Reprinted from The Medical and Surgical Reporter, May 27th, 1893, Oophorectomy in Diseases of the Nervous System. MARY A. DIXON=JONES, M. D., Brooklyn, N. Y. Reprinted from The Medical and Surgical Reporter, May 27th, 1893 Oophorectomy in Diseases of the Nervous System. MARY A. DIXON-JONES, M. D., Brooklyn, N. Y. OOPHORECTOMY IN DISEASES OF THE NERVOUS SYSTEM. MARY A. DIXON-JONES, M. D., Brooklyn, N. Y. I have read with much interest Dr. Allen McLane Hamilton’s article on “ The Abuse of Oophorectomy in Dis- eases of the Nervous System.” He says:1 “ In speaking, as I am about to, it is with a full appreciation of its value, which I believe is exceedingly limited, except where well-marked and previously recog- nized structural disease of the organs is determined.” I cordially agree with Dr. Hamilton that, in every case, the disease should be “ well marked,” and, I would still further emphasize the idea by adding that it should also be, as far as we can judge, incurable, and manifestly doing positive injury to the system. “Previously recognized structural disease of the organs may be determined,” and yet this not be sufficient to demand or warrant the removal of the ovaries; for structural changes may be considerable, and yet produced only by a slight inflam- mation and would not, therefore, justify extirpation. Even more profound changes of structure, resulting from more serious conditions will not, in all cases, render it necessary. Dr. Hamilton says further of this opera- tion: “ Its value is exceedingly limited.” I believe it is absolutely “ limited,” and should never take place for purely nerv- ous con litions, but only for absolute and in- curable disease of the named organs, and maintain that, in no instance, for nervous disease, should healthy ovaries be removed. In 1882, Sir Spencer Wells said:* “ Its introduction in mental and neurotic cases is only to be thought of after long trials of other tentative measures, and the de- liberate sanction of experienced practi- tioners.” In an article of mine published in the Am. Jour, of Obstet., Feb., 1888, referring to the above, and quoting the following expressions from Sir Spencer Wells: “Removal of ovaries while in a state of functional activity,” “Oopho- rectomy, or removal of normal ovaries,” I said: “ I shudder at the thought of re- removing healthy ovaries, or even when the disease is problematical; I would not remove healthy or normal ovaries for dys- menorrhoea or any suffering in the regions of the ovaries; I would not remove them for epilepsy, nor for mental or neurotic disease, even if I had failed after long trials of tentative measures, and had the cordial, full and deliberate sanction of ex- perienced practitions, unless I believed the appendages themselves were diseased.” In an article, in the N. Y. Med. Jour., May 10-17, 1890, again referring to the above, and quoting the following from Dr. T. A. Emmet:* “From the beginning, I have been uncompromising in my oppo- sition to the removal of the ovaries for dysmenorrhma and other nervous dis- orders, due to perverted or impaired nu- 2 Am. Jour. Med. Science, 1886, Vol. II., p, 463. 3 Med. Record, Dec. 28, 1889, p. 711 1 N. Y Med. Jour., Feb., 1893 4 trition, and where the fault lies in the centres,” I then add: “Thus it will be seen that the position which I assumed from the first, and published nearly two years before, is more conservative than Dr. Emmet’s position. I make the ‘ un- compromising ’ sweep of excluding all cases from this operation, except where there is hopeless disease of the organs themselves; that is, I denounce the re- moval of the uterine appendages for any cause, neurotic condition, constitutional disturbance, or for any reason except for incurable disease. When thus diseased they are a continual injury to the system, and their removal is a lasting benefit. To remove healthy organs for any ‘ grave ’ condition of the general system should not be thought of, and cannot, under any circumstances, eventuate in any good; for the normal action and physiological func- tion of healthy organs will always increase the life force, and assist in restoring the system, in whatever way diseased, to a state of health.” . I have never conceived of any circum- stances that would demand the removal of normal ovaries. I regard it as a most serious procedure to remove human ova- ries, and it should not be done without sufficient reason any more than amputa- ting a hand, arm, or leg. A woman is to be inconceivably pitied, who, from any cause, has to lose the organs, and yet, to many, it has been a blessing; it has been their salvation and the means of adding years to their lives. A man is to be in- conceivably pitied who has tuberculous lungs or fatal nephritis, and would con- sider himself inconceivably happy if he thought it possible for him to live after the removal of the fatally diseased lungs or kidney, and especially if thereby his life could, for many years, be prolonged. Another reason why the removal of the ovaries should, as much as possible, be avoided, and women urged to seek early to be cured of any ovarian trouble, is that continuous disease of the organs, not only interferes with health, but may render the person absolutely sterile. In