THE

AMEKICAN JOUKNAL
OF THE MEDICAL SCIENCES. EDITED BY ISAAC HAYS, M.D., FELLOW OF THE PHILADELPHIA COLLEGE OP PHYSICIANS ,' MEMBER OP THE AMERICAN MEDICAL ASSOCIATION J OP THE AMERICAN PHILOSOPHICAL SOCIETY i OP THE ACADEMY OP NATURAL SCIENCES OF PHILADELPHIA, &.c. Ac. ice.

Eatered according to the Act of Congress, in the year 1856, by BLANCHARD AND LEA, in the Office of the Clerk of the District Court of the United States in and for the Eastern District of the State of Pennsylvania.

/ ART. XII. Cases of Nymphomania. By HORATIO R. STORER, M. D., one y of the Physicians to the Boston Lying-in Hospital. (Read before the
Boston Society for Medical Observation, July 21, 1856.)

CASE I.For this case I am indebted to Dr. Sprague.

Margaret Murphy, aged 20, from Ireland; is of middle height, thick set, excessively plethoric. Countenance dull, unintelligent. Is shy and reserved, answering questions with great reluctance. March 25, 1856. Complains of cough of three years' standing, leucorrhoea, dysmenorrhoea, and dysuria, with constant pricking in region of bladder. Thinks she has at times prolapsus uteri. Is unmarried. Commenced menstruating at 14, since which time has always had more or less leucorrhoea. Recurrence of catamenia at first irregular, but of late less so. Always excessive pain at time of discbarge, which usually lasts but a day, and is scanty. Character of discharge generally normal, sometimes clotty, never membranous. Has never had rheumatism. Has severe headache before catamenia, sometimes during intervals. While a child was strong and healthy, and continued so till 1850, previous to her arrival in this country, when she had several fits, which were pronounced by her physician to be epileptic; these extended over a period of three months. In 1853, she entered the Massachusetts General Hospital, coming under the care of Drs. Jacob Bigelow and Perry for uterine hemorrhage, consequent, as she then alleged, upon lifting a heavy tub of clothes. She subsequently re-entered the hospital in 1854 for cough and leucorrhoea, and was then treated by Drs. Shattuck, Bowditch, and Storer, Sen., getting cod-liver and fusel oils, her cervix touched with nitrate of silver, and with relief from neither. Cough troublesome; but little expectoration. Has raised blood frequently, florid and frothy; still does so at times, not at menstrual periods. Upon auscultation and percussion, no evident signs of thoracic disease. Appetite is capricious. Bowels free; relieved daily. Great difficulty in micturition; a small and interrupted stream, attended with urgent desire, and followed by excessive scalding. The pricking sensation already spoken of is constant. No tenderness about spine. Upon digital examination by the vagina and rectum, an excess of heat in vagina, its calibre large. Uterus somewhat enlarged; no tenderness on pressure in its neighbourhood. Cervix rather broad aud short, slightly abraded. Os largely fissured. In other respects genitals normal. Abdomen marked by parturition. Upon asking patient to account for the puerperal signs, she acknowledged having got with child shortly after leaving the hospital in 1855. Was confined at Bridgewater seven months since;

