"By strangers honour'd, by survivors mourn'd."
"By strangers honour'd, by survivors mourn'd."
On the Board of the Commissioners in Lunacy have sat two members of our profession (one still living), to whose services I wish more especially to refer. I allude to Dr. Prichard and Mr. Gaskell.
Apart from his official work, the former will always be remembered in the republic of letters by his learned contributions to anthropology and the literature of mental diseases, in which he is more especially identified with the doctrine of Moral Insanity. Chronicler of the period in which he enunciated or rather developed it, I cannot avoid a brief reference to a theme which has caused so much heated discussion. As an impartial historian I am bound to admit that his views are still by no means unanimously adopted, and that I am only expressing my own sentiments when I avow that what Latham says of Prichard's "Researches into the Physical History of Mankind"—"Let those who doubt its value, try to do without it"—applies to the teaching contained in the remarkable treatise entitled "Different Forms of Insanity in relation to Jurisprudence," published in 1842. We may well be dissatisfied with some of the illustrationsof the doctrine it supports. We may express in different terms the generalization he has made as to the relation of intellect and emotion; but I am greatly mistaken if we shall not from time to time be confronted by facts which instantly raise the question which presented itself with so much force to his acute mind, and which does not appear to me to be successfully met by those who controvert the conclusions at which Prichard arrived. The necessity of admitting in some form or other the mental facts in dispute, is well illustrated by the recent work by Krafft-Ebing on mental disorders. For what does this practised mental expert do? He, although the supporter of mental solidarity and the integrity of the Ego—adverse, therefore, to the psychology in which the theory has been enshrined—feels that he must admit into his classification some term which describes certain emotional or volitional disorders, and can discover none better than "moral insanity"—a practical, though reluctant, admission of the value of Prichard's views after their discussion for forty years. I might also refer as an indication of opinion to a most excellent article in the last number of theJournalby Dr. Savage, who, while recognizing the abstract metaphysical difficulty of conceiving moral as distinct from intellectual insanity, fully admits as a clinical fact the form of mental disease for which Prichard contended, and had he been living he would doubtless have claimed this article as a striking proof of the vitality of his opinions.
One is certainly disposed to exclaim, if observation on the one hand compels us to admit certain mental facts,and the metaphysician on the other declares them to be unmetaphysical, so much the worse for metaphysics!
Mr. Gaskell, in addition to his good work as a reformer at the Lancaster Asylum, where may yet be seen preserved quite a museum of articles of restraint formerly in use in that institution, and his efficient labours as a Commissioner, was also, it may not be generally known, the real cause of the practical steps taken in this country to educate the idiot. It was in 1847 that he wrote some articles inChamber's Journal, giving an account of Seguin's Idiot School at the Bicêtre, which he had visited and been greatly interested in. These articles had the effect of inducing Dr. Andrew Reed to interest himself in the establishment of a school for idiots in England. The Highgate and Colchester Asylums for idiots were instituted—the origin, as it proved, of the great establishment at Earlswood. All, therefore, that has been done for this pitiable class has been effected during the last forty years. The indefatigable Seguin has passed away during the last twelve months. He pursued to the last, with unabated zeal, a study possessing attractions for only a limited number, and advocated the claims of idiots and imbeciles with unceasing energy in the Old World and the New. Fortunately his mantle has descended upon a worthy successor in the person of his son, Dr. E. Seguin, of New York.
It has necessarily happened that the direction of public attention to the larger and better provision for the insane in all civilized lands has led to much consideration,and inevitably some difference of opinion as regards the form and arrangement of asylums. But all will admit that their construction has undergone a vast improvement in forty years. The tendency at the present moment is to attach less importance to bricks and mortar, and the security of the patient within a walled enclosure, than to grant the largest possible amount of freedom, in asylums, compatible with safety. The more this is carried out, the easier, it is to be hoped, will it be to induce the friends of patients to allow them to go in the earliest stage of the disorder to an asylum, as readily as they would to a hydropathic establishment or an ordinary hospital, to which end medical men may do much by ignoring the stupid stigma still attaching to having been in an asylum. The treatment of the insane ought to be such that we should be able to regard the asylums of the land as one vast Temple of Health, in which the priests of Esculapius, rivalling the Egyptians and Greeks of old, are constantly ministering, and are sacrificing their time and talents on the altar of Psyche.[299]
Most heartily do I agree with Dr. Kirkbride when he says that "Asylums can never be dispensed with—no matter how persistently ignorance, prejudice, or sophistry may declare to the contrary—without retrograding to a greater or less extent to the conditions of a past period with all the inhumanity and barbarity connected with it. To understand what would be the situation of a peoplewithout hospitals for their insane, it is only necessary to learn what their condition was when there were none."[300]
In advocating the prompt and facile recourse to an asylum, I include, of course, the cottage treatment of the insane so long ago resorted to by Dr. Bucknill, and extended in so admirable a manner by my immediate predecessor in this chair, whose practical observations last year on the villas and cottages at Cheadle rendered his address one of the most valuable that has been delivered. Moreover, I would not say a word in disparagement of the placing of suitable cases in the houses of medical men, or in lodgings, under frequent medical visitation.[301]I also recognize the value of intermediate or border-land institutions, so long as they are conducted with the sanction of the Commissioners and open to their inspection.
