CHAPTER XXIV.

CLASS SECOND. OF NARCOTIC POISONS GENERALLY.

The term narcotism has been used by different writers with different significations, but is now generally understood to denote the effects of such poisons as bring on a state of the system like that caused by apoplexy, epilepsy, tetanus, and other disorders commonly called nervous. Narcotic poisons, therefore, are such as produce chiefly or solely symptoms of a disorder of the nervous system.

The mode in which most narcotic poisons act has been well ascertained: they act on the brain or spine or both by entering the blood-vessels. Hence they are most active when most directly introduced into the blood, that is, when injected into the veins; and when they are applied to an entire membranous surface, their energy is in the ratio of its absorbing power. Thus, when injected into the chest, they act more rapidly than when swallowed. According to the generally received opinion, they are conveyed with the blood to the brain and spine on which they act. But, according to the views of Messrs. Morgan and Addison, they produce on the inner coats of the blood-vessels a peculiar impression, which is conveyed to the centre of the nervous system along the nerves.

The usual symptoms in man and the higher order of animals are giddiness, headache, obscurity or deprivation of the sight, stupor or perfect insensibility, palsy of the voluntary muscles or convulsions of various kinds, and towards the close complete coma. The symptoms of each poison are pretty uniform, when the dose is the same. But each has its own peculiarities, either in the individual symptoms, or in the mode in which they are combined together.

The morbid appearances they leave in the dead body are commonly insignificant. In the brain, where chiefly the physician is led from the symptoms to expect unnatural appearances, the organs are in general quite healthy. Sometimes, however, the veins are gorged with blood, and the ventricles and membranes contain serosity. The blood appears to be sometimes altered in nature; but the alteration is by no means invariable, and sometimes none is remarked at all. Many of the statements to be found in authors on the morbid appearances caused by narcotics are far from being accurate.

Before proceeding to notice the genera of this class in their order, some remarks must be premised on the principal diseases which resemble them in the symptoms and morbid appearances. Of these the only diseases of much consequence are _apoplexy, epilepsy, inflammation of the brain, hypertrophy of the brain, inflammation of the spinal cord, and syncopal asphyxia_.

_Of the Distinction between Apoplexy and Narcotic Poisoning._

_Of the Symptoms._—The symptoms of apoplexy are almost exactly the same as those of the narcotic poisons, namely, more or less complete abolition of sense and the power of motion, frequently combined with convulsions. This disease commonly arises from congestion or effusion of blood within the skull; but one variety of it, the nervous apoplexy of older authors, or simple apoplexy of the moderns, is believed to be an affection of the brain, unaccompanied by any recognizable derangement of structure.

Apoplexy and narcotic poisoning may be often distinguished by the following criterions:

1. Apoplexy is sometimes preceded at considerable intervals by warning symptoms, such as giddiness, headache, ringing in the ears, depraved vision, or partial palsy. But it is an error to suppose that warning symptoms always occur; nay, if we may trust the experience of M. Rochoux, they are by no means common: of sixty-three cases which came under his notice nine only had distinct precursory symptoms.[1625] Poisoning with narcotics of course has not any precursory symptom except by fortuitous combination. And consequently, if warning symptoms have occurred, the presumption is, that the cause of death is a natural one.

2. Apoplexy attacks chiefly the old. It is not, however, confined to the old. On the trial of Captain Donnellan for poisoning Sir T. Boughton, Mr. John Hunter mentioned that he had met with two instances of death from apoplexy in young women; my colleague Dr. Alison has related to me a similar case; Professor Bernt has described another of a young girl who died apoplectic from extravasation of blood over the whole brain and in the ventricles also;[1626] and Mr. Greenhow, a surgeon of London, has even noticed a case of apoplexy from effusion of blood over the surface of the brain in a child two years and a half old.[1627] On this subject the treatise of Rochoux supplies excellent information: of his sixty-three cases sixty-one were above thirty years of age, two less than thirty, none younger than twenty.[1628] It is plain, therefore, that apoplexy in young people is rare. On the other hand, a great proportion of cases of poisoning with the narcotics when they have been taken intentionally (and such cases are most likely to lead to medico-legal questions), has occurred among the young, especially of the female sex.

3. The next criterion is, that apoplexy occurs chiefly among fat people. But it is here mentioned only that the medical jurist may be cautioned against the belief that it is in all circumstances a correct criterion. Upon this particular Rochoux has furnished some satisfactory data. Among his sixty-three patients thirty were of an ordinary habit, twenty-three were of a thin, meager habit, and ten only were large, plethoric and fat.[1629] In receiving this statement, however, it is necessary to consider, that although the vulgar idea, that most apoplectic people are fat, does not apply to persons in the rank of Rochoux’s patients, who were mostly hospital inmates, yet it may apply better to the upper ranks. For the same circumstances which predispose to apoplexy, namely, great strength, vigorous constitution and good digestive powers, likewise predispose to corpulency, so that whenever the condition of life permits the disposition to corpulency to be developed, the connexion of apoplexy with it will appear.

4. A fourth criterion is drawn from the relation which the appearance of the symptoms bears to the last article of food or drink that was taken. I believe that the effects of the common narcotics, in the cases where they prove fatal, begin not later than an hour, or at the utmost two hours, after they are taken; and in a great majority of instances they begin in a much shorter time, namely, in fifteen or thirty minutes. Hence if it can be proved that the nervous symptoms, under which a person died, did not begin till several hours after he took food, drink or medicine, it appears almost, if not absolutely certain, that a narcotic poison cannot have been the cause of death. To some narcotic, or rather narcotico-acrid poisons this rule certainly will not apply, such as the poisonous fungi and spurred rye; which seldom begin to act for several hours, sometimes for not less than a day and a half. Neither will the rule apply to poisoning with the deleterious gases, as their action has no connexion at all with eating or drinking. But these facts do not form a material objection to the rule laid down; because the circumstances under which cases of the kind occur are generally so apparent, as at once to point out their real nature to a careful inquirer.

