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684 mckelway: poisoning by potassium cyanide. 

losing. A child of two years that had had persistent and very 
dangerous disturbance of digestion with advanced malnutrition 
improved immediately, the digestive tract became nearly normal 
within a few days, and the child repeatedly gained over two pounds 
a week. The last-mentioned child took nothing but bean-flour 
solution; the infants took usually about per cent, of bean flour 
in milk modifications. 

These results are certainly unusual. They need to be controlled 
in several ways before any definite conclusions can be drawn from 
them, but it seems possible that they were due to a special influence 
of the legume flour on metabolism, and, perhaps, to a particular 
influence of the nuclein contained in this flour upon the tissue¬ 
building processes. 

One point that appears to be of some importance we have defi¬ 
nitely determined: it is easily possible to administer in this way 
as much as 0.75 per cent, to 1.0 per cent, of proteid, a fact of decided 
consequence in those co mm on cases in which it is difficult or impos¬ 
sible to administer a proper amount of milk proteid. 

It is desirable to test this preparation further in older children 
and adults who are the subjects of malnutrition. This will neces¬ 
sitate, however, some method of preparing the bean-flour solution 
by which it can be pleasantly flavored, as when unflavored its taste 
prevents its use with older patients for any considerable period. 
Infants, however, take it readily in milk. 


THREE CASES OF POISONING BY POTASSIUM CYANIDE. 
By John Irvine McKelway, M.D., 

OF king’s park, long island, 

ASSISTANT PHYSICIAN, LONG ISLAND STATE HOSPITAL. 


Cases of poisoning by cyanide of potassium are not frequent in 
this country, being met with more frequently in England, Germany, 
and France. The drug is usually taken with suicidal intent; thus, 
in 402 cases of cyanic poisoning collected by Witthaus 1 in 65.4 
per cent, of cases the poison was taken for this purpose. Of this 
number cyanide of potassium was the drug used in 83 cases. Of 
the 256 suicides, but 43 were women, and of those who took cyanide 
of potassium 5 were relatives of photographers and 4 of platers. 
This fact is of interest, as the majority of cases reported occur 
among photographers, electroplaters, mirror-makers, chemists, and 
soldiers, their occupations rendering the procuring of the drug 
comparatively easy. 

I am indebted to Dr. John D. Curran, of Binghamton, New 



mckelway: poisoning by potassium cyanide. 


685 


York, under whose observation the first case came, for permission 
to report it. 

Case I.—A. B., female, aged thirty-eight years, hair-dresser by 
occupation. Had been dyeing a patron’s hair during the afternoon 
with a dye containing silver, thus discoloring her fingers. On her 
way home from work she entered a drug-store, asking for ammonia 
with which to remove the stains. The clerk gave her several large 
pieces of cyanide of potassium, telling her that “this is better than 
ammonia,” advising her to moisten her fingers and rub them with 
the cyanide of potassium, but failing, either through ignorance or 
carelessness, to inform her of the poisonous properties of the drug. 
At ten o’clock that evening she entered her bath-room, a small room 
(dimensions about 6x8 feet), imperfectly ventilated by one small 
window opening into an air shaft. Selecting a piece of cyanide of 
potassium about the size of a hickory-nut, she rubbed it vigorously 
on her fingers and hands, removing the stain. This took about five 
or ten minutes, at the end of which time, and before she had an oppor¬ 
tunity of washing her hands, she was suddenly attacked with vertigo, 
felt faint, “everything turned black before her,” and she experi¬ 
enced much difficulty in breathing. Her husband, in an adjoining 
room, heard her scream, and, rushing in, found her unconscious. 
He carried her into the fresh air and succeeded in a few minutes in 
restoring her to consciousness, she then taking about two ounces of 
whiskey. She improved rapidly, and soon was able to walk up 
stairs and go to bed. At 11.30 p.m. she became much worse, vom¬ 
ited freely, and Dr. Curran was called. He found her with her lips, 
fingers, and extremities deeply cyanosed. She was in a condition 
of shock, as evidenced by her subnormal temperature, cold per¬ 
spiration, rapid, weak heart action, and sighing respiration. Under 
repeated hypodermic injections of strychnine sulphate, grain, 
and atropine sulphate, y), 0 - grain, with the application of external 
heat, she improved for about one and one-half hours, when she 
became restless, active, and tossed her head from side to side. 
This condition of motor activity was probably due to the action of 
the strychnine, which had been given freely during the period of 
collapse. She was readily quieted by the administration of mor¬ 
phine sulphate, f grain, given hypodermically, and fell into a quiet 
sleep, from which she awoke the next morning weak and some¬ 
what prostrated. During the following day she was nauseated, 
her heart action rapid and weak, and she continued to give some 
evidences of shock. She made a rapid and uneventful recovery, 
being up and about the third day. 

