3.5 POISONING BY DATURA STRAMONIUM,P de V - SAMJ Archive ...

16 April 1966 S.A. MEDICAL JOUR AL
POISONING BY DATURA STRAMONIUM
P. DE V. MEIRI 'G, M.B., B.CH., M.R.C.P. (Lo. D. AND Em '.), Medical Regisrrar, Groore Schuur Hospiral,
Observatory, CP
poisoning by Darura srramonium, or stinkblaar as it is
known colloquially in South Africa, is not uncommon in
many parts of the world, particularly in Southern and
Ea t Africa.
Poisoning in 2 children in one family is described here
to illustrate some of the typical clinical features.
Though fairly common in South Africa as a whole,
intoxication appears to be somewhat uncommon in Cape
Town and it seems therefore worth while to report these
2 cases which presented a very characteristic clinical
picture that, once seen, is unlikely to be forgotten.
CASE REPORTS
Case 1
Miriam M. aged 7, a Malay child, presented in the casualty
department towards evening on 31 May with a history that
she had eaten, 2 hours previously, some seeds from a weed
growing in a vacant lot adjacent to her home; subsequently
she became drowsy and extremely restless.
The referring doctor's letter indicated that he found her to
have tachycardia, widely dilated pupils, and that she was
delirious, weak and unable to stand. In his letter he raised
the possibility of some neurotoxic alkaloid.
However, having despatched the child he telephoned Prof.
'. Sapeika of the Department of Pharmacology of the
University of Cape Town, who considered that these symptoms
were highly suggestive of poisoning by belladonna alkaloids,
the cause of which was probably ingestion of seeds from the
stinkblaar (D. srramonium) and that apart from the routine
measures in all poisoning, exhibition of neostigmine was
advisable. The doctor passed this information on to us and
we were thus forewarned.
On arrival the child was extremely excited, almost to the
point of acute mania, with rapid continuous purposeless limb
movements, at times muttering and at times exhibiting screaming
delirium.
The pupils were widely dilated and did not react to light
and the pulse rate was 190 per minute. The mouth was dry
and the face extremely flushed.
Examination of the heart, chest and abdomen in as far as it
was possible in such a restless patient, revealed no other
abnormalities.
Gastric lavage with a solution of sodium bicarbonate was
immediately performed and neostigmine, 0·5 mg., was given
intramuscularly. Forty-five minutes later the pulse rate was
162 per minute, the blood pressure 100/60 mm.Hg, the pupils
were still widely dilated and, though she was still excited and
delirious, she had lost the continuous maniacal excitement
with which she presented in casualty.
The neostigmine was repeated in the same dosage and an
hour later her pulse was 132 per minute and she was fairly
quiet, though still in a confused state with apparent hallucinations.
Every now and then she would exhibit outbursts of wild
excitement during which she would lash out against the cot
sides with her arms and legs; it appeared likely that a convulsion
might occur at any moment. She was therefore given
15 mg. phenobarbitone intramuscularly which, though it may
well have prevented a convulsion, had a rather disappointing
effect on her maniacal outbursts.
The advice of Professor Sapeika was again sought and he
suggested that nothing further would now be gained from
repeating the neostigmine. He felt that he would have preferred
a shorter-acting barbiturate in preference to phenobarbitone,
but that now the most useful drug would be one of
the phenothiazine derivatives.
She was given 25 mg. sparine intramuscularly and gradually
settled into a fitful sleep; this was undoubtedly partly due to
the action of the phenobarbitone. She was detained in hospital
311
for a further 36 hours, and apart from a transient mild
pyrexia and a desire to sleep for most of the next day she
suffered no further ill-effects.
On discharge on the morning of 2 June, the pupils were
still somewhat dilated and very sluggishly reactive to light.
The child was seen finally on 4 June when she was noted to
be a normal, alert and quiet child who showed no aftereffects;
her rather dilated pupils now reacted briskly to light.
Case 2
Moerida M. aged 4. Shortly after Miriam had been sent to
hospital her younger sister exhibited almost identical symptoms.
She was brought hurriedly to the casualty department
where she arrived half-an-hour after her sister. She was semicomatose,
but very restless and reacted promptly to mildly
painful stimuli.
Her pulse rate was 180 per minute. She had widely dilated
pupils and a dry mouth. Her face, too, was noted to be
intensely flushed. There were no other abnormal physical
signs elicited on as full an examination as the circumstances
would permit and a gastric lavage was performed followed by
an intramuscular injection of 0·5 mg. of neostigmine.
An hour later her pulse was 140 per minute, she was conscious
but confused, restless and twitching and the pupils
were still widely dilated. She, too, had the appearance of
imminent convulsions and was given phenobarbitone, 7·5 mg.
intramuscularly. The effect was disappointing, but by this time
expert advice had been obtained in respect of her sister and
sparine, 12·5 mg., was given intramuscularly. This child did
not exhibit such violent excitement as her sister, and did not
Fig. I. A leaf and seed capsule of D. stramonium.

