Of the appearances here briefly enumerated the particulars will be related partly under what is now to be said of the appearances arising from natural causes, which are liable to be confounded with the effects of poisons, partly under the head of individual poisons.
Simple redness of the alimentary mucous membrane in all its forms, whether of mere vascularity, or actual extravasation, not only does not distinguish poisoning from inflammatory disorders of natural origin, but will even seldom distinguish the effects of poison from those of processes that occur independently of disease, and subsequent to death. On the subject of real inflammation, as distinguished from redness originating after death, or pseudo-morbid redness, as it is commonly termed,—a subject of great consequence to the medical jurist,—the reader may consult with advantage a paper by Dr. Yelloly,[195] an essay by MM. Rigot and Trousseau,[196] or that of M. Billard.[197] The former authors proved by experiment, that various kinds of pseudo-morbid redness may be formed, which cannot be distinguished from the parallel varieties caused by inflammation; that these appearances are formed after death, and not till three, five, or eight hours after it; that they are to be found chiefly in the most depending turns of intestines, and in the most depending parts of each turn, or of the stomach; and that after they have been formed, they may be made to shift their place, and appear where the membrane was previously healthy, by simply altering the position of the gut. M. Billard, on the other hand, has laid down their characters, and made a minute arrangement of the several kinds. He has divided them into ramiform, capilliform, punctated, striated, laminated, and diffuse redness,—terms which need hardly be explained. I must be content with merely referring to these sources of information for a particular account of the appearances in question. But it may be right at the same time to quote an instance of the most aggravated form of pseudo-morbid redness, in order to convince the reader that all forms may equally arise from the same causes. Among other example, then, which have been related of laminated redness, or redness in patches from extravasation, M. Billard mentions the case of a man who hanged himself, and in whose body was found, on the mucous membrane of the small intestine where it lay in the right flank, “a large, amaranth-red patch, six finger-breadths wide, covered with bloody exudation, and not removable by washing:” and in the lower pelvis there was a similar patch of even larger dimensions.[198]
Although morbid and pseudo-morbid redness of the inner coat of the alimentary canal cannot be distinguished from one another by any intrinsic character, M. Billard thinks this may be done by attending to collateral circumstances. According to his researches, redness is to be accounted inflammatory only when it occurs in parts not depending in position, or is not limited to such parts: when the mesenteric veins supplying the parts are not distended, nor the great abdominal veins obstructed at the time of death; when the reddened membrane is covered with much mucus, particularly if thick, tenacious, and adhering; when the mucous membrane itself is opaque, so that when dissected off and stretched over the finger, the finger is not visible; when the cellular tissue which connects that membrane with the subjacent coat is brittle, so that the former is easily scratched off with the nail.
Some observations may be here also made on another appearance, allied to the present group, but which there is strong reason to believe always indicates some violent irritation at least, if not even irritation from poison only, in the organ where it is found. It is an effusion under the villous coat of the stomach, and incorporation with its substance, of dark brownish-black, or as it were charred, blood; which is thus altered either by the chemical action of the poison, or by a vital process. In many cases of poisoning with the mineral acids, oxalic acid, arsenic, corrosive sublimate, and the like, there are found on the villous coat of the stomach little knots and larger irregular patches and streaks, not of a reddish-brown, reddish-black, or violaceous hue, like pseudo-morbid redness, but dark-grayish-black, or brownish-black, like the colour of coal or melanosis,—accompanied too with elevation of the membrane, frequently with abrasion on the middle of the patches, and surrounded by vascularity. This conjunction of appearances I have never seen in the stomach, unless it had been violently irritated; and several experienced pathologists of my acquaintance agree with me in this statement. It bears a pretty close resemblance to melanosis of the stomach;[199] but is distinguished by melanotic blackness being arranged in regular abruptly-defined spots, and still better by melanosis not being preceded by symptoms of irritation in the stomach.
Referring to what was already said under the head of the symptoms of gastritis [p. 102], I must again express my doubts whether the appearances now described ever arise in this country from natural disease. In the intestines they are sufficiently familiar to the physician, as arising from idiopathic enteritis, and from dysentery. But in the stomach their existence as the effect of natural disease is very doubtful.
Another kind of coloration of the inner membrane of the stomach, which may be shortly alluded to, because it has actually been mistaken for the effect of irritation from poison, although by no means like it,—is staining of the membrane with a reddish, brownish, yellowish, or greenish tint, observed in bodies that have been kept some time, and produced by the proximity of the liver, spleen, or colon if it contains fæces. No unprejudiced and skilful inspector could possibly mistake this appearance for inflammation. But under the impulse of prejudice it has been considered such, and imputed to poison. On the occurrence of such stains an attempt was made by the French to ascribe to poison the death of the republican general Hoche. He died rather suddenly on his way from Frankfort to join his troops; and as poisoning was suspected, the body was opened in the presence of three French army-surgeons, and a French and two German physicians. The only appearance of note in the alimentary canal was two darkish spots on the villous coat of the stomach. The surgeons drew up a report which imputed his death to poison; but the physicians refused to sign it; and other medical people who were subsequently added to the commission decided with the latter.[200] The surgeons probably would not have been so hasty, if they had not known that the result of their complaisance would have been the levying of a heavy fine on the inhabitants.
