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.