quency of gout in its subjects; this coincidence is much more common in
England than in America. In districts where the ordinary type of gout is
rare it is said that the disease is seldom induced by lead.
The prognosis depends upon the degree of the intoxication; it is favorable
in early instances. Atrophic paralysis is likely to prove difficult of cure and
the mental symptoms of lead encephalopathy may be permanent. The arterial
lesions and those of the viscera which are evidenced by degenerative changes
are usually incurable.
Treatment. Prophylaxis is of the greatest importance and the public
should be more fully instructed concerning the dangers of lead. Special
precautions are required in lead works, paint factories and in exposed trades.
Dust should be avoided as much as possible, and, where this is necessarily
present, thorough ventilation is an absolute essential. The necessity of fre-
quent bathing and thorough washing before eating cannot be too strongly im-
pressed upon the workman. The addition to the bath of sodium hypochlorite
or potassa sulphurata has been suggested upon the ground that the sulphur
neutralizes the lead by forming insoluble compounds with it. Food should
not be permitted upon the premises and the clothing should be changed before
leaving the works. The systematic use of milk in large amounts as a food
is to be recommended. Sulphuric acid lemonade is generally employed as a
prophylactic but is not particularly reliable. Weak or anaemic individuals
should not be employed as workers in lead and it is advisable that women
should be altogether excluded from such occupations.
In treatment the first indication is to remove the patient from the danger
of further poisoning. In general, reliance is placed upon potassium iodide,
saline purgatives, diuretics and the use of hot baths and massage to promote
elimination, and upon the employment of appropriate measures to improve
the patient's nutrition and strength. Potassium iodide is in universal use
and appears to have a beneficial effect though the manner of its action is
not clearly understood. It has been supposed to accelerate elimination
through the kidneys, but it has recently been denied that the drug has any
influence upon excretion by the urine or by the intestinal tract through which
most of the lead escapes from the body. Baths of sulphurated potassium are
efficient, especially if the patient is well soaped afterward and then thoroughly
rinsed and rubbed with a rough towel. For the colic opium or morphine
is often necessary, alum in 2 grain (0.13) doses is of great service and dilute
sulphuric acid is also useful. The constipation may be relieved by a combi-
nation of magnesium sulphate and dilute sulphuric acid and the lead cachexia
is greatly benefited by the latter, given in connection with quinine and ferrous
19
290 THE INTOXICATIONS.
sulphate. In certain instances of chronic plumbism cathartics fail to act
unless morphine is given to overcome the intestinal inhibition produced by
the irritation resulting from the lead. Opiates may also be required for the
relief of the joint pains. For the paralyses strychnine may be administered
but our chief reliance is placed upon electricity and massage (see the section
upon the treatment of multiple neuritis). If the muscles contract in response
to the faradic current this should be employed, but if not the galvanic current
should be used. Nephritis and gout due to lead intoxication should be treated
in the same way as when resulting from other causes and the cerebral symp-
toms must be dealt with according to the special manifestations which present
themselves.
ARSENICAL POISONING.
Acute Arsenic Poisoning as a result of the ingestion of Paris green, or of
one of the various rat or vermin poisons which contain this substance (cupric
arsenite), is common.
Symptoms. These as well as the pathology of the condition closely
resemble those of Asiatic cholera. Large doses often cause no distress for
a considerable period, but, within a half hour or perhaps longer, the patient
experiences dysphagia with a sense of faucial constriction. Epigastric pain,
quickly becoming extreme and general over the abdomen, follows; with it
are associated nausea and excessive emesis and later there is profuse watery
diarrhoea with tenesmus and thirst. The vomitus and stools may contain
blood and there are muscular cramps, headache and dizziness; collapse
ensues, with coldness of the extremities, pallor, small, feeble pulse and sighing
respiration. Coma follows, and death, sometimes preceded by convulsions,
takes place. Rarely the only symptoms noted have been collapse and coma.
Death may occur within 24 hours but usually the patient lingers for several
days. If recovery takes place the symptoms of chronic arsenic poisoning
may develop.
