Although these signs of violent irritation are commonly present, it must at the same time be observed, that some cases have occurred where the stomach and intestines were quite healthy. In a girl who died about thirty minutes after swallowing an ounce of the acid, no morbid appearance whatsoever was to be seen in any part of the alimentary canal.[418] In the case of a girl, described by Mr. Anderson, where death took place in twenty minutes, there was no appearance but contraction of the rugæ of the gullet and stomach, one spot of extravasation in the latter and doubtful softening of its villous coat.[419]
The state of the other organs of the body has not been taken notice of in published cases. In several instances, as in Mr. Taylor’s case, the blood in the veins of the stomach is described as having been black and as it were charred; probably by the chemical action of the acid after death.
The chief part of the treatment of this kind of poisoning is obvious. On account of its dreadful rapidity, remedies cannot be of material use unless they are resorted to immediately after the acid has been swallowed. Emetics may be given, if vomiting is not already free; but time should never be lost in administering them if an antidote is at hand. In particular it is necessary to avoid giving warm water with a view to accelerate vomiting, unless it is given very largely; for moderate dilution will promote the entrance of the poison into the blood, if it has not the effect of immediately expelling it.
The principal object of the practitioner should be to administer as speedily as possible large doses of magnesia or chalk suspended in water. Chalk has been given with great advantage in several cases,[420] and magnesia has also been of service.[421] As no time should be lost, the plaster of the apartment may be resorted to, when chalk or magnesia is not at hand. These substances not only neutralize the acid so as to take away its corrosive power, but likewise render it insoluble, so as to prevent it from entering the blood. There appears no particular reason for using the stomach-pump when antidotes are at hand. But fashion seems to have authorised the employment of this instrument for every kind of poison.[422] Alkalis are inadmissible. As might be inferred from the general statements formerly made on the effect of chemical changes on poisons [p. 28], the alkalis, as they form only soluble salts, will not deprive oxalic acid of its remote or indirect action; and instances are not wanting of their inutility in actual practice.
Oxalic acid is one of the poisons alluded to under the head of General Poisoning,—of whose operation distinct evidence may sometimes (though certainly not always) be found in the symptoms. If a person, immediately after swallowing a solution of a crystalline salt, which tasted purely and strongly acid, is attacked with burning in the throat, then with burning in the stomach, vomiting particularly of bloody matter, imperceptible pulse and excessive languor, and dies in half an hour, or still more in twenty, fifteen, or ten minutes, I do not know any fallacy which can interfere with the conclusion, that oxalic acid was the cause of death. No parallel disease begins so abruptly and terminates so soon; and no other crystalline poison has the same effects.
Poisoning with the Oxalates.—Oxalic acid is one of the best examples of a poison that acts through all its soluble chemical combinations. Dr. Coindet and I found that the oxalates of potash and ammonia are little inferior in energy to the acid. They do not corrode, indeed, and scarcely ever irritate; but they produce tetanus and coma, like the diluted acid. Half a drachm of oxalic acid neutralized with potass will kill a rabbit in seventeen minutes; ninety grains of neutral oxalate of ammonia will kill a strong cat in nine minutes.[423] The binoxalate of potash, the most familiar of the salts of oxalic acid, was not tried by us. But the preceding facts would leave little doubt of its being a poison.
Since the last edition of this work was published several cases have occurred which amply confirm the results of experimental inquiry. In Dr. Babington’s case alluded to above, the greater part of the oxalic acid had been neutralized by bicarbonate of soda [p. 176].—Mr. Tripier has communicated the particulars of a case in which half an ounce of the binoxalate of potash was taken by mistake for bitartrate of potash in hot water, and caused death in eight minutes, after an attack of violent pain and convulsions.[424]—A young woman at Bordeaux was attacked with frequent vomiting after a dose of a drachm and a half of the same salt dissolved in a ptisane. Next morning a similar dose caused bloody vomiting and acute pain at the pit of the stomach; and a third dose the following day excited delirium, more violent vomiting, and death in the course of an hour.[425]—A girl in London swallowed about an ounce of the same salt dissolved in hot water. Sickness and faintness ensued, with imperceptible pulse, cold, clammy skin, rigors, scalding of the mouth and throat, pain in the back, soreness of the eyes, redness of the conjunctivæ, and dilatation of the pupils. Afterwards there was reaction, with a full frequent pulse, hot skin, flushed countenance, headache, thirst, and tenderness of the abdomen. She recovered under the use of chalk, external heat, ether and opium draughts, leeches and sinapisms to the belly, and carbonate of ammonia.[426]
No account has yet been published of the morbid appearances in man.
The proper antidote is sulphate of magnesia. Failing this, weak milk of lime may be given with advantage.
Appendix on Tartaric and Citric Acid.—These two acids may be taken in considerable quantities without injury. Dr. Coindet and I gave a drachm of each in solution to cats, without observing that the animals suffered any inconvenience.[427] Dr. Sibbald, a surgeon of this place, has informed me of an instance in which a patient of his took in twenty-four hours six drachms of tartaric acid, having by mistake omitted the carbonate of potass sent along with the acid to make effervescing draughts; and yet he did not suffer any more inconvenience then the cats on which Dr. Coindet and I experimented.
Pommer, however, found that tartaric acid is scarcely less active than oxalic acid when injected into the blood. When fifteen grains dissolved in half an ounce of water were injected into the femoral vein of a dog in four doses, difficult breathing and discharge of fæces and urine were produced after each operation, and death speedily ensued without any other particular symptom. As in the instance of oxalic acid, the blood in the great veins was not apparently changed in any of its physical qualities. The heart continued contractile long after death, while in the case of oxalic acid its contractility was suddenly extinguished.[428]
The second order of the class of irritants comprehends the alkalis, some of the alkaline salts, and lime. The species which it includes are little allied to one another except in chemical composition; and in particular they are little allied in physiological properties. It appears impossible, however, to make a better arrangement than that proposed by Orfila, which will therefore be here followed.
Most of the poisons of the second order are powerful local irritants. Some of them likewise act indirectly on distant organs; and a few are more distinguished by their remote than by their local effects. This order may be conveniently divided into two groups,—the one embracing the two fixed alkalis with their carbonates, nitrates, and chlorides, and also lime,—the other ammonia, with its salts, and likewise the alkaline sulphurets.
