PREFACE.
In offering this little book to my professional brethren, I do not for one moment wish it to be understood that I claim any originality in the surgical treatment herein described.
Having read with great interest the Lectures on the “Physiology and Pathology of the Central Nervous System,” delivered by Dr. Brown-Séquard before the Royal College of Surgeons of England, in 1858, and published in The Lancet, I was struck with a fact much insisted upon by the learned physiologist, namely, the great mischief which might be caused in the system generally, and in the nervous centres especially, by peripheral excitement.
Constantly engaged in the treatment of diseases of the female genitals, I had been often foiled in dealing successfully with hysterical and other nervous affections complicating these lesions, without being able to assign a satisfactory cause for the failure. Dr. Brown-Séquard’s researches threw a new light on the subject, and by repeated observation I was led to the conclusion that the cases which had puzzled me, and defied my most carefully-conceived efforts at relief, depended on peripheral excitement of the pudic nerve. I at once subjected this deduction to a surgical test, by removing the cause of excitement. I have repeated the operation again and again, and it is the object of this book to show the results.
Daily experience convinces me that all unprejudiced men must adopt, more or less, the practice which I have thus carried out; and I have no doubt that, in properly selected cases, it will prove as successful in their hands as in mine.
It will be observed that the majority of the cases I publish have been taken from the records of the London Surgical Home. I have drawn my illustrations chiefly from this source, because the practice of the Institution being freely open to the profession, the cases have been observed by numerous medical men; and, I may add, that many have become firm converts to my views.
ON THE
CURABILITY OF CERTAIN FORMS OF
INSANITY, EPILEPSY, CATALEPSY,
AND
HYSTERIA IN FEMALES.
CHAPTER I.
INTRODUCTORY.
As the title of this book implies, I do not intend to occupy the attention of my readers with all the numerous varieties of insanity and other nervous disorders to which females are liable, but only those which I believe to be curable by surgical means; nor is it my intention in this category to include slight cases, but to confine myself to such as cause more or less severe functional derangement, or which lead to serious organic lesions.
The class of diseases on which I shall dwell are those depending on (or arising from) a loss of nerve tone, caused by continual abnormal irritation of a nerve centre.
This is no very new theory; but it has been for Dr. Handheld Jones, by a large number of cases and experiments, as collated in his admirable work on “Functional Nervous Disorders,”[[1]] to make it “abundantly clear that the great majority of disorders we have to treat at the present time show more or less marked indications of failure of nervous power.” Dr. Jones confines himself “to such disorders as are termed functional;” and I agree with him that “it seems a vain dispute, whether in strict accuracy there are, or are not, any such disorders; ... for it is perfectly certain that there are very grave disorders in which the most careful scrutiny fails to detect any actual change, in which complete recovery is perfectly possible, and in which the ‘juvantia’ are such as to operate more in modifying the power of the organs than the texture.” Dr. Jones then gives two typical cases of functional and organic disease, between which, as he justly observes, “there intervene numerous instances of more or less mixed character;” and adds, that “disease which commences essentially as functional may end as organic.”
[1]. London, Churchill, 1864.
I am so pleased to be supported by my old friend and colleague in views that I myself have long entertained, that I intend, without further preface, to make his researches the whole substratum of my work; and hope to show how, on the basis of Dr. Jones’s experiments, it is possible to prove the philosophy of my own practice.
Whichever of the terms, “inhibitory influence” (Handfield Jones and Lister), “reflex relaxation” (Brinton), or “reflex paralysis” (Brown-Séquard), be used, the fact is ceded by all, that “the energetic operation of an afferent nerve” (Lister), or some impression acting injuriously on an afferent nerve (Handfield Jones), or, again, “an actually existing irritation” (Brown-Séquard), exerts an injurious effect on its nerve centre, this state being, as Dr. Brown-Séquard thinks, increased or diminished according to the activity of the irritation, and ceasing with its entire removal, or, more probably, as Dr. Handfield Jones affirms, persisting after the cessation of the cause which has morbidly affected it. This latter view appears to me the more generally correct one, because it can hardly be expected that a gradual disease will be suddenly removed, there having been no time for recovery of nerve power.
