THE VALUE OF By
S u
"W.
QUININE.
J.
Moore, L.R.C.P., Rajpootana Political Agency, and Superintendent General Dispell" sarics, Rajpootana. 11
o
e
o n
In the 21st number of the Indian Annals of Medical Science, an article on Remittent and Intermittent fevers, I remarked '? " After much consideration and attentive study of fever cases, treated with both large and small doses of quinine, I have come to the conclusion that the virtues of this substance have been much exaggerated." And continued observation baa confirmed the opinion then expressed. Without going so far as to assert that quinine exerts no kind of power over paroxysmal fever, I feel quite sure that it does not deserve a tithe of the praise which it has obtained. Doubtless, the expression of thesa in
?views will be received anything but of my professional brethren. But I to decide between of
us
;
the majority content to permit time that the routine practice
favourably by am
always provided,
is not persevered with. Paroxysmal most other maladies, have a tendency to terminate in the re-establishment of health ; and that they would do so, irrespective of quinine, in by far tho larger number of instances,
administering quinino
fevers, like
well dispute. But it may be said they quickly, when treated by other agents. This generally received idea I somewhat doubt. I am fully awaro of the existence of tabulated statements, apparently showing that persons treated by quinine recover more rapidly than those
is
a
proposition
do not end
so
none can
August
THE VALUE OF
1, 1870.]
QUININE?BY
taking different, so called, antiperiodics. On the other hand, I have seen patients recover speedily and well, without a particle of quinine. Bigoted Brahmins and others in these districts, while soliciting the attendance of the medical officers, have frequently declined European medicines; yet I have known them recover as both Remittent and thoroughly and certainly as quickly from been saturated by quinine. had as they though Intermittent, this agent, and the Moreover, I have treated patients without as in other cases have terminated as successfully instances, when large doses of the alkaloid had been given. It is very strange that the most powerful, indeed the only be for the cure of maladies which specifics" we possess, should An apropos example of the differare naturally intermitting. the effects of medicinal agents, is ences of opinion as regards ready of the committee appointed 3 or 4 to hand, in the report years into the properties of the cinchona alkaloids. ago to enquire on the physiological and therapeutic effects Certain questions of Quinidini, CMnchonidine, and Chinchonine, was proposed to various medical officers. "While there is generally concurrent testimony, that these alkaloids produce effects, more or less similar to quinine; such as headache, singing in the ears, &c., "
and that intermittent fevers subsided after their use, there is still very considerable difference of opinion with regard to their relative value to each other, and to quina. For instance, Dr. considers cinchonine " next to quinine, in a
Fogo point
of view.
ranked
as an
Dr. Palmer doubts whether
antiperiodic
therapeutical
cinchonine
can
be
at all."
Now the faith in the virtues of
quinine
rests,
first,
on
such
evidence as the above, and secondly, on what is called the united experience of numerous practitioners of medicine. But the latter basis, critically examined, is scarcely than the former. Few, I imagine, have conmore
contradictory
trustworthy cidered it compatible
with
duty,
to
await
the result of
a
fever, without prescribing quina. Neither might I have done so, had I not, as above mentioned,
serious case of
paroxysmal
been obliged to witness the course of paroxysmal fever, undisWhen the medicine is taken, and the turbed by remedies. too often is credited with the cure former the patient recovers, which really should be attributed to the vis medicatrix natural.
And thus quinine is daily honoured by additional favor. So was in former years with mercury,* with with purgatives. Each presumed remedial agent had its period of notoriety, and volumes were written on their curative powers. As now with quinine, practitioners in byegone would
bleeding,
it
have
days,
permit patient to incur the supposed disease without the treatment then in vogue.
dared to
scarcely risk of suffering Even as regards quinine, the method medicine has undergone several changes. a
of the In former days the rule of practice was to clear the prima via before giving the alkaloid. Then it was understood the state of the tongue and and that, as the bowels depended on the fever, general rule, was to these cleanse parts to best stop the fever. the way it was asserted complications in internal
administering
organs resulted that therefore the sooner from the febrile disturbance, and the latter was checked, the more rapidly would the former subside. It was also discovered that quinine, administered at as at first thought. Hence any stage of fever, was not injurious the alkaloid began to be given at all stages of the malady, and in all complications; excepting head affections, which prevailing, it was said quinine could not be borne. Soon however it was recognized that cranial complications were also caused by the fever, and quinine has since been recommended at all times. And I submit the use of this agent has become too much mat-
Similarly
* Some years back Mr. Ilaro wrote : " There cannot be a doubt that it not calomel, certainly salivation, is an antidote to malarious fever. The instant a patient's mouth is sore, the fever leaves him, from that moment the disease vanishes as if charmed; the change ia as if
Jife
to
death."?Jad. An, Med. Sci., No. 2, p. 4S8.