In regard to apoplexy as the disease which resembles most closely the effects of the narcotics, it was formerly stated that this disease is apt to occur soon or immediately after taking a meal (p. 95).[1630] In the greater number of such cases, however, where the meal has been the exciting cause of the disease, the symptoms have begun _immediately_ after, or even during a meal. This is very rarely the case with the symptoms of narcotic poisoning, and never happens in respect to those of the commonest of the narcotics, opium: An interval of 10, 15, 20 or 30 minutes always occurs. The deleterious gases and hydrocyanic acid, with its compounds, are the only familiar narcotic poisons which act more swiftly.

5. Another criterion relates to the progress of the symptoms. The symptoms of narcotic poisoning advance for the most part gradually: but those of apoplexy in general begin abruptly. Sometimes apoplexy commences at once with deep sopor. Narcotic poisoning never begins in that way, except in the instances of hydrocyanic acid and the narcotic gases; the sopor is at first imperfect, and it increases gradually, though sometimes very rapidly. Apoplexy, however, does not always begin with deep sopor; occasionally the sopor begins and increases like that of narcotism.

6. Although there is a great resemblance between the symptoms of apoplexy and those of narcotism, so far as regards their general features, there are particulars which are not indeed always present, but which when present will help to distinguish the one from the other. When the sopor of apoplexy is completely formed, it is rarely possible to rouse the patient to consciousness, and never, I believe, where the risk of confounding apoplexy with poisoning is greatest,—in the cases where death happens neither instantly, nor after the interval of a day, but in a few hours. On the other hand, in many cases of poisoning with the narcotics, and particularly with the commonest variety, opium, the person may be roused from the deepest lethargy, if he is spoken to in a loud voice, or forcibly shaken for some time, or if water is injected into his ear. Even in cases of poisoning with opium, however, the coma may have continued too long to admit of this temporary restoration to sense; the susceptibility of being roused is not so often remarked in other varieties of narcotic poisoning; and in some, such as poisoning with prussic acid, I am not aware that it has ever been remarked, at least in fatal cases.

There are some other symptoms which in special cases may help to distinguish narcotic poisoning from apoplexy. Thus in poisoning with opium convulsions are rare; in apoplexy they are common enough. Bloating of the countenance is likewise much more common in apoplexy than in poisoning with opium. In apoplexy, too, the pupil is generally dilated, while in poisoning with opium the pupil is almost always contracted. But such distinctions do not apply either to the narcotics as a class, or to all cases of any one kind of narcotic poisoning.

7. In the last place, a useful criterion may be derived from the duration of the symptoms in fatal cases. I believe few people die of pure narcotic poisoning who outlive twelve hours; and the greater number die much sooner,—in eight, or six hours. Apoplexy often lasts a whole day, or even longer. On the other hand, the narcotic poisons very rarely prove so rapidly fatal as apoplexy sometimes does. Apoplexy, according to the vulgar opinion, may prove fatal instantly or in a few minutes. The only late author of repute who maintains that opinion is M. Devergie. He mentions the case of an elderly man subject to somnolency, who, after complaining for a short time of headache, became suddenly pale, hung down his head, and expired immediately, and in whose body no other morbid appearance was found, except great congestion of the cerebral membranes.[1631] The best modern pathologists, however, deny that apoplexy proves immediately fatal, and maintain with much apparent reason that when death is so sudden, the cause is commonly disease of the heart, and not apoplexy.[1632] However this may be, it is at all events certain that apoplexy may occasion death in considerably less than an hour. Now the only narcotics in common use which can prove fatal so soon are the narcotic gases, and prussic acid. As to opium, the most common of the narcotic poisons, and by far the most important to the medical jurist, the shortest duration I have yet seen recorded is three hours. Apoplexy often proves fatal in a much shorter time.

From this enumeration of the criterions between apoplexy and the symptoms produced by narcotics, the toxicologist will conclude, that few cases can occur in which he will not be able to give a presumptive opinion of the real cause from the symptoms only,—that in many instances a diagnosis may be drawn with an approach to certainty,—and that on all occasions it will be possible to say without risk of error, whether there are materials for forming a diagnosis at all,—a point which is of great moment when the criterions are not universally applicable.

_Of the Morbid Appearances._—The next subject of inquiry is the distinction between apoplexy and narcotic poisoning, as to the appearances after death. It has been already stated, that the narcotic poisons rarely produce very distinct morbid appearances,—that the greatest extent of unnatural appearance they cause in the brain is congestion of vessels,—and that the physical qualities of the blood appear to be altered, though not invariably.

_Of Simple Apoplexy._—Apoplexy may, in the first place, occasion death without leaving any sign at all in the dead body. Cases of this sort were called nervous apoplexy by the older authors; but for the purpose of avoiding a name that involves a theory as to their nature, they have been more appropriately termed by Dr. Abercrombie simple apoplexy. At one time they were believed to be common. The researches of modern pathologists, however, have shown that they are rare, and that the apparent absence of morbid appearances may be often with justice ascribed to an insufficient examination; for it is not always easy to detect, without minute attention, two disorders little known till in recent times, and sometimes closely allied in their symptoms to apoplexy,—hypertrophy of the brain, and inflammation of its substance. On this account some have even gone so far as to deny altogether the existence of simple or nervous apoplexy; and M. Rostan, who is of this opinion, has supported it by the fact, that in the course of his pathological researches he had examined no less than 4000 heads, and never met with an instance of it.[1633] But although this statement, made by so eminent a pathologist, is sufficient to prove the rarity of the disease, it does not establish its non-existence in the face of positive observations, made by others after the phenomena and effects of cerebral inflammation were well known.

