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a healthy state, all seem to point to childhood as the period when the change occurred. The idea of its being a congenital deformity appears inadmissible, from the following fact, viz., that the portion of the head of the radius, which at the time of death formed no part of the joint, had a smooth articular surface, covered with cartilage. Again: the cicatrices, &c., about the hand would incline us to the opinion of its having been the result of mechanical violence. If this view of the subject be taken, it presents the case in a very interesting light, viz., that of a dislocation of both radii backwards, produced by external causes, and remaining unreduced for a series of years. Sir Astley Cooper never saw a case of dislocation of the radius backward but once, and then in the dead subject, an account of which, together with a drawing, is given in his work on “ Dislocations and Fractures;” other surgeons, however, and especially among the French, have been more fortunate, so that, according to the best authorities, we may conclude, in the words of an author, that this luxation, “though it may be rare, has nevertheless been observed several times." * A luxation of both radial bones backward is a much rarer case, such a one is mentioned by Professor Gibson, in his work on Surgery.
But, in opposition to this view, several reasons of considerable force may be adduced : 1st, the well-known effects of rickets in producing distortion of the bones, amounting, in many instances, even to complete dislocation of their articular extremities : now, the appearances of the heads of the bones, in this case, were exactly those described as characteristic of this disease ; † 2d, the extreme rarity of such an accident is, in a doubtful case, good presumptive evidence against its occurrence; 3d, the analogy of this case with others detailed by authors, as un. doubtedly resulting from rickets. A case given by Professor Cooper, in his “Elements of Surgery,” nearly resembles the one in question : “ There is, in the museum of University College, a humerus that has been twisted by the action of the muscles, in consequence of which the ulna has been moved partly into the place of the radius, and the radius displaced. The upper head of the latter bone, no longer having the hume. rus to play upon, is elongated and altered in shape.” In the present instance, though we have the head of the radius "elongated and altered in shape,” yet it is still in contact with and “plays upon ” the external portion of the trochlea of the humerus, the anterior part of the head, however, and not the superior, as in the normal state, being in contact.
Upon the whole, we would, perhaps, be warranted in suggesting, as most probable, the opinion, that the luxation was the result of external violence, its effects being modified by concomitant or subsequent disease of the bones.
* Sansen — Nouveaux Elemens de Pathologie Medico-Chirurgicale.
VI.-On the Use of Sulphate of Quinine. By J. B. Wilkinson, M.D.,
of Louisiana. Messrs. Editors: The several articles published in your journal upon the subject of Quinine have attracted much attention, and given rise to considerable discussion respecting the modus operandi of that medicine, and of the most advantageous method of exhibiting it. A free and unbiassed opinion upon this subject is much to be desired; for the mind of the enthusiast, although keenly sensitive to imputed error, in the ardor of pursuit may be led astray, and thus defeat the object for which he contends. I do not mean to deny positively the rationality of the views expressed by the preceding contributors to your journal upon this question, but to examine the necessity or expediency of the course recommended and pursued by them. From the large quantities of bark now used to effect what was formerly accomplished by smaller doses, apparently establishes, either that the physical constitution of man is modi. fied, or that the bark is greatly adulterated. The facility of detecting the latter by chemical analysis, would prevent the imposition ; and the fact that the human system is regulated by the same forces, influenced in a similar manner by similar substances, as in former days, and presenting external evidence of similar mechanism, indicates that no material change has taken place in its constitution. How happens it, that the virtues of this medicine should have been discovered so many years ago,— had the necessity existed of giving its active principle in such large doses? The best bark yields about 2 per centum, making the quantity, as formerly given in the crude state, about 10 grains quinine, during the apyrexia ; in this state, too, less soluble, and consequently endowed with less energy than the sulphate quinine. Yet we find that, in the records of medicine, it is adduced as an agent of great virtue and power, obtaining the reputation even of a charmed powder. In the Eastern Continent, where it was first extensively used in fevers, we hear its praises as much sung as they are at the present day. Lind, Clarke, and Balfour, each and all attest its virtues in fevers, intermittent and remittent, yet it is highly improbable that they ever gave as much as twenty grains quinine at any one time. Johnson states, that in the ascent of the Bocca Tigris by the British, intermittent fevers prevailed very extensively, thirty and forty patients coming in daily, and that the use of the bark in the ordinary quantity was entirely successful. We also know that the Jesuits, who first made known this remedy, and who at one time possessed the exclusive privilege of its use, obtained great repute in the cure of fevers : they also used it in the crude state, and consequently could not have given the active principle in large doses. The quantity of quinine now given is, no doubt, often much more than is necessary. In the last three years, during the spring, summer, and autumn, I have treated successfully between 600 and 700 cases of intermittent fover, embracing every variety of form, from the simplest grade, to those cases where complete stupor and insensibility were co-exisient, and succeeded to the cold stage, and those cases in which the paroxysm was ushered in by symptoms and appearance so similar to those indicative of cholera morbus, that unless acquainted with the history of the case, an observer would have declared them cases of the latter disease.
