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.