An accident of a similar nature, for the particulars of which I am indebted to Dr. Swanwick of Macclesfield, occurred at Stockport in the summer of 1830. A family of five persons took for dinner broth made of beef, which, owing to its black colour, the master of the family had previously said to his wife he thought bad and unfit for use. In the course of some hours two boys were attacked with sickness and vomiting, but appear to have got soon well, probably owing to the early discharge of the poison. Next morning a washerwoman who had dined with the family was seized with violent pain in the bowels, diarrhœa, racking pains and weakness in the limbs; and she did not recover for ten days. On the evening of the second day the master of the house was similarly affected, and was ill for a fortnight. And a day later his wife was also seized with a similar disorder, preceded by soreness of the throat and tongue and difficulty of swallowing, and ending fatally in fourteen days. The last person was previously in delicate health, and subject to disorder in the stomach and bowels. The investigation made by the police authorities into the circumstances of this accident was extremely imperfect: but there seems little reason to doubt that unsound meat was the cause.
I am not sure under what head to arrange the following observations, communicated to me by Dr. M’Divitt of Canterbury, and of which he has since published a detailed account.[1594] But they may be mentioned, perhaps not inappropriately, in the present place; and at all events they deserve careful attention, as referring to a description of cases which may be mistaken for other kinds of poisoning.
It is well known that pork in all forms, but especially when fresh, is apt to cause indigestion in many persons who are not accustomed to it. But Dr. M’Divitt has shown by a number of interesting cases, that even in those habituated to its use, it may, from unascertained causes, excite symptoms closely allied to those of irritant poisoning. The effects sometimes begin within three hours, the symptoms being those of an affection of the stomach, such as sudden violent pain in the epigastrium, difficult breathing, irregularity of the pulse, great prostration and alarm, coldness of the extremities and vomiting. If a longer period elapses,—and sometimes no injury accrues for many hours, or even a whole day,—the symptoms indicate an affection of the abdomen, namely, pain in the region of the duodenum, or of the sigmoid flexure of the colon, with the other symptoms just enumerated, but which ere long become attended with more pungent pain, tension and tenderness of the belly, frequency of the pulse, and ineffectual straining to evacuate the bowels. In the less urgent and slower cases of this nature there is little or no vomiting. Sometimes nettle-rash appears. Stimulants, opiates, and blood-letting are of no avail; and the only useful remedies are emetics and cathartics, which speedily put an end to the symptoms by removing their cause. In all the cases related by the author the pork was either fresh or recently salted, fatter than usual, but not ill preserved or otherwise faulty in any appreciable respect. In every instance the individuals had eaten pork often before without injury; and on several occasions others ate without harm the same pork which seemed deleterious.
The fifth order of the irritant class of poisons includes mechanical irritants.
These substances have not properly speaking any poisonous quality; but occasion symptoms like those of poisoning, and even sometimes death itself, in consequence of their mechanical qualities only. They have therefore been excluded from every toxicological system proposed in recent times; but in a medico-legal work on poisoning it would be wrong to pass them without notice.
The most important of the mechanical irritants are those which cause injury by reason of their roughness, sharpness, or size.
