The Human Brain
IT REVIEWS AND BIBLIOGRAPHICAL NOTICES. . Histological and Coarse Methods of Research. :Author: W. Bevan Lewis, L.R.C.P. J. and A. Churchill, London, 1882.
This manual will prove of great service to those engaged in the study of cerebral pathology. Whilst admitting the immense value of microscopical investigation of diseased nervous tissue, the author judiciously warns the student against the common, prevalent, and erroneous tendency to disregard the naked-eye appearances of the brain. On this subject he makes the following pertinent remarks:? 4i I cannot too strongly insist upon this point, for he who would successfully study the morbid anatomy of the brain must, as in the morbid anatomy of other tissues, begin seriously to educate the eye to the coarse appearances presented to the unaided vision. The employment of a hand-lens of two to four inches focal length will prove of service here, the naked-eye appearance being contrasted with the magnified field, and the eye thus educated up to recognizing characters which without the aid of the lens were previously indefinite or unrecognizable. Nothing beyond repeated and energetic etforts in this direction will enlarge the area of the visual field and present to the mind the manifold appearances which constitute an unbroken whole, and which are absolutely necessary to a refined interpretation of the picture presented to the mind’s eye. Repeatedly have I had occasion to observe that the student, after a full curriculum of hospital training?a training which should pre-eminently involve the high culture of the sense of sight, hearing, and touch?fails wholly to appreciate the most obvious abnormalities of the cerebro-spinal tissues, and this because he has neglected to tutor the eye so far as to learn what to look for, and how to look for it. If you place before him the brain of a case of chronic mania, without coarse lesion, and note his observations upon the appearances of a section across the hemisphere, it will be found that beyond a statement that the grey matter is pale, amemic, and wasted, that the white matter is altered in consistence, and presents numerous coarse vessels, his untutored eye teaches him no more; and should he be examined even for the grounds upon which these statements are made, a too evident vagueness will he apparent?his ideas on relative depth of cortex or anemic states of the brain and consistence of its tissue are gauged by no mental standard, and are remarkable only for their indefiniteness. The practised eye of the histologist, however, sees far more: the relative depth of cortex in various regions; the relation borne by this depth to normal standards ; the varied depths of the several laminse of the cortex, their distinctness of outline, general and local vascularity, as well as the deviations in hue dependent upon fatty or upon pigmentary changes.
The cedematous, degenerated aspect of the medullary tracts, the presence of minute sclerosed patches, and a host of other morbid appearances, present to his mind a picture which the unpractised eye wholly fails to appreciate. To those who are liable to err in the direction pointed out, I now address myself in the hope of rendering their studies of the naked-eye appearance of healthy and diseased brain more inviting and instructive, by means of a few simple directions as to what appearances are to be sought and how they are to be looked for.”
This work has supplied a want in medical literature, and we strongly recommend it to the attention of the cerebral histologist.
Report of the Asylum for the Insane, London, Ontario. Returns for the Year ending September 30th, 1881. During the year dealt with in this Report, a considerable movement of patients had taken place in the London Asylum Ont., 970 having been under treatment, while the admissions reached 186, of whom 84 were women. Of this number 89 were transfers from foreign gaols, and 97 were received on medical certificates from private families. Discharges during the year numbered 73, of which one was found to be not insane ; 47 were sent home recovered, 13 improved, and 12 unimproved; 38 deaths occurred, and four escapes, the death-rate being 4 per cent, of entire population.
The probation system is carried out among patients at this asylum with satisfactory results. Thus, during the year under review, 74 were thus placed under care of relatives and friends, 19 of whom returned to the asylum, the remainder being thus classified: 26 discharged recovered, 10 improved, four unimproved, while 15 remained on probation at the close of the year.
The 18 deaths which occurred were all among old persons, the average age reached being over 50 years, and all are assigned to ” natural” causes, a classification which decidedly admits of improvement.
The Inspector’s Report details two ” unfortunate ” circumstances which came to his notice in connection with the asylum. One bore reference to an act of criminal impropriety towards a female patient by a night watchman, who, during temporary absence of the female attendant, found his way to the patient’s room. It is rightly pointed out that such a thing could not have occurred had the attendant been strict in performance of duty, and arrangements have been made to insure this shall be for the future. The second untoward incident was the fracture of a patient’s arm by an attendant, who was duly charged with the offence, fined by the magistrate, and dismissed the service of the asylum. A case of maniacal manslaughter is also reported. In most other respects the Inspector’s Report is very satisfactory.
Dr Burke, the Medical Superintendent of this asylum, appends a separate Report, in which, after detailing the condition of several of the institutions under his charge, he enters on certain instructive and vigorous dissertations. Thus, dealing with ‘-‘prevention of insanity,” he affirms, “insanity is essentially an incurable disease;” but he hurries to explain that apparent curability may be noticed, as depending on ” original constitution.” He adds, that of insanity as of all diseases, ” cure ” means ” spontaneous recovery, more or less aided by management, but seldom, if ever, actually brought about by medical interference.” He then proceeds to urge that a future weapon against the spread of insanity will be found in the regulation of marriages, inasmuch as heredity is mainly chargeable with the preponderance of mental disease. His remarks on marriage are, although not original, so freely expressed that it may be of interest to reproduce them. Dr Burke writes :?
