The first Brazilian neuropsychiatrist, José Martins da Cruz Jobim, tuberculous meningitis and mental disease

O primeiro neuropsiquiatra brasileiro, José Martins da Cruz Jobim, meningite tuberculosa e doença mental

Abstracts

The intersection between infectious diseases, poverty and mental disease was an important subject to the Brazilian Neuropsychiatry in the early 19^th century. José Martins da Cruz Jobim (1802–1878) was engaged in a hygienist approach based on symptomatological and anatomopathological studies. He wrote “Insânia loquaz” (Loquacious insanity), 1831, the first written text about mental illness in Brazil, founded on clinical and pathological data, compatible with tuberculous meningitis. Thus, Jobim deserves the title of the first neuropsychiatrist in Brazil. The authors critically studied the clinical history and the autopsy findings of his cases, and the main health policies at the time.

Brazilian Neurology; Neuropsychiatry; tuberculous; meningitis; history of Neurosciences

A intersecção entre as doenças infecciosas, a pobreza e a doença mental foi um assunto importante para a Neuropsiquiatria brasileira no início do século 19. José Martins da Cruz Jobim (1802–1878) estava engajado em uma abordagem higienista baseada em estudos sintomatológicos e anatomopatológicos. Escreveu “Insânia loquaz”, 1831, o primeiro texto escrito sobre doença mental no Brasil, baseado em dados clínicos e patológicos compatíveis com meningite tuberculosa. Assim, Jobim merece o título de primeiro neuropsiquiatra no Brasil. Os autores estudaram criticamente a história clínica e os resultados da autópsia dos seus casos, bem como as principais políticas de saúde da ocasião.

Neurologia brasileira; Neuropsiquiatria; tuberculose meníngea; história das Neurociências

José Martins da Cruz Jobim (Figure) presented, and later published, “Insânia loquaz ocasionada por uma pneumonia crônica com tubérculos pulmonares” (1831), the first written text on mental disease in Brazil¹−³. The present paper aims to bring together data about infectious diseases, mainly tuberculous meningitis, poverty and mental disorders in the early 19^th century, and to recommend Jobim as the first neuropsychiatrist in Brazil.

Figure.
José Martins da Cruz Jobim and a summary of his professional career (Figure reproduced from the Faculdade de Medicina da Universidade Federal do Rio de Janeiro, former Faculdade de Medicina do Rio de Janeiro).

José Martins da Cruz Jobim (Rio Pardo - RS, 1802, Rio de Janeiro - RJ, 1878) graduated in Medicine at Faculté de Médecine de Paris (1828). His doctoral thesis was “Dissertation sur le vaccin”²,⁶. He was strongly influenced by the doctrine of François Broussais (1772–1838) based on the idea that disease is above all caused by irritation of organs and viscera, and treatment should be aimed at controlling inflammation through bloodletting and diets²,⁶. On returning to Brazil, he was appointed physician of the Santa Casa da Misericórdia do Rio de Janeiro. There he headed one of its wards and was the chief of the Mental Ill Service²,⁶. Later, he was appointed as the first physician at Dom Pedro II Hospice's and, additionally, he was Imperial Chamber physician (1840)²,⁶. He participated in the founding of the Sociedade de Medicina do Rio de Janeiro (SMRJ) (1829), later renamed Academia Imperial de Medicina (1835), and, finally, Academia Nacional de Medicina (1889). He took part of several of its committees and, in 1830, he was in charge of the Committee of Hygiene, to evaluate sanitary conditions in prisons, hospitals, hospices and houses of the exposed (dedicated for care of abandoned children)²,⁶. On June 30, 1835, Jobim made the “Discourse on the diseases that most afflict the poor class of RJ” at the SMRJ⁵. In the Faculdade de Medicina do Rio de Janeiro, he was the Forensic Medicine and Toxicology Professor (1833–1854) and later, Director (1842–1872). His political interest led him to occupy elective positions (General Deputy in Rio Grande do Sul [1849–1851], and Senator in Espirito Santo [1851–1878]), on several mandates. On such periods he stayed away from the effective direction of the Faculdade de Medicina do Rio de Janeiro.