312 S.A. TYDSKRIF VIR GENEESKUNDE 16 April 1966
give cause for great anxieiy. She settled down readily and
slept somewhat restlessly for the remainder of the night, being
kept in hospital the following day and discharged on 2 June.
At this time, her pupils were also still dilated and reacted
very sluggishly to light.
The father of these 2 children was requested to bring parts
of the offending plant for identification and he produced some
leaves and a seedpod of Darura STramonium. The seedpod and
one of the leaves are illustrated (Fig. I).
Moerida was seen finally on 4 June when it was noted that
her pupils were still somewhat dilated though they reacted
briskly to light.
DISCUSSIO
DalUra sTramonium is common in all temperate and
tropical zones. Various names by which it is known include
Jimson weed, Jamestown weed (USA), thorn apple,
Peru apple, devil's apple and stinkblaar.
The plant is a species of the nightshade or Solanaceae
family and is a large coarse herb attaining a height of
3 - 6 feet. The leaves are large and angular and from 4 to
6 inches long. The flowers are white or mauve and are
succeeded by the egg-shaped seed capsule, the size of a
walnut and covered with many sharp spines (Fig. 2).
Fig. 2. The stinkblaar (D. stramonium L.) showing the main morphological
characteristics. (By kind permission of the Cape Argus.)
When ripe, the capsule opens into 4 parts leaving a
central structure bearing numerous dark brown reniform
seeds of a diameter of 2 - 3 mm.
There is evidence that Datura stramonium an'd D. fa/uta
are variants of the same species, and Dyson et al.' state
that the two are morphologically identical except for the
purple pigment anthocyanin in the stem and flower of
tatula. The alkaloids of the genus datura are atropine,
hyoscine, hyoscyamine, meteloidine and nor-hyoscyamine.
The leaf and seed in South Africa have yielded 0·5 and
0·36% of total alkaloids respectively, the chief of which
is hyoscyamine.'
Human poisoning In South Africa IS common, mostly
due to the seed. Prompt treatment is usually followed by
fairly quick recovery. Poisoning usually arises from ingestion
of the seeds by young children, but the seeds known
as lagboontjies among schoolboys in some country
schools, have been used in initiation ceremonies with
hilarious though sometimes dangerous results. Poisoning
is common in East Africa and here the leaf may be
gathered with other greenstuffs and be responsible for
poisoning.'
Wholesale poisoning of African troops occurred from
time to time in East Africa during the Second World War;
and there have been many reports of poisoning both by
ingestion of the seeds and contamination of food by the
leaves and seeds in South Africa, North and South
America, Egypt, East Africa, Australia, and Europe, the
accidental inclusion of the plant in foodstuffs being
usually without serious results.
Hughes'4 experience was that poisoning by the seed
gave a maniacal picture with ceaseless and apparently
purposeless activity, very much like the 2 cases described
in this report, whereas he felt from a study of reports of
poisoning that ingestion of the leaf tended to produce a
comatose picture.
In a report of 2 cases resulting from the ingestion of
seeds of Jimson weed, a colloquial term for this plant in
Tennessee, Hughes (1939)' described a very characteristic
clinical picture including dryness of the tongue, widely
dilated pupils, maniacal and purposeless movement, sometimes
with a clonic component. Diffuse erythema is so
vivid at times that it may simulate the flush of scarlet
fever.
In practically no other condition are the pupils so
widely dilated, and tachycardia is invariable.
Death appears to be a somewhat unusual sequel if
treatment is prompt; immediate gastric lavage is mandatory.
The use of various sedatives is described including barbiturates,
paraldehyde 4 and latterly phenothiazine derivatives:
Hughes administered phenobarbitone to control the
violent clonic limb movement he described in his two
cases, with good results. Ismael 6 appears to be the first to
have recommended the use of parasympathetico-mimetic
drugs. He recommended pilocarpine and pointed out that
it was difficult to judge the dose because of the impossibility
of knowing the amount of actual alkaloid ingested,
and he felt the safest way was to give small repeated doses
regulated according to the reaction of the patient, bearing
in mind that in elderly people it has been known to cause
pulmonary oedema.
I should like to thank Prof. . Sapeika for his very helpful
advice in the management of these patients, and the Curator of
the Bolus Herbarium for the positive identification of the
specimens of D. stramonium. I should also like to thank the
Cape Argus for having provided the illustration of a stinkblaar
plant.
REFERENCES
1. Dyson. L. S. and Coetzee. J. A. (1943): S. Afr. J. Sci .. 40, 162.
2. Wright. F. J. (1944): E. Mr. Med. J., 21, 365.
3. Anderson. T. F. and McNaughton. F. (1944): Ibid., 21. 355.
4. Hughes. J. W. and Clark. J. A. (1939): J. Amer. Med. Assoc.. 112,
2500.
5. Sapeika. '. (1965): Personal communication.
6. Ismael. A. (1915): Practitioner. 94, 121.
7. Watt, J. M. and Breyer-Brandwijk. M. G. (l962\: The Medicinal and
Poisonous Plants of Southern and Eastern Africa. 2nd ed., p. 952.
Edinburgh: E. & A. Livingstone.