9 CASE 
or 
POISONING BY THREE GRAINS OF ATROPIA. 
BY 
S. W. GROSS, A.M., M.D., 
SURGEON TO THE PHILADELPHIA ORTHOPEDIC HOSPITAL. 
EXTRACTED FROM THE 
AMERICAN JOURNAL OF THE MEDICAL SCIENCES, FOR OCTOBER 1S69. 
PHILADELPHIA: 
COLLINS, PRINTER, T05 JAYNE STREET. 
1869. CASE OF POISONING BY ATROPIA. 
On the 3d of November, 1868, I was requested by Dr. De Young, of 
this city, to see his sister, Mrs. H., a stout, healthy woman, forty-three 
years of age, who was labouring under symptoms of narcotic poisoning. 
At 8.20 A. M. she had taken, her stomach being empty at the time, four 
pills compounded from a prescription which he had made some time pre- 
viously, and of which the following is a true and literal cppy :— 
R.—Hydrarg. chlor. mite, ext. rhei, aa 9ss; asafoet. gr. iij ; ft. pil. 
No. IV. 6. 22. 8.—P. De Young. 
Mrs. H. had been in the habit of taking the above pills for the relief of 
constipation and headache, and had always obtained them from the same 
drug store. On the morning in question, about twenty minutes after 
having swallowed the dose, her maid heard herself called twice by some 
one with a strange, husky voice, and, upon entering the room, found, to 
her surprise, that she had been called by Mrs. H., who was dropping 
into an easy chair. Mrs. H. remarked, “ Could there have been anything 
in those pills, I feel so very strangely ?” Her maid then placed her upon 
a lounge, and noticed that her hands were tremulous and her eyes closed; 
but she was quiet, and becoming drowsy. In a few minutes the agitation 
increased, until it became violent, she, at the same time, kicking out her 
feet, and throwing her arms forward. She, however, asked for a glass of 
water. On attempting to move her to her bed, it was found that her 
limbs were powerless, and that she was unable to stand, so that she had 
to be carried. It was now observed that her face was “ very much flushed, 
as if she had been standing over the kitchen fire.” In a few moments a 
meddlesome and pleasant delirium set in, in which she picked at her 
clothes, tried to get out of bed, and imagined she was sewing, or nursing 
her child, or engaged in shopping with her sister. These hallucinations 
lasted for about ten minutes, when she sighed and yawned repeatedly, and 
“dropped into a comfortable sleep,” in which state she remained until the 
arrival of Dr. De Young, at about 10 o’clock; the interval between the 
taking of the medicine and the sopor having been rather more than one 
hour. 
Dr. De Young found his sister in a lethargic state, from which she could 
not be aroused. Her face was flushed ; her respiration appeared quiet and 
natural; and there were, now and then, convulsive movements of the 
hands and feet. An ordinary purgative injection was at once administered, 
followed, soon afterwards, by an emetic of mustard and warm water. A 
messenger was sent to the druggist for a copy of the prescription, and, 
upon his return, it was found that atropia had been substituted for the 
assafoetida. Dr. De Young then ordered more mustard, aloug with syrup 4 
of ipecacuanha, which happened to be in the house, and hurried to the 
drug store to inspect his original prescription. He returned at once, 
calling for aid on several physicians on his way back, and administered 
large quantities of emetics, including about five ounces of syrup of 
ipecacuanha, two ounces of mustard, and one drachm of sulphate of 
zinc. The enema had produced the desired effect during his absence, 
but emesis was not excited, although efforts were made in this direction 
on the part of the patient. The further administration of drugs by the 
mouth was prevented by the occurrence of trismus. 
11.15 A. M. Dr. Charles Carter, of the Northern Dispensary, arrived. 
The condition of the patient at this time, about three hours after the poi- 
son had been taken, is best shown by an extract from his written statement 
to me: “ I found Mrs. II. unconscious, and labouring under a heavy 
stupor. The eyes were closed, the pupils dilated, and the muscular system 
was greatly relaxed, excepting a condition of trismus, which was so well- 
marked that an emetic was administered with great difficulty, and degluti- 
tion was almost impossible. The respiration was laboured, and very much 
like that of an intoxicated person. The pulse was quite good, but neither 
this nor the respiration was counted.” After the lapse of a few minutes 
Dr. Lewis came in, and, at the suggestion of Dr. Carter, administered a 
hypodermic injection of half a grain of acetate of morphia. 
