China officinalis

Lecture XXXV — Rubiaceae — Cinchona rubra

Cinchona.

Ipecacuanha.

Coffea.

Rubiaceae. { Rubia tinctoria. (Madder.)

Galium. (A red dye.

Mitchella.

i Gambier.

To-day, gentlemen, we have before us an order of plants from which we derive three very valuable drugs, Cinchona, Ipecacuanha and Coffea. This order also gives us Gambier (a drug not used in our materia medica) and Mitchella, besides several dyes, as the famous Madder and Galium.

From the fact that these dyes are red, the order derives its name. The first drug on the board is the Cinchona, frequently, although improperly, called China in our nomenclature.

' We shall now proceed with its consideration:

Cinchona Rubra.

Cinchona. < 'Ipecac, Arsenicum, Ferrum met., Veratrum album,.

Carbo veg.

Phosphoric acid, Phosphorus, Rhus tox., Bryonia, Pulsatilla.

Nux vomica, Podophyllum, Eupatorium perf., Natrum mur.

Chininum sulph., Aranea diadema.

Eachesis, Cornus florida, Eucalyptus.

> Pulsatilla, Arsenicum, Ipecac, Veratrum album.

< Selenium, Digitalis.

Loss of fluids.

Anaemia.

Ill-effects of sudden or acute diseases.

Haemorrhage.

Fevers: malarial, intermittent, hectic.

Digestive organs.

Rheumatism.

Neuralgia.

Cinchona.

Cinchona is certainly a wonderful drug, wonderful in the many varieties of its species, wonderful in its composition and wonderful in its effects. It also has a historical value to homoeopathists as being the drug which led Hahnemann to the discovery of the law of cure and enabled him to establish Homoeopathy as a fixed science. It is not a little singular that the natives of Peru, especially in the early days, would not permit the Cinchona tree to be touched, as they believed it to be poisonous and under the charge of special gods. They were, therefore, greatly astonished when Europeans became engaged in the occupation of stripping the bark from the trees and exporting it to Europe. The Cinchona industry has now grown to such an enormous extent as to demand certain restrictions in its gathering and exportation lest the species become extinct. New trees are being continually planted, so that there is no danger of extermination of the drug. There are several varieties of the Cinchona bark, of which, however, I can mention but three, namely, the pale bark, the Calisaya or yellow bark, and, lastly, the red bark, or Cinchona rubra. There are some thirty other species known.

A physician in the West, the value of whose experiments I am inclined to doubt, claims to have discovered in Cinchona rubra a certain specific against intemperance, or the thirst for liquor. He gives the bark in appreciable doses, and claims that in a time varying from one to four weeks it will cure the most confirmed inebriate of his pernicious appetite.

In publishing the accounts of his observations in the journals, he says that he was led to his discovery on treating an "old sot " who had never known a sober day until he had chills and fever, which was cured by red bark.

Cinchona contains a number of alkaloids which are closely related chemically; in fact, many of them are isomeric. They are associated with various organic acids peculiar to the group.

The most important of the Cinchona alkaloids are given below: Quinine, C 20H 24N 2O .

Quinidine, C20H 24N 2O .

Cinchonine, C 20H 2iN 2O.

Cinchonidine, C 20H 24N 2O.

Quinamine, C20H 24N 2O .

Quinic acid, C tH 12O e .

Cincho-tannic acid.

Ouinovic acid, C24H 38 4 .

It now remains for us to study the general effects of Cinchona before we proceed with our consideration of its symptomatology. It has been determined that a solution of Quinine of one part to ten thousand acts destructively on bacteria and infusoria. Thus it will destroy the poisons that propagate many of the contagious diseases, as puerperal fever, scarlatina, etc. You may make use of this propert}' when going from one case of puerperal disease to another, for if you bathe your hair and whiskers in a solution of Quinine \n bay-rum, this will destroy all danger of carrying the contagion and will not prove a source of annoyance to yourselves. On the contrary, it will aid the growth of the hair and beard.

