Читать книгу Treatise on Poisons - Robert Sir Christison - Страница 19

The symptoms caused by the irritating poisons, taken internally, are chiefly those of violent irritation and inflammation of one or more divisions of the alimentary canal.

The mouth is frequently affected, especially when the poison is easily soluble, and possesses a corrosive as well as irritating power. The symptoms referrible to the mouth are pricking or burning of the tongue, and redness, swelling and ulceration of the tongue, palate, and inside of the cheeks.

The throat and gullet are still more frequently affected; and the affection is commonly burning pain, sometimes accompanied with constriction and difficulty in swallowing, and always with redness of the visible part of the throat and gullet.

The affection of the throat and mouth precedes every other symptom when the poison is an active corrosive, and more particularly when it is either a fluid poison or is easily dissolved. Nay, sometimes burning pain of the mouth, throat, and gullet occurs during the very act of swallowing.—On the contrary if the poison is soluble with difficulty, and is only an irritant, not a corrosive, and still more if it is only one of the feebler irritants, the throat is frequently not affected sooner than the stomach, occasionally not at all.

The stomach is the organ which suffers most invariably from the operation of irritant poisons. The symptoms referrible to their operation on it are acute and general burning pain, sometimes lancinating or pricking pain,—sickness, vomiting, tenderness on pressure, tension in the upper part of the belly, and occasionally swelling. Of these symptoms the sickness is generally the first to develope itself. In the instance of corrosive irritants pain commonly commences along with it. The matter vomited is at first the contents of the stomach, afterwards tough mucus, streaked often with blood and mingled with bile, frequently clots of purer blood. The powerful corrosives affect the stomach the moment they are swallowed; irritants which are either liquid or very soluble also affect it very soon; but the more insoluble irritants, such as arsenic, generally do not begin to act till half an hour or even more than a whole hour has elapsed.—The stomach may be affected without any other part of the alimentary canal participating in the injury; but much more frequently other parts suffer also, and in particular the intestines.

The action of irritant poisons on the intestines is marked by pain extending over the whole belly, sometimes even to the anus. This pain, like that of the stomach, is often a sense of burning; but it is also frequently a pricking or tearing pain, and still more frequently a twisting, intermitting pain like that of colic. It is seldom attended with much swelling, but often with tension, and tenderness of the whole belly; and at times the inflammatory state of the mucous coat of the intestines is clearly indicated by excoriation of the anus and prolapsus of the rectum, which is of a bright red colour. The pain of the bowels is most generally attended by purging, rarely with constipation, frequently with tenesmus. The matter discharged, after the alimentary and feculent contents have passed, is chiefly a mucous fluid, often abundant, often also streaked with blood or mixed with considerable quantities of blood. In some cases the intestines are affected when no other part of the alimentary canal suffers, not even the stomach. But much more generally the stomach and intestines are affected together.

In a few very aggravated cases of poisoning with the irritants the whole course of the alimentary canal, from the throat to the anus, is affected at one and the same time.

The symptoms now briefly enumerated are accompanied in almost every instance with great disturbance of the circulation—quick, feeble pulse—excessive prostration of strength,—coldness, and clammy moisture of the skin.

The other symptoms, which are often united with the preceding, do not belong to the irritants as a class. Perhaps, however, among the symptoms of the class may be mentioned those of irritation and inflammation of the windpipe and lungs, and those of irritation in the urinary organs. A great number of the irritant poisons cause hoarseness, wheezing respiration, and other signs which indicate the spreading of the inflammation of the throat to the windpipe: some likewise cause darting pains throughout the chest: and not a few are very apt to cause strangury and other signs of inflammation of the urinary passages.

Of the effects of the irritants when applied externally little need be said at present. Their most striking external symptoms will be noticed under the head of one of the orders of this class, the vegetable acrids. In the chapter on the local action of poisons some account was given of the several effects which are produced by the application of poisons to the skin. It is there stated that some produce merely redness, that others cause blistering, that others bring out a crop of deep-seated pustules, that others corrode the tissues chemically, and so give origin to a deep slough, and that others excite spreading inflammation of the cellular tissue under the skin and between the muscles.

Such is a general view of the symptoms caused by the irritant poisons. This topic will be afterwards taken up in detail under the head of the several species. At present an important subject remains for consideration, namely, the natural diseases whose effects are apt to be mistaken for the effects of poison. The remarks now to be made might be extended to many diseases. In fact, they might be extended to all which prove fatal suddenly, for all such diseases are apt in peculiar circumstances to give rise to a suspicion of poisoning. But those only will be here noticed which occasion the greatest embarrassment to the medical jurist, and which are most likely to come under his review in courts of law. They are the following:—Distension and rupture of the stomach; rupture of the duodenum, biliary ducts, uterus, or other organs in the belly; the effects of drinking cold water; bilious vomiting and common cholera; malignant cholera; inflammation of the stomach; inflammation and perforation of the intestines; inflammation of the peritonæum; spontaneous perforation of the stomach; melæna and hæmatemesis: colic, iliac passion and obstructed intestine.