Among the modern authorities to whom reference may here be made for examples of simple apoplexy, Dr. Abercrombie, M. Louis, my colleague Dr. Alison, and M. Lobstein, may be particularized. Dr. Abercrombie has seen four cases,[1634] M. Louis has recorded three,[1635] M. Lobstein one,[1636] and Dr. Alison informs me, that he has seen one and got the particulars of another from the late Dr. Gregory. In several of these cases the individuals were at the time of the apoplectic seizure affected with other diseases, such as asthma, anasarca, or slight febrile symptoms; but in four of them the coma commenced during a state of perfect health. I have myself seen two of the former class, one occurring during convalescence from a slight pleurisy, the other terminating a complicated case of pulmonary emphysema and catarrh, diseased kidneys and anasarca. Reference may be also made under this head to several cases of apoplexy described in Corvisart’s Journal, as connected with the enormous accumulation of worms in the intestines. Such a connexion is said to be common on the coast of Brittany; and one striking instance is related of a young man, who, after an attack of headache, vomiting, and loss of speech, died comatose in two days, and in whose body no unnatural appearance could be seen except a prodigious mass of worms in the small intestines.[1637]

In none of all the cases of apoplexy now under consideration was there found within the head any appearance corresponding with the symptoms, except occasionally a slight turgescence of vessels.

This form of apoplexy, then, is a very important affection in a medico-legal point of view. The possibility of its occurrence is in fact the chief obstacle, which, in many cases involving the question of poisoning with narcotics, prevents the physician from coming to a positive decision on a review merely of symptoms and appearances after death. Instances will occur where it is impossible to draw a diagnosis between the natural and the violent form of death. And indeed it might even be a fair subject of inquiry, whether death from at least some narcotic poisons, such as opium, is any thing else than death from simple apoplexy.

It may be mentioned,—although too much importance ought not to be attached to the fact, as forming the ground of a diagnosis in certain rapid cases of narcotic poisoning,—that of the instances of simple apoplexy referred to above none proved fatal in less than five hours. This was Dr. Gregory’s case. Dr. Alison’s proved fatal in seven hours; M. Louis’s cases in eight, nine, and ten hours; one of Dr. Abercrombie’s in eight hours; the three others in about twenty-four hours; and M. Lobstein’s in five days.

Another consideration is, that simple apoplexy is undoubtedly very rare, more particularly in persons who enjoy perfect health. Hence, although it is impossible to distinguish the effects of narcotics from this disease by the appearances in the body after death, yet, when the general evidence of poisoning is strong, and none of the medical circumstances are at variance with the supposition of narcotic poisoning, the evidence of poisoning, as judged of by the jury from the whole facts, medical and general, will be commonly sufficient,—so far as regards the possibility of death from simple apoplexy. For such a concurrence of circumstances as is here supposed can scarcely be outweighed by a mere possibility of death from so rare a natural disease.

It is worthy of remark, in reference to charges and suspicions of poisoning during a state of ill health, that simple apoplexy occurring in the course of a considerable period of indifferent health is far from uncommon. Such incidents, however, ought not to be confounded with narcotic poisoning, because the coma comes on gradually. From what I have myself frequently observed, cases of this nature are often connected with the granular disintegration of the kidneys, which has been brought under the notice of physicians by the able researches of Dr. Bright. I have related two instances of the kind,[1638] and several others have been since published by Dr. James Arthur Wilson.[1639] In none of these could there have been any risk of mistaking the phenomena for narcotic poisoning. But it may be well to advert to the subject here for the sake of turning the attention of the profession to the propriety of examining the state of the kidneys in all medico-legal cases of death in a state of coma.

_Of Congestive Apoplexy._—Apoplexy may, in the second place, leave in the dead body no other sign but congestion of vessels within the head. This form or variety of apoplexy is so generally admitted, that it is hardly necessary to mention special instances. But, for the sake of those who may prefer special facts to general propositions, the two following cases by M. Rostan are referred to. One of his patients, without any precursory symptom, was suddenly deprived of sense, soon became delirious and comatose, and expired in a day and a half. The other, also without any previous symptom, became rapidly comatose, and died in twenty-four hours. In both the whole membranes were minutely injected with blood; and in one the whole brain had also a rose-red colour.[1640] In regard to the diagnosis between such cases and poisoning with narcotics, it must be remembered, that congestion of the cerebral vessels is considered by many a common effect of such poisons, and that therefore the diagnosis cannot be rested on the appearances in the dead body. I have not perused a sufficient number of fatal cases of congestive apoplexy to enable me to attempt a diagnosis; but, so far as I have gone, it appears to me, that this form of the disease, which is not often fatal without extravasation also being produced, does not cause death till after an interval of nearly a day at least. Should this prove a general fact, it would form the ground of a diagnosis between congestive apoplexy and many forms of narcotic poisoning, which, if death ensues, prove fatal much sooner.

_Of Serous Apoplexy._—Apoplexy may, in the third place, produce serous effusion on the external surface, and in the ventricles of the brain. This form of the disease, which has been named serous apoplexy, although not very uncommon as an insulated affection, is for the most part united with inflammation of the cerebral substance. Serous effusion is more frequently the termination of an inflammatory disorder of the brain, than of that deranged state which constitutes the apoplectic attack. But nevertheless it does occur in connexion with pure apoplexy, as may be seen, for example, on referring to Dr. Abercrombie’s work,[1641] or to Bernt’s Contributions to Medical Jurisprudence,[1642] or to the Hospital Reports of Dr. Bright.[1643] In such cases the only appearances have been the effusion of an unusual quantity of serum on the surface of the brain, in its ventricles, and in the base of the skull. Cases of this sort agree very exactly as to the signs in the dead body with some cases of narcotic poisoning. When serous effusion is preceded by decided apoplectic symptoms, the disease, so far as I have been able to inquire, is always of several days’ duration. But sometimes the symptoms are to the very last obscure and different from those of apoplexy, as in an instance related by Dr. Abercrombie.[1644]

_Of Apoplexy from extravasation._—The last variety of apoplexy is that which leaves in the dead body extravasation of blood within the head. This, the most common of all its forms, is very rarely imitated by narcotic poisoning. A case, however, will be afterwards mentioned of extravasation produced apparently by poisoning with opium, another of extravasation caused by carbonic acid, another by poisonous fungus, and several by spirits. The existence, therefore, of extravasated blood is not absolutely certain proof, but supplies, in relation to most narcotics, a strong presumption of natural death.

