CHAPTER VIII.

IDIOTCY AND INSANITY, WITH CASES.

As epilepsy is a much graver disease than hysteria, so is the sequel of the former—dementia or idiotcy—much more permanent and difficult to be removed by treatment than insanity, which is the ordinary sequel of hysteria.

I shall give but one case of idiotcy, because I regret to say that I have never yet been able to thoroughly restore the mental powers in any patients suffering from this dreadful affliction. Epilepsy is such a chronic disease, and seems to me to produce not only weakening of the mind, but to cause it to be often entirely lost, that, although we may get, as in the following case, a temporary re-kindling of the mental energies, I fear we are not yet able to give much hope of complete recovery. Even here, however, I have such faith in the efficacy of perseverance in constant watching, that I am almost inclined to believe that, had this patient been in a condition of life to ensure vigilant medical supervision for a lengthened period after operation, we might at last have succeeded in, if not complete, at least, much creator restoration than in a public institution, or to those in humble circumstances, the surgeon is in a condition to promise.

CASE XLII. EPILEPTIC FITS, WITH COMPLETE IDIOTCY—OPERATION—GREAT TEMPORARY RELIEF, BUT NOT PERMANENT BENEFIT.

Mary J., æt. 19, single; admitted into the London Surgical Home Feb. 15, 1864.

This patient was brought to me by Dr. Marley, with the following account:—

“Has the appearance of a child of 10 or 12 years old; mammæ not developed; has had epileptic fits ever since 12 years of age. Is now almost idiotic; stares vacantly; slobbers at the mouth; passes her motions anywhere, without regard to common decency, and cannot retain her urine. I find from her mother that she is incessantly irritating her genitals. Her fits vary in frequency, from two or three a day to four or five a week. Being satisfied of the cause of her fits, I sent her to you.”

_History_, taken at the Home from her mother.—Had perfect health until she reached her eleventh year; was forward in her lessons, and well educated for her age and position. At this time she was suddenly seized with a severe fit, for which no cause could be assigned. A period of two years elapsed before she had a second, when, being placed under medical treatment for eighteen months, she had great relief. Since the expiration of that time to the present she has constantly suffered from fits.

Her intellect did not begin to weaken until two years since, but she ceased growing and learning after the first attack. At this time she does not know her right hand from her left; does not know her mother, and shows no signs whatever of ordinary intelligence. From being cleanly as a child, is now most filthy—in fact, is in every sense an idiot.

Has never menstruated.

_On examination_—although, as stated by Dr. Marley, the mammæ were very rudimentary—there was full development, and indeed abnormal hypertrophy, of the external genitals.

Feb. 18. The usual operation performed, under chloroform. The hands to be restrained, and the patient most carefully watched.

Feb. 19. Has passed a good night, and is quiet.

Feb. 23. Has been very drowsy since the operation. To-day asked for food for the first time, and showed some signs of intelligence.

Feb. 26. Gave rational answers to several questions which were asked her. Also remembers from day to day any promises of delicacies of diet or money.

March 1. Passed a good night; feels free from pain. Was given some printed cards, which she read—_the first time for nine years_.

March 2. Improving much. Is much more modest in her behaviour, but still passes her excretions without regard to time or place. Notices passing events, and remembers names and faces.

March 3. Has given sensible and somewhat witty replies to various questions asked her in the presence of about twenty medical gentlemen, who to-day came to see the operation. When moneys were given her, she at once told their different relative value.

March 4. Morning: Seems no worse for the excitement of yesterday.—Evening: Had a slight fit.

March 5. A little heavy and stupid to-day. Somewhat irritable and obstinate.

March 6. Much better. Has a daily clearer notion of right and wrong. Likes books with pictures and large print. When she comes to hard words, she asks the meaning, like a child, but cannot always grasp the meaning of an explanation.

March 8. Not quite so well to-day. Had a slight epileptic fit this evening, followed by a very severe one in two hours.

March 9. Again much better, but irritable.

March 12. Two fits.

March 16. Not so well: another fit to-day.

She from this time seemed to retrograde; and on the 4th of April was discharged as incurable.

