Transcriber’s Note:
The cover image was created by the transcriber and is placed in the public domain.
ON THE CURABILITY
OF CERTAIN FORMS OF
INSANITY, EPILEPSY, CATALEPSY,
AND
HYSTERIA IN FEMALES.
BY
BAKER BROWN, F.R.C.S. (Exam.)
SENIOR SURGEON TO THE LONDON SURGICAL HOME;
LATE SURGEON-ACCOUCHEUR TO, AND LECTURER ON MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN AT, ST. MARY’S HOSPITAL;
LATE CONSULTING SURGEON TO THE WESTBOURNE DISPENSARY AND PADDINGTON LYING-IN CHARITY;
PRESIDENT OF THE MEDICAL SOCIETY OF LONDON;
FELLOW OF THE OBSTETRICAL SOCIETY OF LONDON;
MEMBER OF THE HARVEIAN SOCIETY;
CORRESPONDING FELLOW OF THE OBSTETRICAL SOCIETY OF BERLIN;
HON. FELLOW OF THE GENERAL ASSOCIATION OF SURGEONS, NORTHERN GERMANY;
MEMBER OF THE BROOKLYN MEDICAL AND SURGICAL SOCIETY;
CORRESPONDING MEMBER OF THE SOCIETY OF MEDICAL SCIENCE OF PESTH;
CORRESPONDING MEMBER OF THE SOCIETY OF MEDICAL SCIENCE OF BRUSSELS;
CORRESPONDING MEMBER OF THE PHYSIO-MEDICAL AND STATISTICAL SOCIETY OF MILAN;
HON. CORRESPONDING MEMBER OF THE MEDICAL SOCIETY OF NORWAY, ETC.
LONDON:
ROBERT HARDWICKE, 192, PICCADILLY, W.
1866.
COX AND WYMAN,
ORIENTAL, CLASSICAL, AND GENERAL PRINTERS,
GREAT QUEEN STREET, W.C.
TO DR. E. BROWN-SÉQUARD. F.R.S., &c.
Dear Dr. Brown-Séquard,
I am deeply indebted for your kind permission to dedicate this work to you. I feel assured that its introduction to the Profession under the auspices of the greatest physiologist of the day will secure for it greater consideration, and lead to a closer examination of its contents, than would otherwise have been the case.
With the greatest respect, believe me to be,
Most faithfully yours,
I. BAKER BROWN.
17, Connaught Square, Hyde Park, W.
March, 1866.
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:—
Case I. Hysteria—Five Years’ Illness—Operation—Cure in Two Months.
D. E., æt. 26, single; admitted into the London Surgical Home Oct. 12, 1859.
History.—She had been a dressmaker in Yorkshire to all the best families around, but for the last five years had been so ill as to render her unable to do any work, and had been entirely supported by her former customers. When in that neighbourhood, on a professional visit to a lady, I was requested to see, amongst others, this poor ci-devant dressmaker. Her physiognomy at once told me the nature of the case; she was much attenuated, having for a longtime been unable to retain any food, always being sick, with great pain, immediately after meals. She had constant acid eructations; was so weak as to be at times unable to cross the room; complained of a burning, aching pain, with great weakness at the lower part of the back. Her catamenia were irregular, with much leucorrhœa; bowels generally costive. She was very melancholy, and expressed a most earnest desire to be cured. I advised her admission to the “Home,” and on October 15, I divided the clitoris subcutaneously. This being my first operation, I did not know the consequences of performing the operation in this manner. For two days the hæmorrhage was profuse and uncontrollable. Sleep was procured by opiates. I ordered ℥ij of olive oil to be rubbed into her chest every night, with a view to nutrition of her attenuated frame. A moderately generous diet was given, but no stimulants. She was quite well in two months, and has never since had a day’s illness. She resumed her occupation as a dressmaker, and recovered nearly all her former customers. 1865.—I have heard almost yearly of this patient, and lately had a letter from the lady to whom I previously referred, saying that my patient is perfectly well and in robust health.
Case II. Two Years’ Illness—Operation—Cures.
P. F., æt. 21, single; admitted into the London Surgical Home Jan. 7, 1861.
History.—Attributes her illness to having strained herself two years ago, when lifting a heavy saucepan from the fire. Has ever since that time suffered great pain in the back and side, much worse when she walks, but tolerably easy in the prone position. Catamenia very irregular, both as to time and quantity. Great pain in defecation. Bowels very constipated. Has been eleven weeks in a metropolitan general hospital, and thirteen weeks in a special hospital for women, from both of which she was discharged as having nothing the matter, because she had no evident disease. She had, however, been treated for uterine disease.
On examination, the uterus was found to be quite healthy; there was, however, evidence of excitation of the pudic nerve.
Jan. 10. The clitoris completely excised.
Jan. 16. Is much better.
Jan. 31. Discharged from the Home, cured. Is quite well in her health, having lost all aches and pains, and being able to defecate without the slightest uneasiness.
