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PSYCHOLOGICAL MEDICINE.
336 and the objection to a district medical ofticer r or. his own annual report as a county oflicial 1 was founded on an erroneous view of the work involved.. Wherever combined districts existed in any counties they ; should be utilised as the basis on which they could1 most conveniently and economically erect a well-adjusted1 ’county sanitary administration. Amongst the duties whichi would ere long probably be imposed on sanitary authorities9 would be the superintendence of vaccination and this wouldi .at once make it imperative that every county council should1 appoint a medical officer of health. The plea that it was ofE ,no use for the-e councils to make such an appointment until1 - they were invested with fuller sanitary powers was met byr - the reply that county councils could hardly expect that theirr sanitary powers should be enlarged until they showed thatt ’they had made an effort to use those with which they were; .already invested. After some remarks by Mr. G. H. FOSBROKE (Worcester), Dr. J. LLOYD ROBERTS (Colwyn Bay), said that in North Wales there was but one county and in South Wales there* ’was but one that had officers of health. Many Englishi
’work,
,reporting
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M1tnicipal and County Laboratory Work. In his absence a paper by Dr. E. C. SEATON(London) was Tread by one of the secretaries. Dr. Seaton’s opinion was "that laboratory work entered more than ever into the daily routine of the public health and sanitary departments of .’most municipalities. After a full retrospect of the facts of the case the scope of sanitary analyses was next In every large town there .dealt with in the paper. was a demand for bacteriological examinations for diagnostic purposes in aid of the general practitioner and .also for hospital purposes which might be provided at a - Central bureau connected with the municipal offices. The - -tirst object of the sanitary authority should be to repress health and not to allow this to become subordinated, it had been for some time past, to the detection of a The concentration of ’certain kind of commercial fraud. ,laboratory work was then discussed by Dr. Seatori, who gave details of the county laboratory of Worcestershire, where the
-injury to .as
analytical chemist, Dr. Duncan, conducted the diagnostic examinations for diphtheria, empyema fluid, tubercle, &c.
Mr. HBNHY MAY (late medical officer of health of Aston considered that no injustice was done bya county medical officer of health being also district medical officer of health. Mr. T. W. H. GARSTANG (Bowdon, Cheshire) advocated "security of tenure" for medical officers of health. He thought that weekly notification of infectious diseases was a matter dependent on local conditions. Dr. E. J. SLADE-KING (Ilfracombe) said that Parliament should make weekly returns absolutely compulsory. If parish medical men were life officers it was much more important that medical officers should be. At this stage of the discussion Dr. J. GROVES (Carisbrooke, Isle of Wight) moved, Dr. SLADE-EiNG seconded, and Mr. HERBERT JONES (Hereford) supported, the following proprosition, which was carried later in the proceedings :—
Manor)
That having regard to the paramount importance to the interests of the public health of security of tenure of office of sanitary officers the State Medicine Section beg to express their approval of the action of the council in promoting a Bill in Parliament to that end and their thanks for the same.
Alderman WALTER SMITH; (London) fadvocatedj that bacteriological examinations should be undertaken by sanitary authorities for medical men gratuitously. Dr. A. K. CHALMERS (Glasgow) said that in his district the bacteriological work was done gratuitously with satisfactory results. The PRESIDENT believed that the ultimate solution of the problem of the relations between the county and district medical officers of health would be found in the appointment of both by the county council. Dr. BOND, in winding up the discussion, said that it was desirable to haveas much elasticity as possible in this matter and that the requirements of efficiency should not impose undue pressure on county finances. Dr. D. S. DAVIES (Bristol) read a paper on Plague and its Prevention as a -Disease Communicable from Animal to Man and at the conclusion he made the following motion which was seconded and carried :— That this meeting considers the time has come when the question dealing with ship-brought plague deserves the attention of the Government, with the view of securing an international agreement whereby merchant vessels shall take the necessary steps for the destruction of rats on board before loading and upon discharge, and, in addition, for the adoption of uniform steps to prevent intercommunication during loading and discharging between ship and shore rats. of
PSYCHOLOGICAL MEDICINE. WEDNESDAY, JULY 31ST. The Presidential Address. Dr. J. B. SPENCE, resident physician and superintendent, Staffordshire County Asylum, Burntwood, delivered the following introductory remarks at the opening of the section :Asylum Administration and Nursing. Dr. Mercier, in his well-known crisp and incisive manner, has in the last number of the British Medical Journal for 1900 given a brief, instructive, and interesting account of the position of affairs in the lunacy world at the commencement of the last century, and it would well repay the labour involved and the time occupied if one had the opportunity to enumerate in detail the various discoveries, improvements, and legal enactments which have so advantageously changed the treatment of the mentally afflicted since that period. Not only, however, were the insane subject to very terrible and inhuman treatment at the commencement of the last century, but in many other directions also the condition of the people was practically in a state as unsatisfactory. Picture to yourselves the prisons of those days-the dens to which debtors were relegated, the condition of the poor in their own homes, the monstrosities practised in the name of justice, when men were sentenced to death, and not only sentenced but in some instances actually hanged, for offences which in these happier days would be considered as severely punished by a few months, or at the most years, of imprisonment in establishments which, when contrasted with the prisons of a century ago, may fairly be said to have made as great an advance as that which has taken place in our asylums or other public hospitals. For