my article on “Sterility in Woman,”4 I gave a number of instances where special treat- ment had removed an incipient ovarian and tubal disease and with the best results. This, I believe, is really what was done in most of the cases, mentioned in the article as being treated for sterility; but I would especially refer to the two in the 5th para- graph, page 319. Perhaps few have had larger opportunities than I to read the in- nate longings of every true woman for children. I have heard the moan from the depths of the human heart. For more than twenty years my practice in the disease of woman has been largely to remove the causes of sterilty and, as I said in the above mentioned paper, “ Planted deep in every true woman’s heart is the love for children, and nothing is more beautiful than a large family of children; no greater happiness can come to a woman.” Dr. Hamilton further remarks in his article: “ So far as as I know, oophorec- tomy has never cured a case of well- established or even incipient organic dis- ease, or has proved to be the least use except in functional disturbances that could have been cured, or at least helped by angencies of a far less dangerous nature.” In this assertion I believe Dr. Hamilton would find many eminent sur- geons and gynecologists who disagree with him. Battey says: “ My cases of epilepsy have given me the most satisfactory re- sults. The cures have been prompt and complete.” He reports, in 1886, 13 cases of epilepsy cured by the operation. On another occasion he said nine out of ten of his cases of ovaro-epilepsy have been completely cured of their epileptic form of seizures. Prof. A. Vanderveer®, of Albany, gives several cases. One, 24 years old, had eleptiform seizures at 14. He operated for the removal of the uterine appendages, May, 27, 1886, and “four years after the operation she had yet no return of the convulsions.” Prof. W. T. Howard says of a patient: “ She would lie in a state of coma, writhing in pain for ten days to- gether; she had taken her weight in bromides and chloral until they had no effect whatever.” He removed the ova- ries and tubes and said: “ She recovered and was like a new being.” Olshausen re- ports a severe case of hystero-epilepsy— “ the troubles,” he says, “were removed after castration.” Dr. Earnest Bohni*, reports a patient, 5 Tr. Med. Society, N. Y., 1882, p. 182. 6 Cor. B. Bl., Schweizer Artz B»s„ 1886. XVI., p. 622, 4 Sterility in Woman—Causes, Treatment and Illus- trative Cases. Med. Rec., N. Y., Sept. 19, 1891. 5 25 years old. The epileptic tits were so severe that it required three persons to hold her, convulsions sometimes lasting three hours, and occurring many times a day. The left ovary was enlarged, in- flamed and sensitive to the slightest touch. Dr. Bdhni removed this and as- serts that, from the day of operation, the patient had no spells. Dr. ;Reamy7 re- ported a case of a young woman who had suffered from constant headache and epi- leptic attacks. She had been treated by various physicians without obtaining any relief. After the removal of the ovaries the headache ceased, the epileptic attacks did not re-appear, and the anxious vacant stare of the contenance entirely disap- peared. Dr. A. Maurer, of Coblentz, re- ports the case of a young girl, whose men- struation appeared at seventeen, was irregular, accompanied by increasing pain in the abdomen, back and lower extremi- ties; the general health became affected, the ovaries were sensitive to the touch. After a while the severe periodical pains became epileptic in character, patient at times unconscious, extremities rigid, body opisthotomous. To make the diagnosis more certain he had the patient chloro- formed; the ovaries were found to be enlarged, and if either one was taken be- tween the fingers, notwithstanding the deep narcosis, there were tetanic convul- sions of the whole body. He concluded: “ The cause of the sickness was the dis- ease of the ovaries. He removed both organs, and reports a complete recovery of the patient.” I find a case reported by Jacob May, M. D.8 “The patient, 31 years old, taken in her third pregnancy with epileptic seisures; they continued increasing in severity, and became so violent as to re- quire the united strength of several per- sons to prevent her from injurying her- self. The doctor recognized that there was tenderness in the region of tubes and ovaries, and consulted with Prof. T. G. Gaillard Thomas, of Hew York, who, after a thorough examination of the case wrote: ‘In my opinion, Mrs. A. suffers from hystero-epilepsy, due to ovarian and tubal disease. You have done all for her which medicine can effect, I unhesi- tatingly recommend Tait’s operation.’ The tubes and ovaries were removed. Six- teen months after the operation the patient wrote: ‘ I have had no fits and no symptoms of any. I am improving every day, and more able to do for my family than*for years past.’ ” On May 21, 1888, Dr. May wrote: “Nearly four years have passed since this operation, and there is no return of epileptic seisures.” Dr. H. M. Boldt,® gives some most in- structive cases. One patient, age 24, both ovaries were prolapsed and very sen- sitive; pressure on either brought on a feeling as though the patient would have a convulsion. Years of medicinal treat- ment and continuous local treatment had been of no service. The ovaries were re- moved. Gradually the convulsions diminished in severity and frequency, and now more than a year has elapsed since the last attack. Another case: Patient aet. 28 years; right tube and ovary much enlarged, prolapsed, bound down by peri- metric adhesions and very sensitive, pres- sure on the ovary brought on hysterical convulsions. On February 12th, 1886, the right appendage was removed. After the operation the nervous symptoms dis- appeared, and since the patient has not had a convulsion. Dr. Chas. Meigs,10 reported a case of Hystero-epilepsy. “Patient had always enjoyed good health till after the birth of her child, six years previously. She was in bed nine weeks after her confinement; and six months after, she commenced having epileptiform seisures at her men- strual periods. They gradually became so violent that the family were about to place her in an insane asylum, when, Oct. 3, 1881, the ovaries and tubes were re- moved. The patient made a speedy re- covery, and has not had one seisure since the day of operation. Donnell Hughes,11 reports three cases, all had disease of the uterine appendages, these were removed; each patient recovered, and each one was afterward free from epileptic convulsions. Dr. J. G. Brooks reports a successful case of “Castration for Hystero-epilepsy.” Dr. W. J. Asdale,12 and Dr. Taber John- 9 Removal of the Uterine appendages for Hystero- epilepsy, Am. Gyn. Jour., June, 1892. lOPhila. Obst. Soc., Jan. 6, 1887, Am. Jour. Obst., Mar. 1887, p. 30. 11 Med. Progress, Louisville, Ky., 1891, p. 490. 12 Pittsburg Med. Review, Dec., 1886. 7 Obst. Soc., of Cincinnati, June 20, 1887, Am. Jour. Obset., April, 1888, pp. 434-436 8 Vir. Med. Monthly, Richmond, 1889, Vol. V., p. 174. 6 son,1* report similar cases with like re- sults. Dr. T. Nelson, Prof, of Clinical Gynecology, Rush Medical College, Chicago.14 “Patient 25 years of age, married six years, no children. The epileptic fits were becoming more fre- quent, and were worse just before the menstrual period. The ovaries were tender, adherent and displaced.” The operation was done on Nov. 20, 188G, with satisfactory results; and he said to his class: “If such a case presents itself to you, and the patient has been under skillful treatment for five or six years, as in this case, without any material benefit, it will become your duty to operate.” G. H. Balleray,15 Patterson, New Jersey, says: “A patient, aged 31, was brought to his office, Oct., 1881, to ascertain if anything could be done to cure her epi- lepsy. Convulsions began ten years pre- viously, and had recurred regularly at each menstrual period, increasing in se- verity till the mental faculties had be- come impaired. The patient had been under the care of several physicians, all of whom administered the bromides in large doses. Both ovaries were found to be enlarged, and tender on pressure. I told the mother of the patient that her daughter could not be cured by drugs, but that the removal of the ovaries might re- sult in a cure. In 1882, the convulsions had recurred with increasing violence at each menstrual period, and the patient was now suffering with acute mania, eyes red and glaring. She had been in con- vulsions all the previous night. The con- vulsions were followed by profound coma, out of this she passed into a manical con- dition. The patient, as well as the rela- tives, were very anxious for an operation. April 27, 1882, both ovaries and tubes were removed. Three months after the operation she had a slight convulsion. She then went fourteen weeks without having a convulsion, then she went four months without an attack; and when I last heard from her, five months had elapsed without a convulsive seisure.” Prof. Lawson Tait,16 reports a case of Hystero-epilepsy. The wife of a physi- cian, 33 years old, Aug., 1887, married eighteen years ; first child born ten months afterwards. In 1874, she aborted on the third month followed by pelvic peritonitis on the right side, and she was unable to leave her bed for three months. One year after she aborted again, and on this occasion a similar inflammatory at- tack occurred on the left side. In the spring of 1885, she was attacked for the first time with a convulsion which lasted about a hour, and similar attacks were re- peated for two months, twice in twenty- four hours, which were very violent, some- times requiring five or six persons to hold her. She made frequent attempts at sui- cide. The husband wrote, Aug. 5th: “She was seized worse than ever, the con- vulsions lasting from three to four hours, followed by wild delirium. This con- tinued for eight days. Ten days since she became worse, and the mania that followed was of a suicidal character. I am certain that nothing will be of service except removal of the uterine appen- dages, as those in the right side have been diseased for eleven years.” Prof. Porro was to remove the appendages on Aug. 17th; he commenced his operation at 11 o'clock, and finished by abandon- ing it at 12.15. He says both tubes and ovaries were so densely adherent, that it was impossible to separate them from the mass of