Treatment consists in immediately emptying the stomach by lavage or by
emetics such as zinc sulphate, 20 to 30 grains (1.33 to 2.0) or a tablespoonful
of mustard to a tumbler of warm water. After the gastric contents have
been removed the organ should be repeatedly washed with warm water on
occount of the insolubility of the arsenic. At the same time large amounts
of freshly prepared ferric hydroxide with magnesium oxide or dialyzed iron,
one ounce (30.0) should be given. The former mixture may be prepared
by using 150 grains (10. o) of magnesiimi oxide to which is added sufficient
water to make a thin magma which is slowly poured into a solution consisting
of ferric sulphate. 10 drachms (40.0) and water, 4 oimces (120.0); the product
is then shaken until a smooth mixture results. If either of these antidotes is
ARSENICAL POISONING. 29 1
unobtainable light magnesia mixed with water may be substituted. The
antidote must be repeated at intervals as long as acute symptoms persist. If
neither magnesia nor the iron preparations are available, dependence may
be placed upon large doses of castor oil and water. The collapse should
be combated by means of subcutaneous injections of brandy or aether and warm
applications made to the abdomen and extremities.
Chronic Poisoning. The medicinal administration of arsenic in too large
doses may induce slight toxic symptoms such as abdominal pain, anorexia,
nausea, indigestion, mild diarrhoea, puffiness of the eyelids, conjunctival
injection and watering of the nose and eyes. Cutaneous eruptions are some-
times caused, and, while these may be in part a result of circulatory disorders,
they are believed to be due chiefly to a direct action of the drug upon the skin.
They may be erythematous, papular, vesicular or pustular and may be asso-
ciated with a swelling resembHng that of erysipelas. Prolonged administration
of arsenic, it is said, may cause herpes zoster.
Arsenic is extensively used in the arts, especially in the manufacture of
wall papers and fabrics, and consequently accidental poisoning among w^orkers
in arsenic is not rare; it may also occur in individuals who use articles con-
taining the drug. The evidence regarding chronic poisoning from occupancy
of rooms decorated with arsenical wall papers is contradictory but the facts
favor its probabihty. Quite as often the poisoning is due to the arsenic which
contaminates aniline dyes as it is to arsenical pigments, consequently chemi-
cal examination should be depended upon rather than color. Epidemic
arsenic poisoning has occurred from the use of beer in the manufacture of
which contaminated glucose has been employed.
Symptoms. In addition to the manifestations mentioned above, chronic
arsenic poisoning is evidenced by a catarrhal condition of the nasal and
phar}Tigeal mucous membranes, vnth sneezing and coughing; the various
cutaneous eruptions appear and in some instances there is a pigmentation
of the skin (arsenic melanosis); eventually the hair and nails fall. Enlarge-
ment of the liver with jaundice is sometimes observed and the later phases
of the disorder are characterized by localized sensory and motor disturbances,
chiefly in the hands and feet, resulting from polyneuritis. There are acute
pain and sensations of formication in the extremities, followed by sensory
paralyses with symptoms analogous to those of locomotor ataxia. These
symptoms are followed by motor paralysis, as a rule confined to the limbs,
but in some instances involving the trunk. The paralysis is usually symmet-
rical and the affected muscles, which are more often those of the extensor
than flexor groups, become atrophied. Herpes zoster of the face or trunk
is common. In very protracted cases the patient may sink into an apathetic
semi-idiotic state or epilepsy may supervene. After death, in addition to
the lesions in the digestive organs and nervous system, a condition of fatty
292 THE INTOXICATIONS.
degeneration of the viscera, especially the liver, kidneys, stomach and heart,
as well as of the muscles, is found.
A more full discussion of the nervous symptoms of chronic arsenical poison-
ing will be found in the section upon multiple peripheral neuritis.
Treatment consists in the discontinuance of arsenic if this is being admin-
istered, or if the condition is the result of arsenical surroundings, a removal
from exposure. Elimination of the drug should be accelerated by means
of laxatives, diuretics, diaphoretics, and the administration of potassium
iodide. ^ The treatment is otherwise symptomatic; the management of the
paralyses will be discussed under the treatment of multiple peripheral neuritis.
Tonics and plenty of nourishing and easily digestible food are indicated.
Recovery usually takes place.
MERCURIAL POISONING.
Synonym. Mercurialism.