In Dr. Handfield Jones’s Lumleian Lectures, delivered last year before the College of Physicians, he thus sums up his views on this subject:—“The essential idea of the inhibitory theory is, that an impression conveyed to a nervous centre by afferent nerves may weaken or paralyze, instead of exciting, its action, either from the congenital or acquired debility and sensitiveness of the nerve itself, or because the impression is unduly intense or absolutely injurious. Both these things have in every case to be considered—viz., the state of the nerve force, and the kind and amount of impression, as the resulting phenomena will vary with the variation of either.”
Dr. Jones next takes it as a matter of certainty, “that a nervous centre may be more or less completely paralyzed without having undergone organic change, in consequence of some enfeebling morbid influence;” and quotes from Dr. Gull[[2]] “a most interesting instance of complete paraplegia induced by sexual excess, in which nothing abnormal could be detected in the cord, even by careful microscopy. This was paralysis from simple exhaustion.”
[2]. “Guy’s Hospital Reports,” 1858. Case xvii.
Still continuing, Dr. Jones draws attention to the anatomical fact of the remarkably close manner in which “the different nerve centres, or parts of a nerve centre, are connected by commissural fibres,” and how, “from a pathological point of view, the same connexion is often very manifest. The general exhaustion induced by excess of venery,” and other cases, “are examples which show how excessive consumption of nerve force in one part weakens it also in others; and this can only be adequately explained by the intricate commissural connexion between the various centres.”
The truth of all these views is well exemplified, as Dr. Kidd has stated, in cases of epilepsy, which “may originate only in irritation of bad teeth acting on the brain, or worms irritating the nerves of the stomach, and so on as to other peripheral irritations; the chief skill being to find out the spot from which the irritation radiates.”
A case is also quoted by Dr. Jones, in the Lumleian Lectures, as having occurred in the practice of Mr. Castle, of New York, where diseased teeth produced paraplegia, which soon ceased after their removal.
Long and frequent observation convinced me that a large number of affections peculiar to females, depended on loss of nerve power, and that this was produced by peripheral irritation, arising originally in some branches of the pudic nerve, more particularly the incident nerve supplying the clitoris, and sometimes the small branches which supply the vagina, perinæum, and anus.
Closer observation satisfied me that the greater or less severity of the functional affections observed, depended on the amount and length of irritation, and the consequent amount of loss of nerve power.
Nor are functional disorders the only consequence, but in some cases, severe organic lesions.
The progress of the disease may be divided into eight distinct stages—No. 8 being arrived at, by gradations more or less distinct, directly from No. 1.
1. Hysteria (including dyspepsia and menstrual irregularities).
2. Spinal Irritation, with reflex action on uterus, ovaries, &c., and giving rise to uterine displacements, amaurosis, hemiplegia, paraplegia, &c.
3. Epileptoid Fits, or Hysterical Epilepsy.
4. Cataleptic Fits.
5. Epileptic Fits.
6. Idiotcy.
7. Mania.
8. Death.
My statement, that death is indeed the direct climax of the series, might be proved by several cases which have occurred in my own practice, one only of which I shall relate. Before doing so, I may mention that Dr. James Russell, of Birmingham, has recorded a case in the Medical Times and Gazette, Oct. 31, 1863, in which a male patient, æt. 32, died under his care in the Birmingham General Hospital. Complete paralysis both of sensation and motion in the lower part of the body and lower extremities attacked him after an unusually excessive venereal indulgence. There had been gradual exhaustion for the last twelve or fourteen years, from this cause. There was no attempt at recovery, and he died in four months from the date of the attack.
The case that occurred in my own practice was as follows: ——, æt. 19, has been gradually becoming ill since the age of nine; does not look older than the latter age, though the sexual organs are as highly developed as they should be. Has been for many months in a metropolitan hospital suffering from acute headache, but has received no benefit. For two years has been perfectly blind.
She was found dead, and with every evidence of having expired during a paroxysm of abnormal excitement.
These cases will illustrate how important it is to arrest the disease ab initio, and the treatment must be the same whether we wish to cure functional disturbance, arrest organic disease, or, finally, if we have only a chance, of averting death itself.
