4. The last variety comprehends cases of perfect recovery, which are

sufficiently numerous even under unpromising appearances. From the average of 55 cases recorded by Tartra it appears that the chances of death and recovery are nearly equal. Twenty-six died, 19 of the primary, 7 of the secondary disorder. Twenty-nine recovered, and of these twenty-one perfectly. Suicidal are for obvious reasons more frequently fatal than accidental cases. Tartra has not taken notice in his treatise of another form of poisoning with the strong acids,—in which the injury is confined to the gullet and neighbouring parts. In Corvisart’s Journal there is the case of a man, who began to drink sulphuric acid for water while intoxicated, but suddenly found out his error before he had swallowed above a few drops; and consequently the chief symptoms were confined to the throat. After his physician saw him he was able to take one dose of a chalk mixture; but from that time he was unable to swallow at all for a fortnight.[265] Martini likewise met with a similar instance of complete dysphagia from stricture in the gullet caused by sulphuric acid.[266] His patient recovered. It also appears exceedingly probable, that the strong acids may cause death, without reaching the stomach or even the gullet, by exciting inflammation and spasm of the glottis and larynx. Such an effect may very well be anticipated from an attempt to commit murder with these poisons; as the person, if he retains consciousness at the time, may become aware of their nature before he has swallowed enough to injure the stomach. Thus, Dr. A. T. Thomson says in 1837, that he once met with the case of a child, who, while attempting to swallow strong sulphuric acid by mistake for water, died almost immediately, to all appearance from suffocation caused by contraction of the glottis; and it was ascertained after death that none of the poison had reached the stomach.[267] Professor Quain describes a similar case, occurring also in a child, where impending death was prevented by artificial respiration, and acute bronchitis ensued, which proved fatal in three days. In this instance thickening of the epiglottis and great contraction of the upper opening of the larynx showed the violent local injury inflicted there, inflammation could be traced down the trachea into the bronchial tubes, but no trace of injury could be detected in the gullet and stomach.[268] In a very interesting and carefully detailed case by Mr. Arnott, where the poison taken was the nitric acid, the injury was confined in a great measure to the gullet and larynx,—the stomach, which was distended with food at the time, being very little affected. The chief symptoms at first, besides great general depression, were croupy respiration and much dyspnœa, which became so urgent, that laryngotomy was performed, and with complete relief to the breathing. But the patient nevertheless rapidly sunk under the symptoms of general exhaustion, and died in thirty-six hours without presenting any particular signs of the operation of the poison on the stomach; and the traces of action found there after death were trifling.[269] The importance of the fact established by these cases will appear from the following medico-legal inquiries. A Prussian medical college was consulted in the case of a new-born child, in which the stomach and intestines were healthy, and did not contain poison, but in which the cuticle of the lips was easily scraped off, the gums, tongue, and mouth yellowish-green, as if burnt, the velum and uvula in the same state, the rima glottidis contracted, and the epiglottis, larynx, and fauces violently inflamed. The College declared, that a concentrated acid had been given, and that death had been occasioned by suffocation. Sulphuric acid was found in the house; and the mother subsequently confessed the crime.[270] A case was formerly quoted (p. 75), where MM. Ollivier and Chevallier found traces of the action of nitric acid on the lips, mouth, throat and upper fourth of the gullet, but not lower. In this instance the reporters came to the opinion from the absence of injury in the more important parts of the alimentary canal, as well as from the marks of nail scratches on the neck, and the gorged state of the lungs, that death had been produced by strangling, after an unsuccessful attempt by the forcible administration of nitric acid. It is quite possible, however, that death might quickly ensue from the effects of the poison on the throat and gullet. In the course of the judicial inquiries M. Alibert stated that he had known repeated instances of death from swallowing nitric acid, although none of it reached lower down than the pharynx. Ollivier in his paper doubts the accuracy of this statement; but the cases quoted above show clearly that such injury may be done to the glottis as will be adequate of itself to occasion death.