Acute Mercury Poisoning from corrosive sublimate or white precipitate
is not unusual. Merciiry bichloride in toxic dosage at once causes a metallic
taste in the mouth, extreme pain in the pharynx and stomach, rapidly followed
by intense retching and emesis. The vomitus soon becomes bloody and
violent purging occurs, the stools being at first serous in character, later
hsemorrhagic. The urine becomes scanty and contains albumin, casts and
blood; the pulse becomes weak and rapid, the temperature falls below normal,
all the vital energies are depressed and death may take place within a short
time.
The post mortem lesions are usually those of a membranous colitis and a
parenchymatous and heemorrhagic nephritis, with general degeneration of
the tubal epithelium; more rarely there is a peculiar deposit of calcium phos-
phate.
Treatment. The stomach should, if possible, be emptied immediately by
means of the stomach tube, or if this is not at hand emesis should be provoked
by faucial irritation, draughts of mustard and warm water or by the hypo-
dermatic injection of apomorphine hydrochloride in dose of ttt of a grain
(0.006). Albumin in the form of the white of egg, that of one being suflScient
antidote for 4 grains (0.24) of corrosive sublimate, the albuminate redis-
solving in an excess, or milk and flour should be given. Tannic acid is also
useful since it protects the mucous membranes of the gastro-intestinal tract
from the action of the drug.
Chronic Mercziry Poisoning is less frequently observed than formerly
when the administration of large doses of the drug was common. Workers
in the metal are sometimes affected, the most profound instances of intoxi-
cation being due to the prolonged exposure to its fumes.
MERCURIAL POISONING. 293
Symptoms. The first evidences of mercurialism are referable to the mouth.
At first there is sUght foetor of the breath, later an unpleasant metallic taste
and tenderness of the teeth when they are forcibly brought together are noted.
These are followed by stomatitis, sponginess of the gums and sahvation.
If the ingestion of the mercury is continued the amount of saliva secreted
becomes enormous; it is irritant and contains mercury. The breath becomes
very foul, the gums are intensely inflamed, bleed at the lightest touch and
are marked at the junction of the teeth by a dark red line. The teeth are
loosened and may faU, the tongue and lips become involved in an obstinate
inflammation which proceeds to ulceration, and, extending as gangrene to
the cheeks, may produce frightful facial deformity. Even the maxiUary
bones may undergo necrosis. Nervous symptoms such as tremors, erythism,
and haUucinations may appear and the faculties may be dulled. There is
general muscular weakness and paralysis with areas of partial anaesthesia
and joint pains may occur. The peripheral neuritis of chronic mercm-ialism
is a much later manifestation than that of plumbism and even after the develop-
ment of the palsies the muscles retain their irritability and do not undergo
atrophy. The reflexes are usually unaffected; rarely they may be exag-
gerated. General nutrition is impaired and metabolism is profoundly affected,
anaemia and marked cachexia resulting. With the cachexia the heart becomes
weakened, the respiration rapid and shallow and the mentality impaired;
the memory is imperfect, the temper irritable and melancholia and even
mania may ensue. The special senses are affected as evidenced by deafness,
dimness of sight and impairment of taste and sensation.
Treatment consists in acceleration of the elimination of the mercury through
aU possible channels. Elimination through the skin is favored by baths of
sulphur and ordinary hot water and diuresis should be induced by causing
the patient to drink as much water as can conveniently be borne and by the
administration of diuretic drugs. Free evacuation of the bowels is necessary
but if marked diarrhoea is present it may call for treatment by means of opiates
and other remedies. The pain may necessitate the employment of opium.
The common belief that potassivun and sodium iodides have an effect in
causing the elimination of the metal has been disputed but never disproven;
at any rate the proper administration of these drugs can do no harm; care,
however, should be taken that the doses are not too large, for the combination
of iodine with mercury in the tissues produces a soluble salt which is very
active and may, at times, cause secondary systemic merciirial poisoning.
Belladonna is sometimes required to diminish the excessive secretion of saHva
and in aU instances a mouth wash of potassium chlorate solution is useful in
the relief of the salivation and stomatitis; tincture of m)Trh may be added
to it and a mouth wash of tannic acid may also be employed. Careful atten-
tion should be given to the general hygiene and the cachexia should be com-
294 THE INTOXICATIONS.
bated by plenty of nutritious food and such tonic and other remedies as may
be indicated. The treatment in other regards is symptomatic; for the neuritis
the methods and means of treatment suggested in the section upon multiple
peripheral neuritis should be employed. Prophylactic means such as those
indicated in the prevention of plumbism should be recommended in estab-
lishments where mercury is used.