1. Distension of the Stomach.—Mere distension of the stomach from excessive gluttony may cause sudden death. Generally indeed the symptoms and appearances in the dead body show that death is the consequence of apoplexy; but sometimes not. In order to preserve the continuity of the succeeding remarks on the diseases of the stomach which imitate poisoning, it may be useful to consider in the present place all the varieties of the effects of distension.

Excessive distension of the stomach, then, sometimes causes sudden death by inducing apoplexy, which is commonly of the congestive kind,—that is, without rupture of vessels. Mérat has related an instructive case of this kind. A man in good health, while greedily devouring an excellent dinner, became suddenly blue and bloated in the face; a clammy sweat broke out over his body; and he died almost immediately. On dissection the stomach was found enormously distended with food, and the vessels of the brain were so gorged, that the brain appeared too large to be contained within the skull.^[141]

There is reason, however, to suppose that death from distension is the consequence not always of apoplexy,—but sometimes of an impression on the stomach itself. Sir Everard Home relates the case of a child, who, being left by its nurse beside an apple-pie, was found dead a few minutes afterwards, and in whose body no appearance of note could be discovered, except enormous distension of the stomach with the pie.—A still more distinct case in point forms the subject of a medico-legal report by Wildberg. A corpulent gentleman died suddenly fifteen minutes after dinner; and as he lived on bad terms with his wife, a suspicion arose that he had been poisoned. His wife said that he fell asleep immediately after dinner; but had not slept many seconds, when he suddenly awoke in great anguish, called out for fresh air, exclaimed he was dying, and actually expired before his physician, who was instantly sent for, could arrive. Wildberg found the stomach so enormously distended with ham, pickles, and cabbage-soup, that, when the belly was laid open, nothing could be seen at first but the stomach and colon. Some white powder, found on the villous coat of the stomach, was at first suspected to be arsenic; but it proved on analysis to be merely magnesia, which the gentleman had been in the habit of taking frequently. The diaphragm was pushed high into the chest by the distended stomach. There was not any particular congestion in the brain. Wildberg very properly ascribed death to simple over-distension of the stomach.^[142]—In all such cases the symptoms may be suspicious; but when carefully considered they can scarce be said to resemble closely the effects of irritant poisoning; and at all events the appearances in the dead body will at once distinguish them.

2. Rupture of the Stomach is not a common occurrence; but it sometimes imitates in its symptoms the effects of the irritant poisons.

It is generally the consequence of over-distension, combined with efforts to vomit. The cause of it seems to be, that the abrupt turn which the gullet makes in entering an excessively distended stomach acts as a valve, so that the contents cannot be discharged by vomiting. A case of this kind is related by M. Lallemand in his Inaugural Dissertation at Paris in 1818.^[143] A woman convalescent from a tedious attack of dyspepsia, being desirous to make amends for her long privations as to diet, ate one day to satiety. Ere long she was seized with a sense of weight in the stomach, nausea, and fruitless efforts to vomit. Then she all at once uttered a piercing shriek, and exclaimed that she felt her stomach tearing open; afterwards she ceased to make efforts to vomit, soon became insensible, and in the course of the night she expired. In the fore part of the stomach there was a laceration five inches long; and a great deal of half-digested food had escaped into the cavity of the abdomen. The coats of the body of the stomach were healthy; but the pylorus or opening into the intestines was indurated; which had been the cause of her dyspepsia.

In other cases of death from rupture the laceration is caused not by the accumulation of food, but by the accumulation of gases arising from depraved digestion, constituting a disease almost the same as that which attacks cattle that have fed on wet clover. A singular example of this rare affection, in which death was preceded by the symptoms of irritant poisoning, has been noticed by Professor Barzelotii.^[144]—Another case, which appears to have been of the same kind, is mentioned in a late French journal. A child, a twelvemonth old, after eating cabbage-soup, died during the night unperceived by its mother. On the body being examined, a great quantity of fetid gas escaped from the abdomen, and a smooth laceration like an incised wound, three inches in length, was found in the lesser arch of the stomach.^[145]

In other cases, however, it is not easy to say what occasions the injury. An instance, for example, has been related, where the accident followed the drinking of a little shrub and water. The individual, a man of middle age, who had been long liable to fits of severe pain in the stomach, going off with vomiting, was suddenly seized the day after one of his fits with violent pain in the epigastrium, extreme tenderness and tension of the muscles, and for a short time with violent vomiting. In seventeen hours he expired. On dissection a dark-brown fluid was found in the cavity of the belly, and the fore part of the stomach presented a laceration four inches long. There were likewise several lacerations, one of them three inches long, which intersected the peritonæal coat alone.^[146] A case probably similar in nature has been described by Dr. Roberts of London, that of a man who died of convulsions in five hours, and presented after death a long rent in the stomach, with escape of its contents into the general cavity of the belly.^[147]

Another rare variety of rupture of the stomach must also be particularly noticed, because the course of the symptoms imitates very closely a case of poisoning with the irritants. It is partial rupture,—or laceration of the inner coat only. A very interesting case of that description has been related by Mr. Chevallier. A youth of fourteen, on the evening after a Christmas feast, at which he ate and drank heartily, was attacked with violent and frequent vomiting. Next morning he said he felt as if the blood in his heart was boiling, he was unable to swallow, the pulse became irregular, and pressure on the heart or stomach gave him excruciating agony. These symptoms continued till the following day, when he vomited two pounds of blood at successive intervals, and soon afterwards expired. The inner coat of the stomach was torn in many places, and that of the duodenum was lacerated almost completely round. No other disease existed in the bowels or elsewhere.^[148]

Some of the cases now mentioned could hardly be distinguished from the effects of certain irritant poisons by the symptoms only. But the morbid appearances in the stomach will at once determine their real nature.