The modern advocacy of the open-door system has been recently brought under the notice of the Association by Dr. Needham, with the view of obtaining a general expression of opinion on a practice, to the wisdom of which he is disposed to demur.
But a less regard for mere bricks and mortar, the removal of high boundary walls and contracted airing-courts, or the introduction of the open-door system, do notlessen the importance of properly constructed asylums. The works of Jacobi in Germany, Kirkbride in America, Parchappe in France, and Conolly in England, must retain their value as classical productions on this subject; while the contributions recently made by Dr. Clouston present not only the general principles of asylum construction, but the minute details of building, in the light of the knowledge and experience of the present day.
I was fortunate in being able to render M. Parchappe some service when he visited England to examine the construction of our asylums. Those who formed his acquaintance on the occasion of this visit may remember his mixed feelings on visiting them, how he demurred on the one hand to what he regarded as too costly and ornamental, while, on the other hand, he liked the English arrangement of the buildings better than the Esquirol-Desportes system. I need not point out that those who have had the planning of the county asylums in England have objected, as well as Parchappe, to the distribution of isolated pavilions upon parallel lines. Parchappe, while far from believing it to be indispensable to make asylums monuments fitted to excite admiration for the richness of their architecture, and indisposed to emulate our asylums, which, he says, only belong to princely mansions, turns nevertheless from the square courts and the isolated pavilions of Esquirol to apostrophize the former in these glowing terms:—
"How much more suited to reanimate torpid intelligence and feeling, or to distract and console melancholy among the unfortunate insane, these edifices majestic intheir general effect and comfortable in their details, these grandiose parks, with luxuriant plantations and verdant flowery lawns, whose harmonious association impresses upon English asylums an exceptional character of calm and powerful beauty!"
Whether a stranger, having read this florid description of our asylums, would not, on visiting them, be a little disappointed, I will not stop to inquire. Probably during this or the following week, some of Parchappe's compatriots may answer the question for themselves.
The fundamental question of the separation of the curable and incurable classes has in different countries been earnestly discussed during the last forty years. Kirkbride has entered his "special and earnest protest" against this separation; his own countryman, Dr. Stearns, on the other hand, has lately advocated it. In Germany, where, following the lead of Langermann and Reil, complete separation of the curable in one building was first realized under Jacobi at Siegburg, there has been a complete reversion to the system of combining the two classes in one institution. Parchappe, who opposed the separation of these classes, as illusory if justice is done to the incurable in the construction of the building provided for them, and mischievous if this is denied them, was constrained to admit, however, in view of the enormous number of lunatics in the Department of the Seine, that it was the least of two evils to separate the epileptic and the idiotic from the curable.
In England the separation principle has been recognized in Hardy's Act (30 Vict., c. 6) for the establishmentin the metropolis of asylums for the sick, insane, and other classes of the poor, 1867; and, again, in the erection of such an asylum as Banstead for Middlesex—and I am informed by Dr. Claye Shaw, who, from holding the office of superintendent there, and formerly superintending the Metropolitan District Asylum of Leavesden, is well calculated to judge, that the experiment has proved successful, that the patients do not suffer, and that the office of superintendent is not rendered unendurable. Regarded from an economic point of view, it has been found practicable to provide buildings at a cost of between £80 and £90 per bed, which, though not æsthetic, are carefully planned for the care and oversight of the inmates. This includes not only the land, but furnishing the asylum.
Five years ago this Association unanimously adopted a resolution, expressing satisfaction that the Charity Organization Society had taken up the subject of the better provision, in the provinces, for idiots, imbeciles, and harmless lunatics, and the following year carried a resolution, also unanimous, that the arrangement made for these classes in the metropolitan district is applicable in its main principles to the rest of England. But it does not follow that the separation of these classes from the county asylums should be so complete, either as respects locality or the governing board, as in the metropolitan district; and, further, the Association expressed a strong opinion that the boarding-out system, although impracticable in the urban districts, should be attempted wherever possible in the country; thegreatest care being taken to select suitable cases, unless we wish to witness the evils which Dr. Fraser has so graphically depicted in his report for 1877 of the Fife and Kinross Asylum. If pauper asylums can, without injury to families, be relieved by harmless cases being sent home to the extent Dr. Duckworth Williams has succeeded in doing in Sussex, and if, as he proposes, they were periodically visited, their names being retained on the asylum books, the enlargement of some asylums might be rendered unnecessary.
