A Treatise on Diseases of the Nervous System
282 REVIEWS AND BIBLIOGRAPHICAL NOTICES.
Illustrated with Lithographs, Photographs, and two hundred and eighty Woodcuts, 2 vols. By James Ross, M.D., M.R.C.P. Lond.; Assistant Physician, Manchester Royal Infirmary; Consulting Physician, Manchester Southern Hospital. Churchill, London, 1881.
Tiie progress of investigation, clinical and experimental, tends to make works on diseases of the nervous system become speedily out of date. Even standard treatises are obsolete in a few years. It is not that the older books were inaccurate in their descriptions of disease, or were wrong in their treatment of it. On the contrary, it is easy to find, in old medical literature, portraitures of disease as vivid, as striking, and as accurate as any that can be found in the pages of our best modern writers. The old authors fall into desuetude, not because their statements are inaccurate, but because, since their day, many additional facts have been observed, interpreted, and embodied with .our previous stock of knowledge. A ripening experience has not merely added new facts, but has discerned the relations that bind them together. And so it happens that nervous diseases are now perhaps as well understood as any other disease whatsoever. The changes in structure that underlie altered function have now to a very large extent been made out; and it is now possible in most cases to say, with a close approach to certainty, what is the precise seat and nature of the disease.
The work before us is a noteworthy one, and is sure to become the standard treatise on diseases of the nervous system. It possesses all the marks of the highest merit in standard works. It is comprehensive; it is accurate; it is thoughtful. The style is plain, simple, and clear?such as befits both a scientific subject and an earnest worker. The illustrations are copious; many of them are original; most of them will be new to English readers, while they are all characterised by the ease with which they are understood and by the appropriateness with which they throw light on matters that otherwise would be difficult of comprehension.
Regarding the plan of the work a few7 words may be said. The first portion, occupying about two hundred and eighty pages, treats of the general pathology of the nervous system, and includes an outline of the structure and functions of the nervous system generally. Chapters on etiology, symptomatology, the elementary affections of the Sensory, of the Motor, and of the Nutritive apparatus follow; and the general diagnosis, prognosis, and treatment of nervous diseases are discussed with considerable fulness. The remainder of the work is occupied with the Special Pathology of the Nervous System.
The divisions under which the Special Pathology is dealt with are five: diseases of the peripheral nerves, of the sympathetic system, of the spinal cord and medulla oblongata, of the encephalon, and lastly ot the encephalo-spinal system. A minute and admirable account of the anatomy and physiology of each portion of the nervous system precedes the descriptions of the diseases to which it is subject When thus examined in the light of physiology, the diseases become much more intelligible; and we do not know any systematic work in which anatomy and physiology have been kept so steadily in view throughout, and in which the application of physiology to medicine has been so fruitful of good results.
This work embodies the outcome of continental, as well as of home, neuropathic research. Not merely is it a credit to the provincial school where so much work of merit has been accomplished ; it is an ornament to English medical literature. Diseases of the Nervous System, especially in Women. By S. Weir Mitchell, M.D. London, Churchill, 1881. This book consists of a pleasant series of lectures by a distinguished American physician. The subjects dealt with are mostly unusual or puzzling varieties of nervous diseases in women, and the mode of treating them.
Formerly no cases were more unsatisfactory as regards treatment than some chronic hvsterial ailments. The patients were confirmed invalids, the despair of physician after physician, who in turn had charge of them. In most cases the patients are weak, pallid, and flabby. The successful treatment of these cases is accomplished by seclusion, rest, massage, electricity, and full feeding. In a comparatively small number of cases the patients are stout; but not well coloured; though fat they do not look healthy. These cases require a little modification in the foregoing treatment. They must first for a while be underfed, and then built up afresh by over feeding. The absolute rest enables the underfeeding to be carried out with safety, while the massage and electricity take the place of exercise. By these means Dr Mitchell, and many other physicians, have had unprecedented success in the treatment of these trying and distressing maladies.
The book is a good and useful one and will repay perusal. Rheumatism: Its Nature, its Pathology, and its Successful Treatment. By T. J. Maclagan, M.D. London : Pickering & Co. 1881. This work, by Dr Maclagan, who was the first to introduce salicylic acid as a remedy for acute rheumatism, is full of suggestive remarks and valuable practical hints. His theory is that acute rheumatism is the effect of miasma, and he quotes Haygarth who “thought that there were several analogies between an ague and a rheumatic fever.” For the facts on which he bases his theory we must refer our readers to Dr Maclagan’s work. They are too numerous for insertion here, as our space is too limited for their enumeration. We are at issue with the author as regards the comparative value of salicylic acid and quinine?he gives his preference to the former drug ; we think the latter is by far the most efficacious remedy, given with bicarbonate of potash, and held in solution by means of a solution of gum arabic.
