Arsenic Poisoning | History, C...

Arsenic is found in significant concentrations in the groundwater of a number of countries.

In its inorganic form, arsenic is extremely hazardous. The greatest concern to human health from arsenic is contaminated water used for drinking, food preparation, and irrigation of food crops.

Arsenic poisoning from drinking water and eating can lead to cancer and skin sores over time. It has also been linked to diabetes and cardiovascular disease.

In prenatal and early childhood exposure has been related to poor cognitive development and an increase in the number of young adults who die.

The most critical measure in impacted communities is to provide a safe water source to prevent further arsenic exposure.

As it is not absorbed from the GIT hence Metallic arsenic (black in colour) is non-poisonous in nature. It is a normal component of all animal tissues, in small amounts.

Toxic Compounds and Their Uses

Arsenious Oxide or Arsenic Trioxide (Sankhya, somalkhar, White Arsenic or Arsenic): A most poisonous form of arsenic. It is tasteless or smell-less and is partially soluble in water. It is used in fruit sprays, sheep dips, for killing weeds, killing insects, poisoning rats, fly strips, calico-printing, painting, synthetic flowers and as for dyeing fabrics.

Copper Arsenite (Scheele's Green) and Copper Acetoarsenite (Paris Green or Emerald Green): For many substances, it is used as a coloring agent included in the art of making confections.

Sodium and Potassium Arsenate: Colorless crystalline material which is solubel in water and is used in dyeing and printing. Becomes toxic if inhaled.

Arsenic sulphide: Yellow orpiment (hartal) or arsenic trisulphide, and red realgar or arsenic disulphide are used in cream that removes hairs, colouring pigment and in fly strip.

Arseniuretted Hydrogen or arsine is a non-coloured gas and has an odour like garlic.

Natural Arsenic Sources: The soil, water and some sea fish (mussels, prawns) are the natural sources of arsenic. Elevated arsenic content of soil and subsoil water of some places is the reason of endemic toxicity (from shallow tube wells inserted for drinking water). 

The two badly affected areas in the world are Bangladesh and West Bengal, India. According to World Health Organization the maximum permissible limit of arsenic in drinking water is 50 µg/l.5.

In 42 districts in southern Bangladesh and in nine adjacent districts in West Bengal, 79.9 million and 42.7 million people respectively are exposed to higher arsenic concentrations in groundwater.  In both these areas, the source of arsenic is naturally present, which contaminates the aquifers which provide water for over one million tube wells.

Tobacco Smoke: Particularly cigars also contains arsenic, and in some beers as impurities.

Historical Use of Arsenic 

Arsenic was used as a healing agent after Greek physicians such as Hippocrates and Galen popularized its use. Fowler's solution was 1% arsenic trioxide preparation which was mostly used during the 19th century.

Use of Fowler Solution: The long term use of Fowler’s solution causes chronic arsenic intoxication. In World War II, it was used for the treatment of syphilis. Arsphenamine (neoarsphenamine), a light yellow compound containing 30% arsenic was used intravenously to treat syphilis, yaws, and some protozoan infections.

Current Therapeutic Uses of Arsenic

Arsenic continues to be an important component of many non-western traditional medicine products. 

In Some Chinese traditional medications, realgar (arsenic sulphide) are present and are present in the form of pills, tablets, and other preparations.

For the treatment of psoriasis, syphilis, asthma, rheumatism, haemorrhoids, cough and pruritus, arsenic is generally used.

It is also recommended as a health tonic, an analgesic and also anti-inflammatory agent. It is also used for the treatment of malignant tumours.

In India, herbal medicines containing arsenic are used for the preparation of some homoeopathic medicines and haematological malignancies. In Korea arsenic is present in herbal medicine which is used for the treatment of haemorrhoids.

Mechanism

• Arsenic interferes with cellular respiration and then uncouples mitochondrial oxidative phosphorylation and then gets combined with the sulfhydryl groups of mitochondrial enzymes, especially pyruvate dehydrogenase and certain phosphatases. Due to this activity, the citric acid cycle is decreased and hence the cellular ATP production also decreases.
• It inhibits the uptake of cellular glucose, formation of glucose, oxidation of fatty acid and the production of acetyl CoA.
• Irritation in the mucus membrane takes place and due to this, the nervous system got depressed.
• Since arsenic is a cancer-causing agent hence due to long exposure to arsenic, can cause cancer in the bladder, skin and lungs.