the marvellous progress that has marked the past century
337 and has rendered the Victorian not rest content with
era a golden one we being merely grateful, but
the acute asylums and enabling them to carry out the work for which they should be, in my opinion,
relieving
There is the difficulty for the small counties power to maintain and promote reserved. direction of useful progress, and that an institution common ’to several would probably be so continue the great work which has made the names required owing to the few cases each of these counties of Tuke, Conolly, the Browns (father and son), Buck- would have to provide for. It has been said also that even nill, Maudsley, Clouston, and many others honoured the individual lowest in the scale of mental degradaI heard it said not tion can appreciate the bright and comfortable surroundand glorious in our specialty. long ago that there was a feeling abroad in favour of ings of the average county asylum. But when all is urged lay management of our large asylums. Well, to those that can be brought forward to support this side of the quesof us who have lived long enough this is nothing tion, I shall still hold the opinion that while no expense Ideas occur in cycles, and what to the experienced should be spared to provide the necessary appliances and the new. is but the repetition of an oft-exploded theory comes to those most favourable environment for the curable, yet in a diswho are new to the subject and who have not given it much tinctly appreciable proportion of the incurably insane and consideration as something which, to put it at its lowest, the mentally deficient a kindly, judicious, and truly philanmerits at least a trial. It does appear to me that in few thropic system of treatment might be adopted without loss other positions is the combination of the medical man with of benefit to the class in question and at a much reduced the good organiser so necessary as at the head of an cost to the long-suffering ratepayer. As to the form in which establishment in which the treatment of the inmates is accommodation should be provided for those suffering from not purely medical or purely reformatory or merely mental disorders of a curable nature, I am delighted to think curative, but where many methods must be employed if that the trend of educated opinion in this country is in ultimate success in dealing with the variety of types favour of segregation, and we are all looking forward with which come under our care is to be looked for. It is interest to the result of the experiment which has been taken in this connexion that I regret the establishment of in hand by the East Sussex County Council and by the the huge asylums to which unhappily use is accustoming authorities whose duty it is to provide accommodation for theIn the medium-sized asylum there is just that amount insane poor of Edinburgh and Aberdeen. Dr. Spence conus. of work which any man who is worthy of his position should cluded by referring to the progressive work of the London be able to supervise with due attention to the various depart- County Council at the Claybury Pathological Laboratory and ments into which the establishment must necessarily be pleaded for the systematic education and training of asylum divided, and where the one governing mind can so utilise attendants. the means of treatment placed at his disposal that whether Dr. W. FORD ROBERTSON (Edinburgh) opened a discussion the individual patient-known to the chief by name, by disupon position, in his family relationships, in his special characterThe -R61e of Toxic Action in the Pathogenesis of Insanity. istics, and in his necessities-requires medical or moral He said that whatever else mind might be it was in thethe of the the the care sick-room or exercise of treatment, first or the of the ward or the farm, place a product of the functional action of certain of quiet stimulating garden cosy effect of the workshop, each can be brought into play without the cerebral neurons. For the normal manifestation of this the risk of producing that friction which practical experience functional action three factors were essential-namely, (1) has shown to be not infrequently present when more than one integrity of the anatomical elements which form the physical controlling influence is in operation. As a question of ex- basis of mind (cortical neurons) ; (2) suitable nutritional pense, I have yet to learn that the medium-sized asylum is conditions for these anatomical elements ; and (3) those more costly in its management than the large establishments sensory impulses which, commencing to impress the which, while they excite the wonder of the inexperienced, anatomical elements at an early period of life, gradually produce only feelings of regret in the minds of those who endow them with their special functional powers and of have to govern them. Nor have I had it proved to me that which the almost continual stimulus is required in order to better results have been produced either in the treatment of call these powers into action. Morbid mental action might the insane individual himself with regard to the promotion of primarily depend upon a fault on the part of any one of his recovery, the increase of his comfort when in fair bodily these factors. He discussed the importance to be attached health, or his treatment when attacked by illness, physical’ or to inherent and acquired faults on the part of the cortical mental. The feeling of consternation that is abroad inneurons, to the effects of sensory impulses, and to unsuitconnexion with the necessity for still further provision for’ able nutritional conditions. The last might consist either in the insane will have to be dealt with and one cannot resistba deficiency of certain nutritive materials required by the the conviction that the time has come when some change inL nerve-cells or in the presence of chemical substances which the classification of our patients might