66
'
WILLIAMS: Quinine Amnaurosis.
QUININE AMAUROSIS. REPORT OF TWO CASES. BY E. WILLIAMS, M.D., CINCINNATI, 0.
THE first cases reported are those of A. Von Grefe, published in Vol. III. of his Archives in I857. Notwithstanding he could detect no ophthalmoscopic changes, the temporary blindness in both eyes was followed by permanent impairment of sight in one eye. Recently Dr. E. Gruening has given a resume of the literature on this subject, in Knapp's Archives, Vol. X. He endeavors to establish the pathognomonic symptoms of this toxic trouble. He says, " On reviewing the unequivocal cases of quinine poisoning with amaurosis, we find a remarkable congruence in their essential features. The patient, after the ingestion of a single dose, or of repeated doses of quinine in varying quantities, suddenly. becomes totally blind and deaf. While the deafness disappears within twenty-four hours, the blindness remains permanent as regards peripheric vision, central vision gradually returning to the normal after some days, weeks, or months. The ophthalmoscope reveals an ischacmia of the retinal arteries and veins without any inflammatory changes. In view of the constancy of these symptoms and the uniformity of the ophthalmoscopic picture, we are entitled to demand for this distinct type of amaurosis a recognized position in the pathology of the optic nerve and the retina." In the same volume from which this quotation is taken, there are reports from other competent observers of similar cases, to which I now add briefly the following two. Dr. J. G. H., aged forty-two, of southern Kentucky, suffered a violent attack, eight years ago, of what was called congestion of the stomach. It lasted about a week, and was attended by severe pains, cramping attacks, and frequent vomiting and
WILLIAMS: Quinine Amnaurosis.
67
retching. With the impression that the trouble was malarious, he took quinine in heroic doses. It was administered hypodermically, per rectum, and on the raw surface of a large blister, endeavoring to retain twenty grains every two hours. During the attack he thinks he took an ounce of quinine. In four days he became suddenly and totally, blind and deaf, not being able to discern light, and hearing absolutely no sound. The only thing heard was the tinnitus. The deafness continued thirty-six hours, and the total blindness four days. In six weeks he was well and could see, as he now says, as well as ever. The hearing- has never been completely regained. His field of vision is concentrically contracted in both eyes. The color sense seems to be now perfect. The optic discs are very white, all the capillaries having disappeared, and the calibre of the main arteries and veins being very much reduced in size. After the ophthalmoscopic examination, I was greatly surprised to find his central vision perfect in both eyes. The other case was a nephew of the doctor, fourteen years old. He was attacked about the same time, with similarly severe symptoms, lasting about as long as with the uncle. The boy was treated likewise heroically, and in the same ways, but the amount he took is not definitely known. He got suddenly blind and deaf, about four days after the severe attack of, so called, cong-estion of the stomach. His color sense was very defective, and even with the best seeing eye he made serious mistakes. The atrophy of his optic discs is extreme. V. = 0.3 in right eye, and with the left he can only count fingers at eight inches, centrally. There is evidently great contraction of his field of vision. He has a nystagmus, the movements being upwards and downwards, and he experiences very great difficulty in accommodating himself to sudden and great changes of illumination. These cases consulted me on the last day of the past month, and the day before I left home. Of course, in the hurry, I could not give them a more detailed and careful examination. But the pathognomonic symptoms are present. In the youth, there is permanent and very great impairment of sight.
68
WILLIAMS: Quinine Amnaurosis.
DISCUSSION. DR. RoOSA.-I think if Von Graefe's cases of amblyopia from the use of quinine are read over in the light of our present knowledge, we shall all have grave doubts whether or not they belong to the category of cases so recently reported in this country. Von Graefe's cases were treated by him as thoug,h they were cases of congestion, and they recovered under that treatment. If I am correct in my recollection, there is no note made of this peculiarity of telescopic vision, or of marked diminution in the calibre of the large vessels and disappearance of some of the capillaries. If these cases were submitted to analysis, I think they would be found to hardly belong to this category. As regards the ophthalmoscopic appearances, I think that it will be remembered by the Society that in very few instances, with the exception possibly of Dr. Buller's case, was the ophthalmoscopic examination immediate on the blindness. I am inclined to think, judging from my own case, long since reported, in which a man took four hundred and eightv grains in twenty-four hours, I am inclined to think, from the results of my examination made three days after the blindness appeared, that the primary ophthalmoscopic condition is not ischaemia, but excessive congestion, and that view, although I am unable to produce any solid proof, is sustained by the analog,ous condition in the ear. In my experiments made fourteen years ago, I found invariably where any effect was produced (in one or two no effect was produced), overloading of the bloodvessels of the drum head, of the auricle and of the canal, and great tinnitus. There was also overloading of the vessels of the conjunctiva. In one case, I thought that I discovered congestion of the vessels of the optic papilla. In these experiments, I gave large doses to healthy people. We need observations on this one point, as to the condition of the bloodvessels of the papilla immediately after the toxic effects are discovered. That the ischaemia occurs within a short period, there can be no doubt. All observations agree in that respect. The patient whose case was reported in the Archives of Otology lived some seven years afterwards, and to the last retained 2' in the telescopic field. DR. BULLER.-I am inclined to agree with Dr. Roosa in regard to the primary congestion. The case I have reported did not show at first an extraordinary degree of diminution of the bloodvessels. At first indeed, the retinal bloodvessels did not appear to be at all diminished, but in a few days there
AGNEW: Removal of a Dislocated Lens.
