QUININE AS A CARDIAC STIMULANT.

930 had given way, and there was a free discharge of faeces. antipyretic drugs; but such reduction is almost always No operation was done, the openings in the scrotum gra- temporary, and in proportion, roughly speaking, to the fall dually closed, and the child recovered. In the other case in temperature, passing off as soon as the latter has the bowel was found to be gangrenous, and firmly adherent regained its former elevation. In those cases, howto the sac. It was poulticed, and came away in a few hours. ever, in which quinine had been the antipyretic given, Twelve days later the bowels acted the right way, the it was gradually observed (1) that the pulse-rate,. wound closed, and the child recovered. Perhaps therefore although it rose with the returning temperature, almost it would have been better in my case to have done nothing, always failed to attain its previous frequency ; (2) that or to have simply incised the scrotum. There might thus sometimes it remained slower, in spite of the temhave been no prolapse of the bowel. On the other hand, perature having gained an even greater elevation; and as it was a hernia of the caecum, the continuity of the (3) that not uncommonly, when the drug failed altogether bowel would perhaps not have been restored as it was in as an antipyretic, the pulse-rate was markedly affected. the cases quoted by Mr. Marsh. The specimen (Fig. 2) shows These observations seemed to point to an action on the heart independent of the antipyresis. Experiments were accordFIG. 2. ingly made to discover if this effect could be gained from doses too small to have any appreciable influence on the temperature ; for if so, the independence of its action on the circulation would be established. The anticipation was fully realised. The following is an illustrative case. Mrs. S. B-, aged forty, was admitted to the Brisbane Hospital on the fifth day of typhoid fever. During the next three days she had nineteen baths, of from fifteen to twenty minutes’ duration. On the last of these her pulse had varied between 124-with a temperature of 103° F. before the bath-and 110, with a temperature of 101 ’4° half an hour after the bath. Three grains of quinine were ordered every three hours The following day (the eighth of the attack) her pulse varied between 110-with a temperature of 103° before the bath-and 100, with a temperature of 1008° half an hour after. Ninth day of fever: pulse 108, with temperature of 103 ’4° before bath; half an hour after, pulse 96, temperature 1024°. Thenceforward no further anxiety was felt concerning the pulse, which continued to range between llO. and 92, although the case did not convalesce until the thirtyfirst day. The effect on the pulse is not limited to a reduction in frequency; the beats become stronger, more sustained, and more distinct, and the change is especially striking in A, Large intestine. B, Small intestine. c, Rod passed into a case where the pulse had been inclined to " run." The large intestine. D, Rod passed into vermiform appendix. E, Rod passed into small intestine. explanation appeared to be that the drug acted as a power. ful tonic or stimulant to the heart. It was determined to the prolapsed caecum, of a curious hammer-headed shape. A treat systematically in this way every case that commenced very fine rod is passed into the everted mouth of the to exhibit signs of cardiac failure, and the following rule vermiform appendix. A rod is passed into the ascending was laid down-three, five, or seven grains of quinine to be colon, which is contracted from disuse, and a rod is passed given every three hours whenever the pulse-rate commenced along the ileum. to range above120. In all three cases there was a complete hernial sac. In The first case was treated on April 15th, 1889. From. the third case this, of course, could not be made out at the that date to the end of the 306 cases were admitted. operation, but it is clearly seen in the specimen. As regards Of these, sixty-nine came year under the rule. Of the 306, the question whether in these cases there was any communidied, a mortality of under 6 per cent.; but eleven cation between the sac and the tunica vaginalis, there was eighteen of these were from perforation, two from profuse haemor. no communication in the first two cases; the third case is rhage, and three from dysentery. In the latter, extensive of course uncertain. ulceration of the rectum was disclosed mortem, so that I wish, in conclusion, to express my thanks to Mr. Eccles, in all of the sixteen death was the post direct result of thethe house surgeon, for his constant care of the children, intestinal lesion. Two only therefore remain to be conand for his help in putting these notes together. sidered. One of these succumbed to acute double lobar Wimpole-street, W. pneumonia, coming on suddenly before any sign of cardiac failure had appeared, and proving fatal in less than twentyfour hours. The other was altogether unusual. The patient, a young girl, had convalesced and been allowed to get up, QUININE AS A CARDIAC STIMULANT. when suddenly the temperature rose, a painful inflammatory BY F. E. HARE, swelling developed in the right submaxillary region, and RESIDENT MEDICAL OFFICER (ON LEAVE), BRISBANE HOSPITAL, she rapidly sank with hyperpyrexia in spite of treatment. QUEENSLAND. The above analysis of the eighteen fatal cases is enough to show that during the eight months and a half no patient, AT the last general meeting of the British Medical died of the usual form of cardiac failure, which under ordiAssociation at Birmingham, Sir Walter Foster stated that nary circumstances is the most frequent cause of death. he had found quinine of great service for reducing the pulse- Most of this result is undoubtedly due to systematic bathing, rate in Graves’ disease, when given in sufficiently large doses. which exerts a most powerful check upon the tendency to This action of quinine is, I believe, but little known, and progressive enfeeblement of the circulation. Thebath,howoccasionally fails, and it is always more potent as a yet it is one that is in many case3 so marked and of such ever, in this respect than as a remedy when once prophylactic great utility that it is difficult to see how it has so generally the condition is developed. Consequently quinine is espeescaped recognition. In typhoid fever, at any rate, there is cially useful in those cases admitted* late in thecourse of the fever. Alcohol is, of course, given in the same cases as no drug that possesses anything approaching its power. At the Brisbane Hospital the cold bath treatment of the quinine, but these are the cases in which alcohol always typhoid fever has been carried out in its entirety for has been administered ; and certainly the amount found the last three years. Baths usually reduce the febrile necessary during the included period has been vastly less temperature with ease, but in some cases, owing to its than formerly. Only quite exceptionally has more than obstinacy, they fail. In these some antipyretic drug four or six ounces of whisky been given even in severe is evidently indicated. Quinine was therefore commonly cases, whereas previously eight, twelve, and even sixteen given for this purpose, in doses of from thirty to forty grains, ounces were no infrequent quantity. as recommended by Liebermeister. Some points in connexion with the action of quinine on Now, of course, anything which depresses the temperature reduces the pulse- the heart are worth noting. 1. The slowing of the pulse. rate. -B3,tlis have this effect in common with all the rate is tardy in appearing, usually twenty-four hourJ,