Rupture of the stomach, it may be observed, does not always occasion the symptoms hitherto related. Sometimes it causes instant death. Thus a healthy coal-heaver in London, while attempting to raise a heavy weight, suddenly cried out, clapped his hand over his stomach, drew two deep sighs, and died on the spot. On dissection a lacerated hole was found in the stomach, big enough to admit the thumb; and the stomach did not contain any food.^[149] This case, along with those of Dr. Roberts and Mr. Weekes, will show that rupture may take place without previous distension.

3. Rupture of the Duodenum is a very rare accident from internal causes. The following instance resembles considerably the symptoms of irritant poisoning. A gentleman, 48 years old, quarrelled violently with another while playing billiards immediately after dinner. Soon afterwards he was seized suddenly with violent pain in the stomach, vomiting, cold extremities, and a failing pulse; and he died very soon. The mucous coat of the duodenum was found much inflamed, and four inches and a half from the pylorus there was a lacerated hole involving a third of the circumference of the gut.^[150]

4. Under the next head may be classed rupture of the other organs of the belly. Rupture of the Biliary Ducts for example, an extremely rare accident, has been known to imitate the symptoms of irritant poisoning, as the following case will show.—An elderly lady, after a slight attack of jaundice, was seized with violent pain in the stomach, and vomiting recurring in frequent fits, and in seventeen hours with extreme tenderness, tension of the muscles, coldness of the skin, and failure of the pulse. She expired in twenty-four hours; and after death the hepatic duct was found torn across, a gall-stone lay at the opening of the cystic duct, the peritonæum was here and there inflamed, and three pounds of blood and bile were effused into the cavity of the abdomen.^[151]—The nature of such cases will be always apparent on dissection, but by no means always from the symptoms.

In like manner rupture of the uterus or its appendages may in certain circumstances occasion similar symptoms, and so be mistaken for the operation of poison. A striking example of the kind once came under my notice. A middle-aged woman much addicted to drinking, and on that account living on indifferent terms with her husband, was suddenly seized at two in the afternoon with pain in the belly, afterwards with vomiting and purging, then with extreme exhaustion and coldness of the extremities; and at ten in the evening she expired. A suspicion of poisoning having arisen in the neighbourhood, a judicial inspection was ordered by the sheriff of Linlithgowshire, where the case happened; and the examination was entrusted to her medical attendant, Mr. Robertson, and myself. On inquiry, it was found that she had taken nothing whatever after breakfasting at eight in the morning, six hours before; and farther, that the pain had begun violently in the lower part of the belly. These two circumstances alone were almost, if not altogether, incompatible with the idea of irritant poisoning having been the occasion of death. But all doubt was completely removed by the inspection of the body; for the lower part of the belly was filled with a great quantity of clotted blood, which had proceeded from the rupture of a Fallopian conception.

5. The next accident which may be noticed on account of its being liable to be mistaken for the effects of poison is sudden death from drinking cold water.

In Britain the most common form of death from this cause appears to have been instant death, arising from the impression on the stomach. It is not an uncommon thing for people to drop down instantaneously and die on the spot, in consequence of drinking freely of cold water or other fluids while over-heated.^[152] There is an interesting report on a case of this kind by Pyl in his Memoirs and Observations. The individual had been quarrelling with a companion, and in the height of a fit of violent passion swallowed a glass of beer; when he dropped down senseless and motionless, and died immediately. His wife suspecting the administration of poison, demanded a judicial inquiry; but nothing was found in the body to account for death. Pyl therefore came to the conclusion that the man died from the sudden impression caused by the cold beer.^[153] Dr. Currie, after quoting several instances of the like kind, relates the following remarkable case which occurred to himself. A young man, having just sat down, panting and bathed in sweat, after a severe match at tennis, drank greedily from a pitcher of water fresh drawn from a neighbouring pump. Suddenly he laid his hand on his stomach, bent forward, became pale, breathed laboriously, and in a few minutes expired.^[154]

But when combined with exposure to a burning sun, as in hot climates, drinking cold water when the body is over-heated seems often to excite along with irritation in the stomach congestive apoplexy. Dr. Watts has given a good account of these effects as they occurred in the neighbourhood of New York during the hot season of 1818. During the summer of that year the thermometer often stood in the shade so high as 92°; and the labourers in consequence could not be restrained from drinking frequently and excessively of cold water. Many were attacked with pain in the stomach, sickness, giddiness, and fainting; next with difficult breathing, and rattling in the throat; then with apoplexy; and not a few perished.^[155] These symptoms are very like the effects of some narcotico-acrid poisons.