labour a very tedious one, lasting seventy-two hours, and delivery being effected by forceps. The child, a boy, died at four months of smallpox. Menstruated for the first time since confinement on March 7th, a little over a fortnight ago; as much pain as ever. April 3. Closely cross-questioned. States additionally that, while at the hospital, she was several times etherized by Dr. H. J. Bigelow; for what she pretends ignorance. Vaginal examination now repeated without further result. Her complaints of dysuria being still very great, the bladder was carefully sounded (without the use of ether), and nothing found. At one time an impression was given of the presence of a foreign body, but the sensation was only momentary. Sounding attended with great pain and shrinking. Patient was then shown to Dr. Hobbs, at my office, and sounded by him, with equal ill success. The urine under the microscope gave no pus, no crystals, and but few epithelial scales. Her statement concerning the etherizations sent me at once for further information to my father, from whom I learned that, while under his care at the hospital, suspecting stone or the like, he had requested one of the surgeons, Dr. Bigelow, to examine her, by whom several foreign bodies, pins and hair-pins, were removed from the bladder. 9th. At Lying-in Hospital, in consultation with my colleague, Dr. Dupee, ether was administered; the urethra was found free throughout its entire extent, but a foreign body was at length discovered in the cavity of the bladder. This, after some manipulation, was removed by Dr. Dupee. It proved to be a long piece of copper wire, broken and twisted upon itself several times, and seemed to have been imbedded in the anterior wall. It was without incrustation, and had the appearance of having been originally taken from the neck of a bottle, as, indeed, she afterwards acknowledged was the case. The operation was followed by considerable hsematuria. 16^A. Patient complained bitterly of being so soon again subjected to operation, asserting that at the other hospital she was allowed a much longer interval. This, however, did not now seem necessary; ether was given, and by a previous arrangement with Dr. Dupee, of alternation, I removed the greater portion of a hair-pin twisted upon itself. 23d. Again etherized, and another fragment of hair-pin removed; this time by Dr. Dupee. 2Qth. Again etherized, and bladder oarefully sounded. After prolonged examination, both by Dr. Dupee and myself, nothing was detected, and her other symptoms, the cough, leucorrhoea, &c., having much improved, and menstruation having taken place more naturally than by her account ever before, she was, by arrangement with Dr. Walker, transferred the next day, on the 30th, to the City Lunatic Asylum, at South Boston, there being reason to fear that she might, unless restrained, do herself serious injury. Her treatment while under my charge was sufficiently simple. I soon learned that her distress was, in part at least, overrated, some of it probably feigned. The cough, which, during her early visits to my office, was very constant, severe, and racking, and which then resisted a succession

of expectorants, seemed immediately to yield after I had admitted her into the Lyingin Hospital, strangely enough showing a marked and sudden decrease with every removal from the bladder; the improvement was undoubtedly owing to her change to the warm moist atmosphere of the hospital. She certainly raised blood; this occurred more than once after her entrance, but I am inclined to think it was from the throat, and that, as was certainly the case with the hsematuria, she overstated the quantity; in which opinion I am confirmed by an auscultation made of the patient by my friend, Dr. Borland, on April 27th, his results agreeing with my own. The leucorrhoea, which seemed previously to have been treated in vain, at one time by merely constitutional measures, at another by local injections, was much benefited by vaginal suppositories, at first of oxide of zinc, and afterwards of alum and catechu, of each gr. xv to the ball. In so plethoric a patient, it did not seem advisable suddenly and entirely to check the discharge, and this was not attempted. The dysmenorrhoea was lessened, perhaps partly by passage of the sound at the preliminary examination, although I have no doubt that the low diet on which she was placed contributed to the result. The diet, for nearly a month, was gruel. She several times eagerly desired to be bled; but I preferred keeping her on low diet, as equally likely to lessen her chance of peritonitis, and more so the chance of her persisting, if at all malingering. Before my suspicions of the true state of the bladder were aroused, I endeavoured, as frequently with success, to allay the dysuria by throwing chloroform vapour into the vagina, and afterwards by a flexible catheter into the urethra and bladder itself; but the pain was not relieved. The urinary tenesmus had been excessive, and I have no doubt that long continued expulsive efforts had at times produced a partial prolapse and protrusion of the anterior wall of the vagina, which she had supposed, as already remarked, to be prolapse of the uterus. It was noticed at every sounding of the bladder, the patient being thoroughly etherized, that in a short time most energetic contractions of the fundus vesicae were invariably produced; as, indeed, had occurred at my early and unsatisfactory examination when ether was not used; which action, had the urethra been at all dilatable, as it was not, even under the stimulus of a powerful sponge tent, would have threatened partial inversion of the organ. These expulsive efforts, suggesting a transference of labour pains, were aocompanied by a profuse flow of limpid urine, which was secreted with remarkable rapidity, or had else, though hardly probable, been collecting in the ureters, the patient generally passing but little in the twenty-four hours. The hsematuria subsequent to each operation was but slight, and lasted but a few hours; a fact rather remarkable when the sharp points of the foreign bodies are taken into consideration, they all having apparently imbedded, not merely entangled, themselves in the mucous membrane, and the difficulty of bringing such bodies through an urethra, whose diameter, though its coats had naturally become somewhat hypertrophied, was not above ordinary size. For the twenty-four hours immediately succeeding each operation, she complained of considerable abdominal pain and tenderness. At first I had some fear of peritonitis, but soon found, upon experiment, that assafoetida, to which she had the usual repugnance, at once allayed her complaints and the pain. This proved invariably the case. My suspicions, hence, that these