It will be recollected how, at the end of the chapter on Hysteria, I gave three cases of extreme nervous irritability, with sleeplessness, and tendency to an unhinging of the mental equilibrium. We now come to insanity itself. It would be vain to talk of the varieties of forms in which this state may be seen, when produced by abnormal peripheral irritation of the pudic nerve. It is, however, worthy of notice how each history seems to tell its own explanation of the cause; and after the first few days of treatment, when excitement, caused by irritation from the wound and a natural repugnance to restraint, has passed off, how rapid is the improvement, and how permanent is the result. I have no hesitation in saying that in no case am I so certain of a permanent cure as in acute nympho-mania; for I have never after my treatment seen a recurrence of the disease, whereas, under medical treatment, of how short duration is but too frequently the benefit.

CASE XLIII. INCIPIENT SUICIDAL MANIA—MANY YEARS’ GRADUAL ILLNESS—OPERATION—CURE.

R. T., æt. 39, single; admitted into the London Surgical Home Oct. 22, 1861.

_History._—Has been ailing for many years, and given great trouble and anxiety to her friends. For some time past she has been very strange in her manner, very restless, never quiet, constantly wakeful, threatening suicide, talking to people, even perfect strangers, of her ailments and their causes, of which she is fully conscious. Was formerly modest and quiet.

_On examination_, she is a fine woman, of restless appearance and manner; eye wandering and unsteady; pupil dilated. The cause of her mental derangement being obvious, on

Oct. 24 the usual operation was performed.

The improvement in her mental and bodily health was wonderful: she gained flesh, and became cheerful and modest. She was discharged six weeks after admission.

When heard of in February, 1863, this patient continued quite well.

The first case of actual insanity that came under my care was a patient of Dr. Warren Diamond, then resident in his private asylum. I cannot do better than transcribe the account which he sent me with the following note:—

“Effra Hall, Brixton, S.

“DEAR SIR,—A month having elapsed since you gave up your patient, I forward some particulars of the case, and shall be glad to answer more fully any special time or state you would like to know more about. You will, perhaps, be able to pick something out of this rambling account that may be interesting to you. Hoping you will excuse omissions, &c.

“Believe me, yours faithfully,

“WARREN H. DIAMOND.”

“I. Baker Brown, Esq.”

CASE XLIV. SEVERAL YEARS’ ILLNESS—TWO MONTHS’ INSANITY—OPERATION—CURE.

“Miss E. R., æt. 34, single; no occupation, living with her friends; hair light reddish-brown; face set and vacant, with an occasional pained expression; eyes fixed and dull; extremities damp and cold; stature moderate and well formed. Has for several years past been looked on by her friends as different from others—strange and eccentric. Would go out and walk away into the country alone for miles, and come back exhausted. When friends called, would start up and run round the garden, or to the top of the house and back again, giving no reason for it but that she must do it. Always exceedingly irritable and passionate. Unless some excitement was going on, was listless and unable to rouse herself. When at parties, was so forward and open in her manners, that she was generally avoided by gentlemen. _Never had an offer of marriage._ Her mother died about a year and a half ago, but she took no notice of the occurrence, and was consequently remarked on by her friends. Since then she has been getting more strange and peculiar. About February last, a sister told her, in joke, that if she did not take care she would soon become a fit subject for Dr. Diamond, little thinking how soon it would happen. She recently made enemies of old friends, so that her brothers could not make out why they fell off. Would sit or stand without noticing them when they called; and asked them what they wanted that they came to her house (she was the eldest of the family).

“I was consulted about her in the end of March, but had then none of her previous history. She was vacant and dreamy; talked of flowers which she called her friends; said ‘people’s faces were masks; that she was quite unable to rouse or employ herself, as she was changed;’ very uncertain in appetite, going a day without her food; not sleeping at night, and for the last few nights showing such great excitement and passion, that her sisters were required to sit up with her.

“I recommended change along the south coast, with sea-bathing, &c. She did not improve; and the attendant informing me of a constant irritation of the vulva, lotions were used, but without benefit. Her general health and appetite improved; but not the mind. She could not sleep, and would not bear narcotics; _stimulants acted as narcotics_, but soon lost their effect.

“Bowels regular; pulse small and slow; action of heart being irritable, and not corresponding at all times to the power or quantity of the pulse. She sits up in bed, nursing the pillow, and talking to it as if it were a baby; says ‘that she died last Sunday’—‘is lost’—‘is buried.’

