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  Ovariotomy and Menstrual Madness - Lessons for Current Practice

On Boxing Day 1851 Charles Dickens attended the Patient's Christmas Dance at St Luke's Hospital for the Insane. On describing his visit in Household Words he commented that the experience of the asylum proved that insanity was more prevalent amongst women than men. Of the 18,759 inmates over the century, 11,162 had been women. He adds, "it is well known that female servants are more frequently affected by lunacy than any other class of persons". Dickens was a great observer and indeed the passage is one of the few references in Victorian literature that makes the link between gender and depression but there are none to my knowledge relating reproductive function to depression. Jane Eyre's 'red room' and Berta Mason's monthly madness, The mad Woman in the Attic may be coded examples of this from Charlotte Brontė's pen. Such information had to pass by the powerful censorship of publishers and lending libraries.

During the 19th century it was well recognised and sincerely believed that women were intellectually inferior to men and should not be educated. This view was so pervasive that many female writers like the Brontės and Marie Ann Evans had to write their great novels under the male psuedonyms of Acton Bell, Currer Bell and George Eliot. Even Lawson Tait, a gynaecologist of enormous intellectual and surgical ability supported this view, suggesting that, "young girls should not play music or read serious books because it makes much mischief with their menstrual cycle and the intellect". This view was compounded by Edward Clark (1873) of Harvard and Sir Henry Maudsley in his infamous article Sex in Mind and Education (1874) believing that, "with one week of the month more or less sick and unfit for hard work", she was intellectually handicapped, "when nature spends in one direction [ie. periods], she must economise in another". In general terms, "she does not easily regain the vital energy that was recklessly spent on learning. if a woman attempts to achieve the educational standards of men. she will lack the energy necessary for childbearing and rearing". This article had a profound effect upon attitudes to education in women and indeed Maudsley's ideas were instrumental in preventing women being admitted as medical students. He partly changed his mind later in his long life but the damage was done.

There was also widely held medical view that young women suffered from neurosthaenia, hysteria, menstrual madness and lunacy as a result of masturbation and nymphomania. Neurosthaenia was a commonplace problem where women went "off their feet", or "living a sofa existence", with Elizabeth Barrett Browning and Florence Nightingale in later life being notable examples of this disorder which would be the 19th century equivalent of chronic fatigue syndrome. Maudsley did recognise the association of physical and emotional symptoms with the women's cycles and with great prescience noted the association of behavioural changes with ovarian cycles, "the monthly activity of the ovaries which marks the advent of puberty in women has a notable effect upon the mind and body wherefore it may become an important cause of mental and physical derangement". Thus it was clear that the cyclical symptoms of insanity or menstrual madness were believed to be due to ovarian function rather than menstruation. Thus there was a treatment which took the form of removal of ovaries. In fact the early surgeons were surprised when removal of the ovaries led to amenorrhoea.

Ovariotomy for larger ovarian cysts was in the mid-19th century being performed by a number of skilled gynaecologists, following the pioneering operation in 1809 by Ephrain McDowell of Nashville, Kentucky who removed a large tumour before the days of anaesthesia from Jane Crawford who famously recited psalms while the surgery was taking place. Ovariotomy became the measure of a surgeon's ability at a time when all advances in abdominal surgery were performed in women with gynaecological disorders. These disorders were both real and imaginary. At least general anaesthesia by ether or chloroform was available from 1846.

It was not until 1872 that normal ovariotomy ie. removal of normal ovaries was performed for a disorder or malady which was not gynaecological. The first surgeon to perform this was Alfred Hegar of Freiberg to be followed seven days later by Lawson Tait of Birmingham and Robert Battey of Georgia, U.S.A. At the latter's insistence, it became known as Battey's Operation but in Britain, 'Tait's Operation' was used, particularly by his enemies.

