Reprinted from The North American Practitioner, 
November, 1891. 
THE PATHOLOGICAL ANATOMY OF ACUTE ARSEN- 
ICAL POISONING.* 
LUDVIG HEKTOEN, M.D., 
PROFESSOR OF PATHOLOGY AND DIRECTOR OF THE PATHOLOGICAL LABORATORY, WOMAN’S MEDICAL COLLEGE 
PROFESSOR OF PATHOLOGICAL ANATOMY IN THE COLLEGE OF PHYSICIANS AND SURGEONS 
PATHOLOGIST TO COOK COUNTY HOSPITAL. 
IN this communication only those anatomical changes that may 
he caused by acute arsenical intoxication and are susceptible of 
demonstration in the fresh cadaver will be considered. While the fre- 
quency of poisoning with arsenic is steadily diminishing in certain 
European cities and countries, this mode of terminating life appears to 
be quite popular in this city. Of 431 cases of fatal poisoning investi- 
gated at the Medico-Legal Institute, in Berlin, during the years 1876, 
’77 and ’7B, only eight were instances of arsenical intoxication; of 120 
cases of suicide by poisoning examined in Vienna during 1874-’75, only 
two had selected arsenic. In France, in 1857, arsenic was the poison 
employed in thirty-five of sixty-three murders by poisoning; in 1860, it 
was used only three times in thirty-two; in 1862, five times in thirty- 
eight. f Of forty-seven cases of acute poisoning admitted into the Cook 
County Hospital:}: in Chicago, during 1890, eight were instances of 
arsenical poisoning; in fifty-nine cases of poisoning investigated by 
the coroner of Cook County! during the year 1890, thirty-two were 
due to arsenic. Five of these fifty-seven cases were murders, and 
two of these by the mixture known as ‘ ‘ Rough on Rats, ’ ’ two 
by arsenic in solution, one by Paris green; in twenty-three out of the 
twenty-seven suicidal poisonings with arsenic “Rough on Rats” was 
used. One, and perhaps the principal reason for this astounding fre- 
quency of arsenical poisoning here, is undoubtedly the ease with 
which the poison is obtainable—any child can be sent to a drug or 
* Read before the Chicago Medico-Legal Society, October 4, 1891. 
t Casper-Simon, Handt. d. Gerichtllchen Medicin 8 ed. 2 Vol. Berlin, 1889, 
$ Mitchell, Cook County Hospital Report. Chicago, 1890. 
1 Hertz, Report of Coroner of Cook County, December, 1891 grocery store for unlimited quantities of arsenic, in the mixture called 
u Rough on Rats.” 
In order to bring before you the anatomical changes of acute 
arsenic poisoning I shall take the liberty to briefly describe the post- 
mortem appearances in two or three instances: 
CASE I. POISONING WITH ‘4 ROUGH ON RATS.5 ’ 
This occurred in a family of four and was due to the sprinkling 
of “ Rough on Rats ” upon the corn eaten at the fatal supper. The 
father died about twelve hours after the poisoning, the mother eigh- 
teen, and in both the clinical symptoms were quite classical. The 
two children recovered. 
The post-mortem examination was made twenty-four hours after 
death. The appearances were quite similar in both, hence, only one 
description is necessary at this time. The external appearances were 
absolutely negative except that the man’s skin was yellowish; the 
facial expression was not indicative of any special emotion. The per- 
itoneal cavity was empty, the peritoneum normal; the stomach was 
dilated in both instances, hanging low down. The sub-serous veins 
were moderately filled with blood; in each case the stomach contained 
about twenty-four ounces of turbid watery fluid of negative odor. 
The mucous membrane was rather pale, opaque and somewhat swollen, 
but in the cardial and pyloric regions were punctiform and linear 
hemorrhages and extensive areas of capillary hypersemia. The com- 
mencement of the duodenum was quite uniformly red, its mucous 
membrane swollen; in the entire small intestines the valvulae con- 
niventes are voluminous, in the upper part irregular areas, greyish 
white in color, surrounded by a red border. These areas were due 
to a false membrane which could be peeled off, leaving a small area 
of necrosis with much capillary injection and hypersemia. In the 
lower part of the ileum was much swelling of the solitary and agmin- 
ate glands, but no croupous areas. The large intestine, as well as the 
small, contained fluid contents, greyish, turbid and full of shreds; the 
follicles were swollen in the upper part of the large intestine. 
