Reprinted from the New York Medical Journal forMay 24, isnT.

A CASE OF TOTAL DBAFNfeSS 'TOFEOWING A DOSE OF QUININE.*

Milton J. Ballin, M. D.,New York,

Adjunct Otologist, Mount Sinai Hospital.

It is a well recognized fact that drugs such asquinine, salicylic acid, morphine, and alcohol, whenadministered in one large dose, or when given insmall doses for a longer period, occasionally exer-cise a deleterious influence upon the nerves ofspecial sense. These drugs, owing to their toxicaction, may, as I have occasionally observed, giverise to pathological conditions in one or morenerves, which partially or totally impair theirfunction, and not infrequently prove of a tem-porary or permanent nature.

This applies especially to quinine, whose toxicaction occasionally produces destructive changesin the terminal filaments of the auditory nerve,which appears to be particularly susceptible to theinfluence of this drug. The idiosyncrasy of someindividuals to the efifect of quinine becomes mani-fest even after the administration of very smalldoses, in that they complain of flushing of the face,headache, tinnitus of varying intensity, and moreor less impairment in the hearing in one or bothears. In almost every case these manifestationsdisappear within a short time, leaving no harmfulsequelae. It happens, however, that cases are metwith in which the deleterious effect of quininemakes itself apparent in pathological conditions inthe labyrinthine portion of one or both ears, withthe result that there is a temporary or permanent

*Presented before the New York Physicians’ Association, Janu-ary 23, 1913.

Copyright, 1913, by A. R. Elliott Publishing Company.

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loss of the hearing function, with or without dis-turbances in coordination.

A very instructive case in which the harmfulaction of quinine is fully demonstrated was re-ferred to me by Professor Politzer, of Vienna,about two years ago.

The patient was a young lady, twenty-one years of age,an American by birth. Her family history was negative.There was no evidence of any acquired or congenital auralcondition in her parents or other immediate relations. Dur-ing the earlier years of her life she had the usual ailmentsof childhood, but never had any affection referable to herears. She was always a robust individual and enjoyedthe best of health. Six years ago she had a severe attackof grippe associated with a marked coryza. A kind neigh-bor, who meant well and thought he could break up hercold, gave her six five grain quinine pills, making, there-fore, a dose of thirty grains. This she took within aperiod of fifteen minutes, the time being about ten o’clockin the evening. Two hours later she complained of anintense headache and severe tinnitus in both ears. Therewas no disturbance in coordination, but she noticed amarked diminution in her hearing which steadily grewworse, so that perception for all sounds was completelylost by the following morning. She did not seek medicalaid immediately hoping that her lost function would intime reestablish itself. Finding that she remained deafin both ears, she consulted different aurists with the hopethat something could be done for her, and finally Profes-sor Politzer, of Vienna, who, after a careful examination,pronounced her case hopeless.

Upon her return to this country she called upon me, andI found, upon inspection, a normal condition of the ex-ternal auditory canals and tympanic membranes. Therewere no evidences of a previous aural trouble, and in-spection of her nose and throat revealed nothing abnor-mal. The tuning fork tests showed an absolute loss ofperception for all tones in both ears. Perception by airconduction was nil, and the vibrating fork placed againstthe mastoid, on either side, or on the vertex of the head,was not perceived as a tone, but interpreted merely asvibrations. In other words, there was a complete absenceof perception for sounds by air and bone conduction, in-dicating, therefore, a bilateral, total nerve deafness. Thatis, we were dealing with a labyrinthine loss of hearing, inwhich both ears were involved.

In order to ascertain whether the vestibular portions ofher labyrinths were functionating, I performed the usualrotatory tests and Barany’s test of injection of cold water

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into the external auditory canals. I noticed, after a fewmoments, that there was a slight nystagmus, which allowedme to assume that the vestibular part of the labyrinthwas still irritable, and that the static reaction was pre-served. This proved of great interest, as it clearly showedthat the destruction, if caused by the toxic action of thequinine, was limited to only the cochlear portion of thelabyrinth. There had been, therefore, a degeneration ofthe terminal filaments of the auditory nerve in the coch-lear part, resulting in the complete loss of hearing, whilethe vestibular part had apparently escaped, inasmuch asthere were no disturbances in coordination. The percep-tion for speech was naturally also entirely lost, but throughpractice she acquired such a dexterity in reading the lipsthat one would hardly believe that she was completelydeaf. Examination of the eyes did not show any changesin the fundi. About a year ago she passed through aconfinement, bearing a healthy normal child. This in noway influenced her aural condition.