931 before its effect is distinctly perceptible. 2. The kidneys and ureter, and made him take violent exercise of is somewhat permanent, so that if a varied nature, to find if possible any complaint of pain the drug be withheld the pulse does not attain its previous elsewhere than in the end of the penis, or any alteration in rate for two or three days. Both of these are in contrast the urine, without any success. Therefore, on Oct. 22nd, I to its action on the temperature, which is never prolonged opened the bladder above the sympliysis, and found its healthy, as we had previously found it on examining beyond thirty-six hours, by even the largest antipyretic interior dose. 3. Its action is not limited to typhoid fever. I have it with the cystoscope. On attempting to introduce the tip obtained similar results in the last stages of phthisis, in of the little finger into the prostatic urethra, the greatest croupous and broncho pneumonia, and in surgical cases resistance was felt, and it was only after using much force, with hectic. I venture to think that the recognition of this both with the finger and with instruments, that it was possible to dilate up this portion of the urethra. Nothing abnormal me of quinine is a point of great importance, and that by it alone many lives might be saved. The difficulty of could be detected in the prostate except that its right meeting the emergency of heart failure in fevers is testified lobe was smaller than the left. Hardly daring to hope that to by the number of drugs that have at various times been this dilatation of the prostatic urethra would be of any service recommended for it. I have given the great majority of to the patient, I introduced a drainage-tube and closed the these a more or less extended trial, without ever being able wound. On Nov. 1st the drainage-tube was removed, and to satisfy myself that I obtained any result, except, perhaps, he passed urine through the urethra. (The reason I took from digitalis. Digitalis, however, had nothing like the the unusual course of introducing a drainage-tube into a effect of quinine, while it appears to have, in doses sufficient healthy bladder was that I wanted to keep the prostatic urethra at rest for a few days.) He was delighted to t9 reduce the pulse-rate, dangers peculiar to itself. Most works on therapeutics seem to imply that quinine find that he had lost the pain since the operation. He is a cardiac depressant. What is the influence of this left the hospital on Nov. 8th, with the object of teaching on practice? A case of typhoid fever is being spending some weeks at the sea-side. I saw him treated with small doses of quinine, two or three grains about the beginning of this year, and found him looking Later on, strong and in much better condition. At times he said every few hours (a common routine treatment). in the usual course of events the pulse becomes weaker he felt a very slight pain in the position of his old and more frequent. The drug is then probably with- trouble, but it did not seem to cause him any concern. drawn on the supposition that it is weakening the heart’s I felt that this case deserved to be put on record because action, whereas this is the very time that the dose should of the obscurity of the causation and pathology of the conbe doubled or even more largely increased. All this has, dition of the prostatic urethra, of the apparent causal conat any rate, frequently happened to myself. nexion of the prostatic stenosis with the local penile pain, and of the happy termination, almost accidentally arrived Aberdeen. at, of a complaint which would not only have considerably abbreviated the course of the man’s life, but would also have VERY SEVERE PAIN IN ANTERIOR, EX- rendered it exquisitely miserable, if in all human probability the intensity of his misery did not lead him to termiTRE MITY OF URETHRA. nate his existence. I trust that this communication may SUPRA-PUBIC CYSTOTOMY; FORCIBLE DILATATION OF lead others to publish accounts of some similar cases they CONTRACTED PROSTATIC URETHRA; RECOVERY. may have observed, which may help to throw light upon this condition, apparently a very rare one. Should the pain BY W. ARBUTHNOT LANE, M.S., recur in this case I will dilate the prostatic