Remarks on the use of Quinine in Intermittent and Remittent Fevers. By L. A. DUGAS, M. D., Professor in the Medical College of Georgia.

Having received during the past season a number of communications requesting my views on the use of quinine in the treatment of our autumnal fevers, I beg leave to reply to them through the medi. um of this Journal.

The fevers of this section of our country, being almost exclusively paroxysmal, it may be well to premise, very briefly, my views of their pathology, by which it will be perceived that I regard them as essentially different from those continued fevers more commonly encountered in colder latitudes, and which have been denominated Typhoid, Typhus, Follicular enteritis, Dothenenteritis, Jail fever, Ship fever, &c.

Our paroxysmal fevers are either intermittent or remittent at their onset; but, if not arrested, the former may, more or less early, become remittent, or the remittent assume the intermittent type; thus showing them to be only different degrees of the same disease. They both present the same paroxysmal phenomena, that is to say, have regular periods of recurrence or exacerbation, and of declen. sion; they are both preceded and accompanied by a general disturb ance, more or less marked, of all the functions of the system, but more especially of those usually termed nervous, as those of sensibility and muscular motion. Lassitude, pains in the limbs, back and head, loss of muscular strength, are premonitory and persistent in both. The activity of the circulation, however great, is not continuous as in the phlegmasiæ, but partakes of the same paroxysmal character as the other phenomena. Indeed it may be established as a

maxim, that no inflammatory disease ever assumes the paroxysmal character, inasmuch as all inflammations pursue an uninterrupted course, whether they terminate in resolution, suppuration or gangrene. Wherever inflammation is exposed to occular observation, it is never seen suddenly to disappear and to return at stated intervals, or otherwise; but it runs a uniform course which cannot be suddenly modified by the efforts of nature nor by any agent with which we are acquainted. Pure inflammation of internal parts, as pneumonia, pleurisy, acute articular rheumatism, enteritis, &c., observes the same course; there is nothing paroxysmal in these diseases; the febrile action is not attended with daily or periodical exacerbations, but gradually progresses to a certain point, and then gradually declines with the subsidence of the inflammation. Periodicity or the paroxys. mal peculiarity is characteristic of the neuroses properly so calledof diseases of the nervous system, which modify the functions of remote organs, and which may be dependent upon congestion, but certainly never upon inflammation. We know of no organ, whose inflammation could furnish us any rational explanation of the varied phenomena of intermittent or of remittent fever. Let us however look to the nervous system for the solution of the problem of these fevers, and all becomes perfectly plain. The languor, lassitude, gen. eral and local pains, tremor, modifications of the capillary as well as of the general circulation and of the secretions, and, above all, the abrupt transitions from a normal state to one of great perturbation, and from this again to comparative health, together with the periodical returns of the morbid manifestations-all indicate manifestly great disturbance of that pervading system whose condition is reflected in every part of the body-the nervous system. There is no other system whose impairment could by any possibility yield us the phenomena above related; still less is there any single organ that could by any modification of its condition, produce such general perturbation of the acts of the economy. Intermittents and remittents then are unquestionably the manifestations of deranged innervation; and if arrested sufficiently early will be attended with but little injury to any organ. A continuance or frequent repetition of this derangement, however, may more or less seriously implicate the parenchy. matous and secerning structures, inducing inflammatory action, and may even terminate in fatal congestions.

With these views of the pathology of paroxysmal fevers, we are ed naturally to the use of such remedies as are calculated to arrest

or to modify the perversion of innervation. Theory alone would indicate a resort to any agent known to blunt the nervous sensibilities, and thus to diminish their mobility or tendency to perturbation. Narcotics would present themselves in the first line. Every one knows that opium, morphine, camphor, alcoholic liquors, sulphuric ether, &c., are valuable remedies in intermittent fevers. Indeed, a favorite prescription with me in such cases is a combination of 2 parts of sulphuric ether, 1 part of tincture of camphor and 1 part of tincture of opium, of which I give a tea-spoonful in a wine-glass of cold water two hours before the expected paroxysm, and half this quantity again at the expected hour of attack; the patient remaining in bed during the effect of the remedy. This rarely fails in uncomplicated cases of intermittent fever; if it does not completely succeed the first day, it will the next. I have frequently averted, or favorably modi. fied even a paroxysm of remittent fever by the administration of a full dose of morphine (togr.) half an hour before the expected exacerbation. But the efficacy of narcotics is not so fully borne out by experience as is that of quinine, an agent which as yet holds a position unique in the materia medica. The most striking peculiari. ty of quinine is its power to prevent the return of periodical affections, and this appears to me to be effected by blunting the susceptibilities of the nervous system. The senses whose acuteness of perception we can most easily observe, are manifestly blunted. Audition is very soon impaired, and so is vision, if the dose of the remedy be large. The effect of quinine on the heart, in our fevers at least, is unquestionably to diminish the force and frequency of its action, and if the quantity administered be large, a general relaxation, attended with a profuse cold sweat, will be produced, resembling and therefore mistaken by the inexperienced for a collapse of fatal tendency. Having tried it in cases of pure phlegmasia, in pneumonia and acute articular rheumatism, for example, without any aggravation of the febrile action, I cannot regard it as a stimulant.