The action of the first group is purely irritant and strictly local. When concentrated, the fixed alkalis and their carbonates produce chemical decomposition, softening the animal tissues, and reducing them eventually to a pulpy mass; which change depends on their possessing the power, as chemical agents, of dissolving almost all the soft solids of the body. When much diluted, they produce inflammation, without corroding the textures; and it does not appear that they are even then absorbed in such quantity as to prove injurious to any remote organ. The action of the alkaline nitrates and of lime is that of irritants only; at least their chemical action is obscure and feeble.
Potass in its caustic state, as usually met with in the shops, forms little gray-coloured cylinders or cakes which have a radiated, crystalline fracture, and an excessively acrid caustic taste, and feel soapy if touched with the wet finger. It deliquesces rapidly in moist air, and then attracts carbonic acid from the atmosphere. It is easily fused by heat, and is exceedingly soluble in water. The solution has a strong alkaline reaction on vegetable colours, restoring reddened litmus to blue, turning syrup of violets or infusion or red cabbage to green, and rendering infusion of turmeric brown. It is distinguished from the alkaline earths when in solution, by not precipitating with carbonic or sulphuric acid, and from soda by the tests to be presently mentioned for its carbonate.
Carbonate of potash [subcarbonate, salt of tartar], is usually sold, when pure, in small white grains, formed by melting the salt and stirring it rapidly as it cools. In its impure state it is called in this country potashes, and when somewhat purified, pearl ash. It has then a mixed grayish, yellowish, or bluish colour, and is sold in crumbly lumps of various sizes. In every state it is deliquescent and very caustic. It cannot be crystallized. It gives out carbonic acid gas with the addition of any stronger acid, such as sulphuric, muriatic, or acetic acid. Its solution precipitates yellow with the chloride of platinum, gives a crystalline precipitate with perchloric acid, when the salt forms not less than a fortieth or fiftieth part,—is similarly acted on by a considerable excess of tartaric acid, if the salt constitute about a thirtieth of the fluid,—and yields with the soluble salts of baryta a white precipitate soluble in nitric acid.
Soda resembles potass closely in chemical as well as physiological properties; and the carbonate bears the same resemblance to the carbonate of potass. The chief differences are the following. The carbonate of soda is easily crystallized, and effloresces on exposure to the air. A solution in twenty parts of water yields no precipitate with either perchloric acid or an excess of tartaric acid, because there is no sparingly soluble perchlorate or bitartrate, as in the case of potash. Its solution is precipitated by antimoniate of potash, because the antimoniate of soda is very sparingly soluble. All its salts remain unaffected by the chloride of platinum, because their base cannot form like potass an insoluble triple salt with the reagent. The acetate of soda is permanent in the air, while the acetate of potass is one of the most deliquescent salts known. In trying this last test, which is very characteristic, care must be taken to avoid an excess of acid in the acetate of soda by expelling it at a temperature of 212°, otherwise the salt is as deliquescent as the acetate of potass.—Another difference is, that the chloride of sodium, being nearly as soluble in temperate as in boiling water, crystallizes with difficulty and but sparingly by cooling a concentrated boiling solution; while the chloride of potassium is much more soluble in hot than in cold water, and crystallizes easily and abundantly when a concentrated boiling solution is cooled down.
Process for Potash and its Carbonate in Organic Mixtures.—The following method has been lately recommended for the detection of potash and its carbonate in complex organic mixtures. Ascertain that the mixture is alkaline in its action on litmus-paper and turmeric-paper, and that it is not ammoniacal in odour. Distil to one-third; ascertain that it has still an alkaline reaction, and evaporate to dryness in a porcelain basin. Agitate the residue, when cold, with absolute alcohol; boil, pour off the liquor, and filter it while hot. Repeat this with the residuum and more alcohol. Distil off most of the alcohol, and evaporate to dryness. Raise the heat to char the residuum, continue the heat as long as vapours come off, remove the charcoaly matter, and incinerate it for forty-five minutes in a silver crucible. Try to separate potash from what remains by means of absolute alcohol; and if this do not succeed, remove carbonate of potash by boiling water. In either case search for potash by litmus-paper, turmeric-paper, chloride of platinum, and perchloric acid.[429]
The conclusiveness of this process depends upon the fact, that absolute alcohol cannot dissolve from solid organic substances such a proportion of lactate, tartrate, acetate, sulphate, or phosphate of potash, or chloride of potassium, as to be acted on by chloride of platinum or perchloric acid.[430]—It is to be observed that carbonate of potash singly is insoluble in absolute alcohol; but it becomes soluble in that fluid, when it is conjoined with various organic matters. Hence it is that this process, intended fundamentally for caustic potash alone, is applicable to carbonate of potash also.
Process for Soda and its Carbonate in Organic Mixtures.—These substances may be separated by the method just described for potash. If the alcoholic solution of the extract of the suspected matter be alkaline in its action on litmus, and be afterwards found to contain soda or its carbonate, the evidence of these substances having been derived from without is satisfactory, because the carbonate of soda contained in many animal matters cannot be so detached. But if no indications of the presence of soda be thus obtained, it is not enough that soda be found in the alcoholic solution of the incinerated alcoholic extract, because the natural carbonate of soda of animal matter may be separated in that manner.[431]
The action of the two fixed alkalis and their carbonates on the animal system is so nearly the same, that the facts which have been ascertained in respect to one of them will apply to all the rest. The operation of potass and its carbonate has been carefully investigated by Professor Orfila,[432] and by M. Bretonneau of Tours.[433]
When caustic potass is injected in minute portions into the veins, it instantly coagulates the blood. Five grains, according to Orfila, will in this way kill a dog in two minutes. But when small doses either of potash itself, or its carbonate, or indeed any of its salts are used, Mr. Blake found, that without coagulating the blood, they arrested the action of the heart in ten seconds, if injected into the jugular vein; and that when they were injected into the carotid artery, they occasioned in four seconds signs of great obstruction in the capillary circulation, and arrestment of the heart’s action in thirty-five minutes, through means of this effect. Next to the salts of baryta he thought the potash salts the most powerful on the heart’s action of all those he tried.[434] When introduced into the stomach potash acts powerfully as an irritant, and generally corrodes the coats of that organ. Thirty-two grains given by Orfila to a dog caused pain in the gullet, violent vomiting, much anguish, restlessness, and death on the third day. On dissection he found the inner coat of the gullet and stomach black and red; and near the pylorus there was a perforation three-quarters of an inch wide, and surrounded by a hard, elevated margin. The observations of Bretonneau are in some respects different. When potass was swallowed by dogs in the dose of 40 grains, he found that the animals, after suffering for some time from violent vomiting, always died sooner or later of wasting and exhaustion; and that the action of the poison was confined chiefly to the gullet, which was extensively destroyed and ulcerated on its inner surface. But when the gullet was defended by the potass being passed at once into the stomach in a caustic holder, larger doses, even several times repeated, did not prove fatal. The usual violent symptoms of irritation prevailed for two or three days; but on these subsiding, the animals rapidly recovered their appetite and playfulness, appearing in fact to be restored to perfect health. Yet there could be no doubt that the stomach all the while was severely injured; for in some of the animals, which were strangled for the sake of examination several weeks after they took the poison, the villous coat was found extensively removed, and even the muscular and peritonæal coats were here and there destroyed and cicatrized. Bretonneau farther adds, that ten or fifteen grains introduced into the rectum caused death sooner than three times as much given by the mouth.
