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.

[Illustration]

                                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.”

Footnote 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.”

Footnote 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.

Footnote 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:—

Footnote 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.

“Perception and volition are lost; the condition resembles that of
‘brown study;’ the circulation and respiration are uninterrupted.”

Catalepsy seems to rank between tetanus and epilepsy, and, according to
Dr. Jones, depends on the simultaneous morbid affection of various nerve
centres which, when separately affected, produce but one
disorder,—hysteria, tetanus, or epilepsy.


              CASE XXIX. HYSTERICAL CATALEPSY—MANY YEARS’
                   DURATION—OPERATION—RELIEF—REMARKS.

  MRS. ——, æt. 33, widow; admitted into the London Surgical Home May 5,
  1865.

  _History._—Never had any children, and but one miscarriage.
  Menstruation began when she was fourteen, and she was then first
  attacked with fits. From the patient’s description, they would seem to
  have then been of a cataleptic character; there was no loss of
  consciousness. From the age of 21 up to the present time, besides
  slight convulsive attacks in the daytime, she has been subject to fits
  at night, occurring irregularly, but averaging one a week, and always
  after each menstrual period. They commence with a strong convulsion,
  which lasts for a few minutes, and is succeeded by perfect rigidity of
  the body and unconsciousness for half an hour or more. Are preceded by
  headache during the day. Catamenia appear regularly, but are scanty.
  Acknowledges constant peripheral excitation, and says that, during
  marriage, she never had pleasure _in coitu_. The dilated pupil, hot
  skin, moist palm, and other unmistakable symptoms, plainly pointed to
  the cause of her disorder.

  May 6. Excision of clitoris and the very elongated nymphæ. Free
  hæmorrhage was allowed before the wound was dressed.

  The operation was, in this instance, only successful in diminishing
  the frequency and intensity of the fits. The following is the
  description given by the house-surgeon of an attack some days after
  the operation:—

  “While conversing with the house-surgeon this morning, she had a
  slight convulsive attack, not lasting more than thirty seconds, and
  characterized by the following phenomena:—No loss of consciousness,
  rigidity of limbs, with tonic contraction of the flexor muscles, and
  strong contraction of the orbicularis palpebrarum.”

  Whenever visited, and frequently when the wound was dressed, these
  fits recurred; but towards the end of the month the number
  considerably diminished.

  She was discharged on June 15th, very much improved in health, and
  decidedly relieved by the operation.


 CASE XXX. HYSTERICAL CATALEPTIC FITS OF LONG DURATION—OPERATION—CURE.

  H. L., æt. 25, single; admitted into the London Surgical Home January
  27, 1864.

  _History._—This patient was sent to me by Dr. Pennefather, of
  Tottenham, with the following letter:—

  “Dear Sir,—The girl —— was some time since suffering from religious
  monomania; she is of hysterical habit and weak constitution, ever
  complaining of abdominal pain or uneasiness.”

  She also gave the following additional account of herself:—

  “Began to feel unwell about twelve months since. Had a very bad fever
  about five months ago, which left her perfectly prostrated. Always
  felt weak, and more or less subject to fits. Menstruation regular and
  never profuse. Great pain in the back and bearing-down feeling in the
  lower part of the body. Complains of great pain in defecation.
  Sea-bathing has benefitted her temporarily. Is incessantly crying
  without cause or power to prevent herself.”

  The day following admission she had a fit of a cataleptic nature, and
  lasting twenty-five minutes. After the fit the patient was left very
  prostrated.

  In addition to symptoms of pudic irritation, there was a small fissure
  of the rectum.

  January 24. Clitoris excised, and fissure divided. There was
  considerable secondary hæmorrhage in the excising, which, however,
  seemed to have a beneficial effect, as after it the patient expressed
  herself as more comfortable, and slept quietly.

  Feb. 14. Much more cheerful; has had no cataleptic attack or symptom
  of hysteria since the operation.

  Feb. 28. Has improved daily, and leaves the Home this day cured.


     CASE XXXI. CATALEPTIC FITS—TWO YEARS’ ILLNESS—OPERATION—CURE.

  M. N., æt. 17; admitted into the London Surgical Home September 4,
  1861.

  _History._—Was perfectly well up to the age of fifteen, when she went
  to a boarding-school in the West of England. In the course of three or
  four months she became subject to all symptoms of hysteria, and from
  that time gradually got worse, having fits, at first mild in character
  and of rare occurrence, but gradually mere severe and frequent, till
  she became a confirmed cataleptic. For several months before
  admission, she had been attacked with as many as four or five fits a
  day, and during the whole journey from the North of England to London
  she was unconscious and rigidly cataleptic. She was seen immediately
  on arrival, and there was no doubt that it was a genuine case of this
  disease. So sensitive was she, that if any one merely touched her bed,
  or walked across the room, she would immediately be thrown into the
  cataleptic state.

  Before making any personal examination, Mr. Brown ascertained both
  from her mother and herself, that she had long indulged in
  self-excitation of the clitoris, having first been taught by a
  schoolfellow. The commencement of her illness corresponded exactly
  with the origin of its cause; in fact, cause and effect were here so
  perfectly manifested, that it hardly wanted anything more than the
  history to enable one to form a correct diagnosis. All the other
  symptoms attending these cases were, however, well marked.

  The next day after admission she was operated upon, and from that date
  she never had a fit. She remained in the Home for several weeks. Five
  weeks after operation, she walked all over Westminster Abbey, whereas
  for quite a year and a half before treatment, she had been incapable
  of the slightest exertion.


    CASE XXXII. CATALEPTIC FITS—MANY YEARS’ DURATION—OPERATION—CURE.

  In 1861 I saw a lady, æt. 50, single—a patient of Dr. Dawson, of
  Newcastle-on-Tyne.

  She had been suffering from cataleptic attacks for several years,
  gradually increasing in severity. As in the previous case, the mere
  touching or shaking of her bed would induce an attack—indeed, the
  simple brushing of her dress by any one passing her when she walked
  out of doors, would immediately be followed by a fit. History and
  examination plainly confirming me in my opinion as to the cause of her
  attacks, the usual treatment was adopted, and from that time to this
  she has never had an attack.


    CASE XXXIII. CATALEPTIC FITS—SIX YEARS’ DURATION—OPERATION—CURE.

  MISS ——, æt. 38, single; admitted into the London Surgical Home August
  10, 1865.

  _History._—Was tolerably well until two years and a half ago, but
  since that time has suffered more or less from menorrhagia, with
  severe pain in back. Has also severe smarting pain in the bowels, and
  has frequently lost a considerable quantity of blood _per anum_. Has
  always been subject to hysterical attacks, but for the last six years
  has had fits of a much more serious character. They have increased in
  severity, duration, and frequency, and it is on account of them that
  she seeks relief. Almost immediately after admission, this patient had
  a fit, and she was kept a fortnight under observation, that the nature
  of the attacks might be thoroughly investigated.