Case III. Hysteria—Thirteen Years’ Illness—Sterility—Operation—Cure, and subsequently Three Pregnancies.
S. S., æt. 33, married; admitted into the London Surgical Home February 23, 1861.
History.—Although married several years, has had no children. About a year ago suffered from pain in the right side, which, however, being treated was cured. In April last the pain returned in the back, and at short intervals has recurred. At times the pain is so severe that she is unable to walk. Has for thirteen years suffered from leucorrhœa, globus hystericus, &c.; and has always had distaste for marital intercourse.
Examination confirming me in the diagnosis I had formed of this case, I, on February 28, operated in the usual manner. Her recovery was retarded by an attack of jaundice, but in May she was discharged cured.
In July, 1862, this patient was seen quite well and ruddy, and had long lost all her old symptoms. She had been once pregnant, but miscarried at three months.
In July, 1865, she came to town with her youngest child. She was quite well, and had never been ill since the operation.
Remarks.—This was the first case of this nature under my care, in which the patient, formerly sterile, became pregnant after removal of the cause of her illness.
Case IV. Hysteria, with Sleeplessness—Six Years’ Illness—Operation—Cure.
H. R., æt. 55, single; admitted into the London Surgical Home Nov. 18, 1861.
History.—For six years has suffered from a feeling of fulness, weight, and heat at the lower part of abdomen, with pain in the back, and “bearing down.” At this time her menses had just ceased. Has not slept well for three or four years. Wakes every hour. Is always restless and fidgety. Frequent desire to micturate, with pain on doing so, and often desire without power to void it. Bowels costive; digestion indifferent.
She is a nervous, restless woman, with glistening and constantly wandering eye—pupils dilated. Has suffered from peripheral irritation for many years.
Nov. 21, 1861. Usual operation performed. A week later, slept well for four hours, the first time for many years.
Dec. 1. Has lost the irritability of the bladder, and passes water every four hours only; lost also the bearing-down pain; restless excitement gone.
Dec. 7. Eats and sleeps well; is cheerful and grateful; leaves the Home cured, having been in only three weeks.
In 1863 was perfectly well.
Case V. Fissure of the Rectum, with Hysteria—Operation for the former—Relief—Subsequent Operation for Hysteria—Cure.
Mrs. L., æt. 55; admitted into the London Surgical Home Dec. 9, 1861.
History.—Is a widow. Has for many years suffered from all the inconveniences of a fissure of the rectum, combined with bad digestion, undue nervous excitability, and sleepless nights. Is very anxious to be cured. It being thought that all these symptoms might be due to a painful fissure of the rectum, the ordinary operation for this affection was performed on December 12. The bowels were opened in a few days without pain, and the fissure was healing well. Being, however, still sleepless, excitable, and irritable, questions were asked which showed that a further operation for removal of another source of irritation was advisable; therefore, on December 24, I performed my usual operation. The next night she slept well. She became quiet and cheerful, and on January 6, 1862, she was discharged quite well.
Remarks.—This case is very interesting, as it shows that there may exist at the same time more than one irritation exerting inhibitory influence.
Case VI. Hysteria, with Epileptiform Attacks in Childhood—Various Ailments for Thirteen Years—Operation—No Benefit.
H. D., æt. 23 single; admitted into the London Surgical Home April, 1862.
History.—When very young, until ten years of age, had frequent fits. Improved in health till she was fourteen years of age, when she began to suffer from abdominal enlargement. First menstruated at nineteen. Is constantly sick after meals. Has been in nearly every hospital in London. The patient is very hysterical, and is always talking religion.
On examination the abdomen was found very tympanitic. Under chloroform this state quite subsided. Walls of abdomen fat and muscular. Body generally well nourished. Evidence of continual irritation of the pudic nerve.
April 3. Operation as usual.
For some time after the operation this patient was much better of the sickness, and great interest was manifested by several visitors in her case; she never, however, received permanent benefit, being a regular impostor, and discovered on several occasions tying handkerchiefs, &c., tightly round her waist to make her abdomen swell. She was discharged as incurable.
Remarks.—This case I have inserted as a warning. It is no fault of the operation if it fail in such cases.
Case VII. Hysteria—Several Years’ Illness—Operation—Cure.
Miss M., æt. 42; admitted into the London Surgical Home April 13, 1862.
History.—Has felt ailing for many years, but for the last two has suffered pain in the uterine region, and, on pressure, over the ovaries. This pain is accompanied by bearing down, and a sense of distension. Suffers from considerable leucorrhœa. Menstruation regular, and during the period the pain is absent. Bowels regular. Sleep disturbed. Feels depressed, and is inclined to melancholia.
On examination there was no congestion of uterus or enlargement of ovaries, but there was evidence of peripheral irritation of the pudic nerve.
April 17. Usual operation performed.
She rapidly improved; sleep and cheerfulness returned, and all pain left her. She expressed herself as not having been so well for many years.