organized tissue in which they were imbedded. Aug. 30th, all the symptoms, including the violent convulsions, had returned with, if possible, greater severity. Four violent convulsions occurred in thirty hours, and she became insane. Mr. Law- son Tait performed the operation on the 23rd; removed the appendages from both sides; operation lasted nine minutes and a quarter. The patient has had no trouble since; is bright, cheerful, and the expres- sion of her face entirely changed.17 The history of cases clearly shows, that many instances of epilepsy, of a remark- ably serious character, have been caused by disease of one or more pelvic organs. Could anything be more natural, than that removing the cause, would eventuate in cure ? When we consider the large supply of nerves to the ovaries, and their multiplied connection with all 13 Vir. Med. Monthly, Richmond, Jan., 1889, p. 261. 14 Med. Nevus, May 3, 1890, Oophorectomy for hys- tero-epilepsy. 15 7V. of Med. Soc., New Jersey, Newark, 1886, pp. 77-79. 16 Lancet, London, 1887, p. 1213. 17 Dr. Chas. N. Dixon Jones, of New York, was, at that time, Mr. Lawson Tait’s first assistant, and was present at this operation. 7 parts of the body, is it at all surprising that disease of these organs, especially in persons of a sensitive, impressible nervous system, should cause nervous disturbances, and possibly epilepsy ? Is it any more improbable, than that epilepsy should be produced by slighter forms of irritation in other and distant parts of the body, as a tape worm in the alimentary canal, a tight prepuce; or, as J. Althamus1* cites, a case in which “revaccination, in a healthy youth of 19, caused attacks of true epilepsy.” Prof. Henry Hartshorn has said that, “losing a meal will, in the epileptic, cause convulsions.” We have innumerable instances given where lack of development or in- efficiency of the generative organs has caused acene. Dr. Edebohls showed me a case in his ward at St. Francis’ Hospital, where repeatedly, month after month, at each menstruation, there was a marked and circumscribed skin eruption on the right side of the face and neck. We are also assured, by well authenticated in- stances, that reflex irritation from dis- eased ovaries has caused changes in the bone, or osteo-malacia, and equally well attested proofs of cures of this disease by removal of the effending organs. Felding says: “Osteo-malacia is a re- flex tropho-neurosis of the bones depen- dent upon ovarian activity;” and Thorn,1* gives a case of a patient who had severe pains in the pelvic bones, with marked deformity, being unable to walk, and showing progressive emaciation and oedema. The diseased uterine annexas were re- moved, after which the patient improved rapidly, the pains in the bones dis- appeared ; she was soon able to walk, and a year after the operation, was perfectly well. Hoffmeier20 reports the case of “a patient who suffered great pain in the bones, and increasing difficulty in walking, and finally was unable to do so without assistance.” He performed “ castration for osteo-malacia,” after which the patient was well, had no further difficulty or pain in walking. F. Winckel, of Munich, and Prof. Schauta, of Prague, report similar cases with equally good results. Ovulation is so important a function, that it is intended to take hold of the whole system, to embrace the whole being, for it is to perpetuate the race, and to give the best characteristics, mental and physical, of the individual. When this function is performed by diseased organs, will not the whole system, in a measure sympathize, and may not the nervous system and the mental conditions also to the same extent be affected ? I have seen a number of cases where disease of the ovaries, not only produced local pains, but evidently caused the mental dis- turbances. Thomas21 said : “ Not a few women are always a little insane during the menstrual period.” This can be said only of sick women, or those who have these organs diseased. Women with a healthy genital organization go through the function of menstruation as naturally, and normally, and painlessly, as the di- gestion of food, by a vigorous stomach. In an article,22 published Feb., 1888, I gave a cut, from my microscopical re- searches in diseased ovaries, representing a varicose enlargement of a non-medul- lated nerve fibre packed in dense fibrous connective tissue, and, as I then said: “ This is the first time, at least to my knowledge, that nerve fibres could be traced in inflamed ovarian tissue with such clearness as this specimen exhibits. Nerve fibres of this kind, so placed, will cause pains aggravated at every menstrual period; or, if in connection with the vaso-motor system, may cause epileptic fits.” Such imprisonment and pressure of nerve fibres must frequently take place in ovaries where there are gyroma, these hard, dense, firm fibrous formations. I have,28 in some instances, counted as many as five gyroma in one section of the ovary. I believe that when we have made more thorough pathological research, most of the cases of severe local pain accompanied by various neuroses, will be found in patients who have gyroma. 