Battey believed that insanity was, "not infrequently caused by uterine and ovarian disease". He describes how he had a southern girl, of more than unusual beauty, as a patient with cyclical vomiting and hysteria. He wanted to remove the ovaries but following discussion at the Southern Medical Society he was unable to find a precedent. He did not perform the surgery and the patient died with him resolving to be less cautious when this clinical problem next came to him. The opportunity came with the 23 year old Julia Omberg who had menstrual epilepsy with bouts of rectal bleeding. He operated and in his much-publicised report claimed that he didn't leave her room for 10 days until she recovered. Although Battey claimed only to performed the operation 15 times from 1872 to 1888, it did become very popular throughout much of Europe and the United States with patients having normal ovaries removed for menstrual madness, oophoromania, hysterical vomiting, epilepsy, dysmenorrhoea and of course those great Victorian disorders of nymphomania and masturbation. Leeches had been applied to the lower abdomen, vulva and anus for these symptoms for decades but from 1880 this treatment had given way to castration in order to prevent insanity and moral decline.

The results were apparently so successful that it was soon performed for "all cases of lunacy" and young surgeons would be given an annexe of a psychiatric hospital where they would remove ovaries from the inmates. Of course there was controversy concerning Battey's Operation. It was regarded as, "one of the unequalled triumphs of surgery" and those denying such treatment were, "wanting in humanity," and "guilty of criminal neglect of patients". This view was supported by the most illustrious surgeons of the time such as Sims, Lawson Tait and Spencer Wells. Those opposing the spaying and desexing of "this pernicious and dreadful operation", performed by, "gynaecological perverts", have been largely forgotten by history.

There is even an example of a sham operation by James Israel of Paris (1880) who cured a patient by making an incision and merely sewing it up, reporting it widely in the literature. Unfortunately Hegar claimed that he saw the same patient a year later, and cured the patient of her incessant vomiting by removing the ovaries. He protested that well-meaning criticism had put German gynaecology 20 years behind the progress made in Britain and that never again "must we German doctors allow somebody to be taken from our hands and be exploited by foreigners"­8. This does underline the perceived importance of this new technique both in the level of surgical advances and treatment of psychiatric/gynaecological conditions. There was great national pride involved in the developments, equivalent to the current pursuits of research into stem cells or diagnostic ultrasound. It was literally the cutting edge of medical progress.

XXXXX viewed the operation as "one of the prerogatives of the executioner" and observed that the bowels rushed out reminding him of the death of Judas Iscariot. It has been estimated from questionable data that 105,000 women had this unnecessary operation performed at a time when mortality would range between 10 and 25%. No doubt it would have continued but for a blistering JAAMA editorial which criticised the operation as being inhumane and not justifiable under any circumstance, and created a reappraisal.

Longo (1979) in his review of the 'Rise and Fall of Battey's Operation: a Fashion in Surgery' clearly concluded that the enthusiasm for the operation was a mistake but it did produce certain benefits such as an improved understanding of pelvic pathology and reproductive physiology. It also improved surgical techniques. History does repeat itself and each generation of surgeons, in this case gynaecologists, have had a fashionable operation which taught the trainee surgeon how to open and close abdomens although in retrospect it can be seen that the operations were either useless or superseded by a better method. This would include ventrosuspension of the uterus for all forms of infertility, tubal surgery, pre-laparoscopic sterilisation and even the current high incidence of caesarean section. Battey's Operation was merely first in this line of teaching opportunities.

The most important question posed by Longo was whether the operation worked. If we regard menstrual madness as severe pre-menstrual syndrome (PMDD) and ovarian ablation by GnRH analogues as a medical castration equivalent to oophorectomy then there is ample evidence that removing the ovarian cycle in this way will improve all of the symptom groups of severe PMS. The 19th century surgeons had no concept of menopausal symptoms or osteoporosis so ultimately this operation would be followed by severe medical problems but it would have had the desired affect of curing cyclical monthly symptoms if the surgeon had been selective in his patients. Unfortunately misplaced over-enthusiasm for the surgery removed any sense of good clinical judgement and great harm was done.