were rather the pains of hysteria, were strengthened by her general behaviour; and, subsequently, by learning of her convulsive seizures in 1850, and the details of the so-called peritonitic nttacks at the Massachusetts General Hospital. The pulse was generally somewhat quickened during the first day, but on the second used to sink to her usual standard, about 84. The removal of the hair-pins and wire was in each case effected by ordinary dressing-forceps, and in each case only after much manipulation. They were not easily detected by the sound, or catheter, or forceps, particularly after the muscular contractions, which were very easily excited, had begun; getting lost between or covered by folds of the mucous membrane. When found, they were not easily dislodged from their position, and evinced a constant tendency to catch athwart the urethra before entering it, or having entered, to get entangled in some portion of its course. From the outset she resolutely denied having introduced anything into the bladder subsequently to her discharge from the Massachusetts General Hospital, and asserted that what we removed had been introduced previously to that time and previously to her confinement, introduced merely to dilate the urethra for dysuria, and had slipped from her hand against her will. Neither of these statements can, however, be true. How she could have ever introduced such irregularlyshaped masses into the bladder, and how, once having had them removed, she could have dared to repeat tho experiment, are mysteries which mental disease, a decided furor uterinus, can alone explain. It is impossible that so thorough a surgeon as Dr. Bigelow could have left anything in the bladder; it is impossible that she could have undergone so tedious a labour under these circumstances, instrumental as it was, without some one of the varieties of vesical fistula having been produced; and it is improbable that the alleged lapse of months, not to say years, would have left no incrustation. The previous medical history of the patient, dating from her arrival in this country, is not uninteresting. The greater part of it she endeavoured to suppress; but, from chance words she let fall at various times, it became possible to ascertain her whole story from the several physicians who successively had charge of her; and, upon subsequently informing her of these discoveries, she acknowledged their truth. On September 2, 1853, she called upon Dr. Salter, then complaining of severe expulsive pains, and stating that she had introduced a cork into the vagina some time previously, which, having forced it up by a bed-wrench, she was now unable to remove. This cork Dr. Salter could not discover either on that or on the following day. A third examination, however, on September 13, was more successful, and the cork was then removed. It was situated high up in the vagina, very near the os, a little back of and in contact with it, the smaller end being uppermost. "A strong effort was required to start it from its bed." The cork is now in my possession, and is of the size to fit a large jogSubsequent to this operation, the leucorrhoea, which had formerly been profuse, continuing and there being some symptoms of metritis, she was advised by Dr. Salter to enter the Massachusetts General Hospital, and did so October 14,1853. She then stated, according to the hospital record as already quoted, entirely suppressing the fact as related to me by Dr. Salter, that having previously strained herself while lifting, she had felt something give way in lower abdomen, followed immediately by escape of blood from vagina. At her entrance, just a month

