INDIAN MEDICAL GAZETTE.
146
A REMARKABLE CASE OF
QUININE
POISONING.* By Surgn.-Capt. A. Ernest Roberts, h.b., i.m.s. Civil
Surgeon, Aligarh,
N.
W. P.
As far as 1 can ascertain tlie subject ot poisoning by quinine Las not received much attention from medical authors,?at any rate I have not
been fortunate in my researches into medical literature in obtaining light and leading upon this ?subject. I am therefore impelled to put the folcase on record as one of remarkable interest lowing O 9
in
many ways.
Mrs.
,
Eurasian, 35, married,
no
children,
in comfortable circumstances, had always enjoyed good general health, but had been troubled for nearly two years with menorrhagia associated with slight uterine retroflexion. This local trouble had been temporarily overcome by treatment, and she had normal periods for three months, when at noon on a certain day in November 1893 I was suddenly summoned to her bedside, as she was declared to be dying. On my arrival I heard that she had swallowed a very large dose of sulphate of quinine an hour or so before, and from the evidence available, which I carefully and critically weighed, I believe the quantity to have amounted to about six drachms. There is no doubt in my mind that she managed to swallow fully five drachms, and there were traces of a little in the vessel from which she drank it, and on her lips, at the time I first saw her. She was lying upon her bed totally unconan scious The whole inert paralysed mass. surface of her body was deadly cold and blanched, or rather livid ; her temperature (axilla) *95?, breathing almost imperceptible, shallow, slow ; pulse 45,? thin and small. Her eyes were closed, ?
pupils considerably dilated,
no
response to
light
;
tendon reflexes not obtained, no response to external stimuli ; and save that she at long intervals uttered a low groan, she appeared to her friends to be dead. My own anticipations were not cheerful.
little, if any, change in hours, during which
her condition she vomited " " substance several times. Indeed coffee-ground definite and obvious signs of rallying were deferred until the early hours of the next day, and it was then ascertained that, in addition to slight deafness, she was "stone blind," even to total non-appreciation of strong sunlight. The deafThere was for several
trouble ; perfect hearing was reweek with the gradual return of long ere all general functional activity, but was traces of the tremendous shock to the general system had disappeared, and doubtless the deness
?ave
no
stored? within
a
moralization induced by the blindness and the terrible circumstances served to accentuate the
profound debility. Bead at the Indian Medical Congress, December 1854.
[April
1895.
I have said that at first the pupils were widely and equally dilated, and did not respond to the stimulus of light ; the blindness was the dense, uncompromising darkness of atrophy. It was not until 48 hours had elapsed that I found an opportunity of using the ophthalmoscope, and the picture I obtained was definite and well marked. There was a blur or haze over the whole perceptible retinal field, there was a distinct deepening of colour (congestion), especially concentrated in the macula ; the discs were not definitely altered in colour, but, if anything, perhaps also of a slightly deeper tint than normal. (I speak under reserve, as J. am not very familiar with the exact shade of the Eurasian disc), but hazy and with ill-defined margins. I can think of nothing more suggestive as an indication of the impressions I received during the first examinations than a rather highly coloured and crude water-colour sketch which had been very slightly smudged, " perhaps I may call it smoky," so that the contours of the vessels were blurred and not well defined. However, this stage was of short duration. The tint of congestion and the blur alike disappeared, and in a week from the onset, I began to fear that optic atrophy would close the The retinal vessels, both veins and arteries, scene. became well-defined and contracted, and the optic discs became distinctly pale ; the pupils remained widely and equally dilated and insensible to light. I made frequent and regular examinations, but my powers of observation did not avail to detect any very decided change in the ophthalmoscopic appearances during a period of quite three months. The general retinal ischsemia and disc pallor did indeed quickly become decided, and remained thus with no perceptible change for about six weeks, when a very slight improvement set in, but at the end of three months, the condition same as previously described at was much the the end of the first week, after the primary congestion passed off. During the fourth and fifth month a certain distinct but small improvement could be noted at considerable intervals, but when I left my charge for six months' leave, the retinal anaemia was still the notable objective sign, the disc having fairly regained its normal tint. So far for the objective signs. As regards the subjective I may briefly add the following
particulars
:?
" The absolute " stone blindness lasted, I believe, for fully two weeks ; the first perception after that was the flash of light from the ophthalmoscopic mirror, but there was no perception of external objects until the third or fourth week, when certain things, a small bright metal time-piece, the looming figure of an individual, were seen at a distance of four to eight yards. This distant vision was a marked feature of the case for two or three months, and though it gradually gained in distinctness of outline and detail, was a blurred impression on a dim and hazy background. A
April
1895.]