  She would have a fit sometimes twice a day; but on an average about
  every other day—either early in the morning or late in the evening.
  She was most generally attacked when walking about the room—sometimes
  when sitting—but she was never observed to have one when asleep. She
  would at the commencement of an attack cease walking, or doing
  whatever she was employed in; her face would become very pale and set;
  the eyelids, at first quivering, would be fixed; the eyes wide open
  and looking upwards, the pupils very dilated. Her mouth would be
  rigidly shut, and during the attack it was impossible by any means to
  open it. Her arms would fall straight by her side, and be immovable;
  the hands unclenched, and fingers extended. If standing, she would be
  quite upright, and require no support. If sitting, she would always
  stand up when a fit was coming on. If lying, she would be extended
  straight on her back. The fit would last for two or three hours, and
  on a few occasions for as many as six hours. The experiment was
  frequently made of moving her arms when in the cataleptic state, and
  on such occasions the limb would remain in the position in which it
  was placed, till the end of the attack. She was always perfectly
  unconscious, and no kind of stimulant was of the slightest use in
  restoring her during the paroxysm—time alone was of avail. The attack
  was sudden, but the recovery to consciousness was but gradual; she
  would appear as if awoke from a deep sleep, and would be very
  exhausted, but express no desire for food, wine, or other stimulants.
  As soon as she recovered, she would sleep for many hours, and awake
  quite well, but still weak.

  Aug. 24. The clitoris was excised, and a painful fissure of the rectum
  divided. She never had a fit after the operation. Menstruation came on
  on the 28th, in moderate flow.

  Oct. 5. This patient has improved wonderfully since operation, and now
  looks extremely well. The wound is quite healed. She takes walks
  daily, and has had no fits, and is to be discharged as cured.

  In November she called at the Home, to say that she was quite well,
  and had never had the slightest return of her former illness; she
  menstruates regularly and normally.

  Feb., 1866. She remains well.




                              CHAPTER VII.
                         EPILEPSY, WITH CASES.


Referring my readers for full information on the pathology and history
of epilepsy to Dr. Russell Reynolds’s exhaustive treatise on the subject
already referred to, I would mention, as shortly as possible, a few
facts which are necessary to be borne in mind, with especial reference
to the class of cases which I am now considering.

Dr. J. C. Prichard, in writing of diseases of the nervous system, has
well said that “few diseases are better characterized by them symptoms
than epilepsy; yet in this instance there is such a variety in the
phenomena as renders it difficult to contrive a definition in a few
words which may comprehend every form of the complaint.”

I have said that when convulsions become chronic they are considered to
take on an epileptiform character. Now, although we know that in a few
cases involuntary spasm may take place in sleep, _i.e._ with loss of
consciousness, I think we may, for all general purposes, take as a
definition of epilepsy a chronic convulsive disease, each convulsive
attack being accompanied with “sudden and complete loss of
consciousness,” this latter symptom being considered by the late Dr.
Todd[5] as “the pathognomonic symptom of the disease,” but only, as Dr.
Reynolds[6] has shown, “when it occurs as a paroxysmal or occasional
event.”

Footnote 5:

  _Medical Times and Gazette_, August 5, 1854, p. 129.

Footnote 6:

  _Op. cit._, p. 31.

The causes of epilepsy are various—“partly physical, partly immaterial.”
Of the former are injuries and tumours of the brain or meninges,
intestinal worms, renal and biliary calculi, &c. &c. These are termed by
Dr. Handfield Jones[7] “eccentric causes.” As “centric causes,” he names
“poisoning of the blood from retention of excrementitious matter; this,
by deranging the nutrition of the nervous tissue, generates the abnormal
excitability, which then manifests itself without any special irritant.
Various causes of exhaustion, such as hæmorrhage and excessive
discharges, venereal excesses, prolonged want of sleep, unremitting
pain,” &c., are all “centric” causes of epilepsy.

Footnote 7:

  _Op. cit._, p. 209.

Dr. Reynolds is right in considering epilepsy an idiopathic disease,
inasmuch as it occurs, without discoverable organic lesion with which it
can be associated, and because there is no structural lesion of the
brain, or spinal cord, to be found constantly associated with it; but
when he says that it is idiopathic because, “in many cases, eccentric
irritation cannot be shown to be the cause of the attacks,” I cannot go
with him. Epilepsy is a name signifying a disease, which may be
idiopathic, or may arise from a variety of causes; but that eccentric
irritation is a powerful and very frequent cause, there is not the
slightest doubt. Dr. Reynolds classes it as second of six in a table
given in his book, physical conditions being mentioned as first; and
finding, in a hundred cases, that 24·63 have no assignable cause, and
18·84 are doubtful, he gives 13·04 as due to eccentric irritation.

In considering peripheral irritation of the pudic nerve as a cause of
this disease, we must, I think, consider mental emotion, which occupies
the highest rank in causes of epilepsy, in conjunction with that second
in the list,—eccentric irritation. I would, therefore, classify the
cause of epilepsy depending on such irritation as both eccentric and
centric. The former, inasmuch as it produces exhaustion, and, by
deranging the nutrition of the nervous tissue, generates abnormal
excitability; the latter, for that it is a physical excitant which is
not only “a mere provocative of the paroxysms, the convulsions being
supposed to ensue as the reflex results of irritation, but that it
actually _sets up_ in the nervous centres that state of excitability
which is the essence of the disorder.” Further still, looking on
epilepsy as a direct sequel of hysteria, when it is produced by
excitation of the pudic nerve, the patients are, in an eminent degree,
predisposed to the disease.

Women are also more naturally prone to epilepsy from mental emotion than
men; “Emotional disturbance being assigned,” says Dr. Reynolds, “as the
cause of their attacks in so many as 36 per cent., whereas in the male
sex there were only 13 per cent. who referred their diseases to that
cause.”

It would be out of place in a work of this nature to detail at length
the symptoms of these attacks. Whether they are truly epileptic will be
seen as the cases are related. I have been very careful to separate
those which seemed to be of an hysterical or epileptoid nature; and have
had the advantage of being able to show the greater number of them to
many eminent members of the medical profession, who have witnessed my
practice in the London Surgical Home.


   CASE XXXIV. EPILEPTIC FITS—TWELVE YEARS’ DURATION—OPERATION—CURE.

  S. F., æt. 41, single; admitted into the London Surgical Home Dec. 16,
  1861.

  _History._—Was always ailing, and hysterical for many years. Catamenia
  appeared early, and always rather profuse. For the last twelve years
  has suffered from epileptic fits; recurring frequently every week or
  fortnight, and lately as often as every day. Has constant headaches;
  is losing memory and all power of concentrating her ideas. Has no
  premonition of seizure; falls down; is unconscious; has frequently
  bitten her tongue; and “froths” at the mouth. Says she has had several
  attacks of hæmatemesis. She was a dressmaker, and had so frequently,
  on her way to or from business, fallen in the streets, that she had
  been carried into almost every hospital in London, and a large number
  of open surgeries.

  _On examination_ there was found every indication of irritation about
  the vulva, and also a small polypus of the os uteri, which latter was
  large and patulous.

  Dec. 19. Usual operation of excision; polypus uteri also removed.

  The recovery of this patient was rapid and uninterrupted. After the
  operation, she never had a fit, and hardly a headache. She was
  discharged Jan. 20, 1862, perfectly well, and with greatly increased
  mental power. When heard of at commencement of 1864, she remained
  well, and had had no recurrence of any of her old symptoms.


