d~dgeon,. - bmj military health · i -teonaris.dudge01i" 47 total acidity is the quinine...

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ON THE -EFFECTS, OF INJECTIONS OF QUI'NINE INTO 'l:HE .TISSTJES OF MAN AND ANIMALS.I'

By COLONEL LEONARD S. D~DGEON,. C.M.G., C.B.E., F.RC.P.Lond. Army Medical ·Service. -f I

Opnsulting Bacteri~logi8t B.S.F. and Member oj'the Advisory Oommittee to the 'War . Office for Infectious Disea8e8 and Sanitation, Eastern Mediterranean .•

[From the J01trnalof Hygiene, ~ol. xviii, No. 3, November 7, 1919.] . .- , .

IN December, 1917,- Lieutenant-Colonel MacGilchrist. of the Indian M.edical Service published a paper on the necrosis produced by intramuscular ipjections of strong solutions of quinine salts.2 It might bean

. advantage to quote the first few lines of this communication: " Ad vocates . of in'tramuscular injections· of strong' solutions of quinine salts for the I' treatment of malaria seldom omit to ·state that no local ill-effects are produced.'~ He-'records a case of. tissue necrosis following on the intramuscular injection of eleven grains of quinine bihydrochloride in thirtyfour minims of water. Death supervened thirteen hours later: MacGilchrist ~specially noted, owing to rapid tissue necrosis, that the track of the needle remained patent. He regards as an established f~ct that most of the quinine injected is precipitated and' probably che~ically· combined with serum proteins in the necrosed tissues and for this reason intramuscular injections of concentrated sQlutions of 'quinine salts are not to be recommended for cases of emergency . Very dilute solutions 'of quinine salts are, 'in his opinion, rapidly and completely absorbed, whether employed subcutaneously or by the intramuscular route. If the views which MacGilchrist puts for~ard in, this and other communications are to be accepted without reserve then intramuscular injections of strong solutions of quinine should' no longer be employed. It was for this reason that Major'7 General Sir M. P. C. Holt, K.G.R, K.C.M.G., n.M.S., B.S.F.,· asked' me to carry out an experimental inquiry on animals as totheeffects produced by intramusc~lar injections of strong solutions of. qu{~ine.

Human muscle was examined from fatal cases of malaria or suspected malaria which h~d received an injection of quinine at periods varying from one hour, to t.liree months {rom the time of th'e inoculation, and in some instances an estimation of quinine in the affected tissues was made. ]'or the experimentaiinquiry cast mules, rabbits, guinea-pigs and frogs were . . .

. I,This paper was not written with, the intention. of deprecating th;' value of intramuscular injections of quinine for the treatment of malaria', but to draw attention to certain facts .with which everyone. who employs this method should be acquainted. Foreign 'substances should ri<?t be injected into the ti~sues of nianexceptby those who hav~; the necessary knowledge of the substance they are injecting a,nd the effects it may produce on the tissues. _ .

~ Indian Med. Gaz., Hi., No. 12. . ,

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46 Effects, of Injections oj Quin.ine into Man and Animals

, used, while the preparations of quinine employed were (a) hihydrochloride' in saline, (b) ~cid sulphate i~ saline,! (0) quinine' alkaloid dissolved in alcohol' ,(~bout the strength, of hospital brandy), (q) and in ether (medicinal)'.. The alkaloid shaken, in blood serum and saline-a preparation which, consisted of one gramme of alkaloid, one cubIc centimetre of ninety per cent alcohol, and olive oq to, three cubic centimetres-and ,a somewhat similarpreparation to the, last mentioned', was tested directly after it arrived in ;the East I

for trial. The quinine solutions hav.e been injected in concentrated and dilute ,soluti,ons. The preparations most commonly employed for intra-

, muscular injections were the ,bihydibchloride of'-quinine in saline, and, to a .less extent, bihydrochloride dissolved in brandy. Human muscle was obtained in all instances from cases, which had' received quinine in some form in concen,trate~ solutions as co'mmonlyemploye<;l for the treatment of malaria. Control observations ,were made on the action on the tissues of animals of a'cids and ether (quinine sol:vents). ,

. Numerous cases were treated with intramuscular ,injections of qf1inine bihydrochloride dissolved jn brandy on the basis. of three grains of the salt per ten pounds of body weight.

'Experimen~s have al~o been made on the al>sorption of quinin~ from the site of inoculation, at periods varying from a few minutes to sev,eral weeks, and as to the question of the s,torage, of the alkaloid in the heart-muscle, li Vel' and kidneys., '

All who have had experience of malarial patients are aware that an apparent am~mia occurs, and a true anremia with considerable blood destruction. Further, a severe hremolytic anremiaa,nd hremoglobinuria is associated' :with malaria and may oqcur at a period of the disease when quinine treat-' meI},t is essential. For ,these reasons it was neceRsary to induce anremia and hremoglobinuria in animals by,means of immune sera so as to observe whether, intramuscular injections of quinine i~ concentrated and dilute ,solutions excited a more intense tiss,uereaction than in the control animals.

All,the chemical, estjmations of residual quinine were undertaken by Captain C~ E. C. Ferrey, O.B.E., R.A.M.C. (T.F.), Analytical Chemist to

. the Central Laboratory, B.S.F." who employed the Stas-Otto process for thes~, investigation's. '

,QUININE AND HJEMOLYSIS.

, Although the purpose of these experiments was to observe the effects of I ...' .

intramuscular injections of 'quinine on the tissues, yet attention must be drawn to the hremolytic activity of quinine as estfmated in vitro; Two. 'so!utions were prepared for the' ,purpose: (1) one per cent bihydrochloride of quinine in saline, (2) ~ solution ofhydrbchloric acid in saline of th,e same

'I Only three experiments were made 'with this salt as it was found to excite more intense necrosis than the other preparati,ons which were ~mployed. '




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total acidity is the quinine solution~0·18 per cent. The total bulk of test solution and saline in' each tube was one cubic centimetre.' The:h!erllolytic end point Of the qninine solution, acting at 379 C. 'for five hours, }Vas 0-16 cubic centimetre, while the acid solution 'alone. induced hremolysis down 'to 0·1', cubic centimetre. Normal saline was employed throughout the experiments ,as the diluting agent.· Further, the hremolytic action was much'more rapid with the acid solution than with the bihydrochloride of quinine in ~salin,e. Normal human serum orcitratedplasma in suitable amounts prevep.ted hremolysis .. ' These results b};iefiy referred to serve to illustrate the h-remolytic action of bihyd:rochloride 'of quinine 1I,nd Of the corresponding acid:. It will be' re~dilyaI>prec-iatedthil£ the, prepal'ati~~s ~of quinine 'employed for intramuscjllar injections 'in the treatment' of :malaria-are of considerably greater stre,ngth than in these eiperiinents on hremolysis in vitro:, The h~molytic activity of a one per cent solution of

'bi-hydrochloride of quinlQ~ is extremely rapid, whIle strong solutions. produce instantaneous han?lolysis. The alkaloid when suspended jn saline induces a much more gradual hremoJysis than the salt in solution, a,ltho~gh, for obvious reaso~s a considerable error must occur in estimating the hreillolytic action :of varying suspensions of quinine: alkaloid in saline. It has been found that the agglutination of human or other red cells, 'well known to be induced ,liy free acids, -is absent in the standard acid~soluti6ns of bi.;, hydrochloride of quinineemployea:in·suitable strengths for such purposes. If 0·05 cubic 'centimetre of the standardl solution of hydrochloric acid already referred to is made up to a total volume of one cubic centimetre, an immediate agglutinat,ion occurs' on the addition of humatlred cells, while with 0·15 cubic' centimetre of the one per cent solution of bihydrochlaride 9f .quinine in cine cubic;~entimetre saline no such effect is induced. All experiments tend to flhowthataltho~gh,quini[}e acts as ~ powerful hremo:': lytic agent the acid employed to dissolve the alkaloid is much more potent in its': effect. " ' '" ' , '

- '. ..\ - .". . ' .' .. -WHA,T IS THE COMPARATIV,E~:FFECT OF' INTRAMUSCULAR INJECTIONS

OF CPNCENTRATED AND, DILUTE, SOLUT!ONSOF QU~NINE.