But what, gentlemen, would be the best-contrived separation of cases, what would the best-constructed asylum avail, unless the presiding authority were equal to his responsible duties? Now, it is one of the happy circumstances connected with the great movement which has taken place in this and other countries, that men have arisen in large numbers who have proved themselves equal to the task. We witness the creation of an almost new character—the asylum superintendent.
One Sunday afternoon, some years ago, Dr. Ray fell asleep in his chair while reading old Fuller's portraits of the Good Merchant, the Good Judge, the Good Soldier, etc., in his work entitled "The Holy and Profane State," and, so sleeping, dreamed he read a manuscript, the first chapter of which was headed, "The Good Superintendent." Awakening from his nap by the tongs falling on the hearth, the doctor determined to reproduce from memory as much of his dream as possible for the benefit of his brethren. One of these recovered fragments runs thus:—"The Good Superintendent hath consideredwell his qualifications for the office he hath assumed, and been governed not more by a regard for his fortunes than by a hearty desire to benefit his fellow-men.... To fix his hold on the confidence and goodwill of his patients he spareth no effort, though it may consume his time and tax his patience, or encroach seemingly on the dignity of his office. A formal walk through the wards, and the ordering of a few drugs, compriseth but a small part of his means for restoring the troubled mind. To prepare for this work, and to make other means effectual, he carefully studieth the mental movements of his patients. He never grudges the moments spent in quiet, familiar intercourse with them, for thereby he gaineth many glimpses of their inner life that may help him in their treatment.... He maketh himself the centre of their system around which they all revolve, being held in their places by the attraction of respect and confidence."[302]
And much more so admirable that it is difficult to stay one's hand. You will, I think, agree with me that what Dr. Ray dreamed is better than what many write when they are wide awake, and those familiar with Dr. Ray's career, and his character, will be of the opinion of another Transatlantic worthy (Dr. John Gray, of Utica) that in this act of unconscious cerebration the dreamer unwittingly described himself—
"'The Good Superintendent!' Who is he?The master asked again and again;But answered himself, unconsciously,And wrote his own life without a stain."
"'The Good Superintendent!' Who is he?The master asked again and again;But answered himself, unconsciously,And wrote his own life without a stain."
In what a strange land of shadows the superintendent lives! But for his familiarity with it, its strangeness would oftener strike him. It becomes a matter of course that those with whom he mixes in daily life are of imperial or royal blood—nay, more, possess divine attributes—and that some who are maintained for half a guinea a week possess millions and quadrillions of gold. He lives, in truth, in a world inhabited by the creatures of the imagination of those by whom he is constantly surrounded—a domain in whichhisviews of life and things in general are in a miserable minority—a phantom world of ideal forms and unearthly voices and mysterious sounds, incessantly disputing his authority, and commanding his patients in terms claiming supernatural force to do those things which he orders them to leave undone, and to leave undone those things which he orders them to do; commanding them to be silent, to starve themselves, to kill, to mutilate or hang themselves; in short, there is in this remarkable country, peopled by so many thousand inhabitants, animperium in imperiowhich renders the contest continuous between the rival authorities struggling for supremacy, sometimes, it must be confessed, ending in the triumph of the ideal forms, and the phantom voices, and the visionary sights, which may be smiled at in our studies, and curiously analyzed in our scientific alembics, but cannot be ignored in practice without the occurrence of dire catastrophes, and the unpleasant realization of the truth that idealism, phantasy, and vision may be transformed into dangerous forms of force. It may be said, indeed, that the appropriatemotto of the medical superintendent is—"Insanitas insanitatum, omnia insanitas."
With such anentourageit is not surprising if the first residence in an asylum as its responsible head—especially an asylum in the olden days—should disconcert even a physician. A German psychologist once declared, after passing his first night in an institution as superintendent, that he could not remain there; he felt overwhelmed with his position. Yet this physician remained not only over the next night, but for thirty-five years, to live honoured and venerated as Maximilian Jacobi, and departing to leave behind him "footprints on the sands of time," from seeing which, others, in a similar hour of discouragement, may again take heart.
I cannot pass from this subject without enforcing, as a practical comment, the necessity of asylum physicians having a very liberal supply of holidays, so as to insure a complete change of thought from not only the objective but the subjective world in which they live, and this before the time comes when they are unable to throw off their work from their minds, as happened to a hard-working friend of mine, who, even during his holiday among the Alps, must needs dream one night that he was making a post-mortem upon himself, and on another night rose from his bed in a state of somnambulism to perform certain aberrant and disorderly acts, not unlike what his patients would have performed in the day.
