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It will be seen at once that in all the percentages there is a great contrast between A, B, and C on the one hand, and D and E on the other.
The two latter, which also had the greatest excess of male admissions, have a high percentage of cases of organic disease, a very low proportion of recoveries, and a very high ratio of deaths.
It is dangerous to work too much with figures and percentages, but I cannot think that the above is only an accidental coincidence, especially when taken with the following further statement as to the cases admitted during 1873 alone. Of the A admissions 70 per cent. recovered during the year, none died, and none were the subject of organic disease.
Of the B admissions 40 per cent. recovered, 6 per cent. died, and 12 per cent. were subject to organic disease.
Of the C admissions 38 per cent. recovered, 14 per cent. died, and 19 per cent. were subject to organic disease.
On the other hand of the D admissions, 30 per cent. were the subject of organic disease, 22 per cent. died, and only 13 per cent. recovered.
Of the E admissions 33 per cent. were the subject of organic disease, 11 per cent. died, and 11 per cent. recovered.
In order to trace out this interesting point a little further, I have gone into the question of the actual increase of pauper insane in the district and in the different Unions during the last ten years. I have taken, as a basis for the population, the census returns of 1861 and 1871 respectively; and for the numbers of insane, the numbers actually under treatment in Asylums on the 31st December, 1863 and 1873 respectively, correcting these numbers, however, as far as possible, for changes in the ratio of the insane in Asylums to those in the Workhouses.
Increase or Decrease per
Increase per cent. of
+2107 + 2.0 + 5.0
- 5.0 + 4.5 + 5.0
E. Whole District.
80 60 40
These figures, while they show a large increase of insanity in the whole district in proportion to the increase of population, are still more striking in reference to the different unions. It will be seen that in A and B there is a slight proportional decrease of the insane; while in D, E, and C the increase in the number of the insane as compared with that of the population has been enormous, in the case of the first mentioned union amounting to no less than 80 per cent., and this in spite of an actual decrease in the population. I find that C, which also shows a large increase, is peculiar in this respect, that much the largest part of this increase took place prior to 1866, the increase since then only amounting to 9 per cent., while in the case of Macclesfield the increase since then has been 70 per cent. The full significance of these figures however lies in this, that it is the same unions in which such a large increase has taken place that I have already shown are distinguished by a growing tendency to an increase of insanity among the men as compared with the women, as well as by the unfavourable nature of the types of insanity.
The following table finally shows the proportion per 1,000 of the total number of pauper insane to the entire population at the end of 1873:
This tells the same story in another form. The above ratio is not excessive as compared with that throughout the country generally; but Cheshire has generally had one of the lowest ratios. In 1871 it was 1.6 per 1,000 over the whole county. This is just the average ratio for A, B, and C, while that for D and E is 2.67.
From all these considerations we must, I think, draw the conclusion that there is a greater development of insanity going on in some portions of this district than in others; and that in these portions the following general facts are observed.
1.-A large increase of insanity relatively to that of the population.
2.-An increasing ratio of insanity among men as compared with women.
3.-A large proportion of cases due to organic disease or degeneration.
4.-A small ratio of recoveries. 5.-A large ratio of deaths.
No doubt 3, 4 and 5 are to some extent dependent upon number 2, owing to the much greater frequency of general paralysis among men than among women.
But the unfavourable nature of the forms of insanity in these districts is certainly not to be altogether accounted for in this way, nor would this account for the large actual increase of insanity.
I shall not attempt here to offer any speculations as to the possible causes of these discrepancies, although the subject is one well worthy of attention. I will only remark that the local hygienic conditions in D and E are far from favourable, and that there is a great deal of intemperance, the usual handmaid of sanitary neglect. It will also require a longer process of induction in future years thoroughly to establish the conclusions brought out by these statistics, and to do away with the risk of the proverbial fallacy which lurks in all statistics. They appear striking and almost conclusive; but of course must not be taken at more than their true value.* Apart from the local interest attaching to these facts, they are, I think, worthy of some attention in another and more general sense.
