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SATURDAY, FEBRUARY 19, 1842.

CLINICAL LECTURE

ON

POISONING BY OXALIC ACID,AND

PHTHISIS, WITH ULCERATED LARYNX,TRACHEA, AND BRONCHIAL TUBES,

DELIVERED AT

KING’S COLLEGE HOSPITAL,BY R. B. TODD, M.D.,

Professor of Anatomy in King’s College, andPhysician to the Hospital.

POISONING BY OXALIC ACID.

WHEN a large dose of, this acid has beentaken, or when it has been taken in a con-

i1:éntrated form, the symptoms set in quickly.In animals thus poisoned the symptoms are,jxquisite abdominal pain, expressed by criesIud struggling soon succeeded by violenteforts to vomit, then by languor and debi-

1!tY, and death without convulsion occurs infrom two to twenty minutes.;>when much diluted the poison seems toactoQ the nervous system. In large dosesU paralyses the heart; in a less dose theannual is seized with tetanic convulsions,acting the muscles of the chest and pre-testing their free action, and causing suflo-.çation. When the dose is still less the

spasms are slight or altogether wanting, andthe animal dies under symptoms of nar-

cotism.In man, death often comes on in a few

minutes when a concentrated dose has beentaken. If the poison have been diluted, thesymptoms are, a burning pain in the stomachand sometimes in the throat ; the pain isgenerally fol!owed by vomiting. If life be

prolonged there is violent irritation of the

bowels, as evinced by pain and frequent in-clination to go to stool, with bloody evacua-tions. The circulation is much depressed;the pulse fails, is very feeble; and the skin iscold and clammy. After some time thereare weakness and lassitude of the limbs, fol-lowed by numbness. In a case recorded byDr. Arrowsmith, an eruption of the skin, incircular patches of a deep red tint, perhaps

erythema, came out, and the leeches whichwere applied to the stomach died almostimmediately after they had bitten.Such are the symptoms as detailed by

Christison. Our patient, a strong youngwoman, was reported to have taken the poi-son about half-past one. She was broughthere about three, p.m. She went to a che-mist’s, and asked for arsenic to clean boot-tops, and was told that that drug was notused for this purpose, but that oxalic acidwas. She was given a paper labelled" poi--son," and the quantity was stated to beabout the same as is usually sold for a doseof salts (a pennyworth). This, we are told,she swallowed, but not entirely; she took itin beer. No more was known respectingthe act to those who accompanied her to thehospital. They informed us that the causeof her committing this rtsh cleecl was a dis-pute with her mistress, but on further inquiryit appears that Cupid had a finger in sthe pie.The only symptom under which she seemedto suffer was pain, yet evidently not exqui-site. There was no failure of the pulse orthe strength. We could not learn that shehad vomited ; there was no redness of thetongue or irritation of the fauces.

Notwithstanding the absence of the orcli-nary signs, I felt it my duty to act as if Iwere certain the poison had been taken. Theready antidote to the poison is lime, given aslime-water or chalk mixture. These were athand, and I had her, therefore, well drenchedwith them, especially with the latter. I felteven that it was better to introduce theseagents into her stomach at once, and to makea harmless oxalate of lime, than lose time inwaiting for the effects of emetics to evacuatethe stomach.Some of you seemed disappointed that I

did not use the stomach-pump. My reasonsfor this were-first, because the patientmade no difficulty about swallowing, conse-quently the fluids we should have introducedby the stomach-pump were taken in muchmore easily and quickly, and without vio-lence. Second, the great value of the sto-mach-pump is to pump in, not to pump out;and however it may be necessary in someinstances to apply it to the latter purpose,it was not required in this, the neutralisation

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of the acid being our great object. Inpumping out there is danger of irritating thecoats of the stomach, of sucking them intothe orifice of the tube, and as oxalic acid isan extremely irritant poison, I felt that thisrisk ought to be avoided. At a little beforefive o’clock the patient seemed composed ;pulse 90, and stomach soft, but somewhatpainful on pressure. She seemed sulky andreluctant to answer. She had been liberallydosed with challcmixture. I prescribed halfa drachm of sulphate of zinc, an emetic,and after its operation directed the chalk tobe resumed. If signs of stomach or bowelirritation manifested themselves, leeches andfomentations were to be applied.You have seen the patient to-day ; she is

now free from pain or fever, but she is re-

ported to have suffered severe griping painin the course of the night, which, indeed, isalmost the only symptom she has had.