May 13. Left the Home, having gained flesh and strength, and being quite cured of all her bad symptoms.
Remarks.—Interest attaches to this case, as instead of exacerbation, there was diminution of the symptoms during menstruation.
Case VIII. Hysteria—Many Years’ Illness—Phantom Tumour—Operation—Cure.
A. B., æt. 24; admitted into the London Surgical Home 16th July, 1862.
History.—Is a single woman, and procures a living by dressmaking. When younger, was a nurse-maid. Catamenia commenced before she was thirteen, but she was not regular until she was nineteen, since which the function has proceeded normally both in time and quantity. Has for many years been ailing, and always had something the matter. Has suffered from intense irritation in the genital region, especially in the bladder, and she has constant pain in the back. For two years has been treated at a dispensary for an abdominal tumour; during this period she has taken much medicine, but without benefit.
On examination the abdomen was found increased in size and universally tympanitic. Under the influence of chloroform the swelling entirely subsided.
July 17. Usual operation performed under the influence of chloroform.
Sept. 2. She was discharged quite cured, all her hysterical symptoms having left her, and the tumour never having been seen since the day of operation.
Case IX. Hysteria—Five Years’ Illness—Sterility—Operation—Cure—Pregnancy—Two Children.
Mrs. O. came under my care in 1862. She had been ill ever since marriage, five years previously; having distaste for the society of her husband, always laid upon the sofa, and under medical treatment. Evidence of peripheral excitement being manifest, I performed my usual operation. She rapidly lost all the hysterical symptoms which had previously existed; and in about a year came up to town to consult me concerning a tumour, which greatly frightened her, as she feared it was ovarian. I discovered that she was six months pregnant. She was delivered at full time of a healthy child. In 1865 she again called on me to show herself, not only in robust health, but pregnant for the second time.
Case X. Hysteria—Irritation of Right Ovary—Menorrhagia—Nine Years’ Illness—Operation—Cure.
C. M. A., æt. 28, single; admitted into the London Surgical Home June 22, 1863.
History.—Since the age of 19 has been more or less subject to uterine flooding; for the first three years lost blood every day. Has been five times in a metropolitan hospital; always better while there, but as bad as ever as soon as she left. The bleeding is much worse at each menstrual period. She passes large coagula; has constant pain in the back, headache, and palpitation of the heart, and cannot sleep; is dreadfully pale and anæmic.
Examination showed great irritation over right ovary, and there was evidence of long-continued peripheral irritation.
July 2. Usual operation.
July 7. Menstruation came on in a moderate flow.
July 10. Menstruation ceased; is much better, and there is sign of returning colour in the face.
July 31. Has improved considerably, and had no return of the bleeding. To be discharged cured.
Case XI. Hysteria—Many Years’ Illness—Operation—Cure—Marriage and Progeny.
Emma K., æt. 22, single; admitted September 16, 1863, into the London Surgical Home.
History.—Commenced menstruating at 15 years of age, but owing to the use of cold water during a period, the secretion was arrested for six months; the function was then restored, and has ever since continued normal. At 16 she suffered from piles, which occasioned very much irritation and pain after each evacuation, aggravated by constipation and by walking. Though regular as to time, there is always excessive catamenial flow, and it lasts for eight days. Has been under long and varied medical treatment, without benefit.
Examination showed peripheral irritation, as evinced by the abnormal condition of the external genitals.
Sept. 17, 1863. The usual operation performed.
Oct. 1. Progressing most favourably.
Oct. 22. Leaves quite cured.
1866. This lady married, and was delivered August, 1865, of a living child. She is still quite well.
It will have been observed that one very prominent symptom in many of the foregoing cases is sleeplessness, or perhaps more properly, frequent wakefulness at nights, and constant restless movements in the day. These are the cases which, if left to go on, are very liable to terminate in insanity. The three following are instances in which the hysteria was verging on this state, and as they can hardly be classed under the head of insanity, I prefer narrating them here.
Case XII. Hysteria—Mental Aberration, and Tendency to Melancholia—Eight Years’ Illness—Operation—Cure.
In December, 1861, a single lady consulted me, giving the following history of her illness:—
Has not been well for seven or eight years; has felt languid, and not so lively as formerly. For the last two years has menstruated every three weeks, and the flow has lasted four or five days. There is considerable white discharge from the vagina after each period, lasting for a week. Great irritation about vulva, perinæum, and anus before and during each menstrual period. For the last five or six years had had occasional irresistible and unaccountable fits of depression; thinks that it is her mind—if her mind were as strong as her body she would be pretty well: her memory is good, but mind weak. Has suffered from great pain at lower part of the back; says she cannot rise from a chair without great difficulty, on account of a feeling of stiffness in hips and trembling of the legs (this is probably owing to a swelling of the hip-joint, as all the joints of her fingers and ankles are swollen). Says she can sit quietly to crochet or needlework, but cannot sit quietly to think, or compose her mind to write a letter: has not written a letter properly for three years. Has been subject to attacks of melancholy and weeping, without any tangible cause, but which she cannot resist. Suffers from want of sleep, and at night frequently lies awake four or five hours together. Appetite good; bowels costive.