They seem to show that the factors which give rise to insanity may vary greatly, even within very narrow limits as regards locality. This we know to be the case with regard
* I find that an analysis of the admissions, discharges, and deaths during the year just ended (1874), shows to a remarkable extent the same peculiarities in the different districts, to which I have drawn attention above. In A, B, and C taken together, the sexes are equal in the admissions, and the percentages of recoveries, of deaths, and of cases of organic disease are respectively 34, 5 and 11, while in D and E, there is a considerable excess of male admissions, and the percentages of recoveries, deaths, and of organic disease are 16, 16 and 28. In regard to the unfavourable nature of the cases, D again heads the list.
to many other diseases, and the modern science of preventive medicine is based largely on this knowledge. May we not hope that some day the knowledge of such differences as I have noticed may lead to the discovery of their causes ? Through careful observation of, and comparison between, the hygienic conditions and prevailing occupations of different places, and of the moral and social habits of the people, the causes of the varying liability to insanity in particular districts may be discovered, and of the various forms which it assumes, as well as the laws which govern its spread and increase. Thus would be laid the foundations of a noble branch of preventive medicine which would have for its object not only to check the ravages of that social scourge, insanity, but to help people to develop their moral, as well as their physical nature, in accordance with the laws of health and the facts of physiology.
On the Physiology of General Paralysis of the Insane and of
Epilepsy.-By GEORGE Thompson, L.R.C.P. Lond. ;
(Continued from page 586, Vol. xx.)
In the introductory remarks contained in the previous portion of this essay, I said that, as far as possible, I would refrain from referring to the condition of the nervous centres as seen after death, except to explain the nature of certain phenomena seen in these diseases during life. Having arrived at the second portion of my subject, I shall draw attention to the condition of the brain and spinal cord where death has been the result of an epileptic fit, or while the patient has been in what is now so well understood as the Status Epilepticus.
But I shall first take a cursory glance at the healthy brain, its structure and functions.
The brain is an erectile organ-in other words, an organ whose functions require that it should be capable of receiving a varying amount of blood. This variation of blood flow is not necessarily general at any given time, but, according to the function to be performed, may be local. It is fair to presume that there are times when the portion of the brain to which is assigned the function of intelligential secretion will be called into active play, while those portions to which
we connect the functions of sense and motion may be at rest. At these times of activity of function, then, whether local or general, a rapid flow of blood is essential. In health the blood vessels are highly distensile, and this distensibility is of a vital, rather than a mechanical character. abundant muscular tissue which they possess, with a corresponding absence of the other constituents of the muscular walls, allows for the vital character of dilatation and contraction of the cerebro-spinal vessels. The gelatinous nature of the reticular tissue allows the relative displacement of the all-important nerve-cells; while the variable ainount of cerebro-spinal fluid allows of expansion of the cerebral mass without compression as the result. The conditions essential to a due performance of the functions of the brain are, then, healthy brain tissue, i.e., cells and fibres; healthy neuroglia, or reticular tissue; healthy vessels-vessels capable of receiving and acting on the command to dilate or to contract, whatever may be the source of such command ; and healthy coverings capable of secreting or absorbing the cerebro-spinal fluid, according to the needs for such secretion or absorption. Given all these conditions, and the MedicoPsychologist would find his occupation gone.
În the disease now under discussion (i.e., epilepsy) it has been proved beyond doubt that at least one of these elements of the brain structure is invariably at fault. This faulty portion is the neuroglia. Dr. Batty Tuke, in the small, but able, portion furnished by him in the “Manual” by Drs. Bucknill and Hack Tuke, shews* how the neuroglia is the subject of no less than five distinct forms of degeneration. These are (a) general sclerosis, (6) disseminated sclerosis, (c) atrophy, (d) miliary sclerosis, (e) colloid degeneration. At least three of these degenerations—the first, second, and fourth—have been found in epileptic subjects; the others occurring thus:-Atrophy in senile dementia, and the colloid form in “ chronic cases. The coarser anatomy of brains of epileptics generally shews hypertrophy, real as to volume, but false as to the actual proportion of nerve tissue; in other words, there is “justt the ordinary amount of nervous matter, plus a certain quantity of interstitial exudation.” The sclerosis of epileptic brains is every day seen. Who has not, in slicing down such a brain, felt the hard resilient touch given to the knife, almost amounting to the sensation given in cutting
* Op. cit., fol. 625. + Handfield Jones, quoted in “Bucknill and Tuke."