chapter ii: previous investigations
TRANSCRIPT
CHAPTER 11.
Previous Investigations.
At the end of the past century and in the beginning of the present, a great interest was taken in the clinical aspects of the deafness brought about by salicylates and quinine preparations. At that time, unfortunately, no particular use of the tuning fork tests had yet been worked out, and hence no fairly exact account was made of the acoustic function in all these studies. On the other hand, in the last 30 years, when these tests have been fully elaborat- ed and employed everywhere, only a few, and, a t that, incomplete investigations have been reported in this field.
In 1872 R o o s a reported an instance illustrating the effect of quinine on the ear. On account of facial neuralgia, a colleague of his had taken quinine several times, and each time the intake of this remedy was followed by pain in the ears and slight deafness. In this paper, however, no information is given about the size of the dose or the degree of the deafness and, of course, there were no fairly precise tuning-fork tests. In 1875 R o o s a described the findings in three healthy subjects who, for the sake of the experi- ment, had been given 0.6 or 0.9 g of quinine: injection of the blood vessels along the manubrium of the malleus and also increased redness of the external ear and of the external auditory meatus. Also these observations, as will be pointed out later on, are of very questionable value.
Nor is the work of K i r c h n e r in 1881 of any particular value. ))Creditable)) persons who claimed they had become deaf after intake of quinine presented a whitish tendon-like discoloration of the tympanic membranes, defective ))bone perception)) and lack- ing perception of the higher tones. No particulars were given as to the size of the dose, the number of examinations and the point
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of time for the appearance of the deafness in relation to the intake of quinine. The anatomical studies on animals reported in the same paper will be discussed later.
A more detailed description of ear symptoms following admi- nistration of salicylates and quinine was given by S c h w a b a c h (1884). A previously healthy man who had an attack of fever was given 1.2 g of quinine chloride. The fever fell off but the intake of quinine (and the febrile disease?) was followed by a severe ear lesion with deafness, tinnitus and vertigo. Seven months later, under treatment for his ear lesion he was given 1 g of sodium sali- cylate x 5, a t intervals of 1 hour - and this resulted in an acute exacerbation of his ear lesion. S c h w a b a c h did not see him, however, till two months after the administration of salicylate. At that time the patient complained of deafness, roaring in the ears and dizziness, with a tendency to aggravation of the symptoms in damp weather. There was bilateral retraction of the tympanic membrane, and the hearing for whisper was markedly impaired in the right ear, ad aurem in the left. C, was heard in the right ear, not in the left. The perception for high tones was lowered. There was occlusion of the tube on the left side, and the hearing was improved on treatment with inflation, but not for the high tones. From this somewhat uncertain and far from clear-cut case S c h w a- b a c h arrived a t the conclusion that the patient was suffering from a combined affection of the middle and internal ear, produced by salicylate and quinine. Another patient was given 30 g of sodium salicylate within two weeks, and this treatment was followed by marked tinnitus, which persisted even 5 years later when S c h w a- b a c h saw him. At that point of time, otoscopy gave normal findings and his hearing was normal.
S c h i 11 i n g (1883) observed 7 persons with ear symptoms after administration of salicylate. In the three most pronounced cases the tympanic membranes were found to be injected; no func- tional acoustic tests were reported. Like K i r c h n e r and R o o s a, therefore, S c h i 1 1 i n g thought the ear symptoms were attributable to vascular changes produced by salicylate.
In 1887 P e r r o n reported a case of deafness and tinnitus after quinine, but the lesion had originated many years before his examination of the patient, and there were also chronic changes
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in the tympanic membranes. Also in D a b n e y's case (1891) of supposed quinine deafness there was a similar long interval between the onset of the lesion and the examination, so tha t the report is of no particular value. A work by S e i t z (1909) who deals merely with the subjective sound phenomena after intake of salicylate, is rather philosophical and gives no acoustic tests whatever; and the same applies to M i u r a's (191 1) report on two cases on deafness after intake of acetanilid.