The following cases came under my own observation while resi¬ 
dent physician in the Pennsylvania Hospital, Philadelphia: 

Case II.—George R., aged thirty-five years, mirror-maker, 
admitted to the Pennsylvania Hospital February 8, 1901, with the 
following history: 



686 mckelway: poisoning by potassium cyanide. 

About fifteen minutes before his admission to the hospital he 
entered a saloon, sat down, and called for a drink of whiskey. 
Upon receiving the Hquor he placed a small quantity of a white 
substance into it and a few minutes later picked up his glass and 
drank the contents. He almost immediately fell forward on his 
face, unconscious, without uttering a sound. He was hurried to 
the hospital, where upon admission his condition was as follows: 
Completely insensible; face cyanosed. Respiration somewhat 
jerky in character, twenty per minute. Jaws clenched, requiring a 
gag to open them. Some mucus in mouth. Characteristic odor of 
bitter almonds on breath. Pulse weak and small. Eyelids closed; 
eyes fixed; pupils dilated, equal, did not react to light or accom¬ 
modation; conjunctival reflexes absent. No escape of urine or 
feces. 

Patient was immediately given a hypodermic injection of strychnine 
sulphate, T jy grain; his jaws separated, the stomach tube intro¬ 
duced, and his stomach thoroughly washed out with warm water. 
Sylvester’s method of artificial respiration was instituted. Despite 
this the cyanosis increased rapidly, and he died eight minutes after 
admission. A considerable quantity of cyanide of potassium, 
properly labelled, was found in his pocket. 

The post-mortem examination made by the coroner’s physician. 
Dr. Wadsworth (to whom I am indebted for the findings), showed 
the heart to be normal, excepting for a considerable deposit of fat; 
the lungs were congested. The stomach was empty; the mucous 
membrane much inflamed, especially toward the pyloric end. The 
liver and kidneys were slightly engorged. 

Case III.—X., male, aged about forty years, was found dead in 
bed in a hotel. He was last seen alive about eight hours before his 
body was discovered. 

The post-mortem examination made by the coroner’s physician, 
Dr. Morton (who kindly furnished me with the findings of the exami¬ 
nation), showed results quite similar to those found in Case II. 
The heart was normal, excepting for beginning atheroma in the 
aorta. The lungs were much congested and dark in color. The 
larynx was also much congested. The mucous membrane of the 
stomach was greatly inflamed, especially at the pyloric end. The 
odor of hydrocyanic acid was noticed immediately upon opening 
the stomach. The liver was engorged, as were also the kidneys. 
The mucous membrane of the bladder was not inflamed. 

Dr. Curran’s case (Case I.) is of great interest, as there was 
apparently poisoning by cyanide of posassium by two methods in 
the one case. The unconsciousness and vertigo, which the patient 
first experienced, were unquestionably caused by the inhalation 
of the drug in a small, poorly ventilated room. The period of 
shock, occurring an hour and one-half later, was undoubtedly due 
to the absorption of the drug through the skin, it being recalled 



mckelway: poisoning by potassium cyanide. 


687 


that after removing the silver stains from her hands with the cyanide, 
the patient had no opportunity of washing her hands, falling uncon¬ 
scious before she could do so. That poisoning by these two methods 
may, and does, occur is proven by cases reported by Souwers 2 and 
by a writer in the British and Foreign Med.-Chir. Review. 3 

The minimum lethal dose of cyanide of potassium varies, accord¬ 
ing to the different authorities, but is generally fixed at from 2 to 
5 grains, Bennett 4 reporting two cases with fatal results after 
taking 2 grains and 4J grains, respectively. Death does not occur 
as rapidly in cases of poisoning by potassium cyanide as in cases 
of hydrocyanic acid poisoning, usually not taking place for from 
fifteen minutes to an hour after the ingestion of the drug. Cases 
are reported, however, in which death has taken place in less than 
ten minutes, Casper-Liman 5 reporting a case in which the drug 
was taken with suicidal intent by a young woman twenty years 
of age, death occurring “immediately.” Valcourt 6 and Haskins 7 
mention cases in which death resulted in two and five minutes, 
respectively. The mortality in cases of cyanic poisoning is high, 
Witthaus 1 stating that in 455 cases, 382, or 84 per cent., died. 
Death in these cases is due to paralysis of the respiratory centre, 
although it would appear that in some cases it is caused by the 
depressant action of the drug upon the heart itself. 

