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to constrict the parts in the most delicately adjusted apposition, neither too tight or too loose. The physiologic peculiarities of the erectile tissue of the genitalia, that of rapid engorgement and depletion, require an unyielding suture material, and one that will permit of the resulting involution as repair proceeds. Moreover, silver wire is easily and surely rendered aseptic, and indeed is supposed to have the property of forming an antiseptic salt with the fluids in the tissues in which it is imbedded. It can remain indefinitely, and the longer it remains within surgical limits the better the results. Three weeks is the orthodox time for the cervix. The application of silver sutures requires some practice and much patience, and takes a little more time, but the last element is not of much moment in minor work with good kidneys and expert anesthesia, which is the only sort that should ever be permitted, as I recently had sad occasion to realize.
In every branch of art there is a troop of imitators who follow so closely the hall-marks of the original that the specious can scarcely be distinguished from the genuine. So closely are mannerisms copied in literature, art, sculpture and the drama, that the imitators create a distinctive school. This accuracy of duplication is rendered possible by the faithful and scrutinizing study of the original pattern.
The unlimited opportunities for the study of models in the arts are obviously impracticable in plastic surgery. We cannot all have the privilege of seeing the peerless Emmet, although a distinguished fellow of this association says that every one who aspires to do this work ought to. I would not presume to say that one must see him or his followers to do good work. I regret that many of his pupils do not or cannot copy his methods, and I don't hesitate to say that those of us who do conscientiously strive to imitate him fall very short in our poor efforts, but we have, at least, the satisfaction of having a correct conception of the highest ideals in surgery.
312 North High Street.
THE THERAPEUTICS OF QUINIA.*
BY MORRIS J. ALEXANDER, M.D.
It may be presumptious that I should have selected for my subject and your patient consideration a remedy which has been used so long and extensively as a weapon against many and varied foes of the human system, and I appreciate the insignificance of my remarks as compared with what has been said and written by high authorities. But medical societies are on the order of experience meetings, and I claim that knowledge imbibed from a mutual comparison of long experiences is of vastly more benefit to the physician and lasting good to humanity than that obtained from all other sources; and although my little offering be of no direct benefit to you, the discussion and criticism thereof (pro or con) may be valuable.
The study of the physiological action of medicines opens the road to their therapeutic uses; experience improves this road and makes its traveling easy.
Quinia, a giant of our materia medica, has been spoken of in this association before; its friends are perhaps too enthusiastic in their praises, its opponents too bitter in their denunciations, but this servant will perform its many duties, for which it exists, faithfully and surely, and many shortcomings may be traced to an unreasonable and exacting master rather than the servant. I do not care to elaborate on the uses of quinia in troubles which are combated more successfully by other drugs; we are interested in what experience has taught us to be the best treatment for the different ailments. If quinia arrests the migration of the white corpuscles, as physiologists have apparently proved, it is indicated in inflammations. The success which has followed its use in the incipiency of such diseases as rheumatism, erysipelas, tonsillitis, pneumonia and pleurisy, may be credited to that effect upon the blood. The high fever of acute articular rheumatism yields sometimes like magic to large doses of quinia. In combina
* Read before Tri-State Medical Association, Memphis, December 21, 1898.
tion with iron it is a time-honored treatment in erysipelas, and if persevered in will usually be successful. I seldom use anything but quinine in tonsillitis, and when used in time it has given me gratifying results. In chronic rheumatism, and when erysipelas and tonsillitis have gone on to suppuration, other treatment is of course indicated.