from
ter of
"W. J. MOORE.
routine;
a
101
system adverse to the progress of Medical
Science. The history
of medicine abundantly demonstrates, that various remedies have their season of notoriety and decline. Cinchona itself is not dignified, by the absence of the usual cyclical changes. About the middle of the 17th century bark used
Avas
Jesuitical Missionaries in
India, but it appears to disrepute for a season, until revived under' the Talbor's Powder," or the " English Remedy."
by
have fallen into of
name
"
again went out of fashion towards the commencement of the present century, James Johnson's bleeding and calomel treatment being then the accepted practice. Quinine is now It
zenith, but not without symptoms of decline! It has been advanced by Ewart and others, that the undoubted
at its
dimunition of the European death ratio from fever, is evidence of the powers of quinine. This seems however a fallacious argument. The mortality among European (soldiers being our chief statistical source) is lessened as regards every disease. And this results from better habits of life, from less intemperance, from greater attention to personal hygiene, from the
general sanitation now practised, from the relinquishment of the mercurial and bleeding system of medicine, but perhaps more than all, from increased invaliding and facilities for Neither
soldiers, nor others now stay in the often the case, before the days of "Waghorn. The indications of treatment in a case of fever may be stated as follows :?1. To reduce excessive heat or cold. 2. To visiting Europe. country
to
die,
as
so
ensure
sufficient, but not too excessive, excretion and elimina-
tion.
3.
To afford tone and
strength
to the
semi-paralysed
and system. 4. To relieve distressing symptoms. 5. To counteract local complications. 6. And lastly, we are told, nerves
in cases of malarious disease, to neutralize any specific poison, which may have set up the fever. But is there no reason for the very existence of that mysterious poison we call malaria ? I defer the consideration of this subject for a future
doubting
paper. But I may mention, that the facts on which the existence and results of malaria have been based, are so contradictory, as to render concord under critical examination apparently
inquiry into the truth of the entertained regarding malaria.?Ind. Annals, Vol. XX.) And if there be no such thing as the malarial poison, and the opinion is gaining ground that there is not, the power of antiperiodics over malaria, must ex necessitate
impossible (vide opinions generally
the author's
specific be
a
presumption.
indeed, such presumption is sufficiently easy of formation reception. Probably no one will now assert, that all the various remedies from time to time brought forward as antiperiodics have, in reality, the slightest power over fever. There is scarcely any remedy which has not been vaunted as possesshas simply resulted from ing antiperiodic properties. Aijd this subsidence of the malady, after the remedy had been taken ; the medicine being forthwith credited with the case. Thus materials of the most opposite chatacter have been described, And
and
indeed still appear, in the most recent Pharmacopoeia, as N&rcotine and Charcoal, Arsenic and remedies for fever. Cobwebs; Opium and Chiretta; Fuming Nitric Acid and and Nim bark; Carbolic Acid and Barberry;
Nitre, Strychnine Hyposulphites
and Black Pepper; Alcohol and Coffee cum multis aliis of both the most powerful and inert of therapeutical agents. Paroxysmal fevers have subsided after the exhibition of all; ergo, all are antiperiodics ! Space will not permit an account, or even a resume, of experiments made with the view of deciding on the action of the
quinine system (for an imperfect digest, vide the article on Fever Ind. Annals, Vol. XXI., previously quoted.) But from Brignet's monograph, and from the recorded effects of large doses of quinine taken accidentally, &c., I believe the action of quinine to be somewhat similar to that of opium or alcohol?stimulating in the first instance, sedative in larger quantities. But in the
THE INDIAN MEDICAL GAZETTE.
