Treatise on Poisons by Sir Robert Christison

are apt to be confounded with the effects of the irritant poisons, there is none which it is of so much importance that the medical jurist should be able to distinguish as cholera. A trial for poisoning with the common poisons hardly ever occurs, but an attempt is made to ascribe death to that disease; for it is very frequent, and its symptoms bear a close resemblance to those of the principal poisons of the class we are now considering. It is unnecessary to give here a detailed account of the symptoms of simple cholera. There is the same burning pain in the stomach and bowels as in irritant poisoning, the same incessant vomiting and frequent purging, the same tension and tenderness of the belly, the same sense of acridity in the throat, and irritation in the anus, the same depression and anxiety, the same state of the pulse. 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.