I have likewise had my fatal cases, probably, however, not exceeding in ratio the number occurring in the practice of those who advocate the ultra quinine treatment.
I treated the above cases, almost in every instance, with quinine, and occasionally, when the quinine could not be obtained, with the bark in substance, or a combination of the bark and snake root. Generally, the quinine was preceded by other remedies; sometimes, a combination of quinine and some of these remedies, and occasionally the quinine was used at once, and alone. The quantity given never exceeded forty grains in twelve hours; generally, twenty grains in the same time answered every purpose. The doses varied from three to ten grains ; rarely, however, as much as the latter: the usual prescription was four or five grains every three hours.
The best period to administer the quinine is, without doubt, imme. diately succeeding the decline or abatement of the paroxysm, and at intervals during the intermission or remission. In the Blackly Hospital, Philadelphia, it was usual, at one time, to give ten grains of quinine with twenty-five drops of laudanum, about an hour before the expected occurrence of the chill. Impressed favorably with this method, from witnessing its operation at that institution, I tried it in my own practice, but have found it much less successful than when the remedy was given directly after the subsidence of the paroxysm, and during the intermission. It is not uncommon for the chill or fever to return at the first accustomed period after the exhibition of the quinine ; but it more rarely happens that a second accession occurs; showing, that the medi. cine required a greater length of time to affect the system; and hence this is proof that the administration of the medicine immediately after the subsidence of the fever is the best period for its use. How frequently do you see buzzing in the ears, dizziness, &c., take place after giving the quinine, without arresting the chill! Now, if these are the specific effects of the quinine, why is not the paroxysm prevented ?
The question that next arises is, can quinine be given with safety or advantage at any other stage of fever than during the apyrexia ? Many individuals, at the head of whom is Dr. Dudley, of Kentucky, censure the practice of using quinine at any other period than during the intermission of fever; I am convinced, however, that it may be used with advantage frequently in the other stages, but that proper judgment and discrimination are required, to know when it may be safely and judiciously given. In the hot stage of fever, when a very short intermission or remission is expected, or a violent exacerbation is anticipated at the succeeding paroxysm, quinine may and should be given. Preliminary measures should, however, be always taken, to obviate, as far as possible, any hurtful tendency that it might at the time exert: these precau. tionary steps are all such as reduce excitement, and counteract local hyperemia. In this, too, we are seconded by those who give quinine in large doses, since they advise anti-phlogistic measures, pursuant to the administration of the sedative doses of quinine. I have undoubtedly seen evil effects result from the use of quinine in the period of excite. ment, and believe, too, that they were induced by its stimulating properties; consequently, I must deprecate its constant employment in fevers without regard to the period, or other concomitant circumstances.
In the cold stage, I have frequently given it, without, apparently, any decided action. When it is given, in this case, to counteract depression, ammonia, camphor, and warm drinks, are decidedly better.
Associated with the anti-periodic property of quinine, it possesses diaphoretic properties, which latter, no doubt, enhance its value as a febrifuge. It does not, probably exert an immediate action on the cutaneous vessels, but possibly, in overcoming the diseased action, establishes indirectly the secernent function. By combination with diaphoretic medicines, we may frequently improve this property of quinine : where gastro-enteric symptoms did not forbid, I have given it in conjunction with the nitrate of potash, with the effect of increasing dia. phoresis, and of lessening arterial action. We have heard much of quinine in yellow fever; but, from the expression of conflicting opinions upon this subject, the medical world has derived no positive advantage. Dr. Mackie, who originated the practice in New Orleans, subsequently stated, that it was a remedy of doubtful efficacy. Dr. Stone, of Woodville, Mississippi, says that, in the epidemic that raged in that village in 1844, the employment of quinine was attended with the most destructive consequences. I have been told, by the highly intelligent house surgeon of the Charity Hospital (Dr. Wederstrandt), that this remedy, in the epidemic that occurred two years ago in New Orleans, met with signal failure. Dr. Johnson, in his account of the Bengal fever, and of the Batavian fever, says, that the use of the bark was very detrimental. The weight of testimony on both sides is very respectable, however, and we must attribute the success or failure of the remedy in this disease to the aspect or type the fever assumed. It is much to be hoped, that as the attention of the medical profession is so engaged with the action of this medicine, in a few years something definite will be established.