American Journal of Insanity. July, 1881. Edited by Dr J. P. Gray, of Utica, N.Y. State Lunatic Asylum, New York. This journal never disappoints us. The following remarks by Dr Jacob Weiss ot’ Vienna on Melancholia deserve especial notice:
” It has become the custom to regard, as a stage of melancholia, conditions of stupor beginning with general depression, under the name of melancholia cum stupore, in contradistinction to melancholia activa or agitata. We have elsewhere insisted that stupor is not to be confounded with the clinical phenomena of melancholia, that the condition of stupor stands in no closer connection with melancholia than with any other form of psychical disturbance ; and if the systematic grouping of different symptoms is to have any significance at all, we must not lose sight of definite characters as belonging to a definite complexus of symptoms. This is not the case, however, if we regard as characteristic the anxious and gloomy frame of mind, with all its concomitant expressions of self-reproach and tendency to suicide, while at the same time we consider the state of total psychical and motor arrest, without spontaneity whatsoever on the part of the patient, likewise a melancholic condition. Depression and fretful self-disparagement, the cardinal symptoms of melancholia, have just as little to do with stupor as with typical mania. It is an error to suppose that there is behind stupor a condition of depression and anxiety. Convalescents from stupor remove all doubt in regard to this point, since they aver that they thought of nothing and were incapable of thinking, intimating that all cerebral activity is impossible. ” This is not the case with melancholies. Psychical processes take place, if in dreary monotony of distressing ideas. The melancholic is never so apathetic and void of all spontaneity, never so listless and indifferent as the patient in a state of stupor. Apart from the intercurrent stages of extreme excitement which frequently supervene under the influence of great anxiety, the melancholic always evinces a certain degree of activity, a necessity to give vent to his woes and self-depreciation, which is entirely excluded by stupor. We may refer, in this connection, to the frequent cases of senile melancholia, which are diagnostically obscured by stupor only in extremely rare instances, indeed almost never.”
The whole of the article, as well as all the other papers, are well worthy of perusal.
The Medical Record, a weekly journal of Medicine and Surgery. New York. July 30, 1881.
We regret to find the following statement, made by the editor, in a notice of Mr. Cyples’s work, ” An Inquiry into the Process of Human Experience ” :? ” It is undoubtedly the tendency of scientific studies to incline the mind toward materialism.” We beg to protest most decidedly against this assertion. A smattering of science no doubt ” puffeth up,” and makes ” the fool ” say ” in his heart there is no God.” It is far otherwise with our deepest philosophic and scientific thinkers, e.g. Bacon, Newton, Bradley, Pascal, Barrow, Whewell, Sir Humphry Davy, Faraday, Brewster, &c. &c. These men ” looked from Nature up to Nature’s God.” We would remind the writer of Lord Bacon’s celebrated aphorism :?” A little philosophy inclineth men’s minds to Atheism, but depth in philosophy bringeth men’s minds to religion.”
The New York Medical Journal and, Obstetrical Review. Edited by Dr Frank P. Foster. August, 1881. New York : D. Appleton & Co.
In this number Dr H. H. Kane discusses the important question of Habits. He is the author of Drugs that enslave. The Opium, Morphine, and Chloral Habits. He contends that there is such a thing as chloral habit, although it has been denied. He instances two cases of chloral-taking which had given rise to habits, after there was no furthei occasion for the use of the drug. The most interesting part of his paper is that in which he discusses the meaning of the word habit. He says:
” It is a term that is, at best, indefinite, and one that has been used by different writers very loosely. There seems to be no single word in any language that expresses precisely the hold upon the system acquired by certain drugs, when taken for a longer or shorter period. Levenstein finds the term ‘morbid craving for morphia’ best suited to his understanding of the peculiarities of these cases. Like the word ‘ habit,’ however, it does not express the matter either fully or clearly. ” Of those people who are addicted to the continual use of morphia and chloral there are two classes, the division resting upon the manner in which the drug was first used. In the one class there is a morbid appetite that may be fed upon excitement, alcohol, absinthe, quinine, hashish, bromide of potassium, chloral, or opium. It may have for its subject anything, and will be classed according to that upon which the appetite becomes most fully fixed. Given a person with such morbid propensities, and let him, either of his own free will or through the agency of another person, begin to use any drug of this class, and he will fix upon that drug in nine cases out of ten and become an habitual user of it. Once habituated to its use, the entire nervous system rebels at its withdrawal, and the victim to his own morbid appetite continues to use the stimulant or sedative, as the case may be, not because the satisfaction first experienced continues, but because any attempt to do without the agent produces such distressing symptoms that the weakwilled patient is compelled to resort to that which he at one and the same time loves and hates. Opium and morphine, but more especially the latter when used subcutaneously, seem to stand first in the list of those substances that have the power to enslave persons of this class.
” In the other class there is no morbid craving for any form of stimulant or narcotic, but the long-continued use of the drug, usually for the relief of pain, produces a systemic state analogous REVIEWS AND BIBLIOGRAPHICAL NOTICES. 287 to that existing in the first class before the drug was taken. In the one the drug ministers to a morbid craving already existing; in the other it establishes a necessity for continuing its use. The objection to the term ‘ craving’ in this connection is that it implies a longing for something that is expected to give pleasure, whereas to the majority of habitues pleasure becomes a meaningless word after a short time, and ‘ inability to do without’ takes its place. It is really an hereditary or acquired involuntary tendency, that through accident or design becomes fixed upon a certain stimulant or narcotic that develops, increases, and perpetuates the tendency.