Here it will be necessary to add a word or two of caution regarding what are called apoplectic cells or cavities, containing blood in the brain. If an apoplectic cell be found, it must not be at once considered as the cause of death. When blood is extravasated in the brain, the patient may gradually recover altogether, and the cell nevertheless continue full. Such persons often die of a subsequent attack of apoplexy, or of inflammation around the cell. We can say with certainty, that an apoplectic cell has been the occasion of death only when the blood is recent, or when it is surrounded by signs of recent inflammation.

So much, then, as to the criterions derived from morbid appearances within the skull, for distinguishing poisoning with narcotics from apoplexy.

It has been proposed to derive other criterions from the state of the blood. But on considering the effects of the individual poisons of the class, it will appear that the state of the blood is by no means characteristic.

It may be useful to conclude this view of the distinctions between poisoning and apoplexy with the particulars of an interesting case, in which the medical witnesses fell into an egregious error by disregarding the most palpable criterions. In 1841, an elderly gentleman at Chambéry in France, subject to apoplexy, one day after having made a hearty dinner and afterwards supped on bread, cheese, and white wine, was suddenly seized with staggering immediately after finishing his wine, and soon lost all consciousness. Emetics and stimulants restored his faculties so far as to enable him to say he felt better and had no pain; but the tongue and mouth were drawn to the left side, and there was great prostration. Four hours after his first seizure the countenance became livid; he again became unconscious and insensible; the twisting of the mouth increased; and the left arm presented spasmodic contraction. Blood-letting and other remedies were resorted to without avail; the pulse, previously strong and regular, became gradually feeble; and in six hours after his first illness he expired, without ever having had convulsions of any kind. On the body being examined seven days after death, great congestion was found in the vessels on the surface of the brain; on raising the brain, a dense dark clot of the size of a large egg escaped from the lower part of the ventricles; and an abundant extravasation of the same nature was found under the _tentorium cerebelli_.

It appears scarcely possible to find a more characteristic case than this of apoplexy from extravasation. The slight intermission in the symptoms was the only unusual circumstance. Yet because the inspectors remarked in various parts of the body a peculiar odour, which they could not at the time characterise, but which they afterwards thought was the odour of bitter almonds,—and misled by the sudden invasion of the symptoms instantly after a meal,—they gave their opinion that death had arisen from some narcotic poison; a chemical examination was made of various textures of the body (not, however, of the contents of the stomach), which yielded obscure and very doubtful indications of hydrocyanic acid; poisoning with hydrocyanic acid was accordingly declared to have been the cause of death; and, in defiance of an able report by Professor Orfila, pointing out the error of the primary witnesses, the nephew and heir of the deceased was condemned.[1645] It is almost unnecessary to point out the impossibility of death having arisen in this case from hydrocyanic acid. The length of time the deceased survived, the want of convulsions, the presence of deflexion of the mouth and tongue, the intermission of the symptoms, and the morbid appearances, all clearly indicate that death in the way supposed was impossible; and the chemical evidence, which it would require too much space to analyze here, was proved by Orfila to be completely unsatisfactory.

_Of the Distinction between Epilepsy and Narcotic Poisoning._

_Of the Symptoms._—Epilepsy is distinguished from other diseases by the abolition of sense and by convulsions. It resembles closely the symptoms caused by prussic acid, and by some of the narcotic gases, such as carbonic acid gas and the asphyxiating gas of privies. It also bears the same resemblance to the effects of many narcotico-acrid poisons, such as belladonna, stramonium, hemlock, and others of the first group of that class, also camphor, cocculus indicus, and the poisonous fungi.

Epilepsy is in general a chronic disease, and for the most part ends slowly in insanity. But sometimes it proves fatal during a paroxysm. The circumstances by which an epileptic fit may be distinguished from narcotic poisoning are the following:

1. The epileptic fit _is sometimes preceded by certain warnings_, such as stupor, a sense of coldness, or creeping, or of a gentle breeze proceeding from a particular part of the body towards the head. Warnings, however, are by no means universal. M. Georget, indeed, has even stated that they do not occur in more than five cases in the hundred.[1646] But this estimate probably underrates their frequency.

2. The symptoms of the epileptic fit _almost always begin violently and abruptly_. The individual is suddenly observed to cry out, often to vomit, and instantly falls down in convulsions. The effects of the narcotic poisons, if we except some cases of poisoning with hydrocyanic acid, the narcotic gases, and a few rare alkaloids, never begin otherwise than gradually, though their progress towards their extreme of violence is often rapid. This distinction is generally an excellent one. But it will not apply so well to some cases of epilepsy in which the convulsions are trivial. Esquirol says an epileptic fit may consist of nothing more than coma, with convulsive movements of the eyes, or lips, or chest, or a single finger.[1647] Still even then the coma generally begins abruptly, so that if the case is seen from the beginning, it can hardly be mistaken for narcotic poisoning. Some forms of epilepsy, in which the fit is constituted merely by giddiness, staring, wandering of the mind, and imperfect loss of recollection,[1648] might be confounded with the milder forms of narcotic poisoning. But collateral circumstances will scarcely ever be wanting to distinguish such cases from one another.

