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Atropine Solution Given by Mistake on Prescription for Pilocarpine
NOTES, CASES, INSTRUMENTS OPTOCHIN AMBLYOPIA B. W. PASTERNACKI, DETROIT
M.D.
On April 7, 1932, I was called to see a patient, a woman 32 years of age, who complained of partial blindness. Two weeks previously she had developed pneumonia and had been given twelve 2-grain tablets of optochin the day of onset. The next day, March 25, the same dosage of optochin was repeated. On the following day head-noises and poor hearing developed and within 60 hours after the first dose of optochin the pa tient was completely blind. At examination the pupils were widely dilated, reacting feebly to strong light. The tension measured 32 mm. in each eye (McLean). The retinae were of a yellow straw-like color, the veins were hardly visible, the arteries were pale and the discs white. The condition no doubt was due to the optochin ac companied by retinitis septica and bi lateral retrobulbar neuritis. Twenty-one days after the onset of the illness she was delivered of a pre mature eight month baby and eight days later an operation for empyema was performed. Three pints of purulent fluid were drained from the pleural cav ity after rib-resection. A week later a large rectal abscess was opened. At this time the laboratory findings were as follows : sputum positive for pneumococcus; urine, albumen two plus, no sugar ; white blood cells 21,800 ; lymphocytes 2 percent, large mononuclear cells 8 percent, neutrophilic cells 90 percent. The Wassermann was nega tive and blood pressure normal. During the first week following April 7, eserine was used in each eye. Antipneumococcus serum was administered daily. From June 1 strychnine sulphate gr. 1/60 was injected in the temporal region changing sides on alternate days. These injections were reduced to two a week after June 20. On August 26, she visited my office and could recognize and describe white metal furniture. Treatments of faradic
current from three dry cells were ap plied for three minutes to the forehead and around the eyes, especially to the supraorbital nerve. Also potassium iodide was given internally. She left the city on September 25, at which time her vision was 5/35 in the right eye and 5/20 in the left eye. The near vision was Jaeger 10 at 34 cm. The visual fields were contracted and there were large paracentral scotomata. The retinal vessels appeared wider than at first, and the discs less white. On March 24, 1933, one year after the illness, the vision was 5/15 in each eye. 5765 Chene Street. ATROPINE SOLUTION GIVEN BY MISTAKE ON PRESCRIPTION FOR PILOCARPINE THOMAS D. ALLEN, CHICAGO
M.D.
Mrs. I. A., 44 years old, was first seen February 6, 1933, having an ad vanced case of noncongestive glaucoma in each eye. The pupils were 3.5 and 5 mm. in diameter, the anterior chambers slightly shallow, the corneae normal, and there was well-defined glaucomatous cupping 4 D. deep, with atrophy, pulsation of retinal arteries, and distinct glaucomatous halo. Tension was O.D. 60, O.S. 62 mm., Schiötz—new scale. There were only a small central field and a temporal island of vision in each eye. Eserine, pilocarpine and suprarenin bitartrate were used in succession and in various combinations for two weeks before the tension fell to 30 or below. After another two weeks because the tension rose to 48 mm. in the right eye, an iridencleisis was done, success fully. The patient was sent home with a small left pupil and a prescription for 1-percent pilocarpine for that eye. Three days later the daughter telephoned that the patient was very dizzy and nau seated and she was brought back to the hospital. Here her left pupil was found widely dilated, tension + 3 , vision hand 102
NOTES, CASES AND I N S T R U M E N T S
movements. She was quite nervous, her mouth was dry, and she was having sev eral loose bowel movements per day. Vigorous treatment with eserine and pilocarpine, heat, and rest in bed was instituted with the result that in a few days tension was so reduced that an iridencleisis was done on this eye also with, fortunately, an excellent result. The bottle of medicine obtained on the prescription was examined physiologi cally and found to contain a pupil di lator—two other patients being used. There was only a minute portion of a drop in the bottle so two drops of physiologic salt solution were added, and these were used in one eye of each of two patients. Within a half hour the pupils of each were widely dilated and remained so for several days. The prescription was traced to the drugstore, found to be correctly writ
1103
ten and a sample of pilocarpine obtained from the bottle of stock solution which the druggist claimed to be the bottle he used in filling the prescription; also a fresh 1-percent pilocarpine solution was made up by the druggist for verification physiologically. Both of these solutions caused prompt miosis, the one from the old solution in the other eye of one of the patients whose one pupil had been dilated by the previous solution. W e are, therefore, forced to the con viction that a mistake was made by the druggist in filling the prescription. This druggist is a most careful man. H e has successfully filled the same post in a large prescription store for many years, and this is the only time he has been known to make a mistake. Moral : It is human to err, but it is sometimes costly. 122 South Michigan Avenue.