well be attempted. were taken up by the cells and then disordered their metaHe contended There is ample scope, I feel sure, for hospitals for the insane bolism. Any such substance was a toxin. to which only paying patients at low rates should be admittedL that by far the larger proportion of inherent predisposition and there is a large class of demented lunatics and unteach--to insanity was not based upon any condition that could able imbeciles in asylums for whom plain housing and plain rightly be called degenerative, but depended merely upon dieting might well answer. There are also epileptics andIthe presence of one extreme of those wide though limited imbeciles in workhouses who should no longer, or only for thedifferences that individuals exhibit in the reactive qualities short time that is required to provide other abodes for them,, of their nerve-cells to various forms of toxic action. He be detained in places which, on the showing of manyr specially insisted upon the importance of the indirect action speakers at a recent Poor-law conference, are quite unsuitedi of toxins upon nerve-cells by causing disease of their nutrient for the care and treatment of such cases. I know full well1 vessels. The various toxic conditions which tended to affect that there is a strong feeling against the herding, as it iss the nerve-cells might arise from (1) exogenous toxic agents, called, of a number of imbeciles and demented people3 (2) infections, and (3) auto-intoxication and auto-infection. together. 1 have heard not so long ago a very forcibly-- Special importance was attributed to alcohol, syphilis, and expressed opinion that it would be an improper thing auto-intoxication, and auto-infection from the gastro-intestinal to remove the demented from our asylums, as the prospect t tract. He maintained that various forms of toxaemia of of recovery should never be lost sight of even in thee gastro-intestinal origin were the chief factors in the pathomost apparently hopeless cases, but with all respect t genesis of a large array of acute and chronic diseases, for the opinion of such a distinguished member of our r including several forms of mental disease. These diseases specialty as Sir James Crichton Browne, I cannot think comprised the various manifestations of arterio-sclerosis, a that for the sake of the very occasional case of recovery to o large proportion of cases of senile insanity, general paralysis, which he referred in his admirable address to the Asylum n locomotor ataxy, chronic alcoholic insanity, dementia Workers’ Association we should be deterred from providing g prsecox, idiopathic epilepsy (as the determining cause of the good and proper but comparatively inexpensive accommoda- fit), and most cases of acute and chronic mania and tion for the class of patients to which I allude. It is not my y melancholia and of chronic Bright’s disease. The large intention for one moment to suggest that the chronic dement majority of cases of insanity were not primarily diseases in the counties should not receive the same amount of caree of the brain at all, but were dependent upon the action of that is given to the corresponding class for whom the e toxins derived from elsewhere, which affected the functional Metropolitan Asylums Board is responsible. What I urge’e activity of the cortical neurons by disordering their is that some such accommodation and treatment should d metabolism and often permanently damaging and even is be provided in the counties as are given in London, thus destroying large numbers of them. He endorsed the
endeavour as far
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our
all means which tend in the
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should should
338 opinion of Dr. Mercier that insanity is a disease of the organism which can only be properly understood and properly dealt with when so regarded." Not until such ’views were generally recognised by alienists and gave direction to their investigations into the nature of insanity, Iwould any important further advances be made towards those great preventive and therapeutic measures that were, beyond all questions, attainable in this department of ,practical medicine.
supply last year?? How, also,
does it happen that in the records of the advance of anatomical science this country is distinctly falling behind its continental neighbours ? A foolish piece of insular prejudice has attached a sense of deprecation to the term made in Germany"; but, as in other sciences, so in anatomy. It is to the article made in Germany we must go if we want to find the most trustworthy and accurate anatomical investigation and the results of the most patient work. It is to German laboratories our men must go if they wish to be trained for research and to find the facilities for original work. It is ANATOMY AND PHYSIOLOGY. not that our students are inferior in ability or less zealous WEDNESDAY, JULY 31ST. in the pursuit of knowledge, but it is largely a question of The Presidential Address. lack of material, as in our schools nearly all the available Dr. A. MACALISTER, Professor of Anatomy in the University material is ear-marked for elementary teaching. -of Cambridge, opened the work of this section with some The reason why the condition of things is so different in ,remarks on Germany is this : that there the law of the land makes proThe Anatomy Act and the Teaching of Anatomy. vision for anatomical teaching. The unclaimed bodies of .He said : One of the consequences of the specialism those persons who die in any public institution are ipso facto - characteristic of the modern development of the sciences sent off to the university of the district. A similar law exists .ancillary to medicine is that many of the more interest- in Russia, Austria, and France. In this country there is no -ing new advances in these branches of knowledge are provision whatever made by law for anatomy. It is left to .not of much interest to the practitioner. This is par- the professor of anatomy to endeavour to obtain what material ticularly the case as regards anatomy. The growth of is wanted. In my recently published Memoir of Professor ’that science of late years has been greatest on its morpho- Macartney I have dealt at some length with the subject