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ORIGINAL ARTICLES.

THE ADMINISTRATION OF QUININ BY

HYPODERMOCLYSIS.*

BY JAMES W. GRAY, M.D., JR.

CLARKSVILLE, TENN.

HOWEVER much we may differ as to the method of infection in malaria, whether we believe it to be transmitted through the bite of the mosquito, "anopheles," or is taken into the human organism by breathing infected air or by drinking infected water, at least we all agree that the successful treatment of this great scourge of our Southern country depends upon the prompt and efficient administration of quinin.

In my opinion very few cases of acute malarial infections are necessarily fatal; and the explanation of the high mortality rate attending malarial attacks, is to be found in the imperfect administration of the specific, quinin.

And believing as I do, that quinin is a true specific for all malarial infections, I consider it a reproach to the profession that there should be any mortality, unless the patient be simply overwhelmed by the initial attack and no opportunity be given for treatment.

In ordinary cases the administration of a sufficient amount of quinin by the mouth, whether in capsule, or preferably, in acid solution, with proper attention to elimination, is usually successful.

But in the pernicious attacks of whatever type, a very brief consideration of the symptoms and morbid anatomy will show how futile it is to expect favorable results from this method of treatment.

The constant nausea and violent vomiting, when the patient is conscious, renders it virtually impossible for anything to be retained. But even though the remedy be retained the almost complete stagnation of the circulation of the mucous membrane of the stomach from a practical occlusion of the arterioles and capillaries by the parasites and infected corpuscles, renders *Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 19, 1901

absorption virtually impossible. Even in cases of ordinary estivo-autumnal fevers, not pernicious, and when the stomach was seemingly in good condition, I have frequently found it very difficult to obtain sufficient absorption to control the paroxysms. It is in this class of cases, especially the pernicious, that the hyperdermatic injection of a warm solution of quinin deep into the muscular tissue is recommended, and has been extensively practiced. The results reported have been fairly satisfactory in the main, but as enormous doses of quinin have been given by the mouth concurrently, I am inclined to be skeptical as to the part played by the hypodermatic medication.

The injection of a strongly acid solution, varying in strength from 10 per cent. to 25 per cent. of quinin invariably produces great pain, induration, frequently local necrosis, and sometimes

even tetanus.

The reaction of the tissues is so violent that I am inclined to think that the quinin quickly becomes practically encysted, and, instead of producing an immediate effect, is absorbed, if at all, in homeopathic doses for months afterward.

In a case of which I have notes, the induration caused by the hypodermatic injection of one dram of a 10 per cent. solution of quinin bimuriate broke down about a year afterward, and I removed the pure salt of quinin, which had been precipitated, from the resulting abscess.

In a series of cases reported in the Journal of the American Medical Association some years since, treated exclusively by the hypodermatic method, a very large percentage (I have mislaid the journal and must speak from memory) of the cases were absolutely unaffected, and the writer was compelled to resort to the administration by the mouth, before a cure was effected. My experience has been the same, and I have abandoned the method.

The direct intravenous injection has been proposed and used to some extent, and is far preferable to the usual hypodermatic injection of a strong solution. The principal objection is the difficulty of the technique, and the danger of paralysis of the heart, if the solution be thrown too rapidly into the circulation. However if slowly and carefully done, it is safe and very effective.

During the past two years I have been using a method that I have not seen mentioned in the current literature on the sub

ject, but which has been entirely satisfactory in every respect. That is the administration of a weak, hot solution, one fourth to one-half of one per cent. of quinin in normal salt solution by hypodermoclysis. The most dangerous manifestations in all malarial paroxysms are characterized by the stasis of the circulation and imperfect elimination of toxins and waste products, and I know of no better method of combatting that tendency than the ingestion of a large quantity of normal salt solution. The addition of the small percentage of quinin in nowise detracts from its value, nor does it add to the irritation, so that we are able to meet two therapeutic indications at

once.

The solution that I prefer is 30 grains of bimuriate of quinin and iron in a pint of normal salt solution, with a medium-sized aspirating needle attached to a Davidson or fountain syringe. The solution may be injected, with due precautions to secure asepsis, into the loose subcutaneous tissue in any part of the body, or in urgent cases, the solution may be thrown directly into a vein. The injection is not very painful, the absorption is rapid, cinchonism prompt, and induration or local necrosis has never been produced.

The method is simple, safe and entirely efficacious.

THREE EYE CASES WITH CLINICAL REPORTS.

BY B. D. WOODSON, M.D.
MONROE, I. T.