” As an example of the second class of cases, we may take those persons who, having absolutely no desire or longing for tobacco, commence its use simply because it is the custom, despite the fact that it sickens them at first. Having continued its use for some time, they find that they have fastened upon themselves a habit that requires no little will power to shake off. Tobacco is the type of those substances that possess less fastening power than morphine. To this class belong alcohol, chloral, hemp, the bromides, quinine, &c. In the case of each, we find persons who can and do use it for a certain length of time without the establishment of that systemic state that calls for a repetition of the dose as soon as the effect of the preceding dose has worn off. The knowledge of this fact, however, does not prove to us that certain persons, owing to some peculiarity wholly unknown to us, will not under the same circumstances become abject slaves to the necessity for continued use.” There are also some valuable Psychological Notes in the same number which will interest all engaged in the treatment of insanity.
Thirty-Eighth Annual Report of the TJtica State Lunatic Asylum.
The report of the managers of the State Lunatic Asylum of Utioa, for the year ending September 30, 1880, is an interesting one in many respects. During the twelve months, 1,088 patients were under treatment, 468 having entered within the year, 620 being the number in the institution at its commencement. Of these, 565 were men, and 523 women ; while the discharges amounted to 271 males, and 203 females. These latter are apportioned as follows: recovered, 155, viz. men, 74, women, 81; improved, 66: men, 40, women, 26; unimproved, 197: men, 117, women, 80 ; not insane, .14 : men, 13, women 1; died, 42 : men, 27, women, 15. Deaths took place in the case of seven patients within eleven days after admission, acute or chronic disease being at the date of their entry well determined. To these must be added two cases of suicide, omitting which and thirteen deaths from paresis, the number of instances of what may be termed preventible mortality is reduced to five?a small percentage on the total number of inmates. These five patients died: three from meningitis, one from cerebral congestion, and one from acute pleurisy. No case of zymotic disease occurred during the year; and the general health throughout the asylum is described as excellent. Certainly the results speak well for the hygienic and sanitary arrangements, in carrying out which considerable expense is shown to have been incurred, from the balance-sheets included in the repoit. It may be that the advice tendered by the superintendent, and followed in part in the Utica asylum, is calculated to bring patients under the most favourable circumstances for treatment in case of illness. It certainly deserves to be noticed. He suggests the construction of a small wing in connection with the wards, for the especial care of the sick ; and the experience obtained on trial of the plan on the women’s side of the house has been of the most favourable kind. It is calculated that such a hospital wing, with necessary bath and service rooms, heating apparatus, &c. costs about ?2,500. It offers very fair prospects of being attended with advantages.
The important subject of staff discipline affords material for some apposite observations in this report, and it appears from it that stringent regulations are enforced in the asylum to ensure the most favourable treatment of patients by those entrusted with their care. ” Nothing,” it is urged, ” short of the highest discipline can secure that degree of oversight and care so essential to the comfort of the patient and his restoration to health”; and we may add that the pages before us amply testify to the zeal and efficiency, with the duty of superintendence, in this particular has been carried out. The truth contained in the following statements might, we fear, be better appreciated in more than one public institution in this country, to the advantage of patients, and the success of the asylum. ” In their daily intercourse with patients, the attendants are required to be governed by the same laws of politeness that are recognised and obeyed in ordinary life. Indeed, they must extend to those under their care far more than the ordinary consideration and kindness of humane society.” With experiences of the uncouth, careless demeanour of state asylum attendants in this country before one, there is some difficulty in understanding that this is written of officials in public asylums for the insane in America. That it simply defines what is, after all, no more than ought to obtain, does not lessen the force of the comparison ; it can only excite an earnest wish that such enlightened rulings may quickly become commonly recognised in place of the harsh, unfeeling principles that seemingly guide the conduct of keepers in British statesupported institutions. The question of restraint, important in itself, doubly so in its issues, is discussed at some length. The managers of the Utica Asylum ” have not failed to observe in some quarters a disposition to create agitation upon questions which might be supposed to have long ago settled themselves in the light of experience, if experience is to be allowed to settle any issue that is acknowledged to rest upon a practical question of fact.
There must be some subjects, however,” they continue, ” upon which experience proves the safest test of practicability ; and such a subject, we believe, is the care and treatment of the insane, and the conduct and management of our lunatic asylums. The managers would refer .especially to the discussions that have arisen among professional men in the care of asylums in regard to the desirability of abolishing and dispensing with all forms of mechanical restraint in the treatment of the insane, and the question whether various proposed substitutes for these things are really in the line of advance, or rather form a retrograde movement in dealing with this fearful malady. This discussion, carried on almost with acrimony by some theorists, is reflected outside of the circle of professional experience, even in the ordinary newspaper press, creating prejudice, not to say alarm, in the popular mind, and is more or less concerned in the legislative inquiries into the internal management of the public institutions that have been prompted from time to time. Feeling, therefore, the importance of the subject, the managers have requested the superintendent of this asylum to include in his annual report to them a full presentation of the present status of professional opinion and practice on this question, whatever it be, fortified by such facts of experience as may throw light upon it and furnish its justification.”
