It has been proposed to derive other criterions from the state of the blood. But on considering the effects of the individual poisons of the class, it will appear that the state of the blood is by no means characteristic.
It may be useful to conclude this view of the distinctions between poisoning and apoplexy with the particulars of an interesting case, in which the medical witnesses fell into an egregious error by disregarding the most palpable criterions. In 1841, an elderly gentleman at Chambéry in France, subject to apoplexy, one day after having made a hearty dinner and afterwards supped on bread, cheese, and white wine, was suddenly seized with staggering immediately after finishing his wine, and soon lost all consciousness. Emetics and stimulants restored his faculties so far as to enable him to say he felt better and had no pain; but the tongue and mouth were drawn to the left side, and there was great prostration. Four hours after his first seizure the countenance became livid; he again became unconscious and insensible; the twisting of the mouth increased; and the left arm presented spasmodic contraction. Blood-letting and other remedies were resorted to without avail; the pulse, previously strong and regular, became gradually feeble; and in six hours after his first illness he expired, without ever having had convulsions of any kind. On the body being examined seven days after death, great congestion was found in the vessels on the surface of the brain; on raising the brain, a dense dark clot of the size of a large egg escaped from the lower part of the ventricles; and an abundant extravasation of the same nature was found under the tentorium cerebelli.
It appears scarcely possible to find a more characteristic case than this of apoplexy from extravasation. The slight intermission in the symptoms was the only unusual circumstance. Yet because the inspectors remarked in various parts of the body a peculiar odour, which they could not at the time characterise, but which they afterwards thought was the odour of bitter almonds,—and misled by the sudden invasion of the symptoms instantly after a meal,—they gave their opinion that death had arisen from some narcotic poison; a chemical examination was made of various textures of the body (not, however, of the contents of the stomach), which yielded obscure and very doubtful indications of hydrocyanic acid; poisoning with hydrocyanic acid was accordingly declared to have been the cause of death; and, in defiance of an able report by Professor Orfila, pointing out the error of the primary witnesses, the nephew and heir of the deceased was condemned.[[1645]] It is almost unnecessary to point out the impossibility of death having arisen in this case from hydrocyanic acid. The length of time the deceased survived, the want of convulsions, the presence of deflexion of the mouth and tongue, the intermission of the symptoms, and the morbid appearances, all clearly indicate that death in the way supposed was impossible; and the chemical evidence, which it would require too much space to analyze here, was proved by Orfila to be completely unsatisfactory.
Of the Distinction between Epilepsy and Narcotic Poisoning.
Of the Symptoms.—Epilepsy is distinguished from other diseases by the abolition of sense and by convulsions. It resembles closely the symptoms caused by prussic acid, and by some of the narcotic gases, such as carbonic acid gas and the asphyxiating gas of privies. It also bears the same resemblance to the effects of many narcotico-acrid poisons, such as belladonna, stramonium, hemlock, and others of the first group of that class, also camphor, cocculus indicus, and the poisonous fungi.
Epilepsy is in general a chronic disease, and for the most part ends slowly in insanity. But sometimes it proves fatal during a paroxysm. The circumstances by which an epileptic fit may be distinguished from narcotic poisoning are the following:
1. The epileptic fit is sometimes preceded by certain warnings, such as stupor, a sense of coldness, or creeping, or of a gentle breeze proceeding from a particular part of the body towards the head. Warnings, however, are by no means universal. M. Georget, indeed, has even stated that they do not occur in more than five cases in the hundred.[[1646]] But this estimate probably underrates their frequency.
2. The symptoms of the epileptic fit almost always begin violently and abruptly. The individual is suddenly observed to cry out, often to vomit, and instantly falls down in convulsions. The effects of the narcotic poisons, if we except some cases of poisoning with hydrocyanic acid, the narcotic gases, and a few rare alkaloids, never begin otherwise than gradually, though their progress towards their extreme of violence is often rapid. This distinction is generally an excellent one. But it will not apply so well to some cases of epilepsy in which the convulsions are trivial. Esquirol says an epileptic fit may consist of nothing more than coma, with convulsive movements of the eyes, or lips, or chest, or a single finger.[[1647]] Still even then the coma generally begins abruptly, so that if the case is seen from the beginning, it can hardly be mistaken for narcotic poisoning. Some forms of epilepsy, in which the fit is constituted merely by giddiness, staring, wandering of the mind, and imperfect loss of recollection,[[1648]] might be confounded with the milder forms of narcotic poisoning. But collateral circumstances will scarcely ever be wanting to distinguish such cases from one another.
The varieties of narcotic poisoning which, in the violence and abruptness of their commencement, bear the closest resemblance to an epileptic attack, are some cases of poisoning with hydrocyanic acid or with the deleterious gases. Both of these varieties, however, when they begin so abruptly, are distinguished from a fatal paroxysm of epilepsy by the fourth characteristic to be mentioned presently; and besides, in abrupt cases of poisoning with hydrocyanic acid, the poison under certain conditions will be found in the body; while in sudden poisoning with the narcotic gases, the nature of the accident is rendered obvious to a cautious inquirer by the collateral circumstances.
3. As in apoplexy, so in epilepsy the patient in general cannot be roused by external stimuli. This, as already observed, is often, although certainly not always, practicable in cases of poisoning with narcotics. Sometimes, too, in the epileptic fit a partial restoration of consciousness may be effected by loud speaking, so that in reply to questions the patient will roll his eyes or move his lips. It is therefore to be understood in applying the present criterion, that it is only a safe guide when, as in many cases of poisoning with opium, the individual can be roused to a state of tolerably perfect consciousness.