Читать книгу On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females - Isaac Baker Brown - Страница 5

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As the title of this book implies, I do not intend to occupy the attention of my readers with all the numerous varieties of insanity and other nervous disorders to which females are liable, but only those which I believe to be curable by surgical means; nor is it my intention in this category to include slight cases, but to confine myself to such as cause more or less severe functional derangement, or which lead to serious organic lesions.

The class of diseases on which I shall dwell are those depending on (or arising from) a loss of nerve tone, caused by continual abnormal irritation of a nerve centre.

This is no very new theory; but it has been for Dr. Handheld Jones, by a large number of cases and experiments, as collated in his admirable work on “Functional Nervous Disorders,”^[1] to make it “abundantly clear that the great majority of disorders we have to treat at the present time show more or less marked indications of failure of nervous power.” Dr. Jones confines himself “to such disorders as are termed functional;” and I agree with him that “it seems a vain dispute, whether in strict accuracy there are, or are not, any such disorders;... for it is perfectly certain that there are very grave disorders in which the most careful scrutiny fails to detect any actual change, in which complete recovery is perfectly possible, and in which the ‘juvantia’ are such as to operate more in modifying the power of the organs than the texture.” Dr. Jones then gives two typical cases of functional and organic disease, between which, as he justly observes, “there intervene numerous instances of more or less mixed character;” and adds, that “disease which commences essentially as functional may end as organic.”

1. London, Churchill, 1864.

I am so pleased to be supported by my old friend and colleague in views that I myself have long entertained, that I intend, without further preface, to make his researches the whole substratum of my work; and hope to show how, on the basis of Dr. Jones’s experiments, it is possible to prove the philosophy of my own practice.

Whichever of the terms, “inhibitory influence” (Handfield Jones and Lister), “reflex relaxation” (Brinton), or “reflex paralysis” (Brown-Séquard), be used, the fact is ceded by all, that “the energetic operation of an afferent nerve” (Lister), or some impression acting injuriously on an afferent nerve (Handfield Jones), or, again, “an actually existing irritation” (Brown-Séquard), exerts an injurious effect on its nerve centre, this state being, as Dr. Brown-Séquard thinks, increased or diminished according to the activity of the irritation, and ceasing with its entire removal, or, more probably, as Dr. Handfield Jones affirms, persisting after the cessation of the cause which has morbidly affected it. This latter view appears to me the more generally correct one, because it can hardly be expected that a gradual disease will be suddenly removed, there having been no time for recovery of nerve power.

In Dr. Handfield Jones’s Lumleian Lectures, delivered last year before the College of Physicians, he thus sums up his views on this subject:—“The essential idea of the inhibitory theory is, that an impression conveyed to a nervous centre by afferent nerves may weaken or paralyze, instead of exciting, its action, either from the congenital or acquired debility and sensitiveness of the nerve itself, or because the impression is unduly intense or absolutely injurious. Both these things have in every case to be considered—viz., the state of the nerve force, and the kind and amount of impression, as the resulting phenomena will vary with the variation of either.”

Dr. Jones next takes it as a matter of certainty, “that a nervous centre may be more or less completely paralyzed without having undergone organic change, in consequence of some enfeebling morbid influence;” and quotes from Dr. Gull^[2] “a most interesting instance of complete paraplegia induced by sexual excess, in which nothing abnormal could be detected in the cord, even by careful microscopy. This was paralysis from simple exhaustion.”

2. “Guy’s Hospital Reports,” 1858. Case xvii.

Still continuing, Dr. Jones draws attention to the anatomical fact of the remarkably close manner in which “the different nerve centres, or parts of a nerve centre, are connected by commissural fibres,” and how, “from a pathological point of view, the same connexion is often very manifest. The general exhaustion induced by excess of venery,” and other cases, “are examples which show how excessive consumption of nerve force in one part weakens it also in others; and this can only be adequately explained by the intricate commissural connexion between the various centres.”

