ACUTE BARBITAL (VERONAL) POISONING


On admission, the usual conditions, giving rise to coma had to be considered; namely, cerebral hemorrhage, alcohol and drug poisoning, epidemic encephalitis, carbon monoxide poisoning, brain tumors, diabetic coma, cerebral syphilis, uremia and unrecognized brain injury.


“REPORT OF CASE WITH FATAL OUTCOME.

“Acute poisoning from barbital is apparently becoming more common in this country. This is probably due to the fact that the drug is so easily obtained without a physicians prescription. It is also due to the increase in the number of persons who seek hypnotic drugs in order to procure sleep; for it seems that the symptom of insomnia is becoming more common among all classes of our population.

“That serious symptoms may arise from overdosage or prolonged use of barbital does not seem to be generally recognized even by the profession, but that this is so is attested by the cases reported in recent medical literature by Little, Hassin and Wein, Taub and Macleod. Boenhein states that, in a series of 286 cases of acute poisoning observed in Sicks service at Stuttgart in thirteen years, barbital was the drug taken in 5.7 per cent. of the cases, and five of the patients died. All of had taken barbital in excess of 10gm.

Acute barbital poisoning, in the absence of a history, may be easily mistaken for a number of other disease giving rise to comatose states. This is especially true of epidemic (lethargic) encephalitis and certain cases of meningovascular syphilis. The case here reported illustrates most of the salient features in the symptomatology.

“REPORT OF CASE.

“History- R.H.M., a man, aged 39, married, white, an American, was admitted to the Anaheima Hospital, October 16, 1921, in a state of profound coma. Friends who accompanied the patient stated that he had been found in a shack in the oil fields in this condition, and it was thought that possibly he had been overcome by carbon monoxide gas from a leaky gas stove used to heat the shack. Search of the patients effects revealed a box containing twenty 5-grain (0.3 gm.) tablets of barbital, and a note to his wife expressing his intention to committing suicide. The patients wife said he had always been in good health except for an attack of influenza in February, 1921, following which he had been subject to many cold and occasional attacks of mental depression. During the summer of 1921, his work had been very arduous, and he had undergone a good deal of mental strain.

“Four weeks prior to admission, he consulted a physician on account of insomnia, and the latter prescribed barbital, five grains, to be taken at bedtime. He took one tablet each night for a week. At the end of the week, he had the prescription refilled, and he took two tablets each night for another week. Two weeks before admission he went on a vacation, but he could not enjoy it because of insomnia, so he returned home after three days.

October, II, he consulted another physician, who prescribed barbital. He also bought box of barbital himself in Pasadena. his wife stated that he was at home every day for the six days preceding admission, and he appeared to be in normal health except that he looked worn out and was quite depressed because of insomnia. She said that he had taken six or seven of the tablets each day for the five days preceding his admission to the hospital. October 16, he resumed his work. That afternoon he was found unconscious and was brought to the hospital.

“Physical Examination.- The patient was well developed. He was in profound coma. The temperature was 101 F. The face was cyanosed and the breathing stertorous, with the mouth open and the maxilla drawn down almost on the chest. The tendon reflexes were very lively. Muscular rigidity was marked. The pupils were round and equal, and reacted to light and to painful stimuli, such as pinching the neck. Hippus was present. No nystagmus was noted. The fundus oculi was normal. The Babinski sign and variants were negative on both sides, as was knee and ankle clonus. The cremasteric reflexes were present. The epigastric and abdominal reflexes were not obtained. At intervals, the patient moaned and moved the limbs. Shouting in his ears elicited no response. Painful stimuli of any degree failed to rouse him. Strong ammonia applied to the nostrils produced no defense movements or wrinkling of the face.

“The radial pulse rate was 100. Both radial pulses were full, equal and regular. The blood pressure was: systolic, 145; diastolic, 95. The heart showed no abnormalities. At intervals, there was profuse perspiration. Respirations were 30 a minute, changing at times to the Cheyne-Stokes type. There was marked dyspnoea and diaphragmatic breathing. Tracheal rales were heard over the lungs. The mouth was open, the tongue swollen and congested. The patient was able to swallow fluids. Mucus tended to collect in the throat, and increased the degree of dyspnoea and cyanosis already present. The abdomen was negative. The urine and feces were passed involuntarily.

“Laboratory Data.- Examination of the blood revealed; erythrocytes, 4,450,000; hemoglobin (Dare), 93; smear, normal; leukocytes, 7,600; carbon monoxide hemoglobin, absent; differential leukocyte count; polymorphonuclears, 68 per cent.; small mononuclears, 25; large mononuclears, 2; eosinophils, I; transitionals, 4; blood Wassermann test, negative; chemical analysis of blood; creatinin, 2.75 mg.; uric acid, 3.1 mg.; urea nitrogen, 19mg.; nonprotein nitrogen, 39 mg.; chlorides, 0.7 mg.; blood sugar, 0.12 per cent.