[271] It seems farther not improbable that, among the terminations of poisoning with the strong mineral acids, scirrhous pylorus must also be enumerated. This is a very rare effect of the action of corrosive poisons. But M. Bouillaud has related an instance of death from scirrhous pylorus in its most aggravated shape, which supervened on the chronic form of the effects of nitric acid, and which proved fatal in three months.[272] In some circumstances the stomach seems to acquire a degree of insensibility to the action of the strong acids. Tartra, in alluding to what is said of certain whisky-drinkers acquiring the power of swallowing with impunity small quantities of the concentrated acids, has related the case of a woman at Paris, who, after passing successively from wine to brandy and from that to alcohol, at last found nothing could titillate her stomach except aqua-fortis, of which she was seen to partake by several druggists of veracity.[273] The fire-eating mountebanks too are said to acquire the same power of endurance; but much of their apparent capability is really legerdemain. On the other hand, a very extraordinary sensibility to the action of the diluted mineral acids has been supposed to exist in the case of infants at the breast,—so great a sensibility, that serious symptoms and even death itself have been ascribed to the nurse’s milk becoming impregnated with sulphuric acid, in consequence of her having taken it in medicinal doses. By two writers in the London Medical Repository griping pains, tremors and spasms have been imputed to this cause;[274] and a writer in the Medical Gazette says he has seen continued griping, green diarrhœa and fatal marasmus ensue,—apparently, he thinks, from ulceration of the gastro-intestinal mucous membrane.[275] Without questioning the great delicacy and tenderness of that membrane in infants, I must nevertheless express my doubts whether so small a quantity taken by a nurse, amounting in the cases in question only to four or six drops a day, could really produce fatal or even severe effects on her child. Sulphuric acid is not less deadly when admitted into the body through other channels besides the mouth. Thus, it may prove fatal when introduced into the rectum. A woman at Bruges in Belgium had an injection administered, in which, being prepared hastily in the middle of the night, sulphuric acid had been substituted by mistake for linseed-oil. The patient immediately uttered piercing cries, and passed the remainder of the night in excessive torture. In the morning the bed-clothes were found corroded, and a portion of intestine had apparently come away; and she expired not long afterwards.[276] Death may also be occasioned by the introduction of this acid into the ear. Dr. Morrison relates a case of the kind, where nitric acid, which is analogous in action, was poured by a man into his wife’s ear, while she lay insensible from intoxication. She awoke in great pain, which continued for two or three days. In six days an eschar detached itself from the external passage of the ear; and this was followed by profuse hemorrhage, which recurred daily more or less for a month. On the day after the eschar came away, and without any precursory symptom referrible to the head, she was attacked with complete palsy of the right arm, and in eight days more with tremors and incomplete palsy of the rest of that side of the body. These symptoms subsequently abated; but they again increased after an imprudent exertion, and she died in a state of exhaustion seven weeks after the injury. The whole petrous portion of the temporal bone was found carious, but without any distinct disease of the brain or its membranes.[277] Sulphuric acid and the other mineral acids are equally poisonous when inhaled in the form of gas or vapour; and they then act chiefly by irritating or inflaming the mucous membrane of the air-passages and lungs. For some observations on their effects in this form both on plants and animals the reader may refer to the Chapter on Poisonous Gases. Sulphuric acid belongs to the poisons alluded to under the head of General Poisoning,—of whose operation satisfactory evidence may be occasionally drawn from symptoms only. If immediately after swallowing a liquid which causes a sense of burning in the throat, gullet, and stomach, violent vomiting ensues, particularly if the vomited matter is mixed with blood; if the mouth becomes white, and stripped of its lining membrane, and the cheeks, neck, or neighbouring parts show vesications, or white, and subsequently brown excoriated spots;—if the clothes show red spots and are moist and disintegrated there,—I cannot see any objection to the inference, that either sulphuric or muriatic acid has been taken. In this opinion I am supported by a good authority, Dr. Mertzdorff, late medical inspector at Berlin.[278] SECTION III.