The last kind of discoloration of the inner coat which requires mention is dyeing from the presence of coloured fluids in the contents. A remarkable instance has been recorded where redness of this nature was mistaken for inflammation, and the death of the individual in consequence ascribed at first to poison. A person long in delicate health died suddenly after taking a laxative draught; and the stomach, as well as the gullet, being found on dissection red and livid in various places, it was hastily inferred by his medical attendants, that these appearances were the effect of poison, and that the apothecary had committed some fatal error in compounding the draught. But another physician, who was acquainted with the deceased, although he did not attend him professionally, strongly suspected he had died a natural death; and happening to know he was in the practice of taking a strong infusion of corn-poppy, inferred that the supposed signs of inflammation were merely stains arising from the habitual use of this substance. Accordingly, on making the experiment, he found that in dogs to which a similar infusion was given, appearances were produced identically the same.[201]
Of the effusion of mucus and lymph from natural causes.—The abundant secretion of tough mucus in the stomach is a sign of that organ having been irritated. But the effusion of lymph is more characteristic. This may be produced by natural inflammation as well as by irritating poisons. As arising from either cause, however, it is rare; and certainly by no means so common as would be supposed from what is said in systematic works; for tough mucus has been often mistaken for it. Reticulated lymph adhering to the villous coat, and accompanied with corresponding reticulated redness of that coat, such as I have seen in animals poisoned with arsenic or oxalic acid, is an unequivocal sign of inflammation.
Of idiopathic ulcers and perforation of the stomach and intestines, and their distinction from those caused by poison.—Both ulceration and perforation may be produced by natural disease. In the ulceration produced by poisons there is generally speaking nothing to distinguish it from natural ulcers; but that caused by some poisons, such as iodine, is said to differ by the surrounding coloration of the membrane; and when the ulcer is caused by a sparingly soluble poison in a state of powder, such as arsenic, the cavity of the ulcer is sometimes filled with the powder. Perforation is a rare effect of the simple irritant poisons; but it is often caused by corrosives. It is imitated by two of the varieties of perforation from natural disease.
The form of natural perforation caused by a common ulcer is precisely the same as that caused by the simple irritants, and is incapable of being distinguished, except when it is attended with scirrhus.
By far the most remarkable variety, however, of spontaneous perforation is that which takes place, without proper inflammatory action, from simple gelatinizing of the coats. It is very apt to be mistaken, and in a celebrated trial, which will be immediately noticed, was actually mistaken for the effect of corrosive poison.
It may be situated on any part of the stomach, but is oftenest seen on the posterior surface. It is sometimes small, more often as big as a half-crown, frequently of the size of the palm, and occasionally so great as to involve an entire half of the stomach. Sometimes there is more than one aperture. The margin is of all shapes, commonly fringed, and almost always formed of the peritoneum, the other coats being more extensively dissolved. In one instance, however, the peritonæal surface was on the contrary the most extensively destroyed;[202] and in a case which occurred in the infirmary here, and was pointed out to me by the late Dr. W. Cullen, the peritonæum alone was extensively softened, and partly dissolved, so as to lay the muscular coat bare on its outer surface. The gelatinization therefore sometimes, though very rarely, begins on the outside of the stomach. Internally the whole is surrounded by pulpiness of the mucous coat, generally white, occasionally bluish or blackish, never granulated like an ulcer, very rarely vascular; and when vascular, the blood may be squeezed out of the loaded and open vessels. The organs in contact with the hole are also frequently softened. Thus an excavation is sometimes found in the liver or spleen; or the diaphragm is pierced through and through. The margins of the latter holes are without any sign of vascular action, but are generally besmeared with a dark pulpy mass, the remains of the softened tissue. The pulp never smells of gangrene; with which, indeed, this species of softening is wholly unconnected. The edge of the hole in the stomach never adheres to the adjoining organ; yet, even when the hole is very large, the contents of the stomach have not always made their escape. Often the dissolution of the coats is incomplete. John Hunter and others, indeed, have said that a stomach is rarely seen without more or less solution of the mucous coat.[203] The best account of the appearances in this state is given by Jaeger of Stuttgardt.[204]
The circumstances under which this extraordinary appearance occurs are singularly various. Professor Chaussier and the French pathologists conceive it to be always a morbid process constituting a peculiar disease; and doubtless cases have occurred in which death appears to have arisen from the stomach being perforated during life by gelatinization.[205] But it has been found much more frequently, when death was clearly the consequence of a different disease, and when there did not exist during life a single sign of disorder in the stomach. Thus it has been found in women who died of convulsions after delivery,—in children who died convulsed or of hydrocephalus,—after death from suppuration of the brain, both natural and the result of violence,—from coma following an old ulcer of the back, which communicated with the spinal canal,—from diseased mesenteric glands,—from phthisis,—from nervous fever,—and after sudden death from fracture of the skull or hanging:[206] and in all of these circumstances it has occurred without any previous symptom referrible to a disorder in the stomach.