This report of the superintendent, Dr John M. Gray, is printed in full, and constitutes an admirable and exhaustive analysis of the opinions held in respect to restraint by a large number of eminent authorities. It forms most instructive reading and reflects infinite credit on the author of the paper, who is thus enabled to put the whole question in judicial form before the eye ; and not least instructive is the final conclusion at which he arrives, and which is but a repetition, to the following effect, of that which, as he says, he uttered twenty years ago : ” We look upon restraint and seclusion, directed and controlled by a conscientious and intelligent medical man, as among the valuable alleviating and remedial agents in the care and cure of the insane. That they are agreeable in their application or use, either to the physician or patient, no one will maintain. Indeed, few, if any, medical prescriptions are agreeable. The bitter and nauseating draughts, the abstinence in diet, the seclusion of the patient to the sick room, and the exclusion therefrom of friends, are prescriptions for the cure of disease, as are the knife and appliances of surgery, and they are adopted and prescribed as such. The physician who would not administer the best remedy because it might offend the taste, or the surgeon who would not use the knife, or other means, because he might thereby cause pain ; or the obstetrician who would lay aside, under any such consideration, the remedies required in critical cases, would be unworthy of the profession, and the confidence of the public.” Occupation for the insane is considered at some length, and expressions are employed in accordance with the general English view that beneficial results are obtained from insistance on a due amount of labour, to be exacted from all capable of healthy employment. There is every indication indeed, that the affairs of the asylum are conducted with the strictest regard to the chief purpose for which it exists, viz., the cure, and improvement of the mentally unsound. The whole report is most satisfactory, and in many places is full of valuable suggestions. Sixty-fourth Annual Report of the Asylum for the Relief of Persons Deprived of the use of their Reason, Philadelphia. The Asylum for the Relief of Persons Deprived of the Use of their Keason is the somewhat extended title of a small institution at Philadelphia, managed by members of the Society of Friends. The sixty-fourth annual report of the Superintendent, Dr John C. Hall, briefly details the changes which have taken place among the inmates under his care during the twelve months covered by it. From it we gather that one hundred and thirty patients were treated in that time, of which number 40?17 men and 23 women?were new arrivals. Thirty-six discharges are chronicled ; of these 14 were restored, six much improved, three were improved, and 13 were stationary. This asylum might, we should imagine, justly claim to be the paradise of chronic cases, judging from the length of time many of the patients have been resident therein. One of the discharged is said to have been an inmate of the asylum ” about fortyseven years,” his removal to a state hospital having been necessitated in consequence of the cost of maintenance. The superintendent cheerfully explains that ” a large majority of those who are at present inmates of the house are chronic cases, in which the hope of recovery is but small,” and further on he adds, ” A number of these have been residents of the asylum more than thirty years, are now quite advanced in life, and will in all probability add to our mortuary list, as similar cases have in the past year.” This touching trustfulness in the certain extinction of the aged chronics, who form the major part of those for whom he is called upon to care, oddly precedes the statement that ” The general health of the patients has, however, been good, there having been no epidemic or endemic disease prevalent.”
The following passage from the report is worthy of note, and will probably be endorsed by all who are widely familiar with the prominent part played by alcohol in the causation of insanity:?” In considering the causes of insanity among those admitted last year, we find seven patients, four men and three women, whose disease was attributable directly to intemperance. I believe its influence in the production of insanity to be rather understated than otherwise. If those cases could be numbered in our statistical tables where the indirect effects of this vice can certainly be traced, the list would be augmented.” The occupation question seems to excite the American superintendents of asylums in a great degree; and even in the little institution maintained by the Philadelphian Quakers, a difficulty arises in respect to it during the colder part of the year. The long winter evenings are with difficulty got through without the aid lent by amusements, and in America these are largely enlisted as a means of expediting the passage of time. In the summer less trouble is met with in this respect, and the Philadelphia asylum is well situated in wooded country, and provided with ample gardens and lawns.
This report includes no special details of scientific interest, but is a plain, unpretending record of the year’s progress. Annual Report of the Kingston, Ontario, Asylum for 1880. During the year ending September 30, 1880, there were under treatment in the Kingston Asylum 491 persons, of whom 245 were male and 246 female patients. Of this number 32 died.
The number of admissions in the twelve months was 68, 31 being women. The discharges amounted to 24, 15 men, 9 women; in addition to these two males ” eloped.” The discharged patients are divided into probationers and permanent. Of the former there were 14, 5 of whom were sent away as “recovered ” and 1 as “improved.” Three others have been returned to the asylum, and 5 were at the time the report was issued still at large on trial. The superintendent explains that, owing to sundry circumstances, the institution under his care contains but few acute cases, the great majority of the residents being incurable, thus bringing the discharges to a very meagre total. He makes the suggestion that were district physicians to urge the immediate removal of patients to the asylum while their insanity is still in the acute stage, much greater benefits to them would be the result. Among the deaths was one of a man subject to severe epileptic attacks, who succumbed during a paroxysm of unusual length. On post-mortem examination the skull was discovered very much thickened and indurated, and in places bony projections into the cavity were found. Disease of the membranes existed also, but the brain attained average weight and development, and ” no disease could be detected with the naked eye.” It is perhaps too much to expect that every asylum shall contribute pathological records concerning the condition of those of its patients who die while under treatment, but there are an infinity of reasons why they should be obtained whenever possible. In many of the better managed institutions this is now attempted as far as possible, and we may by and bye be able to look upon those asylums whence such reports do not emanate, as the exception rather than the rule. The gross results of post-mortem examinations are valuable so far as they go, but they do not go nearly far enough to satisfy the curiosity reasonably felt by the medical psychologist to know what are the conditions set up by the diseases of insanity. Only as knowledge of the most perfect kind in this direction is accumulated, can we hope to make a real advance in the science of treatment.