The truth of all these views is well exemplified, as Dr. Kidd has stated, in cases of epilepsy, which “may originate only in irritation of bad teeth acting on the brain, or worms irritating the nerves of the stomach, and so on as to other peripheral irritations; the chief skill being to find out the spot from which the irritation radiates.”

A case is also quoted by Dr. Jones, in the Lumleian Lectures, as having occurred in the practice of Mr. Castle, of New York, where diseased teeth produced paraplegia, which soon ceased after their removal.

Long and frequent observation convinced me that a large number of affections peculiar to females, depended on loss of nerve power, and that this was produced by peripheral irritation, arising originally in some branches of the pudic nerve, more particularly the incident nerve supplying the clitoris, and sometimes the small branches which supply the vagina, perinæum, and anus.

Closer observation satisfied me that the greater or less severity of the functional affections observed, depended on the amount and length of irritation, and the consequent amount of loss of nerve power.

Nor are functional disorders the only consequence, but in some cases, severe organic lesions.

The progress of the disease may be divided into eight distinct stages—No. 8 being arrived at, by gradations more or less distinct, directly from No. 1.

1. Hysteria (including dyspepsia and menstrual irregularities).

2. Spinal Irritation, with reflex action on uterus, ovaries, &c., and giving rise to uterine displacements, amaurosis, hemiplegia, paraplegia, &c.

3. Epileptoid Fits, or Hysterical Epilepsy.

4. Cataleptic Fits.

5. Epileptic Fits.

6. Idiotcy.

7. Mania.

8. Death.

My statement, that death is indeed the direct climax of the series, might be proved by several cases which have occurred in my own practice, one only of which I shall relate. Before doing so, I may mention that Dr. James Russell, of Birmingham, has recorded a case in the Medical Times and Gazette, Oct. 31, 1863, in which a male patient, æt. 32, died under his care in the Birmingham General Hospital. Complete paralysis both of sensation and motion in the lower part of the body and lower extremities attacked him after an unusually excessive venereal indulgence. There had been gradual exhaustion for the last twelve or fourteen years, from this cause. There was no attempt at recovery, and he died in four months from the date of the attack.

The case that occurred in my own practice was as follows:——, æt. 19, has been gradually becoming ill since the age of nine; does not look older than the latter age, though the sexual organs are as highly developed as they should be. Has been for many months in a metropolitan hospital suffering from acute headache, but has received no benefit. For two years has been perfectly blind.

She was found dead, and with every evidence of having expired during a paroxysm of abnormal excitement.

These cases will illustrate how important it is to arrest the disease ab initio, and the treatment must be the same whether we wish to cure functional disturbance, arrest organic disease, or, finally, if we have only a chance, of averting death itself.

The time required for recovery must depend, not only, as has been already hinted, on the duration of illness, but also on the peculiar temperament of the patient, and judicious after-treatment; this latter requiring long perseverance on the part of both practitioner and the friends of his patient; and it is as we meet a favourable or unfavourable case that the opinions of Brown-Séquard, as to instant cure on removal of irritation, or of Handfield Jones, as to cure after a long interval, are verified.

I have pleasure in stating that, with reference to the origin of most nervous affections of females, I have, in frequent conversation with Brown-Séquard, found that the views of this distinguished physiologist entirely coincide with my own, and he often expressed himself as satisfied that destruction of the nerve causing irritation was the only effective cure; the best mode of carrying out this destruction was, in his opinion, yet to be determined. He used actual cautery.

I hope to be able to show that a far more humane and effectual method is that which I constantly practise, and for the last six or seven years have openly and consistently advocated. Of course, from the very novelty of these views, I have been met with many objections, such as unsexing the female, preventing the normal excitement consequent on marital intercourse, or actually, as some most absurdly and unphilosophically assert, causing sterility: whereas my cases will show fact to be directly converse to all these theories; and it is curious that a physician for many years connected with one of our largest metropolitan hospitals, and recognized as a standard writer on female diseases, has in writing condemned my practice in not very measured terms, but is himself constantly in the habit of trying to subdue this peripheral irritation by continual application of the strongest caustics to the seat of the irritation; thereby showing that he recognizes the source of evil, but is not yet able to see that a superficial sore will not destroy deep-seated nerve irritation. It wants, I imagine, little argument to prove that so far from this practice being beneficial, it is likely, by causing increased irritation, to be positively injurious.