urethra forcibly ASSISTANT SURGEON TO GUY’S HOSPITAL AND TO THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-STREET. and extensively with a suitable lithotrite. I regret to say that after a time the local pain returned, J. W. P-, aged forty-two, builder’s foreman. His but with less severity than before. Forcible dilatation of mother died from consumption, and his six brothers the prostatic urethra relieved this pain, though it did not and sisters from various diseases-two from inflammation remove it. No further light has been thrown upon the condition since the first operation. of the lungs, one from abscess in the side, one from blood St. Thomas’s street, S.E. poisoning, and two from con vulsions in infancy. He was a anarried man, and had always been stout and vigorous till the onset of his present symptoms. These developed about the middle of 1888, and consisted of almost unbearable pain in a position corresponding to the floor of the anterior extremity of the penile urethra. This MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL. pain was so violent and constant as to make it impossible for him to continue his occupation. He was un’1.ble to eat his meals and he lost flesh rapidly. He stated HÆMATURIA IN EAST CENTRAL AFRICA. that he was for some time an out-patient in St. Peter’s BY R. F. CASTLE, M.B., B.C. CAMB., Hospital, where nothing was found, and his pain was not relieved, I saw him at the out-patient department of LATE MEDICAL OFFICER, USAMBARA DISTRICT, EAST CENTRAL AFRICA. Gay’s Hospital, and admitted him into the hospital under the care of a colleague. When under observation, it HÆMATURIA is certainly one of the commonest causes of was seen that though the man complained of constant pain, both amongst the natives and the Europeans complaint he was subject to violent exacerbations lasting from a few in resident Zanzibar and on the adjacent mainland. minutes to three or four hours. During these attacks he The bsematuria in to the be the may be roughly divided into two great appeared greatest agony. Though pain was increased by his getting about, yet he had severe classes-one dependent on the presence of a parasite, the attacks when kept perfectly at rest. The right testicle was other not. The parasitic form is due to the presence of the undescended. Nothing could be made out by examination trematode bilharzia hcematobia in the body, and the ova with the cystoseope, sound, finger, &c., either at this time can invariably be seen in the urine, although the latter or on subsequent occasions. His weight was about 8 st., may appear to be free from blood. The persons who suffer and he appeared wasted and distressed. His usual weight from this disease are very numerous, are usually of the male sex, and are almost invariably under the age was about 10 st. His urine was acid, sp. gr. 1008, and contained no blood or pus. Some crystals of triple phosphate of thirty; after that age the symptoms seem to disappear. were present. He was treated with various drugs, dieted, All the cases which came under my observation were and kept in bed for some time, and apparently with some directly traceable to the patients drinking water from one benefit. He left the hospital on Sept. 1st. of two small rivers which drain part of the Usambara He was readmitted under my care on Sept. 22nd, having district. In both these rivers I have found the free-swimming spent three weeks at a convalescent home. He asserted embryo. In other parts of the same district where water that it was impossible to continue life in his present con- was scarce and the natives derived their whole supply from dition. Considering that the cause of the pain might be mud-holes the disease was apparently unknown. The some condition of the prostate not apparent by the cystoscope, Europeans living in this district are in the habit of boiling to open the and filtering their water before using it; consequently none sound, or finger, in the rectum, I bladder above the symphyais, and examine it bimanually. suffer from the disease. Again, anative will drink three orfour I may say that I had carefully examined the position of the times as much water in the day as a European will, a small

lapsing

effect, when obtained,

__

Clinical Notes:

determined