The skin, muscles, and bones of patients could all be studied during the patient’s lifetime to some degree. The brain, though, could only be fully investigated after death even as its functions could be studied indirectly and its structural defects inferred via reflex and other tests. Looking at the brain of the general paralytic patient in the postmortem room, it was clear to asylum researchers that the condition had a serious impact on the brain substance: it was soft and often riddled with unusual lesions. Doctors seized upon the general paralytic brain as an object that had much to tell them not only about the course of general paralysis, but also about mental disease and neurophysiology more broadly. Lesions were meticulously mapped in diagrammatic form to investigate localisation of brain function, and microscopic examination of the brain tissue revealed the ‘spider cell,’ which promised to reveal something more of the disease’s aetiology.
Upon removing the brain from the skull at postmortem, the most immediately evident of these changes was cerebral softening. One brain, when placed on a flat surface, had “hemispheres that separated widely.” Like the muscles and bones, the brain was susceptible to degenerative, softening influences. Causes of death in asylum annual reports and minutes regularly included “softening of the brain” and the term was still used by some doctors at the beginning of the twentieth century as a synonym for general paralysis. In asylum admission documents, it is clear that “softening of the brain” was a term that could be used by doctors outside the asylum to refer to what they saw as a specific variety of mental disease. One doctor related that the patient had “marked symptoms of brain softening,” and another noted of a criminal lunatic: “His disease is softening of the brain, known as general paralysis of the insane.”
Softening of the brain might have been a key indicator of mental disease, but it was a process that was maddening to the pathological investigator, in some instances reducing the brain to nothing more than a boggy mess. Taming this softened tissue was a frequent challenge for asylum pathologists. Bevan Lewis wrote a series of articles for the neurological journal Brain between 1880–1882, titled ‘Methods of Preparing, Demonstrating, and Examining Cerebral Structure in Health and Disease.’ One part of this series, ‘Physical Properties of Grey and White Matter,’ emphasised the importance of the student’s own senses in observation, as there was “no more exact gauge of consistence of texture than the rough-and-ready methods afforded by the sense of sight and touch.” Here, he described the key differences between a normal brain and the softened, diseased brain: whilst the former was “plump, rounded and compact,” the latter was “flattened,” “squat,” and, when removed from the skull, revealed “flabby” convolutions and little resistance to pressure.
In seeking to make the brain readable for such investigation, or to preserve it for future study or teaching, however, the organ itself posed challenges. Dealing with this softened substance called for new methods of preservation and modes of investigation in order to make the brain properly legible.
Studying the Brain
James F. was admitted to the West Riding Asylum in May 1887. Unfortunately, he was no stranger to the institution, having been discharged just a few months earlier. His sister reported that since his discharge he had continued to wander the streets, often disappearing for days at a time. He refused to give any explanation for his disappearances and when he was at home was said to be going about frightening the local children by “making grimaces” at them.
Entering the Asylum for a second time, James told the admitting doctor an elaborate story about a divorce, an illegitimate child, and a large quantity of jewellery that he possessed. Listening to the delusions of grandeur so characteristic of general paralysis and noting James’s tremulous tongue, flabby muscles, and sluggish reflexes, the doctor diagnosed “Dementia, with General Paralysis.” During his time in the Asylum James’s doctors could do little but watch him slowly succumb to the disease as he lost control over his movements and suffered an increasing number of seizures. Two years after his admission he was having fits every two to three weeks, his speech was slurred, and his patellar reflexes had disappeared completely.
Upon James’s death in July 1889, the West Riding doctors continued to examine his body for hints to the root of his condition. As one trace of James ended in a casebook record, another began in the postmortem book, where his major organs were examined and their appearances recorded in meticulous detail. Half of James’s postmortem record was dedicated to his brain, particularly whether any unusual appearances could be seen on the organ’s surface. Imagined as the root of James’s disorder, the brain was the final part of his body to come under the doctor’s gaze: it was examined closely, divided into sections, and the weight of each section carefully recorded.
James’s doctors were not unusual in their interest in his brain. What was notable at the time of their investigations, though, was the level of detail with which they were able to investigate the organ. Scholars had been musing upon the structure and functions of the brain for many years; in the seventeenth century Thomas Willis had suggested that the complexity of the convolutions of the brain could indicate an individual’s intellectual ability. This analogy between intellect and physical structure could also be seen in Franz Joseph Gall and Johann Gaspar Spurzheim’s early nineteenth-century phrenology.
