Treatise on Poisons by Sir Robert Christison

or inflammation along the course of the alimentary canal. Such cases are the most frequent of all. The person commonly survives twenty-four hours, seldom more than three days; but instances of the kind have sometimes proved fatal in a few hours, and others have lasted for weeks. On the whole, however, if the case is much shorter than twenty-four hours, or longer than three days, its complexion is apt to be altered. In the mildest examples of the present variety recovery takes place after a few attacks of vomiting, and slight general indisposition for a day or two. In regard to the ordinary progress of the symptoms, the first of a decisive character are sickness and faintness. It is generally thought indeed that the first symptom is an acrid taste; but this notion has been already shown to be erroneous. For some account of the sensations felt in the act of swallowing the poison, the reader may refer to what has been stated in p. 200. There is no doubt, that in the way in which arsenic is usually given with a criminal intent, namely, mixed with articles of food, it seldom makes any impression at all upon the senses during the act of swallowing. In some instances the sickness and faintness, particularly when the poison was taken in solution, have begun a few minutes after it was swallowed. Thus in a case mentioned by Bernt, in which a solution of arseniate of potass was taken, the symptoms began violently in fifteen minutes;[602] in one related by Wildberg, where the oxide was given in coffee, the person was affected immediately on taking the second cup;[603] in one related by Mr. Edwards, the patient was taken ill in eight minutes,[604] in one mentioned by M. Lachèse of Angers, violent symptoms commenced within ten minutes after the poison was swallowed with prunes;[605] in a case communicated to me by Mr. J. H. Stallard of Leicester, the symptoms set in with violence ten minutes after it was taken dissolved in tea; nay, in a case of poisoning with orpiment in soup, mentioned by Valentini, the man felt unwell before he had finished his soup, and set it aside as disagreeable.[606] It is a mistake therefore to suppose, as I have known some do, that arsenic never begins to operate for at least half an hour. Nevertheless it must be admitted, that in general arsenic does not act for half an hour after it is swallowed.—On the other hand, its operation is seldom delayed beyond an hour. The following, however, are exceptions to this rule. Lachèse in the paper quoted above mentions an instance where the interval was two hours, and where the issue was eventually fatal. The arsenic had been in very coarse powder. Mr. Macaulay of Leicester has communicated to me a case where the individual took the poison at eight in the evening, went to bed at half-past nine, and slept till eleven, when he awoke with slight pain in the stomach, vomiting, and cold sweats. In this instance the dose was seven drachms, and death took place in nine hours. M. Devergie has related a similar case of poisoning with the sulphuret, where the symptoms did not begin for three hours; and here too the patient fell asleep immediately after swallowing the poison.[607] Professor Orfila has noticed an instance, to be quoted afterwards, where there appears to have been scarcely any symptom at all for five hours[608] (p. 243). I suspect we must also consider as an instance of the same kind the case which gave occasion to the trial of Mrs. Smith here in 1827. A white draught was administered in a suspicious manner at ten in the evening; the girl immediately went to bed; and no symptoms appeared till six next morning, from which time her illness went on uninterruptedly.[609] In three of the preceding cases it will be remarked that sleep intervened between the taking of the poison and the invasion of the symptoms; and it is therefore not improbable that the reason of the retardation is the comparative inactivity of the animal system during sleep.—In voluntary poisoning, as in a case related by Dr. Roget, a slight attack of sickness or vomiting occasionally ensues immediately after solid arsenic is swallowed, and some time before the symptoms commence regularly.[610] The observations now made will often prove important for deciding accusations of poisoning; for pointed evidence may be derived from the commencement of the symptoms, after a suspected meal, corresponding or not corresponding with the interval which is known to elapse in ascertained cases. The reader will see the effect of such evidence in attaching guilt to the prisoner in the case of Margaret Wishart, which I have detailed elsewhere.[611] In the trial of Mrs. Smith, the want of the correspondence just mentioned contributed greatly to her acquittal; for the symptoms of poisoning did not begin till more than eight hours after the only occasion on which the prisoner was proved to have administered any thing in a suspicious manner. As I was not at the time acquainted with any parallel case except that recorded by Orfila, I hesitated to ascribe the symptoms to the draught; and consequently, as the other medical witnesses felt the same hesitation on the same account, the proof of administration was considered to have failed. I am not sure that I should have now felt the same difficulty. The intervening state of sleep probably affords an explanation of the long interval; and the cases noticed by Mr. Macaulay and M. Devergie are parallel, though the interval in them was certainly not so great.