 CASE XXXV. EPILEPTIC FITS—FIVE YEARS’ DURATION—PRECEDED BY CATALEPTIC
          FITS, DURING THE TEN PREVIOUS YEARS—OPERATION—CURE.

  In the beginning of April, 1862, a single lady, æt. 28, came under my
  notice, giving the following account of herself.—When about ten years
  old had a fit, whilst she was sitting at needlework; she fell down
  suddenly as if dead, and remained insensible for two hours; was very
  ill for three weeks after the attack. Was quite well until the age of
  fourteen, when she began to have them every three months. When about
  twenty-two had an interval of eleven months without a fit, but
  frequently fainted during that period. During the time she was in the
  fits she would be perfectly unconscious. She was told that her limbs
  were quite rigid, and always remained in the exact position in which
  they were when the fit commenced. In 1857 the fits changed in their
  nature—the patient at first falling down quietly, but subsequently
  becoming very convulsed, and trying to hurt herself. The first of this
  nature lasted two hours and three-quarters. Has lately had them much
  oftener, but not always of the severe form. Has had eight severe fits
  in the last two years and a half, besides the milder, which come
  sometimes a dozen in a fortnight. Is unconscious, but always knows
  when she has had one. Foams at the mouth, but makes no noise. Has
  frequently fallen down suddenly in church and other public places. Has
  been under many physicians, all of whom have been of opinion that she
  is suffering from genuine epilepsy.

  April 2. Clitoris excised.

  April 6. Has had no attack, but complains of occasional pain in the
  top of her head.

  She never had an attack after the operation. Returned home in a month,
  and shortly afterwards she was thrown out of a pony chaise; she had no
  fit, but wrote that, prior to treatment, a very much slighter accident
  would have immediately produced one.

  I heard of this lady later in the year; she was still quite well. Not
  having heard since from her, as was agreed when she left me, I am
  satisfied that she has had no relapse.


    CASE XXXVI. EPILEPTIC FITS—MANY YEARS’ DURATION—OPERATION—CURE.

  N. L. M., æt. 21; admitted into the London Surgical Home May 9, 1863.

  _History._—Married four years and had two children; the labours have
  been bad, and followed by severe hæmorrhage. Had aborted at six weeks,
  a fortnight previous to admission, and had lost a large quantity of
  blood. First suffered from epileptic fits at puberty; had several
  before marriage, and has had four or five since marriage; but has
  never had a fit when pregnant. Not very regular in menstruation, which
  is accompanied with severe pain. Has constant pain on right side of
  head, in back, loins, &c. Great pain in micturating and on defecation.
  She is always totally unconscious during the fits, and they are
  followed by extreme prostration. Is of melancholy aspect, excessively
  anæmic, and somewhat chlorotic; even the mucous membranes (of mouth
  especially) are blanched. The cause of her fits being diagnosed, the
  usual _operation_ was performed May 14.

  May 18. Progressing excellently.

  May 20. There was great irritability of the bladder, which, however,
  was immediately relieved by an alkaline and henbane mixture.

  May 31. Has not had any return of her bad symptoms until to-day, when,
  on being removed to a strange ward, she had a fit, not of violent
  character, and followed by a heavy drowsiness.

  June 2. Is quite herself again.

  July 4. Has left quite well in every respect, and when heard of many
  months later remained well.

  _Remarks._—The fit following on change of this patient from one ward
  to another where there were strangers, shows how important it is for a
  permanent cure, that visitors and relatives should not be allowed to
  excite and agitate a patient suffering from these attacks after an
  operation is performed, and when the mind is hardly restored to its
  natural balance.


    CASE XXXVII. EPILEPTIC FITS—TWO YEARS’ DURATION—OPERATION—CURE.

  H. C., æt. 20, single; admitted into the London Surgical Home Feb. 24,
  1864.

  _History._—About three years since, first commenced ailing.
  Menstruation ceased for four months, when it appeared for two days.
  Fifteen months then elapsed before the function was restored.
  Epileptic fits have been developed for about two years. The patient at
  the commencement of an attack is strongly convulsed, has no
  premonition, and is perfectly unconscious. Frequently falls when
  walking in the streets. Has often hurt herself in her falls, and also
  bitten her tongue. Has the usual symptoms of bearing-down of the womb,
  and pain in the loins. No pain in defecation. Bowels costive. Pain in
  micturition, and sometimes retention of urine, occasionally not
  passing any for two days.

  March 3. Clitoris excised in the usual manner under chloroform. Was
  restless and hysterical for the first six days, when she improved
  daily, became cheerful, and much more intelligent. She never had
  another fit, and on April 13, being quite cured, was, at her own
  request, retained in the Home as a servant. She remained there under
  observation for six months, during which time she had not only no
  return of her former attacks, but progressively improved in health,
  and her menstruation became quite regular.

  Since that time she has been living as cook in a family which I
  frequently visit, and it is therefore certain that she remains
  perfectly well.


 CASE XXXVIII. SEVERE AND FREQUENT EPILEPTIC FITS FOR THREE YEARS AND A
                          HALF—OPERATION—CURE.

  C. T., æt. 21; admitted into the London Surgical Home June 23, 1864.

  _History._—Health always good till three years ago, when, after a
  severe fright, she became very excited and had a fit. Since that time
  has been continually subject to them. She never passes a day without
  two or three, and frequently has as many as six, or even eight, in the
  twenty-four hours. Is most subject to them at night when sleeping. Is
  always suffering from headache. Her mental powers are somewhat
  impaired, as she has very slight recollection of persons, or of
  events, from day to day. Catamenia very irregular. Has not menstruated
  since March last. Bowels costive; pulse regular and firm. Is of a
  sallow complexion, with vacant and weak expression of countenance.
  Acknowledges great and constant irritation of pudic nerve.

  During the day previous to operation, special notice was taken of the
  nature of the fits. They are epileptic; for although she does not foam
  at the mouth, she has, on more than one occasion, _bitten her tongue_,
  and is _perfectly unconscious_. There is no rigidity, but a constant
  struggling, and, unless restrained, the hands always, during an
  attack, are carried to the seat of irritation.

  June 23. The usual operation of excision was performed under
  chloroform. As soon as she recovered, she managed to remove the
  dressings. Hæmorrhage for two hours was the result. When arrested, two
  grains of opium were administered, which produced sleep. On awaking,
  she again endeavoured to remove the dressings; but, her hands being
  confined, she was unable to do so. She had no more fits, and but a few
  hysterical attacks. On July 17th she was discharged, as her parents
  were anxious for her return. She had not then had a fit of any kind
  for sixteen days.

  August 15. I received the following letter from her father:—


  “Dear Sir,—It would be very unkind in me, and much out of place, to
  hide from you and the world at large what have been my feelings during
  the past three weeks. My daughter, C. T., came to your Home, Stanley
  Terrace, Notting Hill, on the 23rd of June last, to be treated by you
  for epilepsy, or epileptic fits, having been afflicted for three years
  and a half. The class of fit you may better judge of than myself;
  sufficient to say, they were very bad and very frequent. I am happy to
  say, and acquaint you, that since her return she has not had a single
  symptom of fit or hysteria of any kind. Her general health is also
  very good, and fast improving, and I do hope, by the blessing of God,
  she may continue so. If you have any desire to see her, I shall feel
  in duty bound to let her wait upon you, with her mother, at any time
  you may think fit to appoint, as your opinion just at this time might
  have a still more happy effect for the future. You are quite at
  liberty to use this for the benefit of the Institution in whatever way
  you may like or seem good.”