“When out of doors, great difficulty is experienced in getting her in again; she wishes to wander away, without aim or purpose. Having given my opinion to her friends, I was authorized to admit her April 18, 1861. Before she left home, she continued calling out, ‘Take me to a mad-house! take me quick, or I shall never get well!’ She persisted in saying ‘she was dead,’ and ‘she felt buried.’ Answers in monosyllables. Her pupil is contracted and fixed. At night she does not sleep, and is in such a continual state of excitement that the attendant cannot sleep with her. Has lost all natural modesty in manner and speech. Is not blasphemous. Before me is perfectly reserved and correct in her manner. When I ask questions, she will, after a pause, answer in monosyllables, or repeat the question over and over again, as if trying to grasp the meaning and ally her thoughts. Unless walked about, will stand for hours in one place, gaping, yawning, and throwing her arms about listlessly. She was in this state when you saw her, and from what you told me of your experience of the operation and its results, I was led to infer relief from it in this case, as the delusion of having died on a certain day was movable and could be reasoned away; but the heavy oppressed feeling still made her say, ‘But if I am not dead, I am lost, or changed,’ and naturally led back to the idea. I ascribed the state of her mind to weakening of the body, and general nervous irritation caused by long-continued reflex excitation; and I believed that if the source of irritation could be removed, her mental health would follow as her blood became healthy, and fit to make reparation.

“I was led to think more of her uterine state from her expression of pain when she was walked about, and she was reported by the nurse as always complaining of her back, at the lower part, and of great tenderness on pressure over the ovaries.

“May 27, 1861. You operated on her, she being under the influence of chloroform. She was naturally restless afterwards, not understanding why she was kept in bed. Profuse menstruation came on in the evening, which had not happened for four months previously, and then always very scanty and with much pain. Half an ounce of laudanum, with oil, was rubbed into her chest during four hours; she did not, however, sleep, but continued moaning all night.

“May 28. Easier, and more herself—takes her food.

“May 29. Slept well last night, without opiates; says she shall now get well and be able to go home; answers questions more readily, and makes longer replies. _Pupil dilated and acts slowly._ Her nurse says she is quite altered in every way, and compares the change in her mind since the operation to ‘dividing the tightened strings of a fiddle, and letting them all loose.’

“June 2. Left her bed; is still menstruating; appears cheerful; asks questions now, and converses for short periods; has done a few stitches of needlework; says nothing about ‘being lost or dead’ since the operation. Surface of body and extremities warm. Freaky, anxious look about her eyes and nose gone. Laughs and jokes. Says ‘she has been in a dream,’ ‘that things now seem light,’ and ‘that she means to get well.’

“July 3. She has gradually improved and become more natural in her habits and ideas; sleeps soundly every night; takes her meals well; walks about without compulsion; takes a pride in making herself neat, and has washed and dressed herself ever since she left her bed; is perfectly modest in manner and conversation. Her friends remark on the great improvement in her mind, she having had no delusions. Her mental state is, however, weak—what might better be called foolish, with some amount of wilful obstinacy. The family medical attendant, and, in fact, every one who has been in her company, notice the extraordinary change that has taken place in her since your operation. I think the present state of her mind results from the long-continued exhaustion, and to restore it will be a matter of time. Her pupils act naturally.”

I have often since heard of this lady as perfectly well, and as never having had recurrence of illness. In 1865 I was consulted on the propriety of marriage, to which I gave my full consent.

CASE XLV. ACUTE INSANITY—TWO MONTHS—OPERATION—CURE.

Miss ——, æt. 17, moderate height, and well formed, hair light golden, grey eyes and fair complexion, came under my care June 19, 1861.

_History_ (taken from her mother).—When ten years old, had inflammation of the womb, and after she recovered began to menstruate. The function continued regularly until about eight months ago, since when the catamenia have appeared every ten days, and, in fact, have been hardly ever absent. In the latter part of last April she left home for change of air, and returned May 15th, when her mother noticed that she was thinner than before her departure, and, on inquiry, it appeared that during the latter part of her stay she had been very excited, at other times very low, sometimes laughing and singing, and requiring port wine and brandy at all times of the day, though generally abstemious, and never taking wine or other stimuli. The first night after her return home she went to one of her sisters’ rooms and began to talk of being married; did not sleep all that night. May 17th. Was found to be rather wild in the morning; was taken out for a drive during the day; did not sleep that night, from constant excitement of the genitals. Had been seen by her ordinary medical attendant, who ordered opiates, but without the effect of giving her sleep. On the 28th, another physician saw her, and ordered opiates, but without effect, as she did not have an hour’s sleep night or day. May 22nd. An eminent authority in female diseases was called in, and also, among other remedies, ordered opiates at night-time, but with no effect. She continued raving and rambling till June 8th, when a physician, who devotes himself to mental diseases, saw her; he said that her mind was not affected, but that her behaviour was caused simply by debility, and ordered wine, eggs, &c., and a _strong opiate_, but without the desired effect.