Quinine and its salts when topically applied to a denuded surface or to a mucous membrane, act as decided irritants.

Quinine also has a toxic action upon all protoplasm. It is particularly active in preventing amoeboid movement, which, as you know, is possessed by the leucocytes. This is one reason why allopathic physicians have used it to prevent inflammation. Quinine also inhibits enz3 Ttne action, thus retarding tissue metabolism. That is one explanation of its tonic effect. You will see, however, that this property of retarding waste is still more marked in Coffea. Quinine also acts upon the heart substance, weakening that structure. Thus there is impaired circulation.

Another effect of Quinine is that large quantities injected subcutaneously destroy the oxygenating power of the blood. Furthermore it has the ability to reduce hyperpyrexia. This appears to be accomplished mainly by a direct action on the heat-producing foci. It also tends to act on the spleen, producing congestion, inflammation and enlargement of that viscus.

There is still one other property of Quinine which it may be well to remember, and that is its power of abolishing reflex action when taken in large quantities.

Now let me give you the symptoms of cinchonism, that is, the symptoms which follow the excessive use of Cinchona bark or of Quinine. You will find prominent among these symptoms an increase of appetite from stimulation of digestion. Soon nausea and vomiting appear, and even diarrhoea may be added to the gastric disturbances. Then the head becomes affected. There is a peculiar sensitiveness to external impressions, to noises, to bright lights or to anything that is apt to render the patient irritable. There is experienced a peculiar form of headache, which is characterized by dull aching and at other times by throbbing in the head. There are well-marked ringing or roaring sounds in the ears, a very characteristic effect of Cinchona. Vertigo still further complicates the case. If the use of the drug is still persisted in, deafness follows.

In other cases there appears a sort of Cinchona intoxication which is not unlike that produced by alcohol. This is followed by delirium, dilated pupils, then complete stupor with difficult respiration and finally convulsions, these convulsions arising from anaemia of the nerve centres and not from congestion, as is the case with Belladomia. In extreme cases collapse and death from paralysis of the heart end the patient's life. These, then, are the general effects of Cinchona, when that drug is given persistently in increasing doses and at short intervals. They may vary in severity from a simple ringing in the ears to all the symptoms of complete poisoning.

Hahnemann has taught us that Cinchona is useful only when debility or anaemia comes from loss of fluids. In the allopathic school it is used in all forms of debility, given either alone or in combination with iron or sherry wine. But, as I have said before, we have learned from Hahnemann that it is useful only in the anaemia which results from loss of fluids. Hence, you may use it for the results of haemorrhage, whether it be from the mouth, lungs or uterus. You may use it when long-lasting diarrhoea has exhausted the patient. It may even be used when the condition has proceeded further than a simple debility, and that horrible disease known as hydrocephaloid has developed.

In such cases, when Cinchona is the remedy, the child has these symptoms: after violent or long-lasting cholera infantum, it becomes drowsy; the pupils may be dilated, the breathing is very rapid and •superficial; the diarrhoea may have ceased, or the movements may be involuntary; the surface of the body is rather cool, especially the prominent features about the face; thus, the ears, nose, and chin are cold. In just such cases as this, Cinchona will, if there is any vitality remaining, restore the patient to health.

If it should fail, you may still fall back on Calcarea phosphorica, a similar but more deeply-acting drug.

In applying Cinchona to the debility resulting from sexual excesses, remember that it is only curative for the debility resulting from the excessive loss of semen. If there are constitutional troubles it is worse than useless.

Now let us pause and study the relation which Cinchona bears to other drugs applicable to debilitated and anaemic conditions. Ferrum is indicated in pure anaemia, with an appearance of plethora. Arsenicum is the remedy for debility resulting from overtaxing of the muscular tissues, such as follows prolonged exertion, climbing mountains, etc.

Phosphorus is preferably indicated in prostration which is very sudden in its onset, when the nervous system is exhausted. Hence, we may have to use this drug in a variety of diseases, in scarlatina, in measles, in diphtheria, and, in fact, in any disease in which the nervous system seems to have sustained a sudden shock or blow. This is not a Cinchona case, remember.