Characteristic of all these reports, then, is the fact tha t in nearly every instance the examination did not take place until a long time (often several years) after the appearance of the deafness and that the functiona1 acoustic test - let alone the vestibular - is more or less defective.
The authors cited above think they have demonstrated tha t intake of salicylate or quinine may give rise to permanent aural symptoms tha t are attributed to vascular changes in the sound- conducting part of the organ of hearing. These studies, therefore, are not very convincing, not least with regard to the stated per- manent effect of salicylate and quinine on the ear. For one thing, the objection may he raised: tha t the ear lesion might have been produced by the disease against which the drug was given and not by the drug itself.
From this older period, however, there are also some more valuable' experimental studies on the effect of quinine on the ear, which all - in contrast t o those cited so far - are dealing with the acute transitory effect of quinine, not with the postulated permanent effect.
The first one of these is the really classical dissertation by G u d e r (1880) which did not receive the attention i t deserved. G u d e r examined 12 young healthy persons after intake of a single dose of 1 g of quinine chloride, the examinations being made a t an interval of 1/&1 hour in the following 5 hours. The examina- tion included otoscopy, acoustic test (watch), pulse rate, measuring of the rectal temperature and the temperature in the external auditory meatus, together with records of the subjective symptoms.
In the external auditory meatus there was a fall in temperature averaging 0.56" in 2-2y2 hours, but a corresponding fall in the rectal temperature was recorded a t the same time. Otoscopy showed
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no injection of the tympanic membranes - on the contrary in several cases a slight redness along the manubrium present a t the commencement of the experiment was found to disappear comple- tely. The acuity of hearing decreased noticeably in every case, with a maximal decrease 2 1/2 hours after the intake of the drug. In 8 cases there was also a noticeable vertigo, appearing 1 y2 hours after intake of the drug; in a few instances i t was so pronounced that the subjects could not walk straight with their eyes shut, but tottered to the side. All the subjects had tinnitus within 1 y2 hours and 7 of them had a sensation of pressure in the ear, a symp- tom that appears not to have been described before - nor later. There was complete restoration to normal conditions within 24 hours in every case.
According to W i t t m a a c k (1903), Ferreri is said in 1887 to have examined 30 women who were given large doses of quinine (2-4 g in 2 hours) against malaria. Deafness and tinnitus appeared after this treatment. Examination gave a positive outcome of R i n n e's test and lowered perception for high tones. The maximal effect appeared about 4 hours after intake of the drug; and within 24 hours the hearing was normal again. In passing it may be men- tioned that F e r r e r i (1886) also states that quinine may have a curative effect on deafness, and illustrates this assertion with the historical example of G a r i b a 1 d i who is claimed to have been deaf after a cold and to have recovered his hearing after a dose of quinine.
S c h u 1 t z (1887) gave 10 healthy students quinine through several weeks. Tinnitus was observed only in 6 of these subjects, and deafness only in 2 - obviously because the daily doses were relatively small (0.2-0.3 g). In this connection mention is to be made also of a paper by S a c h s in '1881 on the effect of salicy- late. He gave 7 subjects 5 g sodium salicylate within 30 minutes, and found deafness in 6 and tinnitus in all of them. The symptoms appeared after 1-3 hours, and persisted for 16 hours in subjects with normal ear, up to 3 days in persons with abnormal ears.
More recently, only a very few studies have been reported on this question. L a s a r e w & B e 1 i k o w (1930) found impairment of the hearing already 30 minutes after intake of 0.6 g of quinine, involving the perception for deep tones more than that for high ones.
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C h r y s s i c o s & Y a n o u 1 i s (1938) examined 25 persons who had taken large doses of quinine in attempts a t suicide. In several cases they found injection of the tympanic membranes. Regularly there appeared a marked degree of deafness and vestibular phenomena which subsided within a relatively short period.
The two last mentioned papers may be said, however, t o be rather poor as t o the evidence presented, and the functional acoustic tests were carried out only in part.
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