An Unusual Case of Hysteria Associated with Ulcers

Kai Tiaki : the journal of the nurses of New Zealand, Volume XV, Issue 4, 1 October 1926, Page 157

An Unusual Case of Hysteria Associated with Ulcers

The following is the report of a case under the care of the Superintendent of the Timaru Hospital: — N.P., a girl act. 24, was admitted on January 16th, 1923, complaining of an ulcer on the back of the left hand, the result of a burn seven months previously. The ulcer was about an inch m diameter, with a hard edge and a black sloughing base. Treatment: Hypertonic saline foments 4 hourly; ensol bath twice daily. At the end of a week the ulcer was successfully tube grafted, and the patient was discharged on March 3rd, 1923. Re-admitted on June 26th, 1924, complaining of a "chronic" ulcer on the left loot, three months' duration. This ulcer had exactly the same appearance as the previous one. The Wassermann test was negative. Treatment: Hypertonic saline foments and, later, lotio rubra, combined with various tonics and dental treatment. On October 30th the ulcer had decreased to the size of a threepenny piece, but would not heal. A complication now occurred; the ulcer became gangrenous, and began to increase m size and depth. On November 28th it was excised. The pathological report stated that it was of the ordinary chronic type, aetiology unknown. A month later it was worse than before. On January lst, 1925, it was tube grafted: the base had eroded into the first meta-tarsal and carpo-meta-tarsal joints to the depth of half an inch. It became septic, and healing was not complete until April, four months later. A few days before this date, however, a second ulcer had appeared, this time on the dorsal aspect of the fifth toe. This ulcer spread rapidly m spite of ionisation. On August 4th it was excised, the fifth toe being removed to obtain a skin flap to cover m the raw area. The patient's general condition was now very low; she was running a high

temperature and pulse, and felt very ill. A blood test was positive for typhoid!

She recovered slowly, and on September 7th, 1925, the first of a long series of ulcers appeared on the left forearm. Two days later a second appeared just above the first, and a third appeared the next day on the left leg just above the knee.

The appearance of each ulcer was the same. Circular m outline, it had a black gangrenous looking base, which had penetrated through the skin and fascia as far as the muscle layer. The ulcers were discovered each morning by the night nurse when they were the size of a sixpenny piece. Excision of each ulcer was performed under local anaesthetic daily for 76 days, m which time 118 ulcers had been excised. After excision hot foments were

applied four-hourly, and the ulcers healed gradually. It was thought that the ulcers were typhoid m nature, following her acute attack. Once it was suggested that they were self-inflicted, and she was removed from one bed to another, naked, so as to eliminate the possession of an instrument with which they might have been produced. A typhoid vaccine was commenced, but still the ulcers occurred. They were now the size of half-crowns, and usually one appeared nightly. Excision was performed twice a week under general anaethesia, and a further 115 ulcers were excised over a further period of 119 days. The last operation was performed on March 19th, 1926. The grand total now stood at 233 ulcers for 197 days. As may be imagined, the general condition of the patient was bad, and she was going from bad to worse. The bi-weekly anaesthetics were anathema to her, the four-hourly dressings of arms and legs was agony, and her mental state was very low. The exhibition of morphia was not withheld on account of the severe pain.

Life did not seem to promise a ray of hope. On March 19th, 1926, it was again suggested that the site of the ulcers, i.e., the limbs and never the body, favoured an hysterical origin. In consequence her arms and hands were put m plaster. Next morning we were all eager to see whether the usual ulcer was present. To our surprise and relief there was none, and there have been none since. After a week the plasters were bivalved and applied only at night, and finally were discarded altogether. The patient was discharged on June 12th. very well and happy. This case is apparently unique, and constitutes a world's record. All the authorities consulted do not record any case as having more than 19 ulcers artificially produced. In this case we considered the cause to have been long continued pressure between forefinger and thumb, although it is almost unbelievable had not one seen the case. W. GORDON RICH, Timaru, M.8., Ch.B. July 22nd, 1926.