The bulk of this report deals with matters that will have interest only for the subscribers to, and governors of, the institution in question; but the paragraphs relating to winter amusements provided for the inmates are noticeable as showing the extent to which this mode of providing for their wants is practised on the other side of the Atlantic. Indeed, in all American asylums much stress is laid on the necessity of affording frequent evening entertainments to the patients, and, as a rule, the work seems to be well and faithfully carried out. So far as any direct judgment on the advantages conferred by these attempts to divert the minds of the insane for a time from their pre-occupation, can be formed, it must, of course, be drawn from a study of the statistical returns provided in the reports furnished from time to time by professional superintendents, and comparison of them with similar statistics from other places where a like plan of providing amusements is not followed out. We do not propose to do this here any further than to say that any superiority of result is apparently on the side of those who systematically pursue the former course ; and with American institutions for the treatment of insanity generally, it is found that much good is obtained from frequent introduction of such an element of change as is instanced in these entertainments.
The following extract from the Kingston, Ontario, Asylum report under notice, inserted in the inspector’s account of his visit to the institution, will be of interest as showing the necessity for an arrangement which exists in all well-regulated establishments in this country: ” In previous minutes I have called attention to what appeared to me to be a rather serious defect in the asylum service, viz., the performance of ward duty by the mechanical staff of the asylum. It was quite evident that if the carpenter, tailor, gardener, and farmer performed the work required of them in a satisfactory and efficient way, they could not have time to look after patients other than those whose work they were required to direct and supervise. Such being the case, the Medical Superintendent was instructed to detach the employes named from the list of attendants and require of them only the performance of the work their respective designations indicated.” Annual Report for 1880 of the Inspector-General of the Insane, New South Wales.
The official report of Dr F. Norton Manning, InspectorGreneral of the Insane for New South Wales, is a document from which very much interesting and instructive information is to be obtained. It extends over forty-four closely-printed pages of foolscap, and deals with the condition and progress, during the year ending December 31, 1880, of a total of 2,099 patients, distributed through six permanent and one temporary hospitals, and one licensed house. The number of patients admitted for the first time into the hospitals for the insane during the year was 267 male and 145 female, a total of 412 ; and the readmissions numbered 28 males and 30 females, a total of 58. The admissions and readmissions together were 470, being in excess of those for any previous year. The number of patients received from other institutions for the insane?transferred under section 80 of the Lunacy Act?was 66. At the Licensed House, Cook’s River, 5 patients were admitted for the first time, 1 was readmitted, and 9 were received from other institutions. It thus appears that the total admissions to all the institutions was 417, the readmissions 59, and the transfers 75. The largest of these institutions, the Paramatta Free Hospital for the Insane, contained, during- the twelve months, an average number of 744, 562 males and 212 females; 124 patients were admitted, and 41 discharged recovered ; while 3 were absent on leave, and 53 died in the hospital. At the date of the report the number of inmates had risen to 839, and complaints are made of the insufficient accommodation afforded by the existing buildings for the large number it is found necessary to receive within them. The Medical Superintendent reports his regret ” that the new buildings intended for the comfort and reception of the female patients remained almost in the same condition as they were this time last year. No steps have been taken towards completing them, and this excellent block of buildings remains useless and uninhabitable, whilst the female patients are consigned to such accommodation as is a standing reproach to an institution dedicated to the care and alleviation of the most terrible forms of human suffering.” This unsatisfactory state of affairs may well arouse the expostulation of the officials, on whom, moreover, must fall some share of the blame attaching to improper arrangements, however much they may deprecate their existence. With the drawbacks thus apparent it says a good deal for the executive, that it is possible to record a percentage of 46 recoveries on admissions of free patients, while on all classes, the hospital receiving in addition a certain number of criminal lunatics, the percentage of recovered is 39’4 on first admissions. Amongst the deaths we find one at 89 years, this patient having been a resident in the Paramatta Hospital for a quarter of a century. A male, aged 72, died after being 32 years an inmate, and the youngest who succumbed was 26 years old, resident nine months. One patient, over 80, was discharged recovered after 21 days, and the average duration of residence was: of men, 8 years 9 months; women, 10 years 8 months. Two sudden deaths from apoplexy occurred, and the whole 49 who died are accounted for thus:? cerebral disease, 31; thoracic disease, 8, 6 being classed as pulmonary consumption ; general debility, and old age, 9 ; and dysentery and diarrhoea, 1. In spite of the insufficient state of the buildings referred to, the general health of the patients is described as good, and a freedom from epidemics prevailed. In a table showing the causes of insanity of those admitted during 1880 we find the three highest numbers (excluding the ” unknown,” 16) assigned to intemperance, 11; hereditary influence, 7 ; and ascertained congenital defects, 8. The question of amusements has occupied considerable attention, and every effort appears to have been made to secure as much rational recreation as possible to the patients in the hospital. A large theatre is provided in which entertainments and concerts are given, and outdoor recreation at suitable seasons is plentifully allowed and encouraged. The result is described as being in all respects a good one to the patients.
