In the toxicology world, and especially when poisons are involved, Spanish born Mathieu Joseph Bonaventure Orfila is the man.  He is essentially the Godfather of toxicology, and its medicolegal component,  and started us on the path towards detecting poisons in biological specimens.  And in the early 1800’s he wrote several important books on identifying and treating poisons, namely,  “Traité des poisons tirés des règnes minéral, végétal et animal; ou, Toxicologie générale.”

But there is another book (in English) that I find humorous.  Perhaps it’s my odd sense of humor or the concurrent similarity and contrast to today’s medicine, but it makes me chuckle.  In 1883 Dr. William Murrell wrote “What to Do in Cases of Poisoning” (1).  In it he manages to instruct the doctor on what to wear, who to talk to and who to ignore.  He even manages to throw in some thinly veiled insults.  It’s a fun read, and probably of interest to medical toxicologists today.  It is insightful to see how much has changed, and how much has stayed the same . . . 130 years later!

I don’t want to give the impression that Dr. Murrell was some sort of crackpot, because this book would have been a valuable resource in its day – it had 15 editions and was published until 1936.  And secondly, and if you’re a cardiologist you already know this, Dr. Murrell was the first person to advocate the use of nitroglycerin for angina pectoris (2).  Angina pectoris literally means “strangling of the chest” and the pain is often an indicator of a more serious cardiac issue, usually coronary artery disease.  The amazing thing is that we still use nitroglycerin today.  So Dr. Murrell has his place in medical history, and was no slouch.

So in getting back to Dr. Murrell’s “What to Do in Cases of Poisoning”, here are some of the highlights, along with selected poisons I have written about previously – with some snark by your’s truly thrown in for good measure.

“If sent for to a case of poisoning go at once — the patient’s life may depend on your prompt attendance. If at night, do not stop to dress — scanty attire is permissible on these occasions.”

This is sound advice if it takes you an hour to get dressed, and it makes we wonder what “scanty atire” was for Dr. Murrell back in the 1880s.  On second thought, I don’t want to know what he was up to.

“Do not go without a stomach-pump and remember that you will require your hypodermic syringe, and very likely the solution of atropia (atropine). Your knowledge of the treatment of cases of poisoning may be excellent, but if you are without the requisite appliances you are of very little use”

Needing a stomach pump, that was interesting.  Calling it an appliance is even better.  But back then the stomach pump was used for nearly everything – some even did double duty and were used for enemas.  Ewww, careful which end you stick down my throat, Doc.  Nowadays we call a “stomach pump” a “gastric lavage.”  Sounds more legit, doesn’t it?  But the idea was to get rid of whatever poison was in the stomach.  There’s a debate among clinicians today as to the utility of gastric lavage, which has really fallen out of favor in the last 20 years (3).  The consensus seems to be that it is of little practical use except for some extreme situations.

“Enquire of the messenger what is the matter.  His information will probably be unreliable . . . Go straight to your patient and do not waste time in talking to his friends.  Make your diagnosis as quickly as you can, and commence treatment at once.”

I love this.  The messenger’s information will probably be unreliable and his friends are useless.  So much for getting a history.  He seems very rushed.  And this isn’t Cook County Hospital in Chicago, this is a house call.

“Should you have a consultation?  This is a difficult question to answer, so much depends on the particular circumstances of the case. If you are quite sure of yourself and know you can pull your patient through, the fewer people you have the better; but if the issue is doubtful it is a great help to have a friend who will not only give you the benefit of his advice, but will share the responsibility.”

Here’s how I read this: if you know what to do, great, take all the glory, but if you aren’t sure, bring someone else on board so you can blame them when things go wrong.  I can’t really decide whether or not things have changed, but from my recent experiences in the hospital I recall a lot of teamwork, but that’s probably to be expected of brain surgeries.  Any input Doctors?

“It is possible that you may experience a difficulty in remembering the antidotes to various poisons.  If so rest assured that your knowledge of pharmacology is defective.”

I’m not sure how that helps.  I think he just called you an idiot.

Dr. Murrell then goes into detail how to pack your antidote bag and pick out a stomach pump – they only cost 2 pounds then, about 200 pounds today – and sections on common emetics and antidotes.  It’s an interesting read, but lets dive into some poisons, the titles of which I’ve linked to past posts:

Jequirity Beans – Abrus precatorius (containing the toxin abrin):

Rosary pea by Mohanraj Kolathapilly (CC BY 2.0)

“The abrus contains no alkaloid or active principle, but probably a kind of ferment which acts in somewhat the same way as does papayotine giving rise to the formation of enormous numbers of micrococci and bacteria in the blood . . . poisoning in man is not common but there are several cases on record and it is possible that it might be used for the purposes of secret murder. It is difficult to say what the treatment should be, but sweating with pilocarpine and the free administration of stimulants should be tried.”

He got the active poison wrong, which is the toxin abrin, not a fermentation product that produces bacteria, but that was what was thought at the time.  It was many, many years until abrin was discovered and isolated.  And besides, he knew there was no cure, which there isn’t.  But I like the idea of just sweating it out and getting hopped up on Mountain Dew.