N:umerous experiments have been made ~6 solve this qu~stion concern-, ing which information w&s spEicially'required. '", , ' ' .. ' The following detailed des'crip'tions 'express the essential features :- ' .' (I)A l"l!'bbit recei.ved aii'intra~muscular injection'of, 9·0q9 g~amine of -

bihydrochloride of: quini?e'in t,cuhi,c centimetre salin~, and the saml'l qualitity of quinine in 3 cubic ,centimetres of' sa;Iirie into another s.et of niuscles. "" , c • "

, Th~ following day 0·078 gramme of 'the sairie ,preparation' i~ 2 c~bic centimetres of saline was injected in the right side and a similar(,quantity in 4 cubic centimetre~ of saline in the-left.




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,48 Bffects of In{ectionsot Quinine into,' Man and A-nimq,ls - , "\ . I"' ' "". '

Tbe, post-mortem exa~lnation took place o~ the foll9wing day. Th~ / results showyd that no advantage was gainfld by iniecting the quinine in

,twice the quantity of saline. 'The spreading oodema was greater owing to ~ the increase iiI bulk of ,fluid -injected, while the inflammatory process and ' muscle necr9sis iIt both instances was so evident,that noimpoi'tance could be attached to ininute differences - in the affected tissues. If quinine injections are given in such dilubons that tbe action of qui'nine and fr,ee a,cids 0:9, the red ,cells and tissues is reduced, to a Ininimum" then the bulk

Y 'of fluid required would nullify, in my 9pin,ion, any advantage that might be, gained. Further there is it' greater' possibility of suppuraJ;ipn from injection'otquininei'll large bulk into the'tissues at frequent intervaJs., " ,

(2) Four rabbits were injected by the intramuscular route as follo~s::'(a) 0'018' gramme of bihydrochloride of quinine 3.n O·p.cubic centimetre

saline (concentrated). . " ' , " , (b) 0'018 gramme of pihydrochloride of. quinine in .0'5 cubic centimetre ' normal rabbit serum (concentrated). ' , ." (c) 0'0;1.8 'gramme of bihydrochloride of quinin~ ina~e up to two, cubic centimetres with auto-rabbit'serum.· ' , ',' (d) 0'7 cubic' centi'uietre of :t : 5,00Q so~ution of quinine ,,' alkaloid in ether., " , , Ce) 0'18 gramme of bihydrochloride of quinine made lip to two cubic ce~timetres with auto-rabbit serum, and injected by the, intramuscular

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route.' , ·In every instance obvious necrosis occurred. The interval between the,

'time of the inje~tion and tbe autopsy was six days in the case of experi-ments A and 13, four days in C and E,and three days in D., " ' ,

The most intense cbanges we~e induc~d wben, the alkaloid was inj,ec,ted ,with etber. Necrosis of 'muscles in,all stages-wide areas of polynuClear and "mononUclear inflainmation espycially towards, the capsular ar~a

:tbrombosis of vessels~red cell agglutination andbremolytic ch~nges in tbe : tissue blood as well as in tbe intravascular blood. -

(3) A mule was' injected with ~ne gramme of a,lkalol'd of quinine in alcohol'and olive oil (tbree cubic centinletres). On the foll.owing day witll,

, one grauime of the alkaloid in ten cubic centimetres of ether. Although the ,total bulk-of fluid var'iJd considerably in each inoculation

'the final results were similar; further, the concentration of quinin'e in: tbe s9lutions employed did not affect tbe final results. In each instance extensIve necrosis--:-hremorrbage into the tisslies-'.cQngestion of ,blood-vessels and foci o~ acute inflammation were in'et, with., Numerous experiments haveJg~en referred to elsewbere in this cQmmunication which serve to ilhistrate tbe comparative effect~,of concentrated and dilute solutions when-injected into the tiss,ues of anim'~ls., " ' ."

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Leonq,rd S. Dudgeon. .. I' .' " .. ~ -

THE MICROSCOPICAL FINDINGS AS A ,RESULT OF INTRAMUSCULAR ( , , , . . . "

IN.tECTIONS OF QUININE SALTS, 4ND' ALKALOID, QUININE.

,Th~ first effect of an injection of .a quiriine~preparatibn into the tissues '. is necrosis of muscle., The fibres most affepted are completely necr9sed,

,/ : leltving 'the empty' s1;leaths., illdema of the tissues' accompanies' the necrosis, together wi~h agglutinati6n of red CEllls 'and hremolysjs In the vessels and in the blood' which hiJ,s f1seaped :into thetissu'es. These changes

,are in,evidence withiIden minq,tesof the inocu"~atioil. At this period no 'le'ucocytiq reactiQnhas"occurr~d, 'but an intense congestiop of all ,yes'sels

, in, the area has. taken' place., At, the end, of ,9ne hour ,:the leuc~6y'tic -reaction 'may 'not ,be a marke~ leatuni, although in p'reparatlo~s,ofquinirie

which inClude oil' an intense- polynuclear leucocytic, reaction has been ,.9b~erved. The muscle' fibres in the necrotic areas; as 'time advances,

present ,appearances' which' are various as well as distinctive:" In addition ,to the fibres which are',completely necrosed others showfr~gmentation, so that numerous ~'apparent droplets "are observed within the 'sheaths, (PI. I,fig 1).· ,()wiPg-, to a ,~i:tltipli.cation of. the' nuClei of the' sheaths' which occurs and a c'ollapse of the 'sh~aths themselves, the fibrous framework 'of the ,:t;lew tissue is gradually formed. Sh'runkE1l1 fibres with several

,nuclei give'the well-Known· appearallc.eof- pseudo~gif!,~t', cell formatio,D. '-The large tissuecells,ac~ as, phago~y;tes ~or fat droplets;, :t;eq 'celis/ a:nd free, " iron granules. Active ~estruction of the vesseLwalls occurs together with .thrombosis'which :t;l1a")?::br,may not serve as a' conseiv:ati~e'.proc~ss (PI. I,

fig: 3). Polynucle-ar inflammation of the'~ecrosed walls' can', be cl~arly demonstrated.'· Active 'changes occur in the'vessels apart £rpnl thrqmbosis;' such as agglutina~ion of red cells andhremolytic phoI).emena; while ~ similar changes a~e met with outside the vessel walls. In certaih instances/maik~d red cell agglutination occurs within th!3 vessel without the evidence of inflammation (PI. I, fig; 2). '

',' 'In course of t,ime aQsorptio? 'ol muscl~ fragmeD.~ ~Jl,d of inflammatory products takes place, so that finally we have a condition of fibrous myositis such as .is m~t with as a :result <?f traumatic influence or syphilis. Nerye ;£bres are implicated :in the earliest stages. ~t is not ,uncommon to observe that hremorrhages and large vacuoles occupy the space of the' original nerve' fibres.~, Fibro,us tissue formation surrounds, the nerves in, ,the muscles and also the indi'vidual fibres. Largen~rve tr,unks, may be ~cj 'implicated by the oodema'and spreading necrosis' that complete nerv,e degeneration occurs. .,',' .. ' /, . " ", ",' ,".. '

Strands of necrosed musCle fibres may persist for ten to fourteen d!1Ys after an' injection of quinine,. possibly· owing to ,the, diminished ti,ssue absorption which must occur 'as a result of quinine inoculation. The bulk of quinine'however is absorbedfroin,the tissues with extreme rapidity- ' simply a question of ,hours.