I have heard it suggested that superintendents should have six weeks' extra holiday every third year, five of themto be spent in visiting asylums. Whether this is the best way of acquiring an interchange of experience or not, I will not decide, but no doubt the feeling, how desirable it is men should compare notes with their fellow-workers, prompted the founders of our Association (which was expected to be more peripatetic than has proved to be the case) to determine that its members should at its annual meetings carefully examine some institution for the insane.
It is not too much to say that only second in importance to a good superintendent is a good attendant, and of him also Dr. Ray dreamed in his Sunday afternoon vision, and his description is equally excellent.
I am sure that it will be admitted that the last forty years have seen a vast improvement in the character of attendants, and among them are to be found many conscientious, trustworthy men and women, forbearing to their charge and loyal to their superintendent. It is not the less true that for asylums for the middle and higher classes the addition of companionship of a more educated character is desirable, and it is satisfactory to observe that there is an increasing recognition of its importance, as evidenced by the Reports of our asylums.[303]
One word now in regard to the advance in our classification of mental disorders, though I hardly dare to even touch thus lightly upon so delicate a subject, for I have observed that it is one of those questions in ourdepartment of medicine—dry and unexciting as it may at first sight seem to be—which possess a peculiar polemical charm.
Few circumstances are more noteworthy than the attacks which have been made upon the citadel of the Pinel-Esquirol classification, the symptomatological expression of the disease—attacks not new forty years ago, but renewed with great force and spirit by Luther Bell in America, and subsequently by Schroeder van der Kolk in Holland, Morel in France, and Skae in Britain. When Dr. Bell asserted that this system of symptoms "would not bear the test of accuracy as regards the cause of the disease or the pathological condition of the sufferer;" that the forms in use "were merely the changing external symptoms, often having scarcely a diurnal continuance before passing from one to another," and constituting a division useless as regards moral or medical treatment—he expressed in a nutshell all the objections since urged against the orthodox classification by the other alienists I have mentioned. These, however, substituted a mixed ætiological or pathogenetic classification, which Bell did not, and this classification is, in its essential characters, on its trial to-day. The wave of thought which bore these attempts to the surface, was a wholesome indication of the desire to look beneath the mere symptom right down to the physical state which occasioned it, and upon which the somatic school of German alienists had long before laid so much stress. The movement has been useful, if for no other reason than that it has concentrated attention afresh and moredefinitely upon the conditions which may stand in causal relation with the mental disorder, nor has it been without its influence in affecting the terms generally employed in the nomenclature of insanity. At the same time it is very striking to observe how the great types of mental disorder adopted and in part introduced by the great French alienists have essentially held their ground, and if their citadel has had in some points to parley with a foeman worthy of their steel, and even treat with him as an honourable rival, they remain still in possession, and their classification of symptoms seems likely to remain there for long to come. As such, these types are partly founded upon clinical and, to some extent, pathological observation, and may well be allowed with a few additional forms to stand side by side with a somato-ætiological nomenclature, as it grows up slowly and cautiously, reared on scientific observation and research; and had Skae been living he would have rejoiced to hear Mr. Hutchinson assert the other day that in all diseases, "our future classification must be one of causes and not external symptoms, if we would desire to construct anything like a natural system, and trace the real relation of diseases to their origin."
In a sketch, however brief, of the progress of Psychological Medicine since the foundation of this Association in 1841, it would be a serious omission not to notice the important contributions of the late Professor Laycock shortly before as well as after that year. In 1840 he first promulgated the opinion that "the brain, althoughthe organ of consciousness, is subject to the laws of reflex action, and in this respect does not differ from other ganglia of the nervous system."[304]And in a paper read before the British Association, September, 1844, he observed, "Insanity and dreaming present the best field for investigating the laws of that extension of action from one portion of the brain to the other, by which ideas follow each other in sequence, giving as an illustration the case of a patient at the York Retreat, whose will being suspended, he expressed ideas as they spontaneously arose in associated sequence, the combination being singularly varied, but traceable to a common root or centre of impulse." "Researches of this kind," Laycock continues, "whether instituted on the insane, the somnambulist, the dreamer, or the delirious, must be considered like researches in analytical chemistry. The re-agent is the impression made on the brain; the molecular changes following the applications of the re-agent are made known to us as ideas."[305]
Time will not allow me to cite other passages in these remarkable papers, or later ones; but these are sufficient to show the germ at that early period of the doctrine of cerebral reflex action, and the unconscious cerebration of Carpenter, the seeds having been already sown by Unzer and Prochaska, and arising out of it, that of automatic states occasioned or permitted by the abeyance of a higher restraining power—the Will, accordingto Laycock, in the case he employs as an illustration of his doctrine. His teaching in regard to mental and nervous disorders due to vaso-motor disturbance also deserves recognition.