” The object of marriage is to produce men and women to carry on the work of the world, and not to produce syphilitic, tubercular, and insane persons. We call ourselves civilised and religious, and claim to have common sense, yet our Governments license, and our Churches bless, unions the offspring of which are foredoomed to idiocy, imbecility, lingering illness, or premature death. I don’t mean to say that the Church and State combined could prevent children being born of the class of people of which I speak, neither can they prevent altogether murder, theft, or prostitution ; but they do not sanction these, and neither should they countenance what is as bad as any of these?that is, the bringing into the world imperfect and diseased children, who must necessarily be, all their life, wretched themselves and a burden to the world at large. Nor do I say that any special laws should be made against such unions as I speak of; all I claim is that the community, through its Government and Churches, should cease to countenance what is notoriously wrong. No marriage license should issue, nor any marriage ceremony be performed, except in cases where there was a reasonable prospect of healthy issue proceeding from such marriage, and there is no doubt whatever in my mind that either by special enactment, or by the force of public opinion, the reform here contemplated will at last be effected, and disease of all kinds be, through it, enormously reduced in amount. In the meantime, while we are waiting for direct action by the State, something should be done to enlighten and caution the whole people on this point. For this purpose, the powerful influence of the voice of the clergy of all denominations ought to be invoked ; no worthier subject could occupy their talents, and in no way could their energies be more usefully employed than in combating this giant evil. . And it lie3 directly in their path ; for in the case of insanity, its primary causes nearly all consist in violations of the moral law.”
Toronto Asylum for the Insane. Report for 1881. It is apparent, from this Report, that the resources of the Toronto Asylum are inadequate to the demand made upon them, since during the year dealt with there were 88 admissions, or 11 in excess of the capacity of the institution, while the number of applications for admission were no fewer than 223. In explaining the shift he was put to to provide accommodation for the extra patients received, the Superintendent remarks that ” it is difficult to resist the appeal of friends for the admission of acute cases. A large number of these might recover if brought immediately under asylum treatment; hence the desire to receive them.”
The total number of inmates during the year was 762. The discharges reached 54, 40 of whom went out ” recovered,” and eight improved. The number of deaths was 35. In a supplementary table at the end of the volume the recoveries are analysed, with the curious result that of the 40 patients so discharged two were ” recovered for the second time,” two ” recovered for the third time and over,” and the remaining 36 ” recovered the first time.” During five years ending September 1881, no less than 35 patients sent away “recovered” had been readmitted to the Asylum.
Respecting the deaths most meagre details are given. Except that the moitalitv reached 4’59 per cent, of the total population, and that the larger number of fatal illnesses were due to acute diseases, little is said. Six of the cases were chronic, the duration of their recoveries varying from 21 to 27 years. It is much to be regretted that no post-mortem records are included in the Report.
The Inspector’s Report on the Asylum is on the whole favourable, and the fact that a considerable income, amounting to over ?6,000, is derived from paying patients, one-third of the inmates coming under this category, no doubt helps to expl in in great part the general good arrangements. In the matter of restraint, it is gratifying to find that small resort is had to harsh means of punishment, confinement to the seat by means of straps, and occasional seclusion, being the worst form of restraint adopted, and even these but rarely.
New York Hospital and Bloomingdale Asylum; WOtk and llltfA Annual Reports, 1880, 1881.
The Bloomingdale Asylum of New York is in connection with, and under the same board of management as, the New York Hospital and its House of Relief, the same Report including details relating to all three institutions. In this place, however, we shall confine our examination to that section of the two Reports under notice which deals with the changes and condition of the Asylum only. The Bloomingdale Asylum is under the control of Dr. Charles H. Nichols, as medical superintendent, and has recently undergone considerable extension and improvement, especially as regards the completion of a ” Green Memorial Building,” which was opened in 1880. During this year there were admitted 114 patients, and were under treatment a total number of 298. There were discharged recovered 24, improved 30, unimproved seven, and died 23. As the amount of accommodation in the Asylum is increased, it is found that the new wards become speedily filled. Dr Nichols gives utterance to an opinion in consonance with a preceding statement, in these words: ” It has long been obvious to alienists that, throughout the most enlightened countries of the globe, insanity is not only increasing in proportion to population, but is becoming less curable.” In confirmation of this depressing view, he observes that the character of cases received by him illustrates the second conclusion he formulates, since ” not less than 48 of the admissions, 33 men and 15 women, were affected with fo’ms or complications of disease that are insusceptible either Reviews and bibliographical notices. 281 of complete or permanent amelioration. He records 16 cases among the admissions as being afflicted with general paratysis of the insane, in addition to 13 under treatment for the same form of disease at the beginning of the year.