The next largest hospital in point of numbers at the same date, December 31, 1880, is the institution at Gladesville, where during the year a total of 988, or 49G males and 492 females, were under treatment. 247 first admissions, and 54 readmissions were registered, the discharges amounting to 161 males and 123 females, or 284 in all. These are arranged by the medical superintendent thus: 86 males and 51 females recovered ; relieved, 16 males, 17 females ; transferred, 21 males, 32 females ; escaped and not recaptured, 2 males ; and died, 36 males, 23 females, giving a death-rate on the average number resident of 8*60. Among the causes of insanity in those admitted, hereditary influence accounts for 30, intemperance for 18, epilepsy for 19, puerperal state 18, previous attacks 47, and in 114 no cause could be assigned. Some attention is deserving to the significant number of 47 patients out of 311 having been admitted for treatment on account of a recurrence of dangerous symptoms, and it cannot fail to suggest a reopening of the subject of premature discharge so often discussed in these pages. On this point further information is afforded in one of the general tables compiled by the Inspector-General, who records that the total number of readmissions during the year at all the hospitals under his supervision was 58, 54 of whom are credited to Gladesville. This yields a percentage of readmissions to total admissions of 12*39, but even this, as the Inspector-General points out, compares favourably with the numbers obtaining in English asylums, the percentage in them being 13*62 of total entries. In this calculation, in both instances, it should be said that transfers are not considered. The Hospital of Newcastle held, on December 31, 1880, 228 patients, 124 being males and 104 females. Overcrowding here also is seriously complained of, and writing on the almost universal want of space in the hospitals visited by him, the Inspector-General thus delivers himself:
“For the year 1879 it was my duty to report that there, were 263 patients in the public institutions in excess of the number for whom there was proper accommodation?such accommodation being on the standard of cubic space fixed by the English Commissioners in Lunacy as the lowest compatible with health. During the year 1880, the only increase in the amount of accommodation was offered by the removal of the Superintendent of the Hospital for the Insane at Newcastle, from quarters in the main building, to a small detached residence formerly occupied by the Police Magistrate. This gave space for 17 patients with 2 nurses, and was occupied with patients as soon as some necessary alterations and repairs could be effected. Twenty-two patients found accommodation in the wards at Callan Park, and the remainder of the 88 were at the close of the year distributed in the already overcrowded dormitories at Grladesville, Paramatta, and Newcastle. Some minor and necessary alterations were made during the year which slightly affected the accommodation, and the following return shows this accommodation and the number of patients at the close of the year :
Return showing Number for whom there is Dokmitory Accommodation, and the Number in Hospitals for the Insane, December 31, 1880. Number for which there is Dormitory Accommodation Number in Hospital on December 31,1880 Hospitals for the Insane : Gladesville …. Paramatta (Free and Convict) Do. (Criminal) Callan Park …. Newcastle Temporary Hospital for the Insane: Cooma Male 259 573 57 141 111 56 Female 244 123 1,197 437 1,634 Total 503 696 57 141 181 56 Male 335 577 53 129 124 64 1,276 1,197 Total Number in excess of accommodation Female 369 209 437 Total 704 780 59 129 228 64 1,964 1,634 330
” It is, I think, desirable to consider the extent and the character of the existing accommodation, both with regard to the steps which have already been taken to increase it, and to those which may be necessary in the future.”
Then, after detailing the improvements in course of construction, among which the erection of wooden buildings to accommodate 252, one-third the total number of female patients, he continues :
” The experiment of housing the insane in wooden buildREVIEWS AND BIBLIOGRAPHICAL NOTICES. 297 ings has been tried to a greater extent in this Colony than in any other part of the world, and there can be no doubt but that such buildings can be erected more cheaply than more substantial structures, and serve admirably for the accommodation of certain classes of patients. They present, however, special danger from their liability to fire, they need frequent painting and repair, and the experiment has not yet been made long enough to enable a correct idea to be formed as to its ultimate economy.
” Moreover, the experiment has now been carried to the fullest extent compatible with the safety and comfort of the patients, and experience has clearly shown that there are large classes, especially the more noisy, dangerous, and demonstrative, and all those in the acute stages of the malady, who cannot safely be placed in buildings of this kind. About one-third is the greatest number which can be placed in wooden buildings without danger or without imperilling the comfort and recovery of other patients.” The extent of overcrowding at the Newcastle Hospital during 1880 was very considerable, 47 patients being there at the end of the year in excess of the number for whom adequate accommodation could be provided. The Inspector reports of it that?
