Treatise on Poisons by Sir Robert Christison

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: