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tion the excitement of the patient became less, and she was quiet for short periods, but in an unconscious state. The pulse and respiration, and the irritability of the pupil, remained unchanged; but the jaundice became more intense. The hepatic dulness disappeared everywhere. The bowels had been confined for the last three days. The urine, wbich had been drawn by the catheter, was acid, of a reddish-yellow colour, clear, free from albumen, of specific gravity 1018-5. On the addition of nitric acid the discolorations, characteristic of bile pigment, could not be perceived. On standing, the urine threw down a slight deposit
, composed of numerous needles, single and in groups, mixed with yellow epithelial cells from the tubules and the bladder. The patient took some tincture of colocynth, and afterwards jalap. During the night between the 22d and 23d she lay in a comatose state; some of the muscles of the neck and upper extremities exhibited tremulous contractions. The uterine hæmorrhage continued.
On the 23d the jaundice had become more intense. Pulse, 108; respiration, 24, stertorous; temperature not raised, skin dry.
From time to time there was vomiting of grey mucus, mixed with blackish-brown flakes. Notwithstanding the purgatives, the bowels remained costive. The urine became darker, continued acid, and exhibited distinctly the reaction indicating bile pig. ment, but did not contain any biliary acids ; its specific gravity had risen to 1024. "On standing in the cold it deposited greenish-yellow light flakes, consisting exclusively of globular masses of needles of tyrosine. A drop of urine on evaporation upon an object-glass left a residue, which, when seen under the microscope, consisted almost exclusively of crystals of leucine and tyrosine of a very striking form, tinged with biliary matter. Fig. 4, Table III., represents a view of this residue. A sample of urine just drawn by the catheter was freed of colouring and extractive matter by basic acetate of lead; the excess of lead being removed, the residue was concentrated and left to crystallise. After twenty-four hours the tyrosine had crystallised in brownish and greenish-yellow spherical groups of needles (Fig. 3, Table III.), which after recrystallisation (Fig. 5, Table III.) were found sufficiently large in quantity to serve for several elementary analyses. These were performed by Städeler, and the results, together with the tests for and the behaviour of the substance, left no doubt of its being tyrosine. The liquid from which the tyrosine had crystallised consisted of leucine and a glue-like substance. Urea was searched for in vain. Ammonia was present, but in such small quantity as was altogether insufficient to account for the absence of urea by decomposition. The urine when first passed (by the catheter) was acid, contained traces of uric acid, left 4.94 of dry residue and 0.14% of ashes, exhibiting no trace of phosphoric acid and of lime.
The patient died on the third day after her reception into the hospital. The post. mortem examination showed, as the principal lesion, extreme atrophy of the liver, with destruction of its tissue and disintegration of the cells. The weight of the liver to that of the body stood in the proportion as 1 to 68, while in healthy females the proportion is 1:28. From the history of the case and its anatomical features it was concluded that the liver must within six days have lost more than two pounds in weight.
The recital of this and other cases is succeeded by a full discussion of the symptoms, anatomy, and nature of the disease. The therapeutical chapter offers but little matter for congratulation. If, however, anything is calculated to inspire confidence that the efforts of medicine may at a future time be crowned with snccess, it is the mode of analysing disease carried out by the author.
Chapter VI. treats of chronic atrophy of the liver, and contains a rariety of interesting cases
. Chapter VII. gives an account of fatty liver, as found in post-mortem examinations; for our author, like Louis, candidly avows his inability to diagnose this condition during life. This chapter
, although containing many original researches, is rather defective in chemical principles, even in some of those of an elementary nature; for instance, no distinction between neutral fats and fatty acids is set forth, nor is their respective occurrence inquired into. Six distinct chemical compounds are all thrown together under the name of " fat,” a confusion for which, indeed, a short time ago analytical difficulties offered a fair excuse, and these may perhaps be pleaded in behalf of
our author. It will, however, be fairly demanded of future writers to pay great attention to exact chemical definitions of the substances in question, for we now possess tests for the most important distinctions, and these tests are neither troublesome nor costly.
Deposits of pigment in the liver, and the changes which this gland undergoes in consequence of intermittent fever, are described in Chapter VIII. For this inquiry the author had excellent materials afforded him by an epidemic of ague of the worst kind, wbich prevailed at Breslau and in the surrounding country of Silesia after an inundation of the river Oder in the year 1854. The Chapter on Hyperæmia of the Liver and its consequences concludes the volume.