She received all forms of treatment, that is, injectionsof solutions of pilocarpine, sweat cures, electric currents,and large doses of iodides, besides local treatment of theears in the form of catheterization, massage, etc. Allthese proved of no avail, so that treatment was finallyabandoned.

A Wassermann test proved negative. In order to ex-clude the possibility of a long standing hysteria, or someother neurological conditiort, I had her thoroughly exam-ined by Dr. S. P. Goodhart, the neurologist, who foundno manifestations indicative of such a condition. I wastherefore convinced that I was not dealing with a func-tional loss of hearing, but with a true organic lesion.The patient still clings to a vain hope that her lost func-tion may be restored, and is at present receiving injectionsof strychnine and electric currents applied to the mastoidregions. There seems to be no change in her condition,as one would naturally expect, and I therefore have givenup all ideas of restoring her lost hearing, regarding thecase as one doomed to permanent deafness.

The principle upon which this form of lost hear-ing is based was first advanced in 1881 by Kirch-ner (i), who undertook a series of experiments oncats, dogs, rabbits, etc. He administered to theseanimals large doses of quinine, which causedparalyses of the extremities and finally death.The ears were then carefully examined, and Kirch-ner found hyperemia and areas of ecchymosesthroughout the mucous membrane of the middle

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ear and in the structures of the labyrinth. Heattributed these changes to a vasomotor paralysisof the bloodvessels brought about by the toxicaction of the drug. He also noticed a seromucousand hemorrhagic exudate, which, according tohim, produced secondary destructive changes inthe nerve endings, with subsequent loss in thehearing. Whether the changes found by Kirch-ner were due to the action of the drug, as he be-lieved, is questionable, for it must be borne in mindthat these animals received doses sufficient tocause death by strangulation, and this may haveproduced the conditions found post mortem. Ithas been repeatedly observed by careful investi-gators that hemorrhages and hyperemia of thebloodvessels have been found in the ears of animalswhich have been killed by strangulation alone, andnot by the action of poisons.

Among these investigators was Grunert, whoundertook a series of experiments on animals,file killed pigeons and mice by strangulation,and found hyperemia and hemorrhages in themucous membrane of the middle ear and inthe structures of the labyrinth similar tothose observed by Kirchner. Wittmaack (2), in1903, likewise investigated this subject andperformed a series of experiments on animalsby administering large and small doses of quinine.He did not agree with the explanation advanced byKirchner, although he also found similar changesin the middle ear and labyrinth of his animals.Wittmaack did not attribute his findings to thetoxic action of the drug, but was rather inclinedto believe that the changes observed by him weredue to strangulation and the forced respiratoryacts caused by the large doses of the drug. Henoticed, on the other hand, that in those animal s inwhich the doses were small, and in which thepoisonous effects were mild, these changes were en-tirely lacking. This would indicate that the condi-tions found by Wittmaack were not due to the

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direct or rather specific action of the quinine, butwould make one believe that they were secondary.

Wittmaack was also inclined to believe that thereis an ischemia of the membranous labyrinth, similarto an ischemia of the retina, brought about bysome circulatory disturbance due to the specificaction of quinine. This, however, was not basedon facts, as it had not been proved clinically orexperimentally. Upon further investigation hechanged his views. In another group of experi-ments on animals he found, upon more carefulexaminations, changes in the cells of the spiral andvestibular ganglions. That such changes takeplace in these ganglionic cells seems to coincidewith the fact that the toxic action of quinine actsupon cells in general. It is, according to Witt-maack, a protoplasmic poison, and he therefore didnot consider it surprising that it should attack thevery sensitive nerve cells of one of our most sensi-tive organs. As the changes observed in the audi-tory apparatus take place so shortly after the ad-ministration of the drug, he no longer regardedthem as secondary, due to circulatory disturbances,as he at first thought, but rather attributed themto a primary specific action of the poison upon thenerve cells. The primary effect of the toxic actionof quinine makes itself manifest, as a rule, in theform of more or less, tinnitus. This, no doubt, isbrought about by an irritation of the cells of thespiral ganglion. If, on the other hand, one ob-serves an accompanying vertigo varying in inten-sity, it may be assumed that there is a simultaneousinvolvement of the cells in the vestibular ganglion.Witmaack therefore concluded that it was the speci-fic action of the quinine and the circulatory dis-turbances, acting jointly upon the ganglion cel's ofthe auditory nerve in the labyrinth, that most likelyproduced the loss of hearing in cases of quinine in-toxication.