The rationale of phrenology was quite simple: the outer shape of the skull was used to make estimations of the structure of the brain inside. Gall and Spurzheim produced elaborately detailed ‘maps’ of the brain, attempting to locate discrete psychological attributes in specific areas, including characteristics such as amiability or wittiness. Though intriguing, their conclusions rested on some questionable evidence. A frequently cited example was Gall’s recollection of a classmate who had peculiar bulging eyes and an excellent verbal memory, leading him to the conclusion that the frontal lobe was the seat of language (the lobe in his classmate’s case being so well-developed as to push the eyes outwards).
At the same time that Gall and Spurzheim were espousing their doctrine of phrenology, medical men in France were beginning to correlate clinical symptoms with the findings of pathological anatomy and physiological experiment. Here, the focus was less on personality traits or intelligence than the kinds of motor functions. Paul Broca was said to have presented some of the most convincing evidence for a link between cerebral damage and loss of function at an 1861 meeting of the Paris Société d’Anthropologie. There, he presented the brain of a patient, nicknamed ‘Tan’ on account of the only syllable he could utter, who had suffered from language difficulties; his brain had marked frontal lobe damage. Work like Broca’s made a strong case for the place of pathological anatomy in localisation work, gaining a deeper understanding of the brain and mapping its functions.
It did not take long for the French model to reach England, where it arrived into an atmosphere of enthusiastic innovation in medicine—the rise of anaesthesia and antiseptics, for example—and a healthy increase in professional journals that allowed researchers to disseminate their findings beyond their own institutions.
The concept of localisation of function clearly appealed to the physiological method for its supporting evidence, and was closely tied to the earlier doctrine of phrenology. By the end of the 1840s, though, “the full-time, pure physiologist, who … devoted all his time to research on the nervous system” may have distanced himself from the (by then somewhat outmoded) theories of Gall. Instead, as L. Stephen Jacyna argues, he found in physiological psychology “a partly novel way of continuing an old argument.” The work of researchers such as Marshall Hall, on the ‘reflex arc’ of the spinal cord, had made the distinct separation of mind and matter increasingly difficult. The reflex model of function as articulated by Thomas Laycock and Wilhelm Griesinger, for example, precipitated the kind of tests described in “Muscle” that turned the patient’s body into “a machine of its own revealing.”
The reflex model provided the tools through which alienists could imagine the somatic origins of mental disorder. It underwent an important development in the work of John Hughlings Jackson who—influenced by Herbert Spencer (in turn influenced by Gall)—applied evolutionary logic to neurological disorders and achieved widespread renown for his work on epilepsy in the 1870s.
To Jackson mind and body were parallel yet separate, a concept expressed in his “doctrine of concomitance”; this idea allowed the nervous system to be understood from both a psychological and a physiological point of view. Historians have emphasised the contribution of Jackson’s work as primarily conceptual, rather than practical (though it drew strongly on principles from the natural sciences). Even as a basic conceptual framework, Jackson was able to use his theory to remind researchers of the importance of the structure and function of the nervous centres to normal mental and bodily processes. In extending and modifying the theory of evolution with his notion of a “dissolution” that could affect the brain’s functions, he provided a neat, if somewhat vague, explanation of the mechanics of mental decline (though Jackson’s concern was the sensory-motor functioning of the brain, it was difficult to do away entirely with the psychological aspect as studied by Gall).
Jackson’s work strongly influenced David Ferrier; the latter’s investigations into cerebral localisation at the West Riding referred back explicitly to Jackson’s epilepsy studies as he attempted to induce seizures in animals using electric current. James Crichton-Browne, who had invited Ferrier to conduct his research at the West Riding Asylum, encapsulated at once the various influences described above. The French model of matching clinical symptoms to pathological anatomy was central to his approach, and his family background in phrenology had convinced him of the links between material change to the brain and mental disease, leading him to view gross pathology as the “staple of asylum research.” Browsing the contents of the in-house journal the West Riding Lunatic Asylum Medical Reports, one can see that this was an interest held by other staff and visiting doctors to the Asylum, with papers on everything from brain weight to cranial injuries and insanity. Successive superintendents maintained Crichton-Browne’s focus: William Bevan Lewis was a particularly keen observer, producing various articles on pathological technique as well as a substantial guide to histological methods, The Human Brain, in 1882.