RECTAL PROLAPSE TREATED BY VENTROFIXATION OF RECTUM.
noticeable point during the fourth week also was her perception at a distance of dark linear objects, e.g., the parallel beams of the roof of the bungalow, and the cross, bars of the windows in the doorways. Here also the definite objective points It was somewere lost in an indefinable haze. what surprising that she could occasionally read the dial of the clock before mentioned, at four or five yards distance, but could distinguish no neighbouring object. Colour blindness was marked from the first, but about the sixth week she noted the dark blue of my necktie ; red and yellow were, and are still, best distinguished. From the sixth to the eighth week onward, with occasional relapses synchronous, with a return of the monorrhagia, and other disturbances of the general health, she gained ground in all points very slowly but surely, and in April last she could write a letter and read large type,?the effort being exhausting to her visual faculty, and consequently not persevered in. At this stage I lost sight of the case owing to my departure on leave, but I have recently heard from my patient that, although much better in most respects, there is much left to be desired in her visual powers ; she gets about, reads and writes, uses her mirror satisfactorily for toilet purposes, but her colour vision is defective, red and yellow being still most easily distinguished and these at a distance, nearness of approach causing objects to appear black ; the general hazy blur of the background of the visual field being also a trouble to her. I would remark, in conclusion, on the likeness of the early symptoms to embolism or haemorrhage into the disc, but this is of course contraindicated by the bilateralism and the very considerable recovery, not to mention the absence of ophthalmoscopic evidence. Further, I think it will be allowed that in view of the evidence furnished by Laveran (" Paludisme") of the very general fatal effect of doses of quinine smaller than that consumed in this case, my patient has not paid a dear price for her life. The fact that she was frequently losing considerable quantities of blood by menorrhagia probably, I think, militated against her more speedy recovery, and the fact that she has since undergone the operation of curetting with satisfactory results would encourage the hope of ultimate recovery. I would assure anyone who has to treat a similar case of my sincerest sympathy ; it was
certainly a great anxiety to me throughout, not perhaps more in the first days of death-like collapse than in the long and weary weeks of waiting for light.
14?
146
A REMARKABLE CASE OF
QUININE
POISONING.* By Surgn.-Capt. A. Ernest Roberts, h.b., i.m.s. Civil
Surgeon, Aligarh,
N.
W. P.
As far as 1 can ascertain tlie subject ot poisoning by quinine Las not received much attention from medical authors,?at any rate I have not
been fortunate in my researches into medical literature in obtaining light and leading upon this ?subject. I am therefore impelled to put the folcase on record as one of remarkable interest lowing O 9
in
many ways.
Mrs.
,
Eurasian, 35, married,
no
children,
in comfortable circumstances, had always enjoyed good general health, but had been troubled for nearly two years with menorrhagia associated with slight uterine retroflexion. This local trouble had been temporarily overcome by treatment, and she had normal periods for three months, when at noon on a certain day in November 1893 I was suddenly summoned to her bedside, as she was declared to be dying. On my arrival I heard that she had swallowed a very large dose of sulphate of quinine an hour or so before, and from the evidence available, which I carefully and critically weighed, I believe the quantity to have amounted to about six drachms. There is no doubt in my mind that she managed to swallow fully five drachms, and there were traces of a little in the vessel from which she drank it, and on her lips, at the time I first saw her. She was lying upon her bed totally unconan scious The whole inert paralysed mass. surface of her body was deadly cold and blanched, or rather livid ; her temperature (axilla) *95?, breathing almost imperceptible, shallow, slow ; pulse 45,? thin and small. Her eyes were closed, ?
pupils considerably dilated,
no
response to
light
;
tendon reflexes not obtained, no response to external stimuli ; and save that she at long intervals uttered a low groan, she appeared to her friends to be dead. My own anticipations were not cheerful.
little, if any, change in hours, during which
her condition she vomited " " substance several times. Indeed coffee-ground definite and obvious signs of rallying were deferred until the early hours of the next day, and it was then ascertained that, in addition to slight deafness, she was "stone blind," even to total non-appreciation of strong sunlight. The deafThere was for several
trouble ; perfect hearing was reweek with the gradual return of long ere all general functional activity, but was traces of the tremendous shock to the general system had disappeared, and doubtless the deness
?ave
no
stored? within
a
moralization induced by the blindness and the terrible circumstances served to accentuate the
profound debility. Bead at the Indian Medical Congress, December 1854.