—_Of the Morbid Appearances caused by Sulphuric Acid._ The outward appearance of the body in cases of Tartra’s first variety in the action of the acids is remarkably healthy; every limb is round, firm, and fresh-looking. On the lips, fingers, or other parts of the skin, spots and streaks are found where sulphuric acid has disorganized the cuticle. These marks are brownish or yellowish-brown, and present after death the appearance of old parchment or of a burn; sometimes there are little blisters.[279] The lining membrane of the mouth is more or less disorganized, generally hardened, and whitish or slightly yellowish. The pharynx is either in the same state, or very red or even swelled. The rima glottidis, as in the case described by Dr. Sinclair and in that of Mr. Arnott, is sometimes contracted, the epiglottis swelled, or on the contrary shrivelled, and the commencement of the larynx inflamed.[280] The gullet is often lined with a dense membrane, adhering firmly, resembling the inner coat, but probably in general a morbid formation; and the subjacent tissue is brown or red. Sometimes, however, the inner coat or epithelian of the gullet loses its vitality, and is detached in part or altogether. In Mr. Arnott’s case the pharynx and upper gullet were lined by a pale lemon-coloured membrane, which in the lower two-thirds of the canal was completely detached and was plainly the œsophageal membrane; in the case related by Mertzdorff, the whole inner coat of the gullet, as well as that of the throat, epiglottis, and mouth, was stripped from the muscular coat;[281] and in Dr. Wilson’s case (p. 131), which proved fatal in ten months, the upper third of the gullet shone like an old cicatrix, and the lower two-thirds were narrowed, vascular, and softened on the surface.[282] In a few rare cases of chronic poisoning with the mineral acids the gullet is found perforated by an ulcerative process;[283] but it is never perforated by their corrosive action in quickly fatal cases. Occasionally the gullet is not affected at all, though both the mouth and the stomach are severely injured; and an instance has even been published where the acid, in this instance the nitric, left no trace of its passage downwards till near the pylorus.[284] The outer surface of the abdominal viscera is commonly either very vascular or livid, or bears even more unequivocal signs of inflammation, namely, effusion of fibrin and adhesions among the different turns of intestine; and these appearances may take place although the stomach is not perforated.[285] The cause of this appearance, which is seldom observed in poisoning with other irritants, more especially with the metallic irritants, is that the acid passes through the membranes of the stomach by transudation during life,—as will be proved immediately. It must be observed, that the peritonæum is sometimes quite natural after death from sulphuric acid, even although the stomach was perforated. I have seen this in a case which proved fatal in twelve hours. An important appearance in the abdomen, to which less attention has been hitherto paid than it deserves, is gorging of the vessels beneath the peritonæal membrane of the stomach and adjoining organs with dark, firmly coagulated blood, arising from the acid having transuded through the membranes and acted on the blood chemically. My attention was first turned to this appearance by an interesting case, which I saw in 1840 in the Royal Infirmary of this city, and of which an able account has been published by Dr. Craigie.[286] The whole vessels of the stomach were seen externally to be most minutely injected and gorged, and the blood in them was coagulated into firmly-cohering cylindrical masses, as if the vessels had been successfully filled with the matter of an anatomical injection. This appearance was also observed in the superior mesenteric arteries, in the omental vessels, and over the greater part of the mesentery. It was occasioned by the chemical action of the acid coagulating the colouring matter and albumen; for the clotted blood was strongly acid to litmus-paper. So too was the peritoneal surface of the stomach, omentum and intestines. And the acid had transuded through the stomach and into the omentum and tissues of the intestines during life; for in the first place, there was no perforation of the stomach, and secondly, I ascertained that there was no free acid either in the matter discharged from the stomach before death after the free administration of antacids, or in the contents of the stomach obtained at the examination of the dead body. The stomach, if not perforated, is commonly distended with gases. It contains a quantity of yellowish-brown or black matter, and is sometimes lined with a thick paste composed of disorganized tissue, blood and mucus. The pylorus is contracted. The mucous membrane is not always corroded. If the acid was taken diluted, the coats may escape corrosion; but there is excessive injection, gorging, and blackness of the vessels, general blackness of the membrane, sometimes even without softening, as in a case related by Pyl of a woman who first took aqua-fortis and then stabbed herself.