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retain the remedy from any cause, it may be administered hypodermatically-pure amorphous hydrochlorate of quinine being the most suitable preparation for this purpose, it dissolving in an equal weight of water and is less liable to produce abscess. The effect produced when thus used is said to be three or four times greater than when taken by the stomach. In continued malarial fever, quinine in large doses is of no value, but after having fully ascertained that you have a continued case of fever to deal with, from 10 to 15 grains of the sulphate is all that is required in twenty-four hours.
In an article on Continued Malarial Fever, read before this society two years ago, I gave the duration of the disease to be two to six weeks, and stated that large doses of quinine were not called for; from this position I have not yet retreated.
Now if we continue the use of quinine in large doses during this period, we will get a depressed and an enfeebled heart, and an anemia of the brain, with all the nervous disturbances · pertaining thereto, which will prolong the disease and give us a slow and uneventful convalescence. From this I am constrained to believe that we do not get the specific action of the drug in this case. Whether this be due to the stronghold of the enemy, which quinine is unable to take by storm, but is required to deal with more gently in order to overcome its foe; or whether it be due to the new malarial parasite that is unaffected by quinine, of which some of our Memphis pathologists claim to have made a recent discovery, I am unable to say, and will wait until more light upon the subject is produced.
In malarial intoxication characterized by aching of the limbs, back, and head, with a feeling of a general malaise, nothing acts more promptly and gives better results than quinine in 5 to 10 grain doses every four hours until a good effect of the drug is produced, and repeat again in twelve hours, which usually suffices to break up the most obdurate case.
In chronic malarial poisoning or chronic chills, quinine alone is inefficient. It is an antiperiodic in this case, but its power as an antimiasmatic and as a restorative to the structural lesions here produced, seems to be lost. Now as an auxiliary to this my favorite prescription is:
Quinine sulph. 3ii;
iron sulph. (dried) 3i; strychnia sulph. gr. i; arsenious acid gr. ii. Mix well and put in sixty 3-gr. capsules. Sig.: One capsule after each meal. The result of the use of this prescription is most gratifying, and rarely fails to make a permanent cure. The germicidal power of quinine is the explanation of its success in the treatment of malarial disturbances. It is also a prophylactic against the various manifestations of malarial poison, and as such it can be relied on. The morbific cause of malaria consists of pigmented bodies, which penetrate the interior of the red blood corpuscles-pigmented bodies of various shapes and flagellate organisms-both having ameboid movements, the filaments being in active vibration.
In neuralgia of malarial origin, and periodical attacks of headache of non-defined origin, and also of neuralgia of the ophthalmic division of the fifth nerve, quinine often gives good results. Cinchonism is required, however, for quinine to be of much value in these troubles.
As quinine increases the number of leukocytes and prevents acidification and decay of the blood, it occupies a prominent place in the treatment of surgical fevers, pyemia and exhaustive suppurative conditions, and also in septicemia and in hectic fever. It is a destroyer of the bacillus of influenza (la grippe), a large dose of quinine and acetanilid promptly relieving many cases of this disease.
Acute tonsillitis and acute catarrh are often aborted by a full dose of quinine, it being a time-honored remedy in the treatment of the so-called "bad cold." In pneumonia it is a valuable agent, in combination with some of the antipyretics. The effects produced, as a rule, are a decided reduction of temperature, a marked diminution in the frequency of the pulse, a decided moisture of the skin (or a free sweating), a slower and an easier respiration, a relief from pain and the feeling of fullness in the chest, a diminution of the cough, and freer and easier expectoration, and, in fact, a checking of the pulmonary engorgement and inflammation. In acute rheumatism, after the more acute symptoms have subsided, quinine is given with advantage in two to five grain doses, which hasten the elimination of the effete material
and bring about a rapid convalescence, and which will also lessen the tendency to a recurrence of the disease. It is likewise a valuable agent in the eruptive fevers, more especially scarlet fever, erysipelas and measles-being advantageously administered in small doses throughout the course of these diseases.
A CASE OF LARYNGEAL TUBERCULOSIS
Secondary to Tubercular Involvement of the Lymphatics of the Axillary and Infra-Clavicular Regions; Treatment of Tubercular Laryngitis.*
BY RICHMOND MCKINNEY, M.D.