11.40 A. M. I arrived in company with Dr. Ralph Townsend and Dr. 
T. H. Andrews, and found Mrs. H. lying perfectly passive in bed, in a 
state of profound stupor. The muscular system was thoroughly relaxed, 
the trismus having passed off. The skin was cool and moist; the pulse 
was 106, of good volume, and pretty strong. The respiration was 26, 
and heavy, but without stertor. The countenance was somewhat livid. 
The lids were closed; the conjunctive were slightly injected; the pupils 
were dilated three-fourths and insensible to light; and the eyes had a fixed 
and brilliant stare. The tongue, roof of the mouth, and soft palate were 
glazed and parched. Deglutition was impossible, and attempts to intro- 
duce remedies by the mouth were attended with suffocative symptoms. I 
at once threw under the skin half a grain of sulphate of morphia, and 
washed out the stomach thoroughly, injecting afterwards whiskey and 
ammonia largely diluted. The effects of the exhibition of the morphia 
appeared to be scarcely perceptible contraction of the pupil; reduction of 
the respiration to 20; the production of slight stertor; no change in the 
pulse. After the use of the stomach-pump, respiration became very irre- 
gular and feeble, and, at times, appeared almost to cease. The pupils 
regained their uunatural size. Faradaism arid artificial respiration were 
now resorted to, the poles of the battery being applied respectively along 
the course of the phrenic and pneumogastric nerves, and at the hypogas- 
trium. A third half-grain of morphia was again injected at 12 M. 
Under these measures, after the lapse of fifteen minutes, the respiration 
was 14, but very decidedly stertorous; and tne pulse was 102, pretty full, 
but weak. The bad condition of the breathing, indicating as it did in- 
creased narcotism, was, in my opinion, a sufficient reason for withholding 
morphia, and from this time no more was exhibited. The stertor con- 
tinued for half an hour after the induction of artificial respiration. 
2 P. M. Professor Gross now arrived, and suggested flagellation of the 
trunk and extremities with bundles of willow switches, in addition to the 
other measures employed. In the interval, artificial respiration and fara- 
daism had been unceasingly kept up, the former having been very mate- 5 
rially assisted by slapping the chest and face repeatedly with the hands 
immersed in ice-water. The mouth was held open by corks, armed with 
threads to prevent accident, placed between the teeth, and the Marshall 
Hall method was used. The respiration, at times, was very laboured, and 
the countenance livid ; and whenever the artificial measures were relaxed 
for a few moments, the breathing threatened to cease entirely, the tongue 
showing a disposition to fall back and choke up the superior aperture of 
the larynx, whence it had to be dislodged by the fingers. 
6.30 P. M. Up to the present time there has been no change in the 
symptoms; but now the respiration is 20 and becoming more natural, and 
permits of short intervals of rest to myself and fatigued assistants. I drew 
off fourteen ounces of urine, of which I injected twenty drops into the nape 
of the neck of the family cat, with the effect of widely dilating its pupils. 
The bowels were found to have acted, and the extremities being cold were 
enveloped in hot blankets. 
7.45 P. M. Artificial respiration, faradaism, and flagellation stopped. 
Respiration 18. Pulse 108, weak, and of pretty good volume. Muscular 
system still greatly relaxed. Pupils unchanged. The patient appears to 
be in a quiet sleep. Two ounces of whiskey were thrown into the rectum, 
and small lumps of ice were placed in the mouth, the tongue looking like 
a piece of sole-leather. 
8.45 P. M. Respiration began to increase in frequency until it soon 
reached 30. Inspiration roughened and expiratory murmur much pro- 
longed. Coarse mucous rales abundant throughout the chest. Veins of 
the face turgid with blood, and death by apncea imminent, from exhaustion 
and accumulation of fluid in the air-passages. The former measures were 
again vigorously resorted to, and, at the suggestion of Professor Gross, 
veratria ointment, one drachm to the ounce, was briskly rubbed along the 
spine and over the chest and epigastrium. 
9 P.M. Pulse 128; respiration 28. The muscles respond to a weak 
galvanic current, and the patient opens her eyes, and makes voluntary and 
quite strong movements, such as drawing up the lower limbs, rolling her 
head, and twisting the body violently, in response to the flagellation and 
veratria frictions. 