of logical side, and it must be confessed that as yet the anatomical legislation in Great Britain, so I need only inpractical applications of these modern extensions are not dicate one or two of the points in the law which affect the obvious on the surface. I do not say that they are quite teaching of this subject. There is one Act of Parliament, - devoid of practical interest, for it is our experience that c. 75 of the 2 and 3 William IV. passed in 1832. This the scientific curiosities of one period are the funda- Anatomy Act is simply of a permissive nature, one which mental principles of the necessities of the next. Neither neither provides nor even suggests any method whereby -do I mean to say that practical anatomy has ceased to be the bodies can be procured. It only permits any medical man ..groundwork of the studies of the medical student. Present- being licensed by the Home Secretary to practise anatomy day surgery, which boldly adventures into regions of the provided he practises it in a licensed place. It requires that Office must be notified of the receipt of a body .body whereinto our predecessors dared not enter, requires the Homehours of its arrival, and that a medical certificate those who practise it to possess an intimate knowledge of within 24 the cause of death must be sent with the notification. of of the were which a as body century ago parts only regarded .of speculative importance. The knowledge of the minute It further requires that the body must be buried with whatdetails of the relational anatomy of the abdominal organs ever religious rites are usual in the particular denomination .and of cranio-cerebral topography are necessary parts of the to which the deceased belonged, and in a public cemetery, .education of the modern surgeon, as is that of the complex and that the formal burial certificate must be lodged in the system of nerve paths and neuron groups an essential element Home Office at or before a specified date. Under these of the knowledge of a modern physician. The work of the conditions a medical man is not liable to prosecution for the Act provides no .dissecting-room and histological laboratory bulks as largely practical anatomy. Strangely enough, as ever in the curriculum of the twentieth century medical penalties for breaches of it, nor is there any machinery for student, and as with the increased burdens which a wider prosecuting those who infringe it. The Act empowers the .’range of education has made essential the medical student Home Secretary to appoint inspectors, but says nothing - cannot spend quite as much time as heretofore in anatomical whatever as to their duties or authority ; and, although they mysterious powers, it is study it behoves us to see that these departments of our are supposed to be endowed with not from the statute that they derive such, if they really .medical schools are as perfectly equipped as possible. Now it happens, from the nature of the case, that the study possess them. So far the legislation only restricts the practice of anatomy. of practical anatomy labours under difficulties which do not beset any of the other fundamental sciences. The professors Before the Act was passed there was nothing to prevent any in the other departments can in open market procure the man from dissecting a body anywhere, so long as the act was materials for the supply of their laboratories in a way which not capable of being construed into a scandal contra bonos the anatomist cannot. It is true he can buy bones, models, mores. Its only positive provision is that it declares the .and casts, but they are only a very small part of his equip- right of anyone having legal custody of a body to hand it over ment ; it is impossible to teach anatomy without an adequate to the licensed anatomist not sooner than 48 hours after . supply of bodies for the dissecting-room, and every year the death. It does not define what legal possession means, problem of that supply is becoming more acute. This and, considering that it has been decided by more than one -growing difficulty depends on several conditions, some of judicial authority that a corpse is not property and cannot which are inseparable from the material and intellectual be dealt with or bequeathed by deed or will, it is difficult to progress of the age. Better wages and improved education see how one can possess what is not property. The permis,have raised the worker in the community to a higher and sion granted in the Act is no new thing ; from the beginning The proportion of systematic medical training in England in the thirteenth (more independent and satisfactory position. of those who are driven by stress of want into the State- century the right to dispose of a body by those in whose posprovided asylums for the destitute is diminishing. Improved session it was has been unquestioned. The Act therefore ,postal and telegraphic communication enables the relatives of gives no power which did not exist before. The result of .any who, from their faults or misfortunes, have become sub- the Act simply is that the anatomist is made to share merged to receive notification of their whereabouts, and in with the publican and the pawnbroker this distinction- the event of their death increasing facilities of transport that he cannot practise his craft except on licensed .enable them to claim the bodies far more easily than was premises, he himself also being licensed. He is not in any - the case half a century ago. way helped forward towards his supply. He is left to himself It is not, however, the lack of available material that is as to seek out those that have cadavera in custody, and is not yet the chief difficulty. We are a long way off the condition aided in his efforts to persuade them to hand them over of social and ethical perfection in which there is no sub- to him. In practice it comes to this-that the anatomist merged fraction of the population, and while humanity con- seeks the Poor-law guardians and endeavours to obtain his tinues as it is the poor we shall ever have with us, and supply from them. Now, Poor-law guardians are periodically .among them there is little prospect of the disappearance of elected. The constituency returning them is wide and the the class who by their own vices or follies have sundered franchise qualification minimal. The office is much desired themselves from their connexions and who find ultimate by a considerable section of the community and hence the ,refuge in the State-aided asylums. Why, then, should there elections are often contested. The Englishman is a sentibe the difficulty ? How has it come to pa.ss that with no mental person, and thoseseeking his vote can gain the ;great diminution of the number of unclaimed bodies many of interest of the elector in no more sure way than by work,the London medical schools were starved of their needful ing on his feelings and sympathies. Experience has shown