1 said in in another article,24 “Out of a number of cases of epilepsy or hystero-epilepsy, I have, in three instances, performed oophorectomy, not, however, for the epi- lepsy, but because I considered that the 21 Med. and Surg. Reportrr, Phila., Sept. 6, 1879, p. 206. 22 Am. Jour. Obst., Feb. 1888, p. 1154. 23 Represented in JF. Y. Med. Jour., May 10 and 17, 1890. 24 Diagnosis and some of the Clinical Aspects of Gyroma and Endothelioma of the Ovary.” Buffalo Med. and Sur. Jour., Nov., 1892. 18 Archives de Neurologie, quoted in Annals of Gynecology, Dec., 1891, p. 189. 19 Centralblatt fur Gynakologie, 1891, No. 41. 20 Centralblatt/. Gynak. Leipz. 1891, 15, p, 225. 8 ovaries or uterine appendages were past cure, and their removal would benefit the patient, and it is remarkable that in each of these three cases of epilepsy, the ovaries were found to contain large gyromatous formations.” When I visited La Saltpetriere, in Paris, I repeatedly walked through those immense old wards, with their hundreds of sick women, and had an opportunity of studying a number of those cases in connection with their history, and I now query, whether gyroma in the ovaries of these sick women would not account for many of their bodily sufferings, and the abnormal functions of the brain and nervous system. Esquimol and Moul have estimated “that derangement of menstruation form the source of one-sixth of the cases of in- sanity due to physical causes.” In Nov., 1882, I was called to see a patient, 27 years of age, subject to most terrific hystero-epileptic spasms. She was confined to her. bed most of the time, nervous, sleepless, restless, pale, feeble and emaciated; had been twice married and no children. She had just passed through her supposed menstrual period, and had suffered all the night previous with agonizing pains, accompanied by almost continuous spasm and repeated convulsions. The uterus was found in extreme retroversion, and bound firmly down by inflammatory on each side the uterine appendages were wrapped in an inflammatory mass, size of an ordi- nary orange, extremely tender and ad- herent to surrounding structures. These conditions were, without doubt, the cause of the ill health of the patient, and of her serious nervous symptoms. Soon after her first marriage, at the age of 18, she had an attack of supposed “inflammation of the bowels,” but which no doubt was gonorrheal salpingitis. Her health continued to grow worse, and soon after she commenced having epileptic seisures. These convulsions occurred first at the menstrual periods, and she often had as many as ten or fifteen during the night. She had been attended by many physicians, who in turn gave her bromides, electricity and Charcot’s method of pressure, etc. I treated her continuously for months, in hopes of re- ducing somewhat the soreness and in- flammation, but could see no essential improvement. What was to be done with these masses ? Evidently the patient must die if she was not in some way re- lieved. Her multitude of doctors had all faithfully tried, and were powerless to help. These diseased masses could not be cured; they were of no service, and only a source of suffering—suffering so profound and incessant as to throw the whole body in violent convulsions and drive the poor woman to the verge of dis- pair and insanity. What else but to re- move them ? If Tait and Battey had not told us of this means of help, I should then have discovered it. Indeed without knowing what they had done, the neces- sity of such an operation was forced upon my mind. I even mentioned it to the patient. This was in Dec., 1882. Eagerly she seized the idea at once and repeatedly urged that it should be done, and even grew angry that I delayed. Said, “She wanted the operation if she died under it.” So fearful were her con- vulsions that her excellent husband once said: “He would rather she would never come out of ether than be as she had been.” I still hesitated and delayed. In April, I requested Prof. B.F. Dawson, of New York, to see the patient. After a thorough examination he gave it as his opinion that the operation should be done as soon as she could be made ready, that it was her only hope, and if not done, she could look forward only to a short while of miserable existence, and probably end her life in the insane asylum. The 14th of May was fixed for the operation. The principal part was per- formed by Dr. Dawson. Dr. F. W. Rockwell administered the ether. Dr. J. H. H. Burge and Dr. C. N. D. Jones assisted. Every precaution was taken as to perfect antisepsis. On May 15, 1883, Dr. Dawson*5 presented the specimen to the N. Y. Obstetrical Society, mentioning that the “left Fallopian tube was distended to the size of an egg, and that he found the adhesion firmer than in any case on which he had operated, that it was with the greatest difficulty that he was able to remove the ovary, with its and the right tube and ovary were borne down even more firmly than the left.” These he did not succeed in re- moving. The patient succumbed to septicsemia on the 7th day. In my report 2a Amer. Jour. Obstet., Nov. 1883, p. 1192. 9 of this case to the Alumnae Association of the Woman’s Medical College of Penn- sylvania, subsequently published in the Am. Jour, of Obst., I said, “ 1st. This operation should have been performed on this patient five or more years before it was. 2nd. There was no other way to relieve her but by the operation 3rd. Without it she was in constant danger. 