In appearance is fresh-coloured and plump, but she says she is thinner than formerly; dark eyes; large dilated pupils.
On examination there was evidence of great irritation about the vulva, and constriction of the anus, with a very small fissure.
Dec. 21. I divided the fissure, and performed my usual operation.
Dec. 31. Very much improved; swelling of the joints much less.
Jan. 1. She sat up, and feels much better. Her spirits are improved; has no pain in the joints; sleeps well. In another month she returned home quite well, and has continued so to the present time.
Case XIII. Extreme Hysteria, verging on Insanity—Five Years’ Illness—Operation—Cure.
Mrs. ——, æt. 32, married; admitted into the London Surgical Home August 5, 1862.
History.—Has been married twelve years, but has had no children nor miscarriages. Has always enjoyed pretty good health until about five years ago, when she began to suffer from leucorrhœa and great pain during menstruation. Catamenia regular in time and quantity. Her bladder is so irritable that sometimes she has to pass her water every half-hour; the urine sometimes very much loaded. Suffers from headache and giddiness in the morning. Says that for the last three years the act of coition has been accomplished without the least pleasure, but with pain. Bowels are opened regularly and without pain.
August 7. Having diagnosed the cause of the disease, the usual operation was performed.
August 9. A severe attack of erysipelas came on, and she was very ill for some days, but she made a good recovery.
A few days after the operation this patient was observed to be occasionally very violent and unmanageable, and to have at these times a wild maniacal look. On questioning her husband, it appeared that for several years she had been subject to fits of violent excitement, especially during the menstrual period, and that at such times “she would fly at him and rend his skin, like a tigress.”
This patient made a good recovery; she remained quite well, and became in every respect a good wife.
Case XIV. Extreme Hysteria—Incipient Insanity—Operation—Cure.
Mrs. R., æt. 42; admitted into the London Surgical Home Aug. 5, 1862.
History.—Has been married, but has been a widow for twelve years. Is companion to a lady. Never had any family. Has been ailing for some years, but has not suffered severely until the last six months. Suffers most from pain in the lower part of the abdomen, and from constant burning and irritation about the vulva. During the last few months has become very nervous and fidgety; never can remain quiet, and says that lately she “has had a sort of lost feeling, particularly when writing; being unable to compose her thoughts, or concentrate her mental energies.” Has suffered from considerable irritability of the bladder; and her urine is often full of thick deposit. Catamenia regular in time and quantity. Cannot sleep.
On examination, is a very nervous woman, her eyes restless and never quiet; constant twitchings of the limbs, and occasionally an appearance almost of insanity about her expression. There is every evidence of a long-continued inhibitory influence.
August 7. The usual operation performed.
August 8. Feels very comfortable. Slept better last night than for some years.
August 9. Is improving wonderfully: the expression of countenance completely changed.
Sept. 9. Left quite well. Has got fat, and has now a cheerful face and manner. Says she feels a different being, and is quite astonished at her own improvement. Has lost all her nervous twitchings and other uncomfortable symptoms, and has now a comfortable night’s rest.
CHAPTER IV.
SPINAL IRRITATION, WITH CASES
There are perhaps few terms so difficult to define as spinal irritation, for the gradations from hysteria to this state are extremely easy; and, indeed, it will have been seen that in the foregoing chapter most of the patients complained of pain in the spine, and that there was more or less functional disturbance in all of them. The term is also used so freely and vaguely that great caution is necessary in attempting to explain its meaning. Dr. Handfield Jones’s term, “Spinal Paresis,” seems to me an excellent one; by it he means “a state in which, without demonstrable organic change, there is greater or less enfeeblement of the functional power” of the spinal cord. The sensory or motor power may be affected, but rarely both together.
The cause of spinal irritation, or paresis, may be defined in one word—“debility;” this debility always, or almost always, being due to inhibitory irritation.
This state of things may give rise to wide and varied disorders, all the symptoms of which are asthenic in their character, and all of which are marked by extreme nervous prostration.
Without doubt,—for all authors agree on this point, one of the most prominent causes is peripheral irritation of the pudic nerve, producing undue exhaustion.
It is difficult to say how this is produced, but most probably it is that, “owing to the intimate commissural connections between the lumbar enlargement of the cord, where the pudic nerves are implanted (they themselves being small and remote in their origin from the brain); and the superior and nobler nervous centres, the intense excitation of even a small and remote centre is communicated to the others, which, as this subsides, fall as much below, as they have previously been stimulated above par. The depression is proportional to the previous excitement.”
The cases I shall have to relate which may fairly be called cases of spinal irritation are few in number, for the reason I have stated, that they are but a continuation of hysteria,[[3]] and, indeed, but a state of things of which epileptiform and epileptic fits are the direct sequence.
[3]. Vide Cases in previous chapter.
