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.
Section II.—Of the Morbid Appearances caused by Irritant Poisons, compared with those of certain natural diseases.
The next subject for consideration is the morbid appearances produced by the irritants as a class, together with those of a similar nature, which arise from natural causes.
The powerful irritants, which are not corrosives, produce simply the appearances characteristic of inflammation of the alimentary canal in its various stages,—in the mouth, throat, and gullet vascularity, and also, if the case has lasted long enough, ulceration;—in the stomach, vascularity, extravasation of blood under and in the substance of the villous coat and likewise into the cavity of the organ, abundant secretion of tough mucus, deposition of coagulable lymph in a fine network, ulceration of the membranes, occasionally perforation, preternatural softness of the whole or of part of the villous coat, and on the other hand sometimes uncommon hardness and shrivelling of that coat; in the intestines vascularity, extravasation, and ulceration.—Sometimes several of these appearances are to be seen in the whole alimentary canal at once. In poisoning with arsenic or corrosive sublimate it is no unusual thing to meet with redness or ulceration of the throat, great disease in the stomach, vascularity of the small intestines, ulcers in the great intestines, and excoriation of the anus.—When the poison is an active corrosive much more extensive ravages are sometimes caused, particularly in the stomach. After poisoning by the mineral acids, for example, the whole mucous membrane of the stomach is at times found wanting; nay, large patches of the whole coats may be wanting, and the deficiency supplied by the adhesion of the margin of the aperture to the adjoining viscera, and the conversion of the outer membrane of these viscera into an inner membrane for the stomach.
Of the appearances here briefly enumerated the particulars will be related partly under what is now to be said of the appearances arising from natural causes, which are liable to be confounded with the effects of poisons, partly under the head of individual poisons.
Of redness of the stomach and intestines from natural causes, and its distinction from the redness caused by poisons.
Simple redness of the alimentary mucous membrane in all its forms, whether of mere vascularity, or actual extravasation, not only does not distinguish poisoning from inflammatory disorders of natural origin, but will even seldom distinguish the effects of poison from those of processes that occur independently of disease, and subsequent to death. On the subject of real inflammation, as distinguished from redness originating after death, or pseudo-morbid redness, as it is commonly termed,—a subject of great consequence to the medical jurist,—the reader may consult with advantage a paper by Dr. Yelloly,[[195]] an essay by MM. Rigot and Trousseau,[[196]] or that of M. Billard.[[197]] The former authors proved by experiment, that various kinds of pseudo-morbid redness may be formed, which cannot be distinguished from the parallel varieties caused by inflammation; that these appearances are formed after death, and not till three, five, or eight hours after it; that they are to be found chiefly in the most depending turns of intestines, and in the most depending parts of each turn, or of the stomach; and that after they have been formed, they may be made to shift their place, and appear where the membrane was previously healthy, by simply altering the position of the gut. M. Billard, on the other hand, has laid down their characters, and made a minute arrangement of the several kinds. He has divided them into ramiform, capilliform, punctated, striated, laminated, and diffuse redness,—terms which need hardly be explained. I must be content with merely referring to these sources of information for a particular account of the appearances in question. But it may be right at the same time to quote an instance of the most aggravated form of pseudo-morbid redness, in order to convince the reader that all forms may equally arise from the same causes. Among other example, then, which have been related of laminated redness, or redness in patches from extravasation, M. Billard mentions the case of a man who hanged himself, and in whose body was found, on the mucous membrane of the small intestine where it lay in the right flank, “a large, amaranth-red patch, six finger-breadths wide, covered with bloody exudation, and not removable by washing:” and in the lower pelvis there was a similar patch of even larger dimensions.[[198]]
Although morbid and pseudo-morbid redness of the inner coat of the alimentary canal cannot be distinguished from one another by any intrinsic character, M. Billard thinks this may be done by attending to collateral circumstances. According to his researches, redness is to be accounted inflammatory only when it occurs in parts not depending in position, or is not limited to such parts: when the mesenteric veins supplying the parts are not distended, nor the great abdominal veins obstructed at the time of death; when the reddened membrane is covered with much mucus, particularly if thick, tenacious, and adhering; when the mucous membrane itself is opaque, so that when dissected off and stretched over the finger, the finger is not visible; when the cellular tissue which connects that membrane with the subjacent coat is brittle, so that the former is easily scratched off with the nail.
Some observations may be here also made on another appearance, allied to the present group, but which there is strong reason to believe always indicates some violent irritation at least, if not even irritation from poison only, in the organ where it is found. It is an effusion under the villous coat of the stomach, and incorporation with its substance, of dark brownish-black, or as it were charred, blood; which is thus altered either by the chemical action of the poison, or by a vital process. In many cases of poisoning with the mineral acids, oxalic acid, arsenic, corrosive sublimate, and the like, there are found on the villous coat of the stomach little knots and larger irregular patches and streaks, not of a reddish-brown, reddish-black, or violaceous hue, like pseudo-morbid redness, but dark-grayish-black, or brownish-black, like the colour of coal or melanosis,—accompanied too with elevation of the membrane, frequently with abrasion on the middle of the patches, and surrounded by vascularity. This conjunction of appearances I have never seen in the stomach, unless it had been violently irritated; and several experienced pathologists of my acquaintance agree with me in this statement. It bears a pretty close resemblance to melanosis of the stomach;[[199]] but is distinguished by melanotic blackness being arranged in regular abruptly-defined spots, and still better by melanosis not being preceded by symptoms of irritation in the stomach.