Memoranda on poisons

Front matter

‘ SSS Ec

ATIONAL LIBRARY OF MEDICINE

DANAE

Contents

GENERAL TOXICOLOGY.

PAGE . Definition and Mode of Action of PereRIR CTLs Py arco 5! es) Gee ee ce . Diagnosis of Poisoning, . . : 24 . Duties of the Practitioner in ase of Poisoning, . . ei a, a eee . Treatment of Pekin. HU we od ene Peoeteenon- of Poisons si i) 2" 2A Be « Classification of Poisons, . .-. . . 42 I—CORROSIVE POISONS. . The Concentrated Mineral Acids, .-:. 46 The Corrosive Vegetable Acids, . . . 57 . Corrosive Organic Derivatives: Creasote and Carbolic Acid, . . . 63

. The Caustic Alkalies and their Cartan ates: Potash, Soda, Ammonia, . . 66

Chapter I. Definition And Mode Of Action Of Poisons

TOXICOLOGY (roé:kdv poison, and dAdyorc discourse or description), is that branch. of medical science which treats of the nature, properties, and effects of poisons.

DEFINITION OF A PoIsOoN.—It appears searcely possible to give any definition of a poison which will bear critical examination ; insomuch that some have preferred to deal with the evil effects of any substance, that is, ‘with poisoning, rather than with the substance itself, the so-called poison. Most medicines are poisonous in improper doses, which need not be always very large; and even common salt (chloride of sodium) has caused death.*

* In the year 1839, a young lady residing in the North of England took about half a pound of salt to rid herself of worms. Very soon afterwards she began to suffer from all the effects of an irritant poison, with general paralysis; and in spite of the use of the stomach-pump and of antidotes, she died in a few hours. Dr. Christison has recorded two somewhat similar cases.

A poison has been defined to be any substance which, when applied to the body externally, or in any way introduced into the system, without acting mechanically, but by its own inherent qualities, is capable of destroying life. For a cherry-stone may cause death by becoming arrested in the vermiform appendix, and thus producing peritonitis ; boiling water may cause death also ; but neither are poisons: the one acting mechanically, the other by its heat merely.

THe LAW oF Porsons.—Any substance which can injure the health or destroy life is, by the law, regarded as a poison, if given with the intent to do mischief. But the whole law of poisoning must, from a recent decision of Lord Chief Justice Cockburn with the assent of Justice Hawkins, be considered unsettled. In this instance some cantharides had been exhibited with criminal intent, but because there had not been given enough to do harm no conviction followed.

In accordance with the Pharmacy Act certain substances have been defined as poisons within the meaning of that act, so as to put some restriction on their sale to the public.

ADMINISTRATION OF POISON. — Poisons may be introduced into the body in various ways, and in various forms. Thus, they may be administered by the mouth, or by the rectum, by the vagina, or by the lungs, or underneath the skin, and they may be given in the form of solids, liquids, or gases, uncombined or mixed with various matters. ,

DEFINITION AND MODE OF ACTION OF POISONS. 19

Some agents are more readily absorbed than others ; whilst some textures permit of absorption taking place more quickly through them than other tissues. Hence it is that the most diffusible poisons prove most rapidly fatal, especially when introduced directly into the circulation by a wound in a bloodvessel or lymphatic, or when they are injected into the subcutaneous connective tissue. Their action is also speedy when applied either in a gaseous state to the pulmonary air-cells, or as a fluid to that of the stomach or intestines. The serous membranes, such as the peritoneurh, possess an activity of absorption superior to

that of the mucous membranes ; while absorp-

tion through the unbroken skin is slow, on account of the partially impermeable cuticle. Poisons taken into the stomach when that organ is empty, being less diluted, act much more speedily than when it is full. It is remarkable that the agents which most affect the nervous system do not appear to act at all when applied directly to the brain or the trunks of nerves. There are also some poisons, as curare and snake poison, which, although most deadly when introduced into the blood through a wound, are comparatively harmless when swallowed.

The effects of poisons may be considered as local and remote.

The local effects of poisons may be due to (a) ordinary chemical action, or to(b) the specific action of the substance employed, and these are unfortunately various.