It is, however, well to draw attention to the fact that it is in cases of spinal irritation that we observe functional derangements, which are very likely to pass into actual organic diseases; and it is in this class of cases, which are essentially of a chronic character, that very long and persistent perseverance must be pursued. I would, therefore, advise all who meet with them to warn their patients beforehand that they must not be weary and faint-hearted if recovery do not come as soon as hoped for.
Case XV. Spinal Irritation, and supposed Uterine Displacement—Six Years’ Illness—Operation—Cure.
In 1860, I was requested to see a young lady, æt. 20, of whom I had the following history:—For six years she had been confined to a spinal couch, and had also been supposed to suffer from retroversion of the uterus. She had worn a spinal apparatus, attached to which was a steel spring, pressing on sacrum and pubis, and intended “to support the perinæum, and keep the uterus in position.” Had been treated with caustics and other therapeutic agents for uterine disease. I found the uterus normal in position and healthy in appearance; but on further questioning and examination, I diagnosed peripheral irritation of the pudic nerve. My opinion was strongly contested, as I was told that the young lady was very religious; but, as I explained, her illness was to be attributed solely to a physical condition, and was not at all necessarily immoral; I was then met with the objection that, in the event of marriage my operation might interfere with marital happiness and prevent procreation. I explained how, physiologically, these objections were untenable, but was then unable to adduce actual cases in contradiction of them.
Ultimately I performed my operation in the usual manner. For want of proper attention on the part of the nurse, the dressing was three times displaced; but, nevertheless, at the end of a month this lady was well enough to walk three miles.
Up to this date she has remained quite well.
Case XVI. Dysmenorrhœa—Five Years’ Illness—Operation—Cure.
D. A., æt. 23; admitted into the London Surgical Home Aug. 4, 1863.
History.—Has never been very strong; but five years ago had an attack of gastric fever. Since then has suffered constantly from great pain during the menstrual period. Occasionally loses a great deal, and passes large clots of blood. During this time has suffered almost constantly from leucorrhœa. Suffers severely from pain over region of left ovary and in the spine. Is hardly ever free from headaches. Is very restless; never sleeps well; frequently faints; and has little or no appetite. All her ills are exaggerated at the menstrual epoch.
August 7. Usual operation performed.
Sept. 1. Is menstruating without pain.
Sept. 30. Again menstruating without pain, and in normal quantity. Is to be discharged cured.
Case XVII. Spinal Irritation and Loss of Use of Right Leg—Five Years’ Illness—Operation—Cure.
M. B., æt. 30, single; admitted into the London Surgical Home Nov. 15, 1861.
History.—Five years ago first began to suffer pain in the right leg, which was ascribed to sciatica. Fourteen months since this pain became so bad that she could not walk, and she lost all use of her right leg, at the same time felt great weakness and pain in the back, preventing her sitting. For eight months has been confined to a “spinal couch.” Is a spare anæmic woman; dark hair and eyes; dilated pupils; very restless and nervous in her movements, and of a very irritable temper. Has suffered from peripheral irritation since an early age.
Nov. 26, 1861. Usual operation performed.
Dec. 27. She has gradually improved in health and temper since the operation, and is now quite able to walk about her room without help.
She was a long time before her nerve tone was thoroughly restored, but she ultimately got quite strong and continues well.
Case XVIII. Hysteria and Spinal Irritation Twelve Years—Fissure of Rectum, recent Duration—Operation—Cure.
R. C. R., æt. 35 years, single; admitted into the London Surgical Home April 15, 1861.
History.—Has been suffering for nearly twelve years, at intervals of from six months to six weeks, with pain in the womb and right side, sudden spasms of the limbs, coming on at frequent and irregular intervals. Great pain down the spine and lower part of the back and loins. Has often attacks of severe sickness. Is usually costive. Has lately suffered great pain in defecation. Catamenia regular. Great want of sleep and appetite. Says she is always low-spirited, moping, and listless. Has had much medical treatment.
On examination there was found evidence of peripheral excitement of the pudic nerve, and there also existed a fissure of the rectum.
April 18. The usual operation performed, and the fissure of the rectum incised.
After this time defecation was performed without pain. Sleep, appetite, and cheerful spirits returned. She had no more spasmodic twitchings, but she still complained of intense pain in the back on sitting and walking. She was discharged in June much relieved, but not well.
Nov. 9 1861. I received a letter from this lady, stating that she now suffered no pain and was perfectly well. She was stout, and better in every respect than she had been for the last twelve years.
Case XIX. Menorrhagia—Mental Delusion—Two Years’ Illness—Operation—Cure—Subsequent Marriage and Progeny.