Absinthe – Wormwood (containing thujone):

Artemisia absinthium

“This is the Artemesia absinthium . . . it contains a volatile oil and a bitter principle absinthe . . . Treatment consists of an emetic and the free use of stimulants . . . the habitual use of the liqueur produces a condition which has been called absinthism.  It is characterised by restlessness at night with disturbed dreams, nausea and vomiting in the morning, trembling of the hand and tongue, (and) vertigo . . . prognosis is not unfavourable if the habit be discontinued.”

He pretty much nailed it, and Absinthe was common in his day.  Now, I believe the whole “absinthism” was blown wayyy out of proportion by the prohibitionists and the French wine industry, but there may be a little truth to it.  The primary remedy is to just stop.  I can envision him saying “how’s this workin’ for you?”  Click on the link above to read a bit about the history.

Morphia, chronic (containing morphine) – no link yet:

Heroin bottle (public domain, via Wikimedia)

“The introduction of the hypodermatic syringe has placed in the hands of man, a means of intoxication more seductive than any which has hitherto contributed to his craving for narcotic stimulation. So common now are the instances of its habitual use and so enslaving is the habit when indulged in by this mode, that a lover of his kind must regard the future of society with no little apprehension.”

Wow.  Tell us how you really feel Dr. Murrell . . . don’t hold back.  What I find interesting, and it’s something I’ve never thought about before, because it is so common, is to place the “blame” on the hypodermic syringe – not the drug itself.  Mind blown.  But he’s not wrong.  Now for the treatment;

1. The patient must give up the custody of the syringe and morphia solution. 2. The dose must be diminished gradually so as to make but little demand on the moral strength and self-control of the patient . . . 3. The bowels should be kept well open . . . 8. If there is much depression, stimulants may be given, but cautiously and only in measured doses. Dry iced champagne is useful and so is coca wine.

So he doesn’t advocate going “cold turkey,” which is most likely a good thing.  And he saw the need to be compassionate towards the patient and to keep their “moral strength” up.  Good man.  But here he goes with alcohol as a stimulant again, but it’s champagne, so it’s all good.  Now coca wine?  That would be a stimulant – it contains cocaine after all, and was the fore bearer to . . . . Coca-Cola.  Today, more than half of all heroin related deaths have cocaine on board, too.

Physostigma – Calabar bean (containing physostigmine):

Physostigma venenosum by Franz Kohler (public domain, copyright expired)

“How taken – Beans left about and eaten by children. Symptoms – Giddiness, faintness, prostration, loss of power in the lower extremities . . . death from asphyxia. Treatment – 1. stomach pump . . . 2. Atropia . . . 5. Stimulants freely, brandy.”

I’m not so sure about his symptoms or treatment.  Left whole, the beans may not have a huge effect, but crushed up or chewed they would have a hypermotility of the GI system – that is, vomiting and diarrhea.  So I’m guessing the stomach pump wasn’t needed.  The atropine though is brilliant.  Physostigmine, as we know, stimulates acetylcholine receptors.  Atropine is an antagonist – works against – the acetylcholine receptors.  This is how we treat physostigmine poisoning today, and the reverse, treating atropine poisoning with physostigmine.  But there’s the brandy again.  I wonder if he always had brandy on him?  One for the patient, two for me.

Tobacco – Nicotiana tabacum (containing nicotine):

Tobacco leaves by Dannele Bailey (CC BY-ND 2.0)

“How taken, — Mistaken for coffee. Overdose given as an emetic. Tobacco chewing. Used as a compress for wounds. Taken to cure worms. Applied locally to cure itch. Used to procure abortion. Symptoms, — Nausea, vomiting accompanied by great weakness and faintness. Confusion of ideas, dimness of sight, weak pulse, cold skin covered with clammy perspiration. Pupils at first contracted then dilated . . . Treatment – 1. Stomach pump . . . 3. Nux vomica or strychnine . . . 4. Stimulants, brandy, champagne.”

Here we find lots of uses for tobacco, but mistaken for coffee?  How on earth?  Whatever.  I like his use of strychnine though.  It seems horrific, because we’ve all read and heard about how poisonous strychnine is.  But strychnine works against acetylcholine receptors while nicotine stimulates them – they work more specifically on different receptor subtypes, but we can ignore that fact for now.  And he’s decided to have more of a party and throw champagne into the mix.  I like that.

The point of all this is bring this text to your attention – its copyright is expired so it is readily downloadable into any format, just click on the reference below – but also to show what the standard of care was back in the 1880’s.  Things have definitely changed, but some have stayed the same.  I think by knowing the history of where we came from, whether we are medical doctors or toxicologists, can only help us.  Or at least give us some appreciation for the tools and resources we have today.

References:
1. Murrell, William. What to Do in Cases of Poisoning. London: H. K. Lewis, 1883.
2. Brucefye, W. “William Murrell.” Clinical Cardiology 18.7 (1995): 426-27.
3. Benson, B. E., K. Hoppu, W. G. Troutman, R. Bedry, A. Erdman, J. Höjer, B. Mégarbane, R. Thanacoody, and E. M. Caravati. “Position Paper Update: Gastric Lavage for Gastrointestinal Decontamination.” Clinical Toxicology 51.3 (2013): 140-46.