” At the close of the year 89 males and 83 females?a total of 172?were imbecile or idiotic, suffering from congenital defect, or an arrest of intellectual development, whilst the remainder were dements, the intellect after development having failed from different forms of brain disease. No less than 30 males and 32 females suffered from epileptic fits, but in several cases in which epilepsy was present on admission it had ceased under care and treatment, but not before it had permanently affected the mental condition. The majority of the patients? 143 in number?were under 20 years of age.
” The Institution had been quite free during the year from epidemic disease, and though measles were for months prevalent in the city, and several of the attendants’ children suffered, no patient was attacked. He attributed this result largely to the care exercised by the Superintendent, and to the excellent sanitary arrangements of the Hospital. In one case a patient was somewhat thoughtlessly forwarded from another Government institution only ten days after recovery from measles, but precautions were taken to isolate him after arrival and to prevent any chance of infection.”
The remaining hospital reports which are included, are the convict and criminal houses at Paramatta, the Callan Park Hospital for males only, and containing 129 patients, the Cooma temporary hospital, and the Cook’s River licensed house. Of the temporary hospital the Inspector-General reports more favourably than of any other institution visited by him in his official capacity. He writes that ” the number of patients in this Hospital at the close of 1879 was 57, all males. Three patients were admitted direct, and seven were transferred from Grladesville, making a total of 67 under care. Of these one, an aged and feeble man, was transferred to Grladesville, and two died, leaving 64 on December 31, 1880. The death-rate was lower than at any other institution. The cause of death was epilepsy in one case and pulmonary consumption in the other.”
At Darlinghurst a reception house for the insane is established, whence patients are drafted to permanent hospitals, or, if speedy recovery ensue after their admission, they are discharged either in the care of friends, or to the mercy of the law, according to their description as criminal or free patients.
The following statement, showing the number of patients who passed into this reception house during 1880, and their ultimate disposal is interesting:
Remaining . … Received …. Sent to Gladesville . Paramatta . Callan Park Newcastle . Cook’s River Hyde Park Asylum Police Court Discharged of Sound Mind ? to care of Friends Died …. Remaining 31st December, 1880 Male Female Total 3 202 122 2 49 1 1 1 26 1 2 1 4 126 328 111 233 2 49 1 1 1 .. i 1 8 34 1 1 2 3 4 i 6
The licensed house for the insane at Cook’s River is reported on in the highest terms by the Inspector-General, and it certainly appears as though a much greater degree of comfort was experienced there than in the public institutions. During 1880, five patients were admitted for the first time, one was readmitted, and nine transferred from the hospitals, which, with 133 in the house at the end of 1879, gives a total under treatment of 148. Of these four recovered, two were discharged relieved, two transferred, five died, and on December 31, 1880, there were left resident 135 patients. The recoveries give the very high percentage of 66*66 on the admissions, and the deaths reach an average of only 3*79 on the average number resident. These results speak very well indeed for the efficient management and excellent arrangements of this Asylum, and this is evidently acknowledged by the Inspector-General, who pointedly remarks that even when his visits were quite unexpected, he never failed to find the patients well cared for and comfortable, and everything in good order in the Institution.
We have perused the report of the Inspector-General for New South Wales with very considerable interest, and while there is a good deal of evidence in it of a need for sweeping changes in the arrangements made on behalf of the Colonial insane, we can notwithstanding congratulate the author of the report on the conspicuous care with which his share of the labour has been accomplished, and also on the admirable assistance rendered to him by the various hospital medical superintendents. Eighth Annual Report of the Western Hospital for the Insane of the State of Wisconsin.
The trustees’ report on the operations of the Asylum under their control in Wisconsin, puts the amount per head required for maintenance of patients in the institution at $4^, equivalent to about 17s. 9d. sterling, per week. This sum is somewhat in excess of that which is regarded as sufficient to support a patient for the same time in this country, since a usual charge of 15s. is made on account of pauper patients transferred to private institutions. The expenditure on account of buildings and improvements is reduced to a minimum, as the trustees point out, by the fact that in this institution it is not considered necessary to have high wire or wood fences such as are common in many other places ; they say these have never been required, considering it more advisable to permit the fullest amount of freedom from restraint both inside and outside, consistent with the well-being of each individual. There exists a growing tendency in this direction, on the part of American asylum officials, and the consequences attending the introduction of greater freedom have, in all instances reported, been of a beneficial kind. The report of the superintendent, Dr Walter Kempster, shows a total of 719 patients; 363 male, and 356 female patients under treatment during the year ; and under ” discharged,” we find 42, male, 22, females, 20; recovered, 77, 28 men, 43 women; improved, 77 males, 38 females; unimproved, 39; and two women sent away as not being insane. Deaths numbered 38, 23 being men, 15 women. The ages of the re300 REVIEWS AND BIBLIOGRAPHICAL NOTICES. covered patients varied from 20 to 80, and the causes are arranged in a table from which it appears that phthisis is held accountable for 14 of the whole, four of them being males; chronic brain wasting is credited with three deaths; general puresis two ; and acute meningitis two. Here once more we cannot refrain from expressing a wish that facilities were generally existent to enable accurate histological reports to be made on all the cases of death in asylums; and, in the case under notice, if the energetic superintendent had spent on this work the time devoted in writing the elaborate psychologicomedical essay appended to his account of the year’s work, we venture to think a much greater amount of permanent good would have resulted. This lengthy paper is in many respects excellent reading, but the views it propounds ought to be familiar to all well educated superintendents. When he deals with more practical questions, Dr Kempster is more likely to effect good by suggesting food for general reflection. For instance, his inquiry into the causes for a preponderance of cases of dementia and melancholia among the admissions into the asylum. He has been struck by the continuance of this excessive proportion, even after the exciting causes primarily set down had been removed. After referring to the numbers in foreign institutions, he adds :
” In this hospital the percentages are as follows : of those admitted with the asthenic form of disease, as melancholia and dementia, there were 17*11 per cent, native and 22-04 per cent, of foreign born, a total proportion of .39-15 per cent, of the asthenic (depressed) type, against 6-86 per cent, of native, and 7*06 per cent, of foreign born, or a total of 13*92 per cent, of the sthenic. In other words, the number of those admitted into the Northern Hospital, with melancholia and dementia, is 19*60 per cent, greater than it is in foreign hospitals, having only the native born as patients, and 14*03 per cent, greater than in the eastern hospitals where nationalities are more nearly equal than they are here. Thus, in foreign institutions where all, or nearly all of those admitted are native born, there are 6*11 percent, more cases of the asthenic than of the sthenic forms.”