  A twelvemonth later, this patient was still free from any return of
  the fits.


CASE XXXIX. EPILEPSY, WITH DEMENTIA—ONE YEAR’S DURATION—OPERATION—CURE.

  A. H., æt. 17; admitted into the London Surgical Home June 28, 1864.

  _History._—Catamenia first appeared three years ago. They have
  continued regular to the present time. About twelve months since was
  observed, whenever sent on an errand from home, that she would wander
  about in an absent manner, and return home having forgotten all about
  any message which had been given her. About this time fits were first
  developed; they increased in frequency and intensity, and she now has
  them daily, and one or more of less violent character nearly every
  night in her sleep. When seized, she falls, struggles violently, foams
  at the mouth, often bites her tongue, and is totally unconscious to
  all around her. After a fit, she sinks into a deep sleep, which lasts
  for two hours. Has no recollection on awaking of what has taken place.
  Acknowledges to frequent injurious habits, but is unconscious of their
  being the cause of her illness. Is vague in all her ideas and
  conversation, and has almost entirely lost her memory.

  Both history and personal examination plainly showed what was the
  cause of her attacks.

  On July 7 the clitoris was completely excised. She had no return of
  the fits; and on the 23rd the following report appears in the
  case-book:—“Left her bed to-day. Is greatly changed; quite rational in
  all her movements; converses freely and quietly, remembers passing
  events from day to day, and it is indeed almost impossible to
  recognize in her the half-idiotic, almost demented girl who entered
  the Home less than a month ago.”

  She remained in the Home some time longer for observation. Fits never
  returned; her mind improved daily, and she was discharged as perfectly
  cured.


CASE XL. EPILEPTIC FITS—TWO YEARS AND A HALF DURATION—OPERATION—RELIEF.

  S. Z., æt. 16, single; admitted into the London Surgical Home October
  20, 1865.

  _History._—Was strong and well until two and a half years ago, when
  she had an epileptic fit in the middle of the night. Can assign no
  cause for the attack. For a long time had a fit once a month, but
  latterly once a week. The catamenia appeared six months before the
  first fit, and have always been regular. There is no exacerbation at
  menstrual epoch. Complains of great irritation of pudendals for three
  years.

  Nov. 2. Since admission this patient has been watched: she has had two
  fits, both of a genuine epileptic character.

  Mr. Brown this day performed his usual operation. She went on well
  till the 10th, when she had a slight fit; there being irresistible
  irritation, the hands were restrained. A lotion of bromide of ammonium
  was ordered to be applied to the wound, and 20 grains of the bromide
  to be given in water three times daily.

  She convalesced well, and had no more attacks till the 29th, when, her
  hands having been released only a few minutes previously, she had a
  fit, and the nurse found one hand on the wound. She was conscious
  during the attack, which was not so violent as before treatment.

  Dec. 2. Discharged relieved. If this patient could be under control
  for a few months, she would probably be cured.


         CASE XLI. EPILEPTIC FITS, WITH DEMENTIA—THIRTY YEARS’
                        DURATION—OPERATION—CURE.

  M. F., æt. 44, single; admitted into the London Surgical Home December
  8, 1865.

  _History._—Epileptic fits first attacked her when she was about 14, at
  which age she menstruated. For the first few years there was a long
  interval between each, but they gradually became more frequent and
  violent. Latterly she has had several during the week of each
  menstrual period, and as a rule none in the interval. Catamenia have
  been tolerably regular in appearance, but rather profuse. Is tall,
  pale, and thin; has a dull and somewhat vacant expression; is very
  eccentric in her manners and conversation; is frequently observed,
  both day and night, by the nurses to practise injurious habits, to
  which she acknowledges for the last thirty years. The fits are genuine
  epileptic.

  _On examination_, there is evidence of very long-continued peripheral
  irritation, and also a fissure of rectum.

  Dec. 12. The usual operation on clitoris and rectum.

  Dec. 13. In the absence of nurse, removed the dressing, and
  immediately had a fit. To have opium 1 grain, with ¼ grain of extract
  of belladonna, every six hours.

  Under this treatment the patient improved daily, became cheerful,
  rational, tractable, and much more sensible in her conversation.

  She passed two menstrual epochs, but without a fit, and she was
  discharged perfectly cured.

I have a much larger number of cases occurring in private practice, but,
for that reason, am obliged to omit them. I shall, however, when a
longer time has elapsed, publish them.




                             CHAPTER VIII.
                   IDIOTCY AND INSANITY, WITH CASES.


As epilepsy is a much graver disease than hysteria, so is the sequel of
the former—dementia or idiotcy—much more permanent and difficult to be
removed by treatment than insanity, which is the ordinary sequel of
hysteria.

I shall give but one case of idiotcy, because I regret to say that I
have never yet been able to thoroughly restore the mental powers in any
patients suffering from this dreadful affliction. Epilepsy is such a
chronic disease, and seems to me to produce not only weakening of the
mind, but to cause it to be often entirely lost, that, although we may
get, as in the following case, a temporary re-kindling of the mental
energies, I fear we are not yet able to give much hope of complete
recovery. Even here, however, I have such faith in the efficacy of
perseverance in constant watching, that I am almost inclined to believe
that, had this patient been in a condition of life to ensure vigilant
medical supervision for a lengthened period after operation, we might at
last have succeeded in, if not complete, at least, much creator
restoration than in a public institution, or to those in humble
circumstances, the surgeon is in a condition to promise.


    CASE XLII. EPILEPTIC FITS, WITH COMPLETE IDIOTCY—OPERATION—GREAT
              TEMPORARY RELIEF, BUT NOT PERMANENT BENEFIT.

  Mary J., æt. 19, single; admitted into the London Surgical Home Feb.
  15, 1864.

  This patient was brought to me by Dr. Marley, with the following
  account:—

  “Has the appearance of a child of 10 or 12 years old; mammæ not
  developed; has had epileptic fits ever since 12 years of age. Is now
  almost idiotic; stares vacantly; slobbers at the mouth; passes her
  motions anywhere, without regard to common decency, and cannot retain
  her urine. I find from her mother that she is incessantly irritating
  her genitals. Her fits vary in frequency, from two or three a day to
  four or five a week. Being satisfied of the cause of her fits, I sent
  her to you.”

  _History_, taken at the Home from her mother.—Had perfect health until
  she reached her eleventh year; was forward in her lessons, and well
  educated for her age and position. At this time she was suddenly
  seized with a severe fit, for which no cause could be assigned. A
  period of two years elapsed before she had a second, when, being
  placed under medical treatment for eighteen months, she had great
  relief. Since the expiration of that time to the present she has
  constantly suffered from fits.