Phosphoric acid is somewhat different from Phosphorus . It is to be thought of in debility of nervous origin, when it is not connected with an} 7 pain except, perhaps, a simple burning in the spine or in the limbs. The mind is rather apathetic, and the patient is inclined to be drowsy and sleepy. The characteristic of this sleepiness is that he is easily aroused from it and is wide awake.

Zincum is good when the brain becomes affected in the course of nervous diseases, scarlatina or summer complaint of infants. Especially is it useful in scarlatina when the child has not sufficient strength to develop an eruption.

You may use Cinchona for haemorrhages, and here you can scarcely do without the drug. The haemorrhage ma)

7 come from any orifice of the body; the blood is apt to be dark and clotted; the flow is so profuse as to have almost produced exsanguination of the body; there is coldness of the face, of the whole body in fact; the features show the presence of collapse; there is gasping for breath; the patient demands to-be fanned. Now, this fanning is desired, not for the purpose of cooling the patient, but is called for because of the instinctive demand for more oxygen, which the fanning produces by changing the strata of air about the patient's head. Cinchona is frequently called for in ante-partum and post-partum haemorrhages; in such cases you do not give it in a single dose, but repeatedly, at short intervals, until the consequences of the hsemorrhage have been removed.

There is another condition in which I would recommend Cinchona, and that is, when retained placenta is attended with haemorrhage- Pulsatilla does no good. I know that it has been recommended in these cases to take away the after-birth by manual interference, but it has been my practice to administer Cinchona until the tonicity of the uterus is restored, and then remove the placenta.

The nearest remedy to Cinchona in these symptoms is Ipecacuanha > which is useful when there is profuse bright red flow of blood, usually accompanied by nausea, and sometimes by very hard, labored breathing. Sometimes there is coldness of the surface of the skin, which is covered with cold sweat. It is one of our best remedies in the haemoptysis of incipient phthisis.

Belladonna is useful when the haemorrhage is of bright blood, coagulating rapidly, and feeling hot to the parts over which it flows. Trillium controls haemorrhage when the flow is either bright red or dark, and occurs in women who flood after every labor.

Millefolium is suited for a profuse, bright red flow, unattended with pain; it is much like Aconite, but it lacks the restlessness, anxiety and fever of that remedy; it has, also, continuous flow after an injury. Sabina is to be used when the flow is bright red with clots, and is worse from any motion. The haemorrhage is attended with pain extending from the pubes through to the sacrum, and with pains in the legs.

Carbo vegetabilis is to be given when there is a continuous dark passive haemorrhage. The patient wants to be fanned. The skin is cool and bluish, and the pulse rapid and weak.

Secale is said to be best adapted to thin scrawny women. The flow of blood is passive; it is attended with tingling in the limbs. Although the surface of the body is cold, the patient persistently expresses her desire to be uncovered.

Erigeron is said to be useful in profuse haemorrhage similar to that of Sabina, but associated with irritation of the bladder and rectum. Hamamelis is suited to passive venous haemorrhages, especially when the part from which the flow of blood proceeds feels sore and bruised.

Acalypha Indica is useful in haemoptysis after fits of dry coughing. Cinnamomum, profuse haemorrhage from a strain or misstep. Cyclamen, profuse haemorrhage, with dizziness and obscured vision, as from a fog. This is different from the natural syncope resulting from excessive or sudden bleeding. It may follow slight losses of blood in women of a delicate build, whose weakness is cerebro-spinal. You may also compare Ledum, Vinca minor and Phosphorus if the haemorrhage is caused by uterine polypi.

When reaction has been established after haemorrhage, you may still give Cinchona if there is headache with violent throbbing of the carotid arteries. This is not a Belladonna symptom. It is here an indication of anaemia, whereas under Belladonna, this symptom is indicative of hyperaemia.

