Quinine Idiosyncrasy and Cinchonine

Abstract

THE case recorded below is of interest not only on account of the long duration of the intussusception, but also because of the condition found at the first (palliative) operttion, and the discovery at the second operation of a tumour which proved on examination to be a carcinoma.A man, aged 68, had for a year been greatly troubled by conistipation. Three days prior to admission to hospital he had taken a large dose of purgative, and the bowe!s had acted once; there had been no action since, but Dain in the rectum and copious discharge of blood-stained mucus. Vomiting had not occurred. The abdomen was considerably distended, and peristalsis was obvious. Onexmining the rectum the anal sphincters were found to be very lax, and a tense smooth mass was discovered reaching to within half an inob of the external orifice.The patient on overhearingaremark that " there was something to be felt" volunteered the fact that he himself had made that d iscovery over a year previously, and had noticed something inside tle rectum constantly, this discovery coinciding in point of time with the onset of his constipation.Immediate operation was advised; this the patient refused, but changed his mind on the following day, when the symptoms of intestinal obstruction had become more distressing.'The patient was anaesthetized and placed in the lithotomy position, to facilitate a more tthorough -examination. On passing a speculum it was found that the rectal mass was trunk-shaped, aud digital examination failed to reach any attachment to the rectal wall. The ouly possible diagnosis seemed to be chronic intussuseeption causing obstruction, through engorgement brought about by purgation.The patient was placed flat on the operating table and the abdomen opened by retracting the left lower rectus outwards. An intussusception of the sigmoid into the rectum was found, the ensheathing joining the entering layer, at a point about one inch above the recto-sigmoid junction. All the iutestines were greatly distended, the large intestine, as far back as the caecum, being a solid mas of faecal material; this seemed to bear out the patient's statement of the duration of the trouble. All attempts to reduce the intussusception proved of no avail, even thtough one band was placed in the rectum to manipulate its apex. In these circumstances some palliative measure had to be decided on, the choice lying between caecostomy and colostomy. Eventually colostomy was performed through the outer left rectus with the idea that it would give more efficient drainage to the overloaded intestine, and in the event of the patient refusing furtheroperative measures allow him to get about. The colostomy was opened at the end of twenty-four hours by simply cutting across one of the longitudinal bands. The patient got on well, but the discharge of blood-stained mucus from the rectum continued. IDIOsYNCRASY to quinine is much less common than one would gather from the textbooks. One of us has been in the Malay States for twenty years, and the otlier for iore than thirty-fiv...