Tag Archives: medical technology

The Ophthalmoscope: Viewing The Living Brain

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.

The ophthalmoscope in use, 1872. © Wellcome Images.

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.

Sir Thomas Clifford Allbutt. © National Portrait Gallery, London.

[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.

Images of optic neuritis taken from Allbutt’s 1871 book.

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.

Further Reading

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).

The strange case of the cerebro-graphometer

This week’s post continues a theme that’s been addressed in a couple of previous contributions: the drive to identify and chart brain lesions. Already, we’ve seen how brain slates and printed diagrams were used as a means to map the location of lesions found at post mortem, marking out pathological findings in permanent visual form. But what about less invasive methods – those that could be applied to the living patient?

Phrenology – making deductions about an individual’s personality or state of mind by examining the shape of the skull – is generally agreed to have been waning in popularity by the late 19th century. Its basic tenets, however, could still be seen within localisation theory, as mental diseases were increasingly viewed as the result of somatic, localised lesions.

This melding of phrenological and localisation theory is wonderfully illustrated by an instrument described in the British Medical Journal in 1896. At a meeting of the Royal Academy of Medicine in Ireland that February, Robert H. Cox described a new method of localising brain lesions: his ‘cerebro-graphometer’.

Robert H. Cox’s ‘cerebro-graphometer’.

The instrument was employed alongside ‘a diagrammatic map of a hemisphere of the brain, prepared from readings made by the use of the same instrument on the cadaver and casts of the brain in situ’ (casts were often taken of the brain or inside of the skull at post mortem for museum and teaching purposes). The brilliantly-named cerebro-graphometer consisted ‘of the mechanical device, technically known as “lazy tongs”’. Despite its rather sinister appearance, it was met with positive acclaim by members of the meeting, who were impressed with its simplicity and durability (it could be rendered aseptic for the next use by boiling, for example).

By April 1897, Cox was able to report that the instrument, now perfected, was being manufactured by the surgical instrument makers Arnold & Sons. Describing the cerebro-graphometer’s use, localisation became an activity with its own specialised, performative ritual:

‘Localising is performed as follows: Extend the instrument and apply the end of the lettered loop, marked V, to the occipital protuberance and the other end to the glabella, then press down the loop to the scalp in the middle line and close the circle round the head, so that the 10 on the numbered loop will lie on the lettered loop. Consult the chart for the bearings, and place the number 10 on the letter of longitude, when the number of longitude will rest over the part sought for.’

Once in position, ‘to find any given point – say Broca’s lobe – it was only necessary to consult the map or list of indices for the bearings’. (Keep in mind that one of the selling points of this was the instrument’s ‘simplicity’; the mind boggles at the complexity of alternative methods…)

Diagram for use with Cox’s device.

Like all the best stories, however, there was a minor scandal to come. A month after Cox’s triumphant article in April, a letter to the BMJ begged to inform him that ‘the instrument has been forestalled, for I have possessed for the last ten years an instrument so exactly like his that the illustration might have been taken from it’. The author, William Warwick Wagstaffe, called his own instrument a ‘brain mapper’ (a name, he noted, that he ‘certainly prefer[red] to “cerebro-graphometer”’) and it had been made by Maw & Sons in 1886. Upon its production, Wagstaffe had distributed it to several colleagues for their observations, but ill health had prevented him from collating the final results (after a ‘breakdown in health’ in 1878, he was never to return to active work, having previously acted as Senior Assistant Surgeon and Lecturer in Anatomy at St Thomas’s Hospital in London).

William Warwick Wagstaffe’s ‘brain mapper’.

Cox maintained that the cerebro-graphometer was superior to the brain mapper as ‘[o]nly one motion is necessary to directly localise any given point on the surface of the brain’. Neither Cox’s nor Wagstaffe’s device appeared to enjoy great fame, however. References are almost entirely absent from contemporary journals, and one imagines that the simplicity of the design was its downfall, with individual doctors crafting their own versions rather than buying a more costly one via a surgical instrument retailer. One wonders what happened to those few that were properly manufactured (I have a ridiculous mental image of the lab Christmas party, full of tipsy doctors wearing them as party hats). Perhaps some examples survive in medical museums?

