Treatise on Poisons by Sir Robert Christison

important topic for the medical jurist, because both the symptoms before death and the appearances in the dead body are occasionally very like the effects of some of the most active irritant poisons. The following is a statement of the most material facts hitherto ascertained on this subject; but it must be premised that a good deal of obscurity still hangs over some parts of it. Spontaneous perforation of the stomach is of three kinds. One is the last stage of some varieties of scirrhus. The indurated membrane ulcerates, the ulcer penetrates first the villous, then the muscular, and at last the outer or peritoneal coat, so that the contents of the stomach escape into the belly. The symptoms of the perforation are a sense of something giving way in the pit of the stomach, acute pain gradually extending over the whole abdomen, great tenderness and tension, excessive prostration, and death commonly within twenty-four hours. The symptoms which precede the perforation in general clearly indicate organic derangement of the stomach, namely, aggravated dyspepsia of long standing. Several cases of this description may be seen in a thesis by M. Laisné,[175] a pupil of Professor Chaussier. Two characteristic cases have been published by Dr. Crampton;[176] and Mr. Alfred Taylor has referred to several others, the stomachs of which are preserved in Guy’s Hospital Museum, and gives the particulars of some which had occurred in the practice of that institution or to his friends.[177] Occasionally no symptom exists prior to the perforation, as in an instance related by Dr. Kelly of a stout healthy servant, who was suddenly seized with excruciating pain in the stomach and expired in eighteen hours, and in whose body the stomach was found perforated in the middle of an extensive thickening and induration of the villous coat.[178] The second variety of perforation takes place by simple ulceration without previous scirrhus. In one of Dr. Crampton’s papers will be found some remarks by Mr. Travers, along with a case of this kind. The subject of it was a man of a strumous habit, who enjoyed good health, till one day at dinner he was suddenly attacked with acute pain in the pit of the stomach, and died in thirteen hours. The stomach was found perforated in the centre of a superficial ulcer of the mucous coat, occupying two-thirds of the ring of the pylorus.[179] This case shows that the present variety of perforation may take place without the preliminary organic disease being indicated by any symptom. The circumstances under which it commenced are peculiarly important in relation to the medical jurisprudence of poisoning. Another case which has been lately described with great exactness by M. Duparcque, was preceded only by very trivial dyspeptic symptoms. Here the whole mischief arose from a small ulcer eight lines long and five in breadth on the inside of the stomach, and not more than a line and a half in diameter at the perforation through the peritonæum.[180] Several excellent examples of the same disease have been related by Dr. Abercrombie.[181] In one of these the ulcer in the centre of which the perforation had been formed, was not bigger than a shilling, and the rest of the stomach quite healthy. A very instructive case of a similar nature, but of unusual duration, has been related by Mr. Alfred Taylor. A young woman, after suffering for some time from nausea and constant craving for food, but inability to indulge it, and occasionally from pain in the stomach, was attacked suddenly with the usual symptoms of perforation, and died forty-two hours afterwards. The villous coat of the stomach, though generally healthy, presented at the lesser curvature several small elevated points, and in the middle of two of these a sharply-defined ulcer, one affecting the mucous coat only, while the other, which was half an inch in diameter where it affected the mucous coat, perforated the muscular and peritonæal coats by a hole no bigger than a crow-quill.[182] A case still more remarkable has been also related by the same author, where the circumstances naturally gave rise to a strong suspicion of poisoning. A young female in a noble family, subject to slight dyspepsia, was suddenly attacked, three hours after a meal, with violent vomiting and pain in the belly. Collapse soon ensued, and in fifteen hours she died, under so strong suspicions of poisoning that various antidotes were administered. This suspicion was in some measure borne out by proofs of an intrigue having been carried on between her and a male person in the house, and by the discovery after death of the signs of recent sexual intercourse. On examining the cavity of the abdomen, however, there was found, at the upper and back part of the stomach near the pylorus, an oval perforation, half an inch wide, surrounded by a firm, smooth, almost cartilaginous margin, without any inflammation near it. Mr. Taylor properly points out, that the sudden occurrence of such violent symptoms so long after a meal is incompatible with the action of any poison which could cause perforation in fifteen hours; and that the characters of the perforation were those of a natural disease long latent. He could not detect a trace of any poison in the stomach.[183]—In some cases, as in that of M. Duparcque, the pain at the moment the perforation is completed is not at first violent, because the close proximity of some adjoining organ, such as the liver, prevents the contents of the stomach from escaping for a time, so that inflammation of the peritonæum is but gradually developed. The third variety of spontaneous perforation is of a much more singular kind. It is produced not by ordinary ulceration, but by a jelly-like softening of the coats. The gelatinization sometimes extends over a great extent of surface, affecting chiefly the villous coat, so that the aperture through the other membranes is surrounded by extensive pulpiness of the internal membrane. It is seldom accompanied by vascularity. Its symptoms are exceedingly obscure. In adults there is very rarely any symptom at all till the perforation is complete;[184] in children, as appears from a paper by Dr. J. Gairdner of this city, and another by Dr. Pitschaft, a German author,[185] the early symptoms indicate an obscure chronic gastritis. The nature of this singular disease will be discussed in the section on the morbid appearances. At present it may merely be observed, that the injury caused to the coats of the stomach seems to be precisely the same with the gelatinization, which is sometimes found after death in persons who had no symptoms of an affection of the stomach, and which is ascribed by John Hunter,[186] and most British pathologists, to the solvent action of the gastric juice in the dead body. This disease is well described by Laisné in his thesis formerly quoted. The following is a good example: a young lady, previously in good health, was awakened at three one morning with excruciating pain in the stomach, which nothing could alleviate. She expired seven hours after; and on dissection two holes were found in the back part of the stomach, surrounded with much softening of the villous coat.[187] Another case will be mentioned in page 118.—The appearances produced by this disease have been mistaken for the effects of corrosive poisons.