The carbonate of potass possesses properties similar in kind, but inferior in degree to those of the caustic alkali. Two drachms given by Orfila to a dog killed it in twenty-five minutes, violent vomiting and great agony having preceded death. The stomach was universally of a deep-red colour on its inner surface.
Potash and its carbonate are absorbed in the course of their action, and may be detected by Orfila’s process in the liver, kidneys, and urine.[435]
The actions of soda and its carbonate seem on the whole the same with those of potash; but they are not so energetic. In one respect however soda and its salts differ most materially from those of potash. For while the latter, when admitted directly into a vein, act by arresting the action of the heart, soda and its salts, according to the inquiries of Mr. Blake, have no such effect, but cause death by obstructing the circulation of the pulmonary capillaries, and preventing the return of blood from the lungs to the left side of the heart. This conclusion seems to flow from the following facts. The respiration becomes in a few seconds laborious and soon ceases, whilst the heart continues to beat vigorously: arterial pressure is greatly reduced, while venous pressure is much increased owing to accumulation of blood in the right side of the heart: after death the lungs are found congested and often full of froth: and the heart continues contractile, very turgid in the right side, but quite empty of blood in its left cavities.[436]
Poisoning with the caustic alkalis is rare. In 1842, a lady suffering from inflammation of the bowels took an ounce of solution of potass by mistake for kali-water, or a solution of bicarbonate of potash surcharged with carbonic acid. She suffered severely at the time, and died in a fortnight, probably of the conjunct effects of her disease and the poison.[437] This is the only case I have found in print of poisoning with a caustic alkali. But the effects of their carbonates have been several times witnessed, and appear to resemble closely those of the concentrated mineral acids.
The symptoms are in the first instance an acrid burning taste, and rapid destruction of the lining membrane of the mouth; then burning and often constriction in the throat and gullet, with difficult and painful deglutition; violent vomiting, often sanguinolent, and tinging vegetable blues green; next acute pain in the stomach and tenderness of the whole belly; subsequently cold sweats, excessive weakness, hiccup, tremors and twitches of the extremities; and ere long violent colic pains, with purging of bloody stools and dark membranous flakes. So far the symptoms are nearly the same in all cases; but in their subsequent course several varieties may be noticed.
In the worst form of poisoning death ensues at an early period, for example within twenty-four hours, nay even before time enough has elapsed for diarrhœa to begin. A case of this kind, which has been very well described by Mr. Dewar of Dunfermline, and which arose from the patient, a boy, having accidentally swallowed about three ounces of a strong solution of carbonate of potass, proved fatal in twelve hours only.[438] Here death was owing to the general system or some vital organ being affected through sympathy by the injury sustained by the alimentary canal.
In the mildest form, as in a case related by Plenck[439] of a man who swallowed an ounce of the carbonate of potass, the symptoms represent pretty nearly an attack of acute gastritis when followed by recovery,—the effects on man being then analogous to those observed by Bretonneau in animals, when the poison was introduced into the stomach without touching the gullet.
But a more common form than either of the preceding is one, similar to the chronic form of poisoning with the mineral acids, in which constant vomiting of food and drink, incessant discharge of fluid, sanguinolent stools, difficulty of swallowing, burning pain from the mouth to the anus, and rapid emaciation, continue for weeks or even months before the patient’s strength is exhausted; and where death is evidently owing to starvation, the alimentary canal being no longer capable of assimilating food. Two characteristic examples of this singular affection have been recorded in the Medical Repository,[440] and a third, of which the event has not been mentioned, but which would in all likelihood end fatally, has been communicated by M. Jules Cloquet to Orfila.[441] Of the two first cases, which were caused by half an ounce of carbonate of potass having been taken in solution by mistake for a laxative salt, one proved fatal in little more than a month, the other three weeks afterwards. In Cloquet’s case, at the end of the sixth week the membrane of the mouth was regenerated; but the gullet continued to discharge pus, and the stools were purulent and bloody.
Another form perhaps equally common with that just described, and not less certainly fatal, commences like the rest with violent symptoms of irritation in the mouth, gullet, and stomach; but the bowels are not affected, and by and by it becomes apparent that the stomach is little injured; dysphagia or even complete inability to swallow, burning pain and constriction in the gullet, hawking and coughing of tough, leathery flakes, are then the leading symptoms; at length the case becomes one of stricture of the œsophagus with or without ulceration; the bougie gives only temporary relief, and the patient eventually expires either of mere starvation, or of that combined with an exhausting fever. Mr. Dewar has related a very striking example of this form of poisoning with the alkalis.[442] His patient, after the first violent symptoms had exhausted themselves, which took place in sixteen or eighteen hours, suffered little for four or five days till the sloughs began to separate from the lining membrane of the mouth, throat, and gullet. The affection of the gullet then became gradually predominant, and terminated in stricture, of which she appears to have been several times so much relieved as to have been thought in a fair way of recovery. After repeatedly disappointing Mr. Dewar’s hopes of a successful issue by her intemperance in the use of spirituous liquors, she died of starvation about four months after swallowing the poison. Sir Charles Bell has noticed three parallel cases, and has given delineations of the appearance in the gullet of two of them.[443] One of his patients did not die till twenty years after swallowing the poison, which in this instance was soap-less; yet he does not hesitate to ascribe the stricture to that cause, and says death arose purely from starvation.