after the operation by Dr. Salter, she was flowing, but not profusely, and had great pain in head, back, and limbs, with both dysuria and incontinence of urine. Abdomen full, tympanitic, exquisitely tender on pressure; but pulse only 92, and rather feeble. She left the hospital in November, 1853, not relieved, and sought a female friend, by whose advice "instruments" were introduced, which she found herself unable to extract; and shortly after, December 9, she entered Deer Island Hospital, where she was relieved. Dr. Moriarty writes me, that at entrance she was suffering with pleurisy, and that when convalescent three pieces of German silver spoon, the "instruments" alluded to, were removed from the upper part of her vagina. She left Deer Island on April 8, 1854, the leucorrhoea and dysuria still continuing, and re-entered the Massachusetts General Hospital, June 13. At that time, according to her account, the urine had for several months regularly been withdrawn by catheter. While in the hospital, caustic was repeatedly applied to her cervix uteri for leucorrhoea. On August 24th, a hair-pin and ordinary pin were removed from the bladder by Dr. Bigelow. On September 3d, another hair-pinthis operation being followed by symptoms of peritonitis; and, on October 2d, a fragment of a third hair-pin. These specimens were at the time exhibited by Dr. Bigelow to the Society for Medical Improvement.1 She was discharged November 5th, few of her syinp 1 Extracts from Records, &c., vol. ii. p. 139, Am. Journ. of the Med. Sci., Jan. 1855, p. 57. Dr. Bigelow at the same time described a new method of operating; he had turned the points by vaginal manipulation. This, in 1856, I was unable to do. toma having abated. For some time after leaving the hospital she continued under Dr. Bigelow's care as a private patient. In June, 1855, she reapplied at the Massachusetts General Hospital as an out-patient, and was treated by Dr. Abbot, who did not sound her bladder, but ausculted abdomen, and from this diagnosed pregnancy, which at first she stoutly denied, but she afterwards admitted that her last catamenia had been in December, 1854. Dr. Abbot at one time discovered large vesications on the inner side of each thigh, which he supposed had been purposely caused for purposes of excitement, by blisters, though this was also denied. She was confined in September, 1855, at Bridgewater, as already said. She next applied to Dr. Herrick, who, however, advised her again to enter the hospital; and finally, early this spring, she placed herself under the charge of Dr. Sprague, who prescribed expectorants for the cough, and introduced an India rubber pessary; the pressure of which, however, upon the bladder, she was not able to endure. As previously stated, the patient was sent to the Lunatic Hospital at South Boston on May 30th; but, to my surprise, she again appeared at my office on Juno'21st, asserting that she had that day been discharged as "not insane." She again complained of pricking in the neighbourhood of the bladder, which was not the case when I last saw her. From this, my expectations that she would return to her old habit seem confirmed. I now refused to deal further with her, believing that merely palliative treatment without proper restraint would be useless. She then put herself under the care of Dr. Hobbs, who, it will be recollected, examined her with me at the outset, on

April 3d, and I have since heard that she has lately been seen again among the out-patients at the Massachusetts General Hospital. Each step in the above history but goes to confirm the very evident opinion that, if we forget her having imprudently got with child, "she is," to quote from a characteristic note by Dr. Bigelow, "a good girl, unfortunately biassed by genito-urinary proclivities." I am inclined to think that she masturbates, though, as is usual, she denies it. Her manners are those of that habit. Her expression, when unconscious of being observed, is at times decidedly lecherous. She expressed great dislike of the various gentlemen who had previously had charge of her and of those who saw her with me; but yet, though she acknowledged that the catheter wag not always necessary, and that she could pass it perfectly well herself, she was constantly asking that it should be done by others. Her clitoris was not at all enlarged.1 1 It would be difficult to decide upon the original exciting cause of irritation in this case. It has been ingeniously asked me by Dr. Buckingham, if she had been troubled by oscorides previously to her first experiment upon herself; a question that the patient would probably have been unable to answer, and which I carelessly neglected to put, although irritation of the vagina from the presence of asenrides in the rectum, both sympathetically and by actual transit of the parasites, is now recog