The opinions of pathologists are divided as to its nature. The French conceive it arises from a morbid corrosive action, which, however, may extend after death, in consequence of the fluids acquiring a solvent power. Hunter ascribed it entirely to the solvent power of the gastric juice after death. There are difficulties in the way of both doctrines. A full examination of the whole inquiry, which is one of much interest and considerable complexity, would be misplaced in this work; but some remarks are called for, by reason of the important medico-legal relations of the subject, and the uncertainty in which it is at present involved.
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.
It is not difficult to draw the distinction between these perforations and the effects of poison. The throat and gullet may be partially disorganized or corroded by the strong corrosives; but they are very rarely penetrated, since the greater part of the poison must pass into the stomach or be rejected by vomiting. Destruction of the mucous coat is a common consequence, and stricture occasionally follows; but I have hitherto met with only one instance among the innumerable published cases of poisoning with the mineral acids, alkalis, and other corrosives, where the gullet was perforated. In that case the perforation was the result of slow ulceration from poisoning with sulphuric acid, where life was prolonged for two months.[223] Perforation from simple corrosion never occurs. The intestines are never perforated by chemical corrosion from within, for either the poison is in a great measure expelled from the stomach by vomiting, or the pylorus contracts and prevents the passage of every poison that is sufficiently concentrated to corrode. Both the small and great intestines might be corroded from without, in consequence of the poison escaping through a hole in the stomach. I am not acquainted, however, with any case of the kind where, intestinal perforation has occurred.
When the intestines are pierced by true ulceration, it is impossible to tell whether it arose from natural disease or an irritant poison.
The mode of forming a diagnosis between the symptoms and appearances of irritant poisoning and those of natural disease being thus explained, the different species of poisons which have been arranged in the class of irritants will now be considered in their order.
The irritant class of poisons may be divided into five orders: the acids and their bases; the alkalies and their salts; the metallic compounds; the vegetable and animal irritants; the mechanical irritants. In a short appendix some substances will be mentioned which are not usually considered poisonous, but are capable of causing violent symptoms when taken in large doses.
The greater number of poisons included in the first order have a very powerful local action. Most of them possess true corrosive properties when they are sufficiently concentrated. Most of them likewise act remotely. One of them, oxalic acid, is evidently not so much an irritant as a narcotico-acrid; but since its most frequent action as seen in man is irritation, it seems inexpedient to break the natural arrangement for the sake of logical accuracy. This is far from being the only instance where the toxicologist is compelled to violate the principles of philosophical classification.
In the present Order are included four of the mineral acids, the sulphuric, nitric, muriatic and phosphoric, with their bases, phosphorus, sulphur, and chlorine: To these may be added iodine and bromine, with their compounds, and also oxalic and acetic acid, two of the vegetable acids.
Of the mineral acids, the most important, because the most common, are sulphuric, hydrochloric, and nitric acids. They are remarkably similar in their effects on the animal economy. Phosphoric acid is of much less consequence, and will be noticed cursorily.
Sulphuric acid (vitriolic acid, vitriol—oil of vitriol), hydrochloric acid (muriatic acid,—spirit of salt) and nitric acid (aqua-fortis), have been long known to be possessed of very energetic properties; and consequently cases of poisoning with them have often been observed. The instances of the kind hitherto published have been chiefly the result of suicide; a considerable number have originated in accident; and, however extraordinary it may appear, a few have been cases of murder. Tartra, in an excellent memoir on the subject of poisoning with nitric acid, quotes an instance of a woman having been poisoned while in a state of intoxication by that acid being mixed with wine and poured down her throat.[224] Valentini has related the case of a woman who was killed by frequent doses of sulphuric acid given under the pretence of administering medicines.[225] In 1829 an hospital servant was condemned at Strasbourg for trying to murder his wife in like manner, by first making her ill with tartar-emetic and then giving her sulphuric acid in syrup, under the pretence of curing her.[226] At the Aberdeen autumn circuit in 1830 a woman Humphrey was convicted of murdering her husband by pouring the same acid down his throat while he lay asleep with his mouth open.[227] On the whole, considering the powerful taste and excessively acrid properties of these poisons, it is probable that they will seldom be resorted to for the purpose of making away with another person, who is an adult, and in a state of consciousness. Of late, however, there have been several instances in our country of murder committed on infants in this barbarous manner. A woman Malcolm was executed here in 1808 for murdering her own child, an infant of eighteen months, by pouring sulphuric acid down its throat;[228] another woman Clark was tried for the same crime at Exeter in 1822; a man was executed lately at Manchester for murdering in the same way his son, a child four years and a half old;[229] and the particulars of an interesting trial will be presently noticed, that of Overfield, who was executed at Shrewsbury in 1824, for poisoning his child in the like manner.[230]
In a medico-legal point of view, the mineral acids are interesting on another account. Of late a new crime has arisen in Britain, the disfiguring of the countenance by squirting oil of vitriol on it. It originated in Glasgow, during the quarrels in 1820, between masters and workmen regarding the rate of wages,[231] and became at last so frequent, that the Lord Advocate, in applying for an act of Parliament to extend the English Stabbing and Maiming act to Scotland, added a clause which renders the offence now alluded to capital. In 1828 a woman Macmillan was tried here and condemned under that act.[232] The crime afterwards became common in England. Three cases were noticed in the newspapers as having occurred in London, in November, 1828; and two others near Manchester in the spring of 1829. It is now much less frequent.