Dr. Henry Monro, again, in a treatise published in 1851, put forward a theory of the pathology of insanity, the essence of which was that the cerebral masses having lost their static equilibrium exhibit in their functions two different degrees of deficient nervous action (coincidently), viz. irritable excess of action and partial paralysis. He maintained that these two states do not fall alike upon all the seats of mental operations, but that there is "a partial suspension of action" of "higher faculties, such as reason and will," while there is an irritable excess of action of the seats of the more elementary faculties, such as conception, etc., and hence delusions and the excessive rapidity of successive ideas. Dr. Monro compares this condition to a case of paralysis, combined with convulsions; and discusses the question whether the temporary and partial paralysis occurring as he supposes in insanity, "results directly and entirely from excessive depression of the nervous centres of those higher faculties, or partly in anindirectmanner from nervous energy being abstracted to other parts which are in more violent exercise at the time."[306]
This, it will be seen, is a still clearer statement of the doctrine that insanity is caused by the depression or paralysis of the higher nervous centres and excessive action of others.
As is well known, Dr. Hughlings Jackson, whose views regarding active states of nerve structures as liberations of energy or discharges, are familiar to us all, has adopted and extended Laycock's doctrine, which he designates as "one of inestimable value," and has urged the importance of Monro's doctrine of negative and positive states in cases of insanity, using the term "insanity" in an exceedingly wide sense. He has pointed out that Anstie and Thompson Dickson have also stated the doctrine that so-called "exaltation of faculties" in many morbid states is owing to "insubordination from loss of control," and that the same was said in effect by Symonds, of Bristol. Adopting the hypothesis of evolution as enunciated by Herbert Spencer, Dr. Hughlings Jackson thinks that cases of insanity, and indeed all other nervous diseases, may be considered as examples of Dissolution, this being, I need not say, the term Spencer uses for the process which is the reverse of Evolution. Insanity, then, according to this view, is dissolution beginning at the highest cerebral centres, which centres, according to Jackson, represent or re-represent the whole organism. There are distinguishable, he believes, cases of uniform dissolution, the process affecting the highest centres nearly uniformly, and cases of partial dissolution in which only some parts of these centres are affected. The dissolution, again, whether uniform or partial, varies in "depth;" the deeper it is, the more general are the manifestations remaining possible. The degree of "depth" of dissolution is, however, but one factor in this comparative study of insanity.Another is the rapidity with which it is effected. To this, Dr. Jackson attaches extreme importance, believing that degrees of it account for degrees of activity of those nervous arrangements next lower than thosehors de combatin the dissolution. Another factor is the kind of person to whom dissolution "comes." And the last factor is the influence of circumstances on the patient undergoing mental dissolution. All factors should, of course, be considered in each case, or, as Dr. Jackson characteristically puts it, "insanity is a function of four variables." I refer to these opinions to show the direction in which some modern speculation on the nature of insanity tends, that thus tracing the course of thought in recent years we may see how, step by step, certain views have been reached, some of them generally adopted, others regarded as still requiring proof before they can be accepted.
The negative and positive view of the nature of insanity receives support, I think, from the phenomena of Hypnotism which, about forty years ago, attracted, under the name of Mesmerism, so much attention in England in consequence of the proceedings of Dr. Elliotson in the hospital and college where we meet to-day. This was in 1838, and Braid's attention was arrested by what he witnessed in 1841. It is no reason because we have re-christened mesmerism that we should ignore the merit of those who, as to matters of fact, were in the right, however mistaken their interpretation may have been.
Elliotson recorded some striking examples of inducedhallucinations and delusions, and in an article in theJournalin 1866, I endeavoured to show how suggestive similar instances which I then reported are in relation to certain forms of insanity, and also in relation to sudden recovery from mental disease; the conclusion being forced upon us that there may be cases in which no change takes place in the brain which the ablest microscopist is likely to detect, but a dynamic change—one more or less temporary in the relative functional power of different cerebral centres, involving loss or excess of inhibition.
Nor can I, in connection with the reference to cerebral localization, allow to pass unrecorded the researches of Fritsch, Hitzig, and Ferrier, on account of the intimate, although only partial relation in which they stand to mental pathology—a relation promising to become more intelligible and therefore more important as the true meaning of the psycho-motor centres becomes better understood; for that we are only on the threshold of this inquiry must be evident, when men like Goltz, Munk, and other investigators call in question the conclusions which have been arrived at.
But be the final verdict what it may, when I look back to the time when "Solly on the Brain" was our standard work, and then turn to Ferrier's treatise on its functions, to the remarkable works of Luys, and to Dr. Bastian's valuable contribution to the International Series, I cannot but feel how unquestionable has been the advance made in the physiology of the brain, strangely bent as Nature is on keeping her secrets wheneverthe wonderful nexus which binds together, yet confounds not, mind and brain, is the subject of investigation.