[287] More commonly, however, along with the blackness there is softening of the rugæ or actual removal of the villous coat, and occasionally regular granulated ulceration with puriform matter on it.[288] The stomach is not always perforated. But if it is, the holes are commonly roundish, and the coats thin at the margin, coloured, disintegrated, and surrounded by vascularity and black extravasation. In some rare cases there is no mark of vital reaction except in the neighbourhood of the aperture. A case of this kind is related by Mertzdorff: The margin of the hole was surrounded to the distance of half an inch with apparent charring of the coats, and this areola was surrounded by redness; but the rest of the stomach was grayish-white.[289] I examined with the late Dr. Latta of Leith a similar case, where the limitation of the injury was evidently owing to the stomach having been at the time filled with porridge. The patient, a child two years old, died in twelve hours; and on the posterior surface of the fundus of the stomach, towards the pylorus, there was a hole as big as a half-crown, which was surrounded to the distance of an inch with a black mass formed of the disorganized coats, and of incorporated charred blood. But the rest of the stomach was quite healthy. The most remarkable instance of chemical destruction of the coats yet known to me is a case mentioned by Mr. Watson of this city, where suicide was effected by cutting the throat about half an hour after two ounces of sulphuric acid had been swallowed. The individual was at first thought to have died simply of the wound of the throat. But on dissection the usual signs of acid poisoning were found; and among other effects, it was observed that nearly three-fourths of the stomach had been entirely destroyed.[290] The perforation, if the patient lives long enough, is generally accompanied with a copious effusion into the belly of the usual muddy liquor of peritonitis; and the outer surface of the viscera feels unctuous, as if from a slight chemical action of the acid on them. The acid has actually been found in the contents poured out from the stomach into the sac of the peritonæum.[291] One would expect to find the acid always in the stomach when it is perforated. Nevertheless it is sometimes almost all discharged. In Mertzdorff’s case, that of an infant who was killed in twelve hours, a hole was found in the stomach ¾ths of an inch in diameter, and the contents of the stomach were effused into the belly: yet by a careful analysis the whole acid he could procure from the contents and tissues together was only 4½ grains. Sometimes of course the disappearance of the acid may be owing, as in Dr. Craigie’s case, to the effectual administration of antacids during life. The inner coat of the duodenum often presents appearances closely resembling those of the stomach. Sometimes, however, as in the case just related from Mertzdorff, and in the infant I examined, the inner coat of the small intestines is not affected at all, probably because in such rapid cases the pylorus retains a state of spasmodic contraction till death or even after it. The urinary bladder is commonly empty. The thoracic surface of the diaphragm is sometimes lined with lymph, indicating inflammation of the chest. In the case which was fatal in two hours [p. 131], Professor Remer found the surface of the lungs, as well as that of the liver and spleen, brown and of a leathern consistence, and the tissue beneath scarlet;—appearances which he thinks arose from the acid penetrating in vapour and acting chemically. I have not found this appearance mentioned by any other writer; but I have seen it in animals poisoned with oxalic acid. The blood in the heart and great vessels has been several times seen forming a firm black clot. Kerkring[292] relates an instance of the kind; in Dr. Latta’s case the appearance was very distinct; and it is dwelt on strongly in a recent paper by M. Bouchardat.[293] Bouchardat thinks this state of the blood is simply the effect of the absorbed acid; but coagulation of the blood in the heart and great vessels,—a striking appearance in contradiction to what is observed after death from most other poisons,—is more probably the healthy state of the blood, and not the effect of the particular poison. The general appearance of the body of those who have died of the second or chronic variety of poisoning with the acids, is that of extreme emaciation. The stomach and intestines are excessively contracted: The former has been found so small as to measure only two inches and a half from the cardia to the pylorus, and two inches from the lesser to the greater curvature.