American Journal of Insanity, January 1880
1G1 REVIEWS AND BIBLIOGRAPHICAL NOTICES. :Author: John P. Gray, M.D., Utica, N. Y. State Lunatic Asylum. John Wiley & Son, Astor Place, New York.
This Journal continues to maintain its very high reputation. The first article is an ? interesting one on the responsibility of Asylum Superintendents in America, in which some knotty legal points having reference to the laws of the United States are dis- cussed. The second article relates to English laws on lunacy, which more immediately concerns us. Upon review of the whole evidence before the Dillwyn Committee, the writer concludes that the only possibility of unfair dealing lies between the party placing a person in confinement, and the medical superintendent of the institution, and he thinks absolute impossibility of fraud or collusion might be secured by the interposition of a magis- trate’s authority between the party sending the patient, and the authority to whose custody he is committed. He, however, candidly quotes the evidence of Mr. Percival before the Com- mittee as follows. It is opposed to the American system and appears to us conclusive :?
” My own idea is that if you substitute any magistrate or official person as the party to sign the order, it will be most mischievous to the liberty of the subject, and very prejudicial to the alleged lunatic, for this reason; there is, I think, no greater safeguard for the due performance of a duty than indi- vidual, personal responsibility. Such responsibility, if it is not duly exercised, a jury will visit with damages, and in cases of false imprisonment juries give very heavy damages. At the present time the responsibility is such that very many decline to take it upon themselves for the benefit of the lunatic, even when his benefit loudly demands it. I think that this safeguard is very well supplemented by certificates and reports, and by visits by the commissioners and others. If you allow a magistrate either to sign the order or to countersign the order, you will at once destroy all the responsibility of the relative or other person. If a person is falsely imprisoned under a magistrate’s order there can be no remedy. If a magistrate has acted bona fide he will be relieved from all responsibility; he cannot be visited with a verdict for damages, and there will be no remedy for the lunatic. Besides, the magistrate will become simply a minis- terial officer in the matter, and will be guided, if not absolutely, to a very great extent, by the certificate, so that really it will come to this, that the only safeguard will be the certificates. The great safeguard now is the responsibility of the individual who signs the order.”
The report of the case of sarcoma of the dura mater, by Dr Edward N. Brush, is interesting from the fact of the patient retaining his intelligence until coma set in not long before death, although, in addition to the tumour, which weighed Im- pounds, there was an abscess the size of a pigeon’s egg in the left posterior central convolutions.
The Journal of Nervous and Mental Disease.?Edited by Drs. Jewell, Bannisteh, Hammond, Clymer, and Mitchell. January 1880. Chicago.
This number opens with an able article by Dr Jewell, on Neurasthenia, under which term he includes all the various forms of defective nervous power, whether inherited or acquired. He premises his remarks by stating that the causes of disease in general are not only complicated but often subtle and un- known. With regard to cases of neurasthenia, he groups them according to their apparent mode of production, as follows :? ” 1. Hereditary or diathetic neurasthenia. This is a class of cases often met with, and to which reference will be made here- after at greater length. 2. Dyspeptic neurasthenia. 3. .4m- milative or trojphic neurasthenia. 4. Genito-urinary neuras- thenia. 5. Neurasthenia from over-work and from over- excitation. 6. Diseases in which neurasthenia forms a prominent factor. Besides these clinical groups, others should be made, such as partial and general neurasthenias, mental and bodily neurasthenias, and various subordinate groups named according to the parts of the body or groups of organs affected.”
With respect to the first class, he makes the following practical remarks:?” Persons are daily coming into life, to pass their days until death, from beginning to end, below the plane of an average nerve-nutrition. They seldom present us with localised, destructive disease, but from first to last lack an average volume of nerve power and endurance, whether mental or physical, and joined with this condition of things, there is undue sensibility. In these cases the energy of nutrition is low. Recuperative power is far below what is ordinarily met with. Such persons are frail and puny from the cradle to the grave. They ane at all times easily exhausted. They are with difficulty rested. They are usually thin in flesh, but they are not always so. They are often quite fleshy, and in a few cases may have a ruddy exterior. But they are neurasthenic all the same. If females, they are prone to hysteria, to headaches, irregularities in the action of the circulatory organs, especially to disordered cardiac action, to neuralgias, to be unduly excitable, and to be easily exhausted, or they may be easily kept awake, and thus lose sleep, from comparatively slight dis- turbances.”