It must be evident to you, from what Ihave told you of the ordinary symptoms ofoxalic acid poisoning, that this patient tookbut a small portion of the drug, and that notin a concentrated form. This case has not,therefore, afforded you a fair specimen of themore striking effects of this poison, hut it ihas given you an opportunity of observingthe course of treatment which ought to bepursued in all cases of this kind, real or

suspected, and therefore it has not been de-void of considerable practical utility. Thetoo frequent occurrence of such cases can-not fail forcibly to impress upon us the la-mentable want of some legislative enactmentto prevent the indiscriminate sale of poison-ous drugs. A fearful responsibility rest3upon the vendors of such articles, and itwould seem that some stringent law uponthis subject is as much to be desired fortheir protection as for that of others of thepublic.

CASE II.-PHTHISIS PULMONALIS.

This patient, William Roseberry, had beenin the house since the 13th of October, 1841.We had ascertained by auscultation that hehad a large cavity occupying nearly the wholeof the upper part of the left lung, and thatthe inferior lobe was solidified probably bytubercular deposit, and contained severalsmall cavities.A very remarkable point in this case was

the extreme scantiness of the expectoration,which, when in greatest quantity, never ex-ceeded an ounce and a half. He sufferedvery much from violent irritating cough,which could not be controlled.About a fortnight before death he was

seized suddenly with pain under the left

breast, and increased difficulty of breathing.On examination of the principal region, thesound on percussion was clear, almost tym-panitic, over the fifth, sixth, and seventh ribstowards the sternum ; and here a distinctamphoric breathing was audible, accompa-

nied with metallic ringing, which, it6t<Mawas most manifest when the patient coughedI at once concluded, and, as you will,ber, mentioned it to you at the time, t&&taperture had formed in the lung thrownwhich air passed at each inspiration intopleural cavity : pleurisy was thus excited,and fluid poured out. Air and fluid thussimultaneously existed in the lower part ofthe cavity of the pleura; the air was pre-vented rising by the obliteration of the pleuralsac above through the adhesion of its twolayers. The quantity of air and fluid wassupposed to be small, as the lung being sol&ucirc;1would not allow of much compression. :.,

This patient also laboured under anotherunpleasant symptom-hoarseness to such adegree that at times he was almost inaudible.There was no pain on pressure of the larynx,and the epiglottis examined by the finger-seemed quite free from disease: degluti-tion, too, was easy. I thought it possiblethat there might be some slight laryngealdisease, but felt more disposed to refer thehoarseness to bronchial disease&mdash;ulcerationsof the tube which occasionally accompasyphthisis ; and that this tube was the seat considerable irritation I felt convinced fromthe long continuance of his severe and ha-rassing cough, which was of that irritablespasmodic kind that indicates bronchial-affection, and which resisted the influence ofthe strongest sedatives. On one occasiononly had this patient loose stools, and theitthey were unaccompanied with pain or-tenderness. He had abundant night-sweatyFrom the history of the case we learned

that he had been ailing for three years beforehis admission; his chief symptom during,that time being debility, accompanied withfrequent attacks of palpitation of the heart.Two years ago he spat blood to the extentof a pint without any bad effect, except theweakness consequent upon it; he had asecond attack of haemoptysis three weeksbefore his admission. .

Three months ago cough and night-sweatscame on, with a little expectoration. Thesesymptoms with dyspnoea progressively ia-creased until he came into the hospital.Now, what did the autopsy reveal to us?

! First, we found the whole upper part ofthe left lung one enormous excavation. Thiscavern presented all the usual characters; itwas traversed by bands passing from onepart of its wall to the other ; its walls werevery thin, being composed of a thin layer ofpulmonary substance, and of thickenedpleura ; below it was separated from the in-ferior lobe by extremely thickened pleura;the inferior lobe was also extensively dis-eased ; crude tubercles were scattered in vastnumbers through its substance, rendering itsolid; and there were two or three excava.tions in the centre, each rather larger than awalnut. From the lowest of these a fistulous

passage, formed by the sloughing of the lung’s

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nce, opened into the pleura about thetre of the base of the lung and above the