Many instances have occurred of persons having swallowed fragments of steel, copper, iron, broken glass, or entire prune-stones, cherry-stones, and the like,—who not long afterwards were attacked with signs of inflammation, or some other abdominal disease, and were carried off by it as by the administration of poison. The disorders thus induced are almost always of a chronic or lingering kind, and commonly depend on gradual perforation of the intestines by the foreign body pressing on the coats. In general the illness ends in inflammation of the peritonæum. Sometimes the irritating substance perforates the skin and muscles as well as the intestines, and escapes outwardly; and a few individuals have even recovered under these circumstances. An excellent account of the ordinary course of such accidents is given in the London Medical and Physical Journal. The person swallowed a chocolate bean, and after experiencing many uneasy sensations throughout the belly for several days, was attacked with peritonitis and died.[1595] Mr. Howship has related the particulars of the case of a woman, died after two years of constant suffering, in consequence of having swallowed a large quantity of cherry-stones.[1596] Dr. Marcet has also described the case of a sailor who died in a similar way after swallowing several large clasp-knives.[1597] Thus too, although it is a familiar fact, that needles and pins are in general swallowed with impunity, death nevertheless sometimes arises from this cause. Guersent mentions the case of a child who died in the course of two months of frequent vomiting caused by swallowing a pin, which was found after death pinning the stomach, as it were, to the liver.[1598] Dupuytren relates the case of a woman, who, after swallowing an incredible number of needles and pins, became very lean and was confined to bed by the excruciating pain excited on motion by the needles and pins escaping through the skin. There were seldom less than fifty tumours or abscesses on various parts of the body; and Dupuytren, on opening about a hundred of these, invariably found one or more needles or pins in each. She laboured under general debility, irritative fever, and marasmus, and at length died hectic. After death many hundred pins and needles were found among the muscles and viscera.[1599] Many other examples might be referred to, but these will suffice for information on the ordinary effects of mechanical irritants of the kind under consideration.
From the case of Dr. Marcet and other similar facts, it appears that large and even angular bodies do not always cause serious mischief, nay, that they have been frequently swallowed without any material injury. Dr. Marcet’s sailor in the course of his life had repeatedly swallowed several clasp-knives in quick succession: and nevertheless recovered perfectly after some days of slight illness. As to prune and cherry-stones, buttons, coins, needles, pins, and the like, they have been very often taken, and even sometimes in large quantities, without any harm. It is indeed extraordinary, and almost incredible, if the facts were not authenticated beyond the possibility of a doubt, how much mechanical irritation the alimentary canal has been subjected to, without sustaining any injury. Mr. Wakefield mentions that a man, who was committed to the House of Correction, swallowed seven half-crowns, to prevent the prison authorities from depriving him of them. He suffered no inconvenience for twenty months; when, after an attack of sickness, slight bowel-complaint, and general tenderness of the belly, he discharged them all at one evacuation.[1600] Many singular instances to the same effect have been related in the various medical journals of Europe. At the head of the list, however, may be placed the following, which is related by the late Professor Osiander of Göttingen, in his work on Suicide.
A young German nobleman tried to kill himself in a fit of insanity by swallowing different indigestible substances, but without success. He never suffered any particular inconvenience except a single attack of vomiting daily, though in the course of seven months after being detected he passed the following articles by stool—150 pieces of sharp, angular glass, some of them two inches long—102 brass pins—150 iron nails—three large hair pins, and seven large chair-nails—a pair of shirt-sleeve buttons—a collar-buckle, half of a shoe-buckle, and three bridle-buckles—half a dozen sixpenny pieces—three hooks, and a lump of lead—three large fragments of a currycomb, and fifteen bits of nameless iron articles, many of them two inches in length.[1601]
Before such articles occasion serious harm, it is necessary that some cause coincide, by means of which the foreign bodies are detained long in the same part of the intestines; otherwise the irritation they produce is too trivial to excite disease.
The only substance of this kind which it is necessary to particularize is pounded glass. A common notion prevails that pounded glass is an active poison. There is no doubt, indeed, that it does possess some irritant properties even when finely pulverized; for it titillates and smarts the nostrils, and inflames the eyes. There is also little doubt that when swallowed in fragments of moderate size, especially if the stomach is empty, it may wound the viscera. But it is in this way only that it has any action when swallowed, and even then its effects are by no means uniformly serious. It can have no chemical action on the stomach; it cannot act through absorption, as it is quite insoluble: and when finely pulverized, it cannot easily wound the villous coat of the alimentary canal, on account of the abundance and viscidity of the lubricating mucus.