202
differing from both opium and alcohol in not exciting stupor, unless in exorbitant doses, and in never producing intoxication. It also, like alcohol, exerts some amount of antiseptic influence. I have
already mentioned, that I do not go so far as to quinine has no power over paroxysmal fever. I admit that it has a power similar to some of the effects of alcohol, but I do not credit it with any specific properties whatever. I believe the indications of treatment would be fulfilled as well, by the administration of alcohol as quinine. For if we dispense with that indication, in which we are told to neutralize the poison, (the existence of which is doubtful) the remaining indication for which quinine is given, namely, to afford tone and strength to the nerves and system generally, can be better met by alcohol and nourishment. "Whether by the constant use of alcohol, we should not lay ourselves more open to an affirmative answer to the question I see latterly proposed at home, viz., " Do doctors make drunkards?" is quite another matter. But alcohol might be disguised, if necessary, and rendered as unpalatable as quinine itself. For the generality of people, however, there is little doubt that a dose of alcohol is a much more pleasant remedy, than the nauseous " Queen of medicines"?quinine. Alcohol is an agent certainly possessing some power over an ague fit. Mons. Herard (Gazette des Hospitaux, July 1861) and Mons. Leriche (Gazette Ilebdom, et. Med., s. 8 CIdr. An. 1861) have both treated cases of uncomplicated ague with alcohol alone, given at the commencement of the cold fit, the dose being a petit verre. The former speaks very decidedly of the success of this treatment. The employment of alcohol as a prophylactic has also been recommended by Mons. Gules Guyot (Z' Union Medical, September 1860.) I am also in possession of the notes of several cases, where quinine proving useless, an expected paroxysm was escaped by taking a strong glass of brandy and water, on the first symptom presenting. The value of fermented liquor, in malarious cachexia, ha3 moreover been recorded by the African traveller, Sir Samuel Baker. After a lengthened privation, during which no kind of alcohol had been available, he arrived at Kamrasi in a very debilitated state, consequent on repeated attacks of fever. Here spirit was procured in the shape of sweet potato whisky. The author writes: " Every day I drank hot toddy. I became strong, and from that time the fever left me." Neither was this due to change of climate, as ho remained in malarious localities long afterwards. No person is more impressed than myself with the actual necessity of temperance, especially in a tropical climate, and no one is more aware of the grave maladies directly or indirectly proceeding from intemperance. But I fail to perceive the abuse of any agent to be an argument against its use. Certainly not in medicine. Otherwise neither opium, nor chloroform, nor strychnine, with many other agents, would be prescribed. But this subject need not be pursued. The present paper is simply devoted to a consideration of the therapeutical effects of different agents, on a certain class of diseases. The frequent failure of quinine, in its supposed specific action, has led to the theory, as advanced by Maclean, that some blood depurnnt is required in combination where the alkaloid fails in curing paroxysmal fever. The author just named states In certain cases, where the system has been a long time subjected to the influence of malaria, quina some times fails, until some blood depurant has been usedmentioning especially the bicarbonate or acetate of potash (Lancet, April 10th, 1859.) Similarly, others would combino it with nitric aether, or tincture of lytta (Medical Times, Jan. 1S6S), or with eolomel, as recently proposed by Mr. Hare, ( Treatment of Malarious Fevers.) As a general rule, diaphoretics and diuretics are recommended. But it so happens that the skin and urino are the routes by which the matcries morbi, or at least effete matter is passed from the system, during or after febrile disturb? Now,
assert
ance.
[August 1,
1870,
The perspiratory process terminates the paroxysm, and
?with the albuminous
fluid,
many other constituents must escape.
While the urine, increased in quantity, contains a great proportion of uric acid, followed probahly by a deposit of urates, the remedies used with quinine are those promoting the flow of the two excretions, and would act in similar manner without combination with the alkaloid; thus furnishing additional evidence that the latter is not the principal therapeutic agent. I do not forget that both Dupre and Bence Jones have discovered in the
blood,
traces of
a
substance
resembling quinine.
Also that the conclusion has been hastily drawn, that fever may depend on the absence of this substance. But the quantity thus discovered in the human system, is so infinitesimal, and
initiatory, that I do not think any con., can be based on this point. To show that I do not stand alone, in regarding the much vaunted specific claims of quinine as falsely based, I refer to
our
knowledge
argument, pro.
of it so
or
various independent and scattered opinions on the subject. Some years since at the Military Hospital of Tille, Mons. de Chambas used to cure his fever
patients with water labelled Protoxide of Hydrogen (Bull Gen. dc Therapeutic, May 1861.) Mr. Lowe of Madras, writing of Bangalore fever, remarks :?" In my hands quinine has neither proved prophylactic nor antiperiodic, but it has shown, that positive harm may attend its administration, unless the disease has been met, and the current of event changed, by other agents. After full remission, I found quinine did not prevent relapse. The long use of quinine acted in no way as a prophylactic, and when administered during a
remission it neither
prevented
a
recurrence
of the paroxysms,
