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]]