The mineral acids are also very interesting on scientific grounds. They afford the purest examples of true corrosive poisons, their poisonous effects depending entirely on the organic injury they occasion in the textures to which they are applied. It is of use to set out, in investigating the effects of poisons, by determining the phenomena presented under such circumstances. When made aware of the rapidity with which other irritating poisons prove fatal, and the slight signs they commonly leave of their operation, one cannot fail to be struck with discovering what the animal frame will sometimes endure from these the most violent of all irritants, and nevertheless recover.
In laying down the mode of determining by chemical evidence a case of supposed poisoning with any of the three mineral acids mentioned above, it will be unnecessary to notice any of their chemical properties, except those from which their medico-legal tests are derived.
The only common properties that require notice are, their power of reddening the vegetable blue colours, for showing which litmus-paper is commonly used, and is most convenient: and their power of staining and corroding all articles of dress, especially such as are made of wool, hair, and leather. This last property is specified, though a familiar one, because it always forms important evidence in criminal cases. In order to give precision to such evidence, it is necessary to remember, that if the article of dress is a coloured one, it is generally rendered red by the mineral acids; but that the vegetable acids also will redden most articles of dress, although they do not corrode them.
Sulphuric acid is extensively employed in very many trades, is used even for some domestic purposes, and is consequently familiar to every one. Hence it is the mineral acid which has been most commonly used as a poison, especially for committing suicide. Of 35 cases of poisoning with the mineral acids which occurred in England in the years 1837 and 1838, 32 were caused by this acid (p. 90).
Sulphuric acid is known as a poison chiefly in the form of the concentrated commercial acid. But a few cases of poisoning have also been produced by blue-liquor or the solution of indigo in strong sulphuric acid; and one instance[233] has been recorded of poisoning with the aromatic sulphuric acid of the Pharmacopœias, which is an infusion of aromatics in a mixture of sulphuric acid, ether and alcohol. In the following remarks on its tests, it will be sufficient to consider it first in the concentrated form,—secondly, in a state of simple dilution,—and thirdly, when mixed with various impurities, more especially with vegetable and animal matter. The acid solution of indigo may be known by the tests for the concentrated acid, and its blue colour, removable by a solution of chlorine; and the aromatic sulphuric acid may be distinguished by its odour and the tests for the diluted acid.
1. When concentrated it is oily-looking, colourless, or brownish from having acted on organic particles, without odour, much heavier than water, and capable of quickly corroding animal substances. If from these properties, and its effect in reddening litmus, its exact nature be not considered obvious, it may be heated with a few chips of copper; when sulphurous acid is disengaged and may be readily recognised by its odour.
2. When diluted, it may be distinguished from all ordinary acids by solution of nitrate of baryta occasioning a heavy white precipitate of sulphate of baryta, which is insoluble in nitric acid. Selenic and sulphurous acids, however, and also, as Mr. Alfred Taylor informs me he has lately found, the fluo-silicic acid, are similarly acted on in all respects. But selenic and fluo-silicic acids in all forms, and sulphurous acid in a state of solution, are so seldom met with, being known only in the laboratory of the scientific chemist, that they can scarcely be considered sources of fallacy. Sulphuric acid may at once be distinguished from sulphurous acid, by the latter possessing a peculiar pungent odour. From the two other acids it may be distinguished by collecting and drying the barytic precipitate, mixing this with charcoal, converting it into sulphuret of barium by heating it in a platinum spoon before the blowpipe, and then adding diluted muriatic acid to the sulphuret, so as to disengage sulphuretted hydrogen gas,—which again is easily known by its odour, or its property of blackening paper dipped in solution of acetate of lead. A much more important source of fallacy than these is the possible presence of a bisulphate in solution, or a neutral sulphate along with any other free acid; for these substances will present the same reactions with litmus and barytic salts as free sulphuric acid itself. Much has been published lately upon this point; but the difficulty has not yet been satisfactorily overcome. It may be got rid of indeed by proving, that no bisulphate or neutral sulphate is present. Their absence may be shown by no solid residuum being left on evaporating the suspected fluid, or at least no more than a mere haziness, owing to the sulphate of lead which commercial sulphuric acid always contains in small quantity. Or as Orfila suggests, we may establish their absence still better by concentrating the fluid, and finding that neither carbonate of soda, which would cause a precipitate with earthy or metallic bases, nor chloride of platinum, which would do so with potash or ammonia in combination, nor fluo-silicic acid, which precipitates soda salts, has any effect when applied to separate portions of the subject of inquiry. But suppose it appears in the course of these trials that one or more bases are actually present, how is it to be settled whether the sulphuric acid, indicated by litmus and a salt of baryta, is really free or not? To this question I must reply, that no method has yet been proposed, which is at once satisfactory and easily available. Mr. Alfred Taylor proposes to concentrate the fluid, and agitate it with alcohol, in the hope that the alcohol will remove sulphuric acid, and not a sulphate, from the water.[234] But it removes sulphuric acid from a bisulphate even when dry, and still more when a little water is present. Orfila[235] proposes, in the case of sulphuric acid in vinegar,—where there is both a vegetable acid and a neutral sulphate of lime,—to concentrate to a sixth, and agitate the residuum with four times its volume of sulphuric ether, in the expectation that this fluid will remove the free acid alone, and separate it from sulphates. But notwithstanding the authority of his name for the fact, pure ether will not remove sulphuric acid from a watery fluid; and etherized alcohol, which does remove it, takes it away also, like alcohol itself, from bisulphates. These results I have observed in some careful trials made along with Dr. Douglas Maclagan. I suspect, therefore, that where sulphates or bisulphates do exist, there is no absolutely satisfactory way of determining whether free sulphuric acid also co-exists, except by a quantitative analysis, for ascertaining whether the amount of acid and of bases corresponds with this supposition or not. And it is scarcely necessary to add, that so operose a method is scarcely applicable to ordinary medico-legal investigations.