THE LocaL EFFECTS oF Poisons.—The local effects are mainly of three kinds, viz. :

(a.) Corrosion, or chemical decomposition, as is seen in the effects of the strong mineral acids and alkalies.

(b.) Irritation or inflammation, varying from simple redness, in its mildest, to ulceration and gangrene in its most severe degree, such as may result from the use of corrosive sublimate ;

(c.) And « local specific effect, produced on the sentient extremities of the nerves, as is felt on the local application of prussic acid, aconite, etc.

THE REMOTE EFFECTS OF PoIsonN.—The remote effects are those influencing organs at some distance from the part to which the poison has been applied. These may be either common or specific.

(a.) Common, such as the constitutional indications of inflammatory fever, however, produced.

(b.) Specific, like the constitutional effects of opium, in contracting the pupil, producing constipation, and so on, over and above its local influence in relieving pain.

Various narcotic poisons produce but little local change, though their remote effects are very remarkable. For example, belladonna, in whatever way it may be introduced into the system, by swallowing, hypodermic injection, or direct application to the eyeball, paralyzes the ciliary nerves, and so causes dilatation of

DEFINITION AND MODE OF ACTION OF PoIsoNs. 21 the pupil, and accommodation for distant vision.

Many substances have both a local and remote action, as is well seen in the influence of cantharides upon the part to which they are applied, in producing blisters, and their remote effects upon the urinary organs, there producing strangury, and sometimes bloody urine.

The remote action of a poison may be said, according to the views now prevalent, to be due in every instance to its absorption either into the veins or the lymphatics, except where there is a direct continuity of effect traceable from the point where the poison was applied, to the point where the remote effect is shown. The part played by the nerves in producing the remote effect of a poison is not clear, but undoubtedly many of the symptoms recorded in anomalous cases of poisoning have been due to their influence. To illustrate what is meant, the great tendency to convulsions of various kinds in many cases of poisoning might be cited. This is just what is seen in ordinary practice, where a local irritation may give rise to reflex phenomena of various kinds, but if very intense, or occurring in a neurotic subject, may induce convulsions: witness the convulsions of teething and of worms.

It is not worth while to describe here the various experiments by which the absorption of poisons into the circulation has been proved, the fact may be taken for granted. Nevertheless, it is well to bear in mind that certain substances affect certain organs in particular, even when they influence or attack more than one. Thus, to give a few examples: morphia and alcohol specially affect the brain; strychnia, the spinal cord; curare, the motor system of nerves; digitalis, the heart; stramonium, the lungs; antimony and arsenic, the stomach ; mercury, the liver; cantharides, the urinar organs ; ergot, the uterus, and so on. In all of them the action is complex, yet the organs named seem to be specially picked out for the production of their respective effects.

Let it not be forgotten that a patient may die from the shock of a dose of a powerful poison, as he may from the shock of a mechanical injury.

MODIFICATION OF THE ACTIONS OF POrsons.—The same poison does not invariably act in the same way, even when a number of people are attacked at the same time.

By far the most important of the modifying agencies is (a) the quantity or dose. Many substances which are deadly in large doses are exceedingly useful as remedies in small quantities ; such are prussic acid, opium, digitalis, arsenic, etc. Then again (b) the mechanical state of aggregation is of consequence ; a solid being usually much less active than a fluid or a gas, and a pure and soluble substance much more active than one mixed with foreign insoluble materials. Even more important is (c) the chemical constitution of the poisonous agent. As already pointed out, poisonous effects result from absorption of the poisoning body, and absorption implies solution ; the more soluble,