A young lady, æt. 20, came under my care in 1863, having for two years past suffered from almost constant menorrhagia, during which time she had suffered great irritability of temper, been disobedient to her mother’s wishes, and had sleepless nights, restless desire for society, and was constantly seeking admiration; all these symptoms culminating in a monomania that every gentleman she admired was in love with her, and she insisted on always sending her carte de visite to her favoured one for the time being. In her quieter moments she would spend much time in serious reading. On being consulted, I quickly discovered that all these symptoms arose from peripheral excitement, and that there existed no organic disease to cause the menorrhagia. The usual plan of treatment was followed with the most rapid and marked success. She went the full interval between the ensuing menstrual periods, and the secretion was normal in quantity. All her delusions disappeared, and after three or four months of careful watching, with change of air, she was perfectly well in every respect. A year afterwards she married, and ten months later gave birth to a healthy son. She is now again pregnant.
Case XX. Spinal Irritation, giving rise to Menorrhagia and Amaurosis—Operation—Cure.
A single lady, æt. 35, came under my care in 1863. Had been out of health for some years, suffering from continuous menorrhagia, seldom being free more than ten days or a fortnight in the month. Was thin and spare in appearance; often complaining of headache, especially over the brow and orbits; and, in fact, nearly a confirmed invalid. Latterly she had become almost blind from amaurosis; she could only read the largest type, and not at all by candle-light. Had come to London from the country, and placed herself under the care of one of the most eminent ophthalmic surgeons, who had treated her for three months without the slightest benefit. When I saw her I immediately discovered that long-continued peripheral excitement had caused all her disorders. Quickly after the operation, menstruation became regular; in ten days she was able to read in bed; in a month she was quite well. I frequently hear of her now, as in robust health.
Remarks.—Beyond a grain of opium after the operation, this patient never had any medicine. I have had other cases exactly similar, with like result.
Case XXI. Spinal Irritation—Loss of Power in Lower Extremities—Operation—Rapid Improvement.
Last year I was requested to see a lady, æt. 46, who had been married to a second husband seventeen years without issue, but had two children by her first marriage. Had not menstruated for two years. Has been in ill health for many years, and undergone a variety of medical treatment without benefit. In May, 1863, first began to lose the power of her legs, and to suffer from attacks of pain in the back, shooting up to the spine. She was at this time in Paris, where she consulted several men of eminence, and was treated for uterine disease, but still without benefit. She returned to London in June, 1863, and placed herself under the care of her usual medical attendant. Relief, after some time, not being afforded, she consulted several eminent surgeons in the metropolis. She was told that she had paralysis of the lower extremities, and that nothing could be done with a hope of effecting cure. From January, 1865, she was for six months under the care of an eminent general practitioner, who exhausted the resources of his art, but in vain. She was, in fact, “given up.”
As a last resource, I was applied to. I saw her in August at her own house. Her countenance had a worn and haggard expression; her body was emaciated; skin harsh, dry, and scaly; the lower extremities hung as if paralyzed, but sensibility and voluntary motion—the latter, however, very weak—were not entirely absent. She complained of severe spasmodic attacks of agonizing pain shooting up the spine, like tetanic shocks. Her appetite was very defective, digestion was impaired, the bowels disordered, and sleep was hardly ever procured. There was also partial ptosis of the left upper eyelid. On examination, I found a deep and acutely painful fissure, with large piles and loose skin around the anus, and all the well-marked signs of peripheral irritation of the clitoris.
August, 1865. I operated, Dr. Kidd administering chloroform. I divided the fissure, tied the piles with three ligatures, cut off the loose skin around the anus, and removed the clitoris and elongated labia in my usual manner.
It was gratifying to observe the early relief of her more severe symptoms; by the third day the spasmodic attacks ceased, little or no pain was complained of, and the improvement of the digestive system was most marked, the patient enjoying chops, game, &c., within ten days, and no longer “a martyr to flatulence and dyspepsia.” The digestion was, however, easily deranged, and great care was necessary. At the end of seven weeks, having already on several occasions been driven out in a carriage, she was removed to the country, where she remained for three weeks. It may be here stated that the patient suffered much from the very sultry weather of September, and that improvement was much more rapid when colder weather set in. On her return, she was able to stand for a few minutes with her hands resting on the shoulders of another. Remaining in town for some weeks, she again left for the sea-side, where she stayed about three weeks, and returned to town in the beginning of this year. Her condition is now as follows:—
She looks remarkably well in the face, which has entirely lost its expression of suffering. She is free from pain. Sensibility in the lower extremities is perfect; their muscular power is greatly improved. She can raise herself from a chair so as to rest on her hands and feet, and is able to walk across her room, holding the hands of her maid, who retreats before her. She sleeps well every night, and her digestion is in very fair order. She is now able to sit up to all her meals, and to sit in an upright chair for hours together, whereas formerly she was constantly in the recumbent position.
CHAPTER V.
EPILEPTOID CONVULSIONS, OR HYSTERICAL EPILEPSY, WITH CASES.