  Her intellect did not begin to weaken until two years since, but she
  ceased growing and learning after the first attack. At this time she
  does not know her right hand from her left; does not know her mother,
  and shows no signs whatever of ordinary intelligence. From being
  cleanly as a child, is now most filthy—in fact, is in every sense an
  idiot.

  Has never menstruated.

  _On examination_—although, as stated by Dr. Marley, the mammæ were
  very rudimentary—there was full development, and indeed abnormal
  hypertrophy, of the external genitals.

  Feb. 18. The usual operation performed, under chloroform. The hands to
  be restrained, and the patient most carefully watched.

  Feb. 19. Has passed a good night, and is quiet.

  Feb. 23. Has been very drowsy since the operation. To-day asked for
  food for the first time, and showed some signs of intelligence.

  Feb. 26. Gave rational answers to several questions which were asked
  her. Also remembers from day to day any promises of delicacies of diet
  or money.

  March 1. Passed a good night; feels free from pain. Was given some
  printed cards, which she read—_the first time for nine years_.

  March 2. Improving much. Is much more modest in her behaviour, but
  still passes her excretions without regard to time or place. Notices
  passing events, and remembers names and faces.

  March 3. Has given sensible and somewhat witty replies to various
  questions asked her in the presence of about twenty medical gentlemen,
  who to-day came to see the operation. When moneys were given her, she
  at once told their different relative value.

  March 4. Morning: Seems no worse for the excitement of
  yesterday.—Evening: Had a slight fit.

  March 5. A little heavy and stupid to-day. Somewhat irritable and
  obstinate.

  March 6. Much better. Has a daily clearer notion of right and wrong.
  Likes books with pictures and large print. When she comes to hard
  words, she asks the meaning, like a child, but cannot always grasp the
  meaning of an explanation.

  March 8. Not quite so well to-day. Had a slight epileptic fit this
  evening, followed by a very severe one in two hours.

  March 9. Again much better, but irritable.

  March 12. Two fits.

  March 16. Not so well: another fit to-day.

  She from this time seemed to retrograde; and on the 4th of April was
  discharged as incurable.

It will be recollected how, at the end of the chapter on Hysteria, I
gave three cases of extreme nervous irritability, with sleeplessness,
and tendency to an unhinging of the mental equilibrium. We now come to
insanity itself. It would be vain to talk of the varieties of forms in
which this state may be seen, when produced by abnormal peripheral
irritation of the pudic nerve. It is, however, worthy of notice how each
history seems to tell its own explanation of the cause; and after the
first few days of treatment, when excitement, caused by irritation from
the wound and a natural repugnance to restraint, has passed off, how
rapid is the improvement, and how permanent is the result. I have no
hesitation in saying that in no case am I so certain of a permanent cure
as in acute nympho-mania; for I have never after my treatment seen a
recurrence of the disease, whereas, under medical treatment, of how
short duration is but too frequently the benefit.


        CASE XLIII. INCIPIENT SUICIDAL MANIA—MANY YEARS’ GRADUAL
                        ILLNESS—OPERATION—CURE.

  R. T., æt. 39, single; admitted into the London Surgical Home Oct. 22,
  1861.

  _History._—Has been ailing for many years, and given great trouble and
  anxiety to her friends. For some time past she has been very strange
  in her manner, very restless, never quiet, constantly wakeful,
  threatening suicide, talking to people, even perfect strangers, of her
  ailments and their causes, of which she is fully conscious. Was
  formerly modest and quiet.

  _On examination_, she is a fine woman, of restless appearance and
  manner; eye wandering and unsteady; pupil dilated. The cause of her
  mental derangement being obvious, on

  Oct. 24 the usual operation was performed.

  The improvement in her mental and bodily health was wonderful: she
  gained flesh, and became cheerful and modest. She was discharged six
  weeks after admission.

  When heard of in February, 1863, this patient continued quite well.

The first case of actual insanity that came under my care was a patient
of Dr. Warren Diamond, then resident in his private asylum. I cannot do
better than transcribe the account which he sent me with the following
note:—

                                                “Effra Hall, Brixton, S.

  “DEAR SIR,—A month having elapsed since you gave up your patient, I
  forward some particulars of the case, and shall be glad to answer more
  fully any special time or state you would like to know more about. You
  will, perhaps, be able to pick something out of this rambling account
  that may be interesting to you. Hoping you will excuse omissions, &c.

                                          “Believe me, yours faithfully,

                                                  “WARREN H. DIAMOND.”

  “I. Baker Brown, Esq.”


 CASE XLIV. SEVERAL YEARS’ ILLNESS—TWO MONTHS’ INSANITY—OPERATION—CURE.

  “Miss E. R., æt. 34, single; no occupation, living with her friends;
  hair light reddish-brown; face set and vacant, with an occasional
  pained expression; eyes fixed and dull; extremities damp and cold;
  stature moderate and well formed. Has for several years past been
  looked on by her friends as different from others—strange and
  eccentric. Would go out and walk away into the country alone for
  miles, and come back exhausted. When friends called, would start up
  and run round the garden, or to the top of the house and back again,
  giving no reason for it but that she must do it. Always exceedingly
  irritable and passionate. Unless some excitement was going on, was
  listless and unable to rouse herself. When at parties, was so forward
  and open in her manners, that she was generally avoided by gentlemen.
  _Never had an offer of marriage._ Her mother died about a year and a
  half ago, but she took no notice of the occurrence, and was
  consequently remarked on by her friends. Since then she has been
  getting more strange and peculiar. About February last, a sister told
  her, in joke, that if she did not take care she would soon become a
  fit subject for Dr. Diamond, little thinking how soon it would happen.
  She recently made enemies of old friends, so that her brothers could
  not make out why they fell off. Would sit or stand without noticing
  them when they called; and asked them what they wanted that they came
  to her house (she was the eldest of the family).

  “I was consulted about her in the end of March, but had then none of
  her previous history. She was vacant and dreamy; talked of flowers
  which she called her friends; said ‘people’s faces were masks; that
  she was quite unable to rouse or employ herself, as she was changed;’
  very uncertain in appetite, going a day without her food; not sleeping
  at night, and for the last few nights showing such great excitement
  and passion, that her sisters were required to sit up with her.

  “I recommended change along the south coast, with sea-bathing, &c. She
  did not improve; and the attendant informing me of a constant
  irritation of the vulva, lotions were used, but without benefit. Her
  general health and appetite improved; but not the mind. She could not
  sleep, and would not bear narcotics; _stimulants acted as narcotics_,
  but soon lost their effect.

  “Bowels regular; pulse small and slow; action of heart being
  irritable, and not corresponding at all times to the power or quantity
  of the pulse. She sits up in bed, nursing the pillow, and talking to
  it as if it were a baby; says ‘that she died last Sunday’—‘is
  lost’—‘is buried.’

