DEPÓSITO DE BIENES FISCALES

John D. Billings, author of a stunningly detailed firsthand account of a soldier’s life with the Army of the Potomac, wrote, “Quinine was always and everywhere prescribed with a confidence and freedom which left all other medicines far in the rear. Making all due allow- ances for exaggerations, that drug was unquestionably the popular dose with the doctors.”56_{In hospital records, field prescription books,}

and therapeutic manuals and guides, quinine or cinchona (sometimes both) was doled out as a matter of course, whether on land or sea.

Sulfate and extract of cinchona were used essentially where qui- nine was indicated. Dr. William M. McPheeters had compared both sulfates in ninety cases of remittent and intermittent fevers and found cinchona “very little, if any, inferior to sulphate of quinia.”57 _This,

plus the unrelenting demand for quinine sulfate, suggested that prep- arations of cinchona might serve as a useful substitute or perhaps even as a coequal febrifuge with quinine. The board of revision for the U.S. Army supply table recommended that fluidextract of cin- chona be made a standard item. Edward R. Squibb, who had served on the board, considered the preparation of red cinchona bark, cala- mus, sugar, and alcohol a tonic remedy “well adapted to the convales- cence from typhoid and miasmatic diseases.”58 _{At the U.S. Army}

Laboratory in Philadelphia John Maisch manufactured 12,305 pounds of the product throughout the war.59 _{This notwithstanding, the sur-}

geon general’s office reported that “sulphate of cinchonia was occa- sionally used during the war,” but that the “opinion formed was unfa- vorable to its use.”60

For most surgeons and hospital stewards, quinine sulfate was con- sidered superior in strength and purity to other cinchona derivatives. In fact, the medicinal virtues of quinine hardly knew any therapeutic bounds. Quinine was used not only as a cure for fever and as a general enervating tonic—similar to but often regarded as more powerful and effective than stomach “bitters”—it was also used as prophylaxis for fever (see Figure 7.1). This came early in the war in the form of a rec- ommendation by the U.S. Sanitary Commission. As a test, the com- mission issued to regimental surgeons, upon request, 220 gallons of solution of quinine sulfate in alcohol (quinine “bitters”), from which they reported “a marked improvement in the health and efficiency of the men.”61 _{Based on the recommendation of the Committee of In-}

FIGURE 7.1. The discovery of quinine sulfate from cinchona bark in 1820 by the French chemists Pierre-Joseph Pelletier (1788-1842) and Joseph-Bienamé Caventou (1795-1877) became one of the therapeutic sensations of the century. Quinine sulfate was one of the few demonstrably effective drugs of the Civil War. Efficacious against malaria, it was often used indiscriminately for all fevers. By 1827 Pelletier and Caventou proudly announced that the use of qui- nine was sweeping Europe, with French manufacturers producing about 90,000 ounces annually. Although the French article was first preferred in the United States (above left), William Farr, along with Powers and Weightman, soon gave Americans a reliable domestic source for the much-prized medicine (above right), with Rosengarten and Sons soon to follow. Civil War demands would have Rosengarten and Sons and Powers and Weightman producing some nineteen tons of quinine sulfate from 1861 to 1865. Illustrations courtesy of Merck Archives, Merck & Co., Inc., Whitehouse Sta- tion, New Jersey.

quiry chaired by William H. Van Buren, the surgeon general ordered that quinine and alcohol be distributed generally in the field, particu- larly where the miasmatic fevers where most feared (see Figure 7.2).62_{Soon, just about every hospital steward quickly became famil-}

iar with the bitter draught of quinine and alcohol (usually whisky but sometimes wine or whatever “stimulant” could be had). Typical was Edwin Witherby Brown, steward for his 81st Ohio Volunteer Infantry unit, who noted in his diary while encamped near Corinth, Missis- sippi: “This was a malarial section and as a preventive I had to fix two barrels of whiskey with quinine—take myself as well as give every man in camp a dose every morning. In this way we prevented ague, chills, etc.”63_{Similarly, assistant surgeon George Martin Towbridge}

of the 19th Michigan Volunteer Infantry noted the daily “Quinine call which must be attended by Drs. as by men.”64

Of course, fever and its prevention was not quinine’s only use. Charles Beneulyn Johnson mixed up whisky and quinine and admin- istered the concoction to his Illinois comrades “for exhaustion.”65