STUDIES ON BRAZILIAN HEALTH INSTITUTIONS (IN)SALUBRITY

Jobim denounced the precarious conditions of life of the individuals in various institutions, mainly at Santa Casa da Misericórdia do Rio de Janeiro (StCMRJ), and he started his commitment to policies focusing on mental illness and on diseases affecting the underprivileged people⁴−⁶. He related his medical observations to the localization of the housings on swampy ground and to the hot and humid climate of Rio de Janeiro. The big three health problems to him were “pulmonary phthisis”, “fevers” and “hypohemia intertropical”. He considered tuberculosis very common in StCMRJ and that the main cause of phthisis in Brazil was the pulmonary overwork required by the local climate. For the intermittent fevers, he said they could be due to the humid, swampy and fertile soil. The recognition of his merit as a physician came with his study of “oppilation” (obstruction, particularly in the lower intestines) and “hypohemia intertropical” as reclassified by him, and later recognized as a parasitic disease by Otto Wucherer (1820–1873). This reflected the conflict between new theories of disease and the other driven by tropical illnesses and poverty, based on sanitary and anatomoclinical knowledge⁴. This clashing was also seen by Vicente de Torres Homem (1837–1887), who did not accept the idea that microscopic creatures “could enslave all cellular pathology” and also based on the pre-germ theory that pervades the work of Jean-Martin Charcot (1825–1893) and William Alexander Hammond (1828–1900)⁷. Regarding the epidemiology at the time, it is remarkable that even the upper classes died of infectious diseases: Dom Pedro I (1834), of tuberculosis, at the age of 36 years in Lisbon, and his 10 years-old daughter, Paula Mariana (1833), in Rio de Janeiro, probably of encephalitis caused by intermittent fever (Jobim was one of her physicians)²,⁶,⁸.

THE CASE REPORTS AND JOBIM'S “INFECTIOUS PSYCHIATRY”

On December 30, 1830, Jobim read at the medical meeting of the Sociedade de Medicina do Rio de Janeiro a report about a man “admitted to the Hospital in a state of madness, speaking loud, with hallucinations, where different people appeared, and to whom he talked always in quarrelsome way; this with great fickleness, changing every moment the subject. In the midst of these disorders of intelligence he ate and drank as if nothing had occurred. When he happened to be silent, if one asked him something, vociferations and dialogues began. He loosed weight, released purulent sputum, and died in 1830”. The autopsy showed “in the belly, purulent serosity with some adhesions; in the chest, adhesion of the upper half of the lungs to the costal pleura, the upper part of the lungs were hepatized, in the left there were three large caves, in the right two small ones, numerous small tubercles irregularly circumscribed; the pericardium was dilated and contained serous fluid. Much serous fluid was present between the arachnoids, beneath this membrane, over the convexity of the right cerebral hemisphere, there was blood evenly spread, the brain substance was in perfect state; the lateral ventricles had the triple of their capacity, and were filled with a clear serous fluid, and the lower end of the transverse septum was ruptured leading to communication between the two ventricles”¹.

He mentioned also another patient, a 40 years old white male, with nervous system tuberculosis — a tuberculoma —, in a state of stupor⁵, described as follows: “[…] a tuberculous mass, the size of a pigeon's egg, in the middle of the lower part of the median lobe of the left cerebral hemisphere, its circumference was softened, but the center was hard and similar to a tophaceous concretion; the surrounding cerebral substance was softened and suppurated, up to the distance of two to three lines.” Jobim was also interested in other areas of “infectious psychiatry”, such as hydrophobia (1831). This was the subject of his thesis for admission to the Faculdade de Medicina do Rio de Janeiro ⁶.