  “When out of doors, great difficulty is experienced in getting her in
  again; she wishes to wander away, without aim or purpose. Having given
  my opinion to her friends, I was authorized to admit her April 18,
  1861. Before she left home, she continued calling out, ‘Take me to a
  mad-house! take me quick, or I shall never get well!’ She persisted in
  saying ‘she was dead,’ and ‘she felt buried.’ Answers in
  monosyllables. Her pupil is contracted and fixed. At night she does
  not sleep, and is in such a continual state of excitement that the
  attendant cannot sleep with her. Has lost all natural modesty in
  manner and speech. Is not blasphemous. Before me is perfectly reserved
  and correct in her manner. When I ask questions, she will, after a
  pause, answer in monosyllables, or repeat the question over and over
  again, as if trying to grasp the meaning and ally her thoughts. Unless
  walked about, will stand for hours in one place, gaping, yawning, and
  throwing her arms about listlessly. She was in this state when you saw
  her, and from what you told me of your experience of the operation and
  its results, I was led to infer relief from it in this case, as the
  delusion of having died on a certain day was movable and could be
  reasoned away; but the heavy oppressed feeling still made her say,
  ‘But if I am not dead, I am lost, or changed,’ and naturally led back
  to the idea. I ascribed the state of her mind to weakening of the
  body, and general nervous irritation caused by long-continued reflex
  excitation; and I believed that if the source of irritation could be
  removed, her mental health would follow as her blood became healthy,
  and fit to make reparation.

  “I was led to think more of her uterine state from her expression of
  pain when she was walked about, and she was reported by the nurse as
  always complaining of her back, at the lower part, and of great
  tenderness on pressure over the ovaries.

  “May 27, 1861. You operated on her, she being under the influence of
  chloroform. She was naturally restless afterwards, not understanding
  why she was kept in bed. Profuse menstruation came on in the evening,
  which had not happened for four months previously, and then always
  very scanty and with much pain. Half an ounce of laudanum, with oil,
  was rubbed into her chest during four hours; she did not, however,
  sleep, but continued moaning all night.

  “May 28. Easier, and more herself—takes her food.

  “May 29. Slept well last night, without opiates; says she shall now
  get well and be able to go home; answers questions more readily, and
  makes longer replies. _Pupil dilated and acts slowly._ Her nurse says
  she is quite altered in every way, and compares the change in her mind
  since the operation to ‘dividing the tightened strings of a fiddle,
  and letting them all loose.’

  “June 2. Left her bed; is still menstruating; appears cheerful; asks
  questions now, and converses for short periods; has done a few
  stitches of needlework; says nothing about ‘being lost or dead’ since
  the operation. Surface of body and extremities warm. Freaky, anxious
  look about her eyes and nose gone. Laughs and jokes. Says ‘she has
  been in a dream,’ ‘that things now seem light,’ and ‘that she means to
  get well.’

  “July 3. She has gradually improved and become more natural in her
  habits and ideas; sleeps soundly every night; takes her meals well;
  walks about without compulsion; takes a pride in making herself neat,
  and has washed and dressed herself ever since she left her bed; is
  perfectly modest in manner and conversation. Her friends remark on the
  great improvement in her mind, she having had no delusions. Her mental
  state is, however, weak—what might better be called foolish, with some
  amount of wilful obstinacy. The family medical attendant, and, in
  fact, every one who has been in her company, notice the extraordinary
  change that has taken place in her since your operation. I think the
  present state of her mind results from the long-continued exhaustion,
  and to restore it will be a matter of time. Her pupils act naturally.”

  I have often since heard of this lady as perfectly well, and as never
  having had recurrence of illness. In 1865 I was consulted on the
  propriety of marriage, to which I gave my full consent.


          CASE XLV. ACUTE INSANITY—TWO MONTHS—OPERATION—CURE.

  Miss ——, æt. 17, moderate height, and well formed, hair light golden,
  grey eyes and fair complexion, came under my care June 19, 1861.

  _History_ (taken from her mother).—When ten years old, had
  inflammation of the womb, and after she recovered began to menstruate.
  The function continued regularly until about eight months ago, since
  when the catamenia have appeared every ten days, and, in fact, have
  been hardly ever absent. In the latter part of last April she left
  home for change of air, and returned May 15th, when her mother noticed
  that she was thinner than before her departure, and, on inquiry, it
  appeared that during the latter part of her stay she had been very
  excited, at other times very low, sometimes laughing and singing, and
  requiring port wine and brandy at all times of the day, though
  generally abstemious, and never taking wine or other stimuli. The
  first night after her return home she went to one of her sisters’
  rooms and began to talk of being married; did not sleep all that
  night. May 17th. Was found to be rather wild in the morning; was taken
  out for a drive during the day; did not sleep that night, from
  constant excitement of the genitals. Had been seen by her ordinary
  medical attendant, who ordered opiates, but without the effect of
  giving her sleep. On the 28th, another physician saw her, and ordered
  opiates, but without effect, as she did not have an hour’s sleep night
  or day. May 22nd. An eminent authority in female diseases was called
  in, and also, among other remedies, ordered opiates at night-time, but
  with no effect. She continued raving and rambling till June 8th, when
  a physician, who devotes himself to mental diseases, saw her; he said
  that her mind was not affected, but that her behaviour was caused
  simply by debility, and ordered wine, eggs, &c., and a _strong
  opiate_, but without the desired effect.

  June 17. Was much worse. The last physician again saw her; said that
  she was quite mad, must be taken from home, and could never recover.
  She called her mother “Monsieur le Diable,” and her father “God.” She
  was constantly irritating her clitoris, and indulged in most immodest
  behaviour. Was ordered ext. cannabis indicæ, and slept three hours.
  19th. No better, and on this day I first saw her; she was then wild in
  expression of countenance, and on entering the room she addressed me
  as “Your Majesty,” and said “I was the Queen.” She also asked, “Why
  has your Majesty condescended to visit me?”

  June 21. Before operating, the patient being under chloroform, I made
  an examination, and found my diagnosis verified by the existence of
  all the ordinary local symptoms. The hymen was quite absent. (In one
  of her paroxysms she had stuffed a pocket handkerchief into the
  vagina.) I performed my usual operation, and immediately administered
  two grains of opium. She passed a tolerable night, not being noisy,
  but not sleeping.

  June 22. Tolerably quiet. Not aware of what is passing around her, but
  apparently comfortable. To have broth and milk diet—_no stimulants_.

  June 23. Passed a quiet night; but did not sleep much, though she had
  a grain of opium. Dressing removed. Wound looking well.

  June 24. Has not passed quite such a good night—rather noisy.

  June 25. Menses came on. Has had a very bad night, and been very
  troublesome. Chloroform administered to insensibility several times in
  the course of the day. A liniment, containing seven drachms of soap
  liniment and one drachm of laudanum, to be rubbed in to the chest
  constantly. This seemed to quiet her.

  June 27. Has passed a rather better night, sleeping a little; but
  towards morning she became very noisy, and chloroform was again
  administered. To have the liniment rubbed in at night.

  June 28. A much better night.

  June 29. Has had a very fair night; and from this time she gradually
  improved, sleeping well and being generally quite rational; her
  appetite also improved.

  July 7. Menstruation occurred, and she was not so well for a day or
  two, as she attempted to irritate the wound; but, being carefully
  watched, was prevented.

  July 10. Catamenia ceased. Is quiet again.