Case I. Trachoma. Jno. B., aged 31 years, consulted me in July, 1900. He gave the following history: Has had "sore eyes "for seven years, his eyes giving him a great deal of pain of late, especially when in the sunlight. His sight has been gradually growing worse all the time, despite the treatment. that he has had from several physicians.

Upon examination I found him to have trachoma, with entropion of upper lids; narrowed palpebral fissures, with some haziness of both cornea (pannus). His vision was 20-50 in right eye and 20-40 in left eye.

I advised an operation to relieve the ingrowing eyelashes

and narrowed palpebral fissure, to be followed by local treatment to lids, to which he readily consented.

On July 21, assisted by Dr. C. E. Riggan, who kindly administered the anesthetic, I proceeded to do the combined operation of canthotomy and entropion after the manner of Hotz, of Chicago.

The operation was done in as aseptic manner as possible, and the wounds healed by first intention.

The stitches were removed on the fourth day. After ten days had elapsed from the operation the lids did not fit so tightly over the globe of the eye, and could be easily everted. I applied sulphate of copper to lids daily for six weeks and instilled a 1 per cent. solution of atropin in the eyes to quiet. the iris.

After using the copper for six weeks his eyes had made wonderful improvement, so I changed the local treatment. In place of sulphate of copper I used a 2 per cent. solution of silver nitrate applied daily to everted lids, washing off the lids afterward with water, and left off the atropin as his eyes were not so painful and the cornea were clearing up some.

After using the silver nitrate for four weeks, I changed to a 30 per cent. solution of protargol applied to the lids daily. I used the protargol for six weeks; his lids were well at the expiration of the six weeks of protargol treatment, and his acuity of vision was normal in each eye.

The treatment of trachoma requires a great deal of patience upon the part of patient and physician. It is not best to rely upon one remedy for this trouble. It seems as though trachoma will improve so far with one remedy and then stop, and right here is the time to change to something else for a while.

Case II. Iritis. Mr. G., aged 50 years, was referred to me by Dr. Wilson on March 1, 1901. He gave the following history: He had an attack of smallpox in December, 1900; during the latter part of his illness his left eye began to give him a great deal of pain, also severe pain in temple and brow of corresponding side; the pain was worse at night. Has always had good health, with exception of a mild attack of articular rheumatism several years ago. No specific history.

Upon examination I found a loss of luster and pattern of iris and almost immobile pupil. There was no mucous or muco-purulent discharge from the eye. The tension of the eye was about normal. His tongue was heavily coated. On dropping a 3 per cent. solution of atropin into the eye, the pupil dilated to only a small extent, and very irregularly.

Upon these symptoms I based my diagnosis of iritis, with posterior synechiæ.

He was instructed to remain in a dark room and was purged freely with calomel. After the calomel had acted he was given four grains of salicylate of soda every three hours in the daytime. Two drops of a 4 per cent. solution of atropin was instilled into the eye every two hours with the hope of breaking up the adhesions. He was given a small amount of a 4 per cent. solution of cocain to drop into the eye occasionally to relieve him. This line of treatment was kept up for one week, with but little improvement. The atropin had failed to break up the adhesions, so I put him on a 1 per cent. solution of atropin. His tongue still being heavily coated and bowels inactive, he was given a good laxative every night and acetate of potash was given after meals, the salicylate of soda being continued. A small blister of cerate of cantharides was placed in the temple for its counterirritant effect. The iodide of potash was also given for its eliminative properties, but with negative results. This line of treatment was vigorously kept up for three weeks, with but little improve

ment.

At this time of the treatment the patient was ordered to bed, the diuretic and laxative treatment being continued, also the 1 per cent. solution of atropin into the eye. The patient was kept in bed for several days, and as his eye pained him about as badly as when sitting up, he was allowed to sit up in a dark, comfortable room.

At the expiration of two months' treatment on this line, the conjunctiva was free from its intense redness, the eye had ceased to pain him, and the patient was allowed to return home. After being home for three weeks he wrote me that his eye was doing nicely, and that he could see a "frying-size chicken" a distance of two hundred feet.

I have seen quite a number of cases of iritis due to the recent epidemic of smallpox. The early diagnosis of iritis and prompt and energetic treatment of it will save much suffering, and in many cases the sad plight of permanent blindness.

Case III. Enucleation. J. G., aged 38 years, consulted me June 24, 1901. He gave the following history: Several years ago he was severely burned in face and right eye by a premature explosion, while blasting in a well. At the time the eye pained him greatly for quite a while, but under treatment of his family physician the inflammation subsided, and

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