Accordingly, M. Lesauvage ascertained that 2½ drachms of the powder may be given to a cat at once without hurting the animal,—that in the course of eight days seven ounces might be given to a dog without any bad consequence, although the period chosen for administering it was always some time before meals,—and that even when the glass was in fragments a line in length, no symptoms of irritation were induced. Relying indeed on these results he himself swallowed a considerable number of similar fragments; and did not sustain any injury.[1602] Caldani likewise, an Italian physician, after some experiments on animals, gave a boy fifteen years old several drachms of pounded glass, without observing any bad effects; and at his request Mandruzzato repeated his experiments on animals, and himself swallowed on two successive days two drachms and a half each day without sustaining any injury.[1603]
Similar observations have been made by others also. Dr. Turner of Spanish Town, Jamaica, has informed me, that an attempt was made there by a negro to poison a whole family by administering pounded glass; but, although a large quantity was taken by seven persons, none of them suffered any inconvenience. Not long ago the occurrence of a similar case at Paris gave rise to a careful investigation of the whole subject by Baudelocque and Chaussier. A young man, Lavalley, married a girl who was pregnant by him; but it was agreed that she should live with her father till her delivery was over. A month after the marriage Lavalley invited his wife and father-in-law to dinner; and his wife ate heartily boiled pork, bloody-sausages, and roast-veal, and subsequently drank coffee with brandy in it. On returning home in the evening she became unwell, continued so all night, next morning was seized with violent pain in the stomach and vomiting, and died in convulsions. The period of her death is not mentioned in the report I have seen. A suspicion of poisoning having arisen after burial, the body was disinterred in forty-two days; and, although it was much decayed, black points and patches could be distinguished in many parts of the bowels, together with a quantity of broken down glass. The medical inspectors accordingly declared that she had died of poisoning with pounded glass; and the husband was imprisoned. Baudelocque and Chaussier, who were consulted, ascribed the black patches to putrefaction or venous congestion, and declared that in whatever way the glass had got into the bowels, she had not died of poisoning with the substance, as pounded glass is not deleterious.[1604] A similar opinion as to the properties of pounded glass was more lately given by Professor Marc, when consulted on a case of attempted poisoning, in which the person against whom the attempt was made felt the rough particles in his mouth while taking the second spoonful of soup in which the glass was contained.[1605]
This opinion certainly appears to be in general true. At the same time instances are not wanting to render it probable, that pounded or broken glass is occasionally hurtful. Thus, passing over the more doubtful examples recorded by the older authors, we have the two following cases related by good authorities in the most modern times. One has been published by Mr. Hebb of Worcester. A child, eleven months old, died of a few days’ illness in very suspicious circumstances. On Mr. Hebb being requested by the coroner to examine the body, he found the inside of the stomach lined with a tough layer of mucus streaked with blood; the villous coat was highly vascular, and covered with numberless particles of glass of various sizes, some of which simply touched, while others lacerated it; and no other morbid appearance could be detected in the body.[1606] The other case is described by Portal. A man undertook for a wager to eat his wine-glass, and actually swallowed a part of it. But he was attacked with acute pain in the stomach, and subsequently with convulsions. Portal made him eat a surfeit of cabbage; and having thus enveloped the fragments, administered an emetic, which brought away the glass and vegetables together.[1607] The same feat has undoubtedly been sometimes accomplished with impunity. For example, in the Edinburgh Medical and Surgical Journal, an instance is related of a man who champed and swallowed three-fourths of a drinking-glass without suffering any harm; and the person mentioned by Osiander swallowed many pieces of glass, and sustained no inconvenience (p. 503). But these facts will not altogether outweigh the equally pointed narratives of Portal and Mr. Hebb. And, on the whole, the medical jurist must come to the conclusion, that broken and pounded glass, though generally harmless, may sometimes prove injurious or even fatal.[1608] Powdered glass, however, is probably inert.
Another variety of injury from the mechanical irritants is inflammation from hot liquids, such as melted lead or boiling water. These, when swallowed, may unquestionably cause serious mischief, and even death; and the symptoms they induce are exactly those of the irritant poisons properly so called.