  July 11. Went out in a bath chair, and said she enjoyed the airing.
  From this time she gradually got better, and on the 28th she went into
  the country for change. Her menses came on five weeks from the last
  appearance; she was quite quiet all the time. Since then she has
  menstruated regularly every three weeks, and in normal quantity.

  A year after operation she had a slight relapse of melancholy, and
  fears were entertained that she was again going to be ill; but a brisk
  purgation of calomel completely dispersed all symptoms.

  1866. I have frequently heard of this young lady. She is now in good
  health, moving in high society, and universally admired.


            CASE XLVI. HYSTERICAL HOMICIDAL MANIA—ONE YEAR’S
                        DURATION—OPERATION—CURE.

  In December, 1861, Mrs. —— came under my care, by the recommendation
  of Dr. Forbes Winslow. She gave me the following history of herself:—

  _History._—She was 57, and had had four children and two premature
  labours. The last child was born twenty-three years ago. Twenty months
  since had an attack of erysipelas in the face, with eruptions on
  different parts of the body. Has never been well since, and last
  August had another attack of erysipelas. Is constantly suffering with
  shiverings, followed by burning heat and sweating, with prickling heat
  of the skin. For the last year has never slept for more than an hour;
  always waking with a _start_; feeling frantic, and very hot and
  flushed. Has a constant feeling that she will be lost eternally, and
  of this she is constantly speaking.

  From her husband I learnt the following:—

  After her last confinement, twenty-three years ago, she had puerperal
  mania, from which she did not completely recover for six months. About
  a year ago she began to show symptoms of mental derangement, first
  exhibited in religious subjects, she constantly declaring that her
  soul was irrevocably lost. About eight months ago she first tried to
  destroy herself, by endeavouring to jump out of the window, &c., and
  it was at this time thought advisable to place her in an asylum, where
  she was kept four months, and when she left she was for a time much
  better. While an inmate of the asylum, was made to take much exercise,
  for which her husband says she is always better.

  She gradually got worse, and came under the care of Dr. Forbes
  Winslow, to whom I am indebted for the case. Her husband says that for
  the last two or three months she has slept pretty well from 10 p.m.
  till 2 a.m., when she would suddenly wake, and warn him that a
  “frenzy” was coming on. This frenzy consisted in her rising up,
  fighting out with her arms, and scratching or tearing any one near
  her; in the paroxysm the desire was always to destroy her husband.
  After a few minutes the mania would subside, and be succeeded, first
  by a kind of stupor, and then very profuse perspirations. One
  peculiarity about her is, that when in this state she does or says
  anything foolish, she knows it, and is afterwards very annoyed and
  ashamed of her conduct. She has a great fear that she will be
  permanently mad.

  The appetite has always been good, though she has said lately that she
  cannot bear food, and that it always causes a horrid taste in her
  mouth. She has, in a desultory manner, read many medical works, and
  fancies that every one of her organs is in some way or other diseased.

  _On examination_, she had the appearance of a woman about 60. Her
  eyes, of a dark grey, were never quiet, and could not look you
  straight in the face; the pupil was much and constantly dilated. The
  tongue quite clean, and pulse good. Heart, lungs, and other organs
  seemed to be healthy. She owned with great shame to long-continued
  pernicious habits.

  Dec. 14. I performed my usual operation.

  Dec. 21. Has very much improved, and had no “frenzies” since the
  operation; sleeps well, and for many hours, but will not own to being
  better. Complains of her skin being dry, and “burning hot.” It is,
  however, moist and cool; at times she perspires freely.

  Dec. 26. Both husband and nurse consider her much improved. She has
  been up both yesterday and to-day; sleeps and eats well. She is,
  however, sulky; says she is very bad, and shall soon die.

  A fortnight later she was quite well, being entirely free since the
  operation from maniacal attacks; but she complained to my son, Mr.
  Boyer Brown, that I had unsexed her. He answered that nothing of the
  sort had been done, but that the operation had prevented her from
  making herself ill. From this time she steadily improved, and walked
  out with her husband every day, who called on me many weeks later to
  express his gratitude for the complete restoration of his wife to
  health; for whereas before his nights were passed in constant fear,
  rendering his life most wretched, his home was now one of comfort and
  happiness both night and day.


CASE XLVII. ACUTE HYSTERICAL MANIA—FOUR MONTHS’ DURATION—OPERATION—CURE.

  Miss ——, æt. 23, was sent to me by Mr. Radcliffe, stating that she had
  been brought over from Ireland as an insane patient, and that
  everything had been settled for her admission to some asylum, when he
  was induced to consult me on the last day before her entering one. He
  stated that the paroxysms always came on at half-past five or six
  every evening: I replied, if the attacks depended on peripheral
  irritation, that an operation would at once prevent recurrence of the
  attacks. She was accordingly admitted into the London Surgical Home
  Feb. 6, 1864.

  When admitted, said she had taken no food for three days, and asked
  for a cup of tea, which was given her. Enema was also administered.

  3.45 p.m. Was seized with a fit, throwing her arms up over her head,
  and then appearing as if comatose. In about twenty minutes revived:
  the lips began to quiver, and she gradually became conscious, saying,
  “I want a knife—I want blood!” She asked for the matron’s hand, that
  she might bite it off.

  [The fit coming on earlier on this day was doubtless due to excitement
  consequent on her removal.]

  5 p.m. Mr. Baker Brown saw her; as soon as he came near her, she
  seized his shoulder with great violence; was wild, and would not
  answer questions; but gradually became soothed, and allowed an
  examination.

  _Externally_, the abdomen showed signs of a child having been born,
  and the mammæ had certainly contained milk. The _clitoris_ was
  enlarged and hard; the _nymphæ_ long and flabby; the mucous membrane
  roughened and discoloured.

  _Per vaginam_, the _uterus_ was found to be retroverted; there was
  also a fissure of the _rectum_.

  _Operation_, 5.30 p.m. Was very violent under the first attempts to
  administer chloroform. She was long in being brought under its
  influence, but when once thoroughly anæsthetized, bore it exceedingly
  well.

  The clitoris was excised, the elongated nymphæ removed, and the
  fissure of the rectum divided. The wounds were dressed in the usual
  manner, and the patient having had two grains of opium administered,
  was ordered to be constantly watched.

  In twenty minutes awoke from the chloroform. Was calm, and slept at
  intervals during the night.

  Feb. 7, 10 a.m. Visited by Mr. B. Brown. Present—Mr. I. B. Brown,
  junior, House-Surgeon, and Matron. Pulse quick but steady; tongue
  brown and furred; breath offensive; gums spongy; pupil natural;
  countenance rather flushed; skin moist and warm.

  The following answers were given to questions asked of her by Mr.
  Brown, seventeen hours after operation, and are in her own words;
  much, however, of the information was volunteered without questions:—

  “Last March, instead of sliding down a slope, I jumped. This caused
  displacement of my womb. I suffered great agonies. I was fomented with
  hot water. I thought it was my back that was hurt. Since then I have
  been subject to fainting and weakness. I suffer great irritation about
  my private parts—cannot keep my hands away. The irritation is worse at
  night. I am obliged to relieve the irritation by rubbing—sometimes for
  two or three minutes at a time. There is always a discharge. I feel
  very depressed afterwards. At times I have lost my brain, and felt as
  if I did not care for living. I would like to have my hands untied; I
  will be very quiet. Have been separated from my relatives for three
  years. I shan’t tell you how long I have been married—(a pause). I am
  very rude—I beg your pardon. I have been married three years. I had a
  baby two years ago: it was not born at the full time—I think five
  months. I don’t know whether it was alive. I left home with my friend
  when I was sixteen (?). It is two years since I left him. I am now
  twenty-three.

