EPIDEMIC ENCEPHALITIS
Authors: A. J. Hall
Journal: BMJ (1918)

IMEDRUL JOUIRNAZ 46 the fever ceased within the same period of tinme.The imninediate results of the injection of the cinchonine salts were tlhus very satisfactory, and will be found to compare favourably, especially as regards the more serious nmalignant tertian variety, witlh those of administering quinine by various methods in tlle army in England as reported by J. W. W. Steplhens and hiis colleagues.4Witlh regard to relapses the patients could not be kept in llospital long enouglh to furnislh com-iplete data.Four were discharged free from relapses on from the fifthl to tlle twenty-fourtlh day, while in other cases after from one to four injections relapses were recorded from between the sixth to tlhe thirtv-third days, very much in the same way as in the army cases after similar quinine treatment.I did not use the cinclhonine salts witlh the object of or expectation of preventing relapses by a few injections, but in order to rapidly control the fever and cause the parasites to disappear from the blood, after wliclh a prolonged course of oral administration of quinine is indicated to prevent a recurrence of the fever.The following recent case will serve to illustrate the value of preliminary intramuscular injections of cinchonine salts in cases of malaria in wlliclh oral administration cannot safely or conveniently be relied oIn.A lady consulted me for what was obviously a benign tertian malaria, from which she had suffered on and off for over a year.Rtecently the attacks had become more frequent and severe, and she had to go to bed every other day during them; while, when she took quinine, she vomited, and it failed to control the fever.The blood showed benign tertian parasites in every field of an oil immersion lens, indicating a severe infectionl, lnot without danger if unchecked.I injected 7i grains of cinichonine bihydrochloride into the deltoid muscle on the day before an attack was due, and warned the patient that this could not be expected to stop completely the attack due the next day.Twenty-four hours later she felt quite well, and her blood was quite free from parasites, and, as a matter of fact, she had no attack.Three more 10-grain doses were given at daily intervals, after which she could take quinine by the mouth without trouble.On inquiry regarding the amount of discomfort after the injections, she said it was so little that she could with difficulty locate the spot the day after the injection.There was some cinchonism after the 10-grain doses. CONCLUSION.Cinclhoninie bilhydrochloride in a 1 in 2 solution carefully sterilized in an autoclave is so rapidly absorbed that I consider it to be almost as quick and effective in its action in severe malaria as quinine or cinclhonine salts intra- venously, witlhout the inconveniences and possible dangers of the latter, although in such rare extreme infections as that wlich I reported last year5 intravenous injections are advisable.In severe cases of malaria and during the prevalence of pernicious cases, as well as in patients who vomit orally administered quinine, I suggest the furtlher trial of intramuscular injections of 7-, 10, and in adult imales up to 15 grains of cinchonine biliydrochloride (or in less severe cases, if preferred, the cinclhonine acid hydrobromide, wlhich produces less cinchonism) during tlho first few days of an attack of malaria, to rapidlv control the fever and tlle infection, to be followed by a full course of quinine orally to prevent relapses.REFERENCES.