3. It is seldom that the medical jurist is called on to search for sulphuric acid in either of the states already mentioned. Much more generally it has mingled with and acted on various organic substances. The circumstances in which it has usually to be sought for in the practice of medical jurisprudence are twofold,—on the one hand, in stains on clothes,—and on the other, in vomited matter, the contents of the stomach, or organic mixtures generally.
Process for analyzing stains on clothes.—When sulphuric acid is thrown upon your clothes, it produces a permanent red, reddish-brown, or yellowish stain, destroys the cloth entirely or renders it brittle, and in consequence of its strong attraction for water keeps the stain long in a moist state. In the course of the decomposition of the cloth a part of the acid is itself decomposed, sulphurous acid being disengaged. But it is an important medico-legal fact, that after a time the change either goes on very slowly, or is arrested altogether, possibly by the dilution of the acid with moisture from the atmosphere; and that consequently it may be discovered in a free state in stains after a much longer interval than would à priori be expected. In the case of Macmillan formerly alluded to, Dr. Turner and I, who were employed by the crown to examine the different injured articles of dress, found on a man’s hat, stock, shirt-collar and coat many discoloured and corroded spots, which were sour to the taste fourteen days after the crime was committed; in the subsequent case of Mrs. Humphrey I discovered six-tenths of a grain of free sulphuric acid in two small spots on a blanket seven weeks after the crime; and from an express experiment on the same blanket with two drops of acid of known strength, it appeared that only one-half of the acid disappeared in seven weeks. It may therefore be inferred, that, in every instance where stains have been produced by concentrated sulphuric acid on clothes, at least on woollen clothes, and no attempt has been made to remove the remaining acid by washing or neutralization, a sufficient quantity will be present even after several weeks to admit of being satisfactorily detected by chemical analysis.
The following are the steps of the process which appear to me the most delicate and equivocal. Cut away the stained spots; boil them for a minute or two in several successive small portions of distilled water; and filter if necessary. Next prove the acidity of the fluid by litmus, and likewise by the taste if the quantity of solution is large enough to allow of so coarse a test being used; and with a few drops ascertain the existence of sulphuric acid in one form or another by nitrate of baryta and nitric acid, as mentioned in the process for the pure diluted acid. If no precipitate appears, the search for sulphuric acid is at an end. But if a precipitate is produced, ascertain the absence of bisulphates and sulphates by proving the absence of bases, according to the method described in the process for the simple diluted acid. If, however, bases be found in material proportion to the acid, the analysis is subject to all the difficulties mentioned above in speaking of the detection of the diluted acid in similar circumstances.
Process for the contents of the stomach and other complex mixtures.—When sulphuric acid has been mixed with various mineral and organic substances, it may in no long time cease to exist in the free state. Part may be decomposed by organic matter in the way formerly mentioned. Or the whole may be neutralized at once by earthy or alkaline carbonates, administered purposely as antidotes. Or it may also be neutralized more slowly by the gradual development of ammonia in consequence of the decay of the animal matter co-existing in the mixture. Thus in a case mentioned by Mertzdorff of a child killed in twelve hours with sulphuric acid, the contents of the stomach did not redden litmus, but on the contrary had an ammoniacal odour; and they contained a considerable quantity of a soluble sulphate, probably the sulphate of ammonia.[236] In like manner MM. Orfila and Lesueur found that when this acid was left some months in a mixture which contained putrefying azotized matter, it was gradually neutralized by ammonia.[237] It appears from Orfila’s latest researches,[238] that in most cases of acute poisoning with this substance some free acid will be found in the contents or tissues of the stomach, provided alkalis or earths were not given as antidotes, and the examination of the body be made before decay sets in.
