prevent the next succeeding fit, but it nearly always diminishes its severity. In ninety-nine cases out of a hundred the second following attack does not develop.
When giving quinine it is well to administer an aperient and to keep the patient in bed; in ordinary cases neither aperient nor rest in bed is absolutely necessary. In cachectics, however, and in all obstinate cases, both are valuable adjuvants.
My practice in the treatment of ordinary malarial fevers is to give quinine for a week in the doses mentioned. At the same time, with a view to prevent recurrence of fever, I direct the patient, particularly if I have found the crescent form of the parasite in the blood—— for such cases are especially prone to relapse—— on one day a week (to give precision to my directions I generally mention Sunday) to take a mild saline, sulphate of soda or Carlsbad salts, in the morning, and three 5-gr. doses of quinine during the day, or 15 gr. in one dose. After the first week, iron and arsenic in pill, tabloid, or solution are prescribed for a fortnight, and, after an interval of a week, for another fortnight. The weekly aperient and quinine had better be kept up for six weeks or two months or longer. In other cases I recommend, after the preliminary week, 5 gr. of quinine daily; this dose to be kept up for three months, and repeated for a month every spring and fall for two years.
Dose of quinine: toxic effects.—— There is great difference of opinion and practice about the dose of quinine. Some give 30 gr. at a dose, some give 3 gr. The former, in my opinion, is too large a dose for ordinary cases, the latter too small. It must never be lost sight of that occasionally quinine in large doses produces alarming effects; not singing in the ears and visual disturbances merely, but actual deafness and even amblyopia, both of which may prove very persistent and occasionally permanent. It may also produce profound cardiac depression and gastric disturbance, and even death from syncope. Urticaria is another, and not very uncommon, effect
