the other rejects it. The reason for this divergence is the difficulty in differential diagnosis between genuine blackwater fever and quinin intoxication.
We have already pointed out, in another section, the factors entering into this diagnosis, and among them, needless to say, the blood examination holds a high place. The following general rules are usually applicable:
When, without quinin preceding, hemoglobinuria occurs and the blood examination shows the presence of a malarial infection, quinin is undoubtedly to be exhibited. When the hemoglobinuria occurs after one dose of quinin, while the anamnesis shows that the patient previously took quinin without bad effect, and parasites are present in the blood, quinin is also to be exhibited. If a paroxysm of hemoglobinuria should follow within a few hours, the repetition of the drug should be made dependent on whether or not the parasites have in great part disappeared. In the former case the quinin may be stopped, at least for a time. But if the blood examination shows that the parasites have increased in number, the quinin is to be continued.
When the anamnesis shows that the patient suffered previously from hemoglobinuria following quinin, and the blood examination is negative, quinin is to be absolutely avoided. When the case manifests a severe malarial infection (numerous parasites on examination) and at the same time an assured intolerance to quinin in the shape of hemoglobinuria, the decision is very difficult.
In such cases we must bear in mind that the patient's life may be endangered by one dose of quinin and again by the omission of it, on account of increasing infection. Something must be done, and there is no time for experimentation with other remedies. Consequently if the symptoms continue to increase in severity, there is nothing to do but play va banque and grasp at quinin. Not too small a dose should be given, for then nothing is accomplished in regard to the infection, and a paroxysm of hemoglobinuria is produced just the same. Still, we cannot recommend Steudel's colossal doses of 8 to 10 gm. pro die, but would suggest 1.0 to 2.0.
Tomaselli went to considerable trouble to find a substitute for quinin for these cases, or at least a means by which its poisonous property would be rendered inactive, but without result. In one case only he succeeded in evading the paroxysm by the simultaneous employment of opium with the quinin. Coglitore asserts that he has obtained good results by a combination of quinin with opium and ergotin. He recommends:
B. Quinin. sulph.............................0.75
Ergotin. Bon jean..........................0.30
Sig.-Div. in dos. iii. One powder every hour.
Further observations are required to determine the value of this combination.*