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M1tnicipal and County Laboratory Work. In his absence a paper by Dr. E. C. SEATON(London) was Tread by one of the secretaries. Dr. Seaton’s opinion was "that laboratory work entered more than ever into the daily routine of the public health and sanitary departments of .’most municipalities. After a full retrospect of the facts of the case the scope of sanitary analyses was next In every large town there .dealt with in the paper. was a demand for bacteriological examinations for diagnostic purposes in aid of the general practitioner and .also for hospital purposes which might be provided at a - Central bureau connected with the municipal offices. The - -tirst object of the sanitary authority should be to repress health and not to allow this to become subordinated, it had been for some time past, to the detection of a The concentration of ’certain kind of commercial fraud. ,laboratory work was then discussed by Dr. Seatori, who gave details of the county laboratory of Worcestershire, where the
-injury to .as
analytical chemist, Dr. Duncan, conducted the diagnostic examinations for diphtheria, empyema fluid, tubercle, &c.
Mr. HBNHY MAY (late medical officer of health of Aston considered that no injustice was done bya county medical officer of health being also district medical officer of health. Mr. T. W. H. GARSTANG (Bowdon, Cheshire) advocated "security of tenure" for medical officers of health. He thought that weekly notification of infectious diseases was a matter dependent on local conditions. Dr. E. J. SLADE-KING (Ilfracombe) said that Parliament should make weekly returns absolutely compulsory. If parish medical men were life officers it was much more important that medical officers should be. At this stage of the discussion Dr. J. GROVES (Carisbrooke, Isle of Wight) moved, Dr. SLADE-EiNG seconded, and Mr. HERBERT JONES (Hereford) supported, the following proprosition, which was carried later in the proceedings :—
Manor)
That having regard to the paramount importance to the interests of the public health of security of tenure of office of sanitary officers the State Medicine Section beg to express their approval of the action of the council in promoting a Bill in Parliament to that end and their thanks for the same.
Alderman WALTER SMITH; (London) fadvocatedj that bacteriological examinations should be undertaken by sanitary authorities for medical men gratuitously. Dr. A. K. CHALMERS (Glasgow) said that in his district the bacteriological work was done gratuitously with satisfactory results. The PRESIDENT believed that the ultimate solution of the problem of the relations between the county and district medical officers of health would be found in the appointment of both by the county council. Dr. BOND, in winding up the discussion, said that it was desirable to haveas much elasticity as possible in this matter and that the requirements of efficiency should not impose undue pressure on county finances. Dr. D. S. DAVIES (Bristol) read a paper on Plague and its Prevention as a -Disease Communicable from Animal to Man and at the conclusion he made the following motion which was seconded and carried :— That this meeting considers the time has come when the question dealing with ship-brought plague deserves the attention of the Government, with the view of securing an international agreement whereby merchant vessels shall take the necessary steps for the destruction of rats on board before loading and upon discharge, and, in addition, for the adoption of uniform steps to prevent intercommunication during loading and discharging between ship and shore rats. of
PSYCHOLOGICAL MEDICINE. WEDNESDAY, JULY 31ST. The Presidential Address. Dr. J. B. SPENCE, resident physician and superintendent, Staffordshire County Asylum, Burntwood, delivered the following introductory remarks at the opening of the section :Asylum Administration and Nursing. Dr. Mercier, in his well-known crisp and incisive manner, has in the last number of the British Medical Journal for 1900 given a brief, instructive, and interesting account of the position of affairs in the lunacy world at the commencement of the last century, and it would well repay the labour involved and the time occupied if one had the opportunity to enumerate in detail the various discoveries, improvements, and legal enactments which have so advantageously changed the treatment of the mentally afflicted since that period. Not only, however, were the insane subject to very terrible and inhuman treatment at the commencement of the last century, but in many other directions also the condition of the people was practically in a state as unsatisfactory. Picture to yourselves the prisons of those days-the dens to which debtors were relegated, the condition of the poor in their own homes, the monstrosities practised in the name of justice, when men were sentenced to death, and not only sentenced but in some instances actually hanged, for offences which in these happier days would be considered as severely punished by a few months, or at the most years, of imprisonment in establishments which, when contrasted with the prisons of a century ago, may fairly be said to have made as great an advance as that which has taken place in our asylums or other public hospitals. For
the marvellous progress that has marked the past century
337 and has rendered the Victorian not rest content with
era a golden one we being merely grateful, but
the acute asylums and enabling them to carry out the work for which they should be, in my opinion,
relieving