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50 Effects of Injections of Quinine 'into Man and Animals'

EXPERI'MENTSTO ILLUSTRATE ,THE EFFECTS ON THE T--rSSUES OF

,CERTAIN PRE'PARATIONS OF QUININE. . . , '

,A cast' mule w~s inject~d with the following preparations. The 'results' were as fo1l6ws :---,-' ' ,

Number of inocu

lation' Site C;r inoculation" Nature of'inbcuJation

" . '. ,

N~ked.eye appearances at autopsy

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'I Interval be· ' twe~n inocn.~.r

Jntion and examinati0D:

-- -' --'-------' ------' ---------'-- - . ." ,

1, B_aqk, neitr side 10 c.c, ether .. Extensi:l,e nec~osis,6 or 7' 'in. long, ? days 3 to 4 .in. wide, Slight sUB-erficial

2, "Near fore legs .. 'n ,,' " aidema', __,' , . , ' Extensive tissue ,necrosis. Slight ',5

,oedema, 3

,4 5

6,

Back, off side.. 0'25 grm. of alka· ,Widespread oedema. Very ~xten. 4 " , loidal quinine in - sive, necrosis

Off fore leg .. N~ar hi'nd leg, ••

Off hind leg

10 c,c. ether

5 c.';: of 4:3 'per cent HOI in sa:Jine

5 c.c.,of 25 per cent , bihydrochloride "

of quinine in sa, line (same, total, acidity as' above, (5))

3 Extensi~e oedem~ spreadi~g along 2 "

24 hOllrs i:nilscl~ septa: Marked necrosis

'n - "

,,'t'qi's' experiment gives ,an excellent survey, of th'e 'effect,produC;-ed-by '" ethe~-quir11ne' alk8.loid dissolved in ether-'-:bihydr9cbloride' of' quinin'e in'

sallne"::':":hydro'chloiic acid made, t9 the same' total acidity as'tbe"solutionof qmnme. In Experiment 3 of th'is~eries 0:25 gramme of. alk~loi'dal quinine ~as injected in no less than ten cubic pentimetres ether, yet the effect on

, the 't~ssues was considerable., . Here the quinine w.as given in dilute solution, but the solvent efnp!oyed was la:rgely responsible' for the effect. Experi~lents 5 and 6' of thisDs~ries )3how sImilar_effects on th,e tissties, yet qUInine' was not employed in Series' 5.' The result-must have\ been' due;. therefore', ' tq the solvent. This fact must never-be lost l!.igh~ of in any discussion on the, que'stion of tissue necrosis induc~d 'by quinine, as will be referred_ to

, elsewhere in this communication.

Intramuscular I~jections of Alkaloidal Q:uinine in Sixty per cent Alcohol. • • - _ 1 • '. "

Sever,al animalsr~ceived i~tramuscular injections. 0'£ ,quinine dissolved in ~lcohol, either concentrated' or in dilute solutions. ' 'J'he rabbit used ill the experiment to be referred to in detail was, injected daily foI.' six days with 0'04 gramme in one 'cubic centimetre of sj~ty per cent alcohol.. BIQod counts were made with the object of determining whether a leucocytosis wOllldbe induced or an alteration i~ the red cell-hffillloglobin system'. The injections were made iri a different muscular area on eiwh 09casi<?n. Certain tissues wer~ -preserved at the autopsy for quinine estimatioD, and t1J.e entire

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.' Leonard'S. Dudgeo,,? 51

Ideal aiea ~as removed for.a ~imilar .p·urpose except for a.small portion reserved for illicroscopy. 'Firs~'injection: there was marked oodema and a long ·line of muscle necrosis. A typicalflhro-myositis had been. produced around the necrosed muscle, in which all possible changes were recognized. ~umerous new-formed "blo.od-vessels w~r.e present, also blood pigment and scattered hremorrhages'. Degeneration ,of ,the vessel walls was evident;

,The effect of the second inocrilation was 'simlla.r except that a well-d~veloped, interstitial neuritis was found in the nerve from the affect8il area~ , No quihinewas 'd~tecte9. in the)ocal Jesion. The:third injection had produced; ,

'a largehremorrhagic area superficial to 'a, diffuse black-brown necrosis of\ muscle .. Numerous foci of pdlynuciear cells were present.' No q'llinillEi was ,obtained from the locai lesion .. Fourth_injection, made,f6ur days before death, showed very considerable oodema of muscle. and necrosis. Tbromboses of some of the large ve!\sels were presen~ with necrosis of the muscula.r

. walls. The degenerated muscle fibres were fragmented and were,under-goi~g ~ pr9cess o~ gradu~l absorption, by w4ic?t h~ghly cellular patent' sheaths remained, the walls of which ultimately coalesced and thus assisted in the formation of the, fibrous, scar. ' ';

Intramuscular Injections of Quinine A?,kaloid in Alcohol, "

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-Differential comit of lencocytes-Ist c~lumn = per,\,ent,

. , 2nd columll-/~~number per'c.m~. I •• Quinine .ilka. Leueo· ------ i - loid in 60 per,

. Weights Reel cell • H.B. C;I. :cytes Nucleat~d ' cimt alcohol, • - ,Dates gnn; per (",mm. ,.per (colour. per red cells, Finely -Large . intramuscular

cent index) c.mm. number granu' Lympho· hya- injections, .

\ ' lar cyte • total bulk of to por oxyphil lines fiuld ",. 1 c.c. - cent Iou· '- , cocytes 1 2 1 . 2~ I ,2

-- --- - -- ----------- --3;827 4,895

I

, 15.7:18 1,000 5,400,000 83 0'7 8,980 2 43'0 55'0 1'5 133 ' 0'04. grI!l. 15.7.18 950' - - - 7,909 1 48-5 3,831 50'0 3,950 1'0 '79 0'04 .. 17.7.18 950 5,200,000 84 O'S 7,600 3 27'5 2,190 38'0 5,168 3'5 266' 0'04, ." ~ 18'.7.18 955" - - - .. 7,020 1 32-5' 2,275 61-0 4,27.0 .5'5, 385 ,00;:)4 .. 19.7.18 1,000 5,200;OOC 82 0'7 7;100 30 27'5 1,952 ' 65·0 4,615 6'5 461 0'04 ,.,. 20.7.18 1,000 5,3UO,000 82 ' 0'7 7.,150 - - - - ,.... - - 0'04 .. 21.7.18 950 80 0'8 I, 27'0 63'0 IQ'O, 690 -

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'5,000,000 6,990 1,863 4,347 22.7.18 923 5,200;000 84 0'8 7,520 0 22'0 1,650 -68'0 5,100 8'0 600 Rabbit killed ,

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]fifth injection:' Diffuse hremorrhage I aijd -aidema together with a -promitlent area of greyish brown, diy, muscular necrosis' had ocqurred.

Sixth injection-: This was completed forty-eight hours before ·death: . The changes noted ~t the autopsy were similar_to those referred to as a

'result· of the. previous inoculation. ThemicroscopicaJ ?ppearances Were SImilar, but of a more acute type. There was a very marked" polynuclear inflammation, ~hun'dant hremorrhages, and active hre'molytic changes .. The

'muscle fibres were l'necrosed, fragmented, an,d brqken up into CO~l'se. -granules, and hffimorrhages had occurred among the nerve bundles. Both




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"5~ Effects 'Of Injections ?f Quinine into ' Mafb.,a1id 'Ani"';'als

kidIleys and liver removed' at the aut'opsyJorty~eight hours a;iter the last, / intramuscltl~t injection were free from quinin~, although' Q'24gramme of

alkaloidalquinine had been .injected' in. eight'days, and the last injection ,was oniy forty-eigh,t hours before deat~ , It will be readily appreciated from those experiments described'in detail that: alk~loidal quinine, given in sixty· per cent alcohol excites intense changes in t,he tissues in the :inocu- ,

, lated area. ' , -, ' , ' ,

InjectiQn of Quinin.e' Alkaloid with Olive pil.' , ' ' ~ I ' ' , , '"

T~e following preparation wa~ tried for intramuscufar injections -:-:-;,', " Quiriine alkaloid ' ,1/' • • • ,1 grm.' ,','

Alcohol 90 per1cent ' •• " 1 c.c.', , Olive ,oil (neutral) , " . . . to3 c,c. '

Injection's were made of 0'2 cubic centimet~e of the above ,mix;ture into rabbits. ' Some animals reqeived one injection. others aEi many as five on successive days,The chief ~eatures in ~uch experiments are concentration