In the chapter on hysteria, cases have been recorded of frequent faintings, without spasms, and of spasmodic twitchings of limbs without fainting, i.e. without loss of consciousness. We now come to cases more marked and chronic, and having many of the characters of epilepsy. They may be brought to us by the friends of the patient as genuine epileptics. The diagnosis is in some cases difficult, but for the most part easy. Dr. Russell Reynolds[[4]] has summed up the distinctive features so ably that I cannot do better than quote his final remarks on this subject:—
[4]. “Epilepsy: its Symptoms, Treatment, and Relation to other Chronic Convulsive Diseases.” By J. Russell Reynolds, M.D. London: Churchill, 1861.
“The paroxysm resembles epilepsy, and sometimes closely, but it differs in essential particulars. The difference is not one only of degree, neither is it to be determined by the relation of hysterical convulsion to pain, nor solely by the nature of the spasm. The diagnosis is to be based upon a combination of features. The paroxysms follow hysteric prodromata. At their onset there is constriction of the throat and epigastrium; there are plaintive cries, sobbings, or laughings, which reappear at the close; sensibility, perception, and volition are rarely, if ever, completely lost; the face undergoes little change; there is a twinkling movement of the eyelids; there is no marked dilatation of the pupil; there is rarely foaming or bitten tongue; the attacks are of long duration; respiratory movements are disorderly, but there are no evidences of marked asphyxia; the pulse is small; there is no stupor, but only general exhaustion after the attack; and although the paroxysms may recur for many years, and be followed by a peculiar kind of mania, they are rarely followed by dementia.”
I fully agree with Dr. Reynolds that what are called the “diagnostic signs of hysteria,” as frequent micturition of clear pale urine, tympanitis, nausea, &c., have no value in aiding our inquiry as to the nature of these fits: they may be witnessed, and with as great frequency, after epileptic seizures.
One practical point exists; namely, that in hysterical epilepsy the patient seldom, I believe never, in falling hurts herself, whereas true epileptics frequently suffer considerable bodily injuries.
Case XXII. Nine Years’ Illness—Epileptiform Attacks—Three Years’ Duration—Operation—Cure.
G. M., single; admitted into the London Surgical Home December 18, 1860.
History.—For the last nine years has suffered greatly and regularly during the menstrual periods. Has been much worse for the last three years, during which time has, at each menstrual period, been frequently taken in a fit, dropping down suddenly and fainting right off; this state lasting for two or three hours. Being in service, this has caused her much trouble, as none of her employers would keep her. For the last six months has suffered severe pain over right ovary, increased by exercise or pressure, and at the menstrual period. Believing that the dysmenorrhœa and fits both arose from the same cause, on January 3, clitoris was cut down to the base. After this operation she never had a fit, and all untoward symptoms left her except the dysmenorrhœa; she was therefore re-admitted May 27, 1861, and there being some narrowing of the cervix, it was incised with the hysterotome. June 21, catamenia came on without pain, and continued to do so regularly. In July she was well enough to return to service.
April, 1865. Her mother called at my house to say that this patient had been married some months, and was shortly expecting her confinement. She had remained quite well since the operation.
Case XXIII. Epileptoid Fits—Fifteen Years—Illness for Twenty-six Years—Operation—Cure.
F. A. C., æt. 41, single; admitted into the London Surgical Home Nov. 6, 1863.
History.—Says she had congestion of the brain fifteen years ago; since that period cannot remember being well, but from the age of fifteen has been of delicate health. Has suffered from fits for the last fourteen or fifteen years; is never long free from them. During an attack she is not entirely unconscious, but possesses no power to control them nor to speak. Has pain at lower part of spine of a gnawing character. She is a miserable, nervous creature, with pinched features and a wandering restless expression of the eye. There is evidence of injurious peripheral irritation since a very early age.
Nov. 12. Operation as usual under chloroform.
Nov. 19. Is wonderfully better. The expression of her face is much happier, and the face itself has filled out considerably. No pain in the back since the operation.
Dec. 24. Discharged perfectly cured.
Case XXIV. Hysterical Epilepsy—Long Duration—Operation—Cure.
G. C., æt. 25; admitted into the London Surgical Home Jan. 28, 1864.
History.—Has been delicate from childhood. For some months has suffered from a peculiar dragging pain in the lower part of the abdomen. Menstruates regularly. Suffers from “burning” and irritability of bladder. Has constant and severe headache. Has for a long time suffered from “epileptic fits” (on careful observation they were found not to be genuine epileptic), occurring twice or thrice a week. Is a melancholy object, with “woe-begone” expression; listless and indifferent to conversation and surrounding objects; when spoken to, does not answer rationally, and frequently only in monosyllables. Is very reserved and taciturn.
Feb. 4. Patient being under chloroform, the clitoris was excised.
Feb. 13. Progressing favourably; much improved in appearance; more cheerful; converses freely and rationally; expresses herself as grateful for her restoration to health.
March 1. Having had no return of the fits, and lost all her hysterical symptoms, she was discharged cured.
Case XXV. Hysteria and Epileptiform Attacks—Many Years’ Illness—Operation—Cure.