Lastly, drinking cold water sometimes causes symptoms more nearly allied to those of the pure irritants. Thus some persons, on eating ices, or drinking iced-water, or cold ginger-beer in the hot days of summer, are attacked with violent colic. Others in the like circumstances are attacked with violent fits of vomiting.^[156] Haller has even mentioned an instance of a man, who after swallowing a large draught of cold water while over-heated, was seized with symptoms of acute gastritis, and died in fifteen days: and in the dead body the stomach was found gangrenous and ulcerated at its fundus.^[157] M. Guérard relates a similar case, that of a quarter-master who, swallowing iced-beer after a hurried journey in a hot day, was attacked in six hours with shivering, then with heat and tightness in the pit of the stomach, vomiting of every thing he took, anxiety, thirst and frequency of the pulse; next with extreme prostration, cessation of pain, hiccup, and lividity of the face; and he expired in five days. Signs of inflammation were found in the stomach, such as great redness internally, with spots of extravasation, and a blackish matter like what he vomited.^[158] Cholera has also been sometimes referred to the same cause. In the hot summer of 1825 it was remarked that a great number of persons who used to frequent a particular coffee-house in the Palais-Royal at Paris, and the owner among the rest, were severely affected with cholera. Poison being suspected to be the cause, a judicial inquiry was instituted. It was proved, however, that similar accidents had been observed at other coffee-houses, in other cities, and likewise in former hot seasons; and when the whole medical evidence was referred to a commission of physicians and chemists, they gave their opinion, that the disease was owing to the incautious use of ices and iced-water in an unusually hot summer.^[159] Perhaps cholera arising thus may prove fatal. The following extraordinary case, which appears to have been of this nature, was communicated to me by the late Dr. Duncan, junior. A bookbinder in this city, previously in excellent health, rose one morning at six to kindle his fire, and took a large draught of cold water from a pitcher used in common by the whole family. He went immediately to bed again, complaining of pain in the pit of the stomach, and extreme anxiety, and affected with incessant vomiting. In twelve hours he died without any material change in the symptoms, and no disease whatever could be detected in the dead body. Dr. Duncan satisfied himself from general circumstances, that poisoning was quite out of the question; so that, however extraordinary it may appear, his death could be accounted for in no other way than by ascribing it to the cold water.—Hoffmann says he was acquainted with instances where fatal inflammatory fever was induced by drinking too freely of cold water, and a suspicion of poisoning in consequence excited.^[160]

6. Of Bilious Vomiting and Simple Cholera.—Of all the diseases which are apt to be confounded with the effects of the irritant poisons, there is none which it is of so much importance that the medical jurist should be able to distinguish as cholera. A trial for poisoning with the common poisons hardly ever occurs, but an attempt is made to ascribe death to that disease; for it is very frequent, and its symptoms bear a close resemblance to those of the principal poisons of the class we are now considering.

It is unnecessary to give here a detailed account of the symptoms of simple cholera. There is the same burning pain in the stomach and bowels as in irritant poisoning, the same incessant vomiting and frequent purging, the same tension and tenderness of the belly, the same sense of acridity in the throat, and irritation in the anus, the same depression and anxiety, the same state of the pulse.

It would be wrong, however, to infer from these resemblances that the two affections are always undistinguishable. Some cases of irritant poisoning certainly cannot be distinguished by their symptoms from cholera. Many other cases are similarly circumstanced, because their particulars cannot be accurately collected. But there is no doubt that in others the distinction between poisoning and cholera may be drawn by the physician who has been able to ascertain the symptoms in detail. At present those points of difference only will be noticed which relate to the irritants as a class; others will be mentioned under the head of poisons individually.