“Cerebrospinal fluid examination revealed; Wassermann Nonne, Noguchi and Rose-Jone tests, negative; cell count, 8; colloidal gold curve, negative. The urine and cerebrospinal fluid contained no hematoporphyrin. Urine analysis, October 16, 17, 18 and 19, were all completely negative.

“Clinical Notes.- October 17, the patients general condition was much the same. Increasing difficulty in respiration was relieved by oxygen inhalations. The patient moved his head more than on the day of admission. A lumbar puncture did not cause any movement of the patient, nor did it rouse him in the least degree from coma. Feces and urine were passed involuntarily. The temperature range in twenty-four hours was from 99 to 103.8 F.

October 18, the temperature rose to 104.5 F. at 8 p.m., and remained high all day. The muscles were now flaccid. The limbs took the position determined by gravity. The tendon reflexes were now diminished. Cyanosis was marked at times, and there was much tracheal rattling. Coarse mucous rale were heard through out both lungs. Dyspnoea was increasing. The twenty-four hour temperature range was from 99.5 to 104.5 F.

“October 19, the patient was in very poor condition, sweating profusely, with extreme dyspnoea and cyanosis. Oxygen inhalation failed to give relief. At noon, breathing was definitely of the Cheyne-Stokes type, and the lungs were full of mucous rales. The patient died at 3.10 p.m.

“Treatment.- Frequent inhalations of aromatic spirits of ammonia were ordered; strychnin sulphate one-thirtieth grain, hypodermically, every four hours and camphor in oil hypodermically, as required. Hot coffee enemas, 6 ounces (178 c.c.) every six hours, were prescribed. Sodium bicarbonate solution, 3 per cent., by proctocylism, was given every other hour.

Fluids were given by mouth. The colon was washed out with high soda enemas, morning and evening. Oxygen inhalation was prescribed as required, for dyspnoea and cyanosis, and caffeine sodiobenzoate, 7 grains (0.46gm.) hypodermically, also as required. Tepid sponge baths were given frequently to reduce temperature, and on account of the sweating.

“COMMENT.

“It was estimated that the patient had taken more than 300 grains (20 gm.) of barbital in a period of less than four weeks, 175 grains (11.6 gm.) of which was taken four or five days preceding admission. On admission, the usual conditions, giving rise to coma had to be considered; namely, cerebral hemorrhage, alcohol and drug poisoning, epidemic encephalitis, carbon monoxide poisoning, brain tumors, diabetic coma, cerebral syphilis, uremia and unrecognized brain injury.

“Blood and serologic tests ruled out syphilis and carbon monoxide poisoning.

“Urine analysis and blood sugar examination excluded diabetes. The previous history of good health and freedom from bad habits practically excluded brain tumor, alcoholism and kidney disease.

“History and physical examination eliminated trauma.

“Carbon monoxide poisoning seemed a plausible explanation for the symptoms at the time of admission, but a more detailed history and the negative blood examination went against this opinion.

“Epidemic encephalitis was simulated very closely, but the definite history of ingestion of large amounts of barbital, together with the extreme degree of coma, which is not the rule is epidemic encephalitis, led to a definite diagnosis of barbital poisoning.

“This case, or so far as I can ascertain, is the only one reported in recent medical literature which had a fatal outcome.

EFFECTS OF PROHIBITION IN NEW YORK.-

“Increase in alcoholism.- Dr.S.Dana Hubbard, director of public health education of the department to health, has recently made public figures showing that, since the last year before the prohibition law went into effect, there has been a constant increase in this city in the number of arrests for drunkenness, the number of deaths due to wood alcohol poisoning and the number of persons admitted to Bellevue and Kings County hospitals suffering from acute alcoholism. The figures show that during the last year 5,624 persons suffering from acute alcoholism were admitted to those two hospitals, as against 3,345 for the preceding year.

Likewise the number of deaths from alcoholism nearly doubled last year. For 1922, the deaths numbered, 295 as against 141 for 1921. The number of deaths, however, is smaller than it was in the years preceding prohibition. In 1916, for example, 690 persons died in this city from alcoholism. The low mark was reached in 1920, with 127 deaths, but since that time there has been a rapid increase. Dr. Hubbards figures have been verified by those of the police department, which show that 7,866 persons were arrested in this city for drunkenness in 1922, as against 6,233 in 1921. In 1920, the number of arrests was 5,936. Dr. Hubbards interpretation of the figures is that prohibition has increased the number of immoderate drinkers, and that those who drink have switched from beer to spirits”.

Day by day, in every way, were growing wetter and wetter!.

William Cole