It is a general characteristic of Cinchona to produce a nervous erethism with its symptoms of debility, a fact which allies it more with Arsenicum than with the torpid Carbo veg. The mind is over-active, although lacking endurance. Ideas crowd on the mind in unwelcome profusion, preventing sleep. On closing the eyes he sees persons and figures. The surface of the body is sensitive to the touch. This susceptibility is more imaginary than real. If the patient has a slight pain he feels it unbearably, and he dreads the slightest attempt to approach him lest you touch him, yet firm pressure or rubbing relieves. He exhibits a similar sensitiveness to a draught of air, which always makes him worse. These hints are appropriate to neuralgic and other pains. Arnica has this fear of being approached in gout; Spigelia has an actual sensitiveness of the whole surface, the least touch sends a sudden shock through the entire frame.

You may have to use Cinchona to cure asthenopia, but only when it occurs as the result of haemorrhage or loss of fluids. An examination with the ophthalmoscope shows the disk to be pale and anaemic. The pupils are apt to be dilated; the eyes ache on attempting to use them, as in reading or writing, and objects appear blurred.

We now come to the study of the action of Cinchona on the digestive organs. It is very useful for dyspepsia occurring especially after loss of fluids. Digestion is so weak that the stomach cannot tolerate any food at all. Should the patient's supper come to him later than usual he is sure to suffer in consequence. The stomach is distended with flatus, but belching relieves only momentarily or not at all. The least food or drink taken increases this symptom, so that after taking but a small quantity, he feels full, as though he had eaten an enormous meal. He complains often after eating of a sensation as of a lump in the mid-sternum, as though food were lying there. This is situated higher up than is the "hard-boiled egg" sensation of Abies nigra. Pulsatilla also has the same sensation in the same locality. This state, when Cinchona is the remedy, is often the result of loss of fluids, drinking tea to excess, and beers, fruits, etc. The appetite is often voracious when not capricious; thirst for cold water; drinks little and often; longs for acids, brandy, sweetmeats; buzzing in the ears. Aconite has anxiety, relieved by very cold water or ice. Veratrum album desires ice-cold water. The following also crave cold water: Pulsatilla, Plumbum, Scilla.

Cinchona is an excellent remedy in the gastric troubles of children who are continually asking for dainties, but who reject substantial kinds of food. On awaking in the morning they are cross and irritable. They have a bad taste in the mouth and a white-coated tongue. Cinchojia is useful in some diseases of the bowels, especially when associated with marked tympany. The abdomen is enormously distended; when you percuss it, it gives forth a sound almost like that caused by striking the tense head of a drum. It is particularly when this tympany occurs early in the disease that Cinchona does good; then this symptom shows early debility. I^ater in the course of the disease, when it results from decomposition, Cinchona is less valuable, and you must resort to such remedies as Terebinthina, Colchicum, etc. The diarrhoea of Cinchona is very characteristic. The stool is lienteric in character. It is worse at night and after eating. This is attended with rapid exhaustion and emaciation. In appearance the stools may be yellow, watery or brown, and very offensive. Cinchona is one of our best remedies for diarrhoea occurring in hot weather after eating fruits.

The nearest allies to the drug here are Ferrum metallicum, Arsenicum album, Phosphoric acid, Oleander, Iris versicolor and Podophyllum. Arsenicum and Ferrum both have profuse lienteric diarrhoea, coming on during or after eating.

Phosphoric acid differs from Cincho7ta in that, while the stools are frequent and copious, they are not attended with much debility. Iris versicolor is indicated in summer diarrhoea. The stools, are copious and are associated with vomiting. The patient is worse at about two or three o'clock in the morning. It differs from Veratrum album in the absence of coldness.

Podophyllum . is to be used for profuse gushing diarrhoea, coming on in the morning, or more during the day than at night. The stools may contain undigested food and often, in children, deposit a mealy sediment.

The Oleander diarrhoea is also lienteric. The patient passes in his stool the food which he had eaten the day before.