The first difference is, that in cholera the sense of acridity in the throat does not precede the vomiting, as it sometimes does in poisoning. In cholera this sensation is caused by the vomited matter irritating the throat, or perhaps by the irritation in the stomach being propagated upwards by continuity of surface. But, whatever may be its cause, it is certain that the sense of acridity or burning sometimes remarked in cholera never begins before the vomiting. In many cases of poisoning, though certainly not in all, it is the first symptom.—The next difference is, that in cholera the vomiting is never bloody. I have been at some pains to investigate this point: and I have been unable to find any instance of the cholera of this country, which has been accompanied with sanguinolent vomiting; neither is such a symptom mentioned in any accounts I have read of malignant cholera. This article of diagnosis will, of course, be open to correction from the experience of other practitioners. Lastly, a material difference is, that the simple cholera of this country very seldom proves fatal so rapidly as poisoning with the irritants usually does. Death from irritant poisoning is on the whole seldom delayed beyond two days and a half, and frequently happens within thirty-six hours, sometimes within six hours, or even less. Malignant cholera frequently proves fatal in as short a time; but with regard to the cholera of this country, I believe it may be laid down as a rule hitherto unshaken by all the controversy to which the subject has given rise,—that death is not often caused by it at all, and that death within three days is very rare indeed. A few cases of death within that period, nay, even within twelve hours, have certainly occurred; but their great rarity is obvious from the fact, that many practitioners of experience have not met with a single instance, and others with only one case in the course of a long practice. Dr. Duncan, senior, mentioned to me a case, the only one of the kind he had met with, which commenced soon after the individual ate a sour orange in the Edinburgh theatre, and which proved fatal in twelve hours. Dr. Duncan, junior, also met with a single case, which was the instance already noticed of cholera produced by drinking cold water. Dr. Abercrombie also once, and once only, met with a case fatal within two days.^[161] Mr. Tatham, a late writer on this subject, met with an instance which proved fatal in twelve hours.^[162] Dr. Burne of London has likewise related an instance of death within fifteen hours occurring in a child.^[163] And I was informed in 1831 of a case at Leith which ended fatally in twenty-six hours, and was at first supposed by the unprofessional inhabitants of the place to be an instance of epidemic or malignant cholera. My colleagues, Drs. Home, Alison, and Graham, never met with an instance fatal in so short a time as two or three days; at a meeting of the Medico-Chirurgical Society of this city, none of the members present could remember to have seen such a case;^[164] and of the witnesses who were brought to swear to this point on a well-known trial, all of them physicians of extensive practice, not one could depose that such a case had ever come within his personal observation.^[165] It has been stated however in a controversial publication written by the late Dr. Mackintosh of this place, that the author had seen many cases fatal within the period now mentioned.^[166] This is incomprehensible. For my own part, I cannot help repeating, as the result of the whole inquiry, that simple cholera rarely causes death in this country, in the period within which irritant poisoning commonly proves fatal,—that, consequently, every case of the kind will naturally be apt to lead, in peculiar circumstances, to suspicion of poisoning,—and that in charges of poisoning, rapid death under symptoms of violent irritation in the alimentary canal, like those of cholera, must always be considered an important article of a chain of circumstantial or presumptive evidence.

7. Of Malignant Cholera.—The history of this disease affords a fair promise that, in so far as British practitioners are concerned, it may ere long be excluded from the list of those which imitate irritant poisoning. Meanwhile, however, malignant cholera must be allowed to bear, in its essential symptoms and their course, a marked resemblance to poisoning with the irritants. So much indeed is this the case that some authors have actually compared its phenomena to the effects of arsenic, tartar-emetic, and other powerful acrids. In many cases the two affections are undoubtedly not so distinguishable by symptoms as to warrant a physician to rely on the diagnosis in a medico-legal inquiry. But in many other instances the distinction may be drawn satisfactorily. Thus the uneasiness in the throat which sometimes attends cholera never precedes the vomiting. The vomiting in cholera is never bloody. The colour and expression of the countenance and whole body are peculiar. In frequent instances the early signs which resemble poisoning are followed by a secondary stage, sometimes of simple coma, sometimes of typhoid fever, which a practised person may easily distinguish from the secondary phenomena produced by some irritants. Lastly, no mistake can arise where the patient, before presenting the symptoms common to both affections, experiences violent burning pain or certain tastes, during or immediately after the swallowing of food, drink, or some other article.

8. Of Inflammation of the Stomach.—Chronic inflammation of the stomach is a common disease; which, however, on account of the slowness of its course, is not liable to be confounded with the ordinary effects of irritant poisons. Acute inflammation, on the contrary, follows precisely the same course as that of irritant poisoning. But great doubts may be entertained whether true acute gastritis ever exists in this country as a natural disease. Several of my acquaintances, long in extensive practice, have stated to me, that their experience coincides entirely with that of Dr. Abercrombie, who observes he has “never seen a case which he could consider as being of that nature.”^[167] An important observation of the same purport has been made by M. Louis, one of the most experienced and accurate pathologists of the present time. He says, that during six years’ service at the hospital of La Charité, during which he noticed the particulars of 3000 cases and 500 dissections, he did not meet with a single instance of fatal primary gastritis. The disease only occurred as a secondary affection or complicating some other disease which was the cause of death.^[168] So far as I have hitherto been able to inquire among systematic authors, the descriptions of idiopathic acute gastritis appear to have been taken from the varieties caused by poison.

