Liable as all residents in the Tropics are to be attacked with fever at times and places where skilled medical assistance is not obtainable, it may be well to conclude this chapter with a few words on the treatment of the malady. This really resolves itself into the adequate administration of quinine; for provided a sufficiency of the drug can be got into the circulation, it will, I believe, always cure malaria; but it is one thing to make the sick man swallow the drug and another to secure a sufficiency of it being absorbed into the blood; and unless this takes place, the remedy can have no more effect than as much oatmeal or any other inert substance. Anyone who has suffered from a severe attack of malaria, or had the nursing of a case, must have noticed that want of power to tolerate or digest even the lightest food, is one of its most prominent symptoms. In the more virulent type of the disease, nausea and vomiting is one of its most distressing features, and are nothing more than the outward manifestations of the fact that the digestive organs have ceased to perform their functions, and this may be equally the case, even where these additional evidences of the fact are not so prominent.
A little reflection will show that it is very unlikely that quinine or any other drug will be absorbed by a stomach that can no longer deal with even the lightest food, and hence it is not surprising that the severer forms of remittent fever will often resist quinine for long periods. For the same reason that quinine so often fails to do good in virulent cases, it is equally obvious that it is unlikely to do harm, and the absurd theory that “blackwater fever” is the outcome of treating malaria with quinine may now, I think, be said to be abandoned by all, save perhaps one or two of its original propounders; for though quinine appears to be of but little value in the treatment of that doubtfully malarial disease, it has now again and again been shown to occur in patients who have taken no quinine at all.
It cannot, therefore, be too strongly insisted upon that, in spite of failure to produce immediate effects, the administration of quinine should be steadily persisted in, as sooner or later in almost all cases a sufficiency will be absorbed to check the disease.
From what has been said, it is clearly important to do our best to put the digestive organs, if possible, in a position to perform their functions, and as in the majority of cases the sluggish bowels are loaded with half-digested or undigested food, it is a good general rule, as a preliminary to the administration of quinine, to administer some unirritating laxative, for which purpose nothing can be better than our old friend and bugbear of childhood, castor oil; and the dose should be repeated whenever constipation becomes a symptom in the course of the case. Once the laxative has acted, the sooner quinine is administered the better, and, unless the patient be one of those unfortunately constituted persons who are unable to take it—and there are some few to whom quinine seems as poisonous as it is to the malarial parasite—it should be given in full doses to the extent of 20 or even 30 grains (1 to 2 grammes of metric system) in the twenty-four hours. A dose of 10 grains, followed by others of 5 grains each, will usually be found a convenient plan of administration; but there are cases which do better with smaller doses more frequently administered. The best way to give it is, I think, to stir up the powder in a little milk; and it may be well here to offer a word of caution as to the employment of the drug in the form of tabuloids. For some reason, the drug appears difficult of digestion in this form, for I have repeatedly found fever yield at once to the ordinary powdered form of the drug, after days of fruitless treatment with quinine tabuloids obtained from firms of so high a reputation that the suggestion of the substitution of some less expensive material for quinine is quite untenable. The indiscriminate use, too, of antipyrin, phenacetin, &c., is also to be deprecated. They are all powerful depressants; and though they afford great relief to the aches and weariness of an attack of fever, undoubtedly have no effect whatever in curing the disease, even if they do not, as I have often been inclined to suspect, tend to prolong it. Where the suffering is very acute, an occasional dose may be of use for securing rest, but anything like continuous dosing with medicines of this sort should be carefully avoided. On the other hand, the old-fashioned “fever mixture,” composed of ten or fifteen drops of nitrous ether with a drachm of Minderus’ spirits (liquor ammoniæ acetatis), every four hours, in a wineglass of water, is often of great use in favouring perspiration, besides acting as a useful diuretic; and may be recommended as not only affording much relief to the patient’s subjective symptoms, but also of being absolutely safe even in inexperienced hands.
Except in the weakness of very prolonged attacks, stimulants should be but sparingly given, but they should not be withheld when the patient is flagging, and obviously falling into what is known as a “typhoid state.”
It is almost needless to remark that care is required in the matter of diet. During the febrile periods “slops” only should be given, and then in not too large quantities at a time; but in those cases where there is a distinct fever-free interval between the paroxysms of the disease, a great deal of license may be allowed, and solid food of a light digestible sort is often not only well tolerated, but even beneficial, while it is almost needless to say that these intervals of returned digestive power should always be seized upon to get a liberal supply of quinine into the system. During convalescence the administration of 10 to 15 grs. a day of quinine should be maintained for at least a week after the disappearance of all febrile symptoms, and some ordinary tonic, such as Easton’s syrup, is often useful in facilitating the return to strength.
The least sign of a relapse, as evidenced by a rise of temperature, of however temporary a character, should be met with a further treatment with quinine for at least a week or ten days, as it is a clear sign that the disease is scotched, but not killed, and that some of the parasites are still lingering, in a latent condition, within the system; for the patient cannot really be considered as cured till the last of these is put an end to.
The length to which this chapter has attained may be justified by the fact that the universality and the extent of the mischief wrought by malaria in tropical climates renders the subject by far the most important of all in connection with the preservation of health in the tropics; and the writer trusts his readers may be moved to do as much as they possibly may to preserve themselves and their neighbours from the havoc wrought by this insidious disease, for without an informed and intelligent public opinion to back them, no possible efforts on the part of sanitary officials and medical men can be expected to exercise any great or lasting effects on the prevalence of the disease.