The varieties of narcotic poisoning which, in the violence and abruptness of their commencement, bear the closest resemblance to an epileptic attack, are some cases of poisoning with hydrocyanic acid or with the deleterious gases. Both of these varieties, however, when they begin so abruptly, are distinguished from a fatal paroxysm of epilepsy by the fourth characteristic to be mentioned presently; and besides, in abrupt cases of poisoning with hydrocyanic acid, the poison under certain conditions will be found in the body; while in sudden poisoning with the narcotic gases, the nature of the accident is rendered obvious to a cautious inquirer by the collateral circumstances.

3. As in apoplexy, so in epilepsy the patient _in general cannot be roused_ by external stimuli. This, as already observed, is often, although certainly not always, practicable in cases of poisoning with narcotics. Sometimes, too, in the epileptic fit a partial restoration of consciousness may be effected by loud speaking, so that in reply to questions the patient will roll his eyes or move his lips. It is therefore to be understood in applying the present criterion, that it is only a safe guide when, as in many cases of poisoning with opium, the individual can be roused to a state of tolerably perfect consciousness.

4. When a person dies in a fit of epilepsy, _the paroxysm generally lasts long_, sometimes more than a day. So far as I have been able to ascertain (though on this point it must be confessed authors are singularly silent), it never proves fatal in a shorter time than several hours, unless there have been many previous fits; and even then it rarely proves fatal more rapidly. I have met with a case which, after many previous fits, proved fatal in little more than an hour.[1649] In an instance mentioned by Mr. Clifton of irregularly recurring epilepsy, the patient after being exempt for four months was attacked twice a day for four days, and during an interval of ease fell down in the street and died. General congestion and excessive softening of the brain were found.[1650] I have met with a case very like this, where death was owing to enormous extravasation of blood into the ventricles. So rapid a termination never occurs except after several paroxysms; and probably never without well-marked appearances in the dead body. The variety of poisoning with which epilepsy is most apt to be confounded, poisoning with hydrocyanic acid, has hitherto always proved fatal within three-quarters of an hour, and can probably never prove fatal so late as a whole hour after the symptoms begin, unless the dose has been small and given repeatedly. Poisoning with the gas of privies,—another variety, which sometimes imitates precisely a fit of epilepsy, appears not to prove fatal in its convulsive form later than two hours after the exposure.

5. M. Esquirol, a writer of high authority, says that epilepsy _very rarely proves fatal in the first paroxysm_. I suspect it may be said that the first paroxysm never proves fatal. For the cases considered and described as such have been either inflammation of the brain or its membranes, or hypertrophy of the brain, or inflammation of the spinal cord, or effusion of serum or blood into the spinal canal, or worms in the intestines,—all of which may be known by the morbid appearances. I have also seen cases of continued fever with typhomania and convulsions, which might have been considered by a careless observer examples of epilepsy fatal in the first fit. On the present characteristic it would be wrong to speak with confidence, as the question regarding the possible fatality of epilepsy in the first fit must depend greatly on the degree of extension given to the term epilepsy. I can only say, that in the course of reading I have not hitherto met with an instance fatal in the first paroxysm, which might not have been referred by the morbid appearances to one or other of the diseases mentioned above.

_Of the Morbid Appearances._—With regard to the morbid appearances found in the bodies of epileptics, much difference of opinion prevails among pathologists. The most frequent are tumours within the cranium, excrescences from the bone or dura mater, concretions in the brain itself, or abscesses there, and effusion into the ventricles or on the surface of the brain. Other appearances which have also been remarked are probably little connected with the disease; and at all events have been often seen when epilepsy did not precede death.[1651]

The morbid appearances connected with epilepsy are not always to be looked for within the head. The cause which produces the fit is often some irritation in distant organs.—The presence of worms in the intestines of children may occasion fatal epilepsy. It is believed also that they may cause fatal epilepsy even in adults; and whether their presence has been the cause of death or not, it is certain that they have been found enormously accumulated in the stomach or intestines of adult epileptic subjects.[1652] The most recent information on this subject is furnished by M. Gaultier de Claubry. In a girl seven years old, who died of convulsions in six days, he found eleven _lumbrici_ in the general cavity of the belly, and the coats of the stomach perforated with holes, in some of which other worms were sticking. In another child of the same age, who died in seven days of convulsions, he found thirty-six worms in the peritoneal sac, a great mass of them in the stomach, and twenty-seven making their way through holes in its coats.[1653] In a singular case related by M. Lepelletier of a boy twelve years old, who died of convulsions in four days, the only morbid appearance found was a perforation of the gullet six lines in diameter, through which two lumbrici had made their way into a cavity in the middle right lobe of the lungs, while another was sticking in the hole, six more occupied the lower part of the gullet, and three lay in the stomach.[1654]—The irritation of teething may also excite epilepsy, and in cases where it has proved fatal may be recognized by the redness and swelling of the gum, by the tooth being on the point of piercing the alveolar process, and by the turgescence of vessels around.[1655]—A well-known but rather rare cause is the presence of some hard substance in the course of a nerve. This variety, like those already mentioned, may prove fatal in the fit, as appears from the following interesting case. A stout young woman became suddenly liable to epilepsy, and, after suffering repeated fits in the course of twenty months, died comatose in a paroxysm of thirty-three hours’ duration. The fits having always begun with acute pain in a particular part of the thigh, this part of the body was carefully examined, and a bony tumour as big as a nut was found on a branch of the sciatic nerve.[1656]—Other appearances might likewise be here enumerated, which have been supposed the cause of symptomatic epilepsy.[1657] But few of these have been so thoroughly ascertained as to be allowed much influence on a medico-legal opinion.

