Another very common appearance is the presence of a sanguinolent fluid, or even actual blood in the cavity of the stomach. In several of the cases which have come under my own notice, the subject of analysis was a thick, dirty brownish-red fluid, evidently containing a large proportion of blood; and many other examples of the same nature are on record.[[742]] In Laborde’s case formerly mentioned actual clots were found among the contents; in the instance of a woman who died in five days, as related by Zittmann, half a pound of coagulated blood was found in the stomach;[[743]] and in another case mentioned by Professor Bernt, the stomach contained no less than three pounds of black ichor mixed with clots of blood.[[744]] A good deal of reliance has been placed on bloody effusion in proof of the administration of arsenic or some other active irritant. It is of some importance, as it appears not to be an effect of that irritation which causes cholera.
Among the appearances observed in the stomach the presence of arsenic may be included, though not properly speaking a morbid appearance. Under the head of the medical evidence of poisoning generally it was stated, that many causes conspire to remove from the stomach during life poisons which have actually caused death. In addition to the illustrative cases there alluded to, I may here also refer to an interesting case communicated to me by Mr. J. H. Stallard, and already noticed for a different purpose [p. [235]]. Arsenic in no large quantity had been swallowed in tea, and death took place in four hours only. Here none of the poison could be detected by Marsh’s process, either in the contents of the stomach, or in its tissues, or in the liver.—In the instance of arsenic, however, the operation of the causes which tend to remove the poison is prevented by various circumstances, in particular by its insolubility and firm adhesion to the stomach. Hence it happens, that even after long-continued vomiting a portion still generally remains behind, either in the contents of the stomach or in its tissues. Sometimes the arsenic exists dissolved in the contents; more commonly it is present there in the solid form; and is then either in loose particles, or enveloped in coagulated mucus,[[745]] or in little clots of blood,[[746]] or is wrapped up in the more solid parts of the contents.[[747]] Frequently it adheres to the coats of the stomach, and is then either scattered in the form of fine dust or collected in little knots. The adhering particles are always covered by mucus; they are often surrounded by redness of the membrane or by effused blood; and sometimes they are imbedded in little ulcers.—A remarkable appearance which the arsenic sometimes puts on is a brilliant yellowness of its surface, owing to its conversion into the sulphuret. This appearance existed in six cases which have come under my own notice, first in one related in the Edinburgh Medico-Chirurgical Transactions,[[748]] next in the instance of Margaret Warden,[[749]] again in the case of a young woman whose death gave rise to the trial of John Lovie held at Aberdeen in the Autumn Circuit of 1827, again in a case described by Dr. Wood, which I had an opportunity of examining;[[750]] and lastly, in two others which I had occasion to examine in 1842 and 1843. In one of these, the case of Mr. Gilmour, adverted to at p. [265], Drs. Wylie and M’Kinlay, who examined the body in the country, found the inner surface of the stomach thickly sprinkled with small yellow particles, some of which were very bright. In all of these cases oxide was found, as well as the sulphuret of arsenic. In the case related by Dr. Nissen [p. [264]], a similar yellow appearance, observed on the surface of the arsenic, was ascribed with justice to the action of sulphuretted hydrogen-water, which had been given as an antidote during life.[[751]] In a very important case examined here a few years ago by my colleague Dr. Traill, and which will be noticed more particularly for a different purpose afterwards, this conversion of the oxide into sulphuret had taken place to a great extent [p. [277]]. In every instance of the kind yet examined, however, the conversion has been only partial, so that a large proportion of oxide could easily be detected by the usual process.
Care must be taken not hastily to consider as arsenic every white powder which may be found lining the inside of the stomach. Many other white powders may obtain entrance from without; and besides, small, white, shining, pulverulent scales, not unlike finely powdered arsenic, but rarely composed of animal matter, sometimes form naturally on the mucous coat of the stomach and intestines. In a medico-legal report published a few years ago, Professor Orfila has noticed two instances in which these scales were mistaken for arsenic;[[752]] in another published not long after he mentions that he found white particles which crackled when bruised, and appeared brilliant before the microscope, and which nevertheless were not arsenic.[[753]] Buchner too says he is acquainted with an instance where, in a medical inspection on account of a suspicion of poisoning, the villous coat of the stomach was found lined with a white granular substance which presented the properties of a fat and contained no mineral admixture;[[754]] and in the case of Warden I remarked a similar appearance, which, as arsenic was found in the stomach, I was disposed to consider a sprinkling of that poison, until the contrary was ascertained by analysis. The present caution, therefore, is not superfluous.