The effects of boiling water have been investigated experimentally by Dr. Bretonneau of Tours; and the results illustrate forcibly the observations which have been repeatedly made in the course of this work, respecting the slight constitutional derangement caused by such poisons as have merely a local irritating power. He found that when boiling water was injected in the quantity of eight ounces into the stomach of dogs, it excited inflammation, passing on to gangrene, both in the villous and muscular coats. The symptoms, however, were trifling. For a day or two the animals appeared languid; but in three days they generally became lively and playful, one of them actually lined a bitch, and it was only on strangling them and examining the bodies, that the extent of the mischief was discovered.[1609]
I am not aware that any such case have hitherto occurred in man. Death from drinking boiling water, indeed, is not an uncommon accident, particularly in Ireland and some parts of England, where children, who are in the habit of drinking cold water from the tea-kettle, have swallowed boiling water by mistake. It appears, however, that in these instances death is not owing to inflammation of the gullet and stomach, but to inflammation of the upper part of the windpipe,—the water never passing lower than the pharynx. The best information on this subject is contained in an interesting paper by Dr. Hall.[1610] He has there given the particulars of four cases which came under his notice; from which it follows that the disease induced is always cynanche laryngea, proving fatal by suffocation. Two of his patients died suffocated; another, while in imminent danger, was relieved by tracheotomy, but died afterwards of exhaustion; the fourth recovered suddenly during a fit of screaming, when apparently about to be choked; and it was supposed that the vesicles around the glottis had been burst by the cries.
Pouring melted lead down the throat was a frequent mode of despatching criminals and prisoners in former ages. Only one authentic case is to be found on record of death from this cause in modern times. It occurred at the burning of the Eddistone light-house. A man, while gazing up at the fire with his mouth open, received a shower of melted lead from the building, and expired after twelve days of suffering. Seven ounces and a half of lead had reached the stomach; and the stomach was severely burnt, and ulcerated.[1611]
In concluding the Irritant Poisons, and before proceeding to the next class, the Narcotics, it is necessary to observe, that besides the substances which have been treated of, there are others not usually considered poisons, and some that are even used daily for seasoning food, which, nevertheless, when taken in large quantities, will prove injurious and even occasion all the chief symptoms of the active irritants. These substances connect the true poisons with substances which are inert in regard to the animal economy.
It is impossible to particularize all the articles of the kind now alluded to. But in illustration, I may refer in a few words to six common substances, pepper, Epsom salt, alum, cream of tartar, sulphate of potash, and common salt.
Pepper, which is daily used by all ranks with impunity, will nevertheless cause even dangerous symptoms when taken in large quantity. In Rust’s Journal is noticed the case of a man affected with a tertian ague, who after taking between an ounce and a half and two ounces of pepper in brandy, was attacked with convulsions, burning in the throat and stomach, great thirst, and vomiting of every thing he swallowed. His case was treated as one of simple gastritis, and he recovered.[1612]
A very striking instance, which may be arranged under the present head, has also been related to me, of apparent poisoning with Epsom salt. A boy ten years old took two ounces of this laxative partly dissolved, partly mixed in a tea-cupful of water; and had hardly swallowed it before he was observed to stagger and become unwell. When the surgeon saw him half an hour after, the pulse was imperceptible, the breathing slow and difficult, the whole frame in a state of extreme debility, and in ten minutes more the child died without any other symptom of note, and in particular without any vomiting. The circumstances having been investigated judicially, it appeared that the substance taken was pure Epsom salt; that the father, who was doatingly fond of the child, gave the laxative on account of a trifling illness which he supposed might arise from worms; and that on the most careful inspection of the body, no morbid appearance whatever could be found in any part of it. For the particulars of this singular case, I am indebted to Dr. Dewar of Dunfermline, the medical inspector under the sheriff’s warrant. It shows that in certain circumstances even the laxative neutral salts may be irritating enough to cause speedy death.