There is the difficulty for the small counties power to maintain and promote reserved. direction of useful progress, and that an institution common ’to several would probably be so continue the great work which has made the names required owing to the few cases each of these counties of Tuke, Conolly, the Browns (father and son), Buck- would have to provide for. It has been said also that even nill, Maudsley, Clouston, and many others honoured the individual lowest in the scale of mental degradaI heard it said not tion can appreciate the bright and comfortable surroundand glorious in our specialty. long ago that there was a feeling abroad in favour of ings of the average county asylum. But when all is urged lay management of our large asylums. Well, to those that can be brought forward to support this side of the quesof us who have lived long enough this is nothing tion, I shall still hold the opinion that while no expense Ideas occur in cycles, and what to the experienced should be spared to provide the necessary appliances and the new. is but the repetition of an oft-exploded theory comes to those most favourable environment for the curable, yet in a diswho are new to the subject and who have not given it much tinctly appreciable proportion of the incurably insane and consideration as something which, to put it at its lowest, the mentally deficient a kindly, judicious, and truly philanmerits at least a trial. It does appear to me that in few thropic system of treatment might be adopted without loss other positions is the combination of the medical man with of benefit to the class in question and at a much reduced the good organiser so necessary as at the head of an cost to the long-suffering ratepayer. As to the form in which establishment in which the treatment of the inmates is accommodation should be provided for those suffering from not purely medical or purely reformatory or merely mental disorders of a curable nature, I am delighted to think curative, but where many methods must be employed if that the trend of educated opinion in this country is in ultimate success in dealing with the variety of types favour of segregation, and we are all looking forward with which come under our care is to be looked for. It is interest to the result of the experiment which has been taken in this connexion that I regret the establishment of in hand by the East Sussex County Council and by the the huge asylums to which unhappily use is accustoming authorities whose duty it is to provide accommodation for theIn the medium-sized asylum there is just that amount insane poor of Edinburgh and Aberdeen. Dr. Spence conus. of work which any man who is worthy of his position should cluded by referring to the progressive work of the London be able to supervise with due attention to the various depart- County Council at the Claybury Pathological Laboratory and ments into which the establishment must necessarily be pleaded for the systematic education and training of asylum divided, and where the one governing mind can so utilise attendants. the means of treatment placed at his disposal that whether Dr. W. FORD ROBERTSON (Edinburgh) opened a discussion the individual patient-known to the chief by name, by disupon position, in his family relationships, in his special characterThe -R61e of Toxic Action in the Pathogenesis of Insanity. istics, and in his necessities-requires medical or moral He said that whatever else mind might be it was in thethe of the the the care sick-room or exercise of treatment, first or the of the ward or the farm, place a product of the functional action of certain of quiet stimulating garden cosy effect of the workshop, each can be brought into play without the cerebral neurons. For the normal manifestation of this the risk of producing that friction which practical experience functional action three factors were essential-namely, (1) has shown to be not infrequently present when more than one integrity of the anatomical elements which form the physical controlling influence is in operation. As a question of ex- basis of mind (cortical neurons) ; (2) suitable nutritional pense, I have yet to learn that the medium-sized asylum is conditions for these anatomical elements ; and (3) those more costly in its management than the large establishments sensory impulses which, commencing to impress the which, while they excite the wonder of the inexperienced, anatomical elements at an early period of life, gradually produce only feelings of regret in the minds of those who endow them with their special functional powers and of have to govern them. Nor have I had it proved to me that which the almost continual stimulus is required in order to better results have been produced either in the treatment of call these powers into action. Morbid mental action might the insane individual himself with regard to the promotion of primarily depend upon a fault on the part of any one of his recovery, the increase of his comfort when in fair bodily these factors. He discussed the importance to be attached health, or his treatment when attacked by illness, physical’ or to inherent and acquired faults on the part of the cortical mental. The feeling of consternation that is abroad inneurons, to the effects of sensory impulses, and to unsuitconnexion with the necessity for still further provision for’ able nutritional conditions. The last might consist either in the insane will have to be dealt with and one cannot resistba deficiency of certain nutritive materials required by the the conviction that the time has come when some change inL nerve-cells or in the presence of chemical substances which the classification of our patients might well be attempted. were taken up by the cells and then disordered their metaHe contended There is ample scope, I feel sure, for hospitals for the insane bolism. Any such substance was a toxin. to which only paying patients at low rates should be admittedL that by far the larger proportion of inherent predisposition and there is a large class of demented lunatics and unteach--to insanity was not based upon any condition that could able imbeciles in asylums for whom plain housing and plain rightly be called degenerative, but depended merely upon dieting might well answer. There are also epileptics andIthe presence of one extreme of those wide though limited imbeciles in workhouses who should no longer, or only for thedifferences that individuals exhibit in the reactive qualities short time that is required to provide other abodes for them,, of their nerve-cells to various forms of toxic action. He be detained in places which, on the showing of manyr specially insisted upon the importance of the indirect action speakers at a recent Poor-law conference, are quite unsuitedi of toxins upon nerve-cells by causing disease of their nutrient for the care and treatment of such cases. I know full well1 vessels. The various toxic conditions which tended to affect that there is a strong feeling against the herding, as it iss the nerve-cells might arise from (1) exogenous toxic agents, called, of a number of imbeciles and demented people3 (2) infections, and (3) auto-intoxication and auto-infection. together. 