Recent Progress in the Treatment of Thoracic Diseases

F. I. KNIGHT
1883 Boston Medical and Surgical Journal  
In view of these facts and of the constantly recurring experience that patients refer their new aural symptoms or a decided and serious increase of old aural symptoms to a course of quinine, ought not the ears to be carefully considered iu prescribing the drug, and especially in ordering large doses or pushing the medicine to its specific effect of tinnitus aurium ? Ought not the existence of inflammation of the ears or of decided tissue changes due to previous inflammations be regarded as
more » ... be regarded as contra-indications to large and long-continued doses of quinine, only to be neglected in most urgent cases? It certainly seems to me that more attention should be given to its possible effect upon the ears than is often done. Of the great value of the drug in an immense number of cases there can be no question ; of its absolute necessity in many cases there is scarcely a doubt, but there still remain many instances in which, as I believe, the medicine is given in larger and more continued doses than is necessary for the slight ailments for which it is prescribed, and always with the risk to the ears. Again, there are many instances where the medicine is pushed to its specific effect from indifference or carelessness, where equally good results could be obtained by keeping within the danger line, the tinnitus aurium being the signal given by nature, at least in the majority of cases, of the congestion of the labyrinth. Finally, where large and continued doses are absolutely necessary, and where it is desirable to push the drug to its specific effect, might it not be posible to produce the desired result, and yet occasionally interrupt the administration for one, two, or three days, thus allowing the congestion of the ears to subside? Certainly a continuous congestion for a long time is more likely to result in a decided inflammation with exudation, either free or within the tissues, than an intermittent congestion. Symptoms of acute inflammation of the ears are well known : earache, fullness, throbbing, often subjective noises, more or less deafness, etc. A few questions from the physician, even if the symptoms are not mentioned by the patient, will bring them to light. With old changes in the ears, the results of previous inflammations, the diagnosis is not so easy. The history of previous pain, severe and long continued, or an otorrhoea of some duration, even if years before, would make one suspect some tissue changes ; an existing, although slight, subjective noise of any character, aud any degree of deafness in either ear, would also point to the same conclusion. Certainly where any of these symptoms exist the physician should be upon his guard iu prescribing quinine, and especially iu giving it in large doses. Ño fixed rules can be given for doses, for with this medicine, more than with many others, the idiosyncrasies of individuals to the action of the drug are most marked ; while six grains iu twenty-four hours produce slight tinnitus in one person, many times that amount produce no effect in another individual, aud it would be interesting to know whether in the diseases iu which very large doses are considered necessary, as, for instance, in severe malaria, the medicine is borne to a greater amount without tinnitus than in the same person when in a state of health. To formulate the conclusions of this paper, we have, -(1.) Clinical experience the world over is that quinine occasionally produces serious injury to the ears. (2.) From our present knowledge, both clinical aud experimental, we are justified in asserting that the action of quinine upon the ears is to produce congestion of the labyrinth and tympanum, and sometimes distinct inflammation with permanent tissue changes. (3.) That the action of the drug upon the ears should always be considered in prescribing it, and changes in the ears, due to existing or previous inflammation of those organs, constitute a contra-indication to the medicine in large doses or for a long time except under urgent circumstances. (4.) That where large and continuous doses are absolutely necessary an occasional intermission of the administration is desirable, if possible, to diminish the risks to the ears. read a timely paper on this subject at the last annual meeting of the British Medical Association.2 He says that the discovery of the tubercle bacillus, by Koch, and the highly interesting series of experiments which led up to it, have naturally caused us to review phthisis in its various aspects, and especially in that which relates to contagion. How far consumption is infectious is a question which has been under discussion for centuries, and on which great difference of opinion has prevailed, and still prevails, in various countries, the north of Europe holding, as a rule, its non-contagiousness, and the south its contagiousness. The chief difficulty lies in the fact that many of the most potent agents of causation in phthisis, such as dampness of soil, bad ventilation, and deficient food, are also conditions which would promote the multiplication of low organisms ; and, on the other hand, heredity, which is the source of a large amount of phthisis, cannot be reconciled in its action with the bacillus theory ; for, if a man had strongly inherited phthisis in his tissues, are we to believe the bacilli have been transmitted in the seminal fluid of his father ? How can we account for the cases where the parents having died of consumption the children are necessarily attacked, on arriving at a certain age, with a severe type of the disease ? [This does not seem to us necessarily an argument against infection. The child may inherit not the germ, but such a condition as makes him, at a certain age, more liable than others to infection, that is, he offers a more favorable soil for the development of the germ. Rep.] The microscope tells us that Koch's bacilli are present in phthisical sputum in fair abundance. Now, when we consider the number of consumptive people who, being under no restriction, go about coughing and expectorating freely in the streets and parks of London, and remember that this sputa abounds in bacilli, that it dries, and becoming dust is wafted about in the atmosphere, and doubtless inhaled by a large proportion of the population, we must admit that tbe bacilli, though ever present, are not very active in ill doing, and probably because the soil they enter is not always suitable. The forms of contagion in phthisis which have been most discussed are the following : (1.) Infection 1 through breathing the same atmosphere, that is, infection by inhalation. (2.) Infection through marriage. (3.) Infection through the milk of diseased animals, or even of phthisical women. With reference to the first form of infection, Dr. Williams publishes a continuation of the health statistics of the Brompton Hospital resident staff. It will be remembered that the late Dr. Cotton, in the year 1867, published a report of the health of the residents from 1846, the year iu which the hospital was opened. The two together form a set of statistics extending over a period of thirty-six years, and relating to several hundreds of individuals subjected more or less to contact and association with consumptive patients for periods varying from three months upwards. The hospital commenced in 1846 with ninety beds, which, in 1856, were increased to 200. In 1873 a temporary utilization of the ordinary dwelling-houses, which stood on the site of the new building, raised the number of new beds to 240, which was maintained till 1879, when the temporary wing was closed. At present there are again about 240 beds in use, funds being as yet wanting to allow the whole number of 337 to be maintained. The ventilation of the hospital is now carried on by extraction, by coils of steam pipes placed in towers in different parts of the building, the air being changed two or three times au hour. There is, in addition, extraction by the fire-places. Admission of air takes place at one wing at the level of the galleries and wards ; in the other at the basement, the air being heated in winter before admission. Previous to the introduction of the extraction system, in 1877, the left
doi:10.1056/nejm188303081081003 fatcat:madfp4p6gbhidisniklx5oazwq