There is, I believe, no difference of opinion in relation to the value of quinine in the treatment of intermittent fevers. I will, therefore, now confine my remarks to Remittent fevers, comprehending under this term, bilious, malignant, congestive, and country fevers. These are usually preceded by premonitions, which if properly attended to, would enable us to avert their development with great ease. It is, however, exceedingly rare that medical aid is invoked thus early, and the physician is generally called in only during the first or second

strong paroxysm; often much later. The paroxysm, when once fully developed, will usually run its course despite of any efforts we may use to check it. I therefore generally direct merely a foot-bath, and the free use of cold drinks, as water, lemonade, or soda water, until the period of remission. Should there be, however, such a determina. tion to some vital organ as to threaten serious injury before the equilibrium of the circulation be restored by the subsidence of the exacerbation, I abstract blood with cups to the spine, sometimes (though rarely) deplete from the arm, and urge the use of revulsives, as hot and stimulating pediluvia, and sinapisms to the spine, epigastrium, feet, &c.; if the head be congested, the affusion of cold water to it, continued until the pulse be depressed, and repeated as this reacts, is the most efficacious application I know of. Saline enemata, especially if the bowels are full, should not be omitted, as cathartics will very rarely act during the stage of excitement. If the congestion be attended with cold clammy skin, a small and feeble pulse, and prostration of the vital energies, I advise, in addition to the revulsives, large and repeated doses of the above-mentioned combina. tion of ether, laudanum and camphor, until reaction take place.

The exacerbation having subsided, our treatment should be directed to the prevention of its return, and my invariable rule is never to permit the occurrence of another paroxysm after I see the patient. But, it will be asked, can this rule be carried out? I answer that it can in the great majority of cases, and that in those in which we fail to accomplish all we desire, we yet so modify the state of things that success is almost certain on the day following. If we be fully impressed with the belief that the fever being once arrested the patient will rapidly return to health, the importance of the rule cannot fail to be appreciated; and that such is the fact will not for a moment be denied by any one who has ever tried the practice we recommend. I repeat, that if all our efforts be directed to the prevention of another paroxysm-if we resolve never to allow a patient to have another exacerbation after we see him, the cure of remittent fevers will almost invariably be effected in a day or two.

In the accomplishment of our resolve, quinine must be regarded as the sheet anchor of our dependence, for although we may resort to other means, these can never be but of secondary value. Nor is it necessary in ordinary cases to use such large quantities of the quinine as are recommended by some. The quantity I use in one remission is usually from 15 to 20 grs., but I have sometimes given 30 or 40 grs.;

never more. It is rare that less than 15 grs. will prevent the expected paroxysm. Whatever be the quantity we may estimate as neces sary, this should be given in such a manner as to have the system fully under its influence an hour or two before the time of the previous exacerbation, and to continue its influence a couple of hours after this time. If the period of remission be eight hours, we may admin. ister 2 grs. hourly-if it be five hours, we may give 3 grs. hourlyif three hours, 5 grs. hourly-and if only one hour, we should give 20 grs. at once, and smaller doses subsequently, if necessary, to insure success. According to my observation the number of doses is a matter of but little moment-the quantity given in a remission is all important. This will depend upon the violence of the attack, the number of paroxysms that have occurred before we see the patient, and the kind of treatment to which he may have been previously subjected. As a general rule, the quantity should be increased as the period of remission is shortened, and in proportion to the number of paroxysms that have preceded its use. I am inclined to think also that it requires more quinine to prevent a paroxysm in one who has been depleted or acted on by emetics and cathartics than in one who has previously been subjected to no medication. The convalescence is certainly more rapid when no debilitating process has been instituted, and health is almost immediately restored if the disease be arrested with quinine on the occurrence of the very first paroxysm. There is some choice in the mode of administration, for the sulphate of quinine will act more slowly if given in powder than in solution, and still more so in pills than in powder. Whenever, therefore, a prompt effect is necessary, the solution should always be preferred. If the stomach will not retain it, it may be thrown up the rectum with a little flax-seed tea or thin starch, in about the same dose as if given by the stomach. In this way it acts remarkably well, and, in the treatment of children, who evince great reluctance to its taste, this mode of administration is peculiarly happy.

But the query is often made: would you give the quinine in cases of remittent fever in which the head is evidently affected,-when there is intense cephalalgia, or corna, or delirium? in cases in which the stomach seems implicated-the patient vomiting frequently and rejecting every thing he takes? in cases in which the bowels are too loose, or very easily disturbed? in cases in which the liver is either torpid or secretes inordinately? in cases in which one paroxysm runs into the succeeding so completely as scarcely to leave any re