The following are the only specific accounts I have hitherto met with of an affection of the nature of idiopathic acute gastritis; and the reader will be at no loss to perceive that in each of them it admits of being viewed differently. The first two are the cases of inflammation referred by Haller and Guérard to drinking cold water incautiously [p. 100]. The next is a remarkable incident related by Lecat, and occurring in 1763. A girl, nineteen years old, was attacked while in good health with shivering, faintness, acute pain in the belly, cold extremities and imperceptible pulse; and she died in sixteen hours. The stomach was found red, and checkered with brownish patches and gangrenous pustules (probably warty black extravasation): yet it was supposed to have been ascertained that she had not taken any thing deleterious.^[169] This narrative is certainly to appearance pointed. But when it is added, that the girl’s mother was attacked about the same time with precisely the same symptoms and died in four hours, I think the reader, when he also considers the imperfect mode in which chemical inquiries were then conducted, will by no means rest satisfied with Lecat’s assurance that nothing deleterious was swallowed. The last is an equally singular case given by Dr. Hastings, of Worcester, where poisoning with cantharides was suspected. A young lady, liable to indigestion, but at the moment in better health than usual, was attacked with sickness before breakfast and after it with vomiting. Three days elapsed before she was seen by her medical attendant, who found her sinking under incessant vomiting, severe pain in the loins, strangury, bloody urine, and swelling of the clitoris, attended with red extravasation of the eyes, and a red efflorescence on the skin. Death followed next day amidst convulsions; and there was found in the dead body extravasation of blood between the kidneys and their outer membrane, into the pelvis of each kidney, and into the bladder,—redness of the bronchial membrane, and gorging of the air-cells with blood,—and general redness of the inside of the stomach, with numerous extravasated spots in the submucous coat.^[170] It seems to have been clearly proved at the coroner’s inquest that poisoning was here out of the question. But the case appears rather to have been one of renal irritation or inflammation than of gastritis, and the affection of the stomach secondarily merely.

The question as to the possibility of acute gastritis being produced by natural causes is one of very great interest to the medical jurist. For its possible occurrence is the only obstacle in the way of a decision in favour of poisoning, from symptoms and morbid appearances only, in certain cases by no means uncommon, which are characterised by signs of violent irritation during life, early death, and unequivocal marks of great irritation in the dead body, namely, bright redness, ulcers, and black, granular, warty extravasation. In regard to these effects, it may with perfect safety be said, that they can very rarely indeed all arise from natural causes; and for my own part, the more the subject is investigated, the more am I led to doubt whether they ever arise in this country from any other cause than poison. The possible occurrence of a case of the kind from natural causes must be granted. But this concession ought not to take away from the importance of the contrary fact as one of the particulars of a chain of circumstantial proof.

In whatever way the fact as to the existence of idiopathic acute gastritis may eventually be proved to stand, an important criterion of this disease, as of cholera, will be that the sense of burning in the throat, if present at all, does not precede the vomiting.

9. Inflammation of the Intestines in its acute form is more common than inflammation of the stomach, as a natural disease. It is generally accompanied, however, with constipation of the bowels. Acute enteritis, unless we choose with some pathologists to consider cholera as of that nature, is very rarely attended with purging.

There is a variety of intestinal inflammation, observed only of late by pathologists,^[171] but now well known, which bears a close resemblance to the effects of the irritants. It is a particular variety of ulceration commonly situated near the end of the small intestines, accompanied at first with trifling or insidious symptoms, and terminating suddenly in perforation of the gut. It begins with tubercular deposition under the mucous membrane in roundish patches. Then an ulcer appears on the middle of one or more of these patches, gradually spreads over them, and at the same time penetrates the other coats. At last when the peritoneal coat alone is left, some trifling accident ruptures it, the fæcal matters escape into the sac of the peritonæum, and the patient dies in great agony in the course of one or two days, or in a few hours. Such cases, if not distinguished by the symptoms, will be at once recognized by the morbid appearances. Perforation of the intestines, with similar symptoms, also takes place without the previous tubercular deposit, by simple ulceration of the coats.^[172]

Another form of intestinal inflammation may also be here particularized, because it imitates the effects of the irritants in the cases in which they prove slowly fatal. It is a form of aphthous ulceration of the mucous membrane of the alimentary canal, which appears to affect almost every part of it from the throat downwards, and begins commonly in the throat. I once met with a remarkable case in which it appeared in the form of little white ulcers in the back of the throat, and gradually travelled downwards to the stomach and from that to the intestines,—being characterized by burning pain in every one of its seats, and successively by difficulty of swallowing, by sickness, vomiting, and tenderness of the stomach, and finally by purging. Such cases resemble the slow forms of poisoning with arsenic. But they differ in attacking the several divisions of the alimentary canal in turn, while in the examples of poisoning with arsenic now alluded to, the whole canal from the mouth to the anus is affected simultaneously. Dr. Abercrombie has described a similar disorder, which he appears to have occasionally seen affecting both the stomach and intestines at the same time; but he seems to doubt whether it ever occurs as an idiopathic disease, or independently of some co-existing or preceding fever or local inflammation.^[173]

10. Inflammation of the Peritonæum, or lining membrane of the belly, will not require many remarks. When acute, it is rarely attended in its early stage by vomiting; rarely also by irregular action of the intestines, and never by diarrhœa; and it is at once distinguished in the dead body by unequivocal marks of peritonæal inflammation, which are very seldom caused by irritant poisons.^[174]

11. The subject of Spontaneous Perforation of the Stomach is an important topic for the medical jurist, because both the symptoms before death and the appearances in the dead body are occasionally very like the effects of some of the most active irritant poisons. The following is a statement of the most material facts hitherto ascertained on this subject; but it must be premised that a good deal of obscurity still hangs over some parts of it.