69
was great diminution, and in the course of a week the vessels became extremely small, and have remained so ever since. This patient, whom I still see occasionally, has retained a narrow field, without any impairment of central vision. Six months ago she came to me imagining that there was some further loss of sight, but such proved to be not the case. The first ophthalmoscopic examination, if I remember rightly, was made the day following the occurrence of the blindness.
AN OPERATION WITH A DOUBLE NEEDLE, OR BIDENT, FOR THE REMOVAL OF A CRYSTALLINE LENS DISLOCATED INTO THE VITREOUS CHAMBER. BY C. R. AGNEW, M.D., NEW YORK.
To remove a dislocated lens from the anterior chamber of the eye is difficult, and to remove one from the vitreous chamber and save the integrity of the organ is perilous, and more difficult than any other operation in ophthalmic surgery. Excellent authorities therefore agree in recommending, in many cases, the practice of enucleation rather than to incur the immediate and later risks of attempted removal of dislocated crystalline lenses. In numerous cases of dislocated lens the aqueous and vitreous humors are altered in their physical condition, being commingled or degenerated. When that is so, the instant that an opening is made for introducing a scoop, or other instrument, to extract the misplaced and mobile lens, there is a quick loss of the fluid contents of the eye. The eye-wall falls in, the cornea crumples, and the lens, eluding the instrument used for its removal, sinks into the vitreous chamber. If detachment of the retina or choroid with haemorrhage does not immediately occur, great violence is done by the operator in prodding- after the lens. If the lens be finally extracted, secondary consequences occur, which cause the wounded eye IO
'
WILLIAMS: Quinine Amnaurosis.
QUININE AMAUROSIS. REPORT OF TWO CASES. BY E. WILLIAMS, M.D., CINCINNATI, 0.
THE first cases reported are those of A. Von Grefe, published in Vol. III. of his Archives in I857. Notwithstanding he could detect no ophthalmoscopic changes, the temporary blindness in both eyes was followed by permanent impairment of sight in one eye. Recently Dr. E. Gruening has given a resume of the literature on this subject, in Knapp's Archives, Vol. X. He endeavors to establish the pathognomonic symptoms of this toxic trouble. He says, " On reviewing the unequivocal cases of quinine poisoning with amaurosis, we find a remarkable congruence in their essential features. The patient, after the ingestion of a single dose, or of repeated doses of quinine in varying quantities, suddenly. becomes totally blind and deaf. While the deafness disappears within twenty-four hours, the blindness remains permanent as regards peripheric vision, central vision gradually returning to the normal after some days, weeks, or months. The ophthalmoscope reveals an ischacmia of the retinal arteries and veins without any inflammatory changes. In view of the constancy of these symptoms and the uniformity of the ophthalmoscopic picture, we are entitled to demand for this distinct type of amaurosis a recognized position in the pathology of the optic nerve and the retina." In the same volume from which this quotation is taken, there are reports from other competent observers of similar cases, to which I now add briefly the following two. Dr. J. G. H., aged forty-two, of southern Kentucky, suffered a violent attack, eight years ago, of what was called congestion of the stomach. It lasted about a week, and was attended by severe pains, cramping attacks, and frequent vomiting and
WILLIAMS: Quinine Amnaurosis.