Leather et al. used a GnRH analogue (Zoladex) to ablate ovarian cycles and PMS symptoms. It was effective and the inevitable menopausal symptoms and demineralisation of bone was prevented by 'add-back', oestradiol and progestogen. PMS symptoms recurred with the progestogen component of the 'add-back', an observation first made by Magos in hysterectomised patients receiving cyclical progestogen. This study was a model of the aetiology of PMS and explains the efficacy of the 19th century ovariotomy and the 20th century hormonal suppression of ovulation. It is this progesterone/progestogen intolerance which is the essential cause of these pre-menstrual symptoms.

Current therapy for severe PMS is varied, being psychiatric, cognitive or hormonal. But the cornerstone of hormonal treatment relies upon suppression of ovulation and removal of the hormonal changes, whatever they are, that follow ovulation in the luteal phase. For example when are there no cyclical hormonal changes such as during pregnancy not only are there no cyclical mood symptoms but depression is uncommon to be followed by a greater instance of depression post-partum when there is a fall of levels of placental/ovarian hormones, with the recurrence of cyclical PMS when the periods return. There are now adequate placebo controlled studies showing that suppression of ovulation results in an improvement in severe pre-menstrual syndrome (or PMDD or menstrual madness). Magos first used oestradiol implants in a dose known to suppress ovarian activity and found that every PMS symptom cluster was improved when compared with placebo. Oestradiol implants are not appropriate for young women wishing to become pregnant, so moderately high dose oestradiol (200mg) was given by percutaneous patch and studied in a crossover trial which again showed the benefit of suppression of ovulation compared with placebo.

It is necessary to prevent endometrial hyperplasia with progestogen usually in the form of cyclical oral therapy for 7-14 days each month. But as PMS patients are progestogen intolerant the troubles and symptoms may recur. This is often solved by insertion of local intrauterine progestogen in the form of a Marina IUS which protects the endometrium and avoids the need for oral progestogens. In spite of this there are still patients whose cycles are not totally suppressed with high dose oestrogens and who still have their own endogenous cycles or iatrogenic progestogenic cycles. These patients can usually be cured by the ultimate Battey's Operation, namely hysterectomy and bilateral salpingo-oopherectomy.

Cronje et al. published the results of 49 such women collected over 10 years from 2 busy PMS clinics, with all but one being symptom free and enthusiastic about the treatment. Such surgery is rarely required but effective however it is significant that some disapproving correspondence following this publication referred to the 19th century scandal of Battey's Operation.

References

. Panay N. Studd JWW. The psychotherapeutic effects of estrogens. Gynecol Endocrinol 1998; 5:353-65

. Studd JWW. Prophylactic oophorectomy at hysterectomy. BR Obstet Gynaecol 1989;96:506-9

. Leather AT, Studd JWW, Watson NR, Holland EFN. The treatment of severe premenstrual syndrome with goeslin with and without 'add-back'
estrogen therapy: a placebo-controlled study. Gynecol Endocrinol 1999;13:48-55

. Leather AT, Studd JWW, Watson NR, Holland EFN. The prevention of bone loss in young women treated with GNRH analogues with 'add-back'
estrogen therapy. Obstet Gynecol 1993;81:104-7

. Cronje WH, Vashisht A, Studd JWW 2004 Hysterectomy and bilateral oophorectomy for severe premenstrual syndrome.
Hum Reprod. 2004 Sep;19(9):2152-5. Epub 2004 Jun 30.
PMID: 15229203

. Israel J. 1880 Ein Beitrag zur Wurdigung des Werthes der Castration bei hysterischen Frauen.
Berliner klinische Wochenschrift, 48 241-246

. Hegar A. 1880 Zur Israel'schen Scheincastration
Berliner klinische Wochenschrift, 48 680-684


Article - PMS for Menopause International

. www.studd.co.uk


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