10 P. M. The patient shows signs of returning consciousness. She ex- 
claimed “ O my,” and turned voluntarily upon her side. At the expiration 
of ten minutes she attempted to expectorate, and, on being asked if she 
would take whiskey, nodded affirmatively, and swallowed four tablespoon- 
fuls of equal parts of that fluid and water. The veratria ointment was 
now discontinued, and Chapman’s ice-bag was placed along the spine. 
IIP. M. Artificial respiration has been kept up at intervals, and the 
ice-bag was used about twenty minutes. On being asked how she felt, she 
replied “Better,” and on being slapped, she said, “ You hurt me.” She 
now swallowed one tablespoonful of strong beef extract, and a few moments 
later, she took another with difficulty. 
11.10 P.M. Symptoms of suffocation suddenly set in, and notwith- 
standing an immediate and vigorous resort to the former measures, con- 
tinued briskly for nearly half an hour, resuscitation was impossible. Death 
occurred about fifteen hours after taking the poison. 
Autopsy, made for the Coroner by Dr. Shapleigh, in the presence of 
Professor Gross, Dr. Townsend, Dr. De Young, and myself, thirty-eight 
hours after death, and twenty-four hours after a strong solution of carbolic 
acid had been thrown into the abdominal cavity. 6 
Body large and well developed. Some dirty fluid issuing from the mouth 
and the nose. Rigor mortis well pronounced, and nails purple. Face 
livid, but not tumid. Pupils dilated one-half; cornese clear; conjunctiva; 
not injected, and lids natural. Large suggillations over the back, and the 
buttocks and posterior surface of the lower limbs livid. The muscles and 
fasciae of the dorsal and lumbar regions infiltrated with dark, fluid blood. 
On opening the spinal column, the dura mater and pia mater were seen to 
be injected and ecchymosed, while the cord itself was decidedly softened. 
The vessels of the scalp were distended with liquid blood. The dura 
mater was wonderfully adherent to the inner surface of the cranium. 
The vessels of the pia mater were turgid with blood, and there was large 
subarachnoid serous effusion. The brain tissue was greatly softened, so 
much so, indeed, that the corpus callosum was torn asunder merely by 
separating with the fingers the cerebral hemispheres. The lungs were 
congested and the bronchi filled with mucus. The heart was very soft, 
readily permitting the finger to be thrust through its walls, and its cavities 
contained fluid blood. The lining membrane of the aorta and larger ves- 
sels was deeply stained, and nowhere in the vascular system was clotted 
blood found. The intestines were pale, but the stomach presented suggil- 
lations at its cardiac extremity. The kidneys were congested. The blad- 
der was empty, and there was no appearance of menstruation. 
Remarks.—The dose of atropia, for internal use, at the commence- 
ment of the exhibition, is, according to the United States Dispensatory, 
about one-thirtieth of a grain. In the case now recorded, three grains of 
the alkaloid were taken, which is a much larger quantity than I find to 
have been heretofore reported. Some idea of the enormous amount taken 
may be formed, when I state that that quantity is said by Geiger1 to be 
equal to six hundred grains of the extract of belladonna, and by Pfitzner2 
to be the equivalent of seven hundred and twenty grains of the same 
preparation. The present case, therefore, ought to afford several points 
of interest, to which I shall briefly invite attention. 
The physiological action of atropia on man has of late years been the 
subject of careful experiment and research, the more recent and most able 
writers on the topic being Dr. John Harley,3 and Dr. Meuriot.* They 
both agree that it is a powerful cardiac stimulant in medicinal doses, the 
force and frequency of the whole circulation, as well as the tone and volume 
of the arteries, being increased by it. In excessive or poisonous doses, on 
the other hand, the drug diminishes the force of the heart’s action and the 
tone and volume of the bloodvessels, with only a moderate acceleration of 
the circulation, or ultimate decrease of the rapidity of the heart’s action. 
My observations in the case under consideration lead me to coincide in 
the above statements, with the exception of that which relates to the effect 
1 Professor S. R. Percy. Prize Essay on Atropia. Reprint from the New York 
Medical Journal, December, 1868. 
Ibid. 
3 The Old Vegetable Neurotics. London, 1869. 
4 De la Metbode Physiologique a l’Etude de la Belladone. Paris, 1868. 7 
of excessive doses on the frequency of the circulation. When I first saw 
the patient, the pulse was 106, at which it remained for eight hours, 
when it increased two beats. One hour and a quarter later it was 128, 
w'hich was the maximum reached. The effect of an excessive dose- of 
the drug upon the vascular system may, therefore, be thus expressed: 
Marked and persistent increase in the rapidity of the circulation; decrease 
in the force of the pulsations; and loss of volume and tone of the blood- 
vessels. 