Spontaneous perforation of the stomach is of three kinds. One is the last stage of some varieties of scirrhus. The indurated membrane ulcerates, the ulcer penetrates first the villous, then the muscular, and at last the outer or peritoneal coat, so that the contents of the stomach escape into the belly. The symptoms of the perforation are a sense of something giving way in the pit of the stomach, acute pain gradually extending over the whole abdomen, great tenderness and tension, excessive prostration, and death commonly within twenty-four hours. The symptoms which precede the perforation in general clearly indicate organic derangement of the stomach, namely, aggravated dyspepsia of long standing. Several cases of this description may be seen in a thesis by M. Laisné,^[175] a pupil of Professor Chaussier. Two characteristic cases have been published by Dr. Crampton;^[176] and Mr. Alfred Taylor has referred to several others, the stomachs of which are preserved in Guy’s Hospital Museum, and gives the particulars of some which had occurred in the practice of that institution or to his friends.^[177] Occasionally no symptom exists prior to the perforation, as in an instance related by Dr. Kelly of a stout healthy servant, who was suddenly seized with excruciating pain in the stomach and expired in eighteen hours, and in whose body the stomach was found perforated in the middle of an extensive thickening and induration of the villous coat.^[178]

The second variety of perforation takes place by simple ulceration without previous scirrhus. In one of Dr. Crampton’s papers will be found some remarks by Mr. Travers, along with a case of this kind. The subject of it was a man of a strumous habit, who enjoyed good health, till one day at dinner he was suddenly attacked with acute pain in the pit of the stomach, and died in thirteen hours. The stomach was found perforated in the centre of a superficial ulcer of the mucous coat, occupying two-thirds of the ring of the pylorus.^[179] This case shows that the present variety of perforation may take place without the preliminary organic disease being indicated by any symptom. The circumstances under which it commenced are peculiarly important in relation to the medical jurisprudence of poisoning. Another case which has been lately described with great exactness by M. Duparcque, was preceded only by very trivial dyspeptic symptoms. Here the whole mischief arose from a small ulcer eight lines long and five in breadth on the inside of the stomach, and not more than a line and a half in diameter at the perforation through the peritonæum.^[180] Several excellent examples of the same disease have been related by Dr. Abercrombie.^[181] In one of these the ulcer in the centre of which the perforation had been formed, was not bigger than a shilling, and the rest of the stomach quite healthy. A very instructive case of a similar nature, but of unusual duration, has been related by Mr. Alfred Taylor. A young woman, after suffering for some time from nausea and constant craving for food, but inability to indulge it, and occasionally from pain in the stomach, was attacked suddenly with the usual symptoms of perforation, and died forty-two hours afterwards. The villous coat of the stomach, though generally healthy, presented at the lesser curvature several small elevated points, and in the middle of two of these a sharply-defined ulcer, one affecting the mucous coat only, while the other, which was half an inch in diameter where it affected the mucous coat, perforated the muscular and peritonæal coats by a hole no bigger than a crow-quill.^[182] A case still more remarkable has been also related by the same author, where the circumstances naturally gave rise to a strong suspicion of poisoning. A young female in a noble family, subject to slight dyspepsia, was suddenly attacked, three hours after a meal, with violent vomiting and pain in the belly. Collapse soon ensued, and in fifteen hours she died, under so strong suspicions of poisoning that various antidotes were administered. This suspicion was in some measure borne out by proofs of an intrigue having been carried on between her and a male person in the house, and by the discovery after death of the signs of recent sexual intercourse. On examining the cavity of the abdomen, however, there was found, at the upper and back part of the stomach near the pylorus, an oval perforation, half an inch wide, surrounded by a firm, smooth, almost cartilaginous margin, without any inflammation near it. Mr. Taylor properly points out, that the sudden occurrence of such violent symptoms so long after a meal is incompatible with the action of any poison which could cause perforation in fifteen hours; and that the characters of the perforation were those of a natural disease long latent. He could not detect a trace of any poison in the stomach.^[183]—In some cases, as in that of M. Duparcque, the pain at the moment the perforation is completed is not at first violent, because the close proximity of some adjoining organ, such as the liver, prevents the contents of the stomach from escaping for a time, so that inflammation of the peritonæum is but gradually developed.

The third variety of spontaneous perforation is of a much more singular kind. It is produced not by ordinary ulceration, but by a jelly-like softening of the coats. The gelatinization sometimes extends over a great extent of surface, affecting chiefly the villous coat, so that the aperture through the other membranes is surrounded by extensive pulpiness of the internal membrane. It is seldom accompanied by vascularity. Its symptoms are exceedingly obscure. In adults there is very rarely any symptom at all till the perforation is complete;^[184] in children, as appears from a paper by Dr. J. Gairdner of this city, and another by Dr. Pitschaft, a German author,^[185] the early symptoms indicate an obscure chronic gastritis. The nature of this singular disease will be discussed in the section on the morbid appearances. At present it may merely be observed, that the injury caused to the coats of the stomach seems to be precisely the same with the gelatinization, which is sometimes found after death in persons who had no symptoms of an affection of the stomach, and which is ascribed by John Hunter,^[186] and most British pathologists, to the solvent action of the gastric juice in the dead body. This disease is well described by Laisné in his thesis formerly quoted. The following is a good example: a young lady, previously in good health, was awakened at three one morning with excruciating pain in the stomach, which nothing could alleviate. She expired seven hours after; and on dissection two holes were found in the back part of the stomach, surrounded with much softening of the villous coat.^[187] Another case will be mentioned in page 118.—The appearances produced by this disease have been mistaken for the effects of corrosive poisons.

