Continuing the theme of medical technologies in the asylum, I’d like to turn to another, much more common instrument, but one whose role in psychiatric study is less well-known: the ophthalmoscope.
Created and described by Helmholtz in 1851, the ophthalmoscope was an instrument that allowed one to see into the back of the eye, revealing specific retinal conditions in diagnoses such as leukaemia, syphilis and diabetes. In particular it revealed the optic disc, the point at which the optic nerve reaches the eye from the brain, thus giving privileged access to the condition of the cerebral matter and the state of circulation in the brain. Short of opening up the skull, this was the only means to view any part of the brain in a living patient; and given that asylum doctors in the nineteenth century were committed to a somatic view of mental illness, and were looking for the physical (cerebral) causes of insanity, this was a useful tool. Yet a conservative medical profession in Britain was often resistant to new instruments replacing the experience and acumen of trained physicians, believing that such experimental, laboratory methods could never supplant the use of unaided senses in the clinic. There were thus initially few British adherents, with Thomas Clifford Allbutt (1836-1925) complaining in 1871 that he could ‘count upon the fingers of one hand’ the number of physicians working with the ophthalmoscope in England.
[There was a strong rumour, still perpetuated today, that Allbutt was the model for Dr. Lydgate in George Eliot’s Middlemarch (first published in serialised form between 1871 and 1872). This is probably wrong, though Eliot did visit Allbutt in September 1868, and wrote that he was a ‘good, clever, graceful man, enough to enable one to be cheerful under the horrible smoke of ugly Leeds’!]
Allbutt, the main proponent of ophthalmoscopy in nineteenth century Britain, was a physician and lecturer at the Leeds General Infirmary, and conducted some of his work at the nearby West Riding Lunatic Asylum (some patients under his care would occasionally make the same journey too). In his classic monograph On the Use of the Ophthalmoscope in Diseases of the Nervous System and of the Kidneys (1871), Allbutt included an appendix of two hundred and fourteen cases of insanity he had observed with an ophthalmoscope at the asylum. He found changes in the eye in a large proportion of those diagnosed with old or organic cases of brain disease. The usefulness of the ophthalmoscope in the asylum was clear to him, as he argued it would help remove ‘the metaphysical or transcendental habit of thought’ and bring a ‘more vigorous and more philosophical mode of investigation’ to disorders of the brain.
Allbutt’s work was continued at the asylum by Charles Aldridge, a young doctor who investigated blood supply in the brain using the ophthalmoscope, a tool which he said was ‘able to diagnose obscure cerebral affections through its instrumentality’. It had long been thought that blood flow, particularly an increased level leading to cerebral inflammation, was at the root of many instances of mental disease. As late as 1879, Bucknill and Tuke still argued that it ‘is most probable that inflammation is not the condition of insanity, but is the exciting cause of a secondary pathological state upon which the symptoms of insanity immediately depend’. The frequency with which inflammation, clots and congestion were found in post-mortem asylum cases was evidence of this.
Physiological experiments had shown that blood flow – and the nutrients, oxygen, and poisons it might contain – was crucial to normal cerebral functioning, and thus provided a route for doctors to describe and explain various mental conditions. In three papers in the 1870s, Aldridge presented his observations of cases of epilepsy, general paralysis and dementia using the ophthalmoscope. He concurred with Allbutt that general paralytics displayed atrophy of the optic disc, and further claimed that one could estimate how long the disease had existed by the relative amount of atrophy. Epilepsy, he found, was concurrent with a state of ‘passive hyperaemia’, whereby blood flow away from the brain was impeded, creating cerebral pressure. By contrast, dementia, whose sufferers were characterised by paleness of the optic disc, probably had its origin in a state of anaemia of the brain. The ophthalmoscope seemed to offer the possibility of diagnosis in all types of insanity.
However, whilst the ophthalmoscope did eventually become a popular instrument amongst general medical clinicians – and those dealing with disorders of the eye or nervous system in particular – it never really took hold in asylum practice. It could be used in the diagnosis of general paralysis, but this was a disease which could be more easily confirmed through other symptoms. And in other forms of insanity the ophthalmoscope was less reliable, as there was no constant causal relationship between lesions in the brain and observations of the eye. Instead, doctors would have to rely on other diagnostic criteria, and wait for the mortuary to make any specific claims about the state of the brain. The ophthalmoscope in the asylum is illustrative of the way in which the potential uses and limits of new medical technologies are tested, and also of the way nineteenth-century asylum doctors followed a variety of leads in their attempts to link mental diseases with specific physical causes.
C. Aldridge, ‘The Opthalmoscope in Mental and Cerebral Diseases’, ‘Opthalmoscopic observations in general paralysis, after the administration of certain toxic agents’, ‘Ophthalmoscopic observations in acute dementia’, West Riding Lunatic Asylum Medical Reports, 1-4 (1871-1874).
T.C. Allbutt, On the Use of the Ophthalmoscope in Diseases of the Nervous System and of the Kidneys (London/New York: Macmillan & Co., 1871).
C. Lawrence, ‘Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain 1850-1914’, Journal of Contemporary History, 20 (1985).
G. Rosen, The Specialization of Medicine, with particular reference to ophthalmology (New York: Froben Press, 1944).