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ULCERATION AND SOFTENING OF THE STOMACH.

Essex, in August, 1846, the reddened state of the mucous membrane, in a case of arsenical poisoning, was plainly perceptible, on removing a layer of arsenic, nineteen months after interment. (See, on this question, a case of suspected poisoning, by Orfila, Annales d'Hyg. 1839, i. 127.) If, however, there be the least doubt respecting the origin of the discoloration, it would be unsafe to rely upon the appearance as evidence of poisoning, unless poison were detected.

Ulceration.-In irritant poisoning, the stomach is occasionally found ulcerated; but this is, comparatively speaking, a rare occurrence. In such cases the mucous membrane is removed in small distinct circular patches, under the edges of which the poison (arsenic) is often found lodged. Ulceration of the stomach is perhaps a more common result of disease, than of the action of poison. As a consequence of disease, it is very insidious, going on often for weeks together, without giving any indications of its existence, except perhaps slight gastric disturbance, with occasional nausea, vomiting, and loss of appetite. In this case the ulceration is commonly seen in small circumscribed patches. It is worthy of remark, as one means of diagnosis, that ulceration has never been known to take place from arsenic or any irritant poison, until symptoms indicative of irritant poisoning have occurred. In ulceration from disease, the mucous membrane is commonly only reddened in the neighbourhood of the ulcer. In ulceration from poison, the redness is generally diffused over other parts of the stomach, as well as over the duodenum and small intestines. A case, however, occurred in Guy's Hospital, some years ago, in which, with a small circular patch of ulceration near the cardiac opening, the whole mucous membrane was red and injected:-but this singular condition of the stomach, so closely resembling the effects of an irritant poison, was unaccompanied by any marked symptoms of irritation during life. The history of a case previous to death, will thus commonly enable us to determine to what cause the ulceration found may be due. Care must be taken to distinguish ulceration from corrosion. Ulceration is a vital process: the substance of a part is removed by the absorbents as a simple result of inflammation. rosion, on the other hand, is a chemical action;-the parts are removed by the immediate contact of the poison: they are decomposed: their vitality is destroyed, and they combine with the corrosive matter itself. Ulceration requires time for its establishment, while corrosion is either an instantaneous or a very rapid effect.

Cor

Softening. The coats of the stomach are not unfrequently found so soft as to yield and break down under very slight pressure; and this may be the result either of poisoning, of some spontaneous morbid change in its structure during life, or of the solvent action of the gastric juice after death. As this condition in the stomach, when caused by poison, is commonly produced by those substances only which possess corrosive properties, it follows that in such cases traces of their action will be perceived in the mouth, fauces, and oesophagus In softening from disease, the change will be confined to the stomach alone, and it is commonly found only at the cardiac extremity of the organ. When softening is really caused by an irritant poison, it is generally attended by other striking and unambiguous marks of its operation. Softening is not to be regarded as a common character of poisoning: it is only an occasional appearance. I have met with a case, in which the coats of the stomach were considerably hardened by sulphuric acid. Softening can never be inferred to have proceeded from poison, unless other well marked changes are present, or unless the poison be discovered in the softened parts. The stomachs of infants have been frequently found softened from natural causes:-such cases could not be mistaken for poisoning, since the history during life,-the want of other appearances indicative of poisoning, and the total absence of poison from the viscera, would prevent such a suspicion from being entertained.

Perforation. The stomach may become perforated either as a result of poisoning or disease.

Perforation from poisoning.-This may occur in two ways:-1. By corrosion;

PERFORATION OF THE STOMACH FROM DISEASE.

51

2. By ulceration. The perforation by corrosion is by far the most common variety of perforation from poisoning. It is occasionally witnessed where the strong mineral acids have been taken, especially sulphuric acid:-the stomach, in such cases, is blackened and extensively destroyed,-the aperture is large, the edges are rough and irregular, and the coats are easily lacerated. The poison escapes into the abdomen, and may be readily detected by chemical analysis. The perforation from ulceration caused by irritant poison (arsenic,) is but little known. There are, so far as I know, only three instances on record. In a great number of poisoned subjects examined during many years past at Guy's Hospital, not a single case has occurred. It must, then, be looked upon as a very rare appearance in cases of irritant poisoning.