The detection of sulphuric acid in complex organic mixtures, simple though it appears at first sight, is one of the most difficult problems in medico-legal chemistry. The difficulty arises from a variety of sources,—from the probable presence of neutral sulphates along with free hydrochloric, acetic, or some other acid,—the possible presence of a bisulphate,—the occasional neutralization of the sulphuric acid by antidotes given during life, or ammonia evolved during decay after death,—or its neutralization, together with the development of a different free acid, by its having displaced this acid from a salt existing in the mixture.
The subject was investigated in most of its relations in the last edition of the present work, and a process proposed which overcame some difficulties, but left others untouched. The inquiry has been since undertaken also by M. Devergie and Professor Orfila, but with most success in Germany by Dr. Simon.[239] The result of all these researches is, that a satisfactory process for detecting sulphuric acid in organic mixtures still remains to be discovered. Meanwhile the most eligible method appears to me to be the following.
a. If the mixture be acid, add distilled water, if necessary, boil, filter, and test a few drops of the fluid with nitrate of baryta, followed by nitric acid. If there be no precipitate, the search for sulphuric acid is at an end. If a precipitate form, distil the fluid from a muriate of lime or oil bath, at a temperature not above 240°, till the residuum acquire a thick syrupy consistence; and preserve apart the last sixth of the distilled liquor. In this liquor test for hydrochloric acid by litmus-paper and nitrate of silver, and for acetic acid by litmus-paper, and the odour and taste of the liquid. If these acids be not in the distilled fluid, they are not in the residuum. In a portion of this residuum search for nitric acid, and in another portion for oxalic acid, by the processes for these poisons in complex mixtures. If all these acids be thus proved to be absent, it is most unlikely that the acidity of the mixture is owing to any other but sulphuric acid, especially in the case of the contents or textures of the stomach.
Dilute now what remains of the syrupy extract, and add nitrate of baryta with nitric acid. If a precipitate arise, there is a strong presumption that the acidity of the mixture was owing either to a bisulphate or to free sulphuric acid. And between these the question may be almost settled, first by the probability or improbability of a bisulphate having come in the way, and secondly, by the symptoms and morbid appearances. The result however cannot justify more than a presumptive opinion.—But if hydrochloric, acetic or nitric acid be indicated in the subject of analysis, or an acid sulphate, the whole process is vitiated, and it is scarcely possible to arrive at any trustworthy conclusion.
The difficulties adverted to above have been made the ground-work of various processes; which however seem to me all imperfect.—It has been proposed to divide the mixture into two equal parts, to precipitate one directly by a barytic salt, to do the same with the other after drying and incinerating it, to compare the weight of the precipitates, and to infer the presence of free sulphuric acid if the former is more than double the latter. Various objections however may be brought against this check, not the least serious being its difficulty in ordinary hands, whenever the precipitates are none of them considerable.—Simon proposes to exhaust the residuum of evaporation with absolute alcohol, in the hope that free sulphuric acid will alone be taken up;[240] but he himself found that neutral sulphates are dissolved partially; and besides, alcohol removes sulphuric acid from bisulphates.—Orfila proposes to remove free sulphuric acid by agitating the concentrated liquor with sulphuric ether, and separating and evaporating off the ether; for he holds that all neutral and acid salts of sulphuric acid are insoluble in ether.[241] This proposal is unaccountable. Simon stated in his paper three years before, that ether does not remove sulphuric acid from watery fluids containing it. And Dr. Douglas Maclagan and I, on inquiring into the matter, found that we could not, by means of ether, separate a particle of sulphuric acid from an ounce of rice soup and mucilage to which ten drops of the acid had been added. The process of Orfila for establishing the absence of bases in a simple watery solution is applicable to organic mixtures also, after incineration. But if bases be present in material quantity, all the difficulties now in question remain in full force.
b. When the mixture is neutral, sulphuric acid may be detected in it by the first steps of the preceding process. But the inference, that it once existed free can only be drawn when the subject of examination is not in a state of decay, when the quantity of sulphate of baryta obtained is considerable, when the administration of an antidote is proved, and when the ashes after incineration contain the antacid base which is said to have been administered. Even then the inference is only presumptive.
It was formerly observed that the action of the strong mineral acids is independent of the function of absorption. They act by the conveyance along the nerves of an impression produced by the irritation or destruction of the part to which they are applied. There is very little difference between the three acids in the symptoms they excite or the action they exert.
When sulphuric acid is introduced directly into a vein it causes death by coagulating the blood. Thus, when Professor Orfila injected in the jugular vein of a dog half a drachm diluted with an equal weight of water, he observed that the animal at once struggled violently, stretched out its limbs, and expired; and on opening the chest immediately, he found the heart and great vessels filled with coagulated blood.[242]—Nitric acid and hydrochloric acid act in the same way.
If, on the other hand, they are introduced into the stomach, the blood as usual remains fluid for some time after death; the symptoms are referrible almost solely to the abdomen; and in the dead body the stomach is found extensively disorganised, and the other abdominal viscera sometimes inflamed. If the dose be large, and the animal fasting, death may take place in so short a time as three hours: but in general it lives much longer.[243]
When the strong mineral acids are applied outwardly, they irritate, inflame, or corrode the skin. The most rapid in producing these effects is the nitric, or rather the nitrous acid. The strong, fuming nitrous acid even causes effervescence when dropped on the skin.
