2 
PREVENTION OF THE MISUSE OF POISONS. 
which caused the death of the patient in a few minutes. It was found that 
cyanide of potassium had been accidentally substituted for carbonate of ammonia, 
so that the fatal dose contained twenty grains of a powerfully poisonous salt, 
which mixed with the lemou juice would evolve hydrocyanic acid. The quan¬ 
tity of cyanide of potassium in the dose, if pure, would represent 415 grains of 
the diluted hydrocyanic acid of the Pharmacopoeia ; and allowing for the im¬ 
purities generally present in commercial cyanide of potassium, there would still 
have been present probably three-quarters of an ounce of prussic acid of the 
Pharmacopoeia strength. 
With reference to this part of the case the first impression produced is one of 
surprise that the patient, after having his suspicions excited, should have taken 
the fatal dose, which must have differed essentially from the medicine, ostensibly 
the same, which he had previously used. But no doubt his suspicions were to a 
great extent removed after he had called the attention of the dispenser to the 
subject, and had a fresh mixture made. And then the presence of carbonate of 
potash in the commercial cyanide of potassium, which we presume was used, 
w r ould afford an effervescence with the lemon juice, similar, if not equal, to that 
caused by carbonate of ammonia. These considerations may serve to account 
for the fact that the medicine was taken, although there were sufficient grounds 
for suspecting that there was something wrong in it. 
But now turning to the dispensing establishment where the medicine was 
prepared. This was one of the first houses in Dublin, and the arrangements 
adopted in the establishment for preventing mistakes such as that which oc¬ 
curred, appear, as described by one of the firm, to be perfectly good ; but in 
two respects the rules of the house had been broken through. In the first place, 
a stone jar, containing cyanide of potassium, was unlabelled and out of its place. 
This indicates a great want of attention with reference to a most important pro¬ 
vision. Then, in the next place, the bottle for carbonate of ammonia used in 
dispensing being empty, was given to a porter to be filled, and the filling of the 
bottle was performed without the presence of a second person, whose duty it 
would have been, according to the rules, to see that it was properly filled. The 
porter finding the jar of cyanide of potassium, mistook this for carbonate of 
ammonia, and filled the bottle with the poisonous salt, which was afterwards 
used by the dispenser for carbonate of ammonia in making the mixture. It is 
difficult to understand how two persons accustomed to the handling of these 
substances could have made this mistake, and especially when it is considered 
that the attention of the dispenser was called to a difference in the appearance 
of the medicine, which he was required to make up a second time, on the as¬ 
sumption that some mistake had been made. We fully admit the force of the 
statement made in a recent number of the ‘ British Medical Journal,’ that this 
case forcibly illustrates, with reference to the education of pharmaceutists, “ the 
necessity for such scientific culture and training in habits of observation as 
would render the mistaking of cyanide of potassium for carbonate of ammonia, 
or similar mistakes, almost impossible.” 
The other case to which we have alluded was that of the substitution of 
strychnia or a salt of strychnia for acetate of morphia, in preparing a solution, 
which being taken by a medical man in what would have been a full dose if 
correctly prepared, was converted into a poisonous dose not only by the unex¬ 
plained circumstance that the bottle labelled acetate of morphia contained 
strychnia, which was used in the preparation, but also by the substitution of the 
London Pharmacopoeia process for that of the British Pharmacopoeia. That a 
wholesale house should have sent out strychnia for acetate of morphia seems to 
indicate that there must have been something wrong here again in the labelling 
and keeping of the stores; and that a chemist and druggist should still continue 
to use the London Pharmacopoeia as the standard authority for the preparation 