—There is a limit, however, to the possible interval in such cases. It seems impossible that the action of the poison shall be suspended for three entire days. Yet death has been ascribed to arsenic in such circumstances. A child 3½ years old having swallowed eight grains with bread and butter, but being soon made to vomit forcibly by emetics, presented no decided symptom at the time, or for three days more; but on the fourth day difficult breathing ensued, with anxiety of expression, frequency of the pulse, and heat of the skin; and next day death took place. There was no morbid appearance found in the body.[612] I do not know of any parallel instance of death from arsenic, and cannot admit that the poison was the cause of the symptoms and fatal event. Soon after the sickness begins, or about the same time, the region of the stomach feels painful, the pain being commonly of a burning kind, and much aggravated by pressure. Violent fits of vomiting and retching then speedily ensue, especially when drink is taken. There is often also a sense of dryness, heat, and tightness in the throat, creating an incessant desire for drink; and this affection often precedes the vomiting. Occasionally it is wanting, at other times so severe as to be attended with suffocation and convulsive vomiting at the sight of fluids.[613] Hoarseness and difficulty of speech are commonly combined with it. The matter vomited is greenish or yellowish; but sometimes streaked or mixed with blood, particularly when the case lasts longer than a day. In no long time after the first illness diarrhœa generally makes its appearance, but not always. In some cases, instead of it, the patient is tormented by frequent, ineffectual calls: in others the great intestines are scarcely affected. About this time the pain in the stomach is excruciating, and is often likened by the sufferer to a fire burning within him. It likewise extends more or less downwards, particularly when the diarrhœa or tenesmus is severe; and the belly is commonly tense and tender, sometimes also swollen, though not frequently,—sometimes even on the contrary drawn in at the navel.[614] When the diarrhœa is severe, the anus is commonly excoriated and affected with burning pain.[615] In such cases the burning pain may extend along the whole course of the alimentary canal from the throat to the anus. Nay at times the mouth and lips are also inflamed, presenting dark specks or blisters.[616] Sometimes there are likewise present signs of irritation of the lungs and air-passages,—almost always shortness of breath (which, however, is chiefly owing to the tenderness of the belly),—often a sense of tightness across the bottom of the chest, and more rarely decided pain in the same quarter, darting also through the upper part of the chest. Sometimes pneumonia has appeared a prominent affection during life, and been distinctly traced in the dead body.[617] In many instances, too, the urinary passages are affected, the patient being harassed with frequent, painful and difficult micturition, swelling of the penis, and pain in the region of the bladder, or, if a female, with burning pain of the vagina and excoriation of the labia.[618] Sometimes the irritation of the urinary organs is so great as to be attended with total suppression of urine, as in a case related by Guilbert of Montpellier, in which this symptom continued several days.[619] During the late contentions among chemists, physiologists, and physicians, occasioned by the case of Madame Lafarge, it was alleged by Flandin and Danger that in animals the urine is always suppressed, by Orfila that it is always secreted, by Professor Delafond of the Alfort Veterinary School, that it is never suppressed, but always diminished, and sometimes even to a sixth of the natural quantity.[620] There is, however, no invariable rule in the matter. And in fact, urinary symptoms are seldom present unless the lower bowels are likewise strongly irritated; but are then seldom altogether wanting. They are rarely well marked in cases of the present variety, unless life is prolonged three days or more. When symptoms of irritation of the alimentary canal have subsisted a few hours, convulsive motions often occur. They commence on the trunk, afterwards extend over the whole body, are seldom violent, and generally consist of nothing else than tremors and twitches. Cramps of the legs and arms, a possible concomitant of every kind of diarrhœa, is peculiarly severe and frequent in that caused by arsenic. The general system always sympathizes acutely with the local derangement. The pulse commonly becomes very small, feeble and rapid soon after the vomiting sets in; and in no long time it is often imperceptible. This state is naturally attended with great coldness, clammy sweats, and lividity of the feet and hands. Another symptom referrible to the circulation which has been observed, though, very rarely, is palpitation.[621] The countenance is commonly collapsed from an early period, and almost always expressive of great torture and extreme anxiety or despair; the eyes are red and sparkling; the conjunctiva often so injected as to seem inflamed; the tongue and mouth parched; and the velum and palate sometimes covered with little white ulcers. Delirium sometimes accompanies the advanced stage, and stupor also is not unfrequent. Coma occasionally precedes death, as in Mr. Stallard’s case (p. 235), in which the symptoms of irritation, at first very violent, gradually gave place in two hours to complete insensibility, proving fatal in two hours more. Very often, however, the patient remains quite sensible to the last. Death in general comes on calmly, but is sometimes preceded by a paroxysm of convulsions.