ACUTE MANIA AND MELANCHOLIA AS SEQUELS OF GYNECOLOGICAL OPERATIONS. BY T. GAILLARD THOMAS, M.D. FROM THE MEDICAL NEWS, April 13, 1889. [Reprinted from The Medical News, April 13,1889.] ACUTE MANIA AND MELANCHOLIA AS SEQUEL/E OF GYNECOLOGICAL OPERATIONS} By T. GAILLARD THOMAS, M.D. The object of this paper is to place on record what I think must be a rather remarkable experience as to the occurrence of acute mania and melancholia as sequelae of gynecological operations. Before proceeding with my subject, I desire to call attention to the fact that I do not announce these peculiar and alarming states as complications, or necessarily as results, of operative procedure, but merely as sequels which may or may not be depend- ent upon it. Further, in this connection I would disclaim the position that the operations performed for the relief of diseases peculiar to women are espe- cially liable to such sequences; but all the surgery which I do being of this character, I am forced, as I limit myself to my personal experience, to confine myself to this field. Let me clearly and distinctly define my idea of the conditions entitled acute mania and acute melan- cholia. The former is a sudden, decided, and violent aberration of the intellect, usually following 1 Read before the New York Academy of Medicine, April 4, 1889. 2 THOMAS, a preexisting melancholia of slight character, and marked by mental exaltation, violent and frequent ebullitions of emotional nature, rapid and irregular muscular efforts, and which is usually unattended by a tendency to inflict injury upon the patient herself or her attendants. The eyes are bright and piercing in their glance; the tongue red at the edges and furred at the centre; the pulse rapid, and the tem- perature somewhat, though, in the early stages of the affection, not much elevated. The patient speaks with a sharp, metallic, unsympathetic voice, pitched high, and talks rapidly and incoherently. Acute melancholia is a rapidly developed aberra- tion of the intellect, marked by depression of the mind instead of exaltation. The patient is less ex- cited and less turbulent; sadder, quieter, and more depressed in her bearing. She looks gloomy, and often declares that her death will certainly occur very soon. At times she becomes calm; at others she weeps and bemoans the fact that she is pursued by a Nemesis, in consequence of some crime which she has either committed, or of which she is falsely accused. I shall relate to-night six illustrative cases. Out of these, four were violent, and showed great mental exaltation throughout; two were melancholic in their development, but they were acutely, violently melancholic, bustled about wringing their hands in their busy distress, and after a short illness they died, as did two of the four who presented symp- toms of pure exaltation. ACUTE MANIA AND MELANCHOLIA 3 Case I.—Mary M., aged ■ twenty-one, single, by occupation a cook, had, during the year before I saw her, noticed an abdominal enlargement which had steadily and rapidly increased. During this time she had emaciated very rapidly, was at the time that she came under my care extremely weak and low-spirited, and now felt that, unless relieved very soon, she would die from exhaustion. Physical ex- ploration revealed a large accumulation of fluid in the peritoneum, and, in addition, a round tumor occupying the whole of the left side of the abdomen. Although the case was not looked upon as a favor- able one for operation* it was determined that, since extirpation of the tumor offered the only chance for the saving of life, it should be resorted to. Accord- ingly I undertook the operation. The patient rallied well after it. She was kept upon beef tea, milk, and gruels, and quieted by the administration of opium. Her pulse kept up to about ioo, respira- tion was normal, and nothing existed to excite alarm, except the extreme nervous depression of the patient. She asserted that she would certainly die, and really seemed convinced that such would be the case. With the exception of this symptom, she appeared to be progressing favorably until the seventh night. Then she seemed more than usually nervous and excitable, and desired to see the priest, who was accordingly sent for. On visiting her early on the morning of the eighth day, I found that a great change had come over her during the night. Her eyes were wild and haggard, her face maniacal, her tongue red and dry, and she constantly talked in an incoherent and vio- lent manner, as is so often found to be the case in puerperal mania. As I entered the room she cov- ered her face with the bedclothes, and screamed out 4 THOMAS, that I had leagued with the priest to murder her. Nothing would pacify her, or dissuade her from this view. After soothing her for some time, I suc- ceeded in getting near enough to her to find that the pulse was beating at 160 to the minute. She remained in the maniacal state which I have de- scribed till evening, when she sank into coma and died. No post-mortem.could be obtained. At the time of this patient’s death, now exactly twenty years ago, I regarded the condition which destroyed her life as one of acute septicaemia, a pathological factor which was only then coming into notice, and one of which we knew almost nothing. That I was in error, I am now convinced by long and melancholy familiarity with septicaemia, and my conviction will, I think, be shared by all in this assembly. This case was by far the most rapid that I have ever met with. Its acute stage could not have lasted more than thirty-six or forty hours. Its prodromic, or melancholic, stage had existed ever since the ope- ration. It was in all probability that mental state which made the patient constantly persist in the asseveration that her death was certain. An examination of the membranes of the brain would have been most interesting in this case, but the patient’s family, who were very ignorant people, would not yield to any solicitations in reference to the matter. Case II.—Mrs. X., a wealthy and fashionable lady, came under my care on account of very severe suffering at her menstrual periods. She was thirty- ACUTE MANIA AND MELANCHOLIA. 