Is the exhibition of quinine, in large doses, attended with hazard ?
Of the fact, that fatal effects have resulted from the use of quinine in large doses, we have irrefragable testimony. Besides the occurrence of cases in this country, the reports of physicians in Paris, who, a few years since, treated rheumatism with large doses of quinine, make men. tion of frequent deaths occasioned by this method." I have witnessed bad effects in several instances, which were clearly demonstrable to the action of quinine. In one case, during the autumn of 1843, I was called to see a patient, Mrs. B who was affected with ague and fever. She was a woman of good constitution, and had usually enjoyed good health. As the chill occurred late in the day, I requested her to take quinine in the morning of the following day, and at intervals during the day, stating the quantity and period at which it was to be taken. I left her walking about the house, apparently very little indisposed. Early on the following day, I was sent for to see Mrs. B., and upon my arrival found her in convulsions — insensible, with a rapid, feeble pulse, cool skin, and pale face. She continued in this condition about half an hour, and expired. Upon inquiry, I learned from her daughter that she arose early in the morning, expressed herself quite well, and said that she would take all the quinine at one dose, but without weighing it ; took out about a table spoonful from the ounce vial, and, mixing it with water, drank the whole : she then remained in the room a few ino
ments, walked out into the yard, and fell down in a convulsion ; the termination of her life, about two hours after she fell in this convulsion, I have already related. The inference is here, plainly, that she died from the effects of the quinine.
Miss whom I attended for chill and fever, after other medicine, was ordered quinine. On my visit the next day, I found she had suffered again from the chill. Her mother informed me, that her head had been so much affected with the quinine, that she had been compelled to desist from its use. I again prescribed the quinine, in four. grain doses. After taking the second dose, the head became dizzy – ached severely — roaring in her ears occurred, and, in attempting to walk to her room, she fell upon the floor. I reduced the dose, and cured her without the return of those unpleasant symptoms. Now, with this susceptibility to the influence of this medicine, might not convul. sions or insensibility have occurred from the effect of ten or twenty grains of the sulphate. I attended the father of this young lady, and found his head so much affected with the quinine, that I was compelled to give it per anum. During the past week, I attended a boy aged about 15. He suffered from remittent fever, accompanied with some degree of pneumonia. His intellect was perfectly clear. I gave him a combination of 20 grs. sulph. quinine, 10 grs. calomel, 10 of ipecacuanha, divided into four doses. During the night, he became highly delirious, attempted to get out of bed, and had high fever. I then discontinued the use of the quinine : his excitement of brain subsided, fever abated, and finally recovered, under other treatment.
I could adduce numerous cases illustrating the evil effects of quinine, did circumstances require it. That quinine is a specific for fevers will destroy a fever, as an alkali does an acid, as some writers wish us to think, I do not believe; neither do I believe that quinine cures fevers, by repairing the losses occasioned to the nervous system by the poisonous cause of fevers, since the action of the quinine is too rapid to admit of its assimilation by the vital organism. It is not at all necessary to employ this hypothesis in explanation of its modus operandi. It may act by immediately decomposing or neutralizing the malaria, or whatever we may consider or term the poison which generates fever: thus, the antidotal effects of ammonia to the poison of serpents and spiders, may be considered as illustrative of its action. It has been observed, that it is a medicine whose action is sui generis, altering or modifying the vital forces in a peculiar manner, which tends to restore them from disease to health. It exercises some invisible, inscrutable, mysterious influence on the human system, of which we only know the result
. Nature has revealed to us, probably, all that is worth knowing; and the means by which this is achieved, like the elementary principle of most of her laws, will, in all probability, be forever buried in oblivion. I believe, if any medicine deserves the name of a specific, quinine deserves this appellation in the cure of intermittent fever.
In all diseases characterized by periodicity of type, quinine may be used to advantage in some stage of the disease.
With proper precaution, quinine may be used in every stage of periodic fever with benefit; but cases occur in which its use is attended with hazard and bad consequences to the patient. These ill effects