DEFINITION AND MODE OF ACTION OF POISONS. 23 therefore, the compound is, the more speedy are its effects, whilst compounds insoluble in water, or any of the juices of the body are inert. It is not, however, enough that the substance be insoluble in water ; it must be so also in the gastric juice and other digestive fluids, or it may give rise to characteristic symptoms. Thus, calomel is insoluble in water, yet it is a powerful medicine; orpiment is insoluble in water, yet, when swallowed,-it may give rise to symptoms of arsenical poisonin and so on. The mental (d), and bodily (ey condition of the recipient must be taken into account. Thus, in excited maniacs, and in certain convulsive disorders, doses of sedatives may be given without producing any effect, which in ordinary individuals might give rise to serious consequences. The bodily condition, especially as influenced by habit, is still more important. It may be broadly stated, that by gradually increasing the dose of a substance ordinarily poisonous, in course of time enormous quantities may be borne without producing immediate ill-effects. This is especially seen in the practice of opium-eating and smoking, and in a less degree in arsenic-eating, as practiced in Styria. The latter instance is, however, contrary to the usual rule; for whereas with vegetable substances, such as opium, the dose requires to be constantly increased to keep up the effects, with minerals, the contrary seems to be the case, especially with antimony and mercury, which cannot be long given without danger to the recipient. ;

Chapter II. The Diagnosis Of Poisoning

THE chief characteristics of poisoning are, that the symptoms commence suddenly, not long after swallowing any substance, the individual being, up to that time, in a state of health; that these symptoms progress steadily, and are uniform in their nature throughout their course; and that they prove more or less speedily fatal.

There are many exceptions to these rules. Thus, if the stomach be loaded the appearance of the symptoms may be delayed some hours. Intoxication will mask the effect of narcoties. Again, the individual poisoned may possibly be suffering from disease, and an agent may be given which will only aggravate existing symptoms, not produce new ones. The fact must not be forgotten that sometimes a poisonous draught is substituted for a harmless ~ medicine. And lastly, after a poison has manifested its effects the symptoms may remit fora time.

When poison is administered with criminal intent it is generally in such a dose as to take immediate effect, although this is by no means necessary, as there are numerous substances which accumulate in the system, and when given in small and repeated quantities, ultimately prove fatal, notably antimony. It must also be remembered that there are many dis-

DIAGNOSIS OF POISONING. 25 eases, as cholera, internal hemorrhage from the bursting of an aneurism, etc., which commence suddenly, and rapidly run to a fatal termination. In inflammation of the stomach or intestines, especially from improper food, the symptoms often set in suddenly, and might be mistaken for poisoning; such is also the case in intestinal obstruction, and yet again in ulceration and perforation of the bowels, such as may occur in latent typhoid. So also in organic diseases of the heart, where the symptoms may have remained latent for some time, death often occurs suddenly from syncope. The diagnosis of the effects of irritant poisons is not so difficult as it is in the case of narcotics or other neurotics, where the symptoms are very similar to those produced by apoplexy, epilepsy, tetanus, convulsions, or other forms of disease of the brain.

Generally speaking, a person may be supposed to be suffering under the effects of a poison, if soon after taking food or drink, he be seized with violent pain, vomiting, purging, and convulsions; or if he be attacked under the same circumstances with delirium, or great drowsiness. It must not be forgotten, however, that poisons may be introduced into the body, not only (a) by the mouth, along with food and drink, but also (b) by means of suppositories and enemata, or (c) in females by vaginal injections, or (d) by inhalation, or (e) by subcutaneous injection, or (f) through the true skin after the removal of the cuticle. Should death ensue, the presumption of unfair play will of course be strengthened by the discovery of post-mortem appearances similar to those known to be produced by the poison from which the person apparently suffered.

The post-mortem appearances, however, except in a few instances, are not very characteristic; nevertheless they may be of great negative value in proving that a certain poison has not been administered, or that the patient died from the effects of disease.

The detection of poison in some of the food which has been left untaken or in the matters vomited would seem to be conclusive evidence of the administration of poison ; but it is to be recollected that designing persons have mixed noxious materials with food, or vomited matters, or feeces, in order to feign poisoning, or to cast unjust imputations upon others; and it is quite possible that a patient, after having taken poison, may die from natural causes.

CHAPTER ITI.

THE DUTIES OF THE PRACTITIONER IN CASES OF POISONING.

WHEN called to a case of supposed poisoning during life the practitioner’s duty is twoold.

I. His FIRST AIM MUST BE TO PRESERVE LIFE.

II. His SECOND, TO FORWARD THE IN- TERESTS OF JUSTICE.

But if he reaches the spot too late to save life his duties are undivided, for he has but to see that justice is done, and in order that there be no failure in this respect it is important that all his observations should be made as carefully as possible, and committed as speedily as possible to writing.