, , of the alkaloid and the introduction ofa ,fatty subs,tance on the assu~ption that it would act aS'a tissue protector. - ,To atoid,n~~dlessrepetjtiorlit will be:sufficient to ref~r to,one experiment in detail. ' , A 'rabbi~ received five intraniuscull,tr injection's of't,he alkaloid in oil commencing with T16'cubic ceritim!3tre containing hll>lf a grain of' quinine' on five successive 'days .. E,ach 'inoc\llation,'w,as made intoa aifferent area ,of f:resh' tissue.;' The ahimal.was killed ,eleven days from tlie first. commence-11lent of th,e expe'rinie~t. Duringthe period it lost 160 grammesin'"weight., ' No advantg,ge would be gained by reQording the'tissue' chabge~ ~et with in '" each muscular Ine~. The nak~d-!3ye appearanCAs w,ere profguud in each: '

" fo(:nis, as occurs with all con'gentrated injections of 'quinine, while the oil I

exerted no beneficial action. ' pn the ether h!1nd an injection of one grain " . of the a).kaloid for a rabbit must be regarded as a full dose~ The muscles

were soft; showed 'large areas ,of necrosis, thrombosis of vessels ,and hreworrhages into the' muscular tissue: The red hremorrhagic zone was sparply defined from the necrosed,pale area;. _

Microscopically an extensive fibro-myosit,ishad develope'd with diffuse 'muscle necrosis. f.. polynuclear inflammation was far more in Avidence than has ,occurred in experilll,ents~ith 'other preparations of quinIne: ' Nerve fibres embedded in the muscle tissue weredeg~nerated, while in the older,

,lesions fibrous tissue C?ould be recognized among'the fibres and surrounding, them. '- ' '"

Th~'second izijection amou~te'd to one grain of the alkaloid in a total, bulk' of t cubic centimetre.' It had the advantage, therefqp~; for ,this' experiment, of concentration., The -inoculation was made in the muscles in the front of'the thigh.; At the autopsy, ten days'latet it was found that the necrosis had spread'tothe muscles at the back of the thigh and the great sciatic nerve was surrounded by necrosed an'a inflammatory tissue: The

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Leona'rd S. Du,d.qeon , ,

nerve was removed, entire and sections were, prepared in "Marchi to 'at -various levels. An 'extreme degree of nerve degeneration was noted; in fact, very few of the ,fibres escaped (PI. I, fig. 4). Some w~re completely' degenerated, others patchy, ,while- actual hremorrhage.s into the nerve had ta;ken place. Here we have an example of the destruction of the sciatic nerve following an injection of quinine. The inoculation was made distant from the nerve, directly into a muscle, and 'in such a manner that escape of fluid was well-nigh impossible. The ,necrosis, however, was so excessive that it had extended right through. the thigh muscles and implIcated the sciatic nerv,e with disastrous results for the ,animal." This fact, however; will be referred to later. The entire liver'and both'kidneys were examined for evidence,of quinine storage,- but no alkaloid was detected.' '

The Injection.of Quinine Alkaloid in Creosote and Fat.

A' preparation ~hich was sent to Macedonia for triai consisting of one gramme of quinine alkaloid, 0'75 cubic centimetre Qf- beech wood creosote and five cubic centime'tres of 'neutral fat, -was not found to 'possess any' special advantage over the other preparations referred to. Mules receivedintramuscular injections of the above preparation, causing extenRive necrosis and a gelatinous spreading subcutaneousoodema. A lesion some6~ inches long, 3 inches deep, and ~~ inches wide was produced, by the injection o'f ten cubic centimetres into 'the muscle of a mule. Chemical a:qalyses of the

,necro'sed muscle showed that the quinine had been absorbed-with rapidity. Two experim~nts will be quoted to illustrate this point. ~

Amount Date Post,mortem Amount of injected ' date quinine recovere,d

Expreiment 1 . 50.0. 21st 25th 0'003 grm. ~

" 2 50.0. 22nd 25th 0'063

" Similar evidence in' the case of human muscle was als~, obtained.

'A cast brown horse was ,inoculatedvntralnus(Jularly with biitydrochloride of quinine in saline as illustrated in the accompanying ~able :'-

Number Amount of bihydrochlorida of ·of experi. ment ' quin!ne employed

, ,1 2'5 grm. in 5' 0.0. saline, 2 1'125 grm. in 2'5 0.0. saline

, 3 4'5 grm. in 10 c.c. saline .. ,

4 2'25 grm. in5 c.c. saline .• 5 1'125 grm. in 2'5 c.o. saline

6 1'!25 grm. in2·fj cc. saline

Interval bet ween inoculation and

autopsy f

-------13 days 8 ,;.

3

2 " 30 hours

11

Naked-eye appearance of,the tissues at , the autopsy

,. Marked necrosis and fibrosis , LocJ1lized necrosis separated from a fibrous

zone by a line of hremorrhage_ Long tract of necrosis with marked cedema

of muscle 'Localized necrosis with 'cedema • 0

Very extensive gelatinous cedema with ~ocalized necrosis .-

IJocalized necrosis with wide tracts of hremorrhage

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54· Effects of Injections of Quinine into Man' and Animals

A brief account of the microscopical ap'pearances of ,the lesions referred to in the previous table will be recorded.

No.I. Fibrous myositis:with comple,te capsulation .of the necrotic muscular tissues. Active polynuclear' inflammation pres.ent.

No. 2. Fibrous'myositis completely enclosing necrosed muscle-hremorrhagic foci and polynuclear inflammation.

'No. 3. Extensivenec~osis of muscular· tissue· and of the walls o~ blood "vessels resulting in hremorrh~ge and active hremolytic ' changes' in the

diffused blood. Agglutination of red cells very obvious. -No. 5.- Wi!ie ne'crosis o~ muscular tissue and an iritepse leucocytic

reaction in an'd around muscular fibres 'which are fissured. fragmented, and show all stages of degeneration. Active hroriJ.Olytic changes and masses of agglutinated red cells present. /

No. 6. ,Diffuse muscle necrosis with long.tracts of oodematous tissue 'evident.-" Hremorrhagic foci and active hremolytic phenomena present. Walls of blood-vessels necrosed and ruptured.

A cast grey m~tle was irijected intramuscularly with certain solutions of . quinine with the following "esults :-

Numbt>r of ex."

periment Amount orquinine injected

and total bulk of fluid \

Amount obtained at

autopsy

Interval between the intramuscular

injections and the post-mortem

examination

Appearances of the muscle lesions . at the autopsy

---- ---------- .. -------. ------'--------------. ----1 4'1 grm. alkaloid in 10 c.c. O·014grm. 8 days .. FibrosisaIidextensive necrosis

of 70 per cen t alcohol 2 4'5 grm. bihydrochloride 0'020

" . 7

" .. Central black' necrosis, scat-

- in 10 c.c. saline tered hremorrhages. Gela-tinous redema

3 2'25 grm. bihydrochloride 0'003 "

6 "

.. Central necrosis with hremor, in 5 c.c . .-saline , , rhagiczone at periphery.

.. . Gelatinous redema 4 Ditto .. .. .. 0'0085·" '5

" .. Ditto (PI. 1I, fig. 5)

5 1'25 grm. bihyd!,ochloride 0'012 " 4

" .. Changes similar, but le si OD,S

in 2'5 c.c.,saline less extensive 6. 4'1 grm. alkaloid in io C.c. 0'074

" 3

" .. Extensive gelatinous redema

of 70 per cent alcohol , surrounding a wide area 0

dry necrosis (7) 7 2'05 grm. alkaloid in 5 c.c. 0'048

" 2

" .. Central black necrosis with

. of 70 per, cent alcohol redematous tissue around 8 2'25 grm. bihydrochloride 0'938

" 1 hour .. Extensive drY' necrosis about

in 5 c. c: saline 4 inches square -• This does not represent 'the sum total because some of the extract was'blown out of a flask. '

In each instance a different area of the animal's body was used for the injection. .

Th£l mule was killed one hour after the lltstinoculation·. At the postmortem examination the affected tissues in the region of the injections and some of the ~urrounding healthy tissue were' removed for estimation of quini~e content, while a small portion was reserved for microsc·opy.