Secondly. The extensive disease of the

lung might account for the absence of expec-toration. There was abundance of purulentin the cavern, but the mechanicalfor the expulsion of the fluid were

completely destroyed; not a vestigebronchial tube remained in this lobe,save the large one which communicated withthe tubercular cavity. The only force, then,by which the fluid in this cavern could beexpelled, was that derived from the contrac-tion of the walls of the chest. In the healthy of lung, expectoration is effected by thisforce, aided very powerfully by the muscularcontractions of the bronchial tubes and thetrachea; but in our patient the latter forcewas cut off by the ulcerative process, and itwas evidently impossible that the parietesof the chest could exert much influence onthe bag with inert walls, into which the

upper lobe of the lung was converted by thedisease.Thirdly. The violent irritating cough andthe hoarseness were both accounted for.There was in the larynx suflicient disease toexplain the latter. A small penetratingtileer existed at the posterior extremity ofeach chorda vocalis, passing down throughthe mucous membrane, and laying bare thearytenoid cartilage. The trachea and bronchiwere most extensively ulcerated. The ulce-ration was not, as is usually the case,limited to the mucous membrane on the pos-ferior wall of the trachea and bronchi, thewhole mucous membrane was involved, andthe cartilaginous rings likewise. The secondring of the trachea was eaten away at itsmiddle, and presented an ulcer with jaggededges larger than a fourpenny-piece. Notone of the rings of the trachea had escapedulceration. The mucous membrane everywhere exhibited numerous small ulcers:the ulcerations were not confined to the tra-thea, but extended to the bronchial tubes ofthe left lung.

. Ulcerations of the trachea and bronchi arenot common : those of the bronchi are less

frequent than those of the trachea ; but thoseof the trachea, according to Louis, are more frequent than those of the larynx.

Louis ascribes the ulceration to the irrita- tion occasioned by the diseased expectora- itions passing over the mucous surface ; and 1on this hypothesis he explains the more fre- tqueut occurrence of ulceration at the poste- rior dependent portions of the trachea and larger bronchi, because the expectoratedmatter is more apt to tarry in that position. IThis case afforded us some striking illus- trations of Louis’ opinion ; the ulcerations c

were limited to the trachea and left bronchi; the tubercular expectoration was entirely Jconfined to the left side. Whatever few a

tubercles existed on the right side were in

the crude state, and therefore no tubercularmatter was expelled from that side, conse-quently the mucous membrane of the right

’ bronchial tube was unaltered. Even in theleft lung there were appearances still more

strikingly confirmatory of this view. In the! inferior lobe a large portion of the pulmonary! tissue was solidified, and interspersed withunsoftened tubercles ; there were, likewise,a few excavations from softened tubercles.

It was remarkable that those tubes whichled to tubercular cavities were ulcerated,while those which led to the unsoftenedtubercles were free from ulceration. Inshort, those tubes through which the tuber-cular matter passed were ulcerated, but thosethrough which it could not have escapedwere free from disease.

Fourthly. We had here evidence of theperforation of the trachea during life, so asto establish a communication with the bron-chial glands at its bifurcation. Many ofyou remember that some weeks before thispatient’s death we were surprised at ob-serving in his spitting-pot a quantity of whitematter resembling the curd of milk. Wewere quite at a loss to account for this atfirst; but as he had been taking at that timelarge doses of sulphuric acid, we attributedit to the effect of the acid on the milk, ofwhich he partook freely, and supposed thatthe curds came from the stomach. This kindof expectoration did not occur again.

; On opening the bronchial glands we found

a quantity of white curdy matter, similar tothat which we saw in the vessel six weeksbefore ; it was perfectly milk white; had acurdy appearance, but seemed mixed with aquantity of fine chalky particles. It is notunlikely that this matter escaped from thebronchial glands into the trachea, and was ex.pectorated. There was pleuritis and purulenteffusion into the lower half of the left pleura.The pleural cavity corresponding to theupper lobe of the lung was, as we antici-pated, obliterated by previous inflammation :consequently, the effusion or pleurisy didnot reach higher than the inferior lobe. Wehad here, however, abundant cause for theamphoric resonance and metallic tinkling towhich I had directed your attention duringthe latter days of his life ; sometimes thesesounds occur in a large tubercular excava-tion, but that they did not in this case existin the cavern in the upper lobe was provedfrom the fact that they were only heard atthe lower part of the chest: the heart, also,was evidently pushed into the mesial plane.Although during his illness his bowels werevery slightly disturbed, there was, neverthe-tess, some ulceration of Peyer’s glands,chiefly affecting the lower ones nearest thec&aelig;cum : the solitary glands, too, were en-

larged, and some of them ulcerated; butBrunner’s glands were healthy, as is, so far -15 I know; always the case in phthisis.

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