5 five years of age, the mother of four children, and a stout, well-made, and very handsome woman. Her health was perfectly good except in this respect; as her menstrual periods approached—that is, about five or six days before them—she would begin to suffer such intolerable neuralgic pain in the regions of the ovaries that her life was rendered wretched. She was seen with me in consultation by two of the most eminent general practitioners of this city, and sus- tained by their concurrence, and encouraged by the wishes of her family, I removed the ovaries. She recovered rapidly, but at the end of three weeks a low grade of melancholia developed, which soon took on the form of violent acute mania, marked by tendency to strike her attendants. So violent did she become that I removed her to one of the best lunatic asylums near this city. Here she remained for four or five months, entirely insane. Then she recovered and returned home, and al- though six or eight years have now elapsed she is perfectly well; free, of course, from menstrual troubles, and the ornament and stay of a charming family circle. I have seen her within the past month, and no one would suspect that the well-poised and quiet woman of to-day was ever a lunatic in the wards of an asylum for the insane. Case III.—A Jewess, multipara, aged thirty-five years, entered my service in the Woman’s Hospital and was submitted to the operation of perineorrhaphy. There was nothing peculiar in this operation as to severity, or any other feature, and after it she did perfectly well until the ninth day, when the sutures were removed. At that time she became violently maniacal, talking constantly, jumping out of bed, throwing her arms about, and berating her attend- ants in strong, though not absolutely improper, lan- 6 THOMAS, guage. It proved so utterly impossible to control her that a straight jacket had to be applied. The patient raved violently for four days, and then fell into a comatose condition and died. Case IV.—Mrs. R., a multipara, forty-two years of age, who had for years suffered from retroflexion of the uterus which was marked by profuse men- struation, came to me from Liverpool, England, for the repair of a badly lacerated cervix uteri. The operation was performed at my private hospital, and presented no peculiar features. Five or six days after this Dr. Chambers, my associate in the hos- pital, told me that the patient’s manner struck him as very peculiar, and asked me to observe it closely. But I could detect nothing until some time after re- moval of the sutures, which took place on the ninth day. Then she told me that in a few days she wanted to have a private conversation with me about a terrible crime which she had committed some years ago, and the memory of which had ever since produced the greatest remorse in her mind. Two weeks after operation the patient went to the home of some of her friends in this city, rather odd in her manner and inclined to allude to the myste- rious circumstance of which I have just made men- tion, but still sane in the general acceptation of the term. After remaining away for two weeks, she returned to my hospital, suffering from acute melancholia. She was constantly depressed on account of remorse for a supposed crime; would sit silent for hours; then get up and pace the room slowly and solemnly, wringing her hands, weeping, and bemoaning her sad lot. She continued in this state, gradually growing weaker, for ten days, when she became comatose and died. Uncontrollable insomnia was one of the most marked features of the case. ACUTE MANIA AND MELANCHOLIA. 7 Case V.—Mrs. C., a multipara, sixty-five years old, was submitted by me in my private hospital to amputation of the breast. Even before operation she seemed to be a flighty and eccentric person, but after it all her symptoms were intensified. On the ninth day the sutures were removed, and from this date the patient became greatly depressed, was sure that she could not recover, and wept almost con- stantly. She suffered during the earlier part of her illness from insomnia, and continued to do so until the symptoms of coma began to show themselves. As the state of acute melancholia advanced she would cry bitterly by the hour, refusing to speak, and even to answer questions by nodding the head. She re- fused all nourishment, and for a time was sustained entirely by rectal alimentation. Feeding by the stomach pump was thought of, but rejected, because in the patient’s weak condition the overcoming of the resistance necessary for passing a tube down the oesophagus would have produced a dangerous result. This patient lived for about two weeks after the breaking out of the attack, and then slowly passed into coma, and died. Toward the close of the case the urine became albuminous, and presented hyaline casts, but not earlier. Case VI.—Mrs. M., a widow over sixty years of age, who had in early life borne several children, entered my private hospital to have a cancerous breast removed. Even before the operation, her manner struck both Dr. Chambers and myself as being queer, but the thought that she suffered from any real mental aberration was far from our minds. About a week after the operation she began to grow noisy and irritable, and by the ninth day, when the sutures were removed, she was at times, during the night chiefly, absolutely maniacal. Then periods of 8 THOMAS, perfect calm and lucidity of intellect would occur and last for hours. At the end of three weeks from the time of oper- ation, partly in consequence of her earnest desire, partly because we thought that a change of scene and surrounding would benefit her, she was allowed to return home. Here, in a few days, violent mania developed, and at the time of the present writing the patient is still insane. What her exact condition now is I cannot say, for I have to rely merely upon non-professional reports. There is very little literature extant upon this sub- ject, which until very recently has appeared to at- tract no attention. For obtaining what little there is I am indebted to two of my friends, Dr. Paul F. Munde and Dr. Andrew J. McCosh, who have kindly looked it up for me. Prior to the year 1887 there is nothing. During that year Dr. Edward J. Ill, of Newark, N. J., published a very interesting little pamphlet, embodying his own experience and that of some of our German colleagues, entitled “Acute Psychoses following Gynecological Operations.” Dr. Ill collected the records of ten cases, in which acute