67
retching. With the impression that the trouble was malarious, he took quinine in heroic doses. It was administered hypodermically, per rectum, and on the raw surface of a large blister, endeavoring to retain twenty grains every two hours. During the attack he thinks he took an ounce of quinine. In four days he became suddenly and totally, blind and deaf, not being able to discern light, and hearing absolutely no sound. The only thing heard was the tinnitus. The deafness continued thirty-six hours, and the total blindness four days. In six weeks he was well and could see, as he now says, as well as ever. The hearing- has never been completely regained. His field of vision is concentrically contracted in both eyes. The color sense seems to be now perfect. The optic discs are very white, all the capillaries having disappeared, and the calibre of the main arteries and veins being very much reduced in size. After the ophthalmoscopic examination, I was greatly surprised to find his central vision perfect in both eyes. The other case was a nephew of the doctor, fourteen years old. He was attacked about the same time, with similarly severe symptoms, lasting about as long as with the uncle. The boy was treated likewise heroically, and in the same ways, but the amount he took is not definitely known. He got suddenly blind and deaf, about four days after the severe attack of, so called, cong-estion of the stomach. His color sense was very defective, and even with the best seeing eye he made serious mistakes. The atrophy of his optic discs is extreme. V. = 0.3 in right eye, and with the left he can only count fingers at eight inches, centrally. There is evidently great contraction of his field of vision. He has a nystagmus, the movements being upwards and downwards, and he experiences very great difficulty in accommodating himself to sudden and great changes of illumination. These cases consulted me on the last day of the past month, and the day before I left home. Of course, in the hurry, I could not give them a more detailed and careful examination. But the pathognomonic symptoms are present. In the youth, there is permanent and very great impairment of sight.
68
WILLIAMS: Quinine Amnaurosis.
DISCUSSION. DR. RoOSA.-I think if Von Graefe's cases of amblyopia from the use of quinine are read over in the light of our present knowledge, we shall all have grave doubts whether or not they belong to the category of cases so recently reported in this country. Von Graefe's cases were treated by him as thoug,h they were cases of congestion, and they recovered under that treatment. If I am correct in my recollection, there is no note made of this peculiarity of telescopic vision, or of marked diminution in the calibre of the large vessels and disappearance of some of the capillaries. If these cases were submitted to analysis, I think they would be found to hardly belong to this category. As regards the ophthalmoscopic appearances, I think that it will be remembered by the Society that in very few instances, with the exception possibly of Dr. Buller's case, was the ophthalmoscopic examination immediate on the blindness. I am inclined to think, judging from my own case, long since reported, in which a man took four hundred and eightv grains in twenty-four hours, I am inclined to think, from the results of my examination made three days after the blindness appeared, that the primary ophthalmoscopic condition is not ischaemia, but excessive congestion, and that view, although I am unable to produce any solid proof, is sustained by the analog,ous condition in the ear. In my experiments made fourteen years ago, I found invariably where any effect was produced (in one or two no effect was produced), overloading of the bloodvessels of the drum head, of the auricle and of the canal, and great tinnitus. There was also overloading of the vessels of the conjunctiva. In one case, I thought that I discovered congestion of the vessels of the optic papilla. In these experiments, I gave large doses to healthy people. We need observations on this one point, as to the condition of the bloodvessels of the papilla immediately after the toxic effects are discovered. That the ischaemia occurs within a short period, there can be no doubt. All observations agree in that respect. The patient whose case was reported in the Archives of Otology lived some seven years afterwards, and to the last retained 2' in the telescopic field. DR. BULLER.-I am inclined to agree with Dr. Roosa in regard to the primary congestion. The case I have reported did not show at first an extraordinary degree of diminution of the bloodvessels. At first indeed, the retinal bloodvessels did not appear to be at all diminished, but in a few days there
AGNEW: Removal of a Dislocated Lens.
69
was great diminution, and in the course of a week the vessels became extremely small, and have remained so ever since. This patient, whom I still see occasionally, has retained a narrow field, without any impairment of central vision. Six months ago she came to me imagining that there was some further loss of sight, but such proved to be not the case. The first ophthalmoscopic examination, if I remember rightly, was made the day following the occurrence of the blindness.
AN OPERATION WITH A DOUBLE NEEDLE, OR BIDENT, FOR THE REMOVAL OF A CRYSTALLINE LENS DISLOCATED INTO THE VITREOUS CHAMBER. BY C. R. AGNEW, M.D., NEW YORK.
To remove a dislocated lens from the anterior chamber of the eye is difficult, and to remove one from the vitreous chamber and save the integrity of the organ is perilous, and more difficult than any other operation in ophthalmic surgery. Excellent authorities therefore agree in recommending, in many cases, the practice of enucleation rather than to incur the immediate and later risks of attempted removal of dislocated crystalline lenses. In numerous cases of dislocated lens the aqueous and vitreous humors are altered in their physical condition, being commingled or degenerated. When that is so, the instant that an opening is made for introducing a scoop, or other instrument, to extract the misplaced and mobile lens, there is a quick loss of the fluid contents of the eye. The eye-wall falls in, the cornea crumples, and the lens, eluding the instrument used for its removal, sinks into the vitreous chamber. If detachment of the retina or choroid with haemorrhage does not immediately occur, great violence is done by the operator in prodding- after the lens. If the lens be finally extracted, secondary consequences occur, which cause the wounded eye IO
