- Email: [email protected]
NOTES OF A CASE OF HYPERPYREXIA.1
641 under that of "Facts indicating insanity," and " as observed by himself." Under this title one medical man stated as a per,onal fact: "called meafool." Irrelevant statements cannot strengthencertificate, but may assist in making it invalid, In acourtof law, where the reception of any such irrelevant matter would be prejudicial to the interest of his client, I question very much whether the counsel engaged would not object to the reception of any such evidence, as being contrary to the requirements of the statute, and with every probability of his objection being entertained. Undoubtedly much of this kind of information should be reported to the asylum medical officer, but unfortunately the present form of certificate is defective in containing no place or heading for its insertion. When, although important, it is unable to be included under the second heading, it is always the better plan to let it form the subject of a letter to the asylum medical officer, when at the same time many medical points - such as any history of syphilis-may be noted, and which could not always be stated in any form of certificate. It rarely happens that an entire certificate is irrelevant ; the following, however, is rather a remarkable example of one, and contains all the 11 facts" recorded by the certifier :-" In the summer he repeatedly was in the search of adders, would endeavour to play with them, so subjecting himself to be stung, which he has been on one occasion very severely ; would kill them and eat their hearts. On my asking the reason, he would say if he ate a number they would cure the epileptic fits which he has suffered from for eleven years. On several occasions he has threatened to take the life of his smaller brothers and sisters." This statement contains no symptom of insanity-a belief in the curative powers of adder fat, &c., is prevalent amongst the squatters resident on the common lands in the Bagshot Sands district ; and amongst the lower orders generally an ignorant belief in the efficacy of a large number of very unorthodox remedies for epilepsy is very common. The threats of violence were not inconsistent with perfect sanity. The greater portion of it consists of hearsay evidence, and none of it apparently refers to the day of examination. The certificate was returned for correction, when the medical man added the following :"He is sullen, morose, and dejected. Answers questions in -an incoherent manner, and appears quite indifferent as to his fate." 10. When called to a case of reported insanity, he must not too readily take it for granted that the patient is insane, and especially must this be borne in mind if he be a stranger to the family, and therefore probably unacquainted with the manner and habits of the person he is about to examine. It behoves him to be exceedingly particular, more especially in any doubtful case, in investigating and thoroughly satisfying himself of the nature of the symptoms. Especial care must be taken when the so-called delusion is single. Any statements that are asserted to be delusions, and yet which might be true, need the most searching inquiry. For instance, the following single one appeared in a certificate :"She has a delusion that some one pays for her retention in the workhouse." An assertion that was quite likely to be true, but if even a delusion, it was a very weak one. The most difficult case for a medical man to deal with, and the one most likely to be brought under his notice, is that where the single delusion is reported to be that of jealousy on the part of the husband or wife, the subject of which strenuously asserts it to be well-grounded. The possibility of the latter, and the probability as to motive, should be well considered by the medical man before he pronounces any opinion on the case. If there were an entire absence of any other symptoms of insanity, I should for my own part refuse to sign a certificate Febrile delirium is occasionally mistaken for insanity. The acceptation of truths as delusions does occasionally take place. The certificate of a patient recently brought to the Brookwood Asylum commences thus :-" He has various delusions, all bearing on engineering projects. His first and chief project is to carry a triple tunnel under the English Channel from England to France." At first sight this has all the appearance of a delusion, but as a carefully-considered scheme I have cause to believe it was a reality. The man had been an engineer, and had conceived and worked out on paper a plan for such a tunnel, which had met with the approval of many leading men of the day (the papers proving this are in my possession). There was no reason to doubt the man’s insanity, the symptoms of which appeared in the certificate. He had overworked his brain, had broken down, a.nd becoming pauperised was sent to a county asylum.
Now if this single symptom had been depended upon to prove him insane, and the question of his sanity or insanity had subsequently been inquired into by a court of law, no doubt the medical certifier would have got into serious trouble. 11. He should take into consideration the existence of blindness, deafness, partial paralysis, malformation, defects in speech, loss of teeth, infirmities of temper, peculiarities of gesture, eccentricities of conduct, or in the mode of speech, &c., many of which cause the person to be examined to be somewhat awkward and ungainly in speech and manner, especially if associated with any nervousness. These states are not unfrequently jotted down as proofs of insanity. In one certificate I received was the sentence " a vacant expression as one of the facts indicating insanity, and yet it appeared to be entirely owing to deafness. Deaf persons, even when sane, are frequently listless and vacant, and, moreover, are apt to be suspicious from a belief in thinking they are always being talked about. 12. He should well consider that the element of any change in the habits, conversation, affections, disposition, dress, residence, choice of companions, &c., is of the greatest importance to notice in the certificate. In themselves all the varieties of demeanour and speech may be perfectly natural to the individual, and are therefore perfectly consistent with sanity. If, on the contrary, any of these show a marked change (often a complete antithesis) to his previous condition, they become valuable evidence of insanity. The lower classes of society may be considered as perfectly sane, even when from the force of habit they employ the most coarse and objectionable language ; but The .ame low-life and often obscene utterances emanating from the mouth of a lady, and presenting a strong contrast to her mode and previous style of conversation, would, especially when taken in connexion with other symptoms, be a strong indication of mental impairment. Change in the style of language is well reported in the following extract from a certificate (thepatient was a well-educated gardener) :that he is constantly 2, Facts hearsay. " His wife says using the most violent and obscene language before her and the children, which has never before been his habit." 13. He should be careful to use proper terms to express his meaning. In the two sentences, "incoherence of speech and manner," and "her manner wild and incoherent," the words " incoherence " and " incoherent " used with respect to "manner"are inapplicable. Again, in the sentence " all her conversation is illusive,"the term " illusive " was used in a sense that scarcely agreed with the subsequent context. He should avoid as much as possible the use of or single words to express the patient’s" conversation irrelevant"" and demeanour, such, for instance, as ......
