Chapters in the History of the Insane in the British Isles Part 33

One word now in regard to the advance in our cla.s.sification 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 our department of medicine--dry and unexciting as it may at first sight seem to be--which possess a peculiar polemical charm.

Few circ.u.mstances are more noteworthy than the attacks which have been made upon the citadel of the Pinel-Esquirol cla.s.sification, 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 a.s.serted 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 pa.s.sing from one to another," and const.i.tuting a division useless as regards moral or medical treatment--he expressed in a nutsh.e.l.l all the objections since urged against the orthodox cla.s.sification by the other alienists I have mentioned. These, however, subst.i.tuted a mixed aetiological or pathogenetic cla.s.sification, which Bell did not, and this cla.s.sification 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 more definitely 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 cla.s.sification 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-aetiological 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 a.s.sert the other day that in all diseases, "our future cla.s.sification 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 a.s.sociation in 1841, it would be a serious omission not to notice the important contributions of the late Professor Layc.o.c.k shortly before as well as after that year. In 1840 he first promulgated the opinion that "the brain, although the 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 a.s.sociation, 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 ill.u.s.tration the case of a patient at the York Retreat, whose will being suspended, he expressed ideas as they spontaneously arose in a.s.sociated sequence, the combination being singularly varied, but traceable to a common root or centre of impulse." "Researches of this kind," Layc.o.c.k continues, "whether inst.i.tuted on the insane, the somnambulist, the dreamer, or the delirious, must be considered like researches in a.n.a.lytical 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 pa.s.sages 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, according to Layc.o.c.k, in the case he employs as an ill.u.s.tration 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 ma.s.ses 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 an _indirect_ manner 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 Layc.o.c.k'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 d.i.c.kson 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 those _hors de combat_ in the dissolution.

Another factor is the kind of person to whom dissolution "comes." And the last factor is the influence of circ.u.mstances 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 induced hallucinations and delusions, and in an article in the _Journal_ in 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 pa.s.s 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 whenever the 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 a.s.sociates 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 the current 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 ma.s.ses, 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 an abyss, 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 reply to 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 Lelut published his work ent.i.tled "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 a century 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 a.s.sert 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 the _Edinburgh Medical Journal_ of 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 is unable 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 be _generally_ distinguished 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) anaemic, 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 the _degree_ of 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 has described 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 our _Journal_ (January, 1876), and those of Dr. Crichton Browne, published with ill.u.s.trations in the "West Riding Reports," must be regarded along with M. Voisin's large work and Hitzig's article in Ziemssen's "Cyclopaedia,"

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 a.s.suming 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 princ.i.p.al 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 cases been "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 acc.u.mulating 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 those who, although they may still often see as "through a gla.s.s 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 cla.s.sification 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 question whether 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 aside _moral_ treatment, 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 inst.i.tution was opened, large blood-lettings--in the standing, rec.u.mbent, or sitting posture, to the amount of thirty or forty 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 inst.i.tution entered upon its G.o.dlike 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 slain its 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?

"For nought so vile that on the earth doth live, But to the earth some special good doth give; Nor aught so good, but strained from that fair use, Revolts from true birth, stumbling on abuse."

Employed without discrimination, regarded as a talisman in insomnia and excitement--petted, in short, when it ought to have been restrained--chloral became for a time the spoilt child of psychological medicine, and, like other spoilt children, it has disappointed the fond hopes of its parents.

When it is possible for a physician in asylum practice to write as Dr.

Pritchard Davies has written this year in our _Journal_, "On Chemical Restraint," to the effect that chloral, the bromides, and other sedatives are unnecessary, or even injurious; when, on the other hand, we have Dr. Hills replying that his experience at the Norfolk Asylum leads him to an entirely opposite conclusion; and Dr. Stokes, in America, writing thus in his report, after 7425 patients have been under treatment in his asylum, "without wis.h.i.+ng to undervalue the great importance of an efficient system of moral treatment, great results can only be expected from a patient and persevering administration of powerful remedial agencies"--I say when such contrary opinions can be expressed by practical men, one feels how impossible it is to dogmatize upon the good effected by pharmaceutical remedies in insanity, and how far we are yet from witnessing a consensus of opinion in regard to their value.

It must be frankly granted that Psychological Medicine can boast, as yet, of no specifics, nor is it likely, perhaps, that such a boast will ever be made. It may be difficult to suppress the hope, but we cannot entertain the expectation, that some future Sydenham will discover an anti-psychosis which will as safely and speedily cut short an attack of mania or melancholia as bark an attack of ague.