Absorption and Excretion

• The absorption takes place through GIT, lungs, skin or through the parental fluid.
• In almost all tissues it is present; in the liver, it is present in the largest amount then in the kidney and in the spleen.
• If the patient survives then – muscle (for a few months) and in bones, hair, nails and skin (sulfur-containing keratin) for years.
• A major part of arsenic is excreted through urine and some parts are excreted through faeces, bile, sweat, milk, nails and hair.
• In the case of chronic poisoning, the deposition of arsenic generally occurs in nails and hairs.
• After absorption, it is secreted in the stomach and intestine even if it is absorbed through the mouth or by any other route.

Acute Poisoning

When a large dose of arsenic is taken for a short duration of time.

Table 1 - Signs and Symptoms

Fatal Dose: 120-200 mg of arsenic trioxide (adults), 2 mg/kg (children) is fatal dose.

Fatal Period:1-2 days.

Treatment for Arsenic Poisoning

• Hemodynamic stabilization is of primary importance, and large amounts of crystalloid solutions may be required because of significant GI losses (i.e. vomiting and diarrhoea).
• Gastric lavage is done continuously with huge amount of warm water and milk; activated charcoal does not adsorb arsenic effectively and is not advised in patients whom coingestants are not suspected.
• Demulcents (butter or greasy substances) avoid absorption.
• Whole bowel irrigation with polyethylene glycol may be efficient to avoid GIT absorption of arsenic.
• Antidote is BAL or dimercaprol and DMSA.
• Alkalis should not be given by mouth as they increase the solubility of arsenic.
• Purgatives (castor oil/magnesium sulphate) are given to remove unabsorbed poison from intestine.
• To combat shock and improve alkali reserve, Glucose-saline with sodium bicarbonate is useful.
• Hemodialysis or exchange transfusion may be done[10]

Postmortem Finding

It depends upon the amount of dose and the period which has elapsed before death.

Externally the body becomes dehydrated and appears blue in color. The eyeball got sunken. The skin appeared wrinkled. Rigour Mortis last for a long time. Putrefaction is retarded.

Internally- Given in the below table:

Table 2 - Post Mortem Appearance in Internal Body Organ

Chronic Poisoning

It may occur due to:

• Recovery from acute poisoning.
• Accidental ingestion of small doses repeatedly by those working with the metal.
• Intake of food/drink in which there are traces of arsenic (may be homicidal in nature).

Sign and Symptoms

It generally occurs in 4 stages:

• The first stage of nutritional and gastrointestinal disturbances- gradual emaciation is the 1st sign. There is loss of appetite, nausea and alternating attack of vomiting and diarrhoea are common.
• The second stage of catarrhal changes.

Table 3 - Second Stage of Chronic Poisoning - Sign and Symptoms

• The third stage is of skin rashes.

Table 4 - Third Stage of Chronic Poisoning - Signs and Symptoms

• The fourth stage of nervous disturbance.

Table 5 - Fourth Stage of Chronic Poisoning - Sign and Symptoms

Treatment

• Take out the patient from the source of exposure and applies the doses of BAL.
• Vitamin B complex and sodium thiosulphate are helpful.
• Symptomatic treatment.

Postmortem Appearance 

Table 6 - Postmortem Appearance in Chronic Poisoning

Medicolegal Aspects 

It can be used for the following purpose:

Homicidal purpose: In the past it was a popular homicidal agent because it is less expensive and easily accessible. The fatal dose is small. The fatal period was also small. It has no taste; no odour hence can be mixed easily into food without anyone’s notice. The symptoms also develop gradually and resemble cholera. Very less quantity is needed.

Disadvantages:

• It slows down putrefaction.
• Its presence can be easily detected in decomposed/buried bodies.
• Arsenic can be found in bones, hair and nails for several years and also in charred bones or ashes.
• It can be used to kill cattle.
• Accidental death may be due to admixture with articles of food or from its improper medicinal use. Chronic poisoning results from drinking well water containing arsenic.
• Arsenic exposure can be occupational in those working in a metal foundry, mining, glass production or in the semiconductor industry.
• It is sometimes ingested or applied locally in the form of a paste or ointment on abortion sticks to procure abortion.

Postmortem Imbibitions of Arsenic

While performing postmortems and exhumations, the imbibition from natural sources should be taken into consideration.

Hence necessary measures should be taken so that arsenic could not be able to percolate in the body through any of the natural sources like soil, groundwater etc.

If there is arsenic contamination outside then it can be easily absorbed by keratin tissue. Then in such case, the concentration will be higher in hair and nails and in the case of poisoning, the concentration of arsenic will be more than in soil/water.

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