Perforation from disease.-This is by no means an unusual occurrence. Many cases of this description will be found reported elsewhere. (Guy's Hosp. Rep. No. 8.) It is invariably fatal when it proceeds so far that the contents of the stomach escape into the abdomen; but sometimes the stomach becomes glued to the pancreas during the ulcerative process, and then the individual may recover. Several specimens of this kind of adhesion have been met with in post-mortem inspections. The symptoms from perforation commonly attack the individual. suddenly, apparently while enjoying perfect health. Hence these cases may be easily mistaken for those of irritant poisoning. The principal facts observed with regard to this formidable disease are the following:-1. It often attacks young females from eighteen to twenty-three years of age. 2. The preceding illness is extremely slight, sometimes there is merely loss of appetite or capricious appetite, with uneasiness after eating. 3. The attack commences with a sudden and most severe pain in the abdomen, generally soon after a meal. In irritant poisoning, the pain usually comes on gradually, and slowly increases in severity. 4. Vomiting, if it exist at all, is commonly slight, and is chiefly confined to what is swallowed. There is no purging:-the bowels are generally constipated. In irritant poisoning, the vomiting is usually severe, and purging seldom absent. 5. The person dies commonly in from eighteen to thirty-six hours:-this is also the average period of death in the most common form of irritant poisoning, i. e. by arsenic; but in no case yet recorded has arsenic caused perforation of the stomach, within twenty-four hours; and it appears probable that a considerable time must elapse before such an effect could be produced by this or any irritant. 6. In perforation from disease, the symptoms and death are clearly referrible to peritonitis. 7. In the perforation from disease, the aperture is commonly of an oval or rounded form, about half an inch in diameter, situated in or near the lesser curvature of the stomach, and the edges are smooth. The outer margin of the aperture is often blackened, and the aperture itself is funnel-shaped from within outwards, i. e. the mucous coat is the most removed, and the outer or peritoneal coat, the least. The coats of the stomach, round the edge of the aperture, are usually thickened for some distance; and when cut, they have almost a cartilaginous hardness. These characters of the aperture will not alone indicate whether it be the result of poisoning or disease; but the absence of poison from the stomach, with the want of other characteristic marks of irritant poisoning, would enable us to say that disease was the cause. Besides, the history of the case during life would materially assist us in our diagnosis. The great risk in all these cases is, that the effects of disease may be mistaken for those of poisoning; for we are not likely to mistake a perforation caused by irritant poison for the result of disease. Notwithstanding the well marked differences above described, it is very common to meet with cases of imputed poisoning where death has really occurred from peritonitis following perforation. Within a recent period I have had to examine several cases of this kind: one of them will be found elsewhere recorded (Guy's Hosp. Reports, Oct. 1850, page 226.) In another the body was exhumed after several months' burial, and the stomach was found perforated from disease in the usual situation.

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RULES TO BE OBSERVED IN CASES OF POISONING.

Spontaneous or Gelatinized Perforation.-The stomach is occasionally subject to a spontaneous change, by which its coats become softened and give way, generally at the cardiac extremity. As the extravasation of the contents of the organ in such a case never gives rise to peritoneal inflammation, and no symptoms occur prior to death to indicate the existence of so extensive a destruction of parts, it is presumed to be a post-mortem change, and the stomach is supposed to undergo a process of solution soon after death. It is commonly attributed to the solvent action of the gastric juice,-the spleen, diaphragm, and other viscera being sometimes softened. (For some remarks on this subject, by Dr. Budd, see Med. Gaz. vol. xxxix. p. 895.) In January, 1845, I met with an instance of this perforation in a child between two and three years of age. It was seized with convulsions, became insensible, and died twenty-three hours afterwards. After death, the cardiac end of the stomach was found destroyed to the extent of three inches, and the edges were softened and blackened. There was no food in the stomach, nor had any thing passed into the organ for thirty-two hours before. death! It was therefore impossible to ascribe death to the perforation, or the perforation to poison. (For a full account of this case, see Med. Gaz. vol. xxxvi. p. 32.) The inspection of the body, with the general history of the case, will commonly suffice to remove any doubt in forming an opinion as to whether the extensive destruction commonly met with has or has not arisen from poison. Thus, in a post-mortem perforation, the aperture is always situated in that part of the stomach which lies to the left of the cardia, is very large, of an irregular form, and ragged and pulpy at the edges, which have the appearance of being scraped. The mucous membrane of the stomach is not found inflamed. There is occasionally slight redness, with dark brown or almost black lines (stria) in and near the dissolved coats, which have an acid reaction. It can only be confounded with perforation by the action of corrosives; but the well marked symptoms during life, and the detection of the poison after death, together with the changes in the fauces and oesophagus, will at once indicate the perforation produced by corrosive poison. A case of extensive perforation of the stomach, as the result of the action of the gastric fluids, has been recently reported by Dr. Barnes. (See Med. Gazette, vol. xli. p. 293.)