"
vacancy." Above all,
when he has finished writing his certificate, he should be careful to reperuse it. If this had been done after the certifier had written, " has an expression of deep dejection and an unsmiling countenance," it is prohable he would have struck out the latter sentence as being superfluous. (To be continued.)
NOTES OF A CASE OF HYPERPYREXIA.1 BY G. H. PHILIPSON, M.A., M.D. CANTAB.,
F.R.C.P.L.,
SENIOR PHYSICIAN TO THE NEWCASTLE-UPON-TYNE INFIRMARY; PROFESSOR OF MEDICINE IN THE UNIVERSITY OF DURHAM.
A.
vant,
B-, aged twenty-three, unmarried, was
admitted into the
a
domestic
ser-
Newcastle-upon-Tyne Infirmary,
under my care, on July 4th, 1879. From information obtained from her mother, the patient’s life during the past three years had been one of difficulty and hardship. In former years the patient’s parents had been in good circumstances, but through misfortune their children had been obliged to enter service to gain their livelihood. Three years ago the patient had suffered from an attack of rheumatic fever, and then her medical attendant had been obliged to have recourse to narcotic remedies, but had strictly enjoined that she had not to take more than was absolutely necessary to relieve her suffering. Contrary, 1
A paper read at the Northumberland and Durham Medical
Society.
642
however, to his injunctions, she had taken them in large she was much eased. After repetition, however, the effect quantities, and suffered in health in consequence thereof. was less marked, yet she was always most solicitous for the She also habitually would drink spirits of camphor, eau de administration, and became much excited if it was post. Cologne, or anything spirituous in nature. She obtained poned, a course which was considered expedient. On July 24th the temperature in the left axilla was large quantities of chlorodyne and other narcotic preparations unknown to her parents. She could not remain easy 117°, the highest recorded. On this day, in the right for more than half an hour without taking something stimu- axilla, the temperature was 110°, and in the mouth 102°, the left axilla was again lating or sedative in nature. She pawned silver articles and On July 28th the temperature in linen goods, and even her own clothes, to obtain chlorodyne. 117°, whereas in the right axilla it was 114°, and in On July 29th the temperature in the She sometimes would lie for hours in a deep sleep, and then the mouth 112°. would become frenzied, threatening to make an end of her- right axilla was 115°, the highest recorded in this situ. self. If she was not able to obtain chlorodyne or some other tion, whereas in the left axilla it was 110°, and in the narcotic or stimulant, she became very depressed. According mouth 116°, the highest recorded in this situation. to her own version, she took these substances for the purpose Respecting the precautions taken as to the thermometric of relieving the severe pain from which she suffered. She observations, it may be stated that the thermometers were admitted that she had taken as much as five teaspoonfuls of placed and removed by the clinical clerk, and often under Collis Browne’s chlorodyne at one time. the direct supervision of the senior house-surgeon. Further,that In March, 1877, she was three weeks confined to bed, on account of the excessively high temperature three thermo. with a severe pain in her left side, the severity of which, meters of greater range than usual were specially obtained upon several occasions, produced fainting. The pain became from Brady and Martin of Newcastle-upon-Tyne, and em. more severe, especially after movement or exertion, and in ployed. These three thermometers were fixed at the same
order to obtain relief she resorted to a mixture of ether, ammonia, and opium, which she was in the habit of taking, .and without which she said she could not exist. Her sight at this time would become dim, and for days she was almost blind. Her medical attendant becoming alarmed lest any hurtful result might arise from the careless self-administration of these uncertain medicines, forbade the chemist to supply her with them. However, it was discovered that subsequently she had procured the same articles from other chemists. The patient was a young woman of medium stature, stout and of pale sallow complexion. Her countenance was dull and heavy; she was inert, easily excited, and highly sensitive. She complained of great pain in the chest and back, which was greatly intensified when the cuticular surface was touched. The pain was more especially associated with the intercostal muscles, was constant and very severe, and was In the middle of worse at night and in the early morning. the sternal region, in the left axilla and at the left side of the vertebral column, the tenderness was extreme. There was general hyperæsthesia of the surface, but the sensitiveness was most marked over the back and especially the left side. The skin generally was hot and dry; during the night, and at times during the day, she sweated profusely; the sweat was very sour and disagreeable in odour, and was strongly acid in reaction. She complained of great thirst, the tongue was thickly coated, micturition was difficult, and sometimes for a whole day no urine was voided. The urine was very dark, contained a copious sediment composed of urates and phosphates; its reaction was strongly acid, specific gravity 1030, and contained neither albumen nor sugar. The bowels were constipated. The catamenia had been absent for four months. The heart-sounds, base and apex, were sharp, but were without murmur; no friction,