4th. The operation to her was not as much suffering, nor as much of a shock, or as great a trial as was a week of her usual suffering.”26 A few weeks after the publication of the .above-mentioned case in the Journal of Ostetrics, I received a letter from Mr. Lawson Tait, Birmingham, Eng., dated November 23, 1884, in which occurs the following sentence: “I agree with your conclusions concerning it absolutely. That poor girl’s life would have been saved had the operation been done months or perhaps years before. The whole gist of modern abdominal surgery lies in an earnest aud continuous plea for early in- terference. There can be no doubt that the only regret about all such cases is that they are allowed to go on so long without operation.” Even if the epilepsy results from deep lesion of the nervous system, yet a disease of the uterine appendages will aggravate the conditions and be a source of increased suffering, and there is no reason why a person should not be relieved as much as possible. On May 30, 1888, a patient, M. G., was brought by her mother to see me at Throop Avenue Dispensary. She was an epileptic; the epilepsy following a severe attack of pelvic inflammation, the patient complained especially of the dis- tress in the pelvis; said the suffered so much and so constantly that her life was no good. Examinations showed that she had had repeated attacks of peritonitis, one ovary was enlarged into a blood cyst, size of an orange; there was salpingitis of both tubes; and the appendages, on each side, were bound in by inflammatory adhesions. I informed the mother and daughter that these organs could not be cured; that, in the present state, they were not only a cause of increased suffer- ing, but attended by some danger. The mother and daughter were both anxious that an operation should be performed. They called again and, in a few days, the mother brought the daughter to the hos- pital, 725 Green Ave. It was deemed ad- visable to perform the operation as soon as possible; it took place on Dec. 13, 1888. The tumor was found to be a blood cyst, bound firmly by pseudo-membranous adhesions to the walls of the pelvis; so also were the other ovary and the tubes, and all gave evidence of long existing dis- ease. The patient made an excellent re- covery and was able to be up in two weeks, free from pain, and every day seemed to grow stronger and better, and did not at the time have a return of the epilepsy. The mother called frequently at the hospital to see her daughter, always expressed herself more than pleased. As this operation seemed to be of such essential benefit I passed the patient over to the department of general surgery for the depressed bone of the skull to be raised, as so many physicians whom she had consulted, had considered this the cause of the epilepsy. This operation was successfully performed Jan. 25, 1889, and from it the patient made an excellent recovery, but, after it, the attacks of epi- lepsy seemed to recur, but they again gradually commenced to diminish in num- ber. Certainly the patient was cured of her pelvic trouble, and to that extent her general system was benefited. Both the last-named patients had chronic salpingitis, and the ovaries of each, from microscopical investigation, were found to contain large gyromatous formations. Those in the first patient were in a state of intense inflammation. When the ovaries are thus diseased their removal does good, but when the organs are normal the operation can result in no benefit to the individual. I am so con- vinced of this that when I find a case, where the removal has been an apparent failure, I at once conclude that the organs were not diseased. Schroeder stated that he had operated 12 times for the removal of healthy ovaries for neurosis; three times with good results; one patient was well 8£, another 7, another 3 years after removal. He says emphatically of one, a case of severe hystero-epilepsy, • “the 26 The day before the operation I saw her in agonizing pain, and when afterwards I saw the dis- tended Fallopian tube and its thin walls, I marveled that it had not then burst and, probably, with fatal results. 10 young girl was entirely cured.” In these three cases, that were apparently so bene- fitted, I venture to say that the ovaries were pathological though the report might say, “ they were normal,” or “very little changed.” We cannot always tell by oc- ular appearance whether an ovary is dis- eased or not. Some of the most seriously diseased ovaries I have ever examined and which were removed because the woman had untold suffering—in some instances the sufferings were so severe that their lives were almost compromised—yet, from external or naked eye, appearances of the organs there were no special indication of disease. One such ovary I found, by microscopical examination, to be infil- trated with cancer; another had endothe- lioma so far advanced that it gave the pa- tient the appearance of a far-advanced stage of phthisis. She suffered such dis- tress that she could not work, and the organs were so sensitive