CHAPTER IV.

RULES TO BE OBSERVED IN INVESTIGATING A CASE OF POISONING-WITH RESPECT TO THE PATIENT WHILE LIVING-THE INSPECTION OF THE BODY-THE EXHUMATION OF BODIES -DISPOSAL OF THE VISCERA. IDENTITY OF SUBSTANCES. PRESERVATION OF ARTICLES FOR ANALYSIS. ON THE USE OF NOTES-WHEN ALLOWED TO BE USED IN EVIDENCE-MEDICO-LEGAL REPORTS.

WHEN a practitioner is called to a case of poisoning, it is above all things necessary that he should know to what points he ought to give his attention. It is very proper that every effort should be made by him to save life when the individual is living: but while engaged in one duty, it is also in his power to perform another, supposing the case to be one of suspected criminal poisoning,namely, to note down many circumstances which may tend to detect the perpetrator of the crime. There is no person so well fitted to observe these points as a medical man; but it unfortunately happens, that many facts important as evidence, are often overlooked. The necessity for observing and recording them is not perhaps generally known. A medical man need not make himself officious on such occasions, but he would be sadly unmindful of his duty as a member of

CIRCUMSTANTIAL EVIDENCE.

53

society, if he did not aid the course of justice by extending his scientific knowledge to the detection of crime. It is much to the credit of the medical profession, that the crime of murder by poisoning-a form of death from which no caution or foresight can protect an individual, is so frequently brought to light, by the announcement of suspicious facts of a medical nature to magistrates and coroners; and on several occasions the highest compliments have been passed by judges on medical practitioners who have been thus indirectly the means of bringing an atrocious criminal to the bar of justice.

The following appear to me to be the principal points which demand the attention of a medical jurist in all cases of suspected poisoning:-1. With respect to

SYMPTOMS.

1. The time of their occurrence,their nature. 2. The exact period at which they were observed to take place after a meal, or after food or medicine had been taken. 3. The order of their occurrence. 4. Whether there was any remission or intermission in their progress, or whether they continued to become more and more aggravated until death. 5. Whether the patient had laboured under any previous illness. 6. Whether the symptoms were observed to recur more violently after a particular meal, or after any particular kind of food or medicine. 7. Whether the patient has vomited:-the vomited matters, if any, (especially those first ejected,) to be procured:-their odour, colour, acid or alkaline reaction noted, as well as their quantity. 8. If none be procurable, and the vomiting have taken place on the dress, furniture, or floor of a room,-then a portion of the clothing, sheet, or carpet, may be cut out and reserved for analysis;-if the vomiting have occurred on a deal floor, a portion of the wood may be scraped or cut out; or if on a stone pavement, then a clean piece of rag or sponge soaked in distilled water, may be used to remove any traces of the substance. [Some years since, an animal was poisoned by arsenic. None of the poison could be detected in the stomach, but it was easily found in a portion of deal floor, rendered humid by the liquid matters which the animal had vomited during the night.] The vessel in which vomited matters have been contained will often furnish valuable evidence, since heavy mineral poisons fall to the bottom, or adhere to the sides of the vessel. [Whether the patient experienced any sensation of acridity or burning in the throat or mouth, previous to the occurrence of vomiting. Dr. Griffith notes this inquiry as especially important, where the poison is supposed to be one of the irritants.-H.] 9. Endeavour to ascertain the probable nature of the food or medicine last taken, and the exact time at which it was taken. 10. Ascertain the nature of all the different articles of food used at a meal. 11. Any suspected articles of food, as well as the, vomited matter, to be as soon as possible sealed up in a clean glass vessel, labelled, and reserved for analysis. 12. Note down, in their own words, all explanations voluntarily made by parties present, or who are supposed to be concerned in the suspected poisoning. 13. Whether more than one person partook of the food or medicine:-if so, whether all these persons were affected, and how? 14. Whether the same kind of food or medicine had been taken before by the patient or other persons without ill effects following. In the event of the death of the patient, it will be necessary for the practitioner to note down-15. The exact time of death, and thus determine how long a period the person has survived after having been first attacked with the suspicious symptoms. 16. Observe the attitude and position of the body. 17. Observe the state of the dress. 18. Observe all surrounding objects. Any bottles, paper-packets, weapons, or spilled liquids lying about, should be collected and preserved. 19. Collect any vomited matters near the deceased. Observe whether vomiting has taken place in the recumbent position or not. If the person has vomited in the erect or sitting posture, the front of the dress will commonly be found covered with the vomited matters.