A table showing probable exciting causes in those admitted into the asylum, gives ” scrofulosis” as the cause in 23 cases; ” intemperance ” in 15 ; “subacute meningitis” in 14; hereditary, either alone, or with other causes, 15 ; and unknown, 34. The total number of admissions for the year was 173, 92 being men. The total number under treatment for the twelve months reached 719, 303 of whom were males ; and a series of instructive and carefully prepared tables, relating to these numbers is appended to the reports of the medical officer. This is well conceived and well executed, and exhibits the institution it refers to as in an excellent condition, and one on which the executive is to be congratulated.
Twenty-third Annual Report of the Nova Scotia Hospital for Insane, for the year 1880.
The medical superintendent of the Nova Scotia Hospital for Insane, reports that during 1880 there were under his care 453 patients, of whom 43 were discharged as recovered, 28 as improved, and 1 as unimproved, while 20 died in the institution, bringing the whole number discharged to 92. The deathrate is given as 4*4 of the whole number under treatment, and on the admissions 22-47 ; the number of new entries having been 89, of whom no less than twenty-five had formerly been inmates, viz., 17 once, 5 twice, 2 three times, and 1 four times; 21 of these readmissions, it is instructive to learn, had been discharged as recovered, while only one had gone out ” unimproved,” and only three as ” improved.” Among the 20 deaths is included that of one man, by suicide, through jumping from a window. The superintendent reports that only 20 per cent, of the windows are guarded, and it is to be hoped so serious an oversight may not longer continue to facilitate suicidal dangers on the part of patients.
On the subject of ” recoveries,” the superintendent offers the following remarks. We would draw attention especially to the lines we have italicised, they bear their own suggestive moral. ” The recovery rate has been very favourable (48*3), nearly fifty per cent., the mean of all former years being (43*1) fortythree ; but less than last year (54), fifty-four per cent. ” Kecovered patients are always discharged on trial, so that we have a satisfactory report from the friends as to the recovery of the patient before the final discharge. The monthly average of patients continually out on trial, for the past year, has been (121), twelve and half persons. Even the two cases that go to swell the death-rate, who died from incidental causes when out on trial, would have appeared as recoveries, if after two months there had been no recurrence of insanity, and this would in all probability have been the case.
” Patients discharged as 4 improved,’ are also on trial for a varying period before their final discharge. ” Our recovery rate is much above the average of other insane asylums and hospitals, because from limited accommoPART II. VOL. VII. NEW SERIES. Y dation a preference is given lo those labouring under acute disease, such cases (for this hospital is specially designed for their accommodation) are never refused admission.
” As previously stated (43) forty-three cases, different persons, have left the hospital so well as to be able to fill their accustomed places in society. Among these were nine who had been discharged as recovered in previous years?six of whom were each discharged once, two twice, and one three times, making in the hospital statistics 13 recoveries from these nine persons in addition to their discharges this year. Thirty-four (34) had never previously been under treatment.”
The treatment of the insane is dwelt on at some length in the report, and is intended apparently for the information of the public in this matter. We have room only for one quotation from this part of the paper. ” We treat our violent cases as we would children. If they tear clothes, we put on raiment too strong to be torn; if they strip themselves, we button or tie the clothing so that it cannot be undone by the patient. If they pick the face or scratch themselves, we sew up the sleeves of the dress or jacket so that the fingers cannot be used for such a purpose. If they pound with their hands so as to hurt themselves, or if they strike others, we muffle the hands; but every patient who is physically able has the free run of the hall inside, and the grounds outside, along with the other patients.”
A number of carefully constructed tables are appended to the Report, which is generally well compiled and instructive.
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