1 have heard not so long ago a very forcibly-- Special importance was attributed to alcohol, syphilis, and expressed opinion that it would be an improper thing auto-intoxication, and auto-infection from the gastro-intestinal to remove the demented from our asylums, as the prospect t tract. He maintained that various forms of toxaemia of of recovery should never be lost sight of even in thee gastro-intestinal origin were the chief factors in the pathomost apparently hopeless cases, but with all respect t genesis of a large array of acute and chronic diseases, for the opinion of such a distinguished member of our r including several forms of mental disease. These diseases specialty as Sir James Crichton Browne, I cannot think comprised the various manifestations of arterio-sclerosis, a that for the sake of the very occasional case of recovery to o large proportion of cases of senile insanity, general paralysis, which he referred in his admirable address to the Asylum n locomotor ataxy, chronic alcoholic insanity, dementia Workers’ Association we should be deterred from providing g prsecox, idiopathic epilepsy (as the determining cause of the good and proper but comparatively inexpensive accommoda- fit), and most cases of acute and chronic mania and tion for the class of patients to which I allude. It is not my y melancholia and of chronic Bright’s disease. The large intention for one moment to suggest that the chronic dement majority of cases of insanity were not primarily diseases in the counties should not receive the same amount of caree of the brain at all, but were dependent upon the action of that is given to the corresponding class for whom the e toxins derived from elsewhere, which affected the functional Metropolitan Asylums Board is responsible. What I urge’e activity of the cortical neurons by disordering their is that some such accommodation and treatment should d metabolism and often permanently damaging and even is be provided in the counties as are given in London, thus destroying large numbers of them. He endorsed the
endeavour as far
as
lies in
our
all means which tend in the
,
should should
338 opinion of Dr. Mercier that insanity is a disease of the organism which can only be properly understood and properly dealt with when so regarded." Not until such ’views were generally recognised by alienists and gave direction to their investigations into the nature of insanity, Iwould any important further advances be made towards those great preventive and therapeutic measures that were, beyond all questions, attainable in this department of ,practical medicine.
supply last year?? How, also,
does it happen that in the records of the advance of anatomical science this country is distinctly falling behind its continental neighbours ? A foolish piece of insular prejudice has attached a sense of deprecation to the term made in Germany"; but, as in other sciences, so in anatomy. It is to the article made in Germany we must go if we want to find the most trustworthy and accurate anatomical investigation and the results of the most patient work. It is to German laboratories our men must go if they wish to be trained for research and to find the facilities for original work. It is ANATOMY AND PHYSIOLOGY. not that our students are inferior in ability or less zealous WEDNESDAY, JULY 31ST. in the pursuit of knowledge, but it is largely a question of The Presidential Address. lack of material, as in our schools nearly all the available Dr. A. MACALISTER, Professor of Anatomy in the University material is ear-marked for elementary teaching. -of Cambridge, opened the work of this section with some The reason why the condition of things is so different in ,remarks on Germany is this : that there the law of the land makes proThe Anatomy Act and the Teaching of Anatomy. vision for anatomical teaching. The unclaimed bodies of .He said : One of the consequences of the specialism those persons who die in any public institution are ipso facto - characteristic of the modern development of the sciences sent off to the university of the district. A similar law exists .ancillary to medicine is that many of the more interest- in Russia, Austria, and France. In this country there is no -ing new advances in these branches of knowledge are provision whatever made by law for anatomy. It is left to .not of much interest to the practitioner. This is par- the professor of anatomy to endeavour to obtain what material ticularly the case as regards anatomy. The growth of is wanted. In my recently published Memoir of Professor ’that science of late years has been greatest on its morpho- Macartney I have dealt at some length with the subject of logical side, and it must be confessed that as yet the anatomical legislation in Great Britain, so I need only inpractical applications of these modern extensions are not dicate one or two of the points in the law which affect the obvious on the surface. I do not say that they are quite teaching of this subject. There is one Act of Parliament, - devoid of practical interest, for it is our experience that c. 75 of the 2 and 3 William IV. passed in 1832. This the scientific curiosities of one period are the funda- Anatomy Act is simply of a permissive nature, one which mental principles of the necessities of the next. Neither neither provides nor even suggests any method whereby -do I mean to say