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BRITISH PHARMACEUTICAL CONFERENCE. 
this circumstance the draught phial was filled with laudanum in mistake, by the 
druggist himself. 
No. 14. This was an instance of Burnett’s fluid, administered by mistake for fluid 
magnesia, with a fatal result. 
No 15. A second fatal case from the same cause. 
No. 16. A solution of morphia was sent to a lady, for her own use, with directions 
now to take it, but it was not labelled “ Poison.” The nurse carelessly administered a 
portion to the infant, in mistake for dill water, with a fatal result. 
No. 17 is a case of accidental poisoning by chloroformic anodyne. The record 
simply states that the patient had given to her by mistake six drachms of the anodyne. 
The result was fatal. 
No. 18 is a case of laudanum being sold by a druggist himself in mistake for tincture 
of rhubarb, with a fatal result. 
No. 19 is a second case of the same, also with a fatal result. No attempt to ac¬ 
count for, or excuse the carelessness. 
No. 20. This is an instance of a man being poisoned fatally by taking saltpetre 
instead of Epsom salts, sold to him by a druggist in mistake. 
No. 21. This is the third recorded case in two years, in which laudanum has been 
sold by a druggist in mistake for tincture of rhubarb, with a fatal result. 
No. 22. In this case two lads, aged fourteen and sixteen, were fatally poisoned by 
sheep-dipping powder containing arsenic. It was folded in brown paper, not labelled, 
and was mistaken for sulphur. 
No. 23. This case demonstrates the necessity of a legal restriction to prevent un¬ 
qualified persons from dealing in poisons. A grocer’s wife, in the absence of her 
husband, supplied an applicant with five grains of strychnia, in mistake for calomel. 
The poor victim, a young woman twenty-seven years of age, expired in great agony in 
less than fifteen minutes after taking it. 
No. 24. In the same month we have recorded a second case of poisoning by 
strychnia, and as if to teach us humility, in this instance the mistake was made by a 
well-educated and experienced chemist’s assistant in an old and well-regulated esta¬ 
blishment. One witness said, he considered the arrangements of the establishment to 
be exceedingly good, and he knew that elaborate pains were taken to have the pre¬ 
scriptions checked; but it was proved that the strychnia had been kept in a state of 
powder for the convenience of dispensing, and not in its crystalline form; and that 
the bottle containing the powdered strychnia was kept on the same shelf as the James’s 
Powder, for which it had been mistaken, and was separated from it by only one bottle. 
The strychnia bottle was labelled “Poison.” The jury have since pronounced the 
assistant “not guilty,” when tried for manslaughter. 
No. 25. In our last case, a surgeon’s assistant was making solution of morphia ; he 
turned it into a measure, from which he began to filter it into a bottle ; he retired from 
the surgery for a few minutes, during which time the surgeon came in, made up a 
mixture, and thinking it water in the measure, used it as such, with a fatal result. 
Such are the simple facts of the twenty-five cases before us, and it would not be 
difficult to engage your attention for some time, in commenting upon them ; but we 
doubt not you have felt as we have upon each case as it was brought before you, and 
are disposed rather to gather from them the lessons of wisdom and charity they arc 
designed to teach, than to indulge in harsh criticism upon those who have already 
suffered so severely from the consequences of their error. 
Your Committee, however, think it will only be doing our brethren justice to show 
that less than half of these cases can be laid at the doors of a legitimate chemist and 
druggist, by classifying them as follows :— 
There are 10 cases in which the mistake was committed by the administrator; 
2 cases by a surgeon ; 
1 by a wholesale house ; 
1 bv a grocer’s wife ; 
11 by retail chemists or their assistants. 
Your Committee have had correspondence with various chemists of standing in 
several parts of the kingdom, and it is now their pleasing duty to mention the various 
suggestions that have been brought under their notice. They are classed under the 
three heads of Shop Arrangements. Dispensing, Sale of Poisons. 
