In the first place, then, it appears difficult, if not impossible, to comprehend how a vital erosive action can account for the perforations observed after death from diseases wholly unconnected with the stomach, and unattended during life by any symptom of disorder in that organ. For, not to dwell on other less weighty arguments,—on the one hand, there is during life no symptom of perforation, an accident which if deep stupor be not present at the same time is always attended with violent symptoms when it arises from any cause but gelatinization,—and on the other hand, there is frequently no escape of the contents of the stomach into the cavity of the abdomen, though the hole is of enormous size, and its edge not adherent to the adjoining organs.—All such perforations, however, are perfectly well accounted for, on the other theory, by what is now known of the properties of the gastric juice. This will appear from the following exposition.
The power of the gastric juice to dissolve the stomach and other soft animal textures was long thought to be fully proved by the well-known researches of Spallanzani,[[207]] Stevens,[[208]] and Gosse.[[209]] In later times doubts were entertained on the subject in consequence of negative results having been obtained by other experimentalists, more especially by Montégre.[[210]] But these apparently discrepant facts and opinions have been reconciled by the ulterior experiments of Tiedemann and Gmelin on digestion;[[211]] who found that the nature and quality of the fluid secreted by the stomach vary much in different circumstances,—that, when its villous coat is not subjected to some stimulus, the fluid which lines it is not acid, and does not possess any particular solvent action,—but that when the membrane is stimulated by the presence of food or other sources of excitement, the quality of the secretion is materially changed, for it becomes strongly acid and is capable of dissolving alimentary substances both in and out of the body. And still more lately the solvent power of the proper gastric juice over the stomach, and its capability of producing perforation in animals after death, have been established in the most satisfactory manner by Dr. Carswell,[[212]] who has shown by a series of incontrovertible facts,—that in the rabbit when killed during the digestion of a meal, and left for some hours afterwards in particular positions, all the phenomena of spontaneous gelatinized perforations observed at times in man, may be easily produced at will,—that acidity of the gastric juice is an invariable circumstance when such perforations are remarked,—and that the appearances in question as they occur in the rabbit are the result of chemical action alone, and occur only after death. Thus, then, the physiological experiments of Tiedemann and Gmelin, together with the investigations of Carswell, not merely establish positively the fact, that the stomach may be perforated after death by the gastric juice, but likewise account clearly for the negative results obtained by other experimentalists. For example, passing over earlier experiments, they explain sufficiently the negative results obtained by Dr. Pommer of Heilbronn,[[213]] an experimentalist of some reputation in Germany; for, falling into the error of some of the less recent experimentalists on this subject, he made his observations on animals killed slowly by starving,—in which circumstance there is no proper gastric juice in the stomach, and consequently no solvent action can exist.
These statements relative to the causes and phenomena of gelatinized perforation in the stomach supply the strongest possible presumption which analogy can furnish, that a great proportion of spontaneous gelatinized perforations in the human subject are owing to the action of the gastric juice after death. And this presumption is increased to something not far removed from demonstration by the circumstance, that in man the process of softening has actually been traced extending in the dead body. This interesting fact was first noticed by Mr. Allan Burns.[[214]] In the body of a girl who died of diseased mesenteric glands he found an aperture in the fore part of the stomach with the usual pulpy margin, and the liver in contact with the hole uninjured. In two days more the liver opposite the hole had become pulpy, and its peritonæal coat quite dissolved; and the back part of the stomach opposite the hole was also dissolved, so that only its peritonæal coat remained. Dr. Sharpey has communicated to me a similar observation. On finding in the body of a child the stomach perforated and gelatinized, but the adjoining organs uninjured, he sewed up the body, to show the appearances to some of his friends next day. By that time the peritonæal surfaces of the spleen and left kidney were found much softened and pulpy where they lay in contact with the hole in the stomach. I have since met with a similar occurrence where the perforation affected the duodenum (p. [120]).