Billings observed that the “proverbial prescription of the average army surgeon was quinine, whether for stomach or bowels, headache or toothache, for a cough or for lameness, rheumatism or fever and

FIGURE 7.2. “Quinine call” was a familiar camp routine for the boys in blue, as shown in this sketch fromHarper’s Weekly from March 15, 1865. Illustration

ague.”66_{Surgeon William Watson’s affinity for quinine earned him}

the nickname “Old Quin” among the soldiers of the 105th Pennsylva- nia Volunteers.67 _{The Seminole Wars in Florida that flared up be-}

tween 1817 and 1855 with the intermittent regularity of the fevers to which its participants were prone was an excellent—and success- ful—proving ground for the army’s use of quinine.68_{But quinine’s}

demonstrable benefits in malarial conditions held an implicit danger in a medical era that could claim few genuine and consistent reme- dies. The real merits of quinine in malarial fevers undoubtedly caused many medical men to extrapolate rather wildly and assume that qui- nine and its derivatives of cinchona were a veritable panacea. Indeed, Dr. John W. Churchman pointed out that after calomel and whisky, the remedy most missed from the dispensary was quinine.69_Church-

man admitted “that a generation of practitioners had sprung up trained to transform their patient’s mouths into funnels gapping for quinine.”70

By the 1850s and 1860s quinine had reached its apex in the physi- cian’s armamentarium. Cinchona spp. were mentioned thirteen times among the primary list of substances in the United States Pharmaco-

poeia of 1850, twelve times in 1860, and thirteen times again in

1870.71_{Cinchonaspp. covered nearly fifty pages in the 1858 edition}

of the United States Dispensatory, and ten pages were spent discuss- ing three different preparations of quinine.72 _{Never before or since}

were cinchona and quinine so prominently featured in the pharma- ceutical compendia.

The therapeutic importance of quinine and cinchona forced the medical profession to explain its expansive therapeutic properties within the existing corpus of knowledge regarding health and heal- ing. Here Dr. Frederick William Headland stepped up confidently to offer his opinion of quinine:

It appears from the character and results of its medicinal in- fluence, that it is exerted primarily in the blood, and not on the nerves [as Sir J. Martin and others had asserted]. It is included in the Restorative group of Haematics, and the general results of its action differ widely from those of a Catalytic Haematic. It produces no marked effect on the system in health [i.e., a healthy person]. Its operation consists in the cure of general de- bility, however produced, and in the prevention of periodic dis- orders in the blood. Debility depends on a want in the blood, and

not on any active morbid process; and there are circumstances which render it likely that Ague may be curable by the supply of a similar want.

Quinine is also serviceable in Gout, Srufula, Dyspepsia, and other disorders; in all of which other medicines, which stimulate the secretion of the bile, are more or less applicable. Torpidity of the liver is likewise a usual accompaniment of the various forms of debility, and occurs in intermittent, remittent, typhoid, and yellow fevers; in each of which this medicine has been recom- mended, and used with advantage. In fact it may be said, that in all diseases in which Quinine is used there is a failure in the se- cretion of bile; and in all diseases in which there is a failure in the secretion of bile, Quinine is serviceable.73

It was a view that undoubtedly caught the attention of the Ameri- can medical community for several reasons. First, it accorded with what they already believed: namely, that biliary imbalance was the cause of most disease. To suggest that quinine corrected a disorder by adjusting bile secretion not only made sense to most practitioners, it had the additional benefit of seemingly substantiating the premise of bile’s primacy in health. Second, it supported the notion that quinine was not only a specific in malarial fevers but was also a “restorative hæmatic” for a whole range of diseases only vaguely understood. Third, by wartime Headland had an established reputation on both sides of the Atlantic. He was a member of the Royal Society of Physi- cians and the London Medical Society, whose treatise on the action of medicines had received award-winning acclaim. The American phar- maceutical leader William Procter greeted the fourth edition of Head- land’s Action of Medicines in the System with considerable enthusi- asm, stating that “few writers on this subject have kept closer to the inductive path that leads to ultimate success, and shown more acute- ness in observation, than has our author.”74

