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.