It must be admitted, then, that the action of the gastric juice after death is quite sufficient to account for the greater number of gelatiniform perforations in the human stomach.
But in the second place, it seems scarcely possible to explain every perforation of the kind in this way. The solvent action of the gastric juice for example, affords no explanation of a singular case related by M. Récamier,[[215]] where, after death in the secondary stage of small-pox, the stomach was transparent and brittle, and perforated in the splenic region by a gelatinized hole large enough to admit the fist,—although the fluid in the stomach was subsequently found incapable of dissolving another stomach, and almost destitute of free acid. And still less will the solvent action of the gastric juice account for such cases as those of Laisné and Gastellier, quoted in pp. [107]–8, or the French medico-legal case to be mentioned in p. [118],—where death is preceded by a short illness, indicating a violent disorder of the stomach, and sometimes even characterized by all the marked symptoms of perforation. In the last description of cases, which are comparatively very rare, it seems necessary to admit that the gelatinization takes place during life; unless, indeed, it be supposed that the stomach is first perforated during life by ordinary ulcerative absorption, and then gelatinized after death, in consequence of the irritation existing before death having given rise to an unusual secretion of gastric juice.
Passing now to the differences between these gelatinized perforations, and the perforations caused by corrosive poisons, it may in the first instance be observed, that the margin of a corroded aperture is sometimes of a peculiar colour,—for example, yellow with nitric acid, brown with sulphuric acid or the alkalis, orange with iodine. But a much better, perhaps indeed an infallible criterion, and one of universal application, is the following. Either the person dies very soon after the poison is introduced, in which case vital action may not be excited in the stomach: or he lives long enough for the ordinary consequences of violent irritation to ensue. In the former case, as a large quantity of poison must have been taken, and much vomiting cannot have occurred, part of the poison will be found in the stomach: In the latter case, the poison may have been all ejected; but in consequence of the longer duration of life, deep vascularity, or black extravasation must be produced round the hole, and sometimes too in other parts of the stomach; changes which will at once distinguish the appearance from a gelatinized aperture. There is no doubt that the stomach may be perforated by the strong corrosives, and yet hardly any of the poison be found in the stomach after death. Thus in a case related by Mertzdorff of poisoning with sulphuric acid, where life was prolonged for twelve hours, he could detect by minute analysis only 4½ grains of the acid in the contents and tissue of the stomach. But then the hole was surrounded by signs of vital reaction, and so was the spleen upon which the aperture opened.[[216]] Judging from what I have often seen in animals killed with oxalic acid, which is the most rapidly fatal of all corrosives, so that little time is allowed for vital action, and also several times in persons who had died quickly from the action of sulphuric acid, I believe no poison can dissolve the stomach, without such unequivocal signs of violent irritation of the undissolved parts of the villous coat, as will secure an attentive observer from the mistake of confounding with these appearances the effects of spontaneous erosion. Spontaneous erosion is very generally united with unusual whiteness of the stomach, and there is never any material vascularity.