modify them in degree." Mr. Lowo further believes that quinine interrupts secretion, and therefore, the elimination of the poison, and that it is injurious in all visceral complications. (Madras Quarterly Journal, 1866.) There is very similar testimony, particularly as regards the prophylactic powers of quinine, from Dr. Livingstone, who states the men of his party were equally liable to African fever, whether they took quinine or not (Narrative of Expedition to Zamberi, p. 78.) The American Surgeon "Woodward also doubts the powers of quinine particularly as a prophylactic (Diseases of the United States Army, 1863.) Dr. Rogers, formerly surgeon to the Panama Railway works, states when exposure has been continuous, protection cannot be obtained from quinine. (American Medical Times, August 1862.) Dr. Beattie of Bombay asserts he has lost all faith in quinine as a remedy. (On efficacy of large doses of JSitre in curing fever, read at meeting, Bombay Medical and Physical Society, Uh April, 1868.) Dr. Juggobundoo Bo3e, after eight years' experience, states that his "faith in quinine is shaken, while admitting that it checks fever, it does not seem to obviate the tendency to recurrence." Tho inhabitants of districts where epidemic fever prevails, maintain that quinine only checks its appearance without eradicating the poison from the system ; that it induces a state of constitution nor
did it
favourable to a return of the disease; and that its prolonged use is followed by a febrile state shown by the coming on in tho
evening of headache, lassitude, and burning of the hands and feet. (Indian Medical Gazette, 1868.) Some among the most enthusiastic supporters of quinine, who dwell on the good effects of the remedy in tho Mauritius, remark, that it is ai1 absolute cure for malarial fever, is not exactly tho case; it stops malarial fever, but only for a timo" (Report on the malarious fever of the Mauritius: by Drs. Small and Power, Army Med. San. and Statistical Report, 1866.) Waring remarks^ " that quinine is inadequate to eradicate malarious poison when it has become engrained, as it were, in tho system It " appears extremely probable, that its continued "
an
in largo doses, under such circumstances, exei'cises W'c injurious influence on the brain and nervous system" ( us, tropical resident at Home.) Dr. Pystcr of Sandoway tells Colonel " an as antiperiodicand failed often use
quiniue
very,
August 1,
"
HISTOEY OP H. M.'S 58th KEGrT.?BY J. D. AMBROSE.
Commissioner of Arrakan, adds corroborative testipersonal observations" (Report of Hospitals and Dr. in British Burmah, 1868.) Still more
Shakespear, mony,
1870.] MEDICAL
from
recently Dispensaries no power of Birch states, " Quinine seemed to possess cutting In all cases, quinine acted feebly." short the fever Medical Gazette, May 2, 1870.) (Dalhousie as a Sanitarium, Indian have also little confidence in the remedy, Hakeems native Many inwards." Lastly, the " experiasserting that it drives the fever has a less powerful ments of Dr. Bintz of Boim, show, quinine and putrescence, than arsenic preventive action on fermentation and some other substances. (Lancet, 1868.) I have to remark In addition to this published evidence, medical men, I have almost generally that in conversation with ....
found
a
really
less confidence in the power of
quinine,
than
after reading standard works and would imagine to prevail devoted to medicine. W hile admitting antiperiodic periodicals, in specific powers. As evidencmany do not believe one
properties,
to be the general impression, I cannot do ing what 1 imagine made to me on the better than quote a communication kindly war of the Dr. Mey Cunningham Agency" I have subject by of quinine, but I believe a very high opinion of the value that a very large number of cases might be as well cured withsee them in the outset, and have an if we could out
always
it,
the poison by means of emetics and is a mistake to attach too much still greater to administer importance to quinine as a specific, it as such without having used sufficient means for
opportunity of eliminating It purgatives, &o
rectifying
the disorder of the liver and bowels, which will always be found to accompany a recent attack of fever." To recapitulate. I doubt the specific powers of quinine, because? 1. Paroxysmal fevers
have,
more
than any other
maladies,
a
tendency spontaneous decline. 2. Patients recover without quinine. to
or at least the largest class of 3. All antiperiodics, (the only, are remedies for intermedicines credited with specific powers) diseases declining or spontaneously. mitting maladies, Statistical evidence regarding the powers of quinine is 4.
doubtful.
So called practical experience is derived from giving 5. quinine according to rule, and not from comparison with cases treated without quinine. 6. In former years as much confidence was placed in other measures as now in quinine. 7. Diminution of mortality may be accounted for without attributing it to quinine. 8. There is doubt if the malaria, for which quinine is regarded as the antidote, really exists. 9. Indications of treatment may be fulfilled without quinine, in 10. Many substances, very different composition, have
similar to, or been credited with powers
quinine. 11.
The action of
quinine
approaching
appears to be
those of
simply stimulating
and tonic?not peculiar and specific. which we are advised to com12. Depurating agents, with bine
quinine, will
act
equally well,
administered
independently,
or less 13. Other observers have more decidedly expressed powers of quinine. the on specific of confidence their want 14. Lastly, there is a general feeling that the powers of quinine are too highly rated in text-books on medicine.
A remarkable physiological fact i9 established by Mr. 1?. J. J^ee in a paper " on the organs of vision in the common Mole," in the Proceedings of the Royal Society for April last. Mr. Leo proves that the Mole at'the time of birth is endowed with organs of vision of considerable perfection, while in mature age it is deprived of the means ot sight in consequence of certain changes which take place in the base of the skull?opticin the destruction of the loramina most
closing up?terminating
important structures?optic nerves?ou which the joyment of the gensc of the eight depends.
en-
163
S u
"W.