The carbonate of soda, though a salt in very common use, has not hitherto been the cause of accident, which has found its way into print. It is plainly much less actively corrosive than carbonate of potass, and is therefore probably in every sense less energetic.
The morbid appearances caused by potass, soda, and their carbonates differ with the nature of the case.
In the boy who died in twelve hours Mr. Dewar found the inner membrane of the throat and gullet almost entirely disorganized and reduced to a pulp, with blood extravasated between it and the muscular coat. The inner coat of the stomach was red, in two round patches destroyed, and the patches covered with a clot of blood;—its outer coat, as well as all the other abdominal viscera, was sound.
In the two chronic cases mentioned in the Medical Repository the mischief was much more general, the whole peritonæum being condensed, the omentum dark and turgid, the intestines glued together by lymph, the external coats of the stomach thick, the villous coat almost all destroyed, what remained of it red and near the pylorus ulcerated, and the pyloric orifice of the stomach plugged up with lymph so as barely to admit a small probe.
In Mr. Dewar’s patient who died of stricture of the gullet the intestines were sound, the inner surface of the stomach red especially towards the cardia, the inner and muscular coats of the gullet thickened and firmly incorporated together by effused lymph, the inner coat here and there wanting, the passage of the gullet every where contracted, and to such a degree about two inches above the cardia as hardly to pass a common probe. In Sir C. Bell’s cases the appearances were similar.
Orfila says he is led to conclude from a great number of facts that of all corrosive poisons potass is the one which most frequently perforates the stomach.[444] This appearance, however, has not been mentioned in any case of poisoning in the human subject.
In the treatment of poisoning with the alkalis the first object is evidently to neutralize the poison. This may be done either with a weak acid, or with oil. Of the acids the acetic in the form of vinegar is most generally recommended, as it is not itself injurious. A successful case in very unpromising circumstances, where two ounces and a half of carbonate of potash had been taken by mistake for cream of tartar, and where the antidote was not administered for half an hour, has been related by M. Liégard of Caen. Great relief was experienced to the burning in the throat and stomach, the chilliness, difficult breathing, and frequent efforts to vomit, which were the first symptoms; and after repeated alternations of collapse and reaction, convalescence was established in eight days.[445]—M. Chereau thinks that for the mineral alkalis and their carbonates fixed oil is a preferable antidote to vinegar; and he has given the heads of two cases of poisoning with large doses of carbonate of potass, in which the free employment of almond oil prevented the usual fatal consequences. It appears to act partly by rendering the vomiting free and easy, partly by converting the alkali into a soap. It must be given in large quantity, several pounds being commonly required.[446] For the subsequent treatment the reader may consult the paper of Mr. Dewar, which contains many useful hints on the management of the most complex description of cases.
The nitrate of potass [nitre, saltpetre, sal-prunelle], is a dangerous poison. It has been often mistaken for the saline laxatives, especially the sulphate of soda, and has thus been the source of fatal accidents.
It exists in commerce and the arts in two forms, fused and crystallized. The fused nitre [sal-prunelle] is sold in little button-shaped masses, spheres of the size of musket-balls, or larger circular cakes, of a snow-white tint. The crystallized salt [sal-petre] is sold in whitish, sulcated crystals, which are often regular and large. They are six-sided prisms, more or lest flattened, and terminated by two converging planes. In both forms nitre has a peculiar, cool, but sharp taste.
Its chemical properties are characteristic. In the solid form, it animates the combustion of burning fuel, and yields nitrous fumes when heated with strong sulphuric acid. In solution it is precipitated yellow by the chloride of platinum, and yields, when not greatly diluted, a crystalline precipitate with perchloric acid. The crude salt of commerce contains chloride of sodium; and hence the odour disengaged by sulphuric acid may be mixed with that of chlorine or hydrochloric acid gas. When mixed with any vegetable or animal infusion by which it is coloured, crystals may sometimes be easily procured in a state of sufficient purity by filtration and evaporation. But if not, then the same process must be resorted to with that formerly recommended for nitric acid (p. 143), the first step of neutralization with potass being of course dispensed with.—A process nearly the same with this has been suggested by M. Kramer of Milan. He proposes to free the liquid in part of animal matter by adding acetate of lead, transmitting sulphuretted-hydrogen through the filtered fluid to remove any excess of lead, boiling the fluid after another filtration, and then proceeding with acetate of silver to remove chlorides, as in the process I have adopted. In this way he found nitre even in the blood.[447]
This substance forms an exception to the general law formerly laid down with regard to the effect of chemical neutralization on the local irritants. Both its acid and its alkali are simple irritants; yet the compound salt, though certainly much inferior in power, is still energetic. Nay, the experiment of Orfila and the particulars of some recently published cases tend even to prove, that the action of its alkali and acid is materially altered in kind by their combination with one another; for, besides inflaming the part to which it is applied, nitre has at times produced symptoms of a secondary disorder of the brain and nerves.