that practical anatomy has ceased to be the bodies can be procured. It only permits any medical man ..groundwork of the studies of the medical student. Present- being licensed by the Home Secretary to practise anatomy day surgery, which boldly adventures into regions of the provided he practises it in a licensed place. It requires that Office must be notified of the receipt of a body .body whereinto our predecessors dared not enter, requires the Homehours of its arrival, and that a medical certificate those who practise it to possess an intimate knowledge of within 24 the cause of death must be sent with the notification. of of the were which a as body century ago parts only regarded .of speculative importance. The knowledge of the minute It further requires that the body must be buried with whatdetails of the relational anatomy of the abdominal organs ever religious rites are usual in the particular denomination .and of cranio-cerebral topography are necessary parts of the to which the deceased belonged, and in a public cemetery, .education of the modern surgeon, as is that of the complex and that the formal burial certificate must be lodged in the system of nerve paths and neuron groups an essential element Home Office at or before a specified date. Under these of the knowledge of a modern physician. The work of the conditions a medical man is not liable to prosecution for the Act provides no .dissecting-room and histological laboratory bulks as largely practical anatomy. Strangely enough, as ever in the curriculum of the twentieth century medical penalties for breaches of it, nor is there any machinery for student, and as with the increased burdens which a wider prosecuting those who infringe it. The Act empowers the .’range of education has made essential the medical student Home Secretary to appoint inspectors, but says nothing - cannot spend quite as much time as heretofore in anatomical whatever as to their duties or authority ; and, although they mysterious powers, it is study it behoves us to see that these departments of our are supposed to be endowed with not from the statute that they derive such, if they really .medical schools are as perfectly equipped as possible. Now it happens, from the nature of the case, that the study possess them. So far the legislation only restricts the practice of anatomy. of practical anatomy labours under difficulties which do not beset any of the other fundamental sciences. The professors Before the Act was passed there was nothing to prevent any in the other departments can in open market procure the man from dissecting a body anywhere, so long as the act was materials for the supply of their laboratories in a way which not capable of being construed into a scandal contra bonos the anatomist cannot. It is true he can buy bones, models, mores. Its only positive provision is that it declares the .and casts, but they are only a very small part of his equip- right of anyone having legal custody of a body to hand it over ment ; it is impossible to teach anatomy without an adequate to the licensed anatomist not sooner than 48 hours after . supply of bodies for the dissecting-room, and every year the death. It does not define what legal possession means, problem of that supply is becoming more acute. This and, considering that it has been decided by more than one -growing difficulty depends on several conditions, some of judicial authority that a corpse is not property and cannot which are inseparable from the material and intellectual be dealt with or bequeathed by deed or will, it is difficult to progress of the age. Better wages and improved education see how one can possess what is not property. The permis,have raised the worker in the community to a higher and sion granted in the Act is no new thing ; from the beginning The proportion of systematic medical training in England in the thirteenth (more independent and satisfactory position. of those who are driven by stress of want into the State- century the right to dispose of a body by those in whose posprovided asylums for the destitute is diminishing. Improved session it was has been unquestioned. The Act therefore ,postal and telegraphic communication enables the relatives of gives no power which did not exist before. The result of .any who, from their faults or misfortunes, have become sub- the Act simply is that the anatomist is made to share merged to receive notification of their whereabouts, and in with the publican and the pawnbroker this distinction- the event of their death increasing facilities of transport that he cannot practise his craft except on licensed .enable them to claim the bodies far more easily than was premises, he himself also being licensed. He is not in any - the case half a century ago. way helped forward towards his supply. He is left to himself It is not, however, the lack of available material that is as to seek out those that have cadavera in custody, and is not yet the chief difficulty. We are a long way off the condition aided in his efforts to persuade them to hand them over of social and ethical perfection in which there is no sub- to him. In practice it comes to this-that the anatomist merged fraction of the population, and while humanity con- seeks the Poor-law guardians and endeavours to obtain his tinues as it is the poor we shall ever have with us, and supply from them. Now, Poor-law guardians are periodically .among them there is little prospect of the disappearance of elected. The constituency returning them is wide and the the class who by their own vices or follies have sundered franchise qualification minimal. The office is much desired themselves from their connexions and who find ultimate by a considerable section of the community and hence the ,refuge in the State-aided asylums. Why, then, should there elections are often contested. The Englishman is a sentibe the difficulty ? How has it come to pa.ss that with no mental person, and thoseseeking his vote can gain the ;great diminution of the number of unclaimed bodies many of interest of the elector in no more sure way than by work,the London medical schools were starved of their needful ing on his feelings and sympathies. Experience has shown
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