[April
1895.
I have said that at first the pupils were widely and equally dilated, and did not respond to the stimulus of light ; the blindness was the dense, uncompromising darkness of atrophy. It was not until 48 hours had elapsed that I found an opportunity of using the ophthalmoscope, and the picture I obtained was definite and well marked. There was a blur or haze over the whole perceptible retinal field, there was a distinct deepening of colour (congestion), especially concentrated in the macula ; the discs were not definitely altered in colour, but, if anything, perhaps also of a slightly deeper tint than normal. (I speak under reserve, as J. am not very familiar with the exact shade of the Eurasian disc), but hazy and with ill-defined margins. I can think of nothing more suggestive as an indication of the impressions I received during the first examinations than a rather highly coloured and crude water-colour sketch which had been very slightly smudged, " perhaps I may call it smoky," so that the contours of the vessels were blurred and not well defined. However, this stage was of short duration. The tint of congestion and the blur alike disappeared, and in a week from the onset, I began to fear that optic atrophy would close the The retinal vessels, both veins and arteries, scene. became well-defined and contracted, and the optic discs became distinctly pale ; the pupils remained widely and equally dilated and insensible to light. I made frequent and regular examinations, but my powers of observation did not avail to detect any very decided change in the ophthalmoscopic appearances during a period of quite three months. The general retinal ischsemia and disc pallor did indeed quickly become decided, and remained thus with no perceptible change for about six weeks, when a very slight improvement set in, but at the end of three months, the condition same as previously described at was much the the end of the first week, after the primary congestion passed off. During the fourth and fifth month a certain distinct but small improvement could be noted at considerable intervals, but when I left my charge for six months' leave, the retinal anaemia was still the notable objective sign, the disc having fairly regained its normal tint. So far for the objective signs. As regards the subjective I may briefly add the following
particulars
:?
" The absolute " stone blindness lasted, I believe, for fully two weeks ; the first perception after that was the flash of light from the ophthalmoscopic mirror, but there was no perception of external objects until the third or fourth week, when certain things, a small bright metal time-piece, the looming figure of an individual, were seen at a distance of four to eight yards. This distant vision was a marked feature of the case for two or three months, and though it gradually gained in distinctness of outline and detail, was a blurred impression on a dim and hazy background. A
April
1895.]
RECTAL PROLAPSE TREATED BY VENTROFIXATION OF RECTUM.
noticeable point during the fourth week also was her perception at a distance of dark linear objects, e.g., the parallel beams of the roof of the bungalow, and the cross, bars of the windows in the doorways. Here also the definite objective points It was somewere lost in an indefinable haze. what surprising that she could occasionally read the dial of the clock before mentioned, at four or five yards distance, but could distinguish no neighbouring object. Colour blindness was marked from the first, but about the sixth week she noted the dark blue of my necktie ; red and yellow were, and are still, best distinguished. From the sixth to the eighth week onward, with occasional relapses synchronous, with a return of the monorrhagia, and other disturbances of the general health, she gained ground in all points very slowly but surely, and in April last she could write a letter and read large type,?the effort being exhausting to her visual faculty, and consequently not persevered in. At this stage I lost sight of the case owing to my departure on leave, but I have recently heard from my patient that, although much better in most respects, there is much left to be desired in her visual powers ; she gets about, reads and writes, uses her mirror satisfactorily for toilet purposes, but her colour vision is defective, red and yellow being still most easily distinguished and these at a distance, nearness of approach causing objects to appear black ; the general hazy blur of the background of the visual field being also a trouble to her. I would remark, in conclusion, on the likeness of the early symptoms to embolism or haemorrhage into the disc, but this is of course contraindicated by the bilateralism and the very considerable recovery, not to mention the absence of ophthalmoscopic evidence. Further, I think it will be allowed that in view of the evidence furnished by Laveran (" Paludisme") of the very general fatal effect of doses of quinine smaller than that consumed in this case, my patient has not paid a dear price for her life. The fact that she was frequently losing considerable quantities of blood by menorrhagia probably, I think, militated against her more speedy recovery, and the fact that she has since undergone the operation of curetting with satisfactory results would encourage the hope of ultimate recovery. I would assure anyone who has to treat a similar case of my sincerest sympathy ; it was
certainly a great anxiety to me throughout, not perhaps more in the first days of death-like collapse than in the long and weary weeks of waiting for light.
14?