Unlike some other instruments discussed on this blog, the cerebro-graphometer (or brain mapper, if you’re in the Wagstaffe camp) was interesting in its ability to be applied to both the living and the deceased patient. Missing from Cox’s and Wagstaffe’s accounts, however, is the practical issue of how such instruments were employed in a hospital context. Other than reference to the difficulty of hair being caught within the instrument’s folds, we know nothing of how patients actually experienced the process. Perhaps they were fascinated, as William Lauder Lindsay noted of some of his patients when he took blood samples – they badgered him with questions about what their samples revealed, even persuading him to demonstrate his own blood under the microscope. For some, the experience may have been more disturbing, especially if one had deduced that such examinations were also made upon the dead. For others, it was perhaps just another in a long list of physical investigations that were simply a tedious nuisance.

Though it’s difficult to uncover the patient experience via brief reports like those found in the BMJ, looking at evolving investigative techniques can – as Jacyna and Casper note in The Neurological Patient in History – show us ‘how the patient has been constituted in the era of modern medicine’. By asking this question, we can in turn find out much about the knock-on effects of new medical technologies and practices: on theory, everyday routines, and therapeutic efforts. Unfortunately for Cox and Wagstaffe, it seems that their devices were limited in their impact – yet they remain for me an intriguing illustration of medical thinking and innovation in the last part of the 19th century.

Further reading

Robert H. Cox, ‘A New Method for Localising Brain Lesions’, British Medical Journal (3 Apr. 1897).

Robert H. Cox, Correspondence: ‘A New Method of Localising Brain Lesions’, British Medical Journal (30 Oct. 1897).

L. Stephen Jacyna and Stephen T. Casper (eds.), The Neurological Patient in History (NY: University of Rochester Press, 2012).

‘Reports of Societies’, British Medical Journal (21 Mar. 1896).

W. W. Wagstaffe, ‘A New Method of Localising Brain Lesions’, British Medical Journal (1 May 1897).

- Jennifer Wallis

NOTE All reasonable effort has been made to seek permissions for the images contained within this post. If you are the copyright holder, please contact us.

Medical technology in the asylum – and plans for the blog

With the Science in the Asylum conference completed, we’re excited to begin a more regular blog schedule, with posts each Monday from myself, Mike, and guest contributors. Submissions are strongly encouraged – the conference brought us into contact with several people working on the history of science and medicine in relation to the asylum, and we’d love to find more of you! Please get in touch here.

This is the first of our Monday blogs, and takes up a theme we plan to revisit in some future posts: the use of medical technologies within the asylum.

By the 19th century, as doctors increasingly focused on bodily lesions as the site of disease, there was hope that disturbances of the mind might also have somatic origins. It was commonsensical, for example, that the activity of the brain depended upon its blood supply; thus, blood vessels were often identified as the starting point of disease. Daniel Hack Tuke’s Dictionary of Psychological Medicine noted that ‘capillary disorder could lead to a wide variety of dysfunctions’, and suggested that circulatory issues were the cause of many mental diseases. Indeed, during microscopical and post-mortem investigations, the poor state of patient’s blood vessels was often noted.

How could such bodily change be examined in the living patient though? In Medicine and the Reign of Technology, Stanley Reiser lists the new pulse-recording instruments that appeared in the 19thcentury. Among these, Étienne-Jules Marey’s sphygmograph of 1860 was crucial. By resting one end of a piece of metal on a pulsating artery, and attaching a pen to the other, the pulse could be made visible as each movement was traced onto a strip of paper.

Marey’s sphygmograph. © Wellcome Images

By the 1880s, Marey’s device had been eclipsed by Robert Ellis Dudgeon’s ‘pocket sphygmograph’, a smaller device that was especially useful for the asylum physician who dealt with restless or excitable patients.

Dudgeon’s less cumbersome ‘pocket’ sphygmograph. © Wellcome Images

Sphygmographs had their problems: each model might produce a slightly different result, or be further affected by the technique of the person using it. Nevertheless, George Thompson at Bristol Asylum said that he ‘implicitly trusted [the] instrument as a means of discovering at least one form of brain-disease’. He applied the sphygmograph to almost every form of mental disease found in the asylum, but found the most striking results in general paralysis (now understood to refer to neurosyphilis).

In the West Riding Medical Reports in 1871,Thompson described his experiments on the pulse of general paralytic patients at the West Riding asylum. He presented two tracings, one from his own research and one from W.B. Carpenter’s Principles of Human Physiology. They bore a remarkable resemblance. Whilst Thompson’s example represented the pulse of a general paralytic, Carpenter’s showed the pulse of a healthy person in a state of chill.