The experiments of Orfila upon dogs show that on these animals it has a twofold action, the one irritating, the other narcotic. He found that an ounce and a half killed a dog in ninety minutes when the gullet was tied, and a drachm another in twenty-nine hours: that death was preceded by giddiness, slight convulsions, dilated pupil, insensibility and palsy; that after death the stomach was externally livid, internally reddish-black, and the heart filled in its left cavities with florid blood; that when the gullet was not tied the animals recovered after several attacks of vomiting, and general indisposition for twenty-four hours; and that when the salt was applied externally to a wound it excited violent inflammation, passing on to gangrene, but without any symptom which indicated a remote or indirect operation.[448] Mr. Blake found that this salt, when injected into the veins of a dog in the dose of fifteen grains dissolved in twenty-four parts of water, causes sudden depression and arrestment of the action of the heart, and death in less than a minute; but that, like other salts of potash, it has no influence on the capillaries of the lungs, though a powerful effect in obstructing the systemic capillary system.[449]—When taken in the ordinary way, it is absorbed in the course of its action, and has been detected both in the blood and the urine by Kramer of Milan.[450]
As to its effects on man, it must first be observed, that considerable doses are necessary to cause serious mischief. In the quantity of one, two, or three scruples, it is given medicinally several times a day without injury; and Dr. Alexander found by experiments on himself, that an ounce and a half, if largely diluted, might thus be safely administered in the course of twenty-four hours.[451] Sometimes, too, even large single doses have been swallowed with impunity. A gentleman of my acquaintance once took nearly an ounce by mistake for Glauber’s salt, and retained it above a quarter of an hour: nevertheless, except several attacks of vomiting, no unpleasant symptom was induced. M. Tourtelle has even related an instance where two ounces were retained altogether and caused only moderate griping, with considerable purging and flow of urine.[452] Resting on such facts as these Tourtelle, with some physicians in more recent times,[453] has maintained that nitre is not a worse poison than other saline laxatives; and some practitioners of the present day have consequently ventured to administer it for the cure of diseases, in the quantity of half an ounce in one dose.[454] It is not easy to say, why these large doses are at times borne by the stomach without injury,—whether the cause is idiosyncrasy, or a constitutional insensibility engendered by disease, or some difference in the mode of administering the salt. But at all events, the facts which follow will leave no doubt that in general it is a dangerous and rapid poison in the dose of an ounce.
Dr. Alexander found that, in the quantity of a drachm or a drachm and a half, recently dissolved in four ounces of water, and repeated every ninety minutes, the third or fourth dose caused chilliness and stinging pains in the stomach and over the whole body; and these sensations became so severe with the fourth dose, that he considered it unsafe to attempt a fifth.[455]
Two cases which were actually fatal have been described in the Journal de Médecine for 1787, the one caused by one ounce, the other by an ounce and a half. In the latter the symptoms were those of the most violent cholera, and the patient died in two days and a half;[456] in the former death took place in three hours only, and in addition to the symptoms remarked in the other there were convulsions and twisting of the mouth.[457] In both the pulse failed at the wrist, and a great tendency to fainting prevailed for some time before death. Dr. Geoghegan has communicated to Mr. Taylor a case where an ounce and a half taken by mistake caused severe pain in the stomach, vomiting, and death in two hours.[458]
Similar effects have been remarked in several cases which have been followed by recovery. A woman in the second month of pregnancy, immediately after taking a handful of nitre in solution, was attacked with pain in the stomach, swelling of the whole body and general pains; she then miscarried, and afterwards had the usual symptoms of gastritis and dysentery, united with great giddiness, ringing in the ears, general tremors and excessive chilliness. She seems to have made a narrow escape, as for three days the discharges by stool were profuse, and composed chiefly of blood and membranous flakes.[459] Dr. Falconer has related another instance, where also the patient’s life seems to have been in great danger. The quantity taken was two ounces, and it was swallowed in half a pint of warm water by mistake instead of a laxative salt. Violent pain in the belly was immediately produced, in half an hour frequent vomiting, and in three hours a discharge of about a quart of blood from the stomach. After the administration of gruel and butter the symptoms began to subside; but they receded slowly; and even six months afterwards the man, though otherwise in good health, had frequent pain in the stomach and flatulence.[460] In the case of a female in the second month of pregnancy, described by Dr. Butter, miscarriage did not take place, although the symptoms were very violent and lasting. The quantity taken was two ounces. The symptoms were first bloody vomiting, afterwards dysentery, which continued seven days; and on the tenth day a nervous affection supervened exactly like chorea, and of two months’ duration.[461] The effects of the poison in the latter period of this woman’s illness tend to establish the existence of a secondary operation on the nervous system. But this kind of action is more strongly pointed out by the following cases. Three puerperal women in the Obstetric Hospital of Pavia got each an ounce of nitre by mistake for sulphate of magnesia. Two, who vomited immediately, did not suffer. The third, who retained the salt fifteen minutes, had pain in the stomach and vomiting, followed by paleness of the countenance, stiffness of the jaw, some stupor, and convulsive movements of the limbs; which symptoms continued till next day, when she gradually recovered.[462] A German physician, Dr. Geiseler, met with an instance, in which the only disorder produced appeared to depend on derangement of the cerebral functions. A woman, after swallowing an ounce of nitre instead of Glauber’s salt, lost the use of speech and the power of voluntary motion, then became insensible, and was attacked with tetanic spasms. This state lasted till next day, when some amelioration was brought about by copious sweating. It was not, however, till eight days after, that she recovered her speech, or the entire use of her mental faculties; and the palsy of the limbs continued two months.[463] Her case resembles the account given by Orfila of the effects of nitre on animals.
The morbid appearances observed in man are solely those of violent inflammation of the stomach and intestines. In Laflize’s case, which proved fatal in three hours, the stomach was distended, and the contents deeply tinged with blood; its peritonæal coat of a dark-red colour mottled with black spots; its villous coat very much inflamed and detached in several places. The liquid contents gave satisfactory evidence of nitre having been swallowed; for a portion evaporated to dryness deflagrated with burning charcoal. In Souville’s patient, who lived sixty hours, the stomach was every where red, in many places checkered with black spots, and at the centre of one of these spots the stomach was perforated by a small aperture. The whole intestinal canal was also red. In Dr. Geoghegan’s case, the stomach contained bloody mucus, and its villous coat was brownish-red, and here and there detached. He could not detect any nitre in it.
There can be little doubt that the chlorides of soda, potass, and lime are active poisons; but the first two have alone been hitherto carefully investigated by physiological experiments.
The two alkaline chlorides are usually seen in the form of colourless solutions. That of potass is little known in this country; but that of soda is familiar to all in the shape of Fincham’s chloride of soda or bleaching liquid. The chloride of lime, which is best known of them all, is usually in the form of a dry powder, deliquescent, and acrid, commonly termed bleaching powder. All these substances are easily known by their peculiar odour of chlorine, and the copious disengagement of that gas on the addition of sulphuric acid.
