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.
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]]