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Leonard S. Dudgeon 55

We can inf~r· from the results of Jhe chemical investigation of the muscle lesions IJ.S illustrated in the' accompanying tabl~ that the bulk of the quinine is absorbed whether injeci~ed as an alkaloid in alcoh()l or as the bihydrochloride in Raline., It was also found tha~ at the expiration of one hour from the time of the inQculation to the death of, the animal only 0'938 gramme of alkaloid was recovered out of 2'25 grammes injected.

It may be, an advantage while referring to the rate of qQinine absorption to cite the following experiment. " " '

0'1 g~amme of bihydrochloride of quinine it;l 0'25 cubic centimetre' saline was injected into .the thigh, muscles of both hind legs of a guineapig; ten minutes 'later a' similar~quantity was inoculated into the' .musCles oCthe le~t foreleg, and the animal was killed immediately. The left hind leg was amputated aa the hip-joint and handed to Captain l,!'errey entire. He obtained 0'061 gramme of ~lkaloid from the tis!jues, which amount§ to 0',075. gramme qf .the bihydrochloride., The tissues in' the injected areas showed spreading oodema and marked necrosis of muscle. Agglutination

. \ . of l'ed cells and hremolytic changes had occurred. N:o tissue reaction was' present. " ,

. The tissues examined immediately after the intramuscular injection were oodematous and the muscles showed evidence of necrosis.

Microsc;pic~l C~angesin the Affe~ted Tissu.es.' I

Lesions Nos. 1 and 2. The tissue changes in the affected muscles, which are' of eight and seven days standing, respectively~ were similar, although quinine alkaloid was injected_ in the first case and quinine bihydrochloride :in the second .. Microscopically, there was typical fibrous myositis with diffuse muscle degeneration; The abundance of nuclei in the IQuscles among the fragmented fib,res was very apparent, and' in some. installces

r

gave the well-known appearances of pseudo-giant cell formation: Large hremorrhages were observed, more especially 'in relation to "strands of necros(s. Mononuclear cells were nu,merous throughout the 'new-formed fibrous tissue, and foci of polynuclear phagocytes. The free jron reaction was demonstrated, and spider cells lying in the fibrous tissue were. filIe(l

. with these granules. \ Lesions Nos. 3 and 4 resulted from the injection of qUInine bihydro

chloride on successive days. The fibrous tissue formation was somewhat similar to that which has been referred to in the case of the: first two expe~iments. Large tracts of structu~eless walls filled witl;! tinged serum were abundant,. as also scattered hrem.orrhages and phagocytosis· of red cells by large mononuclear cells. Necrosis pf muscle and splitting up of muscle fibres were-more evident 'than in the 'first two experiments. .

Lesion No. 5., Rxtensive necrosjs of muscle and" vaquolation" had occurred. Some of the larger blood-vessels were tbrombos~d and complete necrOSIS of the muscular walls was evident, while. other vessels showed

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56 Effects, of Injections of 'Qu~riine into Man, and Animals

intense polynuclear inflammation. Strands of poly.nuclear cells were scattered all through the connectiv~ tissue stroma.

, Lesion No. 6. The most strik,ingfeature in this experiment W!tS a zone of necrosed muscle with fibrosis divided from a layer of vacuolated and distorted muscle cells, by a 'broad line of hremorrhage, while acute redema, extended for 'some distance between the fibres.' , '

, L(!sion No. 7. This lesion showed two distinct pathological changes:(1) Hremorrhagic area which contained tracts of free blood and con-'

gesti'on of blo04-vessels together with areas of hremolysed blood in which were present agglutinatea red ,cells. 'Intense, polynuclear inflammation

, had occurred in the ~essel walls and alLstages'of~uscle degeneration. (2) Necrotic' area. The contrast' with the vascular. area was most

marked. Extensive necrosis of, muscle with putlyingfibres' swollen. vacuolated, and distorted, and 1;lecrosis of the muscular walls of the large blood-vessels was found: Throughout the whole tissue there was poly'Qu-, clear inflammation. '

Lesion' !fo. 8. This was produced at the end'of one hour by one injection of ~'25 grammes' of bihydrochloride of, quini.ne.' Wide tracts of h,remorrhage occurred 'along the muscle bundles with acute redema, spreadiug in all directions.' , Muscle fibres were necrosed and in all stages " of degeneration: I1;1 one portiol). of 'tbe affected muscles wide' areas of hremorrhage 'had occurred with direct des(ruction of large blood-vessels.' In ~his area 'intens,e polynuClea~ in'fiammll,tioIi was present, while in an adjoining area leucocytic reaction was absent. Rings of polynuclear' cells we~e in, evidel)ce in the sheath of tbemuscle ,fibres, infiltrating the fibres, and dividing them up i'nto large granular ma,sses. Wide areas of lyse~ and partly lysed red cells were present. Phagocytoeis of ,red blood corpuscles by'large ,mononuclear cells was very evide'nt, also clumps of a.,gglutinated. erythrocytes.. '

Fixa tion of Quinine in the Tissues. ~

These experiments were undertak~n at the sugges~lOn of Captain J. F. Gaskell, R.A.M.C., so as to ascertain whether quinine when injected into the muscles becomes immediately fixed locally, as if- so, 'quinine" absorp-" tion" 'from'the tissues would be only an apparent effect. - ,

,Experiment 1. Cast- Mule. 1'0 gramme of alkaloid' quinine was injected as the bihydroclilorideinto the b~lly of a ieg muscle which had been .exP9sed for this purpose. The blood-vessels wer~ tied immediately by Captain Moir, A.V.C., and the whole muscle and tendons were removed

,without,delay. .The chemical analyses were made by Captain F'. S. Hele, ,. M.]);, R.A.M.C., and the results were as foHows:- ' ,

Watery ext,ract, 0'217 gramme. ' In muscle, 0'595 gramme., In cloth (used in the experil)1ent), 0'026 gramme.

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Lepnard- S.Dudgeon·- 5,7

Total 'quantity , of quinine alkaloid .ob~aiil~d from the muscle, 0'838 'gramm(;l. ,- _ /, '

, Experiment 2: Similar experiment to No. 1 except that the muscle remained in' the, body' for twenty minutes after .the blood-vessels were tied by Captain Moir, A.V.C., .' - ' , ..' I

Chemi~al an;:tlysis by Captain Rele,'R.A.M.C. ' ' , "-Watery extract, 0'307 gramme. In muscle, 0'460 gramme. In cloth, 0'029 gramme. , Total quantity, of quinine alkaloid extr~cted from muscle, 0'796 gramm~. T4e results of these experiments do not suggest that quinine is Jixed in

the tissues ·immediately· after inocul.ation~ to any appreciaple extent. Captain Hele considers that the amount "lost" in the above experiments w.as due. to technical difficulties.

, - '

The" Effects of Intl'~1nuscular Injections of Qui1'!'in~ in 'Animals -, rendered" Anamic. j'- ' ( .

I . -

,TJ:1ese experiments wer~ undertaken to ascertain whether iritra-muscular injections of quinirieproduced more severe tissue changes in animals in which. a severe hannolytic anremia had, been induced than iI). control animals .. The ahremia and /hremoglobinuria were induced by iQjecting rabbits with the serum of a 'cat which had been immunized with rabbit's_ cells for the purpose of these experiments. ' The immune serum was injected intravenously. Blood counts were made' at daily int~rvals and the weights of the ~animals were ca~efully recorded.' It was necessary -to have records' of these data because many patients who receive, intramuscular injections of quinine are anremic, and some are suffering from

I various grades ,'of bremolytic t6xremia. The' most exhaustive experiment will be referred to" in detaii. Intramuscular jnjections of oihydrochloride of quinine in saline were given in varying amounts from large 'to excessive doses with the 'object of exc'iting more severe tissue changes in the _anremic animals,than in the control. The quinine injections'were inside previous to and' during the period of severe anremia .. Ther,e was no leucocyt.osi,s. On the contrary, a definite redu·ctiorl. jn the total white cells 'occurred, followed by a ~ise to the total previous to the 'inoculation as the 'condition of the blood improved. " A full record of the three most important varieties of white cells is given, but the o~ly noteworthy feature is the absolute increase in larger hyaline cells, as met with in malarial fever. _ Th'e,animal ' showed the effects of each· injection; but no more so than Ilormal1abbits which· received similar inoculations. When the animal ,was Killed one month,from the ccmlmencement of the experiment, the sites of the quinine' inoculations were represented as patches of scar tissue which were most,' , obvious in the case' of the excessive dose of 0'9 gramme given thirty days' before the death of, the animal. The results :of th~.,microscopicalexamina- ,