Orfila has proved that sulphuric acid, as well as the two other mineral acids, is absorbed; for they may be detected in the urine, when they are introduced either into the stomach or through a wound.[244] He could not succeed, however, in detecting any of them in the liver or spleen; in which organs it will be seen, hereafter, that various other poisons may be discovered by chemical analysis. But Mr. Scoffern seems to have found sulphuric acid in the kidney, even although the individual survived the taking of the poison nearly two days.[245] It is also worthy of remark, that, as will be proved presently, these acids may pass through the coats of the stomach by transudation, and so be found on the surface of the other organs in the belly.
Toxicology is indebted to M. Tartra for the first methodic information published respecting the symptoms caused in man by sulphuric acid and the other mineral acids:[246] but many important additional facts have been made known by numberless cases of poisoning which have since appeared, chiefly in the periodic journals.
The symptoms caused by all the three acids are so nearly the same, that after a detailed account of those occasioned by sulphuric acid, it will not be necessary to add much on the subject under the head of nitric and muriatic acid.
M. Tartra considers that four varieties may be observed in the effects of the mineral acids. 1. Speedy death from violent corrosion and inflammation; 2. Slow death from a peculiar organic disease of the stomach and intestines; 3. Imperfect recovery, the person remaining liable ever after to irritability of the stomach; 4. Perfect recovery.
1. The most ordinary symptoms are those of the first variety,—namely, all the symptoms that characterise the most violent gastritis, accompanied likewise with burning in the throat, which is increased by pressure, swallowing, or coughing;[247]—eructations proceeding from the gases evolved in the stomach by its chemical decomposition;—and an excruciating pain in the stomach, such as no natural inflammation can excite. The lips are commonly shrivelled, at first whitish, but afterwards brownish in the case of sulphuric acid. Occasionally there are also excoriations, more rarely little blisters. Similar marks appear on other parts of the skin with which the acid may have come in contact, such as the cheeks, neck, breast, or fingers; and these marks undergo the same change of colour as the marks on the lips. I had an opportunity of witnessing this in the case of the man who was disfigured by the Macmillans (p. 122) with sulphuric acid. He was cruelly burnt on the face as well as on the hands, which he had raised to protect his face; and the marks were at first white, but in sixteen hours became brownish. The inside of the mouth is also generally shrivelled, white, and often more or less corroded; and as the poisoning advances, the teeth become loose and yellowish-brown about the coronæ. The teeth sometimes become brown in so short a time as three hours.[248] Occasionally the tongue, gums, and inside of the cheeks are white, and as it were polished, like ivory.[249] There is almost always great difficulty, and sometimes complete impossibility, of swallowing. In the case of a child related by Dr. Sinclair, of Manchester, fluids taken by the mouth were returned by the nose; and the reason was obvious after death; for even then the pharynx was so much contracted as to admit a probe with difficulty.[250] On the same account substances taken by the mouth have been discharged by an opening in the larynx which had been made to relieve impending suffocation. The matter vomited, if no fluids be swallowed, is generally brownish or black, and at first causes effervescence, if it falls on a pavement containing any lime. Afterwards this matter is mixed with shreds of membrane, which resemble the coats of the stomach, and sometimes actually consists of the disorganised coats, but are generally nothing more than coagulated mucus. The bowels are obstinately costive, the urine scanty or suppressed; and the patient is frequently harassed by distressing tenesmus and desire to pass water. The pulse all along is very weak, sometimes intermitting, and towards the close imperceptible. It is not always frequent; on the contrary, it has been observed of natural frequency, small and feeble in a patient who survived fifteen days.[251] The countenance becomes at an early period glazed and ghastly, and the extremities cold and clammy. The breathing is often laborious, owing to the movements of the chest increasing the pain in the stomach,—or because pulmonary inflammation is also at times present,—or because the admission of air into the lungs is impeded by the injury done to the epiglottis and entrance of the larynx. To these symptoms are added occasional fits of suffocation from shreds of thick mucus sticking in the throat, and sometimes croupy respiration, with sense of impending choking.
Such is the ordinary train of symptoms in cases of the first variety. But sometimes, especially when a large dose has been swallowed, instead of these excruciating tortures, there is a deceitful tranquillity and absence of all uneasiness. Thus, in the case of a woman who was poisoned by her companions making her swallow while intoxicated aqua-fortis mixed with wine, although she had at first a good deal of pain and vomiting, there were subsequently none of the usual violent symptoms; and she died within twenty hours, complaining chiefly of tenesmus and excessive debility.[252] Occasionally eruptions break out over the body:[253] but their nature has not been described.
Death is seldom owing to the mere local mischief, more generally to sympathy of the circulation and nervous system with that injury. According to Bouchardat death arises from the acid entering the blood in sufficient quantity to cause coagulation.[254] But although this certainly happens sometimes to the blood in the vessels of the stomach and adjacent organs, as will be proved under the head of the morbid appearances, there is no evidence that the same takes place throughout the blood-vessels generally, or in the great veins and heart in particular. Bouchardat’s proofs of the detection of sulphuric acid in the blood are not satisfactory.