QUININE.
J.
Moore, L.R.C.P., Rajpootana Political Agency, and Superintendent General Dispell" sarics, Rajpootana. 11
o
e
o n
In the 21st number of the Indian Annals of Medical Science, an article on Remittent and Intermittent fevers, I remarked '? " After much consideration and attentive study of fever cases, treated with both large and small doses of quinine, I have come to the conclusion that the virtues of this substance have been much exaggerated." And continued observation baa confirmed the opinion then expressed. Without going so far as to assert that quinine exerts no kind of power over paroxysmal fever, I feel quite sure that it does not deserve a tithe of the praise which it has obtained. Doubtless, the expression of thesa in
?views will be received anything but of my professional brethren. But I to decide between of
us
;
the majority content to permit time that the routine practice
favourably by am
always provided,
is not persevered with. Paroxysmal most other maladies, have a tendency to terminate in the re-establishment of health ; and that they would do so, irrespective of quinine, in by far tho larger number of instances,
administering quinino
fevers, like
well dispute. But it may be said they quickly, when treated by other agents. This generally received idea I somewhat doubt. I am fully awaro of the existence of tabulated statements, apparently showing that persons treated by quinine recover more rapidly than those
is
a
proposition
do not end
so
none can
August
THE VALUE OF
1, 1870.]
QUININE?BY
taking different, so called, antiperiodics. On the other hand, I have seen patients recover speedily and well, without a particle of quinine. Bigoted Brahmins and others in these districts, while soliciting the attendance of the medical officers, have frequently declined European medicines; yet I have known them recover as both Remittent and thoroughly and certainly as quickly from been saturated by quinine. had as they though Intermittent, this agent, and the Moreover, I have treated patients without as in other cases have terminated as successfully instances, when large doses of the alkaloid had been given. It is very strange that the most powerful, indeed the only be for the cure of maladies which specifics" we possess, should An apropos example of the differare naturally intermitting. the effects of medicinal agents, is ences of opinion as regards ready of the committee appointed 3 or 4 to hand, in the report years into the properties of the cinchona alkaloids. ago to enquire on the physiological and therapeutic effects Certain questions of Quinidini, CMnchonidine, and Chinchonine, was proposed to various medical officers. "While there is generally concurrent testimony, that these alkaloids produce effects, more or less similar to quinine; such as headache, singing in the ears, &c., "
and that intermittent fevers subsided after their use, there is still very considerable difference of opinion with regard to their relative value to each other, and to quina. For instance, Dr. considers cinchonine " next to quinine, in a
Fogo point
of view.
ranked
as an
Dr. Palmer doubts whether
antiperiodic
therapeutical
cinchonine
can
be
at all."
Now the faith in the virtues of
quinine
rests,
first,
on
such
evidence as the above, and secondly, on what is called the united experience of numerous practitioners of medicine. But the latter basis, critically examined, is scarcely than the former. Few, I imagine, have conmore
contradictory
trustworthy cidered it compatible
with
duty,
to
await
the result of
a
fever, without prescribing quina. Neither might I have done so, had I not, as above mentioned,
serious case of
paroxysmal
been obliged to witness the course of paroxysmal fever, undisWhen the medicine is taken, and the turbed by remedies. too often is credited with the cure former the patient recovers, which really should be attributed to the vis medicatrix natural.
And thus quinine is daily honoured by additional favor. So was in former years with mercury,* with with purgatives. Each presumed remedial agent had its period of notoriety, and volumes were written on their curative powers. As now with quinine, practitioners in byegone would
bleeding,
it
have
days,
permit patient to incur the supposed disease without the treatment then in vogue.
dared to
scarcely risk of suffering Even as regards quinine, the method medicine has undergone several changes. a
of the In former days the rule of practice was to clear the prima via before giving the alkaloid. Then it was understood the state of the tongue and and that, as the bowels depended on the fever, general rule, was to these cleanse parts to best stop the fever. the way it was asserted complications in internal
administering
organs resulted that therefore the sooner from the febrile disturbance, and the latter was checked, the more rapidly would the former subside. It was also discovered that quinine, administered at as at first thought. Hence any stage of fever, was not injurious the alkaloid began to be given at all stages of the malady, and in all complications; excepting head affections, which prevailing, it was said quinine could not be borne. Soon however it was recognized that cranial complications were also caused by the fever, and quinine has since been recommended at all times. And I submit the use of this agent has become too much mat-
Similarly
* Some years back Mr. Ilaro wrote : " There cannot be a doubt that it not calomel, certainly salivation, is an antidote to malarious fever. The instant a patient's mouth is sore, the fever leaves him, from that moment the disease vanishes as if charmed; the change ia as if
Jife
to
death."?Jad. An, Med. Sci., No. 2, p. 4S8.