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£8 Effects .. of Inj~ctions of' Quinine into Man and Animals '.'

tion of the scar ,tIssUe were ,similar in each instance. Fibro-myositisnecrosed muscular tissue-scattered round-celled inflammation, well shown

" asa perivascular effect-an,d small fo~i of polyntlCI~ar inflammation, w~re the conspicuous features of. the various lesions. To quote this experiment i,s sufficient for the_purpose intended, as it is definitely shbwn that quinine, when given by the intramus~mla'r route' m concentrated and massive doses'

'/

Differential count cif leucooytes-1st column = per cent, " 2nd column ~ Inumber per c.mm.

pates Weights Red cells ~~~. (c~i~;,r- ~~~~~. Nucleated I g'rm. per c. mm. cent index) per red cells, . Finely L"mpho' Large, _

c:mm. number granular J hya., per cent oxyphil cytes , lines

Doses of qninine bi·

hydrochloride in saline, total bulk injected on' each occa·

sion >= 1 c.c. of leuco,/ ___ ' ___________ -.:~ __ 1 _' 2 1 2 1 _2 ____ _

29.5.18 1,510 6,000,000 30.5.181,490 - -31.5;18 1,490 -

1.6.18 1,510 6,000,000 2,6.18' '1,515- " -

'3.6.18 '1,445 ~,300,000 4.6.18 1,400 1,500,000 5.6.18 1,400 1,500,000 6.6.18 1,390 2,000,000 7.6.18 1,300 2,056,250 8.6.18 1,330 2,170;060 9.6.18 1,335 3,280,000

10.6.18 ,1,365 3,290,000 11.6.18 1,320' 4,$.00,000 1~.6.1B ~,350 . 4,290,000 30.6.18 1,610 4,496,875

100 :0,'8

100 88 50 32 32 36 40 35 65 65 66 65 82

o·s

0'5 1'0 1'0 0'9 1'0 0'8 1'0 0'9 0'7 0'7 0'9

7,500 _

6,400

7,200 5,000 4,500

,5,200 5,400 5,000 4,~00 6,800 7,260 . 7,280 ' 7,220

'0

_0 o

6'0 7'0 2'0,' 1'0 4'0

16'5 10'0 2'5 2'0 2'0 o

21'9 '1,642

32'6 2,086. 13'0 - .~

'20'0 1,440' '27'0 1,350

, 34'0' 1,530 55:0 2,860 34'3 1,812

,60'0 3,000 30'0 1,470 32'0 2,176 42'0 p,024 29'01,988 1l1'0 - 1,532

76'0 '5, 'ZOO ' 0 o - r - Q'25 grm.

'0'45. " 66'0 ,85'3 79'3 ' 72'3 65:3 44'6 56'6 40'0

,69'0 67'5

,55'0 66'0 ' 58'0

4,224

5.709 3,615 2,938 2,319

. 3;056 2,000 3,381 4.590 3,960 4,756 4,176

0'6' 1'0 o

0'6 o o

. 4'3-o

1'0 0'5 2'0 5'0 9'0

38' 0'6 "

0', 30 o o

232 o

49 34

144 360 648

0'45', "

0'09 grm.

0·045grm.

0·i5 pm.

excites no greater reaction in the tissue of, animals rendered anremic than in th~ case of' the, 'normal, wbile no' general effect occurred even wben th~, inoculations were made on sucmissive days: '. Other experiments compJeted, on these lines ,led to· similar conclusions.' One rabbit, in-which a severe experinien'tal anreinia had been induced, received two massive intra,muscul!1r doses of . qu·inine. during tbe period of hlEmoglobinuria, b~t the effects were, similar to those obtained in the control animals, wbile a diminution in the totalleucocytes was recorded.

Human Muscle.

Muscle tissue fr9~ the region of a previous ql:jinineinocula.tion has been, examined'.from several' cases in the Command. The interval between the inoculation and' the e~alllination varied from sb short ~ period ' as~ on.e' hour

, up td three months. It h\1s been s:u~mested that tbe effects of quinine on .' the tis~ues is ·,not capable of gemonstration until twenty-four hours from the time of the i~ocula~lon. This VIew is errone9,us on experimental

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Leonard K Dudgeon 59

evjdence while it is equaily fallacious in tbe case of a human sub.iect~ A man; comatose from malarial feve'r, was admitted to hospital, 'ail 'intra- ' muscular injection of twenty grains of bihydrochloiide of quinine was given, but the patient died one hour later. At the autopsy a large area of black~green necrosis, about four by fo'Ur inches, ~urrounded by gelatinous redema was discovered at the site of inoculation. Ali cases which I have had the opportunity to examine have received concentrated quinine. Experimentally, quinine injections can be gi-ven and the autopsy performed immediately.-but the necrotic action is quite obvious; No detailed description of the microscopical changes WIll be given in this section except'such ,

- as refer ,to points of special importa1;lce. Certain cases of special interest will be briefly referred to so as to illustrate the most essential features as regards quinine ino~ulation. rrwelve g~ains of bi-hydrochloride of quinine were injected into the right buttock forty-eight hours before death. - At the autopsy a largE} area of complete necrosis of muscle was observed together with a wide traqt' of hffimorrhage due, as, was proved on. microscopic-al exa~ination, to complete destruction of the wall of a large 1trtery. The entire neqrosed muscular tissue, together with ,that tissue in immediate contact, was examined chemically, except for a small-portion reserved for microscopy, put no quinine was detected. Two intra.muscular injections of fifteen and~twenty grains respectively had -been made at an interval of twenty-four hours' and- deatli occurred about twenty hours later. ' 'The resulting lesion was similar in each case~large area of necrosis, a band of hffimorrhageand 'congestio'n, with a .wide tract of gelatinous redenia.

In the case ,of a Greek labourer who had received an Intramuscular injecti<;m of fifteen grains of bihydrochloride of quinine twenty-two hours before death, only 0'02 gramme of the alkaloid was obtained from a large area of necrosis at the seat of the inoculation. The !tbsorption here was rapid in spite of the fact that the patient was dying' from ,fulminating pneumo-coccal se'pticffiniia. _ : _ '

Certain cases of malarial fever with malarial parasites present in the 'circulating blood were complicated with 'blackwater fever, bllt the ,effects from intramuscular injections of bihydrochl9ride of q'uinine were similar to those observed in the uncomplicated cases, except,that the bffimorrhagic zone appeared darker in colour, almost black in sOlne instances (PI. IT,: fig. 6). ,"

One of the most important cases which illustrate the action of quinine! occurred in the 'case of a man who died from blackwater fever and malaria. Four days before death he received an intramuscular injec'tion' of 'twenty grains 6f bihydrochlorideof quinine. "The inoculation was made into the same butt.ock which had byen injected ~hree months-previously with a similar dose for malaria,'} fever. This man had complained of aching and

" cramping pains in lthe_ buttock at the site of the inoculation, especially if he sat for any length of time on a hard seat or had prolonge~ exercise. 'At the autopsy intense'necrosis had occurred a't the site of the recent injectio~




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60 Effects of Iniections of Quinine into MCln and Anim~ls ,

which merged into the old lesion, which showed dense fibrous tissue at the ,centre of the focus, and a definitel:iroad,band of fibrous myositis at the periphery. Acute polynuclear inflammation from the recent injection had' extended to this layer 9f, fibrous myositis. The pain referred to could be

,explained by the patch of dense fi brous tissue in the centre of an imp'ortant muscle surround ea by a, zone of fibrous myositis, but further,owing to a fibro-neuritis which eXIsted in this area. Some' of the nerves of th~ muscle

. were surrounded by dense fibrous tiss~e, and similar foreign tissue 'had, 'replaced'many of the nerve fibres. Siinilar examples were met with in, cases 'of much shorter. duration, and also 'experimentally, a ,fibro-myositis, and fibro-neuritis. '" ' .