Cinchona, as you all know, is a valuable remedy in the treatment of chills and fever. It is useful either in fevers of the tertian or of the quartan type. The chill is unaccompanied by thirst, but there is thirst either before or after the chill. During the chill the patient sits as near as possible to the fire or wraps himself warmly in blankets; but the warmth thus obtained does him no good. The chill is followed by long-lasting heat, during which the patient desires to uncover. He is then usually without thirst. His face is fiery red, and he is often delirious. The sweat which follows is profuse and debilitating, with intense thirst. The apyrexia is by no means free from symptoms. The face is sallow, dingy yellow, from bilious complications, the spleen is enlarged, and there are aching sore feeling in the splenic region and either total loss of appetite, or canine hunger. The feet become oedematous, sometimes from disturbance in the composition of the blood, but mostly from interference with the hepatic and splenic circulations. Sleep is greatly disturbed, and the patient, as soon as he closes his eyes, sees figures, etc., before him.

The Sulphate of Quinine has these same symptoms, with this in addition, the chills recur with clock-like regularity, usually at 3 A. m., with blue nails, and pain in the dorsal vertebrae. But both drugs may be indicated in an anteponing type of fever. The heat is accompanied by excessive thirst and red face. The tongue is yellow down the centre, with pale edges. The heat gradually breaks into a sweat which relieves. The patient is very weak between the periods. Cinchona and its preparations have been so much abused in the treatment of intermittent fever that it is necessary to differentiate them carefully from their concordant remedies.

First of all may be mentioned Coryiusflorida . This drug has sleepiness long before the chill; the patient feels chilly, but is warm to the touch; the heat is associated with drowsiness, and is followed by profuse sweat.

Menyanthes is excellent when the chill predominates, with icy coldness of the tips of the fingers; in fact, all peripheral parts of the body get cold.

In Capsicum the chill begins in the back, with thirst. The patient feels better from heat applied to the back and from wrapping up, just as under Ignatia.

Eupatorium perfoliatum is useful when the chill comes in the morning, or in the morning of one day and in the afternoon of the next; the usual time, however, is nine o'clock in the morning. The chill is often preceded by thirst and bitter vomiting. The drinking of water makes the patient chilly. The fever is usually followed by very slight sweat.

Lachesis may be used after the abuse of Quinine, when the chills return in the spring.

Canchalagua is indicated in spring ague, with severe chill; the hands are puckered up like a washerwoman's.

Eucalyptus is a remedy which has been highly recommended in malarial fevers, but I must say to you that I know little or nothing about it.

Ipecacuanha is useful in intermittent fever when the type has been spoiled by Quinine. You can obtain no clearly defined picture of the case. Everything is confused. Ipecacuanha seems to have the property of developing the symptoms and of curing the case, or it provides you with sufficient data to enable you to select the appropriate remedy. The characteristic symptom of Ipecacuanha during the paroxysm is short chill, followed by long fever. Usually we find gastric symptoms, with a preponderance of nausea.

Sepia is also to be thought of in cases that have been spoiled by Quinine or by bungling administration of Homoeopathic remedies. Another remedy which may be utilized for the removal of the bad effects of Quinine is Arsenicum album. It is called for when the paroxysms occur more or less periodically. Thirst is great. The spleen is swollen. Dropsical symptoms appear. Paroxysms of neuralgia appear in the face, and recur regularly. Arsenicum may be indicated when almost any form of disease assumes the malarial type. In these cases you will find the ordinary remedies of no value whatever. Still another remedy in severe cases is Carbo veg. This is especially of service after the abuse of Quinine, when there is thirst during the chill; when the body is icy-cold, and especially is this coldness noticed from the knees down; and when there is lack of reaction. You will be surprised to see how nicely an apparently hopeless case will rally under one or the other of these remedies.

There is a constitution developed by the marsh miasm for which it is necessary to use deep-acting remedies. Foremost among these stands Aranea diadema. This drug is suited to persons who may not have any distinct type of fever, but who suffer at every cold or damp change in the weather. The symptoms seem to be ill-defined. At one time they feel dyspeptic, at another they ache all over; but in all cases the constitutional taint is at the bottom of the whole trouble. Aranea diadema will so change the type of constitution that the patient will escape any further injury when exposed to dampness. Malaria officinalis should be compared in this condition. In some cases you will have to use Ferrum metallicum as an antidote to Quinine, especially when we have the masked anaemia peculiar to this drug. The face is easily flushed, and the bloodvessels throb. The spleen is enlarged, and dropsical symptoms are manifested mostly about the feet.