June 17. Was much worse. The last physician again saw her; said that she was quite mad, must be taken from home, and could never recover. She called her mother “Monsieur le Diable,” and her father “God.” She was constantly irritating her clitoris, and indulged in most immodest behaviour. Was ordered ext. cannabis indicæ, and slept three hours. 19th. No better, and on this day I first saw her; she was then wild in expression of countenance, and on entering the room she addressed me as “Your Majesty,” and said “I was the Queen.” She also asked, “Why has your Majesty condescended to visit me?”

June 21. Before operating, the patient being under chloroform, I made an examination, and found my diagnosis verified by the existence of all the ordinary local symptoms. The hymen was quite absent. (In one of her paroxysms she had stuffed a pocket handkerchief into the vagina.) I performed my usual operation, and immediately administered two grains of opium. She passed a tolerable night, not being noisy, but not sleeping.

June 22. Tolerably quiet. Not aware of what is passing around her, but apparently comfortable. To have broth and milk diet—_no stimulants_.

June 23. Passed a quiet night; but did not sleep much, though she had a grain of opium. Dressing removed. Wound looking well.

June 24. Has not passed quite such a good night—rather noisy.

June 25. Menses came on. Has had a very bad night, and been very troublesome. Chloroform administered to insensibility several times in the course of the day. A liniment, containing seven drachms of soap liniment and one drachm of laudanum, to be rubbed in to the chest constantly. This seemed to quiet her.

June 27. Has passed a rather better night, sleeping a little; but towards morning she became very noisy, and chloroform was again administered. To have the liniment rubbed in at night.

June 28. A much better night.

June 29. Has had a very fair night; and from this time she gradually improved, sleeping well and being generally quite rational; her appetite also improved.

July 7. Menstruation occurred, and she was not so well for a day or two, as she attempted to irritate the wound; but, being carefully watched, was prevented.

July 10. Catamenia ceased. Is quiet again.

July 11. Went out in a bath chair, and said she enjoyed the airing. From this time she gradually got better, and on the 28th she went into the country for change. Her menses came on five weeks from the last appearance; she was quite quiet all the time. Since then she has menstruated regularly every three weeks, and in normal quantity.

A year after operation she had a slight relapse of melancholy, and fears were entertained that she was again going to be ill; but a brisk purgation of calomel completely dispersed all symptoms.

1866. I have frequently heard of this young lady. She is now in good health, moving in high society, and universally admired.

CASE XLVI. HYSTERICAL HOMICIDAL MANIA—ONE YEAR’S DURATION—OPERATION—CURE.

In December, 1861, Mrs. —— came under my care, by the recommendation of Dr. Forbes Winslow. She gave me the following history of herself:—

_History._—She was 57, and had had four children and two premature labours. The last child was born twenty-three years ago. Twenty months since had an attack of erysipelas in the face, with eruptions on different parts of the body. Has never been well since, and last August had another attack of erysipelas. Is constantly suffering with shiverings, followed by burning heat and sweating, with prickling heat of the skin. For the last year has never slept for more than an hour; always waking with a _start_; feeling frantic, and very hot and flushed. Has a constant feeling that she will be lost eternally, and of this she is constantly speaking.

From her husband I learnt the following:—

After her last confinement, twenty-three years ago, she had puerperal mania, from which she did not completely recover for six months. About a year ago she began to show symptoms of mental derangement, first exhibited in religious subjects, she constantly declaring that her soul was irrevocably lost. About eight months ago she first tried to destroy herself, by endeavouring to jump out of the window, &c., and it was at this time thought advisable to place her in an asylum, where she was kept four months, and when she left she was for a time much better. While an inmate of the asylum, was made to take much exercise, for which her husband says she is always better.