Roosa (3), who is supposed to have observedchanges in the ears following the use of quinine,

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administered from ten to fifteen grains of the drugto several students. In from one to one and a halfhours later he asserted to have noticed a redness ofthe face and auricles and a marked injection of thevessels along the handle of the malleus. He fur-ther learned that his subjects had severe ringingnoises in both ears. These conditions following soshortly after the absorption of the drug in perfectlynormal individuals warranted Roosa in assuming,with justice, that these changes were caused by thetoxic and specific action of the quinine. Similarobjective changes, however, have not been observedby other investigators.

From the foregoing, therefore, it becomes evi-dent that we cannot regard the changes found inanimals as the true cause of this form of deafnessin man, and must as yet look upon this matter asan unsettled question. This is readily understoodwhen we stop to consider that the pathologicalchanges which give rise to this form of deafnesshave not as yet been clearly established, for thereason that our knowledge is based entirely uponanimal experiments, and we have no record of anycase in which a pathological anatomical or micro-scopical examination has been made of the ears ofan individual who has become deaf from the toxicaction of quinine. If the conditions found in ani-mals, after the administration of doses of quinine,cannot perhaps be attributed entirely to the effectof the drug, it neveretheless seems as though it hadempirically a selective or specific action on theauditory nerve. For, how are we to explain theaural symptoms and the sudden total loss of hear-ing in both ears in the case given above? We havehere a perfectly healthy individual who completelylost her perception for all tones after taking thirtygrains of the drug. She had a perfectly function-ing organ of hearing prior to this, and received noother medication at the time.

That the auditory nerve is particularly sensitiveto the action of quinine, as already stated, is well

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known, for one often meets with individuals whocomplain of tinnitus and a slight impairment inhearing, even after the administration of only afew grains. It would seem, therefore, that in spiteof the fact that we have no fixed data except thoseobserved in animals to explain the phenomena, wemay nevertheless regard our clinical observationsas pointing to a selective or specific action of thedrug on the structures in the labyrinth, and mustalso bear in mind that a personal idiosyncrasy playsan important part. Hence, it behooves us, inprescribing this drug, to exercise precaution, forwhat may seem a small or medium dose for oneindividual may prove harmful to another. It isextremely fortunate and also surprising that onedoes not meet more frequently with cases of deaf-ness following the use of quinine, when one stopsto consider the carelessness with which it is usedand the quantities consumed by the laity.

Cases of quinine deafness are brought to the at-tention of the profession from time to time, andmentionof such instances are made by Dabney (4),Tififany (5), Shilling (6), Perron (7), and others.In all these the loss of hearing remained permanentand treatment also proved futile, as in my case.

I was prompted to report this case as I believe itis extremely interesting in that both auditorynerves became simultaneously affected, giving usa total bilateral, permanent loss of hearing. Itis furthermore of interest in that the de-structive changes, which apparently were dueto the toxic action of the quinine, producedirreparable lesions in the cochlear portionsof both labyrinths only, while the vestibularparts were evidently not involved. We can sur-mise this from the fact that the loss of hearing wasunassociated with any disturbance of coordination.Although the cases in which the action of quinineexercises a deleterious effect upon the auditorynerve are very rare, and one does not often meetwith individuals in whom this drug leaves any tin-

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pleasant sequelae, yet an unfortunate case like thisought to be a warning against its indiscriminateuse.

REFERENCES:i. KIRCHNER: Ueber die Einwirkung von Chinin und Salicyl-

saure a-uf .. das Gehororgan, Berliner khnische W ochenschrift, 1881.No. 49X ’ 2. WITTMAACE.: Sind die Wirkungen des Chinins amGehororgan auf Circulationsstorungen zurtick zu ftihren? Archivfur Physiologic, xcv, 1903. 3. ROOSA: Experiments Concerningthe Effects of Quinine upon the Ear, Monatsschrift fur Ohrenheil-kunde. p. 46, 1876. 4. DABNEY: A Case of Permanent DeafnessProbably Caused by Quinine, Archives of Otology, xix, 1890. 5.TIFFANY: Total Deafness from Quinine St. Joseph Medical Her-ald, ix, 'lB9O. 6, SHILLING: Miinchener drstliches Intelligensblatt,No. 3, 1883. .7, PERRON: Taubheit nach Chiningebrauch, Revuentensuelle de laryngologie, etc., No. 11, 1887.

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