The rationale behind this kind of asylum work in the nineteenth century—insanity as a disease of the brain—meant that the alienist profession was one that could be cautiously optimistic about its ability to relieve the symptoms of, and possibly even cure, mental disease via physical methods. We might view the popularity of such an approach as being in its practical—somewhat self-serving—basis, as holding out the promise of professional autonomy for alienist science. Equally, though, it was an approach that reflected contemporary scientific concerns and, in the case of general paralysis, a degree of desperation. In 1876 Crichton-Browne asked whether “our professional descendants may look back with pity and censure upon the helpless attitude that we have been content to assume in the presence of general paralysis?” It was a devastating disease and its rapid, vicious spread suggested—more so than other mental diseases—that the condition had a physical basis in the brain. Here, then, was a vague sense of hope: that there was a physical condition of the general paralytic brain that could be uncovered by careful investigation and thus form the basis of preventative or curative treatment.
Studies of the brain in the late nineteenth-century asylum aimed to uncover the essential lesions of disease: visceral alterations to the brain substance. Investigations into the pathological nature of conditions such as general paralysis took place alongside efforts to make the recording and classification of pathological information more consistent. Like the meticulous recording of muscle strength or the breaking strain of ribs, the physical properties of the brain became one part of a wider quantitative exercise. The large volume of patients in the country’s asylums, many of them chronic cases, made the need for an efficient bureaucratic apparatus increasingly urgent if doctors were to deal effectively with this growing population.
In 1870, Montrose Asylum’s James C. Howden emphasised that a standard system of recording lesions at postmortem should be instituted so that comparisons could be made between different asylum populations, and he tabulated 235 cases according to the lesions present. John Batty Tuke at Fife and Kinross Asylum quickly took Howden’s advice to heart and included a table of 75 cases in that asylum’s 1871 annual report. Three years later, W.G. Balfour put together another table of lesions as found in 390 patients at Colney Hatch. Unfortunately, these efforts were not the beginning of a widely accepted system, as researchers continued to use their own classification schemes or terminology according to their personal interests and theories. As a result, data from one population could often be interpreted in different ways. At the West Riding Francis Simpson criticised the conclusion of his colleague William Lloyd Andriezen that sclerosis of the brain (an overgrowth of cells) was common in epileptic idiocy and imbecility. Although Andriezen’s research “[led] the reader to suppose that [sclerosis] was present in nearly every case out of fourteen examined by him,” when Simpson checked the postmortem records he found that Andriezen had performed 15 autopsies, only six of which were of the epileptic type he had described.
Simpson suggested that the high number of abnormalities during Andriezen’s time at the Asylum was mere coincidence rather than evidence of characteristic changes in imbecility and idiocy. Andriezen’s selection of case studies for his article was to some extent a consequence of contemporary publishing practices. It was much more attractive to write and publish perfect illustrative cases that justified one’s work (and that of one’s institution) than it was to relate ambiguous findings. Detailed case reports and studies “transformed uncertainty” and made sense of the sometimes anomalous results of lengthy investigations that had been carried out according to the individual researcher’s or institution’s specifications.
The difficulty of instituting standardised systems didn’t discourage asylum doctors from recording postmortem findings in great quantity and detail, however. In 1889, West Riding Pathologist Frederick St. John Bullen assessed the results of 1565 postmortems carried out at the Asylum over a period of 11 years by a number of people, including three successive superintendents (James Crichton-Browne, Herbert Major, and William Bevan Lewis). Though Bullen acknowledged that not all had followed the same system, he was still able to present a wealth of material on the condition of the brains under study. Looking at the Asylum’s postmortem records that Bullen drew upon, it is clear that staff were taking a steadily more systematic approach to recording their findings. Between 1880 and 1900, postmortem records evolved from a continuous block of text to text split into separate sections head, thorax, and so on.
Source: Investigating the Body in the Victorian Asylum: Doctors, Patients, and Practices 2017.
Categories: Medical Reader