Other practitioners follow Dr. Brown-Séquard’s plan of applying actual cautery to the irritant nerve; and many more have advanced as far as the operation—which I was formerly in the habit of practising—subcutaneous division of the nerve. I have long abandoned this method as being no more certain in its effect than kindred operations on various branches of the fifth nerve for tic doloureux.

Another objection has been made that several of my cases have not been permanently cured, but have had relapses in a few weeks or months. This must necessarily be so with all new methods of treatment; but each such case is of incalculable importance, as teaching me to exclude any but temporary hope of relief to some, while to others I can speak all the more positively as to their ultimate permanent recovery.

Experience seems to teach that in those patients whose brains have been so weakened by long-continued peripheral excitement, causing frequent and increasing losses of nerve force, there is not sufficient mental power to enable them to control any less powerful irritation of smaller branches of the pudic nerve, than that removed by operation.

This lesser excitement acts chiefly, I imagine, by preventing restoration, in the same manner as a drunkard whose brain is weakened by long indulgence in his baneful habit cannot resist temptation, but is, however, affected by much smaller quantities of stimuli, than when strong, he was able to take.

A striking instance of this kind occurred to me last year.

One of our most distinguished obstetric physicians requested me to operate on a lady who had been for some twenty years under very many eminent practitioners without any but temporary benefit. The result of the operation was most marked; the irritation subsided, the patient improved in health, and we confidently expected permanent relief. Yet in a few weeks after she left our hands and that of the nurse, irritation, resembling pruritus, gradually returned, and with it the other old symptoms.

In all cases of a similar nature which have come under my care, I have insisted on the importance of the patient being kept for a long time under careful medical watching and good nursing, and from the results already obtained from cases in which these precautions have been exercised, I feel confident of success for the future.

Lastly, objections have been advanced against the morality of the operation, and I am here at a loss how to give an answer, for I can hardly conceive how such a question can be raised against a method of treatment which has for its object the cure of a disease, that is rapidly tending to lower the moral tone, and which treatment is dictated by the loftiest and most moral considerations. I may here observe, that before commencing treatment, I have always made a point of having my diagnosis confirmed by the patient or her friends.

To the philosophical and charitable mind, indeed, the whole subject is one of the greatest interest, and will lead us to ask the question, may not this “inhibitory influence,” originating in early life, act so powerfully on the mind as to unhinge it from that steadiness which is essential to enable it to keep the passions under control of the will; to enable, indeed, the moral tone to overcome abnormal excitement? And if this be true, does not common charity lead us to think that cases treated by friends and spiritual advisers, as controllable at the will of the individual, may be in reality simply cases of physical illness amenable to medical and surgical treatment? Is it not better to look the matter steadily in the face, and instead of banishing the unhappy sufferers from their home and from society, endeavour to check their otherwise hopeless career towards some of the latter stages of this disease, to restore their mental power, and make them happy and useful members of the community?

On this consideration I shall not now dwell further. Every one must feel it to be a vast and important one, affecting the well-being of the whole human race.

All I am now aiming at, is to show that many, if not all, such cases may be cured. If this is done, I shall indeed be able to say that I am amply repaid.

I have the gratification of being able to name the following gentlemen who have been led to adopt my views and treatment in proper cases:—Sir James Simpson; Dr. Beattie, of Dublin; Sir John Fife and Dr. Dawson, of Newcastle-on-Tyne; Dr. Duke, late of Chichester; Dr. Shettle, of Shaftesbury; John Harrison, Esq., of Chester; Drs. Savage, Routh, and Rogers, in London; my eldest son, Mr. Boyer Brown, now practising in New South Wales; with my colleagues in the “London Surgical Home,” Dr. Barratt, and Messrs. Harper, Chambers, I. B. Brown, junior, and Bantock, and very many others.