On November 26th of this year Dr. F. D. Smythe of Memphis referred to me for examination and advice a patient with the following history:
J. L. S., aged 30, a motorman, working for the Memphis Street Railway Company, who bore the appearance of good health, and had a clear family history, presented himself in May, 1898, for relief from a gradual enlargement of the axillary lymphatic glands, which he had been noticing for about two months. Consenting to operative measures these enlarged glands, so far as could be judged, were thoroughly removed, and on examination a number of them were found to have undergone cheesy degeneration. The wound healed slowly, with some local infection resulting, which, however, gradually cicatrized. Two months after operation patient presented himself with enlargement of infra-clavicular glands; also enlargement of lymphatics along free border of pectoral muscle down to nipple of right side. A free incision was made from axilla to nipple, and the glands, which had broken down, were removed. An incision was also made below the clavicle of this side, and the removal of several large, cheesy glands effected. Patient rapidly recovered from this operation, and in the course of six weeks gained twelve pounds.
A few weeks later Mr. S. again presented himself to Dr. Smythe, complaining of fullness, with a sticking sensation about the larynx, and a hacking cough with no expectoration. Examination of his lungs revealed no apex catarrh or further *Read before the Tri-State Medical Association, Memphis, December 21, 1898.
indication of tubercular deposits. At this time the patient, through the courtesy of Dr. Smythe, came into my hands for laryngeal examination. With the mirror I found the larynx
pale, the arytenoids swollen, and the left ventricular band, anteriorly, presented a slight tumefaction suggestive of infiltration. Now, in this instance, there being no hectic when I saw the case, and the man to all appearances enjoying good health, I should most likely have overlooked a diagnosis of beginning tubercular infiltration of the larynx but for the patient's previous history of tubercular glands, together with that peculiar sticking sensation in the larynx complained of— a most common premonitory symptom of beginning laryngeal phthisis, his slight hacking cough, and, finally, his laryngeal picture. I saw this patient but two or three times, and since no ulceration was present, points of infiltration not having broken down, gave him no treatment other than that prescribed by his physician, Dr. Smythe, who had him on codliver oil and hypophosphites. My advice to him was to go to Jacksonville, Fla.
The fact that laryngeal tuberculosis primary in the larynx is so rarely seen lends to this case a degree of unusual interest, for while the laryngeal process in this patient was not primary there could be found no lung involvement, which in nearly every case precedes the laryngeal disease, the process here undoubtedly being secondary to the tubercular disease of the axillary and infra- clavicular lymphatics. A kindred case, and perhaps one of even a greater degree of interest, was that reported by me to the Memphis Medical Society in August, 1897, and published in the September issue, same year, of the MEMPHIS MEDICAL MONTHLY, of an instance of probably primary laryngeal tuberculosis occurring in a child of 12 years of age.
To none of the various chronic throat lesions has closer study been given in the last few years, and in none has treatment, so far as healing the local lesion is concerned, been more successfully applied, than in tubercular laryngitis. But to me it seems that for its radical treatment the various remedies suggested resolve themselves into curettement of the deposits and tubercular necrotic tissue, and the rubbing in of lactic acid, commencing with a twenty per cent. solution and gradually increasing this in strength to eighty per cent. Under this treatment the tubercular ulcers as a rule readily heal, and the results obtained with this method by Herying of Warsaw and Krause of Berlin in a large number of cases are sufficiently encouraging to warrant its carrying out in the most of our cases. Before beginning this procedure the larynx should be thoroughly anesthetized by spraying with a twenty per cent. solution of cocaine, and by applying cocaine crystals to the sites of ulceration. Curettement may be practiced at intervals of several days, the lactic acid solution being rubbed in on a cotton swab two or three times a week, as indicated.
In the treatment of the dysphagia of tubercular laryngitis, resulting, usually, from ulceration of the epiglottis, I have found the most satisfactory means of obtaining relief to be to supply the patient with a box of pastils containing cocaine or morphine, these to be dissolved in the mouth and slowly swallowed at intervals throughout the day.
AN INVOLUNTARY SYMPHYSIOTOMY.
BY B. F. TURNER, M.D.
One hot summer day some four years ago I was sent by Dr. Henning, with whom I was then associated, to attend a case of confinement until he could get to it. I found the patient, a Polish Jewess, some 22 years of age, primipara, living amidst the most unhygienic surroundings. She was small, almost dwarfish in stature, but with a disproportionately large head and shoulders, her build suggesting that of a tendency to rachitis.
* Read before the Tri-State Medical Association, Memphis, December 21, 1898.