A patient was admitt~d to· hospital with' malignant m~laria. He received an intramuscular injection of 1'33 grammes oJ bihydrochloride of quinine but died two hours later. The whole of the necrotic tissue, which was three inches square l surroundeq by oodema, .was remov.ed for chemical inve~tigation, except for a small portion reserved for micr9scopy, There was ,\extensive riecrosis of muscle, necrosis of the walls of blQod-vessels, marked evidence of hremolysis, 'but no acute inflammation was present. '

AIthOl;tgh the patient was inoculated when ih extremis, only 0'344' gramme of alkaloidal quiniI).e was extracted from the tis,sues.' ,

The fact 'that 'necrosis of the ,tissues' always accompanies the int},a-, 'muscular pr subcutaneous injections of ,~uinine is not ,realized' sufficiently

, by medical officers, even those who have employed these methods on a large scale. ,No better illustration of, the correctness 'of this statement can be furnished than by quoti'ng the following instance. 'Owing to certain bad results which had occurred from intramuscular injectiOlis of 'quinine, an Army order was issued 'to the effect that. all divisi'onal officers must report in detail to the D.¥.S. any ill effects subsequent to intramuscular injections of quinine.. One divisional officer after fifteen,months' experience ofthis method of treatment of malaria furnished ,a report to the D.M.S. to the

, effect that a man had died from malaria and at the ,post-mortem examination a wide area of necrosis of 'muscle was found at the sIte of injection. He concluded his evidence with the statement that all medical officers in ' his unit had been warned of this' unfortunate incide~t and that every effort ,

'would be mii:de to prevent it 'recurrence of this disaster! I have discussed the question of quinine necrosis' with inIiluinerable medical officers wh9 ' , have had wide experience of intramuscular i'njections of quinine and it is ' by no means y.ncomtp.ori to learn- from them, that they were unaware that such effects occurred in the tissues apart from negligence. It is this lack of knowledge of the methods of quinine administration which s'erves to explain the cause of many of the disasters wh{cl:! have occurred. It is, therefore, necessary to emphasize that quinine injections should not be given in the vicinity of large nerve trunks, or main arteries, tha;t the injections should not be repeated in the same area of muscular tissue, and that'"

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'Leonard S. -Dudgeon 61 " . .

this method of quinine admlnistratio_n'. should- o~ly be' employed when circumstances demand it.1 '

The chief complications of. intramuscular injections of q.uinine in the human subject'during 1916-17 and 1918 of which 1 have records 'were, as _ follows :(1) FJ'etanus, (2) Gangrene, (3) Abscess formation, (4) Pyremia, (5) N~rve palsies, (6) Hremorrhage from large arteries,. (7) Sciatica, (8) Chronic muscular pain, (9) Pain and deficient movements in affected

" muscles, (10) rrh~omo6sis in varicose yeins;

The R~sults of the Estimation of Quinine Alkaleid' ili Huma~ Muscle " stioseql~ent to Quinine -Injecti~ns.

N~.' 1, -broncho-pne~monia., Intramuscular injections of twenty-one grains of hihydrochloride 9f quinIne into left buttock. Two days J~ter twenty-~iigrains were injected on the opposite side. Death on the following day. Amount6f quinine alkaloid recovered from first injection, 0'227 gramme~ 'and from the second injection, 0'345 gramme. ,

, No. 2, malignant malaria. Intramuscular injection of fifteen grains of; bihyd~ochloride' of quinine. Death foqr days later.· Amount of qiIinine/ -, alkaloid recovered, 0'002 gramme. Thi~ patient had received ten intran;niscul!ir .injections in fourt~en days amounting to 115 grains, and' six intravenous infections which totalled fifty-five grains. _ , ,

No. 3, malignant malaria. Iotramuscu,la.r injection of ten grains of hi::-' -hydrochloride of quinine.. DE,lath three days later. 1\mo~rit of quinine / alkaloid recovered from muscle,'-0'0115 grl,tmme.' . _ -, - '_ '

, No. 4, lobar pneumonia. ~Intramuscular,jrijectiolF-_of fifteen grains,'of _ ,hihydrochloride, of quinine.' 'Death twenty-four houts .later.. Amount of quinine alkaloid recovered from mus,de, 0'048 g~amme. ' , " ,

,No. 5, malignant -malaria. Intramuscular injecti<?n of 'eighteen grains of sulphate of quinine. Ten days later large quantity of pus evacuated. From fifty cubic ce'ntimetresof th,e pu_s, 0'0012 gramme of quinine 'alkaloid , was obtained. " ' , " '- " _ _ ,', -I -, " ,

'No: 6, malignant malaria. ' Intran;mscular injection often grains of hihydrochloride of, quinine: Death twenty-six hours later~, Amount of quinine alkaloid recovered from muscle, 0'041 gramme. -, '

No. t, rdalignant malaria. Intra-muscular injection of twenty grains· of bihydrochloride of. quinine. Death two hours later. Amount of quinine alkaloid recovered ,from muscle, 0'344 gramme.

No. 8, lobar pneumonia, pneumococcal meningitis. 'Intramuscular injection of fifteeii grain~ of bihydrochlolide o~ quinine~ 'Death twenty

. - hours later. AmouIlt of quinine al~aloid recover~d. ~rom m1!-scles, 0'0215 _gramme. _ , '

In ,every instance the quinine was i~je~ted into the musCles in concen-

1 The qral' method of administration7 of quinine is' greatly neglected by some medical

offi'cers who are pla;ced in charge of cases, of malarial fever. :

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62 Effects, of Infections oj Qu'inine into ~an and Animals

trated s~lution~the total quantity ,'of fluid ini~cted, did not amouilt to mor0 than -8. few "Cubic centimetres. . The results show, however,. that theabsorption w~s ,rapid, as only·traces'of quinine_were-recovered from the

. _ entire lesions, apart from al small focus which .was reserved for· microsc?py, and from the-surrounding -n;niscui,ar tissu~. In ,N,o. '7,. twenty ,grains of the bihydrochlorid!:\ of quinine were injected into th~ muscles, an<'1 the patient: died two "hours later, but only. 0'3 gramme was recovered: In each instance the area'of necrosis Was considera-ble, and the tissues 'showed very marked changes onmicroscopicatl examinatjon. ','.

An: Examinatio~~ of Muscle Tissue ,nec~osed from Quinil~e biiections for the Presence of Malwrial Parasites.

Certain sp~ciD;lens of muscular tissue which hadbee~ exami'ned for the presence of malarial parasites subsequent to' the injections of quinine

,showed most unexpected results. The . blo~d cells in th~ necrotic vessels · were completelybremolysed, yet ,malarial parasites were present in' some , inl';.tances'in relatively, large numbers and the, bodies of the, parasites were well stained. The plJ.rasites would 'be diminished in numbers as-compared ~ith, tl1e control ~uscle from another are~.6f th~ body or from some viscer:ti le~ions, but' 'p~rfectly staining parasites were found lying 'in a necrosed vessel in which there were no riqrmal rer cells., It is strong evid~ncethat destruction, of red cells and tissues generally is much more readily excited"

· 'by quinilie solutJons than destruction of malarial parasites :,-:-' " , < ,

'. ',- ,One case will be referred to in deta:il_toempbasize _~his fact: -'-.' '.' ; · . Malignant Mala1'ia.c-Blood film showed a:;ery heavy infection of red -

, cells, with ,the ring' form of parasites:Sporulatingparasi~es were-also numerous. Time 10.30 a.m. .... .

Twenty grains .6f bihydrochloride of qmmne ~ere jnjected- intrarllusculariy at 11 a.m·., ·and twenty grains were injected intravenously. c

Death at 3.45 p.m. _on same day., -Wide areas of necrosis of muscle a~ the s(lat of the quinine injec~ion

existed, ,There was great destruction ofthe walls of blood vessels and the blood cells we're complete'ly lysed, while the l'nuscle tissue itself showed!' considerable .necrosis~ Large dot parasites with well-stained hodies and abundance of pi"gmel,lt were relatively numerous lying among the red cell debris. Parasites however, were far more numerous in the internal organs and in other muscular areas.

