Whilst the above methods of treatment are important, it should be clearly recognised that the one drug which can alone counteract the malarial affection is quinine, and it is upon the proper administration of quinine that successful treatment largely depends.
This proper administration necessitates at the outset rest in bed, and it also necessitates a continuance of the drug for a sufficient length of time. For ordinary cases the best way is to give quinine by the mouth, and here again it is best given in solution, though it can be administered in solid form if the precautions above indicated are duly observed. Various doses have been advocated, but probably the best quantity to administer is 30 grains every twenty-four hours. This is usually given in three doses of 10 grains each, but there would appear to be an advantage in giving four doses instead of three, and Colonel James advocates the following times for administration, i.e. 12 midnight, 6 a.m., 12 noon, 6 p.m. He does so, because such a method of administration is likely to ensure that there shall be a sufficient concentration of quinine in the blood at the time when the youngest forms of the parasite are present. The patient should remain in bed, if possible, for ten days, or, if this is impossible, for at least half that period; and it is essential that the quinine should be given as soon as possible, and quite irrespective of the stage of the attack or the height of the fever. If its administration is followed by vomiting, give a small teaspoonful of bicarbonate of soda in warm water. If this is rejected repeat the dose, and then give some form of stomach sedative, such as bismuth, and dilute hydrocyanic acid or 20 drops of chlorodyne. A mustard leaf applied to the pit of the stomach is often helpful. Sometimes drop doses of tincture of iodine, well diluted, will check these troublesome symptoms. Under ordinary conditions this 30-grain quinine treatment should be steadily continued for at least five days, but in troublesome cases it may be necessary to carry on with it for as long as three weeks. Thereafter what is called the “after treatment” is begun and must be continued for a period of three months, in order to ensure, if possible, an eradication of the infection.
There are several ways of carrying out this after treatment, but one of the simplest and most effective is to administer 10 grains of quinine every day, the dose being taken an hour or two before the time at which the fever was apt to come on during the attack.
If, despite quinine treatment, relapses occur, the patient must go to bed and be treated as for the first attack, and the after treatment must again be carefully carried out.
Under certain conditions quinine has to be injected by the needle, either into the muscles or into a vein; but, as a rule, this should not be done save by the medical attendant. It should, however, be remembered that the drug may be given by the bowel, in which case twice the quantity of quinine which would be administered by the mouth should be given. It is only exceptionally that this procedure will have to be followed, but it is sometimes useful in the case of children.
The feeding of the malaria patient is important. Between the attacks of fever, or during the sweating stage, he should be given food in fluid form, such as chicken broth, eggs beaten up with milk, raisin tea, etc.; and as soon as his stomach will stand it, the diet should be increased. Tonics, such as iron and arsenic, are required during convalescence.
In cases where there is acute malarial poisoning, with temperature 106° F., or even higher, do not wait to undress the patient or get a bath; but empty gallons of water over him, one boy keeping the head constantly soused; while this is being done a bath can be procured and the patient then undressed, or, better still, have his clothes cut off, because it is dangerous to lift such a patient about too much. Remember that when a patient is very ill and weak, he should not be allowed to stand or sit up suddenly, as he may faint.
Delirium with high temperature, say 106° F. or over, is a certain sign that the fever is doing harm, and must be reduced.
The temperature and pulse should be carefully watched when the cold water treatment is employed.