A CASE OF UNRUPTURED TUBAL PREGNANCY OF THIRTEEN MONTHS' DURATION; OPERATION AND RECOVERY
Dr. Scott also quotes a case reported by Stockes 3 in which great prostration and mental weakness lasted for two months after poisoning. He likewise quotes a case privately communicated to him, in which the patient was maniacal for three days and quite insensible for eight days. He remained unable in any way to look after himself for two years, and even after that he was feeble-minded and could not undertake ., any responsible duties. Leppmann 4 has described a case of severe hysteria following
... hysteria following poisoning, also one of cerebral haemorrhage. Levin 5 reports a case in which persistent tachycardia, headache, and restlessness followed CO poisoning, although during the time the patient was in the poisoned atmosphere no severe toxic effects occurred. He questions whether the symptoms were due to the poisoning or to a preexisting hysteria. Izard 6 in a thesis for the doctorate gives a full account of the various nervous sequelse of CO poisoning under the following heads: Motor: Hemiplegia, paraplegia, partial paralysis. Sensory: Subjective, pain ; objective, hyperassthesia, anxsthesia. Sensorial: Affections of sight and hearing, multiple sclerosis, hysteria, chorea, tetany. Intellect : Affections of memory, melancholia, mental confusion, chronic temporary mania, dementia, affections of speech. Mott,7 in a paper on carbon monoxide and nickel carbonyl poisoning, considers very fully the changes in the central nervous system produced by CO, and shows that, microscopically, very definite lesions of the brain can be demonstrated. The cortical vessels are dilated, but in the subcortical white matter the changes are more markedviz., congestion, haemorrhage, and the rupture of small vessels. Sometimes this rupture is into the brain substance, sometimes into the perivascular sheath. The capillary endothelium appears swollen and shows fatty changes. The most marked changes are seen in the white matter of the centrum ovale, especially in the occipital lobe. The chief points of interest of my cases from the mental side seem te be: 1. Was this man's state of confusional insanity due to the action of CO alone on the cerebral tissue or was the mental condition beginning before the CO poisoning ? 2. How does the CO act ? 1. Mott says : "In considering the effect of carbon monoxide poisoning being followed occasionally by mania, melancholia, confusion, and other mental symptoms, it must be remembered that many of the cases were suicidal, and therefore if not actually insane at the time probably possessed an insane and neuropathic temperament." That may be granted. But on the other hand, it is perfectly certain that some cases in which similar mental disturbances have followed CO poisoning were not cases of suicide, as, for example, that quoted above from Dr. Scott's paper, and therefore the power of the CO to produce these effects in some persons without their being insane at the time exists. Moreover, one does not (I speak here with much diffidence before those of far greater experience than myself on these subjects) find similar fatal mental symptoms in the average suicide who fails to carry out his purpose by some other means such as poison, injury, or drowning. In my case, as we have seen, the question of suicide is somewhat complex. Whilst talking over this case with a well-known professor of jurisprudence the other day he said to me : "There is one golden rule to remember: Whenever an obscure death occurs in a person who is going to be married, it is suicide." In his opinion the rule should be applied in this case. 2. How does the CO act on the nervous system ? There are two principal hypotheses : (a) That all the symptoms are produced by the anoxaemia due to the action of the CO on the oxyhaamoglobin of the red cells, with resulting deprivation of oxygen to the nervous tissue and vascular changes, haemorrhages, thromboses, and degenerations ; (b) Le Dosseur's theory 9 that the CO, having once saturated the red cells, becomes dissolved in the serum and attaches itself to the nerve cells and has a direct toxic effect on them. Which, if either, of these two views is correct remains to be proved. Sheffield.