A manual of autopsies : designed for the use of hospitals for the insane and other public institutions

Front matter

Open Knowledge Commons and Harvard Medical School

A MANUAL

AUTOPSIES

Preface

The subject of the adoption in American asylums of some uniform system of reporting autopsies has for several years engaged the attention of the Association of Medical Superintendents of American Institutions for the Insane. It is believed that about three thousand deaths occur annually in the various institutions represented by the Association. Many of these cases are available for the study of pathological conditions in brain and body resulting in insanity; and there is little opportunity for the observation of physical changes produced by mental disease outside of hospitals for the care of the insane. The material afforded the alienist is abundant, particularly since asylums have grown to proportions so large that insanity can be studied in all its clinical, as well as pathological, aspects in recent and chronic cases.

What is desirable, is to cultivate a power of observation and description ; to develop the practice of scientific inquiry into the patient's physical and mental condition while living, and to increase our ability to demonstrate clearly whatever lesions may be visible after death. A uniform method of making such examinations has seemed to be desirable, in order that, by following the same procedure in all cases, we may have the data in a proper form for obtaining the most valuable results. The Medico-Psychological Association, of Great Britain, recognizing the importance of concerted action, has also had this subject under consideration.

iii

IV PREFACE.

Pathology, when aided by intelligent clinical study, will eventually throw great light upon the manifestations of insanity. There are many physical symptoms, and many mental conditions, that are dependent upon local cerebral changes, and the site of such lesions can be very accurately determined during the life of the patient and demonstrated after death. The various motor and special sensory centers have been particularly mapped out, but confirmation is desired in many directions, and fuller knowledge and wider application should be diligently sought. Many patients, through disordered mental states, are unable to aid us in making a diagnosis by intelligent statements of their feelings and conditions; but their acts may often become explainable through the findings of an autopsy. Disordered speech, ataxic conditions, stumbling over objects, convulsive seizures, local atrophies and paralyses, afford interesting indications for special search.

In addition to the degeneration of cerebral areas and tracts affecting the special functions, there are also forms of insanity in which the pathological conditions are well marked and constant. This is notably the case in general paralysis of the insane where the conditions are constant and quite uniform in their general characteristics ; senile dementia, also, presents conditions of cerebral atrophy and compensatory changes which are quite constant.

It should not be a matter of discouragement that our knowledge of mental pathology is imperfect, as the same fact is largely true of many ordinary physical diseases. What we need is to enlarge our knowledge and to differentiate still further the functions of the brain. It is only by cultivating a habit of careful observation and comparison that accurate results can ever be obtained. For the purpose of directing thought in this channel, arousing wider

PREFACE. V

interest, and securing a uniform method of procedure, this Manual has been published with the sanction of the Association.

It is to be hoped that interest and attention can be secured in this matter, and a rule of practice followed of observing carefully what is seen. It should be our aim to avoid deductions and contentious theories. A careful description of the actual appearances of the brain and other organs of the body should be recorded. In many cases there are, undoubtedly, grave physical conditions of a chronic nature, apart from cerebral disease, that so influence the blood supply and the nutrition of the brain as to disturb its functions and produce insanity. It is important, therefore, that the whole body be examined as far as possible. Immediate results or surprising revelations are not expected, but patient endeavor and uniform methods must ultimately result in good.

We should seek to establish in each hospital the practice of making a series of accurate, unembellished records in such a form as to be available as contributions to mental pathology. An autopsy book, apart from all other case records, is kept in many asylums, and should be generally adopted. A large blank book is sufficient, or one containing as headings, at most, the name, date of death, age, clinical history, etc., of the patient. Unanimity and thoroughness in this direction will lead to more careful clinical studies and add new interest to many cases, especially to those which are regarded as chronic, but in which the most valuable and instructive data are often found.

Actuated by these motives, the Committee decided not to recommend any elaborate or burdensome table of forms, but embodied its ideas in the following report and resolutions, which were adopted at the forty-fourth annual

VI PREFACE.

meeting of the Association at Niagara Falls, June 10-14, 1890.

" To the Association of Medical Superintendents of American Institutions for the Insane.

Gentlemen : Your Committee, to which was referred the consideration of the subject of autopsies in connection with asylums and hospitals for the insane, desires to make the following report: —

During the year the Committee has held two meetings for consultation, both at Baltimore. At the first meeting, in addition to two members of the Committee, there were also present Dr. W. H. Welch, Professor of Pathology of the Johns Hopkins University and Pathologist to the Johns Hopkins Hospital, and Dr. I. W. Blackburn, Pathologist to the Government Hospital for the Insane at Washington, D. C. The second meeting was held on Friday, May 16, 1890, also at Baltimore, at which Dr. Godding, Dr. Cowles, and Dr. Hurd were present (a majority of the Committee), in addition to Drs. Welch and Blackburn, as before. At this second meeting, after a full discussion of all the bearings of the question, the following conclusions were unanimously adopted : —

1. That it is not advisable to make any attempt to tabulate the results of autopsies in any uniform set of tables, as has sometimes been suggested, both in asylums and general hospitals. It is, however, advisable that every post-mortem be made according to an established routine, and for the guidance of the person making it a little manual should be prepared, which shall give the order and method of pathological procedure to be adopted by every asylum or hospital for the insane.

PREFACE. Vll

2. That accompanying such a manual there should be outline representations of the cortex of the brain, a scheme of the distribution of the cerebral vessels, and diagrams of sections through the various regions of the brain. This will permit of a uniform, graphic record, by pathologists and even by non-expert physicians, of the location of gross lesions like softenings, scleroses, or hemorrhages.

3. That pathologists and non-expert physicians who make autopsies should record accurately what they find, giving gross appearances and conditions, omitting inferences and opinions. In other words, they should describe to the best of their ability what they actually see, and leave the task of interpreting appearances and drawing inferences as to morbid processes to persons who have had special training in pathology and pathological work.

The above conclusions were in thorough accord with the views of Dr. Welch and Dr. Blackburn, and were confirmed by a verbal expression from Dr. Gannett, of Boston, transmitted through Dr. Cowles.

Your Committee consequently recommends that Dr. Blackburn, of the Government Hospital, prepare, with the co-operation of Dr. Welch and other pathologists, who have shown an interest in the matter, such a Manual of Autopsies, with diagrams, outlines, and schematic representations, for submission to the next annual meeting of the Association. To carry into effect these recommendations the Committee begs leave to offer the following resolutions : —

Resolved, That Dr. Blackburn, the Pathologist to the Government Hospital for the Insane, be requested to prepare for publication, as early as practicable, a manual of post-mortem examinations, for submission to the members

Vlll • PREFACE.

of the Association, with a view to its adoption at the next annual meeting.

Resolved, That the Secretary of the Association be authorized to procure the printing and distribution of the same at the expense of the Association."

On motion the report of the Committee was accepted, and the resolutions accompanying it were adopted.

In accordance with the foregoing action of the Association, this Manual, prepared by Dr. I. W. Blackburn, the Pathologist to the Government Hospital for the Insane, is herewith presented.

The Committee desires to record its appreciation of the work accomplished by Dr. Blackburn, and to express acknowledgments to Drs. W. H. Welch, Professor of Pathology, W. T. Councilman, Associate in Pathology, of the Johns Hopkins University and Hospital, and to W. W. Gannett, Instructor in Pathology at the Harvard Medical School, and Henry J. Berkley, Visiting Physician, Bay View Asylum, for assistance rendered.

Henry M. Hurd, Daniel Clark, J, Committer Edward Cowles, H. E. Allison,

Contents

PAGE

PREFACE, v

LIST OF ILLUSTRATIONS, xii