On the subject of the deaths which took place in the AsyiUm, Dr Nichols gives many useful and instructive particulars :? ” Four patients, two men and two women, died in the acute stage of their disease; one man from the exhaustion of delirious mania (Bell’s mania), and one from the exhaustion of acute melancholia supervening upon chronic alcoholism; one woman in puerperal mania, from metro-peritonitis, and one in melancholia, from the exhaustion of the disease and of the loss of blood from a suicidal attempt. The remaining 19 deaths occurred in chronic and entirely hopeless cases. Ten, nine men and one woman, died from paresis; five, three men and two women, in dementia, all the men with progressive paralysis, and the women, one from senile debility, and the other from pneumonia, supervening upon phthisis pulmonalis ; and three men from the exhaustion of chronic melancholia, and one “woman in chronic manin, from Bright’s disease.
” The four acute cases died from six to eight days after admission, the average period of treatment having been seven and a quarter days. The ten deaths in cases of paresis took place at periods after admission varying from three months and nineteen days to three years, six months, and thirteen days, the average duration of treatment having been one year, ten months, and twenty-four Tdays. Six of the paretics were more, and one other was a little less than two years in the Asylum. The short period that elapsed between the admission and death in two cases, reduced the average duration of treatment to less than two years. It usually requires many years to lay a foundation for paresis, as for gout, but the attack is generally sudden and marked by such urgent symptoms as require immediate treatment. It follows that the duration of the recognised disease does not, as a rule, greatly exceed the duration of treatment. Twenty-five or more years ago, one year was thought to be about the average life of a patient affected with general paralysis, but experience shows that that average has since been extended to at least double the period at first assigned to it. As the disease increases in frequency it appears to decrease in its exhaustive activity; and there has undoubtedly been some increase in the skill of its ameliorative treatment,
” The other nine cases, all chronic, died at periocs after their admission ranging from two months and twelve days to thirty-two years, ten months, and thirteen days, the average having’ been live years, ten months, and eight -foa days.” During 1881 the number of patients in the Asylum for treatment swelled to 343, the admissions having reaehed 129. There were discharged recovered, 46 ; improved, 48; unimproved, nine; and died, 16; giving a percentage mortality of 4*7. Of the 46 recoveries, two were made by the same male patient; and of the number, seven were recoveries from second, three from third, one each from fourth and fifth, one from tenth, one from sixteenth attacks, the remaining 32 being from first attacks.
The average duration of treatment of the cases recovered was four months and twenty-five days, the shortest period having been twenty days, the longest one year, eight months, and twenty days. Adding, however, the time the disease was reported or existing prior to admission to the Asylum, the average duration is raised to seven months and sixteen days; and on this subject Dr Nichols remarks, with much show of justice, that k’ the recorded duration of disease before admission is generally the estimate of friends who are naturally indisposed, and often unable, to realise that their relatives are suffering from mental disturbance, until some very striking manifestation of it takes place, and, in a majority of cases, the disease has unquestionably existed much longer than the friends realise or admit. And in respect to the duration of treatment in the cases reported as recovered, it is often much too short. In most cases that recover each case is a new experience to the near friends of the patient, many of whom are unable to realise that advanced convalescents have not always reached a state of sound, enduring health, and yield to their importunities to be taken home. A considerable proportion of relapses and second attacks that take place, as well as of the peculiarities that are sometimes observed after attacks of mental derangement, are unquestionably due to insufficient length of treatment in a state of seclusion from the ordinary relations and duties of life. ” Sixteen patients, nine men and seven women, died ; two men from paresis ; two, one man and one woman, from pulmonary consumption ; two men from pneumonia which supervened upon great prostration from other maladies ; three, one man and two women, from apoplexy followed by paralysis and convulsions; three, two men and one woman, of exhaustion of clnonic insanity; one man from senile decay; one woman each from renal anasarca, meningitis, and suicide. In the latter case a coroner’s jury exonerated the Institution from neglect or blame. One death occurred in three, two in seven, and one in eighteen days after admission. Of course, those patients were in the fatal stages of their maladies when admitted. One man and one woman had been inmates of the institution over twenty years, and one man for the long period ol forty-four years, six months, and twelve days.”
Sixty-Fifth Annual Report of Philadelphia Asylum.
This report is mainly made up of descriptions of masonry and building alterations effected during the year. In reference to its very meagre information of direct interest to alienists, it indicates that forty-six patients were admitted, and thirty-three discharged during the twelve months; eight deaths occurred during the same period, concerning which it is explained that ” the first was a woman fifty-four years of age, who died of organic disease of the brain. The second, a man thirty years of age, died of chronic meningitis, the result of a blow upon the head. The third, a man aged fifty-one, died from suicide. The fourth, a man sixty-seven, had been an inmate over four years and died of marasmus. The fifth case, a man who had been an inmate about ten years, died of peritonitis. The sixth, a woman seventy years of age, and the seventh, a man aged seventy-seven years, each died of serous apoplexy. The last case, a man twenty-eight years old, died from the exhaustion of acute mania.
” Of those discharged, fifteen were restored, seven were much improved, three were improved and eight were stationary. Of the restored two had been under care between one and t^o months, eight between two and six months, one eleven months, and four between one and two years.”
Of this report as of so many similar productions, it is impossible to say anything except that it would be infinitely invaluable if it contained, in place of the details interesting to builders and tradesmen, some scientific information on the subject of insanity, as shown within the walls of the Asylum.
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