It cannot, I apprehend, be denied, that in many cases of epilepsy no decided morbid appearance is to be found in the body; and that in many others the appearances are either so equivocal as not to be satisfactorily recognized in any circumstances, or so hidden in their situation that they may escape notice, unless the inspector’s attention be drawn to the particular spot by a knowledge of the symptoms.

Hence in actual questions as to the occurrence of narcotic poisoning when the symptoms resemble epilepsy, it will be seldom possible to found on the absence of morbid appearances more than a presumptive opinion that death did not proceed from the natural cause. It is right to remember, however, that in considering the absence of morbid appearances in reference to the diagnosis of narcotic poisoning and epilepsy, the attention should be confined to cases of epilepsy which prove fatal during the fit. Now I suspect no such case ever occurs, at least in adults, without an adequate cause being discoverable in the dead body, either in the head, or in the course of some nerve, or in the accumulation of worms in the intestines. This statement must not be considered as made with confidence; but it deserves investigation.

From all that has now been said on the subject of epilepsy as a disease which imitates many varieties of narcotic poisoning, the medical jurist will probably arrive at the conclusion, that, although a diagnosis cannot always be drawn with certainty, yet in numerous cases the consideration of the symptoms and appearances after death will enable him to say positively that poisoning is out of the question, and in many others that poisoning is highly probable.

_Of the Distinction between Meningitis and Narcotic Poisoning._

Inflammation of the inner membranes of the brain, which constitutes the _acute hydrocephalus_ or acute _meningitis_ of authors, is not in general apt to cause much ambiguity; for its progress is commonly gradual, well-marked and less rapid than most cases of narcotic poisoning: and the appearances in the dead body, such as effusion of serum, lymph or pus on the outer surface of the brain or in the ventricles, are for the most part obvious.

Dr. Abercrombie, however, has described a form of it occurring among children during the existence of other diseases, particularly of the chest, which might be the cause of perplexity; for its course is sometimes finished within a day, its symptoms are delirium, convulsions and coma intermingled, and the only morbid appearance is congestion of vessels on the surface and in the substance of the brain.[1658] The affection now alluded to imitates closely, both in its progress and in its signs after death, some varieties of poisoning with the vegetable narcotico-acrids, such as belladonna, stramonium, and hemlock. But the latter cases, when they prove fatal, seldom last nearly so long as a day, while the instances of meningitis under consideration rarely cause death within twenty-four hours. Dr. Abercrombie also notices a parallel disease occurring among adults; but it is in them always marked by a considerably longer, though often more obscure course.[1659]

Dr. Bright takes notice of a similar affection under the title of “Arachnitis with excessive irritability” occurring chiefly among very intemperate people, but independently of previous disease. In general the disorder has a well-marked course of at least several days’ duration. But in two of the instances he has given the early stage was very obscure, the only symptoms having been headache and sickness of no great severity for four or five days; after which delirium came suddenly on, and was followed by coma, and by death within thirty-six or forty hours. The sole appearances found within the head were some serous effusion and vascularity on the surface of the brain and in the ventricles.[1660] To these illustrations may be added the heads of a remarkable case which occurred here in the person of an eminent lawyer, and for the particulars of which I am indebted to Dr. Maclagan. For three days there had been occasional headache, not great enough to prevent him pursuing his ordinary avocations, yet becoming so troublesome on the morning of the third day as to induce him to have leeches applied. But next morning he was seized rather suddenly with quickly increasing coma, and in forty hours more he expired. In this instance the whole surface of the arachnoid membrane, both over the hemisphere and in the ventricles, was found lined with soft, yellowish-green lymph.

In such cases it is apparent that an inspection after death will often unfold their real nature, where the history of the symptoms may leave it in doubt. But even without an inspection it is not likely that a careful physician could mistake them for narcotic poisoning; for independently of other considerations, the severe symptoms are ushered in by a precursory stage of ill health, commonly indicating an obscure affection of the head, and such as no one but a careless observer could fail to discover and appreciate.

It is not improbable, however, that acute meningitis may seem to prove suddenly fatal, in consequence of its course being in a great measure latent. The following case reported by Mr. Davies of Somers Town, seems of this nature. A woman, who had previously complained only of slight headache, was attacked after breakfast with violent vomiting for half an hour, when she fell down, and immediately expired. After death there was found great gorging of the vessels of the cerebral membranes, with opacity and thickening of the pia mater and arachnoid coats, and an effusion of nearly five ounces of bloody serum under the dura mater.[1661] Such a case might give rise to great perplexity in a charge of poisoning, until the examination of the body unfolded its true nature.

I should scarcely have thought it necessary to mention _chronic meningitis_ among the diseases apt to imitate the effects of narcotic poisons, because it is commonly marked by a long and distinct course. But the following case, for which I am indebted to Dr. Arnoldi of Montreal, will show that, like other diseases of the head, chronic meningitis may be latent in its early stage, and may, after developing itself, terminate in a day, and then in some measure imitate poisoning with narcotics. A middle-aged female, subject for a twelvemonth to a purulent discharge from the left ear, and occasional headache, which was supposed to be rheumatic, was seized one morning with acute pain in the head, followed in a few hours by convulsions and tendency to coma; under which symptoms she died within twenty hours, although treated actively from the commencement. On dissection, the brain and pia mater were found healthy, except at the part corresponding with the petrous portion of the left temporal bone, where the brain was a little softened. The corresponding part of the temporal bone and the adjacent part of the occipital were completely denuded and covered with pus, which had established a passage for itself into the cavity of the ear.

_Of the Distinction between Inflammation of the Brain and Narcotic Poisoning._

Inflammation of the brain itself, the _ramollissement_ of French writers, occasionally excites symptoms not unlike those produced by some narcotic poisons; and in a few instances its course has appeared to be equally short. It requires particular notice, because the appearances left in the dead body are sometimes apt to escape observation.

