Case XLVII. Acute Hysterical Mania—Four Months’ Duration—Operation—Cure.
Miss ——, æt. 23, was sent to me by Mr. Radcliffe, stating that she had been brought over from Ireland as an insane patient, and that everything had been settled for her admission to some asylum, when he was induced to consult me on the last day before her entering one. He stated that the paroxysms always came on at half-past five or six every evening: I replied, if the attacks depended on peripheral irritation, that an operation would at once prevent recurrence of the attacks. She was accordingly admitted into the London Surgical Home Feb. 6, 1864.
When admitted, said she had taken no food for three days, and asked for a cup of tea, which was given her. Enema was also administered.
3.45 p.m. Was seized with a fit, throwing her arms up over her head, and then appearing as if comatose. In about twenty minutes revived: the lips began to quiver, and she gradually became conscious, saying, “I want a knife—I want blood!” She asked for the matron’s hand, that she might bite it off.
[The fit coming on earlier on this day was doubtless due to excitement consequent on her removal.]
5 p.m. Mr. Baker Brown saw her; as soon as he came near her, she seized his shoulder with great violence; was wild, and would not answer questions; but gradually became soothed, and allowed an examination.
Externally, the abdomen showed signs of a child having been born, and the mammæ had certainly contained milk. The clitoris was enlarged and hard; the nymphæ long and flabby; the mucous membrane roughened and discoloured.
Per vaginam, the uterus was found to be retroverted; there was also a fissure of the rectum.
Operation, 5.30 p.m. Was very violent under the first attempts to administer chloroform. She was long in being brought under its influence, but when once thoroughly anæsthetized, bore it exceedingly well.
The clitoris was excised, the elongated nymphæ removed, and the fissure of the rectum divided. The wounds were dressed in the usual manner, and the patient having had two grains of opium administered, was ordered to be constantly watched.
In twenty minutes awoke from the chloroform. Was calm, and slept at intervals during the night.
Feb. 7, 10 a.m. Visited by Mr. B. Brown. Present—Mr. I. B. Brown, junior, House-Surgeon, and Matron. Pulse quick but steady; tongue brown and furred; breath offensive; gums spongy; pupil natural; countenance rather flushed; skin moist and warm.
The following answers were given to questions asked of her by Mr. Brown, seventeen hours after operation, and are in her own words; much, however, of the information was volunteered without questions:—
“Last March, instead of sliding down a slope, I jumped. This caused displacement of my womb. I suffered great agonies. I was fomented with hot water. I thought it was my back that was hurt. Since then I have been subject to fainting and weakness. I suffer great irritation about my private parts—cannot keep my hands away. The irritation is worse at night. I am obliged to relieve the irritation by rubbing—sometimes for two or three minutes at a time. There is always a discharge. I feel very depressed afterwards. At times I have lost my brain, and felt as if I did not care for living. I would like to have my hands untied; I will be very quiet. Have been separated from my relatives for three years. I shan’t tell you how long I have been married—(a pause). I am very rude—I beg your pardon. I have been married three years. I had a baby two years ago: it was not born at the full time—I think five months. I don’t know whether it was alive. I left home with my friend when I was sixteen (?). It is two years since I left him. I am now twenty-three.
“After the accident, suffered great pain.” Mr. Brown here looked at her gums, and she immediately said, “Oh, yes; I had mercury given me by Surgeon ——, in Dublin: he said it was my spine. He did not examine my womb. Dr. —— examined it, and said there was great displacement. I have been better for treatment at times. My brain has been affected. I have fought very much. I have wanted a child’s blood. I have had it sometimes by sucking the wounds of a child. When in a fit, I don’t know what is going on around, or what is being said, but I recognize people’s voices. I am not regular. Was kept in bed last September for six weeks for flooding; was so for ten days after I was put in bed. Was the same in Paris last year. I was studying in Paris to fit myself for a governess.”
The following are extracts from a letter voluntarily sent to Mr. Brown by a lady with whom the patient lived for many months, and left only three weeks previous to admission. Having stated that for some time she was hysterical, and becoming daily more excitable, the letter says—
“On the 13th of September last, she for the first time seemed delirious when going to bed. This was mentioned next morning to Surgeon ——, who declared it to be nervous irritability of the spine.... On the 27th, Dr. —— was called in, and at once gave his opinion that there was ailment of the womb. He then ordered small blisters on the lower part of the stomach, which in less than ten hours relieved her, and removed the mania. She had not any reason for many days previous, and was sinking.... On the 3rd of October, Dr. —— fixed an instrument to support the womb; and, except during the time when the intensity of pain caused it, there was no delirium; for a few days she got claret, which seemed to excite her greatly, so it was discontinued; but on the 13th of October I was desired to give her port wine in abundance. She was excessively weak, and mania so dreadful, that she made several attempts to injure herself and me. She got as many as eight large glasses of best port on some days; strong beef-tea, chicken soup, and all the nourishment possible. It was not only suggested, but it was advised to remove her to a lunatic asylum; however, feeling that certainly nine-tenths of her time she was perfectly sane, and could know well where she was and with whom, I did not like the idea of placing so young a creature in an asylum. I kept her here, and watched her day and night; she never was left alone for one moment for three months.... I ought to mention that the order for abundance of wine, &c., was from the opinion that ‘want of blood to the brain’ caused the mania; and that the intense inflammation of all internal organs was relieved by blisters on the lower part of the stomach and by mercury.”
Feb. 8. Lint removed from rectum, and wounds dressed. Is calm and rational; passed a quiet day.
Feb. 10. Very restless; obliged to restrain hands and legs.
Feb. 11. Better; says her head feels heavy; countenance cheerful; manner quiet and rational.
Feb. 12. Very excited and irritable; constantly managing to free her hands; will allow no one near her.—2 p.m.: Is quite maniacal; has managed to irritate the wounds, and also the mammæ. To have one grain of opium in pill, and ten grains of bromide of ammonium three times a day.
Feb. 13, 6 a.m. Hands again free; repeat opium. Slept afterwards till 4 p.m., when she awoke calm and rational.—9 p.m. Slept again.
Feb. 14. Very restless, and at times violent. Bandages removed and jacket substituted.
Feb. 15. Much better; rational, and conversing cheerfully.
Feb. 16. Improving.
Feb. 17. At her urgent request, hands were freed, but shortly after she became excited.
Feb. 19. More sensible; had to-day symptoms of a severe bilious attack, which upset her for some days.
Feb. 24. Much better; allowed to see her sister—the first time since the operation.
March 1. Much improved; has written to her sister, and amused herself knitting and reading during the day.
March 2. Allowed to dress; seemed to enjoy the change, and is very cheerful.
March 4. Visited by her sister; has been quietly cheerful all day. Is certainly improving wonderfully.
March 20. Took a walk, and enjoyed it.
March 25. Spent the day away from the Home with her sister; returned looking quite well, and all the better for the change.
April 2. Discharged quite cured.
This patient remained perfectly well, and I hear has since been legally married.