The shreddy masses in the gastric and intestinal contents con- 
tained, microscopically, epithelial cells, round cells, mucus corpus- 
cles, and octahedral crystals of arsenic; in the rectum octahedra were 
found with ease. The mesenteric glands were larger than usual, 
they were soft and pale red on the cut surface. The pancreas and 
spleen seemed normal in both cases. The kidneys were also appar- 
ently normal except some capsular adhesions in the man. The liver 
was about normal in size; on the cut surface the lobules seemed large 3 
but the outlines were indistinct, the color yellowish. The heart was 
of normal size, in both cases there were sub-endocardial areas of blood 
extravasation in the left ventricle; the myocardium was pale yellowish 
gray, it was comparatively flabby and teased specimens show indis- 
tinct transverse striae The lungs were oedematous, the pleurae 
smooth and shining. The brain and its membranes were apparently 
normal. The pharynx, oesophagus and larynx were unchanged. 
Chemical examination showed abundant arsenic in the gastric and 
intestinal contents, in the liver and in the kidneys of both the man 
and the woman. 
To recapitulate: In these two cases solid arsenic in the mixture 
known as 1 ‘Rough on Rats’ ’ produced in twelve and eighteen hours acute 
parenchymatous gastritis, acute croupous enteritis with hemorrhages 
and capillary hyperaemia, acute follicular enteritis, swelling of the 
mesenteric glands, cloudy swelling of the liver and of the myocardium 
and sub-endocardial ecchymoscs. 
CASE 11. ARSENICAL POISONING. 
A wealthy family near Maplewood, in this city, was mysteriously 
poisoned with arsenic in the early summer of 1890, the father and a 
male servant dying. This is the sensational Kuhn tragedy and 
mystery. The arsenic, probably in solution, was placed either in the 
coffee, or in some pie, or in both, and in spite of appropriate treat- 
ment, the cases having been correctly diagnosed ante-mortem by Dr. 
T, J. Conley, the servant died in twelve hours and the father in 
twenty-four. In both these cases the changes differed considerably 
from the previous, hence a brief description of the autopsy cf the 
servant will be permitted. 
It was made ten hours post-mortem. 
The body was well nourished, muscular, about thirty-five years 
old; there were no external marks of violence; the peritoneal cavity 
was empty and the peritoneum normal; the stomach was somewhat 
dilated and hanging low down, it contained twenty ounces of greyish 
granular fluid, the mucous membrane was very much swollen, 
covered with large flakes of viscid mucus, its tissue was the seat of 
innumerable hemorrhagic areas occurring singly and in crops. 
The hemorrhages occupy the summit of the folds as well as the 
depressions between them; the submucosa is swollen also and distended 
with clear fluid; the contents of the duodenum are watery, its mucous 
and submucous coat are greatly swollen, and here and there are 
occasional hemorrhages. The jejeunum and ileum contain about 
eighteen ounces of faintly yellowish fluid which looks like rice water; 4 
the swelling diminishes from above downward, while the solitary and 
agminate follicles are considerably enlarged near the ileoctecal valve. 
The mucous membrane of the large intestine is pale, not much 
swollen, covered with strands of mucus, the contents rice water like. 
The mesenteric glands are swollen, the liver shows indications of 
cloudy swelling; the kidneys seem normal; the respiratory organs and 
the upper parts of the intestinal tract are intact. The heart showrs 
nothing abnormal, and the brain and its membranes show no structu- 
ral changes. 
Arsenic in abundant quantities was demonstrated by Prof. 
Haines in the gastro-intestinal contents, and in the liver and the 
kidneys. To recapitulate: In this case the changes consisted of 
acute catarrh of the stomach and the small intestine, with 
oedema of the gastric and duodenal submucosa, submucous hemor- 
rhages, follicular swelling of the small intestine, acute catarrh of 
the large intestine, with a commencing parenchymatous degeneration 
of the liver. 
CASE 111.-—SUICIDAL PARIS GREEN POISONING 
An old man swallowed a quantity of Paris green and died in 
about ten hours. Autopsy ten hours later. 
Lips livid, skin over face pale, mouth and oesophagus normal, 
mucous membrane of pharynx is swollen and quite red. The 
stomach is considerably dilated with gas and fluid of a bluish or 
greenish tint, upon the inner surface are masses of mucus with green 
particles in it; the mucosa is greatly swollen and thrown into 
numerous folds; in it are numerous hemorrhages, the free surface of 
which appears eroded. 
The contents of the small intestine show particles of green 
throughout the entire extent; the mucosa is much swollen; in some 
places opaque areas of varying size and form with slight superficial 
loss of substance can be observed, one of these areas is about three 
inches long, but does not include in all its parts the entire mucous 
membrane; in some parts there are fine hemorrhages in the vicinity of 
these areas, and there is a quite general capillary hypertemia, the soli- 
tary glands are markedly prominent, but the increase in the Peyer’s 
patches is not so marked. In the ceccum the poison is microscopi- 
cally visible but not any further into the large intestine, the mucous 
membrane of which is pale and free from corrosion. 