other adventitious sound, was The pulse was 84, and the respirations were 18 in the minute. The case was regarded as one of hysteria, associated with amenorrhoea and intercostal neuralgia. She was placed in bed between blankets, and was ordered the milk diet, consisting of three pints of milk and boiled rice, with two bottles of potash-water, each day. She was also prescribed the compound iron and aloes mixture, three times each day. During the first’ few days after her admission, there was not anything particular to note concerning her state, with the exception of the temperature, which became abnormally high. On the evening of July 7th it was 101° F., and on the evening of the 9th it became 112°. The following morning the temperature was 1l2°, and on the evening of the llth it was again 101°. For the next three days the temperature remained between 100° and 103°. On the evening of the 16th the temperature again rose to 111°, and on the and on the evening of morning of the 18th it fell the same day it rose to 112°. Three days after her admission, on account of the very high temperature and of the increased severity of the pain, Dr. J. D. Dixon, the senior house-surgeon, deemed it expedient to substitute for the iron and aloes mixture, twenty grains of the salicylate of soda in an ounce of water every four hours. Notwithstanding the continuation of the salicylate of soda, the pain became so intense that it was decided to administer morphia hypodermically. At first one-quarter of a grain of the acetate of morphia was employed, by which
pleuritic, heard upon auscultation.
pericarditic
or
or
to 100°,
time, one being placed in the mouth and one in each of the The temperatures in the evening were always axillae. taken previous to the administration of the hypodermic in. jection. During the time the thermometers were in posi. tion a nurse was placed at the patient’s bedside, and was instructed to watch carefully for, and to prevent any, movement of the arms of the patient. Occasionally the patient was sullen and obstinate, and it was impossible to persuade her to allow the temperature to be taken. On July 26th the salicylate of soda was omitted, andshe was prescribed ten grains of the sulphate of quinine, with diluted sulphuric acid and water, three times each day. At this time the sour smell of the perspiration became more intense, the hands were unsteady, and the skin com. menced to peel off the fingers. On the surface of the trunk a roseolous eruption was also noticed. Her lower extremi. ties were cold and she had shiverings. She also complained of severe pain in the head and face. For several nights she was very violent, and caused much disturbance in the ward. As she continued to complain much of the pain in her head and face, on July 28th four decayed molar teeth were extracted. During their extraction she remained perfectly quiet. Shortly afterwards she said, "No one knows what a woman can do when she is determined," and then she fainted. During the remaining days of her stay in the hospital she became exceedingly troublesome, and gave rise to much di. comfort to the other patients, so much so that it was neces. sary for her mother to be sent for, and to be requested to She threatened to make remove her from the infirmary. away with herself, and required constant and most careful watching. On the evening preceding her departure the temperature was 98°, while five days before it had been 117’. The temperature of the atmosphere during the whole time was always between 50° and 60°. About the middle of September, 1879, the patient reo turned to the infirmary to visit a friend in the female ward. From the nurse’s account, she appeared to be in good health, and looked well. Remarks.-As has been recounted, upon admission the diagnosis was entered as hysteria, associated with amenor. rhoea and intercostal neuralgia, and the sequence of events shows that the view taken was correct. The treatment was ordered accordingly. Subsequently, however, when the excessively high temperature was registered, the acuteness and the severity of the suffering indicated the propriety of the administration of remedies antipyrexial in nature; but, as was clearly manifested, without any distinctive influence, The most important point of interest unquestionably was the excessively high temperature. The highest temperature registered was 117°, 19° above the normal temperatureof health. Occasionally cases of very high temperature have been recorded. Of such, excluding those the result of spinal injury, or after surgical operation, the following may be
specified.
Wunderlich2 " refers to a case, in a girl aged eighteen. who was often attacked with partial hyperæmias, urticoic eruptions, local sweatings, and very changeable and varied symptoms in different internal organs. Besides this, at other times than the local hyperæemias of the skin, she ex. hibited all over the surface of the body, from 1/5° to ½° C. 2
Medical Thermometry, p. 166.