In a few cases the stomach is the only situation where morbid appearances are visible, even though life has been prolonged for so much as two days. This state of matters is well exemplified by a French case of death in forty-three hours, where the stomach presented much redness and extravasated patches, but where the intestines, the larynx and the contents of the head and chest were in a natural condition.[[755]] Such limitation, however, of the diseased appearances are rare.
Redness of the mucous membrane of the intestines is often present when the stomach is much inflamed. Dissolution of the mucous coat is much less frequent in the intestines than in the stomach. Ulceration occasionally occurs in lingering cases. In the case of Mitchell, which has been several times alluded to, the inner coat of the duodenum was dark-red, pulpy, thickened, easily separable; and on a spot as big as a crown piece, both the inner and the muscular coats were wanting.[[756]] Perforation of the small intestine was found in a case communicated to me by Mr. Sandell, and detailed at page [277]. But as the person survived only eight hours, and had laboured under symptoms of disease in the bowels for some days before taking the arsenic, it is unlikely that this appearance, which has not been observed, to my knowledge, in any other instance, arose from the action of the poison.
The signs of inflammation are seldom distinct in the small intestines much lower down than the extremity of the duodenum; and they do not often affect the colon. But the rectum is sometimes much inflamed, though the colon, and more particularly the small intestines, are not. Dr. Male mentions, that in man he has found the rectum abraded, ulcerated, and even redder than the stomach itself;[[757]] and Dr. Baillie also notices two cases in which the lower end of the rectum was ulcerated.[[758]] A common appearance in lingering cases is excoriation of the anus,[[759]] and it is said that even gangrene has been produced.[[760]]
A late writer draws attention to the fact that in the only two fatal cases he had seen the whole colon was contracted to an extraordinary degree;[[761]] and this state is mentioned in other cases. The appearance deserves notice; but of course whatever empties the colon thoroughly will have the same effect.
The chief appearances in the alimentary canal have now been mentioned. The next quarter in which deceased appearances are to be met with is the cavity of the chest. Here are sometimes seen redness of the pleura, redness and congestion of the lungs, redness of the inner surface of the heart, and redness of the lining membrane of the windpipe.
Redness of the diaphragmatic part of the pleura, or even of the whole of that membrane, has been at times observed; as one would expect, indeed, from the pectoral symptoms which occasionally prevail during life. Inflammation of the lungs themselves has also been noticed. Dr. Campbell twice found great congestion of blood in the lungs of animals poisoned by the application of arsenic outwardly.[[762]] Sproegel likewise found the pleura, pericardium, and whole lungs deeply inflamed in animals.[[763]] Dr. Venables found the pleura of a bright crimson colour in some poultry maliciously poisoned with arsenic,—more redness there indeed than in the stomach.[[764]] Mr. James says that in his experiments on animals he constantly found the lungs much gorged with blood, unless when death occurred quickly; but that he could see no evidence of the congestion being inflammatory.[[765]] A distinct example of advanced pneumonia in man is related in Pyl’s Magazine: the patient died after vomiting and purging incessantly for eight days; and on dissection the lungs were found “in the highest state of inflammation; and so congested as to resemble a lump of clotted blood.”[[766]] A distinct case of the same nature is related in Henke’s Journal; this patient had obvious pneumonic symptoms during life; and in the dead body the lungs were found so gorged, that, on being cut into, nothing could be seen but clotted blood in their cellular structure.[[767]] In a case formerly adverted to [p. [252]] of death from arsenic applied externally for scirrhus, excessive congestion was found in the lungs, “both lungs being completely gorged with blood, and presenting all the characters of pulmonary apoplexy.”[[768]] In another described by Dr. Booth of Birmingham, where death occurred in seven hours only, the lungs presented sufficient congestion to have completely impeded respiration.[[769]]
It has been alleged that the inner surface of the heart has been found red from inflammation. In a case examined judicially at Paris by Orfila, the left cavities of the heart were of a mottled red hue, and in the ventricle were seen many small crimson specks which penetrated into the muscular part of the parietes. The right cavities had a deep reddish-black tint, and the ventricle of that side contained specks like those in the other, but more faint. Orfila adds, that he had previously seen the same appearance in animals.[[770]] These observations are not satisfactory. There is no evidence that the observer drew the distinction between the redness of inflammation, and that produced by the dyeing of the membrane with blood after death. The subject was afterwards brought before the Royal Academy of Medicine at Paris by M. Godard, who had also observed the appearance in question in a person killed by arsenic, and who dwelt strongly on it as characteristic of this species of poisoning. It was distinctly proved, however, by many members present that the appearance arises from various other causes.[[771]]