With reference to the dyspeptic form of the disease (diges- tive neurasthenia), he says there are two chief ways in which it becomes of practical importance :?
” First, by diminishing the quantity and deteriorating the quality of the supply of materials to the blood. In such cases there may be, as already said, no over-action or over-excitation, or lack of rest, or any hereditary tendency to neurasthenia, or excessive or unnatural discharge to waste the materials of the blood for the nutrition of the higher tissues, though any or even all these conditions may be present with the dyspepsia in any given case. Under such circumstances, the tissues become worn and feeble in action, and once in this unhappy condition, a repair of damage is almost impossible without a cure of the dyspepsia Secondly, dyspeptic disorders of the stomach may be related to neurasthenia, or certain of its phenomena, in an indirect or reflex way. The stomach, small intestine, liver, &c., have very important nervous relations, not only with the ganglionic system, but also with the spinal cord and medulla.” The third form of neurasthenia, the assimilative, is one which Dr Jewell thinks has never been clearly recognised. He considers it to be owing to ” a defect of the process of assimila- tion itself, a sort of paresis” of ” the intimate process of nutrition, as it is accomplished between the tissues and the blood.”
The fourth form is the genito-urinary neurasthenia, which comprises those cases of exhaustion from sexual excesses, with which every medical man is familiar.
Dr Jewell reserves the forms spoken of under the fifth head for discussion on a future occasion.
Lastly, he makes the following remarks with reference to the forms of disease in which neurasthenia is a prominent element:?
” There are many cases of neurasthenia presenting a com- bination of all the forms already described. Such may be called complex. But it is rather to forms of nervous disease more or less distinct, in which neurasthenia is a factor, to which I would, at present, call your attention. First among such nervous affections is hysteria. A careful analysis of the multiform phenomena of hysteria reveals consistently, two features?undue excitability, or mobility, and loss of nerve power. No case of typical hysteria can be found, in which these two elements are not present. But to particularise: the morbid increase of the sensibility of the nervous system is especially observable in respect to simple reflex and emotional excitability… . Keflex responses of the nervous system, whether from a peripheral or a cerebral source, occur in hysteria more easily than in health. As respects the emotions in hysteria, they are altogether more easily excitable than in health, and the cerebral reflexes or impulsive actions to which emotional excitations tend to give rise, occur more easily than in the normal state. … In the next place I would direct your attention to melancholia, which, so far as its symptoms go, embraces morbidly distressing and at times exciting emotion, and side by side with this, loss of will power and of thought power. Such cases may, of course, include, as they often do, localised disease in the nervous system, more especially the brain, but, in the majority of instances, such is not the fact. There is brain exhaustion, and it may be morbid excitation from some source. There may be hereditary weakness of nervous organisation, deficient nutritive supply, in- sufficient sleep, and too much work and worry. In all these ways, singly or combined, that state of brain exhaustion may occur, coupled with an unhealthy cerebral circulation, which together are the essential conditions of most melancholias. In such cases the cure is usually effected, sooner or later, by much sleep, the best nourishment possible, and the removal as far as possible of causes of nervous exhaustion.”
The whole of Dr Jewell’s article will well repay attention. Seventh Annual Report of the Northern Hospital for the Insane of the State of Wisconsin. Madison, Wisconsin : The psychological observations of Dr Walter Kempster, the Medical Superintendent, deserve especial attention, as they form a striking contrast to the ordinary routine of asylum reports. The following remarks on the return of persons to asylums with second attacks of insanity are well worthy of con- sideration : ?