Thompson’s pulse tracing of a general paralytic patient.

…And Carpenter’s tracing of a healthy individual suffering from ‘chill’.

To Thompson, it was evident that in both cases a contraction of the vessels was being recorded. He concluded that general paralysis was ‘a disease … owing to a considerable extent to persistent spasm of the vessels’.

Could halting this spasm also halt the degenerative process that was characteristic of general paralysis? James Crichton-Browne was one of several alienists who used Calabar bean for this purpose. Calabar is a poisonous seed from an African plant, lethal if ingested in anything more than minute quantities. It was put to a number of uses in the 19th century due to its ability to paralyse muscle, and proved to be the first effective drug treatment for glaucoma. It was suggested that Calabar could lead to an improvement in general paralytic patients such as ‘S.M.’:

‘When admitted to the West Riding Asylum he had exalted ideas; there [was] inequality of the pupils, tremor of the lips, and awkwardness of gait. … [After three months of treatment with Calabar bean] there was such marked improvement in his condition that the use of the extract was discontinued.’

Calabar beans. © Wellcome Images

Calabar’s relative scarcity in the historical record suggests it was seen as an occasional palliative measure rather than cure, however. Writers on the subject were at pains to point out that they knew of no authenticated cases of cure; those patients who recovered enough to be discharged were often re-admitted later, any improvement proving only temporary.

These experiments with the sphygmograph in the Victorian asylum are interesting for a number of reasons. Many historians have emphasised how new medical technologies in the 19th century served to remove the patient’s subjective experiences from the picture, with doctors relying on supposedly ‘objective’ mechanical data. In the case of the sphygmograph, data didn’t necessarily eclipse the patient, with the tool employed alongside established methods of clinical examination including consideration of the patient’s own testimony.

Looking at the use of such technology in an asylum context can also expand our understanding of the asylum’s place within contemporary medical landscapes. Christopher Lawrence describes the sphygmograph as a tool with limited usage, partly because experimental physiology only developed as a specialty in the 1870s. The use of it in the asylum suggests that researchers there were drawing inspiration from a wide variety of medical disciplines – a spirit of innovation also evident in the invention of instruments and post-mortem tools by members of the alienist community.

Examining such research can also problematise wider assumptions about the development of the medical profession and the resulting impact on patients. As described above, post-mortem findings could raise questions that were investigated further in the laboratory, the findings of which then informed clinical intervention. The notion of an easy split between the laboratory and clinical contexts, then, is perhaps less applicable to the asylum at this time.

Forgotten episodes within the history of asylum research are often forgotten because they don’t involve a breakthrough discovery, a success story, or a bizarre intervention that raises our anxieties about patient care. Yet they can also be places where we might find alternative viewpoints to the pictures presented in broader histories of medicine. Perhaps then, unusual endeavours such as Thompson’s should grab our attention not as side projects in the historiography, but as narratives with wider historical significance.

Further reading

William Bevan Lewis, ‘Teachings of the Sphygmograph in General Paralysis of the Insane’, Journal of Mental Science 27 (1881).

T. Duncan Greenlees, ‘Observations with the Sphygmograph on Asylum Patients’, Journal of Mental Science 32 (1887).

Christopher Lawrence, ‘Physiological Apparatus in the Wellcome Museum. 1. The Marey Sphygmograph’, Medical History 22 (1978).

Christopher Lawrence, ‘Physiological Apparatus in the Wellcome Museum. 2. The Dudgeon Sphygmograph and its Descendants’, Medical History 23 (1979).

Alex Proudfoot, ‘The Early Toxicology of Physostigmine: A Tale of Beans, Great Men and Egos’, Toxicological Reviews 25 (2006).

Stanley Joel Reiser, Medicine and the Reign of Technology (Cambridge: CUP, 1978).

George Thompson, ‘On the Physiology of General Paralysis of the Insane and of Epilepsy’, Journal of Mental Science 20 (1875).

George Thompson, ‘The Sphygmograph in Lunatic Asylum Practice’, West Riding Lunatic Asylum Medical Reports 1 (London: J & A Churchill, 1871).

Keith Wailoo, Drawing Blood: Technology and Disease Identity in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1997).

- Jennifer Wallis