On the whole this work is a very practical and learned performance, by which the author will no doubt sustain and increase bis reputation. We have been highly gratified by its perusal, and derived much information from its pages. We look forward with great interest to the publication of the second volume, which is promised in the course of this summer. Of the Atlas we can speak in the highest terms of praise. The objects are well selected, seem correctly drawn, and the artistic execution of the engravings is unsurpassed.
1. On the Prevention and Treatment of Mental Disorders. By GEORGE ROBINSON,
M.D., Fellow of the Royal College of Physicians of London, Fellow of the Royal Medical and Chirurgical Society, Joint Lecturer on the Practice of Medicine and Lecturer on Mental Diseases in the Newcastle-on-Tyne College of Medicine, &c.
London, 1859. Pp. 228. 2. A Letter to the Right Honourable the Earl of Shaftesbury on the Laws which
Regulate Private Lunatic Asylums; with a Comparative View of the Process " De Lunatico Inquirendo” in England and the Law of “Interdiction” in France. By EDWARD J. SEYMOUR, M.D., F.R.S., late Senior Physician to St. George's Hospital.
London, 1859. 3. What shall we do with our Lunatics ? By ALFRED Eccles, Fellow of the Royal
College of Surgeons.—London, 1859. pp. 16.
We welcome every additional attempt to throw light upon the mysterious wanderings of the human mind, and to remove the prejudices and fears which so interrupt and frustrate the intentions of those who would show us how best to deal with a difficulty which ignorance makes a scourge; and we augur well for the future when we find so many able contributors coming forward to supply the deficiency of past years ; for we cannot but be struck with the fact of how rarely the distinguished physicians whom we have been accustomed to regard as authorities in this department of medicine have appeared in the literary arena. It is encouraging to believe that the true explanation of this is, that insanity has come to be regarded more in the light of an ordinary malady amenable to ordinary treatment, and that it is not thought necessary, as it formerly was, to banish from our sight, and, if possible, from our memory, the sufferers from this grievous affliction. We hope to see the unreasonable dread of insane persons still further dissipated ; and we believe that nothing is so likely to accomplish this desirable end as the correct information of the public mind upon a subject which, for the sake of all concerned, necessarily requires secrecy as regards individuals, but not mystery as regards the nature and treatment of the malady. It is much to be regretted that this secrecy operates prejudicially with the public upon those who are concerned in the treatment of the insane ; and we must admit that it is the more unfair because it is observed entirely in the interest of the patients and their friends, and not of those upon whom it entails obloquy, suspicion, and distrust. We may say that there is an hereditary
predisposition, if not universal, at least very general, to regard all insane persons as necessarily out of the pale of society; and it is to be regretted that some psychological writers have rather strengthened this view of the matter, by maintaining that there can be no degrees of insanity, no partial incapacity, no limited responsibility—that, in fact, a person must either be perfectly insane or perfectly sane, and that there cannot exist any intermediate mental condition which partakes of the nature of both these states. Dr. Robinson says :
“Nothing has so much tended to confuse the study of mental disease, or to impart harshness to the treatment of the insane, as a forgetfulness of the natural constitution and infirmities of the human mind. It has, until recently, been most unjustifiably assumed that a broad and unmistakeable line of demarcation existed between the sane and insane ; that the detection of insanity was therefore always a matter of facility and certainty; that the lunatic was, as it were, a creature of another world, cut off by his distemper from all sympathy or kindred associations with the rest of mankind, and that the latter were consequently justified in treating him with silent neglect, if not with actual cruelty. . . . . Is there not a certain natural range of disorder incident to every mind as regards strength, harmony, and extent of development? And do not the eccentricities, the proneness to vice and crime, the indulgence of evil passions, the follies, the vanities, the weaknesses of daily life demonstrate the universality of this inherent tendency to mental disorders For as the body, in the creative energies of its original conformation, in the ever varying combinations and mutations of the matter of which it is composed, in its diversified and counterbalancing functions, in the very delicacy and completeness of its arrangements, constantly engenders within itself the elements and germs of disease; even so the mind, poised in a still more sensitive balance, equally composite in its nature, and infinitely more exquisite in its sympathies, and above all, vivified and penetrated by the spiritual attributes of immortality, also carries with it in its marvellous excellences and endowments the weakness of elevation and the fragility of beauty. Philosophy and religion, therefore, alike enjoin humility and humanity in our dealings with the insane. The one forces us to admit that no man is at all moments perfectly or equally rational, and the other, in its doctrine of original sin, ever recalls to our memory the preponderating tendency of the worst and weaker parts of our mental and moral nature."
The question asked by Mr. Eccles : “What shall we do with our Lunatics ? is a most important one. The social position and means of the patient will, in perhaps the majority of cases, determine how and where he shall be treated. It seems to be agreed by all that home is not, as a rule, the place in which the disturbed mind is most likely to regain its lost balance; and that relatives, by reason often of their affectionate anxiety, are not the best persons to exercise that judicious control which is required.
As, then, in the words of Dr. Seymour, “it is quite impossible that the greater number of lunaties can be treated at home,” the question arises, where then? The poorest class of patients can only go to the public hospitals and county asylums, where they are most liberally provided and well cared for, so that the inquiry is almost entirely limited to the upper and middle classes. The course which is least at variance with their accustomed habits, is to place them under the immediate care of a medical practitioner in his own family, and this for many cases we are disposed to regard as the best course where the means are adequate to afford suitable remuneration for such an anxious charge. Next to this, Mr. Eccles advocates the practice of placing insane patients in a private house for themselves, or in lodgings, with a proper attendant, rather than incurring the stigma which doubtless to some extent attaches to those who have been in an asylum—the association with other insane persons being, in his opinion, also objectionable and occasionally prejudicial. Dr. Seymour differs with Mr. Eccles upon this point; as a perfectly disinterested observer, being unconnected with asylums, and having for several years acted as Metropolitan Commissioner in Lunacy, his opinion is entitled to considerable weight. His great objection is that in lodgings the patient is necessarily left very much to the
mercy of servants, and that under such circumstances there are too often opportunities for improper treatment, which cannot happen without being known in a licensed house. We are disposed to agree with Dr. Seymour and to differ with Mr. Eccles as to the effect of association in the majority of cases of insanity, for it must not be forgotten that a most essential part of the treatment of insanity consists in presenting to the disordered mind a succession of new ideas in the least exciting form,
for the purpose of displacing those which have perhaps been gaining prominence through a prolonged period of neglected self-discipline; the order and regular habits of a wellmanaged asylum are perhaps better calculated to carry out this treatment than the luxurious freedom advocated by Mr. Eccles, which, though doubtless applicable to a certain class of cases of a mild form and where there are abundant means, is wanting in what we believe to be of paramount importance in the management of a disordered mindviz., efficient control-whilst it is only the wealthy who can meet the necessary expense.
The expense,” Dr. Seymour says, “ of a private dwelling, medical attendance, and personal attendance, beyond a very short period, is so very great, that only a very few families can afford it, and at length they are obliged to have recourse to a licensed house. In every view, then, of fortune, convenience, or necessity, the great majority of persons of inoderate fortnne, thus afflicted, must have recourse to a licensed house ; the great object, then, snrely, is to make the licensed houses-the necessary retreat of the larger number of the afflictedas perfect as possible. Still the feeling fostered by novel-writers (who never, as fars I know, really depict à lunatic case)—the feeling for absolute secresy which pervades society, the idea that when there is secresy there is opportunity for injustice—all these operate on the public mind to decry similar institutions."
After deprecating the unreasoning outery and hostility manifested against those who undertake the ungrateful duty of passing a large portion of their lives with these examples of suffering humanity,” Dr. Seymour goes on to express his opinion that the law as it exists is amply sufficient if the working staff of the Commission is increased. Dr. Robinson thinks,
“That the present law of lunacy, and the administrative machinery employed under it, greatly need improvement and that in any future legislation, the utmost care should be taken to approach this difficult subject in a calm, conscientious spirit, and one utterly removed from passion or prejudice; for it needs the utmost power of intellect and clearness of moral perception to reconcile in a law of lunacy the conflicting claims of personal and public interest, to preserve at the same time the liberty of the subject and the security of society, and to ensure the humane and kind treatment of the lunatic without denying to the persons entrusted with his charge the ordinary protection afforded by English law to English subjects."
Mr. Eccles agrees with Dr. Seymour, that the present law, with some small modifications, would be amply sufficient, though he differs with him as to the expediency of any considerable addition to the working staff of the Commission. His views are thus. stated :
“I trust Parliament will not be led by the parade of a few exceptional cases to legislate hastily. The present law of lunacy, consolidated with some small modifications, would be amply sufficient to protect the lunatic if it were rigidly enforced. Its efficiency, or the reverse, is entirely in the hands of the executive. I do not think the large increase of the Commission, or harassing patients with constant visits by ever-changing officials and doctors, desirable. I would rather take stringent measures to secure that none but persons of character and skill should be allowed to take charge of the lunatics—would make it necessary that the certificate should bear the signature of one public medical officer, deputed to examine such cases, and of one private practitioner, and that within one month the patient should be visited by a Coinmissioner, who should countersign the certificate or institute a formal inquiry, and should report on the accommodation, treatment, &c."