This disease in its well-marked form has been noticed by various authors from Morgagni downwards. But the first regular accounts of it were given in 1818 by Dr. Abercrombie,[1662] and in 1819 by M. Rostan[1663] of Paris, and Professor Lallemand[1664] of Montpellier. Its symptoms are allied to those of apoplexy and epilepsy. But the comatose state is generally preceded by delirium or imperfect palsy, and often by a febrile state of the circulation. Contraction of the voluntary muscles, once supposed to be a distinguishing sign of this disease, is neither essential nor peculiar to it. In the dead body it is recognized by the presence either of an abscess in the brain,—or more commonly of a nucleus of disorganized cerebral tissue surrounded by unnatural redness or softness,—or sometimes of a clot of blood surrounded by similar softening. Occasionally, when the disease kills in its early stage, nothing is found but redness of a part of the brain, and slight softening of the tissue, recognizable only by scraping it with the edge of the scalpel.

In the form in which it is commonly seen, and as described by Rostan and Lallemand from a great number of cases, it can hardly be confounded with the effects of narcotic poisons; for its course is much slower, being seldom less than several days when it proves fatal.[1665] Yet in some instances it may prove fatal instantly. Lancisi notices the case of an Italian nobleman, who after an apoplectic fit became liable to frequent attacks of lethargy,—who at length died quite suddenly more than a year afterwards,—and in whose brain an organized clot was found, with extensive suppuration of the brain around it.[1666] An unequivocal case of the same kind has been related by Mr. Dickson, a navy-surgeon. An elderly sailor, who for months before had done duty, eaten his rations, and drunk his grog as usual, suddenly dropped down while in the act of pulling his oar, and died at once; and after death there was found in the middle lobes of the brain an extensive abscess, which had made its way to the surface.[1667] Such cases might, in certain circumstances, be mistaken for the effects of large doses of hydrocyanic acid; but the morbid appearances are of course quite characteristic. M. Louis has related an instance like the last two, but where the disease was altogether latent. His patient after a long illness died of diseased heart, the ventricles of which communicated together. He never had a symptom of disorder of the head; yet on dissection an extensive recent softening was found in the right _corpus striatum_ and another in the right _thalamus_.[1668]

None of the treatises I have seen on the subject make mention of a variety of this disease intermediate between suddenly fatal cases and those which last several days,—a form in which the patient’s illness endures for a few hours only, and which, both in the special symptoms and in their course, imitates exactly the effects of some narcotics. Two such cases have come under my notice, both of them judicial, poisoning having been suspected. One of them proved fatal in an hour and a half, the individual having previously been in excellent health; and the only appearance of disease was softening of a considerable part of the surface of the brain where it lies over the left orbit. The other was more remarkable in its circumstances. In November, 1822, a man, who had previously enjoyed excellent health, was found one morning in a low lodging-house in the Lawnmarket comatose, and convulsed; and he died seven hours afterwards. The neighbours spread a report, that the woman of the house had poisoned him, with the view of selling the body; and by an odd coincidence the police, when they went to apprehend the woman, found an anatomist hid in a closet. The body was judicially examined by Sir W. Newbigging and myself; and we found an ulcer on the forepart of the left hemisphere of the brain, and a small patch of softening on each middle lobe.

It is only in cases like the last two that the disease is likely to be mistaken for the effects of poison; and the morbid appearances will at once distinguish them. But it is requisite to remember that softening of the brain when not far advanced is apt to escape notice, as it is not necessarily attended with a change in the colour of the diseased part. In the first of the two cases I have related, the cause of death was very nearly assumed to have been simple apoplexy, when at length the true disorder was unexpectedly noticed. I presume, indeed, that strictly speaking, both of the cases which came under my notice ought to be considered as simple apoplexy excited by pre-existing _ramollissement_.

_Of the Distinction between Hypertrophy of the Brain and Narcotic Poisoning._

This disease is not here mentioned, because its symptoms and progress resemble very closely those of poisoning with the narcotics; for it causes epileptic symptoms, which, besides that they are preceded for some time by other head affections, very seldom prove fatal in less than three days. But some notice of it is necessary, because the disease is rare and of recent discovery, so that the appearances left by it in the dead body may escape observation. Besides, the physician is at present imperfectly acquainted with it, and therefore, when a more extensive collection of cases shall have been made, it may be found to prove at times fatal so rapidly as to admit of being confounded with narcotic poisoning. Hypertrophy of the brain, it is true, is always a chronic or slow disease, but, like other diseases of the brain, its early stages may possibly be so completely latent that the patient may appear to die of a few hours’ illness. This, however, must be left to the determination of future experience. The most rapid case yet published proved fatal twenty-four hours after the first appearance of symptoms.

The appearances left in the body are increased density and firmness of the whole brain or a part of it,—flattening of the convolutions on their outer surface, so that their grooves are almost obliterated and the investing membrane uncommonly dry,—unusual emptiness of the blood-vessels of the brain and its membranes,—and a protrusion of the brain upwards on removal of the skull-cap, as if the organ were too large for its containing cavity.[1669]

Some pathologists doubt the existence of hypertrophy of the brain as a distinct disease, and conceive that the appearance of flattening of the convolutions is produced by serum effused between the dura mater and arachnoid membrane. But this explanation will not account for those cases in which it is expressly stated that little or no fluid was to be found in any part of the brain or in the base of the skull.