12. The gullet may be perforated in a similar manner either with or without symptoms. Under the head of the morbid appearances (119) two instances will be mentioned in which there were no corresponding symptoms. In the following case symptoms did pre-exist. A man, six weeks after being bit by a dog, which was killed without its state of health having been ascertained, was attacked with a sense of strangling, impossibility of swallowing, delirium, excessive irritability, glairy vomiting; and he died within twenty-four hours. The gullet, a little above the diaphragm, was perforated by a hole two-thirds of an inch in diameter, with thin edges; and effusion had taken place into the posterior mediastinum.^[188]

13. Perforation of the alimentary canal by worms may here also be noticed shortly as a disease liable in careless hands to be confounded with irritant poisoning. This is far from being a common accident, and very rarely takes place during life. In most of the cases in which it has been witnessed the symptoms antecedent to death were those not of irritant, but of narcotic poisoning, and were then owing simply to the great accumulation of worms in the alimentary canal. On this subject the reader is referred to the article Epilepsy in the introductory remarks on the effects of the narcotic class of poisons. But at times the symptoms have been like those of irritant poisoning. Thus the following is a case of perforation by worms during life giving rise to all the phenomena and symptoms of peritonæal inflammation. A soldier at Mauritius was seized with slight general fever and severe pain, at first in the pit of the stomach, and afterwards over the whole belly, which on the third day began to enlarge. A tendency to suppression of urine and costiveness ensued, then bilious vomiting; and he died on the fourth day, the belly having continued to increase to the end. On dissection, several quarts of muddy fluid were found in the sac of the peritonæum, the viscera were agglutinated by lymph, a round worm was discovered among the intestines between the navel and pubes, and the ileum was perforated six inches from the colon by a hole corresponding in size with the worm.^[189]—A singular case, not however fatal, but which confirms the fact, that worms may make their way through the intestines and other textures during life, is mentioned in Rust’s journal. A woman after a tedious illness first vomited several lumbrici, and was then seized with a painful swelling in the left side, which in the process of time suppurated, and discharged along with the purulent matter three other worms of the same species.^[190] Another instance of the same kind, where the perforation of the gut succeeded strangulated hernia, and was followed by the discharge of two lumbrici and ultimate recovery, is detailed in the Revue Médicale.^[191]

Symptoms like those of narcotico-acrid poisoning may be caused by worms without perforation. A girl, eight years old and in excellent health, was suddenly seized with violent colic pains, vomiting, bloody stools, tenderness and swelling of the belly, followed by convulsions and coma, and proving fatal in seven hours. No other explanation of the case could be discovered on dissection except the presence of several hundred ascarides in the intestines and thirteen in the stomach.^[192]

14. The next diseases to be mentioned are melæna and hæmatemesis, or purging and vomiting of pure or of altered blood.

It is hardly possible to mistake them for poisoning, as the pain which accompanies them is seldom acute, and the discharge of blood generally profuse.

15. The last are colic, iliac passion, and obstructed intestine. As the symptoms of some poisons are the same with those of colic, it is of course sometimes impossible to distinguish the natural disease from the effects of poison by attending to the abdominal symptoms only. But the distinction in severe cases of poisoning may almost always be drawn from collateral symptoms and extraneous circumstances.—The iliac passion is distinguished by a complete reversion of the vermicular motion of the intestines in consequence of which the fæces are often discharged by vomiting. I am not aware that stercoraceous vomiting is ever caused by poisoning.—A case has been recorded in Corvisart’s journal, in which iliac passion, originating in obstruction of the ileum by hardened fæces, and proving fatal in twenty-six hours, gave rise to a judicial inquiry into the possibility of poisoning.^[193] Another instance, that led to a strong suspicion of poisoning, has been lately published by M. Rostan, in which there was continued vomiting and pain of abdomen, proving fatal in two days, and arising from the small intestines being obstructed by an adventitious band.^[194] In this case the first inspectors failed to observe the true cause of the symptoms; but Rostan and Orfila, who were appointed to examine the body a second time, discovered the constriction, and were unable to find any poison in the stomach by analysis. Stercoraceous vomiting occurred during life; which might have been held sufficient to settle the real nature of the case.—Obstruction of the intestines arising from twisting of the gut, intussusception, foreign bodies, or strangulated hernia, is easily known by the seat where the pain begins, by the obstinate constipation, and also by the excessive enlargement of the belly,—which last, however, is rather an equivocal symptom.

The preceding observations will enable the medical jurist to determine, how far a diagnosis may be drawn from the symptoms between poisoning with the irritant and the diseases which resemble it. It will be remarked that the most embarrassing disease, on account of its frequency, and peculiar symptoms, is cholera. Cholera, however, may be recognised in some instances even considered in regard to the irritants as a class; and we shall presently find that it may be distinguished still better from the effects of some individual poisons.