Atropia in medicinal doses is generally considered to accelerate the 
respiration, an opinion particularly insisted upon by Dr. Meuriot. Dr. 
Harley, however, concludes, from extended observation, that small doses 
exert no influence whatever upon this function. The inquiries of Dr. 
Harley refer solely to the action of medicinal doses, and so far these 
observers agree. But Dr. Meuriot states that the alkaloid in poisonous 
doses decreases the frequency of the respiratory movements, through 
paralysis of the pneumogastric nerves. His positive conclusions are not, 
however, borne out by the experience in the present case, in which the 
respiration was very decidedly increased in frequency. Thus, at the time 
of my visit, it was 26, and it was only after eight hours of active treat- 
ment that it fell to 18. The subsequent acceleration was doubtless due to 
exhaustion. 
With regard to the cerebro-spinal nervous system, it is usually taught 
that atropia always produces restlessness, insomnia, and delirium, and that 
poisonous doses prolong these effects for many hours, until the patient 
generally passes into coma. Both Dr. Harley and Dr. Meuriot insist 
upon these effects; but in the case here recorded the restlessness and 
delirium were evanescent, and, instead of insomnia, lethargy soon set in, 
and was quickly followed by profound stupor. 
The action of the drug on the hollow viscera in this case was somewhat 
obscure. About two hours after taking the pills, the bowels moved under 
the stimulus of an injection, and eight hours later, when the patient’s urine 
was drawn off, it was observed that they had acted again. How far this 
effect was due to the purgative action of the calomel and rhubarb, taken 
early in the morning, I am unable to decide; nor is it in my power to 
state whether the urine was passed at the same time. Poisonous doses of 
belladonna are said to provoke frequent micturition; but this could scarcely 
have been possible in this case, as I drew off fourteen ounces of urine ten 
hours after the taking of the drug, and none was found in the bladder 
after death. Retention of urine had possibly occurred, along with sup- 
pression of the secretion from congestion of the kidneys ; and this view will 
appear the more probable when it is remembered that the effects of atropia 
are much more decided when the quantity of urine is small; in other words, 
that they are proportionate to the activity of the kidneys, through which 
organs the alkaloid is principally, if not entirely, eliminated. 8 
Atropia is said to be an emmenagogue. However this may be, no such 
action could be discovered in the present instance, notwithstanding the fact 
that the patient had menstruated twenty-seven days previously. 
The treatment of poisoning by belladonna and atropia has, of late years, 
been invested with great interest, particularly with regard to the employ- 
ment of opium and morphia as antidotes, the mass of evidence being in 
favour of the view that these agents are mutually antagonistic in their 
action. So fully impressed was I with this fact, that I took with me, on 
my visit, sulphate of morphia and a hypodermic syringe, and resorted to 
the so-called antidote, with the following results. 
Nearly three hours after symptoms of poisoning had set in, one-half a 
grain of acetate of morphia was thrown under the skin. The apparent 
effect of this was to relieve the trismus. In fifteen minutes half a grain of 
sulphate of morphia was introduced. This brought down the respiration 
from 26 to 20, but produced slight stertor, and effected no change in the 
pulse. After the lapse of an additional fifteen minutes, the respiration in 
the meanwhile having been very irregular and feeble, another half grain 
was used. In fifteen minutes the pulse was reduced two beats; the respira- 
tion was 14, and very decidedly stertorous; and the bad breathing con- 
tinued for half an hour after the vigorous use of artificial respiration and 
faradaism. A grain and a half of morphia, therefore, used hypodermically 
during the space of half an hour, merely intensified the poisonous effects 
of the atropia and still further jeoparded life. 
It is not my object to vannt, or detract from the merits of any particu- 
lar remedy or treatment, but to furnish facts as they actually occurred, 
with the view of throwing additional light on a very important and a 
much-vexed question. With this end in view, I must confess that the. 
experience in this case goes to justify and corroborate the conclusions of 
Dr. Harley on the question of the antagonistic action of opium and bella- 
donna and their alkaloids. From a careful analysis of the recorded cases, 
he shows “that the evidence of antagonism in any given case is incon- 
clusive” (p. 309) ; and “that all the effects of atropia, excepting, perhaps, 
the influence on the heart, are intensified and prolonged by the action of 
morphia, induced previously, or at any time during the operation of the 
former” (p. 291). I may, therefore, be allowed to express the opinion 
that, in the present state of our knowledge on this subject, it would be 
unsafe to rely on opium or morphia, to the exclusion of other measures, 
when an excessive dose of belladonna or atropia has been taken, and par- 
ticularly so when the system is fully under the effects of the drug. 