_Of the Distinction between Diseases of the Spinal Cord and Narcotic Poisoning._

It is not necessary to say much on the acute diseases of the spinal cord, which are apt to be confounded with the effects of narcotic poisons. The diseases are extravasation of blood into the spinal canal, inflammation of the membranes, and inflammation [_ramollissement_] of the cord itself. These disorders are commonly marked by obvious and characteristic symptoms, as well as a much slower course than that of the affections induced by narcotic poisons. But occasionally they approach closely the characters of some of the slow cases of narcotic poisoning,—palsy being absent, the leading symptoms consisting of delirium, convulsions, and coma, and the fatal event occurring within the third day. Dr. Abercrombie and M. Ollivier have related examples of the kind arising from extravasation of blood,[1670] serous effusion,[1671] and softening of the cord.[1672] Such cases are exceedingly rare; but the possibility of their occurrence should impose on the medical jurist the necessity of examining the spine with care in all judicial cases of alleged narcotic poisoning, especially when death has not been rapid.

_Of the Distinction between syncopal Asphyxia, and Narcotic Poisons._

The only other natural disease requiring notice under the present head is the _Asphyxia Idiopathica_ of the late Mr. Chevallier. It may be the cause of embarrassment in questions regarding narcotic poisoning, when the course of the symptoms to their fatal termination is rapid, and was not witnessed by any person; for it causes death with equal rapidity, and its signs in the dead body are very obscure. It has been observed chiefly among women in the latter months of pregnancy, or soon after delivery; but it has also been known to attack the male sex. It generally commences during a state of perfect health, and is seldom preceded by any warning of danger. The person suddenly complains of slight sickness, giddiness, and excessive faintness, immediately seems to sleep or swoon away, and expires gently without a struggle. The only appearance of note found in the dead body is unusual flaccidity and emptiness of the heart.[1673] But even these slight appearances are not constant; for in a case related by Rochoux of a woman who, while in a state of perfect health, suddenly grew pale, slipped off her chair, and died on the spot, the auricles of the heart contained a great deal of blood.[1674] This singular disorder appears to consist of nothing else than a mortal tendency to fainting; and it may prove fatal either in the first fit of syncope, or after an hour and a half.—Under the same head are probably to be arranged the cases of sudden death described by M. Devergie under the title of Death by Syncope. He has given scarcely any account of the circumstances attending death; but it may be inferred from his classification of the cases that fainting immediately preceded it. In all of them he found blood in both sides of the heart; and the blood, contrary to what happens in other kinds of sudden death, had separated into clear serum, and fibrin free of colouring matter.[1675]—Under the same head also may be noticed a denomination of cases, which, though alluded to before by various pathologists, were first distinctly characterized by M. Ollivier, where death is caused on a sudden, apparently by the disengagement of a large quantity of aëriform fluid from the blood in the heart and great vessels. Among the instances described by Ollivier, it appears that death repeatedly occurred quite suddenly while the individuals enjoyed sound health; and the only appearances of any note found in the body were tympanitic distension of the heart, absence of blood there and in the great vessels, and the existence of a gaseous fluid in numerous globules throughout the blood-vessels of the brain. The circumstances of death and the appearances in the dead body are much the same with those observed from the admission of air into the veins during surgical operations. A case of this kind, owing to its suddenness, might be confounded with the effects of the more active narcotic poisons, such as hydrocyanic acid, especially as its characters in the dead body might escape notice.[1676]

Death often takes place from sudden syncope in _organic diseases of the heart_. Such cases may be confounded with the most rapid variety of poisoning with hydrocyanic acid; and if the duration of the symptoms preceding death is unknown, they may give rise to a suspicion of poisoning generally. But they are at once distinguished by the morbid appearances. A trivial organic derangement may be the occasion of instant death.

The genera comprehended in the class of narcotics are opium, henbane, lettuce-opium, solanum, hydrocyanic acid, and the deleterious gases. Of these genera the last is by no means a pure one, for it includes many gases which act as irritants only; but it is more convenient to consider them together, than to distribute them into separate classes. Some other vegetable substances besides henbane, lettuce-opium, and solanum, possess nearly the same properties; but as they likewise cause irritation, they are arranged more appropriately in the next class, the narcotico-acrids.

Most narcotic vegetables owe their poisonous properties to a peculiar principle, probably of an alkaline nature, and slightly different in each. This discovery was made with regard to opium in 1812; and the discovery of the active principle in that drug has been followed by the detection of analogous principles in most narcotics, as well as in many narcotico-acrids.

These principles are generally crystalline, soluble in alcohol and the acids, little soluble in water, free from mineral admixture, and entirely destructible by heat. When purified with the greatest care, they still retain decided alkaline properties; but on account of their number and the low power of neutralization their alkaline nature was long denied; and they have been conventionally styled alkaloids.

In their natural state they exist in combination with various ternary acids, some of which are peculiar; and they are likewise intimately blended, or more probably united chemically, with other inert principles of the vegetable kingdom, particularly resinous and extractive matters, to which they adhere with great obstinacy.

They are all highly energetic, and generally concentrate in themselves the leading properties of the substance from which they are obtained.

The experiments, which have led to the conclusion, that the narcotic poisons act on the brain by entering the blood-vessels, have been repeated with their alkaloids, and have yielded similar results. But the alkaloids are in equal quantities much more energetic than the crude poisons. Their effects indeed are truly formidable, and some well authenticated instances of their action appear hardly less marvellous than the most extravagant notions entertained in ancient times of the operation of poisons. One of them, the principle of nux vomica, which, however, does not belong to the present class, is so active that in all probability a man might be killed with the third part of a grain in less than fifteen minutes.

It is very difficult to detect some of the vegetable alkaloids; and it is fortunate, therefore, that they are rare, and not to be procured but by complex processes.

Chemical analysis does not by any means supply so good evidence of poisoning with the narcotics as it does of poisoning with the irritants. Their chemical properties are not very characteristic, and they are not well developed unless with a larger quantity of the poison than will usually be met with in medico-legal investigations. This remark, however, does not apply universally; and it is probable, that, as organic analysis goes on improving, better and more delicate processes will be discovered.