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
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
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
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
. 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
estrogen therapy: a placebo-controlled study. Gynecol Endocrinol
. Leather AT, Studd JWW, Watson NR, Holland EFN. The prevention
of bone loss in young women treated with GNRH analogues
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.
. 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
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