  “After the accident, suffered great pain.” Mr. Brown here looked at
  her gums, and she immediately said, “Oh, yes; I had mercury given me
  by Surgeon ——, in Dublin: he said it was my spine. He did not examine
  my womb. Dr. —— examined it, and said there was great displacement. I
  have been better for treatment at times. My brain has been affected. I
  have fought very much. I have wanted a child’s blood. I have had it
  sometimes by sucking the wounds of a child. When in a fit, I don’t
  know what is going on around, or what is being said, but I recognize
  people’s voices. I am not regular. Was kept in bed last September for
  six weeks for flooding; was so for ten days after I was put in bed.
  Was the same in Paris last year. I was studying in Paris to fit myself
  for a governess.”

  The following are extracts from a letter voluntarily sent to Mr. Brown
  by a lady with whom the patient lived for many months, and left only
  three weeks previous to admission. Having stated that for some time
  she was hysterical, and becoming daily more excitable, the letter
  says—

  “On the 13th of September last, she for the first time seemed
  delirious when going to bed. This was mentioned next morning to
  Surgeon ——, who declared it to be nervous irritability of the
  spine.... On the 27th, Dr. —— was called in, and at once gave his
  opinion that there was ailment of the womb. He then ordered small
  blisters on the lower part of the stomach, which in less than ten
  hours relieved her, and removed the mania. She had not any reason for
  _many_ days previous, and was sinking.... On the 3rd of October, Dr.
  —— fixed an instrument to support the womb; and, except during the
  time when the intensity of pain caused it, there was no delirium; for
  a few days she got claret, which seemed to excite her greatly, so it
  was discontinued; but on the 13th of October I was desired to give her
  port wine in abundance. She was excessively weak, and mania so
  dreadful, that she made several attempts to injure herself and me. She
  got as many as eight large glasses of best port on some days; strong
  beef-tea, chicken soup, and all the nourishment possible. It was not
  only suggested, but it was advised to remove her to a lunatic asylum;
  however, feeling that certainly nine-tenths of her time she was
  perfectly sane, and could know well where she was and with whom, I did
  not like the idea of placing so young a creature in an asylum. I kept
  her here, and watched her day and night; she never was left alone for
  one moment for three months.... I ought to mention that the order for
  abundance of wine, &c., was from the opinion that ‘want of blood to
  the brain’ caused the mania; and that the intense inflammation of all
  internal organs was relieved by blisters on the lower part of the
  stomach and by mercury.”

  Feb. 8. Lint removed from rectum, and wounds dressed. Is calm and
  rational; passed a quiet day.

  Feb. 10. Very restless; obliged to restrain hands and legs.

  Feb. 11. Better; says her head feels heavy; countenance cheerful;
  manner quiet and rational.

  Feb. 12. Very excited and irritable; constantly managing to free her
  hands; will allow no one near her.—2 p.m.: Is quite maniacal; has
  managed to irritate the wounds, and also the mammæ. To have one grain
  of opium in pill, and ten grains of bromide of ammonium three times a
  day.

  Feb. 13, 6 a.m. Hands again free; repeat opium. Slept afterwards till
  4 p.m., when she awoke calm and rational.—9 p.m. Slept again.

  Feb. 14. Very restless, and at times violent. Bandages removed and
  jacket substituted.

  Feb. 15. Much better; rational, and conversing cheerfully.

  Feb. 16. Improving.

  Feb. 17. At her urgent request, hands were freed, but shortly after
  she became excited.

  Feb. 19. More sensible; had to-day symptoms of a severe bilious
  attack, which upset her for some days.

  Feb. 24. Much better; allowed to see her sister—the first time since
  the operation.

  March 1. Much improved; has written to her sister, and amused herself
  knitting and reading during the day.

  March 2. Allowed to dress; seemed to enjoy the change, and is very
  cheerful.

  March 4. Visited by her sister; has been quietly cheerful all day. Is
  certainly improving wonderfully.

  March 20. Took a walk, and enjoyed it.

  March 25. Spent the day away from the Home with her sister; returned
  looking quite well, and all the better for the change.

  April 2. Discharged quite cured.

  This patient remained perfectly well, and I hear has since been
  legally married.


                CASE XLVIII. INCIPIENT MANIA—ONE YEAR’S
             DURATION—OPERATION—CURE—SUBSEQUENT PREGNANCY.

  In 1863, Mrs. S. M., married, mother of three children, æt. 30, came
  under my care, because she had been suffering for more than a year
  from menorrhagia, which had gradually affected her mind, causing her
  to have a great distaste for her husband; so much so, that he and his
  friends were induced seriously to contemplate a separation. On the
  first examination, her face indicated mental disturbance, eyes
  restless, pupils dilated, and manner generally excitable. She told me
  that she could not sleep at night, complained of constant weary
  uneasiness in her womb, pain in her back, great pain on defecation,
  constant desire to micturate. She said she was glad to be away from
  home, as she made every one around her unhappy. Believed that she
  would be a permanently insane patient, and never expected to return to
  her family again.

  On more minute examination, I found irritable clitoris and labia, a
  painful fissure of the rectum, with great relaxation of the sphincter
  ani, which, on inquiry, was found to be caused by the frequent
  introduction of her finger, with a view to peripheral irritation. At
  her own request, she had long been separated _à mensâ_ from her
  husband, on account of her great distaste for him and cohabitation
  with him.

  I pursued the usual surgical treatment, which was followed by
  uninterrupted success; and after two months’ treatment, she returned
  to her husband, resumed cohabitation, and stated that all her distaste
  had disappeared; soon became pregnant, resumed her place at the head
  of her table, and became a happy and healthy wife and mother. She was
  in due time safely delivered, and has ever since remained in perfect
  health.

  _Remarks._—From observations of this case, one feels compelled to say,
  may not it be typical of many others where there is a judicial
  separation of husband and wife, with all the attendant domestic
  miseries, and where, if medical and surgical treatment were brought to
  bear, all such unhappy measures would be obviated?

A careful perusal of the cases related in the foregoing pages will show
that all the theoretical objections mentioned in the introductory
chapter, as having been raised against my treatment, have been fully
contradicted by facts. Of the permanency of the result, I myself am
fully satisfied; and I hope at a future time, by a much larger number of
cases, to confirm others in the same opinion.


           COX AND WYMAN, PRINTERS, GREAT QUEEN STREET, W.C.

------------------------------------------------------------------------




                          TRANSCRIBER’S NOTES


 1. P. 42, changed “prodomata” to “prodromata”.
 2. Silently corrected typographical errors and variations in spelling.
 3. Archaic, non-standard, and uncertain spellings retained as printed.
 4. Footnotes were re-indexed using numbers.
 5. Enclosed italics font in _underscores_.