[294] Tartra says the intestines are sometimes no thicker than a writing quill. They are in other respects sound outwardly, except that they sometimes adhere together. Internally the pylorus is contracted. In a case of slow poisoning, fatal in three months, which has been described by Dr. Braun of Fürth, the chief appearance besides excessive emaciation was a thickening of the coats round and behind the pylorus to such a degree that the opening of the pylorus was formed of an almost cartilaginous ring several lines broad, and only wide enough to pass a quill.[295] There are spots over the stomach apparently of regenerated villous tissue, smoother and redder than the natural membrane. At the points where the stomach adheres to the neighbouring organs, its coats are sometimes wanting altogether, so that when its connections are torn away, perforations are produced. The other parts of the body are natural. It may in some circumstances be necessary to determine from the appearances in the dead body whether sulphuric acid has been the occasion of death or has been introduced into the body after death. This may always be easily done. If a few drachms of sulphuric acid be injected into the anus immediately after death, and the parts be examined in twenty-four hours, it will be found, that wherever the acid touches the gut, its mucous coat is yellowish and brittle, its muscular and peritonæal coats white, as if blanched, and the blood in the vessels charred; the injury is confined strictly to the parts actually touched, is surrounded by an abrupt line of demarcation, and shows no sign of inflammatory redness. Nitric acid produces nearly the same effects. The whole tunics are yellow, and the disorganization is greater. For these facts we are indebted to Orfila.[296] In closing this account of the morbid appearances, some observations will be required on the force of evidence derived from them; because circumstances may exclude all other branches of medical proof. In many instances both of acute and of chronic poisoning with the strong acids, I conceive, contrary to the general statements of most systematic writers on modern medical jurisprudence, that distinct evidence might be derived from morbid appearances only. Thus, what fallacy can intervene to render the following opinion doubtful? In a case several times alluded to as described by Mertzdorff, there were vesicles and brown streaks on the lips, neck, and shoulders, similar to the effects of burning,—almost total separation of the lining membrane of the mouth, throat, epiglottis, and gullet,—perforation of the stomach, with a margin half an inch wide, which was extensively charred, and surrounded by a red areola. From the appearances alone Mertzdorff declared that the child must have been poisoned with sulphuric acid. Perhaps he should have said sulphuric or muriatic acid. Or take the case of Richard Overfield, who was condemned at Shrewsbury Assizes in 1824 for murdering his own child, a babe three months old, by pouring sulphuric acid down its throat. In the dead body the following appearances were found: The lips were blistered internally and of a dark colour externally; the gullet was contracted and its inner coat corroded; the lining membrane of the mouth and tongue of a dull white colour; the great curvature of the stomach corroded and converted into a substance like wet brown paper; the stomach perforated and a bloody-coloured fluid in the sac of the peritonæum.[297] If to these appearances be added the fact that the child’s dress was reddened, what is there to prevent the medical jurist from declaring, without reference to chemical evidence, that this case must have been one of poisoning by sulphuric acid or some other mineral acids? In like manner in the case of Mrs. Humphrey, who was condemned at Aberdeen in 1830 for murdering her husband by pouring sulphuric acid down his throat while he was asleep, there was found, on examining the dead body, two brown spots on the outside of the lips,—whiteness of the inside of the lips and of the gums,—glazing of the palate,—redness, with here and there ash-coloured discoloration, of the uvula, posterior part of the throat, pharynx and epiglottis,—abrasion of most of the inner coat of the gullet,—erosion and dark-red ulceration of the inner coat of the stomach in winding furrows. When to these appearances it is added, that the man was in good health only forty-seven hours before death, and was taken ill instantaneously and violently with burning pain in the throat and stomach,[298] it is not easy to see what other opinion could be formed of the case, unless that he died of poisoning with a mineral acid, and probably with sulphuric acid. Among the appearances justifying an opinion where chemical evidence happens to be wanting, not the least important seems to me to be the peculiar turgescence and