By ERNEST W. WHITE, M.B. Lond., M.R.C.P., Senior Assistant Medical Officer
to the Kent Lunatic Asylum; Associate, Late Scholar, of King's College,
London.
The following case, from its hopelessness at the outset, yet ultimate
recovery under the duly recognized forms of treatment, is of such interest
as to demand publicity, and will afford encouragement to others in moments
of doubt.
M.A. S----, aged fifty-three, was admitted into the Kent Lunatic Asylum at
Chartham on Oct. 3, 1882, suffering from melancholia, the duration of
which was stated to have been three months. She had several times
attempted suicide by drowning and strangulation. She was on admission
ordered a mixture containing morphia and ether thrice daily, to allay her
distress. On Oct. 10 she attempted suicide by tying a stocking, which she
had secreted about her person, round her neck. Shortly afterward, with
similar intent, she threw herself downstairs. On Jan. 4, 1883, she
attempted to strangle herself with her apron. On the 30th of November
following, at 4 P.M. she evaded the attendants, and made her way to the
bath-room of of No. 1 ward, the door of which had been left unfastened by
an attendant. She then suspended herself from a ladder there by means of
portions of her dress and underclothing tied together. A patient of No. 1
ward discovered her suspended from the ladder eight minutes after she had
last seen her in the adjoining watercloset, and gave the alarm.
The woman was quickly cut down, and the medical officers summoned. In the
interval cold affusion was resorted to by the attendant in charge, but the
patient was to all appearances dead. The junior assistant medical officer,
Mr. J. Reynolds Salter, M.B. Lond., arrived after about three minutes, and
at once resorted to artificial respiration by the Silvester method. A
minute or so later the medical superintendent and myself joined him. At
this time the condition of the patient was as follows: The face presented
the appearance known as facies hippocratica: the eyeballs were prominent,
the corneæ glassy, the pupils widely dilated, not acting to light, and
there was no reflex action of the conjunctivæ; the lips were livid, the
tongue tumefied, but pallid, the skin ashy pale, the cutaneous tissues
apparently devoid of elasticity. There was an oblique depressed mark on
the neck, more evident on the left side; the small veins and capillaries
of the surface of the body were turgid with coagulating blood the surface
temperature was extremely low. She was pulseless at the wrists and
temples. There was no definite beat of the heart recognizable by the
stethoscope.
There was absolute cessation of all natural respiratory efforts, complete
unconsciousness, total abolition of reflex action and motion, and
galvanism with the ordinary magneto-electric machine failed to induce
muscular contractions. The urine and fæces had been passed involuntarily
during or immediately subsequent to the act of suspension. As the
stethoscope revealed that but a small amount of air entered the lungs with
each artificial inspiration, the tongue was at once drawn well forward,
and retained in that position by an assistant, with the result that air
then penetrated to the smaller bronchi. Inspiration and expiration were
artificially imitated about ten times to the minute. In performing
expiration the chest was thoroughly compressed. The lower extremities were
raised, and manual centripetal frictions freely applied. In the intervals
of these applications warmth to the extremities was resorted to.
About ten minutes from the commencement of artificial respiration we
noticed a single weak spasmodic contraction of the diaphragm, the feeblest
possible effort at natural respiration. Simultaneously, very distant weak
reduplicated cardiac pulsations, numbering about 150 to the minute, became
evident to the stethoscope. The reduplication implied that the two sides
of the heart were not acting synchronously, owing to obstruction to the
pulmonary circulation induced by the asphyxiated state. Artificial
respiration was steadily maintained, and during the next half hour
spasmodic contractions of the diaphragm occurred at gradually diminishing
intervals, from once in three minutes to three or four times a minute.
These natural efforts were artificially aided as far as possible. At 5:45
P.M. natural respiration was fairly though insufficiently established, the
skin began to lose its deadly hue, and titillation of the fauces caused
weak reflex contractions. Flagellation with wet towels was now freely
resorted to, and immediately the natural efforts at respiration were
increased to twice their previous number. The administration of a little
brandy and water by the mouth failed, as the liquid entered the larynx.