â– y ANTIMONIAL POISONING.
Acute Antimonial Poisoning resembles in its symptoms acute arsenical
intoxication, the chief manifestations being those of intensely acute gastro-
intestinal irritation. At autopsy the mucous membrane of the stomach and
intestine is found in a state of hj^ersemia and tumefaction; erosions and
ecchymoses are usually present. There are often pustules in the mouth,
oesophagus, stomach and small intestine and pulmonary congestion or inflam-
mation may be demonstrable.
Treatment. The vomiting caused by the drug itseK usually obviates the
employment of emetics but if free emesis has not taken place gastric lavage
is indicated or apomorphine hydrochloride, tV of a grain (0.006) hypoder-
matically or zinc sulphate, 20 to 30 grains (1.33 to 2.0) by mouth should be
administered. The bowels should be cleared of the poison in this situation
by a purge. The antimony in the stomach may be precipitated by tannic
acid in doses of 30 grains (2.0); the tannate thus formed should be washed
out. If the acid is unobtainable a strong infusion of hot tea may be substi-
tuted. The gastric irritation may be alleviated by mucilaginous drinks
and milk. The cardiac depression should be combated by means of hypoder-
matic injections of alcohol, aether or strychnine and hot applications to the
abdomen and extremities are indicated.
Chronic Antimony Poisoning is of rare occurrence and difl&cult of diagnosis,
the symptoms being of indefinite character. They consist of headache,
vertigo, depression, impaired vision, nausea, vomiting, gastric disturbance
with pain, diarrhoea, albuminuria, emaciation, weakness, exhaustion and
ultimate collapse. The resemblance of the symptoms to those of catarrhal
gastro-enteritis renders the diagnosis of chronic antimony intoxication, when
the drug is given with homicidal intent, very difficult.
After death antimony is said to be found in the liver, spleen, kidneys, bones
and muscles; fatty degeneration of the viscera is also observed. The pro-
tracted administration of tartar emetic is stated to produce pustular erup-
tions.
Treatment consists in stopping the drug and in the employment of symp-
tomatic and stimulative measures.
lODISM. 295
lODISM.
lodism, the term applied to the train of symptoms resulting from the pro-
longed administration of the iodides, is induced by all these salts; the basic
ion does not appear to be concerned in the effect produced. Owing to the
fact that iodine is more readily freed from it, ammonium iodide is said to be
more likely to cause iodism than the other salts.
Symptoms. These may be separated into two groups, (i) Frequently
there is catarrh of the respiratory passages which commences in the nasal
mucous membrane and is evidenced by a profuse watery discharge; the inflam-
mation extends upward and downward producing conjunctivitis and perhaps
severe headache due to involvement of the frontal sinuses. Accompan^ang
this there is faucial swelling and irritation, the tonsils may become inflamed,
and laryngitis and bronchitis may result. Laryngeal oedema may occur and
cause death unless relieved. Somewhat later an eruption may appear, con-
sisting of erythematous patches or papules which may become pustular;
other eruptions have been observed. (Edema of the face is met in some
instances and there may be albuminuria. Nervous manifestations such as
neuralgia, tinnitus aurium, convulsive movements, disturbed inteUection
and rarely atrophy of the mammje and testes, have been described. (2)
Iodic cachexia, in which rapid emaciation takes place, is a late phenomenon
and intense cardiac palpitation and ravenous appetite may develop.
The local manifestations of iodism can sometimes be prevented by the
administration of alkalies and hence it is thought that the variation of their
extent in different individuals, or in the same person at different times, may
be explained by a varying degree of acidity. A tolerance may be established
and sometimes the symptoms disappear while the drug is still being taken.
Even though the manifestations may be intense they usually cease soon after
treatment is discontinued and the chewing of pellitory will hasten the elimi-
nation of iodine in the chronic forms. WTien iodic cachexia has occurred
the symptoms may not disappear for a considerable time.
BROMISM.
