Quinine.

FINLEY ELLINGWOOD, M. D., CHICAGO

Quinine is one of the most important remedies in materia medica, and yet, I am inclined to think, it is given with less discretion, with less thought, than almost any other one remedy. This may be due to the fact that it was at one time one of perhaps a dozen remedies, which were well known to the profession, and this before anyone thought of applying a remedy specifically either with reference to its own influence or with reference to the conditions for which it was given.

The first of the salts of quinine used was the sulphate, and without investigation the profession fell into the habit of prescribing the sulphate, and no other form of quinine. Nearly all the observations have been made on the action of this salt. Thus a very bad habit has been formed. There is no doubt that several of the other compounds of this cinchona salt will work just as well as the sulphate, some will work better, and the most of them are more soluble and more pleasant of administration.

I discarded the sulphate years ago for everything except when a positive anti-periodic effect was immediately desired. Instead of this I have used the bisulphate, because of its greatly superior solubility.

The fact that I expected more of the sulphate as an anti-periodic, was largely because of its popularity in that field, and not from any observations I had made myself, as I am sure I have obtained just as good results in a quicker time from the bisulphate. I now find a slightly increased dose of the bisulphate superior in every way to the sulphate in every field in which I am inclined to use it.

The hydrochloride is a superior salt to the sulphate and will answer many purposes. The hydrobromate, the arsenate and the valerianate all have their special place. The tannate is used very commonly because it is comparatively tasteless. The taste of none of the salts is harder to disguise than that of the sulphate.

No specific remedy which we prescribe has plainer indications nor those more exact than this remedy, and unless the indications present be specific the remedy must not be given.

Quinine will act favorably upon the system if the skin be soft; if the mucous membranes of the mouth are moist and if the tongue is moist and inclined to clean; if the pulse is full and soft and the temperature declining or at normal. In other words, when the secretory functions of the body are in a working condition, quinine will produce no unpleasant results.

Quinine is specially an antiperiodic. It will overcome malarial periodicity, especially if the above named conditions are present when the agent is administered. It destroys the plasmodium malariae readily, even in the minute quantity of one part to twenty thousand of water. Its influence upon malarial conditions can thus be readily understood.

It is profoundly tonic; under limited conditions it is antipyretic and also antiseptic. It has specific oxytoccic powers over the parturient uterus.

In the administration of quinine as an antiperiodic, the beneficial influences are not altogether in proportion to the size of the dose. Enormous doses may abort a chill if given during its course, or during the course of the fever. They are very likely, however, to increase the nervous erethrism and the temperature; whereas, if proper doses be given during the intermission, from one to three hours preceding the anticipated attack, or at the time when the temperature has reached its lowest point, small doses will accomplish positive results.

In continued fever, with a sufficiently marked remission occurring at a given time each day, or on alternate days, the agent should be given during the remission, provided the temperature declines to a point sufficiently low to admit of a temporary restoration of the suspended secretions. This point is not usually above 100.5 degrees. If the remission be short, a single dose may be given. As a result the temperature does not run as high as on the previous day, and the next remission is more marked and of longer duration. At this time perhaps, two full doses, two hours apart, may be given. The fever is still lower and the remission so marked by the third day that the agent, in reasonable doses, may be continued through the exacerbation, the temperature at no time probably rising above 101 degrees and not increasing above normal after the third day.

The writer has adopted this course for so many years, with perfectly satisfactory results, that the method is confirmed in his mind as the proper one in all cases where malaria is the cause.

Where continued fever exists, quinine is of no benefit if there is no marked remission or other evidences of malaria. It is thus of no use during the progress of typhus, typhoid and other protracted fevers. In such cases it causes nerve irritation and increased temperature, especially if there is deficient secretion.

When the fever is broken and there is a tendency towards a restoration of secretion, and the temperature is normal or subnormal, then this agent is a vitally important one. Here the bisulphate, being readily absorbed, produces the happiest results.

In intermittent fevers it is excellent practice to give the remedy in broken doses during the intermission. The absorption of the sulphate of quinine takes place so slowly that the period of between four and six hours is required, under favorable circumstances, to develop the full effect of the remedy. A dose of from two to four grains, given five hours before the expected paroxysm, will exercise its full influence upon the paroxysm when it should appear.

If another dose of two and one-half grains be given two hours after the first dose, and a third dose of the same size be administered after another period of two hours, or one hour before the chill will occur, the effect of the agent will be uniformly continued during the time in which both the chill and the fever would have reached their highest point. The repetition of this course on the second and third days will usually be sufficient to overcome the most severe cases. It is well to adopt the same course on the seventh, fourteenth and twenty-first days following the attack.

The following formula is of excellent service in those cases in which the liver and other glandular organs have been profoundly influenced by the disease, and where the nervous system shows considerable depression.

Mix. Sig. Ft. capsulae, No. xii.

One capsule in the manner above specified every two hours until three are taken. When the paroxysms no longer appear, two or three grains of quinine may be given regularly every three hours during the day.

In the treatment of congestive chill, and in malignant conditions of malarial origin, quinine is specific, but should be given in much larger doses, and usually with some direct stimulant and in conjunction with the use of external heat. It may be given in doses of twenty grains preceding the attack, or with stimulants during the attack. If a severe attack is fully anticipated, large doses should be repeated every two or three hours during the entire remission.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.