He should, 1. Inquire as to the time at which any substance was last taken by the sufferer;

2. The nature of the symptoms, observed from the beginning of the illness onwards;

3. The hour at which they commenced, and

4. The precise time at which death occurred.

5. He must take possession of any food, medicine, vomited matters, urine, or feces which may be in the room; and he is to seal them up, in new and clean vessels, duly labelled for examination. No old pickle-jars or bottles, or anything of the kind must be used. Then the (@) position and (b) temperature of the body are to be observed, the appearance (c) of the cowntenance, the presence or absence (d) of rigor mortis, with the nature (e) and warmth of the apartment, (f) the situation of any niarks of violence, and (qg) the condition of the inside of the mouth and gullet.

PosT-MORTEM EXAMINATIONS.—In addition to the ordinary rules to be observed in conducting post-mortem examinations, something more must be done, in cases of suspected poisoning, with a view to preserving portions of the body for subsequent examination. The alimentary canal is the most important organ to be thus secured, and it should be removed in separate portions. A double ligature should be passed round the cesophagus in the chest, and the duodenum a few inches below the pylorus should be secured in like manner; by cutting across the gullet and gut between these ligatures, the stomach may be removed without any danger of spilling its contents. It is best to open the stomach after it has been introduced into the receptacle prepared for it, so that its pathological condition may be noted as early as possible. Another ligature should be tied low down in the rectum, and the intestines removed and introduced into a separate vessel prepared for them, and then examined like the stomach. Sometimes it may be necessary to remove the gullet in like fashion. As much blood as possible should be saved for the chemist, and a portion of the liver, if not the whole organ, should also be secured. When everything has been tied up, the jars should be (a) sealed, (b) numbered, (c) labelled, and (d) initialled, to prevent subsequent confusion and to facilitate identification. In women, the vagina, uterus, and ovaries must be inspected. The brain, spinal cord, and thoracic viscera ought likewise to be examined, and portions of the spleen, kidneys, and muscles should be reserved for analysis. No antiseptic or preservative fluid is to be used. When possible it will be best to make the autopsy within twenty-four hours after death; taking care to — make the examination patiently, thoroughly, and with a mind free from any bias. For poison may be found in a body, and yet a question may arise as to its having been the cause of death. Hence in these investigations every organ of the body is to be examined, in order to learn whether any disease has existed toa sufficient extent to account for the fatal result.

BEHAVIOR OF SUSPECTED PERSONS.— Any suspicious conduct on the part of those surrounding the poisoned individual should be caretully noted: Acts of the kind arrange themselves in three heads, as occurring (a) be-

‘fore, or (6) during the fatal illness, or (c) after death. With the first category the practitioner has ordinarily nothing to do, but his attention to those coming under the second and third is often essential service to the ends of justice.

Though by far the most notable of the accounts given of the circumstances which should attract the attention of the practitioner in a case of poisoning has been presented to us by Christison, in his classic work on Poisons, it will, perhaps, be best here to give an admirable example recorded by Dr. Ogston. The case was one of poisoning by arsenic, with which a man named Burnett murdered his wife, and was tried in Aberdeen in 1829. Now,

1. The arsenic was bought, not at the nearest place where it was obtainable, but ina distant town.

2. It was purchased under false pretences— viz., for the destruction of rats; but no proof could be got of the presence of these rats.

3. This purchase was made not long before his wife’s death, which he (the husband) had predicted as likely to take place soon.

4. He had lived away from his wife for two years ; but, just before she was taken ill from the effects of the poison, he had returned, and remained with her all night.

5. A daughter, who attended on her mother, was, on this night, sent away to another part of the house.

6. He administered a dose of what he called medicine to his wife, though he had not been accustomed to do so.

7. When he went to bed he did not undress, but lay down ready to be disturbed.

8. When his wife was taken ill from the arsenic, he opposed sending for any proper medical aid ; but, on the other hand,

9. Showed some laxative powders, one of which he said he had administered to his wife.

10. He destroyed the vomited matters.

11. He broke the teacup in which he had given his wife the arsenic.

— He pushed on the funeral of his deceased wife.