The past forty years have witnessed a great change in the recognition of mental disease as an integral part of disorders of the nervous system, and medical psychology is less and less regarded as a fragment detached from the general domain of medicine. Contributions from all lands have conspired to produce this effect, the somatic school of psychologists in Germany having exerted, probably, the most influence. And we are proud to number in France among our roll of associates a physician who, not only by his pathological researches into diseases of the brain and cord, but by his clinical study of affections closely allied to mental derangement, has by the brilliant light he has thrown upon the whole range of diseases of the nervous system, advanced the recognition of which I have just spoken. I need not say that I refer to our distinguished honorary member, Professor Charcot.
No one will deny that the relations of mind and brain, physiologically and pathologically considered, have in our own country been ably handled by Dr. Maudsley. Those who most widely differ from some of his conclusions will acknowledge this ability, and that his works are expressed in language which, with this author, is certainly not employed to conceal his thoughts. To trace the influence of these writings, and those of Herbert Spencer, Bain, and others of the same school, on thecurrent belief of psychologists would, however, carry me far beyond the legitimate limits of an address, but I may be allowed to observe that here, as elsewhere, we must not confound clearly ascertained facts in biology and mental evolution with the theories which are elaborated from them. The former will remain; the latter may prove perishable hay and stubble, and when we overlook or ignore this distinction, it must be admitted that we expose ourselves to the just rebuke of the celebrated Professor of Berlin when he protests against "the attempts that are made to proclaim the problems of research as actual facts, the opinion of scientists as established science, and thereby to put in a false light before the eyes of the less informed masses, not merely the methods of science, but also its whole position in regard to the intellectual life of men and nations." He is surely right when he insists that if we explain attraction and repulsion as exhibitions of mind, we simply throw Psyche out of the window and Psyche ceases to be Psyche;[307]and when, allowing that it is easy to say that a cell consists of minute particles, and these we call plastidules, that plastidules are composed of carbon and hydrogen, oxygen, nitrogen, and are endued with a special soul, which soul is the product of some of the forces which the chemical atom possesses, he affirms that this is one of those positions which is still unapproachable, adding, "I feel like a sailor who puts forth into anabyss, the extent of which he cannot see;" and, again, "I must enter my decided protest against the attempt to make a premature extension of our doctrine in this manner—never ceasing to repeat a hundred-fold a hundred times, 'Do not take this for established truth.'"[308]
We all believe in cerebral development according to what we call natural laws or causes, and in the parallel phenomena of mind; as also in the arrested and morbid action of brain-power by infractions of laws or by causes no less natural. In this sense we are all evolutionists. The differences of opinion arise when the ultimate relations of matter and mind are discussed, and when a designing force at the back of these laws is debated. But these questions in their relation to mental evolution, as to evolution in general, do not enter the domain of practical science, and are not affected by the degree of remoteness, according to our human reckoning, of this force or "Ultimate Power."
It will not be denied that at least the foundations of the pathology of insanity have been more securely laid in cerebral physiology during the last forty years, in spite of the fact that the relation of the minute structure of the brain to its functions, and the nature of the force in operation, still elude our grasp. The so-called disorders of the mind having been brought within the range of the pathologist, what can he tell us now of the post-mortem lesions of the insane? Can he give a satisfactory replyto the question asked by Pinel in his day, "Is it possible to establish any relation between the physical appearances manifested after death, and the lesions of intellectual function observed during life?"[309]
It is a little more than forty years since Lélut published his work entitled "The Value of Cerebral Alterations in Acute Delirium and Insanity," and Parchappe his "Recherches," to be followed by other works containing valuable contributions to the pathological anatomy of mental disease. To attempt to enumerate the contributions to this department abroad and at home would be simply impossible on the present occasion. I cannot, however, omit to notice how early Dr. Bucknill was in the field, as his laborious examination of a number of brains of the insane to determine the amount of cerebral atrophy and the specific gravity, bear witness, as also his demonstration of the changes which take place, not only in the brain and its membranes, but in the cord, in general paralysis; these observations, along with those of Dr. Boyd, having been fully confirmed by subsequent observers.
I recall here, with interest, a visit I paid eight and twenty years ago to Schroeder van der Kolk at Utrecht, whom I found full of enthusiasm (although racked at the time with neuralgia) in the midst of his microscopical sections. And this enthusiasm I cannot but suspect insensibly coloured what he saw in the brains and cords of the insane, or he would hardly have said, as he did say, that he had never failed during a quarter of acentury to find a satisfactory explanation after death of the morbid mental phenomena observed during life.
It must not, however, be forgotten that Parchappe, just forty years ago, was able to speak as strongly in regard to the brains of general paralytics; and that of others he said that it would be nearer the truth to assert that you can, than that you cannot, distinguish between a sane and an insane brain.
