BISMUTH 553 orally and 1 to 3 grains intramuscularly. It is a constituent of Injectio bismuthi sdlicylatis in the proportion of 2 grains in 20 minims. The dose is 10 to 20 minims intramuscularly. 4. ^ Precipitated Bismuth.—It is prepared by the reduction of a solution of bismuth trichloride in hydrochloric acid by means of hypophosphorous acid. It is a grey, in- soluble powder, easily diffusible in water, and contains 98.5 per cent of metallic bismuth. It is an official preparation, the dose being 1 to 3 grains intramuscularly. It is contained hi Injectio bismuthi (Bismostab), the dose of which is 8 to 15 minims intramuscularly. The organic salts of bismuth which have recently come into use in medicine are bismuth subgallate (dermatol), bismuth oxyiodogallate (airol), bismuth arsphenamine sulphonate (bismarsen), bismuth stovarsol (bistoval) and certain other preparations, popularly known by the trade names of trepol, neotrepol, muthanol, etc. Symptoms.—A metallic taste ; salivation; pain in the throat and abdomen ; sore mouth; vomiting; purging, the stools being greyish-black ; a violet black line is formed on the gums which may be inflamed, ulcerated or even gangrenous ; the garlic-like odour (bismuth breath) probably due to the presence of tellurium as an impurity; the weak and feeble pulse ; pain over the preecordial region; suppressed or scanty urine which is dark and contains albumin and casts; collapse and lastly death. W. H. Resnik36 reports a case of bismuth poisoning in a woman suffering from diabetes after she had taken internally 5 to 7 ounces of bismuth subnitrate in a fortnight. The symptoms comprised a bluish-black discoloration of the gums, which were swollen and inflamed; a similar discoloration of the tongue, most noticeable at the apex of the papillae and arranged in vertical striations along the lateral margins; a patchy diffuse dis- coloration of the buccal mucosa; swelling and tenderness of the parotid glands ; moderate anaemia and basophilic stippling of the red cells. Bismuth was detected in the urine. Recovery followed the withdrawal of the salt. Paul Blum37 states that in cases of syphilis treated by intravenous injections of bismuth salts stomatitis appears to have been most frequently observed, although gastro- intestinal, renal and hepatic lesions have been described. Cases have been reported in which patients under treatment of intravenous injections of bismuth salts developed quite suddenly severe albuminuria, followed by the passage of epithelial, granular and hyaline casts. He emphasizes the point that the lesions in the mouth and intestine are the first signs of bismuth poisoning—they are the danger signals which indicate the necessity for a systematic examination of the urine. Fatal Dose.—A dose of two drachms of bismuth subnitrate has caused the death of an adult. Recovery has, however, occurred after a dose of one ounce given in milk for X-ray examination of the stomach.38 Fatal Period.—Death occurred hi nine days after bismuth subnitrate was given by the mouth. In many cases death may not occur for several weeks. An infant,39 1 month old, died within forty-four hours after the administration of 190 grains of bismuth sub- nitrate by the mouth as a remedy for diarrhoea. A man died within less than five minutes after an intravenous injection of 15 mg. of bismuth tartrate suspended in 5 cc. of sterile distilled water.40 A Hindu male died within two hours after the intramuscular injection of neotrepol into the gluteal region.41 A case is cited in which injection of bismuth paste into the left knee joint was followed by death in about six weeks.42 Treatment.—Use the stomach tube or emetics. Give intravenous injection of 0.5 gramme of sodium thiosulphate hi a 10 per cent solution. Administer demulcents. Give ice to relieve vomiting and morphine to relieve pain. Give purgatives and clear the bowel by high enemata. Post-mortem Appearances.—The gums are spongy. The mouth and throat show brownish-purple membranous patches. The mucus membrane of the oesophagus, stomach and small and large intestines is red and inflamed. Sometimes the mucous membrane of the caecum and colon is ulcerated. The spleen is congested. The liver shows fatty degeration, and the kidneys may show tubular necrosis. Tests.—l. Hydrogen sulphide in a weak acid solution gives a black precipitate, insoluble in ammonia, but soluble in strong nitric acid. 2. Potassium iodide yields a brown precipitate, soluble in excess to an orange solution. 36. Bull. Johns Hopkins Hospital, May 1926, p. 323 ; Brit. Med. Jour., June 26, 1926. Ep., p. 107. 37. Presse Medicate, July 29, 1922, p. 105; Brit. Med, Jour., Oct. 28, 1922, Ep., p. 58. 38. Philips, Cleveland Med, Jour., June 1917, p. 419. 39. Harold F, Roe, Jour. Amer. Med. Assoc,, July 29, 1933, p. 352. 40. Stephen H. Curtis, Jour. Amer. Med. Assoc.; Nov. 22, 1930, p. 1588. 41. Chenoy, Ind. Med. Gaz., May 1926, p. 234. 42. Phillips, Cleveland Med. Jour., June 1917, p. 419.