from
ter of
"W. J. MOORE.
routine;
a
101
system adverse to the progress of Medical
Science. The history
of medicine abundantly demonstrates, that various remedies have their season of notoriety and decline. Cinchona itself is not dignified, by the absence of the usual cyclical changes. About the middle of the 17th century bark used
Avas
Jesuitical Missionaries in
India, but it appears to disrepute for a season, until revived under' the Talbor's Powder," or the " English Remedy."
by
have fallen into of
name
"
again went out of fashion towards the commencement of the present century, James Johnson's bleeding and calomel treatment being then the accepted practice. Quinine is now It
zenith, but not without symptoms of decline! It has been advanced by Ewart and others, that the undoubted
at its
dimunition of the European death ratio from fever, is evidence of the powers of quinine. This seems however a fallacious argument. The mortality among European (soldiers being our chief statistical source) is lessened as regards every disease. And this results from better habits of life, from less intemperance, from greater attention to personal hygiene, from the
general sanitation now practised, from the relinquishment of the mercurial and bleeding system of medicine, but perhaps more than all, from increased invaliding and facilities for Neither
soldiers, nor others now stay in the often the case, before the days of "Waghorn. The indications of treatment in a case of fever may be stated as follows :?1. To reduce excessive heat or cold. 2. To visiting Europe. country
to
die,
as
so
ensure
sufficient, but not too excessive, excretion and elimina-
tion.
3.
To afford tone and
strength
to the
semi-paralysed
and system. 4. To relieve distressing symptoms. 5. To counteract local complications. 6. And lastly, we are told, nerves
in cases of malarious disease, to neutralize any specific poison, which may have set up the fever. But is there no reason for the very existence of that mysterious poison we call malaria ? I defer the consideration of this subject for a future
doubting
paper. But I may mention, that the facts on which the existence and results of malaria have been based, are so contradictory, as to render concord under critical examination apparently
inquiry into the truth of the entertained regarding malaria.?Ind. Annals, Vol. XX.) And if there be no such thing as the malarial poison, and the opinion is gaining ground that there is not, the power of antiperiodics over malaria, must ex necessitate
impossible (vide opinions generally
the author's
specific be
a
presumption.
indeed, such presumption is sufficiently easy of formation reception. Probably no one will now assert, that all the various remedies from time to time brought forward as antiperiodics have, in reality, the slightest power over fever. There is scarcely any remedy which has not been vaunted as possesshas simply resulted from ing antiperiodic properties. Aijd this subsidence of the malady, after the remedy had been taken ; the medicine being forthwith credited with the case. Thus materials of the most opposite chatacter have been described, And
and
indeed still appear, in the most recent Pharmacopoeia, as N&rcotine and Charcoal, Arsenic and remedies for fever. Cobwebs; Opium and Chiretta; Fuming Nitric Acid and and Nim bark; Carbolic Acid and Barberry;
Nitre, Strychnine Hyposulphites
and Black Pepper; Alcohol and Coffee cum multis aliis of both the most powerful and inert of therapeutical agents. Paroxysmal fevers have subsided after the exhibition of all; ergo, all are antiperiodics ! Space will not permit an account, or even a resume, of experiments made with the view of deciding on the action of the
quinine system (for an imperfect digest, vide the article on Fever Ind. Annals, Vol. XXI., previously quoted.) But from Brignet's monograph, and from the recorded effects of large doses of quinine taken accidentally, &c., I believe the action of quinine to be somewhat similar to that of opium or alcohol?stimulating in the first instance, sedative in larger quantities. But in the
THE INDIAN MEDICAL GAZETTE.