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RULES FOR THE EXAMINATION OF THE BODY.

INSPECTION OF THE BODY.

20. Note the external appearances of the body, whether the surface be livid or pallid. 21. Note the state of the countenance. 22. Note all marks of violence on the person or discomposure of the dress,-marks of blood, &c. 23. Observe the presence or absence of warmth or coldness in the legs, arms, abdomen, mouth, or axillæ. 24. The presence of rigidity or cadaverous spasm in the body. To give any value to the two last-mentioned characters, it is necessary for the prac titioner to observe the nature of the floor on which the body is lying, whether this be clothed or naked, young or old, fat or emaciated. All these conditions create a difference in respect to the cooling of the body and the access of rigidity. 25. If found dead-When was the deceased last seen living, or known to have been alive? 26. Note all circumstances leading to a suspicion of suicide or murder. 27. The time after death at which the inspection is made. 28. Observe the state of the abdominal viscera. If the stomach and intestines be found inflamed, the seat of inflammation should be exactly specified; also all marks of softening, ulceration, effusion of blood, corrosion, or perforation. The stomach should be removed and placed in a separate vessel, a ligature being applied at the cardiac and pyloric ends. 29. The contents of the stomach should be collected in a clean graduated vessel:-notice a the quantity, b the odour tried by several persons, c the colour, d acid or alkaline reaction; e presence of blood, mucus or bile; fpresence of undigested food: and here it may be as well to observe, that the presence of farinaceous matters (bread) would be indicated by the addition of iodine water, if the contents were not alkaline-of fat, by heat; g other special characters. 30. The contents of the duodenum should be separately collected, ligatures being applied to it. 31. Observe the state of the large intestines, especially the rectum, and note the condition of their contents. The discovery of hardened fæces in the rectum would prove that purging had not existed recently before death. In one case which I had lately to examine, this became a question of considerable importance. 32. The state of the larynx, fauces, and oesophagus,-whether there be in these parts any foreign substances, or marks of inflammation or corrosion. This is of essential importance, as it throws light upon the question, whether the poison swallowed was irritant or corrosive, and whether it had or had not a local chemical action. 33. The state of the thoracic viscera:-all morbid changes noted. 34. The state of the brain. 35. The condition of the genital organs should be examined, as, in the female, poison has been sometimes introduced into the system by the vagina.

Such are the points to which, in the greater number of cases of suspected poisoning, a medical jurist should attend. By means of these data, noted according to the particular case to which they are adapted, he will in general be enabled, without difficulty, to determine the probable time of death, and the actual means by which death was brought about. He may thereby have it in his power also to point out the dish or article of food which had contained the poison, if the case be one of poisoning; and to throw light upon any disputed question of suicide or murder in relation to the deceased. Many cases of poisoning are rendered obscure, owing to these points not having been attended to in the first instance.

I have not considered it necessary to enter into any details respecting the mode of performing an inspection. This the practitioner will have acquired during his study of anatomy: and the only essential points, in addition to those mentioned, are-1. To examine all the important organs for marks of natural disease; and 2. To note down any unusual pathological appearances, or abnormal deviations; although they may at the time appear to have no bearing on the question of poisoning. It is useful to bear in mind on these occasions, that the body is inspected, not merely to show that the individual has died from poison, but to prove that he has not died from any natural cause of disease. Medical practi