CASE II.Mrs. B., American, aged 24, of under size, gross habit, pale and pasty complexion; is
in easy circumstances; was married at 17, seven years since; no children, and has never miscarried; has enjoyed, she thinks, on the whole, tolerably good health. Bowels are now, and have been, freely moved daily. Appetite is, and has been, constantly good. Menstruates regularly; has just done so; discharge continuing nearly a week, very scanty, attended on the first day or two after it commences with more or less aching pain in the back and head, and frequently throughout the period in the right iliac region. At times pain under the left breast, and frequently palpitation. Abdomen inclined to bloat; sudden tumefaction, and as sudden subsidence. Has constantly trifling leucorrboea, but hardly sufficient to require napkin. Has during past three years been under the care of several physicians; one of whom thought necessary for a long time to apply nitrate of silver to cervix twice weekly. The probable effect, not an unfrequent one of this treatment, may easily be conceived from the further history. Some little dysuria; scalding at and after flow. For several months has been troubled by bad dreams, excessively lascivious in their character. Can hardly meet or converse with a gentleman but that next night fancies she has intercourse with him. Has frequently such thoughts by day, sometimes when in conversation; though thinks she would at once repel an improper advance on part of any man, and is not conscious of having

ever shown to such what was passing in her mind. Is much afraid that if further increase of malady, may not be able to restrain herself. At such times is conscious of a "spasm" within genitals, and of the emission of a mucous jet, one or more drops, which stains linen. This emission did not occur at first, but now always takes place; whether awake or asleep, in the latter case, waking her; whether in bed or abroad; whether alone or with others.1 Husband has been a wine merchant; is still interested in the business; is a high liver, and has twice had attacks of apoplexy. Is much older than herself. Does not think he has missed having connection with her a single night since marriage, even at times of menstruation (this assertion repeated). Has frequently come to her three times in a night, and always with a seminal emission (this assertion also repeated). Has of late complained that he found physical obstruction to intercourse on her part, though she thinks it rather an increasing failure by him in erection. Has herself always lived well, by his orders; meat three times each day, nized as not uncommon; and a case illustrative of the latter class happened to be under my care nt that very time. 1 The questions upon this point were naked in consequence of a previous conversation with Dr. John P. Reynolds upon Duverncy's glnnds, and similar occurrences in patients of his own. Dr. Herrick has since related to me another very interesting case. brandy at dinner. Enjoys intercourse greatly; is conscious of excessive local excitement, so great that she not unfrequently faints during penetration; this, however, being no check to husband. Has, with him, always desired children; and thinks from that longing arose present excess. Has not told these points of her history to former physicians; knew that she should, but such questions were not asked; though, as the answers prove, they were necessary to a correct understanding of the case. Is sure that if husband should restrain himself, and keep from her, she could not keep from him. Has tried it. Did not hegin menstruating till just before marriage; was then ignorant of sexual matters, and innocent of impure thoughts. Had never masturbated, but was conscious of undefined but strong desire, which often led her to clasp in embrace her brothers more fervently than usual. Was on this account early married by advice of mother, who herself acknowledges similar warmth and precocity. Has never had impure companions; has not been in habit of reading impure publications of any sort; has contrihuted tales, &o., to magazines, but has not overstated any of her symptoms in this history. Generally spends evenings at home; does not keep late hours, both having same desire to retire early.

Upon examination, heart and lungs apparently without disease; no tenderness along spine, nor in any part of abdomen. Heat of vagina rather above standard; its size good; no obstruction. Uterus somewhat enlarged; this also evident by rectum; no displacement; cervix much elongated, and moderately thickened; signs to touch of slight abrasion. Os almost imperforate, not admitting sound; anterior lip much the larger. Speculum not used, because not needed. As in the other case, not the slightest enlargement of clitoris. Excessive irritability in its neighbourhood, gentle touch causing her to shriek out, not with pain, as she herself said, but with excitement. She now acknowledges constant itching in that region. This first interview with the patient was had on May 16th, when the following treatment was prescribed, at the same time giving her fully to understand that if she continued her present habits of indulgence, it would probably become necessary to send her to an asylum: 1. Total abstinence from husband; if not possible otherwise, by temporary entire separation. 2. Meat but once in the day. 3. Brandy and other stimulants not at all. 4. Novel writing to be given up. 5. Hair-pillows and mattress in place of feathers. 6. Cold sponge-bath morning and night. 7. Cold enemata at night. 8. Frequent lotion of anterior vaginal commissure with solution of borax. No. LXIV.OCT. 1856. 26 9. Two-dracbin doges, nightljr of. eqqal, parts of the tinctures of henbane, valerian, and lupulin; the last, as the others, given merely as a hypnotic, and not as an aqaphrodisiac, its alleged effects iu this respect being afterwards recalled to my mind by Dr. Read. ., i, , }U. Iron; gr. iss of the sacch. carb- thrice daily in pill. 11. Exercise, fresh ,ir,,and occupation of mind by more and cheerful friends.,, i.,,)..... -,-.-,. ,.| i i,-: Mrs. B. saw me next on May 30th, two, weeks later. Abstinence in accordance with iny advice, proving otherwise impossible, the husband had at once left the city. Patient found the change a