that the marital relations were unendurable. Though at the time of the operation the ovaries did not show such manifest appearance of dis- ease; still I lenew there was as much neces- sity for their removal as if they had been tubes full of pus. I presented micro- scopical slides of a number of ovaries, so affected to the New York Pathological Society. I gave a specimen of one to Prof. Prudden, then president of the soci- ety, and sent a microscopical slide of the same ovary to Waldeyer, of Berlin. Both of these eminent pathologists, from a microscopical examination, returned a written diagnosis of “carcinoma,” showing that in the estimation of these two dis- tinguished authorities, it was a most seri- ous form of degeneration. In many instances the most experienced cannot tell by naked-eve appearances whether an ovary, even when freshly removed, is diseased or not; yet on one occasion I saw a few physicians, not ex- perts, attempt to diagnose the condition of ovaries that had soaked for four years, part of the time in chromic acid solution, and part of the time in alcohol; and de- cide whether the surgeon was justified in removing them! “ 0 tempore! 0 mores!” Many of these specimens were cases of pyosalpinx, some of endothelioma and chronic oophoritis; one, where the right ovary and tube formed part of the wall of an abscess that extended into the adjoining pelvic aponeurosis ; another where a pelvic abscess had most detroyed one of the Fallopian tubes; and another was the cirrhosed ovary of an old woman who had had removed an interligamentous tumor, 9 to 12 inches diameter. They might at least have recognized some dis- ease from the remnants of adhesion. Leaving this digression, I was insisting that it should be an established rule that ovaries should not be removed for abnor- mal mental conditions or any nervous disorder, unless there is a well recognized disease of the organs. It is not the abol- ition of the function that does good, nor because this function itself does harm, but it is, the ineffectual effort made to perform it by diseased organs. We have the report, that at the Samar- itan Hospital, for Women and Children, Belfast, Ireland, 27 healthy ovaries and tubes were removed for masturbation and insanity, with no especially good results. This, of course, we might expect if the organs were normal. Dr. Wm. Lezyn- sky 28 reports a case of oophorectomy that took place at the City Lunatic Asylum, Feb. 23, 1880. “The patient had then been, fora period, extending beyond three months, in condition of catilepsy; receiv- ing artificial alimentation, either by aid of stomach tube or enemata. On the 14th of February, at the 'suggestion of Dr. Allen McLane Hamilton, the inhalation of nitrous oxide was resorted to. This patient had had no menstruation since her admission into the asylum, and the history of the case gave no indication of disease in the pelvis or of the pelvic organs; and there could be no reason for the removal of the ovaries, as according to the examination subsequently made by Prof. Wm. H. Welch, they were found normal. The patient died of septicaemia three days and twenty-two hours after the operation.” Prof. Allen McLane, in his article above quoted 28 further says: “I do not think this operation permissable in any case of insanity.” This is certainly true when said of healthy organs. No such operation should, under any circumstances, take place in case of insanity, unless the person has evident disease of the organs or tubes, and 27. Tr. Acad. Med., Ire., Dublin, 1887, p. 208. 28. N. Y. Med. Jour., June, 1887, p. 707-9 29. AT. Y. Med. Jor., Feb., 1893. 11 this disease is doing positive damage to the system. Under those circumstances, I do not see why a woman should not be relieved as much as possible of suffering, whether she be insane or not. Eminent surgeons and gynecologists tell us that many insane women, who have been ope- rated on in this way, have been cured of their insanity. “Of so called ovarian maniacs,” Prof.Wm. Goodell, of Philadel- phia, has reported “ five cases, with four cures by removal of the ovaries.” On this occasion, he said: “After the lapse of many years, my cases of oophorectomy for insanity, for hystero-epilepsy, for hystero- mania showed positive and permanent benefit, adding: 30 “Should I meet with a case of insanity limited to the catemenial periods, I should not hesitate to remove the ovaries.” He says further: 31 “What insane asylum does not hold incurable women, whose mental infirmities seem to depend upon the act of ovulation; or, at least, to be greatly exasperated by its re- currence. We have hitherto stood by with folded hands, dooming the sufferer to helpless invalidism, or to an untimely end. Fortunately, there is a remedy that promises much—one first proposed by Robert Beatty.” Prof. T. G. Thomas says: “In one of his cases, the insanity was confined to the period of ovulation and, after the removal of the uterine ap- pendages, the menstrual insanity was entirely relieved.” Dr. Stansbury Sutton says of one of his cases: “After the re- moval of the diseased appendages, the patient’s insanity soon disappeared, and she remained free from mental disease and nervousness.” Dr. Noggerath 32 gives a case of “the