On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females

CHAPTER III. HYSTERIA, WITH CASES. — Case I. Hysteria—Five Years’ Illness—Operation—Cure in Two Months. — Case II. Two Years’ Illness—Operation—Cures. — Case III. Hysteria—Thirteen Years’ Illness—Sterility—Operation—Cure, and subsequently Three Pregnancies. — Case IV. Hysteria, with Sleeplessness—Six Years’ Illness—Operation—Cure. — Case V. Fissure of the Rectum, with Hysteria—Operation for the former—Relief—Subsequent Operation for Hysteria—Cure. — Case VI. Hysteria, with Epileptiform Attacks in Childhood—Various Ailments for Thirteen Years—Operation—No Benefit. — Case VII. Hysteria—Several Years’ Illness—Operation—Cure. — Case VIII. Hysteria—Many Years’ Illness—Phantom Tumour—Operation—Cure. — Case IX. Hysteria—Five Years’ Illness—Sterility—Operation—Cure—Pregnancy—Two Children. — Case X. Hysteria—Irritation of Right Ovary—Menorrhagia—Nine Years’ Illness—Operation—Cure. — Case XI. Hysteria—Many Years’ Illness—Operation—Cure—Marriage and Progeny. — Case XII. Hysteria—Mental Aberration, and Tendency to Melancholia—Eight Years’ Illness—Operation—Cure. — Case XIII. Extreme Hysteria, verging on Insanity—Five Years’ Illness—Operation—Cure. — Case XIV. Extreme Hysteria—Incipient Insanity—Operation—Cure.

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 20organism, 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:—

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.

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.

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.

23Examination 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.

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.

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.

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 25nearly 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.

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.

26May 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.

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.

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 27medical 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.

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.

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.

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.

30Jan. 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.

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.

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 — Case XV. Spinal Irritation, and supposed Uterine Displacement—Six Years’ Illness—Operation—Cure. — Case XVI. Dysmenorrhœa—Five Years’ Illness—Operation—Cure. — Case XVII. Spinal Irritation and Loss of Use of Right Leg—Five Years’ Illness—Operation—Cure. — Case XVIII. Hysteria and Spinal Irritation Twelve Years—Fissure of Rectum, recent Duration—Operation—Cure. — Case XIX. Menorrhagia—Mental Delusion—Two Years’ Illness—Operation—Cure—Subsequent Marriage and Progeny. — Case XX. Spinal Irritation, giving rise to Menorrhagia and Amaurosis—Operation—Cure. — Case XXI. Spinal Irritation—Loss of Power in Lower Extremities—Operation—Rapid Improvement.

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 33their 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.

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, 34that 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.

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.

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.

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.

36Nov. 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.

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.

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.

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 38candle-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.

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 39her 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 40hands 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. — Case XXII. Nine Years’ Illness—Epileptiform Attacks—Three Years’ Duration—Operation—Cure. — Case XXIII. Epileptoid Fits—Fifteen Years—Illness for Twenty-six Years—Operation—Cure. — Case XXIV. Hysterical Epilepsy—Long Duration—Operation—Cure. — Case XXV. Hysteria and Epileptiform Attacks—Many Years’ Illness—Operation—Cure. — Case XXVI. Epileptiform Fits and General Hysteria—Four Years’ Duration—Operation—Cure. — Case XXVII. Epileptiform Fits—Six Years’ Duration—Operation—Cure. — Case XXVIII. Hysterical Epilepsy—Three Years and a Half Duration—Operation—Cure.

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:—

“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 42diagnosis 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.

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.

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 44fifteen 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.

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.

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.

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 46symptoms. 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.”

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.

47July 19. Discharged cured, not having had one hysterical attack since the operation.

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. — Case XXIX. Hysterical Catalepsy—Many Years’ Duration—Operation—Relief—Remarks. — Case XXX. Hysterical Cataleptic Fits of Long Duration—Operation—Cure. — Case XXXI. Cataleptic Fits—Two Years’ Illness—Operation—Cure. — Case XXXII. Cataleptic Fits—Many Years’ Duration—Operation—Cure. — Case XXXIII. Cataleptic Fits—Six Years’ Duration—Operation—Cure.

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 49think, 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.

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 50loss 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.

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:—

51“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.

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 52several 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.

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.

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 54in 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. — Case XXXIV. Epileptic Fits—Twelve Years’ Duration—Operation—Cure. — Case XXXV. Epileptic Fits—Five Years’ Duration—Preceded by Cataleptic Fits, during the Ten previous Years—Operation—Cure. — Case XXXVI. Epileptic Fits—Many Years’ Duration—Operation—Cure. — Case XXXVII. Epileptic Fits—Two Years’ Duration—Operation—Cure. — Case XXXVIII. Severe and Frequent Epileptic Fits for Three Years and a Half—Operation—Cure. — Case XXXIX. Epilepsy, with Dementia—One Year’s Duration—Operation—Cure. — Case XL. Epileptic Fits—Two Years and a Half Duration—Operation—Relief. — Case XLI. Epileptic Fits, with Dementia—Thirty Years’ Duration—Operation—Cure.

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 56convulsive 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.”

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.

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; 57but 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, 58the 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.

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 59the 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.

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 60last 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.

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 61cause 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.

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.

62March 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.

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.

63June 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.

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.

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.

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

History.—Epileptic fits first attacked her when she was about 6614, 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. — Case XLII. Epileptic Fits, with Complete Idiotcy—Operation—Great Temporary Relief, but not Permanent Benefit. — Case XLIII. Incipient Suicidal Mania—Many Years’ Gradual Illness—Operation—Cure. — Case XLIV. Several Years’ Illness—Two Months’ Insanity—Operation—Cure. — Case XLV. Acute Insanity—Two Months—Operation—Cure. — Case XLVI. Hysterical Homicidal Mania—One Year’s Duration—Operation—Cure. — Case XLVII. Acute Hysterical Mania—Four Months’ Duration—Operation—Cure. — Case XLVIII. Incipient Mania—One Year’s Duration—Operation—Cure—Subsequent Pregnancy.

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 68have 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.

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.

69Has 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.

70She 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.

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 71been 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:—

“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.

“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.

73“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.

74“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 75that 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.

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, 76among 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 77towards 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.

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 78never 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 79straight 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.

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 80prevent 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.

81The 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 82Mr. 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.

83Feb. 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.

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?

85A 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.