Cinchona—to return to that drug—is also of essential service in the treatment of hectic types of fever, such types of fever as indicate a long-lasting suppurative process. The surgeon is called upon to employ this drug very frequently when, after emptying an abscess, symptoms of hectic fever develop. The cheeks are red. The patient is excessively nervous, the nervous irritability being greatly disproportionate to the patient's strength. He is so greatly prostrated by the fever that he can scarcely raise his head. Diarrhoea adds to his weakness. Copious night-sweats also exhaust him. Along with Cinchona in this connection you must place in your mind its analogues, which are chiefly Arsenicum album and Carbo veg. You will often meet with a severe case in which Cinchona runs its course, and no longer produces improvement. You will then have to select Arsenicum or Carbo veg., according to the symptoms of the case.

Carbo veg., as well as Cinchona, is to be remembered as a remedy to prevent collapse following the opening of a cold abscess, such as occurs in spinal caries. The symptoms of the two remedies are almost identical, and your choice between them may be difficult unless you find other symptoms in the case pointing distinctly to one or the other drug.

Psorinum, like Cinchona, is useful in some cases of night-sweats. It is indicated when profuse sweats occur after acute illnesses, as typhoid fever, etc. The patient is very despondent, hopeless of recovery; remains weak, with trembling of the hands and weak back and joints. Sulphur is very similar.

Another form of suppurative trouble in which you may use Cinchona is in suppuration of the lungs, particularly in drunkards, when the trouble is associated with hectic fever.

You may also be called upon to use Cinchona in disorganized states, either of the external tissues or of the lung substance. In the latter case the remedy is indicated by the hectic symptoms and by the foetid breath. Here Cinchona vies with Arsenicum, Secale, and Lachesis. Do not confound the foetid breath just mentioned with that arising from certain forms of bronchitis, in which the sputum is retained a long time and undergoes decomposition in the lungs. While the patient is breathing quietly you can notice no extraordinary odor. As soon as he gives a deep cough the breath becomes horribly offensive. This kind of cough calls for Capsicum, and, perhaps next in importance, for Sanguinaria Canadensis.

You will find Cinchona often indicated in inflammatory rheumatism, not in the beginning of the disease, but later when the fever has be-^ come intermittent in its character. The joints still remain swollen. The characteristic pains in these cases are jerking and pressing. The patient will not permit you to approach, crying out with pain if you touch the affected parts, so exquisitely sensitive is the surface. Quinine sulphate is also useful in a similar condition.

Ci?tcho?ia is also a neuralgic remedy. It is especially suited to neuralgia of the infraorbital nerve on either side when the symptoms are typical in their return, and when the slightest touch or draught of cold air makes the patient worse. If the neuralgia is of malarial origin Cinchona is increasingly indicated.

You may here compare Cedron, which is applicable to malarial neuralgia, usually supraorbital, when the attacks return with clocklike regularity.

In jaundice you should use Cinchona when the surface of the body and the sclerotica are yellowish. The liver is swollen and sensitive to the touch, and there is a feeling in the right hypochondrium as of subcutaneous ulceration. The stools are whitish, and are accompanied by foetid flatus, or else there is diarrhoea. It is especially indicated in jaundice arising from sexual excesses, from loss of animal fluids, from abuse of alcohol, and from gastro-duodenal catarrh.

The antidotes to Cinchona are Arsenicum album, Ipecac, Carbo veg. y Lachesis, Pulsatilla, Ferrum metallicum and Verat7'um album. The indications for most of these have already been given you. Cinchona and Morphia are antagonistic in brain symptoms. Cinchona and Belladoiina are antagonistic in heart symptoms, temperature, etc.