disappearance of insanity immediately after the removal of an ovar- ian cyst.” He emphasizes: “Immediately after the removal of the cyst, the patient had her reason restored.” Ed. Cotterell33 tells of a patient, 37 years of age, who had long suffered from melancholia, and was always much worse during the catamenial periods. Immedi- ately after the birth of her youngest and fifth child, she became quite insane, and more than once attempted to commit sui- cide. Menstruation very scanty, and attended with a good deal of pain. March, 1887, he removed the uterine appendages, and now nearly three years have passed, she has had no return of her old symp- toms. According to his statement, both ovaries and tubes were affected. He says, “I know by experience that genuine men- strual epilepsy cannot be cured by drugs, and therefore I should have no hesitation in recommending the removal of the ova- ries and tubes in any case in which medi- cation has had a fair trial, without pro- ducing any beneficial result.” In July, 1887, I was called at the re- quest of a physician in Bridgeport, Ct., to see a young woman in Ansonia, who had a long time been under treatment.34 She was 27 years old, lying helpless in bed, a mental and physical wreck; married seven years, had no children, and was as incapa- ble of being a wife as a mother. The uterus was found to be retroverted, drag- ged down by enlarged and diseased ovaries. She entered the Woman’s Hospital of Brooklyn, July 12, 1887, brought to it in her husband’s arms. She all the time had hallucinations, some of which could not be dispelled, often threatening to jump from the window, etc. The diseased ovary and enlarged tubes were extremely sensi- tive; and after some weeks’ treatment, it was advised that they be removed. Dr. A. M. Jacobus was present and assisted at the operation. The patient gradually re- gained her mental and physical health, and when last heard from was well, and able to care for her household. A micro- scopical examination showed also that the patient had pyosalpinx, chronic oophoritis, and the ovaries contained gyromatouSr growths. E. D. Bondurant,*5 M. M., admitted to the Ala. Insane Hospital, Aug. 23, 1871;. 31 years of age, mother of four children, youngest child born Dec., 1870. Seven months after, she menstruated and im- mediately thereafter developed symptoms of mental derangement; the periods of comparative sanity were shorter. The evident close- relations existing between the functions of ovulation and the mental symptoms led to the opinion, held by Dr. Bryce, and concurred in by Dr. J. Marion 30. Boston Med. & S. Jour., June 19, 1879, p. 845. 31. Tr. of Med. Soc., of Penn., 1878-9, p. 598-600. 32. Trans. Obst. Soc., -A/n. Jour, of Ohst., June, 1889. 33. The Removal of the Uterine Appendages for the Cure of Ovarian Insanity.”—Lancet, London, 1891, 14, p. 365. 34 Case reported in The Pittsburgh Med, Jtev., Oct.. 1889. 35 Cases of oophorectomy for insanity. Am. Jour. Insanity, Utica, N. Y., 1885-6, XLII, p. 342. 12 Sims and Dr. Robert Beatty, to whom a statement of her case was submitted. The history further states: “After the removal of the ovaries, the patient began slowly to improve, mental symptoms gradually subsiding, and is able to attend to her household duties.” Lawson Tait36 gives notes on oophorectomy in ten cases for menstrual epilepsy and mania. In the five there was a complete arrest of the epilepsy and the mania was slowly dis- appearing. In the second, there was great relief. He gives also the case of a girl, seven years of age, who had suffered all her menstrual life with severe menstrual epilepsy. Lately this had as- sumed the additional character of acute mania at the periods. The patient was an inmate of the Binghampton Borough Asylum. She was with the consent of the commissioners placed under the care of Mr. Lawson Tait. Her ovaries were removed. The effect of the operation was an immediate and most marked im- provement in her physical health, an en- tire absence of the mania, and a diminu- tion of the fits from fifteen a month to three, with marked amelioration of the severity. Similar cases have lately been reported as occurring at the Insane Asylum, at Norristown, Pa. One patient, in whom the first attacks of mania followed the birth of her child, 29 years previously, probably some sepsis then introduced. The attacks were always jireceded by periods of severe pain in the right or left ovary. The ovaries and tubes were re- moved July 2, 1892, and in a little more than four weeks the patient went home, completely restored in body and mind. Another, where “the internal trouble dated from an abortion produced five years previously; the ovaries and tubes removed the same date as above, and on the 17th of September, 1892, the patient went home well, physically and mentally.” Other cases, equally interesting, are given, all showing that pelvic disease may in some, so disturb the nervous system as to cause insanity, and that removing the diseased organs will relieve the physical sufferings of the patients, and, in many instances, restore them to mental health. Is there any reason why they should not be helped ? I plead, in the interests of humanity, for these poor overburdened women.