The action of chloride of soda on the animal body has been examined by Segalas, who infers that it is an irritant poison, which, however, at times occasions symptoms of an affection of the nervous system. He remarked that three ounces of the solution, commonly sold in Paris under the name of Labarraque’s disinfecting liquid, caused immediate death by coagulating the blood in the heart, when injected into a vein in a dog. Two ounces introduced into the peritonæum excited palpitation, oppressed breathing, constant restlessness, and death in ten minutes; and three drachms did not prove fatal for some hours, tetanic spasms being produced in the first instance, and peritonæal inflammation being found after death. One ounce introduced into the stomach of a dog excited immediate vomiting, and no farther inconvenience; and two ounces retained by a ligature on the gullet brought on violent efforts to vomit, from which the animal was gradually recovering, when it was killed in twenty-four hours for the sake of observing the appearances. The stomach was found generally inflamed and interspersed with dark, gangrenous-like spots.[464]
I am not acquainted with any case of poisoning with these substances in the human subject. But it is probable that symptoms of pure irritation and inflammation will occur, and that moderate doses may prove fatal.
Lime, the last poison of the present group, is a substance of little interest to the toxicologist, as its activity is not great.
Its physical and chemical properties need not be minutely described. It is soluble, though sparingly, in water; and the solution turns the vegetable blues green, restores the purple of reddened litmus, gives a white precipitate with a stream of carbonic acid gas, and with oxalic acid a very insoluble precipitate, which is not redissolved by an excess of the test.
Its action is purely irritant. Orfila has found that a drachm and a half of unslaked lime, given to a little dog, caused vomiting and slight suffering for a day only, but that three drachms killed the same animal in five days, vomiting, languor, and whining being the only symptoms, and redness of the throat, gullet, and stomach, the only morbid appearances.[465]
Though a feeble poison, it has nevertheless proved fatal in the human subject. Gmelin takes notice of the case of a boy who swallowed some lime in an apple-pie, and died in nine days, affected with thirst, burning in the mouth, burning pain in the belly, and obstinate constipation.[466] A short account of a case of this kind of poisoning is also given by Balthazar Timæus. A young woman, afflicted with pica or depraved appetite, took to the eating of quicklime; and in consequence she was attacked with pain and gnawing in the belly, sore throat, dryness of the mouth, insatiable thirst, difficult breathing and cough; but she recovered.[467] It is well known that quicklime also inflames the skin or even destroys its texture, apparently by withdrawing the water which forms a component part of all soft animal tissues. When thrown into the eyes it causes acute and obstinate ophthalmia, which may end in loss of sight. On this account it will belong, I presume, to the poisons included in the Scottish act against disfiguring or maiming with corrosives.
The second group of the order of alkaline poisons, including ammonia with its salts, and the sulphuret of potass, have a double action on the system, analogous to that possessed by many metallic poisons. They are powerful irritants; but they produce besides, through the medium of the blood, a disorder of some part of the nervous system; and their remote is sometimes more dangerous than their local action. The nervous affection produced by ammonia and the sulphuret of potass closely resembles tetanus, and therefore depends probably on irritation of the spinal column.
Of the Chemical tests for the Ammoniacal Salts.—Ammonia is when pure a gaseous body; but as commonly seen, it exists in solution in water, which dissolves it in large quantity. The solution has the usual effects of alkalis on vegetable colours, with the difference, however,—that the changes of colour are not permanent under the action of heat. It forms a yellow precipitate, as potass does, with chloride of platinum. It may at once be distinguished from other fluids by its peculiar pungent odour, which is possessed by no other substance except its carbonate.
Various carbonates are known in chemistry, but the only one known in commerce or met with in the shops is the sesqui-carbonate (subcarbonate—smelling salt—volatile salt—hartshorn). It is solid, white, fibrous, and has the same odour as pure ammonia. Its solution differs little in physical properties from the pure liquid ammonia; but, unlike it, is precipitated by the salts of lime.
The hydrochlorate (muriate of ammonia—sal-ammoniac)—is known by its solid, white, crystalline appearance; its ductility; its volatility; and by the effect of caustic potass and nitrate of silver, the former of which disengages an ammoniacal odour, while the latter causes in a solution of the salt a white precipitate, the chloride of silver.
Of the action of the Ammoniacal Salts, and their effects on man.—To determine the action of ammonia on the animal system, Professor Orfila injected sixty grains of the pure solution into the jugular vein of a dog. Immediately the whole legs were spasmodically extended; at times convulsions occurred; and in ten minutes it died. The chest being laid open instantly, coagulated florid blood was seen in the left ventricle, and black fluid blood in the right ventricle of the heart. No unusual appearance was discernible any where else except complete exhaustion of muscular irritability.[468] The experiments of Mr. Blake also show that ammonia introduced in large doses into the veins acts by suddenly extinguishing the irritability of the heart. Small doses first lower arterial pressure from debility of the heart’s action, and then increase it by obstructing the systemic capillaries. When injected into the aorta from the axillary artery, it causes great increase of arterial pressure, owing to the latter cause; and then arrests the heart, while the respiration goes on. Four seconds are sufficient for the ammonia to pass from the jugular vein into the heart, so as to be discovered there by muriatic acid causing white fumes.[469] Half a drachm of a strong solution, introduced by Orfila into the stomach of a dog and secured by a ligature on the gullet, caused at first much agitation. But in five minutes the animal became still and soporose; after five hours it continued able to walk; in twenty hours it was found quite comatose; and death ensued in four hours more. The only morbid appearance was slight mottled redness of the villous coat of the stomach. A third dog, to which two drachms and a half of the common carbonate were given in fine powder, died in twelve minutes. First it vomited; next it became slightly convulsed; and the convulsions gradually increased in strength and frequency till the whole body was agitated by dreadful spasms; then the limbs became rigid, the body and head were bent backwards, and in this state it expired, apparently suffocated in a fit of tetanus.[470]