” This disease does not differ from- others in liability to recurrence?especially where predisposition or environment foster the germs of disorder. For instance, certain people are liable to repeated attacks of lung disorder, others to bowel or kidney trouble, others to rheumatism and its allied complaints, each attack recurring after some breach in hygienic conditions by which the general tone is impaired and health interfered with. This is a matter of common observation, and is recog- nised by all; it simply indicates that lungs or stomach or kid- neys, or the muscular or arterial system, are the weak points in family or individual organisation, giving way when more than ordinary strain is put upon them, and so the individual may have one, two, three?a dozen attacks of either form of disease and recover, providing no serious lesion results in the organ specially affected. Brain disease follows precisely the same general laws as do other forms, recurring when the conditions reCur which gave origin to the first attack, and subsiding when health is restored, providing, as before, that no serious organic change has taken place within the brain which precludes it from properly performing its functions. In the one instance a chronic change in liver, heart, stomach, and so on, precludes the affected organ from acting properly; so in the other a chronic change in brain tissue prevents that organ from properly per- forming its function?the ultimate condition in each case being that in repeated attacks the affected organ succumbs. In the one instance the nature of the complaint does not often prevent the family or friends from properly caring for the sufferer; in the other, the manifestation of disease is of such a character as to preclude, in many instances, proper care at home, and society is called upon to care for them ; it may be in one or a half-dozen attacks.
” There is one important item, however, to be taken into consideration. I believe that in many cases second attacks of insanity occur because the individual is removed from treatment and required to pick up the tangled ends dropped from the mental grasp on the approach of disease and again attempt to weave them into the daily fabric of his life, before the brain has had time to recover from its first shock of disease, and is in a proper state to perform labour. In this respect, it differs from the other organs, which have a specific amount of work to do. But the brain is often in the hands of a hard task-master, who lashes it onward to its own overthrow, when it should be nursed and protected from violence without or within. It is therefore important that everyone should know that, in a great measure, he carries in his own hands that which shall contribute to his weal or woe according as he uses or abuses it.”
He speaks encouragingly as to the cure of chronic cases of insanity, and states that nineteen of the cases discharged as re- covered from his hospital had been insane upwards of one year. His remarks on the causes of insanity are those of a man who has thought earnestly on the subject:?
” In attempting to arrive at a satisfactory conclusion as to the causation of insanity, we are at the outset met by a com- plex question not easily solved. To explain this, let each endeavour for a time to resolve into component parts the ideas which lead one presumably sane to do certain acts or perform certain offices, or in other words, to analyse one’s own mental operations, giving the steps, one by one, by which conclusions are reached, and the reasons for such conclusions. The task will be no easy one, and there are but few who undertake the experiment. Now if this matter of analysis is so difficult for an individual to do for himself, how much more difficult is it for one to analyse the conditions existing in the mind of another, especially when the operation of that mind is affected by disease. To resolve the tangled web of causation and determine what item is harmful and what item harmless to mental health is a task that only infinitude can comprehend. It is impossible under the most favourable states to separate into elementary parts all the minute circumstances leading up to a final change from a sane to an insane state; it is, indeed, often difficult to draw the line between these two conditions, and to say where one ends and the other begins, so subtle are the beginnings. It is not often that one grand catastrophe overtops mental health ; it is the constant recurrence of unfavourable acts or thoughts, the steady disregard of healthful conditions, the accumulation of adverse surroundings which, from selection or misfortune, heap themselves upon the individual; the oft-repeated disregard of the common laws of hygiene, ignoring temperance in all things, deviating from established principles either in thought or morals ; in fact, any or all things which tend to lower vitality and produce disease, operate as a cause. Now, it is impossible to separate out from all the rest one factor which would be more likely to produce disease than its congeners, and if we could do so it would not affect the result. Each individual organism has its own peculiarities, its own weaknesses, and what might seriously retard healthy growth in the brain tissue of one person might not so seriously affect the same tissue in another.”
On the question of hereditary transmission, Dr Kempster refers to the interdependence of diseased states, and gives instances of the mutual convertibility of different forms of hereditary disease which substantiate Dr Winn’s theory of the correlation of force in hereditary disease. Dr Kempster was apparently not aware that in 1869 Dr Winn published a treatise on the ” Nature and Treatment of Hereditary Disease.” * He also wrote an article in the Journal of Psychological Medicine for October 1875, vol. i. (new series), part II., in which he gave additional arguments in support of his theory.
Published by David Bogue, 3 St. Martin’s Place, London.
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