Referring to what was already said under the head of the symptoms of gastritis [p. [102]], I must again express my doubts whether the appearances now described ever arise in this country from natural disease. In the intestines they are sufficiently familiar to the physician, as arising from idiopathic enteritis, and from dysentery. But in the stomach their existence as the effect of natural disease is very doubtful.
Another kind of coloration of the inner membrane of the stomach, which may be shortly alluded to, because it has actually been mistaken for the effect of irritation from poison, although by no means like it,—is staining of the membrane with a reddish, brownish, yellowish, or greenish tint, observed in bodies that have been kept some time, and produced by the proximity of the liver, spleen, or colon if it contains fæces. No unprejudiced and skilful inspector could possibly mistake this appearance for inflammation. But under the impulse of prejudice it has been considered such, and imputed to poison. On the occurrence of such stains an attempt was made by the French to ascribe to poison the death of the republican general Hoche. He died rather suddenly on his way from Frankfort to join his troops; and as poisoning was suspected, the body was opened in the presence of three French army-surgeons, and a French and two German physicians. The only appearance of note in the alimentary canal was two darkish spots on the villous coat of the stomach. The surgeons drew up a report which imputed his death to poison; but the physicians refused to sign it; and other medical people who were subsequently added to the commission decided with the latter.[[200]] The surgeons probably would not have been so hasty, if they had not known that the result of their complaisance would have been the levying of a heavy fine on the inhabitants.
The last kind of discoloration of the inner coat which requires mention is dyeing from the presence of coloured fluids in the contents. A remarkable instance has been recorded where redness of this nature was mistaken for inflammation, and the death of the individual in consequence ascribed at first to poison. A person long in delicate health died suddenly after taking a laxative draught; and the stomach, as well as the gullet, being found on dissection red and livid in various places, it was hastily inferred by his medical attendants, that these appearances were the effect of poison, and that the apothecary had committed some fatal error in compounding the draught. But another physician, who was acquainted with the deceased, although he did not attend him professionally, strongly suspected he had died a natural death; and happening to know he was in the practice of taking a strong infusion of corn-poppy, inferred that the supposed signs of inflammation were merely stains arising from the habitual use of this substance. Accordingly, on making the experiment, he found that in dogs to which a similar infusion was given, appearances were produced identically the same.[[201]]
Of the effusion of mucus and lymph from natural causes.—The abundant secretion of tough mucus in the stomach is a sign of that organ having been irritated. But the effusion of lymph is more characteristic. This may be produced by natural inflammation as well as by irritating poisons. As arising from either cause, however, it is rare; and certainly by no means so common as would be supposed from what is said in systematic works; for tough mucus has been often mistaken for it. Reticulated lymph adhering to the villous coat, and accompanied with corresponding reticulated redness of that coat, such as I have seen in animals poisoned with arsenic or oxalic acid, is an unequivocal sign of inflammation.
Of idiopathic ulcers and perforation of the stomach and intestines, and their distinction from those caused by poison.—Both ulceration and perforation may be produced by natural disease. In the ulceration produced by poisons there is generally speaking nothing to distinguish it from natural ulcers; but that caused by some poisons, such as iodine, is said to differ by the surrounding coloration of the membrane; and when the ulcer is caused by a sparingly soluble poison in a state of powder, such as arsenic, the cavity of the ulcer is sometimes filled with the powder. Perforation is a rare effect of the simple irritant poisons; but it is often caused by corrosives. It is imitated by two of the varieties of perforation from natural disease.
The form of natural perforation caused by a common ulcer is precisely the same as that caused by the simple irritants, and is incapable of being distinguished, except when it is attended with scirrhus.
By far the most remarkable variety, however, of spontaneous perforation is that which takes place, without proper inflammatory action, from simple gelatinizing of the coats. It is very apt to be mistaken, and in a celebrated trial, which will be immediately noticed, was actually mistaken for the effect of corrosive poison.
It may be situated on any part of the stomach, but is oftenest seen on the posterior surface. It is sometimes small, more often as big as a half-crown, frequently of the size of the palm, and occasionally so great as to involve an entire half of the stomach. Sometimes there is more than one aperture. The margin is of all shapes, commonly fringed, and almost always formed of the peritoneum, the other coats being more extensively dissolved. In one instance, however, the peritonæal surface was on the contrary the most extensively destroyed;[[202]] and in a case which occurred in the infirmary here, and was pointed out to me by the late Dr. W. Cullen, the peritonæum alone was extensively softened, and partly dissolved, so as to lay the muscular coat bare on its outer surface. The gelatinization therefore sometimes, though very rarely, begins on the outside of the stomach. Internally the whole is surrounded by pulpiness of the mucous coat, generally white, occasionally bluish or blackish, never granulated like an ulcer, very rarely vascular; and when vascular, the blood may be squeezed out of the loaded and open vessels. The organs in contact with the hole are also frequently softened. Thus an excavation is sometimes found in the liver or spleen; or the diaphragm is pierced through and through. The margins of the latter holes are without any sign of vascular action, but are generally besmeared with a dark pulpy mass, the remains of the softened tissue. The pulp never smells of gangrene; with which, indeed, this species of softening is wholly unconnected. The edge of the hole in the stomach never adheres to the adjoining organ; yet, even when the hole is very large, the contents of the stomach have not always made their escape. Often the dissolution of the coats is incomplete. John Hunter and others, indeed, have said that a stomach is rarely seen without more or less solution of the mucous coat.[[203]] The best account of the appearances in this state is given by Jaeger of Stuttgardt.[[204]]
The circumstances under which this extraordinary appearance occurs are singularly various. Professor Chaussier and the French pathologists conceive it to be always a morbid process constituting a peculiar disease; and doubtless cases have occurred in which death appears to have arisen from the stomach being perforated during life by gelatinization.[[205]] But it has been found much more frequently, when death was clearly the consequence of a different disease, and when there did not exist during life a single sign of disorder in the stomach. Thus it has been found in women who died of convulsions after delivery,—in children who died convulsed or of hydrocephalus,—after death from suppuration of the brain, both natural and the result of violence,—from coma following an old ulcer of the back, which communicated with the spinal canal,—from diseased mesenteric glands,—from phthisis,—from nervous fever,—and after sudden death from fracture of the skull or hanging:[[206]] and in all of these circumstances it has occurred without any previous symptom referrible to a disorder in the stomach.
The opinions of pathologists are divided as to its nature. The French conceive it arises from a morbid corrosive action, which, however, may extend after death, in consequence of the fluids acquiring a solvent power. Hunter ascribed it entirely to the solvent power of the gastric juice after death. There are difficulties in the way of both doctrines. A full examination of the whole inquiry, which is one of much interest and considerable complexity, would be misplaced in this work; but some remarks are called for, by reason of the important medico-legal relations of the subject, and the uncertainty in which it is at present involved.