The time required for recovery must depend, not only, as has been already hinted, on the duration of illness, but also on the peculiar temperament of the patient, and judicious after-treatment; this latter requiring long perseverance on the part of both practitioner and the friends of his patient; and it is as we meet a favourable or unfavourable case that the opinions of Brown-Séquard, as to instant cure on removal of irritation, or of Handfield Jones, as to cure after a long interval, are verified.
I have pleasure in stating that, with reference to the origin of most nervous affections of females, I have, in frequent conversation with Brown-Séquard, found that the views of this distinguished physiologist entirely coincide with my own, and he often expressed himself as satisfied that destruction of the nerve causing irritation was the only effective cure; the best mode of carrying out this destruction was, in his opinion, yet to be determined. He used actual cautery.
I hope to be able to show that a far more humane and effectual method is that which I constantly practise, and for the last six or seven years have openly and consistently advocated. Of course, from the very novelty of these views, I have been met with many objections, such as unsexing the female, preventing the normal excitement consequent on marital intercourse, or actually, as some most absurdly and unphilosophically assert, causing sterility: whereas my cases will show fact to be directly converse to all these theories; and it is curious that a physician for many years connected with one of our largest metropolitan hospitals, and recognized as a standard writer on female diseases, has in writing condemned my practice in not very measured terms, but is himself constantly in the habit of trying to subdue this peripheral irritation by continual application of the strongest caustics to the seat of the irritation; thereby showing that he recognizes the source of evil, but is not yet able to see that a superficial sore will not destroy deep-seated nerve irritation. It wants, I imagine, little argument to prove that so far from this practice being beneficial, it is likely, by causing increased irritation, to be positively injurious.
Other practitioners follow Dr. Brown-Séquard’s plan of applying actual cautery to the irritant nerve; and many more have advanced as far as the operation—which I was formerly in the habit of practising—subcutaneous division of the nerve. I have long abandoned this method as being no more certain in its effect than kindred operations on various branches of the fifth nerve for tic doloureux.
Another objection has been made that several of my cases have not been permanently cured, but have had relapses in a few weeks or months. This must necessarily be so with all new methods of treatment; but each such case is of incalculable importance, as teaching me to exclude any but temporary hope of relief to some, while to others I can speak all the more positively as to their ultimate permanent recovery.
Experience seems to teach that in those patients whose brains have been so weakened by long-continued peripheral excitement, causing frequent and increasing losses of nerve force, there is not sufficient mental power to enable them to control any less powerful irritation of smaller branches of the pudic nerve, than that removed by operation.
This lesser excitement acts chiefly, I imagine, by preventing restoration, in the same manner as a drunkard whose brain is weakened by long indulgence in his baneful habit cannot resist temptation, but is, however, affected by much smaller quantities of stimuli, than when strong, he was able to take.
A striking instance of this kind occurred to me last year.
One of our most distinguished obstetric physicians requested me to operate on a lady who had been for some twenty years under very many eminent practitioners without any but temporary benefit. The result of the operation was most marked; the irritation subsided, the patient improved in health, and we confidently expected permanent relief. Yet in a few weeks after she left our hands and that of the nurse, irritation, resembling pruritus, gradually returned, and with it the other old symptoms.
In all cases of a similar nature which have come under my care, I have insisted on the importance of the patient being kept for a long time under careful medical watching and good nursing, and from the results already obtained from cases in which these precautions have been exercised, I feel confident of success for the future.
Lastly, objections have been advanced against the morality of the operation, and I am here at a loss how to give an answer, for I can hardly conceive how such a question can be raised against a method of treatment which has for its object the cure of a disease, that is rapidly tending to lower the moral tone, and which treatment is dictated by the loftiest and most moral considerations. I may here observe, that before commencing treatment, I have always made a point of having my diagnosis confirmed by the patient or her friends.