Prof. Bartholow says that a large dose of quinia may jugulate such diseases as pneumonia and pleurisy. This statement is evidently dictated by actual experience. In my own practice I remember a number of cases in which I believe this drug suppressed what I had pronounced pneumonia, and so marked was this action that in my first case I doubted the correctness of my diagnosis. After exudation and infiltration have taken place, I believe the systematic use of quinia will tend to check progress of inflammatory action into unaffected lung tissue. If, in any of the acute diseases, the fever rise to alarming proportions it will, preceded by some of the safer new antipyretics, hold it in safer boundaries, and prevent a subsequent high temperature; it may be given with safety for a number of days. Acute catarrhal affections of the mucous membranes of the respiratory organs, commonly known as colds, have long been treated with quinia, and usually with success. In the treatment of la grippe and pertussis it is almost indispensable. Its ozonizing properties, so inimical to germ life, render it valuable on theoretical grounds in other microbic affections, but experience has not given it a permanent place in such troubles. Some authorities attribute fine results to its use in suppressing or at least modifying suppurative and putrefactive changes, and it is no doubt markedly beneficial in mastitis and mild septicemia after parturition as an adjunct to surgical interference. I believe the question whether or not quinia, in large medicinal doses, will produce abortion is settled in the negative. I have prescribed it in the different advancements of pregnancy, sometimes in quite large doses, and in prophylactic doses for a long time, without bad results. Indeed, the physician living in a malarial district knows that some women, pregnant, require larger doses for the relief of intermittent fevers than at other times. Such has certainly been my experience. But it is acknowledged that quinia will
strengthen the pains of parturition. I have purposely reserved for last consideration the virtue of this drug, which has first brought it to the knowledge of the civilized world, namely, its destructive influence upon the plasmodium malariæ. I will not dwell upon its history, nor the fact that this great Mississippi Valley has been rendered habitable by its introduction.
There can no longer be a doubt as to the benefit derived from a daily use of quinia as a prophylactic against malaria. Two grains twice or thrice daily will protect in a large majority. A man, I care not whence he may hail, leading a temperate and regular life, can live and enjoy fair health in this valley, by the daily employment of such protective treatment, till acclimated by a season's sojourn in his environment.
Dr. William S. Thayer, in his most excellent contribution to Loomis and Thompson's System of Medicine, covers the ground well as regards the use of quinia as a treatment in malarial infection. My experience, however, has been that, in the treatment of intermittent and remittent fevers, doses of one to two grains three times a day will seldom, if ever, resist the return of a paroxysm. I hardly think a physician. could feel satisfied unless his patient be under the influence of at least fifteen to twenty grains of quinia before an expected chill; and as subsequent paroxysms have a tendency to appear one or two hours before schedule-time, that amount should be circulating in his blood several hours before what is termed his "chill-time." In the pernicious type of malarial fevers, the congestive chill and fever, quinia has robbed the grave of many victims, who without its administration were doomed to certain death. The patient must at once be cinchonized. Hypodermic injections of a soluble salt of quinine must be the resort.
During seasons marked by heat and moisture and consequent widespread malarial infection, quinia is accused of not doing satisfactory work, as patients frequently have returns of chills several days or weeks after apparent convalescence. But this is no fault of the drug. Reinfection is quite frequent in such seasons, and a prolonged use of quinia in prophylactic doses, in combination with tonics, is indicated. Physicians
who have practiced for a number of years in river bottoms no doubt have met cases of intermittent fevers which seem to run into a remittent or irregular type for several days, the thermometer often registering as high as 104 or 105, notwithstanding the previous vigorous administration of quinia. I cannot account for this condition in any other way than that of a septicemic fever superinduced by the remains within the blood of necrotic material, the debris of red corpuscles and plasmodia-more than the eliminative organs can dispose of for a time. Supportive and eliminative treatment is called for, and to prevent reinfection small doses of quinia are advisable. To many of you there may be nothing new in what I have said. I make no claim to any new employment for such an old drug; I wish to create no sensation. But there are some who regard quinia as a dangerous, or at least harmful, remedy, and it has been urged even that malarial hematuria or hemoglobinuria is caused by its use. So often has this accusation been hurled forth that physicians are handicapped by the patient's fears of hematuria in their treatment of malarial infection. I have met young physicians who were in doubt as to the reliability of quinia, and that bete noir, hematuria, seemed to stare them in the face constantly. And when we have such a world-renowned investigator as Prof. Koch take a stand against the use of quinine, and state that he is convinced that it produces malarial hemoglobinuria, many of us must hesitate, and, I fear, lives are lost through this uncertainty. I quote from a special article in the December 17th number of the Medical News: "This declaration of Professor Koch had an unfortunate effect, it is said, even in our own. army during the recent war. Some of the men refused to take quinine as a prophylactic; others stricken with malaria refused to take the drug as a remedy, or at least objected to its exhibition to them in doses sufficient to secure prompt and effectual results. Even some medical men were discouraged from prescribing as much quinine as they might otherwise have employed because of Koch's declaration." Now, is this not a sad plight to be put in, on account of a hasty, unsupported statement?
But while Koch is an eminent bacteriologist (no one denies