COMMENTS

Jobim's report display evident symptoms of a confusional state (agitation, vociferation) and psychotic features (hallucinations), characteristic of the acute phase of the disease⁹, underpinned by pathological findings in the abdominal and thoracic cavities suggestive of tuberculosis, with hepatization, cavitation and the presence of tubercules in the lungs. It is known that tubercles may reach the central nervous system and rupture into the subarachnoid space or into the parenchyma (tuberculomas, abscesses). Serous exudate and hemorrhage in the meninges may be responsible for obstruction of CSF flow and the severe ventricular dilatation (obstructive hydrocephalus). The other reported case, suggestive of tuberculoma, presented different signs, the more prominent being a deterioration of consciousness.

It must be remembered that the first report of tuberculous meningitis is often attributed to the Scottish physician Robert Whytt (1768) and his remarkable treatise “On the Dropsy in the Brain”, and its link with tuberculosis and its pathogen was not made until the end of the next century¹⁰.

Jobim's case report exemplifies a medical practice that would be current in Brazil far later (end of 19^th century), the anatomoclinical practice. The author asked himself, already in the title, if the agitated madness, with severe loquacity, humor variations and evidence of hallucinations, could be caused by a severe pulmonary disease, manifested in life and confirmed by autopsy³.

In conclusion, the analysis of the reported cases allows relating the behavioral symptoms with the infectious pathological aggression to the brain and its coverings. It is possible to recognize in such clinical manifestations their neuropsychiatric nature. Jobim, one of the most important pioneers of Psychiatry, was the first one to write a clinical-pathological text on mental disease in Brazil. In this way, he may be considered, without any doubt, a neuropsychiatrist, the first in Brazil.

References

• ¹
  José Martins da Cruz Jobim. Insânia loquaz, ocasionada por uma pneumonia crônica, com tubérculos pulmonares? Observação do sr. dr. Jobim, membro titular, lida na Sociedade de Medicina, na sessão de 30 de dezembro de 1830. Rev Latinoam Psicopat Fund 2005:VIII;557-558. Publicado originalmente em Semanário de Saúde Pública (Rio de Janeiro) 1831;36:185.
• ²
  Jobim, José Martins da Cruz. Dicionário Histórico-Biográfico das Ciências da Saúde no Brasil (1832-1930). Casa de Oswaldo Cruz/Fiocruz. Available at: http://www.dichistoriasaude.coc.fiocruz.br
  » http://www.dichistoriasaude.coc.fiocruz.br
• ³
  Oda AMGR. Apresentação a “Insânia loquaz” (Jobim, 1831) e a “Reflexões sobre o trânsito livre dos doidos pelas ruas da cidade do Rio de Janeiro” (Sigaud, 1835). Rev Latinoam Psicopat Fund 2005;8:554-556.
• ⁴
  Edler FC. A Escola Tropicalista baiana: um mito de origem da medicina tropical no Brasil. Hist cienc saude-Manguinhos 2002;9:357-385.
• ⁵
  Fernandes R. O Conselheiro Jobim e o Espírito da Medicina de Seu Tempo. Brasília: Editora do Senado Federal; 1982.
• ⁶
  Santos Filho LC. História Geral da Medicina Brasileira. São Paulo: Edusp/Hucitec; 1991.
• ⁷
  Gomes MM. Neuronosology: historical remarks. Arq Neuropsiquiatr 2011;69:559-562.
• ⁸
  Gomes MM, Chalub M. Dom Pedro I of Brazil and IV of Portugal: epilepsy and peculiar behavior. Arq Neuropsiquiatr 2007;65:710-715.
• ⁹
  Williams M, Smith HV. Mental disturbances in tuberculous meningitis. J Neurol Neurosurg Psychiatry 1954;17:173-182.
• ¹⁰
  Ruhräh J. The history of tuberculous meningitis. Med Library Hist J 1904;2:160-165.

Publication Dates

• Publication in this collection
  Mar 2013

History

• Received
  19 Sept 2012
• Received
  25 Sept 2012
• Accepted
  2 Oct 2012