Resting on the description now given of the spontaneous and poisonous varieties of corrosion, it is an easy matter to decide a controversy, which at the time it occurred made a great deal of noise, and upon which the opinions of toxicologists have been unnecessarily divided. It is the question regarding death by poison which occurred in the trial of Mr. Angus at Liverpool in 1808 for the murder of his housekeeper Miss Burns. The poison suspected was corrosive sublimate. The symptoms were those of irritation in the alimentary canal,—vomiting, purging, and pain. In the dead body there was not any particular redness either of the intestines or of the stomach. But on the fore part of the stomach an aperture was found between the size of a crown piece and the palm of the hand; it had a ragged, pulpy margin; and the dissolution of the inner coat extended two inches from it all round the hole. No mention is made of adhesion or coloration of the margin. This description, it will be remarked, answers exactly that given above of spontaneous gelatinized perforation; and the absence of the signs of vital action around the hole and in the rest of the stomach is incompatible with the effects of a strong corrosive poison, unless death had occurred very soon after it was swallowed. This, however, was out of the question; for then the poison would have been found in the stomach,—which it was not.[[217]]
The case of Angus is not the only instance in recent times of spontaneous perforation having given rise to an opinion by medical men in favour of poisoning, and consequently to a criminal trial. Six years afterwards a similar incident occurred in France. A young woman near Montargis having died of a short illness, and a large erosion having been found in the stomach after death, six practitioners, on a view of the parts, and without referring to the antecedent symptoms or attempting an analysis of the contents of the stomach, declared that she died of the effects of some corrosive poison. The husband and mother-in-law, against whom there does not appear to have been a shadow of general evidence, were therefore imprisoned and subsequently tried for their lives. Luckily, however, an intelligent physician of the town saw the error of the reporters, and after vainly endeavouring to persuade them to revise their opinion, was the means of the case being remitted to the medical faculty of Paris. That distinguished body, with Professor Chaussier at its head, gave a unanimous and decided opinion, not only that there was not any proof of poisoning, but likewise that the woman could have died of nothing else than spontaneous perforation. The leading features of the medical evidence will at once show how indefensible the conduct and opinion of the original reporters were. The last meal taken by the woman before she became ill, and the only one at which poison could have been administered by the prisoners, was her supper; her illness did not begin till past six next morning; the symptoms were mortal coldness, fainting, general pains, headache, pain in the stomach, purging and colic, without vomiting, and she died after twenty-four hours’ illness; the morbid appearances were general redness of the stomach, softening and pulpy destruction of a third part of its posterior parietes, and nevertheless the presence in the stomach of a pint and a half of fluid matter, containing evidently the remains of soup taken by the woman after she felt unwell. On the decision of the Parisian faculty the prisoners were discharged; and the original reporters were deservedly handled with great severity in several publications that appeared not long after.[[218]]
Of perforations of the Gullet and Intestines from natural causes, and their distinctions from those produced by poisons.—The intestines, and sometimes even the gullet, may be perforated by the same erosive or solvent process as the stomach. Thus Mr. Allan Burns observes, that in four plump children, whose previous history he could not learn, he found every part of the alimentary canal, from the termination of the gullet down to the beginning of the rectum, reduced to a gluey, transparent pulp, like thick starch. The bodies were quite free from putrefaction; but the abdomen exhaled a very sour smell when opened. No other organic derangement could be detected.[[219]] The particulars of a similar case, with an account of the symptoms, have been lately published by Mr. Smith, a London surgeon. In the body of a child who died of protracted diarrhœa subsequent to weaning, the whole intestines, from the duodenum to the sigmoid flexure of the colon, were found fourteen hours after death gelatinous, semitransparent, and so soft and brittle that they could not bear their own weight, but tore when lifted between the fingers. The stomach and rectum were healthy.[[220]] I lately met with the following instance, where the erosion clearly took place after death. In the body of a girl who died within twelve hours of poisoning with red-precipitate, the stomach and duodenum were found much inflamed, but quite entire and firm three days after death. Eighteen days afterwards, when I had an opportunity of examining these organs, their textures remained firm everywhere, except a few inches below the pylorus, where I found two apertures in the duodenum, each as big as a crown, and surrounded by extensive jelly-like softening.
The following case from Laisné’s treatise shows that the gullet may be also dissolved in the same way. A woman three days after delivery was attacked with puerperal peritonitis, and died in four days. In the belly were found the usual morbid appearances of peritonitis: but in addition there was in the lower part of the gullet a large oval aperture two inches long, which penetrated through the posterior mediastinum into the lungs.[[221]] Another singular instance of the same kind has already been mentioned under the head of the symptoms (see p. [107]). Another has been described by Dr. Marshall Hall. In a child who died of bronchitis, an opening was found in the gullet about the size of a pea, so that the canal of the gullet communicated with the sac of the pleura; and several veins appeared also to have been opened.[[222]] The stomach was likewise perforated.