She gradually got worse, and came under the care of Dr. Forbes Winslow, to whom I am indebted for the case. Her husband says that for the last two or three months she has slept pretty well from 10 p.m. till 2 a.m., when she would suddenly wake, and warn him that a “frenzy” was coming on. This frenzy consisted in her rising up, fighting out with her arms, and scratching or tearing any one near her; in the paroxysm the desire was always to destroy her husband. After a few minutes the mania would subside, and be succeeded, first by a kind of stupor, and then very profuse perspirations. One peculiarity about her is, that when in this state she does or says anything foolish, she knows it, and is afterwards very annoyed and ashamed of her conduct. She has a great fear that she will be permanently mad.

The appetite has always been good, though she has said lately that she cannot bear food, and that it always causes a horrid taste in her mouth. She has, in a desultory manner, read many medical works, and fancies that every one of her organs is in some way or other diseased.

_On examination_, she had the appearance of a woman about 60. Her eyes, of a dark grey, were never quiet, and could not look you straight in the face; the pupil was much and constantly dilated. The tongue quite clean, and pulse good. Heart, lungs, and other organs seemed to be healthy. She owned with great shame to long-continued pernicious habits.

Dec. 14. I performed my usual operation.

Dec. 21. Has very much improved, and had no “frenzies” since the operation; sleeps well, and for many hours, but will not own to being better. Complains of her skin being dry, and “burning hot.” It is, however, moist and cool; at times she perspires freely.

Dec. 26. Both husband and nurse consider her much improved. She has been up both yesterday and to-day; sleeps and eats well. She is, however, sulky; says she is very bad, and shall soon die.

A fortnight later she was quite well, being entirely free since the operation from maniacal attacks; but she complained to my son, Mr. Boyer Brown, that I had unsexed her. He answered that nothing of the sort had been done, but that the operation had prevented her from making herself ill. From this time she steadily improved, and walked out with her husband every day, who called on me many weeks later to express his gratitude for the complete restoration of his wife to health; for whereas before his nights were passed in constant fear, rendering his life most wretched, his home was now one of comfort and happiness both night and day.

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.

CASE XLVIII. INCIPIENT MANIA—ONE YEAR’S DURATION—OPERATION—CURE—SUBSEQUENT PREGNANCY.

In 1863, Mrs. S. M., married, mother of three children, æt. 30, came under my care, because she had been suffering for more than a year from menorrhagia, which had gradually affected her mind, causing her to have a great distaste for her husband; so much so, that he and his friends were induced seriously to contemplate a separation. On the first examination, her face indicated mental disturbance, eyes restless, pupils dilated, and manner generally excitable. She told me that she could not sleep at night, complained of constant weary uneasiness in her womb, pain in her back, great pain on defecation, constant desire to micturate. She said she was glad to be away from home, as she made every one around her unhappy. Believed that she would be a permanently insane patient, and never expected to return to her family again.

On more minute examination, I found irritable clitoris and labia, a painful fissure of the rectum, with great relaxation of the sphincter ani, which, on inquiry, was found to be caused by the frequent introduction of her finger, with a view to peripheral irritation. At her own request, she had long been separated _à mensâ_ from her husband, on account of her great distaste for him and cohabitation with him.

I pursued the usual surgical treatment, which was followed by uninterrupted success; and after two months’ treatment, she returned to her husband, resumed cohabitation, and stated that all her distaste had disappeared; soon became pregnant, resumed her place at the head of her table, and became a happy and healthy wife and mother. She was in due time safely delivered, and has ever since remained in perfect health.

_Remarks._—From observations of this case, one feels compelled to say, may not it be typical of many others where there is a judicial separation of husband and wife, with all the attendant domestic miseries, and where, if medical and surgical treatment were brought to bear, all such unhappy measures would be obviated?

A careful perusal of the cases related in the foregoing pages will show that all the theoretical objections mentioned in the introductory chapter, as having been raised against my treatment, have been fully contradicted by facts. Of the permanency of the result, I myself am fully satisfied; and I hope at a future time, by a much larger number of cases, to confirm others in the same opinion.

COX AND WYMAN, PRINTERS, GREAT QUEEN STREET, W.C.

TRANSCRIBER’S NOTES

1. P. 42, changed “prodomata” to “prodromata”. 2. Silently corrected typographical errors and variations in spelling. 3. Archaic, non-standard, and uncertain spellings retained as printed. 4. Footnotes were re-indexed using numbers. 5. Enclosed italics font in _underscores_.