The liver measures ctm.; it is very flabby, the 
capsule is smooth; the parenchyma is brownish in color with yellow 
spots and the lobules are enlarged with indistinct outlines and a con- 5 
gested centre. The kidneys are of about normal size, in the cortex 
are found numerous pin head size hemorrhages; the mucous mem- 
brane of the ureters and of the bladder is swollen and shows a few 
ecchymoses. 
The myocardium is opaque yellowish red and underneath the en- 
docardium of the left ventricle are many extravasations. 
The lungs and pleurae are quite normal, ditto brain. 
Recapitulation: Acute gastro-intestinal catarrh with hemorrhagic 
crosinous and capillary hyperaema; cloudy swelling of liver, acute 
parenchymatous nephritis with swelling of and extravasation into 
ureteral and vesical mucous membranes, acute parenchymatous myo- 
carditis, subendocardial extravasation. 
If we now pass in brief review the various changes that may be 
produced by arsenic, it will at once become very evident that they are 
exceedingly fitful and freakish, subject to marked variation in intensity 
and extent, not bearing a constant relation to the quantity introduced, 
nor to the time elapsing between the ingestion and the fatal end, so 
that a general description of all the changes that may be produced 
would rarely apply to a single concrete case. 
Commencing with the mouth and the upper part of the digestive tract 
it may be said as a general rule that arsenic does not produce any 
changes upon the mucous membrane of the pharynx and oesophagus, 
when taken in its usual forms, although Woodman and Tidy* state 
that congestion of the gullet, mouth and windpipe from the applica- 
tion of the poison during vomiting, is general. 
Externally the stomach and intestines do not usually present any 
changes although it is common to find the stomach somewhat dilated 
with gas and fluid, but the serous surface is almost always smooth 
and shining while the amount of blood in the subserous veins may 
vary within wide limits; the authors just quoted, state that inflamma- 
tion of the peritoneum is occasionally found, but, except in very rare 
cases, where it is secondary to perforation of the stomach this does 
not seem to have been described by other reliable observers. The 
contents of the stomach are usually a little bloody with considerable 
adherent viscid mucus; the mucous membrane is usually swollen, 
in some places it may be markedly opaque and greyish yellow in 
color, the epithelial cells under the microscope showing typical paren- 
chymatous degeneration; at times it may be the seat of areas of capil- 
lary injection and hemorrhages, especially in the cardiac and pyloric 
regions and small areas of necrosis may be observed on the surface of 
the hemorrhagic district; then there may be croupous areas, that is, 
♦Forensic Medicine and Toxicology, I’hilad., 1887. 6 
places covered with a more or less easily removable grayish mem- 
brane which microscopically shows a fibrinous network entangling 
mucus corpuscles, epithelial and round cells and often octohedral 
crystals of arsenic; the submucosa may be doubly thickened from 
oedema; perforation and gangrene are very rare occurrences, but cases 
are stated to be on record. Similar processes may continue into the 
duodenum and a considerable distance into the small intestine; usual- 
ly the contents of the small intestine are rice-water like, the mucous 
membrane may show catarrhal enteritis, areas of croupous inflamma- 
tion together with hemorrhages, districts of capillary hypersemia and 
areas of necrosis and erosion, the follicles, solitary and agminate 
glands may be, and very frequently are, enlarged either from oedema 
or from cell multiplication. 
The mucous membrane of the large intestine is also often the seat 
of a catarrhal or follicular enteritis with swelling of the mucosa and 
the production of viscid mucus; octahedrals may be found microscop- 
ically, and Woodman and Tidy* state that the rectum is invariably 
the seat of an acute inflammation, a statement that seems to me to be 
too sweeping. 
Simple hypersemia of the intestinal and gastric mucous membrane 
is exactly similar in appearance whether it owes its existence to phys- 
iological or to pathological conditions. The differentiation will de- 
pend upon the nature of the secretion and upon the appearance of the 
interstitial tissue and the lymphatic apparatus. 
Acute gastric catarrh is always accompanied by the production 
of a viscid glairy, clear mucus; acute intestinal catarrh results in the 
outpouring of a considerable amount of watery fluid, an acute catarrh 
of the large intestine on the other hand, again leads to the production 
of mucus. If a few hours pass between the commencement of the in- 
flammation and death and especially if the irritant be of some intensi- 
ty, it nearly always leads to inflammatory oedema of the mucosa and 
submucosa and to considerable increase in the size of the regional 
lymphatic glands. 