643 in the vagina, The body was that of a young woman about twentyright axilla, as well as in the right groin, there was a two years of age, well-nourished. There was no sign of higher temperature than in the left, the dif- decomposition ; the colour of the skin all over the body persistently The was of a light olive. On the body being opened in the lerence being sometimes as much as 1° C. (= 2.7° F.) highest temperature in this case was 103’1° Fahr. This very usual manner by a longitudinal incision down the median remarkable behaviour of the temperature, which lasted almost line from the ensiform cartilage to the pubis, a layer of fat a year, could scarcely mean anything else but a disturbance was observed about one inch and a half thick, of a yellow of the vaso-motor nervous system, which, whilst it affected colour, darker than usual. On opening the cavity of the both sides, affected the right much more than it did the left." abdomen a rush of a considerable quantity of air took place, Dr. Graham Steel3 of Manchester has recounted a case and on the intestines being exposed the presence of acute that was under his care in the Manchester Royal Infirmary, inflammation could be noticed in the pinky colour and in a female, aged twenty, suffering from hysteria, in whom almost universal glueing together of the intestines with the temperature was over 1164°. coagulable lymph, with here and there a patch of redness, Dr. Horatio Donkin,4 of the Westminster Hospital, re- and about three pints of grumous serous fluid of a brownish ported that, in a female nurse, aged nineteen, during an dirty red. The serous covering of the liver was dull-looking
(= 36’ to -9’ Fahr.) higher temperature than in the
attack of enteric fever, the temperature was over 111°. The other points of interest, in reviewing the case under consideration, would appear to be the non-persistent character of the hyperpyrexial condition, its want of uniformity over the surface of the body, and the slight prejudicial influence of the condition upon the patient. The non-persistent character of the hyperpyrexial condition was very remarkable, and would appear to be of significant importance in estimating the amount of actual danger to the sufferer. Often the exaltation of temperature was of very short duration : a second observation taken very shortly after the registration of a high degree might again be high, or, on the contrary, be of a lower degree, or even be the normal temperature of 98°. Respecting the want of uniformity of the temperature over the surface of the body, it was no unusual circumstance for the difference to amount to several degrees. As an illustration of this anomaly the following instance of the state may be referred to. On the ?4tli of July the temperature in the left axilla was 117°, that in the right axilla was 110°, and that in the mouth was 102’. This non-correspondence was no unusual circumstance. It was also distinctly associated with a corresponding difference in the hyperaesthesia. The exaltation of sensitiveness was generally most marked on the left side of the spine, the left side of the thorax, and the left arm. This want of uniformity of the temperature, conjoined with a difference in the hyperaesthesia, may be inferred to be another indication that the individual was in no imminent danger. Regarding the apparently slight prejudicial influence of the high temperature upon the state of the patient, it is to be remembered that while the temperature was so increased as to be considered almost incompatible with life, and while she was reeking in perspiration, her mind was unclouded, and she answered questions quite coherently, the only alteration in her physical condition being that of peevishness and waywardness, a statement fittingly described as " hysterical." Another point worthy of allusion is that the pulse and the respiration never altered, the ratio being 4’5 to 1, corresponding with the normal pulse-respiration ratio. This is of diagnostic import, for, in the ordinary pyrexial condition, in which the rise of temperature is persistent, the pulse and the respiration also increase synchronously. The conclusion, therefore, in the contemplation of the ease, is, that in the absence of pericarditis, endocarditis, or other inflammation, the hyperpyrexial condition was the consequence of an influence derived from the vaso-motor nervous system, or a neurosis, and that the many and characteristic manifestations of hysterical state very fittingly indicate that the designation of hysterical neurosis is the
appropriate epithet to apply to the case. For the very complete and extended thermometric record I am indebted to Dr. J. D. Dixon, the senior house-surgeon, and Mr. W. H. Davis, the clinical clerk. For the notes oi the case I have further to express my obligation to Mr. W. H. Davis.
most
and opaque, and looked as if macerated by the fluid ; some of which, no doubt, had escaped from the stomach; on
looking at which, but without removing it,
a brownish-red observed on the front wall of the viscus, a little to the left of the centre. The stomach was carefully removed, and the opening of the ulcer was examined from the inside ; it had the appearance of being of rather long-standing, as there was much thickening of the wall of the organ in the neighbourhood of the ulcer. There were also two other ulcers, rather larger than the one that had perforated the stomach, on the posterior wall, about the same level as the perforation ; they were not so deep as the ulcer in the front, but so little tissue remained that when very lightly felt the wall gave way. The gastric inner surface appeared otherwise healthy. There was observed on the outer surface at the lower part of the stomach a wrinkle, as if the organ was forming the usual hour-glass appearance or contraction that takes place in this disease. The uterus was pale and rather contracted; the ovaries dark-coloured and nodulated, and on cutting into them several cysts were divided, which spurted forth a light-coloured fluid. In the right one a yel-
spot about the size of
a
sixpence
was
lowish cavity was observed, not so large as a corpus luteum, but evidently the product of some inflammatory action. The mesenteric glands were also somewhat enlarged. The rest of the body appeared healthy. There had been no marked symptoms of disease in the patient before, the only observable one being the olive colour of the skin, described above, which had existed for about two months, with loss of appetite, and a slight complaint of pain after food. I think the above fully exemplifies the insidious nature of the disease. Trinity-street. S.E.