R. D., æt. 31; admitted into the London Surgical Home Feb. 17, 1864.
History.—Married eight years, with one child. Her husband is in the navy, and often absent from home. Previous to her marriage had a severe illness, in which she was delirious, and again in 1860, when she lost her reason for six weeks. “Was very feverish and could retain no food on the stomach.” The menstrual periods are most irregular, six or eight months sometimes elapsing between each appearance. Has not menstruated since June last. Has great difficulty in passing her urine. For many years has suffered from fits of an epileptiform character, having, in an attack, convulsions and rigidity, but never hurting herself in falling, foaming at the mouth, nor biting her tongue.
Feb. 18. Clitoris excised.
Feb. 24. Much improved, free from pain or difficulty in micturition. Is quite cheerful, and has had no attack since the operation.
March 26. Still gaining strength, looks much better, and says she now feels well.
March 28. Discharged cured.
Case XXVI. Epileptiform Fits and General Hysteria—Four Years’ Duration—Operation—Cure.
Mrs. F., æt. 44; admitted into the London Surgical Home April 23, 1864.
History.—Married sixteen years, but her husband has been abroad for the past seven years. Had inflammation of the womb four years ago, and since that time has continually suffered from bearing-down pains. Frequent desire to micturate. Pain in the loins and spine, sleepless nights, loss of appetite, and other hysterical symptoms. Has slight “epileptic fits” two or three times a week, more frequently at catamenial periods, which are regular in appearance and not profuse. Has no premonition of fits; is but partially conscious; at first struggles, then becomes rather rigid, and on recovery is always exhausted. Patient is most anxious to be cured of her attacks, of the cause of which she is fully conscious.
April 25. Clitoris excised, under chloroform.
April 26. Had a good night, better than for years.
April 30. Progressing most favourably. Patient expresses great gratitude for the relief she has obtained. She left the Home a month later, looking and feeling quite well; the last note in the case-book being “a very grateful patient.”
Case XXVII. Epileptiform Fits—Six Years’ Duration—Operation—Cure.
F. W., æt. 33, single; admitted into the London Surgical Home May 23, 1864.
History.—Has suffered from fits for more than six years, much more frequently the last six months; having now as many as four or five during the day—always one or two. The fits vary in length from one to three hours’ duration. Is conscious during the attacks, but unable to speak, or in any way to control them. Is invariably worse during the menstrual periods. Suffers from palpitation of the heart.
Examination showed a highly inflamed and sensitive condition of the external generative organs; the patient herself confirmed my opinion of the cause of her attacks.
May 28. Clitoris excised—free hæmorrhage allowed before the dressings were applied.
June 12. Left her bed to-day; has had no fit since the operation, and says she feels well.
June 20. Takes daily exercise, is free from pain, the wound is healed, and her health daily improving. Action of the heart much more moderate.
July 19. Discharged cured, not having had one hysterical attack since the operation.
Case XXVIII. Hysterical Epilepsy—Three Years and a Half Duration—Operation—Cure.
C. E. S., æt. 24, single; admitted into the London Surgical Home Oct. 17, 1864.
History.—Has been ill for about three years and a half, suffering frequently from an aggravated form of hysterical attacks, with many of the characters of epilepsy, but with only partial insensibility, and without foaming. Is often sick, and suffers from severe pain on the right side, with a feeling of pressure on the lower bowel, with a dragging and bearing-down pain around the loins. Catamenia regular; more subject to the fits at these periods. No difficulty in micturition, but a rather frequent desire to micturate; and urine often loaded.
Oct. 20. The clitoris was excised.
This patient improved very rapidly; passed upwards of a month and a menstrual period in the Home without any return of the fits. All pain over the ovarian regions, and in the loins, &c., left her, and she was discharged Nov. 26, perfectly cured.
CHAPTER VI.
CATALEPSY, WITH CASES.
This affection is extremely rare, and I consider myself favoured in Having witnessed three well-marked cases. “It occurs chiefly,” says Dr. Jones, “in those who have weakly and excitable nervous systems, feeble health, and ill-governed minds, and who may be said to possess neither a ‘mens sana,’ nor a ‘corpus sanum.’” That this is true there is not the least doubt, and the first case—one of semi-catalepsy, or hysterical catalepsy—shows how completely it is a nervous affection, and depending, at any rate at the commencement of the disease, very much on mental control.
There are also, it is true, one or two rare cases on record which were caused by growths on the brain; and it is sometimes “encountered in tubercular meningitis, or chronic softening of the brain.”—Reynolds.
That the cause in the three cases in my own practice was excitation of the pudic nerve, may, I think, most fairly be concluded, from the fact that after the operation neither patient had a single fit.
To those who have not seen a patient suffering from this disease, a few words from Dr. Reynolds may be necessary:—
“The pathognomonic symptom is the persistence of the limbs in a state of balanced muscular contraction, so that they retain the position in which they were placed at the commencement of the attack. The limbs may be readily moved by the observer, but they retain the attitudes in which they are left, and these sometimes for hours, sometimes for days.