1G 
TIIE PHARMACEUTICAL JOURNAL AND TRANSACTIONS. 
[July G, 1S72, 
have occasionally left my prescriptions at Mr. Birkett’s 
to bo made up. 1 have not before left any similar pre¬ 
scription at Mr. Birkett’s. The morphia was given to 
alleviate pain, and it is well known that an overdose 
produces certain death. Children and aged or infirm 
persons are particularly susceptible of its influence. A 
little before twelve o’clock the same night Mr. Birkett 
came to me at Lancaster, and told me what had occurred. 
I followed him to Morecambe almost immediately. I 
applied galvanism externally, ammonia through the 
nostrils, and hot coffee through the mouth. I sent for 
Mr. C. Johnson at two o’clock in the morning, and he 
brought additional galvanic apparatus to my aid, but all 
the means used were of no avail; we never restored the 
patient to thorough consciousness. The mere exclama¬ 
tion “ Oh, dear,” twice, I don’t consider as consciousness 
in my sense of the term. She died, I think, about seven 
o’clock in the morning. The symptoms throughout the 
night were very pronoimced, leaving no doubt that she 
was suffering from an overdose of morphia. The eyes 
were for the most pai't closed, and the breathing was 
slow—about six times in one minute, instead of twenty. 
Yesterday I made a post-mortem examination of the 
body, in conjunction with Mr. C. Johnson. I first 
opened her head and found the membrane very much 
congested, not very firmly adherent. The brain sub¬ 
stance was softened, owing to post-mortem changes. 
There was an excess of fluid in the ventricles, and a 
large number of bloody points apparent on the section 
of the brain, showing that the whole organ was much 
congested. On examining the abdomen I found an 
enormous tumour, probably weighing between 201b. 
and 301b., which was adherent to the walls of the 
stomach, parts of the intestines, and the abdominal walls. 
The lining membrane of the stomach was congested, 
owing to post-mortem changes, and contained a coloured 
fluid it was not possible to analyse. The liver also con¬ 
tained cysts, and was much congested. The heart was 
remarkably thin, very soft in texture, and the valves 
healthy. The lungs were compressed but not congested. 
All these symptoms made the system peculiarly sus¬ 
ceptible to morphia. The condition of the brain corre¬ 
sponded with the symptoms during the last part of her 
life as to induce me to consider that the immediate cause 
of death was the action of morphia. The prescription 
produced is written in an usual form, and written in such 
a way that I thought it to be quite incapable of being 
misunderstood. It is not so common to put the word 
divide in prescriptions as the form I have used. The 
deceased was not in the habit of taking morphia, and the 
first dose, would, therefore, act more powerfully. I pro- 
duce a copy of the certificate of death. In that certifi¬ 
cate I attribute death to dropsy from diseased liver, 
accelerated by an overdose of morphia. 
By Mr. Tilly: Deceased could not have lived very 
long, but I did not consider her on her death bed. She 
might have lived a month, or it might only have been a 
day.. I considered her recovery beyond all hope. In the 
certificate I gave I ascribed death to have resulted from 
dropsy from diseased liver, accelerated by an over-dose 
of morphia. In my evidence I ascribe death to the 
action of the morphia. 1 have known Edmondson for 
six or seven years—in fact, I think almost as long as he 
has been in Mr. Birkett’s employ. I have many times 
had. communication with him in the course of my pro¬ 
fession, and have found him of fair ability, and intelli- 
gent in his business. It is usual to mention in the pre¬ 
scription the material of which the pills are to be made, 
but it. is not usual to say divide. I gave him verbal 
directions as to dividing the morphia into six pills. It 
is quite, possible that Edmondson misunderstood my 
verbal directions. It might have made the prescription 
more plain to have said divide. The remedies were ap¬ 
plied immediately I arrived at the house. A grain of 
morphia is not an unusual dose, but that quantity is not 
often administered in a pill. A grain of morphia would 
not kill a healthy person. In cases of delirium tremens' 
two grains are sometimes given. The verbal directions- 
about the lotion were very special. 
By the Coroner : I have been 25 years in actual prac¬ 
tice and never recollect prescribing a grain of morphia 
in one dose. 
Mr. Tilly, in addressing the jury, said that he hardly 
thought that the evidence which Mr. Johnson had given 
that day was reconcilable with the cause of death as 
stated on the certificate, and the matter would be fresh, 
in his mind at the time he made out the certificate. Mr. 
J ohnson then stated that deceased had died from dropsy, 
accelerated by an over-dose of morphia, but in his evi¬ 
dence that day he stated that death had resulted from 
morphia. Supposing the latter supposition to be the" 
correct one, they must all agree that the drug had been 
administered by mistake, and therefore, he contended, 
they would be justified in returning a verdict to the 
effect that death had occurred through misadventure. 
He thought every one would absolve Mr. Birkett front 
all blame whatever in the matter; it was not to be ex¬ 
pected that Mr. Birkett could personally superintend, or 
personally make up, all prescriptions that came to his 
shop,—it would be an impossibility for him to do so; 
but he had provided an assistant whom they had heard 
described as possessing full average ability and intelli¬ 
gence for the situation in which he was placed—a young- 
man whom he had had in his employ for eight years— 
and it might therefore be assumed that Mr. Birkett had 
done everything that was necessary for the requirements 
of his customers, and consequently that not the slightest 
blame or negligence could be attached to him. He 
thought it was a misfortune that any special directions- 
were given at all; suppose the prescription had been 
handed over to some one else to make up, what would 
have become of the verbal directions ? The prescription 
should have contained all that was necessary, and nothing- 
been left to intentions ; for it was the verbal directions 
that the young man had misunderstood. Lamenting as 
they all did, the painful occurrence, they must neverthe¬ 
less, be satisfied with the conduct of Edmondson, which 
had been consistent and straightforward throughout. 
Supposing he had said nothing about it directly he had 
found out his mistake, but had got the pills back again, 
and destroyed them, how would they have been able to 
prove anything against him ? But, on the contrary, he 
came before them and told them candidly how the mis¬ 
take had occurred—that he had misunderstood the verbal 
direction which had been given to him. Mr. Tilly con¬ 
cluded by stating that the form of prescription was to* 
his mind somewhat ambiguous, and contended that under 
the circumstances the jury would bo justified in return¬ 
ing a verdict to the effect that deceased had died fronn 
dropsy, accelerated by a dose of morphia administered 
by misadventure or accident. 
The coroner very carefully summed up the evidence.. 
He agreed with Mr. Tilley that the certificate as to the- 
cause of death, and the evidence which Mr. Johnson 
had given that day, were inconsistent with each other. 
In the first instance, Mr. Johnson was of opinion that 
death was simply accelerated by morphia; but that day 
he stated that the immediate cause of death was from; 
the action of the morphia. It was only fair to remember 
that he was able to speak with more certainty on the 
latter point from the post-mortem examination which ho 
had made. He thought no one could charge Mr. Birkett 
with any negligence in the matter; he did all that a just 
and right-minded man could do under the circumstances. 
On finding out the mistake which had been made he 
secured the pills, and at once went to Lancaster for Mr. 
Johnson, and acquainted him with the occurrence. The 
latter gentleman followed him down almost immediately; 
and all had been done that skill and diligence could sug¬ 
gest, but, unfortunately, without effect. The prescrip¬ 
tion might have been more explicit, but Mr. Johnson 
said it was written in the usual form, and in a way that 