202
differing from both opium and alcohol in not exciting stupor, unless in exorbitant doses, and in never producing intoxication. It also, like alcohol, exerts some amount of antiseptic influence. I have
already mentioned, that I do not go so far as to quinine has no power over paroxysmal fever. I admit that it has a power similar to some of the effects of alcohol, but I do not credit it with any specific properties whatever. I believe the indications of treatment would be fulfilled as well, by the administration of alcohol as quinine. For if we dispense with that indication, in which we are told to neutralize the poison, (the existence of which is doubtful) the remaining indication for which quinine is given, namely, to afford tone and strength to the nerves and system generally, can be better met by alcohol and nourishment. "Whether by the constant use of alcohol, we should not lay ourselves more open to an affirmative answer to the question I see latterly proposed at home, viz., " Do doctors make drunkards?" is quite another matter. But alcohol might be disguised, if necessary, and rendered as unpalatable as quinine itself. For the generality of people, however, there is little doubt that a dose of alcohol is a much more pleasant remedy, than the nauseous " Queen of medicines"?quinine. Alcohol is an agent certainly possessing some power over an ague fit. Mons. Herard (Gazette des Hospitaux, July 1861) and Mons. Leriche (Gazette Ilebdom, et. Med., s. 8 CIdr. An. 1861) have both treated cases of uncomplicated ague with alcohol alone, given at the commencement of the cold fit, the dose being a petit verre. The former speaks very decidedly of the success of this treatment. The employment of alcohol as a prophylactic has also been recommended by Mons. Gules Guyot (Z' Union Medical, September 1860.) I am also in possession of the notes of several cases, where quinine proving useless, an expected paroxysm was escaped by taking a strong glass of brandy and water, on the first symptom presenting. The value of fermented liquor, in malarious cachexia, ha3 moreover been recorded by the African traveller, Sir Samuel Baker. After a lengthened privation, during which no kind of alcohol had been available, he arrived at Kamrasi in a very debilitated state, consequent on repeated attacks of fever. Here spirit was procured in the shape of sweet potato whisky. The author writes: " Every day I drank hot toddy. I became strong, and from that time the fever left me." Neither was this due to change of climate, as ho remained in malarious localities long afterwards. No person is more impressed than myself with the actual necessity of temperance, especially in a tropical climate, and no one is more aware of the grave maladies directly or indirectly proceeding from intemperance. But I fail to perceive the abuse of any agent to be an argument against its use. Certainly not in medicine. Otherwise neither opium, nor chloroform, nor strychnine, with many other agents, would be prescribed. But this subject need not be pursued. The present paper is simply devoted to a consideration of the therapeutical effects of different agents, on a certain class of diseases. The frequent failure of quinine, in its supposed specific action, has led to the theory, as advanced by Maclean, that some blood depurnnt is required in combination where the alkaloid fails in curing paroxysmal fever. The author just named states In certain cases, where the system has been a long time subjected to the influence of malaria, quina some times fails, until some blood depurant has been usedmentioning especially the bicarbonate or acetate of potash (Lancet, April 10th, 1859.) Similarly, others would combino it with nitric aether, or tincture of lytta (Medical Times, Jan. 1S6S), or with eolomel, as recently proposed by Mr. Hare, ( Treatment of Malarious Fevers.) As a general rule, diaphoretics and diuretics are recommended. But it so happens that the skin and urino are the routes by which the matcries morbi, or at least effete matter is passed from the system, during or after febrile disturb? Now,
assert
ance.
[August 1,
1870,
The perspiratory process terminates the paroxysm, and
?with the albuminous
fluid,
many other constituents must escape.
While the urine, increased in quantity, contains a great proportion of uric acid, followed probahly by a deposit of urates, the remedies used with quinine are those promoting the flow of the two excretions, and would act in similar manner without combination with the alkaloid; thus furnishing additional evidence that the latter is not the principal therapeutic agent. I do not forget that both Dupre and Bence Jones have discovered in the
blood,
traces of
a
substance
resembling quinine.
Also that the conclusion has been hastily drawn, that fever may depend on the absence of this substance. But the quantity thus discovered in the human system, is so infinitesimal, and
initiatory, that I do not think any con., can be based on this point. To show that I do not stand alone, in regarding the much vaunted specific claims of quinine as falsely based, I refer to
our
knowledge
argument, pro.
of it so
or
various independent and scattered opinions on the subject. Some years since at the Military Hospital of Tille, Mons. de Chambas used to cure his fever
patients with water labelled Protoxide of Hydrogen (Bull Gen. dc Therapeutic, May 1861.) Mr. Lowe of Madras, writing of Bangalore fever, remarks :?" In my hands quinine has neither proved prophylactic nor antiperiodic, but it has shown, that positive harm may attend its administration, unless the disease has been met, and the current of event changed, by other agents. After full remission, I found quinine did not prevent relapse. The long use of quinine acted in no way as a prophylactic, and when administered during a
remission it neither
prevented
a
recurrence
of the paroxysms,