Several cases of poisoning with ammonia or its carbonate have occurred in the human subject. Plenck has noticed shortly a case which proved fatal in four minutes, and which was caused by a little bottleful of ammonia having been poured into the mouth of a man who had been bitten by a mad-dog.[471] The symptoms are not mentioned, but it is probable, from the rapidity of the poisoning, that a nervous affection must have been induced. More generally, however, the effects are simply irritant; and the seat of the irritation will vary with the mode in which the poison is given. If it is swallowed, the stomach and intestines will suffer; if it is imprudently inhaled in too great quantity, inflammation of the lining membrane of the nostrils and air-passages will ensue. Huxham has related a very interesting example of the former affection, as it occurred in a young man, who had acquired a strange habit of chewing the solid carbonate of the shops. He was seized with great hemorrhage from the nose, gums, and intestines; his teeth dropt out; wasting and hectic fever ensued; and, although he was at length prevailed on to abandon his pernicious habit, he died of extreme exhaustion, after lingering several months.[472] But the most frequent cases of poisoning with ammonia have arisen from its being inhaled, and thus exciting bronchial inflammation. An instructive instance of the kind has been related by M. Nysten. A medical man, liable to epilepsy, was found in a fit by his servant, who ignorantly tried to rouse him by holding assiduously to his nostrils a handkerchief dipped in ammonia. In this way about two drachms appear to have been consumed. On recovering his senses, the gentleman complained of burning pain from the mouth downwards to the stomach, great difficulty in swallowing, difficult breathing, hard cough, and copious expectoration, profuse mucous discharge from the nostrils, and excoriation of the tongue. The bronchitis increased steadily, and carried him off in the course of the third day, without convulsions or any mental disorder having supervened.[473] A case precisely similar is related in the Edinburgh Medical and Surgical Journal. A lad, while convalescent from an attack of fever, was seized with epilepsy, for which his attendant applied ammonia under his nose “with such unwearied, but destructive benevolence, that suffocation had almost resulted. As it was, dyspnœa with severe pain of the throat and breast, immediately succeeded; and death took place forty-eight hours afterwards.”[474] A third instance has been recorded of analogous effects produced by the incautious use of ammonia as an antidote for prussic acid. The patient had all the symptoms of a violent bronchitis, accompanied with redness and scattered ulceration of the mouth and throat; but he recovered in thirteen days.[475] A fourth case, similar to the preceding, has been related by M. Souchard of Batignolles. A druggist, who inhaled while asleep the fumes of ammonia from a broken carboy, awoke in three-quarters of an hour, with the mucous membrane of the mouth and nostrils corroded, and a bloody discharge from the nose. A severe attack of bronchitis followed, during which he could not speak for six days; but being actively treated with antiphlogistic remedies, he recovered.[476]—An extraordinary case has been published by Mr. Paget of death from injecting ammonia into the blood-vessels. A solution weak enough to allow of the nose being held over it was injected into a nævis in a child two years old. An attack of convulsions immediately followed, and in a minute the child expired.[477]
Nysten’s case is the only one in the human subject in which the morbid appearances were ascertained. The nostrils were blocked up with an albuminous membrane. The whole mucous coat of the larynx, trachea, bronchi, and even of some of the bronchial ramifications, was mottled with patches of lymph. The gullet and stomach showed red streaks here and there; and there was a black eschar on the tongue, and another on the lower lip.
Of Poisoning with Hydrochlorate of Ammonia.—The effects of the hydrochlorate of ammonia on animals have been examined by Professor Orfila and Dr. Arnold; but I have not yet met with any instance of its operation as a poison on man. When given to dogs it irritates and inflames the parts it touches, and causes the ordinary symptoms of local irritation. But it also acts remotely. For, first, like arsenic, and other poisons of the third order of irritants, it produces inflammation of the stomach, in whatever way it is applied to the body,—Orfila having found that organ affected when the salt was applied to the subcutaneous cellular tissue;[478] and, secondly, according to the experiments of Arnold, it causes, when swallowed, excessive muscular weakness, slow breathing, violent action of the heart, and tetanic spasms,—effects which cannot arise from mere injury of the stomach. Half a drachm will thus kill a rabbit in eight or ten minutes;[479] and two drachms a small dog in an hour.[480]
The liver of sulphur, or sulphuret of potass of the pharmacopœias, the last poison of this order to be mentioned, is allied to the ammoniacal salts in action. It is of no great consequence in a toxicological point of view in this country, being put to little use; but several accidents have been caused by it in France, where it is employed for manufacturing artificial sulphureous waters; and farther, its properties should be accurately ascertained, because till lately it was erroneously resorted to as an antidote for some metallic poisons.
Chemical Tests.—It has a grayish, greenish, or yellowish colour when solid; its dust smells of sulphuretted hydrogen, which is also copiously disengaged from it by the mineral acids: and it forms with water a yellow solution of the same odour.—In composite fluids it may be detected by heating it with acetic acid, and passing the disengaged gases through solution of acetate of lead, in which a black precipitate of sulphuret of lead is produced, from the action of sulphuretted-hydrogen.[481]
Action and Symptoms.—Orfila found that a solution of six drachms and a half, secured in the stomach of a dog by a ligature on the gullet, caused death by tetanus in seven minutes, without leaving any morbid appearance in the body; that inferior doses caused death in the same manner, but at a later period, and with symptoms of irritation in the alimentary canal, which also was seen red, black, or even ulcerated after death; that a solution of twenty-two grains injected into the jugular vein killed a dog in two minutes, convulsions having preceded death, and the heart being found paralysed immediately after it; and that a drachm and a half thrust in small fragments under the skin occasioned death in thirteen hours with coma and extensive inflammation of the cellular tissue.[482] There can be no doubt, therefore, that liver of sulphur is a true narcotic acrid poison.—It is absorbed, and may be detected in the blood, liver, kidneys, and urine by Orfila’s process.[483]
Orfila has collected three cases of poisoning in the human subject with this substance;[484] and a fourth has been related by M. Cayol.[485] Of these cases two proved fatal in less than fifteen minutes; and the symptoms were acrid taste, slight vomiting, mortal faintness, and convulsions, with an important chemical sign, the tainting of the air with the odour of sulphuretted-hydrogen. The dose in one case was about three drachms. The two other patients, who recovered, were for some days dangerously ill. The symptoms were burning pain and constriction in the throat, gullet, and stomach; frequent vomiting, at first sulphureous, afterwards sanguinolent; purging, at first sulphureous; sulphureous exhalations from the mouth; pulse at first quick and strong, afterwards feeble, fluttering, and almost imperceptible; in one case sopor; finally severe inflammation of the gullet, stomach and intestines, which abated in three days. One of these patients took four drachms of sulphuret of soda, the other two ounces of sulphuret of potass; but it is probable, that the latter dose was partly decomposed by long keeping.