This term has been given to the toxic symptoms resulting from the pro-
longed administration of the bromides. The condition is rarely caused by
hydrobromic acid although this substance contains a relatively large propor-
tion of bromine. ^
Symptoms. The first of these is usually a papular acneiform eruption
appearing chiefly upon the face and back. In marked instances the papules
become pustules which may coalesce, forming small abscesses which at times
become ulcers. At other times the rash resembles eczema and sometimes
there is an erythema or a brown pigmentation of the skin. The tongue is
296 THE INTOXICATIONS.
coated and there are digestive disturbances; frequently there is a coryza which
may be associated with increased bronchial secretion and mild conjunctivitis.
These manifestations are attributed to a local irritant action partly due to
the salt action of the bromine salt and partly to decomposition of the bromide,
with liberation of bromic acid and bromine by the free acids in different situa-
tions, as hydrochloric acid in the stomach, carbon dioxide in the air passages,
etc. This action takes place more readily in old age and if renal insufficiency
is present. From the influence of the drug on the nervous system the cuta-
neous sensibility and the sensitiveness of the faucial mucous membrane are
distinctly reduced while the sexual desire becomes diminished. There is
indisposition on the part of the patient to any exertion, he is easily fatigued,
his gait is uncertain and there is often marked muscular tremor. The intel-
lect is dulled and the memory impaired, the patient takes little interest in
his surroundings, his speech is slow and he may stammer, mispronouncing
words or omitting several from a spoken sentence. The facies is apathetic
and stupid and the eyes are heavy and without lustre. Mental excitement,
confusion and sometimes delirium may follow the continued use of mioderate
doses, especially of the potassium salt. The habitual user of bromides is
unable to sleep without them, and a gradual increase of the dose is required
to induce slumber, consequently the systemic effects are usually disastrous.
In addition the patient's powers of resistance to disease are lowered and inter-
current affections, such as pneumonia or even bronchitis, may result in death.
Notwithstanding the severity of the symptoms of bromism, they soon dis-
appear after the withdrawal of the drug and its elimination from the system.
Treatment consists in stopping the administration of the bromides and in
the employment of measures calculated to relieve the symptoms and to support
the patient.
BORISM.
The continued internal use of too large amounts of boric acid or borax
(sodium biborate) results in a train of symptoms which has been denominated
borism. In some instances even moderate doses of these substances have a
mild aperient action while in large amounts they are gastro-intestinal irri-
tants and cause emesis and piirging. Other symptoms produced by toxic
quantities are dryness of the pharynx and dysphagia, intense muscular weak-
ness, pain in the back and vesical tenesmus with albuminaria and sometimes
haematuria, impairment of sight, headache, insomnia and nervous depression,
which may be followed by fatal collapse. A rise of temperatiire is frequently
observed and in the course of 2 or 3 days, if death does not supervene, scaly,
papular or eczematous eruptions appear upon the skin. The symptoms
are evidenced more rapidly when the drugs are taken by mouth but mani-
festations of the same character may result from their free application in the
ALCOHOLISM. 297
rectum, vagina or other parts. Boric acid and borax are rapidly absorbed from
the mucous membranes and from abrasions, and serious instances of poisoning
have been reported as due to the use of the acid as an antiseptic dressing.
In chronic poisoning the symptoms are often very similar to those of acute
intoxication, the cutaneous manifestations are, however, more prominent and
may constitute the only positive evidence of toxic effect, although there are usu-
ally indications of more or less gastro-intestinal and renal irritation. CEdema
of the face and extremities may occur as a result of the latter, and consequently
it is advisable to keep a careful watch of the condition of the urine whenever
these drugs are administered. The hair often becomes dry and falls, and
the eruption upon the skin may resemble a seborrhoeic eczema, appearing
as reddish patches which desquamate like psoriasis, or papules attended
with marked pruritus. The most common eruption is said to be scaly, assum-
ing the form of a seborrhoeic dermatitis, but usually associated with much
more oedema. Sometimes the skin and mucous membranes are dry, the
lips become fissured, the nails are striated and a blue line similar to that of
plumbism may appear upon the gums. The question of the effect of the con-
tinued and habitual introduction into the organism of boric acid or borax
as employed in the preservation of food, is of considerable interest. The
results of careful experimentation conducted by the Bureau of Chemistry,
United States Department of Agriculture, show, on the whole, that 7^ grains
(0.5) daily is too much for a normal man to receive regularly; on the other
hand a normal individual may take this quantity of boric acid or borax, ex-