E a. He refused to allow an inspection of the ody.

14. Finally he had been sere se with another and younger woman, to whom he was

about to be married when arrested, a few days - after his wife’s death.

Chapter IV. Treatment Of Poisoning

WHEN the practitioner is called in to a case of poisoning while yet there is life, he must set himself to preserve it in whatever way he best can. In this, of course, he must be guided by circumstances, but several broad rules may be laid down. All have one end, but the order may be varied.

This is the first rule—

NEVER WAIT FOR A REMEDY, HOWEVER PERFECT, IF AN IMPERFECT ONE IS AT HAND.

THAT IS BEST WHICH IS READIEST, the grand rule being LOSE NO TIME.

Most of the modes of treatment come under one or other of the four following heads:

I. GET RID OF THE POISON.

II. STOP ITS ACTION.

Ill. REMEDY THE MISCHIEF IT HAS DONE.

IV. FIGHT AGAINST THE TENDENCY TO DEATH.

I. TO GET RID OF THE POISON.

This is ordinarily the first thing to be done, but not always. To do so when the poison has been swallowed, two means may be emhee vomiting or the stomach-pump.

he latter is one of the most certain means we possess of emptying the stomach; and by means of it (a) this viscus may be washed out, and the (b) antidote, if any be known, administered. In speaking hereafter, however, of the treatment to be adopted in each particular instance, it will be seen that there are some cases, such as poisoning by corrosives, in which this instrument cannot be used. It might not only cause laceration of the tissues, but even perforation of the cesophagus or stomach, and deliver its contents into the pleura or peritoneum. Itis hardly necessary to mention that in all cases a certain knack is required in its employment; the tube having, on more than one occasion, been introduced into the trachea, and the lungs injected with water, etc. It is always best to keep the point of the tube gently pressed against the back part of the pharynx and esophagus until it reaches the stomach. It isa good rule also to withdraw less fluid than is pumped into the stomach. Supposing, however, that this instrument is not at hand, or that it isan improper occasion for its employment, two means are available for emptying the stomach—the use of a syphon arrangement, or vomiting, natural or artificial. Nowadays, when india-rubber tubing is so common, it may not be amiss to bear in mind its uses in such cases. Fairly thick tubing is" easily introduced into the stomach either through the mouth or through the nose. Once introduced into the stomach by means of an ordinary funnel, it is likewise easy to introduce a quantity of lukewarm water through the tube into the stomach, then by placing the patient flat on his face, the tube may be used to empty the fluid contents of that organ. Vomiting is, in many instances, one of the first and most important signs of poisoning, especially by irritant substances. When such is the case, it is only necessary to foster the tendency by copious draughts of lukewarm.water ; but if there be no vomiting, and the stomach-pump be not at hand, an emetic must be given. Of these remedies perhaps there is not one which can be generally used with so much advantage as the sulphate of zinc in 20-grain doses ; for not only is it more rapid in its action, but its ‘effects are less depressing than those of any other emetic except mustard. TIpecacuan wine (six or eight drachms), or a scruple of powdered ipecacuanha, with the same quantity of the ordinary carbonate of ammonia, may be administered in a wineglassful of water. In the absence of these, mustard, as aforesaid, proves an excellent substitute. A teaspoonful or two is to be given in warm water, and frequently repeated. Common salt (a handful in a pint of lukewarm water) may be used with good effect. Let it not be forgotten that vomiting may also be excited by tickling the fauces, as well as by the free administration of warm water. —

When the poison has been applied locally, as in snake-bite, to prevent its absorption, a ligature must be applied between the trunk and the wounded part, as near the latter as possible ; while the deleterious substance is to be removed by free incisions and plentiful washings. Sucking by the mouth or by cuppinglasses may also be employed. The most amentable class of cases of this kind with which in this country we are acquainted are those resulting from the bite of amad dog. In all of these the wound should be promptly cauterized by means of strong fuming nitric acid, the fluid being allowed to permeate everywhere, and potass being at hand to neutralize it when its work is done. Should this not suffice to arrest the action of the poison, where symptoms appear, the only remedy which, up to the present moment, seems to offer a chance of recovery, is curare. "

II. To stor THE ACTION OF THE POISON IF IT CANNOT BE READILY AND IMMEDIATELY REMOVED. ;

The means whereby this is effected is ordinarily the administration of an antidote. As no universal antidote is known, the treatment will of course vary with the substance taken.