To the philosophical and charitable mind, indeed, the whole subject is one of the greatest interest, and will lead us to ask the question, may not this “inhibitory influence,” originating in early life, act so powerfully on the mind as to unhinge it from that steadiness which is essential to enable it to keep the passions under control of the will; to enable, indeed, the moral tone to overcome abnormal excitement? And if this be true, does not common charity lead us to think that cases treated by friends and spiritual advisers, as controllable at the will of the individual, may be in reality simply cases of physical illness amenable to medical and surgical treatment? Is it not better to look the matter steadily in the face, and instead of banishing the unhappy sufferers from their home and from society, endeavour to check their otherwise hopeless career towards some of the latter stages of this disease, to restore their mental power, and make them happy and useful members of the community?
On this consideration I shall not now dwell further. Every one must feel it to be a vast and important one, affecting the well-being of the whole human race.
All I am now aiming at, is to show that many, if not all, such cases may be cured. If this is done, I shall indeed be able to say that I am amply repaid.
I have the gratification of being able to name the following gentlemen who have been led to adopt my views and treatment in proper cases:—Sir James Simpson; Dr. Beattie, of Dublin; Sir John Fife and Dr. Dawson, of Newcastle-on-Tyne; Dr. Duke, late of Chichester; Dr. Shettle, of Shaftesbury; John Harrison, Esq., of Chester; Drs. Savage, Routh, and Rogers, in London; my eldest son, Mr. Boyer Brown, now practising in New South Wales; with my colleagues in the “London Surgical Home,” Dr. Barratt, and Messrs. Harper, Chambers, I. B. Brown, junior, and Bantock, and very many others.
CHAPTER II.
SYMPTOMS AND PROGRESS OF DISEASE—AGE AND CLASS OF PATIENTS TO BE TREATED—OPERATION—AFTER-TREATMENT, ETC.
Every medical practitioner must have met with a certain class of cases which has set at defiance every effort at diagnosis, baffled every treatment, and belied every prognosis. He has experienced great anxiety and annoyance, and felt how unsatisfactory was his treatment to the friends of his patient: and this, not so much because he was ignorant of the cause, as that he was unable to offer any hope of relief.
The period when such illness attacks the patient is about the age of puberty, and from that time up to almost every age the following train of symptoms may be observed, some being more or less marked than others in the various cases.
The patient becomes restless and excited, or melancholy and retiring; listless and indifferent to the social influences of domestic life. She will be fanciful in her food, sometimes express even a distaste for it, and apparently (as her friends will say) live upon nothing. She will always be ailing, and complaining of different affections. At first, perhaps, dyspepsia and sickness will be observed; then pain in the head and down the spine; pain, more or less constant, in the lower part of the back, or on either side in the lumbar region. There will be wasting of the face and muscles generally; the skin sometimes dry and harsh, at other times cold and clammy. The pupil will be sometimes firmly contracted, but generally much dilated. This latter symptom, together with a hard cord-like pulse, and a constantly moist palm, are, my son informs me, considered by Mr. Moore, Colonial Surgeon of South Australia, pathognomonic of this condition. There will be quivering of the eyelids, and an inability to look one straight in the face. On inquiring further, there is found to be disturbance or irregularity in the uterine functions, there being either complete cessation of the catamenia, or too frequent periods, generally attended with pain; constant leucorrhœa also frequently existing. Often a great disposition for novelties is exhibited, the patient desiring to escape from home, fond of becoming a nurse in hospitals, “sœur de charité,” or other pursuits of the like nature, according to station and opportunities.
To these symptoms in the single female will be added, in the married, distaste for marital intercourse, and very frequently either sterility or a tendency to abort in the early months of pregnancy.
These physical evidences of derangement, if left unchecked, gradually lead to more serious consequences. The patient either becomes a confirmed invalid, always ailing, and confined to bed or sofa, or, on the other hand, will become subject to catalepsy, epilepsy, idiotcy, or insanity. In any case, and more especially when the disease progresses as far as these latter stages, it will almost universally be found that there are serious exacerbations at each menstrual period.
On personal examination, the peculiar straight and coarse hirsute growth; the depression in the centre of the perinæum; the peculiar follicular secretion; the alteration of structure of the parts, mucous membrane taking on the character of skin; and muscle having become hypertrophied and generally tending towards a fibrous or cartilaginous degeneration; will all be recognized by the practitioner who has once had his attention drawn to these subjects.