The good results of artificial respiration were manifest in this case. 
On several occasions death by apncea was imminent, when efforts in this 
direction were relaxed, and to it principally, if not entirely, do I ascribe 
the remarkable prolongation of life. Hence, I fully indorse the opinion 
expressed by Dr. Harley that our efforts must be directed to sustain the 9 
breathing in the treatment of poisoning by belladonna. Veratria was 
also, probably, of essential service. At all events, it proved to be a 
powerful spinal stimulant. 
Professor Percy suggests that, when a large dose of atropia has been 
taken, and it has become absorbed into the system, much good may be 
expected from the free administration of diluents. From numerous experi- 
ments upon dogs, he concludes— 
“As a rule, if atropia is given without water, the effects are much more 
irritative, and last much longer, than when a sufficiency of water is allowed. 
When death takes place where water is not allowed, there is always con- 
gestion of the kidneys. Morphia, although an antidote to atropia in ordi- 
nary cases where water is freely allowed, is hardly an antidote where fluid 
is entirely withheld. A much larger dose of atropia may be borne without 
danger, if care is taken to keep the system well supplied with fluids; and 
the effects of poisoning pass off much more rapidly if warm diluents are 
prudently administered. Where diluents are freely given, the kidneys per- 
form their function, and gradually remove the poison from the system; but 
where large doses of the medicine are given unaccompanied with liquids, 
the kidneys are unable to eliminate either the poison or the urea, and the 
animal consequently dies, frequently only from uraemic poisoning, at other 
times from the double effect of the poisoning from the alkaloid, and uraemic 
poisoning as well.” (p. 12.) 
When it is remembered that atropia is eliminated principally by the 
kidneys—elimination by the skin and mucous surfaces being very slight— 
the foregoing suggestions of Professor Percy would appear to be of value, 
and should be thoroughly tested. 
The post-mortem appearances were of a negative character, as they 
merely pointed to rapid decomposition. A microscopic examination of the 
blood, made by myself, disclosed a few shrivelled and crenated corpuscles 
floating amid others of natural size and shape. Dr. Keen was unable to 
discover any in the specimen sent to him ; but found bodies, which may 
have been deformed blood-cells, and a large amount of granular matter. 
The blood never coagulated ; it was thoroughly decomposed. 
A word in regard to the means of detecting the alkaloid in instances of 
poisoning by it. The perusal of the case shows that a cat was subjected 
to the usual physiological test, the injection of the urine of the patient 
under the skin, the effect of which was dilatation of the pupils. At the 
post-mortem examination of the body of the deceased, I was enabled to 
collect about a drachm and a half of the cerebro-spinal fluid, mixed with 
a little blood, which was afterwards separated from it. On the evening of 
the 13th of November, or ten days after death, I threw twenty drops of 
that fluid beneath the skin of the nape of the neck of a kitteu. In two 
minutes the pupils were dilated so widely as to leave the merest line of the 
irides perceptible. After an hour they were in the same condition; and 
the kitten had lost its playfulness, avoided the light, and, when it was 
made to walk, it moved very slowly, as if with hesitation. This experi- 10 
ment, showing as it did how deeply the fluids of the body were saturated 
with the poison, is entirely novel, and may prove not only of interest to 
the physiologist, but highly important in a medico-legal point of view. 
This case was the subject of criminal action against the druggist who 
compounded the prescription, at the April term, 1869, of the Oyer and 
Terminer Court of the First Judicial District of Philadelphia, Judges 
Brewster and Ludlow presiding. The jury returned a verdict of involun- 
tary manslaughter, with a recommendation to mercy. The counsel for the 
accused moved, however, for a new trial, and the case is, therefore, unde- 
termined. 
In conclusion, I must express my thanks to Professor Gross, Dr. Carter, 
Dr. Townsend, and Dr. Andrews for their valuable assistance and the 
unwearied interest which they evinced in the management of the case now 
recorded. 
Philadelphia, July, 1869.