The hemorrhages and the hemorrhagic erosions will be more 
marked in cases of severe and prolonged vomiting and in cases of poi- 
soning with arsenic in a solid form. The hemorrhagic necrosis is 
probably in part due to the production of capillary thrombosis as 
shown by Silberraann;f from its point of arrest in the stomach or in- 
testine arsenic is absorbed into the capillaries and lymphatics; here it 
causes thrombosis in the vessels and a consecutive hemorrhagic necro- 
*Loc. Cit. 
t Virchow’s Archlv, Band 117. sis may follow, the tissue succumbing completely to the action of the 
gastric juice and to the attack of intestinal microbes. 
The croupous exudate seems to be formed only where solid arsenic 
has been taken. Lesser* states expressly that he has never observed 
it except in such instances but not invariably even then; this is a 
point of some practical importance. The mesenteric glands are usual- 
ly swollen red and soft partaking of the general regional lymphatic 
enlargement. Cloudy swelling and fatty degeneration are found fre- 
quently in the liver, though Woodman and Tidyf state that no post- 
mortem appearances are found in this organ, but Lesserf and Casperf 
have observed such changes in 18, in 9 and 7 hours, the liver being 
flabby, increased perhaps in size, the parenchyma being opaque and 
brownish with yellow areas, enlarged lobules with indistinct outlines, 
congested centres and pale cortical zones; microscopically the cells 
are large and granular with indistinct nuclei, acetic acid may dissolve 
some of the granules and boiling alcohol and ether others. Accord- 
ing to Ziegler:}; various poisons such as phosphorus, arsenic and the 
ferments which produce fever, may like imperfect oxygenation, lead to 
disintegration of the albumen of the tissues and so to fatty degenera- 
tion. 
The kidneys may show no changes at all or they may be the seat of 
parenchymatous degeneration and small cortical hemorrhages, the urin- 
ary sediment corresponding exactly to that in acute nephritis generally; 
the urethral and vesical mucous membrane may also be swollen and 
show hemorrhagic extravasations in occasional instances. The heart 
is often the seat of a parenchymatous myocarditis, especially the mus- 
cles of the left ventricle which are soft and flabby in consistence, grey- 
ish yellow in color on the cut surface and under the endocardium of 
the papillary muscles, the microscope showing typical cloudy swell- 
ing in the muscle fibres with even areas of fatty degeneration. 
Underneath the endocardium, especially if not exclusively, in the 
left ventricle, arc very frequently found small irregular shaped but 
typical areas of hemorrhagic extravasation, similar to those observed 
in cases of asphyxia. Any changes in the Jungs directly referable to the 
action of arsenic cannot be said to occur except that sub-pleural hem- 
orrhages are found quite often. The brain and spinal cord and their 
membranes are usually negative on macroscopical examination although 
the arsenic accumulates in them in greater quantities than in the 
other tissues of the body. In the peripheral nerves arsenic produces 
* Atlas der Gerichtllchen Medic.in, Berlin, 1883. 
+ Loc. Cit. 
$ Ziegler, Pathological Anatomy and Pathogenesis, 1887. 8 
well marked microscopic changes, the consideration of which would 
he out of place at the present time. The blood is stated to be dark 
in color and to coagulate feebly and imperfectly collecting in the heart 
and the large veins, no thick, firm and solid clots being formed. In 
connection with this it is interesting to note the experiments of Silber- 
mann* who by means of injections of various poisonous substances, 
and among them arsenic into animals, came to the conclusion that 
many of the clinical phenomena and anatomical changes in arsenical 
intoxication are directly referable to the power of arsenic to cause a 
vascular dyscrasia resulting in primary capillary thrombosis with the 
formation of secondary stagnation thrombi; he observed the forma- 
tion of capillary thrombi, autochthonous thrombi in smaller vessels, 
especially veins, and even in the heart, in animals who were injected 
with arsenical solutions and vivisected during the violent symptoms 
of poisoning that soon followed, arsenic acting as a typical blood 
poison. The occurrence of hsemo-globinuria after the inhalation of 
arseniuretted hydrogen shows what destructive action arsenic in this 
form may produce upon the red corpuscles and the occurence of thrombo- 
sis in the capillaries and larger vessels would certainly explain the 
hemorrhages some of the areas of necrosis and degeneration as well 
as many of the clinical symptoms observed in cases of arsenical poi- 
soning. This phase of arsenical poisoning will undoubtedly be the 
subject of future and fruitful investigation. It at once suggests itself 
that the microscopic demonstration of capillary thrombosis in a suit- 
able case of supposed’ arsenical poisoning would go far to settle the 
question of ante- or post-mortem introduction of the poison in case 
doubt should arise on this point. 
119 Loomis St. 
* Virchow's Archlv. Band 117 Heft 3, Berlin, 1889