Dr. Bright takes notice of a similar affection under the title of “Arachnitis with excessive irritability” occurring chiefly among very intemperate people, but independently of previous disease. In general the disorder has a well-marked course of at least several days’ duration. But in two of the instances he has given the early stage was very obscure, the only symptoms having been headache and sickness of no great severity for four or five days; after which delirium came suddenly on, and was followed by coma, and by death within thirty-six or forty hours. The sole appearances found within the head were some serous effusion and vascularity on the surface of the brain and in the ventricles.[[1660]] To these illustrations may be added the heads of a remarkable case which occurred here in the person of an eminent lawyer, and for the particulars of which I am indebted to Dr. Maclagan. For three days there had been occasional headache, not great enough to prevent him pursuing his ordinary avocations, yet becoming so troublesome on the morning of the third day as to induce him to have leeches applied. But next morning he was seized rather suddenly with quickly increasing coma, and in forty hours more he expired. In this instance the whole surface of the arachnoid membrane, both over the hemisphere and in the ventricles, was found lined with soft, yellowish-green lymph.
In such cases it is apparent that an inspection after death will often unfold their real nature, where the history of the symptoms may leave it in doubt. But even without an inspection it is not likely that a careful physician could mistake them for narcotic poisoning; for independently of other considerations, the severe symptoms are ushered in by a precursory stage of ill health, commonly indicating an obscure affection of the head, and such as no one but a careless observer could fail to discover and appreciate.
It is not improbable, however, that acute meningitis may seem to prove suddenly fatal, in consequence of its course being in a great measure latent. The following case reported by Mr. Davies of Somers Town, seems of this nature. A woman, who had previously complained only of slight headache, was attacked after breakfast with violent vomiting for half an hour, when she fell down, and immediately expired. After death there was found great gorging of the vessels of the cerebral membranes, with opacity and thickening of the pia mater and arachnoid coats, and an effusion of nearly five ounces of bloody serum under the dura mater.[[1661]] Such a case might give rise to great perplexity in a charge of poisoning, until the examination of the body unfolded its true nature.
I should scarcely have thought it necessary to mention chronic meningitis among the diseases apt to imitate the effects of narcotic poisons, because it is commonly marked by a long and distinct course. But the following case, for which I am indebted to Dr. Arnoldi of Montreal, will show that, like other diseases of the head, chronic meningitis may be latent in its early stage, and may, after developing itself, terminate in a day, and then in some measure imitate poisoning with narcotics. A middle-aged female, subject for a twelvemonth to a purulent discharge from the left ear, and occasional headache, which was supposed to be rheumatic, was seized one morning with acute pain in the head, followed in a few hours by convulsions and tendency to coma; under which symptoms she died within twenty hours, although treated actively from the commencement. On dissection, the brain and pia mater were found healthy, except at the part corresponding with the petrous portion of the left temporal bone, where the brain was a little softened. The corresponding part of the temporal bone and the adjacent part of the occipital were completely denuded and covered with pus, which had established a passage for itself into the cavity of the ear.
Of the Distinction between Inflammation of the Brain and Narcotic Poisoning.
Inflammation of the brain itself, the ramollissement of French writers, occasionally excites symptoms not unlike those produced by some narcotic poisons; and in a few instances its course has appeared to be equally short. It requires particular notice, because the appearances left in the dead body are sometimes apt to escape observation.
This disease in its well-marked form has been noticed by various authors from Morgagni downwards. But the first regular accounts of it were given in 1818 by Dr. Abercrombie,[[1662]] and in 1819 by M. Rostan[[1663]] of Paris, and Professor Lallemand[[1664]] of Montpellier. Its symptoms are allied to those of apoplexy and epilepsy. But the comatose state is generally preceded by delirium or imperfect palsy, and often by a febrile state of the circulation. Contraction of the voluntary muscles, once supposed to be a distinguishing sign of this disease, is neither essential nor peculiar to it. In the dead body it is recognized by the presence either of an abscess in the brain,—or more commonly of a nucleus of disorganized cerebral tissue surrounded by unnatural redness or softness,—or sometimes of a clot of blood surrounded by similar softening. Occasionally, when the disease kills in its early stage, nothing is found but redness of a part of the brain, and slight softening of the tissue, recognizable only by scraping it with the edge of the scalpel.
In the form in which it is commonly seen, and as described by Rostan and Lallemand from a great number of cases, it can hardly be confounded with the effects of narcotic poisons; for its course is much slower, being seldom less than several days when it proves fatal.[[1665]] Yet in some instances it may prove fatal instantly. Lancisi notices the case of an Italian nobleman, who after an apoplectic fit became liable to frequent attacks of lethargy,—who at length died quite suddenly more than a year afterwards,—and in whose brain an organized clot was found, with extensive suppuration of the brain around it.[[1666]] An unequivocal case of the same kind has been related by Mr. Dickson, a navy-surgeon. An elderly sailor, who for months before had done duty, eaten his rations, and drunk his grog as usual, suddenly dropped down while in the act of pulling his oar, and died at once; and after death there was found in the middle lobes of the brain an extensive abscess, which had made its way to the surface.[[1667]] Such cases might, in certain circumstances, be mistaken for the effects of large doses of hydrocyanic acid; but the morbid appearances are of course quite characteristic. M. Louis has related an instance like the last two, but where the disease was altogether latent. His patient after a long illness died of diseased heart, the ventricles of which communicated together. He never had a symptom of disorder of the head; yet on dissection an extensive recent softening was found in the right corpus striatum and another in the right thalamus.[[1668]]
None of the treatises I have seen on the subject make mention of a variety of this disease intermediate between suddenly fatal cases and those which last several days,—a form in which the patient’s illness endures for a few hours only, and which, both in the special symptoms and in their course, imitates exactly the effects of some narcotics. Two such cases have come under my notice, both of them judicial, poisoning having been suspected. One of them proved fatal in an hour and a half, the individual having previously been in excellent health; and the only appearance of disease was softening of a considerable part of the surface of the brain where it lies over the left orbit. The other was more remarkable in its circumstances. In November, 1822, a man, who had previously enjoyed excellent health, was found one morning in a low lodging-house in the Lawnmarket comatose, and convulsed; and he died seven hours afterwards. The neighbours spread a report, that the woman of the house had poisoned him, with the view of selling the body; and by an odd coincidence the police, when they went to apprehend the woman, found an anatomist hid in a closet. The body was judicially examined by Sir W. Newbigging and myself; and we found an ulcer on the forepart of the left hemisphere of the brain, and a small patch of softening on each middle lobe.
It is only in cases like the last two that the disease is likely to be mistaken for the effects of poison; and the morbid appearances will at once distinguish them. But it is requisite to remember that softening of the brain when not far advanced is apt to escape notice, as it is not necessarily attended with a change in the colour of the diseased part. In the first of the two cases I have related, the cause of death was very nearly assumed to have been simple apoplexy, when at length the true disorder was unexpectedly noticed. I presume, indeed, that strictly speaking, both of the cases which came under my notice ought to be considered as simple apoplexy excited by pre-existing ramollissement.