The most reliable antidotes will be mentioned in connexion with each particular poison, as far as specific antidotes are likely to | be of service.

An antidote should possess the following properties: (a) It should be capable of being taken in a large dose without danger;(b) it should act upon the poison, whether liquid or solid;(c) it should be capable of combining with the poison immediately, at(d) a temperature equal to or below that of the body;(e) its action should be quick; and (f) lastly, it should deprive the poison of its deleterious properties,

Antidotes mostly operate (a) by forming harmless chemical combinations, or (b) by producing insoluble compounds, and thus preventing or delaying absorption. In most cases they have no effect upon the constitution; but some may be looked upon as a kind of counterpoison. Thus, the antagonistic action of opium and belladonna seems fairly made out, and we might perhaps include under this head chloroform as, in some degree, an antidote to strychnia.

Animal charcoal, which has been proposed as an antidote, seems to act ina great measure mechanically, but it has also a power of absorbing alkaloids, which may render it useful. Such substances as magnesia and gruel are sometimes, and often most usefully, given with the view of protecting the walls of the stomach.

Ill. To REMEDY THE MISCHIEF DONE; and, IV. OBVIATE THE TENDENCY TO DEATH.

Unfortunately, in a great number of instances, too great an interval has elapsed between the exhibition of the poison and the time when the first-mentioned indications can _ be fully carried into effect; for, as before im-

lied, if absorption has taken place, direct antiotes will be of little avail.

Our object must then be to palliate the symptoms as they arise, as well as to neutralize the - effects of the poison on the constitution, by remedies of an opposite character. Thus, in poisoning by depressing agents (like digitalis)

and narcotics (as opium), or such as arrest certain modes of nervous force (as curare), all lowering measures must be avoided, and agents used which will exert a contrary effect, as stimulants, galvanism, etc. Shock must also be taken into account, in dealing with such cases. In many forms of poisoning this is too much overlooked, and the only idea which enters the practitioner’s head is to get rid of the poison.

- Direct injection of liquid ammonia into the veins has been found successful in the treatment of snake-bite in Australia, by Professor Halfo6rd and others, but this has totally failed in India (Fayrer), where such acutely poisonous snakes—-if we may use the term—as the cobra are encountered.

Claude Bernard has shown the importance of particularly attending to the way in which poisons destroy life. For example, curare paralyzes the motor nerves, puts a stop to all motion, suspends respiration, and so brings on suffocation ; yet by keeping up artificial respiration for a sufficient length of time, life may be preserved till the poison is eliminated and the danger over. Strychnia attacks the sensitive portion of the spinal nervous system; but if the external excitement, which perpetuaily provokes reflex action, and thereby brings on fatal convulsions, be guarded against, recovery may ensue. A frog, poisoned by strychnia, rapidly dies if frequently excited ; whereas left perfectly quiet under a bell-glass, it will, ceteris paribus, recover.

DETECTION OF POISONS. 37

Lastly, we must endeavor to promote the elimination of the poison from the body. To give an example, in chronic lead poisoning, lodide of potassium is useful, apparently by rendering the lead more soluble, and so more easily got rid of by the kidneys or bowels.

Chapter V. Detection Of Poisons

THE detection of a poison is, in many instances, no easy matter ; it should not, therefore, be rashly undertaken, except by one well skilled in the minutize of the processes to be adopted ; whilst, on the other hand, there are so many points of practical importance which may be noted by the practitioner in charge of a patient suffering from poisoning, that his attention should be specially directed tothese. The exact determination of the cause of death will - depend partly on the symptoms noted during life, partly on the appearances found after death. These come within the province of the ordinary practitioner ; on the other hand, the special physical, chemical, and physiological portions of the inquiry should be referred to the expert. Ina book of this scope it is impossible to give full details with regard to these last, but a brief sketch may be useful.