M.D.
On April 7, 1932, I was called to see a patient, a woman 32 years of age, who complained of partial blindness. Two weeks previously she had developed pneumonia and had been given twelve 2-grain tablets of optochin the day of onset. The next day, March 25, the same dosage of optochin was repeated. On the following day head-noises and poor hearing developed and within 60 hours after the first dose of optochin the pa tient was completely blind. At examination the pupils were widely dilated, reacting feebly to strong light. The tension measured 32 mm. in each eye (McLean). The retinae were of a yellow straw-like color, the veins were hardly visible, the arteries were pale and the discs white. The condition no doubt was due to the optochin ac companied by retinitis septica and bi lateral retrobulbar neuritis. Twenty-one days after the onset of the illness she was delivered of a pre mature eight month baby and eight days later an operation for empyema was performed. Three pints of purulent fluid were drained from the pleural cav ity after rib-resection. A week later a large rectal abscess was opened. At this time the laboratory findings were as follows : sputum positive for pneumococcus; urine, albumen two plus, no sugar ; white blood cells 21,800 ; lymphocytes 2 percent, large mononuclear cells 8 percent, neutrophilic cells 90 percent. The Wassermann was nega tive and blood pressure normal. During the first week following April 7, eserine was used in each eye. Antipneumococcus serum was administered daily. From June 1 strychnine sulphate gr. 1/60 was injected in the temporal region changing sides on alternate days. These injections were reduced to two a week after June 20. On August 26, she visited my office and could recognize and describe white metal furniture. Treatments of faradic
current from three dry cells were ap plied for three minutes to the forehead and around the eyes, especially to the supraorbital nerve. Also potassium iodide was given internally. She left the city on September 25, at which time her vision was 5/35 in the right eye and 5/20 in the left eye. The near vision was Jaeger 10 at 34 cm. The visual fields were contracted and there were large paracentral scotomata. The retinal vessels appeared wider than at first, and the discs less white. On March 24, 1933, one year after the illness, the vision was 5/15 in each eye. 5765 Chene Street. ATROPINE SOLUTION GIVEN BY MISTAKE ON PRESCRIPTION FOR PILOCARPINE THOMAS D. ALLEN, CHICAGO
M.D.
Mrs. I. A., 44 years old, was first seen February 6, 1933, having an ad vanced case of noncongestive glaucoma in each eye. The pupils were 3.5 and 5 mm. in diameter, the anterior chambers slightly shallow, the corneae normal, and there was well-defined glaucomatous cupping 4 D. deep, with atrophy, pulsation of retinal arteries, and distinct glaucomatous halo. Tension was O.D. 60, O.S. 62 mm., Schiötz—new scale. There were only a small central field and a temporal island of vision in each eye. Eserine, pilocarpine and suprarenin bitartrate were used in succession and in various combinations for two weeks before the tension fell to 30 or below. After another two weeks because the tension rose to 48 mm. in the right eye, an iridencleisis was done, success fully. The patient was sent home with a small left pupil and a prescription for 1-percent pilocarpine for that eye. Three days later the daughter telephoned that the patient was very dizzy and nau seated and she was brought back to the hospital. Here her left pupil was found widely dilated, tension + 3 , vision hand 102
NOTES, CASES AND I N S T R U M E N T S
movements. She was quite nervous, her mouth was dry, and she was having sev eral loose bowel movements per day. Vigorous treatment with eserine and pilocarpine, heat, and rest in bed was instituted with the result that in a few days tension was so reduced that an iridencleisis was done on this eye also with, fortunately, an excellent result. The bottle of medicine obtained on the prescription was examined physiologi cally and found to contain a pupil di lator—two other patients being used. There was only a minute portion of a drop in the bottle so two drops of physiologic salt solution were added, and these were used in one eye of each of two patients. Within a half hour the pupils of each were widely dilated and remained so for several days. The prescription was traced to the drugstore, found to be correctly writ
1103
ten and a sample of pilocarpine obtained from the bottle of stock solution which the druggist claimed to be the bottle he used in filling the prescription; also a fresh 1-percent pilocarpine solution was made up by the druggist for verification physiologically. Both of these solutions caused prompt miosis, the one from the old solution in the other eye of one of the patients whose one pupil had been dilated by the previous solution. W e are, therefore, forced to the con viction that a mistake was made by the druggist in filling the prescription. This druggist is a most careful man. H e has successfully filled the same post in a large prescription store for many years, and this is the only time he has been known to make a mistake. Moral : It is human to err, but it is sometimes costly. 122 South Michigan Avenue.