mental aberration followed gynecological op- erations. Of these, three occurred in his own prac- tice ; one, a case of acute mania, and another, a case of melancholia, followed ovariotomy; and the third, a case of melancholia, resulted from the perform- ance of a minor operation upon the bladder. All recovered. Reports of the seven cases which follow were all drawn forth by the discussion excited by a paper ACUTE MANIA AND MELANCHOLIA 9 read by Graube before the Berlin Gynecological So- ciety in 1887. One case reported by Graube oc- curred after perineorrhaphy, performed by Paul Ruge, and is entitled by the reporter a case of hypochon- driasis. The second case was reported by Duerelius as following amputation of the cervix. Czempin reported five cases of acute insanity which occurred at Dr. A. Martin’s hospital. Of these, two followed excision of the rectum for carcinoma; one an oper- ation for prolapse of the uterus; one an excision of hemorrhoids, and one followed ovariotomy, which ended fatally on the tenth day, the mania being the cause of death. In the same year Guanck reported a case of severe melancholia following simple perineorrhaphy. . In 1888 Werth, of Kiel, read a paper on this sub- ject before the German Gynecological Society at Halle, in which he stated that in three hundred op- erations on the female genital tract he had in six instances observed psychical disturbances, due to the operation. In two cases the operation was total extirpation of the uterus; in two removal of the ovaries, and in two ovariotomy. One patient was violently excited before the operation. In five cases the mental disturbance took the form of melancholia and in one of mania. In one case the psychosis appeared five days after the operation ; in one eight days after; in one two weeks after; in another three weeks after, and in the two remaining cases it devel- oped after the patients had been discharged. Of the six cases three recovered ; one after fifteen days, one after four months, and one after eight months. 10 THOMAS, In two of the remaining cases there was no improve- ment, and the third patient committed suicide three months and a half after the operation. The phe- nomenon could not be referred to iodoform poison- ing, as the drug was used sparingly or not at all. Sanger, in discussing this paper, said that he re- called several cases in which cerebral symptoms had developed after gynecological operations. In two instances these were clearly referable to iodoform, though little was used on the dressings. In spite of the facts stated, however, he believed that patients with pelvic troubles having a tendency to psychoses should be treated in the same manner as other women. In an article by Fillebrown, of Hamburg, pub- lished in the American Journal of Obstetrics for January, 1889, the author mentions three cases of mental disturbance following gynecological opera- tions, observed by Prochowick, of that place. In one case there was removal of the uterus; in one, cystocele and perineorrhaphy, with amputation of the cervix; and in the third, ovariotomy. In one case intense melancholia came on in four months after operation, and when the report was made, nearly three years after, although the patient had improved very decidedly, there were still periods when she showed signs of excitement. In the second case melancholia appeared three months after opera- tion, and one year after, at the time of his writing, the patient still had attacks at intervals, though she was improving steadily. In the third case violent mania developed three months after operation, from which the patient entirely recovered. ACUTE MANIA AND MELANCHOLIA. II In four out of my six cases there was evidence of eccentricity even before operation; and in two of these four cases it was quite marked at times. In all my cases except one there were distinct prodromic symptoms following operation and antedating by some days the formal outburst. In none of my cases could I discover evidences of hereditary tendency to insanity. Out of my six cases, four died, one completely recovered, and one case is still in progress. In all my cases except one the renal secretion was carefully watched and examined ; and in none did the kidneys appear to be factors in the mental state. In four out of my six cases not a particle of iodo- form was used at any time ; so these are out of con- sideration in reference to iodoform poisoning as a factor. In the two remaining cases iodoform was used, as I always use it, very cautiously and entirely on the line of cutaneous union, where absorption would have been next to impossible. Should the suspicion enter the mind of anyone that one or more of my violently maniacal cases may have been instances of sudden and severe septicaemia marked by delirium, I can merely point to my very large experience with septicaemia in its various forms, and reply that I feel very confident that the suspicion is unfounded. It will be seen that, my cases being added to those recorded by others, twenty-six instances of acute mental aberration following upon the performance of gynecological operations are now placed upon record. 12 ACUTE MANIA AND MELANCHOLIA. Before concluding, permit me to propound to this learned body certain questions which in this con- nection have suggested themselves to my own mind. ist. Were these twenty-six cases of mania and melancholia really due to the operations which im- mediately antedated them, or did they follow as mere coincident states, post hoc sed non propter hoc ? 2d. Any great mental strain may be followed by mania. Is it at all remarkable that in the vast num- ber of gynecological operations which have been performed during the last quarter of a century in America and Germany, twenty-six cases of this malady should have occurred ? 3d. If the mania which followed operative pro- cedures in these twenty-six cases was a consequence of them, how in the future is a tendency to the acci- dent to be avoided ? 4th. Are the operations of gynecology any more likely than other surgical procedures to disturb the condition of the mind ? It has been said that an ignorant man may ask in a moment questions which a philosopher cannot answer in an age. In the present connection I willingly assume the former of these positions. 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