[622] In some cases it takes place quite unexpectedly, as if from sudden deliquium, as in a case mentioned by Dr. Dymock of this city. The patient, a girl who had taken two ounces intentionally, rose from her bed without help two hours and a half afterwards, went to a chair at the fireside, and had scarce sat down when she expired.[623] Various eruptions have at times been observed, especially in those who survive several days; but they are more frequent in the kind of cases to be considered afterwards, in which life is prolonged for a week or more. The eruptions have been variously described as resembling petechiæ, or measles, or red miliaria, or small-pox. In the case already quoted from Guilbert a copious eruption of miliary vesicles appeared on the fifth day, and for fifteen days afterwards. They were attended with perspiration and abatement of the other symptoms, and followed with desquamation of the cuticle. Another external affection which may be noticed is general swelling of the body. Several cases of this nature have been described by Dr. Schlegel of Meiningen; and in one of them the swelling, particularly round the eyes, appears to have been considerable.[624] In some cases of the kind now under consideration a short remission or even a total intermission of all the distressing symptoms has been witnessed, particularly when death is retarded till the close of the second or third day.[625] This remission, which is accompanied with dozing stupor, is most generally observed about the beginning of the second day. It is merely temporary, the symptoms speedily returning with equal or increased violence. Sometimes the remission occurs oftener than once, as in a case related in the London Medical and Physical Journal. The patient, a child seven years old, lived thirty-six hours in a state of alternate calm and excitement; and during the state of calm no pulse was to be felt at the wrists.[626]—So far as at present appears a long intermission is impossible. In cases such as those now described death often occurs about twenty-four hours after the poison is swallowed, and generally before the close of the third day. But on the one hand life has been sometimes prolonged, without the supervention of the symptoms belonging to a different variety of cases, for five or six days,[627] nay perhaps even for several weeks. And, on the other hand, the symptoms of irritation of the alimentary canal are sometimes distinct, although death takes place in a much shorter period than twenty-four hours. Metzger has related a striking case, fatal in six hours, in which the symptoms were acute colic pain, violent vomiting, and profuse diarrhœa;[628] and Wildberg has related a similar case fatal in the same time.[629] Hohnbaum describes another fatal in five hours;[630] and I met with as brief a case in this city in 1843, where all the usual symptoms of irritation in the stomach and bowels were violent. These symptoms were also present at first in Mr. Stallard’s case, which was fatal in four hours; Pyl has recorded one, where all the signs of irritation in the stomach and intestines were present, except vomiting, and which proved fatal in three hours;[631] and Dr. Dymock met here with a similar instance which lasted only two hours and a half.[632] This is one of the shortest undoubted cases of poisoning from arsenic I have hitherto found in authentic records. Dr. Male mentions one, which was fatal in four hours;[633] Wepfer another equally short;[634] Johnston another fatal in three hours and a half;[635] and I shall presently mention others without symptoms of irritation which ended fatally in two, five, or six hours [p. 242].[636] Wibmer has even quoted a case fatal in half an hour; but there seems to have been some doubt whether the poison taken was arsenic.[637] Such is an account of the symptoms of poisoning by arsenic in their most frequent form. It will of course be understood, that they are liable to a great variety as to violence, as well as their mode of combination in actual cases;—and that they are by no means all present in every instance. The most remarkable and least variable of them all, pain and vomiting, are sometimes wanting. A case, in which pain was not felt in the stomach, even on pressure, although the other symptoms of inflammation were present, has been briefly described in the Medical Repository.[638] A similar case fatal in fourteen hours and a half, where there was much vomiting and some heat in the stomach, but no pain or tenderness, has been related by Dr. E. Gairdner.[639] Another very striking example of this anomalous deficiency has been detailed by Dr. Yellowly. A lad sixteen years old died twenty-one hours after swallowing half an ounce of the white oxide; and the presence of inflammation was denoted all along by sickness, vomiting, purging, and heat in the tongue; yet he never complained of pain, neither did he ever seem to his friends to suffer any. Another anomaly in the case was, that the pulse, contrary to what is usual, was very slow: twelve hours after he took the poison, the pulse was 40, and two hours before death it was so slow as 30.[640] These deviations from the ordinary course of the symptoms are taken notice of merely to put the practitioner on his guard, and prevent the medical jurist from drawing hasty conclusions. Upon the whole, they are rare; and the symptoms of poisoning by arsenic are in general very uniform.