bard one, but was endeavouring to follow out faithfully all my other directions. As yet no marked alteration, but thinks she is better. June 17. Accompanied by sister, from whom I was able to verify her aocounts of general health, &c. Now a little over a month since commencing treatment. Has had within a week a slight attack of dysentery; this now ?5 '' .',*,''< ,' ".u, ' '.': l'"''''';1 - '"' , Husband still absent. The lascivious dreams have not occurred for several days, nor the sudden vaginal emissions. The local irritation and ,heat have also much diminished, and as regards these most troublesome symptoms, she feels greatly relieved. Since last visit, her appetite for food, which was formerly voracious, has lessened; but the leueorrhuea has increased, the discharge being thinner and less tenacious. Is now compelled to wear napkins constantly. For this, ointment pessaries were directed, each to contain gr. xv of oxide of zinc. . Has again menstruated, more freely, and with less pain. To continue course formerly prescribed. The patient is still under treatment. I nqw consider the case much more hopeful as regards the mental symptoms, which, bowover, will for some time require decided enforcement of very strict laws. Both the wife and the husband must be taught moderation, which done, there seems no very good reason why, after dilatation of the os, and perhaps, if it should be needed, application of potassa fusa, the patient should not realize her hopes, and get with child. "..,,' ,. . , , iv, _< Most writers seem to consider that nymphomania must be attended, as cause or symptom, by ungovernable pruritus, though this I <Jo pot believe to be always the case. ,Itwas present as such iu Case II., and in the immediate neighbourhood of the clitoris. It was also present iu Case I., but in a different situation, and of rather different typo, though to an equally great extent, "pricking," but here only for within the v,-igjna, at its very end, and in the immediate neighbourhood of the bladder, the sensation, moreover, being that of all others which ^ould have been expected from the peculiar bodies introduced. In both cases, the effect of unnatural or excessive stimulus became itself worse stimulus still, and so an active cause. Apart from their furnishing different manifestations of but one and the sme disease, these eases are of valuo as bearing upon two interesting questions..' ' r -' i '!< r .i'I..' '-: '-,, They both go to prove Duchatelet's opinion, bused upon frequent examination of prostitutes, to be correct, that excessive sexual appetite and excessive sexual indulgence are by no means necessarily attended in the female by a clitoris at all enlarged, while Case II. is a marked instance of that peculiar and forcible emission, still denied by many, of mucus from the female gemtal canals during heat, and under mental excitement alone, which, when occuring during intercourse, gavo origin to the old and fanciful idea of a true

temen mulUbre." 1, ', , ' i . r ' '.1 i.'u v.is/l.r I.I i:'" ' ',.'.i 7 CUESTER ST., BOSTON. Aug. 1, 1856. , .,.! ,/!r>,.- i . i .. *_. ' /! i< 'iiii ]K" .1/ TI '\, '.,.; .i ., 'i '" . '"' Y. /. iIt'li-nl ''I 'r,'. , '"' <:'!1 ,. i u. ji ,- , * . < '' ' . . ,i ic a r dii*' Lin .I lr ;' .uai