modify them in degree." Mr. Lowo further believes that quinine interrupts secretion, and therefore, the elimination of the poison, and that it is injurious in all visceral complications. (Madras Quarterly Journal, 1866.) There is very similar testimony, particularly as regards the prophylactic powers of quinine, from Dr. Livingstone, who states the men of his party were equally liable to African fever, whether they took quinine or not (Narrative of Expedition to Zamberi, p. 78.) The American Surgeon "Woodward also doubts the powers of quinine particularly as a prophylactic (Diseases of the United States Army, 1863.) Dr. Rogers, formerly surgeon to the Panama Railway works, states when exposure has been continuous, protection cannot be obtained from quinine. (American Medical Times, August 1862.) Dr. Beattie of Bombay asserts he has lost all faith in quinine as a remedy. (On efficacy of large doses of JSitre in curing fever, read at meeting, Bombay Medical and Physical Society, Uh April, 1868.) Dr. Juggobundoo Bo3e, after eight years' experience, states that his "faith in quinine is shaken, while admitting that it checks fever, it does not seem to obviate the tendency to recurrence." Tho inhabitants of districts where epidemic fever prevails, maintain that quinine only checks its appearance without eradicating the poison from the system ; that it induces a state of constitution nor
did it
favourable to a return of the disease; and that its prolonged use is followed by a febrile state shown by the coming on in tho
evening of headache, lassitude, and burning of the hands and feet. (Indian Medical Gazette, 1868.) Some among the most enthusiastic supporters of quinine, who dwell on the good effects of the remedy in tho Mauritius, remark, that it is ai1 absolute cure for malarial fever, is not exactly tho case; it stops malarial fever, but only for a timo" (Report on the malarious fever of the Mauritius: by Drs. Small and Power, Army Med. San. and Statistical Report, 1866.) Waring remarks^ " that quinine is inadequate to eradicate malarious poison when it has become engrained, as it were, in tho system It " appears extremely probable, that its continued "
an
in largo doses, under such circumstances, exei'cises W'c injurious influence on the brain and nervous system" ( us, tropical resident at Home.) Dr. Pystcr of Sandoway tells Colonel " an as antiperiodicand failed often use
quiniue
very,
August 1,
"
HISTOEY OP H. M.'S 58th KEGrT.?BY J. D. AMBROSE.
Commissioner of Arrakan, adds corroborative testipersonal observations" (Report of Hospitals and Dr. in British Burmah, 1868.) Still more
Shakespear, mony,
1870.] MEDICAL
from
recently Dispensaries no power of Birch states, " Quinine seemed to possess cutting In all cases, quinine acted feebly." short the fever Medical Gazette, May 2, 1870.) (Dalhousie as a Sanitarium, Indian have also little confidence in the remedy, Hakeems native Many inwards." Lastly, the " experiasserting that it drives the fever has a less powerful ments of Dr. Bintz of Boim, show, quinine and putrescence, than arsenic preventive action on fermentation and some other substances. (Lancet, 1868.) I have to remark In addition to this published evidence, medical men, I have almost generally that in conversation with ....
found
a
really
less confidence in the power of
quinine,
than
after reading standard works and would imagine to prevail devoted to medicine. W hile admitting antiperiodic periodicals, in specific powers. As evidencmany do not believe one
properties,
to be the general impression, I cannot do ing what 1 imagine made to me on the better than quote a communication kindly war of the Dr. Mey Cunningham Agency" I have subject by of quinine, but I believe a very high opinion of the value that a very large number of cases might be as well cured withsee them in the outset, and have an if we could out
always
it,
the poison by means of emetics and is a mistake to attach too much still greater to administer importance to quinine as a specific, it as such without having used sufficient means for
opportunity of eliminating It purgatives, &o
rectifying
the disorder of the liver and bowels, which will always be found to accompany a recent attack of fever." To recapitulate. I doubt the specific powers of quinine, because? 1. Paroxysmal fevers
have,
more
than any other
maladies,
a
tendency spontaneous decline. 2. Patients recover without quinine. to
or at least the largest class of 3. All antiperiodics, (the only, are remedies for intermedicines credited with specific powers) diseases declining or spontaneously. mitting maladies, Statistical evidence regarding the powers of quinine is 4.
doubtful.
So called practical experience is derived from giving 5. quinine according to rule, and not from comparison with cases treated without quinine. 6. In former years as much confidence was placed in other measures as now in quinine. 7. Diminution of mortality may be accounted for without attributing it to quinine. 8. There is doubt if the malaria, for which quinine is regarded as the antidote, really exists. 9. Indications of treatment may be fulfilled without quinine, in 10. Many substances, very different composition, have
similar to, or been credited with powers
quinine. 11.
The action of
quinine
approaching
appears to be
those of
simply stimulating
and tonic?not peculiar and specific. which we are advised to com12. Depurating agents, with bine
quinine, will
act
equally well,
administered
independently,
or less 13. Other observers have more decidedly expressed powers of quinine. the on specific of confidence their want 14. Lastly, there is a general feeling that the powers of quinine are too highly rated in text-books on medicine.
A remarkable physiological fact i9 established by Mr. 1?. J. J^ee in a paper " on the organs of vision in the common Mole," in the Proceedings of the Royal Society for April last. Mr. Leo proves that the Mole at'the time of birth is endowed with organs of vision of considerable perfection, while in mature age it is deprived of the means ot sight in consequence of certain changes which take place in the base of the skull?opticin the destruction of the loramina most
closing up?terminating
important structures?optic nerves?ou which the joyment of the gensc of the eight depends.
en-
163