That recovery frequently takes place, even after the ingestion 
of large doses, is shown by cases reported by Higgins, 8 Wigles- 
worth, 9 Stevenson, 10 Quintin, 11 Brockett, 12 and Gillibrand, 18 in 
which from 19J grains to 50 grains of cyanide of potassium have 
been taken, the patient in each instance recovering. While death 
takes place more slowly in fatal cases of cyanide of potassium 
poisoning than in fatal cases of hydrocyanic acid poisoning, recov¬ 
ery is more delayed in these cases than in those of hydrocyanic acid 
poisoning. Unconsciousness generally persists from two hours 
to six or eight hours, Dobson, 14 Quintin, 11 and others reporting 
cases in which the period of unconsciousness extended over this 
length of time, and one remarkable case is reported 15 in which the 
unconsciousness persisted for three days, the patient not being 
discharged from the hospital for ten days. In the other cases cited 
the patients have usually been discharged in from three to four 
days. 

Autopsy has usually shown the left ventricle of the heart empty 
and firmly contracted, the right containing uncoagulated blood. 
The stomach is frequently found much inflamed, especially toward 
the pyloric end. The lips, mouth, and stomach at times show 
evidences of corrosive poisoning, probably due to the carbonate of 
potassium used in the manufacture of the cyanide of potassium. 

The most important factor in the treatment of cases of cyanic 
poisoning is the promptness with which it is instituted. Immediate 
evacuation of the stomach and intestinal canal, the administration 

VOL. 129, NO. 4.—APRIL, 1905. 45 



688 SAILER, RHEIN: EVENTRATION OF THE DIAPHRAGM. 

of cardiac and respiratory stimulants, artificial respiration, friction 
of the extremities, and cold affusions to the spine, with the patient 
in a warm bath, or the use of the alternate hot and cold douche to 
the spine, offer the best results. Various drugs have been sug¬ 
gested as additions to water in washing out the stomach: hydrogen 
peroxide; potassium permanganate; ferric and ferrous salts in 
combination; carbonate of potash in solution or in combination 
with sulphate of iron and ether. Of these probably the best is the 
permanganate of potassium, the use of which is recommended by 
Kossa 16 and other writers. Witherstine 17 calls attention to the 
article of Heim, 18 in which the author states that “morphine seems 
to be the antidote to cyanide of potassium, and vice versa.” 

References. 

1. Witthaus. Toxicology, 1896, vol. iv, p. 604. 

2. Souwers. Philadelphia Medical Times, 1877-1878, vol. viii. p. 345. 

3. British and Foreign Med.-Chir. Review, July, 1876, p. 231. 

^ 4. Bennett. Medical Record, 1894, vol. xlv. p. 742. 

5. Casper-Liman. Handbuch d. ger. Med., 8te Aufl., Bd. ii. p. 496. 

6. Valcourt. Union m6dicale, 1875, 3 8., tome xx. p. 626. 

^—7. Haskins. Boston Medical and Surgical Journal, 1870, vol. lxxxii. p. 21. 

_^8. Higgins. Medical Record, 1891, vol. xl. p. 687. 

^9. Wiglesworth. British Medical Journal, 1897, vol. i. p. 1039. 

Stevenson. Lancet, 1871, vol. i. p. 806. 

11. Quintin. Berl. klin. Wochenschrift, 1885, Bd. xxii. p. 120. 

^12. Brockett. Lancet, 1886, vol. ii. p. 1174. 

Gillibrand. Lancet, 1876, vol. ii. p. 223. 
yl4. Dobson. British Medical Journal, 1896, vol. i. p. 17. 

15. Med.-Chir. Rundschau, 1867,195, ex Friedreich’s Bl. f. ger. Med., 1868, Bd. xix. p. 452. 

16. Kossa. Therap. Monatsh., 1892, Bd. vi. p. 549. 

17. Witherstine. Sajous’ Cyclopaedia of Practical Medicine, 1902, vol. v. p. 337. 

18. Heim. Munch, med. Woch., 1896, No. 37. 


EVENTRATION OF THE DIAPHRAGM, WITH A REPORT 

OF A CASE. 


By Joseph Sailer, M.D., 

PHYSICIAN TO THE PHILADELPHIA HOSPITAL, 

AND 

Robert D. Rhein, M.D., 

DATE RESIDENT PHYSICIAN TO THE PHILADELPHIA HOSPITAL. 


Eventration of the diaphragm has been known ever since J. 
L. Petit reported and named a case in 1790. It may be described 
as an abnormally high position of the left half of the diaphragm, 
with dislocation upward of the abdominal viscera, particularly the 
stomach, on the leftside; hypoplasia of the left lung, and displace¬ 
ment of the heart to the right. It gives rise to physical signs 
closely resembling those '<9^~diapbragmatic hernia. Its proper