In,tramuscular Inje~tioll into Frogs. '

Several frogs received intramuscular injections of quinine bihydrochloride in 'saline in suitable' doses for body weight, and were killed ,three, hours~ later., Th,e muscles at the sites of' the quinine injections. were opaque.· There. was marked cedema, complete necrosis of muscle jibres,




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Leonard S. Dudgeon. 63

-6ther ,fibres vacuolatE)d, or represented as' granular ma~ses andbremolysis of red cells in the affected areas. ," .

Four frogs with an average' weight o'f sixty'grammes were injected (1. M.) with quiuine and the resulting lesions were as follows :~

(1) F,rog injected with 0'0004 gramm~ of quinine bihydrochloride · (0'1 cupic centimetre) and killed twenty-two hours later.. Muscles opaque and showed extensive necrosis .

. (2) Frog, injected with 0'0004, gramme of alkaloid in 0'02 cubic .centi- . metre of ether and killed twenty-two hours, later; Extensive muscular necrosis.? Slight infiammatoryreaction.

, (3) Quinine, injection as in 'case of frog. I.. Aniniai killed three days· later. Extensive ruuscu)~r necrosis-abund.ant hromorrhages-and wide-

· spread'inflammation were very'evident. _ (4) Frog injected with 0'0004 gramme of the alkaloid. suspended in

salin'e'and killed three days later .. Results similar to Experiment 3. These results were similar to those obtained in the case of the warm--

'/ '-

I blooded animals.

PONCLUSlONS.

. . (1) Conce~trated preparations of quinine pr~duce more intense' ne~rosis than ,dilute, but dilute preparations such as are of practical utility excite oodeni~ and .necrosis at the . site of inoculation. The differences betweeri. these t~o methods of qqinine inoculation is oot of sufficient value to justify _

. active opposition to the method com~oilly employed. ',,' .' , ' Inoculation of quinipe in solutions. so dilute as to avoid oodem'a. and tissue ne9rosis is not of practic'al'utility 'in, the hp-man subject .

. (2) A 'concentrated so)utipn of quinine is absorbed. rapidlY,from the tissues as shown by 'chemical analy'sis, ~ even \ in patients who are in extrenLis. It is not apparently. stored 'assucb in liver,kidneys, or heart

. . ,',.

muscle: . (3) It is essential to r~alize that tissue necrosis~spreading oodema.and

· local blood aestruction-are produced by the solvents employed for quinine administratioI;l and the effects are only slightly infe~ior to .those exci~ed by quinine salts. and the alkaloid.. . " .. ' . ' , (4) No advantage was obtained by the addition of olive oil or fat or by . injecting the alkaloid dissolve_d in alcohol,or ether, whether in coricentrated or in a dilute solution., ' . .

(5) Tls8uenecrosis occurs immediately a"nd persists for a considerable period. In some .instances the fibro-myositis which ~esults is associated with a fibro-n~uritis which ca,uses various symptoms definitely related to the pathological processes: .

(6) Necrosis of blood-vessels in the area of inoculation is a common' result. This 'leads to small hromorrhages in,to the tissues, and has caused

- . severe .. hromorrhages. in the human subject, and experimentally, from

. ,




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64 Effects of Injections of Quinine into Man and Animals

~upture of a large vessel. ' 'Th~ destruction 6f the vessel wall is_ associated-with an accompanying thrombosis. , . '

(7) An extensive necrosis proaci'ced by an intramu,scular injection of 'quinine in the neighbourhood of an important nerve trunk, may result in nerve palsy., Experimentally, complete degeneration of the great sciatic and other nerves ,has, been produced apart from any direct injurY,to the,

'nerve at the time of, the inoculation. In the ~umari subject, this disastrous . result may be due to spreading oodema'aIid extensive tissue necrosis.

(8) Experi~eritaIIy,'no leucocytosis has ever 'occurred from 'quinine injections; on the other hand 'a leucopenia may develop, while an increase

'of large hyaline cells' has been recorded on several' occasions. ' , , (9) No essential differences in the degree of tissue necrosis from intra

muscular injElCtioilS .of quinine in 'malarial fever or malarial fever associated with bl~ckwater fever were observed. . .

(10) Repeated intramuscula~ injections 6£ quinine sliould not be given into the slJ.me area of muscle, or tissue directly adjacent, as otherwise permanent injury of muscle 1 or nerves 'may· occur.

A~KNO~LEDGMENTS.

To Captain p. E:. C. 'Ferrey, O.:B.E.,R.A.M.C. (T.F.), Ana,lytical, Chemist to the Central Laboratory of the B.S.F:, I am' gteatly~indebted

. ,for' the whole of the chemical analysis of tlJe tis~ues. for the det~r~ination/ <I I

of the presence' and amount' of, quinine: . This investigation, which has been a labo,rious process, IS of the utmost value.in associatIon with the histological findings. ," I .

To Captain Moir, A.V.C., Bacteriolggistt6the A.v.c., B.B.A., I am indebted for considerable 'pelp in the investigation of the cast mules and horses.which 'wereinoculate'd with quinine. . " ' " ' .

,-Captain A. Wilkin, RA.M:C.,' rendered me 'val~a~le, assistance'dudng the process of the work.' " . '

The tis.sue from hutnan sources has been procured for me by various bacteriologists in the command, to whom my thanks are due., '

To Cp!. P. Pal)ichelli, M.S.l\{.,R.A.M.C. -eT.F.), I am indebted for the illustrations wpich s~rve to expla,in what the text is incapable of defining:

J The gluteal regions, obtained from a man who had daily intramuscular injections of quinine, nine in all, were shown at the British Medical Association meeting in' London, 1919. As a result of the injec~ions wide tracts of muscle were necrosed and only fragments of healthy tissue remained.




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JOURNAL O~' THE ROYAL ARUY ,mDICA L CORPS. JAl\UA UY , 192 1.

PLATE 1.

FIG, 1. FIG. 2.

FIG. 3. FIG . 4 .

'1'0 illustra.tc "On the Effects of Injoctions of Quinine into the Tissues of :!Iran a.nd An imals," by L"~ONARJ) S. DUUGEON, C.1I'I G., C.RE., F,R.C.P.Lond.




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JOURN.H ... OF THE ROYAL AR:\lY l\lEDICAL CORPS. JAN UARY, lDlJl.

FLAT!!: II.

FIG. 5.

FICi. 6.




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_Leonard S.Dudgeon 65

DF1SCRI.PTION OF PLATES I.AND n. FIG. I.-Quinine rabbit, 53-(4). Section of muscle from.a rabbit which had received an

. inhamuscular inje,ction of 0'04 gramme of alkaloid quinine in one cUbic centimetre of alcohOl four days before death.' - .

FIG. 2.-Agglutination of red blood corpuscles in a large vessel in the tissue of-a horse which had been injected with 1'1 grammes of bihydrochloride of quinine thirty hours previously.

FIG. 3.-Complete necrosis of large artery as. a result of an- intramuscular injec.tion of quinine alkaloid in' brandy. - .

FIG. 4.--Section of' ~reat sciatic nerve in a rabbit which had received an intr~muscular injection of 1 grain of quinine alkaloid.in alcohol eleven d~ys previously ...

, FIG.' 5.-Muscle from a mule wbich had received 2'25 grammes of bihydrochloride of quinine in five cubic centimetres of saline five days before death. Natural &ize. A, CEdema, necrosis,

. patches of bremorrhage. B. Hremorrhagic line showing.intense inflammation. C. CEdema.tous muscle.

FIG. 6.-Portion of huma.n muscle from a case of blackwater fever and malaria. Patient had received an intramuscular injectionof 20 grains of bihydrochloride of quinine forty-eight hours before death. Natural siz!l. -

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d~dgeon,. - bmj military health · i -teonaris.dudge01i" 47 total acidity is the quinine...

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