A Mirror OF
HOSPITAL PRACTICE, BRITISH
AND
FOREIGN.
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum dissectionum his tori as, tum aliorum, tum proprias colleotas habere, et eomparare.—MoBGASNi De Sed. et Oau8. Morb.,lib.iv. Proaemium.
et se inter
RICHMOND HOSPITAL. CASE OF INGUINAL HERNIA WITH BONE IN DEATH ; REMARKS. (Under the
care
of Dr.
A.
THE INTESTINE ;
Roberts Law.)
A. B-,aged seventy-four, applied at noon Sept. 15th, 1879, for admission to the hospital, having, he said, walked about two miles in great pain. He gave the following history. On the previous Saturday (13th) night CASE OF he went to bed well, and with no particular swelling; PERFORATING ULCER OF THE STOMACH ; when he rose onfeeling Sunday morning he felt ill, and noticed a DURATION OF ACUTE ATTACK, THIRTY HOURS ; tumour in his left groin. He believed he had been ruptured AUTOPSY EIGHTEEN HOURS AFTER DEATH. for three years, because occasionally a small tumour came in BY JOHN LACEY, M.R.C.S. ENG., &c. his groin, which caused him no pain, and always disappeared without assistance. He had never worn a truss nor had THE following case may be of interest to the profession. advice. He was unable to eat anything all Sunday (14th), The patient, up to the time of the attack, was exceptionally and had calls to stool, but was able to pass only frequent healthy and active. one or two small lumps of f:eces, and no flatus. He felt 3 THE LANCET, 1879, p. 271. sick, but neither retched nor vomited. Thinking the 4 Ibid., 1878, p. 678.
on Monday,
Now if this single symptom had been depended upon to prove him insane, and the question of his sanity or insanity had subsequently been inquired into by a court of law, no doubt the medical certifier would have got into serious trouble. 11. He should take into consideration the existence of blindness, deafness, partial paralysis, malformation, defects in speech, loss of teeth, infirmities of temper, peculiarities of gesture, eccentricities of conduct, or in the mode of speech, &c., many of which cause the person to be examined to be somewhat awkward and ungainly in speech and manner, especially if associated with any nervousness. These states are not unfrequently jotted down as proofs of insanity. In one certificate I received was the sentence " a vacant expression as one of the facts indicating insanity, and yet it appeared to be entirely owing to deafness. Deaf persons, even when sane, are frequently listless and vacant, and, moreover, are apt to be suspicious from a belief in thinking they are always being talked about. 12. He should well consider that the element of any change in the habits, conversation, affections, disposition, dress, residence, choice of companions, &c., is of the greatest importance to notice in the certificate. In themselves all the varieties of demeanour and speech may be perfectly natural to the individual, and are therefore perfectly consistent with sanity. If, on the contrary, any of these show a marked change (often a complete antithesis) to his previous condition, they become valuable evidence of insanity. The lower classes of society may be considered as perfectly sane, even when from the force of habit they employ the most coarse and objectionable language ; but The .ame low-life and often obscene utterances emanating from the mouth of a lady, and presenting a strong contrast to her mode and previous style of conversation, would, especially when taken in connexion with other symptoms, be a strong indication of mental impairment. Change in the style of language is well reported in the following extract from a certificate (thepatient was a well-educated gardener) :that he is constantly 2, Facts hearsay. " His wife says using the most violent and obscene language before her and the children, which has never before been his habit." 13. He should be careful to use proper terms to express his meaning. In the two sentences, "incoherence of speech and manner," and "her manner wild and incoherent," the words " incoherence " and " incoherent " used with respect to "manner"are inapplicable. Again, in the sentence " all her conversation is illusive,"the term " illusive " was used in a sense that scarcely agreed with the subsequent context. He should avoid as much as possible the use of or single words to express the patient’s" conversation irrelevant"" and demeanour, such, for instance, as ......
"
vacancy." Above all,
when he has finished writing his certificate, he should be careful to reperuse it. If this had been done after the certifier had written, " has an expression of deep dejection and an unsmiling countenance," it is prohable he would have struck out the latter sentence as being superfluous. (To be continued.)
NOTES OF A CASE OF HYPERPYREXIA.1 BY G. H. PHILIPSON, M.A., M.D. CANTAB.,
F.R.C.P.L.,
SENIOR PHYSICIAN TO THE NEWCASTLE-UPON-TYNE INFIRMARY; PROFESSOR OF MEDICINE IN THE UNIVERSITY OF DURHAM.