Of course it was the inductive method—the penchant for rational- ism—that was the problem. Extending therapeutic benefits based on false premises, though logical in itself, had been the source of diag- nostic and therapeutic error for centuries. The march of scientific empiricism, whereby hypotheses based on selected theories were checked by systematic observation under controlled conditions, was slow in coming and by the 1860s had not quite arrived.75_{Of course,}

does work on blood (more accurately on the plasmodia invading the

bloodstream). But since there was no clear understanding of micro- bial disease at that time, the rest of his ideas were theories built on the foundations of tradition rather than empirical demonstration. The only thing more absurd than Headland’s notions concerning quinine would be to chide him for these notions. He and all of his colleagues were struggling to understand problems that had vexed humankind since time began. Galen sought to answer this problem of pathology and therapeutics in Roman times, and by Headland’s writing the medical profession was on the brink of casting off the last vestiges his time-honored but flawed notions.76 _{To consider nineteenth-century}

physicians naves, fools, or charlatans because they did not possess

ourknowledge of disease is the folly of twenty-twenty hindsight— unhistorical and unfair.

Yet the Civil War had an unintended benefit: it could serve as a practical proving ground for quinine just as the Seminole Wars had done. The experience with this remedy during those protracted but much smaller engagements in Florida was suggestive of certain dose- response relationships with fevers. The Civil War would be the real test. The problem of dosage was a difficult one. Even prophylactically, recommendations varied widely.77 _{Since many physicians regarded}

quinine and cinchona as a tonic, they tended to keep doses relatively low but repeated. Dr. Thomas Fearn (1789-1863) of Huntsville, Ala- bama, on the other hand, had treated his fever patients successfully with large doses (twenty grains of quinine sulfate or more) and had advocated such during the Seminole Wars. The typical therapeutic dose of quinine sulfate came to be established at ten to twenty grains for intermittent fevers, and fifteen to twenty grains for remittent fe- vers.78_{The “typical” dose for intermittent fevers—three to five grains,}

four times per day—would suggest that the higher end of the scale probably produced the best results.79

Yet individual physicians undoubtedly adopted their own favored doses. In revisiting William F. Norris’s case of Private Rial, it will be recalled that the surgeon fought his patient’s postoperative fever with a prescription that contained quinine sulfate; the dosage he gave was thirty grains, three time per day.80_{Surgeon Ezra Read of the 21st In-}

diana Volunteers established twenty to forty grains as a “full dose” of quinine sulfate.81 _{“I have frequently given quinine in twenty-grain}

the intermittent paroxysm,” reported surgeon David Merritt of the 55th Pennsylvania Volunteers while stationed at Beaufort, South Carolina, “and then, by continuing the remedy in smaller doses, have been much gratified with the result.”82_{Even in the so-called contin-}

ued fevers, quinine was employed. Surgeon W. H. Thayer of the 14th New Hampshire Infantry gave daily doses of quinine sulfate in twelve, twenty, or sixty grains for cases of typhoid fever, depending on the severity of the attack.83_{Surgeon R. N. Barr, while in Summer-}

ville, Virginia, found the cases of fever in his Ohio unit especially ob- stinate. He complained:

There has been a comparatively large number of fever cases, and what is peculiar, every case of illness of whatever character took . . . a typhoid form and yielded slowly to treatment. In most cases my reliance is on quinine, [with] whiskey or brandy in large and repeated doses.84

The problem of dosage was certain to be complicated by the mixed results obtained from such generalized use of the drug under so many different conditions of fever. A fatal dose of quinine is approximately eight grams (or 123.456 grains), so it can be seen from some of the previous examples that many soldiers received exceedingly high doses of the substance. Spread out over a period of time these doses might not produce death, but symptoms of cinchonism would likely have appeared (ringing in the ears, headache, nausea, and blurred vi- sion). But even where dosages were within sound limits, the thera- peutic results would be highly variable.85_{In genuine cases of malaria}

the drug would be very effective, working as a specific against the in- vading plasmodia and—in continued moderate doses—acting to pre- vent recurrence. In other fevers there might be some modest anti- pyretic action and some analgesic action but no cure.86_{Given all the}

problems associated with quinine, in the end it was clearly the one medicinal agent that worked against a known disease. In the words of historian Dale C. Smith, “Probably the Civil War helped remove any lingering doubts of American physicians concerning effective qui- nine dosage.”87

Whatever the effects of quinine in practice, it was in much de- mand. A total of nineteen tons of quinine sulfate and nine-and-a-half tons of sulfate of cinchona in their various dosage forms were distrib- uted by the Purveyor’s Department.88_{A product of such high demand}

could net manufacturers sizeable profits. Where fortunes are to be made, an interesting story is always to be told.