Morbid Appearances.—The morbid appearances in the two fatal cases were great lividity of the face and extremities, and exhaustion of muscular contractility immediately after death; the stomach was red internally, and lined with sulphur; the duodenum also red; the lungs soft, gorged with black fluid blood, and not crepitant.
Treatment.—The most appropriate treatment consists in the instant administration of any diluent, then of frequent doses of the chloride of soda, and lastly the antiphlogistic mode of subduing inflammation. The chloride of soda or lime decomposes sulphuretted hydrogen, the disengagement of which is the probable cause of death in the quickly fatal cases.[486]
The third order of the irritant class of poisons includes the compounds of the metals. These are of great importance to the medical jurist. They are frequently used for criminal purposes; they give rise to the greatest variety of symptoms; and the medical evidence on trials respecting them, while much skill is required on the part of the witness to collect it, is also the most conclusive.
It must not be inferred from their being arranged in the class of irritants that their action is merely local. In fact this is the case with a very few of them only, which produce chemical corrosion. The greater number likewise act indirectly on organs at a distance from the part to which they are applied. Nevertheless the most prominent symptoms generally produced by them are those of violent local irritation; so that they may be justly considered in the place which has been assigned them.
The poisons included in this order are the oxides and salts of arsenic, mercury, copper, antimony, tin, silver, gold, bismuth, iron, chrome, zinc, barium, lead. Many other metals also form poisonous compounds with various acids and other bodies; but these are so rare as to be merely objects of physiological curiosity.
Of all the varieties of death by poison, none is so important to the medical jurist as poisoning with arsenic. On account of the shameful facility with which it may be procured in this country, even by the lowest of the vulgar, and the ease with which it may be secretly administered, it is the poison most frequently chosen for the purpose of committing both suicide and murder. In 1837 and 1838 no fewer than 186 cases of fatal poisoning with arsenic were known to have occurred in England alone (see p. 90). Of 221 cases of murder by poison in France during ten years subsequent to 1829, in which the poison given was ascertained, there were 149 where the substance administered was arsenic.[487] It is fortunate, therefore, that there are few substances in nature, and perhaps hardly any other poison, whose presence can be detected in such minute quantities and with so great certainty.
Metallic arsenic has an iron-gray colour, a specific gravity of 8·308, and a crystalline fracture. It is very brittle. It has a strong tendency to oxidate, so that it undergoes this change in air, in water, and even in alcohol. In air, particularly when moist, it becomes rapidly tarnished, a black powder being formed, which some have regarded as a regular protoxide.[488]—When exposed to heat, metallic arsenic is usually said to sublime at the temperature of 356° F.; but according to some late experiments by Dr. Mitchell of Philadelphia this does not happen under a low red heat, luminous in the dark.[489] In close vessels it condenses unchanged; but when heated in the open air, it passes to the state of white oxide, and rises in white fumes. This substance is a sesquioxide, consisting of two equivalents of metal and three of oxygen. Another oxide likewise exists, which contains two equivalents of metal and five of oxygen, and, possessing strong acid properties, is denominated arsenic acid. The sesquioxide and arsenic acid unite with bases, and produce compounds which, with the exception of those they form with the alkalis, are mostly insoluble. Metallic arsenic unites with sulphur in two proportions, forming an orange-red and a sulphur-yellow compound. The compounds of arsenic have very little chemical action with vegetable and animal principles.
Of the compounds which arsenic thus forms, those which it will be necessary to particularize are the following:—1. The protoxide of Berzelius, or fly-powder. 2. The arsenious acid, or white arsenic. 3. The arsenite of copper, or mineral green. 4. The arsenite of potass as contained in Fowler’s solution. 5. The arsenite of potass; 6. The various sulphurets, pure and impure, namely, realgar, orpiment, and king’s yellow; and 7. Arseniuretted-hydrogen gas.
This substance is rarely known as a poison in Britain, but is a familiar poison in France and Germany, under the names of Poudre à mouches, and Fliegenstein. Of late it has been occasionally used in Scotland for poisoning rats.
It is a fine grayish-black powder, formed by exposing powdered arsenic for a long time to the air; but it also frequently contains fragments of the metal. It is usually considered by chemists to be a mixture of metallic arsenic and its white oxide.
It is acted on by water, the white oxide being found ere long in solution by its proper tests. Oxidation and solution, however, are also effected upon pure metallic arsenic in the same manner. A thousand grains of water take up a grain in the course of half an hour when boiled on the metal.[490]
A very simple and decisive test for fly-powder is derived from the effect of heat. If it is heated in a tube two substances are sublimed, first a white crystalline powder, and then a bright metallic crust, the former being the white oxide, the latter the metal. The metallic crust thus formed possesses physical properties, which distinguish arsenic from all other substances, capable of being sublimed by a low heat: The surface next the tube is very like polished steel, being a little darker in colour, but equal in brilliancy and polish; and the inner surface is either brilliantly crystalline to the naked eye, like the fracture of cast-iron, or has a dull grayish-white colour, but appears crystalline before a common magnifying lens of four or five powers. If these characters be attended to, particularly the appearance of the inner surface, it appears to me scarcely possible to mistake for an arsenical crust any other substance which can be sublimed by any of the methods for subliming arsenic.
If a farther test should be desired, it is only necessary, as was first proposed by Dr. Turner of London,[491] to chase the crust up and down the tube with the spirit-lamp flame till it is all oxidated, when little octaedral crystals of adamantine lustre are formed, on which, either with the naked eye or with the aid of a common lens, triangular facettes may be distinguished.
The niceties to be attended to in applying the preceding tests will be considered presently under the head of the next compound, the sesquioxide.
Arsenious acid, the sesquioxide, or white oxide of arsenic, usually called white arsenic, or simply arsenic, is the most common and important of all the arsenical preparations.
It is met with in the shops in two forms,—as a snow-white gritty powder, and in solid masses generally opaque, but sometimes translucent. When newly sublimed it is in translucent or even almost transparent masses of a vitreous lustre, conchoidal fracture and sharp-edged. By keeping it becomes opaque and white. The nature of the change has not been determined; but some alteration is certainly effected, for Guibourt, who has examined both varieties with care, found that the opaque variety is more soluble in water than the other. He adds that the former is alkaline, the latter acid, in its action on litmus paper; but I have always found the opaque variety acid.[492] The powder soon becomes analogous to the opaque variety of the oxide in mass.