Ammonia was applied to the nostrils, and the surface temperature was
increased by warm applications and clothing. At 6 P.M. artificial
respiration was no longer necessary. The heart sounds then numbered 140 to
the minute, the right and left heart still acting separately. A very small
radial pulse could also be felt. At 6:45 P.M. the woman was put to bed,
warmth of surface maintained, and hot coffee and beef-tea given in small
quantities.
Great restlessness and jactitation set in with the renewal of the
circulation in the extremities. An enema of two ounces of strong beef-tea
was administered at 10 P.M. The amount of organic effluvium thrown off by
the lungs on the re-establishment of respiration was very great and
tainted the atmosphere of the room and adjoining ward. The pupils,
previously widely dilated, began to contract to light at 11 P.M. Imperfect
consciousness returned at 5 P.M. the following day (Dec. 1), and about an
hour later she vomited the contents of the stomach (bread, etc., taken on
Nov. 30). Small quantities of beef-tea were given by the mouth during the
night. At 9 A.M. air entered the lungs freely, and there were no symptoms
of pulmonary engorgement beyond slight basic hypostasis; the pulse
remained at 140, and the heart sounds reduplicated; she was semiconscious,
very drowsy, in a state of mental torpor, with confused ideas when roused,
and she complained of rheumatic-like pains all over her.
The temperature was 100.2°; the facial expression more natural; the tongue
remained somewhat swollen and sore; she was no longer restless; she took
tea, beef-tea, milk, etc., well; the functions of the secreting organs
were being restored; she perspired freely; had micturated; the mucous
membrane of the mouth was moist, and there was a tendency to tears without
corresponding mental depression. The patient was ordered a mixture of
ether and digitalis every four hours. On December 2 the pulse was 136, and
the heart sounds reduplicated. The following day she was given bromide of
potassium in place of the ether in the digitalis mixture. On the 4th the
pulse was 126; reduplication gone. On the 6th the pulse was 82, and the
temperature fell with the pulse rate. She was well enough to get into the
ward for a few hours. Her memory, especially for recent events, was at
that time greatly impaired. On the 12th she still complained of muscular
pains like those of rheumatism. Apart from that, she was enjoying good
bodily health.
A curious fact in connection with this case is that since this attempt at
suicide she has steadily improved mentally, has lost her delusions, is
cheerful, and employs herself usefully with her needle. She converses
rationally, and tells me she recollects the impulse by which she was led
to hang herself, and remembers the act of suspension; but from that time
her memory is a blank, until two days subsequently, when her husband came
to see her, and when she expressed great grief at having been guilty of
such a deed. Her bodily health is now (June 30, 1884) more robust than
formerly, and she is on the road to mental convalescence.
_Remarks._--The successful issue of this case leads me to draw the
following inferences: 1. That in cases of suspended animation similar to
the above there is no symptom by which apparent can be distinguished from
real death. 2. That in artificial respiration alone do we possess the
means of restoring animation when life is apparently extinct from
asphyxia, and that, with the tongue drawn well forward and retained there
by the hand or an elastic band, the Silvester method is complete and
effective. 3. That artificial respiration may be necessary for two hours
or more before the restoration of adequate natural efforts, and that the
performance of the movements ten times to the minute is amply sufficient,
and produces a better result than a more rapid rate. 4. That galvanism,
ammonia to the nostrils, cold affusion, and stimulants by the mouth are
practically useless in the early stage. 5. That on the re-establishment of
the reflex function we possess a powerful auxiliary agent in flagellation
with wet towels, etc. 6. That centripetal surface frictions and the
restoration of the body temperature by warm applications aid recovery. 7.
That the heart, if free from organic disease, has great power of
overcoming the distention of its right cavities and the obstruction to the
pulmonary circulation, although its action may for a time be seriously
deranged, as evidenced by reduplication of its sounds. 8. That when the
heart's action remains excessively feeble, and the right and left heart
fail to contract synchronously, it would be justifiable to open the
external jugular vein. 9. That during recovery the lungs are heavily taxed
in purifying the vitiated blood, as shown by the excessive amount of
organic impurities exhaled. 10. That restlessness and jactitation
accompany the restoration of nerve function, and that vomiting occurs with
returning consciousness. 11. That pains like those of rheumatism are
complained of for some days subsequently, these probably resulting from
the sudden arrest of nutrition in the muscles.
Chartham, near Canterbury.
--_Lancet._
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