The duration of this variety of poisoning with the acids is commonly between twelve hours and three days. But sometimes life is prolonged for a week[255] or a fortnight;[256] and sometimes too death takes place in a very few hours. The shortest duration among the numerous cases of adults mentioned by Tartra is six hours;[257] but Dr. Sinclair, of Manchester, has related a case which lasted only four hours and a half;[258] a man lately died in the Edinburgh Infirmary within four hours; and Professor Remer of Breslau once met with a case fatal in two hours.[259]
The quantity required to produce these effects has not been ascertained, and must be liable to the same uncertainty here as in other kinds of poisoning. The smallest fatal dose of sulphuric acid I have hitherto found recorded was one drachm. It was taken with sugar by mistake for stomachic drops by a stout young man, and killed him in seven days.[260] An infant of twelve months has been killed in twenty-four hours by half a tea-spoonful, or about thirty minims.[261] A man has recovered after taking six drachms.[262]
2. The second variety of symptoms belong to a peculiar modification of disease, which is described by Tartra in rather strong language. It begins with the symptoms already noticed; but these gradually abate. The patient then becomes affected with general fever, dry skin, spasms and pains of the limbs, difficult breathing, tension of the belly, salivation, and occasional vomiting, particularly of food and drink. Afterwards membranous flakes are discharged by vomiting, and the salivation is accompanied with fœtor. These flakes are often very like the mucous membrane of the stomach and intestines; and such they have often been described to be. More probably, however, they are of adventitious formation; for the mere mucous coat of the alimentary canal cannot supply the vast quantity that is evacuated. There is no doubt, however, that the lining membrane of the alimentary canal is occasionally discharged. Dr. Wilson has mentioned an instance of the ejection by coughing of about nine inches of the cylindrical lining of the pharynx and gullet six days after sulphuric acid was taken.[263] Sometimes worms are discharged dead, and evidently corroded by the poison.[264] Digestion is at the same time deranged, the whole functions of the body are languid, and the patient falls into a state of marasmus, which reduces him to a mere skeleton, and in the end brings him to the grave. Death may take place in a fortnight, or not for months. In one of Tartra’s cases the patient lived eight months. The vomiting of membranous flakes continues to the last.
3. The third variety includes cases of imperfect recovery. These are characterized by nothing but the greater mildness of the primary symptoms, and by the patient continuing for life liable to attacks of pain in the stomach, vomiting of food and general disorder of the digestive function.
4. The last variety comprehends cases of perfect recovery, which are sufficiently numerous even under unpromising appearances. From the average of 55 cases recorded by Tartra it appears that the chances of death and recovery are nearly equal. Twenty-six died, 19 of the primary, 7 of the secondary disorder. Twenty-nine recovered, and of these twenty-one perfectly. Suicidal are for obvious reasons more frequently fatal than accidental cases.
Tartra has not taken notice in his treatise of another form of poisoning with the strong acids,—in which the injury is confined to the gullet and neighbouring parts. In Corvisart’s Journal there is the case of a man, who began to drink sulphuric acid for water while intoxicated, but suddenly found out his error before he had swallowed above a few drops; and consequently the chief symptoms were confined to the throat. After his physician saw him he was able to take one dose of a chalk mixture; but from that time he was unable to swallow at all for a fortnight.[265] Martini likewise met with a similar instance of complete dysphagia from stricture in the gullet caused by sulphuric acid.[266] His patient recovered.
It also appears exceedingly probable, that the strong acids may cause death, without reaching the stomach or even the gullet, by exciting inflammation and spasm of the glottis and larynx. Such an effect may very well be anticipated from an attempt to commit murder with these poisons; as the person, if he retains consciousness at the time, may become aware of their nature before he has swallowed enough to injure the stomach.
Thus, Dr. A. T. Thomson says in 1837, that he once met with the case of a child, who, while attempting to swallow strong sulphuric acid by mistake for water, died almost immediately, to all appearance from suffocation caused by contraction of the glottis; and it was ascertained after death that none of the poison had reached the stomach.[267] Professor Quain describes a similar case, occurring also in a child, where impending death was prevented by artificial respiration, and acute bronchitis ensued, which proved fatal in three days. In this instance thickening of the epiglottis and great contraction of the upper opening of the larynx showed the violent local injury inflicted there, inflammation could be traced down the trachea into the bronchial tubes, but no trace of injury could be detected in the gullet and stomach.[268] In a very interesting and carefully detailed case by Mr. Arnott, where the poison taken was the nitric acid, the injury was confined in a great measure to the gullet and larynx,—the stomach, which was distended with food at the time, being very little affected. The chief symptoms at first, besides great general depression, were croupy respiration and much dyspnœa, which became so urgent, that laryngotomy was performed, and with complete relief to the breathing. But the patient nevertheless rapidly sunk under the symptoms of general exhaustion, and died in thirty-six hours without presenting any particular signs of the operation of the poison on the stomach; and the traces of action found there after death were trifling.[269]