induration of vessels under the peritonæum of the stomach and neighbouring organs, occasioned by the chemical coagulation of blood in them. It is an appearance, which, when once seen, cannot be confounded with any natural morbid phenomenon I have ever witnessed. I am far from desiring to encourage rashness of decision, or to revive the loose criterions of poisoning relied on in former times. But there cannot, in my opinion, be a rational doubt that in the instance of sulphuric acid there may often be distinct exceptions to the general law regarding the feebleness of the evidence from morbid appearances; and that a witness would certainly be guilty of thwarting the administration of justice, if, relying on general rules, he refused to admit such exceptions. What natural disease could produce appearances like those described above? Assuredly no form of spontaneous perforation bears any resemblance to that caused in most cases of death from sulphuric acid; nor is it easy to mention any combination of natural diseases which could produce the peculiar conjunction of appearances remarked in the case of the man Humphrey. SECTION IV.—_Of the Treatment of Poisoning with Sulphuric Acid._ Since this acid and the other mineral acids act entirely as local irritants, it may be inferred that their poisonous action will be prevented by neutralizing them. But in applying that principle to the treatment it is necessary to bear in mind their extremely rapid operation; for if much time is lost in seeking for an antidote, irreparable mischief may be caused before the remedy is taken. Should it be possible then to administer chalk or magnesia without delay, these are the antidotes which ought to be preferred; but it may be well for the physician to remember, that in the absence of both he may at once procure a substitute in the plaster of the apartment beat down and made into thin paste with water. M. Chevallier, in a paper on the antidotes for the mineral acids, quotes five cases of poisoning with sulphuric acid and two with nitric acid, where life seems to have been saved by the speedy and free administration of magnesia, although in some cases so large a quantity as two ounces of the poison had been swallowed.[299]—A solution of soap is another antidote of no small value. While the antidote is in preparation, the acid should be diluted by the free use of any mild fluid, such as milk or oleaginous matters.—The alkaline bicarbonates are also excellent antidotes; but their carbonates are ineligible, being themselves possessed of corrosive properties. In a paper on poisoning with the mineral acids by Dr. Lunding of Copenhagen, the author is disposed to ascribe the large proportion of deaths in his practice to the system pursued in the Copenhagen hospital of administering carbonate of potass as an antidote daily for weeks together.[300] On the other hand however it may be mentioned, that in a late memoir, on this description of poisoning Dr. Ebers of Breslau endeavours to show, that there is no reason to dread the administration of the alkaline carbonates, even the carbonate of potash, provided they be given with mucilaginous fluids and syrup in a rather concentrated form; and he gives three cases illustrative of the good effects of this mode of treatment, which he maintains to be free of all danger, and preferable to every other antidotal method, because the remedy may be administered in small volume,—an advantage possessed by it especially over chalk or magnesia.[301] After the proper antidote has been given to a sufficient extent, the use of diluents ought to be continued, as they render the vomiting more easy.—Some have recommended the stomach-pump for administering antidotes and diluents; but this is unnecessary. When it is wished to evacuate the stomach, there is an advantage in allowing it to do so by its own efforts, if possible; because the evacuation is accomplished in this way more completely than by the stomach-pump. Besides, if the patient cannot swallow fluids, still less can he suffer the tube of the stomach-pump to be introduced. On several occasions, indeed, it has been found impracticable to introduce it.[302] The treatment of the surpervening inflammation does not differ from that of inflammation of the stomach. Where there is great difficulty of breathing, evidently from obstruction of the larynx, and where the absence of abdominal pain, tension or vomiting affords a presumption that little injury has been done to the stomach, laryngotomy appears an advisable remedy, and has been known to give very great relief.[303] But the patient may nevertheless die soon of the sympathetic disorder of the circulation. II.—OF POISONING WITH NITRIC ACID. Nitric acid is more frequently used as a poison abroad than in this country. But even in Britain it is not an uncommon cause of severe accidents and death. _Of the Tests for Nitric Acid._