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.