It appears, then, from the opinions of those not connected with asylums, though practising in lunacy, that there is but little wanting in the way of change of the existing laws, but it is hinted that the working of them is susceptible of some improvement.. It certainly does appear, also, that in considering the claims of this most unfortunate class, there is a tendency to overlook the rights of those whose lives and frequently whose fortunes are devoted to their care and treatment; and against this section of our profession there has been an outcry which all the charges substantiated against them do not seem to justify. If the requirements of society necessitate the existence of licensed houses, it would be impolitic on the part of the legislature and of the executive to make the position of the proprietors in any respect more irksome than the nature of their anxious duties renders inevitable; at the same time, society has a right to expect that its afflicted members should not be made to suffer from the interested motives of the persons to whose care they are committed ; it is desirable, therefore, that the responsibility of their detention should not rest upon those who have charge of them, but upon the Commissioners in Lunacy, or other properly constituted and independent authority. If the protection of two medical certificates is not sufficient, by all means increase the protection, and give the public every possible guarantee tbat no person shall be confined as a lunatic who is not of unsound mind, and whose malady does not imperatively call for judicious control and treatment.
It would lead us beyond our limits to go into the question as to what amount of mental infirmity should justify interference with the liberty of the subject, but we should hgre a care lest our jealousy of any infringement of personal liberty should lead us to sacrifice the welfare of the individual and prejudice the interests of society, by withholding the proper remedial means, whatever they may be. It is agreed on all hands that the successful treatment of insanity is in the direct ratio of its early adoption, and that this exercises a far greater influence on the result than the apparent intensity of the symptoms as they are manifested in the early stages of the malady. If, then, it is clear that the mental manifestations are becoming more and more disordered, and the belief is unquestioned that delays can only diminish the probabilities of cure, we cannot surely be too prompt in our endeavours' to rescue a fellowcreature from the most severe affliction to which intelligent beings are liable, nor should we be thrown off our guard by the apparent reasonableness of the patient's conduct and conversation on particular subjects, for it must be remembered that the most notorious of the class called criminal lunatics are those whom society had neglected, if not refused to consider insane, until the world was startled by some frightful act of atrocity which cleared up all doubts as to their mental condition, when, alas! it was too late. Bearing in mind the greatly increased prospect of cure when early treatment is adopted, it is worthy of consideration whether the patient and his family are not less likely to be prejudiced by the imputation of insanity than by the neglect of proper precautions and management in the first stage of the malady. But the refusal to recognise the evidence of insanity is, as Dr. Seymour remarks," the paramount feeling of mankind, whether in the rich or poor," and in his experience as there is no asseveration too strong, no trick too great, to hide even from the medical adviser that others in the family besides the patient have experienced this calamity." How, then, can we hope to remove a prejudice whose strength lies in the weakness of human nature ? It can only be by diffusing more correct knowledge on the subject, that we can hope to dispel the mysterious awe with which the world regards this particular malady in itself; we must show that it is susceptible of amelioration and palliation, and in the majority of cases of as perfect a cure, as any other bodily ailment, if not too long neglected. With reference to the curability of insanity, which is abundantly shown by statistics, Dr. Robinson says:
“My own experience is wholly in favour of the idea, that in the great majority of cases insanity is directly or indirectly the effect of sources of mental disturbance originating in the will or feelings of the persons affec etl, and which may therefore properly be considered as moral in their nature. The mental affection itself may not be immediately produced by the moral disturbing cause, but if the latter excite in the system a series of disordered actions terminating in the former, and which would not otherwise have been in operation, we are surely warranted in regarding it as essentially productive of the attack of insanity. Moreover, in proving that the great majority of cases of insanity arise from moral causes, we prove that it is in general a preventible disease. Many physical agencies and bodily infirmities cannct be altogether prevented. But, inasmuch as sound religion and sound philosophy alike enjoin constant warfare against the evil tendencies naturally existing in mankind, we are justified in believing that mental disorders, arising from those moral weaknesses, are by no means necessary and inevitable afflictions. It is no part of man's duty to bow down tamely to miseries of his own creation, and allow the light of his reason, and the best and holiest of his spiritual attributes to be polluted by the offspring of his own vices