A.
vant,
B-, aged twenty-three, unmarried, was
admitted into the
a
domestic
ser-
Newcastle-upon-Tyne Infirmary,
under my care, on July 4th, 1879. From information obtained from her mother, the patient’s life during the past three years had been one of difficulty and hardship. In former years the patient’s parents had been in good circumstances, but through misfortune their children had been obliged to enter service to gain their livelihood. Three years ago the patient had suffered from an attack of rheumatic fever, and then her medical attendant had been obliged to have recourse to narcotic remedies, but had strictly enjoined that she had not to take more than was absolutely necessary to relieve her suffering. Contrary, 1
A paper read at the Northumberland and Durham Medical
Society.
642
however, to his injunctions, she had taken them in large she was much eased. After repetition, however, the effect quantities, and suffered in health in consequence thereof. was less marked, yet she was always most solicitous for the She also habitually would drink spirits of camphor, eau de administration, and became much excited if it was post. Cologne, or anything spirituous in nature. She obtained poned, a course which was considered expedient. On July 24th the temperature in the left axilla was large quantities of chlorodyne and other narcotic preparations unknown to her parents. She could not remain easy 117°, the highest recorded. On this day, in the right for more than half an hour without taking something stimu- axilla, the temperature was 110°, and in the mouth 102°, the left axilla was again lating or sedative in nature. She pawned silver articles and On July 28th the temperature in linen goods, and even her own clothes, to obtain chlorodyne. 117°, whereas in the right axilla it was 114°, and in On July 29th the temperature in the She sometimes would lie for hours in a deep sleep, and then the mouth 112°. would become frenzied, threatening to make an end of her- right axilla was 115°, the highest recorded in this situ. self. If she was not able to obtain chlorodyne or some other tion, whereas in the left axilla it was 110°, and in the narcotic or stimulant, she became very depressed. According mouth 116°, the highest recorded in this situation. to her own version, she took these substances for the purpose Respecting the precautions taken as to the thermometric of relieving the severe pain from which she suffered. She observations, it may be stated that the thermometers were admitted that she had taken as much as five teaspoonfuls of placed and removed by the clinical clerk, and often under Collis Browne’s chlorodyne at one time. the direct supervision of the senior house-surgeon. Further,that In March, 1877, she was three weeks confined to bed, on account of the excessively high temperature three thermo. with a severe pain in her left side, the severity of which, meters of greater range than usual were specially obtained upon several occasions, produced fainting. The pain became from Brady and Martin of Newcastle-upon-Tyne, and em. more severe, especially after movement or exertion, and in ployed. These three thermometers were fixed at the same
order to obtain relief she resorted to a mixture of ether, ammonia, and opium, which she was in the habit of taking, .and without which she said she could not exist. Her sight at this time would become dim, and for days she was almost blind. Her medical attendant becoming alarmed lest any hurtful result might arise from the careless self-administration of these uncertain medicines, forbade the chemist to supply her with them. However, it was discovered that subsequently she had procured the same articles from other chemists. The patient was a young woman of medium stature, stout and of pale sallow complexion. Her countenance was dull and heavy; she was inert, easily excited, and highly sensitive. She complained of great pain in the chest and back, which was greatly intensified when the cuticular surface was touched. The pain was more especially associated with the intercostal muscles, was constant and very severe, and was In the middle of worse at night and in the early morning. the sternal region, in the left axilla and at the left side of the vertebral column, the tenderness was extreme. There was general hyperæsthesia of the surface, but the sensitiveness was most marked over the back and especially the left side. The skin generally was hot and dry; during the night, and at times during the day, she sweated profusely; the sweat was very sour and disagreeable in odour, and was strongly acid in reaction. She complained of great thirst, the tongue was thickly coated, micturition was difficult, and sometimes for a whole day no urine was voided. The urine was very dark, contained a copious sediment composed of urates and phosphates; its reaction was strongly acid, specific gravity 1030, and contained neither albumen nor sugar. The bowels were constipated. The catamenia had been absent for four months. The heart-sounds, base and apex, were sharp, but were without murmur; no friction,
other adventitious sound, was The pulse was 84, and the respirations were 18 in the minute. The case was regarded as one of hysteria, associated with amenorrhoea and intercostal neuralgia. She was placed in bed between blankets, and was ordered the milk diet, consisting of three pints of milk and boiled rice, with two bottles of potash-water, each day. She was also prescribed the compound iron and aloes mixture, three times each day. During the first’ few days after her admission, there was not anything particular to note concerning her state, with the exception of the temperature, which became abnormally high. On the evening of July 7th it was 101° F., and on the evening of the 9th it became 112°. The following morning the temperature was 1l2°, and on the evening of the llth it was again 101°. For the next three days the temperature remained between 100° and 103°. On the evening of the 16th the temperature again rose to 111°, and on the and on the evening of morning of the 18th it fell the same day it rose to 112°. Three days after her admission, on account of the very high temperature and of the increased severity of the pain, Dr. J. D. Dixon, the senior house-surgeon, deemed it expedient to substitute for the iron and aloes mixture, twenty grains of the salicylate of soda in an ounce of water every four hours. Notwithstanding the continuation of the salicylate of soda, the pain became so intense that it was decided to administer morphia hypodermically. At first one-quarter of a grain of the acetate of morphia was employed, by which
pleuritic, heard upon auscultation.