Of the same nature probably are the cases which have lately led some to ascribe poisonous properties to sulphate of potash, a purgative salt at one time in common use. About three years ago several instances of apparent poisoning with this substance occurred in Paris; and one of them proved fatal. This was the case of a woman, recently delivered, who got 100 grains every fifteen minutes till she had taken six doses. Immediately after the first dose she was seized with severe pain in the stomach, nausea, vomiting, numbness, and cramps in the arms and legs, then with dyspnœa and severe purging, and in two hours she expired. The stomach and intestines were emphysematous, but otherwise healthy; and the stomach contained sulphate of potash, but not a trace of any of the common poisons. The stock of this salt in the shop where it had been purchased was found to be perfectly pure.[1613]—A remarkable case of the same kind lately led to a criminal trial in London. A man Haynes was charged with attempting to procure abortion by giving his wife sulphate of potash. It was proved that on two successive evenings he gave her a dose of two ounces of the salt; that she was seized after the first dose with excessive and alarming sickness, from which, however, she soon recovered without apparent harm; but that after the second dose she had violent vomiting and profuse purging, of which she died in five hours, without any alteration in the symptoms, except that she became insensible for five minutes before death. The whole gastro-intestinal mucous membrane was bright red, the vessels of the brain were much congested, and between two and three ounces of blood had escaped from the neighbourhood of the occipital sinus. The salt had been swallowed in a single tumbler of water, so that part of it was undissolved. Mr. Brande, who analyzed the sample which had been used, found it free of all the ordinary irritant poisons. Mr. Coward of Hoxton, to whom I owe the particulars of this singular case, was of opinion, along with other medical gentlemen concerned in it, that death arose from apoplexy brought on by the violent and unceasing vomiting.
Another cathartic, undoubtedly in general very mild in its action, the bitartrate of potash, has also proved fatal, when taken in immoderate quantity. Thus, a man, endeavouring to quench his thirst and cool his stomach the morning after he had been drunk, ate a quarter of a pound of this salt in lumps at once, and a good deal more throughout the day afterwards. He was in consequence attacked with incessant vomiting, frequent purging, and other signs of irritation in the alimentary canal. He died on the third day; and the stomach and bowels were found much inflamed.[1614]
Even common salt has been known to act as a poison when taken in large quantity. A striking instance of the kind occurred in London in September, 1828. A man, who had been in the custom of exhibiting various feats of gluttony, proposed to some of his comrades one afternoon to sup a pound of common salt in a pint of ale, and actually finished his nauseous dish, but not without being warned of his imprudence by an attack of vomiting in the middle of it. He was soon after seized with all the symptoms of irritant poisoning, and died within twenty-four hours. The stomach and intestines were found after death excessively inflamed.[1615] This remarkable case is not without its parallel. In 1839, a girl in the North of England died in consequence of taking upwards of half a pound of salt as a vermifuge.[1616] Not long ago I met with an instance of somewhat similar, but less violent effects. A student having taken upwards of two ounces of salt as an emetic, dissolved in a small quantity of water, was seized with acute burning pain in the stomach, tenderness in the epigastrium and great anxiety, without any vomiting until he drank a large quantity of warm water as a remedy. Before I saw him he had vomited freely, but still suffered severe, intermitting pain, which was removed by a large dose of muriate of morphia.