Having ascertained the cause and nature of the disease, there are one or two points to be considered before operative measures are decided on.
First, as to age. Although there is no doubt that patients may suffer from peripheral irritation of the pudic nerve from the earliest childhood, I never operate or sanction an operation on any patient under ten years of age, which is the earliest date of puberty. In children younger than this, milder treatment with careful watching, will be found sufficient if it be thoroughly persevered in.
There are again, after puberty, cases which give rise to but slight disturbance, but in which the sufferers are they who love to enlist sympathy from the charitable, and will be ill, or affect to be ill, in spite of any and every treatment.
When I have decided that my patient is a fit subject for surgical treatment, I at once proceed to operate, after the ordinary preliminary measures of a warm bath and clearance of the portal circulation.
The patient having been placed completely under the influence of chloroform, the clitoris is freely excised either by scissors or knife—I always prefer the scissors. The wound is then firmly plugged with graduated compresses of lint, and a pad, well secured by a T bandage.
A grain of opium is introduced per rectum, the patient placed in bed, and most carefully watched by a nurse, to prevent hæmorrhage by any disturbance of the dressing. The neglect of this precaution will be frequently followed by alarming hæmorrhage, and consequent injurious results.
The diet must be unstimulating, and consist of milk, farinaceous food, fish, and occasionally chicken; all alcoholic or fermented liquors being strictly prohibited. The strictest quiet must be enjoined, and the attention of relatives, if possible, avoided, so that the moral influence of medical attendant and nurse may be uninterruptedly maintained.
A month is generally required for perfect healing of the wound, at the end of which time it is difficult for the uninformed, or non-medical, to discover any trace of an operation.
The rapid improvement of the patient immediately after removal of the source of irritation is most marked; first in the countenance, and soon afterwards by improved digestion and other evidences of healthy assimilation.
It cannot be too often repeated, that this improvement can only be made permanent, in many cases, by careful watching and moral training, on the part of both patient and friends.
In the large majority of cases, I have administered no medicines, trusting entirely to recovery, after the removal of the source of irritation. Sometimes, however, we may be materially aided by the use of such medicines as the bromides of potassium and ammonium, belladonna, &c.
CHAPTER III.
HYSTERIA, WITH CASES.
It may, perhaps, be necessary before relating cases which I have treated, suffering from hysteria, to state briefly what I understand by this term. The word Hysteria was doubtless originally used in the belief that it depended on excessive reflex action of the nerves of the uterus and ovaries, when these organs were excited by disease or other causes; but this view is a very limited one, for, as Dr. Handfield Jones says, “it does not appear that females suffering with irritable uterus are more hysterical, often not so much so, as those who have no such disorder.” There is, however, as I have already mentioned, in almost all hysterical patients, an exacerbation at the menstrual periods.
Dr. Copland’s opinion, that “increased reflex excitability of the nerves of the female generative organs is one principal causative condition of hysterical affections,” appears to me the correct one. Romberg also says, “from the time when hysteria has taken root, the reflex action preponderates throughout the organism, and renders the individual more dependent upon external stimuli.”
I have alluded in the last chapter to those patients who have no desire to get well. Such I am not considering; and although I believe that all the complaints of an hysterical patient are more or less exaggerated, my experience differs from that of Dr. Handfield Jones, who believes that such patients are not “bonâ fide anxious to get well.” In his view he is supported by Dr. Prout, who considers that “the whole energies of the patient’s mind are bent on deception;” and by Dr. Watson, who says that “the deceptive appearances displayed in the bodily functions and feelings find their counterpart in the mental.” I am confident that I have met with many instances in which the nerve power has become so weakened that the patient, without having organic disease, really feels all the symptoms she describes, and is only too anxious to be cured. The cases I shall now narrate are a few of a large number that have come under my care, and I am not without hope that their relation may show that hysteria, instead of being a term of reproach, does truly represent a curable disease.
The following was the first case that came under my notice, after I had satisfied myself of the correctness of my views on the subject:—