pericarditic
or
or
to 100°,
time, one being placed in the mouth and one in each of the The temperatures in the evening were always axillae. taken previous to the administration of the hypodermic in. jection. During the time the thermometers were in posi. tion a nurse was placed at the patient’s bedside, and was instructed to watch carefully for, and to prevent any, movement of the arms of the patient. Occasionally the patient was sullen and obstinate, and it was impossible to persuade her to allow the temperature to be taken. On July 26th the salicylate of soda was omitted, andshe was prescribed ten grains of the sulphate of quinine, with diluted sulphuric acid and water, three times each day. At this time the sour smell of the perspiration became more intense, the hands were unsteady, and the skin com. menced to peel off the fingers. On the surface of the trunk a roseolous eruption was also noticed. Her lower extremi. ties were cold and she had shiverings. She also complained of severe pain in the head and face. For several nights she was very violent, and caused much disturbance in the ward. As she continued to complain much of the pain in her head and face, on July 28th four decayed molar teeth were extracted. During their extraction she remained perfectly quiet. Shortly afterwards she said, "No one knows what a woman can do when she is determined," and then she fainted. During the remaining days of her stay in the hospital she became exceedingly troublesome, and gave rise to much di. comfort to the other patients, so much so that it was neces. sary for her mother to be sent for, and to be requested to She threatened to make remove her from the infirmary. away with herself, and required constant and most careful watching. On the evening preceding her departure the temperature was 98°, while five days before it had been 117’. The temperature of the atmosphere during the whole time was always between 50° and 60°. About the middle of September, 1879, the patient reo turned to the infirmary to visit a friend in the female ward. From the nurse’s account, she appeared to be in good health, and looked well. Remarks.-As has been recounted, upon admission the diagnosis was entered as hysteria, associated with amenor. rhoea and intercostal neuralgia, and the sequence of events shows that the view taken was correct. The treatment was ordered accordingly. Subsequently, however, when the excessively high temperature was registered, the acuteness and the severity of the suffering indicated the propriety of the administration of remedies antipyrexial in nature; but, as was clearly manifested, without any distinctive influence, The most important point of interest unquestionably was the excessively high temperature. The highest temperature registered was 117°, 19° above the normal temperatureof health. Occasionally cases of very high temperature have been recorded. Of such, excluding those the result of spinal injury, or after surgical operation, the following may be
specified.
Wunderlich2 " refers to a case, in a girl aged eighteen. who was often attacked with partial hyperæmias, urticoic eruptions, local sweatings, and very changeable and varied symptoms in different internal organs. Besides this, at other times than the local hyperæemias of the skin, she ex. hibited all over the surface of the body, from 1/5° to ½° C. 2
Medical Thermometry, p. 166.
643 in the vagina, The body was that of a young woman about twentyright axilla, as well as in the right groin, there was a two years of age, well-nourished. There was no sign of higher temperature than in the left, the dif- decomposition ; the colour of the skin all over the body persistently The was of a light olive. On the body being opened in the lerence being sometimes as much as 1° C. (= 2.7° F.) highest temperature in this case was 103’1° Fahr. This very usual manner by a longitudinal incision down the median remarkable behaviour of the temperature, which lasted almost line from the ensiform cartilage to the pubis, a layer of fat a year, could scarcely mean anything else but a disturbance was observed about one inch and a half thick, of a yellow of the vaso-motor nervous system, which, whilst it affected colour, darker than usual. On opening the cavity of the both sides, affected the right much more than it did the left." abdomen a rush of a considerable quantity of air took place, Dr. Graham Steel3 of Manchester has recounted a case and on the intestines being exposed the presence of acute that was under his care in the Manchester Royal Infirmary, inflammation could be noticed in the pinky colour and in a female, aged twenty, suffering from hysteria, in whom almost universal glueing together of the intestines with the temperature was over 1164°. coagulable lymph, with here and there a patch of redness, Dr. Horatio Donkin,4 of the Westminster Hospital, re- and about three pints of grumous serous fluid of a brownish ported that, in a female nurse, aged nineteen, during an dirty red. The serous covering of the liver was dull-looking
(= 36’ to -9’ Fahr.) higher temperature than in the
