580 IMPORTANT POISONS AND THEIR TREATMENT 



completely dominate the scene. Those acids whose corrosive effects are less 

 prominent, as, for example, hydrochloric acid, may show nervous symptoms 

 which can be referred to the acid, but even this is relatively rare. If an indi- 

 vidual takes large quantities of free acid, e. g., sulphuric acid, what symptoms 

 are produced? The deeply invading eschars which cover all parts of the 

 mucous membrane are characteristic, particularly in those areas which are 

 brought in contact with the acid in deglutition. Severe retching and the 

 vomiting of brown pulpy masses, excessive pain in the gastric region, intense 

 burning in the esophagus, and marked salivation, are the immediate conse- 

 quences of such a toxicosis. The vomited material has an acid reaction; 

 within a few hours the symptoms of marked renal irritation develop. 



If the amount of acid which has reached the stomach is relatively large, 

 and the acid is concentrated with the continuance of vomiting, symptoms of 

 perforative peritonitis soon appear, due to the erosion of the walls of the stom- 

 ach by the acid, and the patient succumbs in a short time, often within a few 

 hours. But even if the amount of acid swallowed was not large, days, even 

 weeks, must elapse before the eschars heal. Dysphagia, salivation, pain on 

 deglutition continue, and often fever follows, the wounds which have been 

 produced by the acid becoming the point of entrance by which pyogenic organ- 

 isms_find their way into the body. An important fact is that all poisonings 

 with corrosive acids, even in cases which apparently run a mild course, may 

 lead to stricture of the esophagus; indeed this is an almost invariable result. 

 Of course the frequency of stricture depends on the variety of the acid. Poi- 

 soning by sulphuric acid almost always produces this symptom, nitric acid 

 less frequently, hydrochloric acid relatively seldom, but there can be no doubt 

 that strictures also occur from hydrochloric acid toxicosis. They are less often 

 seen after poisoning with organic acids, such as acetic acid, etc., perhaps be- 

 cause poisoning with concentrated solution of these acids is relatively rare. 



An important symptom which must be discussed is renal irritation caused 

 by acid toxicosis, which, in my experience, often leads to the typical signs of 

 acute toxic nephritis. Acid nephritis may occur in all acid toxicoses; most 

 frequently, however, we meet with it after poisoning with sulphuric acid. 

 The symptoms are exactly the same as in acute nephritis due to other causes, 

 but I must emphasize the fact that edema does not accompany this form of 

 nephritis, and, furthermore, that dissolved hemoglobin frequently appears in 

 the urine. 



The prognosis in poisoning with acids should always be considered grave, 

 as, even in the mildest cases, it can never be asserted at the onset that stricture 

 of the esophagus, which is invariably so dangerous, may not develop. Even 

 with judicious treatment, stricture may result in under-nutrition, or in actual 

 starvation with all its consequences. 



In regard to the diagnosis, the fact that an acid toxicosis is present may 

 be readily determined from the markedly acid composition of the vomited 

 material, and from the previously described eschars. We must determine with 

 which acid we are dealing by a testing for the presence of that acid to which 

 the pathologic picture points. If, for example, the eschars are yellow or yel- 

 lowish, it may be presumed that nitric acid was the toxic agent. If the mucous 



