Source: Snow, John. London Med. Gazelle, vol. 35, Nov. 22, 1844, pp. 248-250.
Case of acute poisoning by carbonate of lead
By John Snow
Fellow of the Royal Medical and Chirurgical Society.
(For the London Medical Gazette.)
(*This was related to the Westminster Medical Society, on the 19th of November, 1844.)
I was called between 9 and 10 o'clock on Wednesday morning, the 8th of May last, to Henry Woodley, aged 5 years, living at 1, Rose Stree Soho, and found him suffering with symptoms of poisoning. I ascertained that, on the Saturday night previous, he had eaten some white-lead ground up with oil, which another boy had stolen, under the impression it was putty, from the door of an oil shop in the neighbourhood, where it was exposed for sale. The quantity he had was not larger than a marble, and he did not eat it all, as a small portion was found on the floor afterwards. He complained of bellyache the next morning, and his mother gave him a dose of salts and senna: this did not operate, and the pain in the abdomen still remaining on the following day, she gave him rhubarb and jalap, and afterwards castor oil, and the bowels were opened on Tuesday evening for the first time. The child's mother did not think his illness serious, and did not mention it to me, although I was attending her husband; she thought what he had eaten was only putty, which was not poisonous. During Tuesday night the pain in the belly was increased, and vomiting commenced for the first time. On Wednesday morning I saw the child as I have stated. He was in great pain, which he referred chiefly to the scrobiculus cordis; he vomited constantly a brownish liquid containing streaks of blood; his skin was hot, and his pulse was 140 and hard; the face was swollen and of a purple colour; the conjunctiva were red, not only from injection of the vessels, but from blood extravasated and coagulated beneath the membrane; the nostrils contained blood, and the body was spotted with petechiæ; the gums were tense, shriveled, and milk white. Some leeches were applied to the epigastrium, and an emulsion containing Epsom salts was given. He passed some greenish-black semi-fluid [248/249] motions of a very offensive odour. At 11o'clock the pain continued, with occasional vomiting; the pulse was small and the extremities were getting cold; there was palpitation of the heart. At 1 o'clock, on injecting the bowels I found that there was complete relaxation of the sphincter ani. The pulse at the wrist ceased shortly afterwards, the tracheal rale set in, and he died at 2 o'clock, about ninety hours after taking the poison. The heart beat above 100 strokes after the respiration. There was no delirium or other lesion of intelligence.
An examination of the body was made eighteen hours after death, in which I was assisted by my friend Mr. Marshall, of Greek Street, who took notes of the appearances. The cuticle was loosened from a great portion of the body, and a quantity of serum flowed from the nostrils on moving the head. The gums presented the white appearance observed before death; the pericardium was filled with serum deeply tinged with blood, and each pleura contained several ounces of similar fluid. The heart was soft and flabby, and there was a little red fluid blood in the ventricles. There was ecchymosis of the surface of the lungs, and they were engorged posteriorly. There were two spots of ecchymosis beneath the mucous membrane of the œsophagus near its lower end; otherwise this tube was healthy. The stomach contained a little liquid similar to what had been vomited, and, throughout its entire extent, the mucous membrane was dark brown, swollen, and puffy, and there appeared to be extravasation of blood beneath it in addition to great injection of the vessels: this state did not extend to the duodenum or œsophagus. There was a bright red injection of part of the cœcum, but the rest of the alimentary canal was of the natural pale colour, and was not contracted in any part. It contained a little clay-coloured fecal matter in the form of small pellets. The kidnies were large and flabby, and the liver, which was of a darkish colour, instead of presenting its usual firmness, was like soft leather; it could not, however, be torn with greater ease than natural. There was a peculiar odour about the body; not that of putrefaction. The head was not examined. The matters vomited, and those found in the stomach and intestines after death, and likewise the substance of the stomach, were al[l] subjected to a careful chemical examination, but no lead, or, indeed, any other poison, was detected.
Although slow poisoning by white lead is very common, occurring to painters, and several other classes of workmen who use it or manufacture it, acute or sudden poisoning by this, or indeed any other salt of lead, is not common. They are seldom chosen for murder or suicide, and, although extensively used in various trades, they do not often lie exposed, like arsenic or oxalic acid, in such a shape as to be mistaken for any article of food or medicine. In the few authors to whom I have referred, I have not met with any fatal instance of poisoning by a single dose of carbonate of lead. Mr. Taylor mentions, in his Jurisprudence, the case of a woman, attended by Mr. Cross, who took six or eight drams of it, by mistake, for magnesia, and recovered by the use of remedies. Orfila gave half an ounce of it to a dog, and it vomited several times within twelve minutes, and was no worse afterwards; and Dr. Christison quotes from a German journal the case of a young woman who swallowed accidentally an ounce and a half of it, without any bad effects, either at the time or afterwards. That it is very poisonous, however, we have sufficient evidence; for the carbonate is the form in which lead is introduced into the system of painters, and of most artisans who suffer from it, and, generally, of those who are poisoned by water impregnated with this metal. The morning after this child had taken the poison, his mother gave him, as it happened, some Epsom salts amongst senna tea. Now sulphate of magnesia is an antidote for the soluble salts of lead, but as it does not act on the carbonate at ordinary temperatures, it could only be of benefit by neutralizing any portion which might be decomposed by the acids of the stomach, and unabsorbed at the time. Several hours had already elapsed when it was administered, and as it was not repeated, we need not wonder that it did not stop the fatal effects of the poison. In addition to emetics and the stomach pump, Mr. Taylor very judiciously recommends the combination of some weak vegetable acid, as vinegar or lemon-juice, with solution of sulphate of soda or magnesia, in cases of acute poisoning by carbonate of lead. [249/250]
From what I could learn, this child appeared for three days to suffer only from symptoms of lead colic, viz. pain and constipation of the bowels; and the intense and general gastritis of which he died would seem only to have commenced, or at least to have become severe, about twelve hours before death, as it was not till then that vomiting came on.
When I saw the child, which was not till within five hours of his death, he seemed to be labouring under all the effects of a corrosive or irritant poison, which one would have supposed had been taken only a few hours, instead of nearly four days. In the case I have quoted from Mr. Taylor, and in those I have seen recorded, of poisoning by the other salts of lead in large doses, vomiting, and other symptoms of violent gastric irritation, came on soon after the ingestion of the poison. The comparative mildness of the symptoms in this case for three days probably depended on the incorporation of the white lead into a tough mass with oil, which might retard its operation, and cause it to act only by degrees, in proportion as it became digested.
The white, tense, and contracted state of the gums, is worthy of notice. The gums were white and excoriated in a case of poisoning by the acetate of lead, quoted by Mr. Taylor, when the patient recovered. Acetate of lead is administered, occasionally, as a remedy in mercurial ptyalism. Dr. Burton has directed attention to a blue line on the gums in persons suffering under the chronic influence of lead; and I have, in two instances, seen the gums severely ulcerated in painters who had not been taking mercury.
No lead could be detected in the body after death, or in the matters vomited: but we need not be surprised at this, when we consider that the patient survived till the fifth day. It is a negative result that has been obtained in other cases of death from this poison. He had been vomiting several hours before any thing was saved for examination, and the feces passed during life, which exhibited a peculiar colour, such as a mixture of sulphuret of lead with them might be supposed to occasion, were not subjected to analysis.
Frith Street Soho, Oct. 1844.
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