Since that period microscopes of higher power have been sedulously employed by European and American histologists, and in our country the example set by Lockhart Clarke has been followed by many able and successful investigators. I had intended to enumerate in some detail the gains of pathological anatomy in cerebro-mental diseases, and to endeavour to apportion to those who have cultivated this field of research their respective merits; but I find it better to consider what is the practical result of these researches. I may, however, so far depart from this course as to mention the memoirs of Dr. J. B. Tuke in theEdinburgh Medical Journalof 1868 and 1869, and elsewhere, on account of their importance in the history of the morbid histology of insanity.
Returning to the practical question of the knowledge now possessed by the cerebral pathologist, I will put into the witness box Professor Westphal and Dr. Herbert Major, as having enjoyed and utilized large opportunities for making microscopic and macroscopic examinations of the insane, and not being hasty—some think the former too slow—to admit the presence of distinctive lesions.
Now, Professor Westphal informs me that he isunable to trace, in the majority of post-mortems of the insane who have not suffered from general paralysis, any morbid appearance of the brain or its membranes, either with the naked eye or the microscope. He maintains that it would be impossible to designate amongst a hundred miscellaneous brains those which have belonged to insane persons, if the cases of general paralysis had been eliminated.
Dr. Major speaks guardedly; but inclines to think that, even putting aside general paralytics, the sane may begenerallydistinguished from the insane brain. His experience at Wakefield shows that in only seventeen per cent. of the autopsies (excluding general paralysis) the brain showed no decided morbid change. "It must be always remembered," Dr. Major writes, "that the difficulty is not to distinguish between the insane brain on the one hand and a perfectly healthy and vigorous sane brain on the other—the difference between these two extremes is, in my own experience, most striking and startling. The difficulty is to distinguish between the insane brain and that of an individual sane, but in whom the brain is (as in time it may be) anæmic, wasted, or even with tracts of softening. Still," he adds, "I think, generally speaking, the sane organ may be distinguished from the insane, the decision turning largely on thedegreeof the degenerative or other morbid change."
Again, taking only cases of general paralysis, Professor Westphal holds that in by far the greater number of brains of insane persons dying in an advanced stage, morbid appearances similar to those which he hasdescribed in Griesinger's "Archiv. I.," etc., can be traced; the morbid appearances of the cord occurring more constantly than those of the brain.
Dr. Major found that of the post-mortems of paralytics, all displayed appreciable morbid lesions, although in five per cent. of cases they were not typical of general paralysis.
Then coming definitely to the question whether these pathologists have, to any considerable extent, been able to connect the morbid appearances found in cases of insanity with the symptoms, including motor troubles, Dr. Major says that at present he cannot; and Professor Westphal says that he regards "the connection of morbid symptoms with the changes found after death as exceedingly uncertain and doubtful."
I should observe that Dr. Major grounds his statements upon his own recent experience and observation at Wakefield, and that he is not disputing the greater preference shown by certain lesions in general paralysis for particular localities; but only that he does not yet see his way to connect them with the abnormal symptoms present during life. The researches carried on by Dr. Mickle, contributed to ourJournal(January, 1876), and those of Dr. Crichton Browne, published with illustrations in the "West Riding Reports," must be regarded along with M. Voisin's large work and Hitzig's article in Ziemssen's "Cyclopædia," as placing before us whatever evidence can be adduced on the relations between the pathology of general paralysis and cerebral physiology. Hitzig, who from his investigations into the cerebral motor centres,and his position in an asylum for the insane, ought to be qualified to judge, surmises that those localities of the brain by the electrical irritation of which in animals he produced epileptiform attacks bearing the closest resemblance to the attacks of paralytics, are affected in general paralysis. He thinks, moreover, that as destruction of these cortical spots causes disturbance of motion, resembling the symptoms pathognomonic of grey degeneration of the posterior columns observed in general paralysis, there is an added reason for assuming this connection.