In France, though not hitherto, so far as I know, in Britain, several instances have occurred of extensive sickness in particular districts, which have been traced to the accidental adulteration of common salt with certain deleterious articles. In an investigation conducted by M. Guibourt, in consequence of several severe accidents having been produced apparently by salt in Paris and at Meaux, oxide of arsenic was detected;[1617] and this discovery was subsequently confirmed by MM. Latour and Lefrançois, who ascertained that the proportion of arsenic was sometimes a quarter of a grain per ounce.[1618] Another singular adulteration which appears fully more frequent is with hydriodate of soda. At a meeting of the Parisian Academy of Medicine in December, 1829, a report was read by MM. Boullay and Delens, subsequent to an inquiry by M. Sérullas, into the nature of a sample of salt which appears to have occasioned very extensive ravages. In 1829, various epidemic sicknesses in certain parishes were suspected to have arisen from salt of bad quality. In the month of July no less than 150 persons in two parishes were attacked, some with pain in the stomach, nausea, slimy and even bloody purging, others with tension of the belly, puffiness of the face, inflammation of the eyes and swelling of the legs; and in several parishes in the Department of the Marne a sixth part of the population was similarly affected. The salt being suspected to be the source of the mischief, as it had an unusual smell which some compared to the effluvia of marshy ground, M. Sérullas analyzed it, and after him MM. Boullay and Delens; and both analyses indicated the presence of a hundredth of its weight of hydriodate of soda, besides a little free iodine.[1619] Subsequently, in reference to the discovery of arsenic by other chemists in different samples of suspected salt, M. Sérullas repeated his analysis, but could detect none of that poison.[1620] Still more lately the whole subject has been investigated with great care by M. Chevallier.[1621] M. Barruel states that he observed the occasional adulteration of salt with some hydriodate accidentally in 1824, while preparing experiments for Professor Orfila’s lectures. He found it in two samples from different grocers’ shops in Paris.[1622] No satisfactory explanation has yet been given of the source of the adulteration with arsenic; but the presence of hydriodate of soda has been traced to the fraudulent use of impure salt from kelp [see p. 160].
Some difference of opinion prevails among toxicologists in regard to the alleged deleterious qualities of alum. On the whole it scarcely appears so active as to deserve the name of a poison; yet, like other salts, it may in large doses do serious injury. It merits particular mention among the present description of substances, partly on account of a trial at Paris, where dangerous effects were alleged to have been produced by it, and partly for the physiological inquiries made on that occasion. A druggist supplied a lady by mistake with powder of burnt alum instead of gum-arabic; and the lady, who had long laboured under chronic derangement of the stomach and bowels, took a single dose of a solution containing between ten and twenty grains of the salt. She immediately complained of acute pain in the stomach and gullet, burning in the mouth, and nausea; the symptoms of a severe attack of inflammation in the stomach and bowels ensued; and she was not considered out of danger for several days. The druggist was accordingly prosecuted, and heavy damages claimed. The attending physician ascribed the symptoms to the alum. But Marc and Orfila, who were consulted, declared that this was impossible except on the supposition that the lady had a very unusual sensibility of the stomach to irritating substances;—that it was a common thing to give three, four, and even five times the quantity in the treatment of diseases, without any such consequences resulting;—and that at the very time of the inquiry a physician in Paris was using it to the amount of six or eight drachms in a day. From an experimental inquiry conducted by Professor Orfila it appears, that large doses of calcined alum, such as one or even two ounces, excite in dogs little more than one or two attacks of vomiting, even although retained between ten and thirty minutes,—that one ounce will not excite any marked symptoms though secured in the stomach by a ligature,—but that two ounces given in the same way prove fatal in five hours, under symptoms of excessive exhaustion and insensibility.[1623] A similar inquiry was instituted about the same time by M. Devergie, who seems, however, to have remarked more activity in alum than is indicated by Orfila’s experiments. He infers that two ounces may sometimes kill dogs, even though they vomit freely; that half that quantity is fatal if the gullet be tied; that calcined alum is more active than a solution of the salt; that it is a corrosive or irritant; and that probably man is more sensible to its operation than the lower animals.[1624] Whatever may be thought of the effects of alum on the animal body when administered in large doses, it is plain from its frequent medicinal use as an internal astringent that it is not poisonous when given in small doses, like that taken by the patient in the trial alluded to. I may add that it appears very doubtful whether any injury accrues from the long-continued use of very small doses. Bakers, it is well known, are in the practice of using it in minute proportion for improving the whiteness of bread; and it has been imagined that chronic disorders of the stomach and bowels may consequently originate, by reason of its constipating tendency. These fears, however, are not borne out by facts. Either the quantity is insufficient to do harm in the way supposed; or the constitution becomes accustomed to the continual operation of the salt, and does not suffer.
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 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 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.