attack of enteric fever, the temperature was over 111°. The other points of interest, in reviewing the case under consideration, would appear to be the non-persistent character of the hyperpyrexial condition, its want of uniformity over the surface of the body, and the slight prejudicial influence of the condition upon the patient. The non-persistent character of the hyperpyrexial condition was very remarkable, and would appear to be of significant importance in estimating the amount of actual danger to the sufferer. Often the exaltation of temperature was of very short duration : a second observation taken very shortly after the registration of a high degree might again be high, or, on the contrary, be of a lower degree, or even be the normal temperature of 98°. Respecting the want of uniformity of the temperature over the surface of the body, it was no unusual circumstance for the difference to amount to several degrees. As an illustration of this anomaly the following instance of the state may be referred to. On the ?4tli of July the temperature in the left axilla was 117°, that in the right axilla was 110°, and that in the mouth was 102’. This non-correspondence was no unusual circumstance. It was also distinctly associated with a corresponding difference in the hyperaesthesia. The exaltation of sensitiveness was generally most marked on the left side of the spine, the left side of the thorax, and the left arm. This want of uniformity of the temperature, conjoined with a difference in the hyperaesthesia, may be inferred to be another indication that the individual was in no imminent danger. Regarding the apparently slight prejudicial influence of the high temperature upon the state of the patient, it is to be remembered that while the temperature was so increased as to be considered almost incompatible with life, and while she was reeking in perspiration, her mind was unclouded, and she answered questions quite coherently, the only alteration in her physical condition being that of peevishness and waywardness, a statement fittingly described as " hysterical." Another point worthy of allusion is that the pulse and the respiration never altered, the ratio being 4’5 to 1, corresponding with the normal pulse-respiration ratio. This is of diagnostic import, for, in the ordinary pyrexial condition, in which the rise of temperature is persistent, the pulse and the respiration also increase synchronously. The conclusion, therefore, in the contemplation of the ease, is, that in the absence of pericarditis, endocarditis, or other inflammation, the hyperpyrexial condition was the consequence of an influence derived from the vaso-motor nervous system, or a neurosis, and that the many and characteristic manifestations of hysterical state very fittingly indicate that the designation of hysterical neurosis is the
appropriate epithet to apply to the case. For the very complete and extended thermometric record I am indebted to Dr. J. D. Dixon, the senior house-surgeon, and Mr. W. H. Davis, the clinical clerk. For the notes oi the case I have further to express my obligation to Mr. W. H. Davis.
most
and opaque, and looked as if macerated by the fluid ; some of which, no doubt, had escaped from the stomach; on
looking at which, but without removing it,
a brownish-red observed on the front wall of the viscus, a little to the left of the centre. The stomach was carefully removed, and the opening of the ulcer was examined from the inside ; it had the appearance of being of rather long-standing, as there was much thickening of the wall of the organ in the neighbourhood of the ulcer. There were also two other ulcers, rather larger than the one that had perforated the stomach, on the posterior wall, about the same level as the perforation ; they were not so deep as the ulcer in the front, but so little tissue remained that when very lightly felt the wall gave way. The gastric inner surface appeared otherwise healthy. There was observed on the outer surface at the lower part of the stomach a wrinkle, as if the organ was forming the usual hour-glass appearance or contraction that takes place in this disease. The uterus was pale and rather contracted; the ovaries dark-coloured and nodulated, and on cutting into them several cysts were divided, which spurted forth a light-coloured fluid. In the right one a yel-
spot about the size of
a
sixpence
was
lowish cavity was observed, not so large as a corpus luteum, but evidently the product of some inflammatory action. The mesenteric glands were also somewhat enlarged. The rest of the body appeared healthy. There had been no marked symptoms of disease in the patient before, the only observable one being the olive colour of the skin, described above, which had existed for about two months, with loss of appetite, and a slight complaint of pain after food. I think the above fully exemplifies the insidious nature of the disease. Trinity-street. S.E.
A Mirror OF
HOSPITAL PRACTICE, BRITISH
AND
FOREIGN.
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum dissectionum his tori as, tum aliorum, tum proprias colleotas habere, et eomparare.—MoBGASNi De Sed. et Oau8. Morb.,lib.iv. Proaemium.
et se inter
RICHMOND HOSPITAL. CASE OF INGUINAL HERNIA WITH BONE IN DEATH ; REMARKS. (Under the
care
of Dr.
A.
THE INTESTINE ;
Roberts Law.)
A. B-,aged seventy-four, applied at noon Sept. 15th, 1879, for admission to the hospital, having, he said, walked about two miles in great pain. He gave the following history. On the previous Saturday (13th) night CASE OF he went to bed well, and with no particular swelling; PERFORATING ULCER OF THE STOMACH ; when he rose onfeeling Sunday morning he felt ill, and noticed a DURATION OF ACUTE ATTACK, THIRTY HOURS ; tumour in his left groin. He believed he had been ruptured AUTOPSY EIGHTEEN HOURS AFTER DEATH. for three years, because occasionally a small tumour came in BY JOHN LACEY, M.R.C.S. ENG., &c. his groin, which caused him no pain, and always disappeared without assistance. He had never worn a truss nor had THE following case may be of interest to the profession. advice. He was unable to eat anything all Sunday (14th), The patient, up to the time of the attack, was exceptionally and had calls to stool, but was able to pass only frequent healthy and active. one or two small lumps of f:eces, and no flatus. He felt 3 THE LANCET, 1879, p. 271. sick, but neither retched nor vomited. Thinking the 4 Ibid., 1878, p. 678.
on Monday,