Dr. Mickle in his recent excellent work on general paralysis has exercised much cautious discrimination in admitting the relation between the symptoms and the alleged psycho-motor centres, and while his researches in a rich field of observation at the Grove Hall Asylum lead him to find some cerebral lesion in every case, especially in the fronto-parietal region, he cautions against the "too ready indictment of motor centres in the cerebral cortex as answerable for the most frequent and characteristic motor impairment, that of the lips, tongue, face, and articulatory organs generally;" fully believing, however, that in the production of these symptoms the cortical lesion is at the very least an important factor. "Whether the principal mental symptoms can be entirely referred," he says, "to the organic changes in certain frontal (and parietal) convolutions—the motor to those of the so-called cortical motor zone—the sensory to those of certain portions of the temporo-sphenoidal and parietal—must remain a matter of question," while in regard to the convulsive attacks, Dr. Mickle has in some casesbeen "unable to trace a harmony between these and the results of physiological experiment; in other cases they have seemed to harmonize fairly."[310]Dr. Mickle informs me that in the insane other than general paralytics, he has in the majority found some lesion in the brain and membranes.[311]
These results of research in cerebro-mental pathological anatomy and physiology may not seem, when placed side by side with the sanguine opinions of Schroeder van der Kolk and Parchappe, to present so triumphant a proof of progress and solid gain as might be desired or expected, and much, we must admit, has to be done before Pinel's question can be answered with the fulness we should wish. Nevertheless the advance is very considerable, and the best proof of the accumulating knowledge of the morbid histology of the brain and cord in the insane will, I think, be given this week by the collection of microscopical preparations of Gudden, Holler, etc., brought together by the untiring energy of Dr. Savage, including his own at Bethlem Hospital. I have but to point out how impossible such an exhibition would have been forty years ago to give significance to the contrast between 1841 and 1881; thanks to thosewho, although they may still often see as "through a glass darkly," have so wonderfully advanced the application of microscopic examination to the tissue of the brain, and prepared such beautiful sections of diseased brain and cord.
Another proof of progress might have been given, had time allowed of a reference to what has been done in the study of the brains of idiots, both morphologically and histologically, by Mierzejewski, Luys, and others, these results being sufficient to prove, had we no other evidence, the fundamental truth of cerebro-mental pathology—the dependence of healthy mind on healthy brain.
We are surely justified in expecting that by a prolonged examination of every part of the brain structure, and the notation of the mental symptoms, we shall arrive in future at more definite results; that the locality of special disorders will be discovered, and that the correlation of morbid mental and diseased cerebral states will become more and more complete, that the scientific classification of mental maladies may be one day based upon pathological as well as clinical knowledge, and psychology be founded, in part at least, upon our acquaintance with the functions of the brain. Let us hope, also, even though it be a hope in the sense rather of desire than of expectation, that by these discoveries the successful treatment of mental disorders may be proportionately advanced.
I would now turn to the very important questionwhether the treatment of the insane has advanced since 1841?
Of course, so far as this includes moral treatment and management, it has advanced in all civilized countries in a manner calculated, all will admit, to cause the liveliest feelings of satisfaction. Putting asidemoraltreatment, we cannot boast, it must be confessed, of the same unanimity of judgment. If, however, it must be admitted that as respects details,Tot capita, tot sensus, it will be allowed that, notwithstanding the so many heads, and the as many opinions, the general principles of treatment based upon a just view of the general pathology of insanity, are accepted by all. There were too many who, forty years ago, bled freely for mania, and I remember Conolly, at even a later period, complaining of the number of patients brought to him hopelessly demented in consequence of the heroic treatment to which, when maniacal, they had been subjected by men who, no doubt, still believed with Paracelsus when he said, "What avails in mania except opening a vein? Then the patient will recover. This is the arcanum. Not camphor, not sage and marjoram, not clysters, not this, not that, but phlebotomy." Well, this treatment by the Paracelsuses of 1841 has been supplanted by the more rational therapeutics which we witness in 1881.
Dr. Stokes, the highly respected superintendent of the Mount Hope Retreat, Baltimore, thus writes in his last annual report: "Forty years ago, when this institution was opened, large blood-lettings—in the standing, recumbent, or sitting posture, to the amount of thirty orforty ounces—were recommended in acute mania, followed up by local depletion, by leeches, to the number of twenty or thirty, to the temples. The moral treatment, hygienic measures, exercise, and suitable occupation were almost wholly ignored. Drastic purgatives, ... the shower bath, large and frequent doses of tartarized antimony, and mercury to the extent of producing ptyalism, were the most popular remedial agents in the treatment of insanity. This, in general terms, was the system advocated and practised when, forty years ago, this institution entered upon its godlike mission."
If the success of the treatment of insanity bore any considerable proportion to the number of the remedies which have been brought forward, it would be my easy and agreeable duty to record the triumphs of medicine in the distressing malady which they are employed to combat. But this, unhappily, is not the case. Hypodermic injections of morphia, the administration of the bromides, chloral hydrate, hyoscyamine, physostigma, cannabis indica, amyl nitrite, conium, digitalis, ergot, pilocarpine, the application of electricity, the use of the Turkish bath and the wet pack, and other remedies too numerous to mention, have had their strenuous advocates during late years. Each remedy, however, let us hope, leaves a certain residuum of usefulness behind it, though failing to fulfil all the hopes raised on its first trial.
Dr. Ramskill lately avowed his opinion in my hearing that the advent of the bromide has done infinite mischief. Others, attacking chloral, would maintain that while the bromide has slain its thousands, chloral hydrate has slainits tens of thousands. In spite of this, however, Dr. Ramskill, doubtless, continues to employ the bromide; and who would wish to be deprived of chloral, or any other drug, because of its abuse?